CHIEF COMPLAINT: A Fib with RVR

PRESENT ILLNESS: Mr. [**Known lastname **] is an 81 year old man with multiple medical
problems transferred to ICU for suctioning to protect airway.
He has multiple medical problems, including complicated post-op
course after CABG on [**11-25**], recently discharged to [**Hospital 100**] Rehab,
who presents with increasing lethargy and rising white blood
cell count for further evaluation and workup.  His most recent
admission included MVR/CABG with post-op course complicated by
pneumothorax s/p R CT, respiratory distress, left pleural
effusion s/p thoracentesis, mental status changes, MSSA
pneumonia/bacteremia, tracheostomy/PEG, diarrhea. During that
hospitalization, he completed a course of Flagyl (empiric for C.
diff, ultimately negative), ciprofloxacin (for Enterobacter in
the sputum), and nafcillin (for MSSA pneumonia/bacteremia).  At
rehab, he was being treated for cellulitis/abscess around the
tracheostomy site (with wound dehiscence), as well as for MRSA
in sputum, with vancomycin. His white blood cell count has been
rising, and ID consult at rehab was concerned for mediastinitis.
In addition, he has had a change in mental status since his
recent hospitalization (per his family).

MEDICAL HISTORY: - CAD s/p MV repair/CABG on [**2141-11-24**], complicated post-op
course; post CABG echo demonstrated EF 55%
- S/p trach/PEG
- Hx of MSSA pneumonia/bacteremia
- Diabetes - A1c 7.3 in [**2141-9-2**]. alb/Cr ratio 800 in [**2141-10-2**].

MEDICATION ON ADMISSION: - Colace 100mg [**Hospital1 **]
- Aspirin 81mg daily
- Metoprolol 100mg TID
- Atorvastatin 80mg PO daily
- Prilosec 20mg daily
- Lantus 50 units subQ QHS
- Lispro sliding scale q6h
- Warfarin 2mg PO daily
- Tramadol 50mg Q6H PRN
- Ipratropium-Albuterol 1-2puffs INH Q6H PRN
- Captopril 50mg TID
- Furosemide 20mg daily
- Hydralazine 5mg TID
- Vancomycin 1g daily

ALLERGIES: Hydrochlorothiazide

PHYSICAL EXAM: VS: T 96.7F, BP 158/37, HR 84, RR 20, Sat 100% on 60% FM
Gen: Cachectic, trach, no acute distress
HEENT: EOMI, PERRL, MM dry
Neck: no JVD
CV: Irregularly irregular, tachycardic, no murmurs appreciated
Resp: Rhonchorous throughout b/l
Chest: Midline sternotomy scar clean, mild erythma near trach,
eschar near trach site, no purulent discharge
Abd: +BS, soft, ND/NT, no peritoneal signs
EXT: LE's warm, no lower extremity edema.  Left necrotic heel
ulcer, Left great toe necrosis (dry), left anterior ankle ulcer
(open), and right foot erythema.
NEURO: Oriented to hospital, [**2142**]

FAMILY HISTORY: Father died of influenza, mother died of old age.  There is no
family history of premature coronary artery disease or sudden
death.

SOCIAL HISTORY: Social history is significant for quitting tobacco over 35 years
ago. There is no current alcohol abuse. Worked in a cemetery;
never married; never had kids.
Acute on chronic combined systolic and diastolic heart failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Unspecified pleural effusion,Atherosclerosis of native arteries of the extremities with gangrene,Intestinal infection due to Clostridium difficile,Ulcer of heel and midfoot,Cachexia,Atrial fibrillation,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Aortocoronary bypass status,Long-term (current) use of anticoagulants,Gastrostomy status,Tracheostomy status
Ac/chr syst/dia hrt fail,Meth sus pneum d/t Staph,Pleural effusion NOS,Ath ext ntv art gngrene,Int inf clstrdium dfcile,Ulcer of heel & midfoot,Cachexia,Atrial fibrillation,DMII oth nt st uncntrld,Aortocoronary bypass,Long-term use anticoagul,Gastrostomy status,Tracheostomy status
Admission Date:  [**2142-1-5**]              Discharge Date:   [**2142-1-11**]

