CHIEF COMPLAINT: Hypotension.

PRESENT ILLNESS: Paient is a 72 year old male status-post pacemaker, status-post
MI, CABG, status-post CVA with ESRD on HD, DM, recently admitted
[**2162-7-31**] for hyperkalemia/CP and found to have "ST-T changes in
v1-v3"-thought to be secondary to electrolyte abnormalities.
Trop 0.23, Cr 3.8.

MEDICAL HISTORY: -CABG [**1-19**] after MI (at [**Hospital1 2177**]: LIMA to LAD, SVG to OM1, SVG to
PDA)
-Post-operative R.MCA CVA ~1wk after CABG-Pt with resultant
hemiplegia, aphasia, dsyphagia.
-Post-op large RUE DVT
-Status-post respiratory failure from CVA, now weaned of vent.
-Hypertension
-Peripheral vascular disease, status-post left
popliteal-dorsalis pedis bypass with saphenous vein graft
-Status-post sepsis at [**Hospital1 **] in [**Month (only) 958**]
-Diabetes mellitus, Type II. Diagnosed 40 years ago,
complicated by nephropathy, neuropathy (sensory and autonomic
leading to urinary retention) and retinopathy (s/p bilat
vitrectomies, L eye blindness).
-ESRD secondary to diabetic nephropathy + chronic allograft
insufficiency s/p R cadaveric kidney transplant, complicated by

MEDICATION ON ADMISSION: asa 81mg daily
hep SC TID
simvastatin 20mg daily
Glargine 22 units SC QHS/LISPRO SS
albuterol and atrovent nebs Q6hrs
loperamide 2mg daily
metoclopramide 5mg Q8hrs via g-tube
MVI
omeprazole 20mg [**Hospital1 **]
simethicone 80mg daily
acetaminophen 650mg Q6h prn
diphenhydramine 25mg QHS itching

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 96.8, BP 161/94 , HR 60 ,RR 16, 100% on RA. WT 61.4kg.
Gen: NAD, eyes closed, occasional moaning, alert, answers some
questions. No respiratory distress.
HEENT: L.eye without [**Doctor First Name 2281**], pt with eyes closed but can open on
command. anicteric, dry MM, unable to assess oropharynx as pt
will not open mouth.
Neck: Supple, +old tracheostomy area with granulation tissue,
~1cm in size, no LAD, no noticeable JVP.
CV: s1, s2, RR, paced, +2/6 systolic/diastolic flow murmur heard
throughout precordium, no r/g
Chest: b/l AE, +bibasilar crackles on anterior exam.
Abd: +bs, +G-tube in place, soft, Nt, NTD,+RLQ scar c/w R.pelvic
kidney transplant-transplanted kidney palpable-nontender, no
bruits.
Ext: No c/c/e. b/l metatarsal ambutions. L.knee with 2cm
abrasion.
Skin: stage 3 sacral decub ulcer.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+
DP-dopplerable
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+
DP-dopplerable

FAMILY HISTORY: Mother and brother with DM Type 2.

SOCIAL HISTORY: Immigrated from [**Country **] in [**2141**].  Retired from being a civil
engineer at age 47 because of ??????health issues.??????  Currently lives
with wife and 38 [**Name2 (NI) **] daughter.  Denies alcohol, tobacco, drugs.
Glucocorticoid deficiency,End stage renal disease,Atrioventricular block, complete,Other complications due to renal dialysis device, implant, and graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other late effects of cerebrovascular disease, dysphagia,Dysphagia, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Cardiac pacemaker in situ,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Polyneuropathy in diabetes,Background diabetic retinopathy,Gastrostomy status,Neurogenic bladder NOS,Anemia in chronic kidney disease,Peripheral vascular disease, unspecified,Old myocardial infarction,Unspecified visual loss,Long-term (current) use of insulin,Personal history, urinary (tract) infection
Glucocorticoid deficient,End stage renal disease,Atriovent block complete,Comp-ren dialys dev/grft,Hyp kid NOS w cr kid V,Abn react-anastom/graft,Late ef CV dis dysphagia,Dysphagia NOS,DMII renl nt st uncntrld,Status cardiac pacemaker,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Neuropathy in diabetes,Diabetic retinopathy NOS,Gastrostomy status,Neurogenic bladder NOS,Anemia in chr kidney dis,Periph vascular dis NOS,Old myocardial infarct,Visual loss NOS,Long-term use of insulin,Personal history UTI
Admission Date:  [**2162-8-17**]              Discharge Date:   [**2162-8-26**]

