CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: This is a 71 yo female with h/o CAD s/p CABG '[**38**], recent
hospitalization from [**Date range (1) 22383**] for UTI and CHF exacerbation, who
presents again with shortness of breath similar to previous
presention. Pt was discharged on Lasix and followed up with her
PCP, [**Name10 (NameIs) 1023**] noted that the patient had lost 8 pounds and Cr had
bumped from 2.0 -> 2.6. Her lasix was held and pt now presents
again with progressive shortness of breath. It got very bad this
AM with associated substernal chest discomfort that felt like a
pressure, and she was brought into the ED.
.
In the ED, a CXR was taken which shows pulmonary edema, but
could not exclude underlying pneumonia. EKG at the time showed
TWIs in I/aVL and ST depressions in V5-V6, only the TWI in I
being new. Initial enzymes negative x1. She was given 100 mg IV
Lasix, put out 1L, felt much better and transferred to the
floor.
.
On the floor, she notes that she has had a dry cough, feels like
there's something to bring up but cannot. No fever/chills/NS. No
chest pain currently, only mildly short of breath. She has 2
pillow orthopnea at baseline, no PND.
.
Pt also notes chronic left anterior thigh pain, for which she
has had some relief with gabapentin. Opiates were initially
tried, but she developed severe nausea/vomiting and
constipation.
.
ROS:
(+) Rhinorhea on and off for 1 year.
(-) Denies headache, sinus tenderness, or congestion. Denied
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
.

MEDICAL HISTORY: 1. CAD s/p CABG in [**2138**] - Followed by Dr. [**Last Name (STitle) **]
- MI in [**2122**]
- CABG [**2138**] = LIMA-->LAD, VG-->OM, VG--->RCA
- Exercise MIBI ([**3-2**]): Interval development of moderate,
reversible distal anterior wall and apical perfusion defect,
involving the expected LAD territory. Stable, moderate,
predominantly fixed perfusion defect involving the lateral wall

MEDICATION ON ADMISSION: 1. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day [held
since [**2-25**] AM]
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

ALLERGIES: Cardizem / Codeine / Optiray 300 / Heparin Agents

PHYSICAL EXAM: Vitals: T: 98.1 P: 60 BP: 126/50 R: 22 SaO2: 93% 2.5L
General: Awake, alert, mild respiratory distress.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, JVD to mandible, no carotid bruits appreciated
Pulmonary: Lungs with diffuse coarse crackles.
Cardiac: RRR, nl. S1S2, +early 2/6 systolic murmur heard equally
over all heart valves
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: 1+ edema bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor
-DTRs: 2+ patellar bilaterally.
.

FAMILY HISTORY: Her mother had non-alcoholic liver cirrhosis and diabetes type
2. Her father had diabetes and died of lung cancer. One of her
daughters and her son have both required
pacemakers/defibrillators for heart disease. She had a brother
who died of a brain tumor and has an older sister who is
generally in good health. No family history of blood clots.

SOCIAL HISTORY: Ms. [**Known lastname 22321**] [**Last Name (Titles) 22381**] worked as a hairdresser, retired ~5-10 years
ago. She quit tobacco 20 yrs ago (started smoking at 17 yo,
1-2pks/day, unfiltered), rare EtOH. She is divorced but lives
with her son, who helps manages her meds. Has 2 daughters who
work at [**Hospital1 18**] in [**Name (NI) 13042**]. Has another daughter. [**Name (NI) **] her children
and her 7 grandchildren live in the [**Location (un) 86**] area.
Congestive heart failure, unspecified,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Cirrhosis of liver without mention of alcohol,Chronic kidney disease, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Aortocoronary bypass status,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Other and unspecified angina pectoris
CHF NOS,Acute kidney failure NOS,Pneumonia, organism NOS,Cirrhosis of liver NOS,Chronic kidney dis NOS,Gastrointest hemorr NOS,DMII renl nt st uncntrld,Aortocoronary bypass,Nephritis NOS in oth dis,Angina pectoris NEC/NOS
Admission Date:  [**2144-2-26**]              Discharge Date:   [**2144-3-10**]

