CHIEF COMPLAINT: SOB, Pleural Effusions, PNA, pericardial effusion, concern for
tamponade

PRESENT ILLNESS: Ms [**Known lastname 35028**] is a 50yoF with PMH significant for depression,
though negative for cardiac risk factors including CHF or CAD.
She was transferred to CCU on [**2154-10-21**] with concern for
pericardial tamponade.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: negative for DM, HTN, HLD
2. CARDIAC HISTORY:  none
3. OTHER PAST MEDICAL HISTORY:
- Depression / paranoia
- cellulitis in lower extremity x2 2-3 years ago
- breast biopsy several years ago (2 sisters with breast cancer
diagnosed at 35 and 40)

MEDICATION ON ADMISSION: - Abilify 2mg PO qHS
- Levofloxacin,
- Promethazine-codeine
- Multivitamin
- Calcium-magnesium
- Potassium

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
VS: T99.4;  P98;  BP115/73;  RR25;   O2 sat 96% 4L NC; Pulsus
paradoxus 12mmHg
GENERAL: Middle-aged woman in NAD, obese, comfortable and
appropriate though quite anxious
HEENT: NC/AT, PERRL, EOMI OP Clear, MMM
Chest: decreased breath sounds LLL up to mid-lung, otherwise
CTAB
Cardiovascular: borderline tachycardia, NL S1 and S2 with normal
splitting of S2, no JVP appreciated although exam inhibited [**2-13**]
body habitus
ABDOMEN: Soft, mildly tender in epigastric region, non-distended

FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Two sisters have breast cancer, one diagnosed at about age 35,
the other around age 40. Pt has had a breast biopsy several
years ago and states that the results were not concerning. She
says she gets yearly mammograms.

SOCIAL HISTORY: owner of a uniform supply store. Lives with husband, who is a
paramedic. No recent sick contacts. Travels to Caribbean for 1
week of vacation every year.
- Tobacco history:  none
- ETOH:  rare, social
- Illicit drugs: none
Pneumonia, organism unspecified,Cardiac tamponade,Unspecified pleural effusion,Atrial fibrillation,Ostium secundum type atrial septal defect,Acute bronchospasm,Obesity, unspecified,Other abnormal glucose,Depressive disorder, not elsewhere classified,Family history of malignant neoplasm of breast,Delusional disorder,Body Mass Index 39.0-39.9, adult
Pneumonia, organism NOS,Cardiac tamponade,Pleural effusion NOS,Atrial fibrillation,Secundum atrial sept def,Acute bronchospasm,Obesity NOS,Abnormal glucose NEC,Depressive disorder NEC,Family hx-breast malig,Delusional disorder,BMI 39.0-39.9,adult
Admission Date:  [**2154-10-21**]              Discharge Date:   [**2154-10-27**]

Date of Birth:  [**2104-8-29**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
SOB, Pleural Effusions, PNA, pericardial effusion, concern for
tamponade

Major Surgical or Invasive Procedure:
pericardial window, thoracentesis with chest tube

History of Present Illness:
Ms [**Known lastname 35028**] is a 50yoF with PMH significant for depression,
though negative for cardiac risk factors including CHF or CAD.
She was transferred to CCU on [**2154-10-21**] with concern for
pericardial tamponade.

She originally presented to [**Hospital3 **] with 2 weeks of
progressive productive cough, fever, SOB, and DOE despite 2
courses of PO abx (z-pack started [**10-3**]; levaquin started
[**10-16**])for outpatient treatment of PNA, and was found to have a
leukocytosis to 13.7, and a large pericardial effusion, B/L
pleural effusions and LLL opacity on CT scan.

Vitals in ED showed T101.8F, RR 20's-low 30's; winded with any
activity or with talking. Sats high 90's on 4l NC. Of note, she
has had a 50lb intentional weight loss over the last year with
strict diet modification. Prior to this episode, no F/C/NS. She
does also complain of some epigastric discomfort ([**2-21**], dull,
worse with cough). She mentions that she had a few short
episodes of palpitations on exertion in the last weeks prior to
her admission. She denies chest pain, lightheadedness or
dizziness. No sick contacts. Of note she took a cruise to the
Bahamas in late [**Month (only) **] for 1 week. Goes to Caribbean for 1
week every year, otherwise no TB exposure history.
.
ED course: WBC 13.7, chem7 normal. Cardiology was consulted and
bedside echo suggestive of pericardial effusion. Blood cultures
taken. Given PO Azithromycin and IV Ceftriaxone. Given Tylenol
1gm
.
When getting to the CCU, the patient is in NAD, though quite
anxious. Afebrile, hemodynamically stable, mildly tachypnic.
Pulsus paradoxus is 12mmHg.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies exertional buttock or calf
pain. All of the other review of systems were negative except
per above.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.

