CHIEF COMPLAINT: Acute on Chronic Respiratory Failure

PRESENT ILLNESS: 76 y m with PMH of Rheumatoid Arthritis on Humira and
Methotrexate, diastolic heart failure, peripheral neuropathy and
atrial fibrillation with 2 months of progressive DOE with acute
worsening 2 days prior to admission at [**Hospital 1562**] Hospital on
[**2120-5-20**].
.
Patient and wife report that over the last several months he has
progressive shortness of breath with exertion. He denies PND or
orthopnea. His wife also notes that his fingers and toes had
become increasingly 'purple' over the last several weeks. He is
normally very active, doing significant amounts of yard work,
walking up a large [**Doctor Last Name **] on his property and does not normally
have significant shortness of breath. He denies fever/chills,
weight loss and night sweats. He does not wear oxygen at home
and has never been diagnosed with lung disease.
.
On [**2120-5-18**] patient was drinking water and reports that it 'went
down the wrong pipe' this was followed by an episode of severe
coughing and shortness of breath that did not resolve. He then
went to the ED at [**Hospital 1562**] Hospital where he was noted to be
hypoxemic. CT showed diffuse interstitial changes thought to be
secondary to rheumatoid-associated lung disease. Labs were
significant for a normal WBC with 60% PMNs, XX% lymphocytes, 17%
monocytes and 4% eosinophils. He was started on high dose iv
steroids with improvement in his cyanosis and his comfort. He
did not receive any antimicrobials as he was not felt to be
infected. His echo revealed a normal EF of 55% with moderate to
severe TR and moderately elevated pulmonary artery pressures.
EKG showed an rate of 60 with old RBBB and right axis deviation.
Though his symptoms did improve, repeat CT showed worsening of
left lung process and patient was not able to be weaned off
oxygen. He was transferred here to [**Hospital1 18**] for lung biopsy and
further evaluation and management.
.
Yesterday when seen by pulm consult resident, patient reports
that he is feeling fine and is without complaint. He is not SOB
at rest and he is breathing comfortably on supplemental O2. He
denies any tobacco use, chemical exposures, pets or recent
travel.
.
Last night, he was taken to the OR for a VATs and pulmonary
biopsy. He had biopsies performed of the lingula and LLL. He was
extubated post-op but then re-intubated for hypoxia and
increased work of breathing.

MEDICAL HISTORY: Rheumatoid Arthritis dx'ed in [**2116**]
Diastolic Heart Failure
Peripheral Neuropathy
Atrial Fibrillation

MEDICATION ON ADMISSION: On transfer:
MethylPREDNISolone Sodium Succ 125 mg IV Q6H Order date: [**5-29**] @
0401
Metoprolol Tartrate 10 mg IV Q4H hold for MAP < 65 Order date:
[**5-29**] @ 0822
1000 mL LR Continuous at 75 ml/hr Change to peripheral lock when
taking POs Order date: [**5-29**] @ 0402
Pantoprazole 40 mg IV Q12H Order date: [**5-29**] @ 0401
Digoxin 0.1 mg IV DAILY
Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: [**5-27**] @
1742
FoLIC Acid 1 mg IV Q24H Order date: [**5-29**] @ 0822
Propofol 5-40 mcg/kg/min IV DRIP TITRATE TO titrate to adequate
sedation with MAP > 65 Order date: [**5-29**] @ 0822
Heparin 5000 UNIT SC TID Order date: [**5-29**] @ 0401
Insulin SC (per Insulin Flowsheet) Sliding Scale Order date:
[**5-29**] @ 0401
.
Home medications:
Fosamax 70mg qweek
Digoxin 0.125mg qd
Toprol XL 50mg qd
Coumadin 5mg qd
Humira 40mg q2weeks
Folic acid 1mg qd
Methotrexate 2.5mg 5/7 days a week
.

