CHIEF COMPLAINT: L sided weakness, problem with speech

PRESENT ILLNESS: Ms. [**Known lastname 36818**] [**Last Name (Titles) **] an 87 year old woman hx atrial fibrillation on
coumadin, right thalamic infarct, who was last known to be well
at 8pm on [**2178-3-24**], who was found by a nursing aide at 8am on
[**3-25**] to be dysarthria and severely  phasic. The patient was able
to say that she was "cold". She had left-sided weakness. EMS was
called at 8:15am and patient was taken to [**Hospital1 18**]. En route, her
fs was 221 and she vomited two times.

MEDICAL HISTORY: Atrial Fibrillation
CVA
HTN
Hypercholesterolemia
Depression
Anxiety

MEDICATION ON ADMISSION: Lisinopril 5mg daily
Lasix 20mg daily
Synthroid 0.15 mg daily
Diltiazem SR 120mg qam
Vitamin D 400 units daily
Oxybutynin 10mg qam
Labetalol  100mg [**Hospital1 **]
Remeron 30mg qhs
Lipitor 20mg qhs
Coumadin 3mg on Sunday, Monday, Tuesday, Wednesday and 2mg on
Thursday, Friday, and Saturday
Tylenol #3 prn pain
Pericolace two tabs [**Hospital1 **]
Lactulose 30cc daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
========================
VS:  Tc 103.7       BP 175/118  then 119/74       P  185 Vtach
then 124      R  16-21     02 99%
Gen: intubated
Heent: supple neck, no carotid bruits, no lymphadenopathy
Chest: lungs clear to auscultation bilaterally, no wheezes,
rales, or rhonchi
Heart: irregularly irregular, no murmurs,
Abd: soft, non-distended, non-tender, no mass, decreased bowel
sounds
Ext: no cyanosis, clubbing, or edema
Skin: no erythema
Neuro: MS: opens eyes to verbal, follows commands to wiggle
fingers
CN: decreased blink to threat on the left, tracks horizontally,
pupils 4 to 3mm bilaterally, no obvious facial droop
Motor: normal tone and bulk of all four extremities, no tremor
 3/5 Strength of biceps and triceps bilaterally
 2/5 Strength of legs bilaterally
Sensory: withdraws with all four extremities to noxious stimuli
Reflex:  T     BR   B      K    A    toes
Left     2      2     2    2     2    mute
Right    2      2     2    2     2    mute
Coord: unable to assess

FAMILY HISTORY: Mother had CVA.

SOCIAL HISTORY: Lives alone in independent living facility since her husband
died. She has an aide for 12 hours per day, then for 1 hour in
the evening. At baseline, 1 assist transfer to wheelchair. 3
sons who live in the area, 1 son is a physician. [**Name10 (NameIs) 4273**] EtOH,
tobacco or IDU.
Unspecified septicemia,Acute and subacute necrosis of liver,Paroxysmal ventricular tachycardia,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Urinary tract infection, site not specified,Subendocardial infarction, initial episode of care,Septic shock,Acute on chronic systolic heart failure,Encephalopathy, unspecified,Subarachnoid hemorrhage,Long-term (current) use of anticoagulants,Unspecified essential hypertension
Septicemia NOS,Acute necrosis of liver,Parox ventric tachycard,Food/vomit pneumonitis,Meth sus pneum d/t Staph,Urin tract infection NOS,Subendo infarct, initial,Septic shock,Ac on chr syst hrt fail,Encephalopathy NOS,Subarachnoid hemorrhage,Long-term use anticoagul,Hypertension NOS
Admission Date:  [**2178-3-25**]              Discharge Date:   [**2178-4-2**]


Service: EMERGENCY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
L sided weakness, problem with speech

Major Surgical or Invasive Procedure:
Central line placement
Arterial line placement
Intubation
Mechanical ventilation

History of Present Illness:
Ms. [**Known lastname 36818**] [**Last Name (Titles) **] an 87 year old woman hx atrial fibrillation on
coumadin, right thalamic infarct, who was last known to be well
at 8pm on [**2178-3-24**], who was found by a nursing aide at 8am on
[**3-25**] to be dysarthria and severely  phasic. The patient was able
to say that she was "cold". She had left-sided weakness. EMS was
called at 8:15am and patient was taken to [**Hospital1 18**]. En route, her
fs was 221 and she vomited two times.

