CHIEF COMPLAINT: Transfer for GI bleed

PRESENT ILLNESS: Pt is a 70 y/o male with CAD, CHF, PVD, COPD, ESRD, metastatic
melenoma who was transferred from [**Hospital3 **] after being
admitted there a week prior with a GI bleed. The night before he
presented to [**Hospital1 **] (one week prior to transfer) he was in his
usual state of health when he began to develop abdominal pain
and nausea, with subsequent melena and eventual coffee ground
emesis. He went to [**Hospital1 **] where he was admitted to the ICU and
recieved 2-3 units of packed red cells daily. He [**Hospital1 1834**] EGD
twice, the first time limited by active bleeding and the second
revealing a hiatal hernia, duodenitis, and an ulcerated duodenal
lesion in the third part of the duodenum. As it was felt he may
need surgical intervention, he was transferred to [**Hospital1 18**] for
further evaluation and management.
At admission, he complained of mild lightheadedness and chest
pain. He stated his last BM had been two days prior and without
[**Hospital1 **]. He was afebrile with a bp of 82/36 and a hr of 76,
satting 100% on 2Lnc. He was bolused one liter of IVF, resulting
in a bp of 92/44 and a resolution of his symptoms. An initial
hct was 27.2, not significantly different than his hct prior
transfer.

MEDICAL HISTORY: 1.)Coronary artery disease s/p stent x 4
2.)CHF: EF unknown
3.)Peripheral vascular disease s/p stents to both legs and rue
4.)AAA s/p repair x 2
5.)Emphysema
6.)End-stage renal disease on HD MWF ([**Location (un) 2498**] dialysis, Dr.
[**Last Name (STitle) **] x 4 years
7.)Metastatic melanoma s/p bilateral neck dissection and xrt

MEDICATION ON ADMISSION: 1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2*
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2*
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-31**]
Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*3 inh*
Refills:*0*
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 10 days. Disp:*40 Tablet(s)* Refills:*0*
8. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
9. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a
day: with meals. Disp:*90 Tablet(s)* Refills:*2*
10. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet
Sustained Release 24HR(s)* Refills:*2*
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*

ALLERGIES: Morphine Sulfate / Tegretol

PHYSICAL EXAM: gen- chronically ill appearing male, not acutely ill, pleasant
and conversant, NAD
heent- anicteric sclera, op clear with dry mucosa
neck- bilateral well healed surgical scars with firm induration
below each, left IJ in place
cv- rrr, s1s2, [**2-4**] holosystolic murmur at ursb
pul- moves air well, bibasilar rales [**1-2**] way up
abd- soft, nt, multiple surgical scars, nd, nabs, no
hepatomegaly
back- no sacral edema, no cva tenderness
extrm- no cyanosis, 2+ pitting edema throughout entire rue,
otherwise no edema, warm/dry
nails- moderate clubbing, no pitting/color changes/indentations

FAMILY HISTORY: Father died of an MI at 59. 7 brothers with CAD/PVD. Mother died
of breast cancer. Sister died of lung cancer.

SOCIAL HISTORY: Mr. [**Known lastname **] is a retired brick layer, divorced, lives alone, has
supportive sister and brother-in-law. [**Name (NI) **] is actively smoking,
with a 60 pack year hx. No etoh or illicit drug use.
Duodenitis, with hemorrhage,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Acute posthemorrhagic anemia,Chronic airway obstruction, not elsewhere classified,Other and unspecified coagulation defects,Mechanical complication of other vascular device, implant, and graft,Swelling of limb,Other lymphedema,Personal history of irradiation, presenting hazards to health,Personal history of malignant melanoma of skin,Tobacco use disorder,Pain in joint, shoulder region
Duodenitis w hmrhg,Hyp kid NOS w cr kid V,CHF NOS,Ac posthemorrhag anemia,Chr airway obstruct NEC,Coagulat defect NEC/NOS,Malfunc vasc device/graf,Swelling of limb,Other lymphedema,Hx of irradiation,Hx-malig skin melanoma,Tobacco use disorder,Joint pain-shlder
Admission Date:  [**2170-8-6**]              Discharge Date:   [**2170-8-14**]

Date of Birth:  [**2100-2-18**]             Sex:   M

Service: MEDICINE

Allergies:
Morphine Sulfate / Tegretol

Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Transfer for GI bleed

Major Surgical or Invasive Procedure:
Upper Endoscopy and cautery of the bleeding lesion
s/p stenting of R arm arterio-venous fistula by interventional
radiology
-Upper Endoscopy with Biopsy and Pathology at OSH: no diagnostic
abnormalities


