CHIEF COMPLAINT: CODE STROKE for aphasia

PRESENT ILLNESS: The pt is a 89 year-old right-handed woman with a PMH of HTN who
presented to the ED with aphasia. Per her grand-daughter, she
was in her USOH this morning. She was then known to have a
conversation with a neighbor while in bed around 6-6:30 pm. It
she was reportedly not feeling well. It was a "brief
conversation" but no speech impairment was notice. Her family
then came to see her around 7:15pm and was found to be unable to
produce fluent sp each and with limited comprehension. She was
brought to the ED and a code stroke was called. Neurology was at
the bedside at 7:36pm.

MEDICAL HISTORY: - "heart condition"
- asthma/COPD
- HTN
- OA
- Vit D deficiency
- afib (per [**Hospital1 2177**] records in [**2170**] w/ nl echo)
- falls
- memory problems
- urinary incontinence

MEDICATION ON ADMISSION: (confirmed with daughter and PCP [**Name Initial (PRE) 14453**])
-Tylenol 500mg, 1-2 tabs Q6H PRN
-Norvasc 5mg PO daily
-ASA 325mg PO daily
-Flovent aero 200mcg/act 2 puffs [**Hospital1 **]
-Albuterol 90 mcg 2 puffs Q4H PRN
-Lasix 20mg PO daily PRN
-Vitamin D 50,000 Q week x8 weeks (just started prior to
admission, had not yet started)
-MVI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: NIH SS: 6
1a. Level of Consciousness: 0
1b. LOC questions: 1
1c. LOC commands: 0
2. Best gaze: 0
3. Visual: 1
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb ataxia: UA
8. Sensory: UA
9. Best language: 2
10. Dysarthria: 1
11. Extinction and inattention: UA

FAMILY HISTORY: Unable to obtain.

SOCIAL HISTORY: -lives alone but requires some assistance with ADLS
-no EtOH, former tobacco, no drugs
Cerebral embolism with cerebral infarction,Encephalopathy, unspecified,Urinary tract infection, site not specified,Unspecified essential hypertension,Chronic obstructive asthma, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Atrial fibrillation,Unspecified vitamin D deficiency
Crbl emblsm w infrct,Encephalopathy NOS,Urin tract infection NOS,Hypertension NOS,Chronic obst asthma NOS,Osteoarthros NOS-unspec,Atrial fibrillation,Vitamin D deficiency NOS
Admission Date:  [**2171-9-23**]              Discharge Date:   [**2171-10-1**]


Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

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

Major Surgical or Invasive Procedure:
None


History of Present Illness:
The pt is a 89 year-old right-handed woman with a PMH of HTN who
presented to the ED with aphasia. Per her grand-daughter, she
was in her USOH this morning. She was then known to have a
conversation with a neighbor while in bed around 6-6:30 pm. It
she was reportedly not feeling well. It was a "brief
conversation" but no speech impairment was notice. Her family
then came to see her around 7:15pm and was found to be unable to
produce fluent sp each and with limited comprehension. She was
brought to the ED and a code stroke was called. Neurology was at
the bedside at 7:36pm.

I contact[**Name (NI) **] her [**Name (NI) 6435**] office, [**First Name8 (NamePattern2) **] [**Doctor Last Name 11456**], MD [**First Name (Titles) **] [**Last Name (Titles) 2177**]
([**Telephone/Fax (1) 11454**], her [**Medical Record Number 80244**] is [**Numeric Identifier 80245**]). I spoke with the
covering physician who reviewed her records and confirmed that
she has a hx of afib but was not anticoagulated given a history
of falls. No reported recent surgeries, bleeding or head
traumas.

Past Medical History:
- "heart condition"
- asthma/COPD
- HTN
- OA
- Vit D deficiency
- afib (per [**Hospital1 2177**] records in [**2170**] w/ nl echo)
- falls
- memory problems
- urinary incontinence

Social History:
-lives alone but requires some assistance with ADLS
-no EtOH, former tobacco, no drugs


Family History:
Unable to obtain.

