CHIEF COMPLAINT: Right sided weakness.

PRESENT ILLNESS: The pt. is a 87 year-old female with a history of atrial
fibrillation on warfarin, hypertension, hyperlipidemia, and CHF
who presented to an OSH with acute onset right hemiparesis. The
patient is unable to give a history and history per husband.
The patient was in her usual state of health until around 7 am
on the morning of admission when she was noted to be slumping to
the right, was lethargic and not verbal. Her right arm and leg
appeared weak per her husband. She was taken to [**Hospital3 628**]
ED by EMS and was found to be hypertensive with systolic blood
pressure in the 200-220 mmHg range, to have a flaccid right
hemiparesis, and a large territory left MCA stroke on CT scan
(image not available). She was treated with aspirin and
transferred to [**Hospital1 18**] for further evaluation and care.

MEDICAL HISTORY: -hypertension
-atrial fibrillation
-hyperlipidemia
-CHF, EF unknown

MEDICATION ON ADMISSION: -lipitor
-lasix
-lisinopril
-digoxin
-toprol
-warfarin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: Tm: 100.8F Tc: 99.2F P: 73 (67-77) R: 19 BP: 189/79
(148-216/45-120) SaO2: 95% 4L NC I/O: 750/580/12h
General: Lying in bed with eyes closed, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
OP
Neck: supple, no JVD, carotid bruit appreciated on left
Pulmonary: Lungs with decreased breath sounds at bases
bilaterally
Cardiac: irregularly irregular rhythm, S1S2, no murmur
appreciated
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 1+ radial, DP and PT pulses
b/l.
Skin: no rashes or lesions noted.

FAMILY HISTORY: -unknown

SOCIAL HISTORY: -the pt lives with husband
-no recent tobacco use, per husband drinks [**2-3**] alcoholic
beverages/day
-is ambulatory at baseline
Cerebral embolism with cerebral infarction,Acute respiratory failure,Pneumonitis due to inhalation of oils and essences,Congestive heart failure, unspecified,Atrial fibrillation,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Hemiplegia, unspecified, affecting unspecified side,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Encounter for palliative care,Disorders of magnesium metabolism
Crbl emblsm w infrct,Acute respiratry failure,Oil/essence pneumonitis,CHF NOS,Atrial fibrillation,Urin tract infection NOS,Hyperosmolality,Unsp hemiplga unspf side,Hypertension NOS,Hyperlipidemia NEC/NOS,Encountr palliative care,Dis magnesium metabolism
Admission Date:  [**2115-8-28**]              Discharge Date:   [**2115-9-7**]


Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Right sided weakness.

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
The pt. is a 87 year-old female with a history of atrial
fibrillation on warfarin, hypertension, hyperlipidemia, and CHF
who presented to an OSH with acute onset right hemiparesis. The
patient is unable to give a history and history per husband.
The patient was in her usual state of health until around 7 am
on the morning of admission when she was noted to be slumping to
the right, was lethargic and not verbal. Her right arm and leg
appeared weak per her husband. She was taken to [**Hospital3 628**]
ED by EMS and was found to be hypertensive with systolic blood
pressure in the 200-220 mmHg range, to have a flaccid right
hemiparesis, and a large territory left MCA stroke on CT scan
(image not available). She was treated with aspirin and
transferred to [**Hospital1 18**] for further evaluation and care.

In the [**Hospital1 18**] ED, the pt was placed on a labetalol drip for
persistently elevated blood pressure into the 250's systolic.
She was therefore admitted to the ICU overnight where her
neurologic symptoms remained static.  Her blood pressure
decreased into the 180's systolic off labetalol gtt (she did
require the drip for approx. 15min [**Name8 (MD) **] RN for BP of 210mmHg
systolic).

At the time of my encounter, the pt. was not responding to the
examiner's inquiries and not following commands.

ROS: Unremarkable per admission note. Unable to elicit review of
systems this am.

Past Medical History:
-hypertension
-atrial fibrillation
-hyperlipidemia
-CHF, EF unknown



Social History:
-the pt lives with husband
-no recent tobacco use, per husband drinks [**2-3**] alcoholic
beverages/day
-is ambulatory at baseline



Family History:
-unknown

Physical Exam:
Vitals: Tm: 100.8F Tc: 99.2F P: 73 (67-77) R: 19 BP: 189/79
(148-216/45-120) SaO2: 95% 4L NC I/O: 750/580/12h
General: Lying in bed with eyes closed, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
OP
Neck: supple, no JVD, carotid bruit appreciated on left
Pulmonary: Lungs with decreased breath sounds at bases
bilaterally
Cardiac: irregularly irregular rhythm, S1S2, no murmur
appreciated
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 1+ radial, DP and PT pulses
b/l.
Skin: no rashes or lesions noted.

