CHIEF COMPLAINT: obstructive nephrolithiasis

PRESENT ILLNESS: Ms. [**Known lastname **] is an 80 year old female with PMH significant for
atrial fibrillation on coumadin, COPD on 2L NC, HTN, s/p CVA,
recurrent UTI on macrodantin who presents with 3 days of right
sided flank pain. She has been having additional dysuria and
mild nausea at home with poor PO intake but denies any vomiting.
Denies abdominal pains. Endorses feeling chills, sweats and
feverish at home.

MEDICAL HISTORY: - s/p right MCA CVA - [**2189-7-18**] with left-sided hemiplegia
- Atrial fibrillation, on anticoagulation. Target INR 2.0-3.0
- Hypertension
- Hypercholesterolemia
- Glaucoma
- Seizure disorder - followed by Dr. [**Last Name (STitle) 631**]
- Recurrent urinary tract infections on macrodantin
- Depression
- Anemia
- Seborrheic dermatitis
- Left ventricular hypertrophy

MEDICATION ON ADMISSION: - Doxycycline Hyclate 100 mg [**Hospital1 **]
- Duloxetine 30 mg Capsule, Delayed Release(E.C.) daily
- Levetiracetam 500 mg Tablet [**Hospital1 **]
- Nitrofurantoin Macrocrystal 25 mg
- Simvastatin 40 mg Tablet daily
- Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution Q 6hrs
- Pregabalin 75 mg [**Hospital1 **]
- Klor-Con 20 mEq Packet
- Lasix 20 mg Tablet daily
- Albuterol Sulfate 0.63 mg/3 mL q 6hrs
- Diltiazem HCl 60mg [**Hospital1 **]
- Warfarin 3mg Tu, Fri; 2 mg 5X/WEEK [**Doctor First Name **],MO,WE,TH,SA
- Protonix 40 mg Tablet, Delayed Release (E.C.) daily.

ALLERGIES: Penicillins / Sulfa (Sulfonamides) / Erythromycin Ethylsuccinate
/ Zithromax / Zofran

PHYSICAL EXAM: VS: T 100.6F, HR 111, BP 141/75, RR 18, O2 sat 93% on 2.5L NC.
GEN: pale elderly female, pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
Neck: No supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules. Right IJ in
place
RESP: CTA b/l with good air movement throughout
CV: irregular rate, S1 and S2 wnl, no m/r/g
ABD/GU: Right flank TTP, normoactive bowel sounds, soft, no
masses or hepatosplenomegaly, mild suprapubic pain with
palpation
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
RECTAL: deferred

FAMILY HISTORY: mother with breast and ovarian cancer in older age, maternal GF:
 lung cancer (smoker), maternal GM: unknown malignancy. Father
h/o MI, all paternal uncles with heart disease.
Brother with MI at 58.

SOCIAL HISTORY: Lives at home with husband who is her primary care giver.
Wheelchair bound. Quit smoking 15 years ago, ~50 pack year
history
Has three children and a whole group of grandchildren.
Unspecified septicemia,Septic shock,Hydronephrosis,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Calculus of kidney,Severe sepsis,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hematuria, unspecified,Depressive disorder, not elsewhere classified,Epilepsy, unspecified, without mention of intractable epilepsy,Other dependence on machines, supplemental oxygen,Long-term (current) use of anticoagulants
Septicemia NOS,Septic shock,Hydronephrosis,Late ef-hemplga side NOS,Calculus of kidney,Severe sepsis,Atrial fibrillation,Chr airway obstruct NEC,Hypertension NOS,Hyperlipidemia NEC/NOS,Hematuria NOS,Depressive disorder NEC,Epilep NOS w/o intr epil,Depend-supplement oxygen,Long-term use anticoagul
Admission Date:  [**2193-11-9**]              Discharge Date:   [**2193-11-18**]

Date of Birth:  [**2113-9-9**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamides) / Erythromycin Ethylsuccinate
/ Zithromax / Zofran

Attending:[**First Name3 (LF) 689**]
Chief Complaint:
obstructive nephrolithiasis

Major Surgical or Invasive Procedure:
IR-guided percutaneous nephrostomy

History of Present Illness:
Ms. [**Known lastname **] is an 80 year old female with PMH significant for
atrial fibrillation on coumadin, COPD on 2L NC, HTN, s/p CVA,
recurrent UTI on macrodantin who presents with 3 days of right
sided flank pain. She has been having additional dysuria and
mild nausea at home with poor PO intake but denies any vomiting.
Denies abdominal pains. Endorses feeling chills, sweats and
feverish at home.

