CHIEF COMPLAINT: found unresponsive

PRESENT ILLNESS: Ms. [**Known lastname **] is a 69 year-old woman with a PMH of symptomatic
paroxysmal a.fib with RVR s/p pacer and on Coumadin as well as
HTN and DMII who was found unresponsive this AM. She was last
seen well prior to going to sleep last night. This AM she was
found by family in bed, with urinary incontinence and not
responding. Her FSG at that time was 129. Per family, who
arrived later, she was last seen well last night around 10 PM
and was then found around 8:30 this morning in bed. Initially
thought to be sleeping, but then remained unresponsive when
checked again later, so EMS called and Ms. [**Known lastname **] was brought to
[**Hospital1 18**].

MEDICAL HISTORY: Paroxysmal atrial fibrillation (s/p permanent pacemaker,
anticoagulated with warfarin)
Diabetes Mellitus type 2
Hypertension
Hyperlipidemia
Recurrent UTIs (E coli and GNR in recent past)

MEDICATION ON ADMISSION: -Coumadin (noncompliant)
-Metformin (noncompliant)
-Verapamil XR 240 mg qAM and 120mg qPM
-Sitagliptan (unknown dose)
-Losartan 100 mg po qAM

ALLERGIES: Lipitor

PHYSICAL EXAM: At admission:
Vitals: T:  P: 85 R: 18  BP: 194/95 SaO2: 100% on NRB

FAMILY HISTORY: NC

SOCIAL HISTORY: Married, her husband has advanced [**Name (NI) 5895**].
She works in maintenance here at [**Hospital1 **].
-Tobacco history: denies
-EtOH: denies
-Illicit drugs: denies
Cerebral artery occlusion, unspecified with cerebral infarction,Coma,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Physical restraints status,Cardiac pacemaker in situ,Long-term (current) use of anticoagulants
Crbl art ocl NOS w infrc,Coma,Urin tract infection NOS,Protein-cal malnutr NOS,Proteus infection NOS,Atrial fibrillation,Hypertension NOS,DMII wo cmp nt st uncntr,Hyperlipidemia NEC/NOS,Physical restrain status,Status cardiac pacemaker,Long-term use anticoagul
Name:  [**Known lastname 3030**],[**Known firstname 15711**]                   Unit No:   [**Numeric Identifier 15712**]

Admission Date:  [**2167-7-5**]              Discharge Date:   [**2167-7-18**]

Date of Birth:  [**2098-2-3**]             Sex:   F

Service: NEUROLOGY

Allergies:
Lipitor

Attending:[**First Name3 (LF) 3326**]
Addendum:
The patient was not discharged on [**7-17**] due to no bed
availability. The patient has a bed available today and will go
to rehab.

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] [**Hospital1 15**]

Discharge Diagnosis:
bilateral thalami infarct
complicated UTI


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 3327**]

Completed by:[**2167-7-18**]

Admission Date:  [**2167-7-5**]              Discharge Date:   [**2167-7-18**]

Date of Birth:  [**2098-2-3**]             Sex:   F

Service: NEUROLOGY

Allergies:
Lipitor

Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
found unresponsive

Major Surgical or Invasive Procedure:
[**2167-7-14**] PEG placement

History of Present Illness:
Ms. [**Known lastname **] is a 69 year-old woman with a PMH of symptomatic
paroxysmal a.fib with RVR s/p pacer and on Coumadin as well as
HTN and DMII who was found unresponsive this AM. She was last
seen well prior to going to sleep last night. This AM she was
found by family in bed, with urinary incontinence and not
responding. Her FSG at that time was 129. Per family, who
arrived later, she was last seen well last night around 10 PM
and was then found around 8:30 this morning in bed. Initially
thought to be sleeping, but then remained unresponsive when
checked again later, so EMS called and Ms. [**Known lastname **] was brought to
[**Hospital1 18**].


