CHIEF COMPLAINT: 

PRESENT ILLNESS: Patient is a 72-year-old man
with past medical history significant for coronary artery
disease status post coronary artery bypass graft,
hypertension, hypercholesterolemia, and diabetes who was
transferred from an outside hospital after having a large
right-sided MCA stroke in the setting of a cardiac
catheterization on [**2137-3-20**], having subsequent cerebral
edema with midline shift of 1 cm requiring Mannitol
administration.

MEDICAL HISTORY: 1.  Coronary artery disease status post coronary artery
bypass graft in [**2131**].
2.  Percutaneous transluminal coronary angioplasty with
stenting in [**2126**].
3.  Hypertension.
4.  Hypercholesterolemia.
5.  Gastroesophageal reflux disease.
6.  Peptic ulcer disease.
7.  Anemia.
8.  Gout.
9.  Status post appendectomy.
10. Status post multiple herniorrhaphies.
11. Diabetes.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Diabetes and heart attack in father.
Diabetes and heart disease in mother, as well.
Cerebrovascular accident in brother, also coronary artery
disease in other brothers.

SOCIAL HISTORY: Quit tobacco in [**2108**].  One alcoholic drink
per day.  Retired pension administrator.  Very independent.
Pneumonitis due to inhalation of food or vomitus,Iatrogenic cerebrovascular infarction or hemorrhage,Pulmonary collapse,Hyperosmolality and/or hypernatremia,Other and unspecified angina pectoris,Acute pancreatitis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified
Food/vomit pneumonitis,Iatrogen CV infarc/hmrhg,Pulmonary collapse,Hyperosmolality,Angina pectoris NEC/NOS,Acute pancreatitis,Hyp kid NOS w cr kid V,Urin tract infection NOS
Admission Date:  [**2137-3-27**]     Discharge Date:  [**2137-4-5**]

Date of Birth:  [**2065-1-15**]      Sex:  M

Service:

HISTORY OF PRESENT ILLNESS:  Patient is a 72-year-old man
with past medical history significant for coronary artery
disease status post coronary artery bypass graft,
hypertension, hypercholesterolemia, and diabetes who was
transferred from an outside hospital after having a large
right-sided MCA stroke in the setting of a cardiac
catheterization on [**2137-3-20**], having subsequent cerebral
edema with midline shift of 1 cm requiring Mannitol
administration.

On [**2137-3-19**] Mr. [**Known lastname **] was admitted to an outside
hospital with acute coronary syndrome as he was having
intermittent chest pain at rest.  He ruled out for an
myocardial infarction and was taken to the catheterization
lab on [**2137-3-20**].  During the catheterization all grafts
were found and his coronary artery bypass graft was found to
be patent, but there was a 70% circumflex stenosis and an 80%
stenosis posterolateral branch and circumflex with a 70%
stenosis between two lateral left ventricular branches of the
circumflex.

During catheterization patient became less responsive.  No
intervention was performed.  After catheterization patient
was noted not to be moving left arm.  Head CT was performed
which showed a large right MCA stroke.

On [**2137-3-21**] Mr. [**Known lastname **] was intubated for airway
protection given decreased mental status, nausea, vomiting,
and a question of aspiration.  Neurologic exam at that time
revealed left hemiplegia, eyes deviated to the right,
probable field cut and .......... to the left side.  Head CT
showed increased edema.  Patient was started on Mannitol as
well as antibiotics for a possible pneumonia.

From that date until transfer patient remained intubated, and
head CT revealed a slightly increasing edema with a 1 cm
midline shift as well as a right inferior posterior
cerebellar infarct.  Mannitol and Lasix were continued.
Patient was also started on tube feeds and given some free
water boluses for hypernatremia of 150.

He was transferred to [**Hospital6 256**] on
[**2137-3-27**], intubated, for further management.

PAST MEDICAL HISTORY:
1.  Coronary artery disease status post coronary artery
bypass graft in [**2131**].
2.  Percutaneous transluminal coronary angioplasty with
stenting in [**2126**].
3.  Hypertension.
4.  Hypercholesterolemia.
5.  Gastroesophageal reflux disease.
6.  Peptic ulcer disease.
7.  Anemia.
8.  Gout.
9.  Status post appendectomy.
10. Status post multiple herniorrhaphies.
11. Diabetes.

ALLERGIES:  No known drug allergies.

MEDICATIONS ON TRANSFER:
1.  Zocor 80 mg q.d.
2.  Gemfibrozil 600 mg q.d.
3.  Mannitol.
4.  Lasix.
5.  Aspirin.
6.  Cefotaxime.
7.  Regular insulin sliding scale.
8.  Heparin subcutaneously.
9.  Norvasc.
10. Metoprolol.
11. Nystatin swish and swallow.
12. Tylenol p.r.n.

