CHIEF COMPLAINT: Chief Complaint: Mental status changes and hypoxia, found down

PRESENT ILLNESS: Patient is a 62 yo female with PMHx sig. for HTN, CHF, asthma
who was brought to OSH after being found down. She lives with
her niece, the niece's daughter and husband. She had been
complaining of an URI infection for the last 1.5 weeks with
symptoms of fatigue and cough. No fevers or other complaints as
far as the niece knows. She was bedridden for the first 3 days
or so but had been improving, enough to clean the house
yesterday. Overnight, her niece had heard a thump and found the
patient on the floor, with her bifold closet off the runner. She
was complaining of L arm pain. She was also confused, repeatedly
calling for help and asking about her dead dog. She has had her
flu and H1N1 shots this year.
.
The patient was taken to [**Hospital 8125**] Hospital. There, she became
increasingly altered without focal neuro deficits. She had
multiple imaging studies. Head and neck CT scans were negative.
X-rays showed a L humeral fracture. Her labs, inc. chemistries
and cardiac enzymes, were normal except for Cr of 1.3. She
received 1 mg of ativan, 2 mg of morphine, and ???dilantin. On
the way over in the ambulance, pt had reportedly son[**Name (NI) 7884**]
respirations with desaturations, requiring bagging in the
ambulance.
.
In the ED, she only responded to painful stimuli, no gag reflex.
Mental status did not improve with 0.4 mg of Narcan. She was
intubated for airway protection and ventilatory support. She had
some frank blood in the ETT, though the intubation was not
difficult. Labs were sig. for neg serum tox screen, mild
leukocytosis of 11.7, Cr 1.2. Lactate was 1.4. 1st of cardiac
enzymes were neg. CXR and CTA showed pneumonia, no PE. CT head
showed no acute process. X-rays showed comminuted fracture of
the left proximal humerus fx, no hip fractures. ED failed
multiple LP attempts. Patient was acyclovir, vanc, CTX,
levaquin, and flagyl. VS on transfer were: 97.2, 102, 108/67,
20, 96% on 40% FiO2, AC 500 x 20.
.
ROS: Unable to obtain.

MEDICAL HISTORY: HTN
CHF
Asthma

MEDICATION ON ADMISSION: Atenolol 25 mg daily
Verapamil SR 240 mg daily
Triamterene 37.5 and HCTZ 25 daily
ASA 325 mg daily
Montelukast 10 mg daily
Advair 500/50
Piroxicam 1 cap daily
KCl 20 meq daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: BP: P: R: 18 O2:
General: Sedated on 15 of versed.
HEENT: PERRL, sclera anicteric, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds anteriorly
CV: Regular rate and rhythm, normal S1 + S2, soft systolic
murmur at USBs
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ pulses, no edema

FAMILY HISTORY: Heart disease.

SOCIAL HISTORY: Pt lives with her niece's family. She used to work for the
state, caring for the mentally challenged. She is active at
home, helping with chores and going to the gym. She is a remote
smoker, no etoh, no recreational drugs.
Pneumonia, organism unspecified,Acute respiratory failure,Chronic systolic heart failure,Encephalopathy, unspecified,Closed fracture of unspecified part of upper end of humerus,Unspecified fall,Asthma, unspecified type, unspecified,Unspecified essential hypertension
Pneumonia, organism NOS,Acute respiratry failure,Chr systolic hrt failure,Encephalopathy NOS,Fx up end humerus NOS-cl,Fall NOS,Asthma NOS,Hypertension NOS
Admission Date:  [**2169-2-23**]              Discharge Date:   [**2169-3-1**]

Date of Birth:  [**2107-2-18**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Chief Complaint: Mental status changes and hypoxia, found down