In the ED, her exam was pupils reactive, with eye deviation to
the right, not following commands, and non verbal. Her arms were
drifting down bilaterally. At 9:49am, the patient developed
ventricular tachycardia. Vitals were BP 175/118 and HR 124. She
was given amiodarone 150mg iv once, followed by amiodarone
0.5mg/min drip. Patient was intubated and sedated with Propofol.
Her rhythm became atrial fib with rate in the 120's to 140's.
Her BP decreased to 119/74.

CT brain did not show early signs of infarct or bleed. CTA did
not show cutoff of an intracranial vessel. CT perfusion shows
increased mean transit time of the right MCA and left ACA
region. Patient was outside the window for TPA or mechanical
clot retrieval.  She was admitted to the SICU.

Past Medical History:
Atrial Fibrillation
CVA
HTN
Hypercholesterolemia
Depression
Anxiety


Social History:
Lives alone in independent living facility since her husband
died. She has an aide for 12 hours per day, then for 1 hour in
the evening. At baseline, 1 assist transfer to wheelchair. 3
sons who live in the area, 1 son is a physician. [**Name10 (NameIs) 4273**] EtOH,
tobacco or IDU.


Family History:
Mother had CVA.


Physical Exam:
ADMISSION PHYSICAL EXAM
========================
VS:  Tc 103.7       BP 175/118  then 119/74       P  185 Vtach
then 124      R  16-21     02 99%
Gen: intubated
Heent: supple neck, no carotid bruits, no lymphadenopathy
Chest: lungs clear to auscultation bilaterally, no wheezes,
rales, or rhonchi
Heart: irregularly irregular, no murmurs,
Abd: soft, non-distended, non-tender, no mass, decreased bowel
sounds
Ext: no cyanosis, clubbing, or edema
Skin: no erythema
Neuro: MS: opens eyes to verbal, follows commands to wiggle
fingers
CN: decreased blink to threat on the left, tracks horizontally,
pupils 4 to 3mm bilaterally, no obvious facial droop
Motor: normal tone and bulk of all four extremities, no tremor
 3/5 Strength of biceps and triceps bilaterally
 2/5 Strength of legs bilaterally
Sensory: withdraws with all four extremities to noxious stimuli
Reflex:  T     BR   B      K    A    toes
Left     2      2     2    2     2    mute
Right    2      2     2    2     2    mute
Coord: unable to assess

UPON TRANSFER TO MICU:
======================
97.0 99 121/73 97%RA
GEN: ill appearing, aphasic
HEENT: poor dentition, dry mucus membranes
CV: irregualr, s1, s2, noi m/g/r
RESP: CTA anteriorly, allthough some rhochi laterally
ABD: soft, NT, ND
EXT: minimal edema
NEURO: aphasic, moves all extermities.

Pertinent Results:
ADMISSION LABS:
================
[**2178-3-25**] 10:24PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2178-3-25**] 10:24PM URINE  BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2178-3-25**] 10:24PM URINE  RBC-[**4-8**]* WBC-[**4-8**] BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2178-3-25**] 10:05PM   PT-29.0* PTT-150 IS HIG INR(PT)-2.9*
[**2178-3-25**] 10:03PM   CK(CPK)-49
[**2178-3-25**] 10:03PM   CK-MB-NotDone cTropnT-0.67*
[**2178-3-25**] 10:24AM   GLUCOSE-187* LACTATE-3.5* NA+-131* K+-5.0
CL--96* TCO2-24
[**2178-3-25**] 10:10AM   GLUCOSE-210* UREA N-14 CREAT-0.8 SODIUM-132*
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-22 ANION GAP-18
[**2178-3-25**] 10:10AM   ALT(SGPT)-15 AST(SGOT)-23 CK(CPK)-53 ALK
PHOS-90 TOT BILI-0.7
[**2178-3-25**] 10:10AM   cTropnT-0.11*
[**2178-3-25**] 10:10AM   CALCIUM-8.3* PHOSPHATE-3.4 MAGNESIUM-1.8
[**2178-3-25**] 10:10AM   TSH-0.19*
[**2178-3-25**] 10:10AM   WBC-10.6 RBC-4.14* HGB-13.3 HCT-40.3 MCV-97
MCH-32.3* MCHC-33.1 RDW-14.0
[**2178-3-25**] 10:10AM   NEUTS-63.5 LYMPHS-32.8 MONOS-2.1 EOS-1.0
BASOS-0.6
[**2178-3-25**] 10:10AM   PT-17.6* PTT-23.8 INR(PT)-1.6*

