CHIEF COMPLAINT: SOB

PRESENT ILLNESS: 76 year old female with diabetes, hypothyroidism, GERD, and
hyperlipidemia admitted to [**Hospital1 **] with diarrhea, fatigue, bright
red blood per rectum and bilateral lower extremity edema on
[**2153-12-4**]. History per records as difficult for patient to
communicate while on BIPAP.
.
Initially presented to [**Hospital3 **] on [**2153-12-4**] with rectal
bleeding, low back pain, and shortness of breath.  Was
previously hospitalized in [**Month (only) 1096**] with diverticulitis and
positive blood cultures ([**2-18**]) for Strep viridans, sensitive to
penicillins.  Following that hospitalization, she was sent home
on ciprofloxacin.  Since discharge, over the course of [**Month (only) 1096**]
and [**Month (only) 404**], she has had symptoms of continued malaise, poor
appetite, and weight loss of about 10 lbs over the past couple
months.  She has been sleeping often and has had low energy.
One week prior to [**Hospital1 **] admission, she had diarrhea and noted
bright red blood in stool.  Two days prior to [**Hospital1 **] admission,
she admitted to worsening shortness of breath, leg swelling, and
family noted increasing lethargy and confusion.  She presented
to [**Hospital3 **] with these complaints.  Blood cultures drawn
on [**12-4**] grew out an alpha hemolytic strep species with final
culture data pending.  She was placed empirically on IV
ceftriaxone.  She was not febrile during her hospital stay and
felt symptomatically improved after antibiotics were started.
An echo done at [**Hospital1 **] revealed aortic stenosis but no
vegetation or vavulopathy was noted.  Stool was tested given
diarrhea history but this was negative for clostridium
difficile.   Her laboratory analysis was remarkable for
creatinine of 2 with baseline of 0.6; her white count peaked at
11,600.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis. She denies
exertional buttock or calf pain.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Hypothyroidism
Reflux
HTN
Degerenative disc disease
Hyperlipidemia

MEDICATION ON ADMISSION: HOME MEDICATIONS:
Metformin 500mg QAM, 1000 mg QHS
Lisinopril 40mg PO Daily
Simvastatin 20mg PO Qpm
Ergocalciferol one tab PO HS
Atenolol 100mg PO Daily
Levothyroxine 0.125mg po Daily
HCTZ 50mg Daily
Calcium 1250 mg PO Daily
.
Medications on Transfer:
Simvastatin 20 mg daily
calcium carbonate 1250 mg daily
synthroid 0.125 mg daily
atenolol 100 mg daily
protonix 40 mg daily
allopurinol 200 mg daily
diamox 250 mg [**Hospital1 **]
vitamin D 400 U daily
Rocephin
nitrostat

ALLERGIES: Percocet / Codeine

PHYSICAL EXAM: ON ADMISSION
.
VS: T=98 BP=191/90 HR=96 RR=24 O2 sat=100% NRB (6L)
GENERAL: Moderate respiratory distress, face flushed, lying on
left side
HEENT: PERRL, EOMI. Conjunctiva hemorrhages bilaterally.
NECK: JVP difficult to assess due to positioning and body
habitus
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Difficult to auscultate due to BiPap machine. RR, S1/S2.
Systolic murmur, heard at RSB. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Abdominal muscle use. Resp moderate labored. Decreased
respiratory sounds. Diffuse wheezes and crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
URO: external hemorrhoids
EXTREMITIES: 2+ edema to knees bilaterally. 1+ edema in hands.
SKIN: Diffuse ecchymoses in both arms. Non-blanching petechie in
right shin, upper chest, upper back. [**Last Name (un) 1003**] lesions on fingers,
bilaterally. No Osler's notes noted.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: Originally from [**Country 4754**], lives with her husband in an apartment
in [**Name (NI) 392**].
- Tobacco history: none
- ETOH: none
- Illicit drugs: none
Acute and subacute bacterial endocarditis,Acute kidney failure with lesion of tubular necrosis,Acute on chronic diastolic heart failure,Cerebral embolism without mention of cerebral infarction,Thrombocytopenia, unspecified,Alkalosis,Intestinal infection due to Clostridium difficile,Bacteremia,Hemorrhage of rectum and anus,Anemia, unspecified,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Encounter for palliative care,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Mitral valve insufficiency and aortic valve insufficiency
Ac/subac bact endocard,Ac kidny fail, tubr necr,Ac on chr diast hrt fail,Crbl emblsm wo infrct,Thrombocytopenia NOS,Alkalosis,Int inf clstrdium dfcile,Bacteremia,Rectal & anal hemorrhage,Anemia NOS,Other streptococcus,DMII wo cmp nt st uncntr,Encountr palliative care,Hypertension NOS,Hyperlipidemia NEC/NOS,Hypothyroidism NOS,Mitral/aortic val insuff
Admission Date:  [**2153-12-10**]              Discharge Date:   [**2153-12-22**]

