CHIEF COMPLAINT: BRBPR

PRESENT ILLNESS: 67 yo female with autoimmune hepatitis and cirrhosis p/w staph
bacteremia and right hand cellulitis now with 600cc BRBPR. She
had an episode of BRBPR on Sat night with guaiac positive brown
stools since. She went down for an ultrasound today then had 500
cc of bright red blood from below while on the toilet. She had
an EGD a few days ago which showed only grade 1 varices.
Reportedly with colonic varices on an OSH colonoscopy, but we do
not have any record of this. Plan to scope today in ICU. T&C;
ordered for 2 units (Hct 28 <-- 35) and 1 unit platelets (41);
INR 2.8; vitamin K + 4 units FFP. Has right 18g and tenuous 22g
left antecub. Not febrile, surveillance blood cultures pending.

MEDICAL HISTORY: HLD
Autoimmune hepatitis/cirrhosis, diagnoed 14 yrs ago with bx in
[**Male First Name (un) 1056**], complicated by varices
RA
DM2 with neuropathy
HTN, incl hypertensive nephropathy
B12 deficiency
Vitamin D Deficiency
Chronic pain syndrome - "colonic pain" per pt records
Colon polyps (hyperplastic and tubular adenoma)
Diverticulitis
Depression
PAD
s/p chole
s/p appy
s/p TAH/USO
Bladder prolapse repair
[**2172-5-1**] Liver [**Month/Day/Year **]
[**2172-5-12**] ERCP, sphincterotomy, stent placement

MEDICATION ON ADMISSION: 1. omeprazole 20 mg daily
2. nadolol 40 mg daily
3. sucralfate 1 gram QID
4. prednisone 60 mg daily
5. azathioprine 200 mg daily
6. Vitamin D 50,000 unit monthly
7. Lantus 100 unit/mL Solution Sig: 40 untis SQ at bedtime

ALLERGIES: No Known Drug Allergies

PHYSICAL EXAM: Vitals: T: BP: 103/36 P: 67 R: 20 O2: 96% RA
General: Alert, oriented, no acute distress, mild asterixis
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, holosystolic murmur
at LUSB
Abdomen: soft, obese, non-tender, mildly-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley in place
Rectum: small external hemorrhoids not actively bleeding.
Ext: warm, well perfused, 2+ pulses, no edema in legs
Skin: R dorsal hand with erythema, indistinct border, warm to
touch with mild edema, extending to lower forearm; L antecubital
erythema warm to touch, no drainage or breaks in skin

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: originally from [**Male First Name (un) 1056**]; has lived her with family for last
3 years; has her care done at [**Hospital3 934**]. No etoh, illicits
or tobacoo.
Autoimmune hepatitis,End stage renal disease,Obstruction of bile duct,Hepatic encephalopathy,Acute kidney failure with lesion of tubular necrosis,Cellulitis and abscess of hand, except fingers and thumb,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Bacteremia,Hemorrhage of gastrointestinal tract, unspecified,Complications of transplanted liver,Delirium due to conditions classified elsewhere,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Rheumatoid arthritis,Accidents occurring in residential institution,Other B-complex deficiencies,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,External hemorrhoids without mention of complication,Chronic pain syndrome,Long-term (current) use of steroids
Autoimmune hepatitis,End stage renal disease,Obstruction of bile duct,Hepatic encephalopathy,Ac kidny fail, tubr necr,Cellulitis of hand,Hyp kid NOS w cr kid V,Esoph varice oth dis NOS,Bacteremia,Gastrointest hemorr NOS,Compl liver transplant,Delirium d/t other cond,Abn react-org transplant,DMII neuro nt st uncntrl,Neuropathy in diabetes,Rheumatoid arthritis,Accid in resident instit,B-complex defic NEC,Other staphylococcus,Ext hemorrhoid w/o compl,Chronic pain syndrome,Long-term use steroids
Admission Date:  [**2172-4-25**]              Discharge Date:   [**2172-5-21**]

Date of Birth:  [**2105-3-24**]             Sex:   F

Service: SURGERY

Allergies:
No Known Drug Allergies

Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
BRBPR

Major Surgical or Invasive Procedure:
Colonoscopy
[**2172-5-1**] Liver [**Month/Day/Year **]
[**2172-5-12**] ERCP, sphincterotomy, stent placement


