CHIEF COMPLAINT: Bacteremia/ Bleeding from G tube site

PRESENT ILLNESS: 84 year old male per omr with history of CAD s/p stenting, CHF
(EF 55%), Afib, prior cardiac arrest and heart block s/p
pacer/AICD placement, chronic trach, and recent MRSA bacteremia
transitioned from vancomycin to daptomycin presenting from rehab
facility with continued bacteremia and bleeding around G-tube
site.
.
Briefly patient was doing well until [**6-/2162**] when he suffered a
fall that caused multiple fractures. He was hospitalized and
intubated and subsequently trached. He was transferred to rehab
where he spent a good deal of time with multiple readmissions
for various infections and chronic GI Bleeds. In [**2153-8-15**] was
admitted to [**Hospital1 18**] for PNA and found to have MRSa bacteremia. Was
dicharged on Vancomycin. Was readmitted later that month for a
GI bleed. EGD/[**Last Name (un) **] was deferred [**2-16**] to family wishes and
comorbidites. He was discharged again to [**Hospital 100**] Rehab.
Surveilece cultures remained positive and he was readmitted for
infectious work up. TTE, TEE and tagged WBC scan were all
negative for ocult infectious source. On that admission he was
diagnosed with concurrent Pseudomonas and Klebsiella UTI and
treated with Meropenam. Given his persistent MRSA bacteremia he
was switched from Vancomycin to daptomycin.
.
Over the last several days he has been febrile with intermittent
AMS. Blood cultures are persistently positive. Per notes form
his PCP and discussions with the family, he is being admitted
for evaluation for ICD lead explantation and for managment of
fevers.
.
With regards to the bleedign at the G-tube site, the nursing
staff at the rehabilitation facility noted oozing of blood from
around the G-tube site. There was no bleeding at the lumen of
the site. The patient remained normotensive. He remained normal
mental status. The G-tube was clear and patent. There were no
exacerbating or relieving factors. There was no known preceding
trauma to the G-tube.
.
In the ED, initial VS were:  88 130/70   99% 15L
.
FAST positive but hemodynamic stable
CT abd non-con: simple fluid in the abdomen and pelvis, but no
evidence for hematoma. left ventral wall hernia containing
non-obstructed loops of bowel.
.
On arrival to the MICU, he was alert and cooperative and
following commands.

MEDICAL HISTORY: Rectal cancer s/p excision and XRT ([**2157**])
CAD s/p stents (?[**2159**])
CVA in [**2150**] with residual right hand dysthesia
Complete heart block s/p pacemaker
H/o cardiac arrest (now with AICD)
GI bleed secondary to angiectasias in the duodenum ([**1-/2162**]) s/p
cauterization via EGD
Atrial fibrillation, not on coumadin
Systolic CHF (EF 40-45%)
S/p Fall with multiple rib fractures ([**2163-6-23**])
MICU admission [**Date range (1) 108856**]/[**2163**] for hemoptysis, bleeding from
trach
Abdominoperineal resection [**9-/2157**] w/ [**Doctor Last Name **]

MEDICATION ON ADMISSION: Tylenol 650  q4h PRN
Acetylcysteine 100mg TID
Citalopram 20 mg QD
Daptomycin 500mg Q 48h
Docusate 100mg [**Hospital1 **]
Ferrous Sulfate 325mg QD
Lidocaine patch
Metoprolol 12.5mg BIDSimethicone 80mg TID
Sucralfate 1 Gram TID with meals
Fentanyl patch 12 mcg Q 3Days (Last applied [**2163-11-2**])
Albuterol inhaler 2 puffs Q 6hours
Oxycodone 5mg QHS
COMPAZINE 5MG q 8 HOURS
Psyllium seed 1 tsp TID

ALLERGIES: Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

PHYSICAL EXAM: Admission Exam:
General: Alert, no acute distress
HEENT: Trached NC AT
Neck: trach in place
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Coarse bilateral breath sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ostomy in place
GU: Foley in place
Ext: WWP 3+ pitting edema to theknees with bilateral venous
stasis changes.

FAMILY HISTORY: Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.