Major Surgical or Invasive Procedure:
Bronchoscopy x 2

History of Present Illness:
Patient is a 62 yo female with PMHx sig. for HTN, CHF, asthma
who was brought to OSH after being found down. She lives with
her niece, the niece's daughter and husband. She had been
complaining of an URI infection for the last 1.5 weeks with
symptoms of fatigue and cough. No fevers or other complaints as
far as the niece knows. She was bedridden for the first 3 days
or so but had been improving, enough to clean the house
yesterday. Overnight, her niece had heard a thump and found the
patient on the floor, with her bifold closet off the runner. She
was complaining of L arm pain. She was also confused, repeatedly
calling for help and asking about her dead dog. She has had her
flu and H1N1 shots this year.
.
The patient was taken to [**Hospital 8125**] Hospital. There, she became
increasingly altered without focal neuro deficits. She had
multiple imaging studies. Head and neck CT scans were negative.
X-rays showed a L humeral fracture. Her labs, inc. chemistries
and cardiac enzymes, were normal except for Cr of 1.3. She
received 1 mg of ativan, 2 mg of morphine, and ???dilantin. On
the way over in the ambulance, pt had reportedly son[**Name (NI) 7884**]
respirations with desaturations, requiring bagging in the
ambulance.
.
In the ED, she only responded to painful stimuli, no gag reflex.
Mental status did not improve with 0.4 mg of Narcan. She was
intubated for airway protection and ventilatory support. She had
some frank blood in the ETT, though the intubation was not
difficult. Labs were sig. for neg serum tox screen, mild
leukocytosis of 11.7, Cr 1.2. Lactate was 1.4. 1st of cardiac
enzymes were neg. CXR and CTA showed pneumonia, no PE. CT head
showed no acute process. X-rays showed comminuted fracture of
the left proximal humerus fx, no hip fractures. ED failed
multiple LP attempts. Patient was acyclovir, vanc, CTX,
levaquin, and flagyl. VS on transfer were: 97.2, 102, 108/67,
20, 96% on 40% FiO2, AC 500 x 20.
.
ROS: Unable to obtain.


Past Medical History:
HTN
CHF
Asthma


Social History:
Pt lives with her niece's family. She used to work for the
state, caring for the mentally challenged. She is active at
home, helping with chores and going to the gym. She is a remote
smoker, no etoh, no recreational drugs.

Family History:
Heart disease.

Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Sedated on 15 of versed.
HEENT: PERRL, sclera anicteric, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds anteriorly
CV: Regular rate and rhythm, normal S1 + S2, soft systolic
murmur at USBs
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ pulses, no edema


