CHIEF COMPLAINT: Mental status changes

PRESENT ILLNESS: HPI: 63 yo metastatic carcinoid, HTN, hyperlipidemia, s/p recent
admission to [**Hospital1 18**] (d/cd [**8-21**]) who presents with altered mental
status. Pt was admitted to [**Hospital1 **] [**2127-8-1**] with DOE and orthopnea.
Pt had a RLL PNA with b/l effusions (transudative on tap) and
CHF. He was found to have a decreased EF to 35-40%, and P-MIBI
showed moderate reversible defects in the apex and septum.
Cardiac catheterization on [**2127-8-15**] showed mild coronary artery
disease (prox RCA 40%, mid-LAD 50%, 20% stenosis at D2),
elevated RV and LV filling pressures, severely depressed EF,
moderate pulm HTN, mild aortic stenosis (mean gradient 10) with
a restrictive defect. Course was complicated by ARF secondary to
overdiuresis as well as contrast nephropathy, and shock liver.
.
Pt was transferred to [**Hospital 38**] Rehab from [**Hospital1 18**]. He developed
some altered mental status and confusion on [**2127-8-22**]. He also was
found to be hypoxic yesterday to 80s on RA with improvement with
diuresis. Today, pt desatted to 80% at rehab, "was blue in the
face",  and had altered mental status. He was transferred to
[**Hospital6 33**]. Head CT report showed central and
peripheral atrophy, though no mass or hemorrhage. Pt was then
transferred here as most of his care is here. He was noted to be
A&O x 2 initially in ED, then x 0. He was able to speak small
amounts and follow commands initially.
.
In ED,  VS: T: 101.6, HR: 94, BP: 126/52; RR:17; O2: 88RA, 100
4L.
An LP was performed and pt was given Ceftriaxone 2 grams IV x 1,
Vancomycin 1 gram IV x 1, Dexamethasone 13.5 mg IV x 1. Initial
ABG 7.55/29/123/26.
.
Of note, per daughters report, pt had confusion, paranoid
ideations in days prior to d/c from [**Hospital1 **] (no d/c summ yet). also
with this at rehab. Never had this before.

MEDICAL HISTORY: 1. Metastatic carcinoid tumor, Dx'ed [**2123**], was on a study drug
for a year and a half (ended about a year ago) and was on
octreotide for a few months earlier this year but stopped
because of diarrhea
2. hypertension
3. hyperlipidemia
4. carotid endarterectomy [**2120**]
5. depression/anxiety
6. cellulitis 4 weeks ago, given Keflex IV at [**Hospital3 **], now resolved
7. DM2/prediabetic state: random blood sugar was high, was on
glyburide for a brief time but made his sugars low so stopped
8. anxiety attack [**2110**] (collapsed), diagnosed in [**2120**] as MI
9. basal cell carcinoma (chest, low back, MOHS on cheek [**3-31**] and
[**7-1**])

MEDICATION ON ADMISSION: 1. Paroxetine HCl 30 mg Tablet QD
2. Bisacodyl 10 mg Suppository QHS.prn
3. Insulin Regular Human 100 unit/mL as directed
4. Sodium Chloride 0.65 % Aerosol, [**12-29**] Sprays Nasal TID, prn
5. Docusate Sodium 100 mg Capsule PO BID
6. Aspirin 81 mg Tablet, QD
7. Pantoprazole Sodium 40 mg Tablet(E.C.) PO Q24H
8. Heparin Sodium (Porcine) 5,000 unit/mL TID sc.
9. Lactulose 10 g/15 mL, 30 ML PO Q8H prn
10. Furosemide 40 mg Tablet 1 PO BID
11. Toprol XL 25 mg Tablet Sustained Release QD PO
12. Atorvastatin Calcium 20 mg QD

