CHIEF COMPLAINT: unresponsive

PRESENT ILLNESS: The patient is a 81 yo woman with recent diagnosis of Afib, HTN,
recent partial splenic rupture, who is brought to the ED after
she became unresponsive.
.
The patient was recently diagnosed with Afib (this week, when
she developed SOB, HR in the 140's and CP). She underwent a
workup at [**Hospital3 **], including a thyroid biopsy. The plan
was to start her on coumadin and she received lovenox x2 days
(Monday and Tuesday per daughter), but she developed abdominal
pains and was found to have a partial splenic rupture (likely
due a fall [**6-20**] or 2 months earlier). So, she was not started
on coumadin.
.
She was at home with her daughter, when she told her daughter
that she had a headache. She then became unresponsive. This
happened around 3.15 pm. EMS found her to be flaccid on the R
(face, arm and leg). PB was 118/72 and FS was in the 80's.
.
In the ED, her NIHSS was 24 (see below). She is in Afibb. A STAT
CT head showed  L-MCA sign.
.
NIHSS: 25
1a. Level of consciousness: 2
1b. LOC questions: 2 (age and month)
1c. LOC commands: 2
2. Best gaze: 1
3. Visual: 2
4. Facial Palsy: 2
5. Motor Arm: 0/4
6. Motor Leg: 0/4
7. Limb ataxia: 0
8. Sensory: 1
9. Best Language: 3
10. Dysarthria: 0
11. Extinction: 2
.
ROS:
-unable

MEDICAL HISTORY: - recent AFib; not on coumadin
- thyroid nodules: biopsy on [**7-5**] at [**Hospital **] Hosp
- HTN
-proteinuria
-restless legs
-partial splenic rupture
-multiple falls
-hearing loss on the L

MEDICATION ON ADMISSION: -colace
-MOM
-nitro 0.4mg PRN
-fosamax 70mg q week
-salsalate 750mg [**Hospital1 **] PO
-neurontin 600mg PO BID
-cardizem 240mg PO daily

ALLERGIES: Pergolide Mesylate

PHYSICAL EXAM: VITALS: Tafebrile HR BP120/49 RR  sO2100% FM
GEN: pale
HEENT: mmm
NECK: no carotid bruits
LUNGS: Clear to auscultation bilaterally
HEART: [**Last Name (un) 3526**] [**Last Name (un) 3526**], normal S1 and S2, no murmurs
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema
.
MENTAL STATUS:
Awake, eyes open, not following commands, non-verbal.
.
CRANIAL NERVES:
No blink to threat from the R, does blink from the L. PERRL.
Dolls across midline. Responds to nose tickle. R-facial droop.
Has gag.
.
MOTOR SYSTEM: Decreased bulk. Tone flaccid in RLE and RUA,
normal LLE, some gegenhalten LUE. Spontaneous movements of LUE
and LLE antigravity. No spontaneous movement on the R, but
triple flexion on the RLE.
.
SENSORY SYSTEM: Triple flexion to noxious in RLE; no response
RUE; withdrawal on the L (UE and LE)
.
REFLEXES:
B T Br Pa Pl
Right  1 1 1 2 -
Left   1 1 1 2 -
upgoing bilaterally.
.
COORDINATION: deferred
.
GAIT: deferred

FAMILY HISTORY: - MI and strokes; no ca

SOCIAL HISTORY: lives with her daugther. Former smoking, not much, stopped in
'[**78**]. 3 kids. No alcohol. Does not drive. Some memory problems at
baseline.
Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Unspecified essential hypertension,Nontoxic uninodular goiter
Crbl emblsm w infrct,Food/vomit pneumonitis,Atrial fibrillation,Hypertension NOS,Nontox uninodular goiter
Admission Date:  [**2103-7-6**]              Discharge Date:   [**2103-7-12**]

Date of Birth:  [**2022-10-12**]             Sex:   F

Service: NEUROLOGY

Allergies:
Pergolide Mesylate

Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
unresponsive

Major Surgical or Invasive Procedure:
cerebral angiography and intraarterial tPA administration


