CHIEF COMPLAINT: Lethargy and not using left arm and not
talking.

PRESENT ILLNESS: Mrs. [**Known lastname 53131**] is a 73 year old
woman with hypertension and atrial fibrillation.  She was
recently an inpatient at [**Hospital3 **] since [**2157-12-13**] following a fall three days prior in which she fractured
the greater tuberosity of her left humerus.  At 5:30 PM on
the day of admission, the physician staff was called to the
patient's bedside as she was slumped in her chair and
unresponsive to sternal rub.  The exact onset was not
witnessed and was unclear, however, at that time she was
noted to be hypotensive to 80/40 with sluggish pupils and a
flaccid left arm.  She received a 500 cc bolus of normal
saline and her pressure came up to 120/60.  She was
transferred to [**Hospital6 256**] for
further evaluation.  Computerized tomography scan done
emergently in the Emergency Room showed a large right middle
cerebral artery infarction with a dense MCA sign suggestive
of occlusion.  She was additionally febrile to 101.6.  In
addition an electrocardiogram which was done showed large ST
elevations in V3 and V4 with deep T wave inversions, also ST
depression with T wave inversions in V5 and V6.  The
Cardiology Team was consulted and initially the patient was
admitted to the Coronary Care Unit given the large myocardial
infarction that was occurring concomitantly with the large
stroke.  However, as it was deemed that the patient would not
be a good cardiac catheterization candidate for intervention
due to the very large size of the right middle cerebral
artery stroke and the risk of hemorrhagic transformation with
the use of heparin or other stronger antiplatelets she was
transferred to the Neurology Intensive Care Unit Service.

MEDICAL HISTORY: 1.  Hypertension; 2.  Atrial
fibrillation;  3.  Bipolar disease; 4.  Congestive heart
failure.

MEDICATION ON ADMISSION: 1.  Ceftriaxone
2.  Cardizem 240 mg p.o. q.d.
3.  Colace
4.  Hydrochlorothiazide 25 mg p.o. q.d.
5.  Lithium 300 mg p.o. q.d.
6.  Digoxin 0.125 mg p.o. q.d.
7.  Lopressor 12.5 mg p.o. q.d.
8.  Multivitamins
9.  Thiamine
10. Folate
11. Ativan
12. Serax for possible alcohol withdrawal

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Not obtained at this time.

SOCIAL HISTORY: Significant alcohol use but unclear what the
quantities are.  She lives with her husband at home and has
been functioning independently and doing cooking and her own
errands.
Acute myocardial infarction of inferolateral wall, initial episode of care,Cerebral artery occlusion, unspecified with cerebral infarction,Atrial fibrillation,Congestive heart failure, unspecified,Pulmonary collapse,Unspecified pleural effusion,Mitral valve disorders,Diseases of tricuspid valve
AMI inferolateral, init,Crbl art ocl NOS w infrc,Atrial fibrillation,CHF NOS,Pulmonary collapse,Pleural effusion NOS,Mitral valve disorder,Tricuspid valve disease
Admission Date:  [**2157-12-19**]       Discharge Date:  [**2157-12-30**]

Date of Birth:   [**2084-4-24**]       Sex:  F

Service:  Neurology

CHIEF COMPLAINT:  Lethargy and not using left arm and not
talking.

HISTORY OF PRESENT ILLNESS:  Mrs. [**Known lastname 53131**] is a 73 year old
woman with hypertension and atrial fibrillation.  She was
recently an inpatient at [**Hospital3 **] since [**2157-12-13**] following a fall three days prior in which she fractured
the greater tuberosity of her left humerus.  At 5:30 PM on
the day of admission, the physician staff was called to the
patient's bedside as she was slumped in her chair and
unresponsive to sternal rub.  The exact onset was not
witnessed and was unclear, however, at that time she was
noted to be hypotensive to 80/40 with sluggish pupils and a
flaccid left arm.  She received a 500 cc bolus of normal
saline and her pressure came up to 120/60.  She was
transferred to [**Hospital6 256**] for
further evaluation.  Computerized tomography scan done
emergently in the Emergency Room showed a large right middle
cerebral artery infarction with a dense MCA sign suggestive
of occlusion.  She was additionally febrile to 101.6.  In
addition an electrocardiogram which was done showed large ST
elevations in V3 and V4 with deep T wave inversions, also ST
depression with T wave inversions in V5 and V6.  The
Cardiology Team was consulted and initially the patient was
admitted to the Coronary Care Unit given the large myocardial
infarction that was occurring concomitantly with the large
stroke.  However, as it was deemed that the patient would not
be a good cardiac catheterization candidate for intervention
due to the very large size of the right middle cerebral
artery stroke and the risk of hemorrhagic transformation with
the use of heparin or other stronger antiplatelets she was
transferred to the Neurology Intensive Care Unit Service.

