CHIEF COMPLAINT: Sepsis/UTI

PRESENT ILLNESS: HPI: [**Age over 90 **]M with PMH notable for CAD, CHF (EF 20-25%) was brought
to the ED this morning by his family with whom he lives. Prior
to this morning, the pt was at his baseline, and had taken a
number of day trips with his fmaily over the past 2 weeks.  This
morning, the pt's granddaughter went to his basement apt to look
in on him (his son and son's famly live upstairs) and found that
he was trembling and a bit confused. The pt's son then assessed
his father, and gave him Benadryl (1 tab) for the shaking. He
was sweating and clammy, but his temp later was >102 po The pt
then took his usual am meds with Glucerna, but vomited a frothy
emesis. He was then transported to the ED.
.
Per the pt's family, he had been feeling fine prior to this
morning. he had not complained of cough or SOB, nor had he
mentioned difficulty voiding or dysuria. His son empties a
bedside commode in the am for him, and has identified past UTIs
by malodorous urine, which he did not identify today. He had not
complained of CP or SOB. No GI sx, no bowel changes, no previous
fever/chills/malaise. He had not c/o HA or neck stiffness, or
pain of any kind. Pt had no recent exotic travel or known sick
contacts.
.
In the ED, the pt was initially stable but satting 84% RA. ON MD
exam, sat improved (?on NC), but temp was 104 with HR 60s, BP
134/61. He was minimally responsive (s/p benadryl) and exam was
notable for bibasilar rales. Because he was obtunded and had
ememis in ED with ?aspiration, he was intubated for airway
protection and quickly became hypotensive (BP min 105/50 prior
to sedation). He received 5L NS boluses (levophed started after
3L), as well as 2 g CTX, 1 gm vanc, 500 mg metronidazole, 1 g
tylenol, etomidate, succinylcholine, 10 mg dexamethasone, 2mg
midazolam x 2, levophed gtt, propofol gtt. He was subsequently
transferred to the [**Hospital Unit Name 153**] for further therapy and monitoring.

MEDICAL HISTORY: CAD - s/p MI in [**2109**] tx with lytic therapy and rescue
angioplasty
CHF - EF 20-25%
DM2
History of PAF
S/p PPM
Status post permanent pacemaker insertion.
Hypertension
Hypercholesterolemia
L hip replacement [**2119**] c/b femur fx with "slipped prosthetic"
[**2127**]
Past UTIs, most recently with proteus mirabalis (ctx sensitive,
fluoroquinolone resistant)
S/p TURP

MEDICATION ON ADMISSION: 1. Carbamazepine 200 mg Tablet Sig: 0.5 Tablet PO BID
2. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS prn
4. ? Nexium filled in [**7-19**]. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY
6. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID

ALLERGIES: Erythromycin Base

PHYSICAL EXAM: Upon arrival to [**Hospital Unit Name 153**]:
Gen: Elderly man, sedated and unresponsive
HEENT: B/l arcus, no scleral icterus, secretions around ETT
Neck: Large, no LAD
Heart: RR, no
Lungs: Coarse breath sounds b/l, no rales appreciated
Abd: Full with palpable spleen, not form or appreciably
distended, scan BS, soft
Ext: Thin, 1+ DPs, no c/c/e
Skin: No jaundice, icthyosison feet b/l

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Pt is [**Age over 90 **] yo male who lives in basement of sons house. Wife
passed away last year. Retired plumber who worked here at [**Hospital1 18**].
Streptococcal septicemia,Severe sepsis,Acute on chronic systolic heart failure,Urinary tract infection, site not specified,Septic shock,Acute respiratory failure,Atrial fibrillation,Other emphysema,Mitral valve disorders,Pure hypercholesterolemia,Unspecified essential hypertension,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Fitting and adjustment of cardiac pacemaker
Streptococcal septicemia,Severe sepsis,Ac on chr syst hrt fail,Urin tract infection NOS,Septic shock,Acute respiratry failure,Atrial fibrillation,Emphysema NEC,Mitral valve disorder,Pure hypercholesterolem,Hypertension NOS,Old myocardial infarct,DMII wo cmp nt st uncntr,Ftng cardiac pacemaker
Admission Date:  [**2128-10-16**]              Discharge Date:   [**2128-10-26**]


