CHIEF COMPLAINT: nausea and vomiting

PRESENT ILLNESS: [**Known firstname **] [**Known lastname 30279**] is a 75 yo right handed woman with an extensive
cardiac history including mechanical mitral valve presenting for
evaluation of a cerebellar hemorrhage.

MEDICAL HISTORY: - Atrial fibrillation
- Ventricular Fibrillation s/p ICD
- History of congestive cardiac failure (last EF 30% in [**2126**])
- Rheumatic heart disease s/p mitral St.Jude's valve placed [**2112**]
- ? Aortic valve disease
- s/p spontaneous subdural hematoma in [**2126**].  Per our records:
left frontal with extension of the subdural into the dura around
the falx. Also a more acute tentorial subdural hematoma.
- Hypothyroidism
- cataract, awaiting possible surgery
- s/p cholecystectomy

MEDICATION ON ADMISSION: - Sotolol 120mg [**Hospital1 **]
- Lovenox 90mg q12
- Coumadin 4mg
- ASA 81
- Ambien 5mg
- Bumex 1-2mg daily
- Levothyroxine 137mcg
- Potassium 20mg [**Hospital1 **]

ALLERGIES: Heparin Agents / Valium

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Temp 98.2 HR 75 BP 154/70 RR 26 O2 95%
General: Awake, Anxious appearing.
Head and Neck: no cranial abnormalities, ? mild conjuntival
icterus?, mucus membranes dry, no lesions noted in oropharynx
Neck: Supple, no rigidity
Pulmonary: Mild crackles at the bases, occasionally increased RR
to mid 20's (pt reports anxiety, no chest pain or difficulty
breathing).
Cardiac: irregular, + mechanical mitral click and ?AV murmur as
well
Abdomen: midly distended but soft, some tenderness to palpation,
moreso on the right upperquadrant.  Normoactive bowel sounds.
Extremities: 2+ LE edema
Skin: large hematoma over the left lower abdomen, with multiple
other bruises on the arms and abdomen.

FAMILY HISTORY: Mother with [**Name (NI) 11964**], died at 94.  [**Month (only) 116**] have had a small
stroke.
Brother with lung cancer
Multiple aunts and [**Name2 (NI) 12232**] with cancer
(pt says had a colonscopy)

SOCIAL HISTORY: Married.  Retired, used to work odd jobs (Shoe factory, school
bus monitor). Denies any smoking, alcohol or drugs.
Intracerebral hemorrhage,Cerebral edema,Congestive heart failure, unspecified,Atrial fibrillation,Rheumatoid arthritis,Heart valve replaced by transplant,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Automatic implantable cardiac defibrillator in situ,Anticoagulants causing adverse effects in therapeutic use,Heart valve replaced by other means,Panic disorder without agoraphobia,Subdural hemorrhage
Intracerebral hemorrhage,Cerebral edema,CHF NOS,Atrial fibrillation,Rheumatoid arthritis,Heart valve transplant,Long-term use anticoagul,Abnrml coagultion prfile,Status autm crd dfbrltr,Adv eff anticoagulants,Heart valve replac NEC,Panic dis w/o agorphobia,Subdural hemorrhage
Admission Date:  [**2137-10-11**]              Discharge Date:   [**2137-10-25**]

Date of Birth:  [**2062-6-2**]             Sex:   F

Service: NEUROLOGY

Allergies:
Heparin Agents / Valium

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
nausea and vomiting

Major Surgical or Invasive Procedure:
None


History of Present Illness:
[**Known firstname **] [**Known lastname 30279**] is a 75 yo right handed woman with an extensive
cardiac history including mechanical mitral valve presenting for
evaluation of a cerebellar hemorrhage.

The patient reports that yesterday afternoon she began to
develop
a constant, aching pain in the back of her head.  Over the
course
of the evening she had progressive nausea and vomiting/dry
heaves
which prompted her evaluation at [**Hospital 8641**] Hospital.  On arrival
there, the vitals were T 97.8, Pulse 55, RR 17, BP 117/42.  Chem
7 was normal, INR 2.5. A CT of the head was obtained and was
notable for a left cerebellar hemorrhage. The patient was
transferred here for further evaluation and treatment.

Of note, the patient was recently hospitalized at [**Hospital 8641**]
hospital
for 8 days.  She states she went there due to feelings of
chills,
shivering.  She was also nauseated and thought perhaps she had a
urinary tract infaction as her urine was dark. She reports that
there was concern for CHF exacerbation and she was placed on
bipap.  She was also treated with antibiotics, but she is not
sure which or for what type of infection.  She was apparently
briefly on bipap. While hospitalized, her INR was subtherapeutic
and she was placed on a lovenox bridge.

