CHIEF COMPLAINT: gaze preference and not talking

PRESENT ILLNESS: 83 yo man with right parietal SDH x 1 yr, afib on coumadin
subtheraputic, stroke [**2167-7-10**] right precentral gyrus with
residual left UE> LE weakness, who presents to OSH nonverbal and
left gaze preference since 11am on day prior to admission here.
OSH head ct showed increased SDH. Transferred to [**Hospital1 18**] for
neurosurg backup. Here, thought to be having sz given inability
to communicate, left eye gaze preference, and increased SDH on
CT. Given ativan 1mg x 2, loaded with dilantin.  Given 2 u FFP
and vit K for INR reversal (INR 1.7).  Became less
responsive around 2am, neg gag reflex -> intubated.  MRI
obtained which showed multiple areas of new stroke in the
inferior MCA territory, right mca/pca watershed area, a new one
in the CBL. Admitted to ICU.

MEDICAL HISTORY: 1. right parietal SDH x 1 yr
2. afib on coumadin subtheraputic
3. stroke [**2167-7-10**] right precentral gyrus with residual left UE>
LE weakness
4.  PVD s/p right leg angiogram ~ 3 days PTA for toe ischemia
c/b "vessel perforation, " no records to document this only
mentioned in a neuro c/s note from OSH
5. COPD
6. [**Last Name (un) **] syndrome (pseudoobstruction of the bowel, on many
bowel moving meds)
7. COPD
8.  h/o bacteremia with coag neg staph
9. ischemic proctitis
10. OA
11. bilateral PE's per old d/c summaries
12.  alcohol use with h/o withdrawl sz, bilateral cataract
surgery.

MEDICATION ON ADMISSION: mucomyst, albuterol/ipratropium, dig 0.125, tamsulosin
0.4mg, metoprolol 12.5 TID, colace, coumadin (last dose was 10mg
for INR 1.4), senna, bisacodyl, MOM, fleets, lactulose, tylenol,
prn percs (takes 1 QOD per med sheet).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Phys exam:
Vitals:  97.4 F, 101-121, BP 131-162/6-94, RR 22, 100% o2 sat on
AC vent, I/O:  271/140
GEN:  intubated, elderly man
HEENT:  ETT, OGT, clear OP
CHEST: CTA bilat
CV: irreg irreg rhythm without mur
ABD: soft, MT, + distended, + BS
EXTREM: dusky cool right 1st toe, non-dopplerable DP pulse on
the right, dopplerable DP on left and post tib pulses bilat, no
edema

FAMILY HISTORY: unknown

SOCIAL HISTORY: unknown, family not available to speak with.  He was
in a rehab facility prior to presenting to the OSH.
Cerebral embolism with cerebral infarction,Acute myocardial infarction of other specified sites, initial episode of care,Subdural hemorrhage,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Other specified intestinal obstruction,Other and unspecified alcohol dependence, unspecified,Other specified disorders of rectum and anus
Crbl emblsm w infrct,AMI NEC, initial,Subdural hemorrhage,Atrial fibrillation,Chr airway obstruct NEC,Intestinal obstruct NEC,Alcoh dep NEC/NOS-unspec,Rectal & anal dis NEC
Admission Date:  [**2167-8-10**]              Discharge Date:   [**2167-8-16**]


Service: NMED

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
gaze preference and not talking

Major Surgical or Invasive Procedure:
none

History of Present Illness:
83 yo man with right parietal SDH x 1 yr, afib on coumadin
subtheraputic, stroke [**2167-7-10**] right precentral gyrus with
residual left UE> LE weakness, who presents to OSH nonverbal and
left gaze preference since 11am on day prior to admission here.
OSH head ct showed increased SDH. Transferred to [**Hospital1 18**] for
neurosurg backup. Here, thought to be having sz given inability
to communicate, left eye gaze preference, and increased SDH on
CT. Given ativan 1mg x 2, loaded with dilantin.  Given 2 u FFP
and vit K for INR reversal (INR 1.7).  Became less
responsive around 2am, neg gag reflex -> intubated.  MRI
obtained which showed multiple areas of new stroke in the
inferior MCA territory, right mca/pca watershed area, a new one
in the CBL. Admitted to ICU.


