CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
right-handed woman with hypertension, high cholesterol, who
had a large left MCA territory stroke. She was last known to
be in her usual state of health on [**2184-8-22**] at 4:00
p.m.  On [**2184-8-23**] at 11:00 a.m. she apparently fell
and then called a family member.  The family member then
found her at 1:30 p.m. to be confused with slurred speech.
She was taken to the [**Hospital6 256**]
Emergency Department.  Her initial examination at
approximately 5:00 p.m. noted her to be nonfluent with a
right facial droop and a right pronator drift.  MRI/MRA was
done and showed decreased flow in the left internal carotid
artery.  There was a suggestion of a subacute to chronic
infarct in the right periatrial white matter.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Occlusion and stenosis of carotid artery with cerebral infarction,Mitral valve insufficiency and aortic valve insufficiency,Primary pulmonary hypertension,Urinary tract infection, site not specified,Aphasia,Hemiplegia, unspecified, affecting dominant side,Pure hypercholesterolemia,Personal history of malignant neoplasm of large intestine,Osteoporosis, unspecified
Ocl crtd art w infrct,Mitral/aortic val insuff,Prim pulm hypertension,Urin tract infection NOS,Aphasia,Unsp hemiplga domnt side,Pure hypercholesterolem,Hx of colonic malignancy,Osteoporosis NOS
Admission Date:  [**2184-8-23**]       Discharge Date:  [**2184-8-28**]


Service:  NEUROLOGY

HISTORY OF THE PRESENT ILLNESS:  The patient is a [**Age over 90 **]-year-old
right-handed woman with hypertension, high cholesterol, who
had a large left MCA territory stroke. She was last known to
be in her usual state of health on [**2184-8-22**] at 4:00
p.m.  On [**2184-8-23**] at 11:00 a.m. she apparently fell
and then called a family member.  The family member then
found her at 1:30 p.m. to be confused with slurred speech.
She was taken to the [**Hospital6 256**]
Emergency Department.  Her initial examination at
approximately 5:00 p.m. noted her to be nonfluent with a
right facial droop and a right pronator drift.  MRI/MRA was
done and showed decreased flow in the left internal carotid
artery.  There was a suggestion of a subacute to chronic
infarct in the right periatrial white matter.

Upon returning from MRI, at approximately 7:30 p.m., she had
the acute onset of global aphasia and left gaze preference
and right hemiplegia.  A stat head CT and CTA showed absent
flow in the left internal carotid artery.  Her vessel imaging
and examination findings were felt to be consistent with a
large left MCA territory acute stroke.  Due to the unclear
onset of her symptoms, she was felt not to be a TPA candidate
after discussion with the family as well.  She was admitted
to the Intensive Care Unit.

HOSPITAL COURSE IN THE INTENSIVE CARE UNIT:  1.  NEUROLOGY:
A carotid ultrasound was suggestive of distal left ICA
occlusion.  A repeat head CT on [**2184-8-24**] showed a
large acute left MCA stroke in the left frontal lobe
extending into the insula as well as the left parietal lobe
with a blurred [**Doctor Last Name 352**]-white junction.  She was initially loaded
on Dilantin for concern of seizure but this was then
discontinued.

A transthoracic cardiogram was performed and showed left
ventricular systolic dysfunction consistent with coronary
artery disease.  There was no visualized thrombus.  She was
started on aspirin for secondary prophylaxis.

2.  CARDIOVASCULAR:  The patient ruled out for a myocardial
infarction based on enzymes.

3.  RESPIRATORY:  The patient had chest x-rays performed
which were consistent with mild pulmonary edema.  She had
normal saturations on 3 liters nasal cannula.

4.  FLUIDS, ELECTROLYTES, AND NUTRITION:  The patient was
kept n.p.o. with IV fluids running.

5.  INFECTIOUS DISEASE:  The patient was started on
levofloxacin for pyuria with urine culture pending.

6.  CODE STATUS:  The patient was made DNR, DNI by the
family.  On [**2184-8-24**], the patient was transferred to
the Neurology floor.  Her examination at that time showed a
temperature of 97.2, blood pressure 120/58, pulse 61,
respiratory rate 22, oxygen saturation 97% on 3 liters.
General:  She is an elderly appearing female with her eyes
closed in no apparent distress.  Her neck showed no carotid
bruits.  The lungs had bilateral basilar crackles.  Her
cardiac examination showed a regular rate and rhythm with a
II/VI systolic murmur at the left sternal border.  Her
abdomen was soft.  On neurological examination, on mental
status examination, her eyes were closed.  She did not open
her eyes to voice or to painful stimuli.  She had no speech
production.  She was not following commands.  Cranial nerve
examination:  There was deviation of gaze to the left but she
was able to cross the midline with doll's maneuver.  The
pupils were 3 mm bilaterally and reacted to 2 mm.  The left
corneal reflex is present.  Right corneal reflex is absent.
There is a right facial droop.  On motor examination, there
was decreased tone in the right upper and lower extremity.
There was spontaneous movement of the left upper and lower
extremity.  There was extensor posturing of the right upper
extremity in response to noxious stimuli.  There was triple
flexion response of the right lower extremity in response to
painful stimuli.  Reflexes were 1+ and symmetric.  Toes were
upgoing bilaterally.

