CHIEF COMPLAINT: Found Down x4 days

PRESENT ILLNESS: This is an 82 year old male who lives alone, last time normal
was likely Thursday (4 days of newspapers stacked up outside of
house). Found in house in bathtub per nephew may have been lying
next to bathtub breathing shallowly. Has history of prostate ca,
CVA x 2, NKDA. Burn on L shoulder. GCS at the scene was 4. He
was intubated in the field and given 1400cc IVF.
.
In the ED, initial vs were: 98.8, 128, 100/palp, 100% intubated.
Patient was given vanc/zosyn. C-collar placed. Patient had a
temp to 101.8 and was given tylenol. He was started on propofol
in the ED. Acute Care Surgery (ACS) evaled patient in the ED. A
FAST scan was negative. Urine tox was negative and UA revealed
large blood, 500 protein, trace ketones, [**11-10**] RBC and
occasional bacteria. Sodium was found to be 159, Cl at 125,
Bicarb at 17, initial lactate was 2.4 which trended down to 1.5.
CK was 3363. WBC was 12.9, plts 82, INR was 1.3, Fibrinogen at
547. Cr was elevated to 2.6 (b/l 1.2-1.4), BUN 91. Pt had a CT
head/spine/chest/ab/pelv which was significant for probably
aspiration pneumonia at the right base. He recieved about 4L
total. Blood and urine Cx were sent. At the time of transfer the
vitals were 101, 109, 114/68, 17, 100% FiO2 100%. After CXR ET
tube pulled back 3cm.
.
On the floor, patient intubated and unable to provide history.

MEDICAL HISTORY: stroke - MRI reveals subacute infarcts in the inferior division
of the L MCA
Prostate CA -'[**54**]; Tx with radiation seeds, casodex and lupron.
Radiation proctitis
Severe Depression: recently stopped all meds
HTN
Carotid stenosis s/p stenting [**10-26**] on L CEA in [**4-29**]
Nephrolithiasis
Echo in 98 with mod-severe MR, rheumatic deformity, mod pulm HTN

MEDICATION ON ADMISSION: Unclear what meds patient has actually been taking; recent OMR
note reporting that patient stopped all meds.
ATORVASTATIN 80 mg Tablet daily
CITALOPRAM 40 mg daily
CLOPIDOGREL 75 mg Tablet daily
FUROSEMIDE 20 mg Tablet daily
LEVETIRACETAM 250 mg Tablet daily
METOPROLOL TARTRATE 25 mg Tablet
ASPIRIN 325 mg
DOCUSATE SODIUM 100 mg Capsule [**Hospital1 **]

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: Discharge Physical Exam
O: Tc: 98.1 BP: 158/71 HR: 109 RR: 20 O2: 94% RA
General: Lying comfortably in bed, conversive
HEENT: MMM, no scleral icterus
Neck: no JVD
CV: RRR, +S1, S2, no m/r/g
Resp: expiratory wheezing bilaterally, bibasilar crackles
Abd: soft, NT/ND, +bowel sounds, no HSM
Ext: 2+ DP/PT pulses - unstageable sacral pressure ulcer ~4x10
cm, minimal surrounding induration with raised edges.  Rim of
granulation tissue with yellow base with an area of black
eschar.  Stage 2 on left shoulder and upper middle back, both
healing well with granulation tissue and some pigmentation
starting again.
Neuro: AAOx3, able to lift legs off bed ~1 feet, can raise knees
to same level, 4/5 strength upper extremities

FAMILY HISTORY: Unkown

SOCIAL HISTORY: He lives alone in [**Location 1268**]. Widowed from his second
marriage, son lives in [**State 531**] City - [**Name (NI) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name 105692**].
Nephew [**Name (NI) **] is HCP, lives in [**Name (NI) 2498**], sister Sabre, also HCP
lives in [**State 15946**].  He is retired from a medical supplier
shipping business. He has an 80-pack-year smoking history; he
quit 18 years ago. He denies any ETOH or illicit drug use.
Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Cerebral embolism with cerebral infarction,Acute kidney failure, unspecified,Encephalopathy, unspecified,Immune thrombocytopenic purpura,Rhabdomyolysis,Blood in stool,Hyperosmolality and/or hypernatremia,Bacteremia,Depressive disorder, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pressure ulcer, lower back,Barrett's esophagus,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Osteitis deformans without mention of bone tumor,Postinflammatory pulmonary fibrosis,Late effects of cerebrovascular disease, aphasia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Epilepsy, unspecified, without mention of intractable epilepsy,Hypoglycemia, unspecified,Chronic kidney disease, Stage III (moderate)
Food/vomit pneumonitis,Acute respiratry failure,Crbl emblsm w infrct,Acute kidney failure NOS,Encephalopathy NOS,Immune thrombocyt purpra,Rhabdomyolysis,Blood in stool,Hyperosmolality,Bacteremia,Depressive disorder NEC,Hy kid NOS w cr kid I-IV,Pressure ulcer, low back,Barrett's esophagus,Gstr/ddnts NOS w/o hmrhg,Osteitis deformans NOS,Postinflam pulm fibrosis,Late eff CV dis-aphasia,Mth sus Stph aur els/NOS,Epilep NOS w/o intr epil,Hypoglycemia NOS,Chr kidney dis stage III
Admission Date:  [**2170-6-26**]              Discharge Date:   [**2170-7-17**]

Date of Birth:  [**2088-5-12**]             Sex:   M

Service: MEDICINE

Allergies:
Ace Inhibitors

Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Found Down x4 days

Major Surgical or Invasive Procedure:
Endotracheal Intubation
PICC line placement, right brachial vein
Blood transfusion - 1 unit PRBC
Fresh frozen plasma - 2 units
Colonoscopy
EGD


