CHIEF COMPLAINT: Urosepsis

PRESENT ILLNESS: Mr. [**Known lastname 1313**] is a 75y/o gentleman with a DM2, HTN, and history of
nephrolithiasis (no interventions in the past) who is
transferred with urosepsis and an obstructing ureteral calculus.
.
He presented to [**Hospital3 **] on [**5-5**] due to 2 weeks of
feeling generally weak and nauseated, with occasional emesis.
Of note, he had been started on Cipro 11 days prior for UTI,
with no relief, and had been on Nitrofurantoin for the past 4
days.  He started feeling more fatigued so he presented to
[**Hospital1 **] ER where VS were: T 99.2, HR 112 (but up to 130), BP
97/52, RR 20, POx 100% 2L NC.  He was found to be in AFib with
RVR to 130 requiring Diltiazem 10mg IV x3 with subsequent drop
in BP so was switched to Lopressor IV.  18 Fr foley was placed
releasing 4 liters of purulent urine.  Was started on
Vanc/Zosyn.  He was admitted to their ICU where CT showed
moderate hydronephrosis and hydroureter on the right secondary
to an obstructing calculus just above the UVJ measuring about 4
mm.  Urology attempted a right ureteral decompression but was
unable to advance past the stone so he was transferred to [**Hospital1 18**]
for I.R.-guided urostomy tube placement.  Of note, patient was
intubated for the procedure and remains so.  He reportedly had
hypotension in the OR (low blood pressures not documented) so he
required Neosynephrine and Levophed.
.
On arrival to the MICU, he is intubated and sedated. Arrived
only on Levophed which was just turned off.

MEDICAL HISTORY: nephrolithiasis
class III obesity
DM2
HTN
gout

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Patient Outside hospital records.
1. Metoprolol Tartrate 50 mg PO BID
2. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
3. Spironolactone 25 mg PO DAILY
4. HydrALAzine 25 mg PO QHS
5. Levemir 15 Units Breakfast
6. Nateglinide 120 mg PO TIDAC
7. Allopurinol 300 mg PO DAILY
8. ibuprofen *NF* 800 mg Oral TID
9. TraMADOL (Ultram) 50 mg PO QID
10. Nitrofurantoin (Macrodantin) 50 mg PO Q6H

ALLERGIES: No Allergies/ADRs on File

PHYSICAL EXAM: On admission:
Vitals: T: 98.5  BP157/90: P:146 Vented: CMV TV 600 PeeP 5 FiO2
50% O2: 98%
General: Intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular.  Distant heart sounds.  no murmurs,
rubs, gallops
Lungs: Coarse breath sounds anterioly.  Otherwise no wheezes,
rales, ronchi
Abdomen: Obese abdomen otherwise soft, non-tender,
non-distended, bowel sounds present, no organomegaly
GU: foley with dark urine.
Ext: cold extremities.  Poorly palpable pulses.  Trace  edema
but otherwise no clubbing or cyanosis.
Neuro: Pupils reactive.  Winces to pain.

FAMILY HISTORY: Father lost kidney due to stones

SOCIAL HISTORY: retired dry cleaning machine manufacturerer
no ETOH
no tobacco
no illicits
Unspecified septicemia,Acute respiratory failure,Subendocardial infarction, initial episode of care,Calculus of ureter,Urinary tract infection, site not specified,Atrial fibrillation,Acute kidney failure, unspecified,Hemorrhage complicating a procedure,Hydronephrosis,Chronic systolic heart failure,Severe sepsis,Other specified forms of chronic ischemic heart disease,Retention of urine, unspecified,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Gout, unspecified,Diarrhea,Obesity, unspecified,Unspecified deficiency anemia,Body Mass Index 37.0-37.9, adult,Do not resuscitate status,Long-term (current) use of insulin,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Septicemia NOS,Acute respiratry failure,Subendo infarct, initial,Calculus of ureter,Urin tract infection NOS,Atrial fibrillation,Acute kidney failure NOS,Hemorrhage complic proc,Hydronephrosis,Chr systolic hrt failure,Severe sepsis,Chr ischemic hrt dis NEC,Retention urine NOS,BPH w urinary obs/LUTS,Hypertension NOS,DMII wo cmp nt st uncntr,Gout NOS,Diarrhea,Obesity NOS,Deficiency anemia NOS,BMI 37.0-37.9,adult,Do not resusctate status,Long-term use of insulin,Abn react-procedure NEC
Admission Date:  [**2121-5-6**]              Discharge Date:   [**2121-5-14**]