Service: MEDICINE

Allergies:
Erythromycin Base

Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Sepsis/UTI

Major Surgical or Invasive Procedure:
PICC line placement, Pacer Interrogation


History of Present Illness:
HPI: [**Age over 90 **]M with PMH notable for CAD, CHF (EF 20-25%) was brought
to the ED this morning by his family with whom he lives. Prior
to this morning, the pt was at his baseline, and had taken a
number of day trips with his fmaily over the past 2 weeks.  This
morning, the pt's granddaughter went to his basement apt to look
in on him (his son and son's famly live upstairs) and found that
he was trembling and a bit confused. The pt's son then assessed
his father, and gave him Benadryl (1 tab) for the shaking. He
was sweating and clammy, but his temp later was >102 po The pt
then took his usual am meds with Glucerna, but vomited a frothy
emesis. He was then transported to the ED.
.
Per the pt's family, he had been feeling fine prior to this
morning. he had not complained of cough or SOB, nor had he
mentioned difficulty voiding or dysuria. His son empties a
bedside commode in the am for him, and has identified past UTIs
by malodorous urine, which he did not identify today. He had not
complained of CP or SOB. No GI sx, no bowel changes, no previous
fever/chills/malaise. He had not c/o HA or neck stiffness, or
pain of any kind. Pt had no recent exotic travel or known sick
contacts.
.
In the ED, the pt was initially stable but satting 84% RA. ON MD
exam, sat improved (?on NC), but temp was 104 with HR 60s, BP
134/61. He was minimally responsive (s/p benadryl) and exam was
notable for bibasilar rales. Because he was obtunded and had
ememis in ED with ?aspiration, he was intubated for airway
protection and quickly became hypotensive (BP min 105/50 prior
to sedation). He received 5L NS boluses (levophed started after
3L), as well as 2 g CTX, 1 gm vanc, 500 mg metronidazole, 1 g
tylenol, etomidate, succinylcholine, 10 mg dexamethasone, 2mg
midazolam x 2, levophed gtt, propofol gtt. He was subsequently
transferred to the [**Hospital Unit Name 153**] for further therapy and monitoring.


Past Medical History:
CAD - s/p MI in [**2109**] tx with lytic therapy and rescue
angioplasty
CHF - EF 20-25%
DM2
History of PAF
S/p PPM
Status post permanent pacemaker insertion.
Hypertension
Hypercholesterolemia
L hip replacement [**2119**] c/b femur fx with "slipped prosthetic"
[**2127**]
Past UTIs, most recently with proteus mirabalis (ctx sensitive,
fluoroquinolone resistant)
S/p TURP


Social History:
Pt is [**Age over 90 **] yo male who lives in basement of sons house. Wife
passed away last year. Retired plumber who worked here at [**Hospital1 18**].

Had been ambulating with a walker since leaving rehab,
participates in home PT few times a week.


Family History:
non-contributory

Physical Exam:
Upon arrival to [**Hospital Unit Name 153**]:
Gen: Elderly man, sedated and unresponsive
HEENT: B/l arcus, no scleral icterus, secretions around ETT
Neck: Large, no LAD
Heart: RR, no
Lungs: Coarse breath sounds b/l, no rales appreciated
Abd: Full with palpable spleen, not form or appreciably
distended, scan BS, soft
Ext: Thin, 1+ DPs, no c/c/e
Skin: No jaundice, icthyosison feet b/l


