CHIEF COMPLAINT: unresponsive

PRESENT ILLNESS: EU Critical [**Doctor Last Name **] ([**Numeric Identifier 101896**]) aka Ms. [**Known lastname 71492**]  ([**Numeric Identifier 101897**]) is a
[**Age over 90 **]
year-old woman with a history of a fib (coumadin discontinued),
remote right parietal +/- right cerebellar stroke, and
Waldenstrom's macroglobulinemia who presented following a period
of unresponsiveness.
.
According to reports, the patient was last known well around 4pm
on the day of evaluation.  After enjoying lunch with her family,
she became "unresponsive."  Observers noted right eye deviation
before what sounds like horizontal nystagmus.  EMS was called.
Apparently concerned the abnormal eye movements represented
seizure, the patient was given ativan 2 mg IV x 1.  Blood
glucose
was 118.  To protect her airway, the patient was given succ. and
then intubated at the scene.  She was then transported to the
[**Hospital1 18**] for further evaluation and care.

MEDICAL HISTORY: Atrial fibrillation, no longer on Coumadin
Stroke with left sided deficit
Chronic kidney disease, stage III/IV, baseline Cr 1.5-1.8
Anemia of chronic disease
Systolic congestive heart failure, EF 45%
Waldenstrom Macroglobulinemia

MEDICATION ON ADMISSION: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
hold for loose stools.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAMINATION:
Vitals: T: nr P: 86 R: 18  BP: 148/87 SaO2: 100% intub
General: intubated sedated --> prop held for ten minutes
HEENT: Normocepahlic, atruamatic, no scleral icterus noted.
intubated
Cardiac: irreg irreg rhythm, normal S1 and S2.
Pulmonary: coarse breath sounds to auscultation bilaterally ant.
Abdomen: Round Normoactive bowel sounds.  Soft.  Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted.

FAMILY HISTORY: Not related to her fall.

SOCIAL HISTORY: She lives at home and son is in the house. He is a lawyer. She
has 2 daughters, one in [**Name (NI) 6624**] and one in [**Name (NI) 311**]. No alcohol or
current smoking. She was an Opera singer for more than 30 years
with the [**Location (un) 86**] pops. She played piano before her stroke. She
now uses one hand to play the piano.
Cerebral thrombosis with cerebral infarction,Chronic systolic heart failure,Other chronic pulmonary heart diseases,Hemiplegia, unspecified, affecting unspecified side,Anemia of other chronic disease,Pathologic fracture of vertebrae,Atrial fibrillation,Macroglobulinemia,Chronic kidney disease, Stage III (moderate),Aphasia,Homonymous bilateral field defects,Encounter for palliative care,Do not resuscitate status
Crbl thrmbs w infrct,Chr systolic hrt failure,Chr pulmon heart dis NEC,Unsp hemiplga unspf side,Anemia-other chronic dis,Path fx vertebrae,Atrial fibrillation,Macroglobulinemia,Chr kidney dis stage III,Aphasia,Homonymous hemianopsia,Encountr palliative care,Do not resusctate status
Admission Date:  [**2150-2-9**]              Discharge Date:   [**2150-2-11**]


Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
unresponsive

Major Surgical or Invasive Procedure:
none

History of Present Illness:
EU Critical [**Doctor Last Name **] ([**Numeric Identifier 101896**]) aka Ms. [**Known lastname 71492**]  ([**Numeric Identifier 101897**]) is a
[**Age over 90 **]
year-old woman with a history of a fib (coumadin discontinued),
remote right parietal +/- right cerebellar stroke, and
Waldenstrom's macroglobulinemia who presented following a period
of unresponsiveness.
.
According to reports, the patient was last known well around 4pm
on the day of evaluation.  After enjoying lunch with her family,
she became "unresponsive."  Observers noted right eye deviation
before what sounds like horizontal nystagmus.  EMS was called.
Apparently concerned the abnormal eye movements represented
seizure, the patient was given ativan 2 mg IV x 1.  Blood
glucose
was 118.  To protect her airway, the patient was given succ. and
then intubated at the scene.  She was then transported to the
[**Hospital1 18**] for further evaluation and care.


Past Medical History:
Atrial fibrillation, no longer on Coumadin
Stroke with left sided deficit
Chronic kidney disease, stage III/IV, baseline Cr 1.5-1.8
Anemia of chronic disease
Systolic congestive heart failure, EF 45%
Waldenstrom Macroglobulinemia



Social History:
She lives at home and son is in the house. He is a lawyer. She
has 2 daughters, one in [**Name (NI) 6624**] and one in [**Name (NI) 311**]. No alcohol or
current smoking. She was an Opera singer for more than 30 years
with the [**Location (un) 86**] pops. She played piano before her stroke. She
now uses one hand to play the piano.