Date of Birth:  [**2045-7-26**]             Sex:   M

Service: MEDICINE

Allergies:
No Allergies/ADRs on File

Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
Urosepsis

Major Surgical or Invasive Procedure:
Intubation (from OSH)
Extubation [**2121-5-6**]

History of Present Illness:
Mr. [**Known lastname 1313**] is a 75y/o gentleman with a DM2, HTN, and history of
nephrolithiasis (no interventions in the past) who is
transferred with urosepsis and an obstructing ureteral calculus.
.
He presented to [**Hospital3 **] on [**5-5**] due to 2 weeks of
feeling generally weak and nauseated, with occasional emesis.
Of note, he had been started on Cipro 11 days prior for UTI,
with no relief, and had been on Nitrofurantoin for the past 4
days.  He started feeling more fatigued so he presented to
[**Hospital1 **] ER where VS were: T 99.2, HR 112 (but up to 130), BP
97/52, RR 20, POx 100% 2L NC.  He was found to be in AFib with
RVR to 130 requiring Diltiazem 10mg IV x3 with subsequent drop
in BP so was switched to Lopressor IV.  18 Fr foley was placed
releasing 4 liters of purulent urine.  Was started on
Vanc/Zosyn.  He was admitted to their ICU where CT showed
moderate hydronephrosis and hydroureter on the right secondary
to an obstructing calculus just above the UVJ measuring about 4
mm.  Urology attempted a right ureteral decompression but was
unable to advance past the stone so he was transferred to [**Hospital1 18**]
for I.R.-guided urostomy tube placement.  Of note, patient was
intubated for the procedure and remains so.  He reportedly had
hypotension in the OR (low blood pressures not documented) so he
required Neosynephrine and Levophed.
.
On arrival to the MICU, he is intubated and sedated. Arrived
only on Levophed which was just turned off.


Past Medical History:
nephrolithiasis
class III obesity
DM2
HTN
gout


Social History:
retired dry cleaning machine manufacturerer
no ETOH
no tobacco
no illicits


Family History:
Father lost kidney due to stones


Physical Exam:
On admission:
Vitals: T: 98.5  BP157/90: P:146 Vented: CMV TV 600 PeeP 5 FiO2
50% O2: 98%
General: Intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular.  Distant heart sounds.  no murmurs,
rubs, gallops
Lungs: Coarse breath sounds anterioly.  Otherwise no wheezes,
rales, ronchi
Abdomen: Obese abdomen otherwise soft, non-tender,
non-distended, bowel sounds present, no organomegaly
GU: foley with dark urine.
Ext: cold extremities.  Poorly palpable pulses.  Trace  edema
but otherwise no clubbing or cyanosis.
Neuro: Pupils reactive.  Winces to pain.

On discharge:
Vitals: 98.2 98.0 112/56 90 20 98%
General: Obese, Alert, oriented, no acute distress
HEENT: PERRL, EOMI, MMM, sclera anicteric, oropharynx clear
Neck: JVP flat, no LAD
Lungs: CTA anteriorly, unable to auscultate lung bases due to
limited mobility
CV: RRR, nl S1 + S2, no m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly; nephrostomy
tube in place, no tenderness or erythema around site
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
ADMISSION LABS:

[**2121-5-6**] 02:04AM BLOOD WBC-16.6* RBC-3.15* Hgb-9.5* Hct-31.5*
MCV-100* MCH-30.3 MCHC-30.2* RDW-15.1 Plt Ct-277
[**2121-5-6**] 03:03AM BLOOD PT-14.9* PTT-26.7 INR(PT)-1.4*
[**2121-5-6**] 02:04AM BLOOD Glucose-230* UreaN-70* Creat-3.2* Na-137
K-4.4 Cl-110* HCO3-13* AnGap-18
[**2121-5-10**] 12:05AM BLOOD CK-MB-4 cTropnT-0.92*
[**2121-5-10**] 02:05AM BLOOD CK-MB-4 cTropnT-1.00*
[**2121-5-10**] 06:39AM BLOOD CK-MB-4 cTropnT-1.10*
[**2121-5-6**] 02:04AM BLOOD Albumin-3.3* Calcium-7.9* Phos-4.6*
Mg-1.6
[**2121-5-6**] 05:00PM BLOOD calTIBC-150* VitB12-397 Ferritn-560*
TRF-115*
[**2121-5-6**] 02:18AM BLOOD Lactate-1.4

DISCHARGE LABS:

[**2121-5-13**] 06:00AM BLOOD WBC-9.8 RBC-2.90* Hgb-8.8* Hct-28.9*
MCV-100* MCH-30.3 MCHC-30.3* RDW-15.9* Plt Ct-342
[**2121-5-13**] 06:00AM BLOOD PT-13.8* PTT-56.0* INR(PT)-1.3*
[**2121-5-13**] 06:00AM BLOOD Glucose-119* UreaN-21* Creat-1.4* Na-136
K-4.2 Cl-104 HCO3-24 AnGap-12
[**2121-5-10**] 06:39AM BLOOD CK(CPK)-57
[**2121-5-13**] 06:00AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.3*

CTA CHEST [**2121-5-10**]:
1. No evidence of acute aortic bony injury or pulmonary embolus.

2. Bronchiectasis and bronchial wall thickening at the lung
bases bilaterally with associated minimal central
lymphadenopathy.
3. Severe calcified atherosclerotic disease.
4. Trace left pleural effusion.
5. Prominent pumlonary artery suggestive of underlying pulmonary
hypertension.

TTE:
Technically suboptimal image quality. The left atrium is mildly
dilated. There is an apical left ventricular aneurysm. Overall
left ventricular systolic function is moderately depressed (LVEF
= (?) 35 %). Anterior and septal hypokinesis is present, and
extensive apical akinesis with focal dyskinesis is present. The
right ventricle is not well seen but may also be hypokinetic.
The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mitral regurgitation is present but cannot be
quantified. Tricuspid regurgitation is present but cannot be
quantified. There is no pericardial effusion.


Brief Hospital Course:
Mr. [**Known lastname 1313**] is a 75y/o gentleman with nephrolithiasis, DM2, and
HTN presenting with urosepsis, [**Last Name (un) **], and AFib in the setting of
obstructive uropathy and urinary retention.
.
#. Obstructive uropathy with infection: urosepsis.
Pt presented from OSH with concerns for urosepsis.  CT at OSH
showed moderate hydronephrosis and hydroureter on the right
secondary to an obstructing calculus just above the UVJ
measuring about 4 mm.  He was placed initially on broad spectrum
antibiotics (vanc/cefepime) initially.  This was narrowed to
ceftriaxone when urine culture from OSH was reported to be > 100
K E.COLI resistant to Levofloxacin, Bactrim and sensitive to all
other agents. Planned for a two week antibiotic course.
Percutaneous nephrostomy tube was placed by IR (pt was kept
intubated for the procedure) on [**2121-5-6**].  This was complicated
by bleeding from nephrostomy tube when pt was started on heparin
gtt for afib.  IR reassessed the tube and found it to be in
calyx instead of kidney; this was replaced ON [**5-9**] and bleeding
from nephrostomy tube resolved. Creatinine > 4 on admission from
obstructive [**Last Name (un) **], now trending down to 1.4 after nephrostomy tube
placement.  Patient was discharged on IV ceftriaxone, last day =
[**5-18**] for total 2 week course.

