CHIEF COMPLAINT: code stroke

PRESENT ILLNESS: 51 yo F with hx of [**Hospital **] transferred from [**Hospital6 302**]
with facial droop and transient dysarthria.  She reports waking
up with symptoms around 11 AM and was last known well last night
(one note from OSH reports seen normal at 0300).  Her daughter
called her and thought her speech was slurred and garbled.  Her
son who lives with her noticed a left facial droop and she was
taken to [**Hospital6 302**].  EMS noted BP 169/97 and upon
arrival to OSH BP as high as 221/131 with P 110.  She was noted
to have a left forehead-sparing facial droop and intact
strength.
A CTA showed an acom aneurysm.  She received labetalol 20 mg IV
x2 and aspirin 325 mg daily and transferred to [**Hospital1 18**].  Upon
arrival, a code stroke was called.

MEDICAL HISTORY: -HTN

MEDICATION ON ADMISSION: Metoprolol Unknown dose

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Gen; awake, alert, NAD
CV; RRR, no murmurs
Pulm; CTA anteriorly
Abd; soft, nt, nd
Extr; no edema
Neuro;
MS; A&Ox3, alert, interactive.  Able to relate history without
difficulty.  Speech fluent.  Naming, repetition, and
comprehension intact.  Follows midline and appendicular
commands.
CN; PERRL 4mm-->2mm, EOMI, no nystagmus.  Face sensation intact
V1-V3, forehead-sparing left facial droop, palate symmetric,
hearing intact to finger-rub, trapezius symmetric, tongue
midline.
Motor; normal bulk and tone, no drift.  5/5 strength at R and L
delt, bicep, tricp, WrE, FF, IP, ham, quad, TA, gastrocs
Sensory; intact to light touch and pinprick throughout
Coordination; no dysmetria on FNF b/l
Reflexes; upgoing toe on left
Gait; deferred
On discharge her main deficit was the left extremity. Her
Strength was [**1-5**] at wrist flexion and [**12-5**] at finger flexion. 0/5
of finger extension, Wrist extension. She had a left facial
droop. Gait was stable with a walker.

FAMILY HISTORY: -mother with cerebral aneurysm rupture

SOCIAL HISTORY: -smokes tobacco daily, no etoh or drugs.
Cerebral artery occlusion, unspecified with cerebral infarction,Cerebral aneurysm, nonruptured,Other speech disturbance,Other musculoskeletal symptoms referable to limbs,Facial weakness,Unspecified essential hypertension,Tobacco use disorder,Other and unspecified hyperlipidemia,Asthma, unspecified type, unspecified
Crbl art ocl NOS w infrc,Nonrupt cerebral aneurym,Speech disturbance NEC,Muscskel sympt limb NEC,Facial weakness,Hypertension NOS,Tobacco use disorder,Hyperlipidemia NEC/NOS,Asthma NOS
Admission Date:  [**2137-1-23**]              Discharge Date:   [**2137-2-1**]

Date of Birth:  [**2085-4-12**]             Sex:   F

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
code stroke


Major Surgical or Invasive Procedure:
none

History of Present Illness:
51 yo F with hx of [**Hospital **] transferred from [**Hospital6 302**]
with facial droop and transient dysarthria.  She reports waking
up with symptoms around 11 AM and was last known well last night
(one note from OSH reports seen normal at 0300).  Her daughter
called her and thought her speech was slurred and garbled.  Her
son who lives with her noticed a left facial droop and she was
taken to [**Hospital6 302**].  EMS noted BP 169/97 and upon
arrival to OSH BP as high as 221/131 with P 110.  She was noted
to have a left forehead-sparing facial droop and intact
strength.
A CTA showed an acom aneurysm.  She received labetalol 20 mg IV
x2 and aspirin 325 mg daily and transferred to [**Hospital1 18**].  Upon
arrival, a code stroke was called.

Past Medical History:
-HTN


Social History:
-smokes tobacco daily, no etoh or drugs.