History of Present Illness:
This is an 82 year old male who lives alone, last time normal
was likely Thursday (4 days of newspapers stacked up outside of
house). Found in house in bathtub per nephew may have been lying
next to bathtub breathing shallowly. Has history of prostate ca,
CVA x 2, NKDA. Burn on L shoulder. GCS at the scene was 4. He
was intubated in the field and given 1400cc IVF.
.
In the ED, initial vs were: 98.8, 128, 100/palp, 100% intubated.
Patient was given vanc/zosyn. C-collar placed. Patient had a
temp to 101.8 and was given tylenol. He was started on propofol
in the ED. Acute Care Surgery (ACS) evaled patient in the ED. A
FAST scan was negative. Urine tox was negative and UA revealed
large blood, 500 protein, trace ketones, [**11-10**] RBC and
occasional bacteria. Sodium was found to be 159, Cl at 125,
Bicarb at 17, initial lactate was 2.4 which trended down to 1.5.
CK was 3363. WBC was 12.9, plts 82, INR was 1.3, Fibrinogen at
547. Cr was elevated to 2.6 (b/l 1.2-1.4), BUN 91. Pt had a CT
head/spine/chest/ab/pelv which was significant for probably
aspiration pneumonia at the right base. He recieved about 4L
total. Blood and urine Cx were sent. At the time of transfer the
vitals were 101, 109, 114/68, 17, 100% FiO2 100%. After CXR ET
tube pulled back 3cm.
.
On the floor, patient intubated and unable to provide history.

Past Medical History:
stroke - MRI reveals subacute infarcts in the inferior division
of the L MCA
Prostate CA -'[**54**]; Tx with radiation seeds, casodex and lupron.
Radiation proctitis
Severe Depression: recently stopped all meds
HTN
Carotid stenosis s/p stenting [**10-26**] on L CEA in [**4-29**]
Nephrolithiasis
Echo in 98 with mod-severe MR, rheumatic deformity, mod pulm HTN

GERD
HLD
Pagets Disease bone diagnosed in '[**57**]
Dilated esophogus in 04
Barretts esophagus
CRI
Interstitial lung disease
Question of subclinical seizures on Keppra
autonomic neuropathy
impaired glucose tolerance

Social History:
He lives alone in [**Location 1268**]. Widowed from his second
marriage, son lives in [**State 531**] City - [**Name (NI) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name 105692**].
Nephew [**Name (NI) **] is HCP, lives in [**Name (NI) 2498**], sister Sabre, also HCP
lives in [**State 15946**].  He is retired from a medical supplier
shipping business. He has an 80-pack-year smoking history; he
quit 18 years ago. He denies any ETOH or illicit drug use.

Family History:
Unkown

Physical Exam:
Discharge Physical Exam
O: Tc: 98.1 BP: 158/71 HR: 109 RR: 20 O2: 94% RA
General: Lying comfortably in bed, conversive
HEENT: MMM, no scleral icterus
Neck: no JVD
CV: RRR, +S1, S2, no m/r/g
Resp: expiratory wheezing bilaterally, bibasilar crackles
Abd: soft, NT/ND, +bowel sounds, no HSM
Ext: 2+ DP/PT pulses - unstageable sacral pressure ulcer ~4x10
cm, minimal surrounding induration with raised edges.  Rim of
granulation tissue with yellow base with an area of black
eschar.  Stage 2 on left shoulder and upper middle back, both
healing well with granulation tissue and some pigmentation
starting again.
Neuro: AAOx3, able to lift legs off bed ~1 feet, can raise knees
to same level, 4/5 strength upper extremities

Pertinent Results:
I. Labs

A. Admission

[**2170-6-25**] 11:45PM BLOOD WBC-12.9* RBC-6.82* Hgb-15.9 Hct-49.8
MCV-73* MCH-23.3* MCHC-31.9 RDW-16.7* Plt Ct-82*
[**2170-6-25**] 11:45PM BLOOD Neuts-88.9* Lymphs-4.1* Monos-6.4 Eos-0.1
Baso-0.5
[**2170-6-25**] 11:45PM BLOOD PT-14.7* PTT-21.1* INR(PT)-1.3*
[**2170-6-25**] 11:45PM BLOOD Plt Smr-LOW Plt Ct-82*
[**2170-6-25**] 11:45PM BLOOD Fibrino-547*
[**2170-6-25**] 11:45PM BLOOD UreaN-91* Creat-2.6*
[**2170-6-25**] 11:45PM BLOOD ALT-28 AST-72* LD(LDH)-828* CK(CPK)-3363*
AlkPhos-209* TotBili-0.5
[**2170-6-25**] 11:45PM BLOOD Lipase-24
[**2170-6-25**] 11:45PM BLOOD Albumin-2.9*
[**2170-6-25**] 11:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2170-6-25**] 11:45PM BLOOD LtGrnHD-HOLD
[**2170-6-25**] 11:51PM BLOOD Type-ART pH-7.34*
[**2170-6-25**] 11:51PM BLOOD Glucose-135* Lactate-2.4* Na-159* K-4.7
Cl-125* calHCO3-17*
[**2170-6-25**] 11:51PM BLOOD Hgb-17.1 calcHCT-51 O2 Sat-99
[**2170-6-25**] 11:51PM BLOOD freeCa-1.08*

