CHIEF COMPLAINT: Resp failure, altered mental status

PRESENT ILLNESS: [**Age over 90 **] year old female with recent [**Hospital1 18**] discharge after complicated
hospitalization presenting with a one day history of acute
mental status change, dypsnea and hypoxia. Per the [**Hospital1 1501**] notes,
she was initially noted to be confused on the [**11-12**] shift on
[**2163-6-6**], specifically described as "restless, shouting," and was
given 0.5 mg Ativan and 975 mg acetaminophen and 25 mg of
benadryl. She was up that shift, with visual hallucinations and
crying. Staff was unable to redirect or reorient her. She was
sent to the ED for altered mental status evlaution. She was
given an additional dose of 0.5 mg of Ativan for anxiety without
indicates she was complaining about pain in the left knee.
.
In the ED, vitals were 99.6 BP 120/64 HR 64 R 34, 95% NRB/91%
RA. FSBG was 105. She was treated initially with 10 mg IV
decadron and 2 g IV Cefepime and 1 g Vancomycin. She reported
shortness of breath but denied chest pain. The ED team noted
diffuse wheezing and a nonproductive cough. She was guaiac
negative. She was started on IV fluid, then was treated with
nebs, 2 g of magnesium. She was started on CPAP and initially
had improvement, but was unable to tolerate the mask after 45
minutes. Due to increasing agitation the patient was intubated.
CT head has a questionable lesion and Neurology was consulted.
MRI was recommended. She is transferred to the [**Hospital Unit Name 153**] for further
management.
.
On arrival to the [**Hospital Unit Name 153**], the patient is having generalized
clonus, which resolves with sedation.
.
The patient was hospitalized at [**Hospital1 18**] from [**5-23**] through [**2163-5-31**]
for acute cholecystitis. She was medically managed with
antibiotics. Her course was complicated by sepsis from S.
milleri bacteremia, NSTEMI in the setting of sepsis, respiratory
failure requiring intubation, anuric renal failure and the
development of back pain. Given the bacteremia and NSTEMI, echo
was performed which demonstrated a thickened mitral leaflet. It
was determined that she could not tolerate a TEE and the plan
was for her to complete a 14 day course of zosyn followed by a 6
week course of Pen G for presumed endocarditis.
Discitis/osteomyelitis was considered as the patient complained
of back pain during the hospitalization during a period of
bacteremia, but in the absence of neurologic findings, she was
already planned to have a 6 week course of antibiotics, so no
imaging was pursued.

MEDICAL HISTORY: - Hypercholesterolemia
- Coronary artery disease
- Asthma
- Osteoarthritis
- CBD stones s/p 2 ERCP in [**2162**] with stent and stent removal
- Recent hospitalization with multiple insults, see above.

MEDICATION ON ADMISSION: Zosyn 2.25 gm every 8 hours, last dose due [**2163-6-8**]
Celexa 20 mg daily
Nexium 20 mg daily
Lidoderm patch
Aspirin 325 mg daily
Lasix 20 mg daily
MVI
Miralax daily
Colace
Lopressor 12.5 mg po bid
Aricept 5 mg daily
Simvastatin 10 mg daily
Trazodone 25 mg daily
Advair 250/50 mg [**Hospital1 **]
Combivent inhaler 2 puffs qid
Albuterol nebs prn, benadryl prn
Sarna--to back

ALLERGIES: Zoloft

PHYSICAL EXAM: VS: 97.6 100/37 69 16 100% on AC/450/16/8/100%
Gen: elderly, intubated, sedated, does not open eyes to name,
does not withdraw
HEENT: PERRL and midline, intubated
Neck:
Car: Regular
Resp: clear bilaterally, no wheeze, no ronchi
Abd: multiple hematomas, soft, positive bowel sounds
Ext: 2+ LE edema, symmetric to mid-shin
Neuro: sedated, does not follow commands, brisk/symmetric
reflexes in upper and lower extremities. sustained clonus in
feet, no clonus in hands. Toes mute.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: currently residing at [**Hospital1 **]. No tobacco, EtOH.
Daughter is [**Hospital1 93429**], has two other daughters.
Acute respiratory failure,Toxic encephalopathy,Acute kidney failure, unspecified,Other drugs and medicinal substances causing adverse effects in therapeutic use,Pressure ulcer, lower back,Anemia, unspecified,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Asthma, unspecified type, unspecified
Acute respiratry failure,Toxic encephalopathy,Acute kidney failure NOS,Adv eff medicinal NEC,Pressure ulcer, low back,Anemia NOS,Pure hypercholesterolem,Crnry athrscl natve vssl,Asthma NOS
Admission Date:  [**2163-6-6**]              Discharge Date:   [**2163-6-17**]