35Pack year history


Family History:
-mother with cerebral aneurysm rupture


Physical Exam:
Gen; awake, alert, NAD
CV; RRR, no murmurs
Pulm; CTA anteriorly
Abd; soft, nt, nd
Extr; no edema
Neuro;
MS; A&Ox3, alert, interactive.  Able to relate history without
difficulty.  Speech fluent.  Naming, repetition, and
comprehension intact.  Follows midline and appendicular
commands.
CN; PERRL 4mm-->2mm, EOMI, no nystagmus.  Face sensation intact
V1-V3, forehead-sparing left facial droop, palate symmetric,
hearing intact to finger-rub, trapezius symmetric, tongue
midline.
Motor; normal bulk and tone, no drift.  5/5 strength at R and L
delt, bicep, tricp, WrE, FF, IP, ham, quad, TA, gastrocs
Sensory; intact to light touch and pinprick throughout
Coordination; no dysmetria on FNF b/l
Reflexes; upgoing toe on left
Gait; deferred
On discharge her main deficit was the left extremity. Her
Strength was [**1-5**] at wrist flexion and [**12-5**] at finger flexion. 0/5
of finger extension, Wrist extension. She had a left facial
droop. Gait was stable with a walker.


Pertinent Results:
ECHO: The left atrium is mildly dilated. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. However the image quality for the
agitated saline contrast study was suboptimal so cannot
definitively exclude an intracardiac shunt. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are mildly
thickened. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.

No cardiac source of embolus identified (cannot definitively
exclude).

MRI Brain:
FINDINGS: In comparison with the most recent examination, again
a 7 x 11 mm
anterior communicating artery aneurysm is redemonstrated, there
is no evidence
of acute intracranial hemorrhage or mass effect. There is no
evidence of
hydrocephalus. An area of restricted diffusion is identified
involving the
posterior aspect of the right caudate nucleus, extending
inferiorly along the
posterior limb of the right internal capsule and right putamen
with no
evidence of hemorrhagic transformation. These areas demonstrate
low signal
intensity in the corresponding ADC confirming restricted
diffusion. Few foci
of high signal intensity are demonstrated in the subcortical
white matter,
which are nonspecific and may represent areas of small vessel
disease.

The orbits are unremarkable, the paranasal sinuses demonstrate
mucosal
thickening at the ethmoidal, sphenoid and maxillary sinuses with
polypoid
formations, possibly representing a mucous retention cyst.


Brief Hospital Course:
Pt [**Name (NI) 12330**] was admitted to the neurosurgery service after
having been found a large ACOM aneurysm. After an MRI was
completed a right sided stroke was also demonstrated on MRI. She
was then transferred to the stroke service for further care. The
stroke was in the distribution of the anterior choroidal artery.
Her Echo was done but was suboptimal for evaluation of a PFO.
On the stroke service her main problems was uncontrolled
hypertension. She was started on simvastatin 40mg PO qDay and
aspirin 325mg qDay.  She was placed on metoprolol XR 100mg along
with Norvasc 10mg and lisinopril 40mg. Her blood pressure ranged
from low 110's and 170's. She was walking stairs with PT and her
blood pressure did not reach above (systolic) 180. We could not
continue to add medications for blood pressure without the fear
of making her hypotensive. She was evaluated by physical therapy
who cleared her for home with PT. She has a scheduled
appointment with neurosurgery for aneurysm coiling.
She is scheduled for an outpatient ECHO to be done with a bubble
study. She was encouraged to buy a blood pressure cuff for home
monitoring. She is instructed not lift heavy weights > 20 lbs.

Medications on Admission:
Metoprolol Unknown dose

Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*14 Tablet Extended Release 24 hr(s)* Refills:*2*
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
Disp:*1 * Refills:*0*
6. Colace 50 mg Capsule Sig: One (1) Capsule PO twice a day for
2 weeks.
Disp:*28 Capsule(s)* Refills:*1*
7. senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day for 2
weeks.
Disp:*14 Capsule(s)* Refills:*1*
8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
VNA of Southeastern Mass.

