CHIEF COMPLAINT: right hemiparesis, aphasia

PRESENT ILLNESS: 54yo right-handed woman with no significant PMH, nonsmoker, who
presented as a "CODE STROKE" with sudden onset inability to move
her right side or talk. The symptoms began at 10:35PM the day of
admission. She presented at 11:20PM, with neurology at her
bedside within 1 minute. She is from [**Location (un) 61361**], here for an
educational conference, and was having dinner with her
colleagues - one colleague left her umbrella under the table,
and the patient leaned down to get it at 10:30 PM. When she
stood up again, she looked a little dizzy, but had normal
movement and conversation at this point. Within 5 minutes, she
started slurring her speech and having trouble moving the right
leg; within 1 min of onset, she could not move her right side at
all and was barely talking.  Her colleagues helped her to her
hotel room and called EMS, who brought her to the ER.

MEDICAL HISTORY: Headaches occasionally in the past, only once (age 19)
associated with phonophobia, throbbing, visual changes, never
with weakness, paresthesias, or other neurologic symptoms.

MEDICATION ON ADMISSION: MVI
ASA 81 (not taking since [**Month (only) 547**])
Flax seed oil

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Examination on admission:
T 97.9  HR 106  BP 118/79  100%RA  RR 20s
General appearance: thin white female
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, pulses equal throughout
Skull & Spine: Neck movements are full and not painful to
palpation in the paraspinal soft tissues

FAMILY HISTORY: No strokes or heart attacks in family; no connective tissue
disorders or clotting disorders.

SOCIAL HISTORY: Lives with husband and three kids. No tobacco or drug use; ETOH
as above. Works at St. [**Location (un) 68292**]in [**Location (un) 61361**] as an
educator.
Cerebral artery occlusion, unspecified with cerebral infarction,Ostium secundum type atrial septal defect
Crbl art ocl NOS w infrc,Secundum atrial sept def
Admission Date:  [**2175-12-7**]              Discharge Date:   [**2175-12-9**]

Date of Birth:  [**2122-11-21**]             Sex:   F

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
right hemiparesis, aphasia

Major Surgical or Invasive Procedure:
tPA administration
transthoracic and transesophageal echocardiogram

History of Present Illness:
54yo right-handed woman with no significant PMH, nonsmoker, who
presented as a "CODE STROKE" with sudden onset inability to move
her right side or talk. The symptoms began at 10:35PM the day of
admission. She presented at 11:20PM, with neurology at her
bedside within 1 minute. She is from [**Location (un) 61361**], here for an
educational conference, and was having dinner with her
colleagues - one colleague left her umbrella under the table,
and the patient leaned down to get it at 10:30 PM. When she
stood up again, she looked a little dizzy, but had normal
movement and conversation at this point. Within 5 minutes, she
started slurring her speech and having trouble moving the right
leg; within 1 min of onset, she could not move her right side at
all and was barely talking.  Her colleagues helped her to her
hotel room and called EMS, who brought her to the ER.

She denies any tobacco use. She does not take oral
contraceptives. She did take ASA but stopped approximately 6
months prior while renovating her kitchen. She had been drinking
more EtOH than usual since arriving for her conference, and had
not been consuming many other fluids. She had gotten up once on
the plane ride. She has been traveling a lot recently, with the
farthest trip being 3.5hrs to [**Location (un) 86**], which she has done three
times since [**Month (only) 547**]. She denied any swelling, erythema, or
tenderness/pain of her legs.

Past Medical History:
Headaches occasionally in the past, only once (age 19)
associated with phonophobia, throbbing, visual changes, never
with weakness, paresthesias, or other neurologic symptoms.

No other medical problems.

Social History:
Lives with husband and three kids. No tobacco or drug use; ETOH
as above. Works at St. [**Location (un) 68292**]in [**Location (un) 61361**] as an
educator.


Family History:
No strokes or heart attacks in family; no connective tissue
disorders or clotting disorders.

