CHIEF COMPLAINT: increasing dyspnea

PRESENT ILLNESS: 63yo M s/p OLT ([**5-11**]) for HepC cirrhosis/HCC on
immunosuppression, s/p tracheostomy for subglottic stenosis
([**7-11**]), recurrent pna who comes to the ED from [**Hospital 48496**] rehab with c/o increasing dyspnea x 1 month and
multiple pulmonary nodules seen on CT 5d ago.  Associated
pleuritic substernal CP, fatigue, thicker trach secretions, and
night sweats (?chronic).  Denies fever/chills.  +100lb weight
loss over 1 year.  Denies history of exposure to TB, travel
outside of the country, IVDU, imprisonment.  His CT was done at
an OSH, but reportedly showed multiple 7-10mm nodules not
previously seen (last CT chest in OMR [**4-11**]).  Recently d/c from
[**Hospital1 18**] on [**2160-1-22**] for pneumonia, empirically treated with
vanc/ceftaz.
.
In the ED, he was afebrile with baseline O2 requirement.  He
received vanc 1g IV and ceftaz 2g IV.
.
He currently states he feels fine.  His dyspnea is improved.  He
denies CP, chills, abdominal pain, N/V.

MEDICAL HISTORY: 1. OLT: [**5-11**], for HCV/EtOH cirrhosis and HCC, on rapamycin and
Cellcept, c/b wound infection, followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]
2. tracheostomy: x2, [**8-11**] for chronic vent dependency,
subglottic stenosis, tracheomalacia
3. DM2
4. OSA/Pickwickian syndrome
5. COPD
6. Diastolic dysfunction
7. CKD
8. Bipolar d/o
9. HTN
10. H/o VRE, MRSA, C. diff, and resistant Pseudomonas infections
11. Hiatal hernia
12. Pulmonary hypertension

MEDICATION ON ADMISSION: Sirolimus 4mg qd
Cellcept 500mg [**Hospital1 **]
Prednisone 5mg qd
Flovent 110mcg 4puffs [**Hospital1 **]
Atrovent prn
Lansoprazole 30mg qd
Risperidone 2mg qhs
Celexa 10mg qd
Epogen 5000U qMWF
Lorazepam 0.5mg [**Hospital1 **]
NPH
Amlodipine 10mg qd
SC heparin
Nystatin 5mL qid

ALLERGIES: Penicillins / Nsaids / Rapamune

PHYSICAL EXAM: vitals- T 97.8, HR 62, BP 145/60, RR 16, O2sat 100% 40%trach
mask
General- chronically ill-appearing man lying in bed, NAD, mask
to trach, awake and alert, difficulty speaking with trach
HEENT- sclerae anicteric and noninjected, OP clear without
evidence of thrush, moist MM
Neck- trach site appears mildly erythematous, no discharge
Lungs- upper airway secretions, decreased breath sounds and
dullness to percussion 1/3 up b/l (L>R)
Heart- RRR, normal S1/S2, no murmur/rub/gallop
Abd- soft, NT, ND, NABS, large surgical scar, no hepatomegaly
Ext- 1+ LE edema to mid-calf, RLE with 5x5cm area of erythema
and warmth on the lateral aspect of the lower R calf
Skin- erythematous blanching papular (2mm papules) rash over the
neck/chest/upper arms, not pruritic, no excoriations, no facial
rash, no involvement of palms and soles

FAMILY HISTORY: NC

SOCIAL HISTORY: Quit tobacco 8 years ago. Quit alcohol 17 years prior to
admission. Denies any recreational drugs.
Pneumonia, organism unspecified,Acute respiratory failure,Acidosis,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Other specified alveolar and parietoalveolar pneumonopathies,Liver replaced by transplant,Chronic airway obstruction, not elsewhere classified,Pressure ulcer, other site,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia
Pneumonia, organism NOS,Acute respiratry failure,Acidosis,Acute kidney failure NOS,Chronic kidney dis NOS,Alveol pneumonopathy NEC,Liver transplant status,Chr airway obstruct NEC,Pressure ulcer, site NEC,DMII wo cmp nt st uncntr,Hypertension NOS,Pure hypercholesterolem
Admission Date:  [**2160-2-13**]              Discharge Date:   [**2160-2-29**]

Date of Birth:  [**2096-4-23**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Nsaids / Rapamune

