CHIEF COMPLAINT: Massive hemoptysis

PRESENT ILLNESS: 66 yo M with history of thyroid ca metastatic to lungs
bilaterally and to brain and bone, presents to the ED after
presenting to OSH with hemoptysis. He was transferred
immediately to [**Hospital1 18**] and once arrived had multiple cupfuls of
hemoptysis. He was intubated and taken to the OR for rigid
bronch to locate the source of bleeding. Will need angio for
embolization once source is localized. He was recently given a
prescription for sorafenib, but it is unclear if he actually had
started this treatment. Of note, he was admitted to [**Hospital1 18**] in
[**7-28**] with hemoptysis (two small episodes) for which he underwent
bronchoscopic evaluation which demonstrated a likelihood of
suspicious lesions in the right upper lobe and left superior
lingula with no active bleeding. He was discharged at that time
with therapeutic INR. Ortho was consulted to evaluate patient's
current status of known lytic lesions in C1.

MEDICAL HISTORY: Metastatic Thyroid Ca
HTN
Atrial Fibrillation
Pulmonary Embolus [**1-28**] - Anticoagulated with coumadin; has
two small lesions on MRI head c/w mets but not contraindications

MEDICATION ON ADMISSION: ATENOLOL 50 mg--0.5 (one half) tablet(s) by mouth twice a day
GABAPENTIN 100 mg--
Levothyroxine 200 mcg--1 (one) tablet(s) by mouth once a day
Levothyroxine 25 mcg--0.5 (one half) tablet(s) by mouth mon,
wed, fri
OXYCONTIN 40 mg--1 (one) tablet(s) by mouth three times a day
SORAFENIB 800 mg once a day to be administered at 400 mg b.i.d.
doses (script given [**11-28**])
LOVENOX

ALLERGIES: Iodine; Iodine Containing

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: Temp: 96.0 (oral) BP: 102/51 HR: 64 RR: 15 O2sat 100% on A/c
550x15 FiO2 1, peep 5
GEN: intubated, sedated
HEENT: PERRL, anicteric, MM dry, dried blood around nares
NECK: hard collar in place - unable to assess JVP
RESP: Diffuse rhonchi and insp/exp wheezes
CV: RR, S1 and S2 wnl, no m/r/g
ABD: mildly distended, +b/s, soft, tympanitic to percussion
RLE: [**Last Name (un) 938**]/DF/PF intact, [**Last Name (un) 36**] intact to LT over tib/sp/dp,
palpable DP
SKIN: no rashes/no jaundice, pale
NEURO: bilateral downgoing babinski. will reassess when sedation
is weaned.

FAMILY HISTORY: Mother with h/o emphysema.

SOCIAL HISTORY: Lives with wife.  [**Name (NI) 1403**] part time in real estate building and
development and is still currently working.  Retired from full
time work in [**2157-9-22**].
Smoked approximately 30 years ago (quit in [**2126**])
EtOH: drinks 1 glass wine/day
Secondary malignant neoplasm of lung,Acute respiratory failure,Pathologic fracture of neck of femur,Secondary malignant neoplasm of bone and bone marrow,Acute posthemorrhagic anemia,Other iatrogenic hypotension,Other sedatives and hypnotics causing adverse effects in therapeutic use,Personal history of malignant neoplasm of thyroid,Thrombocytopenia, unspecified,Personal history of venous thrombosis and embolism,Atrial fibrillation,Unspecified essential hypertension,Postsurgical hypothyroidism
Secondary malig neo lung,Acute respiratry failure,Path fx neck of femur,Secondary malig neo bone,Ac posthemorrhag anemia,Iatrogenc hypotnsion NEC,Adv eff sedat/hypnot NEC,Hx of thyroid malignancy,Thrombocytopenia NOS,Hx-ven thrombosis/embols,Atrial fibrillation,Hypertension NOS,Postsurgical hypothyroid
Admission Date:  [**2160-1-18**]              Discharge Date:   [**2160-2-12**]

