CHIEF COMPLAINT: confusion, speech arrest

PRESENT ILLNESS: 69 yo M with hx HTN, HLD, afib not on anticoagulation, and [**Hospital 23051**]
transferred from OSH as a code stroke after episode of confusion
this afternoon followed by global aphasia.

MEDICAL HISTORY: [] Cardiovascular - Atrial fibrillation (not on anticoagulatin),
HTN, HL
[] Endocrine - DM2, s/p thyroid surgery
[] Renal - Chronic nephrolithiasis with CKD
[] Gout

MEDICATION ON ADMISSION: Levothyroxine 50 mcq daily
Indomethacin 50 mg TID PRN
Sildenafil 50 mg PRN
Doxazosin 2 mg daily
Metoprolol succinate 25 daily
Lisinopril 20 daily
Allopurinol 100 daily
Pravastatin 40 daily? (not clear which statin the patient was
taking)
Aspirin 81 daily
Digoxin 0.125 mg daily
Sodium Bicarbonate 650 TID
Diltiazem 90 mg [**Hospital1 **]
Atorvastatin 40 daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At admission:
Gen; lying in bed, awake
HEENT; jaw clenched
CV; irreg, no murmurs
Pulm; CTA anteriorly
Abd; soft, nt, nd
Extr; no edema
Neuro;
MS; Awake, but does not follow any commands or attempt to speak.

FAMILY HISTORY: No strokes or seizures.

SOCIAL HISTORY: No tobacco or illicits. Occasional beers on weekends (not
daily).
Cerebral embolism with cerebral infarction,Aphasia,Other and unspecified hyperlipidemia,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other convulsions,Acute gouty arthropathy
Crbl emblsm w infrct,Aphasia,Hyperlipidemia NEC/NOS,Atrial fibrillation,DMII wo cmp nt st uncntr,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Convulsions NEC,Acute gouty arthropathy
Admission Date:  [**2164-8-22**]              Discharge Date:   [**2164-8-30**]

Date of Birth:  [**2094-12-16**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
confusion, speech arrest

Major Surgical or Invasive Procedure:
right knee aspiration


History of Present Illness:
69 yo M with hx HTN, HLD, afib not on anticoagulation, and [**Hospital 23051**]
transferred from OSH as a code stroke after episode of confusion
this afternoon followed by global aphasia.

Per his wife he was in his usual state of health this AM and
after lunch time (? 12:00) appeared confused after returning
home from the grocery store without groceries and was wandering
around the house.  He kept saying "I don't know" in response to
questions.  He went to an OSH and there underwent a noncontrast
CT head and then became globally aphasic and not responding to
any commands and he was transferred here.

Past Medical History:
[] Cardiovascular - Atrial fibrillation (not on anticoagulatin),
HTN, HL
[] Endocrine - DM2, s/p thyroid surgery
[] Renal - Chronic nephrolithiasis with CKD
[] Gout

Social History:
No tobacco or illicits. Occasional beers on weekends (not
daily).

Family History:
No strokes or seizures.

Physical Exam:
At admission:
Gen; lying in bed, awake
HEENT; jaw clenched
CV; irreg, no murmurs
Pulm; CTA anteriorly
Abd; soft, nt, nd
Extr; no edema
Neuro;
MS; Awake, but does not follow any commands or attempt to speak.

CN; PERRL 4mm-->3mm, does not reliably blink to threat on left.
Eyes conjugate in midposition.  Does not track.  Face appears
symmetric.
Motor; normal tone.  able to maintain all limbs symmetrically
and
antigravity.
Sensory; withdraws to pain, but more grimace on right than left
with noxous arm stimulation
Reflexes; toes mute b/l

______________________________________________
At discharge:
awake, alert, intermittently confused, language fluent with
intact comprehension, moving all 4 with full power, DTRs 2 and
symmetric throughout