Family History:
Not related to her fall.

Physical Exam:
PHYSICAL EXAMINATION:
Vitals: T: nr P: 86 R: 18  BP: 148/87 SaO2: 100% intub
General: intubated sedated --> prop held for ten minutes
HEENT: Normocepahlic, atruamatic, no scleral icterus noted.
intubated
Cardiac: irreg irreg rhythm, normal S1 and S2.
Pulmonary: coarse breath sounds to auscultation bilaterally ant.
Abdomen: Round Normoactive bowel sounds.  Soft.  Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted.

NEUROLOGIC EXAMINATION:

Mental Status:
* Degree of Alertness: does not open eyes to loud voice, sternal
rub

Cranial Nerves:
* I: Olfaction not evaluated.
* II: R 2.5--> 2mm, L 2.25--> 2 cm
* III, IV, VI: gaze conjugate; eyes stay midline with doll's eye
maneuver
* V, VII: corneals intact bilat
* VII: face grossly symmetric
* IX, X: gag intact

Motor:
* Tone: increased in LUE

Strength:
* Left Upper Extremity:  withdraws purposefully from noxious
* Right Upper Extremity: extends into stimulus

* Left Lower Extremity:   withdraws purposefully from noxious
* Right Lower Extremity:  withdraws purposefully from noxious

Reflexes:
* Left:  2+ throughout Biceps, Triceps, Bracheoradialis, brisk
Patellar, 1+ Achilles
* Right: brisk thoughout Biceps, Triceps, Bracheoradialis,
Patellar, 1+ Achilles
* Babinski:mute bilaterally

Sensation:
* intact to noxious in all limbs


Pertinent Results:
[**2150-2-9**] 10:09PM   GLUCOSE-249* UREA N-43* CREAT-1.7* SODIUM-136
POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-21* ANION GAP-24*
[**2150-2-9**] 10:09PM   ALT(SGPT)-14 AST(SGOT)-37 ALK PHOS-60 TOT
BILI-0.9
[**2150-2-9**] 10:09PM   CK-MB-3 cTropnT-<0.01
[**2150-2-9**] 10:09PM   ALBUMIN-3.5 CALCIUM-10.0 PHOSPHATE-3.8
MAGNESIUM-2.4 CHOLEST-119
[**2150-2-9**] 10:09PM   %HbA1c-6.7* eAG-146*
[**2150-2-9**] 10:09PM   TRIGLYCER-62 HDL CHOL-55 CHOL/HDL-2.2
LDL(CALC)-52
[**2150-2-9**] 10:09PM   WBC-7.4 RBC-3.99* HGB-9.6* HCT-30.7* MCV-77*
MCH-24.1* MCHC-31.3 RDW-19.3*
[**2150-2-9**] 10:09PM   PLT COUNT-133*
[**2150-2-9**] 05:58PM URINE  HOURS-RANDOM
[**2150-2-9**] 05:58PM URINE  HOURS-RANDOM
[**2150-2-9**] 05:58PM URINE  GR HOLD-HOLD
[**2150-2-9**] 05:58PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2150-2-9**] 05:58PM   TYPE-ART PO2-393* PCO2-27* PH-7.55* TOTAL
CO2-24 BASE XS-3
[**2150-2-9**] 05:58PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2150-2-9**] 05:58PM URINE  BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2150-2-9**] 05:58PM URINE  RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2150-2-9**] 04:36PM   GLUCOSE-149* LACTATE-2.9* NA+-142 K+-4.0
CL--103 TCO2-26
[**2150-2-9**] 04:35PM   UREA N-39* CREAT-1.6*
[**2150-2-9**] 04:35PM   estGFR-Using this
[**2150-2-9**] 04:35PM   LIPASE-82*
[**2150-2-9**] 04:35PM   CALCIUM-10.3 PHOSPHATE-3.6 MAGNESIUM-2.5
[**2150-2-9**] 04:35PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-2-9**] 04:35PM   WBC-6.1 RBC-3.57* HGB-8.9* HCT-27.2* MCV-76*
MCH-25.0* MCHC-32.8 RDW-20.1*
[**2150-2-9**] 04:35PM   PT-15.4* PTT-24.5 INR(PT)-1.3*
[**2150-2-9**] 04:35PM   PLT COUNT-180
[**2150-2-9**] 04:35PM   PLT COUNT-180
[**2150-2-9**] 04:35PM   FIBRINOGE-212

[**Known lastname **],[**Known firstname **] [**Age over 90 101898**] F  92  [**2058-1-23**]

Radiology Report CTA HEAD W&W/O C & RECONS Study Date of
[**2150-2-9**] 6:34 PM


[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]   [**2150-2-9**] 6:34 PM
CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS; CT BRAIN
PERFUSION   Clip # [**Clip Number (Radiology) 101899**]
Reason: ? cva, basilar thrombosis
Contrast: OPTIRAY Amt: 110



[**Hospital 93**] MEDICAL CONDITION:
   [**Age over 90 **]F w. unresponsiveness, intubated at scene w.
unresponsiveness, h/o CVA. pt is
   receivinb nac and bicarb for kidney protection. please do
perfusion imaging as
   well.
REASON FOR THIS EXAMINATION:
   ? cva, basilar thrombosis
CONTRAINDICATIONS FOR IV CONTRAST:
   None.