Date of Birth:  [**2093-10-4**]             Sex:   M

Service: ORTHOPAEDICS

Allergies:
Iodine; Iodine Containing

Attending:[**First Name3 (LF) 4277**]
Chief Complaint:
Massive hemoptysis

Major Surgical or Invasive Procedure:
1. Rigid Bronchoscopy
2. Pulmonary angiography, s/p bilateral bronchial artery
embolization
3. Right hip long stem bipolar hemiarthroplasty
4. Curretage right proximal and distal femur lesions

History of Present Illness:
66 yo M with history of thyroid ca metastatic to lungs
bilaterally and to brain and bone, presents to the ED after
presenting to OSH with hemoptysis. He was transferred
immediately to [**Hospital1 18**] and once arrived had multiple cupfuls of
hemoptysis. He was intubated and taken to the OR for rigid
bronch to locate the source of bleeding. Will need angio for
embolization once source is localized. He was recently given a
prescription for sorafenib, but it is unclear if he actually had
started this treatment. Of note, he was admitted to [**Hospital1 18**] in
[**7-28**] with hemoptysis (two small episodes) for which he underwent
bronchoscopic evaluation which demonstrated a likelihood of
suspicious lesions in the right upper lobe and left superior
lingula with no active bleeding. He was discharged at that time
with therapeutic INR. Ortho was consulted to evaluate patient's
current status of known lytic lesions in C1.

On review of his past oncologic history, he was diagnosed in
[**2149**] when he developed significant snoring related problems that
required seeking medical attention.  He saw an
otorhinolaryngologist who at that time reported that he had neck
swelling which was contributing to his snoring and which was
likely related to a thyroid process.  He then reported that he
had this swelling for about 10 years prior to this presentation,
but a workup had not been performed at that time.  A surgical
resection demonstrated a papillary carcinoma.  He subsequently
received radioactive iodine therapy for this disease and
appeared to have tolerated it well.  His treatment was
complicated by atrial fibrillation, and was placed on atenolol.
He subsequently required repetition of his radioactive iodine
treatments because of elevated thyroglobulin levels as well as
because of the appearance of new lung metastases.  In the last
few months, the patient developed right-sided chest discomfort
on exertion localized to the right rib cage. He was started on
coumadin in [**1-28**] for a PE and in the summer of [**2159**], the patient
had two episodes of hemoptysis during exertion, which required a
bronchoscopic evaluation and ablation of the lesion.  Pathology
from this lesion demonstrated metastatic carcinoma of a thyroid
origin. He was subsequently admitted with hemoptysis and
underwent a bronchoscopic evaluation and control of his
bleeding. PET scan evaluation revealed a significant increase in
his disease burden, as well as multiple sites of uptake in the
skeleton. A Thyrogen scan did not reveal Iodine uptake.

He was admitted to the MICU for further work-up and management
after rigid bronchoscopy.


Past Medical History:
Metastatic Thyroid Ca
HTN
Atrial Fibrillation
Pulmonary Embolus [**1-28**] - Anticoagulated with coumadin; has
two small lesions on MRI head c/w mets but not contraindications

to anticoag.
Hypothyroidism

Social History:
Lives with wife.  [**Name (NI) 1403**] part time in real estate building and
development and is still currently working.  Retired from full
time work in [**2157-9-22**].
Smoked approximately 30 years ago (quit in [**2126**])
EtOH: drinks 1 glass wine/day


Family History:
Mother with h/o emphysema.

Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp: 96.0 (oral) BP: 102/51 HR: 64 RR: 15 O2sat 100% on A/c
550x15 FiO2 1, peep 5
GEN: intubated, sedated
HEENT: PERRL, anicteric, MM dry, dried blood around nares
NECK: hard collar in place - unable to assess JVP
RESP: Diffuse rhonchi and insp/exp wheezes
CV: RR, S1 and S2 wnl, no m/r/g
ABD: mildly distended, +b/s, soft, tympanitic to percussion
RLE: [**Last Name (un) 938**]/DF/PF intact, [**Last Name (un) 36**] intact to LT over tib/sp/dp,
palpable DP
SKIN: no rashes/no jaundice, pale
NEURO: bilateral downgoing babinski. will reassess when sedation
is weaned.