[**2170-6-25**] 11:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.026
[**2170-6-25**] 11:50PM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG
[**2170-6-25**] 11:50PM URINE RBC-[**11-10**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2170-6-25**] 11:50PM URINE CastGr-[**2-23**]* CastHy-[**11-10**]*
[**2170-6-25**] 11:50PM URINE Hours-RANDOM Creat-292 Na-11 Cl-25
[**2170-6-25**] 11:50PM URINE Osmolal-726
[**2170-6-25**] 11:50PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG

II. Microbiology
[**2170-6-25**] URINE CULTURE-FINAL {LACTOBACILLUS SPECIES}
BCx x 2 ([**2170-6-25**])
 Blood Culture, Routine (Final [**2170-6-29**]):
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    FINAL
SENSITIVITIES.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    SECOND MORPHOLOGY.
         FINAL SENSITIVITIES.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    THIRD MORPHOLOGY.
         FINAL SENSITIVITIES.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPHYLOCOCCUS, COAGULASE NEGATIVE
                             |          STAPHYLOCOCCUS,
COAGULASE NEGATIVE
                             |          |
STAPHYLOCOCCUS, COAGULASE N
                             |          |          |
CLINDAMYCIN-----------<=0.25 S   <=0.25 S   <=0.25 S
ERYTHROMYCIN----------<=0.25 S   <=0.25 S   <=0.25 S
GENTAMICIN------------ <=0.5 S    <=0.5 S    <=0.5 S
LEVOFLOXACIN----------<=0.12 S     0.25 S   <=0.12 S
OXACILLIN-------------<=0.25 S   <=0.25 S   <=0.25 S
TETRACYCLINE----------   <=1 S      <=1 S      <=1 S
VANCOMYCIN------------     1 S        1 S    <=0.5 S

   Aerobic Bottle Gram Stain (Final [**2170-6-26**]):
      GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
      REPORTED BY PHONE TO [**Month/Day/Year **] [**Doctor First Name 105693**] @1050PM ON [**2170-6-26**].

   Anaerobic Bottle Gram Stain (Final [**2170-6-26**]):
      GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
      REPORTED BY PHONE TO [**Last Name (LF) **], [**First Name3 (LF) 105693**] @1050PM ON [**2170-6-26**].

 STAPHYLOCOCCUS, COAGULASE NEGATIVE.    FINAL SENSITIVITIES.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    SECOND MORPHOLOGY.
         FINAL SENSITIVITIES.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPHYLOCOCCUS, COAGULASE NEGATIVE
                             |          STAPHYLOCOCCUS,
COAGULASE NEGATIVE
                             |          |
CLINDAMYCIN-----------   =>8 R   <=0.25 S
ERYTHROMYCIN----------<=0.25 S      =>8 R
GENTAMICIN------------ <=0.5 S    <=0.5 S
LEVOFLOXACIN----------<=0.12 S   <=0.12 S
OXACILLIN-------------<=0.25 S   <=0.25 S
TETRACYCLINE----------   <=1 S      <=1 S
VANCOMYCIN------------     1 S        1 S

**FINAL REPORT [**2170-6-26**]**

   Legionella Urinary Antigen  (Final [**2170-6-26**]):
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
           (Reference Range-Negative).
      Performed by Immunochromogenic assay.
      A negative result does not rule out infection due to other
L.
      pneumophila serogroups or other Legionella species.
Furthermore, in
      infected patients the excretion of antigen in urine may
vary.

MRSA SCREEN (Final [**2170-6-28**]):    No MRSA isolated.

[**2170-6-27**]: Bcx x 2 pending
[**2170-6-30**]: Bcx x 1 pending

III. Radiology

MRI BRAIN: In the posterior left middle cerebral artery
distribution, there
are several foci of slow diffusion, indicating acute infarct.
These are in
the same [**Month/Day/Year 1106**] territory, but in different locations compared
to the [**2169-4-15**] MRI. The pattern and distribution is again most
suggestive of
thromboembolic disease. There is no intracranial hemorrhage or
edema.

Periventricular and subcortical white matter T2 hyperintense
foci have
progressed since the [**2168**] study, again compatible with chronic
small vessel
ischemic change.

There are no masses, mass effect or other area of infarct.
Ventricles and
sulci are normal in size and configuration. The major
intracranial [**Year (4 digits) 1106**]
flow voids are unremarkable.

MRA BRAIN:

TECHNIQUE: Three-dimensional time-of-flight MR arteriography was
performed.

FINDINGS: The intracranial vertebral and internal carotid
arteries and their
major branches demonstrate diffuse irregularity, although
without overt
occlusion or severe stenosis. This pattern is compatible with
diffuse
atherosclerotic disease. No aneurysm is identified.

IMPRESSION:

1. Scattered foci of restricted diffusion in the left MCA
[**Year (4 digits) 1106**] territory
distribution most compatible with thromboembolic infarcts. These
are in the
same [**Year (4 digits) 1106**] distribution, but in different locations compared
to the [**2168**]
MRI.

2. Diffuse atherosclerotic disease, without occlusion or severe
stenosis.

3. Chronic small vessel ischemic change, progressed since [**2168**].

Findings discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 12 p.m., [**2170-6-28**].

CT C-spine
IMPRESSION:

1. No fracture or malalignment.

2. Multilevel degenerative changes. In the setting of trauma,
cord injury
may occur and if there is concern for cord injury, MRI would be
recommended.

3. Apical emphysema.

Carotid Series
Impression: Right ICA stenosis 40-59%.
Left ICA stenosis 40-59%.

CT Chest
IMPRESSION:
1. No evidence for traumatic injury in the chest, abdomen or
pelvis.