Date of Birth:  [**2072-12-5**]             Sex:   F

Service: MEDICINE

Allergies:
Cardizem / Codeine / Optiray 300 / Heparin Agents

Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
None

History of Present Illness:
This is a 71 yo female with h/o CAD s/p CABG '[**38**], recent
hospitalization from [**Date range (1) 22383**] for UTI and CHF exacerbation, who
presents again with shortness of breath similar to previous
presention. Pt was discharged on Lasix and followed up with her
PCP, [**Name10 (NameIs) 1023**] noted that the patient had lost 8 pounds and Cr had
bumped from 2.0 -> 2.6. Her lasix was held and pt now presents
again with progressive shortness of breath. It got very bad this
AM with associated substernal chest discomfort that felt like a
pressure, and she was brought into the ED.
.
In the ED, a CXR was taken which shows pulmonary edema, but
could not exclude underlying pneumonia. EKG at the time showed
TWIs in I/aVL and ST depressions in V5-V6, only the TWI in I
being new. Initial enzymes negative x1. She was given 100 mg IV
Lasix, put out 1L, felt much better and transferred to the
floor.
.
On the floor, she notes that she has had a dry cough, feels like
there's something to bring up but cannot. No fever/chills/NS. No
chest pain currently, only mildly short of breath. She has 2
pillow orthopnea at baseline, no PND.
.
Pt also notes chronic left anterior thigh pain, for which she
has had some relief with gabapentin. Opiates were initially
tried, but she developed severe nausea/vomiting and
constipation.
.
ROS:
(+) Rhinorhea on and off for 1 year.
(-) Denies headache, sinus tenderness, or congestion. Denied
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
.


Past Medical History:
1. CAD s/p CABG in [**2138**] - Followed by Dr. [**Last Name (STitle) **]
- MI in [**2122**]
- CABG [**2138**] = LIMA-->LAD, VG-->OM, VG--->RCA
- Exercise MIBI ([**3-2**]): Interval development of moderate,
reversible distal anterior wall and apical perfusion defect,
involving the expected LAD territory. Stable, moderate,
predominantly fixed perfusion defect involving the lateral wall

and lateral portion of the inferior wall. Normal left
ventricular cavity size. Mildly depressed left ventricular
function with hypokinesis of the apex and septal akinesis, the
latter being consistent with prior CABG. EF 46%.
- TTE [**6-30**]: EF 40-45%, 2+ TR, 1+ MR
2. AAA - [**3-2**] Abd MRI showed infrarenal AAA 5 x 6 cm with
diffuse atherosclerotic change
- [**2142-7-6**] - underwent endovascular repair of abdominal aortic
aneurysm
- complicated by left external iliac artery avulsion (?apparent

intra-op rupture of iliac) s/p left iliac stent graft to left
CFA, bilateral femoral endartectomies and rt CFA patch
angioplasty [**2142-7-7**] with right groin washout [**2142-7-8**] (for ?
lymphatic leak)
3. DM type II: for 20 years typically under good control unless

she is sick
4. Cryptogenic cirrhosis (?NASH) c/b esophgeal varices and
portal gastropathy, + ttG in [**7-29**]
5. Pancytopenia, uncertain etiology
6. CRI (baseline 1.9)
7. h/o PUD
8. h/o LGIB due to AVM
9. + HIT [**7-30**]
10. Ecoli UTI resistant to bactrim and cipro
11. No prior history of blood clot per her report.
.


Social History:
Ms. [**Known lastname 22321**] [**Last Name (Titles) 22381**] worked as a hairdresser, retired ~5-10 years
ago. She quit tobacco 20 yrs ago (started smoking at 17 yo,
1-2pks/day, unfiltered), rare EtOH. She is divorced but lives
with her son, who helps manages her meds. Has 2 daughters who
work at [**Hospital1 18**] in [**Name (NI) 13042**]. Has another daughter. [**Name (NI) **] her children
and her 7 grandchildren live in the [**Location (un) 86**] area.

Family History:
Her mother had non-alcoholic liver cirrhosis and diabetes type
2. Her father had diabetes and died of lung cancer. One of her
daughters and her son have both required
pacemakers/defibrillators for heart disease. She had a brother
who died of a brain tumor and has an older sister who is
generally in good health. No family history of blood clots.

Physical Exam:
Vitals: T: 98.1 P: 60 BP: 126/50 R: 22 SaO2: 93% 2.5L
General: Awake, alert, mild respiratory distress.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, JVD to mandible, no carotid bruits appreciated
Pulmonary: Lungs with diffuse coarse crackles.
Cardiac: RRR, nl. S1S2, +early 2/6 systolic murmur heard equally
over all heart valves
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: 1+ edema bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor
-DTRs: 2+ patellar bilaterally.
.