Pertinent Results:
[**2164-8-22**] 05:38PM   WBC-9.7 RBC-4.13* HGB-12.9* HCT-36.3* MCV-88
MCH-31.1 MCHC-35.4* RDW-14.0
[**2164-8-22**] 05:38PM   PLT COUNT-157
[**2164-8-22**] 05:38PM   PT-12.6 PTT-25.9 INR(PT)-1.1
[**2164-8-22**] 05:38PM   TSH-1.8
[**2164-8-22**] 05:38PM   ALBUMIN-4.4 CALCIUM-8.7 PHOSPHATE-4.6*
MAGNESIUM-2.2
[**2164-8-22**] 05:38PM   cTropnT-<0.01
[**2164-8-22**] 05:38PM   LIPASE-44
[**2164-8-22**] 05:38PM   ALT(SGPT)-32 AST(SGOT)-31 LD(LDH)-209 ALK
PHOS-91 TOT BILI-0.3
[**2164-8-22**] 05:38PM   GLUCOSE-191* UREA N-39* CREAT-2.5* SODIUM-143
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-27 ANION GAP-16
[**2164-8-22**] 06:07PM URINE  RBC-1 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-0
[**2164-8-22**] 06:07PM URINE  BLOOD-SM  NITRITE-NEG PROTEIN-300
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2164-8-22**] 06:07PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2164-8-22**] 09:04PM   PHENYTOIN-13.8
.
[**2164-8-27**]:JOINT FLUID
JOINT FLUID ANALYSIS WBC   RBC Polys Lymphs Monos NRBC Macro
[**2164-8-27**] 14:44    [**Numeric Identifier 961**]* 3000* 88*    0     6    1*    5
Source: Knee
JOINT FLUID  Crystal Shape Locatio Birefri Comment
[**2164-8-27**] 14:44    FEW NEEDLE I/E1 NEG   c/w monoso2
.
[**2164-8-27**] 2:44 pm JOINT FLUID      Source: Knee.
**FINAL REPORT [**2164-8-30**]**
GRAM STAIN (Final [**2164-8-27**]):
1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2164-8-30**]):    NO GROWTH.
.
IMAGING
[**2164-8-22**]: CT Head without contrast:
FINDINGS: Encephalomalacic changes are present in the right
parietal and occipital lobes in the right MCA and PCA
territories. There is no acute intracranial hemorrhage.
[**Doctor Last Name **]-white matter differentiation remains preserved. The
ventricles are normal in size and configuration. Overall, there
is little change from the outside hospital CT performed three
hours prior. Visualized paranasal sinuses and mastoid air cells
are clear. Soft tissues of the orbits are within normal limits.
Scout images demonstrate the endotracheal tube ending 3.5 cm
above the carina and an OJ tube coursing towards the stomach
although the tip is excluded from view.
IMPRESSION: Encephalomalacic changes involving the right
parietal
and occipital lobes. No acute intracranial process identified.
Little change since the outside hospital CT performed three
hours
prior.
.
[**2164-8-23**]: MR [**Name13 (STitle) 430**] Without Contrast:
IMPRESSION: Acute infarcts in the distribution of the left
posterior cerebral artery. Chronic right posterior cerebral
artery infarct. Brain atrophy.
.
[**2164-8-22**]: Chest Radiograph:
FINDINGS: AP supine portable chest radiograph is obtained. An
endotracheal tube is seen with its tip located approximately 3.6
cm above the carina. The NG tube courses into the left upper
quadrant with its tip just beyond the GE junction. Lung volumes
are low with crowding of bronchovasculature, and no definite
sign
of pneumonia or CHF. No large pleural effusion or pneumothorax.
Bony structures appear grossly intact.
IMPRESSION: Appropriately positioned ET tube. OG tube may be
advanced slightly for more optimal positioning.
.
[**2164-8-23**]: EEG:
IMPRESSION: This 24 hour video EEG telemetry captured no
pushbutton activations and 2 electrographic seizures with no
clinical correlation on video. Occasional interictal sharp wave
discharges were seen over the left frontal temporal admixed with
theta and delta frequency slowing, consistent with a focus of
epileptogenicity. The background rhythm demonstrated an 8 Hz
maximal posterior predominant alpha rhythm intermixed with theta
and delta likely related to a mild to moderate encephalopathy.
.
[**2164-8-22**]: ECG:
Probable sinus tachycardia with first degree A-V block and
atrial
premature beats. Non-specific inferolateral ST segment
depression
and T wave changes. No previous tracing available for
comparison.