ALLERGIES: Niacin

PHYSICAL EXAM: VITAL SIGNS: T 97 BP 137/70 HR 69 RR 19 O2 99% on 60%FiO2, 5
PEEP, 10 PS
GENERAL: intubated and sedated
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. Pupils small and minimally reactive. ETT in
place
CARDIAC: irreg irreg, fixed split S2, no audible murmurs
LUNGS: bibasilar dry crackles.
ABDOMEN: Vertical midline scar, soft, nd, nabs
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. Moves all extremities.
SKIN: stage 2 sacral decubitous ulcer

FAMILY HISTORY: Father with DM. No family history of autoimmune diseases or lung
cancer.

SOCIAL HISTORY: Married, retired from management. Never smoked, rare EtOH, no
illicit drugs. Works outside frequently doing yard work. No
recent travel. No pets. Denies chemical exposure.
Other specified alveolar and parietoalveolar pneumonopathies,Acute and chronic respiratory failure,Chronic diastolic heart failure,Pneumonia due to Hemophilus influenzae [H. influenzae],Iatrogenic pneumothorax,Hypoxemia,Iron deficiency anemia, unspecified,Rheumatoid arthritis,Unspecified hereditary and idiopathic peripheral neuropathy,Other chronic pulmonary heart diseases,Chronic airway obstruction, not elsewhere classified,Unspecified deficiency anemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution
Alveol pneumonopathy NEC,Acute & chronc resp fail,Chr diastolic hrt fail,H.influenzae pneumonia,Iatrogenic pneumothorax,Hypoxemia,Iron defic anemia NOS,Rheumatoid arthritis,Idio periph neurpthy NOS,Chr pulmon heart dis NEC,Chr airway obstruct NEC,Deficiency anemia NOS,Abn react-procedure NEC,Accid in resident instit
Admission Date:  [**2120-5-27**]              Discharge Date:   [**2120-6-8**]

Date of Birth:  [**2043-9-17**]             Sex:   M

Service: MEDICINE

Allergies:
Niacin

Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Acute on Chronic Respiratory Failure

Major Surgical or Invasive Procedure:
VATs
Lung Biopsy
Chest tube placement
Endotracheal intubation
Mechanical ventilation


History of Present Illness:
76 y m with PMH of Rheumatoid Arthritis on Humira and
Methotrexate, diastolic heart failure, peripheral neuropathy and
atrial fibrillation with 2 months of progressive DOE with acute
worsening 2 days prior to admission at [**Hospital 1562**] Hospital on
[**2120-5-20**].
.
Patient and wife report that over the last several months he has
progressive shortness of breath with exertion. He denies PND or
orthopnea. His wife also notes that his fingers and toes had
become increasingly 'purple' over the last several weeks. He is
normally very active, doing significant amounts of yard work,
walking up a large [**Doctor Last Name **] on his property and does not normally
have significant shortness of breath. He denies fever/chills,
weight loss and night sweats. He does not wear oxygen at home
and has never been diagnosed with lung disease.
.
On [**2120-5-18**] patient was drinking water and reports that it 'went
down the wrong pipe' this was followed by an episode of severe
coughing and shortness of breath that did not resolve. He then
went to the ED at [**Hospital 1562**] Hospital where he was noted to be
hypoxemic. CT showed diffuse interstitial changes thought to be
secondary to rheumatoid-associated lung disease. Labs were
significant for a normal WBC with 60% PMNs, XX% lymphocytes, 17%
monocytes and 4% eosinophils. He was started on high dose iv
steroids with improvement in his cyanosis and his comfort. He
did not receive any antimicrobials as he was not felt to be
infected. His echo revealed a normal EF of 55% with moderate to
severe TR and moderately elevated pulmonary artery pressures.
EKG showed an rate of 60 with old RBBB and right axis deviation.
Though his symptoms did improve, repeat CT showed worsening of
left lung process and patient was not able to be weaned off
oxygen. He was transferred here to [**Hospital1 18**] for lung biopsy and
further evaluation and management.
.
Yesterday when seen by pulm consult resident, patient reports
that he is feeling fine and is without complaint. He is not SOB
at rest and he is breathing comfortably on supplemental O2. He
denies any tobacco use, chemical exposures, pets or recent
travel.
.
Last night, he was taken to the OR for a VATs and pulmonary
biopsy. He had biopsies performed of the lingula and LLL. He was
extubated post-op but then re-intubated for hypoxia and
increased work of breathing.