2. Prostate brachytherapy seeds.

3. Left hemipelvis Paget disease. Sclerotic T10 vertebral body
likely
reflects earlier Paget disease, but metastatic disease cannot be
excluded.

3. Ground-glass opacity in bilateral bases, concerning for
aspiration
pneumonia, more pronounced on the right where there is high
density material
that could be barium aspirtated in the past or calcification.

4. Extensive atherosclerotic disease including coronary
calcifications.
Distal aortic stent graft. Possible pulmonary hypertension.

5. ET tube 3.5 cm from the carina.

CT Abdomen
IMPRESSION:
1. No evidence for traumatic injury in the chest, abdomen or
pelvis.

2. Prostate brachytherapy seeds.

3. Left hemipelvis Paget disease. Sclerotic T10 vertebral body
likely
reflects earlier Paget disease, but metastatic disease cannot be
excluded.

3. Ground-glass opacity in bilateral bases, concerning for
aspiration
pneumonia, more pronounced on the right where there is high
density material
that could be barium aspirtated in the past or calcification.

4. Extensive atherosclerotic disease including coronary
calcifications.
Distal aortic stent graft. Possible pulmonary hypertension.

5. ET tube 3.5 cm from the carina.

CT Head
IMPRESSION:

1. No evidence for acute intracranial pathology.

2. Chronic microvascular infarcts and parenchymal atrophy.

3. Chronic-appearing deformity of the medial left orbital wall.

IV. Cardiology

A. ECHO
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size is probably normal
and free wall motion is probably preserved (views are
suboptimal). There is probably right ventricular hypertrophy
(views suboptimal). The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is moderate thickening of the mitral valve
chordae. There is mild to moderate functional mitral stenosis
(mean gradient 6 mmHg) due to mitral annular calcification. Mild
(1+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] There is no pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.


B. EKG
Baseline artifact. Sinus tachycardia. Short P-R interval. Left
atrial
abnormality. T wave abnormalities. No previous tracing available
for
comparison.

Read by:	[**Last Name (LF) **],[**First Name3 (LF) 900**] A.
 	Intervals	Axes
Rate	PR	QRS	QT/QTc	P	QRS	T
127	100	72	284/[**Telephone/Fax (2) 105694**]

[**2170-7-16**]: Sinus tachycardia. Compared to the previous tracing of
[**2170-7-1**] the rate has increased.

CXR [**2170-7-1**]: REASON FOR EXAMINATION: Evaluation of the patient
with new hypoxia and
suspected aspiration.

PORTABLE AP CHEST RADIOGRAPH

COMPARISON: Chest radiograph from [**2170-6-29**].

The right PICC line is at the level of mid low SVC. There is
slightly more
pronounced cardiac silhouette, which may be attributed to
relatively low lung
volumes. The bibasal areas of pleural calcifications and minimal
interstitial
changes are stable. There are no new consolidations that might
represent
areas of aspiration. There is no pleural effusion or
pneumothorax.

Overall, no significant change since the prior study has been
demonstrated.

[**2170-7-13**]: HISTORY: Lower GI bleeding with acute onset of wheezing
and shortness of breath.

FINDINGS: In comparison with the study of [**7-1**], there is
continued mild
enlargement of the cardiac silhouette. However, there is an
increase in the interstitial markings bilaterally, suggesting
elevated pulmonary venous pressure. Blunting of the costophrenic
angles is consistent with small pleural effusions. If the
condition of the patient permits, lateral view would be most
helpful.

KUB [**2170-7-10**]: COMPARISON: Abdominal radiograph from [**2162-8-16**].

FINDINGS: Four abdominal radiographs, one supine and three left
lateral
decubitus, were acquired showing multiple loops of redundant,
air-distended colon. Air fluid levels are seen on the left
lateral decubitus films. There is no evidence of free air in the
abdomen. The visualized osseous structures appear unremarkable.
An intraaortic stent is noted just proximal to the origin of the
iliac arteries. Multiple punctate opacifications over the pelvis
are likely seeds from brachytherapy.

IMPRESSION: Moderately distended colon likely secondary to
ileus.

Colonoscopy [**2170-7-16**]: Procedure: The procedure, indications,
preparation and potential complications were explained to the
patient, who indicated his understanding and signed the
corresponding consent forms. The efficiency of a colonoscopy in
detecting lesions was discussed with the patient and it was
pointed out that a small percentage of polyps and other lesions
can be missed with the test. A physical exam was performed. The
patient was administered moderate sedation. The physical exam
was performed prior to administering anesthesia. Supplemental
oxygen was used. The patient was placed in the left lateral
decubitus position.The digital exam was normal. The colonoscope
was introduced through the rectum and advanced under direct
visualization until the cecum was reached. The cecal sling folds
were seen. The appendiceal orifice and ileo-cecal valve were
identified. Careful visualization of the colon was performed as
the colonoscope was withdrawn. The procedure was not difficult.
The quality of the preparation was fair. Visualization of the
transverse colon and descending colon was poor. The patient
tolerated the procedure well. There were no complications.
Findings:
 Contents: Brownish or yellowish liquid stool was found in the
ascending colon, transverse colon and descending colon. There
was no red blood or melena.
 Flat Lesions A few medium localized angioectasias that were not
bleeding were seen in the rectum. It is compatible with
radiation proctitis.
 Other We did not find the source of bleeding
Impression: Stool in the ascending colon, transverse colon and
descending colon
Angioectasias in the rectum
Otherwise normal colonoscopy to cecum
Recommendations: Please consider Capsule study

