CHIEF COMPLAINT: Superficial femoral artery stenosis

PRESENT ILLNESS: 83 y/o diabetic with PVD, hypertension, and hyperlipidemia, s/p
arthrectomy of right popliteal and stent x 2 of RSFA on the day
of admission.  Post procedure course on day of admission was
complicated by unresponisve episode several hours after lower
extremity cath on the floor and respiratory failure requiring
intubation and transfer to the CCU after being found
unresponsive several hours s/p lower extremity cath.
.
Patient initially had arthrectomy of RSFA and right popliteal on
[**6-9**] and was then referred for peripheral catheterization due to
abnormal ABIs on [**10-10**]. Recent ABI was 0.58 on the right and
showed diffuse disease throughout the right lower extremity
including 75% pRSFA, 50% popliteal, and anterior tibial 75%
stenosis. Pt. has a non-healing ulcer of right heel. She has
been taking Vicodin for pain management.
.
On the day of admission, patient underwent an uncomplicated
arthrectomy of right popliteal and stent x2 of RSFA. Several
hours after procedure, she was found unresponsive, hypertensive
with SBPs to 170s, tachycardic to 130s, and pulse ox of 76% on
NRB. Patient was subsequently intubated and then taken to stat
head CT which did not demonstrate any acute findings of bleed.
She received lasix 80mg IV x 1, morphine 2mg IV x 1 for question
of CHF. Stat CXR demonstrated increased apical interstitial
markings and right greater than left pleural effusions,
consistent either with aspiration pneumonia or increased apical
interstitial edema in the setting of lying supine.
.
She remained intubated for 2 days in the ICU and tolerated
extubation well without complication.  Imaging of her brain was
obtained which did not reveal acute stroke.  Additionally, she
was hypotensive upon transfer to the CCU with mildly decreased
SVR and mildly increased CO most c/w distributive shock.
Although she was afebrile and without elevated WBC count, given
the above picture, she was started on vancomycin and zosyn.
Urine and sputum cultures revealed no growth.  Blood cultures
reveal NGTD.

MEDICAL HISTORY: 1. PVD
2. CHF
3. HTN
4. Renal insufficiency
5. Diabetes
6. Neuropathy
7. Nephropathy
8. Left femoral-tibial artery bypas graft for ischemic left foot
[**2153**]
9. Amputation of left fifth toe [**2153**]
10. CVA [**2154**]
11. Anemia

MEDICATION ON ADMISSION: Folic acid 1 mg qd
Serax 10 mg qhs
Zocor 40 mg qd
Colace 100 mg qd
FeSo4 325 mg qd
Lasix 20 mg qd
Celexa 20 mg qd
Detrol LA 4 mg qd
Namenda 5 mg qd
Abilify 5 mg qd
Glucerna 4 oz. tid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Ht 5' 1" 191 lbs.
VS: T 99.0  BP  110-146/37-48  HR 53-60  O2 sat 92% RA  I/O
1100/1300
Gen: Sittting up in chair, NAD
HEENT:  PERRL,
Neck: Negative carotid bruits, no JVD, supple.  RIJ site dressed
with gauze, CDI
CV:  sinus brady, no mrg apprec
Resp:  CTA b/l, no w/r/r
Abdomen: obese, non-distended, non-tender, + hyperactive BS.
Ext: Bilateral groins without bruit. dopplerable
peripheral pulses. 1+ edema. Right foot dressing at heel is
intact.
Neuro:  CN II-XII grossly intact, AAO to person, place, year as
[**2156**], but states it is [**Holiday **] and cannot recall the month.
Says her sons are 11 and 8, when they are grown.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Widow. Lives in Nursing home. 5 adult children. Smoked for 25
years, 1PPD, but quit nearly 20years ago.
Atherosclerosis of native arteries of the extremities with ulceration,Diastolic heart failure, unspecified,Acute respiratory failure,Chronic kidney disease, unspecified,Acute kidney failure, unspecified,Other shock without mention of trauma,Ulcer of heel and midfoot,Chronic osteomyelitis, ankle and foot,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified hereditary and idiopathic peripheral neuropathy,Other toe(s) amputation status
Ath ext ntv art ulcrtion,Diastolc hrt failure NOS,Acute respiratry failure,Chronic kidney dis NOS,Acute kidney failure NOS,Shock w/o trauma NEC,Ulcer of heel & midfoot,Chr osteomyelit-ankle,DMII wo cmp nt st uncntr,Hypertension NOS,Hyperlipidemia NEC/NOS,Idio periph neurpthy NOS,Status amput othr toe(s)
Admission Date:  [**2157-11-14**]              Discharge Date:   [**2157-11-25**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Superficial femoral artery stenosis

