CHIEF COMPLAINT: Shortness of breath, abd pain

PRESENT ILLNESS: 55 y/o female with HCV cirrhosis c/b recurrent hepatic
hydrothorax s/p TIPS [**6-13**] who presented with nausea, vomiting,
cough and SOB x 3days from recurrent L hydrothorax.

MEDICAL HISTORY: - HCV cirrhosis c/b hydrothorax s/p TIPS [**2111-6-16**]
- hepatic encephalopathy
- Hypothyroidism
- Depression/ anxiety
- MSSA spinal osteomyelitis/ discitis/ epidural
abscess/paravertebral abscess and cord compression s/p C2-C3
laminectomy in [**2107**] with resultant disability and "paralysis"
per OMR
- Prior IV cocaine use of short duration
- Negative PPD several years ago

MEDICATION ON ADMISSION: 1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a

ALLERGIES: Penicillins

PHYSICAL EXAM: ADMSSION EXAM:
VS - Temp F 97.5, BP 116/59, HR 114, RR: 16, 96 O2-sat % RA
GENERAL - patient was somnolent but in NAD A&Ox2 +asterixis
HEENT - Still with small pupils, EOMI, MMM
LUNGS - Lungs with diminshed BS on L and crackles on R. Wheezing
throughout.
HEART - 2/6 SEM heard throughout, nl S1-S2, S3 present
ABDOMEN - NABS, soft/NT, very distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - 2+ peripheral edema
NEURO - awake but lethargic, slow to respond to questions, A&Ox2
does not know month, CNs II-XII grossly intact, muscle strength
[**5-7**] throughout, sensation grossly intact throughout

FAMILY HISTORY: Mother with HTN and DM. Father unknown. Sister passed away from
pancreatic cancer. Grandmother with lung cancer.

SOCIAL HISTORY: On disability since her epidural abscess and laminectomy in
[**2107**]. Prior to that was a nurses aid, teacher, crossing guard
per OMR. Ambulates minimally with a walker and PT at rehab. At
baseline lives with her children but now at [**Hospital3 2558**] since
recurrent admissions.  Former smoker, denies alcohol or current
drug use. Past h/o cocaine use per OMR.
Unspecified septicemia,Defibrination syndrome,Acute kidney failure with lesion of tubular necrosis,Hepatorenal syndrome,Other specified forms of effusion, except tuberculous,Urinary tract infection, site not specified,Acidosis,Unspecified viral hepatitis C without hepatic coma,Sepsis,Anemia, unspecified,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Unspecified acquired hypothyroidism,Encounter for palliative care,Do not resuscitate status
Septicemia NOS,Defibrination syndrome,Ac kidny fail, tubr necr,Hepatorenal syndrome,Effusion NEC exc tb,Urin tract infection NOS,Acidosis,Hpt C w/o hepat coma NOS,Sepsis,Anemia NOS,Depressive disorder NEC,Anxiety state NOS,Hypothyroidism NOS,Encountr palliative care,Do not resusctate status
Admission Date:  [**2112-1-18**]              Discharge Date:   [**2112-2-2**]

Date of Birth:  [**2056-9-29**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Shortness of breath, abd pain

Major Surgical or Invasive Procedure:
Thoracentesis

History of Present Illness:
55 y/o female with HCV cirrhosis c/b recurrent hepatic
hydrothorax s/p TIPS [**6-13**] who presented with nausea, vomiting,
cough and SOB x 3days from recurrent L hydrothorax.

In the ED, initial VS: 97.8 100 130/70 28 98% 4L. Chest X-Ray
showed a large left pleural effusion. A thoracentesis was
performed a 1700cc of fluid was drained. She als had a RUQ U/S
which showed a patent TIPS shunt with wall-wall flow. Expected
forward main portal and reversed left portal flow. However
elevated velocities are seen in the mid and distal portions of
the TIPS (190-200), and normal velocity in the proximal TIPS (68
cm/s), concerning for early stenosis. Patent hepatic veins and
arteries. Small perihepatic [**Last Name (un) 2997**], with secondary gallbladder
wall edema. She was given morphine 5mg x3 and zofran 4mg x2. She
subsequently had worsening SOB and confusion. She received
narcan x1 with improvement in symptoms.