Pertinent Results:
ADMISSION LBAS:
[**2160-1-18**] 03:15AM BLOOD WBC-11.3*# RBC-4.03* Hgb-12.3* Hct-37.9*
MCV-94 MCH-30.6 MCHC-32.4 RDW-13.3 Plt Ct-135*
[**2160-1-18**] 03:15AM BLOOD Neuts-58.9 Lymphs-34.2 Monos-5.0 Eos-1.6
Baso-0.3
[**2160-1-18**] 03:15AM BLOOD PT-13.8* PTT-30.3 INR(PT)-1.2*
[**2160-1-18**] 03:15AM BLOOD Plt Ct-135*
[**2160-1-18**] 04:04AM BLOOD Glucose-261* UreaN-21* Creat-1.0 Na-141
K-4.3 Cl-107 HCO3-26 AnGap-12

CARDIAC ENZYMES:
[**2160-1-18**] 03:15AM BLOOD cTropnT-0.03*
[**2160-1-18**] 04:04AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2160-1-18**] 04:04AM BLOOD CK(CPK)-68
[**2160-1-18**] 04:04AM BLOOD Calcium-8.4 Phos-5.5* Mg-2.0

[**2160-1-18**] 06:43AM BLOOD Type-[**Last Name (un) **] pO2-64* pCO2-93* pH-7.08*
calTCO2-29 Base XS--5 Intubat-INTUBATED

EKG: Sinus tachycardia with ST depressions in anteroseptal
leads.

IMAGING:
CXR: Inumerable small nodules c/w mets with marked progression
since [**7-28**], fluffy hilar infiltrates bilaterally c/w hemorrhage
given clinical scenario of hemoptysis. Tip of ET tube not
visualized.

[**2160-1-18**] Pulmonary Angiography:
No active extravasation but multiple hypervascular masses,
likely metastases.  Bronchial artery embolization was performed
bilaterally.

PET [**11-28**]: IMPRESSION: Diffuse abnormal FDG uptake in the lungs
and bone consistent with metastatic disease, which compared to
prior exam shows slight increase in disease burden. Again noted
are the large lytic lesions in the right femoral head/neck and
C1 which remains high risk for fracture.


Brief Hospital Course:
# Hemoptysis:
Mr. [**Known lastname 20598**] was admitted from an outside hospital with massive
hemoptysis.  Pulmonary angiogram on [**2160-1-18**] showed no active
extravasation but multiple hypervascular masses, likely
metastases.  Bilateral bronchial artery embolization was
performed without complication, and he was extubated several
hours after the procedure.  Hematocrit remained stable
overnight, and he was hemodynamically stable without further
episodes of hemoptysis.  Of note, as an outpatient he was on
lovenox at treatment doses for a PE that he had in [**1-28**].  In
addition, he was recently started on sorafenib, a VEGF pathway
inhibitor that carries a bleeding risk; he had two doses of the
medicine, the last of which was taken around [**2160-1-8**]. Per Dr.
[**Name (NI) **], pt will likely not be a candidate for continued sorafenib
therapy. He will need further oncologic options discussed as his
health improves.
.
The patient underwent pulmonary angiogram [**2160-1-18**] which showed
no active extravasation but was notable for multiple
hypervascular masses, thought to likely represent metastases.
Bilateral bronchial artery embolization was performed without
complication, and he was extubated several hours after the
procedure. Post-procedure, he was hemodynamically stable except
for an episode of difficult to control Afib with [**Month/Day/Year 5509**] (max rate
200's) thought to be precipitated by beta-blocker withdrawal
that converted with esmolol gtt, digoxin, and reinstitution of
metoprolol. As his hematocrit remained stable and he was without
further episodes of hemoptysis x 48 hours, he was transferred to
OMED for consideration of chemotherapy. Before transfer he did
spike a fever to 101 and was pan-cultured but no antibiotics
were started. Of note, he required no blood product transfusions
this admission.
.
On the floor, the patient began again to have small volume
hemoptysis (dark blood mixed with sputum per report) and was
noted to be hypoxic to 76-77% on 4L NC which improved to the 90%
on NRB. He also was febrile to 102.0 but otherwise
hemodynamically stable and in NAD. Labs notable for Hct decrease
trend from 29.5->28.5->26.5. CXR prelim read with slight
increase in diffuse fluffy bilateral opacities but otherwise
unchanged. He was transferred to the [**Hospital Ward Name 332**] ICU for close
monitoring and consideration of repeat rigid bronchoscopy, which
was ultimately not pursued (his more significant problem in the
[**Name (NI) 153**] was [**Name (NI) 5509**] as below).
.
As his admission proceeded and he was otherwise stable in the
[**Hospital Unit Name 153**], he continued to have some low-volume hemoptysis which
suggested that some portion of his prior hemoptysis was due to
the malignancy itself rather than other factors.