Service: MEDICINE

Allergies:
Zoloft

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Resp failure, altered mental status

Major Surgical or Invasive Procedure:
Intubation/extubation
Central line placement and removal


History of Present Illness:
[**Age over 90 **] year old female with recent [**Hospital1 18**] discharge after complicated
hospitalization presenting with a one day history of acute
mental status change, dypsnea and hypoxia. Per the [**Hospital1 1501**] notes,
she was initially noted to be confused on the [**11-12**] shift on
[**2163-6-6**], specifically described as "restless, shouting," and was
given 0.5 mg Ativan and 975 mg acetaminophen and 25 mg of
benadryl. She was up that shift, with visual hallucinations and
crying. Staff was unable to redirect or reorient her. She was
sent to the ED for altered mental status evlaution. She was
given an additional dose of 0.5 mg of Ativan for anxiety without
indicates she was complaining about pain in the left knee.
.
In the ED, vitals were 99.6 BP 120/64 HR 64 R 34, 95% NRB/91%
RA. FSBG was 105. She was treated initially with 10 mg IV
decadron and 2 g IV Cefepime and 1 g Vancomycin. She reported
shortness of breath but denied chest pain. The ED team noted
diffuse wheezing and a nonproductive cough. She was guaiac
negative. She was started on IV fluid, then was treated with
nebs, 2 g of magnesium. She was started on CPAP and initially
had improvement, but was unable to tolerate the mask after 45
minutes. Due to increasing agitation the patient was intubated.
CT head has a questionable lesion and Neurology was consulted.
MRI was recommended. She is transferred to the [**Hospital Unit Name 153**] for further
management.
.
On arrival to the [**Hospital Unit Name 153**], the patient is having generalized
clonus, which resolves with sedation.
.
The patient was hospitalized at [**Hospital1 18**] from [**5-23**] through [**2163-5-31**]
for acute cholecystitis. She was medically managed with
antibiotics. Her course was complicated by sepsis from S.
milleri bacteremia, NSTEMI in the setting of sepsis, respiratory
failure requiring intubation, anuric renal failure and the
development of back pain. Given the bacteremia and NSTEMI, echo
was performed which demonstrated a thickened mitral leaflet. It
was determined that she could not tolerate a TEE and the plan
was for her to complete a 14 day course of zosyn followed by a 6
week course of Pen G for presumed endocarditis.
Discitis/osteomyelitis was considered as the patient complained
of back pain during the hospitalization during a period of
bacteremia, but in the absence of neurologic findings, she was
already planned to have a 6 week course of antibiotics, so no
imaging was pursued.


Past Medical History:
- Hypercholesterolemia
- Coronary artery disease
- Asthma
- Osteoarthritis
- CBD stones s/p 2 ERCP in [**2162**] with stent and stent removal
- Recent hospitalization with multiple insults, see above.


Social History:
currently residing at [**Hospital1 **]. No tobacco, EtOH.
Daughter is [**Hospital1 93429**], has two other daughters.

Family History:
Non-contributory

Physical Exam:
VS: 97.6 100/37 69 16 100% on AC/450/16/8/100%
Gen: elderly, intubated, sedated, does not open eyes to name,
does not withdraw
HEENT: PERRL and midline, intubated
Neck:
Car: Regular
Resp: clear bilaterally, no wheeze, no ronchi
Abd: multiple hematomas, soft, positive bowel sounds
Ext: 2+ LE edema, symmetric to mid-shin
Neuro: sedated, does not follow commands, brisk/symmetric
reflexes in upper and lower extremities. sustained clonus in
feet, no clonus in hands. Toes mute.


