CHIEF COMPLAINT: Found down

PRESENT ILLNESS: [**Age over 90 **]yo Russian woman (was English teacher) with h/o HTN,
hyperlipidemia who presents to the ED after having been found
down and minimally responsive by home health aid this morning;
last seen normal at approximately 10pm last night. Home health
aid reports having found pt. in her bedroom on the floor not
speaking well nor moving well. EMS was called and she was
transferred to [**Hospital1 18**] ED for further evaluation. Further details
surrounding events prior to having been found down are unclear.

MEDICAL HISTORY: 1. Hypertension.
2. Hypercholesterolemia.
3. Depression.
4. Dizziness.
5. Incontinence
6. Glaucoma
7. s/p Right iridectomy

MEDICATION ON ADMISSION: Clonidine
Metoprolol
Ambien
Lipitor
Prozac
Zyprexa
Nitroglycerin
Senna

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Temp:97.4 BP: 140/60 HR:72 RR:15 O2sat 97% RA
GEN: pleasant, comfortable, NAD
HEENT: Right pupil larger and w/ abnormal shape s/p iridectomy
and unresponsive to light. Left pupil round and responsive to
light, EOMI, anicteric, dry MM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: Rhonchorus anteriorly however appears to be upper airway
sounds transmitting, fine rales bibasilar
CV: RRR, S1 and S2 wnl, no m/r/g appreciated on exam
ABD: nd, +b/s, soft, nt, +hernia just superior to umbilicus,
reducible
EXT: trace-1+ bipedal edema, 1+ DP/PT pulses b/l
SKIN: chest with ?senile purpura
NEURO: Alert, not following commands in English (per neuro note
in ED, not following commands in Russian either). Moving all 4s.
Right biceps with 3.5/5, grip [**3-5**]. Left biceps with 4.5/5, full
grip (although does not grip when instructed to do so). Unable
to assess for sensory deficits. Moving b/l LEs however does not
cooperate with strength exam. 2+DTRs patellar, biceps,
brachioradialis (right sl. more brisk than left). Downgoing toes
b/l.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Lives at home alone with daily home aide's help. No
etoh/tob/illicits. Born in [**Country 532**]
Cerebral embolism with cerebral infarction,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Rhabdomyolysis,Atrial fibrillation,Unspecified essential hypertension,Pure hypercholesterolemia,Hemorrhage, unspecified,Anticoagulants causing adverse effects in therapeutic use
Crbl emblsm w infrct,Subendo infarct, initial,Acute kidney failure NOS,Food/vomit pneumonitis,Urin tract infection NOS,Rhabdomyolysis,Atrial fibrillation,Hypertension NOS,Pure hypercholesterolem,Hemorrhage NOS,Adv eff anticoagulants
Admission Date:  [**2200-1-5**]              Discharge Date:   [**2200-1-17**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Found down

Major Surgical or Invasive Procedure:
Midline placement

History of Present Illness:
[**Age over 90 **]yo Russian woman (was English teacher) with h/o HTN,
hyperlipidemia who presents to the ED after having been found
down and minimally responsive by home health aid this morning;
last seen normal at approximately 10pm last night. Home health
aid reports having found pt. in her bedroom on the floor not
speaking well nor moving well. EMS was called and she was
transferred to [**Hospital1 18**] ED for further evaluation. Further details
surrounding events prior to having been found down are unclear.

.
En route to the emergency department she was reportedly febrile
to 101.5 (no EMS note in chart), however on arrival to the ED,
initial vitals were 98.6 159/80 77 20 95% RA. Labs revealed a
WBC count of 19.5 with neutrophilia of 82%. Chemistries
demonstrated creatinine of 2.2 up from previous baseline
0.7-0.9. Urinalysis was also c/w UTI. Urine and serum tox
screens were negative. CXR on wet read was thought concerning
for infiltrate, however official read was negative for
consolidation. She received 750mg IV levofloxacin, 500mg IV
flagyl, and 1g IV vancomycin. She had one episode of vomiting in
the ED and received 4mg IV zofran. Troponin was elevated to 0.41
with CK MB of 36, no EKG changes and she received ASA 600mg PR.
She was started on IV NS at 150cc/hour.
.
Trauma w/u including CT C-spine and X-ray of right hip were
negative for fracture/dislocation. CT head demonstrated possible
loss of [**Doctor Last Name 352**]-white matter differentiation seen in the region of
the left insular cortex, concerning for acute infarct. Neurology
was consulted and felt CT head and exam c/w probable left MCA
stroke, but outside window for thrombolytics. MRI/MRA was
recommended although not performed in the ED.
.
ROS: Unable to assess. However, niece [**Name (NI) **] who last spoke w/
aunt last night says her aunt was feeling well, had eaten 3 full
meals yesterday and was not c/o N/V/diarrhea/abdominal pain,
dysuria/hematuria, cough, fevers/chills,
numbness/tingling/weakness.