Discharge Diagnosis:
Primary Diagnosis:
Right Caudate/putamen/IC stroke
ACOM aneurysm


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Ms. [**Known lastname 12330**],
    It was a pleasure taking care of you during your hospital
admission. You were admitted after you developed a facial droop
and difficulty with your speech. Since your admission, some of
your neurological symptoms have improved. You continue to have
residual weakness of your right arm. However, we recommend
continuing physical therapy as an outpatient.

Please follow up with your neurosurgeon, Dr. [**First Name (STitle) **] and your
neurologist, Dr. [**Last Name (STitle) **] in the next month.

Followup Instructions:
You will need to follow up with Dr. [**First Name (STitle) **] in Neurosurgery
([**Telephone/Fax (1) 4296**]) on [**2-21**] at 10:45 in the [**Hospital Unit Name **], [**Location (un) 3202**], [**Hospital Unit Name 12193**].

You have a follow up echocardiogram on [**2-21**] at 1:00 in the
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) **] ([**Telephone/Fax (1) 62**]).

You have a follow up appointment with Dr. [**Last Name (STitle) **] in Neurology
([**Telephone/Fax (1) 2574**]) on [**3-15**] at 3:00 in the [**Hospital Ward Name 23**] Building, [**Location (un) 6749**].



Completed by:[**2137-2-1**]
{'Cerebral artery occlusion, unspecified with cerebral infarction,Cerebral aneurysm, nonruptured,Other speech disturbance,Other musculoskeletal symptoms referable to limbs,Facial weakness,Unspecified essential hypertension,Tobacco use disorder,Other and unspecified hyperlipidemia,Asthma, unspecified type, unspecified'}


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: 51 yo F with hx of [**Hospital **] transferred from [**Hospital6 302**]
with facial droop and transient dysarthria.  She reports waking
up with symptoms around 11 AM and was last known well last night
(one note from OSH reports seen normal at 0300).  Her daughter
called her and thought her speech was slurred and garbled.  Her
son who lives with her noticed a left facial droop and she was
taken to [**Hospital6 302**].  EMS noted BP 169/97 and upon
arrival to OSH BP as high as 221/131 with P 110.  She was noted
to have a left forehead-sparing facial droop and intact
strength.
A CTA showed an acom aneurysm.  She received labetalol 20 mg IV
x2 and aspirin 325 mg daily and transferred to [**Hospital1 18**].  Upon
arrival, a code stroke was called.

MEDICAL HISTORY: -HTN

MEDICATION ON ADMISSION: Metoprolol Unknown dose

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Gen; awake, alert, NAD
CV; RRR, no murmurs
Pulm; CTA anteriorly
Abd; soft, nt, nd
Extr; no edema
Neuro;
MS; A&Ox3, alert, interactive.  Able to relate history without
difficulty.  Speech fluent.  Naming, repetition, and
comprehension intact.  Follows midline and appendicular
commands.
CN; PERRL 4mm-->2mm, EOMI, no nystagmus.  Face sensation intact
V1-V3, forehead-sparing left facial droop, palate symmetric,
hearing intact to finger-rub, trapezius symmetric, tongue
midline.
Motor; normal bulk and tone, no drift.  5/5 strength at R and L
delt, bicep, tricp, WrE, FF, IP, ham, quad, TA, gastrocs
Sensory; intact to light touch and pinprick throughout
Coordination; no dysmetria on FNF b/l
Reflexes; upgoing toe on left
Gait; deferred
On discharge her main deficit was the left extremity. Her
Strength was [**1-5**] at wrist flexion and [**12-5**] at finger flexion. 0/5
of finger extension, Wrist extension. She had a left facial
droop. Gait was stable with a walker.

FAMILY HISTORY: -mother with cerebral aneurysm rupture

SOCIAL HISTORY: -smokes tobacco daily, no etoh or drugs. 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Cerebral aneurysm, nonruptured,Other speech disturbance,Other musculoskeletal symptoms referable to limbs,Facial weakness,Unspecified essential hypertension,Tobacco use disorder,Other and unspecified hyperlipidemia,Asthma, unspecified type, unspecified'}