Pertinent Results:
[**2144-2-26**] 06:50AM   CK-MB-NotDone proBNP-8900*
[**2144-2-26**] 06:50AM   CK(CPK)-30
[**2144-2-26**] 06:50AM   cTropnT-0.02*
[**2144-2-26**] 06:50AM   WBC-3.9* RBC-4.05* HGB-11.5* HCT-33.8* MCV-83
MCH-28.5 MCHC-34.1 RDW-17.7*
[**2144-2-26**] 06:50AM   NEUTS-81.3* LYMPHS-12.4* MONOS-5.6 EOS-0.5
BASOS-0.3
[**2144-2-26**] 01:50PM   CK-MB-2 cTropnT-0.09*
[**2144-2-26**] 01:50PM   CK(CPK)-27
[**2144-2-26**] 10:15PM   CK(CPK)-39
[**2144-2-26**] 10:15PM   UREA N-60* CREAT-2.5*
[**2144-2-26**] 10:15PM   CK-MB-NotDone cTropnT-0.02*
.
[**2-26**] IMPRESSION: AP chest compared to [**2143-2-4**]:
Moderately severe pulmonary edema is probably responsible for
the increasing opacification in both lower lungs since [**2-4**], taken in the setting of chronic pulmonary [**Month (only) 1106**] congestion
and baseline interstitial edema. Nevertheless the relatively
focal opacification in the right mid and both lower lung zones
could represent coexistent pneumonia. Small bilateral pleural
effusions are probably present. Heart size top normal,
unchanged.
.

Brief Hospital Course:
71 yo female with h/o CAD s/p CABG '[**38**], recent hospitalization
from [**Date range (1) 22383**] for UTI and CHF exacerbation, who presents again
with CHF exacerbation due to recent decrease in diuresis. Brief
hospital course by problem below:
.
#) Dyspnea: likely [**2-28**] failure given recent d/c of lasix. In
difficult position [**2-28**] intravascular volume depletion with Cr
remaining elevated to 2.6. Also ? of PNA given CXR findings.
Initially given Lasix 100mg IV in ED with good response,
continued to diurese as needed to keep O2 sats up and decrease
work of breathing.   Ruled out MI with CEx3, and was not a
candidate for intervention anyway given HIT+ and multiple
comorbities. Unlikely component of pneumonia given unproductive
cough, absence of fever and no bump in WBC; however, given
ambiguous CXR possibly having underlying pneumonia, giving
levfloxacin 250 daily starting [**2-28**]. Gave Nitro paste prn for
chest discomfort. Consulted cards: recent echo from [**2144-2-3**] with
normal EF, mild MR. Unlikely to have changed in interim.
[**Hospital 22384**] medical management by d/c'ing nadolol, started Coreg
12.5 [**Hospital1 **], Imdur changed to 180 daily and titrated up to 240,
Hydral changed to 50mg tid and then increased to 75mg tid as
pressure tolerated.  For diuresis, pt needed increasing doses to
keep her O2 level>92%, eventually up to 340mg IV lasix in one
day (120 AM, 100 afternoon, 120 PM) and still requiring 15L NRB,
so pt sent to CCU for lasix drip and closer monitoring. In the
CCU she was stabilized with a Lasix drip and then called out to
the floor with the impression that her dyspnea was
multi-factorial, including will pneumonia (levofloxacin d/c'ed
s/p 10 day course) and anemia with dyspnea improving when Hct
>30, transfusing as necessary.
.
#) Acute on Chronic Renal Failure: etiology likely related to
DM2 and chronic intravascular depletion. Lasix only as needed
above so as to avoid intravascular depletion. Helding ACE-I.
Renal consult to help manage fluid balance- added zaroxyln to
lasix initially, but changed to diuril with lasix as it is given
IV and may bypass problems if pt has bowel wall edema.  After
return from CCU, pt was d/c'ed on 120mg [**Hospital1 **] PO lasix.
.
#) Pancytopenia: chronic of unknown etiology; likely [**2-28**] liver
disease (cryptogenic cirrhosis). D/c'ed on home dose of EPO.
.
#) DM2: continued Lantus 28u daily, [**1-28**] if pt not eating, SSI.
.
#) Code Status: Full, confirmed with patient [**2144-2-26**]
.

Medications on Admission:
1. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day [held
since [**2-25**] AM]
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. Epoetin Alfa 2,000 unit/mL Solution Sig: 1000 (1000) units
Injection Qweek.
5. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO BID (2 times a
day).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6

hours).
9. Moexipril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
BID
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
12. Lantus Insulin 27 units + SSI


Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for pain: For
chest pain; take one every five minutes up to three times; if it
does not work, please call your PCP or come to the ED.
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: Four (4) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*120 Tablet Sustained Release 24HR(s)* Refills:*2*
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
10. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
Disp:*12 injection* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
12. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Take with the 25mg tab.
Disp:*60 Tablet(s)* Refills:*2*
13. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day:
Take with 3.125 mg tablet.
Disp:*60 Tablet(s)* Refills:*2*
14. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
Disp:*50 neb* Refills:*2*
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
Disp:*50 neb* Refills:*2*
17. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous at bedtime.
Disp:*qs 1 month units* Refills:*2*
18. Home O2
Home O2 at 2L/minute continuous; pulse dose for portability


Discharge Disposition:
Home With Service

Facility:
Shouthshore VNA

Discharge Diagnosis:
Primary Diagnoses:
-CHF exacerbation
-Pneumonia
-Acute renal failure
Secondary Diagnoses:
-CAD
-AAA
-DM2
-cryptogenic cirrhosis
-pancytopenia
-CRI
-HIT


Discharge Condition:
Stable


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Your
ideal body weight is 140 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1200 mL
.
Return to the ED or call your PCP if you have:
-fever, chills, night sweats
-chest pain, shortness of breath, palpitations
-nausea, vomiting, diarrhea
-any new or concerning symptoms
.

