CHIEF COMPLAINT: shortness of breath at NH

PRESENT ILLNESS: 81 yo woman with HTN, CAD, afib, ESRD on HD with recent
admission to [**Hospital **] hospital with likely aspiration PNA and sepsis
with enterococcal and yeast UTI tx. with broad spectrum abx.,
presents from [**Location (un) 582**] NH with SOB, found to have ST elevations
(BL LBBB) V1-4 on EKG in the field. Brought in as code STEMI.
Pt. reports new unproductive cough without fever, chills over
last few days. + increased PND, DOE with mild exertion. denies
dysuria. Last dialyzed monday, with plan for dialyis today. Per
pt., also recent change in her dialysis center.
.
In field and [**Name (NI) **], pt. received 4x81mg ASA, 600mg plavix, started
on heparin/integrillin gtt, given 500cc, BNP >50,000, HR 112 in
afib, BP 140/79, O2 sat 98% NRB. Pt is DNR/DNI, declined
catheterization.
.
On review of symptoms, she denies prior history of stroke, TIA,
bleeding at the time of surgery, myalgias, joint pains,
hemoptysis, black or red stools. She also denies any recent
fevers, chills or rigors. She denies any increased LE edema,
exertional buttock or calf pain. She does have h/o deep venous
thrombosis, + unproductive cough X 3-4 days. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
+ dyspnea on exertion, + paroxysmal nocturnal dyspnea,
+orthopnea, abscence of ankle edema, palpitations, syncope or
presyncope.

MEDICAL HISTORY: - h/o CAD with EF 35-40%, LBBB
- Afib, not on anticoagulation
- HTN
- DVT s/p IVC filter
- DM2
- ESRD on HD [**3-1**] cholesterol emboli s/p PCI in [**2187**], AV fistula
L antecubitus, R SCL tunneled tessio
- Hypercholesterolemia
- OA
- h/o GI bleed
- h/o mild dementia
- Bilateral hip surgery
- dry gangrene [**3-1**] cholesterol emboli
- h/o gastric ulcers. received protonix [**Hospital1 **] X months

MEDICATION ON ADMISSION: - digoxin .125 qdaily
- provigil 50 qdaily
- lansoprazole
- ASA 81mg
- diltiazem 60mg q6h
- hep 5000bid
- simvastatin 20mg qdaily
metoprolol 75 tid
- epogen
- colace, senna, bisacodyl, miralax, PRN
- duoderm over sacral area
- nepro feeds 40cc/h x 12h with 200cc flushes tid

ALLERGIES: Levaquin

PHYSICAL EXAM: VS: T 96.0, BP 121/106, HR 102, RR 27, O2 97% on NRB
Gen: elderly woman, mildly tachypneic, soft spoken, able to
speak full sentences on NRB, Oriented x 2. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pale, +pallor or cyanosis of the oral mucosa.
Neck: Supple with JVD to ear
CV: PMI located in 5th intercostal space, midclavicular line.
sl. tachy, irregularly irregular, soft S1, S2. No S4, no S3
noted
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were mildly labored, with decreased BS in R>L base, rales above,
occ. inspiratory wheeze on L. R SCL tessio line C/D/I, no TTP
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. dry eschar of lateral 1st and
2nd toes bilaterally. mild thrill over L antecubitum
Skin: No stasis dermatitis, ulcers, scars, or xanthomas. mild
skin breakdown over coccyx
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

FAMILY HISTORY: negative for early CAD

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. Quit in [**2140**]. There is no history of alcohol abuse.
.
Congestive heart failure, unspecified,End stage renal disease,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Other left bundle branch block,Pure hypercholesterolemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Gastrostomy status
CHF NOS,End stage renal disease,Urin tract infection NOS,Hyp kid NOS w cr kid V,Anemia in chr kidney dis,Crnry athrscl natve vssl,Atrial fibrillation,Left bb block NEC,Pure hypercholesterolem,Osteoarthros NOS-unspec,Gastrostomy status
Admission Date:  [**2188-4-16**]              Discharge Date:   [**2188-4-17**]