EGD [**2170-7-16**]:
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
moderate sedation. A physical exam was performed prior to
administering anesthesia. Supplemental oxygen was used. The
patient was placed in the left lateral decubitus position and an
endoscope was introduced through the mouth and advanced under
direct visualization until the third part of the duodenum was
reached. Careful visualization of the upper GI tract was
performed. The vocal cords were visualized. The procedure was
not difficult. The patient tolerated the procedure well. There
were no complications.
Findings: Esophagus:
 Mucosa: A salmon colored mucosa distributed in a segmental
pattern, suggestive of Barrett's Esophagus was found. Two cold
forceps biopsies were performed for histology at the
gastro-esophageal junction.
Stomach:
 Mucosa: Patchy erythema and congestion of the mucosa were noted
in the whole stomach. These findings are compatible with
gastritis. Localized A few erosions of the mucosa with no
bleeding was noted in the stomach body. These findings are
compatible with gastritis.
Duodenum:
 Mucosa: Localized erythema and congestion of the mucosa with no
bleeding were noted in the duodenal bulb compatible with
duodenitis.
Impression: Mucosa suggestive of Barrett's esophagus (biopsy)
Erythema and congestion in the whole stomach compatible with
gastritis
A few erosions in the stomach body compatible with gastritis
Erythema and congestion in the duodenal bulb compatible with
duodenitis
Otherwise normal EGD to third part of the duodenum
Recommendations: follow-up biopsy results
Please continue using PPI PO
Pt needs surveillance EGD for his barrett's esophagus
Antireflux regimen: Avoid chocolate, peppermint, alcohol,
caffeine, onions, aspirin. Elevate the head of the bed 3 inches.
Go to bed with an empty stomach.

Discharge Labs:

[**2170-7-10**] 02:02AM BLOOD WBC-12.0* RBC-4.32* Hgb-10.1* Hct-31.0*
MCV-72* MCH-23.3* MCHC-32.4 RDW-17.7* Plt Ct-197
[**2170-7-10**] 06:32AM BLOOD WBC-11.6* RBC-4.18* Hgb-9.8* Hct-30.3*
MCV-73* MCH-23.4* MCHC-32.3 RDW-18.1* Plt Ct-207
[**2170-7-10**] 01:57PM BLOOD Hct-29.6*
[**2170-7-10**] 10:28PM BLOOD Hct-31.6*
[**2170-7-11**] 09:54PM BLOOD Hct-28.1*
[**2170-7-12**] 05:54AM BLOOD WBC-8.2 RBC-3.69* Hgb-8.6* Hct-26.6*
MCV-72* MCH-23.2* MCHC-32.2 RDW-18.6* Plt Ct-238
[**2170-7-12**] 12:10PM BLOOD WBC-8.1 RBC-3.48* Hgb-8.0* Hct-25.1*
MCV-72* MCH-23.0* MCHC-31.9 RDW-18.5* Plt Ct-197
[**2170-7-12**] 10:22PM BLOOD Hct-30.9*
[**2170-7-13**] 05:16AM BLOOD WBC-12.1* RBC-4.30* Hgb-10.4*# Hct-31.5*
MCV-73* MCH-24.1* MCHC-32.9 RDW-19.1* Plt Ct-276
[**2170-7-15**] 05:47AM BLOOD WBC-13.2* RBC-3.87* Hgb-9.3* Hct-28.1*
MCV-73* MCH-24.2* MCHC-33.2 RDW-19.6* Plt Ct-273
[**2170-7-16**] 05:22AM BLOOD WBC-13.0* RBC-3.76* Hgb-9.1* Hct-27.9*
MCV-74* MCH-24.1* MCHC-32.5 RDW-20.2* Plt Ct-287
[**2170-7-17**] 04:57AM BLOOD WBC-13.5* RBC-3.76* Hgb-8.9* Hct-28.0*
MCV-74* MCH-23.7* MCHC-31.9 RDW-20.7* Plt Ct-334
[**2170-7-12**] 05:54AM BLOOD PT-20.3* PTT-30.5 INR(PT)-1.9*
[**2170-7-12**] 03:00PM BLOOD PT-21.7* PTT-31.8 INR(PT)-2.0*
[**2170-7-14**] 08:54AM BLOOD PT-15.2* PTT-30.3 INR(PT)-1.3*
[**2170-7-15**] 05:47AM BLOOD PT-15.1* PTT-28.2 INR(PT)-1.3*
[**2170-7-16**] 05:22AM BLOOD PT-16.3* PTT-27.7 INR(PT)-1.4*
[**2170-7-9**] 06:53AM BLOOD Glucose-90 UreaN-22* Creat-2.0* Na-138
K-3.5 Cl-104 HCO3-27 AnGap-11
[**2170-7-10**] 06:32AM BLOOD Glucose-97 UreaN-22* Creat-1.7* Na-139
K-3.3 Cl-109* HCO3-21* AnGap-12
[**2170-7-11**] 05:24AM BLOOD Glucose-75 UreaN-19 Creat-1.6* Na-138
K-3.5 Cl-106 HCO3-22 AnGap-14
[**2170-7-12**] 05:54AM BLOOD Glucose-86 UreaN-17 Creat-1.8* Na-141
K-3.1* Cl-109* HCO3-24 AnGap-11
[**2170-7-13**] 05:16AM BLOOD Glucose-134* UreaN-12 Creat-1.6* Na-139
K-3.2* Cl-107 HCO3-22 AnGap-13
[**2170-7-15**] 05:47AM BLOOD Glucose-92 UreaN-11 Creat-1.7* Na-140
K-3.0* Cl-106 HCO3-23 AnGap-14
[**2170-7-16**] 05:22AM BLOOD Glucose-94 UreaN-13 Creat-1.6* Na-141
K-3.3 Cl-108 HCO3-23 AnGap-13
[**2170-7-17**] 04:57AM BLOOD Glucose-88 UreaN-16 Creat-1.5* Na-141
K-3.3 Cl-107 HCO3-23 AnGap-14
[**2170-7-13**] 05:16AM BLOOD ALT-13 AST-22 LD(LDH)-326* AlkPhos-116
TotBili-0.4
[**2170-7-12**] 05:54AM BLOOD ALT-12 AST-18 LD(LDH)-275* AlkPhos-95
TotBili-0.4
[**2170-7-1**] 04:42PM BLOOD CK-MB-2 cTropnT-0.05*
[**2170-7-1**] 10:00PM BLOOD CK-MB-3 cTropnT-0.07*
[**2170-7-2**] 05:57AM BLOOD CK-MB-2 cTropnT-0.05*
[**2170-7-15**] 05:47AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.8
[**2170-7-16**] 05:22AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.9
[**2170-7-12**] 05:54AM BLOOD Albumin-2.5* Calcium-8.3* Phos-3.1 Mg-2.0
[**2170-7-11**] 05:24AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.9 Iron-47
[**2170-7-11**] 05:24AM BLOOD calTIBC-157* Hapto-186 Ferritn-350
TRF-121*
[**2170-7-7**] 06:16AM BLOOD VitB12-903* Folate-6.3
[**2170-7-7**] 06:16AM BLOOD TSH-2.2
[**2170-6-26**] 03:02PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2170-7-17**] 04:57AM BLOOD IgA-462*
[**2170-7-17**] 04:57AM BLOOD tTG-IgA-PND