Past Medical History:
1. right parietal SDH x 1 yr
2. afib on coumadin subtheraputic
3. stroke [**2167-7-10**] right precentral gyrus with residual left UE>
LE weakness
4.  PVD s/p right leg angiogram ~ 3 days PTA for toe ischemia
c/b "vessel perforation, " no records to document this only
mentioned in a neuro c/s note from OSH
5. COPD
6. [**Last Name (un) **] syndrome (pseudoobstruction of the bowel, on many
bowel moving meds)
7. COPD
8.  h/o bacteremia with coag neg staph
9. ischemic proctitis
10. OA
11. bilateral PE's per old d/c summaries
12.  alcohol use with h/o withdrawl sz, bilateral cataract
surgery.


Social History:
unknown, family not available to speak with.  He was
in a rehab facility prior to presenting to the OSH.


Family History:
unknown

Physical Exam:
Phys exam:
Vitals:  97.4 F, 101-121, BP 131-162/6-94, RR 22, 100% o2 sat on
AC vent, I/O:  271/140
GEN:  intubated, elderly man
HEENT:  ETT, OGT, clear OP
CHEST: CTA bilat
CV: irreg irreg rhythm without mur
ABD: soft, MT, + distended, + BS
EXTREM: dusky cool right 1st toe, non-dopplerable DP pulse on
the right, dopplerable DP on left and post tib pulses bilat, no
edema

NEURO
MS: does not open eyes to voice or pain off sedating meds, does
not follow commands
CN:  pupils left slightly greater than the right by <1mm, both
reactive but sluggish, left gaze preference, left beating
nystagmus that extinguishes, no blink to threat
MOTOR: spontaneously moves LUE, LLE, and RLE.  normal tone.
DTR:  DTR 1 Tri/[**Hospital1 **]/BR RUE and 3 on LUE, 2 patellar and achilles
on the right, 2 patellar and achilles on the left, upgoing toe
right, down going toe on the left
SENSORY: extensor response to pain RUE otherwise withdrawls to
pain
[**Last Name (un) 7058**] & GAIT: unable to test

Pertinent Results:
[**2167-8-10**] 06:40PM BLOOD PT-16.2* PTT-27.7 INR(PT)-1.7
[**2167-8-10**] 06:40PM BLOOD Glucose-140* UreaN-24* Creat-0.9 Na-140
K-3.8 Cl-102 HCO3-26 AnGap-16
[**2167-8-11**] 07:36PM BLOOD CK-MB-9 cTropnT-0.51*
[**2167-8-11**] 12:54PM BLOOD CK-MB-13* MB Indx-7.9* cTropnT-0.56*
[**2167-8-11**] 06:29AM BLOOD CK-MB-16* MB Indx-9.4* cTropnT-0.51*
[**2167-8-10**] 06:40PM BLOOD WBC-11.8* RBC-4.39* Hgb-13.0* Hct-38.0*
MCV-87 MCH-29.7 MCHC-34.3# RDW-13.0 Plt Ct-149*

TTE [**2167-8-12**]:

The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. LV
systolic function
appears mildly depressed. Resting regional wall motion
abnormalities include
inferior and inferolateral severe hypokinesis/akinesis with
hypokinesis
elsewhere. The ascending aorta is moderately dilated. The aortic
valve
leaflets are mildly thickened. There may be mild aortic stenosis
(gradient
measurement is technically suboptimal). Mild (1+) aortic
regurgitation is
seen. The mitral valve leaflets are mildly thickened. Moderate
to severe (3+)
mitral regurgitation is seen. The mitral regurgitation jet is
eccentric. There
is borderline pulmonary artery systolic hypertension. There is
an anterior
space which most likely represents a fat pad, though a loculated
anterior
pericardial effusion cannot be excluded.

Compared with the findings of the prior study (tape reviewed) of
[**2166-6-2**], left
ventricular systolic function now appears slightly less vigorous
and
segemental wall motion abnormality is now visualized (may have
been present
previously but views were technically suboptimal). Mitral
regurgitation is now
more prominent.

Head CT [**8-10**]:  Slight interval increase in size of right
parietal subdural hematoma since the prior study. No evidence of
shift of the normally midline structures. Interval posterior
fight frontal infarct.