This morning she reports feeling confused and somewhat short of
breath but improved from prior to the pleurocentesis. She denies
ABD pain, n/v. The patient is not currently able to provide
significant history because of her confusion.

She has continued to have very low urine output and was bolused
1 L NS. Her labs were notable for an increase in her creatinine
from 0.9 to 1.2, and a wbc increase from 10 to 15. Lactate on
admission was 3.4 and repeat lactate this morning was 6.6. She
has remained tachycardic since admission.

Past Medical History:
- HCV cirrhosis c/b hydrothorax s/p TIPS [**2111-6-16**]
- hepatic encephalopathy
- Hypothyroidism
- Depression/ anxiety
- MSSA spinal osteomyelitis/ discitis/ epidural
abscess/paravertebral abscess and cord compression s/p C2-C3
laminectomy in [**2107**] with resultant disability and "paralysis"
per OMR
- Prior IV cocaine use of short duration
- Negative PPD several years ago

Social History:
On disability since her epidural abscess and laminectomy in
[**2107**]. Prior to that was a nurses aid, teacher, crossing guard
per OMR. Ambulates minimally with a walker and PT at rehab. At
baseline lives with her children but now at [**Hospital3 2558**] since
recurrent admissions.  Former smoker, denies alcohol or current
drug use. Past h/o cocaine use per OMR.


Family History:
Mother with HTN and DM. Father unknown. Sister passed away from
pancreatic cancer. Grandmother with lung cancer.

Physical Exam:
ADMSSION EXAM:
VS - Temp F 97.5, BP 116/59, HR 114, RR: 16, 96 O2-sat % RA
GENERAL - patient was somnolent but in NAD A&Ox2 +asterixis
HEENT - Still with small pupils, EOMI, MMM
LUNGS - Lungs with diminshed BS on L and crackles on R. Wheezing
throughout.
HEART - 2/6 SEM heard throughout, nl S1-S2, S3 present
ABDOMEN - NABS, soft/NT, very distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - 2+ peripheral edema
NEURO - awake but lethargic, slow to respond to questions, A&Ox2
does not know month, CNs II-XII grossly intact, muscle strength
[**5-7**] throughout, sensation grossly intact throughout

DISCHARGE EXAM:
Vital signs not checked for several days
Exam unchanged:
Icteric
Abdomen is soft, nontender, nondistended
Somnolent but arousable

