CHIEF COMPLAINT: Respiratory Distress, Hypotension

PRESENT ILLNESS: 84 year old male with multiple co-morbidities, including rectal
cancer s/p resection and radiation in [**2157**], coronary artery
disease s/p stents, systolic CHF, dilated cardiomyopathy, atrial
fibrillation, history of cardiac arrest and complete heart blood
s/p AICD/pacemaker, recent trach/peg who presented with
respiratory distress, fevers and hypotension. The patient
desaturated one day before admission to 85% at [**Hospital 100**] Rehab
although improved to 92% with suctioning out copious amounts of
thick yellow, brown secretions. Per his wife and daughter, he
had been doing well with the trach, often having it capped in
the last week - up until 2-3 days ago when he needed to be on
the vent more frequently. He reportedly had a fever to 103.0
yesterday and 102.0 today at rehab and had a CXR performed there
showing LLL pneumonia; he was treated with Vancomycin 1 gram X1
there.
.
On arrival to the [**Hospital1 18**] ED, the patient was being bagged by EMS
upon arrival, hypotensive to SBP80s, not tachypneic, never
febrile, satting stably on his trach settings. He was mentating
well, complaining only of buttocks pain (stable) and answering
questions appropriately. CXR [**Last Name (un) **] ED similar to priors and he was
treated with Levofloxacin and Cefepime. Given persistent
hypotension SBP80s and decreased UOP (50cc/4-5 hours) despite
1.5L IVF, a RIJ CVL was placed and levophed started at 0.06. He
also had a midline IV from before and 18 gauge PIV. His troponin
was 0.11 so he was also given aspirin 325mg. VS on transfer to
MICU: Afebrile, HR70, BP86/40, RR16, 95% on PEEP5, FiO2 60%,
TV500.
.
Upon arrival to the MICU, the patient was resting comfortably in
bed.
.
Review of systems:
(+) Per HPI
(-) [**Last Name (un) 4273**] headache, sinus tenderness, congestion. [**Last Name (un) 4273**] chest
pain, chest pressure, palpitations, or weakness. [**Last Name (un) 4273**] nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits.

MEDICAL HISTORY: - Rectal cancer s/p excision and XRT ([**2157**])
- CAD s/p stents
- Complete heart block s/p pacemaker
- h/o cardiac arrest (now with AICD)
- Afib
- Systolic CHF (EF 40-45%)
- s/p Fall with multiple rib fractures ([**2163-6-23**])
- h/o GI bleed

MEDICATION ON ADMISSION: Medications (per D/C summary and [**Hospital 100**] Rehab records):
* Acetaminophen 650mg q8 hours PRN pain
* Acetaminophen 325mg q8 hours PRN pain
* Lidocaine patch X2
* Trazodone 25mg qHS
* Carvedilol 3.125mg twice daily
* Citalopram 20mg daily
* Docusate 10mL twice daily
* Ferrous sulfate 325mg elixir daily
* Folate 1mg daily
* Lasix 40mg daily
* Gabapentin 300mg twice daily
* Lisinopril 2.5mg daily
* Multivitamin daily
* Omeprazole 20mg
* Protein supplements daily
* Albuterol HFA inhaler
* Simethicone 80mg every 8 hours
* Oxycodone 5 every four hours PRN tracheal pain, dressing
changes
* Miconazole powrder qHS
* Levofloxacin 750mg daily, completed course [**2163-7-21**]
* Gentamicin nebulizer 80mg q12 hours nebulizer

ALLERGIES: Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

PHYSICAL EXAM: Admission Exam:
Vitals: T: Afebrile BP: 105/47 P: 61 R: 13 O2: 100%
General: oriented, no acute distress, sleepy
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, RIJ CVL
Lungs: Diffusely rhonchorous, rales; no wheezes
CV: RRR, [**3-20**] holosystolic murmur heard best over apex with
dulling of S1 and S2 over apex. Otherwise S1 S2 clear and of
good quality over rest of precordium.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding; ostomy bag in place
GU: three way irrigation foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; dry stasis changes on bilateral lower extremities

FAMILY HISTORY: Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.