ALLERGIES: Nitroglycerin

PHYSICAL EXAM: PE:
T:99.3; BP: 124/46; HR: 72; RR: 33; O2: 99 3L
Gen: Unresponsive; can follow some verbal command
HEENT: Right pupil >left ~5:4 cm. reactive to light. Corneal
reflexes
 intact. When light is shined in eye, eyes deviate to the left
 upperward direction.
Neck: JVD ~8 cm to earlobe.
CV: III/VI systolic murmur best LLSB
Lungs: ?crackles at bases anteriorly. Good air movement.
Abd: Midline scar. Ecchymoses. +small masses under scar
Ext: No edema. DP 2+
Neuro: As per HEENT. Pt able to wiggle toes when asked. He is
 nonverbal and cannot follow all commands. CN unable to be
tested.
 Cannot follow command. +b/l clonus in LE. Babinski: left
upgoing?
 right downgoing; Patellar reflexes 3+. Biceps, brachio [**1-29**].

FAMILY HISTORY: Early CAD

SOCIAL HISTORY: Lives alone, has two daughters
Distant tobacco use (25 pack-years, quit 30 years ago), distant
EtOH use (quit 28 yrs ago), no drugs
Unspecified septicemia,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Paroxysmal ventricular tachycardia,Alkalosis,Chronic diastolic heart failure,Diseases of tricuspid valve,Malignant neoplasm of liver, secondary,Severe sepsis,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Malignant neoplasm of ill-defined sites within the digestive organs and peritoneum
Septicemia NOS,Acute kidney failure NOS,Pneumonia, organism NOS,Parox ventric tachycard,Alkalosis,Chr diastolic hrt fail,Tricuspid valve disease,Second malig neo liver,Severe sepsis,Hyperlipidemia NEC/NOS,Hypertension NOS,Crnry athrscl natve vssl,Chr pulmon heart dis NEC,DMII wo cmp nt st uncntr,Mal neo GI tract ill-def
Admission Date:  [**2127-8-23**]              Discharge Date:   [**2127-8-29**]

Date of Birth:  [**2063-11-28**]             Sex:   M

Service: MEDICINE

Allergies:
Nitroglycerin

Attending:[**First Name3 (LF) 33596**]
Chief Complaint:
Mental status changes

Major Surgical or Invasive Procedure:
none

History of Present Illness:
HPI: 63 yo metastatic carcinoid, HTN, hyperlipidemia, s/p recent
admission to [**Hospital1 18**] (d/cd [**8-21**]) who presents with altered mental
status. Pt was admitted to [**Hospital1 **] [**2127-8-1**] with DOE and orthopnea.
Pt had a RLL PNA with b/l effusions (transudative on tap) and
CHF. He was found to have a decreased EF to 35-40%, and P-MIBI
showed moderate reversible defects in the apex and septum.
Cardiac catheterization on [**2127-8-15**] showed mild coronary artery
disease (prox RCA 40%, mid-LAD 50%, 20% stenosis at D2),
elevated RV and LV filling pressures, severely depressed EF,
moderate pulm HTN, mild aortic stenosis (mean gradient 10) with
a restrictive defect. Course was complicated by ARF secondary to
overdiuresis as well as contrast nephropathy, and shock liver.
.
Pt was transferred to [**Hospital 38**] Rehab from [**Hospital1 18**]. He developed
some altered mental status and confusion on [**2127-8-22**]. He also was
found to be hypoxic yesterday to 80s on RA with improvement with
diuresis. Today, pt desatted to 80% at rehab, "was blue in the
face",  and had altered mental status. He was transferred to
[**Hospital6 33**]. Head CT report showed central and
peripheral atrophy, though no mass or hemorrhage. Pt was then
transferred here as most of his care is here. He was noted to be
A&O x 2 initially in ED, then x 0. He was able to speak small
amounts and follow commands initially.
.
In ED,  VS: T: 101.6, HR: 94, BP: 126/52; RR:17; O2: 88RA, 100
4L.
An LP was performed and pt was given Ceftriaxone 2 grams IV x 1,
Vancomycin 1 gram IV x 1, Dexamethasone 13.5 mg IV x 1. Initial
ABG 7.55/29/123/26.
.
Of note, per daughters report, pt had confusion, paranoid
ideations in days prior to d/c from [**Hospital1 **] (no d/c summ yet). also
with this at rehab. Never had this before.