History of Present Illness:
Pt is a 70 y/o male with CAD, CHF, PVD, COPD, ESRD, metastatic
melenoma who was transferred from [**Hospital3 **] after being
admitted there a week prior with a GI bleed. The night before he
presented to [**Hospital1 **] (one week prior to transfer) he was in his
usual state of health when he began to develop abdominal pain
and nausea, with subsequent melena and eventual coffee ground
emesis. He went to [**Hospital1 **] where he was admitted to the ICU and
recieved 2-3 units of packed red cells daily. He [**Hospital1 1834**] EGD
twice, the first time limited by active bleeding and the second
revealing a hiatal hernia, duodenitis, and an ulcerated duodenal
lesion in the third part of the duodenum. As it was felt he may
need surgical intervention, he was transferred to [**Hospital1 18**] for
further evaluation and management.
At admission, he complained of mild lightheadedness and chest
pain. He stated his last BM had been two days prior and without
[**Hospital1 **]. He was afebrile with a bp of 82/36 and a hr of 76,
satting 100% on 2Lnc. He was bolused one liter of IVF, resulting
in a bp of 92/44 and a resolution of his symptoms. An initial
hct was 27.2, not significantly different than his hct prior
transfer.


Past Medical History:
1.)Coronary artery disease s/p stent x 4
2.)CHF: EF unknown
3.)Peripheral vascular disease s/p stents to both legs and rue
4.)AAA s/p repair x 2
5.)Emphysema
6.)End-stage renal disease on HD MWF ([**Location (un) 2498**] dialysis, Dr.
[**Last Name (STitle) **] x 4 years
7.)Metastatic melanoma s/p bilateral neck dissection and xrt


Social History:
Mr. [**Known lastname **] is a retired brick layer, divorced, lives alone, has
supportive sister and brother-in-law. [**Name (NI) **] is actively smoking,
with a 60 pack year hx. No etoh or illicit drug use.

Family History:
Father died of an MI at 59. 7 brothers with CAD/PVD. Mother died
of breast cancer. Sister died of lung cancer.

Physical Exam:
gen- chronically ill appearing male, not acutely ill, pleasant
and conversant, NAD
heent- anicteric sclera, op clear with dry mucosa
neck- bilateral well healed surgical scars with firm induration
below each, left IJ in place
cv- rrr, s1s2, [**2-4**] holosystolic murmur at ursb
pul- moves air well, bibasilar rales [**1-2**] way up
abd- soft, nt, multiple surgical scars, nd, nabs, no
hepatomegaly
back- no sacral edema, no cva tenderness
extrm- no cyanosis, 2+ pitting edema throughout entire rue,
otherwise no edema, warm/dry
nails- moderate clubbing, no pitting/color changes/indentations

neuro- a&ox3, no cn defects, motor [**5-3**] distally and proximally
in all extremities, no focal sensory deficits, finger-to-nose
exam with mild tremor but no major deficit

Pertinent Results:
[**2170-8-6**] 05:08PM   PT-14.9* PTT-30.4 INR(PT)-1.5
[**2170-8-6**] 05:08PM   PLT COUNT-122*
[**2170-8-6**] 05:08PM   ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+
MICROCYT-1+
[**2170-8-6**] 05:08PM   NEUTS-86.6* LYMPHS-4.5* MONOS-5.8 EOS-3.0
BASOS-0.1
[**2170-8-6**] 05:08PM   WBC-5.7 RBC-3.19*# HGB-9.7*# HCT-27.2*#
MCV-85# MCH-30.3 MCHC-35.5* RDW-17.9*
[**2170-8-6**] 05:08PM   ALBUMIN-2.4* CALCIUM-7.6* PHOSPHATE-3.0
MAGNESIUM-1.5*
[**2170-8-6**] 05:08PM   GLUCOSE-80 UREA N-32* CREAT-2.5*# SODIUM-132*
POTASSIUM-3.2* CHLORIDE-95* TOTAL CO2-28 ANION GAP-12
Discharge Hct was stable at 32.
-------------------
Shoulder X-ray for R shoulder Pain: Right shoulder 3 views on
[**2170-8-13**]; the superior aspect of the glenoid demonstrates
subchondral lucencies. The glenohumeral joint space is within
normal limits. No dislocation or fracture. A subclavian stent is
noted. There is a central venous catheter, incompletely imaged.

IMPRESSION: Possible subchondral lucency of the superior aspect
of the bony glenoid may be seen with degenerative changes. MRI
or CT is recommended for additional evaluation.
------------------
A-V fistulogram
.
CONCLUSION:

1. Balloon angioplasty of the terminal, central portion of the
right cephalic vein stenosis, using 6 mm, 8 mm and eventually 8
mm cutting balloons. Moderate angiographic improvement was
noted, as well as reduction of mean pressure gradient from 20 to
10 mm Hg across this stenotic area.