SOCIAL HISTORY: Resident of [**Hospital 100**] Rehab w plans to return home; previously had
lived in [**Location 745**] with his wife, now w some depression about
moving out of their 42 year home. Has two children. Retired
computer science professor.
- Tobacco:  5 cigars daily for 30 years, quit [**2150**] s/p CVA
- Alcohol:  Previously [**1-16**] glasses/week, generally per wife
"affects him quite a bit," changing his mood and making him sick
- Illicits: [**Month/Day (2) 4273**]
Pneumonia, organism unspecified,Pressure ulcer, stage IV,Bacteremia,Chronic systolic heart failure,Other primary cardiomyopathies,Acute kidney failure, unspecified,Atrial fibrillation,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Coronary atherosclerosis of native coronary artery,Colostomy status,Tracheostomy status,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Personal history of irradiation, presenting hazards to health,Percutaneous transluminal coronary angioplasty status,Personal history of traumatic fracture,History of fall,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Automatic implantable cardiac defibrillator in situ
Pneumonia, organism NOS,Pressure ulcer, stage IV,Bacteremia,Chr systolic hrt failure,Prim cardiomyopathy NEC,Acute kidney failure NOS,Atrial fibrillation,MRSA elsewhere/NOS,Anemia NOS,Crnry athrscl natve vssl,Colostomy status,Tracheostomy status,Hx-rectal & anal malign,Hx of irradiation,Status-post ptca,Hx traumatic fracture,Personal history of fall,Hx TIA/stroke w/o resid,Status autm crd dfbrltr
Admission Date:  [**2163-9-4**]              Discharge Date:   [**2163-9-8**]

Date of Birth:  [**2079-1-17**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Respiratory Distress, Hypotension

Major Surgical or Invasive Procedure:
Right internal jugular (CVL) (discontinued)
Arterial line (discontinued)
PICC (placed [**2163-9-8**])

History of Present Illness:
84 year old male with multiple co-morbidities, including rectal
cancer s/p resection and radiation in [**2157**], coronary artery
disease s/p stents, systolic CHF, dilated cardiomyopathy, atrial
fibrillation, history of cardiac arrest and complete heart blood
s/p AICD/pacemaker, recent trach/peg who presented with
respiratory distress, fevers and hypotension. The patient
desaturated one day before admission to 85% at [**Hospital 100**] Rehab
although improved to 92% with suctioning out copious amounts of
thick yellow, brown secretions. Per his wife and daughter, he
had been doing well with the trach, often having it capped in
the last week - up until 2-3 days ago when he needed to be on
the vent more frequently. He reportedly had a fever to 103.0
yesterday and 102.0 today at rehab and had a CXR performed there
showing LLL pneumonia; he was treated with Vancomycin 1 gram X1
there.
.
On arrival to the [**Hospital1 18**] ED, the patient was being bagged by EMS
upon arrival, hypotensive to SBP80s, not tachypneic, never
febrile, satting stably on his trach settings. He was mentating
well, complaining only of buttocks pain (stable) and answering
questions appropriately. CXR [**Last Name (un) **] ED similar to priors and he was
treated with Levofloxacin and Cefepime. Given persistent
hypotension SBP80s and decreased UOP (50cc/4-5 hours) despite
1.5L IVF, a RIJ CVL was placed and levophed started at 0.06. He
also had a midline IV from before and 18 gauge PIV. His troponin
was 0.11 so he was also given aspirin 325mg. VS on transfer to
MICU: Afebrile, HR70, BP86/40, RR16, 95% on PEEP5, FiO2 60%,
TV500.
.
Upon arrival to the MICU, the patient was resting comfortably in
bed.
.
Review of systems:
(+) Per HPI
(-) [**Last Name (un) 4273**] headache, sinus tenderness, congestion. [**Last Name (un) 4273**] chest
pain, chest pressure, palpitations, or weakness. [**Last Name (un) 4273**] nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits.


Past Medical History:
- Rectal cancer s/p excision and XRT ([**2157**])
- CAD s/p stents
- Complete heart block s/p pacemaker
- h/o cardiac arrest (now with AICD)
- Afib
- Systolic CHF (EF 40-45%)
- s/p Fall with multiple rib fractures ([**2163-6-23**])
- h/o GI bleed

Social History:
Resident of [**Hospital 100**] Rehab w plans to return home; previously had
lived in [**Location 745**] with his wife, now w some depression about
moving out of their 42 year home. Has two children. Retired
computer science professor.
- Tobacco:  5 cigars daily for 30 years, quit [**2150**] s/p CVA
- Alcohol:  Previously [**1-16**] glasses/week, generally per wife
"affects him quite a bit," changing his mood and making him sick
- Illicits: [**Month/Day (2) 4273**]


Family History:
Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.