Wet Read: JKSd MON [**2150-2-9**] 7:47 PM
1. thrombus of left MCA and ACA with corresponding large infarct
of the
entire left MCA and ACA territory. No mismatch present on
perfusion between
CBV and CBF to suggest a penumbra. basilar artery patent. no
acute hemorrhage.


Final Report
EXAMINATION: CTA head and neck with CT perfusion of the brain.

INDICATION: Unresponsive.

COMPARISON: [**2150-2-9**] non-contrast head CT.

TECHNIQUE: Initially, non-contrast head CT was performed.
Subsequently,
contrast was administered intravenously and serial axial images
through the
head and neck were obtained in the arterial phase. CT perfusion
was also
performed of the brain as per protocol.

FINDINGS:

NON-CONTRAST HEAD CT:
There is a large infarction involving the left MCA and ACA
territories with
loss of [**Doctor Last Name 352**]-white matter differentiation, and diffuse edematous
changes with
effacement of adjacent sulci and of the left lateral ventricle.
In addition,
there is right parietal encephalomalacia, compatible with remote
infarct.
There is no evidence of hemorrhage.

CTA NECK:
The aortic arch has mild calcific arteriosclerosis with no
stenosis of the
great vessel origins. The right brachiocephalic, left common
carotid and left
subclavian have separate origins off the arch.

The bilateral common, external, and cervical right internal
carotid arteries
have regions of minimal calcific arteriosclerosis, but no
flow-limiting
stenosis. The vertebral arteries have no flow-limiting stenosis.
There is
mild calcific arteriosclerosis of the left vertebral artery
origin. The left
vertebral artery is dominant. The proximal left internal carotid
artery is
unremarkable. There is mild tapering of the left high cervical
internal
carotid artery.

CTA HEAD:
There is a thin linear filling defect within the petrous and
remaining
intracranial left internal carotid artery. This extends through
the carotid
siphons, the supraclinoid left carotid. The lumen of the
communicating segment
then quickly tapers with low-density filling defect extending
from the left
lateral wall, and occluding this vessel just proximal to its
bifurcation and
just distal to the left posterior communicating artery origin
which is patent.
The left MCA and ACA are occluded from their origin with
minimal, faint
peripheral filling of M2 and M3 branches.

The right intracranial carotid has mild calcific
arteriosclerosis, with no
evidence of flow-limiting disease. The right anterior
communicating artery
and branches are patent. No anterior communicating artery is
identified.

The posterior circulation is unremarkable.

The examination is otherwise significant for left greater than
right maxillary
sinus mucosal thickening; the left-sided maxillary thickening is
contiguous
with a carious left maxillary premolar. In addition, there is
patchy
opacification of the left mastoid air cells and degenerative
osseous changes.
There is mild right greater than left pleural/parenchymal
pulmonary scarring
and mild mediastinal adenopathy, partially visualized. There are

heterogeneous thyroid nodules with calcifications as well. An
endotracheal
tube terminates in the mid thoracic trachea.An esophageal tube
is partially
visualized.

CT PERFUSION:
There is markedly increased mean transit time and decreased
blood flow and
decreased blood volume within the left MCA and ACA territories,
with no
evidence of significant penumbra.

IMPRESSION:
1. Dissection of the left internal carotid artery at the
craniocervical
junction. The dissection flap extends through the petrous
carotid and carotid
siphon, and leads to occlusion of the left MCA and ACA and
distal left
internal carotid artery just proximal to its bifurcation. It is
difficult to
determine which is the true and false lumen. The left posterior
communicating
artery is patent and arises just proximal to the occlusion.