.
[**2164-8-24**]: TTE:
The left atrium is mildly dilated. The left atrium is elongated.
The right atrium is moderately dilated. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). There is considerable beat-to-beat variability of
the
left ventricular ejection fraction due to an irregular
rhythm/premature beats. Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic arch is mildly dilated. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**2164-8-24**]: Carotid Studies:
Impression: Right ICA with stenosis <40%.
Left ICA with stenosis 0%.
.
[**2164-8-26**]: CT Head Without Contrast:
IMPRESSION:
1. Evidence of prior chronic infarction in the right
parietooccipital region.
2. Focal ill-defined hypodensities in the left occipital region
corresponding with areas of acute left PCA infarcts seen on
recent MR study.
3. No new large acute territorial infarction. No hemorrhage or
mass effect.
.
[**2164-8-26**]: Bilateral Knee Plain Films:
FINDINGS: Due to swollen joints the patient is unable to
internally rotate the knee. Mild soft tissue swelling. The
presence of small effusions is likely. Bilateral mild
degenerative changes in the femorotibial joint and severe
degenerative changes in the femoropatellar joint. No evidence of
fracture. No evidence of chronic inflammatory changes
.
[**2164-8-27**]: EEG:
IMPRESSION: This EEG gives evidence mainly for an
encephalopathic-
appearing abnormality with background slowing and bursts of
slowing with
suppressive bursts. This would suggest widespread diffuse
cortical, as
well as subcortical, neuronal dysfunction. There are some
asymmetric
features suggesting attenuation of background posteriorly on the
right
and increased epileptiform interictal activity from the left
temporal
posterior frontal region suggesting there may be more isolated
structural damage.
.
[**2164-8-27**]: ECG:
Atrial fibrillation with a controlled ventricular response.
Compared to the previous tracing of [**2164-8-23**] the ventricular
response has slowed. The lateral ST-T wave changes are less
prominent. Otherwise, no diagnostic interim change.
.
[**2164-8-28**]: EEG:
IMPRESSION: This EEG gives evidence for mild to moderate diffuse

encephalopathy with superimposed focal slowing over the right
posterior
quadrant and more significantly fairly continuously across the
left
temporal and, to a lesser degree, posterior lateral frontal
region. The
left temporal frontal area also exhibits intermittent interictal

epileptic activity spontaneously and two short runs of
unsustained but
increased frequency discharges. Cardiac monitor continues to be
abnormal.


Brief Hospital Course:
Brief Hospital Course:
69 yo M h/o AF (not on anticoagulation), HTN, HL, DM2, CKD from
chronic nephrolithiasis p/w confusion, speech arrest, and
convulsive seizure of unclear etiology.

[] Seizure - The patient had an episode of confusion (answering
"I don't know" to all questions) followed by speech arrest. He
was subsequently able to follow commands but would not
verbalize. While in the ED of an OSH and en route to a CT
scanner, his jaw clenched and he reportedly had a convulsive
seizure. He was sedated and intubated and transferred to [**Hospital1 18**]
for further care. He was loaded with phenytoin. He had no
lateralizing signs on his neurologic exam, and an EEG on [**8-23**]
showed no seizure activity but did show intermittent left
frontal and temporal sharp waves and intermittent diffuse
slowing of the background rhythm. On MRI he was found to have a
subacute left occipital-temporal ischemic stroke, likely the
etiology of his seizures. He has had no further witnessed
seizure activity but was monitored on LTM. He was extubated
without difficulty and his mental status has cleared. LTM showed
no seizures and it was stopped. On [**2164-8-26**] the patient was found
on the floor and was unable to tell how he got there. Out of
concern for seizure as the etiology, he was loaded with Keppra
and placed on EEG for another 24 hours. Again the EEG failed to
show any seizure activity. The phenytoin is slowly being tapered
off and the patient is being continued on Keppra 1 g po bid. The
patient's alertness level decreased initally when started on the
2 AEDs but has now improved since the phenytoin taper. He has
follow up in [**Hospital 878**] clinic.