MICROBIOLOGY:
=============
[**2178-3-25**] 8:23 pm SPUTUM     Site: ENDOTRACHEAL
GRAM STAIN (Final [**2178-3-26**]):
      >25 PMNs and <10 epithelial cells/100X field.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2178-3-28**]):
      OROPHARYNGEAL FLORA ABSENT.
      STAPH AUREUS COAG +.    HEAVY GROWTH.
         SENSITIVITIES: MIC expressed in MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S

[**2178-3-25**] 10:24 pm URINE
URINE CULTURE (Final [**2178-3-28**]):
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--     4 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN----------    64 I
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----  =>16 R

[**2178-4-1**] 10:52 am SPUTUM     Site: EXPECTORATED
Source: Endotracheal.
GRAM STAIN (Final [**2178-4-1**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2178-4-4**]):
      OROPHARYNGEAL FLORA ABSENT.
      YEAST.    SPARSE GROWTH.
      YEAST.    RARE GROWTH.  2ND TYPE.
      STAPH AUREUS COAG +.    RARE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE #
246-1943Y([**2178-3-25**]).

[**3-25**] BCx x 2: negative
[**3-29**] BCx x 2: negative
[**3-29**] UCx: negative
[**3-31**] BCx x 1: negative
[**3-31**] C. diff: negative
[**3-31**] UCx: negative
[**4-1**] BCx x 2: negative
[**4-1**] UCx: negative
[**4-2**] BCx: negative

[**3-31**] DFA negative for Influenzae A & B

STUDIES:
========
[**3-25**] CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS
IMPRESSION:
1. CT perfusion findings are consistent with acute ischemia in
the right MCA and right MCA/ACA watershed distribution as well
as the left ACA distribution. Possible acute ischemia in the
left PCA territory. No evidence for intravascular thrombus or
intracranial hemorrhage.
2. 3-mm left PCA P2 segment aneurysm without evidence for
hemorrhage.

CHEST (PORTABLE AP)  [**2178-3-25**]
IMPRESSION:
1. Endotracheal tube extending into the left main stem bronchus.
Repositioning is required. This was discussed with the nurse
caring for the patient, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at cell number [**Serial Number 36819**], at
approximately 10:45 a.m.
2. Increased opacity of the left lung base, possibly
representing aspiration. Followup radiographs are recommended.
3. Stable cardiomegaly with no evidence of acute congestive
heart failure.

EKG [**3-25**]
Atrial fibrillation, average ventricular rate 120. Left anterior
hemiblock.  Intraventricular conduction delay. Non-specific
lateral repolarization changes. Cannot exclude anterior
myocardial infarction of indeterminate age though unlikely.
Compared to the previous tracing of [**2177-3-13**] ventricular response
rate to atrial fibrillation is faster, ventricular ectopy is
absent, and the late precordial R wave progression (suggesting
interval anterior myocardial infarction)is new.

CHEST (PORTABLE AP)  [**2178-3-26**]
IMPRESSION:
1) Endotracheal tube abutting the right lateral tracheal wall.
The tube should be slightly advanced for more optimal placement.
2) Proximal gastric tube, with the side port just below the
gastroesophageal junction, might be edvanced 15-20 cm.
3) Improving left upper lobe aeration with persistent bibasilar
opacities, likely atelectasis.

MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST [**2178-3-26**]
IMPRESSION:
No evidence for acute ischemia.
Extensive small vessel ischemic sequela.
Aneurysm of the left PCA and left Posterior Communicating
Artery.

Portable TTE (Complete) Done [**2178-3-26**]
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Overall left ventricular systolic function is
severely depressed (LVEF= 20 %) secondary to akinesis of the
interventricular septum, anterior free wall, and apex. Right
ventricular chamber size is normal. with focal hypokinesis of
the apical free wall. The ascending aorta is mildly dilated. The
aortic valve is not well seen. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.

Compared with the findings of the prior study (images reviewed)
of [**2177-7-18**], the left ventricular ejection fraction is now
severely reduced, most likely secondary to coronary artery
disease and intercurrent myocardial infarction.

[**2178-3-27**] EEG
IMPRESSION: Abnormal portable EEG due to the slow and
disorganized background, bursts of generalized slowing, and
occasional additional  slowing on the right side. The first two
abnormalities signify a widespread encephalopathic condition
affecting both cortical and  subcortical structures.
Medications, metabolic disturbances, and infection are among the
most common causes. There was additional focal  slowing on the
right, indicating subcortical dysfunction and likely related to
the abnormality described on the requisition. Nevertheless,
there were no epileptiform features. An abnormal cardiac rhythm
was
noted.

LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT  [**2178-3-29**]
LIVER/GALLBLADDER ULTRASOUND: This evaluation is limited due to
lack of patient mobility. The liver is of normal echotexture
with no gross focal lesions identified. There is no intra- or
extra-hepatic ductal dilatation. The common duct measures 5 mm.
The gallbladder is not visualized and likely absent. There is
appropriate forward portal venous flow. The pancreas is not
demonstrated due to overlying bowel gas. The spleen is
incompletely visualized, however, appears to measure 7 cm. There
is a small amount of perihepatic fluid.
IMPRESSION:
Limited examination. Small perihepatic fluid. Otherwise
unremarkable liver gallbladder ultrasound.

CHEST (PORTABLE AP)  [**2178-4-2**]
The ET tube tip is 3 cm above the carina but note is made that
the tip impinges the right tracheal wall, thus it should be
repositioned to prevent stricture or malacia. The right internal
jugular line tip terminates in distal SVC. The NG tube tip
passes below the diaphragm with its tip most likely below the
inferior margin of the film. The heart size is mildly enlarged
but stable. The mediastinal silhouette is unremarkable.
Bilateral pleural effusions are moderate-to-large, slightly
progressed since yesterday although it might be contributed by
slightly different position of the patient. No evidence of
failure is present. No focal consolidations worrisome for
pneumonia are identified although they may be obscured by
overlying effusion.

Portable TTE (Complete) Done [**2178-4-2**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is severe
regional left ventricular systolic dysfunction with akinesis of
the septum, mid- and distal anterior wall and distal LV
segments/apex, with relative preservation of
inferolateral/lateral wall contraction (LVEF = 25-30%). Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.

IMPRESSION: Severe regional left ventricular systolic
dysfunction. Mild right ventricular systolic dysfunction. Mild
aortic regurgiation.
Compared with the prior study (images reviewed) of [**2178-3-26**],
biventricular function has slightly improved, although the
regional distribution of wall motion abnormalities is similar.
Severity of mitral regurgitation and pulmonary hypertension has
lessened. The other findings are similar.

Brief Hospital Course:
The patient is an 87M w/ h/o right thalamic bleed and residual
left leg weakness, CVA in [**2169**], HTN, afib on coumadin who
presented [**3-25**] from independent living after being found to be
nonverbal and have left-sided weakness by her nurse aide. Her
blood sugar was 221 and she vomited twice on the way to the
hospital. Soon after arriving to the ED, she went into ?vtach
for about 5 minutes and was started on an amio drip after an
amio load of 150mgx1. She was intubated and converted back to
her native rhythm, afib in the 120s, and put on labetalol for
rate control. Her last INR before this was 1.5 on [**3-19**]. Head
CT/CTA showed evidence of acute right MCA/watershed stroke and
the patient was admitted to the neuro ICU service. She was
outside the window for TPA or mechanical clot retrieval. She was
febrile to 104 and started on Vanc/Zosyn. She required pressors
(neosynephrine) until [**3-26**] at 5pm and was also extubated on
[**3-26**]. Her urine was found to be growing E. coli and sputum to be
growing coag+ staph.