Pertinent Results:
Labs on Admission:
[**2163-6-6**] 03:06PM BLOOD WBC-8.3 RBC-3.13* Hgb-9.0* Hct-27.8*
MCV-89# MCH-28.8 MCHC-32.3 RDW-13.7 Plt Ct-360
[**2163-6-6**] 03:06PM BLOOD Neuts-71.3* Lymphs-22.7 Monos-2.8 Eos-2.8
Baso-0.3
[**2163-6-6**] 03:06PM BLOOD PT-13.9* PTT-37.0* INR(PT)-1.2*
[**2163-6-6**] 03:06PM BLOOD Glucose-107* UreaN-22* Creat-1.2* Na-142
K-4.7 Cl-101 HCO3-33* AnGap-13
[**2163-6-6**] 03:06PM BLOOD ALT-37 AST-54* CK(CPK)-34 AlkPhos-100
TotBili-0.5
[**2163-6-6**] 03:06PM BLOOD Calcium-9.1 Phos-3.7 Mg-2.2
[**2163-6-7**] 05:51AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS
Barbitr-NEG Tricycl-NEG
[**2163-6-6**] 08:01PM BLOOD Type-ART Temp-37.2 pO2-121* pCO2-57*
pH-7.37 calTCO2-34* Base XS-6 Intubat-NOT INTUBA
[**2163-6-6**] 03:20PM BLOOD Lactate-1.1
.
Troponin trend:
[**2163-6-6**] 03:06PM BLOOD cTropnT-0.07*
[**2163-6-8**] 04:09AM BLOOD CK-MB-11* MB Indx-13.3* cTropnT-0.25*
[**2163-6-8**] 10:00AM BLOOD CK-MB-16* MB Indx-14.5* cTropnT-0.37*
[**2163-6-9**] 03:16AM BLOOD CK-MB-12* MB Indx-13.5*
.
Last set of labs:
[**2163-6-10**] 04:36AM BLOOD WBC-9.0 RBC-3.02* Hgb-9.1* Hct-27.4*
MCV-91 MCH-30.3 MCHC-33.4 RDW-14.7 Plt Ct-309
[**2163-6-10**] 04:36AM BLOOD PT-13.9* PTT-31.8 INR(PT)-1.2*
[**2163-6-10**] 04:36AM BLOOD Glucose-96 UreaN-22* Creat-1.1 Na-139
K-4.0 Cl-107 HCO3-27 AnGap-9
[**2163-6-10**] 04:36AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.9
.
Imaging:
CT Torso:
1. Diffuse ground-glass opacities predominantly within the upper
lobes which may represent infection and or aspiration. Small
bilateral pleural effusions, slightly enlarged compared to the
prior study. Mild superimpsoed edema noted.
2. Interval decompression of the gallbladder which currently
appears
contracted, with gallbladder wall thickening and a small amount
of
pericholecystic fluid and wall enhancement. These findings may
be consistent with chronic cholecystitis.
3. Stable aneurysm of the right superior pulmonary vein.
.
MRI head: No acute abnormality is seen. There is no evidence for
acute ischemia or abscess.
.
MRI c-spine: Multilevel cervical spondylosis. No definite
evidence for infectious sequela in the cervical spine.
.
CXR [**2163-6-9**]: Stable radiographic exam of the chest with
unchanged position of lines and tubes, stable cardiomegaly and
bibasilar opacification likely atelectasis.
.
ECHO: There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is mild regional
left ventricular systolic dysfunction with infero-lateral
hypokinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. with
borderline normal free wall function. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is minimal functional
mitral stenosis due to mitral annular calcification. Mild to
moderate ([**1-7**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
.
Microbiology:
BAL: STAIN (Final [**2163-6-8**]): 3+  (5-10 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2163-6-10**]): OROPHARYNGEAL FLORA
ABSENT. YEAST.    ~[**2154**]/ML.
LEGIONELLA CULTURE (Preliminary):    NO LEGIONELLA ISOLATED.
FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.
.
Legionella Urinary Antigen  (Final [**2163-6-8**]): NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
.
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2163-6-7**]):
      Negative for Influenza A viral antigen.
      Refer to respiratory viral culture for further
information.

   DIRECT INFLUENZA B ANTIGEN TEST (Final [**2163-6-7**]):
      NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
      Refer to respiratory viral culture for further
information.

   Rapid Respiratory Viral Antigen Test (Final [**2163-6-7**]):
      Respiratory viral antigens not detected.
      SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA
A,B AND
      RSV.
.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2163-6-7**]): Feces
negative for C.difficile toxin A & B by EIA.
.
URINE CULTURE (Final [**2163-6-7**]):    NO GROWTH.
.
Blood culture: No growth to date


