CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: 70M sent from [**Hospital1 1501**] w/ h/o recent PNA, as well as CHF, COPD
presents after noted to be dyspneic and hypoxic at [**Hospital1 1501**]. Room air
sat on arrival was low 80s, was given O2, Steroids, Bipap, and
rose to 90s-100s. HR initially 130s-> improved to 110s.
Transiently dropped pressure to 80s, but came up spontaneously.
Gas 7.31/67/85 on Bipap. Pt adamantly refused intubation in ED,
initially agreed to short term BIPAP, refusing after short trial
in MICU. He states his breathing currently feels well. Pt states
he has 4 sons, but he wants to make his own medical decisions,
and is very clear that he does not want intubation. He denies
any recent fever, chills, chest pain, abdominal pain. He has
lower back pain where is he noted to have diffusely macerated
skin. Initial trial at foley insertion with pus returned. Pt
states he has chronic indwelling foley after past surgery.
.
In ED labs significant for BNP 3800, elevated troponin with Cr
1.0, although prior hx of renal failure. Also noted to have RBBB
on EKG, but no STT changes per ED. CXR limited by motion. Given
Vanco/levo in ED in addition to 20mg lasix IV.
.
Pt refused intubation in ED, prior documentation at rehab with
full code.

MEDICAL HISTORY: most per phone conversation with rehab nurse:
DM II
HTN
COPD (on 3-4L NC O2 per pt)
CHF
CAD
ARF
Hemorrhagic cystitis
Skin ulcers

MEDICATION ON ADMISSION: ASA 81mg daily
Cyclopentolate drops L eye [**Hospital1 **]
Dexamethasone maxidex 5mL [**Hospital1 **] L eye
brinzolamide 5 mL L eye [**Hospital1 **]
Albuterol
Advair
Atrovent
FeSo4 300mg TID
Panptoprazole 40 mg [**Hospital1 **]
Losartan 50md daily
Toprol XL 75mg daily
Tramadol 50mg TID
Theophylline 300mg PO BID
Bumex 2mg PO QOD

ALLERGIES: Penicillins / Heparin Agents

PHYSICAL EXAM: Temp 98.4, BP 150/54, HR 112, RR 26, O2 sat 95% on 4L NC
GENERAL: elderly, obese male, mild respiratory distress, awaker,
fully oriented, coherent
HEENT: OP clear, anicteric, L nares with some fresh bleeding
NECK: full neck, unable to examine for JVD
CARDIOVASCULAR: regular tachycardic, no murmurs
LUNGS: diffuse wheezes, no crackles
ABDOMEN: obese, non-distended, non-tender
BACK: large area of erythema, macerated skin, and ulceration
starting at coccyx
EXTREMITIES:
NEURO: AAOx3, moves all extremities

FAMILY HISTORY: NC

SOCIAL HISTORY: has 4 sons, closest in [**Name (NI) **], states it is not a closely
knit family, does not want any of them to be primary decision
makers. 60 pack year smoking hx, previous heavy etoh hx, not
recently.
Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Acute on chronic diastolic heart failure,Acidosis,Pressure ulcer, lower back,Atrial fibrillation,Acute cystitis,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Benign neoplasm of bones of skull and face
Acute respiratry failure,Obs chr bronc w(ac) exac,Ac on chr diast hrt fail,Acidosis,Pressure ulcer, low back,Atrial fibrillation,Acute cystitis,Hypertension NOS,DMII wo cmp nt st uncntr,Ben neo skull/face bone
Admission Date:  [**2117-5-24**]              Discharge Date:   [**2117-6-2**]

Date of Birth:  [**2046-6-16**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Heparin Agents

Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
none

History of Present Illness:
70M sent from [**Hospital1 1501**] w/ h/o recent PNA, as well as CHF, COPD
presents after noted to be dyspneic and hypoxic at [**Hospital1 1501**]. Room air
sat on arrival was low 80s, was given O2, Steroids, Bipap, and
rose to 90s-100s. HR initially 130s-> improved to 110s.
Transiently dropped pressure to 80s, but came up spontaneously.
Gas 7.31/67/85 on Bipap. Pt adamantly refused intubation in ED,
initially agreed to short term BIPAP, refusing after short trial
in MICU. He states his breathing currently feels well. Pt states
he has 4 sons, but he wants to make his own medical decisions,
and is very clear that he does not want intubation. He denies
any recent fever, chills, chest pain, abdominal pain. He has
lower back pain where is he noted to have diffusely macerated
skin. Initial trial at foley insertion with pus returned. Pt
states he has chronic indwelling foley after past surgery.
.
In ED labs significant for BNP 3800, elevated troponin with Cr
1.0, although prior hx of renal failure. Also noted to have RBBB
on EKG, but no STT changes per ED. CXR limited by motion. Given
Vanco/levo in ED in addition to 20mg lasix IV.
.
Pt refused intubation in ED, prior documentation at rehab with
full code.