Past Medical History:
Rheumatoid Arthritis dx'ed in [**2116**]
Diastolic Heart Failure
Peripheral Neuropathy
Atrial Fibrillation


Social History:
Married, retired from management. Never smoked, rare EtOH, no
illicit drugs. Works outside frequently doing yard work. No
recent travel. No pets. Denies chemical exposure.


Family History:
Father with DM. No family history of autoimmune diseases or lung
cancer.

Physical Exam:
VITAL SIGNS: T 97 BP 137/70 HR 69 RR 19 O2 99% on 60%FiO2, 5
PEEP, 10 PS
GENERAL: intubated and sedated
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. Pupils small and minimally reactive. ETT in
place
CARDIAC: irreg irreg, fixed split S2, no audible murmurs
LUNGS: bibasilar dry crackles.
ABDOMEN: Vertical midline scar, soft, nd, nabs
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. Moves all extremities.
SKIN: stage 2 sacral decubitous ulcer


Pertinent Results:
[**2120-5-27**] 07:58PM   GLUCOSE-191* UREA N-31* CREAT-0.9 SODIUM-138
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-23 ANION GAP-16
[**2120-5-27**] 07:58PM   estGFR-Using this
[**2120-5-27**] 07:58PM   CALCIUM-8.3* PHOSPHATE-3.0 MAGNESIUM-2.2
[**2120-5-27**] 07:58PM   DIGOXIN-0.5*
[**2120-5-27**] 07:58PM   WBC-9.5 RBC-3.28* HGB-11.2* HCT-31.6* MCV-97
MCH-34.1* MCHC-35.3* RDW-14.7
[**2120-5-27**] 07:58PM   PLT COUNT-142*
[**2120-5-27**] 07:58PM   PT-14.4* PTT-25.3 INR(PT)-1.3*