Major Surgical or Invasive Procedure:
Catheterization for stenting of right superficial femoral artery

History of Present Illness:
83 y/o diabetic with PVD, hypertension, and hyperlipidemia, s/p
arthrectomy of right popliteal and stent x 2 of RSFA on the day
of admission.  Post procedure course on day of admission was
complicated by unresponisve episode several hours after lower
extremity cath on the floor and respiratory failure requiring
intubation and transfer to the CCU after being found
unresponsive several hours s/p lower extremity cath.
.
Patient initially had arthrectomy of RSFA and right popliteal on
[**6-9**] and was then referred for peripheral catheterization due to
abnormal ABIs on [**10-10**]. Recent ABI was 0.58 on the right and
showed diffuse disease throughout the right lower extremity
including 75% pRSFA, 50% popliteal, and anterior tibial 75%
stenosis. Pt. has a non-healing ulcer of right heel. She has
been taking Vicodin for pain management.
.
On the day of admission, patient underwent an uncomplicated
arthrectomy of right popliteal and stent x2 of RSFA. Several
hours after procedure, she was found unresponsive, hypertensive
with SBPs to 170s, tachycardic to 130s, and pulse ox of 76% on
NRB. Patient was subsequently intubated and then taken to stat
head CT which did not demonstrate any acute findings of bleed.
She received lasix 80mg IV x 1, morphine 2mg IV x 1 for question
of CHF. Stat CXR demonstrated increased apical interstitial
markings and right greater than left pleural effusions,
consistent either with aspiration pneumonia or increased apical
interstitial edema in the setting of lying supine.
.
She remained intubated for 2 days in the ICU and tolerated
extubation well without complication.  Imaging of her brain was
obtained which did not reveal acute stroke.  Additionally, she
was hypotensive upon transfer to the CCU with mildly decreased
SVR and mildly increased CO most c/w distributive shock.
Although she was afebrile and without elevated WBC count, given
the above picture, she was started on vancomycin and zosyn.
Urine and sputum cultures revealed no growth.  Blood cultures
reveal NGTD.


Past Medical History:
1. PVD
2. CHF
3. HTN
4. Renal insufficiency
5. Diabetes
6. Neuropathy
7. Nephropathy
8. Left femoral-tibial artery bypas graft for ischemic left foot
[**2153**]
9. Amputation of left fifth toe [**2153**]
10. CVA [**2154**]
11. Anemia


Social History:
Widow. Lives in Nursing home. 5 adult children. Smoked for 25
years, 1PPD, but quit nearly 20years ago.

Family History:
non-contributory

Physical Exam:
Ht 5' 1" 191 lbs.
VS: T 99.0  BP  110-146/37-48  HR 53-60  O2 sat 92% RA  I/O
1100/1300
Gen: Sittting up in chair, NAD
HEENT:  PERRL,
Neck: Negative carotid bruits, no JVD, supple.  RIJ site dressed
with gauze, CDI
CV:  sinus brady, no mrg apprec
Resp:  CTA b/l, no w/r/r
Abdomen: obese, non-distended, non-tender, + hyperactive BS.
Ext: Bilateral groins without bruit. dopplerable
peripheral pulses. 1+ edema. Right foot dressing at heel is
intact.
Neuro:  CN II-XII grossly intact, AAO to person, place, year as
[**2156**], but states it is [**Holiday **] and cannot recall the month.
Says her sons are 11 and 8, when they are grown.