Date of Birth:  [**2060-12-20**]             Sex:   M

Service: MEDICINE

Allergies:
Hydrochlorothiazide

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
A Fib with RVR

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Mr. [**Known lastname **] is an 81 year old man with multiple medical
problems transferred to ICU for suctioning to protect airway.
He has multiple medical problems, including complicated post-op
course after CABG on [**11-25**], recently discharged to [**Hospital 100**] Rehab,
who presents with increasing lethargy and rising white blood
cell count for further evaluation and workup.  His most recent
admission included MVR/CABG with post-op course complicated by
pneumothorax s/p R CT, respiratory distress, left pleural
effusion s/p thoracentesis, mental status changes, MSSA
pneumonia/bacteremia, tracheostomy/PEG, diarrhea. During that
hospitalization, he completed a course of Flagyl (empiric for C.
diff, ultimately negative), ciprofloxacin (for Enterobacter in
the sputum), and nafcillin (for MSSA pneumonia/bacteremia).  At
rehab, he was being treated for cellulitis/abscess around the
tracheostomy site (with wound dehiscence), as well as for MRSA
in sputum, with vancomycin. His white blood cell count has been
rising, and ID consult at rehab was concerned for mediastinitis.
In addition, he has had a change in mental status since his
recent hospitalization (per his family).

Initial WBC was 22 with 88% neutrophils, no bands.  His CT head
was negative for bleeding but revealed evidence of sinusitis.
His CT torso revealed b/l pleural effusions, L>R, but no
evidence of mediastinitis or fluid collection.  He was on
vancomycin already for MRSA in sputum at rehab, and this was
continued to cover for cellulitis.  Flagyl was added for emperic
coverage Cdiff.  He triggered on the floor twice for Afib with
RVR, which responded to IV nodal agents (15mg dilt and 5mg
metoprolol).  He also was requiring frequent suctioning from his
trach and thus was transferred to MICU for increased nursing
needs.


Past Medical History:
- CAD s/p MV repair/CABG on [**2141-11-24**], complicated post-op
course; post CABG echo demonstrated EF 55%
- S/p trach/PEG
- Hx of MSSA pneumonia/bacteremia
- Diabetes - A1c 7.3 in [**2141-9-2**]. alb/Cr ratio 800 in [**2141-10-2**].

- Hypertension
- PVD - sx of claudication, seen on MRA
- Iron-deficiency anemia - Hct around 30, no colonscopy
- Spinal stenosis

Social History:
Social history is significant for quitting tobacco over 35 years
ago. There is no current alcohol abuse. Worked in a cemetery;
never married; never had kids.


Family History:
Father died of influenza, mother died of old age.  There is no
family history of premature coronary artery disease or sudden
death.

Physical Exam:
VS: T 96.7F, BP 158/37, HR 84, RR 20, Sat 100% on 60% FM
Gen: Cachectic, trach, no acute distress
HEENT: EOMI, PERRL, MM dry
Neck: no JVD
CV: Irregularly irregular, tachycardic, no murmurs appreciated
Resp: Rhonchorous throughout b/l
Chest: Midline sternotomy scar clean, mild erythma near trach,
eschar near trach site, no purulent discharge
Abd: +BS, soft, ND/NT, no peritoneal signs
EXT: LE's warm, no lower extremity edema.  Left necrotic heel
ulcer, Left great toe necrosis (dry), left anterior ankle ulcer
(open), and right foot erythema.
NEURO: Oriented to hospital, [**2142**]


Pertinent Results:
STUDIES:
CT Chest/Abd/Pelvis [**2142-1-5**]: 1. Slight increased overlap of the
osseous structures at the sternotomy site suggests the
posibility of movement. 2. Large left pleural effusion with
complete left lower lobe collapse, which is stable. There may be
a loculated component to the left pleural effusion and there is
suggestion that the effusion may be entirely simple. There is
increased size of a now moderate right pleural effusion. 3. No
fluid collection in the mediastinum surrounding the tracheostomy
site. 4. Dense three-vessel coronary artery calcification and
abdominal atherosclerotic plaque.  5. Stable right
nonobstructing colonic inguinal hernia and new left colonic
inguinal hernia. Neither bowel loop protrudes significantly into
the respective inguinal canals and there is no sign of
obstruction or entrapment. Correlate with clinical exam. 6.
Stable right [**Month/Day/Year **] nodule. 7. Interval development of tiny
stones in the gallbladder.

CT Head [**2142-1-5**]: 1. No acute intracranial abnormality detected.
2. Near-total opacification of the mastoid air cells bilaterally
which has increased since previous study. There is an air-fluid
level within the left maxillary sinus with aerated secretions
which is also noted in study from [**Month (only) **] which may be
consistent with acute sinusitis.