Brief Hospital Course:
ASSESSMENT AND PLAN: 76 M w/ pmh Rheumatoid Arthritis on Humira
and Methotrexate, diastolic heart failure, atrial fibrillation
with p/w hypoxic respiratory failure s/p vats and Lingula/LLL
biopsy.
.
#. Hypoxic respiratory failure: He appeared to be stable on 3L
NC prior to the VATS procedure and per the OSH report, he
dramatically improved clinically (and his pulmonary infiltrates
improved) w/ steroids. Apparently he initally did well after
extubation but then had increased work of breathing and hypoxia.
It seems possible that he could have had flash pulmonary edema
vs aspiration that caused acute decompensation requiring
intubation. His CXR at the time of re-intubation looks
dramatically worse than the prior CXR altough we have already
been able to wean FiO2.
.
#. S/p VATS: Chest tube in place draining sero-sanguenous fluid.
Small PTX on am CXR
- would likely plan to d/c chest tube when drainage is < 100 cc/
24 hrs.
- appreciate thorasics input
- daily CXR to eval for worsening PTX
.
#. Rheumatoid arthritis:
.
#. Macrocytic Anemia: Unclear etiology.
- check b12, folate, iron studies
- trend for now
- guaiac all stools
.
#. CHF: Normal EF from OSH report but h/o diastolic dysfunction.
As a result, likely does not tolerate a rapid rate or severe
hypertension well.
- maintain excellent BP control
- rate control as below
.
#. Afib: on digoxin and metoprolol for rate control as an
outpatient and coumadin for anticoagulation.
- re-start coumadin per thorasics
- as no systolic dysfunction, would opt to d/c digoxin and rate
control w/ metoprolol for now
.
FEN: replete lytes prn
.
PPX: Sc heparin, bowel regimen prn, ranitidine
--
[**5-31**]
- path c/w UIP
- discussed with rheum: hold humira x2wk post vats, hold mtx
indefinitely
- staph from sputum sensitivities pending
.
ACCESS: PIV's
.
CODE STATUS: Presumed full
.
EMERGENCY CONTACT: Wife [**Name (NI) 14880**] [**Name (NI) 732**] ([**Telephone/Fax (1) 83370**]
.
DISPOSITION: ICU pending resolution of above
.
[**5-30**]
- Extubated, high O2 requirement, on 80% facemask
- CT placed to waterseal, PTX stable
- Weaned to 5L NC
.
[**5-31**]
- weaned steroid down to 60mg methylpred
- increased ptx on AM CXR but thoracics ok with keeping on water
seal
- attempted to reach outpt rheum - no answer from office. spoke
with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] rheum attending here rec HOLD humira x2 weeks
post VATS, then may restart if no infection identified. would
HOLD mtx indefinitely and defer further tx choices to outpt
rheum
- path prelim c/w UIP, discussed with family
- vanc trough 7, increased to 1g [**Hospital1 **] from 750mg [**Hospital1 **]
- seen by speech and swallow failed swallow -> made npo
.
[**6-1**]
- increased PTX, changed CT to suction from water seal
- changed zosyn dosing
- MIE Q2H, chest PT
- NG tube placed, pulled out of position with question
aspiration event, replaced
.
[**6-2**]:
- desat to 70s up to 70% facemask PLUS nasal canula, but
subsequently weaned weaned down to 35% without NC
- afib with rvr got 5mg metoprolol with good response
- CT placed back to suction given inc. size of PTX -> waterseal
this AM
- Family mtg held, ok to reintubate, if reach point with little
hope of improvement, family will likely withdraw care
.
[**6-3**]
- chest tube put on waterseal again in AM, but ptx worse on
repeat chest film to returned to low wall suction
- restarted digoxin
- pulled out NGT
--------
[**6-4**]
-HR mainly in the 70-80s but occasional sympathetic driven
spikes to 140-150. continued dig 0.125mg daily and changed PO
lopressor to 5mg IV lopressor IV q4hrs
-patient desats with any slight movement, for the most part on
6L NC
-plan to call family regarding any need for intubation and they
will likely say to not intubate at this point, still full code
currently though
-I/O goal even, by 7 p.m. even
-changed CT to water seal, no real change in PTX, per thoracics
attg patient will need pleuradesis as he will unlikely improve
given stiff lungs related to ILD
-MIE stopped
-decreased solumedrol to 20mg IV x 1 today, with a plan to
continue weaning rapidly
-S+S to re-eval [**2120-6-5**]
-haldol 0.5mg started tid prn anxiety
-------
[**6-6**]
- family meeting regarding goals of care
- thoracics placed pneumo stat
- repeat evening CXR with worsening PTX so placed on suction
- 9 pm repeat evening CXR improved
- started bactrim for PNA
- d/c'ed all nonessential po meds
--------------
-re-trial of pneumo-stat failed
-chest tube replaced and placed to suction, plan to place to
water seal in a.m. prior to discharge home with hospice.
-scripts for zydis and morphine given to palliative care who
picked up meds for patient


Medications on Admission:
On transfer:
MethylPREDNISolone Sodium Succ 125 mg IV Q6H Order date: [**5-29**] @
0401
Metoprolol Tartrate 10 mg IV Q4H hold for MAP < 65 Order date:
[**5-29**] @ 0822
1000 mL LR Continuous at 75 ml/hr Change to peripheral lock when
taking POs Order date: [**5-29**] @ 0402
Pantoprazole 40 mg IV Q12H Order date: [**5-29**] @ 0401
Digoxin 0.1 mg IV DAILY
Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: [**5-27**] @
1742
FoLIC Acid 1 mg IV Q24H Order date: [**5-29**] @ 0822
Propofol 5-40 mcg/kg/min IV DRIP TITRATE TO titrate to adequate
sedation with MAP > 65 Order date: [**5-29**] @ 0822
Heparin 5000 UNIT SC TID Order date: [**5-29**] @ 0401
Insulin SC (per Insulin Flowsheet) Sliding Scale Order date:
[**5-29**] @ 0401
.
Home medications:
Fosamax 70mg qweek
Digoxin 0.125mg qd
Toprol XL 50mg qd
Coumadin 5mg qd
Humira 40mg q2weeks
Folic acid 1mg qd
Methotrexate 2.5mg 5/7 days a week
.


Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB or wheezing.
2. Morphine Concentrate 5 mg/0.25 mL Solution Sig: 5-20 mg PO q1
hour as needed for pain.
Disp:*30 mL* Refills:*0*
3. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO twice a day.
Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*2*
4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
four times a day.
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
7. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO three times
a day as needed for anxiety.
Disp:*45 Tablet(s)* Refills:*1*
8. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO twice a day as needed for anxiety.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*1*


Discharge Disposition:
Home With Service

Facility:
Hospice of [**Hospital3 **]

Discharge Diagnosis:
Primary Diagnosis:
1. Hypoxic Respiratory Failure
2. UIP
3. Rheumatoid arthritis

Secondary Diagnosis:
1. Congestive Heart Failure
2. Macrocytic Anemia
3. Atrial fibrillation


Discharge Condition:
Stable. On 6L of nasal cannula oxygen while at rest.


Discharge Instructions:
You were admitted with increasing shortness of breath.  You were
transferred to [**Hospital1 18**] for a lung biopsy and further evaluation
and management.  You had a VATs and pulmonary biopsy procedure.
Afterwards, you had trouble breathing so you were re-intubated
for low oxygen levels.  You were then transferred to the ICU.
Your oxygenation got better, and you were taken off the
ventilator. Thoracic surgeons also followed you in the hospital.
You are being sent home with a chest tube to "water seal"
meaning there is no significant suctioning applied to the space
between your lung and chest wall but air cannot enter from the
outside.

Please continue to take your medications as prescribed.

Speech and Swallow consult saw you, and recommended nectar
thickened liquids.  You should also increase your supplemental
oxygen prior to movement.

Please keep all your medical appointments.

If you have any of the following symptoms, please call your
doctor: fever>101, chest pain, increased shortness of breath,
abdominal pain, or any other concerning symptoms.

Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**1-5**] weeks.
{'Other specified alveolar and parietoalveolar pneumonopathies,Acute and chronic respiratory failure,Chronic diastolic heart failure,Pneumonia due to Hemophilus influenzae [H. influenzae],Iatrogenic pneumothorax,Hypoxemia,Iron deficiency anemia, unspecified,Rheumatoid arthritis,Unspecified hereditary and idiopathic peripheral neuropathy,Other chronic pulmonary heart diseases,Chronic airway obstruction, not elsewhere classified,Unspecified deficiency anemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution'}


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: Acute on Chronic Respiratory Failure

PRESENT ILLNESS: 76 y m with PMH of Rheumatoid Arthritis on Humira and
Methotrexate, diastolic heart failure, peripheral neuropathy and
atrial fibrillation with 2 months of progressive DOE with acute
worsening 2 days prior to admission at [**Hospital 1562**] Hospital on
[**2120-5-20**].
.
Patient and wife report that over the last several months he has
progressive shortness of breath with exertion. He denies PND or
orthopnea. His wife also notes that his fingers and toes had
become increasingly 'purple' over the last several weeks. He is
normally very active, doing significant amounts of yard work,
walking up a large [**Doctor Last Name **] on his property and does not normally
have significant shortness of breath. He denies fever/chills,
weight loss and night sweats. He does not wear oxygen at home
and has never been diagnosed with lung disease.
.
On [**2120-5-18**] patient was drinking water and reports that it 'went
down the wrong pipe' this was followed by an episode of severe
coughing and shortness of breath that did not resolve. He then
went to the ED at [**Hospital 1562**] Hospital where he was noted to be
hypoxemic. CT showed diffuse interstitial changes thought to be
secondary to rheumatoid-associated lung disease. Labs were
significant for a normal WBC with 60% PMNs, XX% lymphocytes, 17%
monocytes and 4% eosinophils. He was started on high dose iv
steroids with improvement in his cyanosis and his comfort. He
did not receive any antimicrobials as he was not felt to be
infected. His echo revealed a normal EF of 55% with moderate to
severe TR and moderately elevated pulmonary artery pressures.
EKG showed an rate of 60 with old RBBB and right axis deviation.
Though his symptoms did improve, repeat CT showed worsening of
left lung process and patient was not able to be weaned off
oxygen. He was transferred here to [**Hospital1 18**] for lung biopsy and
further evaluation and management.
.
Yesterday when seen by pulm consult resident, patient reports
that he is feeling fine and is without complaint. He is not SOB
at rest and he is breathing comfortably on supplemental O2. He
denies any tobacco use, chemical exposures, pets or recent
travel.
.
Last night, he was taken to the OR for a VATs and pulmonary
biopsy. He had biopsies performed of the lingula and LLL. He was
extubated post-op but then re-intubated for hypoxia and
increased work of breathing.