Pertinent Results:
[**2157-11-14**] Cardiac cath:
1. Severe R SFA stenosis and a severe focal right popliteal
artery
stenosis.
2. Successful PTCA and stenting of the R SFA.
3. Successful atherectomy of the right popliteal artery.
.
[**2157-11-15**] Echocardiogram:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Regional left ventricular wall motion is
normal. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION:
Mild symmetric left ventricular hypertrophy with preserved
regional/global biventricular systolic function. Mild mitral
regurgitation.
.
Heel x-ray:
1) Focal osteopenia and slight ill definition of the posterior
calcaneus deep to the ulcer.  The differential diagnosis
includes prior debridement vs. osteomyelitis.
2) 1 cm lucent focus along dorsum of talus, not fully evaluated
here -- this is non-aggressive in appearance and most likely
represents an erosion, cyst, or enchondroma.
.
CT head:
1.  No evidence of acute intracranial hemorrhage.
2.  Evidence of prior infarct in the right frontal lobe, and
possible chronic small vessel ischemia in the left frontal lobe.
 Also no evidence of acute infarction is seen, please note that
diffusion-weighted MRI is highly more sensitive for acute or
supra-acute infarction.
3.  Possible aneurysm at the right carotid siphon.
.
MRI/MRA brain:
1.  No evidence of acute infarction.
2.  Right frontal encephalomalacia, consistent with chronic
infarction. According to the patient's online medical record,
these findings correspond with a known cerebrovascular accident
in [**2154**].
3.  Bilateral chronic small vessel infarction, with a single
tiny, chronic hemorrhagic residuum in the left centrum
semiovale.
4.  Stable appearance of the major tributaries of the circle of
[**Location (un) 431**], again revealing a hypoplastic left posterior
communicating artery and A1 segment of the left anterior
cerebral artery.
.
MRI Foot: 1.  Large soft tissue ulcer over the posterolateral
heel with adjacent marrow changes amd cortex loss in the
calcaneus concerning for osteomyelitis. 2.  Nonspecific
subchondral signal changes surrounding the tarsometatarsal and
talonavicular joints likely reflect degenerative/early
neuropathic changes.
.

Brief Hospital Course:
83 y/o diabetic woman with PVD s/p arthrectomy of right
popliteal and stent x 2 of RSFA admitted to the CCU on [**2157-11-14**]
after being found unresponsive without clear etiology.
.
# Respiratory Failure:  On the day of admission, shortly after
her right SFA procedure, she was found unresponsive and
desaturated on a nonrebreather.  She was intubated for airway
protection and transferred to the ICU.  She was extubated 2 days
later on [**2157-11-16**] without complication.  The cause of her
initial episode of unresponsiveness is not entirely clear, but
she was without respiratory compromise since her original
episode.
.
# Mental Status Change:  As above, etiology for patient's acute
mental status change in which she was found unresponsive in not
entirely clear. Differential diagnosis includes TIA
(particularly given patient's prior stroke in right frontal
lobe) or seizure although she has no prior history and an EEG
performed was negative.  Head CT and brain MRI were negative for
acute stroke.  She has mild dementia at baseline and was back to
her baseline mental status at the time of discharge.
.
#  Right foot ulcer: Patient was admitted with stable right foot
ulcer with concern for possible osteomyelitis.  ESR was 56-->70,
CRP 86.4-->61.9.  Vascular surgery saw the patient.  Initially,
chemical debridement was initiated with Accuyzyme.  An MRI of
the foot was performed to evaluate for osteomyelitis and
revealed changes potentially consistent with osteomyelitis.  She
was taken to the OR for debridement by podiatry.  No
osteomyelitis was found in the OR.  The patient was switched
from IV Vanc/Zosyn to PO Augmentin for 14 days and she will f/u
with podiatry in 1 week and continue Vac dressing with changes
every 4 days.  Final cultures and pathology reports are pending
at the time of discharge and should be followed up by the
patient's primary care doctor.
.
#  Peripheral Vascular Disease:  The patient is s/p LE
angiography and peripheral stent placement (RSFA).  Lower
extremity noninvasive studies were obtained prior to surgery to
ensure adequate blood flow for proper heeling after her right
heel debridement.  She was continued on aspirin and plavix and
will followup with vascular surgery as an outpatient.
.
# Cardiac:
Pump:
The patient has an EF 55% on [**2157-11-15**] echocardiogram. She had
been given IV fluid in the ICU for concern of distributive shock
and following extubation had a 2L O2 requirement.  CXR revealed
pulmonary edema and small bilateral effusions.  She was diuresed
with IV lasix and her oxygen requirement resolved with both
pulmonary edema and effusions improving with diuresis.  She will
be discharged on her home lasix dose.
.
Rhythm:
She had asymptomatic sinus bradycardia while inpatient.
Titration of her beta blocker was thus limited by her rate.
.
Coronary Artery Disease:
She is without any documented diagnosis nor history of CAD,
although she does have DM, HTN, and known peripheral vascular
disease, and given her age, likely has element of CAD.  She was
continued on her aspirin and BBlocker.
.
#  Decreased hematocrit:  She had a hct drop to 22.9 from 27 on
[**11-16**] while remaining hemodynamically stable. Given recent LE
angiography, there was concern for RP bleed, hematoma formation,
or other GI source. However, the patient was negative for occult
blood. She received 2 units pRBCs with appropriate bump from 22
to 29.2 and was observed clinically.  Her hematocrit remained
stable since that time.  She required no further blood
transfusions and no source of bleeding was identified.
.
#  Acute Renal Failure:  Creatinine increased from 1.1 to 1.6.
She had significant dye load with various imaging and, thus, her
ARF was concerning for contrast-induced nephropathy or possibly
ATN.  Her elevated creatinine improved back to baseline 0.9-1.1
and on the day of discharge, her creatinine was 1.0.
.
#  Hypertension: The patient had slightly elevated SBPs during
this admission.  She was put on a BB and ACEI.  Her medications
were titrated during this hospitalization to gain better control
of her hypertension.  She will likely need further titration in
the outpatient setting.
.
#  Hypercholesterolemia: Stable, Patient was continued on her
home dose of Zocor
.
#  Diabetes Mellitus: Patient was put on Glargine and covered
with an insulin sliding scale.  She will continue Glargine and
an insulin sliding scale.
.
#  Shock: As above, the patient had an episode during her
hospitalization where she was found unresponsive and required
intubation and transfer to the CCU.  After arrival to the CCU,
she was found to have hypotension with MAPs 40s to 50s, which
were responsive to dopamine.  Shock etiology was most consistent
with distributive with initial swan findings with mildly
decreased SVR and mildly increased CO. [**Last Name (un) **] stim test was not
suggestive of adrenal insufficiency. She had no positive urine,
sputum, or blood cultures.  Given concern for distributive
shock, despite no positive cultures, she was covered broadly
with antibiotics (vancomycin and zosyn). The patient became
hemodyamically stable and was extubated and transferred out of
the CCU back to the medical floors.  She had no further episodes
of unresponsivness, or hypotension for the remainder of her
hospitalization.  Her IV antibiotics were changed to PO
augmentin, as above, and she will continue a 14 day course.