Past Medical History:
Paroxysmal atrial fibrillation (s/p permanent pacemaker,
anticoagulated with warfarin)
Diabetes Mellitus type 2
Hypertension
Hyperlipidemia
Recurrent UTIs (E coli and GNR in recent past)

Social History:
Married, her husband has advanced [**Name (NI) 5895**].
She works in maintenance here at [**Hospital1 **].
-Tobacco history: denies
-EtOH: denies
-Illicit drugs: denies


Family History:
NC

Physical Exam:
At admission:
Vitals: T:  P: 85 R: 18  BP: 194/95 SaO2: 100% on NRB

General: unresponsive
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Pulmonary: lcta anteriorly
Cardiac: RRR, S1S2
Abdomen: soft, nondistended, +BS
Extremities: warm, well perfused

Neurologic: no eye opening, no commands. Groans to sternal rub.
R
pupil 5 mm, irregular and nonresponsive to light. L pupil 1 mm
and nonresponsive to light. R eye deviated to right in primary
gaze, left eye in midline. No blink to threat when eyes held
open. +Dolls eyes. + corneals, stronger on right than left. +gag
reflex. No spontaneous movements. No movement initially to
noxious stimuli UE b/l, though she did have some delayed slight
movements of LUE after nailbed pressure. Brisk withdrawal of LE
b/l to nailbed pressure. Grimaces to noxious stimuli throughout.
Unable to elicit reflexes. Extensor plantar response on left,
Equivocal response on right.

At discharge:
Neuro exam: responds with moderate stimulation, eyes have been
opening spontaneously,  grimaces to noxious, says some
intelligble words occasionally, mod-severe dysarthria. Follows
simple commands. Right pupil 5, left pupil 2 and both
non-reactive. Brainstem reflexes intact otherwise.  Moves all 4
ext, but the right less briskly. Makes purposeful movements with
all extremities and withdraws to noxious stimuli x 4.


Pertinent Results:
[**2167-7-5**] 11:15AM   WBC-6.5 RBC-4.75 HGB-14.0 HCT-40.1 MCV-84
MCH-29.5 MCHC-35.0 RDW-14.3
[**2167-7-5**] 11:15AM   PT-16.3* PTT-22.5 INR(PT)-1.4*
[**2167-7-5**] 11:15AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2167-7-5**] 11:15AM   cTropnT-<0.01
[**2167-7-5**] 11:15AM   GLUCOSE-131* UREA N-11 CREAT-0.7 SODIUM-143
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-28 ANION GAP-14
[**2167-7-5**] 11:50AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2167-7-5**] 11:50AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2167-7-5**] 11:50AM URINE  UCG-NEGATIVE
[**2167-7-5**] 08:55PM   TYPE-ART PO2-135* PCO2-42 PH-7.42 TOTAL
CO2-28 BASE XS-3

Blood cultures on [**7-5**], and 2 on [**7-8**] were no growth.
MRSA screen [**7-5**] was negative.
Urine culture [**2167-7-8**]:
URINE CULTURE (Final [**2167-7-16**]):
      PROTEUS MIRABILIS.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.
         Piperacillin/tazobactam sensitivity testing available
on request.
      ENTEROCOCCUS SP..    10,000-100,000 ORGANISMS/ML..
         TETRACYCLINE SENSITIVE, MIC <= 2 MCG/ML.
         Sensitivity testing performed by Sensititre.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PROTEUS MIRABILIS
                             |          ENTEROCOCCUS SP.
                             |          |
AMPICILLIN------------   <=2 S   <=0.12 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
TETRACYCLINE----------                  S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S
VANCOMYCIN------------              <=1 S

Urine Culture [**2167-7-12**]:
URINE CULTURE (Preliminary):
      GRAM NEGATIVE ROD(S).    >100,000 ORGANISMS/ML..
      PROTEUS MIRABILIS.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.
         Piperacillin/tazobactam sensitivity testing available
on request.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PROTEUS MIRABILIS
                             |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------   0.5 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=2 S



[**7-5**] EKG: Ventricular paced rhythm. Compared to the previous
tracing of [**2165-11-11**] no change.

