CHIEF COMPLAINT: Altered mental status

PRESENT ILLNESS: 77 year old woman with complicated PMHx. including CVA with
residual Lt. sided hemiparesis was at home with her daughter
when she began exhibiting signs of a URI with sneezing, upper
airway congestion, lethargy (evening of [**9-9**]).  The following
morning, she was noted to be eating less, less energetic, less
responsive, and had a fever of 102.  At approximately 4 pm on
[**9-10**], her daughter called her mother's primary physician's
office, and was instructed to bring her mother to the [**Name (NI) **]
immediately.  For unclear reasons, she did not do so, and
continued to try to get her mother to eat and drink and take
tylenol, which she was unsuccessful in doing.  By approximately
8 pm, her mother was increasingly lethargic and was not
responding to voice.  Her daughter called EMS, and on arrival
they noted that she was responsive only to painful stimuli, and
had alot of upper airway secretions and appeared to be in
respiratory distress.  She was subsequently intubated at the
scene and was transported to the [**Hospital1 18**] ED.  On arrival in the
ED, she was noted to have a fever to 102, and was tachy in AFib
with a rapid response in the 170's.  Her blood pressure was
160's over palp.  2 peripheral IV's were placed, and she was
sedated with propofol and maintained on AC ventilation.  1500 cc
of NS were bolused, and she was administered Vancomycin,
Levofloxacin, and Flagyl emperically for suspected infectious
etiology, and given a stated PCN allergy (dtr. initially related
this and then retracted - unclear if she has or not).  She had
blood cultures drawn X 2 (negative to date), and UA and culture
(unremarkable), CXR (clear), and LP (clear).  Her
anticoagulation for PAF was not reversed (INR on presentation
was 3.1) prior to her LP in the ED, but the tap was clear
without red cells (nonetheless, she will need to be observed
with neuro checks q 2 hours as possible given her propofol
sedation to evaluate for emerging possible epidural hematoma
formation).  A CT of the head and abdomen are currently pending,
and after these have been completed, she is planned for
admission to the ICU, dx: ams and acute respiratory failure.

MEDICAL HISTORY: Ascending Aortic Aneurysm
Polymyalgia Rheumatica
Recurrent UTI's on Macrodantin ppx. chronically
HTN
CVA (multiple?) with residual Lt. hemiparesis and expressive
aphasia
? of a seizure d/o
Pacemaker for sick sinus syndrome and PAF (overdrive pacing)
GERD
PAF on coumadin
Anxiety
PTSD (initial trauma WWII)
Depression
Multinodular goiter
Diabetes (type 2)

MEDICATION ON ADMISSION: Atenolol 50 daily
Warfarin 2 mg daily
Lisinopril 10 mg daily
Macrodantin 100 mg twice daily
Remeron 15 mg HS
Olanzapine 5 mg daily
Protonix 40 mg daily
Restoril PRN

ALLERGIES: Penicillins / Codeine / Latex

PHYSICAL EXAM: 100.1  78  135/66  16  94% sat with BMV on 100% O2.
Intubated, sedated
Thin, elderly
No rash
Prosthetic Lt. eye, rt eye pupil reactive
No LAD
CTA
[**Last Name (un) **] [**Last Name (un) **], no MR, no S3
Abdomen thin, non-distended, soft, bowel sounds diminished
1+ periperal edema, LE venous stasis changes.
Strong (3+) periperal pulses on warm, dry extremities.

FAMILY HISTORY: Maternal fatal MI

SOCIAL HISTORY: Lives with daughter, has 8 grown children, is Italian, and has
'reverted to her native language' since her CVA per dtr.  She
worked as a laundress.  Unknown tob hx./etoh hx (dtr. not
available to answer this).
Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Intestinal infection due to Clostridium difficile,Fitting and adjustment of cardiac pacemaker,Encephalopathy, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Unspecified essential hypertension,Polymyalgia rheumatica,Hypopotassemia,Iron deficiency anemia, unspecified,Nontoxic multinodular goiter
Acute respiratry failure,Food/vomit pneumonitis,Atrial fibrillation,Int inf clstrdium dfcile,Ftng cardiac pacemaker,Encephalopathy NOS,DMII wo cmp nt st uncntr,Late ef-hemplga side NOS,Hypertension NOS,Polymyalgia rheumatica,Hypopotassemia,Iron defic anemia NOS,Nontox multinodul goiter
Admission Date:  [**2141-9-10**]              Discharge Date:   [**2141-10-5**]