SOCIAL HISTORY: Resident of [**Hospital 100**] Rehab; previously had lived in [**Location 745**] with
his wife, now w some depression about moving out of their 42
year home. Has two children. Retired computer science professor.
Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Methicillin resistant Staphylococcus aureus septicemia,Severe sepsis,Septic shock,Pressure ulcer, stage IV,Acute posthemorrhagic anemia,Chronic systolic heart failure,Urinary tract infection, site not specified,Chronic respiratory failure,Hyperosmolality and/or hypernatremia,Atrioventricular block, complete,Other gastrostomy complications,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Chronic kidney disease, unspecified,Percutaneous transluminal coronary angioplasty status,Personal history of sudden cardiac arrest,Automatic implantable cardiac defibrillator in situ,Tracheostomy status,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Personal history of irradiation, presenting hazards to health,Encounter for palliative care,Do not resuscitate status,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Chr duoden ulcer w hem,MRSA septicemia,Severe sepsis,Septic shock,Pressure ulcer, stage IV,Ac posthemorrhag anemia,Chr systolic hrt failure,Urin tract infection NOS,Chronic respiratory fail,Hyperosmolality,Atriovent block complete,Gastrostomy comp NEC,Atrial fibrillation,Crnry athrscl natve vssl,Chronic kidney dis NOS,Status-post ptca,Hx sudden cardiac arrest,Status autm crd dfbrltr,Tracheostomy status,Hx-rectal & anal malign,Hx of irradiation,Encountr palliative care,Do not resusctate status,Abn react-procedure NEC
Admission Date:  [**2163-11-4**]              Discharge Date:   [**2163-11-17**]

Date of Birth:  [**2079-1-17**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
Bacteremia/ Bleeding from G tube site


Major Surgical or Invasive Procedure:
Endoscopy x3: Performed by Dr. [**Last Name (STitle) **] on [**2163-11-7**] and
[**2163-11-8**]


History of Present Illness:
84 year old male per omr with history of CAD s/p stenting, CHF
(EF 55%), Afib, prior cardiac arrest and heart block s/p
pacer/AICD placement, chronic trach, and recent MRSA bacteremia
transitioned from vancomycin to daptomycin presenting from rehab
facility with continued bacteremia and bleeding around G-tube
site.
.
Briefly patient was doing well until [**6-/2162**] when he suffered a
fall that caused multiple fractures. He was hospitalized and
intubated and subsequently trached. He was transferred to rehab
where he spent a good deal of time with multiple readmissions
for various infections and chronic GI Bleeds. In [**2153-8-15**] was
admitted to [**Hospital1 18**] for PNA and found to have MRSa bacteremia. Was
dicharged on Vancomycin. Was readmitted later that month for a
GI bleed. EGD/[**Last Name (un) **] was deferred [**2-16**] to family wishes and
comorbidites. He was discharged again to [**Hospital 100**] Rehab.
Surveilece cultures remained positive and he was readmitted for
infectious work up. TTE, TEE and tagged WBC scan were all
negative for ocult infectious source. On that admission he was
diagnosed with concurrent Pseudomonas and Klebsiella UTI and
treated with Meropenam. Given his persistent MRSA bacteremia he
was switched from Vancomycin to daptomycin.
.
Over the last several days he has been febrile with intermittent
AMS. Blood cultures are persistently positive. Per notes form
his PCP and discussions with the family, he is being admitted
for evaluation for ICD lead explantation and for managment of
fevers.
.
With regards to the bleedign at the G-tube site, the nursing
staff at the rehabilitation facility noted oozing of blood from
around the G-tube site. There was no bleeding at the lumen of
the site. The patient remained normotensive. He remained normal
mental status. The G-tube was clear and patent. There were no
exacerbating or relieving factors. There was no known preceding
trauma to the G-tube.
.
In the ED, initial VS were:  88 130/70   99% 15L
.
FAST positive but hemodynamic stable
CT abd non-con: simple fluid in the abdomen and pelvis, but no
evidence for hematoma. left ventral wall hernia containing
non-obstructed loops of bowel.
.
On arrival to the MICU, he was alert and cooperative and
following commands.


Past Medical History:
Rectal cancer s/p excision and XRT ([**2157**])
CAD s/p stents (?[**2159**])
CVA in [**2150**] with residual right hand dysthesia
Complete heart block s/p pacemaker
H/o cardiac arrest (now with AICD)
GI bleed secondary to angiectasias in the duodenum ([**1-/2162**]) s/p
cauterization via EGD
Atrial fibrillation, not on coumadin
Systolic CHF (EF 40-45%)
S/p Fall with multiple rib fractures ([**2163-6-23**])
MICU admission [**Date range (1) 108856**]/[**2163**] for hemoptysis, bleeding from
trach
Abdominoperineal resection [**9-/2157**] w/ [**Doctor Last Name **]


Social History:
Resident of [**Hospital 100**] Rehab; previously had lived in [**Location 745**] with
his wife, now w some depression about moving out of their 42
year home. Has two children. Retired computer science professor.

- Tobacco: 5 cigars daily for 30 years, quit [**2150**] s/p CVA
- Alcohol: Previously [**1-16**] glasses/week, generally per wife
"affects him quite a bit," changing his mood and making him sick

- Illicits: Denies


Family History:
Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.