Date of Birth:  [**2107-4-11**]             Sex:   F

Service: MEDICINE

Allergies:
Levaquin

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
shortness of breath at NH

Major Surgical or Invasive Procedure:
none

History of Present Illness:
81 yo woman with HTN, CAD, afib, ESRD on HD with recent
admission to [**Hospital **] hospital with likely aspiration PNA and sepsis
with enterococcal and yeast UTI tx. with broad spectrum abx.,
presents from [**Location (un) 582**] NH with SOB, found to have ST elevations
(BL LBBB) V1-4 on EKG in the field. Brought in as code STEMI.
Pt. reports new unproductive cough without fever, chills over
last few days. + increased PND, DOE with mild exertion. denies
dysuria. Last dialyzed monday, with plan for dialyis today. Per
pt., also recent change in her dialysis center.
.
In field and [**Name (NI) **], pt. received 4x81mg ASA, 600mg plavix, started
on heparin/integrillin gtt, given 500cc, BNP >50,000, HR 112 in
afib, BP 140/79, O2 sat 98% NRB. Pt is DNR/DNI, declined
catheterization.
.
On review of symptoms, she denies prior history of stroke, TIA,
bleeding at the time of surgery, myalgias, joint pains,
hemoptysis, black or red stools. She also denies any recent
fevers, chills or rigors. She denies any increased LE edema,
exertional buttock or calf pain. She does have h/o deep venous
thrombosis, + unproductive cough X 3-4 days. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
+ dyspnea on exertion, + paroxysmal nocturnal dyspnea,
+orthopnea, abscence of ankle edema, palpitations, syncope or
presyncope.


Past Medical History:
- h/o CAD with EF 35-40%, LBBB
- Afib, not on anticoagulation
- HTN
- DVT s/p IVC filter
- DM2
- ESRD on HD [**3-1**] cholesterol emboli s/p PCI in [**2187**], AV fistula
L antecubitus, R SCL tunneled tessio
- Hypercholesterolemia
- OA
- h/o GI bleed
- h/o mild dementia
- Bilateral hip surgery
- dry gangrene [**3-1**] cholesterol emboli
- h/o gastric ulcers. received protonix [**Hospital1 **] X months


Social History:
Social history is significant for the absence of current tobacco
use. Quit in [**2140**]. There is no history of alcohol abuse.
.


Family History:
negative for early CAD

Physical Exam:
VS: T 96.0, BP 121/106, HR 102, RR 27, O2 97% on NRB
Gen: elderly woman, mildly tachypneic, soft spoken, able to
speak full sentences on NRB, Oriented x 2. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pale, +pallor or cyanosis of the oral mucosa.
Neck: Supple with JVD to ear
CV: PMI located in 5th intercostal space, midclavicular line.
sl. tachy, irregularly irregular, soft S1, S2. No S4, no S3
noted
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were mildly labored, with decreased BS in R>L base, rales above,
occ. inspiratory wheeze on L. R SCL tessio line C/D/I, no TTP
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. dry eschar of lateral 1st and
2nd toes bilaterally. mild thrill over L antecubitum
Skin: No stasis dermatitis, ulcers, scars, or xanthomas. mild
skin breakdown over coccyx
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

guaiac negative


Pertinent Results:
Admission labs:

[**2188-4-16**] 11:20PM   HCT-30.9*
[**2188-4-16**] 05:24PM   CK(CPK)-8*
[**2188-4-16**] 05:24PM   CK-MB-NotDone cTropnT-0.12*
[**2188-4-16**] 05:24PM   IRON-27*
[**2188-4-16**] 05:24PM   calTIBC-140* VIT B12-903* FOLATE-GREATER TH
FERRITIN-1797* TRF-108*
[**2188-4-16**] 11:20AM URINE  COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.018
[**2188-4-16**] 11:20AM URINE  BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2188-4-16**] 11:20AM URINE  RBC-0 WBC->50 BACTERIA-0 YEAST-NONE
EPI-0
[**2188-4-16**] 10:40AM   GLUCOSE-135* UREA N-29* CREAT-3.2* SODIUM-134
POTASSIUM-5.0 CHLORIDE-92* TOTAL CO2-29 ANION GAP-18
[**2188-4-16**] 10:40AM   estGFR-Using this
[**2188-4-16**] 10:40AM   CK(CPK)-24*
[**2188-4-16**] 10:40AM   cTropnT-0.13*
[**2188-4-16**] 10:40AM   CK-MB-NotDone proBNP-[**Numeric Identifier 15160**]*
[**2188-4-16**] 10:40AM   WBC-11.0 RBC-2.66* HGB-8.2* HCT-27.2*
MCV-102* MCH-30.7 MCHC-30.0* RDW-19.9*
[**2188-4-16**] 10:40AM   NEUTS-82.4* LYMPHS-13.5* MONOS-2.9 EOS-0.8
BASOS-0.3
[**2188-4-16**] 10:40AM   PLT COUNT-526*
[**2188-4-16**] 10:40AM   PT-13.2 PTT-31.1 INR(PT)-1.1