Neurologic:
-mental status: Pt. was lying in bed with eyes closed.  Opened
eyes to voice transiently, opened eyes to sternal rub.  Did not
follow commands.

-cranial nerves:  PERRL 3 to 2mm and sluggish.  Pt did not
appear to respond to threat in the right visual field.  Left
gaze preference.  Vestibuloocular reflex intact. Facial droop on
right.

-motor: normal bulk throughout. Tone flaccid on right, normal on
left. No adventitious movements noted.  Pt would move left arm
and leg spontaneously and would withdraw from pain.  Only weak
arm flexion in response to pain in right arm.  No movement noted
in right leg.

-sensory: Pt withdrew from painful stimuli on left and grimaced
to painful stimuli on right.

-DTRs: 3+ biceps, triceps, brachioradialis, patellar and 1+
ankle jerks bilaterally. Plantar response was extensor
bilaterally.
-grasp reflex elicited on left.

Pertinent Results:
Laboratory Data on admission:
[**2115-8-28**] 12:35PM BLOOD WBC-13.9* RBC-4.44 Hgb-14.9 Hct-43.0
MCV-97 MCH-33.6* MCHC-34.7 RDW-11.8 Plt Ct-260
[**2115-8-28**] 12:35PM BLOOD Neuts-91.2* Lymphs-7.0* Monos-1.7*
Eos-0.1 Baso-0.1
[**2115-8-28**] 12:35PM BLOOD PT-15.0* PTT-23.3 INR(PT)-1.5
[**2115-8-28**] 12:35PM BLOOD Glucose-166* UreaN-27* Creat-1.1 Na-144
K-4.4 Cl-104 HCO3-27 AnGap-17
[**2115-8-28**] 10:40PM BLOOD Calcium-9.3 Phos-3.3 Mg-2.0
.
Laboratory data on transfer to floor:
[**2115-8-30**] 07:05AM BLOOD WBC-19.9* RBC-3.40* Hgb-11.6* Hct-33.8*
MCV-100* MCH-34.0* MCHC-34.2 RDW-11.6 Plt Ct-178
[**2115-8-30**] 07:05AM BLOOD Plt Ct-178
[**2115-8-30**] 03:00PM BLOOD Glucose-136* UreaN-28* Creat-1.0 Na-148*
K-3.1* Cl-112* HCO3-27 AnGap-12
[**2115-8-28**] 10:40PM BLOOD CK-MB-NotDone cTropnT-0.06* proBNP-[**Numeric Identifier 63929**]*
[**2115-8-30**] 03:00PM BLOOD Calcium-9.0 Phos-2.8 Mg-2.9*
.
Radiologic Data:
CT HEAD WITHOUT IV CONTRAST: There is a large region of edema
involving the left frontal, parietal, and temporal lobes, with
loss of the [**Doctor Last Name 352**]-white differentiation. This is consistent with
an evolving left middle cerebral artery distribution infarct.
The cortex is involved and there is effacement of the sulci in
this area. There is an old right middle cerebral artery
distribution infarct. There is no evidence of intracranial
hemorrhage.
FINDINGS: Note is made of multiple areas of high signal
intensity on T2-
weighted images and FLAIR, representing chronic small vessel
ischemia. Note is made of multiple small areas of cerebellar
lacunes. No evidence of acute hemorrhage noted.
.
CXR: ?CHF vs. interstitial lung disease. No evidence for PNA.