PAST MEDICAL HISTORY:  1.  Hypertension; 2.  Atrial
fibrillation;  3.  Bipolar disease; 4.  Congestive heart
failure.

ALLERGIES:  No known drug allergies.

MEDICATIONS ON ADMISSION:
1.  Ceftriaxone
2.  Cardizem 240 mg p.o. q.d.
3.  Colace
4.  Hydrochlorothiazide 25 mg p.o. q.d.
5.  Lithium 300 mg p.o. q.d.
6.  Digoxin 0.125 mg p.o. q.d.
7.  Lopressor 12.5 mg p.o. q.d.
8.  Multivitamins
9.  Thiamine
10. Folate
11. Ativan
12. Serax for possible alcohol withdrawal

SOCIAL HISTORY:  Significant alcohol use but unclear what the
quantities are.  She lives with her husband at home and has
been functioning independently and doing cooking and her own
errands.

FAMILY HISTORY:  Not obtained at this time.

PHYSICAL EXAMINATION:  On arrival temperature was 101.6,
blood pressure 116/44, pulse 74, respirations 26.  In general
she is lying in bed and looking to the right.  Her head is
normocephalic and atraumatic.  The sclera are nonicteric.
The mucous membranes are moist.  Neck is supple.  There is no
lymphadenopathy.  There are no carotid bruits.
Cardiovascular examination was irregular with S1 and S2.  The
lungs were initially clear to auscultation bilaterally.  The
abdomen was soft, nontender.  The extremities showed no edema
and distal pulses were intact in all four extremities.  On
neurological examination her eyes were opened and she
followed visually after painful stimulus.  There was no
following of any commands and there was no spontaneous speech
or sound.  She did not track faces when instructed to do so.
Cranial nerves revealed that the discs were flat and sharp
with no hemorrhage.  There was no blink to threat on either
side.  Pupils were 3 to 2 mm, reactive bilaterally to light.
The extraocular movements were difficult to assess but she
was able to cross midline after painful stimulus was
involved.  There was a left facial droop.  The left corneal
reflex seemed less robust.  The gag was present, and the
tongue was midline.  Motor examination revealed normal bulk
without adventitious movements.  There was a dense left
hemiplegia with the left arm, much worse than the leg.  The
left arm was initially able to withdraw weakly and the left
leg was externally rotated and withdrew more weakly than the
right leg to pain.  The right side moved spontaneously and
with good strength.  Sensory examination revealed that she
responded to pain in all four extremities with a grimace or
withdrawal.  Reflexes:  The left was 2+ throughout the
triceps, biceps, brachioradialis, patellae but absent
Achilles.  The right side revealed 3+ reflexes in the upper
extremities, 2+ patella and again 0 at the Achilles.  The
toes were downgoing on the left and mute on the right.

LABORATORY DATA:  Upon admission laboratory data were notable
for white count of 23.9, hematocrit was 46.3,  The
coagulation studies were normal.  The chem-7 was normal.  The
electrocardiogram was as mentioned before.  Computerized
tomography scan of the head showed again a right dense MCA
sign with a large hypodensity completing the entire right
middle cerebral artery territory.  There was a very little
[**Doctor Last Name 352**]-white distinction throughout the right MCA territory.

HOSPITAL COURSE:  As mentioned earlier, Ms [**Known lastname 53131**] was
initially admitted to Coronary Care Unit and then transferred
to Neurology Intensive Care Unit for further care.  She was
intubated for airway protection and extubated shortly
thereafter.  She did have respiratory distress after
extubation and a chest x-ray did reveal a total left lung
collapse with intermittent re-expansion of the left upper
lobe.  This was possibly due to blockage of aspiration event
and she was initially started on Levofloxacin and Flagyl was
added on and initiation of this treatment began on [**2157-12-19**].  After extubation she was able to be supported by
supplemental oxygen and the pulmonary team was consulted.
Although they did recommend deep suctioning and chest
computerized tomography scan they felt that bronchoscopy
might give her the best chance for possibly clearing the
blockage and the airways.

An extensive discussion with the family was had regarding the
possibility that she would need to be intubated for the
bronchoscopy and it is not clear whether she would be
extubatable immediately after that.  The son was made health
care proxy and after discussion he and his family felt that
the patient would not want to be intubated again and this
procedure was postponed.  She was stable on supplemental
oxygen, namely nasal cannula and was transferred to the floor
on [**2157-12-25**].  Further studies done in the interim
included a carotid ultrasound which showed no diastolic flow
in the right internal carotid artery.  An echocardiogram was
done which was suboptimal quality but did show depressed
systolic function and moderate mitral regurgitation and
tricuspid regurgitation as well.  In addition a plain film of
her left humerus was taken because of a suspected fall after
the stroke and it did seem to reveal a small fracture at the
region of the greater tuberosity.