D/C labs
[**2188-4-17**] 02:44AM BLOOD WBC-10.7 RBC-3.06* Hgb-9.4* Hct-30.4*
MCV-99* MCH-30.7 MCHC-31.0 RDW-21.3* Plt Ct-486*
[**2188-4-17**] 02:44AM BLOOD Glucose-89 UreaN-21* Creat-2.5* Na-139
K-4.8 Cl-102 HCO3-32 AnGap-10
[**2188-4-17**] 02:44AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2188-4-16**] 05:24PM BLOOD calTIBC-140* VitB12-903* Folate-GREATER
TH Ferritn-1797* TRF-108*
[**2188-4-17**] 02:44AM BLOOD Triglyc-108 HDL-41 CHOL/HD-2.8 LDLcalc-53
[**2188-4-17**] 02:44AM BLOOD Digoxin-1.5

ECHO:

LEFT ATRIUM: Elongated LA.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.

LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Mild-moderate global left ventricular hypokinesis. No resting
LVOT gradient.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Paradoxic septal motion consistent with conduction
abnormality/ventricular pacing.

AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter.

AORTIC VALVE: Mildly thickened aortic valve leaflets. No AS.
Mild (1+) AR.

MITRAL VALVE: Moderately thickened mitral valve leaflets.
Moderate thickening of mitral valve chordae. Mild functional MS
due to MAC. Mild to moderate ([**1-30**]+) MR. [Due to acoustic
shadowing, the severity of MR may be significantly
UNDERestimated.]

TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild
[1+] TR. Mild PA systolic hypertension.

PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.

PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild to moderate global left ventricular
hypokinesis (LVEF = 35-40%). Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. There is moderate thickening of the mitral
valve chordae. There is mild functional mitral stenosis (mean
gradient 3mmHg) due to mitral annular calcification. Mild to
moderate ([**1-30**]+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.


Brief Hospital Course:
# CAD/Ischemia: s/p stent placement in [**2187**]. EKG non-diagnostic
in setting of LBBB. troponin leak 0.13, CK, CK-MB negative on
first set. No intervention, per pt. preference anyway, though
this likely represents subendocardial ischemia from CHF
exacerbation.  CK-MBs low though troponins chronically positive,
partially [**3-1**] renal dz.  though to have a component of ischemia
[**3-1**] stretch from CHF exacerbation.
- asa, plavix loaded in ED. will continue asa 325 and restart
Plavix as she had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] in [**Month (only) **], unclear why patient off
plavix.
- on lopressor, unclear why not on [**Name (NI) **] consider adding as an
outpatient
- continue statin
- lipid panel, A1c show good lipid control, though HDL low
.
# Pump: likely combination of acute on chronic systolic and
diastolic congestive heart failure. Last EF 35-40%. BNP [**Numeric Identifier 15160**].
Unclear why having acute exacerbation, though may relate to
either poor BP control, Afib, infection.  h/o
hypertension-mediated acute pulmonary edema, though no HTN here.
 repeat CXR shows improved pulm. edema
- ECHO showed EF 35%-40% with mild global HK
- renal consulted for dialysis for fluid removal, dialyzed 2.2 L
on wednesday, as well as 3 liters on day of discharge.
- pt. likely should be on ACE-I, as no allergy or known
contraindication.  Can be started as an outpatient.
.
# Rhythm: in afib with rapid ventricular response initially.
Her home metoprolol and diltiazem were restarted with better
rate control.  BPs during HD tolerated these medications, so
likely should be given on day of dialysis.
- continued digoxin post dialysis
- no anticoagulation in past, likely [**3-1**] previous GI bleed, but
could not obtain documentation of this.
.
# ESRD: renal consulted, dialyzed X 2.  Should restart her
dialysis on previous schedule.  on MWF schedule.  Needs a lower
dry weight (goal per outpt. dialysis 62 kg), here was 70kilos
post 1st day 2.2 L dialysis. Weight at discharge was 68kg.
Continued nephrocaps and sevelamer.
.
# UTI: pyuria on U/A, started cefpodoxime, with plans to treat
for 7d, first day [**4-16**], to be dosed after dialysis, urine cx
pending on discharge and needs to be followed up as an
outpatient to ensure appropriate antibiotic coverage.
.
# HTN:
Continued diltiazem, lopressor, add low dose ACE added as
tolerated
.
# Anemia: h/o GI bleed [**3-1**] ulcers, unclear if she had f/u EGD to
ensure healing of ulcers
- PPI
- B12, folate, wnl, Fe studies c/w anemia of chronic disease due
to renal dysfunction
- unclear if she ever had repeat EGD.  Should have one as
outpatient if not.
.
# Dx/AMS: continue buproprion, risperidone (recently initiated)

