CHIEF COMPLAINT: DOE, weight gain

PRESENT ILLNESS: This is a 77 yo with PMH significant for ESRD s/p transplant in
[**2170**], CKD with Cr of 2, DM, dCHF presented with DOE,
nonproductive cough and weight gain over the last month. She
presented to her outpatient provider yesterday for these sx's
and was found to desat to 85% on RA with ambulation, so was sent
to the ED.

MEDICAL HISTORY: HTN
DMII poorly controlled on insulin (reports takes BS 3x per day,
often high 100s to 200)
ESRD [**2-22**] DM/HTN s/p deceased donor renal transplantation in
[**3-26**].
-baseline Cr 2.0
-last bx [**12-27**]- high proportion of glomeruli sclerosed
-pt reports adherence to immunosuppressive meds
-hemodialysis for 1.5 yrs prior to txplant
-CAD s/p PCI--[**2163**] stenting of the RCA, restented in [**2170**]
-Hypothyroidism
-Hyperlipidemia

MEDICATION ON ADMISSION: Humalog insulin 15 units [**Hospital1 **]
NPH 36 units QAM, 36 units QPM
Cell cept 1000mg [**Hospital1 **]
tacrolimus 1.5mg [**Hospital1 **]
Bactrim 80-400 one daily
levothyroxine 88mcg daily
Norvasc 10mg daily
atorvastatin 20mg daily
Toprol XL 100mg daily
Diovan 160mg daily
furosemide 40mg daily
fenofibrate 144mg daily
ergocalciferol 50,000 units Qmonth
albuterol PRN
Os-Cal D 2 tabs daily
ASA 325mg daily

ALLERGIES: Penicillins / Iodine; Iodine Containing / Lisinopril

PHYSICAL EXAM: Vitals - T: 98.4 BP:136/58 HR:62 RR:18 02 sat:94 on 3L
GENERAL: Pleasant, obese older woman in NAD
HEENT: Normocephalic, atraumatic. No scleral icterus.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVD of approximately 9cm above RA.
LUNGS: Crackles to midway up lung fields.
ABDOMEN: NABS. Soft, NT, ND. No HSM. No induration, tenderness
to palpation of renal transplant in lower right quadrant. No RLQ
erythema or ecchymoses. No bruits in RLQ.
EXTREMITIES: 1+ edema in lower extremities to knee bilaterally.

FAMILY HISTORY: Brother died [**2-22**] cardiac arrest during a kidney transplant
surgery; other siblings with DM and HTN

SOCIAL HISTORY: widow, no children, retired from [**Hospital1 18**], lives with sister and
other family members, cares for [**Age over 90 **] year old mother at home. Able
to exercise with 15-20 minutes walking daily.
Smoking- quit smoking 15 years ago, prior had [**3-24**] cigs/day
ETOH- None
Illicits- None
Acute on chronic diastolic heart failure,Acute respiratory failure,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Complications of transplanted kidney,Pyelonephritis, unspecified,Mixed acid-base balance disorder,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, Stage V,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Calculus of kidney,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Personal history of tobacco use
Ac on chr diast hrt fail,Acute respiratry failure,Subendo infarct, initial,Acute kidney failure NOS,Compl kidney transplant,Pyelonephritis NOS,Mixed acid-base bal dis,Hyp kid NOS w cr kid V,Chron kidney dis stage V,Crnry athrscl natve vssl,Status-post ptca,Old myocardial infarct,Calculus of kidney,Abn react-org transplant,DMII oth nt st uncntrld,Long-term use of insulin,Adv eff insulin/antidiab,Hyperlipidemia NEC/NOS,Hypothyroidism NOS,History of tobacco use
Admission Date:  [**2173-11-22**]              Discharge Date:   [**2173-12-4**]

Date of Birth:  [**2096-7-19**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Iodine; Iodine Containing / Lisinopril

Attending:[**First Name3 (LF) 3043**]
Chief Complaint:
DOE, weight gain

Major Surgical or Invasive Procedure:
none


History of Present Illness:
This is a 77 yo with PMH significant for ESRD s/p transplant in
[**2170**], CKD with Cr of 2, DM, dCHF presented with DOE,
nonproductive cough and weight gain over the last month. She
presented to her outpatient provider yesterday for these sx's
and was found to desat to 85% on RA with ambulation, so was sent
to the ED.