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
increasing dyspnea

Major Surgical or Invasive Procedure:
VATS with wedge biopsy

History of Present Illness:
63yo M s/p OLT ([**5-11**]) for HepC cirrhosis/HCC on
immunosuppression, s/p tracheostomy for subglottic stenosis
([**7-11**]), recurrent pna who comes to the ED from [**Hospital 48496**] rehab with c/o increasing dyspnea x 1 month and
multiple pulmonary nodules seen on CT 5d ago.  Associated
pleuritic substernal CP, fatigue, thicker trach secretions, and
night sweats (?chronic).  Denies fever/chills.  +100lb weight
loss over 1 year.  Denies history of exposure to TB, travel
outside of the country, IVDU, imprisonment.  His CT was done at
an OSH, but reportedly showed multiple 7-10mm nodules not
previously seen (last CT chest in OMR [**4-11**]).  Recently d/c from
[**Hospital1 18**] on [**2160-1-22**] for pneumonia, empirically treated with
vanc/ceftaz.
.
In the ED, he was afebrile with baseline O2 requirement.  He
received vanc 1g IV and ceftaz 2g IV.
.
He currently states he feels fine.  His dyspnea is improved.  He
denies CP, chills, abdominal pain, N/V.

Past Medical History:
1. OLT: [**5-11**], for HCV/EtOH cirrhosis and HCC, on rapamycin and
Cellcept, c/b wound infection, followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]
2. tracheostomy: x2, [**8-11**] for chronic vent dependency,
subglottic stenosis, tracheomalacia
3. DM2
4. OSA/Pickwickian syndrome
5. COPD
6. Diastolic dysfunction
7. CKD
8. Bipolar d/o
9. HTN
10. H/o VRE, MRSA, C. diff, and resistant Pseudomonas infections
11. Hiatal hernia
12. Pulmonary hypertension

Social History:
Quit tobacco 8 years ago. Quit alcohol 17 years prior to
admission. Denies any recreational drugs.

Family History:
NC

Physical Exam:
vitals- T 97.8, HR 62, BP 145/60, RR 16, O2sat 100% 40%trach
mask
General- chronically ill-appearing man lying in bed, NAD, mask
to trach, awake and alert, difficulty speaking with trach
HEENT- sclerae anicteric and noninjected, OP clear without
evidence of thrush, moist MM
Neck- trach site appears mildly erythematous, no discharge
Lungs- upper airway secretions, decreased breath sounds and
dullness to percussion 1/3 up b/l (L>R)
Heart- RRR, normal S1/S2, no murmur/rub/gallop
Abd- soft, NT, ND, NABS, large surgical scar, no hepatomegaly
Ext- 1+ LE edema to mid-calf, RLE with 5x5cm area of erythema
and warmth on the lateral aspect of the lower R calf
Skin- erythematous blanching papular (2mm papules) rash over the
neck/chest/upper arms, not pruritic, no excoriations, no facial
rash, no involvement of palms and soles