Physical Exam:
Admission Exam:
Vitals: T: Afebrile BP: 105/47 P: 61 R: 13 O2: 100%
General: oriented, no acute distress, sleepy
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, RIJ CVL
Lungs: Diffusely rhonchorous, rales; no wheezes
CV: RRR, [**3-20**] holosystolic murmur heard best over apex with
dulling of S1 and S2 over apex. Otherwise S1 S2 clear and of
good quality over rest of precordium.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding; ostomy bag in place
GU: three way irrigation foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; dry stasis changes on bilateral lower extremities

Discharge Exam:
VS 98.9 73 133/69 24 95% trach collar 50%F1O2
General Appearance: No acute distress, breathing comfortably on
trach collar.
HEENT: PERRL, Conjunctiva pale, Normocephalic, Poor dentition
Cardiovascular: RRR, [**3-20**] holosystolic murmur heard best over
Respiratory:  mild rhonchi throughout all lung fields with
occasional expiratory wheezes
Abdominal: Soft, non-tender, colostomy, PEG, + BS
Extremities: Bilateral LE edema L>R, Chronic skin changes over
bilateral LE suggestive of chronic venous stasis, right knee
tender to palpation
Skin:  Warm, well perfused
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Movement: Purposeful, Tone: Normal, localizes
pain. Able to point out letters on chart for communicating,
appropriate


Pertinent Results:
Blood Counts
[**2163-9-4**] 08:00AM BLOOD WBC-28.2*# RBC-2.71* Hgb-7.9* Hct-24.0*
MCV-88 MCH-29.1 MCHC-33.1 RDW-16.6* Plt Ct-148*
[**2163-9-5**] 02:30PM BLOOD WBC-11.6* RBC-3.00* Hgb-8.8* Hct-26.6*
MCV-89 MCH-29.3 MCHC-33.1 RDW-16.6* Plt Ct-109*
[**2163-9-8**] 02:53AM BLOOD WBC-8.0 RBC-2.81* Hgb-8.3* Hct-25.0*
MCV-89 MCH-29.4 MCHC-33.0 RDW-16.1* Plt Ct-80*

Electrolytes
[**2163-9-4**] 08:00AM BLOOD Glucose-139* UreaN-45* Creat-1.5* Na-136
K-5.0 Cl-99 HCO3-29 AnGap-13
[**2163-9-6**] 02:57AM BLOOD Glucose-106* UreaN-50* Creat-1.3* Na-138
K-4.4 Cl-107 HCO3-25 AnGap-10
[**2163-9-8**] 02:53AM BLOOD Glucose-144* UreaN-48* Creat-1.2 Na-139
K-4.3 Cl-103 HCO3-29 AnGap-11


Brief Hospital Course:
HOSPITAL COURSE
84yo PMHx rectal cancer s/p resection and XRT w ostomy, systolic
CHF (LVEF40-45%), recent trach/peg who presented with
respiratory distress, found to have a pnuemonia, with blood and
sputum cultures growing out MRSA, now improved to baseline
respiratory status being discharged to MACU on 2 week course of
IV antibioitics
.
ACTIVE
# Healthcare Associated Pnuemonia and MRSA Bacteremia - Patient
presented with increasing O2 requirements, leukocytosis and
hypotension; CXR demonstrated LLL PNA; accompanying elevated
Lactate, High SvO2 (93%), hypotension and tachycardia suggested
sepsis; blood and sputum cultures grew out MRSA.  Patient was
initially fluid resuscitated and briefly required vasopressors.
He was treated with vancomycin (initially with cefepime and
levofloxacin as well, which were stopped based upon culture
data).  Patient respiratory status improved, and patient was
able to be weaned off vent to trach collar.  Given MRSA
bacteremia, patient had PICC line changed and underwent TTE that
did not demonstrate signs of valvular lesions; patient was
planned for 2 week course with IV vancomycin.
.
# Sacral decubitus ulcer: Significant, likely stage IV.
Appropriate wound care was provided and his pain regimen was
increased to Oxycodone to 5-10 mg q4 PRN for pain which
successfully curbed decubitus pain.
.
# Coronary artery disease: Stable, continued carvedilol; held
lisinopril given hypotension and will need to be restarted;
started ASA (had been held previously given history of GI
bleeds).
.
# Afib: CHADS4, but off anticoagulation [**2-16**] hemothorax 6/[**2163**].
Discussed with primary cardiologist who recommended considering
restarting [**Year (4 digits) **] as outpatient.