Past Medical History:
1. Metastatic carcinoid tumor, Dx'ed [**2123**], was on a study drug
for a year and a half (ended about a year ago) and was on
octreotide for a few months earlier this year but stopped
because of diarrhea
2. hypertension
3. hyperlipidemia
4. carotid endarterectomy [**2120**]
5. depression/anxiety
6. cellulitis 4 weeks ago, given Keflex IV at [**Hospital3 **], now resolved
7. DM2/prediabetic state: random blood sugar was high, was on
glyburide for a brief time but made his sugars low so stopped
8. anxiety attack [**2110**] (collapsed), diagnosed in [**2120**] as MI
9. basal cell carcinoma (chest, low back, MOHS on cheek [**3-31**] and
[**7-1**])


Social History:
Lives alone, has two daughters
Distant tobacco use (25 pack-years, quit 30 years ago), distant
EtOH use (quit 28 yrs ago), no drugs


Family History:
Early CAD


Physical Exam:
PE:
T:99.3; BP: 124/46; HR: 72; RR: 33; O2: 99 3L
Gen: Unresponsive; can follow some verbal command
HEENT: Right pupil >left ~5:4 cm. reactive to light. Corneal
reflexes
 intact. When light is shined in eye, eyes deviate to the left
 upperward direction.
Neck: JVD ~8 cm to earlobe.
CV: III/VI systolic murmur best LLSB
Lungs: ?crackles at bases anteriorly. Good air movement.
Abd: Midline scar. Ecchymoses. +small masses under scar
Ext: No edema. DP 2+
Neuro: As per HEENT. Pt able to wiggle toes when asked. He is
 nonverbal and cannot follow all commands. CN unable to be
tested.
 Cannot follow command. +b/l clonus in LE. Babinski: left
upgoing?
 right downgoing; Patellar reflexes 3+. Biceps, brachio [**1-29**].


Pertinent Results:
Radiology:
CXR- Cardiac silhouette enlarged. b/l hilar fullness. b/l
pleural effusions. Retrocardiac opacity in LLL.
.
Persantine MIBI [**2127-8-11**]-Moderate reversible defects in the apex
and septum.  Hypokinesis of the septum and apex with a
calculated ejection fraction of 42%.  Transient ischemic
dilatation of the left ventricle.
.
Blood:
[**2127-8-23**] 01:54PM   NEUTS-76.5* LYMPHS-18.8 MONOS-4.0 EOS-0.3
BASOS-0.4
[**2127-8-23**] 01:54PM   WBC-10.2 RBC-3.72* HGB-11.4* HCT-35.3* MCV-95
MCH-30.7 MCHC-32.4 RDW-15.0
[**2127-8-23**] 01:54PM   ALT(SGPT)-57* AST(SGOT)-35 ALK PHOS-105
AMYLASE-44 TOT BILI-2.5*
[**2127-8-23**] 01:54PM   GLUCOSE-112* UREA N-42* CREAT-1.7* SODIUM-135
POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-24 ANION GAP-20
[**2127-8-23**] 02:04PM   LACTATE-3.2*
[**2127-8-23**] 02:04PM   PO2-123* PCO2-29* PH-7.55* TOTAL CO2-26 BASE
XS-4
[**2127-8-23**] 03:30PM   AMMONIA-41
.
[**2127-8-29**] 06:03AM BLOOD WBC-7.8 RBC-3.51* Hgb-10.6* Hct-33.8*
MCV-96 MCH-30.2 MCHC-31.4 RDW-15.6* Plt Ct-218
[**2127-8-29**] 05:53PM BLOOD K-4.2
[**2127-8-29**] 06:03AM BLOOD Glucose-107* UreaN-62* Creat-1.6* Na-137
K-4.5 Cl-99 HCO3-27 AnGap-16
[**2127-8-29**] 11:32PM BLOOD ALT-22 AST-22 LD(LDH)-134 AlkPhos-75
Amylase-25 TotBili-0.9
[**2127-8-28**] 05:50AM BLOOD CK-MB-NotDone cTropnT-0.01 proBNP-[**Numeric Identifier 78447**]*
[**2127-8-29**] 11:32PM BLOOD Albumin-1.9* Mg-2.4 UricAcd-7.3*
[**2127-8-23**] 08:28PM BLOOD Albumin-3.5 Calcium-9.1 Phos-5.7* Mg-1.9
[**2127-8-23**] 08:28PM BLOOD Osmolal-297
[**2127-8-27**] 05:16AM BLOOD TSH-10*
[**2127-8-29**] 06:03AM BLOOD T4-4.7 T3-42* calcTBG-0.98 TUptake-1.02
T4Index-4.8 Free T4-0.8*
[**2127-8-28**] 06:59AM BLOOD Type-ART Temp-37.7 pO2-86 pCO2-43 pH-7.38
calHCO3-26 Base XS-0 Intubat-NOT INTUBA
[**2127-8-29**] 08:22AM BLOOD Lactate-2.2*
.
CSF:
[**2127-8-23**] 04:35PM CEREBROSPINAL FLUID (CSF)  WBC-0 RBC-4* POLYS-0
LYMPHS-75 MONOS-25
[**2127-8-23**] 04:35PM CEREBROSPINAL FLUID (CSF)  PROTEIN-35
GLUCOSE-73 LD(LDH)-47
.
.