Other than the symptoms above, the patient denies any slurred
speech, difficulty swalling, incoordination. She has felt
imbalanced when walking intermittently since her headache began.
She denies any new double vision but reports for the

On neurologic review of systems, the patient reports [**3-21**] ache
over her occiput.  She has no loss of vision, vertigo, tinnitus
or hearing difficulty. Denied focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.

On general review of systems, the patient denied fever or
chills.
She has no cough, shortness of breath.  Denied chest pain or
tightness, palpitations.  She notes rapid breathing but she is
also anxious. She continues to be nauseated and has dry mouth.
She also reports mild diffuse abdominal discomfort. She has no
change in bowel or bladder habits.  No dysuria.


Past Medical History:
- Atrial fibrillation
- Ventricular Fibrillation s/p ICD
- History of congestive cardiac failure (last EF 30% in [**2126**])
- Rheumatic heart disease s/p mitral St.Jude's valve placed [**2112**]
- ? Aortic valve disease
- s/p spontaneous subdural hematoma in [**2126**].  Per our records:
left frontal with extension of the subdural into the dura around
the falx. Also a more acute tentorial subdural hematoma.
- Hypothyroidism
- cataract, awaiting possible surgery
- s/p cholecystectomy


Social History:
Married.  Retired, used to work odd jobs (Shoe factory, school
bus monitor). Denies any smoking, alcohol or drugs.

Family History:
Mother with [**Name (NI) 11964**], died at 94.  [**Month (only) 116**] have had a small
stroke.
Brother with lung cancer
Multiple aunts and [**Name2 (NI) 12232**] with cancer
(pt says had a colonscopy)


Physical Exam:
ADMISSION PHYSICAL EXAM:
Temp 98.2 HR 75 BP 154/70 RR 26 O2 95%
General: Awake, Anxious appearing.
Head and Neck: no cranial abnormalities, ? mild conjuntival
icterus?, mucus membranes dry, no lesions noted in oropharynx
Neck: Supple, no rigidity
Pulmonary: Mild crackles at the bases, occasionally increased RR
to mid 20's (pt reports anxiety, no chest pain or difficulty
breathing).
Cardiac: irregular, + mechanical mitral click and ?AV murmur as
well
Abdomen: midly distended but soft, some tenderness to palpation,
moreso on the right upperquadrant.  Normoactive bowel sounds.
Extremities: 2+ LE edema
Skin: large hematoma over the left lower abdomen, with multiple
other bruises on the arms and abdomen.

Neurologic:
-Mental Status: Alert, oriented x 3.  Able to relate history
without difficulty.  Attentive.  Language is fluent with intact
repetition and comprehension.  Normal prosody.  There were no
paraphasic errors.  Pt. was able to name both high and low
frequency objects.  Speech was not dysarthric. The pt. had good
knowledge of current events.  There was no evidence of apraxia
or
neglect, calculations intact. Registered [**3-14**] and recalled [**3-14**] at
5 minutes.

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk.  Visual fields full on bedside
testing with red pin. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages.
III, IV, VI: horizontal, Left beating nystagmus in primary gaze,
worse on endgaze bilaterally. Poor smooth persuit.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid
bilaterally.

XII: Tongue protrudes in midline.

-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No rigidity. No adventitious movements, such as
tremors, noted. No asterixis.

  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L  5    5   5   5   5  5  5  5   5    5  5    5     5    5
R  5    5   5   5   5  5  5  5   5    5  5    5     5    5

-Sensory: Decreased PP in the soles of the feet and lateral
calves, absent vibration at the toes but present at the ankles.
intact proprioception. No extinction to double simultaneous
stimuli.

-Deep tendon reflexes: hyporeflexic throughout. Plantar response
was mute bilaterally.

-Coordination: ? mild intention tremor on left>right. No
dysmetria on HKS bilaterally.

-Gait: deferred at present.

Physical Exam At Discharge:

Vitals: 98.7 105/55 61 18 99% RA
General: Awake and alert, pleasant, NAD
Head and Neck: NCAT, MMM, OP clear
Neck: Supple, no rigidity
Pulmonary: CTAB
Cardiac: irregularly irregular, + mechanical mitral click and
systolic murmur as
well
Abdomen: soft, non-tender, non-distended.  Normoactive bowel
sounds.
Extremities: 2+ LE edema
Skin: +ecchymoses

Neurologic:
-Mental Status: Alert, oriented x 3.  Able to relate history
without difficulty.  Attentive.  Language is fluent with intact
repetition and comprehension.  Normal prosody.  There were no
paraphasic errors.  Pt. was able to name both high and low
frequency objects.  Speech was not dysarthric. The pt. had good
knowledge of current events.  There was no evidence of apraxia
or
neglect, calculations intact. Registered [**3-14**] and recalled [**3-14**] at
5 minutes.