ECHO [**2142-1-8**] - The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with mild
hypokinesis of the inferior wall. The remaining segments
contract normally (LVEF = 50-55 %). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. A mitral valve annuloplasty ring is present.
Mild (1+) mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction
with good global function. Mild mitral regurgitation. Borderline
pulmonary artery systolic hypertension. Bilateral pleural
effusions. CLINICAL IMPLICATIONS:
Based on [**2141**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

[**2142-1-10**] RUQ U/S - The liver is normal in echotexture without
focal lesion identified. There is no intra- or extrahepatic
biliary dilatation with the common bile duct measuring 3 mm. The
gallbladder is not distended and there is no pericholecystic
fluid or wall edema. In comparison to the previous study there
is significantly less sludge. A tiny echogenic shadowing foci in
the dependent portion of the gallbladder could represent a few
crystals.  IMPRESSION: No evidence of acute cholecystitis.
Interval improvement in gall bladder sludge, but not complete
clearing.

MICRO:
[**2142-1-7**] Sputum -
GRAM STAIN (Final [**2142-1-7**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   BUDDING YEAST.

_________________________________________________________
                             STAPH AUREUS COAG +
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
CEFEPIME--------------               16 I
CEFTAZIDIME-----------             =>64 R
CIPROFLOXACIN---------              =>4 R
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S        4 S
LEVOFLOXACIN----------   =>8 R
MEROPENEM-------------                8 I
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
PIPERACILLIN----------            =>128 R
PIPERACILLIN/TAZO-----            =>128 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------  =>16 R
TOBRAMYCIN------------              <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------   <=1 S


Brief Hospital Course:
81yo M with complicated recent hospitalization now with altered
mental status, cellulitis at tracheostomy site, Afib with [**Hospital 26875**]
transferred to ICU for airway protection/suctioning.

THE PATIENTS FAMILY HAS CONSENTED TO DO NOT HOSPITALIZE ORDER.
They feel the patient would not want further interventions.  The
plan is to complete the current course of antibiotics but that
no further interventions should be performed.  Maintain the
current level of care including his medications, but it anything
were to deteriorate in his health he would not want further
care.  (The patients sister [**Name (NI) 714**] [**Name (NI) 103630**] is his HCP and can
be reached at [**Telephone/Fax (1) 103631**]).

Resp: Underwent tracheostomy during last hospitalization, now on
60% TM with thick secretions.  CT chest with b/l pleural
effusions, L > R, with surrounding atelectasis, and question of
small infiltrate.  Per [**Hospital 100**] Rehab, he was being treated with
Vanco for MRSA in his sputum.  Requiring frequent suctioning per
floor nursing.  He needs to be mainted on vancomycin for a
complete 14 day course (day #1=[**2142-1-5**]).  He should be dosed for
level <20.  Please check levels daily at rehab.
On [**2142-1-10**], pseudomonas grew from his sputum and he was started
on tobramycin and will need to complete a 14 day course.  Also,
during his hospital course he had a left sided thoracentesis
(1.5 L taken off).  The pleural fluid was transudative, likely
secondary to CHF.  He should continue to be diuresed at rehab.
He is currently on lasix 20mg IV TID.  The dosing frequency
should be increased for a goal urine output of -500cc-1L
negative per day until he reaches his dry weight.  He was able
to be weaned from 70% O2 to 35% O2 during his ICU stay.  This
should further be weaned as tolerated at rehab.

ID: Elevated WBC, no fever.  Originally thought to have a
cellulitis around his trach site, but the thoracics team felt
that his site was not infected.  He was started on Vanco/Unasyn
for MRSA and GNR's in the sputum.  The Unasyn was stopped on
when the GNR's grew pseudomonas.  He was switched to tobramycin
(day 1=[**2142-1-10**]) and will need to complete a 14 day course.  He
also was c diff positive during this admission and was started
on flagyl.  He should complete a 14 day course (day 1 should be
considered the last day of all other antibiotics).  We did
consider biliary sources of infection because his LFT's were
slightly elevated, but a RUQ U/S was unremarkable.  Vascular
surgery examined his feet ulcers and felt there was no evidence
of infection.

Atrial fibrillation. The patient had numerous episodes of A fib
with RVR during this hospital course.  Metoprolol was uptitrated
to 100 QID with better rate control, but still in the low 100's.
 He was then started on digoxin with great response.  His HR was
then stable in the 70's.

Transaminitis.  The patient did not have abdominal pain and a CT
abdomen was neg for evidence of choledocholithiasis, although
gallstones seen on scan.  We proceded with a RUQ U/S that was
unremarkable.  This should be followed up as an outpatient.