Physical Exam:
Admission Exam:
General: Alert, no acute distress
HEENT: Trached NC AT
Neck: trach in place
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Coarse bilateral breath sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ostomy in place
GU: Foley in place
Ext: WWP 3+ pitting edema to theknees with bilateral venous
stasis changes.


Pertinent Results:
[**2163-11-4**] 04:15PM   PT-16.8* PTT-38.5* INR(PT)-1.5*
[**2163-11-4**] 04:15PM   PLT COUNT-110*
[**2163-11-4**] 04:15PM   NEUTS-82.7* LYMPHS-10.0* MONOS-6.5 EOS-0.5
BASOS-0.2
[**2163-11-4**] 04:15PM   WBC-17.4*# RBC-3.50* HGB-9.7* HCT-30.0*
MCV-86 MCH-27.6 MCHC-32.2 RDW-17.0*
[**2163-11-4**] 04:15PM   CALCIUM-8.4 PHOSPHATE-3.3# MAGNESIUM-1.9
[**2163-11-4**] 04:15PM   estGFR-Using this
[**2163-11-4**] 04:15PM   GLUCOSE-130* UREA N-88* CREAT-1.9* SODIUM-141
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16
[**2163-11-4**] 04:24PM   GLUCOSE-123* LACTATE-2.1* NA+-140 K+-3.7
CL--105 TCO2-26
[**2163-11-4**] 04:24PM   COMMENTS-GREEN TOP
[**2163-11-4**] 07:14PM   TYPE-ART PO2-60* PCO2-34* PH-7.51* TOTAL
CO2-28 BASE XS-3
[**2163-11-4**] 07:42PM URINE  WBCCLUMP-MOD MUCOUS-OCC
[**2163-11-4**] 07:42PM URINE  AMORPH-OCC
[**2163-11-4**] 07:42PM URINE  RBC-47* WBC->182* BACTERIA-MANY
YEAST-FEW EPI-0
[**2163-11-4**] 07:42PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-LG
[**2163-11-4**] 07:42PM URINE  COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
.
CT ABDDOMEN AND PELVIS Study Date of [**2163-11-4**] 5:01 PM
MPRESSION:
.
1. Diffuse anasarca with small to moderate amount of ascites
within the abdomen and pelvis, but no evidence for hemorrhage.
2. Moderate bilateral pleural effusions which have increased
since the most recent examination. Small pericardial effusion,
increased.
3. Cholelithiasis without evidence for cholecystitis.
4. Parastomal hernia containing nonobstructed, nondilated loops
of small bowel.
5. Prostatic hypertrophy.
6. 15-mm hyperdense left upper pole renal lesion which is
unchanged and may represent a hemorrhagic cyst. This can be
further assessed with MRI if clinically indicated (as prior
renal ultrasound from [**2163-9-5**] did not demonstrate any
abnormality within this area).
.
The study and the report were reviewed by the staff radiologist.

.
.
EKG: AV paced at 70
.
AP CHEST 1:43 P.M. ON [**11-6**].

HISTORY: New right subclavian line.

IMPRESSION: AP chest compared to [**10-18**] through [**11-6**]
at 10:45
a.m.:

Tip of the new right subclavian line ends low in the SVC. There
is no change
in the small-to-moderate right pleural effusion and no
pneumothorax or
mediastinal widening to suggest complications of line insertion.
Severe
cardiomegaly is longstanding. Pulmonary vascular engorgement and
bibasilar
atelectasis are unchanged. Tracheostomy tube is midline.
Transvenous right
atrial and right ventricular pacer defibrillator leads are in
their expected
locations, unchanged. No pneumothorax.
.
[**2163-11-5**] 1:18 am BLOOD CULTURE     Site: ARM
      Source: Venipuncture.

   Blood Culture, Routine (Preliminary):
      STAPH AUREUS COAG +.    FINAL SENSITIVITIES.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         Consultations with ID are recommended for all blood
cultures
         positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.

         VANCOMYCIN Sensitivity testing confirmed by Sensititre.


                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------     1 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------     2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     2 S

   Anaerobic Bottle Gram Stain (Final [**2163-11-6**]):
      Reported to and read back by DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2163-11-6**] AT
0515.
      GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
[**2163-11-5**] 3:45 am URINE      Source: Catheter.