Physical Exam:
NIH SS: 6
1a. Level of Consciousness: 0
1b. LOC questions: 1
1c. LOC commands: 0
2. Best gaze: 0
3. Visual: 1
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb ataxia: UA
8. Sensory: UA
9. Best language: 2
10. Dysarthria: 1
11. Extinction and inattention: UA

Vitals: T: P:85  R: 19 BP: 153/75  SaO2: 95 % RA
General: Awake, cooperative
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity

Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No pedal edema
Skin: no rashes

Neurologic:
-Mental Status: awake, inattentive, follows commands
inconsistently. + dysarthria, paraphasic errors, unable to read,
repeat or name. Only intact spontaneous speech is her name
"[**Known firstname **]" and "I don't know"

CN
I: not tested
II,III: pt does not cooperate with formal VFF testing, unclear
if decreased blink to threat (? L>R), no clear gaze deviation;
pupils  2mm->1mm bilaterally, unable to visualize fundi clearly

III,IV,V: EOMI, no ptosis. No nystagmus
V: UA
VII: ? R NLF flattening
VIII: UA (hearing aids in place)
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: turns head symmetrically
XII: tongue protrudes midline

Motor: Normal bulk and tone; pt does not cooperate with formal
strength testing. + motor impersistence throughout but
antigravity in all extremities; No clear  pronator drift.

  Reflex: No clonus
  [**Hospital1 **] Tri Bra Pat An Plantar
  C5 C7 C6 L4 S1 CST
L 0------------ Mute
R 0------------ Mute

-Sensory: No withdrawal or grimace to pinprick or nox stim
throughout.

-Coordination: pt does not cooperate with formal testing but is
able to take a pen from the R hand without significant dysmetria
but does not try with the L hand

-Gait: deferred

Pertinent Results:
LABS:
[**2171-9-23**] 07:45PM BLOOD WBC-9.5 RBC-4.76 Hgb-13.8 Hct-41.8 MCV-88
MCH-29.0 MCHC-33.0 RDW-15.5 Plt Ct-324
[**2171-9-30**] 05:40AM BLOOD WBC-7.3 RBC-3.83* Hgb-11.4* Hct-33.0*
MCV-86 MCH-29.9 MCHC-34.6 RDW-15.9* Plt Ct-269
[**2171-9-23**] 07:45PM BLOOD PT-12.9 PTT-24.8 INR(PT)-1.1
[**2171-9-30**] 05:40AM BLOOD PT-32.2* PTT-38.6* INR(PT)-3.3*
[**2171-9-23**] 07:45PM BLOOD Glucose-117* UreaN-16 Creat-1.1 Na-136
K-3.7 Cl-102 HCO3-25 AnGap-13
[**2171-9-30**] 05:40AM BLOOD Glucose-103 UreaN-15 Creat-1.1 Na-139
K-4.2 Cl-105 HCO3-23 AnGap-15
[**2171-9-23**] 07:45PM BLOOD ALT-10 AST-15 LD(LDH)-204 CK(CPK)-70
AlkPhos-67 TotBili-0.4
[**2171-9-24**] 02:30AM BLOOD ALT-9 AST-13 LD(LDH)-187 CK(CPK)-61
AlkPhos-62 TotBili-0.6
[**2171-9-24**] 02:10PM BLOOD CK(CPK)-62
[**2171-9-23**] 07:45PM BLOOD CK-MB-3 cTropnT-<0.01
[**2171-9-24**] 02:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2171-9-24**] 02:10PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2171-9-23**] 07:45PM BLOOD Albumin-4.3
[**2171-9-25**] 01:45AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9 Cholest-176
[**2171-9-25**] 01:45AM BLOOD Triglyc-74 HDL-57 CHOL/HD-3.1 LDLcalc-104
[**2171-9-24**] 02:30AM BLOOD %HbA1c-5.9
[**2171-9-23**] 07:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2171-9-24**] 12:21PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.026
[**2171-9-24**] 12:21PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2171-9-24**] 12:21PM URINE RBC->50 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2171-9-29**] 03:40PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2171-9-29**] 03:40PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM

MICRO:
Urine Cx ([**9-24**]): GRAM POSITIVE BACTERIA.  ~1000/ML.  SUGGESTING
STAPHYLOCOCCI.

Blood Cx ([**9-25**]): NGTD x2

Urine Cx ([**9-26**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH FECAL CONTAMINATION.

Urine Cx ([**9-28**]):
      MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
      CONTAMINATION INTERPRET RESULTS WITH CAUTION.
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..
PREDOMINATING ORGANISM.
                              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------------     4 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

Urine Cx ([**9-29**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
     ESCHERICHIA COLI.    >100,000 ORGANISMS/ML.