History of Present Illness:
67 yo female with autoimmune hepatitis and cirrhosis p/w staph
bacteremia and right hand cellulitis now with 600cc BRBPR. She
had an episode of BRBPR on Sat night with guaiac positive brown
stools since. She went down for an ultrasound today then had 500
cc of bright red blood from below while on the toilet. She had
an EGD a few days ago which showed only grade 1 varices.
Reportedly with colonic varices on an OSH colonoscopy, but we do
not have any record of this. Plan to scope today in ICU. T&C;
ordered for 2 units (Hct 28 <-- 35) and 1 unit platelets (41);
INR 2.8; vitamin K + 4 units FFP. Has right 18g and tenuous 22g
left antecub. Not febrile, surveillance blood cultures pending.


Past Medical History:
HLD
Autoimmune hepatitis/cirrhosis, diagnoed 14 yrs ago with bx in
[**Male First Name (un) 1056**], complicated by varices
RA
DM2 with neuropathy
HTN, incl hypertensive nephropathy
B12 deficiency
Vitamin D Deficiency
Chronic pain syndrome - "colonic pain" per pt records
Colon polyps (hyperplastic and tubular adenoma)
Diverticulitis
Depression
PAD
s/p chole
s/p appy
s/p TAH/USO
Bladder prolapse repair
[**2172-5-1**] Liver [**Month/Day/Year **]
[**2172-5-12**] ERCP, sphincterotomy, stent placement


Social History:
originally from [**Male First Name (un) 1056**]; has lived her with family for last
3 years; has her care done at [**Hospital3 934**]. No etoh, illicits
or tobacoo.


Family History:
non-contributory

Physical Exam:
Vitals: T: BP: 103/36 P: 67 R: 20 O2: 96% RA
General: Alert, oriented, no acute distress, mild asterixis
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, holosystolic murmur
at LUSB
Abdomen: soft, obese, non-tender, mildly-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley in place
Rectum: small external hemorrhoids not actively bleeding.
Ext: warm, well perfused, 2+ pulses, no edema in legs
Skin: R dorsal hand with erythema, indistinct border, warm to
touch with mild edema, extending to lower forearm; L antecubital
erythema warm to touch, no drainage or breaks in skin


Pertinent Results:
[**2172-5-16**] 06:00AM BLOOD WBC-7.9 RBC-2.89* Hgb-9.3* Hct-29.0*
MCV-100* MCH-32.1* MCHC-32.0 RDW-19.1* Plt Ct-105*
[**2172-5-21**] 05:30AM BLOOD WBC-5.1 RBC-2.88* Hgb-9.3* Hct-29.4*
MCV-102* MCH-32.4* MCHC-31.7 RDW-21.4* Plt Ct-69*
[**2172-5-16**] 06:00AM BLOOD PT-13.4 PTT-24.6 INR(PT)-1.1
[**2172-5-6**] 03:26PM BLOOD Fibrino-191
[**2172-5-18**] 05:32AM BLOOD Glucose-36* UreaN-75* Creat-1.9* Na-145
K-4.6 Cl-114* HCO3-21* AnGap-15
[**2172-5-21**] 05:30AM BLOOD Glucose-68* UreaN-49* Creat-1.6* Na-143
K-5.0 Cl-115* HCO3-20* AnGap-13
[**2172-5-19**] 05:03AM BLOOD ALT-10 AST-33 AlkPhos-584* TotBili-2.2*
[**2172-5-20**] 05:28AM BLOOD ALT-7 AST-31 AlkPhos-590* TotBili-1.9*
[**2172-5-21**] 05:30AM BLOOD ALT-6 AST-28 AlkPhos-577* TotBili-1.9*
[**2172-5-21**] 05:30AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.8
[**2172-5-21**] 05:30AM BLOOD tacroFK-9.7