Past Medical History:
1. Hypertension.
2. Hypercholesterolemia.
3. Depression.
4. Dizziness.
5. Incontinence
6. Glaucoma
7. s/p Right iridectomy


Social History:
Lives at home alone with daily home aide's help. No
etoh/tob/illicits. Born in [**Country 532**]

Family History:
Unknown

Physical Exam:
VS: Temp:97.4 BP: 140/60 HR:72 RR:15 O2sat 97% RA
GEN: pleasant, comfortable, NAD
HEENT: Right pupil larger and w/ abnormal shape s/p iridectomy
and unresponsive to light. Left pupil round and responsive to
light, EOMI, anicteric, dry MM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: Rhonchorus anteriorly however appears to be upper airway
sounds transmitting, fine rales bibasilar
CV: RRR, S1 and S2 wnl, no m/r/g appreciated on exam
ABD: nd, +b/s, soft, nt, +hernia just superior to umbilicus,
reducible
EXT: trace-1+ bipedal edema, 1+ DP/PT pulses b/l
SKIN: chest with ?senile purpura
NEURO: Alert, not following commands in English (per neuro note
in ED, not following commands in Russian either). Moving all 4s.
Right biceps with 3.5/5, grip [**3-5**]. Left biceps with 4.5/5, full
grip (although does not grip when instructed to do so). Unable
to assess for sensory deficits. Moving b/l LEs however does not
cooperate with strength exam. 2+DTRs patellar, biceps,
brachioradialis (right sl. more brisk than left). Downgoing toes
b/l.


Pertinent Results:
[**2200-1-5**] 10:01PM   %HbA1c-6.2*
[**2200-1-5**] 06:22PM   GLUCOSE-172* UREA N-53* CREAT-2.2* SODIUM-141
POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-15* ANION GAP-20
[**2200-1-5**] 06:22PM   ALT(SGPT)-12 AST(SGOT)-57* LD(LDH)-421*
CK(CPK)-3347* ALK PHOS-110 TOT BILI-0.6
[**2200-1-5**] 06:22PM   CK-MB-58* MB INDX-1.7 cTropnT-0.66*
[**2200-1-5**] 06:22PM   ALBUMIN-4.0 CALCIUM-9.1 PHOSPHATE-4.1
MAGNESIUM-2.0
[**2200-1-5**] 10:34AM   GLUCOSE-223* LACTATE-2.1* K+-5.0
[**2200-1-5**] 10:32AM URINE  HOURS-RANDOM UREA N-518 CREAT-115
SODIUM-89
[**2200-1-5**] 10:32AM URINE  OSMOLAL-492
[**2200-1-5**] 10:32AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2200-1-5**] 10:32AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2200-1-5**] 10:32AM URINE  BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2200-1-5**] 10:32AM URINE  RBC-0-2 WBC-21-50* BACTERIA-MANY
YEAST-NONE EPI-0 RENAL EPI-0-2
[**2200-1-5**] 10:32AM URINE  GRANULAR-0-2 HYALINE-<1
[**2200-1-5**] 10:15AM   GLUCOSE-247* UREA N-55* CREAT-2.2* SODIUM-137
POTASSIUM-6.7* CHLORIDE-107 TOTAL CO2-15* ANION GAP-22*
[**2200-1-5**] 10:15AM   estGFR-Using this
[**2200-1-5**] 10:15AM   CK(CPK)-1870*
[**2200-1-5**] 10:15AM   CK-MB-36* MB INDX-1.9 cTropnT-0.41*
[**2200-1-5**] 10:15AM   CALCIUM-9.6 PHOSPHATE-4.5 MAGNESIUM-2.4
[**2200-1-5**] 10:15AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2200-1-5**] 10:15AM   WBC-19.5*# RBC-4.26 HGB-12.5 HCT-37.3 MCV-88
MCH-29.3 MCHC-33.4 RDW-13.0
[**2200-1-5**] 10:15AM   NEUTS-82.3* LYMPHS-12.6* MONOS-4.6 EOS-0.2
BASOS-0.2
[**2200-1-5**] 10:15AM   PLT COUNT-229
[**2200-1-5**] 10:15AM   PT-12.7 PTT-20.3* INR(PT)-1.1
.
CT HEAD:
FINDINGS: The study is slightly limited by motion. The loss of
[**Doctor Last Name 352**]-white matter differentiation and hypodensity within the
left insular cortex, anterior left temporal lobe, and the left
frontal lobe is today more conspicuous and increased in size
consistent with an evolving left MCA territorial infarct. There
is no mass effect or shift of normally midline structures. The
ventricles are normal in size and symmetric. There is no
evidence of intracranial hemorrhage. Limited views of the
paranasal sinuses demonstrate mild sphenoid sinus mucosal
thickening. Osseous structures are unremarkable. Cataract
surgical change of the right globe is seen.Right nasogastric
tube is in place.
IMPRESSION: Evolution of enlarged left MCA territorial
infarction with no evidence of intracranial hemorrhage or mass
effect.