Date of Birth:  [**2079-11-20**]             Sex:   F

Service: MEDICINE

Allergies:
Percocet / Codeine

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
TEE
Tracheal intubation

History of Present Illness:
76 year old female with diabetes, hypothyroidism, GERD, and
hyperlipidemia admitted to [**Hospital1 **] with diarrhea, fatigue, bright
red blood per rectum and bilateral lower extremity edema on
[**2153-12-4**]. History per records as difficult for patient to
communicate while on BIPAP.
.
Initially presented to [**Hospital3 **] on [**2153-12-4**] with rectal
bleeding, low back pain, and shortness of breath.  Was
previously hospitalized in [**Month (only) 1096**] with diverticulitis and
positive blood cultures ([**2-18**]) for Strep viridans, sensitive to
penicillins.  Following that hospitalization, she was sent home
on ciprofloxacin.  Since discharge, over the course of [**Month (only) 1096**]
and [**Month (only) 404**], she has had symptoms of continued malaise, poor
appetite, and weight loss of about 10 lbs over the past couple
months.  She has been sleeping often and has had low energy.
One week prior to [**Hospital1 **] admission, she had diarrhea and noted
bright red blood in stool.  Two days prior to [**Hospital1 **] admission,
she admitted to worsening shortness of breath, leg swelling, and
family noted increasing lethargy and confusion.  She presented
to [**Hospital3 **] with these complaints.  Blood cultures drawn
on [**12-4**] grew out an alpha hemolytic strep species with final
culture data pending.  She was placed empirically on IV
ceftriaxone.  She was not febrile during her hospital stay and
felt symptomatically improved after antibiotics were started.
An echo done at [**Hospital1 **] revealed aortic stenosis but no
vegetation or vavulopathy was noted.  Stool was tested given
diarrhea history but this was negative for clostridium
difficile.   Her laboratory analysis was remarkable for
creatinine of 2 with baseline of 0.6; her white count peaked at
11,600.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis. She denies
exertional buttock or calf pain.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.

Past Medical History:
1. CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Hypothyroidism
Reflux
HTN
Degerenative disc disease
Hyperlipidemia

Social History:
Originally from [**Country 4754**], lives with her husband in an apartment
in [**Name (NI) 392**].
- Tobacco history: none
- ETOH: none
- Illicit drugs: none

Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.


Physical Exam:
ON ADMISSION
.
VS: T=98 BP=191/90 HR=96 RR=24 O2 sat=100% NRB (6L)
GENERAL: Moderate respiratory distress, face flushed, lying on
left side
HEENT: PERRL, EOMI. Conjunctiva hemorrhages bilaterally.
NECK: JVP difficult to assess due to positioning and body
habitus
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Difficult to auscultate due to BiPap machine. RR, S1/S2.
Systolic murmur, heard at RSB. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Abdominal muscle use. Resp moderate labored. Decreased
respiratory sounds. Diffuse wheezes and crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
URO: external hemorrhoids
EXTREMITIES: 2+ edema to knees bilaterally. 1+ edema in hands.
SKIN: Diffuse ecchymoses in both arms. Non-blanching petechie in
right shin, upper chest, upper back. [**Last Name (un) 1003**] lesions on fingers,
bilaterally. No Osler's notes noted.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

Pertinent Results:
ADMISSION LABS
.