[**4-25**] BCx: 2/2 bottles MSSA
[**4-26**] joint fluid: 1+PMNs, no growth
[**4-27**] BCx: no growth
[**4-27**] stool cultures: no OVA/ PARASITES/ SALMONELLA/ SHIGELLA/
CAMPYLOBACTER
[**4-27**] MRSA swab: neg
[**4-28**] toxoplasma: equivocal
[**4-28**] BCx: NG
[**4-30**] BCx: NG
[**5-1**] UCx: <10k ORGS
[**5-1**] BCx: NG
[**5-1**] VRE swab: VRE positive
[**5-1**] MRSA swab: neg
[**5-2**] sputum: yeast, rare growth TWO COLONIAL MORPHOLOGIES
[**5-2**] PICC tip: no significant growth
[**5-2**] UCx: no growth
[**5-2**] BCx: neg
[**5-3**] RIJ tip: no sig growth
[**5-4**] UCx: NG
[**5-4**] BCx: neg
[**5-4**] MRSA: neg
IMAGING:
[**2172-4-16**] Echo: ormal global and regional biventricular systolic
function. No pulmonary hypertension or clinically-significant
valvular disease seen. EF 70%.
[**2172-4-16**] PMibi: Normal cardiac perfusion. EF >70%
5/8 US: A 1.3 x 1.1 x 2 cm cyst is seen in the pancreas,
suggestive of IPMN
[**4-27**] Colonoscopy: Grade 1 external hemorrhoids, Rectal varices
were seen. They were not actively bleeding. There was a blood
clot on the varix that was washed away. No hemocystic spots were
seen. No therapy was done. Otherwise normal colonoscopy to cecum

[**4-28**] MRI Hand/Wrist: c/w cellulitis throughout hand & fingers,
w/ diffuse soft tissue edema & skin thickening. No definite e/o
osteomyelitis.
[**4-30**] TEE: No discrete valvular veg seen; complex desc aortic
plaque (25cm from incisors) w/highly mobile element ?part of the
cholesterol plaque, intravascular infection or thrombus


Brief Hospital Course:
67 yo F w/ autoimmune hepatitis, cirrhosis who p/w staph aureus
bacteremia and BRBPR. Hepatology was consulted and started her
on azathioprine and prednisone.
Sigmoidoscopy showed rectal varices and grade 1 external
hemorrhoids with no active bleeding and no therapy was done. The
patient was transfused and continued on PPI/sucralfate.
Creatinine increased and it was presumed that she was developing
hepatorenal syndrome. Nephrology was consulted and followed.
[**Month/Year (2) 1326**] surgery was consulted and [**Month/Year (2) **] workup was
expedited. She was listed for liver [**Month/Year (2) **].

MSSA bacteremia source was felt to be from L arm
thrombophlebitis from site of prior IV and R wrist, U/S had no
e/o DVT in LUE. Surveillance cultures were done. PICC line was
placed for extended course of antibiotic therapy. TTE then TEE
was done to look for vegetations on the heart valves. No
vegetations were seen. ID was consulted, vancomycin continued
until speciation and sensitivities isolated MSSA. Vanco was
changed to nafcillin.

Ortho was consulted to evaluate right hand cellulitis. MRI was
done with findings consistent with cellulitis throughout the
hands and fingers, with diffuse soft tissue edema, and skin
thickening. No definite evidence of osteomyelitis. Degenerative
changes at the distal radius, base of the thumb, and MTP
joints were noted (h/o RA). ID recommended switching Nafcillin
to Cefazolin for a 6 week course. Cefazolin started on [**4-27**] and
was to continue until [**6-7**]. On [**5-11**], a double lumen PICC line
was placed via the left basilic venous approach. Final internal
length is 47 cm, with the tip positioned in SVC. The line was
ready for use.

On [**2172-5-1**], a liver donor became available. Donor offer was
accepted and patient underwent liver [**Date Range **]. Surgeon was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].  Please refer to
operative note for details. Two JP drains were placed. JP
outputs were sanguinous (non-bilious. She was transferred to the
SICU immediately postop for management. Initially she was
extubated, but required immediate reintubation for
agitation/tachypnea/severe hypertension. Scheduled clonidine was
started along with several other antihypertensives. Agitation
persisted and Zyprexa was added with resolution of agitation.
However, she continued to be delirious. She was successfully
extubated.