2. No other flow-limiting stenosis.

3. Associated infarction of the left MCA and ACA territories
with no evidence
of significant penumbra.

4. Chronic right parietal lobe infarct.



Brief Hospital Course:
Ms. [**Known lastname 71492**] is a [**Age over 90 **] year-old woman with a history of a fib
(coumadin discontinued), remote right parietal +/- right
cerebellar stroke, and Waldenstrom's macroglobulinemia who
presented following a period of unresponsiveness and was found
to
have evidence of occlusion of the distal left ICA, left ACA and
MCA with
corresponding regions of stroke on CT/CTA brain.  CTP
demonstrated no
appreciable penumbra in the left MCA and ACA region. Although
the official radiology read of the CTA was left ICA dissection
starting in the left petrous canal and extending to the distal
left ICA as well as the MCA and ACA, given her history of atrial
fibrillation, the Neurology team thought that cardioembolism as
a result of afib was the most probable diagnosis.

The morning following her admission to [**Hospital1 18**], the patient's
situation was discussed with the son. [**Name (NI) **] was told that she had a
devastating stroke that had caused complete ischemia of the left
ACA and MCA territories. This stroke severity is associated with
a very high morbidity and mortality. Even if she survived this
event, she would have global aphasia, be unable to move or feel
the right side of her body, have loss of vision in a right
homonymous hemianopsia pattern. She would require a tracheostomy
and a PEG tube. She would require 24/7 nursing care. He agreed
that she should be DNR. He wanted to keep her intubated until
her family could arrive from Europe to say goodbye to her.

The following day she had difficulty maintaining her pressures
and pressors were initiated.  The following morning her son was
attempted to be notified multiple times.  She went asystolic.
With a DNR order, she was not resusitated and she expired.

Medications on Admission:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
hold for loose stools.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2

times a day): hold for loose stools.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every

8 hours) as needed for pain.
6. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO twice a day.
7. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
Disp:*100 ML(s)* Refills:*2*


Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
stroke

Discharge Condition:
deceased

Discharge Instructions:
deceased

Followup Instructions:
deceased


Completed by:[**2150-2-12**]
{'Cerebral thrombosis with cerebral infarction,Chronic systolic heart failure,Other chronic pulmonary heart diseases,Hemiplegia, unspecified, affecting unspecified side,Anemia of other chronic disease,Pathologic fracture of vertebrae,Atrial fibrillation,Macroglobulinemia,Chronic kidney disease, Stage III (moderate),Aphasia,Homonymous bilateral field defects,Encounter for palliative care,Do not resuscitate status'}


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: EU Critical [**Doctor Last Name **] ([**Numeric Identifier 101896**]) aka Ms. [**Known lastname 71492**]  ([**Numeric Identifier 101897**]) is a
[**Age over 90 **]
year-old woman with a history of a fib (coumadin discontinued),
remote right parietal +/- right cerebellar stroke, and
Waldenstrom's macroglobulinemia who presented following a period
of unresponsiveness.
.
According to reports, the patient was last known well around 4pm
on the day of evaluation.  After enjoying lunch with her family,
she became "unresponsive."  Observers noted right eye deviation
before what sounds like horizontal nystagmus.  EMS was called.
Apparently concerned the abnormal eye movements represented
seizure, the patient was given ativan 2 mg IV x 1.  Blood
glucose
was 118.  To protect her airway, the patient was given succ. and
then intubated at the scene.  She was then transported to the
[**Hospital1 18**] for further evaluation and care.

MEDICAL HISTORY: Atrial fibrillation, no longer on Coumadin
Stroke with left sided deficit
Chronic kidney disease, stage III/IV, baseline Cr 1.5-1.8
Anemia of chronic disease
Systolic congestive heart failure, EF 45%
Waldenstrom Macroglobulinemia

MEDICATION ON ADMISSION: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
hold for loose stools.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAMINATION:
Vitals: T: nr P: 86 R: 18  BP: 148/87 SaO2: 100% intub
General: intubated sedated --> prop held for ten minutes
HEENT: Normocepahlic, atruamatic, no scleral icterus noted.
intubated
Cardiac: irreg irreg rhythm, normal S1 and S2.
Pulmonary: coarse breath sounds to auscultation bilaterally ant.
Abdomen: Round Normoactive bowel sounds.  Soft.  Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted.

FAMILY HISTORY: Not related to her fall.

SOCIAL HISTORY: She lives at home and son is in the house. He is a lawyer. She
has 2 daughters, one in [**Name (NI) 6624**] and one in [**Name (NI) 311**]. No alcohol or
current smoking. She was an Opera singer for more than 30 years
with the [**Location (un) 86**] pops. She played piano before her stroke. She
now uses one hand to play the piano. 

### Response:
{'Cerebral thrombosis with cerebral infarction,Chronic systolic heart failure,Other chronic pulmonary heart diseases,Hemiplegia, unspecified, affecting unspecified side,Anemia of other chronic disease,Pathologic fracture of vertebrae,Atrial fibrillation,Macroglobulinemia,Chronic kidney disease, Stage III (moderate),Aphasia,Homonymous bilateral field defects,Encounter for palliative care,Do not resuscitate status'}