Brief Hospital Course:
BRIEF OVERVIEW:
63 yo male with metastatic carcinoid, HTN, DM, CHF, recently
discharged from [**Hospital1 18**] after prolonged course [**1-29**] pneumonia,
admitted to the ICU with MS changes, now with improving mental
status but continued edema and s/s heart failure R>L thought to
be from carcinoid heart.  The patient was transfered to the
floor from the ICU as his mental status improved.  He was
treated with diuretics for heart failure, placed on telemetry,
electrolytes monitored, and had good UOP after an initially poor
UOP.  The patient appeared to be doing well and then went into V
Tach, V fib, and eventually died after a prolonged resuscitation
attempt.
.
1. Mental Status change - The differential diagnosis of etiology
of encephalopathic state was thought to include serotonin
syndrome, underlying pneumonia and bacteremia and acute renal
failure (consistent with asterixis). Encephalitis/ meningitis
was initially entertained, but was thought to be unlikely as CSF
was negative.  The patient was found to becteremic by blood cx
on [**2127-8-23**] ([**3-31**] positive GPC).  The pt was covered with
vancomycin.  The cultures turned out to be growing MRSE and
vancomycin was continued.  The patient remained afebrile and
cultures thereafter remained negative. SSRI was stopped to
prevent worsening of seratonin state.  Ativan was initially used
on the floor to sedate the patient when he was agitated/anxious,
however this was held after one day as it was noted to increase
his sedation/confusion.  As the patient diuresed, infection
cleared, and meds were held, he became more oriented and more
alert.  Whereas he had some paranoia regarding CIA agents on
admission to the ICU and in the day prior, these delusions
resolved on transfer to the floor.
.
2. Fluid status-  The patient was known to have an EF of 35% on
a prior echocardiogram.  He had received a total of 5L of fluid
in the ICU to support pressure working under the assumption that
the patient was intravascularly dry but total volume overloaded.
 Repeat echo showed an EF at this hospitalization of 20-25%.
Severe TR and elevated R-sided pressures were thought to be from
carcinoid heart.  His lungs remained somewhat dull to
ausc/percussion, but he exhibited no crackles.  Based on his
large JVD and edema and these lung findings, it was thought that
he continued to have the R heart failure physiology seen on echo
at this hospitalization and on cath at the past hospitalization.
 On the floor, he was anxious initially and received ativan PRN
initially.  Due to sedation effect, this was held starting on
[**8-27**].  Shortly after arriving on the floor, his breathing took
on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6055**]-[**Doctor Last Name **] pattern and it was felt that he was volume
overloaded both intra and extra-vascularly.  He was diuresed
with IV lasix at increasing doses with poor response.  The
cardiology team was consulted and suggested initiation of IV
hydral and nitrates.  These were started at low doses to
increase forward flow.  The doses were titrated up over two
days, as was lasix until UOP increased.  The pt was OOB to chair
on [**8-29**] with help from PT.  He was mentating well and
continued to diurese.  Goal diuresis was 0.5-1 L net negative
per day.  By [**8-29**] he had reached that goal with fluid
restriction in place.  [**Hospital1 **] labs were monitored to check
electrolytes during diuresis.  The pt was put on telemetry to
monitor cardiac rhythm given extensive heart failure.  On the
night of [**8-29**], the patient went into a poorly tolerated VT
which quickly degenerated into V Fib.  A code blue was called
and resuscitation was attempted unsuccessfully for over 30
minutes.  The patient was declared dead and the code blue was
called off.
.
3. [**Name (NI) 27812**] Pt continually had heart rates 90s-100s.  He
