CHIEF COMPLAINT: left sided shaking, left gaze preference

PRESENT ILLNESS: 85yo woman with PMH significant for atrial fibrillation on
coumadin, h/o stroke in [**10-15**] with residual left sided weakness
and dysarthria, hyperlipidemia presented with left sided
shaking. She was was last seen well at 8pm the evening of
admission and was then found on the floor of the bathroom around
midnight. Her daughter heard her call out that she couldn't get
up; she was lodged between the toilet and the wall. She was
unable to stand without assistance; she did not answer queries
to where she was. She was "looking off to her left" according to
her daughter and was not saying much. She then started shaking
on her left side (beginning with curling of her left side). The
daughter's vantage point was behind the patient and she is
unsure of which side was shaking or if both were.

MEDICAL HISTORY: Stroke, as above; required her to walk with a walker
Recent urinary tract infection, treated with ciprofloxacin from
[**Date range (1) 23742**]
Hypertension
Hyperlipidemia

MEDICATION ON ADMISSION: diovan 80
zocor 40
coumadin 5 qod
atenolol 50
protonix 40
prozac 20
thiamine
folate
cipro [**Date range (1) 23742**]

ALLERGIES: Hydrochlorothiazide / Ace Inhibitors

PHYSICAL EXAM: VS 98.7/98.7 77-97 afib 96-164/37-87 15-17 80/900
Genl: Lying in bed in NAD
Neck: supple
CV: irreg no bruits
Pulm: ctab
Abd: soft benign
Ext: no edema

FAMILY HISTORY: Mother with HTN, stroke

SOCIAL HISTORY: Quit smoking 10yrs ago. No etoh since [**Month (only) 404**] per her daughter;
previous etoh abuse. No other drug use. Lives with her daughter.
In [**Name2 (NI) 404**], was falling and drinking heavily.
Pneumonia, organism unspecified,Other convulsions,Atrial fibrillation,Acute kidney failure, unspecified,Mitral valve disorders,Obstructive chronic bronchitis with (acute) exacerbation,Congestive heart failure, unspecified,Acute respiratory failure,Unspecified transient cerebral ischemia,Encephalopathy, unspecified,Long-term (current) use of anticoagulants,Other and unspecified hyperlipidemia,Occlusion and stenosis of carotid artery without mention of cerebral infarction
Pneumonia, organism NOS,Convulsions NEC,Atrial fibrillation,Acute kidney failure NOS,Mitral valve disorder,Obs chr bronc w(ac) exac,CHF NOS,Acute respiratry failure,Trans cereb ischemia NOS,Encephalopathy NOS,Long-term use anticoagul,Hyperlipidemia NEC/NOS,Ocl crtd art wo infrct
Admission Date:  [**2159-4-12**]              Discharge Date:   [**2159-4-28**]


Service: MEDICINE

Allergies:
Hydrochlorothiazide / Ace Inhibitors

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
left sided shaking, left gaze preference

Major Surgical or Invasive Procedure:
tracheal intubation and mechanical ventilation
arterial line placement
central venous line placement
lumbar puncture

History of Present Illness:
85yo woman with PMH significant for atrial fibrillation on
coumadin, h/o stroke in [**10-15**] with residual left sided weakness
and dysarthria, hyperlipidemia presented with left sided
shaking. She was was last seen well at 8pm the evening of
admission and was then found on the floor of the bathroom around
midnight. Her daughter heard her call out that she couldn't get
up; she was lodged between the toilet and the wall. She was
unable to stand without assistance; she did not answer queries
to where she was. She was "looking off to her left" according to
her daughter and was not saying much. She then started shaking
on her left side (beginning with curling of her left side). The
daughter's vantage point was behind the patient and she is
unsure of which side was shaking or if both were.

Per history, EMS found her awake but with R-sided weakness and
"+GTC seizure activity (eyes deviated towards the right) lasting
<1minute at a time". She received two rounds of ativan 3mg and
another two doses of valium 5mg and was intubated at the scene
by EMS for airway protection.

She presented to [**Hospital1 18**] and a code stroke was called.

Review of systems per her daughter: +malaise, for which she
presented to her PCP one week prior. No neck pain, headache,
cough, fever, chest pain, nausea, vomiting, diarrhea.

Past Medical History:
Stroke, as above; required her to walk with a walker
Recent urinary tract infection, treated with ciprofloxacin from
[**Date range (1) 23742**]
Hypertension
Hyperlipidemia

Social History:
Quit smoking 10yrs ago. No etoh since [**Month (only) 404**] per her daughter;
previous etoh abuse. No other drug use. Lives with her daughter.
In [**Name2 (NI) 404**], was falling and drinking heavily.