INACTIVE
# Anemia - Continued iron supplementation
.
# Systolic CHF: EF 40-45%, continued lasix
.
Transitional Issues:
- Patient is full code
- Will need primary care doctors to discuss [**Name5 (PTitle) **] as
outpatient
- Continue vancomycin for 2 weeks total course

Medications on Admission:
Medications (per D/C summary and [**Hospital 100**] Rehab records):
* Acetaminophen 650mg q8 hours PRN pain
* Acetaminophen 325mg q8 hours PRN pain
* Lidocaine patch X2
* Trazodone 25mg qHS
* Carvedilol 3.125mg twice daily
* Citalopram 20mg daily
* Docusate 10mL twice daily
* Ferrous sulfate 325mg elixir daily
* Folate 1mg daily
* Lasix 40mg daily
* Gabapentin 300mg twice daily
* Lisinopril 2.5mg daily
* Multivitamin daily
* Omeprazole 20mg
* Protein supplements daily
* Albuterol HFA inhaler
* Simethicone 80mg every 8 hours
* Oxycodone 5 every four hours PRN tracheal pain, dressing
changes
* Miconazole powrder qHS
* Levofloxacin 750mg daily, completed course [**2163-7-21**]
* Gentamicin nebulizer 80mg q12 hours nebulizer


Discharge Medications:
1. acetaminophen 325 mg Tablet [**Year (4 digits) **]: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Year (4 digits) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on, 12 hours off.
3. trazodone 50 mg Tablet [**Year (4 digits) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
4. citalopram 20 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).

5. docusate sodium 50 mg/5 mL Liquid [**Year (4 digits) **]: Ten (10) mL PO BID (2
times a day).
6. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid [**Year (4 digits) **]: One (1)
dose PO DAILY (Daily).
7. folic acid 1 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).

8. multivitamin     Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily).

9. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Year (4 digits) **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Year (4 digits) **]:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for sob,
wheeze.
11. simethicone 80 mg Tablet, Chewable [**Year (4 digits) **]: One (1) Tablet,
Chewable PO TID (3 times a day).
12. miconazole nitrate 2 % Powder [**Year (4 digits) **]: One (1) Appl Topical HS
(at bedtime).
13. oxycodone 5 mg Tablet [**Year (4 digits) **]: 1-2 Tablets PO every four (4)
hours as needed for pain: Hold for Sedation or RR<12.
14. aspirin 81 mg Tablet, Chewable [**Year (4 digits) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Lasix 40 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO once a day.
16. Please change and care for lines per nursing routine
17. carvedilol 6.25 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO twice a
day.
18. vancomycin 750 mg Recon Soln [**Year (4 digits) **]: One (1) solution
Intravenous twice a day for 24 days.


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
PRIMARY
Healthcare Associated Pneumonia
Staph Bacteremia

SECONDARY
Systolic CHF
Atrial Fibrillation


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.


Discharge Instructions:
Mr. [**Known lastname 108855**]--

It was a pleasure treating you at [**Hospital1 18**]. You were admitted with
difficulty breathing and low blood pressure.  You were found to
have a pneumonia and an infection in your blood. You were
treated with antibiotics and improved.  You will need to
continue your antibiotics for 2 weeks total.

The following changes to your medications were made:
- STARTED vancomycin (continue until [**2163-9-18**])
- STARTED aspirin
- STOPPED inhaled gentamycin

Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2163-9-28**] at 11:30 AM
With:  DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: WEDNESDAY [**2163-9-28**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Pneumonia, organism unspecified,Pressure ulcer, stage IV,Bacteremia,Chronic systolic heart failure,Other primary cardiomyopathies,Acute kidney failure, unspecified,Atrial fibrillation,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Coronary atherosclerosis of native coronary artery,Colostomy status,Tracheostomy status,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Personal history of irradiation, presenting hazards to health,Percutaneous transluminal coronary angioplasty status,Personal history of traumatic fracture,History of fall,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Automatic implantable cardiac defibrillator in situ'}


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: Respiratory Distress, Hypotension