remained afebrile.  DDx was thought to include intravascular
volume depletion, PE, and anxiety.  CT angio ruled out PE and
LENI's ruled out LE DVT.  The patient was initially having BB
held but was restarted on BB at low dose when tx to the floor.
The HR remained somewhat fast.  At that point, the pt was
thought to be tachycardic [**1-29**] CHF exacerbation in order to
maintain CO.
.
4.ARF- Creatinine baseline was 1.1 - 1.3.  The patient had a
Creatinine between 1.5 and 2.0 at this hospitalization.  It was
thought to be elevated due to poor forward flow in the setting
of low EF.  However, the pt also received a PE protocol chest
CT, which may have further stressed the renal function.  FeNA
was measured to be low consistent with a prerenal picture from
vol depletion or poor forward flow, and pointed away from ATN.
The creatinine seemed to peak in the ICU as more fluid was given
and began to descend as fluid was tapered.  After arriving on
the floor, small amounts of lasix were given for diuresis with
poor response.  UOP was low at 200-300cc/shift.  There was a
second peak in the creatinine as diuresis was increased and
hydral/nitrates were added to the regimen.  This was followed by
a trend downward as the patient's UOP increased on [**8-28**] and 2
so that he was reaching a goal of net 0.5 to 1 L negative.  He
was taking PO well and had a 1-1.2L fluid restriction applied to
limit his intake of fluids.
.
5. Respiratory [**Name (NI) 97891**] Pt had a respiratory alkalosis on
admission. Breathing pattern was shallow and then apnic, but not
[**Last Name (un) **]-[**Doctor Last Name 6056**]. Likely [**1-29**] psychosis and fever. There was also a
gap acidosis in setting of elevated lactate, which resolved
prior to his arrival on the floor.  On the morning of [**8-28**],
the [**Last Name (un) 6055**] [**Doctor Last Name **] respirations appeared more labored, O2 sat
dipped temporarily, and the patient appeared more somnolent.
ABG was done and revealed a normal blood gas.  Lactate was
elevated, but decreased on a f/u with a venous lactate the next
day.   Elevated lactate was thought to be due to hypoperfusion
diffusely rather than an infectious process as the pt was
afebrile.
.
5. DM2- The pt had known DM2 and was put on a diabetic diet and
a sliding insulin scale with regular insulin.  Sugar was well
controlled.
.
7. [**Name (NI) 12329**] Pt was on beta blocker and lasix at home. In the ICU,
both were held for tachycardia of unknown etiology and proposed
intravascular volume depletion, respectively.  BP was low in the
unit and the pt received fluids for support.  By the time he was
transferred to the floor, he was normotensive and was started on
a BB for cardioprotection (low dose given heart failure).  Lasix
was used to diurese and likely had little effect on BP.
Hydral/nitrates were started per cardiology recs and BB was
lowered
.
8. CAD-s/p MI in past. Continued baby ASA, statin. Held beta
blocker initially as above, and then restarted.  The patient
initially ruled out for MI.  He was monitored on telemetry.
.
9. Psychiatry- The patient has a history of depression and
anxiety. On Paxil as outpt, held as above secondary to possible
serotonin syndrome.  Pt had been on medication long-term,
however, he may have had increased serotonin in system if
carcinoid has progressed.  Pt was also having continued paranoid
ideations.  However, was much improved and became cooperative
and less anxious appearing.
.
10. Carcinoid cancer- The patient had known metastasis to the
liver with evidence of carcinoid heart on catheterization.  He
was on experimental protocols in past at [**Hospital1 112**].  He has been on
octreotide as an outpatient and had stopped.  Restarting this
treatment was considered, but the family declined.
.
The patient died after unsuccessful resuscitation for
ventricular tachycardia that degenerated into ventricular
fibrillation.
.