LFTs initially increased. Liver duplex on postop day 0
demonstrated resistive indices in the hepatic arteries are on
the high side secondary to slightly low diastolic flow. LFTs
trended down. Diet was on hold due to mental status. A post
pyloric feeding tube was started and feedings were given. Around
postop day 6, LFTs continued to trend down with the exception of
the alk phos which started to trend up. Alk phos increased to
600 from 300. On [**6-12**], an ERCP was done showing biliary
anastomosis stricture. A sphincterotomy was performed and a
stent placed. Alk phos then trended down to 45. Alk phos started
to rise slowly around postop day 14 ([**5-15**]). Repeat hepatic
duplex demonstrated patent vasculature. There were no dilated
biliary ducts. A liver biopsy was then done ([**5-15**]) to evaluate.
This was negative for rejection. There were prominent bile
ductular proliferation with associated neutrophils and focally
prominent eosinophils and rare plasma cells.

She remained on immunosuppression consisting of steroid taper to
po prednisone, CellCept and Prograf per trough levels (goal of
10).

A post pyloric feeding tube was placed and tube feedings
continued until feeding tube was removed for ERCP on [**5-12**].
Replacement was attempted but tube was found in stomach. Post
pyloric placement was unsuccessful under fluoro on [**5-19**]. A
speech and swallow evaluation was done with recommendations to
allow patient soft solids and thin liquids with chin tuck and
supervision. The decision to leave feeding tube out was made and
patient reported that she would try to eat.

Mental status improved, but she continued to be confused at
times. However, she remained cooperative.

Renal function improved. Foley was removed on [**5-21**] at midnight
and she voided (amount not quantitated as she was incontinent.

Abdominal JP drains were removed by [**5-19**]. Incision remained
intact with staples, but had developed a large bruised/necrotic
area. This was debrided on [**5-16**] and [**5-20**] then a wound VAC was
applied. Wound culture gram stain and potassium hydroxide prep
were negative. Fungal and AFB cultures of wound were pending.

Physical therapy worked with her and got her out of bed using
the Freespan to lift her out of bed. She was severely
debilitated/deconditioned.

Vital signs were notable for SBP that had improved on Lopressor,
hydralazine, clonidine, and amlodipine. On [**5-21**], clonidine taper
was started, decreasing from 0.2mg tid to 0.1mg tid. Hydralazine
was decreased from 10mg q6 to 5mg q6.




Medications on Admission:
1. omeprazole 20 mg daily
2. nadolol 40 mg daily
3. sucralfate 1 gram QID
4. prednisone 60 mg daily
5. azathioprine 200 mg daily
6. Vitamin D 50,000 unit monthly
7. Lantus 100 unit/mL Solution Sig: 40 untis SQ at bedtime


Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection Q 8H (Every 8 Hours).
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours): trough level every Monday & Thursday.
7. prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): see
printed taper schedule.
8. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
9. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
10. cefazolin 10 gram Recon Soln Sig: Two (2) gram  Injection
Q12H (every 12 hours): started [**4-27**]. continue until [**6-7**] for MSSA
bacteremia. .
11. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day): cmv prophylaxis.
12. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for sbp <110 or HR <60.
13. hydralazine 10 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours): hold for sbp <110.
14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day): hold for sbp<100 or hr<60 .
15. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
16. hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO every four
(4) hours as needed for pain.
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
19. olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
20. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
21. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
22. insulin glargine 100 unit/mL Solution Sig: Nine (9) units
Subcutaneous at bedtime.
23. insulin lispro 100 unit/mL Solution Sig: see printed sliding
scale  Subcutaneous four times a day.
24. Labs Work
Every Monday and Thursday
stat cbc, chem 10, ast, alt, alk phos, t.bili, albumin, UA and
trough prograf
fax results to [**Telephone/Fax (1) 697**]
25. Meds
Do not adjust medications without discussing with [**Hospital1 18**]
[**Hospital1 1326**] Office [**Telephone/Fax (1) 673**]


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
autoimmune hepatitis/cirrhosis
s/p liver [**Location (un) **]
biliary anastomosis stricture
MSSA bactereima
right hand cellulitis
DM II


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You will transfer to [**Hospital1 **] Rehab in [**Location (un) 701**]
[**Hospital1 18**] [**Hospital1 1326**] [**Telephone/Fax (1) 673**] should be called if any fever (101
or greater), chills, nausea, vomiting, inability to eat/drink or
take medications, increased abdominal pain or distension,
incision or abdominal wound redness/bleeding/drainage
Labs need to be drawn every Monday and Thursday and sent to
[**Hospital1 18**] for Stat processing.


