CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is an 87-year-old
female with a past medical history significant for atrial
fibrillation and status post a stroke in [**2185-1-5**], who
presented status post fall from her wheelchair.

MEDICAL HISTORY: 1.  Atrial fibrillation with an ejection fraction of
approximately 20%.
2.  Breast cancer; status post mastectomy in [**2178**].
3.  Colon cancer; status post hemicolectomy in [**2175**].
4.  Status post radiation therapy for a bone lesion in [**2180**].

MEDICATION ON ADMISSION: Celexa, lactulose, atenolol,
lisinopril, digoxin, Coumadin, and Glyburide.

ALLERGIES: SULFA.

PHYSICAL EXAM: 

FAMILY HISTORY: No history of malignancy or coronary artery
disease.

SOCIAL HISTORY: The patient denies alcohol or recent tobacco
use.  She lives with her granddaughter who provides
day-to-day care.
Subendocardial infarction, initial episode of care,Atrial fibrillation,Closed fracture of second cervical vertebra,Urinary tract infection, site not specified,Mitral valve disorders,Hyposmolality and/or hyponatremia,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure
Subendo infarct, initial,Atrial fibrillation,Fx c2 vertebra-closed,Urin tract infection NOS,Mitral valve disorder,Hyposmolality,Food/vomit pneumonitis,Acute respiratry failure
Admission Date:  [**2185-9-27**]       Discharge Date:  [**2185-10-11**]


Service:

                        ADDENDUM

HOSPITAL COURSE:  The patient's INR reached a high of 6.7 at
which time she was reversed with Vitamin K.  Her white blood
cell count continued to be elevated on her antibiotic
regimen.

The patient's neurologic exam remained unchanged.  She
complained of persistent neck pain which was eventually
treated with Oxycodone.

The patient was started on tube feeds.  While on tube feeds,
she developed a mild hypernatremia and was treated with
free-water boluses.  In addition, she appeared dehydrated
with decreased urine output, FeNa less than 1, and elevated
BUN to creatinine ratio.  She was treated with intravenous
fluid hydration.  Her electrolytes normalized.

During the [**Hospital 228**] hospital course, she had several
episodes of atrial fibrillation.  Her beta-blocker was thus
titrated up from 50 b.i.d. to 70 t.i.d. over her hospital
stay.  In addition, the patient was restarted on Coumadin
with close monitoring of her INR, and Heparin was
discontinued.

On [**2185-10-4**], the patient was admitted to the
Medical Intensive Care Unit for worsening respiratory
distress.  At this time, a chest x-ray showed increased
opacities throughout her left lung field.  This was
consistent with either pleural effusion, parenchymal
abnormality or left lower lobe lung collapse.

In the Intensive Care Unit, the patient underwent an
ultrasound with a plan to tap any fluid collection found;
however, no fluid was found.  Results were consistent with a
left lung infiltrate, atelectasis or organized pleural fluid
collection.

A follow-up CT scan was then obtained.  This CT scan revealed
no evidence of pulmonary embolism.  It did show a small left
loculated pleural effusion with associated atelectasis.  It
also showed a collapse of the posterior segment of the left
lower lobe.

The patient's respiratory status improved over the following
few days with aggressive chest physical therapy and
suctioning of airway secretions.

She was transferred back to the Medicine Team on [**2185-10-6**].  On the floor, the patient's respiratory status
continued to improve, and she was weaned off oxygen and had
good oxygen saturation on room air.  The patient also
sustained normal sinus rhythm at this time.

An induced sputum was obtained which showed Methicillin
resistant Staphylococcus aureus; however, this was likely
contaminant due to poor sample with several epithelial cells
and few polys.  The patient however was started on Vancomycin
given her elevated white blood cell count.

In addition, a Plastic Surgery consult was obtained as the
patient developed a sacral decubitus ulcer.  It was the
impression of the Plastic Surgery Team that there was also a
Stage II 6 x 7 cm ulcer with eschar with no fluctuants or
surrounding cellulitis.  They felt that the ulcer was
appropriately addressed with Duoderm and that no further
intervention was needed at the time.

Lastly, the patient has had elevated blood glucose levels
during her hospital stay.  Initially she was on Glyburide at
presentation; however, she was started on Insulin as her
sugars remained elevated.  On discharge, her regimen was 20 U
NPH q.a.m. and 20 U q.p.m.  Her sugars seemed reasonably well
controlled with this regimen.

CONDITION ON DISCHARGE:  Stable.

DISCHARGE STATUS:  To rehabilitation.