Family History:
Mother with HTN, stroke

Physical Exam:
VS 98.7/98.7 77-97 afib 96-164/37-87 15-17 80/900
Genl: Lying in bed in NAD
Neck: supple
CV: irreg no bruits
Pulm: ctab
Abd: soft benign
Ext: no edema

NEURO
MS: Intubated, examined off sedation x 10min. Moving right side
spontaneously more than the left. Not following commands or
opening her eyes.

CN:
CN I: not tested
CN II: Pupils 4->2 b/l.
CN III, IV, VI: EOMI no nystagmus
CN V: +corneal reflexes b/l
CN VII: full facial symmetry

Motor: Tone increased in legs, R>L. Moving all limbs
spontaneously and antigravity.

Sensory: withdraws to pain in all limbs.

Reflexes: brisker on the right, toes up b/l

Coordination and gait were not able to be assessed.

Pertinent Results:
Labs:
.
On admission [**2159-4-12**] 12:30AM:
WBC-13.1* RBC-3.38* Hgb-10.9* Hct-32.2* MCV-95 MCH-32.1*
MCHC-33.7 RDW-14.5 Plt Ct-366
Neuts-92.1* Bands-0 Lymphs-3.6* Monos-3.8 Eos-0.4 Baso-0.1
PT-21.4* PTT-35.5* INR(PT)-2.1*
Glucose-213* UreaN-13 Creat-1.1 Na-138 K-4.1 Cl-100 HCO3-19*
AnGap-23*
ALT-19 AST-29 LD(LDH)-374* CK(CPK)-98 AlkPhos-124* Amylase-79
TotBili-0.6
Calcium-8.1* Phos-3.9 Mg-1.3*
Albumin-3.7
ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
Cardiac enzymes negative x 2
.
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012 Blood-TR
Nitrite-NEG Protein-NEG Glucose-TR Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-6.5 Leuks-NEG RBC-[**2-12**]* WBC-0-2 Bacteri-OCC
Yeast-NONE Epi-0
.
Other pertinent labs:
Free T4-0.83*  TSH-0.45
[**2159-4-23**] Ammonia-40
.
.
Studies:
.
CXR ([**4-12**]): Mild hydrostatic edema presumably cardiogenic in
etiology.
Retrocardiac opacity likely reflects atelectasis, although an
underlying
infection cannot be entirely excluded.
.
Head CT ([**4-12**]): No CT evidence of acute cortical stroke.  Chronic
ischemic
changes and age-appropriate atrophy as above
.
CTA/CTP ([**4-12**]):
1. Small, 3 mm focal dilatation at the origin of the posterior
communicating artery and the internal carotid artery on the left
could represent an aneurysm.
2. 50% stenoses of the left common carotid artery at the level
of the bulb and the origin of the left internal carotid artery,
respectively.
3. 60% stenosis of the right internal carotid artery in the
neck.
4. Diffuse. vascular atherosclerotic, calcific disease.
.
MRI/A ([**4-12**]):
1. No evidence of acute infarction by diffusion-weighted
imaging.
2. Subacute versus chronic, likely chronic right posterior
cerebral artery territory infarct in the occipital lobe.
3. Evidence of small vessel ischemia.
4. Three-mm aneurysm extending posteriorly of the left
supraclinoid portion of the internal carotid artery.
.
Head CT ([**4-16**]): Stable appearance of the brain.
.
CT c-spine ([**4-12**]): Severe degenerative changes throughout the
cervical spine somewhat limiting assessment. Possible fractures
identified at the left anterior arch of C1, as well as within
the dens.  MRI is recommended for further evaluation.
.
MR [**Name13 (STitle) **] ([**4-14**]): 1.  The changes seen on CT at C1-2 level
appear to be due to advanced degenerative change with thickening
of the transverse ligament and degenerative pannus formation.
No evidence of fracture of the odontoid process or lateral
masses of C1 or C2 identified. 2.  Changes of cervical
spondylosis predominantly from C3-4 to C6-7. 3.  No evidence of
intrinsic spinal cord signal abnormalities or extrinsic
spinal cord compression. 4.  No evidence of ligamentous
disruption.
.
Abd u/s ([**4-23**]): 1.  Distended gallbladder with asymmetric edema
within the gallbladder wall, indeterminate for the presence or
absence of acute cholecystitis.  Recommend further
characterization with a HIDA scan. 2.  Prominent CBD, measuring
0.96 cm in size.  The distal CBD and head of the pancreas are
not well seen- recommend further visualization with contrast
enhanced CT of the Abdomen. 3. Pedunculated cystic lesion
projecting between the lateral left lobe of the liver and the
pancreas. The origin of this cystic lesion is incompletely
resolved with the current study and further characterization
with a CT scan is recommended.
.
RUQ US [**4-25**]:
1. Limited evaluation of the liver, without focal mass lesions.
Normal hepatic vasculature.
2. Minimal gallbladder wall edema and sludge are identified. The
edema would be consistent with third spacing of fluid related to
the patient's underlying hepatic disease.
.
ECHO: The left atrium is mildly dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
systolic function (LVEF>55%). Regional left ventricular wall
motion is normal. [Intrinsic left ventricular systolic function
is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
mitral valve leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid regurgitation jet is
eccentric and may be underestimated. There is borderline
pulmonary artery systolic hypertension.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Moderate mitral regurgitation with mildly thickened leaflets and
supporting structures.
.
EEG ([**4-12**]): Markedly abnormal portable EEG due to the very low
voltage
slow background and with bursts of generalized slowing. There
were some
periods with a markedly suppressed background. These findings
indicate
a widespread encephalopathy.
.
EEG ([**4-16**]): : This 24-hour EEG telemetry captured no
electrographic
seizures. No interictal epileptiform discharges were seen. The
background was slow and disorganized throughout much of the
recording
indicating a mild to moderate encephalopathy.

Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the neurology ICU after being
intubated for airway protection after receiving several rounds
of ativan for seizure activity. Hospital course was complicated
and is reviewed below by problem.

1. seizure: The episode prior to presentation was concerning for
a seizure. She had no prior seizure history, but she had had a
stroke, which could act as seizure focus. For further
evaluation, she underwent CTA, MRA, and EEG. The CTA and MRI
were negative for infarction or stenosis, but showed a 3mm
aneurysm extending posteriorly of the left supraclinoid portion
of the internal carotid artery, which will need to be followed
as an outpatient. EEG initially showed very low voltage slow
background and with bursts of generalized slowing, consistent
with encephalopathy. Repeat showed some improvement but
persistent findings of a mild to moderate encephalopathy. It was
thought that she had a symptomatic seizure secondary to
infection. She was not put on any antiepileptic medications and
had no further evidence of seizures.

2. encephalopathy: This was initially thought to be secondary to
infection. Tox screen was negative. She was treated for presumed
PNA for 7 days and seemed to improve, but then her mental status
began to decline after extubation ([**4-19**], [**4-20**]) with worsening
over the next several days. Lumbar puncture had initially been
considered, but given her improvement it was thought to be low
yield. With decreased responsiveness, the lumbar puncture was
again considered. However, she initially had some respiratory
difficulties making a lumbar puncture high risk (she would have
needed ativan for agitation, with concern for reintubation), and
then she had an elevated INR which did not come down to 1.5 even
after several units of FFP. She was considered to have a low
suspicion for meningitis, but was started on ceftriaxone,
vancomycin, and ampicillin on [**4-23**] for empiric coverage, as the
lumbar puncture could not be performed.  On transfer to the
Medical ICU, lumbar puncture was attempted, but was unsucessful.

3. respiratory distress: Mrs. [**Known lastname **] required intubation twice
for respiratory failure and once for concerns of decreased
responsiveness with an episode of apnea. On [**4-20**] the pulmonary
service was consulted as the patient was wheezing and was noted
to have increased work of breathing (using accessory muscles,
tachypneic). A transthoracic echocardiogram was performed (see
above). She was started on budesonide and diuresed with
improvement of the wheezing.

4. atrial fibrillation: Anticoagulation was established with
heparin gtt whenever coumadin needed to be stopped for
procedures. She was treated with beta-blockers or IVF as needed
for tachycardia.

5. acute renal failure: Her creatinine acutely rose on [**4-19**].
FeNa was low, and she was thought to be total body overloaded
but intravascularly dry. She was given albumin and lasix with
stabilization of the Cr.

6. fever: She was initially treated with ceftriaxone and
vancomycin for 7 days, but all cultures were negative and the
antibiotics were discontinued. They were restarted, with
ampicillin, at meningitic doses on [**4-23**] after the patient
decompensated with a temperature of 104.  Upon transfer to the
medical ICU, broad antibiotic coverage with vancomycin,
ceftriaxone, and zosyn were started.