Date of Birth:  [**2063-12-13**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Codeine / Latex

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:
PEG placement [**2141-9-27**]
Lumbar puncture [**2141-9-11**]

History of Present Illness:
77 year old woman with complicated PMHx. including CVA with
residual Lt. sided hemiparesis was at home with her daughter
when she began exhibiting signs of a URI with sneezing, upper
airway congestion, lethargy (evening of [**9-9**]).  The following
morning, she was noted to be eating less, less energetic, less
responsive, and had a fever of 102.  At approximately 4 pm on
[**9-10**], her daughter called her mother's primary physician's
office, and was instructed to bring her mother to the [**Name (NI) **]
immediately.  For unclear reasons, she did not do so, and
continued to try to get her mother to eat and drink and take
tylenol, which she was unsuccessful in doing.  By approximately
8 pm, her mother was increasingly lethargic and was not
responding to voice.  Her daughter called EMS, and on arrival
they noted that she was responsive only to painful stimuli, and
had alot of upper airway secretions and appeared to be in
respiratory distress.  She was subsequently intubated at the
scene and was transported to the [**Hospital1 18**] ED.  On arrival in the
ED, she was noted to have a fever to 102, and was tachy in AFib
with a rapid response in the 170's.  Her blood pressure was
160's over palp.  2 peripheral IV's were placed, and she was
sedated with propofol and maintained on AC ventilation.  1500 cc
of NS were bolused, and she was administered Vancomycin,
Levofloxacin, and Flagyl emperically for suspected infectious
etiology, and given a stated PCN allergy (dtr. initially related
this and then retracted - unclear if she has or not).  She had
blood cultures drawn X 2 (negative to date), and UA and culture
(unremarkable), CXR (clear), and LP (clear).  Her
anticoagulation for PAF was not reversed (INR on presentation
was 3.1) prior to her LP in the ED, but the tap was clear
without red cells (nonetheless, she will need to be observed
with neuro checks q 2 hours as possible given her propofol
sedation to evaluate for emerging possible epidural hematoma
formation).  A CT of the head and abdomen are currently pending,
and after these have been completed, she is planned for
admission to the ICU, dx: ams and acute respiratory failure.


Past Medical History:
Ascending Aortic Aneurysm
Polymyalgia Rheumatica
Recurrent UTI's on Macrodantin ppx. chronically
HTN
CVA (multiple?) with residual Lt. hemiparesis and expressive
aphasia
? of a seizure d/o
Pacemaker for sick sinus syndrome and PAF (overdrive pacing)
GERD
PAF on coumadin
Anxiety
PTSD (initial trauma WWII)
Depression
Multinodular goiter
Diabetes (type 2)

Social History:
Lives with daughter, has 8 grown children, is Italian, and has
'reverted to her native language' since her CVA per dtr.  She
worked as a laundress.  Unknown tob hx./etoh hx (dtr. not
available to answer this).

Family History:
Maternal fatal MI

Physical Exam:
100.1  78  135/66  16  94% sat with BMV on 100% O2.
Intubated, sedated
Thin, elderly
No rash
Prosthetic Lt. eye, rt eye pupil reactive
No LAD
CTA
[**Last Name (un) **] [**Last Name (un) **], no MR, no S3
Abdomen thin, non-distended, soft, bowel sounds diminished
1+ periperal edema, LE venous stasis changes.
Strong (3+) periperal pulses on warm, dry extremities.

