CHIEF COMPLAINT: Bilateral foot pain and hypotension

PRESENT ILLNESS: Mr. [**Known lastname 2491**] is an 80 year old man with DJD, ? gout, kidney
disease, nonspecific interstitial pneumonitis (?amio toxicity),
dilated cardiomyopathy with EF of 20-25% s/p ICD placement
presenting with bilateral foot pain and falls for 3 weeks. The
patient believes his symptoms began suddenly, and progressed
over a 2 week time. He noted increasing pain, swelling in his
ankle and 1st MTP joints bilaterally. Today, he got up out of
bed felt light headed and nearly fell but quickly sat down
without trma. He also noticed slightly worsening dyspnea on
exertion and generalized weakness. He denied recent foot/leg
trauma, fevers, chills, sweats, rash, other joint pains, recent
travel, tick or insect exposure, sick contacts. Of note, he was
recently admitted to an OSH for "dehydration" after steroid dose
reduction. He was recently seen in pulmonology clinic on [**2189-8-5**]
and had his steroids reduced from 10mg daily to 5mg daily in the
setting of higher doses before this. After his fall, he decided
to come to the ED after talking with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**].
.
In the ED, initial vitals were 98.2 97/65 76 24 98%RA. He denied
SOB but looked dyspneic and upon further questioning admitted to
dyspnea. He was noted to have increased pain and swelling of his
ankles and MCP joints bilaterally and was given cefazolin 1gm IV
ONCE for suspected septic arthritis. He was given 1 5/325 tab of
percocet for his pain. He was subsequently noted to be
hypotensive to 82/43. He was given 1L of NS wide open.
Subsequently his saturation dropped to 94% on RA and he was
placed on 2LNC. For the low blood pressure he was broadened to
vancomycin 1gm IV ONCE. His pressures rose to 92/50 with his
last vitals 99.3 61 18 99%2L.
.
On the floor, he remained asymptomatic but continued to be
transiently hypotensive occasionally to the 80s, and at one
point down to the 60s, and fortunately responded to a 250cc
bolus of NS. He was given dexamethasone 4mg IV ONCE for presumed
adrenal crisis. Ortho was consulted who recommended rheumatology
consultation. Podiatry was consulted who offered to tap the
joint, which a small amount of serosanguinous fluid was sent to
the lab. The patient was subsequently started on
vanc/cefepime/levofloxacin.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.

MEDICAL HISTORY: 1) ILD/NSIP ? in setting of prior amiodarone use
-[**2189-8-5**] outpatient PFTs: FVC of 2.86 liters, which is 73%
predicted, an FEV1 of 1.96 liters to 79% predicted with an
FEV1/FVC ratio of 68, which is 108% predicted. Compared to his
last testing two and a half weeks ago there is a marked decline
in both his forced vital capacity (about 400 mL) and a drop in
his FEV1 by about 400 mL as well

MEDICATION ON ADMISSION: 1) Azathioprine 100mg PO daily
2) Prednisone 5mg PO daily
3) Atorvastatin 10mg PO daily
4) Carvedilol 25mg PO BID
5) Enalapril 5mg PO daily
6) Levothyroxine 125mcg PO daily
7) Omeprazole 40mg PO daily
8) Tramadol 50-100mg PO BID PRN Pain
9) Aspirin 81mg PO daily
10) Bactrim DS tab PO 3x per week
11) folate 1 tab PO daily
12) Vitamin D 1 tab PO daily
Allergies:
1) Oxycontin - agitated delerium
2) Ativan - agitated delerium

ALLERGIES: Ativan / OxyContin

PHYSICAL EXAM: On admission:
General: Alert, oriented, pleasant elderly man mildly dyspneic
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally except right basilar
rales, no wheezes, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal: Guiac negative brown stool.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Musculoskeletal: Bilateral MTP joints with swelling, R>>L,
On discharge:
VS: T 96.9 BP 130/75 P 65 RR 18 SaO2 96% RA
General: AAOx3, pleasant elderly man NAD
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal: Guiac negative brown stool.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Musculoskeletal: Bilateral MTP joints with swelling, R>>L, no
erythema/tenderness/warmth