Brief Hospital Course:
[**Age over 90 **] year old female s/p recent complicated hospitalization
presented with acute AMS and required intubation in ED.
.
# Atered mental status: Her overall picture is most consistent
with a global toxic-metabolic insult given the degree of
impairment and the lack of focal findings on physical
examination. On admission she had lower extremity clonus with
increased tone/rigidity (predominantly in the legs) which
resolved day 3 of hospital stay. Patient was briefly treated
with acyclovir which was discontinued upon normal MRI (no
temporal bleed). For concern of HAP patient started on Cefepime,
Levofloxacin and Vancomycin which was discontinued upon negative
BAL and CXR more consistent with volume overload. No evidence of
stroke on MRI. Due to concern of serotonin syndrome celexa and
aricept were discontinued on admission. EEG demonstrated no
seizure, but supported encephalopathy. Most likely etiology is
toxic encephalopathy secondary to medication use and multiple
co-morbidities. Patient improving at time of discharge, but
remained intermittently confused to severely encephalopathic.
Ordered olanzapine standing [**Hospital1 **], sublinguil olanzapine qhs.
.
# Respiratory failure: Patient intubated in ED prior to
transfer, unclear case of respiratory distress. Appeared to be
for airway protection based on agitation. Once weaned off
sedation, patient extubated herself. At time of discharge stable
on NC with 100% O2 sat. Over course of stay patient was + 6 L,
CXR demonstrated pulmonary edema and aggressive diuresis
improved respiratory status. Influenza and legionella antigen
negative. Continued outpatient COPD inhalers and morphine for
symptoms control of shortness of breath.  Oxygenation was stable
on discharge, patient requiring 2 liters of oxygen.  Pt.
experienced severe expiratory wheezed from the upper airway when
agitated.  This does not respond significantly to nebulizer
treatments of to diuresis.  This resolves when comfortably
sedated.  Oxygen saturations are maintained throughout these
events.
.
# Decreased UOP: Decreased day 1 of hospital stay and improved
throughout admission. Failure most likely contrast-induced
nephropathy vs prerenal (FeNa<1%).  Renal function normalized
during hospital stay; was not monitored towards end of stay once
pt.s family decided on comfort oriented care only.
.
# Elevated troponins: No EKG changes. ECHO demonstrated
improvement from prior ECHO on prior admission. Most likely
related to demand ischemia and trended downwards. Patient
started on high dose ASA and statin - which were discontinued
when goals of care were shifted to comfort/minimal invasiveness.

.
# Hypotension: First day of admission patient's MAP 50 and was
started on Levophed. Blood pressure improved once sedation was
weaned and was stable off pressors.
.
# Anemia: Iron panel consistent with anemia of chronic disease.
Stable at baseline Hct 28 (based on last admission).
.
# Goals of Care: Following discussion with family and HCP
decided on comfort focus due to poor extended prognosis with
complicated medical issues as listed above. All non-essential
medications were discontinued.  She was discharged to a skilled
nursing facility to optimize her symptoms and activity, with
plans for transition to hospice and avoidance of hospitalization
at time of her next event.
.
Contact: HCP Daughter [**Name (NI) 1785**] home [**Telephone/Fax (1) 93430**], cell
[**Telephone/Fax (1) 93431**]




Medications on Admission:
Zosyn 2.25 gm every 8 hours, last dose due [**2163-6-8**]
Celexa 20 mg daily
Nexium 20 mg daily
Lidoderm patch
Aspirin 325 mg daily
Lasix 20 mg daily
MVI
Miralax daily
Colace
Lopressor 12.5 mg po bid
Aricept 5 mg daily
Simvastatin 10 mg daily
Trazodone 25 mg daily
Advair 250/50 mg [**Hospital1 **]
Combivent inhaler 2 puffs qid
Albuterol nebs prn, benadryl prn
Sarna--to back


Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
2. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4
hours) as needed for wheezing.
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-7**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for puritis on back.
8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
9. Morphine 10 mg/5 mL Solution Sig: 2.5 mg PO Q4H (every 4
hours): hold for sedation.
10. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
12. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO twice a day:
hold for sedation.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
14. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Morphine 10 mg/5 mL Solution Sig: 2.5 to 5 mg PO Q3H (every
3 hours) as needed for pain or sob.


Discharge Disposition:
Extended Care

Facility:
[**Last Name (un) 14710**] House (Hospice Home) - [**Location (un) 620**]

Discharge Diagnosis:
Altered mental status/persistent encephalopathy
Respiratory failure


Discharge Condition:
Stable, symptoms well controlled.


Discharge Instructions:
Hospice care should be arranged concurrent with skilled nursing
facility placement.