Brief Hospital Course:
The patient is an 87 year-old female with atrial fibrillation,
hypertension, hyperlipidemia who presented with lethargy and
right sided weakness. She had eye and head deviation to the left
and a dense flaccid hemiplegia on the right. Imaging was
remarkable for a large L-MCA stroke which is consistent with the
physical findings on neurologic examination. The etiology is
likely cardioembolic given history of atrial fibrillation on
sub-therapeutic dose of warfarin. Given the presence of a bruit
and vascular risk factors, artery-to-artery embolism is also
possible.
.
Neuro:
The patient had a R-hemiparesis and was not able to swallow. The
exam remained stable. The patient would repond to vocal cues but
was not able to follow any commands.
.
Cardiovascular:
She ruled out for myocardial infarction. Telemetry was
remarkable for atrial fibrillation and she had pulmonary edema
secondary to heart failure. Her rate was controled with high
doses of metoprolol.
.
Pulmonary:
The patient required supplemental oxygen and could not be weaned
off. CXR showed pulmonary edema, for which the patient received
lasix PRN. She could not be aggressively diuresed given a
significant hypernatremia. A likely aspiration pneumonia added
to her respiratory failure.
.
Infectious disease:
The patient was treated for an aspiration pneumonia with
levaquin and flagyl. Levaquin also covered a UTI. Although she
remained afebrile, her WBC count continued to be elevated and
she continued to deteriorate.
.
FEN:
The patient developed electrolyte imbalances including
hypokalemia, hypomagnesia and, most significantly, a severe
hypernatremia. Potassium and Magnesium were repleted and sodium
was corrected slowly by free H2O boluses via the NGT.
The patient was started on tube feeds as she was not able to
swallow. The feeds increased her respiraty excretions and had to
be held intermittently. After discussion with GI, palliative
care, priest, and family it was decided not to proceed with PEG
tube placement.
.
.
Ms. [**Known lastname **] condition continued to deteriorate and Internal
Medicine was consulted for advise regarding her multiple medical
problems. At that point, palliative care was consulted and a
family meeting, including a priest, was scheduled. It was
decided on [**9-6**]/5 to make Ms. [**Known lastname **] [**Last Name (Titles) **] and withdraw any
invasive tests or aggressive treatments. She was given morphine
and expired in the morning of [**9-7**]/5 with the family present.



Medications on Admission:
-lipitor
-lasix
-lisinopril
-digoxin
-toprol
-warfarin


Discharge Medications:
-

Discharge Disposition:
Expired

Discharge Diagnosis:
patient expired 8/6/5:
1. respiratory failure
2. pneumonia
3. stroke
4. atrial fibrillation with rapid ventricular response
5. chronic heart failure

Discharge Condition:
patient expired

Discharge Instructions:
patient expired

Followup Instructions:
patient expired

                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

Completed by:[**2115-9-9**]
{'Cerebral embolism with cerebral infarction,Acute respiratory failure,Pneumonitis due to inhalation of oils and essences,Congestive heart failure, unspecified,Atrial fibrillation,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Hemiplegia, unspecified, affecting unspecified side,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Encounter for palliative care,Disorders of magnesium metabolism'}


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: Right sided weakness.

PRESENT ILLNESS: The pt. is a 87 year-old female with a history of atrial
fibrillation on warfarin, hypertension, hyperlipidemia, and CHF
who presented to an OSH with acute onset right hemiparesis. The
patient is unable to give a history and history per husband.
The patient was in her usual state of health until around 7 am
on the morning of admission when she was noted to be slumping to
the right, was lethargic and not verbal. Her right arm and leg
appeared weak per her husband. She was taken to [**Hospital3 628**]
ED by EMS and was found to be hypertensive with systolic blood
pressure in the 200-220 mmHg range, to have a flaccid right
hemiparesis, and a large territory left MCA stroke on CT scan
(image not available). She was treated with aspirin and
transferred to [**Hospital1 18**] for further evaluation and care.

MEDICAL HISTORY: -hypertension
-atrial fibrillation
-hyperlipidemia
-CHF, EF unknown

MEDICATION ON ADMISSION: -lipitor
-lasix
-lisinopril
-digoxin
-toprol
-warfarin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: Tm: 100.8F Tc: 99.2F P: 73 (67-77) R: 19 BP: 189/79
(148-216/45-120) SaO2: 95% 4L NC I/O: 750/580/12h
General: Lying in bed with eyes closed, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
OP
Neck: supple, no JVD, carotid bruit appreciated on left
Pulmonary: Lungs with decreased breath sounds at bases
bilaterally
Cardiac: irregularly irregular rhythm, S1S2, no murmur
appreciated
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 1+ radial, DP and PT pulses
b/l.
Skin: no rashes or lesions noted.

FAMILY HISTORY: -unknown

SOCIAL HISTORY: -the pt lives with husband
-no recent tobacco use, per husband drinks [**2-3**] alcoholic
beverages/day
-is ambulatory at baseline 

### Response:
{'Cerebral embolism with cerebral infarction,Acute respiratory failure,Pneumonitis due to inhalation of oils and essences,Congestive heart failure, unspecified,Atrial fibrillation,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Hemiplegia, unspecified, affecting unspecified side,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Encounter for palliative care,Disorders of magnesium metabolism'}