In the ED, initial VS: 97.7 (but spiked up to 101), HR 60, BP
109/78, RR 18. Initial labs notable for leukocytosis to 18.9,
INR 3.5, lactate of 2.5 and grossly positive U/A. CTU showed a
6mm obstructing stone with associated R sided hydronephrosis.
Urology saw patient and recommended urgent stent placement once
INR corrected to < 1.5. Right IJ placed and vanc/ levaquin/
flagyl given (pcn allergy). Also given 10mg IV Vitamin K and 2
Units FFP. She had brief episode of HRs 130s with atrial
fibrillation and RVR confirmed on EKG and telemetry, but now
resolved and down to low 100s. Given 1L NS IVF in ED.

On arrival to the MICU, she appeared well and in no acute
distress. Vitals were: T 100.6F, HR 111, BP 141/75, RR 18, O2
sat 93% on 2.5L NC.


Past Medical History:
- s/p right MCA CVA - [**2189-7-18**] with left-sided hemiplegia
- Atrial fibrillation, on anticoagulation. Target INR 2.0-3.0
- Hypertension
- Hypercholesterolemia
- Glaucoma
- Seizure disorder - followed by Dr. [**Last Name (STitle) 631**]
- Recurrent urinary tract infections on macrodantin
- Depression
- Anemia
- Seborrheic dermatitis
- Left ventricular hypertrophy


Social History:
Lives at home with husband who is her primary care giver.
Wheelchair bound. Quit smoking 15 years ago, ~50 pack year
history
Has three children and a whole group of grandchildren.


Family History:
mother with breast and ovarian cancer in older age, maternal GF:
 lung cancer (smoker), maternal GM: unknown malignancy. Father
h/o MI, all paternal uncles with heart disease.
Brother with MI at 58.


Physical Exam:
VS: T 100.6F, HR 111, BP 141/75, RR 18, O2 sat 93% on 2.5L NC.
GEN: pale elderly female, pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
Neck: No supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules. Right IJ in
place
RESP: CTA b/l with good air movement throughout
CV: irregular rate, S1 and S2 wnl, no m/r/g
ABD/GU: Right flank TTP, normoactive bowel sounds, soft, no
masses or hepatosplenomegaly, mild suprapubic pain with
palpation
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
RECTAL: deferred


Pertinent Results:
Initial Labs:
[**2193-11-8**] 09:25PM   WBC-18.9*# RBC-5.03 HGB-12.2 HCT-38.7 MCV-77*
MCH-24.3* MCHC-31.6 RDW-16.6*
[**2193-11-8**] 09:25PM   NEUTS-85.1* LYMPHS-8.5* MONOS-4.7 EOS-0.4
BASOS-1.3
[**2193-11-8**] 09:25PM   PT-34.3* PTT-34.0 INR(PT)-3.5*
[**2193-11-8**] 09:25PM   PLT COUNT-286
[**2193-11-8**] 09:25PM   GLUCOSE-121* UREA N-16 CREAT-1.0 SODIUM-143
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-31 ANION GAP-18
[**2193-11-8**] pro BNP: 1010
[**2193-11-8**] LACTATE: 2.3
[**2193-11-8**] 10:25PM URINE  HOURS-RANDOM
[**2193-11-8**] 10:25PM URINE  GR HOLD-HOLD
[**2193-11-8**] 10:25PM URINE  COLOR-Amber APPEAR-Cloudy SP [**Last Name (un) 155**]-1.018
[**2193-11-8**] 10:25PM URINE  BLOOD-LG NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-SM
[**2193-11-8**] 10:25PM URINE  RBC->50 WBC-[**12-7**]* BACTERIA-MOD
YEAST-NONE EPI-0-2
[**2193-11-8**] 10:25PM URINE  HYALINE-[**3-22**]*
[**2193-11-18**] 11:22    ALT 19  AST 21  LDH 161  Alk Phos 89   Tot
Bili 0.2