Followup Instructions:
With hospice care as above
{'Acute respiratory failure,Toxic encephalopathy,Acute kidney failure, unspecified,Other drugs and medicinal substances causing adverse effects in therapeutic use,Pressure ulcer, lower back,Anemia, unspecified,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Asthma, unspecified type, unspecified'}


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: Resp failure, altered mental status

PRESENT ILLNESS: [**Age over 90 **] year old female with recent [**Hospital1 18**] discharge after complicated
hospitalization presenting with a one day history of acute
mental status change, dypsnea and hypoxia. Per the [**Hospital1 1501**] notes,
she was initially noted to be confused on the [**11-12**] shift on
[**2163-6-6**], specifically described as "restless, shouting," and was
given 0.5 mg Ativan and 975 mg acetaminophen and 25 mg of
benadryl. She was up that shift, with visual hallucinations and
crying. Staff was unable to redirect or reorient her. She was
sent to the ED for altered mental status evlaution. She was
given an additional dose of 0.5 mg of Ativan for anxiety without
indicates she was complaining about pain in the left knee.
.
In the ED, vitals were 99.6 BP 120/64 HR 64 R 34, 95% NRB/91%
RA. FSBG was 105. She was treated initially with 10 mg IV
decadron and 2 g IV Cefepime and 1 g Vancomycin. She reported
shortness of breath but denied chest pain. The ED team noted
diffuse wheezing and a nonproductive cough. She was guaiac
negative. She was started on IV fluid, then was treated with
nebs, 2 g of magnesium. She was started on CPAP and initially
had improvement, but was unable to tolerate the mask after 45
minutes. Due to increasing agitation the patient was intubated.
CT head has a questionable lesion and Neurology was consulted.
MRI was recommended. She is transferred to the [**Hospital Unit Name 153**] for further
management.
.
On arrival to the [**Hospital Unit Name 153**], the patient is having generalized
clonus, which resolves with sedation.
.
The patient was hospitalized at [**Hospital1 18**] from [**5-23**] through [**2163-5-31**]
for acute cholecystitis. She was medically managed with
antibiotics. Her course was complicated by sepsis from S.
milleri bacteremia, NSTEMI in the setting of sepsis, respiratory
failure requiring intubation, anuric renal failure and the
development of back pain. Given the bacteremia and NSTEMI, echo
was performed which demonstrated a thickened mitral leaflet. It
was determined that she could not tolerate a TEE and the plan
was for her to complete a 14 day course of zosyn followed by a 6
week course of Pen G for presumed endocarditis.
Discitis/osteomyelitis was considered as the patient complained
of back pain during the hospitalization during a period of
bacteremia, but in the absence of neurologic findings, she was
already planned to have a 6 week course of antibiotics, so no
imaging was pursued.

MEDICAL HISTORY: - Hypercholesterolemia
- Coronary artery disease
- Asthma
- Osteoarthritis
- CBD stones s/p 2 ERCP in [**2162**] with stent and stent removal
- Recent hospitalization with multiple insults, see above.

MEDICATION ON ADMISSION: Zosyn 2.25 gm every 8 hours, last dose due [**2163-6-8**]
Celexa 20 mg daily
Nexium 20 mg daily
Lidoderm patch
Aspirin 325 mg daily
Lasix 20 mg daily
MVI
Miralax daily
Colace
Lopressor 12.5 mg po bid
Aricept 5 mg daily
Simvastatin 10 mg daily
Trazodone 25 mg daily
Advair 250/50 mg [**Hospital1 **]
Combivent inhaler 2 puffs qid
Albuterol nebs prn, benadryl prn
Sarna--to back

ALLERGIES: Zoloft

PHYSICAL EXAM: VS: 97.6 100/37 69 16 100% on AC/450/16/8/100%
Gen: elderly, intubated, sedated, does not open eyes to name,
does not withdraw
HEENT: PERRL and midline, intubated
Neck:
Car: Regular
Resp: clear bilaterally, no wheeze, no ronchi
Abd: multiple hematomas, soft, positive bowel sounds
Ext: 2+ LE edema, symmetric to mid-shin
Neuro: sedated, does not follow commands, brisk/symmetric
reflexes in upper and lower extremities. sustained clonus in
feet, no clonus in hands. Toes mute.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: currently residing at [**Hospital1 **]. No tobacco, EtOH.
Daughter is [**Hospital1 93429**], has two other daughters. 

### Response:
{'Acute respiratory failure,Toxic encephalopathy,Acute kidney failure, unspecified,Other drugs and medicinal substances causing adverse effects in therapeutic use,Pressure ulcer, lower back,Anemia, unspecified,Pure hypercholesterolemia,Coronary atherosclerosis of native coronary artery,Asthma, unspecified type, unspecified'}