[] Ischemic Stroke - The patient has evidence on his initial
NCHCT of an old ischemic stroke affecting the right parietal and
occipital lobes, but there were no signs of new areas of
infarction. He subsequently had a NC MRI Brain on [**8-23**] which
showed a left occipital-temporal ischemic stroke. He was started
on warfarin and bridged with a heparin infusion. He is to be
maintained at a goal INR of [**2-16**]. Currently his INR is 4.4 and
please hold his warfarin until his INR is 2.

[] Atrial Fibrillation - The patient was briefly bradycardic to
the 40s overnight on [**8-22**] but this resolved. He was on aspirin
but not on anticoagulation prior to this event. Throughout the
rest of his stay the patient was restarted on his home
medications but continued to have episodes of RVR. His diltiazem
was increased to 90mg po qid and metoprolol was increased to
25mg po bid. Digoxin 0.125mg po daily was continued as well. EP
was consulted and recommended that the digoxin be stopped as
they did not feel it was helping. The metoprolol can be
increased to tid if needed. The patient's heart rate remained
primarily in the 80s on this regimen. Please continue him on
telemetry at rehab to ensure he is stable on this regimen. He
has an outpatient appointment with cardiology.

[] Gout - After transfer to the floor the patient complained of
right knee pain as well as minor left ankle tenderness. His home
medication allopurinol had been held while he was in the ICU but
restarted at transfer. These joints as well as his left knee
were warm and swollen. Rheumatology was consulted who tapped the
right knee and confirmed crystal proven gout in the joint. Given
the large amount of pain the patient was in, we gave him IV
steroids x 1 followed by a po prednisone taper. His pain is much
improved. After he finishes the prednisone taper, please start
colchicine 0.6mg po every other day (renal dosing) to help
prevent future flares. He has follow up in [**Hospital 2225**] clinic.

[] Hyperglycemia - While on the steroids for his gout flare, his
blood sugars have been high. Please continue him on an insulin
sliding scale until the prednisone taper is over.

[] Chronic renal failure - we contact[**Name (NI) **] his PCP and confirmed
that his recent Cr values range around 2.3-2.5. After this we
restarted his previous dose of lisinopril per his PCP, 10mg po
daily.

Medications on Admission:
Levothyroxine 50 mcq daily
Indomethacin 50 mg TID PRN
Sildenafil 50 mg PRN
Doxazosin 2 mg daily
Metoprolol succinate 25 daily
Lisinopril 20 daily
Allopurinol 100 daily
Pravastatin 40 daily? (not clear which statin the patient was
taking)
Aspirin 81 daily
Digoxin 0.125 mg daily
Sodium Bicarbonate 650 TID
Diltiazem 90 mg [**Hospital1 **]
Atorvastatin 40 daily

Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) tab PO Q6H
(every 6 hours) as needed for pain/fever.
3. insulin regular human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED): Insulin sliding scale.
4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-15**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
16. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
18. prednisone 20 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily)
for 2 days: Please taper dose. Give 50mg po daily x 2 days, then
40mg x 2 days, then 20mg x 2 days, then 10mg x 2 days and stop.

19. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO QHS (once a day (at bedtime)) for 4 days.
20. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Please hold until INR is less than 2. Goal INR [**2-16**].
21. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
22. Metoprolol Tartrate 5 mg IV Q8H:PRN tachycardia > 120
hold if SBP<120. Please notify HO by text-page if givein IV MTP.

23. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO every other
day: Please start after prednisone is complete.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 979**] - [**Location (un) 246**]

Discharge Diagnosis:
left PCA stroke
seizures
crystal-proven gout
atrial fibrillation with RVR


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurological exam: awake, alert, intermittently confused,
language fluent with intact comprehension, moving all 4
extremities with full power.