Date of Birth:  [**2089-8-16**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hypotension.

Major Surgical or Invasive Procedure:
Fistulogram with ballon angioplasty.


History of Present Illness:
Paient is a 72 year old male status-post pacemaker, status-post
MI, CABG, status-post CVA with ESRD on HD, DM, recently admitted
[**2162-7-31**] for hyperkalemia/CP and found to have "ST-T changes in
v1-v3"-thought to be secondary to electrolyte abnormalities.
Trop 0.23, Cr 3.8.

Today, the patient arrived in IR to have a scheduled fistulogram
and was found to have a HR in the "40's" and was sent to the ED.
In the [**Name (NI) **], pt reportedly had "complete heart block" (patient has
pacemaker). EP was consulted, pacer interrogated, rate was
increased to 60. Additionally, patient was found to have a BP of
"80's/40's" and was asymptomatic. BP's were recorded in
patient's thigh as he has L.arm fistulogram, R.PICC. Vitals in
the ED were t 98.0, BP 80/40, RR 21, sat 100% RA

Unable to perform cardiac ROS as patient inconsistently
answering questions, but denies CP, DOE, PND, orthopnea,
palpitations.

On review of symptoms, pt has a history of CVA [**1-19**] after CABG,
no known history of deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. No known recent fevers,
chills or rigors. Unable to assess for exertional buttock or
calf pain as patient is non-ambulatory.

Pt currently complains of L.knee pain [**2-13**] abrasion.

Past Medical History:
-CABG [**1-19**] after MI (at [**Hospital1 2177**]: LIMA to LAD, SVG to OM1, SVG to
PDA)
-Post-operative R.MCA CVA ~1wk after CABG-Pt with resultant
hemiplegia, aphasia, dsyphagia.
-Post-op large RUE DVT
-Status-post respiratory failure from CVA, now weaned of vent.
-Hypertension
-Peripheral vascular disease, status-post left
popliteal-dorsalis pedis bypass with saphenous vein graft
-Status-post sepsis at [**Hospital1 **] in [**Month (only) 958**]
-Diabetes mellitus, Type II. Diagnosed 40 years ago,
complicated by nephropathy, neuropathy (sensory and autonomic
leading to urinary retention) and retinopathy (s/p bilat
vitrectomies, L eye blindness).
-ESRD secondary to diabetic nephropathy + chronic allograft
insufficiency s/p R cadaveric kidney transplant, complicated by

postinfectious GN (negative [**Doctor First Name **], ANCA, low complemt), signs of
chronic rejection (sclerotic glomeruli, interstitial fibrosis
3/[**2158**]). On dialysis starting [**2148**]. Tu/Th/sat
-Anemia
-Neurogenic bladder
-BPH status-post TURP [**2157**].
-Chronic osteomyelitis of C-spine and bilateral feet, s/p
bilateral transmetatarsal amputations (R foot [**2145**], L foot
[**2157**]).
-HSV stomatitis/genital
-Recurrent UTI
-blindness in R.eye

Cardiac History:
CABG [**2162-1-27**] anatomy as follows:
SVG-OM1, SVG-PDA, LIMA-LAD

Pacemaker [**2161-11-12**]- for CHB -per report- St. [**Male First Name (un) 923**].