Pertinent Results:
[**2160-2-13**] 01:00PM   WBC-5.7 RBC-3.87* HGB-10.8* HCT-32.3* MCV-84
MCH-27.9 MCHC-33.4 RDW-15.2
[**2160-2-13**] 01:00PM   NEUTS-84.1* LYMPHS-8.5* MONOS-4.2 EOS-1.7
BASOS-1.4
[**2160-2-13**] 01:00PM   PLT SMR-LOW PLT COUNT-90*
[**2160-2-13**] 01:00PM   PT-12.2 PTT-24.1 INR(PT)-1.0
[**2160-2-13**] 01:00PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2160-2-13**] 01:00PM URINE  RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2160-2-13**] 01:00PM   CK(CPK)-33*
[**2160-2-13**] 01:00PM   cTropnT-0.05*
[**2160-2-13**] 01:00PM   CK-MB-NotDone
[**2160-2-13**] 01:00PM   GLUCOSE-128* UREA N-31* CREAT-1.6* SODIUM-142
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-36* ANION GAP-9
[**2160-2-13**] 03:10PM   ALT(SGPT)-23 AST(SGOT)-22 ALK PHOS-173*
AMYLASE-87 TOT BILI-0.2
[**2160-2-13**] 03:10PM   LIPASE-25
[**2160-2-13**] 09:46PM   CK(CPK)-35*
[**2160-2-13**] 09:46PM   CK-MB-NotDone cTropnT-0.05*
.
CXR: Stable small bilateral pleural effusions.  Stable elevation
of
left hemidiaphragm.  No evidence for pneumonia or overt CHF.
.
ECG: NSR at 63bpm, RBBB, TWI in III, Twave flattening in F, no
new changes from prior study in [**2160-1-17**]
.
CT chest [**2-26**] -
IMPRESSION:
1. Mild congestive heart failure with cardiomegaly and small
bilateral pleural effusion.
2. Tiny loculated hydropneumothorax in the medial portion of the
right hemithorax.
3. Increased consolidation in both lower lobes, probably
explained by the combination of atelectasis and BOOP.
4. Increased elevation of the left hemidiaphragm.
5. Mild subcutaneous emphysema in the right chest wall.
6. Status post right VATS procedure.
.
[**2-19**] Lung biopsy.
1.  Right lung, lower lobe, wedge biopsy (A-P):
Patchy organizing pneumonitis
No malignancy identified
2.  Right lung, middle lobe, wedge biopsy (Q-V):
Patchy organizing pneumonitis
No malignancy identified.
*  There is a peribronchiolar chronic inflammatory infiltrate
with focal alveolar collapse and intra-alveolar macrophages and
fibroblastic proliferation. Acute inflammation is limited to
bronchioles. Findings are non-specific.
.
[**2-29**] - Video Swallow eval:
IMPRESSION: Penetration of the vocal cords during swallowing of
both thin and nectar thick liquids. No frank aspiration during
this study.
.
CXR [**2160-2-26**]. Elevation of the left hemidiaphragm is chronic and
left lower lobe atelectasis currently present is intermittent.
Small bilateral pleural effusions are stable on the left but
increased on the right following some improvement in transient
interstitial pulmonary edema. Cardiomegaly with particular left
atrial enlargement is longstanding. Tip of the tracheostomy tube
abuts the lateral wall of the trachea and should be evaluated
clinically. Tip of the left PIC line projects over the margin of
the upper superior vena cava. Dr. [**Last Name (STitle) 15264**] and I discussed these
findings by telephone at the time of dictation
.
LABS from day of DISCHARGE [**2160-2-29**]:
FK506: 4.3
CHEM 7:
141 | 107 | 31
--------------<97
4.2 | 26 | 2.3
.
Ca: 8.3 Mg: 1.9 P: 4.2
CBC:  WBC 4.6 Hct 26 Plt 188
PT: 13.0  INR: 1.1