# [**Last Name (un) **] and urinary retention: Creatinine > 4 on admission, now
1.4  s/p nephrostomy tube placement.  Urology was consulted who
recommended initiation of tamsulosin and voiding trial in [**2-14**]
days.  Patient failed subseuqent voiding trial with 750 cc of
urine in his bladder.  He was intermittently straight - cathed,
but it became increasingly difficult likely secondary to his
BPH.  Thus, a foley was placed prior to discharged.  Per urology
recommendations, the foley should remain in place until the
patient sees his urologist.
.
#. AFib with RVR: new-onset, in the setting of infection.
Per OSH records, pt had no known h/o AFib but was in afib with
rvr at OSH.  Rate-control was attempted with several different
agents including metoprolol, diltiazem, and esmolol drip.
However, he became hypotensive on these agents.  He was then
started on an amiodarone drip.  Given his CHADS of 3 and
increased risk of stroke with potential cardioversion on
amiodarione drip, he was started on heparin gtt. This was
complicated by bleeding from foley as well as nephrostomy tube.
Cardiology consult was obtained who recommended stopping
amiodarone drip and placing pt back on metoprolol.  Metoprolol
doses were adjusted several times for continued elevated heart
rates and low blood pressures, and he was eventually able to be
rate controlled on 50 QID metoprolol tartrate, tansitioned to
200 metoprolol succinate on discharge.  He was continued on
heparin gtt and was initiated on coumadin the day prior to
discharge.  On discharge, he was well rate controlled in the
90s-110s with bursts into the 130s-140s when eating breakfast or
lunch.  These rates would only last for several minutes and
patient remained stable and asymptomatic until resolution.  A
TTE was obtained that revealed EF of 35%, left ventricular
aneurysm, and possibly hypokinetic right ventricle, mild aortic
stenosis.  Cardiology recommended that he undergo non urgent
cardiac catheterization when stable.  He was started on a baby
aspirin.

# Chest Pain and Increased Troponins: On [**2121-5-9**] pt complained
of chest pain radiating to his arm as well as N/V. ECG showed no
changes. CTA negative for PE, but did show evidence of pulmonary
hypertension. He has no known CAD, but cards recommended a
cardiac cath at some point as based on his TTE, likely has 3VD.
Trops have increased to 1.10 with flat CKs and MBs.  Likely
demand ischemia in the setting of sepsis. He was started on
aspirin 81 mg and atorvastatin.  Cardiology did recommend a
non-urgent cardiac cath at some point in the near future.  This
will be discussed at patient's outpatient cardiology
appointment.

# Transaminitis: On day of discharge, patient's AST and ALT were
mildly elevated to 117 and 80, respectively (had been normal on
admission).  Possibly secondary to initiation of atorvastatin.
Atorvastatin was held on day of discharge.  His AST and ALT
should be monitored and trended while at the MACU.

#. HTN: intermittently hyptonsive off home BP meds.
He became hypotensive with IV nodal agents for AFib/RVR in the
OSH ED.  Again became hypotensive in the OR during attempted
ureteral stenting (possibly from vagal response vs. evolving
septic shock).  He also became hypotensive with several
different agents for rate-control for afib.  His home BP
medications,(Hydrochlorothiazide-Triamterene, Spironolactone,
Hydralazine) were held.  He was started on metoprolol for
rate-control.  Given findings of depressed EF on TTE, he was
started on an ACE-I, which should be uptitrated as an
outpatient.

# Loose stools/diarrhea: Patient had frequent loose stool
throughout hospital stay, brown but guiac positive.  A C diff
PCR was negative on [**5-8**], patient's white count remained stable,
and patient looked clinically well.  Given the small amount of
loose stools and his clinical status, the team felt that there
was a low pre test probability for C diff on discharge. If
patient's loose stools continue at rehab, or if clinical status
changes, another C diff PCR test should be sent.
.
#. DM2: stable.  Home oral hypoglycemics were held and he was
placed on home lantus and HISS.
.
#. Anemia: Hct 32 (unclear baseline).  He was guaiac positive at
OSH.  Hct dropped to high 20s but was stable during ICU stay.
He initially had bleeding from foley and nephrostomy tube when
heparin gtt was started which eventually resolved. He will need
outpatient colonoscopy and GI follow-up.