Pertinent Results:
ADMSSION LABS:
[**2112-1-17**] 09:00PM   NEUTS-86.2* LYMPHS-8.1* MONOS-4.0 EOS-1.0
BASOS-0.6
[**2112-1-17**] 09:00PM   PLT COUNT-58*
[**2112-1-17**] 09:00PM   PT-21.4* PTT-38.5* INR(PT)-2.0*
[**2112-1-17**] 09:00PM   GLUCOSE-85 UREA N-13 CREAT-0.9 SODIUM-142
POTASSIUM-3.7 CHLORIDE-108 TOTAL CO2-24 ANION GAP-14
[**2112-1-17**] 09:00PM   estGFR-Using this
[**2112-1-17**] 09:00PM   ALT(SGPT)-65* AST(SGOT)-139* LD(LDH)-344* ALK
PHOS-266* TOT BILI-8.8*
[**2112-1-17**] 09:00PM   LIPASE-57
[**2112-1-17**] 09:00PM   TOT PROT-5.3* ALBUMIN-2.9* GLOBULIN-2.4
[**2112-1-17**] 09:13PM   LACTATE-3.4*
.
Thoracentesis:
[**2112-1-17**] 10:00PM PLEURAL  WBC-120* RBC-1395* POLYS-2* LYMPHS-32*
MONOS-14* MESOTHELI-1* MACROPHAG-51*
[**2112-1-17**] 10:00PM PLEURAL  TOT PROT-0.3 GLUCOSE-103 LD(LDH)-42
.
DIC LABS:
[**2112-1-27**] 02:31AM BLOOD WBC-4.2 RBC-2.56* Hgb-8.1* Hct-25.0*
MCV-97 MCH-31.4 MCHC-32.3 RDW-19.9* Plt Ct-25*
[**2112-1-24**] 05:00AM BLOOD PT-52.7* INR(PT)-6.5*
[**2112-1-24**] 12:44PM BLOOD PT-41.5* PTT-62.4* INR(PT)-4.8*
[**2112-1-25**] 01:23AM BLOOD PT-44.8* PTT-66.0* INR(PT)-4.4*
[**2112-1-25**] 05:30PM BLOOD Fibrino-51*
[**2112-1-25**] 11:41PM BLOOD Fibrino-48*
[**2112-1-26**] 04:10AM BLOOD Fibrino-49*
[**2112-1-22**] 05:20AM BLOOD Glucose-95 UreaN-43* Creat-2.5* Na-144
K-4.1 Cl-106 HCO3-23 AnGap-19
[**2112-1-23**] 05:40AM BLOOD Glucose-97 UreaN-43* Creat-2.4* Na-145
K-3.8 Cl-108 HCO3-25 AnGap-16
[**2112-1-24**] 05:00AM BLOOD Glucose-82 UreaN-42* Creat-2.0* Na-146*
K-3.7 Cl-108 HCO3-25 AnGap-17
[**2112-1-24**] 12:44PM BLOOD TotBili-10.4*
[**2112-1-25**] 05:30PM BLOOD ALT-22 AST-44* AlkPhos-53 TotBili-12.5*
[**2112-1-27**] 02:31AM BLOOD ALT-33 AST-77* AlkPhos-52 TotBili-15.2*
[**2112-1-27**] 02:31AM BLOOD Calcium-10.5* Phos-1.9* Mg-2.2
[**2112-1-24**] 04:45PM BLOOD Type-ART pO2-94 pCO2-48* pH-7.37
calTCO2-29 Base XS-1
[**2112-1-18**] 10:03AM BLOOD Lactate-6.6*
.
CXR [**1-17**] pre-thoracentesis
AP CHEST RADIOGRAPH: There is complete opacification of the left
hemithorax, with mild rightward shift of the mediastinum and
trachea. The right lung is well expanded and appears
unremarkable. Mild pulmonary vascular congestion is seen in the
right lung. There are no pleural effusions on the right.

IMPRESSION: Complete opacification of the left hemithorax,
likely secondary to large pleural effusion and/or consolidation.

.
CXR [**1-17**] Post-thoracentesis
IMPRESSION: Interval improvement in the left lung aeration.
Persistent left lower hemithorax opacity, likely represents
residual atelectasis/pleural effusion.
.
ABD US [**1-17**]
IMPRESSION:
1. Patent TIPS with wall-to-wall flow. However, elevated
velocities in the
mid and distal portion of the TIPS shunt, raises concern for
mild stenosis. However persistent reversal of flow within the
left and anterior right portal vein are reassuring.
2. Cirrhotic liver with a small amount of perihepatic ascites
.
KUB [**1-19**]
FINDINGS: Two supine views of the abdomen demonstrate air-filled

non-distended loops of small and large bowel. No free air or
air-fluid levels are seen on these supine views. No radiopaque
foreign bodies visualized on this exam. No suspicious osseous
lesions.
.
IMPRESSION: Nonspecific bowel gas pattern without evidence of
ileus or
obstruction.
.
ABD US [**1-20**]
IMPRESSION:
1. No hydronephrosis.
2. Prominent extrahepatic common bile duct of uncertain clinical