SOCIAL HISTORY:  Quit tobacco in [**2108**].  One alcoholic drink
per day.  Retired pension administrator.  Very independent.

FAMILY HISTORY:  Diabetes and heart attack in father.
Diabetes and heart disease in mother, as well.
Cerebrovascular accident in brother, also coronary artery
disease in other brothers.

PHYSICAL EXAMINATION ON TRANSFER:  Temperature 101.1, blood
pressure 157/37, heart rate 62, respiratory rate 16, oxygen
saturation 100%, intubated.  General:  He is intubated; not
opening eyes spontaneously but intermittently to commands.
HEENT:  Mucous membranes moist; oropharynx clear; no scleral
icterus or injection.  Neck:  Supple; no lymphadenopathy or
carotid bruits appreciated.  Lungs:  Clear to auscultation
bilaterally.  Heart:  Regular rate and rhythm; S1, S2; no
murmurs.  Abdomen:  Soft, nontender; no distention; normal
bowel sounds.  Extremities:  Warm; some mild edema in the
lower extremities.  Mental status:  Intubated; does follow
some axial and appendicular commands; opens eyes to command;
will fix and follow; tries to lift right arm and leg when
asked to raise both arms or legs; moves toes to command;
positive grasp, reflex on right; not moving left hand.
Reflexes brisk throughout.  Sensation:  Withdraws to painful
stimuli in all extremities.  Motor:  Left upper and left
lower extremity notably weak.  Cranial nerves:  Patient does
not follow past midline to the left; positive gag.  Rest of
facial:  Moves difficult to assess due to intubated.  Gait
and coordination could not be assessed.

LABORATORY VALUES ON ADMISSION:  White count 10.2, hematocrit
30.9, platelets 256, INR 1.4, sodium 150, potassium 4.0,
chloride 116, CO2 23, BUN 41, creatinine 1.6, glucose 124.

Head CT on admission showed a large right MCA stroke with
edema and right to left subfalcine herniation with effacement
of right lateral ventricle.  Supracellular cistern normal
unchanged from prior data from [**2137-3-23**]; slightly more
edematous compared to films from [**2137-3-21**] and [**2137-3-22**].
Also, evidence of right cerebellar infarct.

HOSPITAL COURSE BY SYSTEM:
1.  Pulmonary:  Patient's respiratory status improved and he
was able to be extubated on [**2137-3-28**].  He was diagnosed
with a left lower lobe pneumonia which was felt to be either
ventilator associated or aspiration.  He was started on
Cefepime, Vancomycin, and Levofloxacin by Neurology for this.
His fever curve slowly resolved, as well, on these
antibiotics, and his respiratory status improved both
clinically and radiographically.  Patient has had no new
underlying lung disease.

Patient did not require reintubation and was gradually
transferred from face mask to shovel mask to nasal cannula.

Patient also had some mild pulmonary edema for which he was
diuresed approximately 1500 ml with good response.

2.  Cardiovascular:  Patient's hypertension was difficult to
control throughout much of the hospitalization.  He was kept
on the Amlodipine as from outside hospital.  Metoprolol was
titrated up to 100 mg t.i.d.  He was also started on
Captopril and this was titrated up to 25 mg t.i.d. as well as
started on Hydrochlorothiazide 25 mg q.d.  With this
combination his blood pressure was well controlled.

3.  Ischemia:  Patient complained of no further chest pain
during the hospitalization.  He continued on aspirin, Plavix,
statin, beta blocker, and angiotensin-converting enzyme
inhibitor.  EKGs remained unchanged throughout the
hospitalization and further cardiac workup was deferred
pending neurologic resolution.

4.  Rhythm:  Patient was in sinus rhythm throughout
hospitalization.  Well controlled on beta blocker.

5.  Hematologic:  Patient had a mild hematocrit drop from low
30s to 26 during hospitalization.  He responded well to two
units of packed red blood cells and his hematocrit then
remained stable at 32.  No hemolysis or signs of overt blood
loss were found.

6.  Neurologic:  Patient was transferred from the Neurology
service to the Medical Intensive Care Unit due to respiratory
distress likely secondary to mild pulmonary edema and
pneumonia.  Per Neurology, the Mannitol was stopped and he
was kept on aspirin, Plavix, and statin for stroke
prevention.  His neurologic status improved gradually
throughout the hospitalization.  However, at time of
dictation he is still not able to ambulate or swallow safely.