Microbiology:
[**2193-11-8**] blood cx x2: no growth
[**2193-11-8**] urine cx: no growth
[**2193-11-9**] blood cx x2: no growth to date (pending)
[**2193-11-9**] urine cx (from kidney): no growth

Imaging:
[**2193-11-8**] CXR: There is little interval change. Opacity at the
left base, with associated pleural thickening is chronic,
compatible with a small effusion and associated atelectasis.
There is no superimposed focal consolidation to suggest
pneumonia. Heart size is stable, top-normal. There is mild
pulmonary vascular congestion and likely early interstitial
edema. Calcification of the aortic knob is again noted.
IMPRESSION:  Stable left basilar opacity, compatible with small
effusion and associated atelectasis, without significant
interval change.

[**2193-11-9**] CTU: There is minimal pleural thickening at the bases,
without effusion or consolidation. This is similar in appearance
to prior chest CT [**2193-3-12**]. The liver is normal in size
and appearance, without focal lesions. The patient is status
post cholecystectomy. There is no intra- or extra-hepatic
biliary ductal dilation. The spleen is normal. The pancreas
demonstrates homogeneous enhancement, without ductal dilation or
mass lesions. There are no adrenal nodules or masses. The left
kidney is notable for a punctate non-obstructing stone in the
interpolar region, and a hyperdense cyst demonstrating no
post-contrast enhancement, measuring 12 mm, in the lower pole.
There is no left hydronephrosis, and the left ureter is normal
in caliber throughout its course. However, on the right, there
is moderate hydronephrosis, with associated hydroureter and
periureteral stranding extending into the pelvis, where there is
a 6-mm obstructing stone in the distal ureter. There is a large
right renal cyst, measuring up to 8.4 cm, extending laterally
from the mid pole of the kidney. There is no further focal
hypoenhancing renal lesion or perinephric fluid collection to
suggest pyelonephritis or perinephric abscess.  However, there
is a delayed nephrogram on the right relative to the left.
Subtle urothelial enhancement is also noted. The stomach,
duodenum, and intra-abdominal loops of small bowel are normal in
caliber and configuration. There is no bowel distention or bowel
wall
thickening. There is no free fluid or free air in the abdomen.
There is no
mesenteric or retroperitoneal adenopathy. The aorta is calcified
but normal in caliber, and major mesenteric vessels are patent,
including the superior mesenteric and portal veins. There is no
fluid in the retroperitoneum.  CT PELVIS: Rectum and sigmoid
colon demonstrate scattered diverticula, without evidence for
acute diverticulitis. Uterus and adnexa are unremarkable. A
Foley catheter decompresses the bladder. There is no free pelvic
fluid, and there is no pelvic or inguinal adenopathy. BONE
WINDOWS: No suspicious lytic or sclerotic osseous lesions are
identified. Likely bone islands are seen in the right femoral
head.
_______ seen in the lumbar spine. IMPRESSION: 1. A 6-mm
obstructing distal right ureteral stone with associated
hydroureter and moderate hydronephrosis. There is slight delayed
nephrogram of the right kidney post-contrast administration, but
no focal lesions to suggest pyelonephritis or renal abscess.
There is a large right renal cyst. Minimal urothelial
enhancement is also noted. 2. Punctate non-obstructing left
renal stone, with a single hyperdense renal cyst on the left.
Otherwise, unremarkable left kidney. 3. Sigmoid diverticulosis,
without diverticulitis. 4. Aortic atherosclerosis, without
aneurysm.
.
[**2193-11-11**] Right LENIS: No evidence of DVT at the right lower
extremity.
.
[**2193-11-11**] Chest Port Line Placement: Right PICC terminates in the
upper SVC. Persistent left pleural effusion and atelectasis.
.
DISCHARGE LABS:
WBC 11.3,  Hgb 8.9, Hct 28.2, MCV 79, Plt 375
GLU 103, BUN 20, Cr 0.7, Na 142, K 3.3, Cl 99, HCO3 39*, Ca 8.6,
Mg 1.9, P 2.9


Brief Hospital Course:
In summary, Ms. [**Known lastname **] is an 80yo F with past medical history of
recurrent UTIs, atrial fibrillation, h/o CVA, seizure disorder,
depression who presents now with obstructive nephrolithiasis,
fevers, dysuria, leukocytosis all concerning for septic shock
from a urinary source.