   URINE CULTURE (Preliminary):
      KLEBSIELLA PNEUMONIAE.    >100,000 ORGANISMS/ML..
         Piperacillin/tazobactam sensitivity testing available
on request.
         Cefazolin interpretative criteria are based on a dosage
regimen of
         2g every 8h.
      PSEUDOMONAS AERUGINOSA.    10,000-100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             KLEBSIELLA PNEUMONIAE
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------  =>64 R
CEFEPIME--------------   <=1 S       16 I
CEFTAZIDIME-----------  =>64 R        4 S
CEFTRIAXONE-----------    16 R
CIPROFLOXACIN---------   =>4 R      =>4 R
GENTAMICIN------------   <=1 S        8 I
MEROPENEM-------------<=0.25 S     =>16 R
NITROFURANTOIN-------- =>512 R
TOBRAMYCIN------------  =>16 R      <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

Brief Hospital Course:
84 YOM with MMP most notable of which inclue persistent MRSA
bacteremia of unknown source, recurrent MDR UTI's, PNA, chronic
renal failure presented with fevers, MRSA bacteremia, UTI and
UGIB.
.
# Brief Hospital course: Patient was initially admitted for
infectious w/u due to fevers, and was found to have MRSA
bacteremia (chronic, likely [**2-16**] seeding of ICD), and
Klebsiella/Pseudomonas UTI.  These were treated with IV
vancomycin and meropenem.  He subsequently developed bleeding at
his G-tube site as well as increased dark output from ostomy
bag.  His hct trend was: 30 ([**11-4**]) -> 28 ([**11-5**]) -> 25 ([**11-5**])
-> 22 ([**11-6**]).  He was transfused 1 unit pRBC.  Hct [**11-7**] was 18
and bleeding persisted.  GI and surgery were consulted.  He was
given reglan, and started on ppi iv bid.  GI performed 3 EGDs
that large amounts of blood and an ulcer with visible vessel
around peg insertion site; An initial attempt at clipping the
ulcer caused bright red blood, confirming that this was likely
the cause of the patient's recent bleed. 10cc of epinephrine
were injected around the ulcer. 2 clips were applied around the
ulcer with hemostasis successfully achieved. The PEG was
removed.  Because of his chronic MRSA bacteremia (thought likely
[**2-16**] ICD seeding), TPN was not an option and family felt that a
feeding tube would cause him too much discomfort.  The
palliative care team was consulted for assistance with the
family's decision-making regarding goals of care.  The family
ultimately felt that his current quality of life was not
consistent with what he would have wanted based on remarks he
had made in the past.  They elected to change his goals of care
to comfort-measures only.  On HD#9 he passed away with family at
bedside.  Family declined autopsy.

Medications on Admission:
Tylenol 650  q4h PRN
Acetylcysteine 100mg TID
Citalopram 20 mg QD
Daptomycin 500mg Q 48h
Docusate 100mg [**Hospital1 **]
Ferrous Sulfate 325mg QD
Lidocaine patch
Metoprolol 12.5mg BIDSimethicone 80mg TID
Sucralfate 1 Gram TID with meals
Fentanyl patch 12 mcg Q 3Days (Last applied [**2163-11-2**])
Albuterol inhaler 2 puffs Q 6hours
Oxycodone 5mg QHS
COMPAZINE 5MG q 8 HOURS
Psyllium seed 1 tsp TID


Discharge Disposition:
Expired

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Anemia due to upper GI bleed
Bacteremia
Urinary tract infection


Discharge Condition:
Deceased


Discharge Instructions:
N/A

Followup Instructions:
N/A


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
{'Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Methicillin resistant Staphylococcus aureus septicemia,Severe sepsis,Septic shock,Pressure ulcer, stage IV,Acute posthemorrhagic anemia,Chronic systolic heart failure,Urinary tract infection, site not specified,Chronic respiratory failure,Hyperosmolality and/or hypernatremia,Atrioventricular block, complete,Other gastrostomy complications,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Chronic kidney disease, unspecified,Percutaneous transluminal coronary angioplasty status,Personal history of sudden cardiac arrest,Automatic implantable cardiac defibrillator in situ,Tracheostomy status,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Personal history of irradiation, presenting hazards to health,Encounter for palliative care,Do not resuscitate status,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: Bacteremia/ Bleeding from G tube site