Pertinent Results:
[**2141-9-10**] 11:30PM CEREBROSPINAL FLUID (CSF)  PROTEIN-48*
GLUCOSE-77
[**2141-9-10**] 11:30PM CEREBROSPINAL FLUID (CSF)  WBC-1 RBC-0 POLYS-0
LYMPHS-70 MONOS-30
[**2141-9-10**] 11:30PM CEREBROSPINAL FLUID (CSF)  WBC-1 RBC-0 POLYS-0
LYMPHS-70 MONOS-30
[**2141-9-10**] 10:30PM URINE  GR HOLD-HOLD
[**2141-9-10**] 10:30PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2141-9-10**] 10:30PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2141-9-10**] 10:30PM URINE  RBC-0-2 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2141-9-10**] 10:30PM URINE  MUCOUS-FEW
[**2141-9-10**] 10:30PM URINE  MUCOUS-FEW
[**2141-9-10**] 10:10PM   UREA N-19 CREAT-0.9
[**2141-9-10**] 10:10PM   CK(CPK)-33
[**2141-9-10**] 10:10PM   AMYLASE-49
[**2141-9-10**] 10:10PM   CK-MB-NotDone cTropnT-0.01
[**2141-9-10**] 10:10PM   ASA-NEG ETHANOL-NEG ACETMNPHN-6.7
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2141-9-10**] 10:10PM   WBC-10.6# RBC-4.93 HGB-12.5 HCT-37.3 MCV-76*
MCH-25.3* MCHC-33.4 RDW-14.4
[**2141-9-10**] 10:10PM   WBC-10.6# RBC-4.93 HGB-12.5 HCT-37.3 MCV-76*
MCH-25.3* MCHC-33.4 RDW-14.4
[**2141-9-10**] 10:10PM   PT-21.5* PTT-33.8 INR(PT)-3.1
[**2141-9-10**] 10:10PM   FIBRINOGE-518*
.
Stool C diff [**9-13**]:  CLOSTRIDIUM DIFFICILE.
         FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
.
AP CXR [**10-3**]:  A patchy opacity seen in the right upper lobe,
which may be a composite shadow, however, dedicated PA and
lateral view would be helpful for evaluation of this.
.
AP CXR [**10-1**]:  Small right pleural effusion is new. Left lower
lobe atelectasis has improved. Upper lungs clear. Heart size is
top normal. Atrial transvenous pacer lead heads towards the
tricuspid valve, however, replacement assessment would require
routine radiographs. Ventricular lead apparent standard
placement. No pneumothorax.
.

AP CXR [**9-12**]:
1. Interval increase in right lower lobe consolidation,
consistent with pneumonia and/or aspiration.
2. Interval increase in small left pleural effusion.