Pertinent Results:
[**2128-10-16**] 11:22AM BLOOD Lactate-3.4*
[**2128-10-18**] 03:21AM BLOOD Lactate-0.7
[**2128-10-17**] 03:01AM BLOOD Carbamz-4.0
[**2128-10-16**] 11:20AM BLOOD Cortsol-61.7*
[**2128-10-20**] 06:15AM BLOOD calTIBC-229* VitB12-328 Folate-11.0
Ferritn-188 TRF-176*
[**2128-10-16**] 11:20AM BLOOD cTropnT-<0.01
[**2128-10-16**] 06:09PM BLOOD CK-MB-4 cTropnT-0.02*
[**2128-10-16**] 11:20AM BLOOD ALT-21 AST-27 CK(CPK)-47 AlkPhos-129*
Amylase-77 TotBili-1.0
[**2128-10-16**] 11:20AM BLOOD Glucose-334* UreaN-29* Creat-1.1 Na-140
K-3.8 Cl-98 HCO3-27 AnGap-19
[**2128-10-24**] 06:15AM BLOOD UreaN-14 Creat-0.8 Na-134 K-3.7 Cl-99
HCO3-27 AnGap-12
[**2128-10-16**] 11:20AM BLOOD WBC-35.0*# RBC-4.03* Hgb-12.7* Hct-37.0*
MCV-92 MCH-31.5 MCHC-34.3 RDW-13.3 Plt Ct-235
[**2128-10-24**] 06:15AM BLOOD WBC-11.8* RBC-3.38* Hgb-10.5* Hct-32.0*
MCV-95 MCH-31.0 MCHC-32.7 RDW-13.8 Plt Ct-252
[**2128-10-16**] 11:20AM URINE RBC->50 WBC->50 Bacteri-OCC Yeast-NONE
Epi-0
[**2128-10-16**] 11:20AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
[**2128-10-16**] 11:20AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.019
.
[**2128-10-16**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2128-10-16**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {BETA
STREPTOCOCCUS GROUP B}; ANAEROBIC BOTTLE-FINAL {BETA
STREPTOCOCCUS GROUP B} EMERGENCY [**Hospital1 **]
[**2128-10-16**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL {BETA STREPTOCOCCUS GROUP B} EMERGENCY [**Hospital1 **]
.
Echo [**10-19**]:
The left atrium is moderately dilated. Left ventricular wall
thicknesses and  cavity size are normal. There is severe
regional left ventricular systolic dysfunction with akinesis of
the distal half of the ventricle. Basal segments are
hypokinetic. No masses or thrombi are seen in the left
ventricle. Tissue velocity imaging E/e' is elevated (>15)
suggesting increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets are mildly
thickened. Aortic stenosis is not suggested. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate (2+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**10-20**] Hip Film:
AP film of the pelvis plus two added views of the left hip and
proximal left femur. There is a bipolar left hip
hemiarthroplasty with cemented femoral stem. A poorly visualized
fracture of the proximal femoral shaft has been fixated by
apparent large osseous allografts with associated cerclage wires
and long lateral plate (with four screws below the tip of the
femoral stem). Overall appearances are unchanged from [**2128-10-8**] with no focal bone destruction or evidence of hardware
loosening. The right hip and SI joints are normal.
.
IMPRESSION: No short interval change. No radiographic evidence
infection or loosening.
.
[**10-22**] LLE U/S
UNILAT LOWER EXT VEINS LEFT
Reason: please image left hip and thigh to rule out fluid
collection
.
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with grp B strep bacteremia with history of left
hip fracture last year, hardware in place.
REASON FOR THIS EXAMINATION:
please image left hip and thigh to rule out fluid collection
INDICATION: Left leg swelling. Evaluate for deep venous
thrombosis.
.
LEFT LOWER EXTREMITY VENOUS ULTRASOUND: Grayscale and Doppler
son[**Name (NI) 1417**] of the left common femoral, superficial femoral, and
popliteal veins were performed. There is normal flow,
augmentation, compressibility, and waveforms. Intraluminal
thrombus is not identified.
.
IMPRESSION: No evidence of deep venous thrombosis.
.