Note he was admitted to OSH mid [**Month (only) 116**] to [**2117-5-17**] after being found
on floor in feces. Treated that admit for ARF, hepatitis,
pneumonia.


Past Medical History:
most per phone conversation with rehab nurse:
DM II
HTN
COPD (on 3-4L NC O2 per pt)
CHF
CAD
ARF
Hemorrhagic cystitis
Skin ulcers


Social History:
has 4 sons, closest in [**Name (NI) **], states it is not a closely
knit family, does not want any of them to be primary decision
makers. 60 pack year smoking hx, previous heavy etoh hx, not
recently.

Family History:
NC

Physical Exam:
Temp 98.4, BP 150/54, HR 112, RR 26, O2 sat 95% on 4L NC
GENERAL: elderly, obese male, mild respiratory distress, awaker,
fully oriented, coherent
HEENT: OP clear, anicteric, L nares with some fresh bleeding
NECK: full neck, unable to examine for JVD
CARDIOVASCULAR: regular tachycardic, no murmurs
LUNGS: diffuse wheezes, no crackles
ABDOMEN: obese, non-distended, non-tender
BACK: large area of erythema, macerated skin, and ulceration
starting at coccyx
EXTREMITIES:
NEURO: AAOx3, moves all extremities


Pertinent Results:
EKG: irregular, tachycardic, RBBB, no ST changes or T wave
changes (same as previous read at prior hospitalization)
.
Admission CXR: very poor quality, lung volumes are low. There is
likely a left pleural effusion with associated atelectasis. No
large pneumothorax is identified.
.
Admission Labs:

[**2117-5-24**] 05:00AM   PT-12.9 PTT-24.0 INR(PT)-1.1
[**2117-5-24**] 05:00AM   HYPOCHROM-3+ ANISOCYT-2+ MICROCYT-2+
[**2117-5-24**] 05:00AM   NEUTS-76.4* LYMPHS-17.4* MONOS-4.3 EOS-1.0
BASOS-0.9
[**2117-5-24**] 05:00AM   WBC-17.0* RBC-4.07* HGB-10.6* HCT-35.3*
MCV-87 MCH-26.0* MCHC-30.0* RDW-19.7* PLT COUNT-531*
[**2117-5-24**] 05:00AM   CALCIUM-8.4 PHOSPHATE-4.2 MAGNESIUM-2.1
[**2117-5-24**] 05:00AM   CK-MB-7
[**2117-5-24**] 05:00AM   cTropnT-0.21* proBNP-3799*  CK(CPK)-118
[**2117-5-24**] 05:08AM   LACTATE-2.5*
[**2117-5-24**] 05:00AM   GLUCOSE-159* UREA N-12 CREAT-1.0 SODIUM-138
POTASSIUM-6.3* CHLORIDE-100 TOTAL CO2-29 ANION GAP-15
[**2117-5-24**] 05:30AM URINE  RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0
[**2117-5-24**] 05:30AM URINE  BLOOD-MOD NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2117-5-24**] 05:30AM URINE  COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.016
[**2117-5-24**] 05:31AM   K+-4.4
[**2117-5-24**] 05:31AM   TYPE-ART RATES-/40 PEEP-8 O2-80 PO2-84*
PCO2-67* PH-7.31* TOTAL CO2-35* BASE XS-4 AADO2-417 REQ O2-73
INTUBATED-NOT INTUBA VENT-SPONTANEOU
[**2117-5-24**] 10:12AM   LACTATE-1.4
[**2117-5-24**] 10:12AM   TYPE-ART O2-40 PO2-66* PCO2-64* PH-7.33*
TOTAL CO2-35* BASE XS-4 INTUBATED-NOT INTUBA
[**2117-5-24**] 12:03PM   ALBUMIN-3.2* MAGNESIUM-2.0
[**2117-5-24**] 12:03PM   ALT(SGPT)-15 AST(SGOT)-17 CK(CPK)-39 ALK
PHOS-139* TOT BILI-0.3
[**2117-5-24**] 12:03PM   CK-MB-NotDone cTropnT-0.19*
.
CXR [**6-1**]: AP semiupright view.  Evaluation is limited by patient
positioning and body habitus.  Cardiac and mediastinal contours
are unchanged.  There are moderate bilateral pleural effusions,
left greater than right, and basilar atelectasis, unchanged
compared to the previous study.
IMPRESSION:  Limited study. No interval change
.
R LENI [**5-28**]: IMPRESSION:  Limited study secondary to patient
body habitus.  No evidence of DVT seen within the right common
femoral, proximal superficial femoral, and popliteal veins.
.
Head CT [**5-24**]:
FINDINGS:  Patient motion and positioning within the scanner
somewhat limits assessment.  No intra- or extra-axial hemorrhage
is clearly identified.  There is no mass effect or shift of
normally midline structures.  The ventricles do not demonstrate
any hydrocephalus.  The basal cisterns are visualized. Paranasal
sinuses appear clear.  The patient is edentulous.  Soft tissue
structures appear unremarkable.
.
IMPRESSION:  Limited study.  No obvious intracranial hemorrhage
or mass
effect.
.
Note added at attending review: There is an incompletely
visualized expansile mass in the left maxillary alveolar ridge
and there is a partially calcified mass in the left frontal
sinus. Ct scan of the facial bones suggested.
.
CT Sinus, prelim read: 2.4 x 1.4 cm expansile mass in the left
maxillary alveolar ridge.  There is thinning of the cortical
margins and areas of focal dehiscense.  The findings may be
consistent with an ameloblastoma.  Partially calcified mass in
the left frontal sinus. Right maxillary and ethmoid sinus
mucosal thickening.
.
TTE:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or  color Doppler. There is moderate symmetric left
ventricular hypertrophy. The  left ventricular cavity size is
normal. Due to suboptimal technical quality, a  focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular  cavity is mildly dilated. Right ventricular
systolic function is normal. The aortic root is moderately
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
There is no aortic valve stenosis. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary  artery systolic pressure is normal. There
is no pericardial effusion.
.
Urine Culture:
 URINE CULTURE (Final [**2117-5-27**]):
      PSEUDOMONAS AERUGINOSA.    >100,000 ORGANISMS/ML..
      PROTEUS MIRABILIS.    10,000-100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |          PROTEUS MIRABILIS
                             |          |
AMPICILLIN------------             =>32 R
AMPICILLIN/SULBACTAM--             =>32 R
CEFAZOLIN-------------               16 I
CEFEPIME--------------     2 S      <=1 S
CEFTAZIDIME-----------     4 S      <=1 S
CEFTRIAXONE-----------              <=1 S
CEFUROXIME------------                4 S
CIPROFLOXACIN---------   =>4 R      =>4 R
GENTAMICIN------------   <=1 S     =>16 R
IMIPENEM--------------   <=1 S
LEVOFLOXACIN----------              =>8 R
MEROPENEM-------------<=0.25 S   <=0.25 S
PIPERACILLIN----------     8 S       32 I
PIPERACILLIN/TAZO-----     8 S      <=4 S
TOBRAMYCIN------------   <=1 S        8 I
TRIMETHOPRIM/SULFA----             =>16 R