Brief Hospital Course:
Pt is a a 63yo M s/p OLT ([**5-11**]) for HepC cirrhosis/HCC on
immunosuppression, s/p tracheostomy for subglottic stenosis
([**7-11**]), recurrent pna admitted from [**Hospital3 **] rehab
for increasing dyspnea x 1 month, found to have multiple
pulmonary nodules but no PE seen on CTA.  These nodules were not
previously seen (last CT chest at [**Hospital1 18**] [**4-11**]). Of note, recently
d/c from [**Hospital1 18**] on [**2160-1-22**] for pneumonia, empirically treated
with vanc/ceftaz for unclear duration.
.
## Respiratory Failure - On this admission, patient was
re-started on vanco, ceftaz, and levo for nosocomial PNA.
Infectious disease was consulted for possible
infectious/inflammatory etiology.  Urine legionella, CMV, serum
cryptococcal antigen, and 3 AFB smears were negative. Bronch was
attempted by IP on [**2-15**] but was unsuccessful due to small trach.
 Thoracics were consulted for VATS, and the patient underwent
VATS with BAL and wedge biopsies of right lower lobe and middle
lobes on [**2-18**].  Chest tubes placed to suction postoperatively.
[**Name (NI) 4452**], pt received 1 mg midazolam and intraoperatively 340 mg
Propofol, 125 mcg Fentanyl, 12 mg Vecuronium.  Also received 14
mg of morphine (last given at 10:45 pm), Ceftaz, Vancomycin,
Hydrocort 100 mg IV, Neostigmine, and glycopyrrolate.  EBL was
50 cc and intraoperatively, received 300 cc LR.  In OR, pt had
ABG of 7.30/68/125.  [**Name (NI) **], pt initially placed on
100% trach mask and sent to PACU.  Follow up ABG was 7.08/94/154
and pt was somnolent.  He was briefly placed on CMV for 30
minutes then CPAP PS 10/5.  Repeat ABG was 7.10/71/104.  He was
transferred to ICU for further ventilatory management.
.
     Patient likely developed acute on chronic respiratory
acidosis.  The acute respiratory acidosis was thought to be
secondary to narcotics/sedatives causing hypoventilation as well
as exposure to 100% FIO2 leading to decreased respiratory drive
and causing more shunt lung physiology given his chronic
obstructive lung disease and Pickwickian syndrome. He was
initially placed on ventilator and then eventually weaned off to
trach mask. He required very frequent pulmonary toileting due to
copious amount of sputum production which was thought to be
secondary to his pulmonary nodules vs infection. The pathology
result of the pulmonary nodule biopsy returned as bronchiolitis
obliteran pneumonitis. Liver transplant consultants thought that
Sirolimus was likely the culprit for the cause of BOOP and
discontinued sirolimus on [**2-21**] and increased Cellcept to 1000mg
[**Hospital1 **] and continued prenisone 5mg daily.  They did not feel
necessary to start high dose prednisone for BOOP and felt that
pt would recover with discontinuation of sirolimus. In addition,
BAL and tissue culture from the VATS came back positive for
pseudomonas, GNR, and Coag positive Staph.  These organisms
could very well have been colonized however after discussion
with ID, patient was continued on vanco and ceftaz to finish a
10 day course on [**2160-2-23**].  The chest tube was placed during VATS
procedure was managed by thoracis and initially planeed on
removing the chest tube on [**2160-2-23**] or [**2160-2-24**].   Patient was
tolerating trach mask ok and was transferred to the medical
floor.  On the floor he was continued on ceftaz/vanco for 10
days as above.  FK506 was started on [**2-24**] and increased cellcept
to 1 gm [**Hospital1 **]. He continued to have copious yellow/white thick
secretioning requiring suctioning every few hrs initially.
Chest tubes were discontinued on [**2-26**].  Chest CT was done on
[**2-28**].  On AM [**2-27**] patient was noted to be more lethargic.  He
was also requiring frequent suctioning, nebs.  ABG was near his
baseline however given nursing concern he was transferred back
to Medical ICU.  He was placed on CPAP/PS briefly and tolerated
well and was changed over to trach mask.  Plan is for trach
collar during the day and BIPAP 8/5 at night.
.
# Renal Insufficienty - Post operatively patient was noted to be
in oliguric renal failure.  REnal was consulted.  He had acute
on chronic renal insufficiency.  Urine lytes were sent were
consistent with pre-renal vs. ATN.  The creatinine and urine
output improved with aggressive IV fluids.
.
#  OLT - Liver followed the patient in the unit and discontinued
sirolimus and increased Cellcept as above. Tacrolimus started
[**2160-2-26**] along with mycophenolate, and prednisone.  Continue
Tacrolimus 2mg [**Hospital1 **].
.
#  DM II - Glucose control maintained with Sliding scale
insulin.
.
#  Anemia - Microcytic. Hct stable during this admission.
Hyperplastic polyp on [**7-10**] colonoscopy. Received 1U PRBC on
[**2-25**].  Iron studies suggest anemia of chronic disease, iron
normal.   Epogen was continued.
.
#  Hypertension - Continued on metoprolol and amlodipine.
Started hydral.
.
# RUE swelling - noted to have RUE swelling.  Ultrasound was
done which showed no evidence of DVT.
.
#  Nutrition -  He was started on po diet once he tolerated
trach mask. Speech and swallow were consulted for Passy Muir
Valve Evaluation, but pt was thought not to be safe to use it
due to his tracheal stenosis. Video swallow was performed on
[**2-29**] by speech and swallow who recommended that he can take
Regular diet with thin liquids.  Soup and cereals should be
avoided however.
.
# Ppx: Maintained on SC heparin + pneumaboots. PPI.  Bowel
regimen.
.
# Code status: FULL CODE.  HCP is [**Last Name (LF) 802**], [**Name (NI) **] [**Name (NI) 48497**]
([**Telephone/Fax (1) 48498**], ([**Telephone/Fax (1) 48499**] (cell).

Medications on Admission:
Sirolimus 4mg qd
Cellcept 500mg [**Hospital1 **]
Prednisone 5mg qd
Flovent 110mcg 4puffs [**Hospital1 **]
Atrovent prn
Lansoprazole 30mg qd
Risperidone 2mg qhs
Celexa 10mg qd
Epogen 5000U qMWF
Lorazepam 0.5mg [**Hospital1 **]
NPH
Amlodipine 10mg qd
SC heparin
Nystatin 5mL qid

Discharge Medications:
1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1)  Injection
QMOWEFR (Monday -Wednesday-Friday).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
10. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
11. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
12. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
Two (2)  Inhalation [**Hospital1 **] (2 times a day).
13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
14. Insulin sliding scale
Fingerstick QACHS
Insulin SC Fixed Dose Orders
Breakfast - NPH 5 units;
Bedtime - NPH      2  Units
+ humumlog insulin sliding scale
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
16. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
17. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
18. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic  PRN
(as needed).
19. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q4H (every 4 hours).
20. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed.
21. Lasix 40 mg Tablet Sig: One (1) Tablet PO qAM.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]

Discharge Diagnosis:
Respiratory failure
Bronchiogenic obliterans pneumonitis
Acute on chronic renal failure
Anemia
Hypertension
Diabetes type 2


Discharge Condition:
Stable


Discharge Instructions:
Please continue to administer medications as directed.