Brief Hospital Course:
Brief MICU course:
Patient arrived to the MICU intubated.  He was extubated the
next day.  He was quickly weaned to room air.  He had some word
finding difficulties in the ICU.  He did not remember more
history.  His blood cultures returned positive for 4/4 bottles
with coag negative staph.  An MRI was done which was consistent
with thromboembolic lesions in the brain.  He was called out to
the floor for further work-up.

Floor course:

#Recurrent stroke:
MRI revealed new stroke with scattered foci of restricted
diffusion in the left MCA [**Month/Day/Year 1106**] territory most compatible
with thromboembolic infarcts in the
same [**Month/Day/Year 1106**] distribution but in different locations compared
to the [**2168**] MRI.
His PCP visited in the hospital and confirmed that his current
mental status and neurological function is at baseline. Carotid
series revealed [**Country **] and [**Doctor First Name 3098**] stenosis at 40-59 %. Stroke team
recommended continuing ASA and converting to plavix once
platelets stabilized continue lipitor, follow-up carotid doppler
in 6 months, and lipid panel.  The anti-coagulation meds were
continued until the patient developed a GI bleed.  The meds were
held for 1 week before restarting after the patient had his
colonoscopy/EGD.

# GI bleed - The patient developed GI bleeding on [**7-10**] with
maroon colored stools.  His Hgb/Hct were serially monitored and
were stable, with a slow downward trend.  He remained
hemodynamically stable the entire duration.  GI was consulted
and recommended an EGD and colonoscopy.  After a family meeting,
the patient agreed to undergo the procedures, however he did not
drink enough of the prep to have the procedure.  He did receive
1 unit PRBC as his Hct dropped to a low of 25.1.  After
transfusion, he increased to 31.5.  He tried the prep again 2
days later and was cleaned out enough to undergo the scopes.  GI
performed the procedure on [**7-16**].  They found gastritis and
duodenitis but no obvious source of bleeding.  He was noted to
have Barrett's esophagus on EGD, biopsies were taken, the
results of which were pending on discharge.  H. pylori was
negative. GI recommended the patient be continued on
pantoprazole and to have surveillance EGD of his Barretts.
Please recheck a CBC in the next 1-2 days to ensure no change in
anemia after restarting aspirin plavix on [**7-16**]

# Elevated INR - The patient did develop an elevated INR to a
high of 2.0.  Hemolysis labs and liver synthetic function was
checked and was normal.  It was thought that the coagulopathy
was due to nutritional deficiency as the patient was variously
on clears and NPO for several days before his colonoscopy.  He
received vitamin K and responded quickly with reversal of his
INR.

# Hypertension - The patient was noted to be hypertensive during
the last 2-3 days of his hospitalization.  His metoprolol was
doubled to 50mg PO BID from 25mg PO BID.  If there is more
control needed for his BP, we would recommend amlodipine,
hydralazine, and HCTZ as medications to be used.

# Coagulase-negative Staph Bacteremia: Pt had multiple blood
cultures with coag negative Staph with different morphologies.
This unlikely represents contamination with potential source of
entry from skin penetration given prolonged period down with
resultant pressure ulcers. He was initially started on
vancomycin with PICC placement secondary to loss of access and
subsequently switched to nafcillin given sensitivities. The
patient does have a heart murmur, is afebrile, and has no
vegetations on ECHO. A TEE was not done as the patient did not
have signs/symptoms of endocarditis.  Subsequent blood cultures
were negative.  The patient was instructed to take antibiotics
for 6 more days to finish a 14 day course.  He remained afebrile
during his stay on the floor.

# Acute on chronic Renal failure secondary to possible
rhabdomyolysis: The patient likely had rhabdomyolysis on
admission given his high CK measurement. His Cr trended down,
then increased again.  Urine eosinophils were checked twice, but
were negative, making AIN unlikely.  Renal was consulted, they
were able to look at a urine sample however saw no muddy brown
casts indicative of ATN, or WBC casts indicative of AIN.  The
patient's creatinine stabilized at 1.6-1.8.