2. Balloon angioplasty to 10 and 12 mm of the stenosis in the
central portion of the right subclavian vein and the right
innominate vein stent, with unsatisfactory angiographic and
hemodynamic result. Successful deployment of a 14 x 60 mm Smart
stent across that stenotic area, balloon-dilated to 12 mm, with
moderate angiographic improvement in luminal narrowing and
partial reduction in the degree of collateral venous
opacification. The trans-stenotic mean pressure gradient remains
unchanged (approximately 15 mm Hg).
--------------------
EGD: [**2170-8-8**] Duodenitis of the bulb. Active bleeding site in the
proximal descending duodenum, possibly from an erosion or a
Dielafoye's lesion. Successful cautery and injection.
Erythema and erosion in the antrum compatible with gastritis
Erosions at the GE junction.
Otherwise normal egd to fourth part of the duodenum
Recommendations: continue IV Protonix 40mg [**Hospital1 **]
If rebleeds, would get angiogram by IR to attempt embolization
and surgery consult.
Continue serial hct and transfuse as needed.
Echo [**2170-8-9**]: The left atrium is elongated. Overall left
ventricular systolic function is normal (LVEF 70%). No masses or
thrombi are seen in the left ventricle. There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.


Brief Hospital Course:
70 y/o male with cad, chf, esrd, metastatic melanoma, s/p
radical neck exploration and LN resection transferred from OSH
with GI bleed, s/p
.
#GI bleed -- Ulcerated duodenal lesion seen on OSH EGD. Story
consistent with UGI bleed. Does not appear to be actively
bleeding. He denies NSAID use. Biopsies from OSH are pending.
Concerns include duodenitis in setting of ASA/clopidogrel use,
H. pylori, metastatic lesion.
In the ICU the pt [**Month/Day/Year 1834**] an EGD that demonstrated a small
bleeding area in the duodenum that was cauterized with good
effect and was felt to be the main source of bleeding.  His
hematocrit remained stable subsequently and he was called out to
the floor.

.
#Hypotension -- Likely [**1-31**] to hypovolemia and [**Month/Day (2) **] loss,
responded to bolus. Other possibilities include sepsis (though
does not fit SIRS criteria), cardiogenic (no ECG changes), and
adrenal insufficiency. Exercising caution given CHF and ESRD.
Hypotension was resolved on discharge
.
#RUE edema -- The first step in work-up was an ultrasound
showing no DVT but a possibility of stenosis involving his
AV-fistula.  This was examined with a fistulogram, showing areas
of stenosis at the cephalic vein and more proximally near the
stent he had placed (brachiocephalic vein).  As his CVP was 17,
IR was concerned that opening these lesions could lead to
excessive venous return and CHF, so an echo was obtained.
.
#Anemia -- Pt has some baseline anemia, likely from chronic
disease but also now has acute [**Month/Day (2) **] loss anemia. Follow
frequent hct's and txf for hct < 28, given CAD, PVD, COPD.
.
#CAD -- No evidence of active ischemia, holding asa,
clopidogrel, and metoprolol in setting of GI bleed/hypotension.

.
.


Medications on Admission:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2*
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2*
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-31**]
Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*3 inh*
Refills:*0*
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 10 days. Disp:*40 Tablet(s)* Refills:*0*
8. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
9. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a
day: with meals. Disp:*90 Tablet(s)* Refills:*2*
10. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet
Sustained Release 24HR(s)* Refills:*2*
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Medications:
1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-31**]
Puffs Inhalation Q6H (every 6 hours) as needed.
Disp:*3 inh* Refills:*0*
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
8. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
9. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a
day: with meals.
Disp:*90 Tablet(s)* Refills:*2*
10. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 **] home care

Discharge Diagnosis:
Upper Gastro-Intestinal Bleed
Anemia
End Stage Renal Disease


Discharge Condition:
stable, afebrile, ambulating via walker


Discharge Instructions:
-if you exeperience any new pains, fevers, chills, please call
your PCP immediately
[**Name9 (PRE) 19288**] you continue seeing that your stools are black, tarry and
malodourous and you are feeling weak, or you see bright red
[**Name9 (PRE) **] per rectum, call your primary care physician immediately
[**Name9 (PRE) **] follow up with your PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) **], 1 week
post-discharge, please have Dr. [**Last Name (STitle) **] check your chemistries
and your complete [**Last Name (STitle) **] count
-patient is to have dialysis in [**Location (un) 2498**] 3x/week, Mon, Wed,
Friday. R arm arterio-venous fistula is ready to use for
dialysis.
-please take all medications as directed

Followup Instructions:
Provider [**Name9 (PRE) 11888**],MULTI CUTANEOUS ONCOLOGY Where: CUTANEOUS ONCOLOGY
Date/Time:[**2170-10-24**] 9:15
.
Provider [**Name9 (PRE) **],[**Name9 (PRE) 19848**] CUTANEOUS ONCOLOGY Where: CUTANEOUS
ONCOLOGY Date/Time:[**2170-10-24**] 9:30
.
-Dr. [**Last Name (STitle) **]: Patient was found to have a nodular opacity of the
left upper lobe by CT scan. Follow up imaging is advised in 3
months.