[**7-5**] Head CT and Head and Neck CTA:
FINDINGS:
HEAD CT: Mild edema is visualized in the parietal lobe which may
represent
edema from an ischemic event in the proper clinical setting.
However, there is no evidence of mass effect, hemorrhage, shift
of normally midline
structures, or large vessel territorial infarction. The
ventricles and sulci are normal in size and configuration. No
fracture is identified.
HEAD AND NECK CTA: Recons are currently pending. However, the
carotid and
vertebral arteries and their major branches are patent with no
evidence of
stenosis. Mild atherosclerotic disease is visualized. There is
no evidence
of aneurysm formation or other vascular abnormality.
IMPRESSION:
1. Mild edema is visualized in the right parietal lobe and may
represent
edema from an acute ischemic event in the proper clinical
setting. If
clinical suspicion for stroke is high, MRI is the recommended
study of choice.
2. Recons are pending, but no evidence of distinct vascular
occlusion or
aneurysmal formation.
NOTE ADDED AT ATTENDING REVIEW: I do not confirm the right
parietal edema.
There are extensive changes of subcortical white matter
hypodensity suggesting chronic small vessel ischemia. There are
no findings to suggest acute infarction. There are scattered
cortical calcifications that may reflect old granulomatous
disease. There is an infundibulum at the origin of the left
posterior communicating artery.

[**7-6**] CXR:
IMPRESSION:
1. No evidence of congestive heart failure or pneumonia.
2. Apparent widening of mediastinum, likely due to accentuation
of tortuous aorta by patient rotation. Attention to this area on
a non-rotated radiograph would be helpful in this regard.

[**7-7**] Abd Xray:
FINDINGS: One view of the abdomen is provided. Bowel gas pattern
is
unremarkable. Visualized osseous structures are unremarkable.
The lung bases appear clear. There is a pacemaker seen with
wires in the atrium and
ventricle. The NG tube is seen coursing through the esophagus
into a low
lying stomach.
IMPRESSION: NG tube in stomach around area of pylorus.

[**7-8**] CXR:
ONE VIEW OF THE CHEST:
The lungs are well expanded and clear. The cardiac silhouette is
enlarged. The mediastinal silhouette and hilar contours are
normal. No pleural effusion or pneumothorax is present. An NG
tube terminates with its tip out of view below the diaphragm. A
left-sided pacer terminates with its leads in the right atrium
and right ventricle.
IMPRESSION:
No acute intrathoracic process.

[**7-10**] CXR - Line Placement:
FINDINGS: A left-sided PICC is seen ending in the right atrium.
We recommend withdrawing the PICC approximately 4 cm for
placement at the lower SVC/cavoatrial junction. Otherwise, good
lung volumes without focal
radiopacities. Cardiomediastinal and hilar contours are
unremarkable, with
the exception of a tortuous aorta and a stable moderate
cardiomegaly. No
pleural effusion or pneumothorax. Pacemaker leads ending in
standard
positions, in the right atrium and right ventricle, tip of the
NG tube is
beyond the frame of the radiograph.
IMPRESSION: Tip of the PICC in the right atrium. No evidence of
acute
cardiopulmonary disease.

[**7-13**] Portable CXR:
FINDINGS:
In comparison with study of [**7-10**], the patient is somewhat
oblique, which limits evaluation of the heart and lungs. In
addition, there are extensive pacemaker and other leads,
obscuring the chest.
Nevertheless, there is no definite evidence of acute pneumonia
or vascular
congestion.