significance. The CBD measures up to 7 mm in diameter. No
intrahepatic
biliary dilatation is seen.
3. Small left pleural effusion.
4. Splenomegaly.
.
ABD US [**1-25**]
Comparison is made to previous study dated [**2112-1-17**].
FINDINGS: The liver demonstrates a coarsened echotexture
consistent with
known cirrhosis along with a nodular liver contour. No focal
liver lesions
are identified. There is no intra- or extra-hepatic bile duct
dilation. The
common duct measures 6 mm. Persistent gallbladder wall edema
which is
decreased from previous. Small amount of perihepatic ascites
which has
increased slightly in size from previous. Persistent
splenomegaly measuring
15.6 cm, previously 14.2 cm.
Sludge present within the gallbladder. No pericholecystic edema
or
gallbladder wall edema. There is a small right pleural effusion
and larger
left pleural effusion.
DOPPLER EXAMINATION: The main portal vein has normal hepatopetal
flow with
flow velocity of 40.3 cm/sec. The anterior right and left portal
veins have
restless flow which is appropriate. The TIPS shunt has normal
wall-to-wall
flow throughout the entirety of the shunt. Persistent elevated
velocities
within the mid and distal portion of the TIPS shunt is decreased
from
previous. Flow velocities within the proximal, mid, and distal
TIPS are 84,
152, 155 cm/sec, previously 77, 192, and 190 cm/sec. The hepatic
arteries
have normal arterial flow and waveforms. The right, middle, and
left hepatic
veins are patent. The IVC has normal flow.
IMPRESSION:
1. Patent TIPS with wall-to-wall flow. Persistently elevated
velocities
within the mid and distal portion of the TIPS shunt. The
velocities within the
mid and distal tips are decreased from previous US. Persistent
reversal flow
within the left and anterior right portal vein.
2. Cirrhotic liver with a small amount of perihepatic ascites.
3. Bilateral pleural effusions.
4. Persistent moderate splenomegaly, slightly increased from
previous.
5. Minimal increase in ascites with a small amount of
perihepatic ascites.
Findings were posted on the nonurgent critical findings database
on [**2112-1-25**]
at 20:05.
.
CXR [**1-27**] COMPARISON: [**2112-1-26**].

FINDINGS: As compared to the previous radiograph, the
pre-existing bilateral
parenchymal opacities, accompanied by pleural effusions, are of
stable
severity. Signs of fluid overload are still clearly present.
Moderate
cardiomegaly with extensive retrocardiac atelectasis. No newly
appeared focal
parenchymal opacities.
.
MICRO:
[**2112-1-18**] URINE CULTURE

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S
.
1/15,[**1-19**], [**1-24**], [**1-25**] BLOOD CULTURE NO GROWTH
[**2112-1-25**] C.DIFF NEGATIVE
[**2112-1-18**]  HCV VIRAL LOAD (Final [**2112-1-20**]): 982,897 IU/mL.