On the floor she was stable on supplemental oxygen and the
nasogastric was inserted for nutrition and administration of
medication.  Due to repeated agitation though the patient
discontinued the nasogastric tube multiple times and the
swallowing team assessed her at bedside and recommended
percutaneous endoscopic gastrostomy tube to reliably give her
enough caloric intake to sustain her body weight.  She was
kept NPO except for finally administration of medication
which they did finally say that she could take crushed and
pureed foods.  About three hospital days prior to discharge
the patient went to bronchoscopy after it was determined that
the procedure could now be done given her more stable
respiratory status without need for intubation.  However, the
patient did become tachycardiac and was unable to tolerate
the procedure.  She did report some chest pain earlier that
morning and she again underwent a rule-out myocardial
infarction with cardiac enzymes.  Her electrocardiogram
remained about the same, but was notable for atrial
fibrillation with a rapid left ventricular response.  Her
troponins remained elevated at 0.88 but never quite as high
as the 2.8 that she had earlier on admission.  Her creatinine
kinase were roughly flat, in the 40s.  She was rate
controlled with intravenous Metoprolol and she had a chest
x-ray which did show some moderate vascular engorgement in
addition to the left lung collapse with at this point some
re-expansion of the left upper lobe.  There was again seen a
left-sided pleural effusion which was related to collapse of
lung which had been seen prior.  She was given 20 mg of
intravenous Lasix and her rate was controlled with
intravenous beta blockers.  She seemed to improve
significantly with this and was back to requiring only
supplemental oxygen by nasal cannula.  It should be noted
that an arterial blood gases during that respiratory distress
event revealed a gas of 7.44 with a pO2 of 78 and carbon
dioxide of 35, this was on 35% facemask and 3 liters of nasal
cannula.  After that event she had no further events of
respiratory distress and was able to be maintained on 2 to 3
liters of nasal cannula with satisfactory oxygen saturations.
She was, however, maintained on a stable dose of Metoprolol
as well as short-acting Isosorbide mononitrate.  She was
discontinued off Digoxin after a reconsult to Cardiology
recommended that this be discontinued in the event that this
may innocently inadvertently convert her rhythm to normal
sinus rhythm with possible showering of cardioemboli causing
her to have further strokes.  Because of the concern of
hemorrhagic transformation she was maintained on a baby
Aspirin and increased to a full Aspirin a few days prior to
discharge.  At this point she may be eligible for Coumadin
therapy to prevent further stroke.  However, after further
discussion the family, although cardiac intervention might be
called for given her coronary artery disease and ST elevation
myocardial infarction, they felt that the patient would not
want coronary catheterization and also would not want an
invasive procedure such as placement of percutaneous
endoscopic gastrostomy tube for feeding and nutrition
purposes.  Therefore, they decided that they would allow the
patient to eat and take her medicines by mouth and they did
wish that she continue her medicines as well as antibiotics
for the pneumonia and to be discharged to a facility near
their home in [**Doctor Last Name **].  It was their understanding that
her prognosis was fairly poor given her heart failure, acute
myocardial infarction with lung collapse and unlikely
recovery of motor function of that left side.

On discharge, the patient's speech was fluent but not
prolific.  She was alert, not oriented.  Her left side still
remained flaccid with the arms being more weak than the legs.
She was able to take p.o. nectar-thickened liquids without
choking or any other difficulties, and she did display a good
appetite for puddings and custards.

DISCHARGE DIAGNOSIS:
1.  Right middle cerebral artery infarction.
2.  Atrial fibrillation.
3.  ST elevation and myocardial infarction.
4.  Heart failure with significant severe mitral
regurgitation, tricuspid regurgitation with pulmonary artery
hypertension and depressed systolic function approximately 50
to 55% with regurgitant flow seen by echocardiogram done on
[**2157-12-27**].
5.  Aspiration pneumonia being treated with Levofloxacin and
Flagyl.
6.  Yeast urinary tract infection being treated with
Fluconazole.
7.  Bipolar disorder.

DISCHARGE STATUS:  To nursing home or hospice.

CONDITION ON DISCHARGE:  Fair.