# Transitional Issues:
- Outpatient cardiac catheterization
- Management of INR and coumadin dose
- Nephrostomy tube removal to be determined by urology
- Trending of AST/ALT and reinitiation of statin
- Colonoscopy

CODE STATUS: DNR/DNI

** In patient's discharge paperwork, states that ACE/[**Last Name (un) **] not
prescribed on discharge because not tolerated.  This is a
malfunction in the new electronic med reconciliation form. This
is to clarify that the patient was in fact discharged on an
ACE-I.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient Outside hospital records.
1. Metoprolol Tartrate 50 mg PO BID
2. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
3. Spironolactone 25 mg PO DAILY
4. HydrALAzine 25 mg PO QHS
5. Levemir 15 Units Breakfast
6. Nateglinide 120 mg PO TIDAC
7. Allopurinol 300 mg PO DAILY
8. ibuprofen *NF* 800 mg Oral TID
9. TraMADOL (Ultram) 50 mg PO QID
10. Nitrofurantoin (Macrodantin) 50 mg PO Q6H


Discharge Medications:
1. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. TraMADOL (Ultram) 50 mg PO BID:PRN pain
3. Aspirin 81 mg PO DAILY
4. CeftriaXONE 1 gm IV Q24H
Day 1= [**5-5**]
LAST DAY = [**5-18**]
5. Heparin IV Sliding Scale

6. Metoprolol Succinate XL 200 mg PO DAILY Start: In am
Hold for HD <60 or systolic BP <100.
7. Miconazole Powder 2% 1 Appl TP QID:PRN fungal rash
8. Tamsulosin 0.4 mg PO HS
9. Warfarin 2.5 mg PO DAILY16
10. Lisinopril 2.5 mg PO DAILY
HOLD FOR SBP < 100
11. Allopurinol 100 mg PO DAILY
12. Simethicone 40-80 mg PO QID:PRN Bloating


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Urosepsis
Obstructive uropathy with percutaneous nephrostomy tube
placement
Atrial Fibrillation
Systolic Heart Failure


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.


Discharge Instructions:
You were seen in the hospital because of severe obstruction of
your urinary tract which caused an infection in your urine.
This obstruction was cleared with a nephrostomy tube and your
infection was treated with IV antibiotics.  The nephrostomy
tubes will stay in place for at least the next several week
until you follow-up with a urologist listed below.

While in the hospital, you also developed a fast irregular heart
rate called atrial fibrillation.  We controlle your rate by
increasing your metoprolol.  Because atrial fibrillation
increases your risk of stroke, we also put you on a blood
thinner called coumadin.  Once you are discharged from the
hospital, you will need to have your coumadin levels checked
periodically.

You also had an echocardiogram, or an ultrasound of your heart,
which showed that your heart pumping function has been reduced.
You were seen by our cardiology team, who recommended that you
eventually have a cardiac catheterization to look to see of
there are blockages in your arteries.  You will see a
cardiologist to discuss this procedure with you, as listed
below.

It was a pleasure taking care of you during your hospital stay.

Followup Instructions:
Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4469**]
[**Hospital3 **]
[**5-28**] 1:45 PM

Urology:
Dr. [**Last Name (STitle) 9780**]
[**Name (STitle) 5871**] Hospital
[**2119-6-5**]:30 AM

Once you are discharged from the rehab facility, an appointment
will be made for you to see your primary care doctor.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
{'Unspecified septicemia,Acute respiratory failure,Subendocardial infarction, initial episode of care,Calculus of ureter,Urinary tract infection, site not specified,Atrial fibrillation,Acute kidney failure, unspecified,Hemorrhage complicating a procedure,Hydronephrosis,Chronic systolic heart failure,Severe sepsis,Other specified forms of chronic ischemic heart disease,Retention of urine, unspecified,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Gout, unspecified,Diarrhea,Obesity, unspecified,Unspecified deficiency anemia,Body Mass Index 37.0-37.9, adult,Do not resuscitate status,Long-term (current) use of insulin,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: Urosepsis