FAMILY HISTORY: No history of autoimmune dz such as Lupus, RA

SOCIAL HISTORY: Happily married, retired, formerly involved in magazine
advertising.
- Tobacco: None
- Alcohol: 1 drink of liquor daily, no excess beyond this
- Illicits: None
No h/o STIs, recent travel, tick exposures, etc.
Acute gouty arthropathy,Glucocorticoid deficiency,Chronic systolic heart failure,Other primary cardiomyopathies,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Personal history of systemic steroid therapy,Esophageal reflux,Unspecified acquired hypothyroidism,Knee joint replacement,Automatic implantable cardiac defibrillator in situ,Chronic kidney disease, unspecified,Postinflammatory pulmonary fibrosis
Acute gouty arthropathy,Glucocorticoid deficient,Chr systolic hrt failure,Prim cardiomyopathy NEC,Acute kidney failure NOS,Hyposmolality,Hx systemc steroid thrpy,Esophageal reflux,Hypothyroidism NOS,Joint replaced knee,Status autm crd dfbrltr,Chronic kidney dis NOS,Postinflam pulm fibrosis
Admission Date:  [**2189-8-11**]              Discharge Date:   [**2189-8-13**]

Date of Birth:  [**2109-3-28**]             Sex:   M

Service: MEDICINE

Allergies:
Ativan / OxyContin

Attending:[**Doctor Last Name 10493**]
Chief Complaint:
Bilateral foot pain and hypotension

Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr. [**Known lastname 2491**] is an 80 year old man with DJD, ? gout, kidney
disease, nonspecific interstitial pneumonitis (?amio toxicity),
dilated cardiomyopathy with EF of 20-25% s/p ICD placement
presenting with bilateral foot pain and falls for 3 weeks. The
patient believes his symptoms began suddenly, and progressed
over a 2 week time. He noted increasing pain, swelling in his
ankle and 1st MTP joints bilaterally. Today, he got up out of
bed felt light headed and nearly fell but quickly sat down
without trma. He also noticed slightly worsening dyspnea on
exertion and generalized weakness. He denied recent foot/leg
trauma, fevers, chills, sweats, rash, other joint pains, recent
travel, tick or insect exposure, sick contacts. Of note, he was
recently admitted to an OSH for "dehydration" after steroid dose
reduction. He was recently seen in pulmonology clinic on [**2189-8-5**]
and had his steroids reduced from 10mg daily to 5mg daily in the
setting of higher doses before this. After his fall, he decided
to come to the ED after talking with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**].
.
In the ED, initial vitals were 98.2 97/65 76 24 98%RA. He denied
SOB but looked dyspneic and upon further questioning admitted to
dyspnea. He was noted to have increased pain and swelling of his
ankles and MCP joints bilaterally and was given cefazolin 1gm IV
ONCE for suspected septic arthritis. He was given 1 5/325 tab of
percocet for his pain. He was subsequently noted to be
hypotensive to 82/43. He was given 1L of NS wide open.
Subsequently his saturation dropped to 94% on RA and he was
placed on 2LNC. For the low blood pressure he was broadened to
vancomycin 1gm IV ONCE. His pressures rose to 92/50 with his
last vitals 99.3 61 18 99%2L.
.
On the floor, he remained asymptomatic but continued to be
transiently hypotensive occasionally to the 80s, and at one
point down to the 60s, and fortunately responded to a 250cc
bolus of NS. He was given dexamethasone 4mg IV ONCE for presumed
adrenal crisis. Ortho was consulted who recommended rheumatology
consultation. Podiatry was consulted who offered to tap the
joint, which a small amount of serosanguinous fluid was sent to
the lab. The patient was subsequently started on
vanc/cefepime/levofloxacin.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.


Past Medical History:
1) ILD/NSIP ? in setting of prior amiodarone use
-[**2189-8-5**] outpatient PFTs: FVC of 2.86 liters, which is 73%
predicted, an FEV1 of 1.96 liters to 79% predicted with an
FEV1/FVC ratio of 68, which is 108% predicted. Compared to his
last testing two and a half weeks ago there is a marked decline
in both his forced vital capacity (about 400 mL) and a drop in
his FEV1 by about 400 mL as well

2) Idiopathic DCM, chronic LBBB, sp ICD implantation for primary


3) Hypothyroidism

4) Bilateral TKR

5) T12 compression fracture in [**2188-3-3**]

6) Right peroneal nerve injury [**2189**],now improving

7) CKD
.