LE ulcers: Appear dry and necrotic on heels, but open on
anterior feet.  We consulted the wound care team who gave the
following recommendations. Heels off bed surface at all times.
Waffle Boots to both lower legs.  Moisturize B/L LE's and feet,
periwound tissue [**Hospital1 **] with Aloe Vesta Moisture Barrier Ointment.
Commercial wound cleanser or normal saline to cleanse all
wounds.  Pat the tissue dry with dry gauze.  B/L lower legs and
feet: Keep ulcers dry and eschar intact.   Apply moisture
barrier ointment to the periwound tissue with each DRG change.
Apply a dry protective dressing, ABD's, with Kerlix wrap, change
daily.  We also had vascular surgery evaluate his feet and they
felt that there was no evidence of infection.  At some point in
the future he may be a potential candidate for amputation but
not at this time.  He can follow up with vascular surgery in
clinic.

Diabetes.  The patient had a number of hypoglycemic episodes
during his hospital course.  His home lantus (50 units) was
held.  He was restarted on 10 units of lantus daily because of
hyperglycemia and this was eventually increased further to
25units.  This should be titrated up as needed to maintain blood
sugars between 120-150.


Medications on Admission:
- Colace 100mg [**Hospital1 **]
- Aspirin 81mg daily
- Metoprolol 100mg TID
- Atorvastatin 80mg PO daily
- Prilosec 20mg daily
- Lantus 50 units subQ QHS
- Lispro sliding scale q6h
- Warfarin 2mg PO daily
- Tramadol 50mg Q6H PRN
- Ipratropium-Albuterol 1-2puffs INH Q6H PRN
- Captopril 50mg TID
- Furosemide 20mg daily
- Hydralazine 5mg TID
- Vancomycin 1g daily


Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) unit PO BID (2
times a day).
3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]:
One (1) neb Inhalation Q6H (every 6 hours) as needed.
4. Tramadol 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed.
5. Atorvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
6. Captopril 25 mg Tablet [**Hospital1 **]: Three (3) Tablet PO TID (3 times
a day).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO QID
(4 times a day): hold for SBP <90 or HR<55.
9. Warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
10. Vancomycin 1000 mg IV Q 24H
1st day [**1-6**]
no Vanco dosing until Vanco level <20
11. Heparin Flush Midline (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
12. Digoxin 125 mcg Tablet [**Month/Day (1) **]: 0.5 Tablet PO DAILY (Daily).
13. Ipratropium Bromide 0.02 % Solution [**Month/Day (1) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
14. Furosemide 10 mg/mL Solution [**Month/Day (1) **]: Twenty (20) mg Injection
QID (4 times a day): please hold if SBP<90 or if creatinine
bumps.
15. Tobramycin 200 mg IV Q24H
16. Insulin Glargine 100 unit/mL Solution [**Month/Day (1) **]: Twenty Five (25)
units Subcutaneous once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Atrial fibrillation with RVR
Bilateral Pleural Effusions
C Diff positive
MRSA Pneumonia
Respiratory distress


Discharge Condition:
Stable; oxygenating well on FIO2 35% TM.


Discharge Instructions:
You were admitted to the hospital with respiratory distress and
elevated HR.  You had developed fluid build up in your lung
likely secondary to your elevated heart rate.  We performed a
thoracentesis which is a procedure to remove fluid from your
lung.  We were then able to decrease the amount of oxygen you
have needed to breath.  We also increased your heart medications
to get your heart rate under better control.  The dose of your
captorpil and metoprolol were both increased.  We also started a
new medication called digoxin which was heldful in keeping your
heart rate under good control.

THE PATIENTS FAMILY HAS CONSENTED TO DO NOT HOSPITALIZE ORDER.
They feel the patient would not want further interventions.  The
plan is to complete the current course of antibiotics but that
no further interventions should be performed.  Maintain the
current level of care including his medications, but it anything
were to deteriorate in his health he would not want further
care.

At rehab:
-- He needs to be mainted on vancomycin for a complete 14 day
course (day #1=[**2142-1-5**]).  He should be dosed for level <20.
Please check levels daily at rehab.
-- He was started on tobramycin on [**2142-1-10**] for pseudomonas
growing in his sputum.  He should complete a 14 day course.
Peak and trough levels should be checked daily and the dose
adjusted accordingly.
-- He should continue to be diuresed at rehab.  He is currently
on lasix 20mg IV TID.  The dosing frequency should be increased
for a goal urine output of -500cc-1L negative per day until he
reaches his dry weight.  He was able to be weaned from 70% O2 to
35% O2 during his ICU stay.  This should further be weaned as
tolerated at rehab.
--He also was c diff positive during this admission and was
started on flagyl.  He should complete a 14 day course (day 1
should be considered the last day of all other antibiotics).
--Wound care per instructions in the D/C summary
--Metoprolol was uptitrated to 100 QID with better rate control.
 HE was started on digoxin and is currently well controlled on a
dose of 0.0625 daily.
-- He was restarted on coumadin prior to discharge.  His INR was
1.5 today.  Please adjust dose as needed (he was on 2mg prior to
this admission).  Please check INR daily until level between
[**2-4**].