7.  Gastrointestinal:  Patient had no significant
gastrointestinal complications during hospitalization.  He
was kept on a proton pump inhibitor, and a percutaneous
endoscopic gastrostomy was placed prior to transfer to Rehab
for nutrition as he was not able to swallow effectively.

8.  Endocrine:  Patient was kept on insulin drip until
[**2137-4-4**] for optimal insulin control.  He was then switched
to NPH and regular insulin sliding scale.  Glucose was
maintained within good range with these.

9.  Rheumatologic:  Patient also was found to have a swollen
knee.  Rheumatology was consulted and tapped the knee and
found noninfective arthritis consistent with gout.
He was started on Prednisone for this and then Colchicine, to
which he had good effect.  He also had a gout flare in his
right elbow.

10.  Infectious Disease:  Patient was continued on the
Cefepime, Vancomycin, and Levofloxacin for a 10-day course
for a left lower lobe pneumonia.  He responded well to these.

11.  Renal:  Patient's renal function was stable on
Captopril.  He does have chronic renal insufficiency with a
baseline creatinine going back in the records from 1.7 to
2.0.

Again, patient was kept on tube feeds throughout the
hospitalization.  He was at goal of 75 to 80 ml per hour
throughout much of hospitalization.  Electrolytes were
followed routine.

CODE:  Full.

DISPOSITION:  To rehab.

DISCHARGE DIAGNOSES:
1.  Large MCA cerebrovascular accident.
2.  Left lower lobe pneumonia.
3.  Hypertension.
4.  Diabetes.
5.  Coronary artery disease.
6.  Gout flare.

DISCHARGE MEDICATIONS:
1.  Captopril 25 mg t.i.d.
2.  Hydrochlorothiazide 25 mg q.d.
3.  Insulin standing 70/30 NPH and sliding scale.
4.  Metoprolol 100 mg t.i.d.
5.  Plavix 75 mg q.d.
6.  Amlodipine 10 mg q.d.
7.  Aspirin 81 mg q.d.
8.  Colace.
9.  Simvastatin 80 mg q.d.
10. Protonix 40 mg p.o. q.d.
11. Cefepime.
12. Levofloxacin.
13. Vancomycin.
14. Heparin subcutaneously.

DISCHARGE CONDITION:  Good.




                     DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAD

Dictated By:[**Last Name (NamePattern1) 1737**]

MEDQUIST36

D:  [**2137-4-5**]  15:24
T:  [**2137-4-9**]  15:03
JOB#:  [**Job Number 9883**]


Admission Date:  [**2137-3-27**]       Discharge Date:

Date of Birth:   [**2065-1-15**]       Sex:  M

Service:  MEDICINE

HISTORY OF THE PRESENT ILLNESS:  The patient is a 72-year-old
gentleman with a history of coronary artery disease, status
post CABG, hypertension, and hypercholesterolemia originally
admitted to the Neurology Service after experiencing a large
right MCA stroke in the setting of a cardiac catheterization
on [**2137-3-20**].  Following catheterization, the patient was
noted to not be moving his left arm.  The head CT at that
time at the outside hospital showed a right MCA stroke by
report.  On [**2137-3-21**], the patient was intubated secondary to
poor mental status.  There was also a question of a possible
aspiration pneumonia for which the patient was started on
antibiotics.  The patient was transferred to our hospital to
the Neurologic ICU and the antibiotics, Mannitol, and Lasix
were continued.

The patient was extubated on day number two here at our
hospital and the Mannitol was discontinued as well then.  On
day number three, the patient was doing reasonably well and
transferred out to the Neurologic floor.  A NG tube was put
in place for feeding.  While on the floor, the patient became
tachypneic and went into respiratory distress.  The patient
was subsequently transferred to the MICU and started on
vancomycin, cefepime, in addition to the Levaquin he had
already been on.

On hospital day number 11, the patient's respiratory status
improved.  He was transferred out to the floor in stable
condition on Captopril for better blood pressure control.

PAST MEDICAL HISTORY:
1.  History of hypertension.
2.  Hypercholesterolemia.
3.  Diabetes.
4.  Gastroesophageal reflux disease.
5.  Peptic ulcer disease.
6.  Anemia.
7.  Gout.

MEDICATIONS ON TRANSFER TO THE FLOOR:
1.  Zocor 80 mg once a day.
2.  Gemfibrozil 600 mg once a day.
3.  Lasix 10 mg twice a day.
4.  Mannitol 20 mg q.i.d.
5.  Aspirin.
6.  Regular insulin sliding scale.
7.  Norvasc.
8.  Metoprolol.
9.  Nystatin swish and swallow.