Past Medical History:
1. CARDIAC RISK FACTORS: negative for DM, HTN, HLD
2. CARDIAC HISTORY:  none
3. OTHER PAST MEDICAL HISTORY:
- Depression / paranoia
- cellulitis in lower extremity x2 2-3 years ago
- breast biopsy several years ago (2 sisters with breast cancer
diagnosed at 35 and 40)

Social History:
owner of a uniform supply store. Lives with husband, who is a
paramedic. No recent sick contacts. Travels to Caribbean for 1
week of vacation every year.
- Tobacco history:  none
- ETOH:  rare, social
- Illicit drugs: none

Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Two sisters have breast cancer, one diagnosed at about age 35,
the other around age 40. Pt has had a breast biopsy several
years ago and states that the results were not concerning. She
says she gets yearly mammograms.

Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T99.4;  P98;  BP115/73;  RR25;   O2 sat 96% 4L NC; Pulsus
paradoxus 12mmHg
GENERAL: Middle-aged woman in NAD, obese, comfortable and
appropriate though quite anxious
HEENT: NC/AT, PERRL, EOMI OP Clear, MMM
Chest: decreased breath sounds LLL up to mid-lung, otherwise
CTAB
Cardiovascular: borderline tachycardia, NL S1 and S2 with normal
splitting of S2, no JVP appreciated although exam inhibited [**2-13**]
body habitus
ABDOMEN: Soft, mildly tender in epigastric region, non-distended

GU/Flank: No costovertebral angle tenderness
Musc/Extr/Back: No joint pain, no cyanosis, clubbing or edema
Skin: No rashs, Warm and dry
Neuro: Speech fluent, A+Ox3
Psych: Normal mentation, Normal mood.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAMINATION:
VS: T98.5;  P98.1;  BP108/71;  RR21;   O2 sat 96% ra, pulsus
paradoxus 8mmHg
GENERAL: Middle-aged woman in NAD, obese, comfortable and
appropriate
HEENT: NC/AT, PERRL, EOMI OP Clear, MMM
Chest: decreased breath sounds in left base
Cardiovascular: borderline tachycardia, NL S1 and S2 with normal
splitting of S2, JVP 8cm
ABDOMEN: Soft,non-tender, non-distended, no HSM, BS+
GU/Flank: No costovertebral angle tenderness
Musc/Extr/Back: No joint pain, no cyanosis, clubbing or edema
Skin: No rashs, Warm and dry
Neuro: Speech fluent, A+Ox3
Psych: Normal mentation, Normal mood.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+


Pertinent Results:
ADMISSION LABS:
[**2154-10-21**] 12:31AM BLOOD WBC-13.7* RBC-4.37 Hgb-12.1 Hct-36.4
MCV-83 MCH-27.6 MCHC-33.1 RDW-12.9 Plt Ct-443*
[**2154-10-21**] 12:31AM BLOOD Neuts-82.5* Lymphs-11.8* Monos-4.5
Eos-0.8 Baso-0.4
[**2154-10-21**] 08:07AM BLOOD PT-14.8* PTT-27.4 INR(PT)-1.3*
[**2154-10-21**] 12:31AM BLOOD Glucose-136* UreaN-14 Creat-0.6 Na-136
K-4.1 Cl-99 HCO3-24 AnGap-17
[**2154-10-21**] 12:54AM BLOOD Lactate-1.2
.
RELEVANT LABS:
[**2154-10-21**] 02:10PM PLEURAL WBC-7250* RBC-[**Numeric Identifier 36798**]* Polys-75*
Lymphs-15* Monos-4* Meso-3* Macro-3*
[**2154-10-21**] 02:10PM PLEURAL TotProt-3.5 Glucose-127 LD(LDH)-470
Albumin-2.0
[**2154-10-21**] 02:16PM OTHER BODY FLUID WBC-[**Numeric Identifier **]* RBC-[**Numeric Identifier 91055**]*
Polys-84* Lymphs-6* Monos-4* Macro-6*
[**2154-10-21**] 02:16PM OTHER BODY FLUID TotProt-4.9 Glucose-91
LD(LDH)-[**2100**] Albumin-2.4
.
DISCHARGE LABS:
[**2154-10-27**] 04:39
White Blood Cells 8.2 Hemoglobin 11.0* Hematocrit 33.3  MCV 83
MCH 27.4 MCHC 33.0 31 - 35 %
RDW 13.9
Platelet Count 391 150 - 440 K/uL
Glucose 142  Urea Nitrogen 9 Creatinine 0.5 Sodium 139 Potassium
4.1 Chloride 102 Bicarbonate 31 Calcium, Total 9.0 Phosphate 3.2
Magnesium 1.8

IMAGING:
TTE [**2154-10-21**]:
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%).
PERICARDIUM: Moderate to large pericardial effusion. RV
diastolic collapse, c/w impaired fillling/tamponade physiology.