Pertinent Results:
Labs on admission ([**2169-2-23**]):
.
[**2169-2-23**] 07:48AM BLOOD WBC-11.7* RBC-3.70* Hgb-11.9* Hct-35.1*
MCV-95 MCH-32.1* MCHC-33.8 RDW-12.4 Plt Ct-443*
[**2169-2-23**] 07:48AM BLOOD Neuts-82.6* Lymphs-12.9* Monos-3.3
Eos-0.8 Baso-0.4
[**2169-2-23**] 07:48AM BLOOD PT-12.1 PTT-24.9 INR(PT)-1.0
[**2169-2-23**] 07:48AM BLOOD Glucose-154* UreaN-21* Creat-1.2* Na-141
K-4.0 Cl-107 HCO3-23 AnGap-15
[**2169-2-23**] 07:48AM BLOOD CK(CPK)-306*
[**2169-2-23**] 03:15PM BLOOD ALT-23 AST-27 LD(LDH)-256* CK(CPK)-421*
AlkPhos-68 TotBili-0.3
[**2169-2-23**] 07:48AM BLOOD cTropnT-<0.01
[**2169-2-23**] 03:15PM BLOOD CK-MB-7 cTropnT-0.20*
[**2169-2-23**] 07:52PM BLOOD CK-MB-5 cTropnT-0.09*
[**2169-2-24**] 04:20AM BLOOD Albumin-2.9* Calcium-7.7* Phos-2.7
Mg-1.5*
[**2169-2-23**] 07:48AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.8
[**2169-2-24**] 04:20AM BLOOD VitB12-459 Folate-14.0
[**2169-2-24**] 04:20AM BLOOD TSH-0.60
[**2169-2-23**] 07:48AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2169-2-23**] 09:46AM BLOOD Type-ART Tidal V-500 PEEP-5 FiO2-100
pO2-386* pCO2-48* pH-7.31* calTCO2-25 Base XS--2 AADO2-291 REQ
O2-54 -ASSIST/CON Intubat-INTUBATED
[**2169-2-23**] 07:53AM BLOOD Lactate-1.4
[**2169-2-23**] 07:04PM BLOOD Lactate-1.0
[**2169-2-24**] 04:43AM BLOOD Lactate-0.9
.
Labs on discharge ([**2169-3-1**]):
[**2169-2-28**] 07:00AM BLOOD WBC-6.3 RBC-3.50* Hgb-11.2* Hct-33.1*
MCV-95 MCH-32.1* MCHC-34.0 RDW-12.1 Plt Ct-498*
[**2169-2-28**] 07:00AM BLOOD Glucose-88 UreaN-13 Creat-0.6 Na-143
K-3.7 Cl-105 HCO3-29 AnGap-13
.
MICROBIOLOGY:
.
[**2169-2-23**] BLOOD CULTURE Blood Culture, No growth
[**2169-2-23**] BLOOD CULTURE Blood Culture, No growth
.
[**2169-2-23**] URINE URINE CULTURE-FINAL INPATIENT No Growth.
[**2169-2-23**] URINE Legionella antigen negative
.
[**2169-2-23**] CSF;SPINAL FLUID CRYPTOCOCCAL ANTIGEN-FINAL NEGA.TIVE
.
[**2169-2-23**] 8:50 pm CSF;SPINAL FLUID     Site: LUMBAR PUNCTURE
      Source: LP TUBE#3.
GRAM STAIN (Final [**2169-2-23**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):    NO GROWTH.
FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary):
.
[**2169-2-24**] 6:00 am Influenza A/B by DFA
      Source: Nasopharyngeal swab.
                            **FINAL REPORT [**2169-2-24**]**
   DIRECT INFLUENZA A ANTIGEN TEST (Final [**2169-2-24**]):
      Negative for Influenza A.
   DIRECT INFLUENZA B ANTIGEN TEST (Final [**2169-2-24**]):
      Negative for Influenza B.
.
[**2169-2-23**] 3:49 pm BRONCHOALVEOLAR LAVAGE
   GRAM STAIN (Final [**2169-2-23**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
   RESPIRATORY CULTURE (Final [**2169-2-25**]):    NO GROWTH, <1000
CFU/ml.
   LEGIONELLA CULTURE (Preliminary):    NO LEGIONELLA ISOLATED.
.
[**2169-2-23**] Respiratory viral culture negative
.
.
REPORTS:
CXR [**2169-2-23**]
1. ET tube ending in the right main stem bronchus. Recommend
withdrawal.
2. NG tube with sideport in the distal thoracic esophagus.
Recommend advancement.
3. Incompletely imaged left humeral head fracture.
4. Left lower lobe ill-defined opacity, likely representing
pneumonia.
.
CTA CHEST [**2169-2-23**]:
1. No pulmonary embolism or acute aortic pathology.
2. Scattered ill-defined nodular opacities within the lungs,
likely
infectious in etiology.
.
CT HEAD [**2169-2-23**]:
No acute intracranial process. Sinus disease as noted above.
.
RADIOGRAPH OF L HUMERUS [**2169-2-23**]:
IMPRESSION: Comminuted fracture of the right proximal humerus
.
AP BL HIPS [**2169-2-23**]:
IMPRESSION: No fracture or dislocation.
.
MR HEAD [**2169-2-23**]:
1. No evidence of acute intracranial process.
2. Nonspecific T2/FLAIR hyperintensities in the periventricular
and
subcortical white matter, likely due to chronic small vessel
ischemic disease.
3. Right parotid enhancing nodule. Differential includes
pleomorphic
adenoma. Clinical correlation recommended.
.
ROUTINE EEG [**2169-2-24**]:
IMPRESSION: This is an abnormal routine EEG due to a mildly slow
and
disorganized background. There were no focal, lateralized or
epileptiform abnormalities noted. The background is suggestive
of a
mild encephalopathy.
.
ECG [**2169-2-24**]:
Sinus rhythm. Delayed precordial R wave transition. There is
variation in
precordial lead placement as compared with previous tracing of
[**2169-2-23**].
Otherwise, no diagnostic interim change.
.
CT C-SPINE W/O CONTRAST [**2169-2-24**] (PRELIM):
There are no acute fractures. There is multilevel degenerative
disease of the cervical spine with loss of the normal cervical
lordosis.
Anterior osteophytes and disc space narrowing are present at
multiple levels, most pronounced at C5-C6 with moderate-severe
neural foraminal narrowing on both sides.
.
ECHO ([**2169-2-28**]):
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). The estimated cardiac index is normal (>=2.5L/min/m2).
There is no left ventricular outflow obstruction at rest or with
Valsalva. Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
mild [1+] mitral regurgitation. There is no mitral valve
prolapse. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.