PRESENT ILLNESS: Mr. [**Known lastname 1313**] is a 75y/o gentleman with a DM2, HTN, and history of
nephrolithiasis (no interventions in the past) who is
transferred with urosepsis and an obstructing ureteral calculus.
.
He presented to [**Hospital3 **] on [**5-5**] due to 2 weeks of
feeling generally weak and nauseated, with occasional emesis.
Of note, he had been started on Cipro 11 days prior for UTI,
with no relief, and had been on Nitrofurantoin for the past 4
days.  He started feeling more fatigued so he presented to
[**Hospital1 **] ER where VS were: T 99.2, HR 112 (but up to 130), BP
97/52, RR 20, POx 100% 2L NC.  He was found to be in AFib with
RVR to 130 requiring Diltiazem 10mg IV x3 with subsequent drop
in BP so was switched to Lopressor IV.  18 Fr foley was placed
releasing 4 liters of purulent urine.  Was started on
Vanc/Zosyn.  He was admitted to their ICU where CT showed
moderate hydronephrosis and hydroureter on the right secondary
to an obstructing calculus just above the UVJ measuring about 4
mm.  Urology attempted a right ureteral decompression but was
unable to advance past the stone so he was transferred to [**Hospital1 18**]
for I.R.-guided urostomy tube placement.  Of note, patient was
intubated for the procedure and remains so.  He reportedly had
hypotension in the OR (low blood pressures not documented) so he
required Neosynephrine and Levophed.
.
On arrival to the MICU, he is intubated and sedated. Arrived
only on Levophed which was just turned off.

MEDICAL HISTORY: nephrolithiasis
class III obesity
DM2
HTN
gout

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from Patient Outside hospital records.
1. Metoprolol Tartrate 50 mg PO BID
2. Triamterene-Hydrochlorothiazide 1 CAP PO DAILY
3. Spironolactone 25 mg PO DAILY
4. HydrALAzine 25 mg PO QHS
5. Levemir 15 Units Breakfast
6. Nateglinide 120 mg PO TIDAC
7. Allopurinol 300 mg PO DAILY
8. ibuprofen *NF* 800 mg Oral TID
9. TraMADOL (Ultram) 50 mg PO QID
10. Nitrofurantoin (Macrodantin) 50 mg PO Q6H

ALLERGIES: No Allergies/ADRs on File

PHYSICAL EXAM: On admission:
Vitals: T: 98.5  BP157/90: P:146 Vented: CMV TV 600 PeeP 5 FiO2
50% O2: 98%
General: Intubated and sedated
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Irregularly irregular.  Distant heart sounds.  no murmurs,
rubs, gallops
Lungs: Coarse breath sounds anterioly.  Otherwise no wheezes,
rales, ronchi
Abdomen: Obese abdomen otherwise soft, non-tender,
non-distended, bowel sounds present, no organomegaly
GU: foley with dark urine.
Ext: cold extremities.  Poorly palpable pulses.  Trace  edema
but otherwise no clubbing or cyanosis.
Neuro: Pupils reactive.  Winces to pain.

FAMILY HISTORY: Father lost kidney due to stones

SOCIAL HISTORY: retired dry cleaning machine manufacturerer
no ETOH
no tobacco
no illicits 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Subendocardial infarction, initial episode of care,Calculus of ureter,Urinary tract infection, site not specified,Atrial fibrillation,Acute kidney failure, unspecified,Hemorrhage complicating a procedure,Hydronephrosis,Chronic systolic heart failure,Severe sepsis,Other specified forms of chronic ischemic heart disease,Retention of urine, unspecified,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Gout, unspecified,Diarrhea,Obesity, unspecified,Unspecified deficiency anemia,Body Mass Index 37.0-37.9, adult,Do not resuscitate status,Long-term (current) use of insulin,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