Pt notes that she has found herself looking bloated (to self and
to sister) and pants felt tighter over last month, though no
dietary changes or indiscretion. Also, for past two weeks, has
had cough at night, non-productive. Very occasionally coughs
during the day. Denies orthopnea, PND, chest pain, fever chills.
Reports she is adherent with all meds. Sleeps with 2 pillows,
this is standard for years. She has never had sx of weight
gain/cough before.

Pt reports that she drinks 4 'jars' of water daily and that this
is steady since 4 years ago, when she was told to stay hydrated
for immunosupression drugs post transplant.
In the ED, CXR showed vascular engorgement. BNP was elevated to
2584.
Patient given nitropaste with some improvement in SOB and
transferred to floor for further management.

ROS:
Denies headache, vision changes, confusion, rhinorrhea,
congestion, sore throat, abdominal pain, nausea, vomiting,
diarrhea, constipation,
All other Review of systems as stated above in HPI.


Past Medical History:
HTN
DMII poorly controlled on insulin (reports takes BS 3x per day,
often high 100s to 200)
ESRD [**2-22**] DM/HTN s/p deceased donor renal transplantation in
[**3-26**].
-baseline Cr 2.0
-last bx [**12-27**]- high proportion of glomeruli sclerosed
-pt reports adherence to immunosuppressive meds
-hemodialysis for 1.5 yrs prior to txplant
-CAD s/p PCI--[**2163**] stenting of the RCA, restented in [**2170**]
-Hypothyroidism
-Hyperlipidemia


Social History:
widow, no children, retired from [**Hospital1 18**], lives with sister and
other family members, cares for [**Age over 90 **] year old mother at home. Able
to exercise with 15-20 minutes walking daily.
Smoking- quit smoking 15 years ago, prior had [**3-24**] cigs/day
ETOH- None
Illicits- None


Family History:
Brother died [**2-22**] cardiac arrest during a kidney transplant
surgery; other siblings with DM and HTN


Physical Exam:
Vitals - T: 98.4 BP:136/58 HR:62 RR:18 02 sat:94 on 3L
GENERAL: Pleasant, obese older woman in NAD
HEENT: Normocephalic, atraumatic. No scleral icterus.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVD of approximately 9cm above RA.
LUNGS: Crackles to midway up lung fields.
ABDOMEN: NABS. Soft, NT, ND. No HSM. No induration, tenderness
to palpation of renal transplant in lower right quadrant. No RLQ
erythema or ecchymoses. No bruits in RLQ.
EXTREMITIES: 1+ edema in lower extremities to knee bilaterally.

SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Gait
assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant



Pertinent Results:
Labs on admission:

WBC 5.2 peaked at 20.9   N66  L18.5  M9.7  E4.6  B1.1
Hct 34.9 MCV 85
Plts 358

Coags  13.1 27.1  1.1

140   97   56
---------------- Gluc 96
5.0   34   3.2

Ca 8.8  Mg 2.3  Phos 4.5

ALT/AST  16/27
LDH 308
CK 200
AlkP 49
Tbili 0.6
BNP 2584
MB's all normal x6
Trop <0.01 rose to 0.29 then back down to 0.14
Random [**Last Name (un) 104**] 26.2
TSH 1.1
Tacro 3.7
Lactates all normal
BK virus and strongyloides pending

BCx negative x6
UCx negative x2
CMV VL negative
DFA influenza negative

[**2173-11-23**] echo
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Left
ventricular systolic function is hyperdynamic (EF 70-80%).
Tissue Doppler imaging suggests an increased left ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.

Compared with the findings of the prior study (images reviewed)
of [**2172-8-14**], no major change is evident.

[**2173-11-23**] renal u/s
CONCLUSION: There is new deterioration in vascularization of the
renal
transplant, with markedly decreased diastolic flow, which is now
nearly
absent.The main renal transplant artery and vein are patent. The
most likely
causes for these findings include rejection in the appropriate
clinical
setting, drug toxicity or chronic low flow state.
.

There are two non-obstructing renal calculi.There is no
hydronephrosis.

[**2173-11-25**] CXR
CHEST, TWO VIEWS: Mild cardiomegaly persists. The aorta is
calcified and
tortuous. Mediastinal and hilar contours are normal and
unchanged. There is
cephalization of vessels, peribronchial cuffing and interstitial
edema
consistent with CHF. There is no pleural effusion, focal
consolidation or
pneumothorax.