IMAGING:
ECG ([**9-23**]): Baseline artifact. Atrial fibrillation at a rate of
85 with wider complex beats which are ventricular versus
aberration.

CXR ([**9-23**]): FINDINGS: No previous images. Enlargement of the
cardiac silhouette with hyperexpansion of the lungs. Some
prominence of interstitial markings could reflect elevated
pulmonary venous pressure, chronic lung disease, or both.
No evidence of acute focal pneumonia.

CTA Head/Neck ([**9-23**]): IMPRESSION: Area of ischemia seen within
the left MCA territory. Narrowed region of left M2 segment with
a paucity of distal branches seen.

CT Head ([**9-24**]): IMPRESSION: No evidence of acute intracranial
hemorrhage.

EEG ([**9-24**]): IMPRESSION: Abnormal EEG due to diffuse slowing
with some leftsided accentuation at times with a moderate to
moderately severe diffuse encephalopathy with lateralization to
the left side and accentuation thereof.

TTE ([**9-24**]): The left ventricular cavity size is normal. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%) in limited views. Right
ventricular chamber size and systolic function are probably
normal. The aortic valve leaflets are mildly thickened. There is
no aortic valve stenosis. No aortic regurgitation is seen.
Trivial mitral regurgitation seen in limited views. (Patient
unable to cooperate with completion of the test.)

MRI Head ([**9-24**]): IMPRESSION:
1. Multiple small acute infarcts within the left MCA territory
with associated stenosis of the M2 branches of the left middle
cerebral artery, better evaluated on prior CTA.
2. Mild thickening of the ligaments posterior to the dens
without cord compression- can be degenerative or inflammatory-
to correlate with past history.

Brief Hospital Course:
1. Stroke. The patient is an 89 year old right handed woman with
a history of atrial fibrillation and hypertension who presented
approximately 1 hour after developing global aphasia. CTA
head/neck on admission showed an area of ischemia within the
left MCA territory, narrowed region of left M2 segment with a
paucity of distal branches seen. She was given IV tPA at 9:45 pm
on [**9-23**], and admitted to the NeuroICU. MRI brain showed
multiple small acute infarcts within the left MCA territory with
associated stenosis of the M2 branches of the left middle
cerebral artery, and mild thickening of the ligaments posterior
to the dens without cord compression. Repeat head CT 24 hours
after tPA showed no evidence of acute intracranial hemorrhage.
TTE was of suboptimal image quality, but showed LVEF>55%. FLP:
Chol 176, TG 74, HDL 57, LDL 104, HgA1c: 5.9%, CEs: CK 70-61-62,
TropT <0.01x3. EEG was abnormal due to diffuse slowing with some
leftsided accentuation at times with a moderate to moderately
severe diffuse encephalopathy with lateralization to the left
side and accentuation thereof.
.
It was determined that the most likely cause of her stroke was
cardioembolic in the setting of atrial fibrillaion. She was
started on a heparin gtt for bridge to Coumadin. Her home ASA
was discontinued. She was started on Simvastatin 40 mg qhs. She
will follow up with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in Neurology as an
outpatient.

2. Atrial fibrillation. EKG on admission showed atrial
fibrillation. Given that her stroke was most likely
cardioembolic, her ASA was discontinued and she was started on
Coumadin. Her INR should be monitored daily in rehab, especially
given that she is also on antibiotics for a UTI (see below).

3. Hypertension. Her home blood pressure medications were
intially held in the setting of stroke to allow for
autoregulation. She was restarted on Norvasc 5 mg daily upon
discharge.

4. Urinary Tract Infection. Her UA on [**9-26**] showed 37 WBC and
moderate bacteria. Urine culture on [**9-28**] and [**9-29**] grew
pan-sensitive E. coli. She was started on Bactrim DS PO bid to
complete a 7 day course. Her INR should be monitored carefully
while on antibiotics.