Physical Exam:
Examination on admission:
T 97.9  HR 106  BP 118/79  100%RA  RR 20s
General appearance: thin white female
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, pulses equal throughout
Skull & Spine: Neck movements are full and not painful to
palpation in the paraspinal soft tissues

NIHSS at presentation was 20, for LOC questions (2), LOC
commands (1), R field cut (2), R facial droop (2), R arm
complete paralysis (4), R leg trace mvmt to stim (3), sensation
loss (2), severe aphasia (2), and dysarthria (2).

Mental Status: The patient is alert but only mumbling few words
with marked dysarthria, not sure if neologisms. Can only
comprehend command to open/close eyes, but no other commands.
Could not read, repeat or name.

Cranial Nerves: Absent blink to threat on R hemi-field. The
optic discs are normal in appearance. Eye movements show eyes
midline but with question of L gaze preference? (can move eyes
all the way to r and l without nystagmus).  Pupils react equally
to light, both directly and consensually 2.5->2. Intact corneals
bilat. Facial droop on R - UMN pattern. Hearing is intact to
finger rub. The palate elevates in the midline. The tongue
protrudes in the midline and is of normal appearance. There is
some dysarthria when she tries to speak.

Motor System: Tone lower on R than L arm, equal in legs; RUE 0/5
strength, LUE [**6-2**] throughout; in lower ext, there is trace w/d
to deep nox stim in triple-flexion, but no spont mvmt; on L full
strength as assessed.  Pt could not participate in exam for
drift.  No tremor, myoclonus.

Reflexes: The tendon reflexes are diminished in RUE compared to
L at this time, symmetric at knees and ankles, with R upgoing
toe. L toe down.

Sensory: Sensation could not be assessed in detail, but does not
seem to respond quickly to nox stim on R compared to brisk
response on L (no grimace or HR/BP elev initially), could not
participate in ?ext to DSS or cortical sensory exam due to
aphasia.

Coordination: There is no ataxia on L, could not assess on R.

Gait:  could not be performed

Pertinent Results:
Admission Labs:
139  105  15
------------<80
4.2  22  0.9

MCV 96
WBC 6.6  H/H 13.0/36.7   PLT 196
PT: 11.8  PTT: 26.1  INR: 1.0

D-Dimer-263
cardiac enzymes negative x 3
%HbA1c-5.6
Triglyc-53 HDL-55 CHOL/HD-3.0 LDLcalc-100

Homocys-5.7
[**Doctor First Name **]-NEGATIVE
Lupus-PND
AT III-PND ProtCFn-PND ProtSFn-PND
ACA IgG-PND ACA IgM-PND

U/A and Ucx negative

Imaging:
CT and CTA on admission: negative
MRI: Findings of concern for a tiny evolving left thalamic
infarct.
MRA: L fetal PCA, o/w normal
LENIs: negative
CXR: negative
TTE: Patent foramen ovale. Normal global and regional
biventricular
systolic function. Mild-moderate tricuspid regurgitation
TEE: Patent foramen ovale is present with slight intermittent
color
flow across interatrial septum (no ASD).
Repeat HCT [**12-8**]: Evolving left thalamic infarct.
MRV pelvis: pending