# Thrombocytopenia and Anemia: The patient was noted to have
very low platelets in the 40-60s without evidence of superficial
bleeding. HIT was unlikely given no previous heparin exposure in
the past few months and low platelets on admission before
heparin administration.  TTP was a concern given
thrombocytopenia, anemia, worsening renal function, and
neurological issues. Medication side effect with plavix and
aspirin was a secondary consideration.  A smear revealed true
thrombocytopenia with target cells and microcytosis. Per
hematology consult, his thrombocytopenia likely represents ITP
and is unlikely HIT. His anemia may be secondary to thalassemia
based on the blood smear. He was monitored with daily CBC for
occult blood loss.  Once his platelet level returned to greater
than 100, his plavix was restarted.  The platelets continued to
trend upwards and remained normal through discharge.  An iron
panel was obtained and was consistent with anemia of chronic
disease.  A TTG level was pending at the time of discharge as an
alternate cause of his anemia.

# Hypoxia - The patient was noted to be hypoxic at various times
during his stay, however this was primarily due to the
plethysmograph being placed on a finger.  When the forehead
monitor was used, his saturations were above 93%.

# Shortness of breath - The patient had 2 sudden-onset episodes
of shortness of breath.  The first was ~2-3 hours after
finishing his blood transfusion.  A chest x-ray was obtained
which showed increased right sided pulmonary edema.  It was
thought that he flashed, got lasix 40mg IV with rapid resolution
of his symptoms.  The second time, his SBP was 190/80, with
audible expiratory wheezing.  He received a duoneb treatment
which again, rapidly resolved his symptoms.  Both times, EKGs
were obtained and were unchanged from prior.  The patient
remained asymptomatic during both episdoes and he did not
experience any hypoxia.


#) Pressure ulcers: The patient has several pressure ulcers
presumed from his prolonged time down prior to admission from
prolonged time down prior to admission. Wound care was
immediately consulted to address this issue and their
recommendations were:
TO Wound care:
Site: Left scapula
Type: Pressure ulcer
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Wound Gel (DuoDerm Gel)
Change dressing: qd
Comment: apply large Sofsorb to area, change daily
.
TO Wound care:
Site: right toes
Type: Pressure ulcer
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Gauze - dry
Change dressing: qd
.
TO Wound care:
Site: sacrum (unstageable)
Type: Pressure ulcer
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Wound Gel (DuoDerm Gel) and Mepilex Foam
Change dressing: Other
Comment: change every 3 days
.
TO Wound care:
Site: Left shoulder
Type: Pressure ulcer
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Gauze - dry
Change dressing: qd
.
TO Wound care:
Site: Right hip
Type: Pressure ulcer
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Gauze - dry
Change dressing: qd
.
.

#) Depression: The patient did become combative and refusing to
participate in his medical care around the time his GI bleed
started.  A family meeting was held with the patient's nephew
and his PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].  They spoke to the patient and were
able to convince him to participate in his own care.  He was
much more cooperative after this meeting.  His citalopram was
continued at his home dose.  Psych was consulted and had no
further medication input.  He did sign a health care proxy
naming his nephew, [**Name (NI) **] [**Name (NI) 26160**] ([**Telephone/Fax (1) 105695**]).
.
#) Seizure disorder: The patient had no seizures during his
hospitalization.  He was kept on Keppra.
.
#) Placement issues - The patient was discharged to [**Hospital1 **].

Medications on Admission:
Unclear what meds patient has actually been taking; recent OMR
note reporting that patient stopped all meds.
ATORVASTATIN 80 mg Tablet daily
CITALOPRAM 40 mg daily
CLOPIDOGREL 75 mg Tablet daily
FUROSEMIDE 20 mg Tablet daily
LEVETIRACETAM 250 mg Tablet daily
METOPROLOL TARTRATE 25 mg Tablet
ASPIRIN 325 mg
DOCUSATE SODIUM 100 mg Capsule [**Hospital1 **]


Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO
BID:PRN.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID:PRN.
5. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1)
inhalation Inhalation Q6H (every 6 hours).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q2H (every 2 hours) as
needed for wheeze.
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **]

Discharge Diagnosis:
Primary: Stroke, dehydration, pressure ulcers, acute on chronic
renal failure, thrombocytopenia, bacteremia

Secondary: Depression, seizure disorder, hypoglycemia


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Dear Mr. [**Known lastname 105691**],

It was a pleasure taking care of you during your
hospitalization.  You were admitted after being found lying in
your bathtub for 4 days.  It was determined that you had a
stroke which led you to be unresponsive.  You were treated in
the Medical Intensive Care Unit for 2 days getting fluids, then
were treated on the floor.  Your blood had a bacteria in it that
was treated with antibiotics.  You were found to have pressure
ulcers from lying down so long that were treated by the Wound
Care nurses.  It was  also found that you had a low platelet
level when you were admitted.  This level was watched and it
returned to a normal level.  You developed bleeding from your
gastrointestinal tract.  This caused your blood levels to drop
enough that you needed 1 unit of blood to raise your levels.
The Gastroenterologists (stomach doctors) performed a
colonoscopy and EGD where they used a small camera to look at
your colon and your stomach.  They found some inflammation in
your stomach and first part of the small intestine, but found no
active bleeding in your GI tract.  They also found some changes
in the first layer of the esophagus which will need to be
followed in the future.  You also had worsening of your kidney
function.  We did not figure out why this happened.  We watched
your kidney function and it stablilized.