Brief Hospital Course:
This man is a very unfortunate man with atrial fibrillation not
theraputic on coumadin who presented with worsening subdural
hematoma as well as multiple new strokes specifically in the
inferior MCA territory, right mca/pca watershed area, and the
left CBL. Complicating this picture, he ruled in for myocardial
infarction and on TTE had multiple areas of akinesis.  His 1st
right big toe was purple and cold upon admission.  Our therory
was that he was likely throwing clots all over his body from his
afib.  Treatment was difficult in that treating the strokes with
anticoagulation would worsen the subdural hematoma, potentially
requiring surgical evacuation.  This tough treatment decision
was explained to the patient's family through multiple phone
conversations.  Their schedules did not permit them to meet with
us during hours we were available.  Given his poor quality of
life and multiple organ involvement, the patients 3 children
came to the decision to make him comfort measures only.  He was
extubated, placed on a morphine drip for air hunger, and died at
2:03 am on [**2167-8-16**].  The family denied postmortem exam.


Medications on Admission:
mucomyst, albuterol/ipratropium, dig 0.125, tamsulosin
0.4mg, metoprolol 12.5 TID, colace, coumadin (last dose was 10mg
for INR 1.4), senna, bisacodyl, MOM, fleets, lactulose, tylenol,
prn percs (takes 1 QOD per med sheet).


Discharge Medications:
none, deceased

Discharge Disposition:
Home

Facility:
funeral home

Discharge Diagnosis:
deceased
 - subdural hematoma
 - multiple new strokes
 - ischemic toe
 - myocardial infarction

Discharge Condition:
deceased

Discharge Instructions:
none

Followup Instructions:
none

                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
{'Cerebral embolism with cerebral infarction,Acute myocardial infarction of other specified sites, initial episode of care,Subdural hemorrhage,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Other specified intestinal obstruction,Other and unspecified alcohol dependence, unspecified,Other specified disorders of rectum and anus'}


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: gaze preference and not talking

PRESENT ILLNESS: 83 yo man with right parietal SDH x 1 yr, afib on coumadin
subtheraputic, stroke [**2167-7-10**] right precentral gyrus with
residual left UE> LE weakness, who presents to OSH nonverbal and
left gaze preference since 11am on day prior to admission here.
OSH head ct showed increased SDH. Transferred to [**Hospital1 18**] for
neurosurg backup. Here, thought to be having sz given inability
to communicate, left eye gaze preference, and increased SDH on
CT. Given ativan 1mg x 2, loaded with dilantin.  Given 2 u FFP
and vit K for INR reversal (INR 1.7).  Became less
responsive around 2am, neg gag reflex -> intubated.  MRI
obtained which showed multiple areas of new stroke in the
inferior MCA territory, right mca/pca watershed area, a new one
in the CBL. Admitted to ICU.

MEDICAL HISTORY: 1. right parietal SDH x 1 yr
2. afib on coumadin subtheraputic
3. stroke [**2167-7-10**] right precentral gyrus with residual left UE>
LE weakness
4.  PVD s/p right leg angiogram ~ 3 days PTA for toe ischemia
c/b "vessel perforation, " no records to document this only
mentioned in a neuro c/s note from OSH
5. COPD
6. [**Last Name (un) **] syndrome (pseudoobstruction of the bowel, on many
bowel moving meds)
7. COPD
8.  h/o bacteremia with coag neg staph
9. ischemic proctitis
10. OA
11. bilateral PE's per old d/c summaries
12.  alcohol use with h/o withdrawl sz, bilateral cataract
surgery.

MEDICATION ON ADMISSION: mucomyst, albuterol/ipratropium, dig 0.125, tamsulosin
0.4mg, metoprolol 12.5 TID, colace, coumadin (last dose was 10mg
for INR 1.4), senna, bisacodyl, MOM, fleets, lactulose, tylenol,
prn percs (takes 1 QOD per med sheet).

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Phys exam:
Vitals:  97.4 F, 101-121, BP 131-162/6-94, RR 22, 100% o2 sat on
AC vent, I/O:  271/140
GEN:  intubated, elderly man
HEENT:  ETT, OGT, clear OP
CHEST: CTA bilat
CV: irreg irreg rhythm without mur
ABD: soft, MT, + distended, + BS
EXTREM: dusky cool right 1st toe, non-dopplerable DP pulse on
the right, dopplerable DP on left and post tib pulses bilat, no
edema

FAMILY HISTORY: unknown

SOCIAL HISTORY: unknown, family not available to speak with.  He was
in a rehab facility prior to presenting to the OSH. 

### Response:
{'Cerebral embolism with cerebral infarction,Acute myocardial infarction of other specified sites, initial episode of care,Subdural hemorrhage,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Other specified intestinal obstruction,Other and unspecified alcohol dependence, unspecified,Other specified disorders of rectum and anus'}