7. transaminitis: She was noted to have an acute rise in ALT and
AST on [**4-23**]. RUQ u/s showed gall bladder wall edema without
stones or sludge.  Due to concern for cholangitis, she was
transferred to the Medical ICU team.  Hepatology and General
Surgery consulted and recommended repeat US.  A second US was
obtained and showed minimal gall bladder wall edema with minimal
sludge.  ERCP was recommended when she was more clinically
stable.

8. anemia: She had a slow Hct drop and was given a unit of
PRBCs. Rectal guaiac was negative and her Hct stabilized.

9. hypotension: upon transfer to the Medical ICU she was noted
to have fevers and hypotension.  Upon discussion with her
family, they brought in evidence of a living will, which
outlined her preference for no resuscitation.  Her blood
pressure was supported with IV fluid boluses, per her family's
request to not use vasopressors.  The subsequent day, she showed
evidence of worsened liver and renal function, periods of apnea
on the ventilator, and continued cardiovascular compromise.  A
family meeting was held with her son, [**Name (NI) **] (Health Care Proxy),
and daughter, [**Name (NI) **].  The decision was made to change the
goals of care to comfort only, according to the patient's
predetermined wishes.  She was extubated and started on a
morphine drip, titrated to comfort. The patient passed away
comfortably and was pronounced dead at 8:15pm on [**2159-4-28**].

Commun: HCP son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 68156**](H), [**Telephone/Fax (1) 68157**](C)

Medications on Admission:
diovan 80
zocor 40
coumadin 5 qod
atenolol 50
protonix 40
prozac 20
thiamine
folate
cipro [**Date range (1) 23742**]

Discharge Medications:
Expired

Discharge Disposition:
Expired

Discharge Diagnosis:
Pneumonia, TIA


Discharge Condition:
Expired


Discharge Instructions:
Expired

Followup Instructions:
Expired
{'Pneumonia, organism unspecified,Other convulsions,Atrial fibrillation,Acute kidney failure, unspecified,Mitral valve disorders,Obstructive chronic bronchitis with (acute) exacerbation,Congestive heart failure, unspecified,Acute respiratory failure,Unspecified transient cerebral ischemia,Encephalopathy, unspecified,Long-term (current) use of anticoagulants,Other and unspecified hyperlipidemia,Occlusion and stenosis of carotid artery without mention of cerebral infarction'}


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: left sided shaking, left gaze preference

PRESENT ILLNESS: 85yo woman with PMH significant for atrial fibrillation on
coumadin, h/o stroke in [**10-15**] with residual left sided weakness
and dysarthria, hyperlipidemia presented with left sided
shaking. She was was last seen well at 8pm the evening of
admission and was then found on the floor of the bathroom around
midnight. Her daughter heard her call out that she couldn't get
up; she was lodged between the toilet and the wall. She was
unable to stand without assistance; she did not answer queries
to where she was. She was "looking off to her left" according to
her daughter and was not saying much. She then started shaking
on her left side (beginning with curling of her left side). The
daughter's vantage point was behind the patient and she is
unsure of which side was shaking or if both were.

MEDICAL HISTORY: Stroke, as above; required her to walk with a walker
Recent urinary tract infection, treated with ciprofloxacin from
[**Date range (1) 23742**]
Hypertension
Hyperlipidemia

MEDICATION ON ADMISSION: diovan 80
zocor 40
coumadin 5 qod
atenolol 50
protonix 40
prozac 20
thiamine
folate
cipro [**Date range (1) 23742**]

ALLERGIES: Hydrochlorothiazide / Ace Inhibitors

PHYSICAL EXAM: VS 98.7/98.7 77-97 afib 96-164/37-87 15-17 80/900
Genl: Lying in bed in NAD
Neck: supple
CV: irreg no bruits
Pulm: ctab
Abd: soft benign
Ext: no edema

FAMILY HISTORY: Mother with HTN, stroke

SOCIAL HISTORY: Quit smoking 10yrs ago. No etoh since [**Month (only) 404**] per her daughter;
previous etoh abuse. No other drug use. Lives with her daughter.
In [**Name2 (NI) 404**], was falling and drinking heavily. 

### Response:
{'Pneumonia, organism unspecified,Other convulsions,Atrial fibrillation,Acute kidney failure, unspecified,Mitral valve disorders,Obstructive chronic bronchitis with (acute) exacerbation,Congestive heart failure, unspecified,Acute respiratory failure,Unspecified transient cerebral ischemia,Encephalopathy, unspecified,Long-term (current) use of anticoagulants,Other and unspecified hyperlipidemia,Occlusion and stenosis of carotid artery without mention of cerebral infarction'}