Brief Hospital Course:
Briefly, this is a 77 year old woman who presented with MS
change, fever, afib with RVR, and increased upper airway
secretions who was initially intubated in the field and
transferred to the [**Hospital1 18**] MICU.  The pt was never started on
pressors, she was started on broad spectrum antibiotics
(vanc/levo/flagyl), and she was quickly extubated and
transferred to the medicine service.  The pts CXRs began to
shown signs of aspiration pneumonia, so she was treated with a 2
week course of levofloxacin and vancomycin.  CXRs near the time
of discharge revealed resolved aspiration pneumonia.  However,
the pt always required frequent suctioning for copious
secretions.  During her stay the pt also developed C. diff
colitis and was treated with a 2 week course of flagyl.  The pt
remained encephalopathic throughout her hospitalization, never
returning to her baseline mental status.  She remained on NGT
feeds for the majority of her hospitalization as she failed 3
speech and swallow evaluations.  The pt finally underwent PEG
placement on [**9-27**] and was tolerating her feedings.  The pt had
finally reached therapeutic levels on coumadin immediately prior
to discharge, however pt should remain on a heparin gtt for
several days given pts prior h/o multiple strokes in the past.
.
1. Respiratory Failure/Aspiration Pneumonia: The pt was
intubated in the field prior to the pt coming to the [**Hospital3 **]
ED.  As is was felt the pt likely had aspiration pneumonia, she
was started on broad spectrum antibiotics of vancomycin and
levofloxacin.  The pt was quickly extubated in the MICU and
transferred to the medicine service, again never requiring
pressors.  Prior to [**9-12**], chest films demonstrated only a
suggestion of slight interstitial prominence that may be
consistent with an atypical pneumonia.  On CXR following [**9-12**]
there was evidence of RLL infiltrate and pulmonary engorgement.
The pt was continued on a 2 week course of levofloxacin and
vancomycin (both discontinued on [**9-28**]) for treatment of
aspiration pneumonia.  CXR from [**9-15**] revealed a RLL pneumonia
improving and small BL pleural effusions. CXR again from [**9-24**]
revealed improving bilateral lower lobe aspiration pneumonia.
CXR from [**10-1**] revealed a small right sided pleural effusion and
resolution of the aspiration pneumonia.  Final AP CXR from [**10-3**]
revealed a possibled RUL infiltrate vs shadow, however a repeat
AP/lateral did not reveal the same infiltrate.  Throughout the
hospitalization the pt required frequent suctioning for copious
secretions.
.
2. Fever: Prior to admission, the pt had a fever to 102 at home
and was found to be 101 in the ED.  Admission UA was clear,
admission blood cultures were negative, urine cultures were
negative, initial CXR was without focal infiltrates, and CSF
fluid from the lumbar puncture was clear.  Again, the pt was
immediately started on broad spectrum antibiotics of
levofloxacin, flagyl, and vancomycin. The pts fever resolved
quickly on this regimen.  However, the pt again spiked a fever
on [**9-25**] to 101.4.  The pts WBC also trended up to 16 on [**9-24**].
Blood Cx were drawn and were negative, UA and Urine Cx from [**9-25**]
were negative for signs of infections, and CXR from that day had
revealed resolving aspiration pneumonia.  The pt had many
potential sources of infection, including her foley, NG tube,
and antibiotics.  The source of the fever from [**9-25**] was unclear,
but she remained afebrile with a normalized WBC (WBC 11 on [**9-25**]
and subsequently ranged 7-9) until the time of discharge.
.
3. Altered mentation: It is unclear how many strokes the pt has
suffered, but the daughter describes an expressive aphasia and
residual Lt. sided weakness as well (at least two different
vascular distributions).  CT of the head negative for acute
bleed.  Patient had an EEG on [**2141-9-12**], and that was read as:
"Abnormal EEG due to a diffusely and moderately slowed and
disorganized record with some additional frontal slowing with
blunted sharp components. While there is no evidence of
focality, the record does suggest a diffuse encephalopathy of
mild degree with superimposed increased irritability involving
subcortical or deeper midline structures. This could represent
either a vascular etiology or a toxic and metabolic entity
although no triphasic waves were seen to suggest a full blown
metabolic encephalopathy." There is an unclear explanation for
the change in MS, but her change seemed to have coincided with
the initial aspiration pneumonia.  The pt will need
rehabilitation placement for the deficits and impairments
associated with this changed in mental status.
.
4. Paroxysmal atrial fibrillation -
The pt was in rapid ventricular response on presentation, most
likely triggered by infection.  She responded with rate control,
sedation, IVF and abx alone, and was not initially administered
any nodal agents.  INR was slightly supra-therapuetic on
presentation at 3.1 - and this was not reversed prior to LP in
the [**Last Name (LF) **], [**First Name3 (LF) **] she was administered FFP and Vitamin K for rapid
reversal after the procedure was completed.  Following
extubation the pt required a diltiazem drip.  This was quickly
weened off and the pt was started on lopressor and verapamil.
These medications were titrated up to a final dose of verapamil
160 mg po q 8 hr and lopressor 50 mg po TID.  The pt was also
started on a heparin drip following FFP/VitK administration
along with her coumadin until she was therapeutic again.
Coumadin was held for PEG placement on [**9-27**] and was restarted on
[**9-29**] along with a heparin drip to bridge her again.  Pts INR
only reached therapeutic level of 2 on day of discharge,
requiring several more days of heparin gtt given pts h/o
multiple prior strokes.
.
On [**9-24**] the pt had an episode of bradycardia down to 29 while
sleeping. Pts PCM was interrogated by EP and it was felt the pts
battery was low.  The PCM was changed by EP from dual chamber
pacing to unipolar VVI40 pacing to extend the battery life. The
PCM battery was not changed by EP due to the patient's overall
poor prognosis.
.
5. C. difficile colitis:  Stool culture from [**9-13**] revealed C
diff toxin.  The pt was started on flagyl 500 mg TID on [**9-14**] and
this was continued up until [**9-29**].  Prior to discharge the pt was
not experiencing any further episodes of diarrhea.
.
6.  FEN:  The pt was placed on aspiration precautions and NGT
was placed for tube feedings.  The pt failed speech and swallow
evals 3 times(secondary to her mental status) prior to PEG
placement on [**9-27**].  The pt was tolerating her tube feeds at 90
cc/hr for 16 hrs/day prior to discharge.   Speech and swallow
recommended short term rehab with speech therapy at rehab for
dysphagia management.
.
7. HTN - Initially all antihypertensives were held as it was
unclear if she had suffered a stroke. However head CT was
negative on admission.  The pt was started on po lopressor and
verapamil for both blood pressure and rate control, as well as
lisinopril.  Her medications were titrated up to final doses of
lisinopril 20 mg qd, lopressor 50 mg TID, and verapamil 160 mg q
8 hr with good blood pressure control.
.
8. DM - She carries the diagnosis of NIDDM, and appeared to be
diet controlled at home.  The pt was managed on a simple RISS
with qid FSBG.  Her blood sugars were well controlled throughout
the hospitalization.
.
9. Anemia:  The pt has anemia of chronic disease as her iron is
low, ferritin is high, MCV is normal, and transferrin is low.
(iron 19, ferritin 298, transferrin 193 [**9-14**]).  Her hematocrit
remained stable in the low 30s and she did not require
transfusion.