Brief Hospital Course:
53yo woman with no significant PMH or hypercoagulable risk
factors presented with right hemiparesis and aphasia. NIHSS at
presentation was 20, for LOC questions (2), LOC commands (1), R
field cut (2), R facial droop (2), R arm complete paralysis (4),
R leg trace mvmt to stim (3), sensation loss (2), severe aphasia
(2), and dysarthria (2). Head CT/CTA was completely negative for
bleed or most early signs of stroke.  BG was 80s, BP was 118/79,
normal lytes, renal function, cbc and coags. Her husband was
[**Name (NI) 653**] for confirmation of history and consent; IV TPA was
given at 12:05AM with a total dose of 54.8mg (for weight
134lbs), with 5.5 mg bolus over 1 minute followed by 49.3mg
infusion over 1 hr. Minutes after the bolus, she was able to say
her name, the name of the conference she was attending, was able
to name glasses, though still with paraphasic errors naming
thumb as "[**Doctor Last Name **]," oriented to hospital and situation when asked.
She could move the right arm against gravity on command, and
wiggled her right toes on command. She was admitted to the
neurology ICU for close monitoring post-tPA. She had an MRI
showing some diffusion restriction in the left thalamus but a
normal MRA (except a left fetal PCA). Over the course of the
night she improved and had only a right facial palsy and subtle
right pronator drift the next morning. She continued to improve
and was asymptomatic with no signs on exam by that evening. She
had a repeat head CT 24hours after the tPA; this showed no signs
of hemorrhage but had a hypodensity in the left thalamus
consistent with the acute stroke. Given that she had no vascular
risk factors, no MRA/CTA findings, and had the episode in the
setting of a long plane ride and straining immediately prior to
the event, the most likely etiology of her stroke was thought to
be a venous embolism passing through a PFO. In addition, the
resolution of her symptoms was consistent with a spectacular
shrinking deficit, also indicating an embolic event. She had a
TTE showing a PFO. A TEE also showed the PFO and no ASD. She was
started on aspirin. HbA1C was normal; lipid panel was slightly
elevated and she was started on lipitor. A hypercoagulable
workup was started; [**Doctor First Name **] and homocysteine were normal, the rest
pending; LENIs were negative and MRV of the pelvis pending.
Given the lack of data about the relative efficacy of aspirin,
coumadin, and PFO closure in cryptogenic strokes in the presence
of a PFO, she was informed of the various options. She chose to
take Aspirin 325 mg po qd.

Medications on Admission:
MVI
ASA 81 (not taking since [**Month (only) 547**])
Flax seed oil

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Left thalamic infarct
Patent foramen ovale


Discharge Condition:
Stable; asymptomatic.


Discharge Instructions:
Take all medications as prescribed. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**]. You
have been started also on Lipitor for your cholesterol; you
should tell your doctor if you have any muscle pains, change in
your urine, or other concerning symptoms.

Follow up with your primary care provider and ask for a referral
to a neurologist.

Followup Instructions:
Follow up with your primary care provider and ask for a referral
to a neurologist.
{'Cerebral artery occlusion, unspecified with cerebral infarction,Ostium secundum type atrial septal defect'}


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: right hemiparesis, aphasia

PRESENT ILLNESS: 54yo right-handed woman with no significant PMH, nonsmoker, who
presented as a "CODE STROKE" with sudden onset inability to move
her right side or talk. The symptoms began at 10:35PM the day of
admission. She presented at 11:20PM, with neurology at her
bedside within 1 minute. She is from [**Location (un) 61361**], here for an
educational conference, and was having dinner with her
colleagues - one colleague left her umbrella under the table,
and the patient leaned down to get it at 10:30 PM. When she
stood up again, she looked a little dizzy, but had normal
movement and conversation at this point. Within 5 minutes, she
started slurring her speech and having trouble moving the right
leg; within 1 min of onset, she could not move her right side at
all and was barely talking.  Her colleagues helped her to her
hotel room and called EMS, who brought her to the ER.

MEDICAL HISTORY: Headaches occasionally in the past, only once (age 19)
associated with phonophobia, throbbing, visual changes, never
with weakness, paresthesias, or other neurologic symptoms.

MEDICATION ON ADMISSION: MVI
ASA 81 (not taking since [**Month (only) 547**])
Flax seed oil

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Examination on admission:
T 97.9  HR 106  BP 118/79  100%RA  RR 20s
General appearance: thin white female
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, pulses equal throughout
Skull & Spine: Neck movements are full and not painful to
palpation in the paraspinal soft tissues

FAMILY HISTORY: No strokes or heart attacks in family; no connective tissue
disorders or clotting disorders.

SOCIAL HISTORY: Lives with husband and three kids. No tobacco or drug use; ETOH
as above. Works at St. [**Location (un) 68292**]in [**Location (un) 61361**] as an
educator. 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Ostium secundum type atrial septal defect'}