- stopped provigil
.
# FEN: restarted TFs; has h/o aspiration, but per NH, had been
transitioning to some solids.  Would have oupt.  speech and
swallow consult, when out of acute HF exacerbation
.
# Prophylaxis: hep SC, home PPI, bowel regimen
.
# Code: DNR/DNI confirmed
.
# Communication: HCP is [**Name (NI) 15161**] [**Name (NI) 15162**]([**Telephone/Fax (1) 15163**] (c)
[**Telephone/Fax (1) 15164**] (h); daughter [**Name (NI) 15165**] [**Name (NI) 4702**] ([**Telephone/Fax (1) 15166**];

Medications on Admission:
- digoxin .125 qdaily
- provigil 50 qdaily
- lansoprazole
- ASA 81mg
- diltiazem 60mg q6h
- hep 5000bid
- simvastatin 20mg qdaily
metoprolol 75 tid
- epogen
- colace, senna, bisacodyl, miralax, PRN
- duoderm over sacral area
- nepro feeds 40cc/h x 12h with 200cc flushes tid


Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet [**Telephone/Fax (1) **]: 1.5 Tablets PO TID (3
times a day).
2. Cefpodoxime 100 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO HD PROTOCOL
(HD Protochol) for 3 doses: Give three times/week post HD.
3. Lanthanum 500 mg Tablet, Chewable [**Telephone/Fax (1) **]: One (1) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
4. Digoxin 125 mcg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).

5. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Telephone/Fax (1) **]: One (1) Cap
PO DAILY (Daily).
6. Simvastatin 10 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO DAILY
(Daily).
7. Bupropion 75 mg Tablet [**Telephone/Fax (1) **]: Two (2) Tablet PO DAILY (Daily).

8. Risperidone 0.5 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times
a day).
9. Diltiazem HCl 60 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO QID (4
times a day).
10. Heparin (Porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: One (1)
Injection twice a day.
11. Clopidogrel 75 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY
(Daily).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: Four (4) Tablet,
Chewable PO DAILY (Daily).
14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
15. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
16. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
17. Epogen 10,000 unit/mL Solution [**Last Name (STitle) **]: One (1)  Injection once
a week.
18. Miralax 17 gram (100 %) Powder in Packet [**Last Name (STitle) **]: One (1)  PO
once a day as needed.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 582**] Of [**Location (un) 620**]

Discharge Diagnosis:
End stage renal disease on hemodialysis
Coronary artery disease
Hypertension
atrial fibrillation


Discharge Condition:
All vitals signs stable, afebrile, off oxygen


Discharge Instructions:
You were admitted with shortness of breath. This was from fluid
build up in your lungs. This occured from a combination of
incomplete dialysis and a rapid heart rate. You were dialyzed
twice to get this fluid off and you were given more medications
to slow your heart rate. You did not have a heart attack
although initially your EKG was concerning. However, lab tests
showed no damage to your heart.

Please take all your medications as prescribed and make all your
follow up appointments.