Discharge Instructions:
It was a pleasure caring for you during your stay. You were
admitted to the hospital for evaluation of your shaking and
confusion episodes. These episodes turned out to be seizures.
These seizures were coming from the left side of your brain and
imaging shows that you had a stroke days to weeks prior on the
left side of your brain as well. This damage caused by the
stroke is likely the cause of your seizure events. Additionally
the [**Doctor Last Name **] imaging showed that you suffered a right sided stroke
months previously.
-Your seizures were controlled with the help of an anti-seizure
medicine. Please continue to take one of these medicines, Keppra
1 g by mouth twice a day. We are currently tapering off your
phenytoin. Please take 100mg by mouth at bedtime until (last
dose) [**2164-9-3**], then stop.
- We have you on a blood thinner, warfarin (coumadin) to
decrease the chances of stroke since you have atrial
fibrillation. Your INR will have to be measured frequently by
blood draws. Your goal INR is [**2-16**]. Currently your INR is high so
we are holding the warfarin. Please restart taking 2mg by mouth
at night once the INR is 2. Your dose of this medicine will
likely change as you are being tapered off phenytoin, which is a
medicine that affects your warfarin levels.
-During your stay, your hospital course was complicated by
atrial fibrillation with a difficult to control heart rate. We
consulted the cardiology team, who recommended stop digoxin and
continuing on diltiazem and metoprolol at this time. They do not
currently feel that you would benefit from any other
intervention at this time.
-You had knee pain while in the hospital as well. The
rheumatology team removed some fluid from your right knee and
confirmed crystals present, consistent with a gout flare. Given
the amount of pain you were in, we treated you with steroids to
decrease the inflammation. Please continue to prednisone taper
we have placed you on as written (50mg x2days, 40mg x2days, 20mg
x2days, 10mg x2 days, and then
stop). You should start taking colchicine 0.6 mg by mouth every
other day after finishing this taper to prevent recurrent
attacks. Please continue taking allopurinol 100mg by mouth
daily. For the long term, you need to be consistently on
allopurinol and your dose should be titrated as an outpatient to
reach a uric acid level <6. This can be done by rheumatology.
Please see them in clinic as scheduled.
-While you are on the steroids, your blood sugar has been high.
We have asked that you be monitored with a insulin sliding scale
while you are on steroids. This can be discontinued afterwards.



Followup Instructions:
[**Hospital 2225**] clinic: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2164-10-4**] 3:00pm

Cardiology clinic: Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D.
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2164-10-15**] 1:40pm, [**Hospital Ward Name 23**] Bldg, [**Location (un) **].

[**Hospital 878**] clinic: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2164-11-9**] 10:30, [**Hospital Ward Name 23**] Bldg, [**Location (un) **]
{'Cerebral embolism with cerebral infarction,Aphasia,Other and unspecified hyperlipidemia,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other convulsions,Acute gouty arthropathy'}


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: confusion, speech arrest

PRESENT ILLNESS: 69 yo M with hx HTN, HLD, afib not on anticoagulation, and [**Hospital 23051**]
transferred from OSH as a code stroke after episode of confusion
this afternoon followed by global aphasia.

MEDICAL HISTORY: [] Cardiovascular - Atrial fibrillation (not on anticoagulatin),
HTN, HL
[] Endocrine - DM2, s/p thyroid surgery
[] Renal - Chronic nephrolithiasis with CKD
[] Gout

MEDICATION ON ADMISSION: Levothyroxine 50 mcq daily
Indomethacin 50 mg TID PRN
Sildenafil 50 mg PRN
Doxazosin 2 mg daily
Metoprolol succinate 25 daily
Lisinopril 20 daily
Allopurinol 100 daily
Pravastatin 40 daily? (not clear which statin the patient was
taking)
Aspirin 81 daily
Digoxin 0.125 mg daily
Sodium Bicarbonate 650 TID
Diltiazem 90 mg [**Hospital1 **]
Atorvastatin 40 daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: At admission:
Gen; lying in bed, awake
HEENT; jaw clenched
CV; irreg, no murmurs
Pulm; CTA anteriorly
Abd; soft, nt, nd
Extr; no edema
Neuro;
MS; Awake, but does not follow any commands or attempt to speak.

FAMILY HISTORY: No strokes or seizures.

SOCIAL HISTORY: No tobacco or illicits. Occasional beers on weekends (not
daily). 

### Response:
{'Cerebral embolism with cerebral infarction,Aphasia,Other and unspecified hyperlipidemia,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other convulsions,Acute gouty arthropathy'}