Brief Hospital Course:
The patient Is a 69 year old woman with a history of paroxysmal
atrial fibrillation on warfarin, diabetes mellitus,
hypertension, and hyperlipidemia who was found unresponsive on
the morning of [**7-5**] with at least 12.5 hours of depressed level
of awareness, likely due to acute cerebral infarction affecting
bilateral thalami from a cardioaortoembolic event while
supratherapeutic on warfarin. She was brought to [**Hospital1 18**] late in
the AM of [**7-5**] and she was not given thrombolytic therapy as she
was outside the treatment time window. On exam, she would
grimace to noxious stimuli and withdraw in all extremities but
not follow commands or verbalize. On noncontrast head CT, she
was found to have likely bilateral thalamic hypodensities and
possibly a pontine hypodensity, however no brainstem lesion was
seen on repeat imaging.

NEURO:
For her bilateral thalamic infarcts, she was started on a
heparin infusion to anticoagulate her for prevention of further
thromboembolism. Her exam has steadily improved, including the
ability to repeat some phrases and follow a few simple commands
although she remained very somnolent. We started her on
Modafinil 100mg qAM to help improve her level of awareness and
subsequently added methylphenidate 5mg qAm and qNOON. With the
addition of these stimulant medications she is able to maintain
alertness during the day. Coumadin was started on [**7-16**]. Goal INR
is [**1-8**]. Heparin gtt is to be stopped once INR is therapeutic.

ID:
The patient was mildly febrile and developed a leukocytosis. She
was pancultured and her UA and UCx were positive. She was
initially treated with Bactrim for Proteus but when she
continued to have low grade fevers and leukocytosis, she was
re-cultured on [**7-12**]. These urine cultures are growing 2 types of
GNR, pan-sensitive Proteus and enterococcus, sensitivites still
pending. She was switched to Ceftriaxone on [**2167-7-12**] with a plan
to treat for 7 days (end date [**2167-7-19**]). Leukocytosis and fevers
have resolved since on the CTX.

CARDS:
After initially allowing BP to autoregulate, we restarted home
meds Lostartan 100mg daily and Verapamil 80mg q8h (total 240
daily home does); additionally we added HCTZ 25 mg daily. Blood
pressure has been well-controlled on this regimen.

GI:
The patient has had somnolence and decreased cough and gag
reflex that has required an NGT, and then a PEG for tube feeds
and medication delivery. The speech and swallow therapy team
re-evaluated the patient on [**7-16**] and found that the patient did
well during the day when awake, with purreed diet and
nectar-thick liquids. Please allow this po intake only while the
patient is under 1:1 supervision. Please continue tube feeds
until the patient is able to take in enough nutrition by mouth.

ENDO:
For her diabetes type 2, the patient was maintained on an
insulin sliding scale. Her HgbA1c is 6.7 and her fasting lipid
panel showed TC 225/Trig 108/HDL 49/LDL 154. Pravastatin 40mg po
daily was continued.

PULM:
No issues currently. Maintaining good O2 sats on room air.

RENAL:
Currently no issues.

SOCIAL ISSUES:
The [**Hospital 228**] hospital course was complicated by a visitor
suspected of inappropriate behavior with the patient.
Subsequently her visitors were screened and a password system
was put in place. Social work was involved. Also there was
concern for long term guardianship and the legal process in
appointing a guardian has been initiated during this
hospitalization.

Medications on Admission:
-Coumadin (noncompliant)
-Metformin (noncompliant)
-Verapamil XR 240 mg qAM and 120mg qPM
-Sitagliptan (unknown dose)
-Losartan 100 mg po qAM

Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: One (1) unit
Injection four times a day: Insulin sliding scale.
2. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO LUNCH
(Lunch).
3. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
4. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
5. warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)): Please adjust per INR with goal INR value [**1-8**].
6. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: 1000 (1000) units Intravenous continuous: Please
stop once INR is therapeutic.
7. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours) for 2 days: for
UTI.
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
11. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
12. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

13. modafinil 100 mg Tablet Sig: One (1) Tablet PO qAM ().
14. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) mg
Injection Q15MIN () as needed for hypoglycemia protocol.
15. dextrose 50% in water (D50W)     Syringe Sig: 12.5 gram
Intravenous PRN (as needed) as needed for hypoglycemia protocol.

16. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] [**Hospital1 8**]

Discharge Diagnosis:
Acute ischemic stroke (bilateral thalamus)

Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Neuro: responds to gentle tactile stimulation with eye opening.
Speaks short words and phrases, dysarthric. Follows simple
commands. Right pupil 5, left pupil 2 and both non-reactive.
Brainstem reflexes intact otherwise.  Purposefully moves both
upper extremities and spontaneous movement of lower extremities
bilaterally. Upper extremities power is at least antigravity
([**2-7**]) and lower extremities are at least [**1-10**].


Discharge Instructions:
You were admitted to the hospital for decreased level of arousal
and found to have strokes in bilateral thalami. The most likely
cause of this was a clot from your heart given your history of
atrial fibrillation with a subtherapeutic warfarin level. You
were very sleepy when you first came in but slowly improved. We
started you on two medicines to help your alertness, modafinial
and methylphenidate. Unfortunately your swallowing ability was
intially affected after your stroke. This has continued to
improve over time but we had to insert a feeding tube in the
interim. This would be able to be removed if you are able to eat
and take medicines appropriately in the future. We have
maintained you on a heparin gtt for anticoagulation during your
stay. Please continue on this IV until your INR is therapeutic
(goal INR [**1-8**]).

Followup Instructions:
[**Hospital 878**] Clinic:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2167-10-13**] 1:30pm
[**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg, [**Location (un) **]

Cardiology:
Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2167-11-2**]
3:00
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2167-11-2**] 3:40

Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2168-6-11**] 1:45


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
{'Cerebral artery occlusion, unspecified with cerebral infarction,Coma,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Physical restraints status,Cardiac pacemaker in situ,Long-term (current) use of anticoagulants'}


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: found unresponsive

PRESENT ILLNESS: Ms. [**Known lastname **] is a 69 year-old woman with a PMH of symptomatic
paroxysmal a.fib with RVR s/p pacer and on Coumadin as well as
HTN and DMII who was found unresponsive this AM. She was last
seen well prior to going to sleep last night. This AM she was
found by family in bed, with urinary incontinence and not
responding. Her FSG at that time was 129. Per family, who
arrived later, she was last seen well last night around 10 PM
and was then found around 8:30 this morning in bed. Initially
thought to be sleeping, but then remained unresponsive when
checked again later, so EMS called and Ms. [**Known lastname **] was brought to
[**Hospital1 18**].

MEDICAL HISTORY: Paroxysmal atrial fibrillation (s/p permanent pacemaker,
anticoagulated with warfarin)
Diabetes Mellitus type 2
Hypertension
Hyperlipidemia
Recurrent UTIs (E coli and GNR in recent past)

MEDICATION ON ADMISSION: -Coumadin (noncompliant)
-Metformin (noncompliant)
-Verapamil XR 240 mg qAM and 120mg qPM
-Sitagliptan (unknown dose)
-Losartan 100 mg po qAM

ALLERGIES: Lipitor

PHYSICAL EXAM: At admission:
Vitals: T:  P: 85 R: 18  BP: 194/95 SaO2: 100% on NRB

FAMILY HISTORY: NC

SOCIAL HISTORY: Married, her husband has advanced [**Name (NI) 5895**].
She works in maintenance here at [**Hospital1 **].
-Tobacco history: denies
-EtOH: denies
-Illicit drugs: denies 

### Response:
{'Cerebral artery occlusion, unspecified with cerebral infarction,Coma,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site,Atrial fibrillation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Other and unspecified hyperlipidemia,Physical restraints status,Cardiac pacemaker in situ,Long-term (current) use of anticoagulants'}