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk.  Visual fields full on bedside
testing with red pin. Funduscopic exam revealed no papilledema,
exudates, or hemorrhages.
III, IV, VI: horizontal left beating nystagmus in primary gaze,
worse on endgaze bilaterally. Undershoots and corrections with
saccadic intrusions on smooth pursuit.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and sternocleidomastoid
bilaterally.

XII: Tongue protrudes in midline.

-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No rigidity. No adventitious movements, such as
tremors, noted. No asterixis.

  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L  5    5   5   5   5  5  5  5   5    5  5    5     5    5
R  5    5   5   5   5  5  5  5   5    5  5    5     5    5

-Sensory: Decreased PP in the soles of the feet and lateral
calves, absent vibration at the toes but present at the ankles.
intact proprioception. No extinction to double simultaneous
stimuli.

-Deep tendon reflexes: hyporeflexic throughout. Plantar response
was mute bilaterally.

-Coordination: mild dysmetria on finger to nose on L. No
dysmetria on HKS bilaterally.

-Gait: ambulates steadily with walker

Pertinent Results:
ADMISSION LABS:

[**2137-10-11**] 11:20AM BLOOD WBC-6.4 RBC-3.70* Hgb-12.0 Hct-36.0
MCV-97 MCH-32.3* MCHC-33.2 RDW-15.4 Plt Ct-213
[**2137-10-11**] 11:20AM BLOOD Neuts-87.4* Lymphs-10.0* Monos-2.2
Eos-0.2 Baso-0.2
[**2137-10-11**] 11:20AM BLOOD PT-16.9* PTT-33.4 INR(PT)-1.5*
[**2137-10-11**] 11:20AM BLOOD Glucose-163* UreaN-14 Creat-0.7 Na-135
K-3.9 Cl-99 HCO3-23 AnGap-17
[**2137-10-11**] 11:20AM BLOOD ALT-32 AST-46* AlkPhos-82 TotBili-2.4*
[**2137-10-11**] 11:20AM BLOOD CK-MB-2
[**2137-10-11**] 11:20AM BLOOD cTropnT-<0.01
[**2137-10-12**] 04:31AM BLOOD CK-MB-2 cTropnT-<0.01
[**2137-10-11**] 11:20AM BLOOD Calcium-8.7 Phos-2.9 Mg-2.3
[**2137-10-11**] 04:18PM BLOOD %HbA1c-5.8 eAG-120
[**2137-10-12**] 04:31AM BLOOD Triglyc-83 HDL-35 CHOL/HD-4.7 LDLcalc-111

DISCHARGE LABS:

WBC RBC    Hgb  Hct  MCV  MCH  MCHC RDW Plt Ct
6.1 3.37* 11.3* 32.5* 97 33.5* 34.7 14.4 171
Neuts Bands Lymphs Monos Eos
84*     1     9*     5    1

PT    PTT  INR(PT)
24.1* 33.1   2.3*

Glucose UreaN Creat Na  K  Cl HCO3 AnGap
109       18   0.7 137 3.9 102 26   13

IMAGING:

CT HEAD [**2137-10-11**]: IMPRESSION:
1. Several areas of primarily extra-axial hemorrhage surrounding
the left
cerebellar hemisphere extending into the foramen magnum with
probable
intraparenchymal extension. Consider further evaluation with MRI
with
gadolinium if not contraindicated for further evalaution.
2. Increased density along the left tentorium suggests a small
subdural
hemorrhage.
3. Mild chronic small vessel ischemic disease and age-related
global atrophy.

CXR [**2137-10-11**]: IMPRESSION: Cardiomegaly with mild pulmonary
vascular congestion but no overt pulmonary edema.

ECHO [**2137-10-12**]: Conclusions
The left atrium is dilated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50%). The right ventricular cavity is dilated
with depressed free wall contractility. A bileaflet aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. A bileaflet mitral valve prosthesis is present. The
gradients are higher than expected for this type of prosthesis.
The tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
No intracardiac mass, clot, or vegetation seen, but best
excluded by transesophageal echocardiography.

CT HEAD [**2137-10-12**]: IMPRESSION: Interval slight increase of the
subdural and intraparenchymal left cerebellar hemorrhage with
slight increase of mass effect on the fourth ventricle but no
evidence of hydrocephalus.