Brief Hospital Course:
Ms. [**Known lastname 1692**] is a 55 year old female with HCV cirrhosis complicated
by ascites, hepatic encephalopathy and recurrent hydrothorax
status post TIPS [**6-/2111**] who presented with shortness of breath
now s/p thoracentesis.  She was transferred to the MICU when she
developed DIC in the setting of urinary infection and worsening
encephalopathy.  Due to her multiple medical problems and poor
prognosis, not liver transplant candidate, her family decided
that she would want to be transitioned to comfort measures only
(CMO).
.
ACTIVE ISSUES:
.
#.  Disseminated intravascular coagulation (DIC): Her INR was 2
on admission and rose steadily throughout admssion. When her INR
reached 6, a fibrinogen was sent which was very low. She also
had decreasing hematocrit without obvious source other than
brown guaiac positive stool. The cause of her DIC may be UTI
growing E. coli which has been treated with cefepime and then
transitioned to ceftriaxone. She did not undergo paracentesis on
admission because US did not show significant ascites.  After
treatment with antibiotics she has not had fevers and her
hemodynamics were improved.  Patient transferred to the MICU on
[**2112-1-24**] and DIC labs checked q6 hours. She received two units of
cryoprecipitate resulting in a modest increase in fibrinogen
levels from 30 to about 60. Due to her deteriorating condition
and acute DIC, broad spectrum antibiotics were initiated in the
MICU with vancomycin, cefepime and flagyl.  When her cultures
were negative, these were narrowed to ceftriaxone, and then
Bactrim to treat UTI only for a 7 day course.
.
#. Cirrhosis: MELD 39 during admission however the liver team
felt that she was not a transplant candidate. Her cirrhosis is
due to HCV genotype 1, viral load during this admission
~1,000,000. Was encephalopathic during this admission however
this improved with lactulose and rifaximin.  Also had a
decompensation with recurrent hydrothorax even after TIPS.
After discussion with the family about the poor prognosis of her
cirrhosis, they decided to make her CMO and transition to
inpatient hospice. She remained in the hospital on CMO pending
hospice disposition, but expired on [**2-2**]/12pm.
.
#. Altered mental status: Likely hepatic encephalopathy though
she has had hyperactive delirium characterized by frequent loud
moaning.  The precipitating factor was believed to be the UTI.
She received ativan twice with subsequent somnolence impairing
lactulose administration. She was transferred to the MICU on
[**2112-1-24**] for continued altered mental status. Lactulose enema was
administered and her mental status improved.  She was continued
on lactulose and rifaximin even after she was made CMO so that
she would be able to interact with her family.
.
# Complicated UTI: Urine culture grew E. coli sensitive to
ceftriaxone.  Other cultures no growth to date.  Was treated
with cefepime from [**Date range (1) 94109**] then changed to ceftriaxone, then
Bactrim to complete a 7 day course until [**1-30**].
.
# Acute kidney injury ([**Last Name (un) **]): The renal team did see the patient
due to concern for hepatorenal syndrome (HRS).  They felt that
HRS was possible but the cause of her [**Last Name (un) **] was more likely ATN
from hypotension in the setting of DIC and pre-renal azotemia.
She was treated initially with midodrine and octreotide however
the midodrine was D/Ced because of hypertension and then the
octreotide was also D/Ced when she was made CMO.  Renal US
showed no hydronephrosis.  Her creatinine did show a trend
toward improvement before labs were stopped due to CMO status.
.
# Anemia:  EGD from [**2110**] showed 3 cords of grade I varices in
the gastroesophageal junction. Hemodynamically stable and only
with guiac positive stools but no frank melena or hematemesis.
Her worsening anemia is more likely from DIC.  The primary GI
team did not feel a need to undergo repeat EGD and her
hematocrit stablized.
.
# Pleural Effusion: Originally presented with shortness of
breath, 1.7 L removed, fluid consistent with a transudative
effusion, not infected. She has a history of hepatic
hydrothorax, however this is now recurrent after her TIPS
procedure suggesting further deterioration of liver function.
.
# Goals of care: She was transitioned to comfort measures only
given her acute illness and her poor overall prognosis.  She
remained and oriented until 1-2 days prior to discharge when she
began to get more somnolent.  Her family has been updated with
her status, and would like to be updated with any change.
.
TRANSITIONAL ISSUES:
- Patient was transitioned to CMO care after a family meeting.
Her health care proxy is her sister [**Name (NI) 78820**] [**Name (NI) **] ([**Telephone/Fax (1) 94107**])
who was updated with the patient's status.

Medications on Admission:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a

day).
3. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)

Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO

every six (6) hours as needed for nausea.
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for back pain.
9. Milk of Magnesia 400 mg/5 mL Suspension Sig: Five (5) mL PO
once a day as needed for constipation.

Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q 8H
(Every 8 Hours).
3. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for Abd pain/bloating.

4. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
5. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. tramadol 50 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6
hours) as needed for pain.
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q6H (every 6 hours) as needed for sore throat.
10. lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.

Discharge Disposition:
Expired

Discharge Diagnosis:
PRIMARY DIAGNOSIS
Cirrhosis due to hepatitis c
Disseminated intravascular coagulation
Sepsis secondary to urinary tract infection
Acute kidney injury


Discharge Condition:
Expired

Discharge Instructions:
Expired

Followup Instructions:
Expired


Completed by:[**2112-2-3**]
{'Unspecified septicemia,Defibrination syndrome,Acute kidney failure with lesion of tubular necrosis,Hepatorenal syndrome,Other specified forms of effusion, except tuberculous,Urinary tract infection, site not specified,Acidosis,Unspecified viral hepatitis C without hepatic coma,Sepsis,Anemia, unspecified,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Unspecified acquired hypothyroidism,Encounter for palliative care,Do not resuscitate status'}


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: Shortness of breath, abd pain

PRESENT ILLNESS: 55 y/o female with HCV cirrhosis c/b recurrent hepatic
hydrothorax s/p TIPS [**6-13**] who presented with nausea, vomiting,
cough and SOB x 3days from recurrent L hydrothorax.

MEDICAL HISTORY: - HCV cirrhosis c/b hydrothorax s/p TIPS [**2111-6-16**]
- hepatic encephalopathy
- Hypothyroidism
- Depression/ anxiety
- MSSA spinal osteomyelitis/ discitis/ epidural
abscess/paravertebral abscess and cord compression s/p C2-C3
laminectomy in [**2107**] with resultant disability and "paralysis"
per OMR
- Prior IV cocaine use of short duration
- Negative PPD several years ago

MEDICATION ON ADMISSION: 1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a

ALLERGIES: Penicillins

PHYSICAL EXAM: ADMSSION EXAM:
VS - Temp F 97.5, BP 116/59, HR 114, RR: 16, 96 O2-sat % RA
GENERAL - patient was somnolent but in NAD A&Ox2 +asterixis
HEENT - Still with small pupils, EOMI, MMM
LUNGS - Lungs with diminshed BS on L and crackles on R. Wheezing
throughout.
HEART - 2/6 SEM heard throughout, nl S1-S2, S3 present
ABDOMEN - NABS, soft/NT, very distended, no masses or HSM, no
rebound/guarding
EXTREMITIES - 2+ peripheral edema
NEURO - awake but lethargic, slow to respond to questions, A&Ox2
does not know month, CNs II-XII grossly intact, muscle strength
[**5-7**] throughout, sensation grossly intact throughout

FAMILY HISTORY: Mother with HTN and DM. Father unknown. Sister passed away from
pancreatic cancer. Grandmother with lung cancer.

SOCIAL HISTORY: On disability since her epidural abscess and laminectomy in
[**2107**]. Prior to that was a nurses aid, teacher, crossing guard
per OMR. Ambulates minimally with a walker and PT at rehab. At
baseline lives with her children but now at [**Hospital3 2558**] since
recurrent admissions.  Former smoker, denies alcohol or current
drug use. Past h/o cocaine use per OMR. 

### Response:
{'Unspecified septicemia,Defibrination syndrome,Acute kidney failure with lesion of tubular necrosis,Hepatorenal syndrome,Other specified forms of effusion, except tuberculous,Urinary tract infection, site not specified,Acidosis,Unspecified viral hepatitis C without hepatic coma,Sepsis,Anemia, unspecified,Depressive disorder, not elsewhere classified,Anxiety state, unspecified,Unspecified acquired hypothyroidism,Encounter for palliative care,Do not resuscitate status'}