1. Severe Sepsis: Presented with fever, tachycardia and relative
hypotension from severe sepsis.  Etiology attributed to
pyelonephritis with right hydronephrosis [**2-19**] obstructive
nephrolithiasis in setting of recurrent UTIs and chronic
antibiotics. Started empirically on vancomycin and aztreonam
(given multiple antibiotic allergies including pcn).  After
correction of INR with FFP (see below) had semiurgent IR guided
placement of percutaneous nephrostomy with subsequent drainage
of dark urine.  Patient briefly required phenylephrine
post-procedure, likely partially from sedating medications, but
was able to be weaned off rapidly.  Blood and urine cultures
remained negative, so patient was continued on empiric course of
intravenous antibiotics for 14 days following placement of
nephrostomy tube.

2. Obstructive nephrolithiasis with associated right
hydronephrosis: As above, upon presentation to the ED, CT scan
showed obstructive nephrolithiasis with associated right
hydronephrosis.  On day of admission had IR guided percutaneous
nephrostomy will subsequent relief of pain and rapid
stabilization of hemodynamics.  Will follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 770**] from urology for definitive management.  Dr.[**Name (NI) 825**]
office will call patient with date for removal of percutaneous
nephrostomy tube and kidney stone.  Percutaneous nephrostomy
tube should be flushed daily with 10 cc's of NS.  It should not
be clamped.

3. Atrial fibrillation on coumadin: Presented with atrial
fibrillation with rapid ventricular rate in 130s, likely driven
from underlying illness.  As above, initial INR was
supratherapeutic at 3.5 and reversed with 10mg IV vitamin K and
FFP x 3 units.  Given severe sepsis, heart rate was initially
managed by doses of lopressor IV prn but with stabilization s/p
nephrostomy tube placement, restarted on home AV-nodal blocker.
Dose of diltiazem was uptitrated over the course of hospital
stay to 360 mg Diltiazem XR with HR in 80s at time of discharge.
 Restarted on coumadin following procedure, with INR of 2.5
prior to discharge.  Coumadin dose increased to 3 mg daily.  INR
should be checked regularly and Coumadin adjusted for goal INR
of [**2-20**].

4. Acute on chronic diastolic CHF: Upon presentation, patient
was noted to have peripheral edema, elevated JVP, increased
oxygen requirement and rales consistent with acute CHF in
setting of afib with RVR.  CXR c/w vascular congestion with
bilateral pleural effusions.  Given severe sepsis and potential
hemodynamic instability, diuresed with IV lasix and able to be
weaned down to home oxygen requirement of 2L nasal cannula.  She
is discharged on her home po lasix dose.

5. HTN: The patient was normotensive upon discharge with
systolic blood pressures in the 110s.  She continues on home
lasix dose and increased diltiazem dose as above.

6. The patient's seizure disorder, GERD, and hyperlipidemia were
stable and she was kept on her home medications.


Medications on Admission:
- Doxycycline Hyclate 100 mg [**Hospital1 **]
- Duloxetine 30 mg Capsule, Delayed Release(E.C.) daily
- Levetiracetam 500 mg Tablet [**Hospital1 **]
- Nitrofurantoin Macrocrystal 25 mg
- Simvastatin 40 mg Tablet daily
- Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution Q 6hrs
- Pregabalin 75 mg [**Hospital1 **]
- Klor-Con 20 mEq Packet
- Lasix 20 mg Tablet daily
- Albuterol Sulfate 0.63 mg/3 mL q 6hrs
- Diltiazem HCl 60mg [**Hospital1 **]
- Warfarin 3mg Tu, Fri; 2 mg 5X/WEEK [**Doctor First Name **],MO,WE,TH,SA
- Protonix 40 mg Tablet, Delayed Release (E.C.) daily.