Social History:
Happily married, retired, formerly involved in magazine
advertising.
- Tobacco: None
- Alcohol: 1 drink of liquor daily, no excess beyond this
- Illicits: None
No h/o STIs, recent travel, tick exposures, etc.


Family History:
No history of autoimmune dz such as Lupus, RA

Physical Exam:
On admission:
General: Alert, oriented, pleasant elderly man mildly dyspneic
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally except right basilar
rales, no wheezes, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal: Guiac negative brown stool.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Musculoskeletal: Bilateral MTP joints with swelling, R>>L,
On discharge:
VS: T 96.9 BP 130/75 P 65 RR 18 SaO2 96% RA
General: AAOx3, pleasant elderly man NAD
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal: Guiac negative brown stool.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Musculoskeletal: Bilateral MTP joints with swelling, R>>L, no
erythema/tenderness/warmth

Pertinent Results:
On admission:

[**2189-8-11**] 10:15AM BLOOD WBC-15.9* RBC-3.34* Hgb-11.2* Hct-32.0*
MCV-96 MCH-33.4* MCHC-34.9 RDW-14.2 Plt Ct-230
[**2189-8-11**] 10:15AM BLOOD Neuts-89.4* Lymphs-4.5* Monos-5.7 Eos-0.2
Baso-0.2
[**2189-8-11**] 08:21PM BLOOD ESR-52*
[**2189-8-11**] 10:15AM BLOOD Glucose-147* UreaN-55* Creat-2.4* Na-128*
K-5.5* Cl-97 HCO3-20* AnGap-17
[**2189-8-11**] 08:21PM BLOOD LD(LDH)-229 CK(CPK)-32*
[**2189-8-11**] 10:15AM BLOOD proBNP-2288*
[**2189-8-11**] 08:21PM BLOOD Calcium-8.6 Phos-3.5 Mg-1.7
[**2189-8-11**] 10:15AM BLOOD TSH-1.9
[**2189-8-11**] 10:15AM BLOOD Cortsol-31.9*
[**2189-8-11**] 10:15AM BLOOD CRP-37.9*
[**2189-8-11**] 10:21AM BLOOD K-5.4*
.
[**8-11**] CXR: Increased interstitial markings bilaterally, most
noted in the
periphery and at the lung bases, mildly increased since the
prior study.
Findings consistent with interstitial lung disease, which may
have progressed. Overlying acute component not entirely
excluded.
.
[**8-11**] foot films: No acute fracture or dislocation.

Brief Hospital Course:
80 year old man with DJD, ? gout, kidney disease, chronic
pneumonitis (?amio toxicity), dilated cardiomyopathy with EF of
20-25% and ICD placement for primary prevention and chronic
pneumonitis presenting with bilateral foot pain and falls for 3
weeks with hypotension, [**Last Name (un) **], leukocytosis, worsening intestitial
infiltrates.
.
#) Hypotension: Given low grade fever, leukocytosis, left shift,
persistent pressures, chief concern was initially sepsis;
however sx resolved rapidly after only 1 day on abx so infection
was less likely. Cardiogenic shock due to CHF exacerbation/MI
was also considered but EKG and physical exam ___and echo?___
made this less likely. CXR showing increased interstitial
infiltrate density in setting of steroid-induced
immunosuppression made atypical PNA a concern, and numerous
studies for legionalla,PCP,[**Name10 (NameIs) 3019**],beta galactoman,glucan were
all negative.
Given increasing density of interstitial infiltrates on CXR and
dyspnea, would be concerned about a an atypical pulmonary
infection, although patient arrived with normal rest
saturations. Ultimately, because pt presented with hyponatremia,
hyperkalemia and recent steroid dose reduction, and because sx
resolved rapidly after IV dexamethasone, it was concluded that
adrenal crisis was most likely etiology of hypotension. On Day
#2 he was transferred from MICU to floors where he received
prednisone PO and remained afebrile with stable VS. Cortisol
stim test and random cortisol both were elevated but this is
because pt was being treated with steroids during test.
.
#) Arthritis: Given podagra in left MTP in setting of elevated
serum uric acid, acout gout was diagnosed. There was also
concern for septic arthritis given fever, white count etc so pt
was initially started on broad spectrum abx but synovial fluid
cx were negative. Sample was too small to send for light
microscopy so crystal study could not be performed. Prednisone
treatment ([**Last Name 788**] problem #1) helped treat gout and symptoms
rapidly resolved. Lyme Ab, ESR, CRP, [**Doctor First Name **] were all negative/WNL.