ALLERGIES:  The patient has no known drug allergies.

SOCIAL HISTORY: No recent history of tobacco.  He quit in
[**2108**].  He drinks one alcoholic beverage per day.  He is a
retired pension administrator.

PHYSICAL EXAMINATION ON TRANSFER TO THE MEDICINE SERVICE:
Vital signs:  Temperature 96.8, blood pressure 144/58, heart
rate 57, respirations 18, 96% on room air.  General:  The
patient was lying in bed with NG tube in place, in no acute
distress.  HEENT:  Rosy cheeks.  The mucous membranes were
clear with dry mucus in the mouth.  The pupils were equal,
round, and reactive to light.  His neck was supple.  Chest:
Decreased breath sounds at the lower left base.  He had an
occasional rale.  Cardiac:  Regular rhythm with a I/VI
systolic ejection murmur heard best at the upper sternal
border.  Abdomen:  Soft, nontender, bowel sounds present.
Extremities:  Warm.  He had good pulses with no edema.
Neurologic:  He knows that he is at [**Hospital1 18**].  He knows that it
is [**2136**] and that it was [**Month (only) 547**].  He did not know the exact
date or month.  He will not look past the left midline.  He
does not recognize his left arm as his own.  He did not
respond to tactile stimuli on the left arm.  He did not show
any nystagmus.

LABORATORY/RADIOLOGIC DATA ON TRANSFER: White count 7.3, crit
33.2, platelets 437,000.  His coagulations revealed PTT of
26.4, INR 1.5.  Potassium 5.1.  BUN 52, creatinine 1.5,
glucose 282 on the Chem-7.  Calcium, magnesium, and
phosphorus normal.

The patient had a chest x-ray on [**2137-4-4**] that showed
slightly improved left lower lobe opacity over the prior
study, no new consolidation was appreciated.

He had an echocardiogram on [**2137-4-1**] that showed a left
atrium that was moderately dilated, mild left ventricular
hypertrophy, septal hypokinesis.  His LV function was grossly
depressed but unable to be quantified.  His ascending aorta
was moderately dilated.

Blood cultures, urine cultures, and joint fluid up to date
had not grown anything.

HOSPITAL COURSE:  This is a 72-year-old gentleman with a
history of right MCA stroke, status post cardiac
catheterization procedure transferred to the MICU, Neurologic
ICU, back to the floor, back to the MICU for respiratory
distress, pneumonia and now being transferred back to the
Medicine Floor stable, afebrile, and with an improved mental
status.

In terms of his pulmonary status, the patient was originally
on triple antibiotic coverage with Levaquin, cefepime, and
vancomycin.  Subsequently, peeled back the cefepime and
vancomycin and left the patient on Levaquin for a total of a
14 day course.  His white blood cell count continued to trend
down throughout the remainder of his admission and he
remained afebrile once on the floor.

The patient's oxygenation status remained very well,
saturating 95-99% on room air.  Aggressive chest PT was begun
to help the patient with secretions and that improved his
respiratory status as well.

In terms of the patient's neurologic status, he was status
post the right MCA stroke now with a mild left hemineglect.
His overall mental status continued to improve throughout the
course of his admission to where he could easily relate to
the team the date and the year and where he currently was.
He still remains with some residual weakness in the left
upper extremity as well as inability to look past the left
midline.

In terms of his cardiovascular status, the patient has a
significant CAD history.  However, throughout the remainder
of his admission, he never complained of chest pain.  We
continued him on his Amlodipine, titrated up his Captopril to
maximum blood pressure benefit, in addition to slightly
titrating up metoprolol for better heart rate control.

In terms of his rheumatologic status, the patient has a
history of gout.  He was treated with prednisone and
colchicine.  We began to taper his prednisone slowly
throughout the remainder of the admission and the colchicine
was continued for low-dose prophylaxis.

In terms of FEN/GI, a Speech and Swallow evaluation was
obtained of the patient and determined that the patient was
at great risk for aspiration.  A PEG tube was placed in the
patient on [**2137-4-8**] and tube feeding was begun via the PEG.
The patient's nutritional status remained stable.

In terms of the patient's prophylaxis, he was maintained on
subcutaneous heparin, regular insulin sliding scale, and
pneumoboots.  He had a proton pump inhibitor as well.

CONDITION ON DISCHARGE:  Stable, afebrile, tolerating tube
feeds.

DISCHARGE STATUS:  To an acute rehabilitation facility.

DISCHARGE DIAGNOSIS:
1.  Stroke.
2.  Pneumonia.
3.  Hypertension.
4.  Gout.