History of Present Illness:
The patient is a 81 yo woman with recent diagnosis of Afib, HTN,
recent partial splenic rupture, who is brought to the ED after
she became unresponsive.
.
The patient was recently diagnosed with Afib (this week, when
she developed SOB, HR in the 140's and CP). She underwent a
workup at [**Hospital3 **], including a thyroid biopsy. The plan
was to start her on coumadin and she received lovenox x2 days
(Monday and Tuesday per daughter), but she developed abdominal
pains and was found to have a partial splenic rupture (likely
due a fall [**6-20**] or 2 months earlier). So, she was not started
on coumadin.
.
She was at home with her daughter, when she told her daughter
that she had a headache. She then became unresponsive. This
happened around 3.15 pm. EMS found her to be flaccid on the R
(face, arm and leg). PB was 118/72 and FS was in the 80's.
.
In the ED, her NIHSS was 24 (see below). She is in Afibb. A STAT
CT head showed  L-MCA sign.
.
NIHSS: 25
1a. Level of consciousness: 2
1b. LOC questions: 2 (age and month)
1c. LOC commands: 2
2. Best gaze: 1
3. Visual: 2
4. Facial Palsy: 2
5. Motor Arm: 0/4
6. Motor Leg: 0/4
7. Limb ataxia: 0
8. Sensory: 1
9. Best Language: 3
10. Dysarthria: 0
11. Extinction: 2
.
ROS:
-unable

Past Medical History:
- recent AFib; not on coumadin
- thyroid nodules: biopsy on [**7-5**] at [**Hospital **] Hosp
- HTN
-proteinuria
-restless legs
-partial splenic rupture
-multiple falls
-hearing loss on the L


Social History:
lives with her daugther. Former smoking, not much, stopped in
'[**78**]. 3 kids. No alcohol. Does not drive. Some memory problems at
baseline.

Family History:
- MI and strokes; no ca

Physical Exam:
VITALS: Tafebrile HR BP120/49 RR  sO2100% FM
GEN: pale
HEENT: mmm
NECK: no carotid bruits
LUNGS: Clear to auscultation bilaterally
HEART: [**Last Name (un) 3526**] [**Last Name (un) 3526**], normal S1 and S2, no murmurs
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema
.
MENTAL STATUS:
Awake, eyes open, not following commands, non-verbal.
.
CRANIAL NERVES:
No blink to threat from the R, does blink from the L. PERRL.
Dolls across midline. Responds to nose tickle. R-facial droop.
Has gag.
.
MOTOR SYSTEM: Decreased bulk. Tone flaccid in RLE and RUA,
normal LLE, some gegenhalten LUE. Spontaneous movements of LUE
and LLE antigravity. No spontaneous movement on the R, but
triple flexion on the RLE.
.
SENSORY SYSTEM: Triple flexion to noxious in RLE; no response
RUE; withdrawal on the L (UE and LE)
.
REFLEXES:
B T Br Pa Pl
Right  1 1 1 2 -
Left   1 1 1 2 -
upgoing bilaterally.
.
COORDINATION: deferred
.
GAIT: deferred

Pertinent Results:
Admission Labs:

[**2103-7-6**] 04:24PM   FIBRINOGE-604*
[**2103-7-6**] 04:24PM   PT-12.7 PTT-28.1 INR(PT)-1.1
[**2103-7-6**] 04:24PM   WBC-5.2 RBC-4.06* HGB-13.3 HCT-37.7 MCV-93
MCH-32.7* MCHC-35.2* RDW-14.1 PLT COUNT-254
[**2103-7-6**] 04:24PM   ASA-7 ETHANOL-NEG ACETMNPHN-7.5 bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2103-7-6**] 04:24PM   CK-MB-NotDone  cTropnT-<0.01
[**2103-7-6**] 04:24PM   CK(CPK)-43 AMYLASE-40
[**2103-7-6**] 04:24PM   UREA N-24* CREAT-1.1
[**2103-7-6**] 04:26PM   freeCa-1.24
[**2103-7-6**] 04:26PM   GLUCOSE-84 LACTATE-1.2 NA+-139 K+-5.0 CL--102
TCO2-27
[**2103-7-6**] 04:26PM   PH-7.35 COMMENTS-GREEN TOP
[**2103-7-6**] 08:48PM   PT-13.0 PTT-37.0* INR(PT)-1.1
[**2103-7-6**] 08:48PM   WBC-5.8 RBC-4.33 HGB-13.5 HCT-40.3 MCV-93
MCH-31.2 MCHC-33.6 RDW-14.0 PLT COUNT-286
[**2103-7-6**] 08:48PM   CALCIUM-9.2 PHOSPHATE-4.1 MAGNESIUM-2.2
[**2103-7-6**] 08:48PM   CK-MB-NotDone cTropnT-<0.01
[**2103-7-6**] 08:48PM   CK(CPK)-24*
[**2103-7-6**] 08:48PM   GLUCOSE-110* UREA N-23* CREAT-0.9 SODIUM-136
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16
[**2103-7-6**] 08:56PM   TYPE-ART PO2-163* PCO2-40 PH-7.41 TOTAL
CO2-26 BASE XS-1
.
CTA Head [**7-6**]:
ADDENDUM:  Perfusion images were performed.  They demonstrate
slow transit
times throughout the entire left hemisphere (including ACA and
PCA
territories) as well as in the right ACA distribution.  The
decreased slow
transit time in the right ACA distribution and also in the left
PCA
distribution are thought to be related to collateral attempt.
.
There is also severe decrease in blood volume in the right MCA
distribution. This has been shown to correlate with the ischemic
core.  However, no definitive studies are available to support
this information.
.
Preliminary CTA results are also available and they demonstrate
complete
occlusion of the left internal carotid artery at the level of
the bifurcation by likely emboli.
.
The final CTA images confirm the initial impression of left ICA
occlusion
without other significant stenoses.
.
CT Head [**7-7**]:
FINDINGS:  There is hypodensity involving the left frontal and
parietal lobe [**Doctor Last Name 352**] and white matter with mild focal effacement
consistent with continued evolution of the patient's known left
MCA infarct.  Hypodensity also notably involves the insular
cortex and underlying white matter, with also possible
involvement of the basal ganglia on the left.  There is no
evidence of acute intra- or extra-axial hemorrhage.  There is
slight mass effect producing slight compression of the left
lateral ventricle without midline shift.  The basal cisterns
appear patent.  Periventricular white matter hypodensity is also
again seen and unchanged compared to the previous exam
consistent with chronic microangiopathic disease.
.
The visualized paranasal sinuses appear well pneumatized and
well aerated.
.
IMPRESSION:  Continued evolution of infarction in the
distribution of the left middle cerebral arterial.
.

Brief Hospital Course:
Pt. was admitted to the Neuro ICU after administration of
intraaterial tPA.  Her exam was stable (not improved) overnight,
and she still had dense right sided hemiplegia with no movement
on that side in the morning.  She opened her eyes to voice but
produced no speech and followed no commands.  Repeat imaging in
the AM showed evolution of the stroke but no evidence of midline
shift.  BP was controlled with Labetalol drip initially, then
transitioned to metoprolol PO, and pt. was given ASA and Statin
for secondary stroke prevention.  An NGT was placed and pt was
administed tube feeds.  We discussed with family starting
Heparin and Coumadin given her A fib and likely embolic source
of ischemia, however family did not want these given her risk of
hemorrhagic conversion of her stroke.  In further discussions
with pt's family they felt that she would not have wanted
aggresive care in these circumstances, and elected to follow her
wishes and focus her care on comfort.  ASA, Statin, BB, tube
feeds, and IVF were therefore discontinued, and Morphine and
Ativan were administered as needed for anxiety and pain.  Pt.
was transferred to inpatient hospice for further comfort care.

Medications on Admission:
-colace
-MOM
-nitro 0.4mg PRN
-fosamax 70mg q week
-salsalate 750mg [**Hospital1 **] PO
-neurontin 600mg PO BID
-cardizem 240mg PO daily

Discharge Medications:
1. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day) as needed for
PRN secretions.
2. Scopolamine Base 1.5 mg Patch 72HR Sig: [**11-20**] Patch 72HRs
Transdermal Q72H (every 72 hours) as needed for PRN secretions.

3. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO
Q1-2H () as needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] House Rehabilitation & Nursing Center - [**Location (un) 5087**]

Discharge Diagnosis:
Large left MCA ischemic stroke
Atrial fibrillation


Discharge Condition:
Appears comfortable.  No movement right arm or leg, does not
open eyes to voice.


Discharge Instructions:
Please continue comfort care.

Followup Instructions:
per hospice physicians


                             [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

Completed by:[**2103-7-12**]
{'Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Unspecified essential hypertension,Nontoxic uninodular goiter'}


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: unresponsive

PRESENT ILLNESS: The patient is a 81 yo woman with recent diagnosis of Afib, HTN,
recent partial splenic rupture, who is brought to the ED after
she became unresponsive.
.
The patient was recently diagnosed with Afib (this week, when
she developed SOB, HR in the 140's and CP). She underwent a
workup at [**Hospital3 **], including a thyroid biopsy. The plan
was to start her on coumadin and she received lovenox x2 days
(Monday and Tuesday per daughter), but she developed abdominal
pains and was found to have a partial splenic rupture (likely
due a fall [**6-20**] or 2 months earlier). So, she was not started
on coumadin.
.
She was at home with her daughter, when she told her daughter
that she had a headache. She then became unresponsive. This
happened around 3.15 pm. EMS found her to be flaccid on the R
(face, arm and leg). PB was 118/72 and FS was in the 80's.
.
In the ED, her NIHSS was 24 (see below). She is in Afibb. A STAT
CT head showed  L-MCA sign.
.
NIHSS: 25
1a. Level of consciousness: 2
1b. LOC questions: 2 (age and month)
1c. LOC commands: 2
2. Best gaze: 1
3. Visual: 2
4. Facial Palsy: 2
5. Motor Arm: 0/4
6. Motor Leg: 0/4
7. Limb ataxia: 0
8. Sensory: 1
9. Best Language: 3
10. Dysarthria: 0
11. Extinction: 2
.
ROS:
-unable

MEDICAL HISTORY: - recent AFib; not on coumadin
- thyroid nodules: biopsy on [**7-5**] at [**Hospital **] Hosp
- HTN
-proteinuria
-restless legs
-partial splenic rupture
-multiple falls
-hearing loss on the L

MEDICATION ON ADMISSION: -colace
-MOM
-nitro 0.4mg PRN
-fosamax 70mg q week
-salsalate 750mg [**Hospital1 **] PO
-neurontin 600mg PO BID
-cardizem 240mg PO daily

ALLERGIES: Pergolide Mesylate

PHYSICAL EXAM: VITALS: Tafebrile HR BP120/49 RR  sO2100% FM
GEN: pale
HEENT: mmm
NECK: no carotid bruits
LUNGS: Clear to auscultation bilaterally
HEART: [**Last Name (un) 3526**] [**Last Name (un) 3526**], normal S1 and S2, no murmurs
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema
.
MENTAL STATUS:
Awake, eyes open, not following commands, non-verbal.
.
CRANIAL NERVES:
No blink to threat from the R, does blink from the L. PERRL.
Dolls across midline. Responds to nose tickle. R-facial droop.
Has gag.
.
MOTOR SYSTEM: Decreased bulk. Tone flaccid in RLE and RUA,
normal LLE, some gegenhalten LUE. Spontaneous movements of LUE
and LLE antigravity. No spontaneous movement on the R, but
triple flexion on the RLE.
.
SENSORY SYSTEM: Triple flexion to noxious in RLE; no response
RUE; withdrawal on the L (UE and LE)
.
REFLEXES:
B T Br Pa Pl
Right  1 1 1 2 -
Left   1 1 1 2 -
upgoing bilaterally.
.
COORDINATION: deferred
.
GAIT: deferred

FAMILY HISTORY: - MI and strokes; no ca

SOCIAL HISTORY: lives with her daugther. Former smoking, not much, stopped in
'[**78**]. 3 kids. No alcohol. Does not drive. Some memory problems at
baseline. 

### Response:
{'Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Unspecified essential hypertension,Nontoxic uninodular goiter'}