Medications on Admission:
1. Paroxetine HCl 30 mg Tablet QD
2. Bisacodyl 10 mg Suppository QHS.prn
3. Insulin Regular Human 100 unit/mL as directed
4. Sodium Chloride 0.65 % Aerosol, [**12-29**] Sprays Nasal TID, prn
5. Docusate Sodium 100 mg Capsule PO BID
6. Aspirin 81 mg Tablet, QD
7. Pantoprazole Sodium 40 mg Tablet(E.C.) PO Q24H
8. Heparin Sodium (Porcine) 5,000 unit/mL TID sc.
9. Lactulose 10 g/15 mL, 30 ML PO Q8H prn
10. Furosemide 40 mg Tablet 1 PO BID
11. Toprol XL 25 mg Tablet Sustained Release QD PO
12. Atorvastatin Calcium 20 mg QD

Discharge Disposition:
Expired

Discharge Diagnosis:
The patient died in the hospital.

Discharge Condition:
Expired


Completed by:[**2127-9-1**]
{'Unspecified septicemia,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Paroxysmal ventricular tachycardia,Alkalosis,Chronic diastolic heart failure,Diseases of tricuspid valve,Malignant neoplasm of liver, secondary,Severe sepsis,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Malignant neoplasm of ill-defined sites within the digestive organs and peritoneum'}


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: Mental status changes

PRESENT ILLNESS: HPI: 63 yo metastatic carcinoid, HTN, hyperlipidemia, s/p recent
admission to [**Hospital1 18**] (d/cd [**8-21**]) who presents with altered mental
status. Pt was admitted to [**Hospital1 **] [**2127-8-1**] with DOE and orthopnea.
Pt had a RLL PNA with b/l effusions (transudative on tap) and
CHF. He was found to have a decreased EF to 35-40%, and P-MIBI
showed moderate reversible defects in the apex and septum.
Cardiac catheterization on [**2127-8-15**] showed mild coronary artery
disease (prox RCA 40%, mid-LAD 50%, 20% stenosis at D2),
elevated RV and LV filling pressures, severely depressed EF,
moderate pulm HTN, mild aortic stenosis (mean gradient 10) with
a restrictive defect. Course was complicated by ARF secondary to
overdiuresis as well as contrast nephropathy, and shock liver.
.
Pt was transferred to [**Hospital 38**] Rehab from [**Hospital1 18**]. He developed
some altered mental status and confusion on [**2127-8-22**]. He also was
found to be hypoxic yesterday to 80s on RA with improvement with
diuresis. Today, pt desatted to 80% at rehab, "was blue in the
face",  and had altered mental status. He was transferred to
[**Hospital6 33**]. Head CT report showed central and
peripheral atrophy, though no mass or hemorrhage. Pt was then
transferred here as most of his care is here. He was noted to be
A&O x 2 initially in ED, then x 0. He was able to speak small
amounts and follow commands initially.
.
In ED,  VS: T: 101.6, HR: 94, BP: 126/52; RR:17; O2: 88RA, 100
4L.
An LP was performed and pt was given Ceftriaxone 2 grams IV x 1,
Vancomycin 1 gram IV x 1, Dexamethasone 13.5 mg IV x 1. Initial
ABG 7.55/29/123/26.
.
Of note, per daughters report, pt had confusion, paranoid
ideations in days prior to d/c from [**Hospital1 **] (no d/c summ yet). also
with this at rehab. Never had this before.