PRESENT ILLNESS: 84 year old male per omr with history of CAD s/p stenting, CHF
(EF 55%), Afib, prior cardiac arrest and heart block s/p
pacer/AICD placement, chronic trach, and recent MRSA bacteremia
transitioned from vancomycin to daptomycin presenting from rehab
facility with continued bacteremia and bleeding around G-tube
site.
.
Briefly patient was doing well until [**6-/2162**] when he suffered a
fall that caused multiple fractures. He was hospitalized and
intubated and subsequently trached. He was transferred to rehab
where he spent a good deal of time with multiple readmissions
for various infections and chronic GI Bleeds. In [**2153-8-15**] was
admitted to [**Hospital1 18**] for PNA and found to have MRSa bacteremia. Was
dicharged on Vancomycin. Was readmitted later that month for a
GI bleed. EGD/[**Last Name (un) **] was deferred [**2-16**] to family wishes and
comorbidites. He was discharged again to [**Hospital 100**] Rehab.
Surveilece cultures remained positive and he was readmitted for
infectious work up. TTE, TEE and tagged WBC scan were all
negative for ocult infectious source. On that admission he was
diagnosed with concurrent Pseudomonas and Klebsiella UTI and
treated with Meropenam. Given his persistent MRSA bacteremia he
was switched from Vancomycin to daptomycin.
.
Over the last several days he has been febrile with intermittent
AMS. Blood cultures are persistently positive. Per notes form
his PCP and discussions with the family, he is being admitted
for evaluation for ICD lead explantation and for managment of
fevers.
.
With regards to the bleedign at the G-tube site, the nursing
staff at the rehabilitation facility noted oozing of blood from
around the G-tube site. There was no bleeding at the lumen of
the site. The patient remained normotensive. He remained normal
mental status. The G-tube was clear and patent. There were no
exacerbating or relieving factors. There was no known preceding
trauma to the G-tube.
.
In the ED, initial VS were:  88 130/70   99% 15L
.
FAST positive but hemodynamic stable
CT abd non-con: simple fluid in the abdomen and pelvis, but no
evidence for hematoma. left ventral wall hernia containing
non-obstructed loops of bowel.
.
On arrival to the MICU, he was alert and cooperative and
following commands.

MEDICAL HISTORY: Rectal cancer s/p excision and XRT ([**2157**])
CAD s/p stents (?[**2159**])
CVA in [**2150**] with residual right hand dysthesia
Complete heart block s/p pacemaker
H/o cardiac arrest (now with AICD)
GI bleed secondary to angiectasias in the duodenum ([**1-/2162**]) s/p
cauterization via EGD
Atrial fibrillation, not on coumadin
Systolic CHF (EF 40-45%)
S/p Fall with multiple rib fractures ([**2163-6-23**])
MICU admission [**Date range (1) 108856**]/[**2163**] for hemoptysis, bleeding from
trach
Abdominoperineal resection [**9-/2157**] w/ [**Doctor Last Name **]

MEDICATION ON ADMISSION: Tylenol 650  q4h PRN
Acetylcysteine 100mg TID
Citalopram 20 mg QD
Daptomycin 500mg Q 48h
Docusate 100mg [**Hospital1 **]
Ferrous Sulfate 325mg QD
Lidocaine patch
Metoprolol 12.5mg BIDSimethicone 80mg TID
Sucralfate 1 Gram TID with meals
Fentanyl patch 12 mcg Q 3Days (Last applied [**2163-11-2**])
Albuterol inhaler 2 puffs Q 6hours
Oxycodone 5mg QHS
COMPAZINE 5MG q 8 HOURS
Psyllium seed 1 tsp TID

ALLERGIES: Penicillins / Erythromycin Base / Streptomycin / Citric Acid /
Atenolol / Torsemide / Heparin Agents

PHYSICAL EXAM: Admission Exam:
General: Alert, no acute distress
HEENT: Trached NC AT
Neck: trach in place
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Coarse bilateral breath sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ostomy in place
GU: Foley in place
Ext: WWP 3+ pitting edema to theknees with bilateral venous
stasis changes.

FAMILY HISTORY: Father died in 80s from MI. Mother died in 80s from PE. No
family history of colon, breast, uterine, or ovarian cancer. No
family history of seizures.

SOCIAL HISTORY: Resident of [**Hospital 100**] Rehab; previously had lived in [**Location 745**] with
his wife, now w some depression about moving out of their 42
year home. Has two children. Retired computer science professor. 

### Response:
{'Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Methicillin resistant Staphylococcus aureus septicemia,Severe sepsis,Septic shock,Pressure ulcer, stage IV,Acute posthemorrhagic anemia,Chronic systolic heart failure,Urinary tract infection, site not specified,Chronic respiratory failure,Hyperosmolality and/or hypernatremia,Atrioventricular block, complete,Other gastrostomy complications,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Chronic kidney disease, unspecified,Percutaneous transluminal coronary angioplasty status,Personal history of sudden cardiac arrest,Automatic implantable cardiac defibrillator in situ,Tracheostomy status,Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus,Personal history of irradiation, presenting hazards to health,Encounter for palliative care,Do not resuscitate status,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