Medications on Admission:
Folic acid 1 mg qd
Serax 10 mg qhs
Zocor 40 mg qd
Colace 100 mg qd
FeSo4 325 mg qd
Lasix 20 mg qd
Celexa 20 mg qd
Detrol LA 4 mg qd
Namenda 5 mg qd
Abilify 5 mg qd
Glucerna 4 oz. tid


Discharge Medications:
1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Trazodone 50 mg Tablet Sig: 0.5-1 Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
9. Memantine 5 mg Tablet Sig: One (1) Tablet PO qd ().
Disp:*30 Tablet(s)* Refills:*0*
10. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO qd ().
Disp:*15 Tablet(s)* Refills:*0*
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever, pain.
15. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
Thirty (30) ML PO QID (4 times a day) as needed for indigestion.

16. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1)
Tablet PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
17. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
19. Insulin
Please take Glargine SQ 10 units QHS.
Please continue on a Humalog sliding scale (see attached)
20. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours for 14 days. Tablet(s)
21. VAC dressing
Please change back Q4 days.
22. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
23. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Primary:
Peripheral vascular disease
Diabetes mellitus


Discharge Condition:
Stable. Maintaining oxygen saturation on room air.


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.2L
.
Please call your doctor or return to the emergency room if you
develop chest pain, shortness of breath, lightheadedness,
fevers/chills, worsening pain in your right heel, purulent
discharge from your right heel wound or any other symptoms that
concern you.
.
Please take your medications as prescribed and note that we have
added metoprolol and lisinopril for your blood pressure.
Additionally, please take 14 days of Augmentin for your foot
infection.  Please ensure that your VAC dressing is changed
every 4 days.
.
Please attend all followup visits as below.
.