DISCHARGE DIAGNOSIS:
1.  C2 fracture.
2.  Status post stroke with residual paralysis.
3.  Sacral decubitus ulcer, Stage II.
4.  Demand ischemia with elevation of CK and troponin.

FOLLOW-UP:  The patient is to follow-up with Neurosurgery and
is to have repeat imaging studies in four weeks.

DISCHARGE MEDICATIONS:  Insulin NPH 20 U q.a.m. and 20 U
q.p.m., Vancomycin 1 g q.12 hours, Morphine Sulfate 1-2 mg IV
q.4 hours p.r.n. pain, Furosemide 20 mg p.o. b.i.d., Docusate
Sodium 100 mg p.o. b.i.d., Warfarin 3 mg p.o. q.h.s., Senna 1
tab p.o. b.i.d. p.r.n., Metoprolol 75 mg p.o. t.i.d.,
Albuterol nebs, [**Last Name (un) 33962**] dermal wound p.r.n., Chlorhexidine
Gluconate 15 ml p.o. t.i.d., Calcium Carbonate 500 mg p.o.
t.i.d., Ascorbic Acid 500 mg p.o. b.i.d., Vitamin D 400 U
p.o. q.d., Zinc Sulfate 220 mg p.o. q.d., Somantadine 20 mg
p.o. b.i.d., Citalopram 20 mg p.o. q.d., Digoxin 0.125 mg
p.o. q.d., Lisinopril 20 mg p.o. q.d., Aspirin 81 mg p.o.
q.d.






Dictated By:[**Last Name (NamePattern1) 50901**]
MEDQUIST36

D:  [**2185-10-11**]  08:47
T:  [**2185-10-11**]  09:11
JOB#:  [**Job Number 50902**]


Admission Date:  [**2185-9-27**]       Discharge Date:  [**2185-10-11**]


Service:  Medicine, [**Location (un) **] Firm

HISTORY OF PRESENT ILLNESS:  The patient is an 87-year-old
female with a past medical history significant for atrial
fibrillation and status post a stroke in [**2185-1-5**], who
presented status post fall from her wheelchair.

The patient is status post a stroke in [**Month (only) 404**].  She
developed bilateral weakness (right greater than left) and
aphagia.  The patient had a prolonged hospital course
complicated by pneumonia and recurrent urinary tract
infections.  She is incontinent of urine and feces and has an
indwelling Foley catheter.  Currently, her left side has
recovered some function from the stroke in [**Month (only) 404**], the
patient is left with residual right-sided paralysis and some
speech difficulties.

On [**2185-9-26**] (on the day prior to admission), the
patient was being wheeled by her granddaughter down a ramp
and fell out of her wheelchair.  She rolled onto her neck.
It was a mild fall; per her granddaughter.  The patient
denies loss of consciousness or a change in mental status.
She did have persistent neck pain following the fall.  She
was taken to [**Hospital3 15174**] where she was noted
to have full range of motion in her neck.  However, she was
transferred to the [**Hospital1 69**] after
a computed tomography scan showed a C2 fracture.

In the Emergency Department, at [**Hospital1 188**], she was noted to have elevated creatine kinase levels
and troponin levels with a troponin level of 1.02 and a CK/MB
level of 19.  She was seen by Cardiology who felt no
intervention was needed at this time.  The patient was
already anticoagulated on Coumadin due to her history of
atrial fibrillation.  She was also on a beta blocker and
aspirin.  In addition, the patient also aspirated in the
ambulance on the way to [**Hospital1 69**].

She underwent a computed tomography scan which showed an
oblique fracture involving the body of C2.  The lamina of C2
on the right was fractured.  A computed tomography scan of
the head showed no acute intracranial hemorrhage of mass
effect.  There was a large left frontal scalpel hematoma.
There were remote old infarctions identified.  There was a
calcified meningioma at the left posterior fossae.

PAST MEDICAL HISTORY:
1.  Atrial fibrillation with an ejection fraction of
approximately 20%.
2.  Breast cancer; status post mastectomy in [**2178**].
3.  Colon cancer; status post hemicolectomy in [**2175**].
4.  Status post radiation therapy for a bone lesion in [**2180**].

MEDICATIONS ON ADMISSION:  Celexa, lactulose, atenolol,
lisinopril, digoxin, Coumadin, and Glyburide.

ALLERGIES:  SULFA.

SOCIAL HISTORY:  The patient denies alcohol or recent tobacco
use.  She lives with her granddaughter who provides
day-to-day care.

FAMILY HISTORY:   No history of malignancy or coronary artery
disease.