Completed by:[**2170-10-4**]
{'Duodenitis, with hemorrhage,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Acute posthemorrhagic anemia,Chronic airway obstruction, not elsewhere classified,Other and unspecified coagulation defects,Mechanical complication of other vascular device, implant, and graft,Swelling of limb,Other lymphedema,Personal history of irradiation, presenting hazards to health,Personal history of malignant melanoma of skin,Tobacco use disorder,Pain in joint, shoulder region'}


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: Transfer for GI bleed

PRESENT ILLNESS: Pt is a 70 y/o male with CAD, CHF, PVD, COPD, ESRD, metastatic
melenoma who was transferred from [**Hospital3 **] after being
admitted there a week prior with a GI bleed. The night before he
presented to [**Hospital1 **] (one week prior to transfer) he was in his
usual state of health when he began to develop abdominal pain
and nausea, with subsequent melena and eventual coffee ground
emesis. He went to [**Hospital1 **] where he was admitted to the ICU and
recieved 2-3 units of packed red cells daily. He [**Hospital1 1834**] EGD
twice, the first time limited by active bleeding and the second
revealing a hiatal hernia, duodenitis, and an ulcerated duodenal
lesion in the third part of the duodenum. As it was felt he may
need surgical intervention, he was transferred to [**Hospital1 18**] for
further evaluation and management.
At admission, he complained of mild lightheadedness and chest
pain. He stated his last BM had been two days prior and without
[**Hospital1 **]. He was afebrile with a bp of 82/36 and a hr of 76,
satting 100% on 2Lnc. He was bolused one liter of IVF, resulting
in a bp of 92/44 and a resolution of his symptoms. An initial
hct was 27.2, not significantly different than his hct prior
transfer.

MEDICAL HISTORY: 1.)Coronary artery disease s/p stent x 4
2.)CHF: EF unknown
3.)Peripheral vascular disease s/p stents to both legs and rue
4.)AAA s/p repair x 2
5.)Emphysema
6.)End-stage renal disease on HD MWF ([**Location (un) 2498**] dialysis, Dr.
[**Last Name (STitle) **] x 4 years
7.)Metastatic melanoma s/p bilateral neck dissection and xrt

MEDICATION ON ADMISSION: 1. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2*
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2*
3. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-31**]
Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*3 inh*
Refills:*0*
6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
7. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 10 days. Disp:*40 Tablet(s)* Refills:*0*
8. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
9. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a
day: with meals. Disp:*90 Tablet(s)* Refills:*2*
10. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet
Sustained Release 24HR(s)* Refills:*2*
11. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*

ALLERGIES: Morphine Sulfate / Tegretol

PHYSICAL EXAM: gen- chronically ill appearing male, not acutely ill, pleasant
and conversant, NAD
heent- anicteric sclera, op clear with dry mucosa
neck- bilateral well healed surgical scars with firm induration
below each, left IJ in place
cv- rrr, s1s2, [**2-4**] holosystolic murmur at ursb
pul- moves air well, bibasilar rales [**1-2**] way up
abd- soft, nt, multiple surgical scars, nd, nabs, no
hepatomegaly
back- no sacral edema, no cva tenderness
extrm- no cyanosis, 2+ pitting edema throughout entire rue,
otherwise no edema, warm/dry
nails- moderate clubbing, no pitting/color changes/indentations

FAMILY HISTORY: Father died of an MI at 59. 7 brothers with CAD/PVD. Mother died
of breast cancer. Sister died of lung cancer.

SOCIAL HISTORY: Mr. [**Known lastname **] is a retired brick layer, divorced, lives alone, has
supportive sister and brother-in-law. [**Name (NI) **] is actively smoking,
with a 60 pack year hx. No etoh or illicit drug use. 

### Response:
{'Duodenitis, with hemorrhage,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Congestive heart failure, unspecified,Acute posthemorrhagic anemia,Chronic airway obstruction, not elsewhere classified,Other and unspecified coagulation defects,Mechanical complication of other vascular device, implant, and graft,Swelling of limb,Other lymphedema,Personal history of irradiation, presenting hazards to health,Personal history of malignant melanoma of skin,Tobacco use disorder,Pain in joint, shoulder region'}