Brief Hospital Course:
COPD exacerbation -  Initially admitted to the MICU. No previous
available ABG values, however initial ABG with partly
compensated respiratory acidosis and component of newly worsened
hypercarbia c/w COPD exacerbation. Pt became progressively
sedated over the course of HOD #1 -> continued on BIPAP, pCO2
trended up to 76 (ABG 7.31/76/154).  Pt became more arousable
overnight with continued BIPAP, repeat ABG 7.38/65/188.  He was
started on high dose steroids with solumedrol 125 mg q6hrs and
Q4H scheduled atrovent/albuterol nebs, q2hrs prn.  Placed on
ceftriaxone, azithromycin for cough, productive of yellow
sputum, recent pneumonia, finished a course of this in-house.
On HOD #2 pt. refused further positive pressure ventilation,
BiPAP, or intubation.  Repeat ABGs with pCO2 as high as 80,
pH>7.30.  Prednisone was tapered to 40 mg PO, and pt. was
transferred to the floor as he was refusing any invasive
ventilation.
.
On the floor pt. continued to have elevated PCO2 levels, which
peaked at 95 and then trended down to 70s.  Pt. had no further
sedation or AMS.  He maintained O2 sats 88-92% on 4 L
throughout.  Prednisone was weaned to 30 mg QD after 5 days at
40 mg, and a slow wean should be continued in rehab.
.
CHF exacerbation - EF 55-60% on TTE, evidence of diastolic
dysfunction (see results above).  Difficult to evaluate fluid
status on CXR although he did have marked LE edema on exam, and
elevated BNP suggested CHF exacerbation.  Diuresed with lasix
40mg IV bid, Bun/Cr stable in MICU, with ~ 1L negative QD in the
MICU.  This was initially continued on the floor, and then
decreased to 40 mg daily as he was 2-3 L negative daily -> 1-1.5
negative with 40 IV QD.  On discharge lasix was d/ced and Bumex
reinitiated at 1 mg QD, along with aldactone, which was started
for K+ sparing and to avoid contraction alkalosis.
.
# CAD - elevated troponin on presentation suggestive of previous
ischemic event, trended down.  Continued ASA, metoprolol,
losartan.  No need for statin based on lipids, LDL<70.  Noted to
have allergic reaction to heparin in past, appears most likely
had thrombocytopenia?, but HIT negative.  Covered with
Fondaparinux for DVT prophylaxis in house as it is safe if he
really did have HIT in past.
.
# HTN - continued losartan, metoprolol.  Started on Aldactone on
discharge for K+ sparing and to avoid contraction alkalosis (pt.
was beginning to develop a contraction alkalosis from lasix).
.
# A Fib: continued beta-blocker.  Elected not to anti-coagulate
given acute illness, bleeding risk, though this should be
considered in the future. He had converted back to NSR at 65 BPM
by discharge.
.
# Mass L maxillary ridge- this was noted incidentally on Head CT
performed in MICU.  It was followed up with a CT sinus, the
prelim read of which showed a mass concerning for ameloblastoma.
 ENT was consulted and recommended outpatient work-up by OMFS
and ENT (Dr. [**First Name (STitle) **] from ENT reviewed imaging and felt that it
was c/w frontal sinus osteoma).  Final read of sinus CT was
pending at time of discharge and should be follow up by Dr.
[**First Name (STitle) **]. He will see Dr. [**First Name (STitle) **] in about 2 weeks.

# UTI - treated with ceftriaxone and then cefepime in-house and
discharged on the rest of a 12 day course (see urine culture
above)
.
# Decubitus ulcer - no clear cellulitis, but given past
colonization with MRSA, elevated WBC, initially covered with
vancomycin, stopped after cx's negative x48 hrs, afebrile.
- frequent turns
- continued skin care as recommended by wound care consult (see
page 2 attached)
.
# FEN: cardiac diet
.
* Prophylaxis: no heparin products given previous allergy.
Pneumoboots/Fondaparinux, PPI.
.
* Code status: DNR/DNI, no non-invasive ventilation per several
discussions with pt.

By discharge the patient was much improved but still
significantly SOB with any exertion in bed.  He needs more
diuresis. At rest his Sa02 was 92-96% on [**2-13**] L o2.


Medications on Admission:
ASA 81mg daily
Cyclopentolate drops L eye [**Hospital1 **]
Dexamethasone maxidex 5mL [**Hospital1 **] L eye
brinzolamide 5 mL L eye [**Hospital1 **]
Albuterol
Advair
Atrovent
FeSo4 300mg TID
Panptoprazole 40 mg [**Hospital1 **]
Losartan 50md daily
Toprol XL 75mg daily
Tramadol 50mg TID
Theophylline 300mg PO BID
Bumex 2mg PO QOD


Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
2. Regular Insulin Sliding Scale
please check FS before meals and at bedtime and administer
insulin per sliding scale attached
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Cyclopentolate 1 % Drops Sig: Two (2) Drop Ophthalmic  [**Hospital1 **] (2
times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Dexamethasone 0.1 % Drops, Suspension Sig: Two (2) Drop
Ophthalmic  Q12H (every 12 hours).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  QID
(4 times a day) as needed.
9. Multivitamin     Capsule Sig: One (1) Cap PO DAILY (Daily).
10. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days: [**Date range (1) 110167**]/26.
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO
twice a day.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q4-6H (every 4 to 6 hours) as needed.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Cefepime 1 g Recon Soln Sig: One (1) Recon Soln Intravenous
Q12H (every 12 hours) for 2 days.
17. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-14**] Sprays Nasal
QID (4 times a day) as needed.
18. Fondaparinux 2.5 mg/0.5 mL Syringe Sig: One (1)
Subcutaneous once a day.
19. Bumex 1 mg Tablet Sig: One (1) Tablet PO once a day.
20. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day.
21. Brinzolamide 1 % Drops, Suspension Sig: Five (5) mL
Ophthalmic  twice a day: 5 mL L eye [**Hospital1 **].