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2172-5-28**]
9:50
Provider: [**Name10 (NameIs) **] SOCIAL WORKER Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2172-5-28**] 10:40
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2172-6-4**]
9:50



Completed by:[**2172-5-21**]
{'Autoimmune hepatitis,End stage renal disease,Obstruction of bile duct,Hepatic encephalopathy,Acute kidney failure with lesion of tubular necrosis,Cellulitis and abscess of hand, except fingers and thumb,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Bacteremia,Hemorrhage of gastrointestinal tract, unspecified,Complications of transplanted liver,Delirium due to conditions classified elsewhere,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Rheumatoid arthritis,Accidents occurring in residential institution,Other B-complex deficiencies,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,External hemorrhoids without mention of complication,Chronic pain syndrome,Long-term (current) use of steroids'}


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: BRBPR

PRESENT ILLNESS: 67 yo female with autoimmune hepatitis and cirrhosis p/w staph
bacteremia and right hand cellulitis now with 600cc BRBPR. She
had an episode of BRBPR on Sat night with guaiac positive brown
stools since. She went down for an ultrasound today then had 500
cc of bright red blood from below while on the toilet. She had
an EGD a few days ago which showed only grade 1 varices.
Reportedly with colonic varices on an OSH colonoscopy, but we do
not have any record of this. Plan to scope today in ICU. T&C;
ordered for 2 units (Hct 28 <-- 35) and 1 unit platelets (41);
INR 2.8; vitamin K + 4 units FFP. Has right 18g and tenuous 22g
left antecub. Not febrile, surveillance blood cultures pending.

MEDICAL HISTORY: HLD
Autoimmune hepatitis/cirrhosis, diagnoed 14 yrs ago with bx in
[**Male First Name (un) 1056**], complicated by varices
RA
DM2 with neuropathy
HTN, incl hypertensive nephropathy
B12 deficiency
Vitamin D Deficiency
Chronic pain syndrome - "colonic pain" per pt records
Colon polyps (hyperplastic and tubular adenoma)
Diverticulitis
Depression
PAD
s/p chole
s/p appy
s/p TAH/USO
Bladder prolapse repair
[**2172-5-1**] Liver [**Month/Day/Year **]
[**2172-5-12**] ERCP, sphincterotomy, stent placement

MEDICATION ON ADMISSION: 1. omeprazole 20 mg daily
2. nadolol 40 mg daily
3. sucralfate 1 gram QID
4. prednisone 60 mg daily
5. azathioprine 200 mg daily
6. Vitamin D 50,000 unit monthly
7. Lantus 100 unit/mL Solution Sig: 40 untis SQ at bedtime

ALLERGIES: No Known Drug Allergies

PHYSICAL EXAM: Vitals: T: BP: 103/36 P: 67 R: 20 O2: 96% RA
General: Alert, oriented, no acute distress, mild asterixis
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, holosystolic murmur
at LUSB
Abdomen: soft, obese, non-tender, mildly-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley in place
Rectum: small external hemorrhoids not actively bleeding.
Ext: warm, well perfused, 2+ pulses, no edema in legs
Skin: R dorsal hand with erythema, indistinct border, warm to
touch with mild edema, extending to lower forearm; L antecubital
erythema warm to touch, no drainage or breaks in skin

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: originally from [**Male First Name (un) 1056**]; has lived her with family for last
3 years; has her care done at [**Hospital3 934**]. No etoh, illicits
or tobacoo. 

### Response:
{'Autoimmune hepatitis,End stage renal disease,Obstruction of bile duct,Hepatic encephalopathy,Acute kidney failure with lesion of tubular necrosis,Cellulitis and abscess of hand, except fingers and thumb,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Esophageal varices in diseases classified elsewhere, without mention of bleeding,Bacteremia,Hemorrhage of gastrointestinal tract, unspecified,Complications of transplanted liver,Delirium due to conditions classified elsewhere,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Rheumatoid arthritis,Accidents occurring in residential institution,Other B-complex deficiencies,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,External hemorrhoids without mention of complication,Chronic pain syndrome,Long-term (current) use of steroids'}