CONCLUSIONS: Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). There is a
moderate to large sized pericardial effusion. There is right
ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology.
.
TTE [**2154-10-25**]:
LEFT VENTRICLE: Normal LV thickness, cavity size and global
systolic function (LVEF>55%)
RIGHT VENTRICLE: chamber size and free wall motion are normal.
No AR, AS. Trivial MR.
PERICARDIUM: stable small echodense pericardial effusion,
consistent with blood, inflammation or other cellular elements.

.
Chest x-ray PA/lat [**2154-10-21**]:
1. Enlarged heart consistent with history of pericardial
effusion.
2. Extensive opacification of the left lung suspicious for
pneumonia. The
amount of left pleural fluid may be better assessed with either
decubitus
views or CT.

MICROBIOLOGY:
Blood cultures [**2154-10-21**]: negative
.
Pleural fluid (pleural effusion left): [**2154-10-21**]
GRAM STAIN: 4+   (>10 per 1000X FIELD):   PMN LEUKOCYTES
no microorganisms seen. negative cultures (aerob, anaerob).
negative acid fast smear and culture. negative fungal culture
and potassium hydroxide preparation
WBC 7250/RBC [**Numeric Identifier 36798**]/Prot 3.5/Gluc 127/LDH 470/Alb 2.0
.
Pericardial fluid (pericardial effusion):[**2154-10-21**]
GRAM STAIN: 3+  (5-10 per 1000X FIELD):   PMN LEUKOCYTES
no microroganisms seen.negative cultures (aerob, anaerob).
negative acid fast smear and culture. negative fungal culture.
WBC [**Numeric Identifier **]/RBC [**Numeric Identifier 91055**]/4.9/Gluc 91/LDH [**2100**]/Alb 2.4
.
Sputum: [**2154-10-21**]
GRAM STAIN: <10 PMNs and <10 epithelial cells/100X field. no
microorganisms
negative culture.
.
Urine culture [**2154-10-21**]:    <10,000 organisms/ml
.
MRSA screen [**2154-10-21**]: negative for Staph aureus (Skin, Axillae,
Breast) and neg nasal swab for MRSA
.
PATHOLOGY:
Pericardial biopsy: [**2154-10-21**]
GRAM STAIN: 2+   (1-5 per 1000X FIELD):   PMN LEUKOCYTES.
no microorganisms seen.negative cultures (aerob, anaerob).
negative acid fast smear and culture. negative fungal culture
and potassium hydroxide preparation
.
CYTOLOGY:
Pericardial fluid [**2154-10-22**]: NEGATIVE FOR MALIGNANT CELLS.
Predominantly neutrophils and histiocytes.
.
Pleural fluid [**2154-10-22**]: NEGATIVE FOR MALIGNANT CELLS. Reactive
mesothelial cells, histiocytes, lymphocytes, and neutrophils.