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary: COPD Exacerbation, Diastolic CHF, Frontal Sinus Osteoma
.
Secondary:
Type II DM, well-controlled
HTN
CAD
Morbid obesity
Decubitus Ulcer
Hemorrhagic cystitis


Discharge Condition:
Stable, O2 sats 88-92% on 4L (on home O2)


Discharge Instructions:
Please call your doctor or go to the ER if you have any
shortness of breath, chest pain, fevers, chills, cough, or any
other symptoms that concern you.
.
Please take all medications as prescribed

Followup Instructions:
Oral Surgery: You have an appointment scheduled with Dr. [**Last Name (STitle) **]
on Tuesday, [**7-13**] at 2:00.  His office is located at [**Street Address(2) 110168**], [**Apartment Address(1) 110169**], [**Location (un) **], phone # [**Telephone/Fax (1) 110170**].  You had
a mass in one of the bones in your face that he will follow up
further.
.
ENT: You have an appointment scheduled with Dr. [**First Name (STitle) **] on Friday,
[**6-18**] at 8:30AM.  His office is located at [**Location (un) **].,
[**Apartment Address(1) **].  Please call his office at [**Telephone/Fax (1) 2349**] with any
questions.
.
Primary Care: Please call your primary care doctor to set up a
follow up appointment in the next 1-2 weeks.



Completed by:[**2117-6-2**]
{'Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Acute on chronic diastolic heart failure,Acidosis,Pressure ulcer, lower back,Atrial fibrillation,Acute cystitis,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Benign neoplasm of bones of skull and face'}


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: dyspnea

PRESENT ILLNESS: 70M sent from [**Hospital1 1501**] w/ h/o recent PNA, as well as CHF, COPD
presents after noted to be dyspneic and hypoxic at [**Hospital1 1501**]. Room air
sat on arrival was low 80s, was given O2, Steroids, Bipap, and
rose to 90s-100s. HR initially 130s-> improved to 110s.
Transiently dropped pressure to 80s, but came up spontaneously.
Gas 7.31/67/85 on Bipap. Pt adamantly refused intubation in ED,
initially agreed to short term BIPAP, refusing after short trial
in MICU. He states his breathing currently feels well. Pt states
he has 4 sons, but he wants to make his own medical decisions,
and is very clear that he does not want intubation. He denies
any recent fever, chills, chest pain, abdominal pain. He has
lower back pain where is he noted to have diffusely macerated
skin. Initial trial at foley insertion with pus returned. Pt
states he has chronic indwelling foley after past surgery.
.
In ED labs significant for BNP 3800, elevated troponin with Cr
1.0, although prior hx of renal failure. Also noted to have RBBB
on EKG, but no STT changes per ED. CXR limited by motion. Given
Vanco/levo in ED in addition to 20mg lasix IV.
.
Pt refused intubation in ED, prior documentation at rehab with
full code.

MEDICAL HISTORY: most per phone conversation with rehab nurse:
DM II
HTN
COPD (on 3-4L NC O2 per pt)
CHF
CAD
ARF
Hemorrhagic cystitis
Skin ulcers

MEDICATION ON ADMISSION: ASA 81mg daily
Cyclopentolate drops L eye [**Hospital1 **]
Dexamethasone maxidex 5mL [**Hospital1 **] L eye
brinzolamide 5 mL L eye [**Hospital1 **]
Albuterol
Advair
Atrovent
FeSo4 300mg TID
Panptoprazole 40 mg [**Hospital1 **]
Losartan 50md daily
Toprol XL 75mg daily
Tramadol 50mg TID
Theophylline 300mg PO BID
Bumex 2mg PO QOD

ALLERGIES: Penicillins / Heparin Agents

PHYSICAL EXAM: Temp 98.4, BP 150/54, HR 112, RR 26, O2 sat 95% on 4L NC
GENERAL: elderly, obese male, mild respiratory distress, awaker,
fully oriented, coherent
HEENT: OP clear, anicteric, L nares with some fresh bleeding
NECK: full neck, unable to examine for JVD
CARDIOVASCULAR: regular tachycardic, no murmurs
LUNGS: diffuse wheezes, no crackles
ABDOMEN: obese, non-distended, non-tender
BACK: large area of erythema, macerated skin, and ulceration
starting at coccyx
EXTREMITIES:
NEURO: AAOx3, moves all extremities

FAMILY HISTORY: NC

SOCIAL HISTORY: has 4 sons, closest in [**Name (NI) **], states it is not a closely
knit family, does not want any of them to be primary decision
makers. 60 pack year smoking hx, previous heavy etoh hx, not
recently. 

### Response:
{'Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Acute on chronic diastolic heart failure,Acidosis,Pressure ulcer, lower back,Atrial fibrillation,Acute cystitis,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Benign neoplasm of bones of skull and face'}