Medications on Admission:
Atenolol 50 daily
Warfarin 2 mg daily
Lisinopril 10 mg daily
Macrodantin 100 mg twice daily
Remeron 15 mg HS
Olanzapine 5 mg daily
Protonix 40 mg daily
Restoril PRN

Discharge Medications:
1. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray
Mucous membrane  PRN (as needed).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Morphine 2 mg/mL Syringe Sig: One (1) mg Injection Q4H (every
4 hours) as needed for pain.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Verapamil 80 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours): hold for heart rate less than 55 and SBP less than 100.

8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO DAILY (Daily).
9. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  TID
(3 times a day) as needed for to necessary areas.
12. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection Q4H (every 4
hours) as needed for agitation.
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): For finger stick of 150-200 give
2 units of insulin.  For FS of 201-250 give 4 units. For FS of
251-300 give 6 units. For FS of 301-350 give 8 units.  For FS of
351-400 give 10 units.  For FS of greater than 400 give 10 units
and call your doctor. .
14. Warfarin Sodium 2.5 mg Tablet Sig: Three (3) Tablet PO HS
(at bedtime).
15. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: One (1) as directed Intravenous  ASDIR (AS DIRECTED).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - Acute Rehab

Discharge Diagnosis:
s/p Aspiration pneumonia
s/p C. difficile colitis
Encephalopathy
Atrial Fibrillation


Discharge Condition:
stable and improved with resolution of fever and aspiration
pneumonia.  Mental status not yet at baseline.  INR not yet
therapeutic on coumadin.