Brief Hospital Course:
52 yo female with history of hypertension, congestive heart
failure, and asthma with an upper respiratory tract infection
who presented with acute mental status changes and left proximal
humerus fracture s/p fall and was found to have pneumonia,
intubated for airway protection and respiratory distress.
.
# Respiratory distress:  She was not requiring high amounts of
oxygen initially. CT chest showed scattered nodular infiltrates
suggestive of pneumonia.  It was unclear whether this was a
bacterial superinfection from her viral URI, aytpical pneumonia,
or aspiration pneumonia secondary to her acute mental status
changes. CTA did not reveal a PE.  Microbiology work-up for
respiratory infection, including influenza DFA, urine legionella
antigen, MRSA swab, and sputum culture, was negative.
Bronchoscopy with broncheoalveolar lavage showed no organisms.
Patient was extubated and remained stable.  She was empirically
treated for severe community-acquired pneumonia with
ceftriaxone, vancomycin, and levofloxacin, then transitioned to
ceftriaxone and doxycycline given concern for QT prolongation on
levofloxacin, for a 7-day total course of antibiotics.  Patient
was also treated with oseltamivir x 5 days despite negative
influenza A.  Antibiotics and oseltamivir were stopped on day of
discharge due to patient's resolved respiratory symptoms and
completed course.
.
# Acute mental status changes:  Her presentation was initially
concerning for meningitis/encephalitis, however CSF was negative
for growth of any organisms.  Head CT and MRI did not show any
acute pathology.  EEG showed mild encephalopathy without
evidence of seizure.  She had received Ativan, morphine, and
possibly Dilantin at the OSH; however, she was altered prior to
arrival and had a negative tox screen.  Her mental status
returned to baseline after extubation.  She was kept on
telemetry on the floor and had no recorded events.  Her
transthoracic echo was normal without valvular abnormalities.
In the end, her change in mental status was thought to be
possibly due to a concussion from a mechanical fall as pt denied
loss of sensation, chest pain, shortness of breath, dizziness,
palpitations or any prodrome to fall.  Patient insisted that she
simply lost her balance and may have tripped over one of her
dogs sleeping on the floor.  She was at her baseline, alert and
oriented, on discharge.
.
# Left proximal humeral fracture:   Patient suffered a fracture
of her left proximal humerus s/p her fall at home.  Orthopedic
consult recommended a sling for her arm, and she was given
Percocet and Tylenol as needed for her pain.  She was discharged
with home PT and has a scheduled appointment with ortho in 2
weeks.
.
# Hypertension:  Her antihypertensives were held initially in
the ICU on sedation, then restarted on the floor with normal
blood pressure on discharge.
.
# Congestive heart failure:  She was not noted to be
volume-overloaded on exam throughout her hospitalization.  Her
TTE showed a left ventricular ejection fraction > 55%.

Medications on Admission:
Atenolol 25 mg daily
Verapamil SR 240 mg daily
Triamterene 37.5 and HCTZ 25 daily
ASA 325 mg daily
Montelukast 10 mg daily
Advair 500/50
Piroxicam 1 cap daily
KCl 20 meq daily


Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2)  PO BID (2
times a day): Please take for constipation while on Percocet.
Disp:*12 * Refills:*0*
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
5. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation Q4H (every 4 hours) as needed for wheeze.
6. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
10. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
11. Piroxicam 10 mg Capsule Sig: One (1) Capsule PO once a day.

12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every eight (8) hours as needed for pain for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
13. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day:
Please take for constipation while on Percocet.
Disp:*10 Capsule(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Syncope
Pneumonia, community acquired
Proximal Humerus Fracture
Altered Mental Status
.
Secondary:
Hypertension
Chronic Diastolic Congestive Heart Failure
Asthma


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent

Discharge Instructions:
You were admitted to [**Hospital1 18**] with altered mental status after a
fall at home.  You were found to have pneumonia and were
admitted to the ICU for respiratory distress.  You were given
antibiotics for your pneumonia and Tamiflu for possible
influenza.  You were also found to have a fracture of your arm
(left humerus).  You were evaluated by the orthopedic doctors
but [**Name5 (PTitle) **] surgery is needed, and you will see them in their office
in 2 weeks.
.
You had several medical tests to determine if there was a cause
to your falling, including a study of your heart
(echocardiogram) and to screen for seizures (EEG) and these did
not show any signficant abnormalities.
.
Please take the following medications:
START Tylenol 325mg 1-2 tablets three times a day as needed for
pain.
START Percocet every 8 hours as needed for pain.
Please discuss restarting your KCl 20meq pill per day with your
PCP.

Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Name (NI) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 58182**] for an
appointment within the next week.
.
Please also keep the following appointments:
.
Appointment #1
MD: [**Name (NI) **] [**Last Name (NamePattern1) **]
Specialty: Internal Medicine/ PCP
[**Name Initial (PRE) 2897**]/ Time: Monday, [**3-13**], 3:45pm
Location: [**State **], Suite A, [**Location (un) 2498**] MA
Phone number: [**Telephone/Fax (1) 58182**]
.
Appointment #2
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
Specialty: Nurse Practitioner/ Orthopedics
Date/ Time: Thursday, [**3-9**], 12pm
Location: [**Location (un) **], [**Location (un) 86**].  [**Hospital Ward Name 23**] Building, [**Location (un) **]
Phone number: [**Telephone/Fax (1) 1228**]


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
{'Pneumonia, organism unspecified,Acute respiratory failure,Chronic systolic heart failure,Encephalopathy, unspecified,Closed fracture of unspecified part of upper end of humerus,Unspecified fall,Asthma, unspecified type, unspecified,Unspecified essential hypertension'}


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: Chief Complaint: Mental status changes and hypoxia, found down

PRESENT ILLNESS: Patient is a 62 yo female with PMHx sig. for HTN, CHF, asthma
who was brought to OSH after being found down. She lives with
her niece, the niece's daughter and husband. She had been
complaining of an URI infection for the last 1.5 weeks with
symptoms of fatigue and cough. No fevers or other complaints as
far as the niece knows. She was bedridden for the first 3 days
or so but had been improving, enough to clean the house
yesterday. Overnight, her niece had heard a thump and found the
patient on the floor, with her bifold closet off the runner. She
was complaining of L arm pain. She was also confused, repeatedly
calling for help and asking about her dead dog. She has had her
flu and H1N1 shots this year.
.
The patient was taken to [**Hospital 8125**] Hospital. There, she became
increasingly altered without focal neuro deficits. She had
multiple imaging studies. Head and neck CT scans were negative.
X-rays showed a L humeral fracture. Her labs, inc. chemistries
and cardiac enzymes, were normal except for Cr of 1.3. She
received 1 mg of ativan, 2 mg of morphine, and ???dilantin. On
the way over in the ambulance, pt had reportedly son[**Name (NI) 7884**]
respirations with desaturations, requiring bagging in the
ambulance.
.
In the ED, she only responded to painful stimuli, no gag reflex.
Mental status did not improve with 0.4 mg of Narcan. She was
intubated for airway protection and ventilatory support. She had
some frank blood in the ETT, though the intubation was not
difficult. Labs were sig. for neg serum tox screen, mild
leukocytosis of 11.7, Cr 1.2. Lactate was 1.4. 1st of cardiac
enzymes were neg. CXR and CTA showed pneumonia, no PE. CT head
showed no acute process. X-rays showed comminuted fracture of
the left proximal humerus fx, no hip fractures. ED failed
multiple LP attempts. Patient was acyclovir, vanc, CTX,
levaquin, and flagyl. VS on transfer were: 97.2, 102, 108/67,
20, 96% on 40% FiO2, AC 500 x 20.
.
ROS: Unable to obtain.

MEDICAL HISTORY: HTN
CHF
Asthma

MEDICATION ON ADMISSION: Atenolol 25 mg daily
Verapamil SR 240 mg daily
Triamterene 37.5 and HCTZ 25 daily
ASA 325 mg daily
Montelukast 10 mg daily
Advair 500/50
Piroxicam 1 cap daily
KCl 20 meq daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: BP: P: R: 18 O2:
General: Sedated on 15 of versed.
HEENT: PERRL, sclera anicteric, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds anteriorly
CV: Regular rate and rhythm, normal S1 + S2, soft systolic
murmur at USBs
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ pulses, no edema

FAMILY HISTORY: Heart disease.

SOCIAL HISTORY: Pt lives with her niece's family. She used to work for the
state, caring for the mentally challenged. She is active at
home, helping with chores and going to the gym. She is a remote
smoker, no etoh, no recreational drugs. 

### Response:
{'Pneumonia, organism unspecified,Acute respiratory failure,Chronic systolic heart failure,Encephalopathy, unspecified,Closed fracture of unspecified part of upper end of humerus,Unspecified fall,Asthma, unspecified type, unspecified,Unspecified essential hypertension'}