Social History:
Immigrated from [**Country **] in [**2141**].  Retired from being a civil
engineer at age 47 because of ??????health issues.??????  Currently lives
with wife and 38 [**Name2 (NI) **] daughter.  Denies alcohol, tobacco, drugs.


Family History:
Mother and brother with DM Type 2.

Physical Exam:
VS: T 96.8, BP 161/94 , HR 60 ,RR 16, 100% on RA. WT 61.4kg.
Gen: NAD, eyes closed, occasional moaning, alert, answers some
questions. No respiratory distress.
HEENT: L.eye without [**Doctor First Name 2281**], pt with eyes closed but can open on
command. anicteric, dry MM, unable to assess oropharynx as pt
will not open mouth.
Neck: Supple, +old tracheostomy area with granulation tissue,
~1cm in size, no LAD, no noticeable JVP.
CV: s1, s2, RR, paced, +2/6 systolic/diastolic flow murmur heard
throughout precordium, no r/g
Chest: b/l AE, +bibasilar crackles on anterior exam.
Abd: +bs, +G-tube in place, soft, Nt, NTD,+RLQ scar c/w R.pelvic
kidney transplant-transplanted kidney palpable-nontender, no
bruits.
Ext: No c/c/e. b/l metatarsal ambutions. L.knee with 2cm
abrasion.
Skin: stage 3 sacral decub ulcer.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+
DP-dopplerable
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+
DP-dopplerable

Pertinent Results:
Labs on admission:
[**2162-8-17**] 11:07AM BLOOD WBC-8.5 RBC-4.16* Hgb-12.6* Hct-39.6*
MCV-95 MCH-30.2 MCHC-31.7 RDW-16.2* Plt Ct-252
[**2162-8-17**] 11:07AM BLOOD Neuts-67.9 Lymphs-21.1 Monos-4.2 Eos-5.6*
Baso-1.1
[**2162-8-18**] 05:56AM BLOOD PT-15.3* PTT-44.2* INR(PT)-1.3*
[**2162-8-17**] 11:07AM BLOOD Glucose-80 UreaN-82* Creat-5.2* Na-138
K-4.3 Cl-92* HCO3-28 AnGap-22*
[**2162-8-17**] 11:07AM BLOOD CK(CPK)-59
[**2162-8-17**] 11:07AM BLOOD Calcium-10.0 Phos-6.1*# Mg-2.3

Fistulogram with balloon angioplasty [**2162-8-18**]:
IMPRESSION:
1. Fistulogram demonstrating two severe segmental stenoses.
2. The first stenosis was at the venous outflow tract and was
dilated with 6 mm cutting balloon followed by 8 mm high-pressure
balloon followed by 10 mm high-pressure balloon with good
results.
3. The second severe segmental stenosis was on the venous side
adjacent to the arteriovenous anastomosis. This was dilated with
a 5 mm high-pressure balloon with good results.

TTE [**2162-8-25**]
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are moderately 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. Moderate
(2+) mitral regurgitation is seen. (There is also diastolic
mitral regurgitation). The pulmonary artery systolic pressure
could not be quanitfied. There is no pericardial effusion.

Compared with the findings of the prior study (images reviewed)
of [**2162-6-11**], the degree of mitral regurgitation is increased.
The rhythm now appears to be complete heart block.

Labs on Discharge:

[**2162-8-25**] 04:40AM BLOOD WBC-4.8 RBC-3.75* Hgb-11.0* Hct-35.6*
MCV-95 MCH-29.4 MCHC-31.0 RDW-15.5 Plt Ct-241
[**2162-8-25**] 04:40AM BLOOD Glucose-168* UreaN-49* Creat-4.1* Na-135
K-4.1 Cl-93* HCO3-35* AnGap-11

[**2162-8-21**] 9:00 am BLOOD CULTURE      2 OF 2.

                            **FINAL REPORT [**2162-8-27**]**

   Blood Culture, Routine (Final [**2162-8-27**]):    NO GROWTH.