Discharge Instructions:
Please take all medications as prescribed.
Please return to the ED or call your primary doctor if your
symptoms return or worsen (ie. cough, difficulty breathing,
lethargy)

Followup Instructions:
After discharge from rehab, you should follow up with your
primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3029**], [**Telephone/Fax (1) 250**]


                             [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
{'Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Intestinal infection due to Clostridium difficile,Fitting and adjustment of cardiac pacemaker,Encephalopathy, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Unspecified essential hypertension,Polymyalgia rheumatica,Hypopotassemia,Iron deficiency anemia, unspecified,Nontoxic multinodular goiter'}


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: Altered mental status

PRESENT ILLNESS: 77 year old woman with complicated PMHx. including CVA with
residual Lt. sided hemiparesis was at home with her daughter
when she began exhibiting signs of a URI with sneezing, upper
airway congestion, lethargy (evening of [**9-9**]).  The following
morning, she was noted to be eating less, less energetic, less
responsive, and had a fever of 102.  At approximately 4 pm on
[**9-10**], her daughter called her mother's primary physician's
office, and was instructed to bring her mother to the [**Name (NI) **]
immediately.  For unclear reasons, she did not do so, and
continued to try to get her mother to eat and drink and take
tylenol, which she was unsuccessful in doing.  By approximately
8 pm, her mother was increasingly lethargic and was not
responding to voice.  Her daughter called EMS, and on arrival
they noted that she was responsive only to painful stimuli, and
had alot of upper airway secretions and appeared to be in
respiratory distress.  She was subsequently intubated at the
scene and was transported to the [**Hospital1 18**] ED.  On arrival in the
ED, she was noted to have a fever to 102, and was tachy in AFib
with a rapid response in the 170's.  Her blood pressure was
160's over palp.  2 peripheral IV's were placed, and she was
sedated with propofol and maintained on AC ventilation.  1500 cc
of NS were bolused, and she was administered Vancomycin,
Levofloxacin, and Flagyl emperically for suspected infectious
etiology, and given a stated PCN allergy (dtr. initially related
this and then retracted - unclear if she has or not).  She had
blood cultures drawn X 2 (negative to date), and UA and culture
(unremarkable), CXR (clear), and LP (clear).  Her
anticoagulation for PAF was not reversed (INR on presentation
was 3.1) prior to her LP in the ED, but the tap was clear
without red cells (nonetheless, she will need to be observed
with neuro checks q 2 hours as possible given her propofol
sedation to evaluate for emerging possible epidural hematoma
formation).  A CT of the head and abdomen are currently pending,
and after these have been completed, she is planned for
admission to the ICU, dx: ams and acute respiratory failure.

MEDICAL HISTORY: Ascending Aortic Aneurysm
Polymyalgia Rheumatica
Recurrent UTI's on Macrodantin ppx. chronically
HTN
CVA (multiple?) with residual Lt. hemiparesis and expressive
aphasia
? of a seizure d/o
Pacemaker for sick sinus syndrome and PAF (overdrive pacing)
GERD
PAF on coumadin
Anxiety
PTSD (initial trauma WWII)
Depression
Multinodular goiter
Diabetes (type 2)

MEDICATION ON ADMISSION: Atenolol 50 daily
Warfarin 2 mg daily
Lisinopril 10 mg daily
Macrodantin 100 mg twice daily
Remeron 15 mg HS
Olanzapine 5 mg daily
Protonix 40 mg daily
Restoril PRN

ALLERGIES: Penicillins / Codeine / Latex

PHYSICAL EXAM: 100.1  78  135/66  16  94% sat with BMV on 100% O2.
Intubated, sedated
Thin, elderly
No rash
Prosthetic Lt. eye, rt eye pupil reactive
No LAD
CTA
[**Last Name (un) **] [**Last Name (un) **], no MR, no S3
Abdomen thin, non-distended, soft, bowel sounds diminished
1+ periperal edema, LE venous stasis changes.
Strong (3+) periperal pulses on warm, dry extremities.

FAMILY HISTORY: Maternal fatal MI

SOCIAL HISTORY: Lives with daughter, has 8 grown children, is Italian, and has
'reverted to her native language' since her CVA per dtr.  She
worked as a laundress.  Unknown tob hx./etoh hx (dtr. not
available to answer this). 

### Response:
{'Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Atrial fibrillation,Intestinal infection due to Clostridium difficile,Fitting and adjustment of cardiac pacemaker,Encephalopathy, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Unspecified essential hypertension,Polymyalgia rheumatica,Hypopotassemia,Iron deficiency anemia, unspecified,Nontoxic multinodular goiter'}