5. Contacts: HCP is her daughter [**Name (NI) 71304**] [**Name (NI) **] (H) [**Telephone/Fax (1) 80246**]
(C) [**Telephone/Fax (1) 80247**]
-PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**] at [**Hospital1 2177**] [**Telephone/Fax (1) 11463**]

Medications on Admission:
(confirmed with daughter and PCP [**Name Initial (PRE) 14453**])
-Tylenol 500mg, 1-2 tabs Q6H PRN
-Norvasc 5mg PO daily
-ASA 325mg PO daily
-Flovent aero 200mcg/act 2 puffs [**Hospital1 **]
-Albuterol 90 mcg 2 puffs Q4H PRN
-Lasix 20mg PO daily PRN
-Vitamin D 50,000 Q week x8 weeks (just started prior to
admission, had not yet started)
-MVI

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1186**] - [**Location (un) 538**]

Discharge Diagnosis:
PRIMARY:
Stroke-Left MCA territory, s/p IV tPA, likely cardioembolic
Atrial fibrillation
Hypertension
Urinary Tract Infection

SECONDARY:
Asthma


Discharge Condition:
Slight dysarthria, smile symmetric, no pronator drift, full
strength, gait narrow based and steady, walks with a cane


Discharge Instructions:
You were admitted to the hospital with difficulty speaking and
were found to have a stroke, and you received tPA IV. Your
stroke was most likely due to your irregular heart rhythm
(atrial fibrillation), so you were started on Coumadin. You were
initially in the NeuroICU, but were transferred to the Neurology
floor when your symptoms improved.

The following changes were made to your medications: Your
Aspirin was discontinued during this admission, and you were
started on Coumadin 2 mg QD. You were started on Simvastatin 40
mg every evening. You were found to have a UTI and were started
on Bactrim twice daily to complete a 7 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 will need to make a follow up appointment with your Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1726**] (your PCP) at [**Hospital1 2177**] ([**Telephone/Fax (1) 11463**]) within the next 1
week.

You have a follow up appointment with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in
Neurology ([**Telephone/Fax (1) 2574**]) on [**2171-11-11**] at 2:00 pm in the [**Hospital Ward Name 23**]
Center, [**Location (un) **].  You will need to call the office before the
appointment to update your information.


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

Completed by:[**2171-10-1**]
{'Cerebral embolism with cerebral infarction,Encephalopathy, unspecified,Urinary tract infection, site not specified,Unspecified essential hypertension,Chronic obstructive asthma, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Atrial fibrillation,Unspecified vitamin D deficiency'}


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 for aphasia

PRESENT ILLNESS: The pt is a 89 year-old right-handed woman with a PMH of HTN who
presented to the ED with aphasia. Per her grand-daughter, she
was in her USOH this morning. She was then known to have a
conversation with a neighbor while in bed around 6-6:30 pm. It
she was reportedly not feeling well. It was a "brief
conversation" but no speech impairment was notice. Her family
then came to see her around 7:15pm and was found to be unable to
produce fluent sp each and with limited comprehension. She was
brought to the ED and a code stroke was called. Neurology was at
the bedside at 7:36pm.

MEDICAL HISTORY: - "heart condition"
- asthma/COPD
- HTN
- OA
- Vit D deficiency
- afib (per [**Hospital1 2177**] records in [**2170**] w/ nl echo)
- falls
- memory problems
- urinary incontinence

MEDICATION ON ADMISSION: (confirmed with daughter and PCP [**Name Initial (PRE) 14453**])
-Tylenol 500mg, 1-2 tabs Q6H PRN
-Norvasc 5mg PO daily
-ASA 325mg PO daily
-Flovent aero 200mcg/act 2 puffs [**Hospital1 **]
-Albuterol 90 mcg 2 puffs Q4H PRN
-Lasix 20mg PO daily PRN
-Vitamin D 50,000 Q week x8 weeks (just started prior to
admission, had not yet started)
-MVI

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: NIH SS: 6
1a. Level of Consciousness: 0
1b. LOC questions: 1
1c. LOC commands: 0
2. Best gaze: 0
3. Visual: 1
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb ataxia: UA
8. Sensory: UA
9. Best language: 2
10. Dysarthria: 1
11. Extinction and inattention: UA

FAMILY HISTORY: Unable to obtain.

SOCIAL HISTORY: -lives alone but requires some assistance with ADLS
-no EtOH, former tobacco, no drugs 

### Response:
{'Cerebral embolism with cerebral infarction,Encephalopathy, unspecified,Urinary tract infection, site not specified,Unspecified essential hypertension,Chronic obstructive asthma, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Atrial fibrillation,Unspecified vitamin D deficiency'}