[**2153-12-10**] 10:40PM BLOOD WBC-17.6*# RBC-3.37* Hgb-9.6*# Hct-30.0*
MCV-89 MCH-28.4 MCHC-32.0 RDW-15.2 Plt Ct-165
[**2153-12-10**] 10:40PM BLOOD Neuts-89.6* Lymphs-7.4* Monos-2.7 Eos-0.1
Baso-0.1
[**2153-12-10**] 10:40PM BLOOD PT-14.2* PTT-22.0 INR(PT)-1.2*
[**2153-12-10**] 10:40PM BLOOD Glucose-271* UreaN-105* Creat-2.0*#
Na-139 K-3.5 Cl-100 HCO3-25 AnGap-18
[**2153-12-10**] 10:40PM BLOOD ALT-98* AST-107* LD(LDH)-400*
AlkPhos-248* TotBili-0.5
[**2153-12-10**] 10:40PM BLOOD Albumin-3.1* Calcium-7.7* Phos-5.9*
Mg-1.8
.
STUDIES:
.
ADMISSION CXR:No previous images. Enlargement of the cardiac
silhouette with substantial pulmonary edema. Left pleural
effusion with compressive
atelectasis is also seen.
.
TTE [**12-10**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are moderately thickened.
There is a moderate-sized probable vegetation (~0.8 cm diameter)
on the aortic valve. There is mild aortic valve stenosis (valve
area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is (~0.5
cm) small mobile structure consistent with possible vegetation
on the mitral valve. There is mild functional mitral stenosis
(mean gradient 4 mmHg) due to mitral annular calcification.
Moderate (2+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is no pericardial effusion.

IMPRESSION: Echodense mobile structure on the aortic valve
consistent with probable vegetation. There is also a smaller
mobile structure on the mitral valve which may also be a
vegetation. Preserved biventricular systolic function. Mild
aortic regurgitation and at least moderate mitral
regurgitation.Mild mitral inflow gradient associated with mitral
annular calcification.
.
TEE [**12-12**]:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. Normal interatrial septum by color doppler. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the arch and descending thoracic aorta
down to 35cm from incisors. The aortic valve leaflets are
moderately thickened. Significant aortic stenosis cannot be
excluded. There is a 0.8mm long echodensity on the LVOT side of
the the non-coronary leaflet of the aortic valve c/w a
vegetation. Moderate to severe aortic regurgitation is seen. No
aortic valve abscess is seen. The mitral valve leaflets is
mildly thickenedl. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. Tricuspid
leaflets are normal with trivial tricuspid regurgitation. There
is no pericardial effusion.

IMPRESSION: Moderate sized, mobile echodensity on the
non-coronary leaflet of the aortic valve consistent with
vegetation. Moderate to severe aortic regurgitation. Mild mitral
regurgitation.
.
HEAD MRI [**12-12**]:
1. Punctate focus of high DWI/low ADC signal in the medial right
post-central sulcus. This might be secondary to suceptability
affect from adjacent pial siderosis described below. However, a
small acute to subacute cortical infarct or related to septic
emboli is possible. Assessment is somewhat limited due to lack
of IV contrast. Followup as clinically indicated.

2. Linear loss of signal on susceptabilty within the right
central sulcus and left post-central sulcus is suggestive of
pial siderosis in the setting of prior subarachnoid hemorrhage.
A few tiny scattered foci of negative susceptibility in the
[**Doctor Last Name **] relate to micorhemorrhages/ mineralization from amyloid
agiopathy, etc. CT noncontrast can be helpful.
.
SPINE MRI [**12-12**];
1. Multilevel, multifactorial degenerative changes ; slightly
increased STIR signal at T4 and T4-5 disc can be seen with
degenerative changes- correlate clinically for tenderness and
lab correlation to exclude infection; Slightly increased signal
in the sof ttissues of interspinous region ( se 13, im 10 and
14)- correlate clinically. No definite evidence of infection
otherwise.
.
ADMISSION EKG: Baseline artifact. Probable sinus rhythm. ST-T
wave abnormalities. Since the previous tracing of [**2141-6-21**] the
rate is faster. ST-T wave abnormalities are new. Clinical
correlation is suggested.