Brief Hospital Course:
[**Age over 90 **] year old woman with h/o HTN, hyperlipidemia admitted to MICU
after having been found down with L MCA stroke, NSTEMI, ARF, and
UTI c/b L thigh hematoma.  Hemodynamically stable on admission
but with poor mental status.  She was treated empirically for
UTI with quinolones.  Her MICU course was complicated by atrial
fibrillation with rapid ventricular response.  This eventually
was controlled with metoprolol and amiodarone.  She had been
started on heparin gtt for the NSTEMI and the atrial
fibrillation but this had to be discontinued as the patient
developed a thigh hematoma associated with a ten point decline
in hematocrit.  She was given two units of pRBC with appropriate
rise.  She did also receive lasix for volume overload.
Subsequently she was called out to the floor.  Her mental status
had not improved at this point.  She was unable to take PO's and
was receiving nutrition via NG tube.  Of note, her code status
during her MICU stay was changed by her niece--the next of
[**Doctor First Name **]--to DNR/DNI.   She was stabilized on transfer to the floor
and per disciussion with the patient's niece, palliative care
team, social worker and medical team, the niece conveyed that
the patient would not like any heroic measures.  NGT was
discontinued for pt's comfort.  She received tylenol around the
clock adn morphine for pain control.  She received occasional
Haldol and Zyprexa for agitation.  On [**1-17**] the patient appeared
close to death and decision was made to hold off on transferring
her to an outside care facility. On [**2200-1-17**] the patient expired.

.
# Communication: HCP niece [**Name (NI) **] [**Name (NI) 33931**] [**Telephone/Fax (1) 33932**] (c),
Sister-in-law [**Name (NI) 33933**] [**Name (NI) 33931**] [**Telephone/Fax (1) 33934**]


Medications on Admission:
Clonidine
Metoprolol
Ambien
Lipitor
Prozac
Zyprexa
Nitroglycerin
Senna


Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
PRIMARY:
stroke
SECONDARY
myocardial infarction
urinary tract infection
pneumonia
hypertension
dysphagia


Discharge Condition:
deceased


Discharge Instructions:
expired

Followup Instructions:
deceased
{'Cerebral embolism with cerebral infarction,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Rhabdomyolysis,Atrial fibrillation,Unspecified essential hypertension,Pure hypercholesterolemia,Hemorrhage, unspecified,Anticoagulants causing adverse effects in therapeutic use'}


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 down

PRESENT ILLNESS: [**Age over 90 **]yo Russian woman (was English teacher) with h/o HTN,
hyperlipidemia who presents to the ED after having been found
down and minimally responsive by home health aid this morning;
last seen normal at approximately 10pm last night. Home health
aid reports having found pt. in her bedroom on the floor not
speaking well nor moving well. EMS was called and she was
transferred to [**Hospital1 18**] ED for further evaluation. Further details
surrounding events prior to having been found down are unclear.

MEDICAL HISTORY: 1. Hypertension.
2. Hypercholesterolemia.
3. Depression.
4. Dizziness.
5. Incontinence
6. Glaucoma
7. s/p Right iridectomy

MEDICATION ON ADMISSION: Clonidine
Metoprolol
Ambien
Lipitor
Prozac
Zyprexa
Nitroglycerin
Senna

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: Temp:97.4 BP: 140/60 HR:72 RR:15 O2sat 97% RA
GEN: pleasant, comfortable, NAD
HEENT: Right pupil larger and w/ abnormal shape s/p iridectomy
and unresponsive to light. Left pupil round and responsive to
light, EOMI, anicteric, dry MM, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules
RESP: Rhonchorus anteriorly however appears to be upper airway
sounds transmitting, fine rales bibasilar
CV: RRR, S1 and S2 wnl, no m/r/g appreciated on exam
ABD: nd, +b/s, soft, nt, +hernia just superior to umbilicus,
reducible
EXT: trace-1+ bipedal edema, 1+ DP/PT pulses b/l
SKIN: chest with ?senile purpura
NEURO: Alert, not following commands in English (per neuro note
in ED, not following commands in Russian either). Moving all 4s.
Right biceps with 3.5/5, grip [**3-5**]. Left biceps with 4.5/5, full
grip (although does not grip when instructed to do so). Unable
to assess for sensory deficits. Moving b/l LEs however does not
cooperate with strength exam. 2+DTRs patellar, biceps,
brachioradialis (right sl. more brisk than left). Downgoing toes
b/l.

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Lives at home alone with daily home aide's help. No
etoh/tob/illicits. Born in [**Country 532**] 

### Response:
{'Cerebral embolism with cerebral infarction,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Rhabdomyolysis,Atrial fibrillation,Unspecified essential hypertension,Pure hypercholesterolemia,Hemorrhage, unspecified,Anticoagulants causing adverse effects in therapeutic use'}