Please call your doctor or return to the emergency room if you
experience chest pain, shortness of breath, nausea, vomitting,
fevers, chills or any other symptoms that concern you.

Followup Instructions:
Please call Dr.[**Name (NI) 15167**] office to make a follow up
appointment in the next 1-2 weeks.
{'Congestive heart failure, unspecified,End stage renal disease,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Other left bundle branch block,Pure hypercholesterolemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Gastrostomy status'}


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



### Clinical text :
CHIEF COMPLAINT: shortness of breath at NH

PRESENT ILLNESS: 81 yo woman with HTN, CAD, afib, ESRD on HD with recent
admission to [**Hospital **] hospital with likely aspiration PNA and sepsis
with enterococcal and yeast UTI tx. with broad spectrum abx.,
presents from [**Location (un) 582**] NH with SOB, found to have ST elevations
(BL LBBB) V1-4 on EKG in the field. Brought in as code STEMI.
Pt. reports new unproductive cough without fever, chills over
last few days. + increased PND, DOE with mild exertion. denies
dysuria. Last dialyzed monday, with plan for dialyis today. Per
pt., also recent change in her dialysis center.
.
In field and [**Name (NI) **], pt. received 4x81mg ASA, 600mg plavix, started
on heparin/integrillin gtt, given 500cc, BNP >50,000, HR 112 in
afib, BP 140/79, O2 sat 98% NRB. Pt is DNR/DNI, declined
catheterization.
.
On review of symptoms, she denies prior history of stroke, TIA,
bleeding at the time of surgery, myalgias, joint pains,
hemoptysis, black or red stools. She also denies any recent
fevers, chills or rigors. She denies any increased LE edema,
exertional buttock or calf pain. She does have h/o deep venous
thrombosis, + unproductive cough X 3-4 days. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
+ dyspnea on exertion, + paroxysmal nocturnal dyspnea,
+orthopnea, abscence of ankle edema, palpitations, syncope or
presyncope.

MEDICAL HISTORY: - h/o CAD with EF 35-40%, LBBB
- Afib, not on anticoagulation
- HTN
- DVT s/p IVC filter
- DM2
- ESRD on HD [**3-1**] cholesterol emboli s/p PCI in [**2187**], AV fistula
L antecubitus, R SCL tunneled tessio
- Hypercholesterolemia
- OA
- h/o GI bleed
- h/o mild dementia
- Bilateral hip surgery
- dry gangrene [**3-1**] cholesterol emboli
- h/o gastric ulcers. received protonix [**Hospital1 **] X months

MEDICATION ON ADMISSION: - digoxin .125 qdaily
- provigil 50 qdaily
- lansoprazole
- ASA 81mg
- diltiazem 60mg q6h
- hep 5000bid
- simvastatin 20mg qdaily
metoprolol 75 tid
- epogen
- colace, senna, bisacodyl, miralax, PRN
- duoderm over sacral area
- nepro feeds 40cc/h x 12h with 200cc flushes tid

ALLERGIES: Levaquin

PHYSICAL EXAM: VS: T 96.0, BP 121/106, HR 102, RR 27, O2 97% on NRB
Gen: elderly woman, mildly tachypneic, soft spoken, able to
speak full sentences on NRB, Oriented x 2. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pale, +pallor or cyanosis of the oral mucosa.
Neck: Supple with JVD to ear
CV: PMI located in 5th intercostal space, midclavicular line.
sl. tachy, irregularly irregular, soft S1, S2. No S4, no S3
noted
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were mildly labored, with decreased BS in R>L base, rales above,
occ. inspiratory wheeze on L. R SCL tessio line C/D/I, no TTP
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. dry eschar of lateral 1st and
2nd toes bilaterally. mild thrill over L antecubitum
Skin: No stasis dermatitis, ulcers, scars, or xanthomas. mild
skin breakdown over coccyx
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP

FAMILY HISTORY: negative for early CAD

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. Quit in [**2140**]. There is no history of alcohol abuse.
. 

### Response:
{'Congestive heart failure, unspecified,End stage renal disease,Urinary tract infection, site not specified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Anemia in chronic kidney disease,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Other left bundle branch block,Pure hypercholesterolemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Gastrostomy status'}