Brief Hospital Course:
HOSPITAL COURSE:
76 year old W with diabetes, HTN, hyperlipidemia, admitted to
[**Hospital3 **] with diarrhea, BRBPR, and LE edema, found to
have strep viridans endocarditis, ARF, transaminitis, CHF
exacerbation. Cardiac Surgery was consulted for AVR and felt
patient was not a surgical candidate.  Given her progressive
medical decline despite aggressive care, she was ultimately made
CMO by her family after extensive thought and discussion. She
was started on morphine and scopolamine for symptom control and
expired on [**2153-12-22**] at 1835 in the presence of her family.
.
ACTIVE ISSUES
#Goals of care:  Family decided to make the patient DNR/DNI
after extubation.  Family meeting was held on HD 9 to discuss
goals of care. They decided to pursue aggressive comfort
measures for goals of care. She was extubated with her family at
her bedside. All laboratory tests and medications were
discontinued including antibiotic therapy. She was placed on a
morphine gtt. Palliative care and inpatient hospice were
consulted for recommendations. She expired in the presence of
her family on [**2153-12-22**].
.
# Respiratory distress/CHF: Pt initially admitted in respiratory
distress and found to be volume overloaded in CHF. Likely from
increased LV filling pressures caused by severe AI. Shortly
after admission, pt was intubated in the setting of worsening
respiratory distress with lying down. Initially pursued an
aggressive diuresis regimen including lasix ggt but she did not
respond to this, but did respond to bumex/diuril boluses. This
was continued for several days with good output, but after
discussion with renal it was decided that this method would not
be able to remove all of her fluid so decision was made to move
toward volume optimization with CVVH. Even after volume
optimization the patient was difficult to extubate. The
patient's goals of care were then transitioned to aggressive
comfort measures.
.
# Endocarditis: Initially started on ceftriaxone for s. viridans
endocarditis.  However OSH cultures began growing G- rods so she
was started on Zosyn and CTX was d/c'd. TEE showed 8 mm mobile
vegetation. ESR and CRP both elevated at 30/14.3. MRI of
brain/spine was performed, concerning for punctate lesions in
the brain but neuro did not feel that these were an increase
risk of hemorrhaging. C-[**Doctor First Name **] followed the patient and determined
she was not a candidate for valve repair until her acute issues
resolved. Ultimately she was made CMO by her family, and further
management was discontinued.
.
# Leukocytosis/diarrhea:  Pt noted to have increasing WBC count
with diarrhea. Possible C diff as patient has been on
antibiotics for 2 months.  She was started PO Vanc and IV Flagyl
for coverage, which were ultimately discontinued as goals of
care changed.
.
# HTN: Patient was normally on a regimen of Lisinopril 40 mg and
HCTZ 50 mg at home. sBP in the 180s on presentation to OSH, but
improved after starting on atenolol 100 mg. On admission her SBP
was elevated to 190s.  She was started on a nitro ggt given her
increased filling pressures, which was eventually changed to a
hydralazine for BP control.
.
# Anemia: Noted to have acute hematicrit drop several days post
admission. Unclear source, though when presenting to OSH had
BRBPR and exam demonstrated hemorrhoids. Potentially could have
had splenic infarct, though RUQ ultrasound was not able to exam
the spleen. Iron and hemolysis labs were within normal limits.
She received 2 units of pRBC and hematorcrit remained stable.
.
# Thrombocytopenia: unclear etiology. No culprit medications and
time frame did not qualify for HIT. Likely secondary to overall
clinical picture.
.
# Diabetes: Patient on oral meds at home, and here on humalog SS
and lantus.
.
# HLD: Chronic issue, she was continued on home dose of
Simvastatin 20 mg qd.
.
# Hypothyroidism: Continued home Levothyroxine 0.125mg po Daily
.
TRANSITION OF CARE
Comfort Measures Only

Medications on Admission:
HOME MEDICATIONS:
Metformin 500mg QAM, 1000 mg QHS
Lisinopril 40mg PO Daily
Simvastatin 20mg PO Qpm
Ergocalciferol one tab PO HS
Atenolol 100mg PO Daily
Levothyroxine 0.125mg po Daily
HCTZ 50mg Daily
Calcium 1250 mg PO Daily
.
Medications on Transfer:
Simvastatin 20 mg daily
calcium carbonate 1250 mg daily
synthroid 0.125 mg daily
atenolol 100 mg daily
protonix 40 mg daily
allopurinol 200 mg daily
diamox 250 mg [**Hospital1 **]
vitamin D 400 U daily
Rocephin
nitrostat

Discharge Medications:
not applicable, patient expired

Discharge Disposition:
Expired

Discharge Diagnosis:
endocarditis
cardiac arrest

Discharge Condition:
expired

Discharge Instructions:
not applicable

Followup Instructions:
not applicable
{'Acute and subacute bacterial endocarditis,Acute kidney failure with lesion of tubular necrosis,Acute on chronic diastolic heart failure,Cerebral embolism without mention of cerebral infarction,Thrombocytopenia, unspecified,Alkalosis,Intestinal infection due to Clostridium difficile,Bacteremia,Hemorrhage of rectum and anus,Anemia, unspecified,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Encounter for palliative care,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Mitral valve insufficiency and aortic valve insufficiency'}