CT HEAD [**2137-10-13**]: IMPRESSION:
1. Slight interval increase in size of the left cerebellar
hemispheric
intraparenchymal hemorrhage with increased effacement of the
quadrigeminal
plate cistern, concerning for upward transtentorial herniation.
2. No significant change in quantity of subdural hemorrhage
overlying the
left cerebellar hemisphere, layering on the left leaflet of the
tentorium
cerebelli, and within the foramen magnum.
3. Persistent effacement of the fourth ventricle without a
change in size of the third or lateral ventricles to suggest
acute hydrocephalus.
4. No new intracranial hemorrhage or evidence of acute large
vascular
territorial infarction.

CT HEAD [**2137-10-14**]: IMPRESSION:
No significant change from the study dated [**2137-10-13**], with
no new
intracranial hemorrhage.

ABDOMINAL U/S [**2137-10-14**]: IMPRESSION:
1. No intrahepatic bile duct or CBD dilation.
2. Dilated hepatic veins. Small right pleural effusion.
Note is made that the combination of these findings could
suggest the
possibility of congestive heart failure. Clinical correlation
recommended.

CT HEAD [**2137-10-15**]:
IMPRESSION: Stable left cerebellar hemisphere hemorrhage and
associated mass effect. Stable small left paratentorial and
parafalcine subdural hemorrrhage. Stable small left convexity
subarachnoid hemorrhage.

CT/CTA [**2137-10-17**]:
IMPRESSION:
1. No evidence of AVM or other vascular abnormality.
2. Stable size and associated mass effect of the large left
cerebellar
hemorrhage. No new acute hemorrhage identified.
The study and the report were reviewed by the staff radiologist.


CT head [**2137-10-18**]:
IMPRESSION: Essentially unchanged appearance of the posterior
fossa hematoma and associated mass effect compared to the prior
study of [**2137-10-17**].

Lower extremity dopplers [**2137-10-17**]:
IMPRESSION: No evidence of DVT.

Abd US [**2137-10-14**]:
IMPRESSION:
1. No intrahepatic bile duct or CBD dilation.
2. Dilated hepatic veins. Small right pleural effusion.
Note is made that the combination of these findings could
suggest the
possibility of congestive heart failure. Clinical correlation
recommended.


Brief Hospital Course:
[**Known firstname **] [**Known lastname 30279**] is a 75 yo right handed woman with a complex
cardiac history which includes a mechanical mitral valve who
presented as a transfer from [**Hospital 8641**] Hospital for evaluation of a
left cerebellar hemorrhage.

# Neuro: Patient's INR was already reversed when it was taken in
the ED (and was 1.5).  Her anticoagulation was held because of
her concerning cerebellar hemorrhage.  She was put on mannitol
which helped to control her brain edema, although on [**10-12**] she
had an increase in her bleeding noted on head CT.  Her
neurological exam remained stable.  Cardiology was consulted and
they recommended anticoagulating as soon as it was safe. A
repeat CT was perfomed on [**10-17**] along with a CTA, which showed
stable appearance of her bleed with no underlying AVM or other
abnormalities. She was started on a heparin drip on [**10-17**]. A
second repeat CT on [**10-18**] was stable and she was started on
coumadin. Her PTT and INR were monitored closely. Heparin was
discontinued on [**2137-10-23**]. Coumadin was continued and her INR
gradually increased to 2.3 by [**10-25**]. Per discussion with
cardiology her goal INR will be 2.5-3 to balance the risks of
her mechanical valve with her recent intracranial hemorrhage.
She remained neurologically stable throughout the rest of her
admission. She was seen by PT and OT who recommended rehab
placement upon discharge.

She was having issues with panic attacks at 3am most nights
without chest pain or shortness of breath but with HTN to SBP of
170's.  She reported that panic attacks were common for her.
She was started on trazodone 25mg QHS with improvement.

She also complained of back and leg pain in a sciatic
distribution during her hospital stay. She was started on
Neurontin 300mg TID with improvement.

# Cardiovascular:  she was continued on bumex at 1mg once a day
(she takes 1-2 mg at home).  Her goal SBP was between 120-160,
and was given hydralazine PRN to keep her BP within this goal
range.  We continued her home sotalol dose, and started her on
amlodipine 5mg QD to better control her BP.  We consulted
cardiology for the complicated management issue of
anticoagulation of her mechanical valve while also helping to
control her cerebellar hemorrhage.  They recommended to
anticoagulate her as soon as possible, with an adjusted goal INR
of 2.5-3.