Brief Hospital Course:
The patient is a 72 year old male with a history of CAD s/p
MI-CABG in [**1-19**], s/p CVA and PCM placement, ESRD on HD,
blindness, DM and bilateral toe amputations who was brought into
IR for a scheduled fistulogram and was found to be hypotensive.
He was transferred to the ED where EP evalulated the patient and
found the pacer to be functioning appropriately; however the
rate was increased to 60. Repeat ECG showed appropriate pacing
spikes.  The patient was subsequently transferred to the CCU for
further monitoring.

In the CCU, the patient was minimally responsive, oriented to
name only, but denied any CP/SOB/Abd pain & lower extremity
discomfort. The patient was not felt to be experiencing ACS. ECG
showed appropriate pacer spikes and blood pressure were in the
100's systolic. The patient was sent down to IR for a
completeion of his fistulogram. There, he was found to have two
stenotic lesions which would need to be addressed with balloon
angioplasty under general anesthesia the following day.

The angioplasty was successful, however, the patient required
phenylephrine secondary to hypotension. Several attempts were
made to wean the pressors, however the patient's blood pressure
would drop below 80's systolic. The Lisinopril was discontinued.
It is also worth noting that the patient is not on any
outpatient beta blocker or Ace inhibitor. The patient was
subsequently weaned from pressors and started on empiric
steroids for presumed adrenal insufficiency before transfer to
the floor for further management.

After transfer to the floor:

# Hypotension: Pt was continued on Prednisone 10mg daily and BP
remained stable with sbp>100.  Infectious work up was negative
and given recent revascularization, cardiac event thought less
likely, ECHO showed normal LV systolic function, EF of >55% with
worsening of MR to 2+. Mental status improved significantly with
patient initiating conversations and BS began to improve.
Suspect that pt is adrenally suppressed and should remain on
Prednisone for a prolonged course given that it is his second
failed wean.  Ca/Vit D management were continued per renal
recommendations. Patient to benefit from long steroid taper
verse indefinite prednisone dose of 10mg.

# ESRD: Secondary to diabetic neprophathy, with failed cadaveric
renal transplant. Patient has been on HD since [**48**], tue/[**Last Name (un) **]/sat.
Fistulogram with baloon angioplasty successful [**2162-8-19**]. Patient
was continued on HD regimen and followed by renal. Outpatient HD
was arranged prior to discharge to resume on his
Tuesday/Thursday/Saturday schedule. Patient nutritional
requirements were evaluated and he was continued on Nutren
Renal/Novasource Renal Full strength with Beneprotein, 25
gm/day, at a rate 30 ml/hr, continuous infusion. He was
discharged home with home tube feeds arranged.

# CAD/Ischemia/PVD: Pt s/p CABG [**1-19**] after MI, performed at [**Hospital1 2177**],
anatomy unknown. Unlikely that pt's asymptomatic bradycardia was
related to ACS. Repeat EKG showed appropriate pacer spikes,
enzymes stable. ECHO demonstrated no wall motion abnormality. He
was continued on asa and statin. Beta blockade was not initiated
as heart rate remained pacer dependent.

# Rhythm: s/p pacemaker for "sick sinus syndrome" in [**11-19**]. EP
evalulated pt in ED for question of CHD and found pacer to be
functioning appropriately. His rate was increased to 60 as he
was symptomatic.

# DM: BS elevated since restarting Prednisone. Low dose lantus
of 6units QHS adequately controlled fingersticks on his tube
feed regimen. As patient increases po intake, he may require
additional lantus titration.

# FEN/G-tube leak: Patient unable to sustain adequate nutrition
due to dysphagia resulting from CVA [**1-19**]. During his stay, it
was noted that his G-tube was leaking through a small hole in
the tube just above the skin. G-tube exchange was performed over
wire by IR. Tube feeds were provided as above. Speech and
swallow performed evaluation for pleasure feeds at the request
of his family. Patient cleared for nectar thick liquids and
pureed solids with 1:1 observation.