Brief Hospital Course:
77F with PMH significant for ESRD s/p transplant in [**2170**], CKD
with Cr of 2, DM, diastolic CHF presented with DOE,
nonproductive cough and weight gain over the last month. Wet
crackles halfway up and bilateral LE edema; consistent with
first presentation of decompensated dCHF. Creatinine increase
off baseline on presentation, now returned to baseline,
transplant team following, feels transplant intact.  She was
transferred to the MICU on [**11-27**] in respiratory failure and
managed with BiPAP and diuresis.  She was trasnferred back to
the general medicine service [**11-30**].  Detailed hospital course by
problem.

# ICU course/respiratory failure/hypoxia: Patient admitted with
respiratory failure in the setting of nausea, vomiting and
elevated systolic blood pressures.  Her initial ABG was
7.25/72/130/33 and she was started on BiPAP for acute
respiratory acidosis.  She is a difficult stick and was followed
with VBGs.  Her blood pressure was controlled with metoprolol
and she was diuresed further with a lasix drip.  She was taken
off of BiPAP 11/09 when she was clinically improved.  Her O2
sats were 93-95% on 4L by nasal cannula with a VBG of 7.38/CO2
72/O2 56/HCO3 44 at the time of transfer back to the floor. This
ABG was done while she was completely asymptomatic, and may be
her baseline. Her lung crackles on exam were stable and
unchanged throughout this time.  At the time of discharge, she
still had a mild oxygen requirement (1-2L) to maintain O2 sats
>92%. She had an ABG done prior to discharge which was
7.48/55/64/42 consistent with a metabolic alkalosis with
respiratory compensation likely in the setting of significant
diuresis.  She had a chest CT which was done prior to discharge
as well which showed some ground glass opacities which may be
consistent with pulmonary edema and some bronchial dilation
which may be seen in this age group.  She will be seen in
pulmonary clinic with Dr. [**Last Name (STitle) **] in 1 month with PFTs to
evaluate any upderlying lung disease which may be present as
well.  Room air saturations will be checked by VNA but also
should be checked by outpatient providers in clinic as well.

# CAD with recent NSTEMI: The patient had elevated troponins
from 0.01 on admission to 0.29 in the setting of her admission
to the ICU.  She has known CAD s/p stenting.  Her EKG was stable
and she did not have chest pain.  She was started on an NSTEMI
protocol with heparin drip, aspirin 325mg and plavix loading and
cardiology was consulted.  They felt this was mostly due to
cardiac strain and may have been worsening her diastolic failure
but did not feel that intervention was necessary.  She stayed on
the heparin drip for 48 hours and was transitioned back to her
home medications of aspirin, metoprolol, and atorvastatin. Trops
trended down to 0.14 by time of d/c from MICU.  She is being
discharged on Aspirin 325 mg daily, but should be transitioned
as an outpatient back to 81 mg daily for secondary prevention.

#. Transplant pyelonephritis: the patient had fever to 101.8,
bacteriuria, and pain over her graft site, suggesting
pyelonephritis. Her WBC count was 20 on [**11-26**] and pt was started
on vanc/cefepime and her urine culture was negative, though it
was drawn after antibiotics. Her WBC count trended down on ABx
and so they were continued on transfer to MICU. Her fever curve
trended down through MICU admission. The ID team was consulted.
Given her negative MRSA screen she was narrowed to cefepime only
with the course of 7 days completed during her hospitalization.
Her repeat UA did not show any evidence of infection, and at the
time of discharge, she was afebrile and asymptomatic.

#. Acute on Chronic Diastolic Heart Failure:
Pt initially difficult to diurese with IV Lasix and started on
gtt. No longer edema in LEs but still crackles in lung bases.
Per nephrologist to whom pt is well known, pt has rales at
baseline, so may be difficult to assess fluid status on this
basis. Pt not on home O2; desat to 84% on ambulation suggests
may still have some pulmonary edema vs some other intrinsic
pulmonary process. She was transitioned to Furosemide 80 mg
daily with metolazone 2.5 mg daily for maintenance diuresis. She
will continue on Norvasc, Atorvastatin, Toprol, and aspirin. Her
valsartan was initially held in the setting of her [**Last Name (un) **] on CKD,
though was restarted at the time of discharge with stable
creatinine.