# Papillary Thyroid Cancer:
Mr. [**Known lastname 20598**] is a patient of Dr. [**Last Name (STitle) **].  Despite widespread and
progressive metastasis, he has been able to maintain a fairly
active lifestyle.  He was starting sorafenib therapy rather than
chemotherapy (tumor is iodine neg) as of [**11-28**]; he had two doses
of the medicine, the last of which was taken around [**2160-1-8**]. On
[**2160-1-19**] after embolization of the bronchial arteries, he was
transferred from the MICU to the oncology service, but then had
to return to the MICU after going to [**Date Range 5509**] once again. After
eventually being stabilized in the MICU he was again called out
to the floor for consideration of his oncology plan.

# Atrial Fibrillation:
Mr. [**Known lastname 20598**] has a history of AFib and was on atenolol 25 mg [**Hospital1 **]
for rate control (as well as BP control).  Atenolol was held
upon admission for relative hypotension in teh setting of
hemoptysis.  It was restarted on [**2160-1-19**] when he developed
tachycardia with HR > 200.  His HR improved to the 130 - 140 BPM
range with 25 mg IV of lopressor and 20 mg IV of diltiazem;
atenolol 25 mg [**Hospital1 **] was then restarted. The pt remained
asymptomatic during this time beyond complaints of palpitations
and SBPs did not drop lower than 87. HR remained in the 140-150s
range and esmolol gtt was started. The pt was also started on a
po digoxin load and spontaneously broke out of afib in NSR in
the 70s. Atenolol was also switched to metoprolol to allow
better in house titration of his HR.
.
When transferred to the [**Hospital Unit Name 153**], he had a number of additional
episodes of atrial fibrillation with [**Hospital Unit Name 5509**] which were controlled
with IV diltiazem or IV metoprolol. Early in his [**Hospital Unit Name 153**] admission
he actually had to be intubated given his unstable hemodynamics;
we attempted electrical cardioversion on [**1-21**], but this was
only very briefly successful. We continued to use digoxin and
metoprolol but we were initially concerned about the possibility
of using amiodarone because of its iodine content. Ultimately
after much discussion with endocrine and oncology, we judged use
of the amiodarone to be worth the potential cost (namely,
decreasing the possibility of radioactive iodine, a treatment
which had already failed him). As we loaded him on amiodarone we
ultimately discontinued the digoxin, without any further
significant episodes while in the [**Hospital Unit Name 153**]. Metoprolol was
discontinued because of some intermittent hypotension. He was to
switch from his loading dose to [**Hospital1 **] dosing on [**2160-1-31**].
Anticoagulation was not started because of his hemoptysis.
.
# h/o PE: The pt was on lovenox as an out-patient, which was
held on admission in the setting of the bleed. The risk vs.
benefits of restarting the pt on lovenox will need to be
determined.
.
# Cytopenia: Patient with anemia (baseline Hct 30) and
thrombocytopenia, possibly from bone marrow supression from
malignancy and chemo. Pt had not recieved heparin, so HIT was
judged to be a very unlikely cause of thrombocytopenia. Low Hct
is also likely due to marrow suppression, and prior hemoptysis.
.
#Pain - Seen by pain service. He has significant pain secondary
to bony mets and pathologic fracture of R femoral neck.
Currently on gabapentin, fentanyl patch and dilaudid PRN.
.
# Femoral fracture: Likely while undergoing attempts at
electrical cardioversion, Mr [**Known lastname 20598**] [**Last Name (Titles) 18095**] a pathologic R
femoral neck fracture. Orthopedics followed and towards the end
of his MICU stay began to plan for a possible surgery to
stabilize the fracture. For the patient, the most troubling
issue with the fracture is that it caused him significant pain
with any movement.
.
#. Hypotension: pt had multiple episodes of hypotension during
his [**Hospital Unit Name 153**] stay requiring fluid bolus, though has been stable x 72
hours. Possible etiologies included sepsis, adrenal
insufficiency, or fentanyl/midazolam causing hypotension. Sepsis
seems less likely given negative BCx and no clear source.
Adrenal insufficiency has been evaluated with cortisol level,
and given low albumin, endo feels a cortisol level of 20.5 rules
out adrenal insufficiency. Therefore, most likely cause is
iatrogenic [**2-23**] sedatives. In the latter part of his [**Hospital Unit Name 153**] stay
his pressure was stable, and he had not required further fluid
bolus.
.
Cervical spine metastasis followed by Dr [**Last Name (STitle) 548**] of Neurosurgery.
Follow up will be arranged by their service.  C-collar at all
times until follow up.
.
Patient was taken to the OR on [**2160-2-4**] for R hip long stem
bipolar hemiarthroplasty, tolerated the procedure well without
complications.  EBL: 500cc.  He was transferred to the
Orthopedic service post-operatively.  On POD 1 his Hgb was found
to be 7.4, he was transfused 2 units of pRBC's.  Re-check of the
Hgb on POD 2 found it to be 7.0, he was again transfused 2 units
of pRBC's.  On POD [**3-26**] his Hgb was stable at 8.5.  At discharge
he was tolerating PO, voiding spontaneously, and his pain was
well controlled.  He was hemodynamically stable and afebrile at
discharge.  He was cleared for safe discharge to rehab by PT.