# Goals of Care: Through discussion with social work, palliative
care, and family, decision to continue full code status and
attempt trial at home was reached in accordance with family
wishes. Appropriate VNA, tube feeding, HD services were
arranged. Family was responsible for selecting new PCP in the
[**Name9 (PRE) 1474**] area affiliated with [**Hospital1 18**].

Medications on Admission:
asa 81mg daily
hep SC TID
simvastatin 20mg daily
Glargine 22 units SC QHS/LISPRO SS
albuterol and atrovent nebs Q6hrs
loperamide 2mg daily
metoclopramide 5mg Q8hrs via g-tube
MVI
omeprazole 20mg [**Hospital1 **]
simethicone 80mg daily
acetaminophen 650mg Q6h prn
diphenhydramine 25mg QHS itching


Discharge Medications:
1. Supply
hospital bed with alternating pressure pad, weight 142 lbs, 6 ft
tall
2. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Loperamide 1 mg/5 mL Liquid [**Hospital1 **]: One (1) mg PO DAILY (Daily):
via g-tube.
Disp:*QS ml* Refills:*2*
4. Metoclopramide 5 mg/5 mL Solution [**Hospital1 **]: Five (5) ml PO TID (3
times a day): via g-tube.
Disp:*QS ml* Refills:*2*
5. Therapeutic Multivitamin     Liquid [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily): via g-tube
.
Disp:*QS ml* Refills:*2*
6. Simethicone 40 mg/0.6 mL Drops, Suspension [**Hospital1 **]: Eighty (80)
mg PO BID (2 times a day): via g-tube.
Disp:*qs ml* Refills:*2*
7. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily): via g-tube
.
Disp:*60 Tablet(s)* Refills:*2*
8. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) ml PO BID (2
times a day): via g-tube.
Disp:*QS * Refills:*2*
9. Senna 8.8 mg/5 mL Syrup [**Hospital1 **]: Five (5) ml PO BID (2 times a
day) as needed: via g-tube.
Disp:*QS ml* Refills:*2*
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: via
g-tube.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
12. Prednisone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily): via g-tube.
Disp:*30 Tablet(s)* Refills:*2*
13. Lantus 100 unit/mL Cartridge [**Last Name (STitle) **]: Six (6) units Subcutaneous
at bedtime.
Disp:*QS ml* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Adrenal Insufficiency
End-stage Renal Disease on hemodialysis
Complete heart block with symptomatic bradycardia
Cerebral Vascular Accident, chronic
Dysphagia
Diabetes Mellitus, insulin dependent


Discharge Condition:
Hemodynamically stable, afebrile.


Discharge Instructions:
You were admitted for decreased blood pressure found when you
arrived for your previously scheduled fistulogram. Your
pacemaker was found to be working. You did not have a heart
attack. Your pacemaker was set to a heart rate of 60 beats per
minute. You had your fistulogram which included a ballon
angioplasty (opening of two vessels in the fistula).
.
Your medications were provided through your G-tube. Please take
all medications as directed. Many changes have been made since
you were last at home.
.
Please adhere to your follow-up appointments. They are important
for managing your long-term health.
.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.

Followup Instructions:
Please establish care with a new primary care physician and
follow up in the next 1-2 weeks.

Please continue your regularly schedule hemodialysis on a
Tuesday, Thursday, Saturday schedule.
{'Glucocorticoid deficiency,End stage renal disease,Atrioventricular block, complete,Other complications due to renal dialysis device, implant, and graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other late effects of cerebrovascular disease, dysphagia,Dysphagia, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Cardiac pacemaker in situ,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Polyneuropathy in diabetes,Background diabetic retinopathy,Gastrostomy status,Neurogenic bladder NOS,Anemia in chronic kidney disease,Peripheral vascular disease, unspecified,Old myocardial infarction,Unspecified visual loss,Long-term (current) use of insulin,Personal history, urinary (tract) infection'}


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: Hypotension.