PHYSICAL EXAMINATION ON PRESENTATION:  Physical examination
revealed head, eyes, ears, nose, and throat with dry mucous
membranes.  Pupils were equal, round, and reactive to light.
Extraocular movements were intact.  The chest examination
revealed the lungs were clear to auscultation bilaterally.
Cardiovascular examination revealed a regular rate and
rhythm.  No murmurs, rubs, or gallops appreciated on
examination.  The abdomen was obese, soft, nontender, and
nondistended.  Extremity examination revealed no clubbing or
cyanosis.  There was 1+ edema in the legs bilaterally and 1+
edema in the hands bilaterally.  Neurologic examination
revealed the patient was minimally responsive.  Her strength
was [**3-9**] in her right hand and 3+/5 in her left arm and left
leg.  The patient was unable to move her right leg.  Per
granddaughter, this was unchanged from her baseline.

PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's
white blood cell count was 18.6, her hematocrit was 36.9, and
her platelets were 365.  Her prothrombin time was 22.4, her
partial thromboplastin time was 31.4, and her INR was 3.3.
Chemistry-7 revealed her sodium was 142, potassium was 3.8,
chloride was 107, bicarbonate was 20, blood urea nitrogen was
19, creatinine was 0.7, and blood glucose was 247.  Her CK/MB
was 19, MB index was 14.1, and her troponin I was 102.  Her
digoxin level was 0.8.

PERTINENT RADIOLOGY/IMAGING:  A computed tomography of the
head and neck as described above; oblique fracture involving
the body of C2.

A magnetic resonance imaging of the head revealed multiple
old infarctions involving the brain stem, the right cerebral
peduncle, internal capsule on the right side, and the left
occipital lobe.  Possible new infarction in the right
cerebellar hemisphere.

An echocardiogram revealed left ventricular cavity was
dilated, ejection fraction of 20% to 30%, apical hypokinesis,
ascending aorta dilated, moderate aortic regurgitation, and
moderate pulmonary artery hypertension.

CONCISE SUMMARY OF HOSPITAL COURSE:  The patient was admitted
to the Medicine [**Hospital1 **].  She was seen by the Neurosurgery
Service who recommended a hard collar for the patient's C2
fracture.  The patient's family did not want any surgical
intervention to be done to repair her C2 fracture.  It was
unclear whether or not the patient would have been a
candidate for surgery.

The patient was placed in a hard collar which was then
switched to an Aspen hard collar.  The patient was started on
heparin for her elevated creatine kinase and troponin levels.
Warfarin was held.  She was continued on her beta blocker,
ACE inhibitor, and aspirin.  She was also started on
levofloxacin for her history of recent aspiration and her
history of urinary tract infections.  Flagyl was then added
to her regimen.

Over the next several days the patient's cardiac enzymes
trended down; however, her INR rose in the setting of being
started on levofloxacin and Flagyl.  At this time she was not
taking Coumadin.  Her INR reached a high of 6.7; at which
time she was reversed with 10






                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.  [**MD Number(2) 10451**]

Dictated By:[**Last Name (NamePattern1) 50899**]
MEDQUIST36

D:  [**2185-10-11**]  08:15
T:  [**2185-10-11**]  08:22
JOB#:  [**Job Number 50900**]
{'Subendocardial infarction, initial episode of care,Atrial fibrillation,Closed fracture of second cervical vertebra,Urinary tract infection, site not specified,Mitral valve disorders,Hyposmolality and/or hyponatremia,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure'}


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 an 87-year-old
female with a past medical history significant for atrial
fibrillation and status post a stroke in [**2185-1-5**], who
presented status post fall from her wheelchair.

MEDICAL HISTORY: 1.  Atrial fibrillation with an ejection fraction of
approximately 20%.
2.  Breast cancer; status post mastectomy in [**2178**].
3.  Colon cancer; status post hemicolectomy in [**2175**].
4.  Status post radiation therapy for a bone lesion in [**2180**].

MEDICATION ON ADMISSION: Celexa, lactulose, atenolol,
lisinopril, digoxin, Coumadin, and Glyburide.

ALLERGIES: SULFA.

PHYSICAL EXAM: 

FAMILY HISTORY: No history of malignancy or coronary artery
disease.

SOCIAL HISTORY: The patient denies alcohol or recent tobacco
use.  She lives with her granddaughter who provides
day-to-day care. 

### Response:
{'Subendocardial infarction, initial episode of care,Atrial fibrillation,Closed fracture of second cervical vertebra,Urinary tract infection, site not specified,Mitral valve disorders,Hyposmolality and/or hyponatremia,Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure'}