Cardiology was consulted for her vtach and recommended stopping
amio and starting diltiazem drip as well as titrating up BB
(switching labetalol to metoprolol) and starting ACEI as
tolerated by BP. Troponins rose from 0.11 in the ED to a peak of
0.87 [**3-27**]. CK peaked at 10 and MBI at 4.0 (last values). TTE
found EF of 20% 2/2 akinesis of the interventricular septum,
anterior free wall, and apex; this is down from 55% in [**2177**]
which had normal wall motion. Troponin elevation thought to be
secondary to increased cardiac demand.

MRI head done on [**3-26**] showed no evidence of acute ischemia. The
findings on CT were thought to be possibly artifact per the
neuro team. She failed a speech and swallow eval and NGT was
recommended, although this was attempted twice unsuccessfully
due to patient not cooperating. She was given one dose of
coumadin and her INR increased to 6.9.

On [**2178-3-27**], she was transferred to the MICU service for medical
management of her altered mental status and multiple medical
problems, including dysarthria, aphasia, elevated troponin,
newly depressed EF, coag + staph in sputum and klebsiella in her
urine.

During her course in the MICU, the patient continued to be
altered.  Given newly depressed EF, elevated troponin, VT on
arrival to ED, and new wall motion abnormalities, the priamry
event for her altered mental status may in fact have been an MI,
with hypotension/ischemia exacerbating underlying neurologic
deficits. Infection with staph in sputum and klebsiella in urine
also may have contributed.  EEG was negative for seizure.  For a
presumed NSTEMI, diltiazem drip was changed to esmolol drip for
beta blockade.  Nitro gtt was later instituted for afterload
reduction.  She was also started on digoxin daily.

For her coag + staph in sputum she was continued on vancomycin
for MRSA pneumonia.  Zosyn was switched to ceftriaxone after UCx
sensitivities returned.  However, the patient continued to spike
fevers despite treatment with vancomycin and ceftriaxone.  In
the setting of rising WBC, she was switched to cefepime for
added pseudomonal coverage.  She was pan cultured, which did not
show any new source of infection.

During her course, she became increasingly tachypneic with cough
and was re-intubated for airway protection  and increased work
of breathing.  She remained coagulopathic and received vitamin K
and FFP to reverse.  DIC panel was negative.  Her INR may have
been elevated in the setting of warfarin with amiodarone,
antibiotics and malnutrition.  Her renal function returned to
baseline during her course.  She also was found to have
transaminitis, which was thought to be due to hypoperfusion.  In
this setting, amiodarone and statin were held.  Hep serologies
negative, and RUQ U/S was negative.

Vascular surgery was consulted for concern for ischemic digits
(R fingers > L fingers > toes).  She was started on argatroban
gtt.

Towards the end of her hospitalization, the patient required
pressor support.  After extensive discussion with her HCP and
family, the patient was made CMO.  She expired shortly after
extubation and withdrawal of intensive medical management.

Medications on Admission:
Lisinopril 5mg daily
Lasix 20mg daily
Synthroid 0.15 mg daily
Diltiazem SR 120mg qam
Vitamin D 400 units daily
Oxybutynin 10mg qam
Labetalol  100mg [**Hospital1 **]
Remeron 30mg qhs
Lipitor 20mg qhs
Coumadin 3mg on Sunday, Monday, Tuesday, Wednesday and 2mg on
Thursday, Friday, and Saturday
Tylenol #3 prn pain
Pericolace two tabs [**Hospital1 **]
Lactulose 30cc daily


Discharge Medications:
Expired.