.
#) Acute kidney injury: Creatine bump to 2.4 on admission;
normalized to baseline of 1.8 during stay. Thus was most likely
prerenal etiology from hypotension.
.
#) Dilated cardiomyopathy: Echo on hosp day #3 (done to R/O CHF
as etiology of hypotension) showed no progression of CHF (severe
systolic, EF 20-25%).
.
#) Hypothyroidism: TSH normal when checked to R/O hypothyroid as
etiology of hypotension. Home levothyroxine continued.
.
#) GERD: Omeprazole

Medications on Admission:
1) Azathioprine 100mg PO daily
2) Prednisone 5mg PO daily
3) Atorvastatin 10mg PO daily
4) Carvedilol 25mg PO BID
5) Enalapril 5mg PO daily
6) Levothyroxine 125mcg PO daily
7) Omeprazole 40mg PO daily
8) Tramadol 50-100mg PO BID PRN Pain
9) Aspirin 81mg PO daily
10) Bactrim DS tab PO 3x per week
11) folate 1 tab PO daily
12) Vitamin D 1 tab PO daily
Allergies:
1) Oxycontin - agitated delerium
2) Ativan - agitated delerium


Discharge Disposition:
Home

Discharge Diagnosis:
1. Adrenal insufficiency from stopping steroids
2. Acute gout flare


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted to the hospital yesterday with low blood
pressure and swollen feet. We determined that these problems had
been caused by two different issues: being tapered too quickly
off your steroids, and having a flare-up of your gout. There is
a small chance that you have a joint infection; cultures of your
joint fluid have been negative so far but you should follow up
with your PCP about these results and/or if your symptoms
worsen. You should go to all the appointments scheduled below to
follow up on these problems and decide whether you should be
started on medication for your gout. We have written you a
prescription for Prednisone: 60 milligrams/day for 2 days, 40
milligrams/day for 3 days, 20 milligrams/day for 3 days, and
then then 10 milligrams/day every day after that. We also wrote
you a prescription for Colchicine 0.6 milligrams three
times/day, which you should take as needed if you have another
gout flare.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Department: PRIMARY CARE
When: Thursday [**8-20**] at 2:30PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], M.D. ([**Telephone/Fax (1) 10492**])

Department: RHEUMATOLOGY
WHEN: within 4-6 weeks. Dr.[**Name (NI) 20529**] office will call you
with date of appointment.
With: Dr. [**Name (NI) 9620**] ([**Telephone/Fax (1) 2226**])

Department: REHABILITATION SERVICES
When: WEDNESDAY [**2189-8-19**] at 8:45 AM
With: [**Name (NI) 2482**] [**Name (NI) 2483**], PT, CCS [**Telephone/Fax (1) 2484**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: WEDNESDAY [**2189-8-26**] at 10:20 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: MONDAY [**2189-8-31**] at 11:00 AM
With:  ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**]
Building: None None
Campus: AT HOME SERVICE     Best Parking: None


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
{'Acute gouty arthropathy,Glucocorticoid deficiency,Chronic systolic heart failure,Other primary cardiomyopathies,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Personal history of systemic steroid therapy,Esophageal reflux,Unspecified acquired hypothyroidism,Knee joint replacement,Automatic implantable cardiac defibrillator in situ,Chronic kidney disease, unspecified,Postinflammatory pulmonary fibrosis'}


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: Bilateral foot pain and hypotension