Brief Hospital Course:
Ms [**Known lastname 35028**] is a 50yoF with PMH significant for depression, who
was transferred from [**Hospital3 **] with a large pericardial
effusion, bilateral pleural effusions and a LLL opacity, with a
hospital course complicated by atrial fibrillation with rapid
ventricular response.
.
# Pericardial effusion with cardiac tamponade physiology:
On admission to CCU, an ECHO confirmed a moderate-to-large
pericardial effusion, without echocardiographic signs of
tamponade at that time. Initial EKG on admission showed NSR with
low voltages across all leads without signs for pericarditis.
Repeated measurements of pulsus paradoxus were approximately
12mmHg. She was referred to CT Surgery, and underwent
pericardial window on [**2154-10-21**], during which 1 chest tube on
the left and 1 pericardial drain were placed. She was
transferred still intubated, [**2-13**] bronchospasm/coughing in the
OR, in addition to SVT (10 seconds) and desaturation to SatO2
75%. She was extubated several hours after intervention
uneventfully. Analysis of the pericardial fluid revealed
exudative character, narrowing differential to infectious vs.
malignant vs. rheumatic etiology (despite no prior personal h/o
malignancy or rheumatologic symptoms, although does have a
strong family history of breast ca and a breast biopsy in the
past). Tissue analysis of the pericardium showed fibrinous and
organizing pericarditis. There was no evidence of malignancy in
this sample. Further no significant acute inflammation was
identified. Pericardial fluid cytology was negative for
malignant cells. Sputum, pericardial fluid, blood cultures and
PPD were negative. F/u TTE on [**10-22**] revealed decreased RV
function with septal bowing, likely secondary to constrictive
physioogy from organizing effusion. She was continued on empiric
broad-spectrum antibiotics (Vanc/Cefepime) for total treatment
of 10 days. The pericardial drain was discontinued on [**2154-10-24**]
after 214ml total output and minimal (<20ml) output over
previous 24hours. F/u TTE on [**10-25**] showed normal LV function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is a stable small echodense pericardial
effusion, consistent with blood, inflammation or other cellular
elements. At time of discharge, measurement of pulsus paradoxus
was within normal limits, and pt denied any chest
pain/discomfort, difficulty breathing or any positional
dyspnea/orthopnea related to presenting chief complaint.
.
# LLL PNA complicated by parapneumonic effusion:
CT chest at [**Hospital3 **] identified a LLL opacity thought to
be c/w consolidation vs. mass. Of note, pt had previously
completed outpatient course of levofloxacin and azithromycin
without improvment in symptoms (fevers, SOB) before this
presentation. On transfer, she was considered to have PNA with
resistant organisms vs. post-obstructive PNA vs. malignancy, and
was treated with 10-day course of vanc/cefepime with adequate
improvement of symptoms, resolving leukocytosis and no fever. As
mentioned, a chest tube was placed on the left, which drained a
total output of 1420mL of exudative fluid, negative for
organisms or malignant cells. Sputum, blood and pleural fluid
culture were negative for organisms. PPD was negative. Chest
tube was discontinued on [**2154-10-25**].  At time of discharge, pt
denied fevers/chills, night sweats, cough, and difficulty
breathing. She will need repeat chest CT 4-6 weeks after
discharge to evaluate for resolution of effusion and
consolidation. Furthermore, in outpatient setting PCP should be
sure she is up to date on all recommended malignacy screening
tests, with particular attention to breast cancer given strong
family history.
.
# Afib with RVR:
On hospital day 3 ([**2154-10-23**]), pt was noted to have several
short (<5 minutes) episodes of Afib with RVR (up to
180-200bpm)with spontaneous resolution. These episodes recorded
on telemetry were accompanied by subjective palpitations that
the pt related to previous chest sensations during exertion
during the preceding weeks at home. Etiology of this dysrhythmia
was thought multifactorial, [**2-13**]: irritation of the atrium by
effusion, pericardial drain and PICC line. The PICC line was
subsequently pulled back 2cm, and this coincided with decreased
frequency of these episodes. Pt was started on metoprolol
tartrate 12.5mg [**Hospital1 **], and experienced no additional rhythm
disturbance thereafter. She continued to be in NSR with a rate
in the 70's-80's. She was started on aspirin 325mg daily, given
CHADS2-score of 0. On discharge, the plan included monitoring
for outpatient events with Kings of Hearts monitor.
.
CHRONIC ISSUES:
# Depression: Documented history of this problem.  The patient's
home abilify 2mg PO qPM was continued during this admission.
.
TRANSITIONAL ISSUES:
# Pt will need to schedule follow-up visits with PCP [**Last Name (NamePattern4) **] 2 weeks
and cardiology in 1 month.
# Recommend age-appropriate malignancy screening to rule out
other malignant etiologies.
# Pt will require [**Doctor Last Name **] of Hearts monitoring upon discharge to
evaluate for more episodes of paroxysmal atrial fibrillation,
with twice daily rhythm checks (with teaching).
# Pt will need repeat CT scan in [**4-17**] weeks to evaluate for
resolution of LLL consolidation.
# Pt will need repeat Echocardiogram in 4 weeks to evaluate for
progression/resolution of pericardial effusion
# Pt was started on Aspirin 325mg daily, metoprolol 12.5mg PO
daily, and was sent home with a PICC in place for 2.5 more days
of vancomycin and cefepime with VNA.