#.Acute on chronic kidney injury s/p renal transplant [**2170**]: Most
likely due to poor forward flow in the setting of diastolic CHF.
 Admitted with Cr in the 3's and while in the ICU, the patient's
Cr improved to 1.6 with diuresis.  Her tacrolimus trough was low
at 3.6, so her dose was increased to 3mg [**Hospital1 **]. She was also
continued on home dose Cellcept. BK virus and CMV negative.

#.Hypothyroidism: TSH this admission 1.1 and pt was continued on
current dose of 88mcg daily.

#.Dyslipidemia: She will continue on fenofibrate and
atorvastatin.

# Diabetes type 2: Given episodes of hypoglycemia initially, her
insulin regimen was adjusted multiple times.  At the time of
discharge, she is being discharged on insulin NPH 30 units [**Hospital1 **]
and humalog 6 units with breakfast/dinner.

# HTN: Currently on Metoprolol, amlodipine, valsartan, and
furosemide as above

# Diet: fluid restriction, low salt diet

# CODE: Full

# CONTACT: patient, sister [**Name (NI) **] [**Telephone/Fax (1) 105147**] (work) cell
[**Telephone/Fax (1) 105148**]

# DISPO: to home with home oxygen and VNA services


Medications on Admission:
Humalog insulin 15 units [**Hospital1 **]
NPH 36 units QAM, 36 units QPM
Cell cept 1000mg [**Hospital1 **]
tacrolimus 1.5mg [**Hospital1 **]
Bactrim 80-400 one daily
levothyroxine 88mcg daily
Norvasc 10mg daily
atorvastatin 20mg daily
Toprol XL 100mg daily
Diovan 160mg daily
furosemide 40mg daily
fenofibrate 144mg daily
ergocalciferol 50,000 units Qmonth
albuterol PRN
Os-Cal D 2 tabs daily
ASA 325mg daily


Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
8. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Thirty
(30) units Subcutaneous twice a day.
9. Insulin Lispro 100 unit/mL Solution Sig: Six (6) units
Subcutaneous twice a day: to be taken with breakfast and dinner.

10. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
Disp:*180 Capsule(s)* Refills:*2*
12. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
14. Oxygen
1L/min continuous flow portable oxygen to maintain O2 sat
greater than 92%; Room air sat 84% during inpatient stay

Diagnosis: diastolic heart failure
15. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Acute on Chronic Diastolic Heart Failure
Acute Renal Failure on Chronic Kidney Disease stage 4
Urinary Tract infection


Discharge Condition:
stable, requiring 1L oxygen to maintain sats >92%


Discharge Instructions:
You were admitted to [**Hospital1 18**] for shortness of breath.  You were
found to be in heart failure. There was no evidence of a heart
attack, and the ultrasound of your heart was unchanged.  It is
likely due to salt and water intake, and not enough furosemide
at home.  We have increased your dose, as noted below.  You
should weigh yourself daily and monitor your weights.

You also had some mild renal failure on your labwork.  It
improved with the furosemide, though still was slightly elevated
at the time of your discharge.  You should have repeat
electrolytes next week when are seen in your doctor's office.

During your hospitalization, you had a urinary infection which
was treated with a 7 day course of antibiotics while you were
here.  You also had a short stay in the ICU due to significant
decreased oxygen saturations.   During your hospitalization, you
also had a CT of your chest which showed possibly some more
fluid your lungs.

The following medication changes were made:
1) Furosemide 80 mg daily
2) Tacrolimus 3 mg twice daily
3) Metolazone 2.5 mg daily
4) Valsartan 80 mg daily

Please keep all scheduled appointments.

If you develop any of the following concerning symptoms, please
call your PCP or go to the ED: fevers, chills, nausea, vomiting,
decreased urine output, or difficulty breathing and worsening
swelling in your legs.

Followup Instructions:
Appointment #1
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
Specialty: PCP
Date and time: Tuesday, [**12-7**] at 2:00pm
Location: [**Hospital3 **] - [**Location (un) **], [**Hospital Ward Name 23**]
Bldg, [**Location (un) 895**], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 250**]
Special instructions if applicable: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] is the Nurse
Practitioner you will see in [**Company 191**].