Discharge Disposition:
Expired

Discharge Diagnosis:
1. Respiratory failure
2. Altered mental status
3. Non ST elevation MI
4. Cardiac Arrhythmias (atrial fibrillation, ventricular
tachycardia)
5. Pneumonia
6. Urinary tract infection
7. Acute Renal Failure
8. Coagulopathy
9. Digit Ischemia

Discharge Condition:
Expired.

Discharge Instructions:
None.

Followup Instructions:
None.


Completed by:[**2178-4-25**]
{'Unspecified septicemia,Acute and subacute necrosis of liver,Paroxysmal ventricular tachycardia,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Urinary tract infection, site not specified,Subendocardial infarction, initial episode of care,Septic shock,Acute on chronic systolic heart failure,Encephalopathy, unspecified,Subarachnoid hemorrhage,Long-term (current) use of anticoagulants,Unspecified essential hypertension'}


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: L sided weakness, problem with speech

PRESENT ILLNESS: Ms. [**Known lastname 36818**] [**Last Name (Titles) **] an 87 year old woman hx atrial fibrillation on
coumadin, right thalamic infarct, who was last known to be well
at 8pm on [**2178-3-24**], who was found by a nursing aide at 8am on
[**3-25**] to be dysarthria and severely  phasic. The patient was able
to say that she was "cold". She had left-sided weakness. EMS was
called at 8:15am and patient was taken to [**Hospital1 18**]. En route, her
fs was 221 and she vomited two times.

MEDICAL HISTORY: Atrial Fibrillation
CVA
HTN
Hypercholesterolemia
Depression
Anxiety

MEDICATION ON ADMISSION: Lisinopril 5mg daily
Lasix 20mg daily
Synthroid 0.15 mg daily
Diltiazem SR 120mg qam
Vitamin D 400 units daily
Oxybutynin 10mg qam
Labetalol  100mg [**Hospital1 **]
Remeron 30mg qhs
Lipitor 20mg qhs
Coumadin 3mg on Sunday, Monday, Tuesday, Wednesday and 2mg on
Thursday, Friday, and Saturday
Tylenol #3 prn pain
Pericolace two tabs [**Hospital1 **]
Lactulose 30cc daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM
========================
VS:  Tc 103.7       BP 175/118  then 119/74       P  185 Vtach
then 124      R  16-21     02 99%
Gen: intubated
Heent: supple neck, no carotid bruits, no lymphadenopathy
Chest: lungs clear to auscultation bilaterally, no wheezes,
rales, or rhonchi
Heart: irregularly irregular, no murmurs,
Abd: soft, non-distended, non-tender, no mass, decreased bowel
sounds
Ext: no cyanosis, clubbing, or edema
Skin: no erythema
Neuro: MS: opens eyes to verbal, follows commands to wiggle
fingers
CN: decreased blink to threat on the left, tracks horizontally,
pupils 4 to 3mm bilaterally, no obvious facial droop
Motor: normal tone and bulk of all four extremities, no tremor
 3/5 Strength of biceps and triceps bilaterally
 2/5 Strength of legs bilaterally
Sensory: withdraws with all four extremities to noxious stimuli
Reflex:  T     BR   B      K    A    toes
Left     2      2     2    2     2    mute
Right    2      2     2    2     2    mute
Coord: unable to assess

FAMILY HISTORY: Mother had CVA.

SOCIAL HISTORY: Lives alone in independent living facility since her husband
died. She has an aide for 12 hours per day, then for 1 hour in
the evening. At baseline, 1 assist transfer to wheelchair. 3
sons who live in the area, 1 son is a physician. [**Name10 (NameIs) 4273**] EtOH,
tobacco or IDU. 

### Response:
{'Unspecified septicemia,Acute and subacute necrosis of liver,Paroxysmal ventricular tachycardia,Pneumonitis due to inhalation of food or vomitus,Methicillin susceptible pneumonia due to Staphylococcus aureus,Urinary tract infection, site not specified,Subendocardial infarction, initial episode of care,Septic shock,Acute on chronic systolic heart failure,Encephalopathy, unspecified,Subarachnoid hemorrhage,Long-term (current) use of anticoagulants,Unspecified essential hypertension'}