Brief Hospital Course:
Hospital Course, by Problem:
.
# Grp B strep septicemia: this was felt to be likely due to GU
source given active urinalysis, though urine cx negative.  A TTE
negative was negative for any vegetations adherent to the
patients valves or pacer wires.  The patients' family wished to
defer a TEE.  ID was consulted and recommended 4 weeks IV CTX as
well as
rechecking ESR/CRP in 2 weeks to see if rising.  Of note, a Left
hip plain film and LLE u/s to r/o fluid collection showed no
significant findings.  The longer course was recommended by ID
as the exact source of the bacteremia was unclear and
endocarditis was not fully ruled out.
.
#CVS
Ischemia:  the patient had several sets of CE during this
admission which were negative, despite lateral TWI on the
patients ECG.
Pump:  the patient was slightly overloaded after fluid
resusciation in the ICU.  He was diuresed and then restarted on
his home Lasix dose.  Of note, repeat Echo during this admission
showed an EF of 25% with (worsening) 2+ MR.  His amlodipine and
long-acting nitrate were discontinued during this admission d/t
hypotension.
Rhythm:  the patient was continued on Sotalol, as was
intermittently in A fib.  Per the family, the patient has a
history of several falls.  Further discussion of the
risks/benefits of AC will be deferred to the patient's PCP.
[**Name10 (NameIs) 2351**] his ICU admission, given relative bradycardia, he had his
pacer interrogated and the settings were modified to increase
his baseline HR.  Per EP, pt should follow-up in pacemaker
clinic after his discharge.
Prevention:  the patient was kept on Aspirin.  The patient would
likely benefit from the addition of a statin as an outpatient.
.
#Confusion: the patient was noted to be intermittently confused
during his hospitalization.  During the morning of [**10-25**], the
patient was almost obtunted and barely responsed to sternal rub.
 At this time, CT head/ABG/ECG/Fingerstick/CXR were all
unrevealing.  Later in the day the patient was noted to be
incredibly more alter and conversing with his family memebers.
Per discussion with his sons, the patient gets extremely
confused during most hospital admissions.  Detrol was
discontinued d/t possibility for anticholingeric effects.
.
#Hypoxia/COPD:  on the day of discharge the patient was noted to
be slightly hypoxic (88-92RA).  CXR from the day earlier did not
show over CHF but did show small (B) effusions.  Given the
patient's immoblitiy, a CT scan was ordered which did not show a
PE, but only RLL atelectasis and evidence of emphysema.  The
patient was amublated and did not desat (and in fact, O2 sats
improved to 92-94RA).  The etiology was felt to be from
atelectasis and immobility.  Upon discharge, the patient was
started on a Flovent Inhaler along with Atrovent given the CT
findings.  The patient would likely benefit from outpt PFTs to
characterize the degree of his obstructive lung disease.

Medications on Admission:
1. Carbamazepine 200 mg Tablet Sig: 0.5 Tablet PO BID
2. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS prn
4. ? Nexium filled in [**7-19**]. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY
6. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID

7. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable

PO DAILY
9. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID
10. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (in d/c
summary but never filled in pharmacy)
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.

12. Potassium 20 mEq po qd


Discharge Medications:
1. Carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
2. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*15 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) grams Intravenous  Q24H (every 24 hours) for 4 weeks:
through [**2128-11-16**].
Disp:*46 grams* Refills:*0*
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia/agitation.
Disp:*30 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
Weekly CBC w/ diff, ALT, AST, BUN, and creatinine to be faxed to
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**], Fax: [**Telephone/Fax (1) 1419**]
11. Outpatient Lab Work
ESR and CRP to be drawn [**2128-11-4**].
Fax to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**], Fax: [**Telephone/Fax (1) 1419**]
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
13. Atrovent 18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
four times a day as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*0*
14. Flovent 44 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Gentiva

Discharge Diagnosis:
Primary Diagnoses:
Group B strep bacteremia, source unknown but likely [**3-18**] UTI
Delirium
Systolic congestive heart failure, resolved
Paroxysmal atrial fibrillation
Bradycardia

Secondary Diagnoses:
h/o of coronary artery disease
Type 2 diabetes
Hypertension
Hypercholesterolemia
L hip replacement [**2119**] c/b femur fx with "slipped prosthetic"
[**2127**]


Discharge Condition:
good: afebrile, wbc improved


Discharge Instructions:
Please monitor for temperature > 101, rash, shortness of breath,
or other concerning symptoms.

Stop taking your tolterodine (detrol), norvasc (amlodipine) and
isosorbide dinitrate (isordil).

Please avoid taking benadryl, as this can worsen your confusion.
 Please take the trazodone or haldol instead, as prescribed.

Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9404**] from infectious diseases
on [**2128-11-23**] at 10:30 AM.   Phone: ([**Telephone/Fax (1) 4170**].

Please follow-up with Dr. [**Last Name (STitle) 1007**] within 1-2 weeks to discuss
starting coumadin.  His phone number is [**Telephone/Fax (1) 10492**].