If patient as has fever, chills, increased shortness of breath
please seek further medical care.


Followup Instructions:
Please call [**Telephone/Fax (1) 673**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] to setup an
appointment in [**12-10**] weeks.
.
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4334**] [**Telephone/Fax (1) 45347**] in
[**12-10**] weeks after discharge from rehab.



Completed by:[**2160-2-29**]
{'Pneumonia, organism unspecified,Acute respiratory failure,Acidosis,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Other specified alveolar and parietoalveolar pneumonopathies,Liver replaced by transplant,Chronic airway obstruction, not elsewhere classified,Pressure ulcer, other site,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia'}


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: increasing dyspnea

PRESENT ILLNESS: 63yo M s/p OLT ([**5-11**]) for HepC cirrhosis/HCC on
immunosuppression, s/p tracheostomy for subglottic stenosis
([**7-11**]), recurrent pna who comes to the ED from [**Hospital 48496**] rehab with c/o increasing dyspnea x 1 month and
multiple pulmonary nodules seen on CT 5d ago.  Associated
pleuritic substernal CP, fatigue, thicker trach secretions, and
night sweats (?chronic).  Denies fever/chills.  +100lb weight
loss over 1 year.  Denies history of exposure to TB, travel
outside of the country, IVDU, imprisonment.  His CT was done at
an OSH, but reportedly showed multiple 7-10mm nodules not
previously seen (last CT chest in OMR [**4-11**]).  Recently d/c from
[**Hospital1 18**] on [**2160-1-22**] for pneumonia, empirically treated with
vanc/ceftaz.
.
In the ED, he was afebrile with baseline O2 requirement.  He
received vanc 1g IV and ceftaz 2g IV.
.
He currently states he feels fine.  His dyspnea is improved.  He
denies CP, chills, abdominal pain, N/V.

MEDICAL HISTORY: 1. OLT: [**5-11**], for HCV/EtOH cirrhosis and HCC, on rapamycin and
Cellcept, c/b wound infection, followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]
2. tracheostomy: x2, [**8-11**] for chronic vent dependency,
subglottic stenosis, tracheomalacia
3. DM2
4. OSA/Pickwickian syndrome
5. COPD
6. Diastolic dysfunction
7. CKD
8. Bipolar d/o
9. HTN
10. H/o VRE, MRSA, C. diff, and resistant Pseudomonas infections
11. Hiatal hernia
12. Pulmonary hypertension

MEDICATION ON ADMISSION: Sirolimus 4mg qd
Cellcept 500mg [**Hospital1 **]
Prednisone 5mg qd
Flovent 110mcg 4puffs [**Hospital1 **]
Atrovent prn
Lansoprazole 30mg qd
Risperidone 2mg qhs
Celexa 10mg qd
Epogen 5000U qMWF
Lorazepam 0.5mg [**Hospital1 **]
NPH
Amlodipine 10mg qd
SC heparin
Nystatin 5mL qid

ALLERGIES: Penicillins / Nsaids / Rapamune

PHYSICAL EXAM: vitals- T 97.8, HR 62, BP 145/60, RR 16, O2sat 100% 40%trach
mask
General- chronically ill-appearing man lying in bed, NAD, mask
to trach, awake and alert, difficulty speaking with trach
HEENT- sclerae anicteric and noninjected, OP clear without
evidence of thrush, moist MM
Neck- trach site appears mildly erythematous, no discharge
Lungs- upper airway secretions, decreased breath sounds and
dullness to percussion 1/3 up b/l (L>R)
Heart- RRR, normal S1/S2, no murmur/rub/gallop
Abd- soft, NT, ND, NABS, large surgical scar, no hepatomegaly
Ext- 1+ LE edema to mid-calf, RLE with 5x5cm area of erythema
and warmth on the lateral aspect of the lower R calf
Skin- erythematous blanching papular (2mm papules) rash over the
neck/chest/upper arms, not pruritic, no excoriations, no facial
rash, no involvement of palms and soles

FAMILY HISTORY: NC

SOCIAL HISTORY: Quit tobacco 8 years ago. Quit alcohol 17 years prior to
admission. Denies any recreational drugs. 

### Response:
{'Pneumonia, organism unspecified,Acute respiratory failure,Acidosis,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Other specified alveolar and parietoalveolar pneumonopathies,Liver replaced by transplant,Chronic airway obstruction, not elsewhere classified,Pressure ulcer, other site,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Pure hypercholesterolemia'}