Followup Instructions:
.
Please follow up with Dr. [**Last Name (STitle) **] in podiatry clinic on [**12-2**] at 9:30am on the [**Hospital Ward Name 517**], [**Hospital Ward Name 121**] Building, [**Hospital Ward Name **] 3 ([**Telephone/Fax (1) 19882**].
.
Please follow up with Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 920**] on [**12-9**] at
11:00am.
.
Please followup with Dr. [**Last Name (STitle) **] in two weeks.  You will need
to call to set up this followup appointment at ([**Telephone/Fax (1) 18181**].
.
{'Atherosclerosis of native arteries of the extremities with ulceration,Diastolic heart failure, unspecified,Acute respiratory failure,Chronic kidney disease, unspecified,Acute kidney failure, unspecified,Other shock without mention of trauma,Ulcer of heel and midfoot,Chronic osteomyelitis, ankle and foot,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified hereditary and idiopathic peripheral neuropathy,Other toe(s) amputation 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: Superficial femoral artery stenosis

PRESENT ILLNESS: 83 y/o diabetic with PVD, hypertension, and hyperlipidemia, s/p
arthrectomy of right popliteal and stent x 2 of RSFA on the day
of admission.  Post procedure course on day of admission was
complicated by unresponisve episode several hours after lower
extremity cath on the floor and respiratory failure requiring
intubation and transfer to the CCU after being found
unresponsive several hours s/p lower extremity cath.
.
Patient initially had arthrectomy of RSFA and right popliteal on
[**6-9**] and was then referred for peripheral catheterization due to
abnormal ABIs on [**10-10**]. Recent ABI was 0.58 on the right and
showed diffuse disease throughout the right lower extremity
including 75% pRSFA, 50% popliteal, and anterior tibial 75%
stenosis. Pt. has a non-healing ulcer of right heel. She has
been taking Vicodin for pain management.
.
On the day of admission, patient underwent an uncomplicated
arthrectomy of right popliteal and stent x2 of RSFA. Several
hours after procedure, she was found unresponsive, hypertensive
with SBPs to 170s, tachycardic to 130s, and pulse ox of 76% on
NRB. Patient was subsequently intubated and then taken to stat
head CT which did not demonstrate any acute findings of bleed.
She received lasix 80mg IV x 1, morphine 2mg IV x 1 for question
of CHF. Stat CXR demonstrated increased apical interstitial
markings and right greater than left pleural effusions,
consistent either with aspiration pneumonia or increased apical
interstitial edema in the setting of lying supine.
.
She remained intubated for 2 days in the ICU and tolerated
extubation well without complication.  Imaging of her brain was
obtained which did not reveal acute stroke.  Additionally, she
was hypotensive upon transfer to the CCU with mildly decreased
SVR and mildly increased CO most c/w distributive shock.
Although she was afebrile and without elevated WBC count, given
the above picture, she was started on vancomycin and zosyn.
Urine and sputum cultures revealed no growth.  Blood cultures
reveal NGTD.

MEDICAL HISTORY: 1. PVD
2. CHF
3. HTN
4. Renal insufficiency
5. Diabetes
6. Neuropathy
7. Nephropathy
8. Left femoral-tibial artery bypas graft for ischemic left foot
[**2153**]
9. Amputation of left fifth toe [**2153**]
10. CVA [**2154**]
11. Anemia

MEDICATION ON ADMISSION: Folic acid 1 mg qd
Serax 10 mg qhs
Zocor 40 mg qd
Colace 100 mg qd
FeSo4 325 mg qd
Lasix 20 mg qd
Celexa 20 mg qd
Detrol LA 4 mg qd
Namenda 5 mg qd
Abilify 5 mg qd
Glucerna 4 oz. tid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Ht 5' 1" 191 lbs.
VS: T 99.0  BP  110-146/37-48  HR 53-60  O2 sat 92% RA  I/O
1100/1300
Gen: Sittting up in chair, NAD
HEENT:  PERRL,
Neck: Negative carotid bruits, no JVD, supple.  RIJ site dressed
with gauze, CDI
CV:  sinus brady, no mrg apprec
Resp:  CTA b/l, no w/r/r
Abdomen: obese, non-distended, non-tender, + hyperactive BS.
Ext: Bilateral groins without bruit. dopplerable
peripheral pulses. 1+ edema. Right foot dressing at heel is
intact.
Neuro:  CN II-XII grossly intact, AAO to person, place, year as
[**2156**], but states it is [**Holiday **] and cannot recall the month.
Says her sons are 11 and 8, when they are grown.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Widow. Lives in Nursing home. 5 adult children. Smoked for 25
years, 1PPD, but quit nearly 20years ago. 

### Response:
{'Atherosclerosis of native arteries of the extremities with ulceration,Diastolic heart failure, unspecified,Acute respiratory failure,Chronic kidney disease, unspecified,Acute kidney failure, unspecified,Other shock without mention of trauma,Ulcer of heel and midfoot,Chronic osteomyelitis, ankle and foot,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified hereditary and idiopathic peripheral neuropathy,Other toe(s) amputation status'}