MEDICAL HISTORY: 1. Metastatic carcinoid tumor, Dx'ed [**2123**], was on a study drug
for a year and a half (ended about a year ago) and was on
octreotide for a few months earlier this year but stopped
because of diarrhea
2. hypertension
3. hyperlipidemia
4. carotid endarterectomy [**2120**]
5. depression/anxiety
6. cellulitis 4 weeks ago, given Keflex IV at [**Hospital3 **], now resolved
7. DM2/prediabetic state: random blood sugar was high, was on
glyburide for a brief time but made his sugars low so stopped
8. anxiety attack [**2110**] (collapsed), diagnosed in [**2120**] as MI
9. basal cell carcinoma (chest, low back, MOHS on cheek [**3-31**] and
[**7-1**])

MEDICATION ON ADMISSION: 1. Paroxetine HCl 30 mg Tablet QD
2. Bisacodyl 10 mg Suppository QHS.prn
3. Insulin Regular Human 100 unit/mL as directed
4. Sodium Chloride 0.65 % Aerosol, [**12-29**] Sprays Nasal TID, prn
5. Docusate Sodium 100 mg Capsule PO BID
6. Aspirin 81 mg Tablet, QD
7. Pantoprazole Sodium 40 mg Tablet(E.C.) PO Q24H
8. Heparin Sodium (Porcine) 5,000 unit/mL TID sc.
9. Lactulose 10 g/15 mL, 30 ML PO Q8H prn
10. Furosemide 40 mg Tablet 1 PO BID
11. Toprol XL 25 mg Tablet Sustained Release QD PO
12. Atorvastatin Calcium 20 mg QD

ALLERGIES: Nitroglycerin

PHYSICAL EXAM: PE:
T:99.3; BP: 124/46; HR: 72; RR: 33; O2: 99 3L
Gen: Unresponsive; can follow some verbal command
HEENT: Right pupil >left ~5:4 cm. reactive to light. Corneal
reflexes
 intact. When light is shined in eye, eyes deviate to the left
 upperward direction.
Neck: JVD ~8 cm to earlobe.
CV: III/VI systolic murmur best LLSB
Lungs: ?crackles at bases anteriorly. Good air movement.
Abd: Midline scar. Ecchymoses. +small masses under scar
Ext: No edema. DP 2+
Neuro: As per HEENT. Pt able to wiggle toes when asked. He is
 nonverbal and cannot follow all commands. CN unable to be
tested.
 Cannot follow command. +b/l clonus in LE. Babinski: left
upgoing?
 right downgoing; Patellar reflexes 3+. Biceps, brachio [**1-29**].

FAMILY HISTORY: Early CAD

SOCIAL HISTORY: Lives alone, has two daughters
Distant tobacco use (25 pack-years, quit 30 years ago), distant
EtOH use (quit 28 yrs ago), no drugs 

### Response:
{'Unspecified septicemia,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Paroxysmal ventricular tachycardia,Alkalosis,Chronic diastolic heart failure,Diseases of tricuspid valve,Malignant neoplasm of liver, secondary,Severe sepsis,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Malignant neoplasm of ill-defined sites within the digestive organs and peritoneum'}