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: SOB

PRESENT ILLNESS: 76 year old female with diabetes, hypothyroidism, GERD, and
hyperlipidemia admitted to [**Hospital1 **] with diarrhea, fatigue, bright
red blood per rectum and bilateral lower extremity edema on
[**2153-12-4**]. History per records as difficult for patient to
communicate while on BIPAP.
.
Initially presented to [**Hospital3 **] on [**2153-12-4**] with rectal
bleeding, low back pain, and shortness of breath.  Was
previously hospitalized in [**Month (only) 1096**] with diverticulitis and
positive blood cultures ([**2-18**]) for Strep viridans, sensitive to
penicillins.  Following that hospitalization, she was sent home
on ciprofloxacin.  Since discharge, over the course of [**Month (only) 1096**]
and [**Month (only) 404**], she has had symptoms of continued malaise, poor
appetite, and weight loss of about 10 lbs over the past couple
months.  She has been sleeping often and has had low energy.
One week prior to [**Hospital1 **] admission, she had diarrhea and noted
bright red blood in stool.  Two days prior to [**Hospital1 **] admission,
she admitted to worsening shortness of breath, leg swelling, and
family noted increasing lethargy and confusion.  She presented
to [**Hospital3 **] with these complaints.  Blood cultures drawn
on [**12-4**] grew out an alpha hemolytic strep species with final
culture data pending.  She was placed empirically on IV
ceftriaxone.  She was not febrile during her hospital stay and
felt symptomatically improved after antibiotics were started.
An echo done at [**Hospital1 **] revealed aortic stenosis but no
vegetation or vavulopathy was noted.  Stool was tested given
diarrhea history but this was negative for clostridium
difficile.   Her laboratory analysis was remarkable for
creatinine of 2 with baseline of 0.6; her white count peaked at
11,600.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, cough, hemoptysis. She denies
exertional buttock or calf pain.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations, syncope or presyncope.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- CABG: none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Hypothyroidism
Reflux
HTN
Degerenative disc disease
Hyperlipidemia

MEDICATION ON ADMISSION: HOME MEDICATIONS:
Metformin 500mg QAM, 1000 mg QHS
Lisinopril 40mg PO Daily
Simvastatin 20mg PO Qpm
Ergocalciferol one tab PO HS
Atenolol 100mg PO Daily
Levothyroxine 0.125mg po Daily
HCTZ 50mg Daily
Calcium 1250 mg PO Daily
.
Medications on Transfer:
Simvastatin 20 mg daily
calcium carbonate 1250 mg daily
synthroid 0.125 mg daily
atenolol 100 mg daily
protonix 40 mg daily
allopurinol 200 mg daily
diamox 250 mg [**Hospital1 **]
vitamin D 400 U daily
Rocephin
nitrostat

ALLERGIES: Percocet / Codeine

PHYSICAL EXAM: ON ADMISSION
.
VS: T=98 BP=191/90 HR=96 RR=24 O2 sat=100% NRB (6L)
GENERAL: Moderate respiratory distress, face flushed, lying on
left side
HEENT: PERRL, EOMI. Conjunctiva hemorrhages bilaterally.
NECK: JVP difficult to assess due to positioning and body
habitus
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Difficult to auscultate due to BiPap machine. RR, S1/S2.
Systolic murmur, heard at RSB. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Abdominal muscle use. Resp moderate labored. Decreased
respiratory sounds. Diffuse wheezes and crackles.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
URO: external hemorrhoids
EXTREMITIES: 2+ edema to knees bilaterally. 1+ edema in hands.
SKIN: Diffuse ecchymoses in both arms. Non-blanching petechie in
right shin, upper chest, upper back. [**Last Name (un) 1003**] lesions on fingers,
bilaterally. No Osler's notes noted.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+

FAMILY HISTORY: No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: Originally from [**Country 4754**], lives with her husband in an apartment
in [**Name (NI) 392**].
- Tobacco history: none
- ETOH: none
- Illicit drugs: none 

### Response:
{'Acute and subacute bacterial endocarditis,Acute kidney failure with lesion of tubular necrosis,Acute on chronic diastolic heart failure,Cerebral embolism without mention of cerebral infarction,Thrombocytopenia, unspecified,Alkalosis,Intestinal infection due to Clostridium difficile,Bacteremia,Hemorrhage of rectum and anus,Anemia, unspecified,Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Encounter for palliative care,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Mitral valve insufficiency and aortic valve insufficiency'}