Medications on Admission:
ATENOLOL 50 mg--0.5 (one half) tablet(s) by mouth twice a day
GABAPENTIN 100 mg--
Levothyroxine 200 mcg--1 (one) tablet(s) by mouth once a day
Levothyroxine 25 mcg--0.5 (one half) tablet(s) by mouth mon,
wed, fri
OXYCONTIN 40 mg--1 (one) tablet(s) by mouth three times a day
SORAFENIB 800 mg once a day to be administered at 400 mg b.i.d.
doses (script given [**11-28**])
LOVENOX


Discharge Medications:
1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day for every Mon, Wed, Fri days.
9. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO
SUN,TU,TH,SAT ().
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Oxycodone 40 mg Tablet [**Month/Year (2) **] Release 12 hr Sig: One (1)
Tablet [**Month/Year (2) **] Release 12 hr PO Q8H (every 8 hours).
12. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1)  Subcutaneous
DAILY (Daily) for 4 weeks.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
15. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]

Discharge Diagnosis:
Metastatic thyroid cancer

Discharge Condition:
Stable

Discharge Instructions:
1. C-collar at all times
2. Lovenox daily for 4 weeks
3. Change right thigh dressings daily until no drainage on guaze
4. Weight bearing as tolerated right lower extremity
5. Daily physical therapy to work on gait, strengthening and
range of motion
6. You may shower, no bathing
7. Please check weekly thyroid function tests (TSH, free T4),
report results to Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 1803**])
8. Please call if you develop fevers/chills, increasing pain,
redness and/or drainage from the incision sites
Physical Therapy:
Weight bearing as tolerated right lower extremity
C-collar at all times
Treatments Frequency:
Daily dry sterile dressing changes right lower extremity

Followup Instructions:
1. Follow up with Dr [**First Name (STitle) 4223**] in [**Hospital Ward Name 23**] [**Location (un) **] [**Hospital **]
clinic in 2 weeks with AP pelvis and AP and Lat of the R femur.
2. Follow up with Neurosurgery (Dr [**Last Name (STitle) 548**] by calling
[**Telephone/Fax (1) 1669**] to schedule an appointment.
3. Follow up with your primary care physician (Dr [**Last Name (STitle) 22933**] by
call ing [**Telephone/Fax (1) 22934**] to schedule an appointment in 1 week.
4. Dr [**Last Name (STitle) **] will call you with follow up time and date.
5. Follow up with Oncology medicine (Dr [**Last Name (STitle) **] by calling
[**Telephone/Fax (1) 13006**] to schedule an appointment in 2 weeks.
{'Secondary malignant neoplasm of lung,Acute respiratory failure,Pathologic fracture of neck of femur,Secondary malignant neoplasm of bone and bone marrow,Acute posthemorrhagic anemia,Other iatrogenic hypotension,Other sedatives and hypnotics causing adverse effects in therapeutic use,Personal history of malignant neoplasm of thyroid,Thrombocytopenia, unspecified,Personal history of venous thrombosis and embolism,Atrial fibrillation,Unspecified essential hypertension,Postsurgical hypothyroidism'}