# Endo: pt was maintained on an insulin sliding scale while
inpatient.

# GI: pt appeared mildly jaundiced on admission with LFTs that
showed an elevated Tbili and elevated Dbili.  Hemolysis labs
show some mild hemolysis and cardiology reassured us that her
bili level is normal for a mechanical valve.  In addition we
obtained an abdominal U/S that was unremarkable.

# Pulmonary: CXR showed vascular engorgement but no overt
pulmonary edema/effusion.   She did not have any further
respiratory issues throughout this hospitalization.

# CODE: full

TRANSITIONAL CARE ISSUES:
Will need rehab to regain prior level of functioning.
Will need to remain on coumadin with strict monitoring to
maintain INR 2.5-3.

Medications on Admission:
- Sotolol 120mg [**Hospital1 **]
- Lovenox 90mg q12
- Coumadin 4mg
- ASA 81
- Ambien 5mg
- Bumex 1-2mg daily
- Levothyroxine 137mcg
- Potassium 20mg [**Hospital1 **]


Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever >100.5.
2. levothyroxine 137 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. bumetanide 0.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Pt normally takes [**1-13**] daily Hold for SBP<110 .
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).

7. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
9. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
10. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia or agitation.
12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 12564**] Hospital

Discharge Diagnosis:
Primary: Cerebellar hemorrhage
Secondary: atrial fibrillation, mechanical mitral valve


Discharge Condition:
Condition: stable
Mental status: clear and coherent
Ambulatory status: with assistance
{'Intracerebral hemorrhage,Cerebral edema,Congestive heart failure, unspecified,Atrial fibrillation,Rheumatoid arthritis,Heart valve replaced by transplant,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Automatic implantable cardiac defibrillator in situ,Anticoagulants causing adverse effects in therapeutic use,Heart valve replaced by other means,Panic disorder without agoraphobia,Subdural hemorrhage'}


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: nausea and vomiting

PRESENT ILLNESS: [**Known firstname **] [**Known lastname 30279**] is a 75 yo right handed woman with an extensive
cardiac history including mechanical mitral valve presenting for
evaluation of a cerebellar hemorrhage.

MEDICAL HISTORY: - Atrial fibrillation
- Ventricular Fibrillation s/p ICD
- History of congestive cardiac failure (last EF 30% in [**2126**])
- Rheumatic heart disease s/p mitral St.Jude's valve placed [**2112**]
- ? Aortic valve disease
- s/p spontaneous subdural hematoma in [**2126**].  Per our records:
left frontal with extension of the subdural into the dura around
the falx. Also a more acute tentorial subdural hematoma.
- Hypothyroidism
- cataract, awaiting possible surgery
- s/p cholecystectomy

MEDICATION ON ADMISSION: - Sotolol 120mg [**Hospital1 **]
- Lovenox 90mg q12
- Coumadin 4mg
- ASA 81
- Ambien 5mg
- Bumex 1-2mg daily
- Levothyroxine 137mcg
- Potassium 20mg [**Hospital1 **]

ALLERGIES: Heparin Agents / Valium

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
Temp 98.2 HR 75 BP 154/70 RR 26 O2 95%
General: Awake, Anxious appearing.
Head and Neck: no cranial abnormalities, ? mild conjuntival
icterus?, mucus membranes dry, no lesions noted in oropharynx
Neck: Supple, no rigidity
Pulmonary: Mild crackles at the bases, occasionally increased RR
to mid 20's (pt reports anxiety, no chest pain or difficulty
breathing).
Cardiac: irregular, + mechanical mitral click and ?AV murmur as
well
Abdomen: midly distended but soft, some tenderness to palpation,
moreso on the right upperquadrant.  Normoactive bowel sounds.
Extremities: 2+ LE edema
Skin: large hematoma over the left lower abdomen, with multiple
other bruises on the arms and abdomen.

FAMILY HISTORY: Mother with [**Name (NI) 11964**], died at 94.  [**Month (only) 116**] have had a small
stroke.
Brother with lung cancer
Multiple aunts and [**Name2 (NI) 12232**] with cancer
(pt says had a colonscopy)

SOCIAL HISTORY: Married.  Retired, used to work odd jobs (Shoe factory, school
bus monitor). Denies any smoking, alcohol or drugs. 

### Response:
{'Intracerebral hemorrhage,Cerebral edema,Congestive heart failure, unspecified,Atrial fibrillation,Rheumatoid arthritis,Heart valve replaced by transplant,Long-term (current) use of anticoagulants,Abnormal coagulation profile,Automatic implantable cardiac defibrillator in situ,Anticoagulants causing adverse effects in therapeutic use,Heart valve replaced by other means,Panic disorder without agoraphobia,Subdural hemorrhage'}