DISCHARGE MEDICATIONS:
1.  Isosorbide mononitrate 10 mg p.o. b.i.d.
2.  Metoprolol 25 mg p.o. t.i.d.
2.  Aspirin 325 mg p.o. q.d.
3.  Metronidazole 500 mg p.o. t.i.d. to end on [**2158-1-3**].
4.  Levofloxacin 500 mg p.o. q.d. to end on [**2158-1-3**].
5.  Fluconazole 200 mg p.o. q.d. to end on [**2158-1-6**].
6.  Morphine Sulfate 1 mg intravenously q. 4 hours prn pain
or dyspnea.
7.  Ipratropium nebulizers, one nebulizer inhaled q. 6 hours
prn shortness of breath.
8.  Albuterol nebulizers, one nebulizer, inhaled q. 6 hours
prn dyspnea.
9.  Albuterol/Ipratropium 1 to 2 puffs inhaled q. 6 hours
10. Docusate 100 mg p.o. b.i.d.
11. Atorvastatin 10 mg p.o. q.d.
12. Heparin 5000 units subcutaneous q. 12 hours.
13. Bisacodyl 10 mg p.o./p.r. q.d. prn constipation
14. Senna one tablet p.o. b.i.d. prn constipation

DIET:  Pureed solids with nectar-prethickened liquid with
foods, pudding to be sent six times a day.

FOLLOW UP PLANS:  The patient's primary care physician, [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Name (STitle) **] was contact[**Name (NI) **] and he was made aware of the events.
He was made aware also of the Do-Not-Resuscitate/
Do-Not-Intubate status and also the decision of the family
not to pursue any further intervention such as cardiac
catheterization or feeding tube.  At this point the patient
will discontinue her heart failure medications and
antibiotics with the understanding of the family that these
may help prevent her from being severe respiratory distress.
They will contact their primary care physician for any
further questions related to her care or with the physician
who will be in charge of her care at the nursing home.



                            [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 5930**] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 6125**]

Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36

D:  [**2157-12-29**]  22:04
T:  [**2157-12-29**]  22:39
JOB#:  [**Job Number 53132**]
{'Acute myocardial infarction of inferolateral wall, initial episode of care,Cerebral artery occlusion, unspecified with cerebral infarction,Atrial fibrillation,Congestive heart failure, unspecified,Pulmonary collapse,Unspecified pleural effusion,Mitral valve disorders,Diseases of tricuspid valve'}


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: Lethargy and not using left arm and not
talking.

PRESENT ILLNESS: Mrs. [**Known lastname 53131**] is a 73 year old
woman with hypertension and atrial fibrillation.  She was
recently an inpatient at [**Hospital3 **] since [**2157-12-13**] following a fall three days prior in which she fractured
the greater tuberosity of her left humerus.  At 5:30 PM on
the day of admission, the physician staff was called to the
patient's bedside as she was slumped in her chair and
unresponsive to sternal rub.  The exact onset was not
witnessed and was unclear, however, at that time she was
noted to be hypotensive to 80/40 with sluggish pupils and a
flaccid left arm.  She received a 500 cc bolus of normal
saline and her pressure came up to 120/60.  She was
transferred to [**Hospital6 256**] for
further evaluation.  Computerized tomography scan done
emergently in the Emergency Room showed a large right middle
cerebral artery infarction with a dense MCA sign suggestive
of occlusion.  She was additionally febrile to 101.6.  In
addition an electrocardiogram which was done showed large ST
elevations in V3 and V4 with deep T wave inversions, also ST
depression with T wave inversions in V5 and V6.  The
Cardiology Team was consulted and initially the patient was
admitted to the Coronary Care Unit given the large myocardial
infarction that was occurring concomitantly with the large
stroke.  However, as it was deemed that the patient would not
be a good cardiac catheterization candidate for intervention
due to the very large size of the right middle cerebral
artery stroke and the risk of hemorrhagic transformation with
the use of heparin or other stronger antiplatelets she was
transferred to the Neurology Intensive Care Unit Service.

MEDICAL HISTORY: 1.  Hypertension; 2.  Atrial
fibrillation;  3.  Bipolar disease; 4.  Congestive heart
failure.

MEDICATION ON ADMISSION: 1.  Ceftriaxone
2.  Cardizem 240 mg p.o. q.d.
3.  Colace
4.  Hydrochlorothiazide 25 mg p.o. q.d.
5.  Lithium 300 mg p.o. q.d.
6.  Digoxin 0.125 mg p.o. q.d.
7.  Lopressor 12.5 mg p.o. q.d.
8.  Multivitamins
9.  Thiamine
10. Folate
11. Ativan
12. Serax for possible alcohol withdrawal

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: Not obtained at this time.

SOCIAL HISTORY: Significant alcohol use but unclear what the
quantities are.  She lives with her husband at home and has
been functioning independently and doing cooking and her own
errands. 

### Response:
{'Acute myocardial infarction of inferolateral wall, initial episode of care,Cerebral artery occlusion, unspecified with cerebral infarction,Atrial fibrillation,Congestive heart failure, unspecified,Pulmonary collapse,Unspecified pleural effusion,Mitral valve disorders,Diseases of tricuspid valve'}