Medications on Admission:
- Abilify 2mg PO qHS
- Levofloxacin,
- Promethazine-codeine
- Multivitamin
- Calcium-magnesium
- Potassium

Discharge Medications:
1. vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
Intravenous Q 8H (Every 8 Hours) for 4 days.
Disp:*11 Recon Soln(s)* Refills:*0*
2. aripiprazole 2 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
3. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours) for 4 days.
Disp:*11 Recon Soln(s)* Refills:*0*
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
7. benzonatate 100 mg Capsule Sig: [**1-13**] Capsules PO three times a
day as needed for cough.
Disp:*90 Capsule(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
Community VNA of [**Location (un) 6981**]

Discharge Diagnosis:
Pericardial effusion
Pleural effusion
Hospital Acquired Pneumonia
Atrial Fibrillation


Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.


Discharge Instructions:
Dear Ms. [**Known lastname 35028**],

It was a pleasure taking care of you during your hospital stay
at [**Hospital1 69**]. You were admitted
because you had fluid accumulating around your heart. You were
also found to have pneumonia and fluid accumulating around your
lungs.

You were taken to surgery to remove the fluid around your heart
and lungs and a drain was placed around your heart.  This drain
was then removed.  The fluid accumulation is most likely
secondary to your pneumonia.  You will remain on 4 more days of
IV antibiotics after discharge.

While in the hospital, you also developed several episodes of a
fast irregular rhythm called atrial fibrillation.  We are
prescribing you metoprolol to help control the heart rate and a
full-dose aspirin to help prevent any blood clots from the
rhythm.

We made the following changes to your medications:
- ADDED Metoprolol
- ADDED Aspirin
- ADDED Vancomycin
- ADDED Cefepime
- ADDED Benzonatate
- STOPPED Levofloxacin

Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 91056**] to make a
follow-up appointment within the next week.

We would also like you to see one of our cardiologists for
follow-up. Please call ([**Telephone/Fax (1) 2037**] to make an appointment for
4-6 weeks from your discharge.  You can make the appointment
with Dr. [**Last Name (STitle) **] if you would like.
{'Pneumonia, organism unspecified,Cardiac tamponade,Unspecified pleural effusion,Atrial fibrillation,Ostium secundum type atrial septal defect,Acute bronchospasm,Obesity, unspecified,Other abnormal glucose,Depressive disorder, not elsewhere classified,Family history of malignant neoplasm of breast,Delusional disorder,Body Mass Index 39.0-39.9, adult'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: SOB, Pleural Effusions, PNA, pericardial effusion, concern for
tamponade

PRESENT ILLNESS: Ms [**Known lastname 35028**] is a 50yoF with PMH significant for depression,
though negative for cardiac risk factors including CHF or CAD.
She was transferred to CCU on [**2154-10-21**] with concern for
pericardial tamponade.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: negative for DM, HTN, HLD
2. CARDIAC HISTORY:  none
3. OTHER PAST MEDICAL HISTORY:
- Depression / paranoia
- cellulitis in lower extremity x2 2-3 years ago
- breast biopsy several years ago (2 sisters with breast cancer
diagnosed at 35 and 40)

MEDICATION ON ADMISSION: - Abilify 2mg PO qHS
- Levofloxacin,
- Promethazine-codeine
- Multivitamin
- Calcium-magnesium
- Potassium

ALLERGIES: Sulfa (Sulfonamide Antibiotics)

PHYSICAL EXAM: ADMISSION PHYSICAL EXAMINATION:
VS: T99.4;  P98;  BP115/73;  RR25;   O2 sat 96% 4L NC; Pulsus
paradoxus 12mmHg
GENERAL: Middle-aged woman in NAD, obese, comfortable and
appropriate though quite anxious
HEENT: NC/AT, PERRL, EOMI OP Clear, MMM
Chest: decreased breath sounds LLL up to mid-lung, otherwise
CTAB
Cardiovascular: borderline tachycardia, NL S1 and S2 with normal
splitting of S2, no JVP appreciated although exam inhibited [**2-13**]
body habitus
ABDOMEN: Soft, mildly tender in epigastric region, non-distended

FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Two sisters have breast cancer, one diagnosed at about age 35,
the other around age 40. Pt has had a breast biopsy several
years ago and states that the results were not concerning. She
says she gets yearly mammograms.

SOCIAL HISTORY: owner of a uniform supply store. Lives with husband, who is a
paramedic. No recent sick contacts. Travels to Caribbean for 1
week of vacation every year.
- Tobacco history:  none
- ETOH:  rare, social
- Illicit drugs: none 

### Response:
{'Pneumonia, organism unspecified,Cardiac tamponade,Unspecified pleural effusion,Atrial fibrillation,Ostium secundum type atrial septal defect,Acute bronchospasm,Obesity, unspecified,Other abnormal glucose,Depressive disorder, not elsewhere classified,Family history of malignant neoplasm of breast,Delusional disorder,Body Mass Index 39.0-39.9, adult'}