Appointment #2
MD: [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], MD
Specialty: Pulmonary
Date and time: [**2174-1-11**] at 2:30 PM
Location: Medical Subspecialties: Pulmonary - [**Location (un) **],
[**Hospital Ward Name 23**] Bldg, [**Location (un) **], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 612**]
Special instructions if applicable: Please show up to your appt
at 2:30 for pulmonary function testing prior to your visit with
Dr. [**Last Name (STitle) **] at 3 PM

Appointment #3
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Specialty: Cardiology
Date and time: Tuesday, [**12-7**] at 2:00pm
Location: [**Location (un) **], [**Location (un) **], [**Location (un) 86**], MA
Phone number: [**Telephone/Fax (1) 62**]

Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5250**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2174-1-11**] 2:00
{'Acute on chronic diastolic heart failure,Acute respiratory failure,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Complications of transplanted kidney,Pyelonephritis, unspecified,Mixed acid-base balance disorder,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, Stage V,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Calculus of kidney,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Personal history of tobacco use'}


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: DOE, weight gain

PRESENT ILLNESS: This is a 77 yo with PMH significant for ESRD s/p transplant in
[**2170**], CKD with Cr of 2, DM, dCHF presented with DOE,
nonproductive cough and weight gain over the last month. She
presented to her outpatient provider yesterday for these sx's
and was found to desat to 85% on RA with ambulation, so was sent
to the ED.

MEDICAL HISTORY: HTN
DMII poorly controlled on insulin (reports takes BS 3x per day,
often high 100s to 200)
ESRD [**2-22**] DM/HTN s/p deceased donor renal transplantation in
[**3-26**].
-baseline Cr 2.0
-last bx [**12-27**]- high proportion of glomeruli sclerosed
-pt reports adherence to immunosuppressive meds
-hemodialysis for 1.5 yrs prior to txplant
-CAD s/p PCI--[**2163**] stenting of the RCA, restented in [**2170**]
-Hypothyroidism
-Hyperlipidemia

MEDICATION ON ADMISSION: Humalog insulin 15 units [**Hospital1 **]
NPH 36 units QAM, 36 units QPM
Cell cept 1000mg [**Hospital1 **]
tacrolimus 1.5mg [**Hospital1 **]
Bactrim 80-400 one daily
levothyroxine 88mcg daily
Norvasc 10mg daily
atorvastatin 20mg daily
Toprol XL 100mg daily
Diovan 160mg daily
furosemide 40mg daily
fenofibrate 144mg daily
ergocalciferol 50,000 units Qmonth
albuterol PRN
Os-Cal D 2 tabs daily
ASA 325mg daily

ALLERGIES: Penicillins / Iodine; Iodine Containing / Lisinopril

PHYSICAL EXAM: Vitals - T: 98.4 BP:136/58 HR:62 RR:18 02 sat:94 on 3L
GENERAL: Pleasant, obese older woman in NAD
HEENT: Normocephalic, atraumatic. No scleral icterus.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVD of approximately 9cm above RA.
LUNGS: Crackles to midway up lung fields.
ABDOMEN: NABS. Soft, NT, ND. No HSM. No induration, tenderness
to palpation of renal transplant in lower right quadrant. No RLQ
erythema or ecchymoses. No bruits in RLQ.
EXTREMITIES: 1+ edema in lower extremities to knee bilaterally.

FAMILY HISTORY: Brother died [**2-22**] cardiac arrest during a kidney transplant
surgery; other siblings with DM and HTN

SOCIAL HISTORY: widow, no children, retired from [**Hospital1 18**], lives with sister and
other family members, cares for [**Age over 90 **] year old mother at home. Able
to exercise with 15-20 minutes walking daily.
Smoking- quit smoking 15 years ago, prior had [**3-24**] cigs/day
ETOH- None
Illicits- None 

### Response:
{'Acute on chronic diastolic heart failure,Acute respiratory failure,Subendocardial infarction, initial episode of care,Acute kidney failure, unspecified,Complications of transplanted kidney,Pyelonephritis, unspecified,Mixed acid-base balance disorder,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Chronic kidney disease, Stage V,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Calculus of kidney,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Other and unspecified hyperlipidemia,Unspecified acquired hypothyroidism,Personal history of tobacco use'}