We provided you with a new medication list.  Please take these
medications unless told otherwise by a doctor.


Followup Instructions:
There will be a doctor at the rehab center you are going who
will see you daily.  When you are discharged from the rehab
center, you should make an appointment to see your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **].  Her office number is [**Telephone/Fax (1) 250**].



Completed by:[**2170-7-17**]
{"Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Cerebral embolism with cerebral infarction,Acute kidney failure, unspecified,Encephalopathy, unspecified,Immune thrombocytopenic purpura,Rhabdomyolysis,Blood in stool,Hyperosmolality and/or hypernatremia,Bacteremia,Depressive disorder, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pressure ulcer, lower back,Barrett's esophagus,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Osteitis deformans without mention of bone tumor,Postinflammatory pulmonary fibrosis,Late effects of cerebrovascular disease, aphasia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Epilepsy, unspecified, without mention of intractable epilepsy,Hypoglycemia, unspecified,Chronic kidney disease, Stage III (moderate)"}


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: Found Down x4 days

PRESENT ILLNESS: This is an 82 year old male who lives alone, last time normal
was likely Thursday (4 days of newspapers stacked up outside of
house). Found in house in bathtub per nephew may have been lying
next to bathtub breathing shallowly. Has history of prostate ca,
CVA x 2, NKDA. Burn on L shoulder. GCS at the scene was 4. He
was intubated in the field and given 1400cc IVF.
.
In the ED, initial vs were: 98.8, 128, 100/palp, 100% intubated.
Patient was given vanc/zosyn. C-collar placed. Patient had a
temp to 101.8 and was given tylenol. He was started on propofol
in the ED. Acute Care Surgery (ACS) evaled patient in the ED. A
FAST scan was negative. Urine tox was negative and UA revealed
large blood, 500 protein, trace ketones, [**11-10**] RBC and
occasional bacteria. Sodium was found to be 159, Cl at 125,
Bicarb at 17, initial lactate was 2.4 which trended down to 1.5.
CK was 3363. WBC was 12.9, plts 82, INR was 1.3, Fibrinogen at
547. Cr was elevated to 2.6 (b/l 1.2-1.4), BUN 91. Pt had a CT
head/spine/chest/ab/pelv which was significant for probably
aspiration pneumonia at the right base. He recieved about 4L
total. Blood and urine Cx were sent. At the time of transfer the
vitals were 101, 109, 114/68, 17, 100% FiO2 100%. After CXR ET
tube pulled back 3cm.
.
On the floor, patient intubated and unable to provide history.

MEDICAL HISTORY: stroke - MRI reveals subacute infarcts in the inferior division
of the L MCA
Prostate CA -'[**54**]; Tx with radiation seeds, casodex and lupron.
Radiation proctitis
Severe Depression: recently stopped all meds
HTN
Carotid stenosis s/p stenting [**10-26**] on L CEA in [**4-29**]
Nephrolithiasis
Echo in 98 with mod-severe MR, rheumatic deformity, mod pulm HTN

MEDICATION ON ADMISSION: Unclear what meds patient has actually been taking; recent OMR
note reporting that patient stopped all meds.
ATORVASTATIN 80 mg Tablet daily
CITALOPRAM 40 mg daily
CLOPIDOGREL 75 mg Tablet daily
FUROSEMIDE 20 mg Tablet daily
LEVETIRACETAM 250 mg Tablet daily
METOPROLOL TARTRATE 25 mg Tablet
ASPIRIN 325 mg
DOCUSATE SODIUM 100 mg Capsule [**Hospital1 **]

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: Discharge Physical Exam
O: Tc: 98.1 BP: 158/71 HR: 109 RR: 20 O2: 94% RA
General: Lying comfortably in bed, conversive
HEENT: MMM, no scleral icterus
Neck: no JVD
CV: RRR, +S1, S2, no m/r/g
Resp: expiratory wheezing bilaterally, bibasilar crackles
Abd: soft, NT/ND, +bowel sounds, no HSM
Ext: 2+ DP/PT pulses - unstageable sacral pressure ulcer ~4x10
cm, minimal surrounding induration with raised edges.  Rim of
granulation tissue with yellow base with an area of black
eschar.  Stage 2 on left shoulder and upper middle back, both
healing well with granulation tissue and some pigmentation
starting again.
Neuro: AAOx3, able to lift legs off bed ~1 feet, can raise knees
to same level, 4/5 strength upper extremities

FAMILY HISTORY: Unkown

SOCIAL HISTORY: He lives alone in [**Location 1268**]. Widowed from his second
marriage, son lives in [**State 531**] City - [**Name (NI) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name 105692**].
Nephew [**Name (NI) **] is HCP, lives in [**Name (NI) 2498**], sister Sabre, also HCP
lives in [**State 15946**].  He is retired from a medical supplier
shipping business. He has an 80-pack-year smoking history; he
quit 18 years ago. He denies any ETOH or illicit drug use. 

### Response:
{"Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Cerebral embolism with cerebral infarction,Acute kidney failure, unspecified,Encephalopathy, unspecified,Immune thrombocytopenic purpura,Rhabdomyolysis,Blood in stool,Hyperosmolality and/or hypernatremia,Bacteremia,Depressive disorder, not elsewhere classified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Pressure ulcer, lower back,Barrett's esophagus,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Osteitis deformans without mention of bone tumor,Postinflammatory pulmonary fibrosis,Late effects of cerebrovascular disease, aphasia,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Epilepsy, unspecified, without mention of intractable epilepsy,Hypoglycemia, unspecified,Chronic kidney disease, Stage III (moderate)"}