Followup Instructions:
The following appointments have been made for you:
.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2144-3-17**]
11:10
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2144-6-5**] 10:20
.


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]

Completed by:[**2144-6-21**]
{'Congestive heart failure, unspecified,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Cirrhosis of liver without mention of alcohol,Chronic kidney disease, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Aortocoronary bypass status,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Other and unspecified angina pectoris'}


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

PRESENT ILLNESS: This is a 71 yo female with h/o CAD s/p CABG '[**38**], recent
hospitalization from [**Date range (1) 22383**] for UTI and CHF exacerbation, who
presents again with shortness of breath similar to previous
presention. Pt was discharged on Lasix and followed up with her
PCP, [**Name10 (NameIs) 1023**] noted that the patient had lost 8 pounds and Cr had
bumped from 2.0 -> 2.6. Her lasix was held and pt now presents
again with progressive shortness of breath. It got very bad this
AM with associated substernal chest discomfort that felt like a
pressure, and she was brought into the ED.
.
In the ED, a CXR was taken which shows pulmonary edema, but
could not exclude underlying pneumonia. EKG at the time showed
TWIs in I/aVL and ST depressions in V5-V6, only the TWI in I
being new. Initial enzymes negative x1. She was given 100 mg IV
Lasix, put out 1L, felt much better and transferred to the
floor.
.
On the floor, she notes that she has had a dry cough, feels like
there's something to bring up but cannot. No fever/chills/NS. No
chest pain currently, only mildly short of breath. She has 2
pillow orthopnea at baseline, no PND.
.
Pt also notes chronic left anterior thigh pain, for which she
has had some relief with gabapentin. Opiates were initially
tried, but she developed severe nausea/vomiting and
constipation.
.
ROS:
(+) Rhinorhea on and off for 1 year.
(-) Denies headache, sinus tenderness, or congestion. Denied
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
.

MEDICAL HISTORY: 1. CAD s/p CABG in [**2138**] - Followed by Dr. [**Last Name (STitle) **]
- MI in [**2122**]
- CABG [**2138**] = LIMA-->LAD, VG-->OM, VG--->RCA
- Exercise MIBI ([**3-2**]): Interval development of moderate,
reversible distal anterior wall and apical perfusion defect,
involving the expected LAD territory. Stable, moderate,
predominantly fixed perfusion defect involving the lateral wall

MEDICATION ON ADMISSION: 1. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day [held
since [**2-25**] AM]
2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

ALLERGIES: Cardizem / Codeine / Optiray 300 / Heparin Agents

PHYSICAL EXAM: Vitals: T: 98.1 P: 60 BP: 126/50 R: 22 SaO2: 93% 2.5L
General: Awake, alert, mild respiratory distress.
HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted, MMM, no lesions noted in OP
Neck: supple, JVD to mandible, no carotid bruits appreciated
Pulmonary: Lungs with diffuse coarse crackles.
Cardiac: RRR, nl. S1S2, +early 2/6 systolic murmur heard equally
over all heart valves
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: 1+ edema bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor
-DTRs: 2+ patellar bilaterally.
.

FAMILY HISTORY: Her mother had non-alcoholic liver cirrhosis and diabetes type
2. Her father had diabetes and died of lung cancer. One of her
daughters and her son have both required
pacemakers/defibrillators for heart disease. She had a brother
who died of a brain tumor and has an older sister who is
generally in good health. No family history of blood clots.

SOCIAL HISTORY: Ms. [**Known lastname 22321**] [**Last Name (Titles) 22381**] worked as a hairdresser, retired ~5-10 years
ago. She quit tobacco 20 yrs ago (started smoking at 17 yo,
1-2pks/day, unfiltered), rare EtOH. She is divorced but lives
with her son, who helps manages her meds. Has 2 daughters who
work at [**Hospital1 18**] in [**Name (NI) 13042**]. Has another daughter. [**Name (NI) **] her children
and her 7 grandchildren live in the [**Location (un) 86**] area. 

### Response:
{'Congestive heart failure, unspecified,Acute kidney failure, unspecified,Pneumonia, organism unspecified,Cirrhosis of liver without mention of alcohol,Chronic kidney disease, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Aortocoronary bypass status,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Other and unspecified angina pectoris'}