The patient was continued on supportive care with IV fluids,
aspirin prophylaxis, respiratory monitoring, and
levofloxacin.  Her urine culture returned with no growth to
date and the levofloxacin was discontinued.  Her chest x-ray
showed progressive pulmonary edema and her IV fluids were
decreased.

On [**2184-8-26**], after extensive discussions with the
Neurology Team, her family decided to redirect care towards
comfort measures only.  At this point in time, the next step
would have been a PEG tube placement, but the patient had
previously discussed this with the family that she would not
have wanted this invasive measure.  Therefore, the patient
was placed on comfort measures only.  Her nasogastric tube
was discontinued.  Laboratories and chest x-rays were
discontinued.  Accu-Cheks were discontinued.

Her neurologic examination showed her to be slightly more
alert with eyes open.  However, she did not have any speech
production and was not following any commands.  Her right
upper and lower extremity remained hemiplegic.  She was seen
by the palliative care service and placed on medications as
needed for comfort, including morphine, Ativan, Scopolamine
and Tylenol.  She was screened for hospice care and will
likely be transferred to hospice within the next one to two
days to continue on comfort measures.

CONDITION ON DISCHARGE:  Poor.

DISCHARGE STATUS:  Hospice.

DISCHARGE DIAGNOSIS:  Left middle cerebral artery territory
stroke.

DISCHARGE MEDICATIONS:
1.  Morphine 5 to 20 mg sublingually q. four hours p.r.n.
distress.
2.  Ativan 0.5 to 1 mg sublingually q. four hours p.r.n.
agitation.
3.  Scopolamine 1.5 mg patch transdermally q. 72 hours p.r.n.
secretions.
4.  Tylenol 650 mg p.r. q. four hours p.r.n. fever.




                            [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 12114**]

Dictated By:[**Name8 (MD) 33494**]
MEDQUIST36

D:  [**2184-8-27**]  05:31
T:  [**2184-8-27**]  18:43
JOB#:  [**Job Number 98869**]


Admission Date:  [**2184-8-23**]       Discharge Date:  [**2184-8-30**]


Service:  NEUROLOGY

ADDENDUM TO PREVIOSU DISCHARGE SUMMARY FROM [**2184-8-28**]:  Over
this time course the patient became more alert on
examination.  However, she still had no movement of the right
arm or leg.  She had no speech output.  She did not follow
any commands consistently.  Discussion with the family were
continued and they were made aware that the patient had
became more alert on examination.  However, they continued to
reiterate that the patient's wishes were not to continue with
any invasive care or if she were to have this type of event.
Therefore the patient was continued on comfort measures only.
Her intravenous fluids were discontinued prior to discharge
as the receiving facility and any receiving facility would
require more long term intravenous access.  After discussion
with the family it was decided that the discomfort associated
with placing such a line outweighed any potential benefits of
the intravenous fluid.  She continued to appear comfortable
and did not require any prn morphine or Ativan while she was
here.  She was discharged to hospice on comfort measures only
at this time.

DISCHARGE DIAGNOSIS:
Left middle cerebral artery stroke.

DISCHARGE MEDICATIONS:
1.  Morphine 5 to 20 mg sublingual q 4 hours prn distress.
2.  Ativan .5 to 1 mg sublingual q 4 hours prn agitation.
3.  Scopolamine 1.5 mg patch transdermally q 72 hours prn
secretions.
4.  Tylenol 650 mg pr q 4 hours prn fever.






                            [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 12114**]

Dictated By:[**Name8 (MD) 100556**]
MEDQUIST36

D:  [**2184-8-30**]  12:47
T:  [**2184-8-30**]  13:37
JOB#:  [**Job Number 100557**]
{'Occlusion and stenosis of carotid artery with cerebral infarction,Mitral valve insufficiency and aortic valve insufficiency,Primary pulmonary hypertension,Urinary tract infection, site not specified,Aphasia,Hemiplegia, unspecified, affecting dominant side,Pure hypercholesterolemia,Personal history of malignant neoplasm of large intestine,Osteoporosis, 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: 

PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
right-handed woman with hypertension, high cholesterol, who
had a large left MCA territory stroke. She was last known to
be in her usual state of health on [**2184-8-22**] at 4:00
p.m.  On [**2184-8-23**] at 11:00 a.m. she apparently fell
and then called a family member.  The family member then
found her at 1:30 p.m. to be confused with slurred speech.
She was taken to the [**Hospital6 256**]
Emergency Department.  Her initial examination at
approximately 5:00 p.m. noted her to be nonfluent with a
right facial droop and a right pronator drift.  MRI/MRA was
done and showed decreased flow in the left internal carotid
artery.  There was a suggestion of a subacute to chronic
infarct in the right periatrial white matter.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Occlusion and stenosis of carotid artery with cerebral infarction,Mitral valve insufficiency and aortic valve insufficiency,Primary pulmonary hypertension,Urinary tract infection, site not specified,Aphasia,Hemiplegia, unspecified, affecting dominant side,Pure hypercholesterolemia,Personal history of malignant neoplasm of large intestine,Osteoporosis, unspecified'}