PRESENT ILLNESS: Paient is a 72 year old male status-post pacemaker, status-post
MI, CABG, status-post CVA with ESRD on HD, DM, recently admitted
[**2162-7-31**] for hyperkalemia/CP and found to have "ST-T changes in
v1-v3"-thought to be secondary to electrolyte abnormalities.
Trop 0.23, Cr 3.8.

MEDICAL HISTORY: -CABG [**1-19**] after MI (at [**Hospital1 2177**]: LIMA to LAD, SVG to OM1, SVG to
PDA)
-Post-operative R.MCA CVA ~1wk after CABG-Pt with resultant
hemiplegia, aphasia, dsyphagia.
-Post-op large RUE DVT
-Status-post respiratory failure from CVA, now weaned of vent.
-Hypertension
-Peripheral vascular disease, status-post left
popliteal-dorsalis pedis bypass with saphenous vein graft
-Status-post sepsis at [**Hospital1 **] in [**Month (only) 958**]
-Diabetes mellitus, Type II. Diagnosed 40 years ago,
complicated by nephropathy, neuropathy (sensory and autonomic
leading to urinary retention) and retinopathy (s/p bilat
vitrectomies, L eye blindness).
-ESRD secondary to diabetic nephropathy + chronic allograft
insufficiency s/p R cadaveric kidney transplant, complicated by

MEDICATION ON ADMISSION: asa 81mg daily
hep SC TID
simvastatin 20mg daily
Glargine 22 units SC QHS/LISPRO SS
albuterol and atrovent nebs Q6hrs
loperamide 2mg daily
metoclopramide 5mg Q8hrs via g-tube
MVI
omeprazole 20mg [**Hospital1 **]
simethicone 80mg daily
acetaminophen 650mg Q6h prn
diphenhydramine 25mg QHS itching

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 96.8, BP 161/94 , HR 60 ,RR 16, 100% on RA. WT 61.4kg.
Gen: NAD, eyes closed, occasional moaning, alert, answers some
questions. No respiratory distress.
HEENT: L.eye without [**Doctor First Name 2281**], pt with eyes closed but can open on
command. anicteric, dry MM, unable to assess oropharynx as pt
will not open mouth.
Neck: Supple, +old tracheostomy area with granulation tissue,
~1cm in size, no LAD, no noticeable JVP.
CV: s1, s2, RR, paced, +2/6 systolic/diastolic flow murmur heard
throughout precordium, no r/g
Chest: b/l AE, +bibasilar crackles on anterior exam.
Abd: +bs, +G-tube in place, soft, Nt, NTD,+RLQ scar c/w R.pelvic
kidney transplant-transplanted kidney palpable-nontender, no
bruits.
Ext: No c/c/e. b/l metatarsal ambutions. L.knee with 2cm
abrasion.
Skin: stage 3 sacral decub ulcer.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+
DP-dopplerable
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+
DP-dopplerable

FAMILY HISTORY: Mother and brother with DM Type 2.

SOCIAL HISTORY: Immigrated from [**Country **] in [**2141**].  Retired from being a civil
engineer at age 47 because of ??????health issues.??????  Currently lives
with wife and 38 [**Name2 (NI) **] daughter.  Denies alcohol, tobacco, drugs. 

### Response:
{'Glucocorticoid deficiency,End stage renal disease,Atrioventricular block, complete,Other complications due to renal dialysis device, implant, and graft,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other late effects of cerebrovascular disease, dysphagia,Dysphagia, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Cardiac pacemaker in situ,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Polyneuropathy in diabetes,Background diabetic retinopathy,Gastrostomy status,Neurogenic bladder NOS,Anemia in chronic kidney disease,Peripheral vascular disease, unspecified,Old myocardial infarction,Unspecified visual loss,Long-term (current) use of insulin,Personal history, urinary (tract) infection'}