MEDICAL HISTORY: Rheumatoid Arthritis dx'ed in [**2116**]
Diastolic Heart Failure
Peripheral Neuropathy
Atrial Fibrillation

MEDICATION ON ADMISSION: On transfer:
MethylPREDNISolone Sodium Succ 125 mg IV Q6H Order date: [**5-29**] @
0401
Metoprolol Tartrate 10 mg IV Q4H hold for MAP < 65 Order date:
[**5-29**] @ 0822
1000 mL LR Continuous at 75 ml/hr Change to peripheral lock when
taking POs Order date: [**5-29**] @ 0402
Pantoprazole 40 mg IV Q12H Order date: [**5-29**] @ 0401
Digoxin 0.1 mg IV DAILY
Pneumococcal Vac Polyvalent 0.5 ml IM ASDIR Order date: [**5-27**] @
1742
FoLIC Acid 1 mg IV Q24H Order date: [**5-29**] @ 0822
Propofol 5-40 mcg/kg/min IV DRIP TITRATE TO titrate to adequate
sedation with MAP > 65 Order date: [**5-29**] @ 0822
Heparin 5000 UNIT SC TID Order date: [**5-29**] @ 0401
Insulin SC (per Insulin Flowsheet) Sliding Scale Order date:
[**5-29**] @ 0401
.
Home medications:
Fosamax 70mg qweek
Digoxin 0.125mg qd
Toprol XL 50mg qd
Coumadin 5mg qd
Humira 40mg q2weeks
Folic acid 1mg qd
Methotrexate 2.5mg 5/7 days a week
.

ALLERGIES: Niacin

PHYSICAL EXAM: VITAL SIGNS: T 97 BP 137/70 HR 69 RR 19 O2 99% on 60%FiO2, 5
PEEP, 10 PS
GENERAL: intubated and sedated
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. Pupils small and minimally reactive. ETT in
place
CARDIAC: irreg irreg, fixed split S2, no audible murmurs
LUNGS: bibasilar dry crackles.
ABDOMEN: Vertical midline scar, soft, nd, nabs
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. Moves all extremities.
SKIN: stage 2 sacral decubitous ulcer

FAMILY HISTORY: Father with DM. No family history of autoimmune diseases or lung
cancer.

SOCIAL HISTORY: Married, retired from management. Never smoked, rare EtOH, no
illicit drugs. Works outside frequently doing yard work. No
recent travel. No pets. Denies chemical exposure. 

### Response:
{'Other specified alveolar and parietoalveolar pneumonopathies,Acute and chronic respiratory failure,Chronic diastolic heart failure,Pneumonia due to Hemophilus influenzae [H. influenzae],Iatrogenic pneumothorax,Hypoxemia,Iron deficiency anemia, unspecified,Rheumatoid arthritis,Unspecified hereditary and idiopathic peripheral neuropathy,Other chronic pulmonary heart diseases,Chronic airway obstruction, not elsewhere classified,Unspecified deficiency anemia,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Accidents occurring in residential institution'}