PRESENT ILLNESS: 84 year old male with multiple co-morbidities, including rectal
cancer s/p resection and radiation in [**2157**], coronary artery
disease s/p stents, systolic CHF, dilated cardiomyopathy, atrial
fibrillation, history of cardiac arrest and complete heart blood
s/p AICD/pacemaker, recent trach/peg who presented with
respiratory distress, fevers and hypotension. The patient
desaturated one day before admission to 85% at [**Hospital 100**] Rehab
although improved to 92% with suctioning out copious amounts of
thick yellow, brown secretions. Per his wife and daughter, he
had been doing well with the trach, often having it capped in
the last week - up until 2-3 days ago when he needed to be on
the vent more frequently. He reportedly had a fever to 103.0
yesterday and 102.0 today at rehab and had a CXR performed there
showing LLL pneumonia; he was treated with Vancomycin 1 gram X1
there.
.
On arrival to the [**Hospital1 18**] ED, the patient was being bagged by EMS
upon arrival, hypotensive to SBP80s, not tachypneic, never
febrile, satting stably on his trach settings. He was mentating
well, complaining only of buttocks pain (stable) and answering
questions appropriately. CXR [**Last Name (un) **] ED similar to priors and he was
treated with Levofloxacin and Cefepime. Given persistent
hypotension SBP80s and decreased UOP (50cc/4-5 hours) despite
1.5L IVF, a RIJ CVL was placed and levophed started at 0.06. He
also had a midline IV from before and 18 gauge PIV. His troponin
was 0.11 so he was also given aspirin 325mg. VS on transfer to
MICU: Afebrile, HR70, BP86/40, RR16, 95% on PEEP5, FiO2 60%,
TV500.
.
Upon arrival to the MICU, the patient was resting comfortably in
bed.
.
Review of systems:
(+) Per HPI
(-) [**Last Name (un) 4273**] headache, sinus tenderness, congestion. [**Last Name (un) 4273**] chest
pain, chest pressure, palpitations, or weakness. [**Last Name (un) 4273**] nausea,
vomiting, diarrhea, constipation, abdominal pain, or changes in
bowel habits.

MEDICAL HISTORY: - Rectal cancer s/p excision and XRT ([**2157**])
- CAD s/p stents
- Complete heart block s/p pacemaker
- h/o cardiac arrest (now with AICD)
- Afib
- Systolic CHF (EF 40-45%)
- s/p Fall with multiple rib fractures ([**2163-6-23**])
- h/o GI bleed

MEDICATION ON ADMISSION: Medications (per D/C summary and [**Hospital 100**] Rehab records):
* Acetaminophen 650mg q8 hours PRN pain
* Acetaminophen 325mg q8 hours PRN pain
* Lidocaine patch X2
* Trazodone 25mg qHS
* Carvedilol 3.125mg twice daily
* Citalopram 20mg daily
* Docusate 10mL twice daily
* Ferrous sulfate 325mg elixir daily
* Folate 1mg daily
* Lasix 40mg daily
* Gabapentin 300mg twice daily
* Lisinopril 2.5mg daily
* Multivitamin daily
* Omeprazole 20mg
* Protein supplements daily
* Albuterol HFA inhaler
* Simethicone 80mg every 8 hours
* Oxycodone 5 every four hours PRN tracheal pain, dressing
changes
* Miconazole powrder qHS
* Levofloxacin 750mg daily, completed course [**2163-7-21**]
* Gentamicin nebulizer 80mg q12 hours nebulizer

ALLERGIES: Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

PHYSICAL EXAM: Admission Exam:
Vitals: T: Afebrile BP: 105/47 P: 61 R: 13 O2: 100%
General: oriented, no acute distress, sleepy
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, RIJ CVL
Lungs: Diffusely rhonchorous, rales; no wheezes
CV: RRR, [**3-20**] holosystolic murmur heard best over apex with
dulling of S1 and S2 over apex. Otherwise S1 S2 clear and of
good quality over rest of precordium.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding; ostomy bag in place
GU: three way irrigation foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; dry stasis changes on bilateral lower extremities

FAMILY HISTORY: Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.

SOCIAL HISTORY: Resident of [**Hospital 100**] Rehab w plans to return home; previously had
lived in [**Location 745**] with his wife, now w some depression about
moving out of their 42 year home. Has two children. Retired
computer science professor.
- Tobacco:  5 cigars daily for 30 years, quit [**2150**] s/p CVA
- Alcohol:  Previously [**1-16**] glasses/week, generally per wife
"affects him quite a bit," changing his mood and making him sick
- Illicits: [**Month/Day (2) 4273**] 

### Response:
{'Pneumonia, organism unspecified,Pressure ulcer, stage IV,Bacteremia,Chronic systolic heart failure,Other primary cardiomyopathies,Acute kidney failure, unspecified,Atrial fibrillation,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Anemia, unspecified,Coronary atherosclerosis of native coronary artery,Colostomy status,Tracheostomy status,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Personal history of irradiation, presenting hazards to health,Percutaneous transluminal coronary angioplasty status,Personal history of traumatic fracture,History of fall,Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits,Automatic implantable cardiac defibrillator in situ'}