DISCHARGE MEDICATIONS:
1.  Amlodipine 10 mg once a day.
2.  Aspirin 81 mg once a day.
3.  Captopril 50 mg three times a day.
4.  Levaquin 500 mg once a day.
5.  Colchicine 0.6 mg once a day.
6.  Heparin 5,000 units twice a day.
7.  Hydrochlorothiazide 25 mg once a day.
8.  Insulin sliding scale.
9.  Lansoprazole 30 mg once a day.
10. Metoprolol 125 mg twice a day.
11. Prednisone 15 mg once a day.
12. Simvastatin 40 mg once a day.
13. Plavix 75 mg once a day.

FOLLOW-UP PLANS:  The patient is to follow-up with his
primary care physician within one week.  He will also need
neurologic follow-up.

The remainder of her course, from [**4-10**] onward, will be dictated
in an addendum.


                            [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 4446**]

Dictated By:[**Last Name (NamePattern1) 3809**]
MEDQUIST36

D:  [**2137-4-9**]  05:07
T:  [**2137-4-9**]  17:20
JOB#:  [**Job Number 9884**]


Name:  [**Known lastname 1058**], [**Known firstname **]                     Unit No:  [**Numeric Identifier 1059**]

Admission Date:  [**2137-3-27**]     Discharge Date:  [**2137-4-12**]

Date of Birth:   [**2065-1-15**]     Sex:  M

Service:

The date of this discharge summary addendum will cover
[**2137-4-11**] to [**2137-4-12**].

HOSPITAL COURSE:  Over the course of the next two days of the
patient's hospitalization, he had a PEG tube placed.  On
[**2137-4-11**], the patient was noted to have slight abdominal pain and
was noted to be tender to palpation.  We checked a serum amylase
and lipase levels, which were mildly elevated.  We decided given
that this pancreatitis picture, to keep the patient NPO over the
course of the next day and to watch the patient's abdominal
exams.

The following day on [**2137-4-12**], the patient was entirely pain
free.  His enzymes had trended down for the past two days,
and he began on his tube feeds without incident.  The patient
was being discharged today in stable condition afebrile with
no abdominal pain and with stable hematocrit.

DISCHARGE DIAGNOSES:  As outlined in the prior discharge
summary.

DISCHARGE MEDICATIONS:  To be addendum as follows:  The
metoprolol is 100 mg twice a day.  All the other medications
are the same.

FOLLOW-UP PLANS:  The follow-up plans still remains the
patient is to followup with his primary care physician within
one week.  He will also need a follow-up appointment with
Neurology with Dr. [**First Name (STitle) 1060**] within 3-4 weeks.



                       DR.[**Last Name (STitle) 1035**],[**First Name3 (LF) 1034**] 12-AAD

Dictated By:[**Last Name (NamePattern1) 1061**]

MEDQUIST36

D:  [**2137-4-12**]  10:27
T:  [**2137-4-12**]  10:40
JOB#:  [**Job Number 1062**]
{'Pneumonitis due to inhalation of food or vomitus,Iatrogenic cerebrovascular infarction or hemorrhage,Pulmonary collapse,Hyperosmolality and/or hypernatremia,Other and unspecified angina pectoris,Acute pancreatitis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified'}


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: 

PRESENT ILLNESS: Patient is a 72-year-old man
with past medical history significant for coronary artery
disease status post coronary artery bypass graft,
hypertension, hypercholesterolemia, and diabetes who was
transferred from an outside hospital after having a large
right-sided MCA stroke in the setting of a cardiac
catheterization on [**2137-3-20**], having subsequent cerebral
edema with midline shift of 1 cm requiring Mannitol
administration.

MEDICAL HISTORY: 1.  Coronary artery disease status post coronary artery
bypass graft in [**2131**].
2.  Percutaneous transluminal coronary angioplasty with
stenting in [**2126**].
3.  Hypertension.
4.  Hypercholesterolemia.
5.  Gastroesophageal reflux disease.
6.  Peptic ulcer disease.
7.  Anemia.
8.  Gout.
9.  Status post appendectomy.
10. Status post multiple herniorrhaphies.
11. Diabetes.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Diabetes and heart attack in father.
Diabetes and heart disease in mother, as well.
Cerebrovascular accident in brother, also coronary artery
disease in other brothers.

SOCIAL HISTORY: Quit tobacco in [**2108**].  One alcoholic drink
per day.  Retired pension administrator.  Very independent. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Iatrogenic cerebrovascular infarction or hemorrhage,Pulmonary collapse,Hyperosmolality and/or hypernatremia,Other and unspecified angina pectoris,Acute pancreatitis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Urinary tract infection, site not specified'}