PRESENT ILLNESS: Mr. [**Known lastname 2491**] is an 80 year old man with DJD, ? gout, kidney
disease, nonspecific interstitial pneumonitis (?amio toxicity),
dilated cardiomyopathy with EF of 20-25% s/p ICD placement
presenting with bilateral foot pain and falls for 3 weeks. The
patient believes his symptoms began suddenly, and progressed
over a 2 week time. He noted increasing pain, swelling in his
ankle and 1st MTP joints bilaterally. Today, he got up out of
bed felt light headed and nearly fell but quickly sat down
without trma. He also noticed slightly worsening dyspnea on
exertion and generalized weakness. He denied recent foot/leg
trauma, fevers, chills, sweats, rash, other joint pains, recent
travel, tick or insect exposure, sick contacts. Of note, he was
recently admitted to an OSH for "dehydration" after steroid dose
reduction. He was recently seen in pulmonology clinic on [**2189-8-5**]
and had his steroids reduced from 10mg daily to 5mg daily in the
setting of higher doses before this. After his fall, he decided
to come to the ED after talking with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1007**].
.
In the ED, initial vitals were 98.2 97/65 76 24 98%RA. He denied
SOB but looked dyspneic and upon further questioning admitted to
dyspnea. He was noted to have increased pain and swelling of his
ankles and MCP joints bilaterally and was given cefazolin 1gm IV
ONCE for suspected septic arthritis. He was given 1 5/325 tab of
percocet for his pain. He was subsequently noted to be
hypotensive to 82/43. He was given 1L of NS wide open.
Subsequently his saturation dropped to 94% on RA and he was
placed on 2LNC. For the low blood pressure he was broadened to
vancomycin 1gm IV ONCE. His pressures rose to 92/50 with his
last vitals 99.3 61 18 99%2L.
.
On the floor, he remained asymptomatic but continued to be
transiently hypotensive occasionally to the 80s, and at one
point down to the 60s, and fortunately responded to a 250cc
bolus of NS. He was given dexamethasone 4mg IV ONCE for presumed
adrenal crisis. Ortho was consulted who recommended rheumatology
consultation. Podiatry was consulted who offered to tap the
joint, which a small amount of serosanguinous fluid was sent to
the lab. The patient was subsequently started on
vanc/cefepime/levofloxacin.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.

MEDICAL HISTORY: 1) ILD/NSIP ? in setting of prior amiodarone use
-[**2189-8-5**] outpatient PFTs: FVC of 2.86 liters, which is 73%
predicted, an FEV1 of 1.96 liters to 79% predicted with an
FEV1/FVC ratio of 68, which is 108% predicted. Compared to his
last testing two and a half weeks ago there is a marked decline
in both his forced vital capacity (about 400 mL) and a drop in
his FEV1 by about 400 mL as well

MEDICATION ON ADMISSION: 1) Azathioprine 100mg PO daily
2) Prednisone 5mg PO daily
3) Atorvastatin 10mg PO daily
4) Carvedilol 25mg PO BID
5) Enalapril 5mg PO daily
6) Levothyroxine 125mcg PO daily
7) Omeprazole 40mg PO daily
8) Tramadol 50-100mg PO BID PRN Pain
9) Aspirin 81mg PO daily
10) Bactrim DS tab PO 3x per week
11) folate 1 tab PO daily
12) Vitamin D 1 tab PO daily
Allergies:
1) Oxycontin - agitated delerium
2) Ativan - agitated delerium

ALLERGIES: Ativan / OxyContin

PHYSICAL EXAM: On admission:
General: Alert, oriented, pleasant elderly man mildly dyspneic
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally except right basilar
rales, no wheezes, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal: Guiac negative brown stool.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Musculoskeletal: Bilateral MTP joints with swelling, R>>L,
On discharge:
VS: T 96.9 BP 130/75 P 65 RR 18 SaO2 96% RA
General: AAOx3, pleasant elderly man NAD
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Rectal: Guiac negative brown stool.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Musculoskeletal: Bilateral MTP joints with swelling, R>>L, no
erythema/tenderness/warmth

FAMILY HISTORY: No history of autoimmune dz such as Lupus, RA

SOCIAL HISTORY: Happily married, retired, formerly involved in magazine
advertising.
- Tobacco: None
- Alcohol: 1 drink of liquor daily, no excess beyond this
- Illicits: None
No h/o STIs, recent travel, tick exposures, etc. 

### Response:
{'Acute gouty arthropathy,Glucocorticoid deficiency,Chronic systolic heart failure,Other primary cardiomyopathies,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Personal history of systemic steroid therapy,Esophageal reflux,Unspecified acquired hypothyroidism,Knee joint replacement,Automatic implantable cardiac defibrillator in situ,Chronic kidney disease, unspecified,Postinflammatory pulmonary fibrosis'}