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: Massive hemoptysis

PRESENT ILLNESS: 66 yo M with history of thyroid ca metastatic to lungs
bilaterally and to brain and bone, presents to the ED after
presenting to OSH with hemoptysis. He was transferred
immediately to [**Hospital1 18**] and once arrived had multiple cupfuls of
hemoptysis. He was intubated and taken to the OR for rigid
bronch to locate the source of bleeding. Will need angio for
embolization once source is localized. He was recently given a
prescription for sorafenib, but it is unclear if he actually had
started this treatment. Of note, he was admitted to [**Hospital1 18**] in
[**7-28**] with hemoptysis (two small episodes) for which he underwent
bronchoscopic evaluation which demonstrated a likelihood of
suspicious lesions in the right upper lobe and left superior
lingula with no active bleeding. He was discharged at that time
with therapeutic INR. Ortho was consulted to evaluate patient's
current status of known lytic lesions in C1.

MEDICAL HISTORY: Metastatic Thyroid Ca
HTN
Atrial Fibrillation
Pulmonary Embolus [**1-28**] - Anticoagulated with coumadin; has
two small lesions on MRI head c/w mets but not contraindications

MEDICATION ON ADMISSION: ATENOLOL 50 mg--0.5 (one half) tablet(s) by mouth twice a day
GABAPENTIN 100 mg--
Levothyroxine 200 mcg--1 (one) tablet(s) by mouth once a day
Levothyroxine 25 mcg--0.5 (one half) tablet(s) by mouth mon,
wed, fri
OXYCONTIN 40 mg--1 (one) tablet(s) by mouth three times a day
SORAFENIB 800 mg once a day to be administered at 400 mg b.i.d.
doses (script given [**11-28**])
LOVENOX

ALLERGIES: Iodine; Iodine Containing

PHYSICAL EXAM: ADMISSION PHYSICAL EXAM:
VS: Temp: 96.0 (oral) BP: 102/51 HR: 64 RR: 15 O2sat 100% on A/c
550x15 FiO2 1, peep 5
GEN: intubated, sedated
HEENT: PERRL, anicteric, MM dry, dried blood around nares
NECK: hard collar in place - unable to assess JVP
RESP: Diffuse rhonchi and insp/exp wheezes
CV: RR, S1 and S2 wnl, no m/r/g
ABD: mildly distended, +b/s, soft, tympanitic to percussion
RLE: [**Last Name (un) 938**]/DF/PF intact, [**Last Name (un) 36**] intact to LT over tib/sp/dp,
palpable DP
SKIN: no rashes/no jaundice, pale
NEURO: bilateral downgoing babinski. will reassess when sedation
is weaned.

FAMILY HISTORY: Mother with h/o emphysema.

SOCIAL HISTORY: Lives with wife.  [**Name (NI) 1403**] part time in real estate building and
development and is still currently working.  Retired from full
time work in [**2157-9-22**].
Smoked approximately 30 years ago (quit in [**2126**])
EtOH: drinks 1 glass wine/day 

### Response:
{'Secondary malignant neoplasm of lung,Acute respiratory failure,Pathologic fracture of neck of femur,Secondary malignant neoplasm of bone and bone marrow,Acute posthemorrhagic anemia,Other iatrogenic hypotension,Other sedatives and hypnotics causing adverse effects in therapeutic use,Personal history of malignant neoplasm of thyroid,Thrombocytopenia, unspecified,Personal history of venous thrombosis and embolism,Atrial fibrillation,Unspecified essential hypertension,Postsurgical hypothyroidism'}