If you do not see someone regular for assessment of your
pacemaker, please schedule a follow-up appointment with our
pacer clinic within 3 months. Phone: [**Telephone/Fax (1) 59**].
{'Streptococcal septicemia,Severe sepsis,Acute on chronic systolic heart failure,Urinary tract infection, site not specified,Septic shock,Acute respiratory failure,Atrial fibrillation,Other emphysema,Mitral valve disorders,Pure hypercholesterolemia,Unspecified essential hypertension,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Fitting and adjustment of cardiac pacemaker'}


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: Sepsis/UTI

PRESENT ILLNESS: HPI: [**Age over 90 **]M with PMH notable for CAD, CHF (EF 20-25%) was brought
to the ED this morning by his family with whom he lives. Prior
to this morning, the pt was at his baseline, and had taken a
number of day trips with his fmaily over the past 2 weeks.  This
morning, the pt's granddaughter went to his basement apt to look
in on him (his son and son's famly live upstairs) and found that
he was trembling and a bit confused. The pt's son then assessed
his father, and gave him Benadryl (1 tab) for the shaking. He
was sweating and clammy, but his temp later was >102 po The pt
then took his usual am meds with Glucerna, but vomited a frothy
emesis. He was then transported to the ED.
.
Per the pt's family, he had been feeling fine prior to this
morning. he had not complained of cough or SOB, nor had he
mentioned difficulty voiding or dysuria. His son empties a
bedside commode in the am for him, and has identified past UTIs
by malodorous urine, which he did not identify today. He had not
complained of CP or SOB. No GI sx, no bowel changes, no previous
fever/chills/malaise. He had not c/o HA or neck stiffness, or
pain of any kind. Pt had no recent exotic travel or known sick
contacts.
.
In the ED, the pt was initially stable but satting 84% RA. ON MD
exam, sat improved (?on NC), but temp was 104 with HR 60s, BP
134/61. He was minimally responsive (s/p benadryl) and exam was
notable for bibasilar rales. Because he was obtunded and had
ememis in ED with ?aspiration, he was intubated for airway
protection and quickly became hypotensive (BP min 105/50 prior
to sedation). He received 5L NS boluses (levophed started after
3L), as well as 2 g CTX, 1 gm vanc, 500 mg metronidazole, 1 g
tylenol, etomidate, succinylcholine, 10 mg dexamethasone, 2mg
midazolam x 2, levophed gtt, propofol gtt. He was subsequently
transferred to the [**Hospital Unit Name 153**] for further therapy and monitoring.

MEDICAL HISTORY: CAD - s/p MI in [**2109**] tx with lytic therapy and rescue
angioplasty
CHF - EF 20-25%
DM2
History of PAF
S/p PPM
Status post permanent pacemaker insertion.
Hypertension
Hypercholesterolemia
L hip replacement [**2119**] c/b femur fx with "slipped prosthetic"
[**2127**]
Past UTIs, most recently with proteus mirabalis (ctx sensitive,
fluoroquinolone resistant)
S/p TURP

MEDICATION ON ADMISSION: 1. Carbamazepine 200 mg Tablet Sig: 0.5 Tablet PO BID
2. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID
3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS prn
4. ? Nexium filled in [**7-19**]. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY
6. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO TID

ALLERGIES: Erythromycin Base

PHYSICAL EXAM: Upon arrival to [**Hospital Unit Name 153**]:
Gen: Elderly man, sedated and unresponsive
HEENT: B/l arcus, no scleral icterus, secretions around ETT
Neck: Large, no LAD
Heart: RR, no
Lungs: Coarse breath sounds b/l, no rales appreciated
Abd: Full with palpable spleen, not form or appreciably
distended, scan BS, soft
Ext: Thin, 1+ DPs, no c/c/e
Skin: No jaundice, icthyosison feet b/l

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Pt is [**Age over 90 **] yo male who lives in basement of sons house. Wife
passed away last year. Retired plumber who worked here at [**Hospital1 18**]. 

### Response:
{'Streptococcal septicemia,Severe sepsis,Acute on chronic systolic heart failure,Urinary tract infection, site not specified,Septic shock,Acute respiratory failure,Atrial fibrillation,Other emphysema,Mitral valve disorders,Pure hypercholesterolemia,Unspecified essential hypertension,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Fitting and adjustment of cardiac pacemaker'}