Followup Instructions:
--Please make an appointment to see Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] or Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 2450**] within 1 week of discharge from rehab


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Acute on chronic combined systolic and diastolic heart failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Unspecified pleural effusion,Atherosclerosis of native arteries of the extremities with gangrene,Intestinal infection due to Clostridium difficile,Ulcer of heel and midfoot,Cachexia,Atrial fibrillation,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Aortocoronary bypass status,Long-term (current) use of anticoagulants,Gastrostomy status,Tracheostomy status'}


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: A Fib with RVR

PRESENT ILLNESS: Mr. [**Known lastname **] is an 81 year old man with multiple medical
problems transferred to ICU for suctioning to protect airway.
He has multiple medical problems, including complicated post-op
course after CABG on [**11-25**], recently discharged to [**Hospital 100**] Rehab,
who presents with increasing lethargy and rising white blood
cell count for further evaluation and workup.  His most recent
admission included MVR/CABG with post-op course complicated by
pneumothorax s/p R CT, respiratory distress, left pleural
effusion s/p thoracentesis, mental status changes, MSSA
pneumonia/bacteremia, tracheostomy/PEG, diarrhea. During that
hospitalization, he completed a course of Flagyl (empiric for C.
diff, ultimately negative), ciprofloxacin (for Enterobacter in
the sputum), and nafcillin (for MSSA pneumonia/bacteremia).  At
rehab, he was being treated for cellulitis/abscess around the
tracheostomy site (with wound dehiscence), as well as for MRSA
in sputum, with vancomycin. His white blood cell count has been
rising, and ID consult at rehab was concerned for mediastinitis.
In addition, he has had a change in mental status since his
recent hospitalization (per his family).

MEDICAL HISTORY: - CAD s/p MV repair/CABG on [**2141-11-24**], complicated post-op
course; post CABG echo demonstrated EF 55%
- S/p trach/PEG
- Hx of MSSA pneumonia/bacteremia
- Diabetes - A1c 7.3 in [**2141-9-2**]. alb/Cr ratio 800 in [**2141-10-2**].

MEDICATION ON ADMISSION: - Colace 100mg [**Hospital1 **]
- Aspirin 81mg daily
- Metoprolol 100mg TID
- Atorvastatin 80mg PO daily
- Prilosec 20mg daily
- Lantus 50 units subQ QHS
- Lispro sliding scale q6h
- Warfarin 2mg PO daily
- Tramadol 50mg Q6H PRN
- Ipratropium-Albuterol 1-2puffs INH Q6H PRN
- Captopril 50mg TID
- Furosemide 20mg daily
- Hydralazine 5mg TID
- Vancomycin 1g daily

ALLERGIES: Hydrochlorothiazide

PHYSICAL EXAM: VS: T 96.7F, BP 158/37, HR 84, RR 20, Sat 100% on 60% FM
Gen: Cachectic, trach, no acute distress
HEENT: EOMI, PERRL, MM dry
Neck: no JVD
CV: Irregularly irregular, tachycardic, no murmurs appreciated
Resp: Rhonchorous throughout b/l
Chest: Midline sternotomy scar clean, mild erythma near trach,
eschar near trach site, no purulent discharge
Abd: +BS, soft, ND/NT, no peritoneal signs
EXT: LE's warm, no lower extremity edema.  Left necrotic heel
ulcer, Left great toe necrosis (dry), left anterior ankle ulcer
(open), and right foot erythema.
NEURO: Oriented to hospital, [**2142**]

FAMILY HISTORY: Father died of influenza, mother died of old age.  There is no
family history of premature coronary artery disease or sudden
death.

SOCIAL HISTORY: Social history is significant for quitting tobacco over 35 years
ago. There is no current alcohol abuse. Worked in a cemetery;
never married; never had kids. 

### Response:
{'Acute on chronic combined systolic and diastolic heart failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Unspecified pleural effusion,Atherosclerosis of native arteries of the extremities with gangrene,Intestinal infection due to Clostridium difficile,Ulcer of heel and midfoot,Cachexia,Atrial fibrillation,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Aortocoronary bypass status,Long-term (current) use of anticoagulants,Gastrostomy status,Tracheostomy status'}