Discharge Medications:
1. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheeze.
5. pregabalin 75 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Klor-Con 20 mEq Packet Sig: One (1) packet PO once a day.
8. diltiazem HCl 360 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
9. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Heparin Flush (10 units/ml) 2 mL IV PRN PICC
12. vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous once a day for 4 days.
13. aztreonam in dextrose(iso-osm) 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous every eight (8) hours for 4 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Hospital - [**Hospital1 8**]

Discharge Diagnosis:
Primary Diagnoses: Septic Shock, Pyelonephritis,
Nephrolithiasis, Atrial Fibrillation with Rapid Ventricular
Response
Secondary Diagnoses: Chronic Obstructive Pulmonary Disease,


Discharge Condition:
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Lethargic but arousable.


Discharge Instructions:
You were admitted to the hospital with a severe infection
secondary to a kidney stone.  You initially were treated in the
intensive care unit, but as you improved you were moved to the
general medical floor.  A tube was placed to relieve the
obstruction caused by the stone and your infection was treated
with IV antibitiotics.  You will continue to take IV antibiotics
for several more days.
.
The following changes were made to your medications:
You were STARTED on VANCOMYCIN and AZTREONAM for your infection.
Your DILTIAZEM dose was CHANGED.
Your DOXYCYCLINE and NITROFURANTOIN were STOPPED.  You should
speak to your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 9533**]
NITROFURANTOIN in the future.
Your COUMADIN (WARFARIN) dose was INCREASED.  Your INR should be
checked on Wednesday ([**2193-11-20**]) and your Coumadin dose should be
titrated to a goal INR of [**2-20**].
.
You will need several follow-up appointments as detailed below.
.
It was a pleasure taking care of you.


Followup Instructions:
You should be [**Date Range 653**] by Dr.[**Name (NI) 825**] office from Urology
about a follow-up procedure to remove the nephrostomy tube and
kidney stone.  If you do not hear from them after 7-10 days,
please give them a call at [**Telephone/Fax (1) 5727**].

Department: SURGICAL SPECIALTIES
When: [**Telephone/Fax (1) **] [**2193-12-30**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD [**Telephone/Fax (1) 5727**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Unspecified septicemia,Septic shock,Hydronephrosis,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Calculus of kidney,Severe sepsis,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hematuria, unspecified,Depressive disorder, not elsewhere classified,Epilepsy, unspecified, without mention of intractable epilepsy,Other dependence on machines, supplemental oxygen,Long-term (current) use of anticoagulants'}


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: obstructive nephrolithiasis

PRESENT ILLNESS: Ms. [**Known lastname **] is an 80 year old female with PMH significant for
atrial fibrillation on coumadin, COPD on 2L NC, HTN, s/p CVA,
recurrent UTI on macrodantin who presents with 3 days of right
sided flank pain. She has been having additional dysuria and
mild nausea at home with poor PO intake but denies any vomiting.
Denies abdominal pains. Endorses feeling chills, sweats and
feverish at home.

MEDICAL HISTORY: - s/p right MCA CVA - [**2189-7-18**] with left-sided hemiplegia
- Atrial fibrillation, on anticoagulation. Target INR 2.0-3.0
- Hypertension
- Hypercholesterolemia
- Glaucoma
- Seizure disorder - followed by Dr. [**Last Name (STitle) 631**]
- Recurrent urinary tract infections on macrodantin
- Depression
- Anemia
- Seborrheic dermatitis
- Left ventricular hypertrophy

MEDICATION ON ADMISSION: - Doxycycline Hyclate 100 mg [**Hospital1 **]
- Duloxetine 30 mg Capsule, Delayed Release(E.C.) daily
- Levetiracetam 500 mg Tablet [**Hospital1 **]
- Nitrofurantoin Macrocrystal 25 mg
- Simvastatin 40 mg Tablet daily
- Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution Q 6hrs
- Pregabalin 75 mg [**Hospital1 **]
- Klor-Con 20 mEq Packet
- Lasix 20 mg Tablet daily
- Albuterol Sulfate 0.63 mg/3 mL q 6hrs
- Diltiazem HCl 60mg [**Hospital1 **]
- Warfarin 3mg Tu, Fri; 2 mg 5X/WEEK [**Doctor First Name **],MO,WE,TH,SA
- Protonix 40 mg Tablet, Delayed Release (E.C.) daily.

ALLERGIES: Penicillins / Sulfa (Sulfonamides) / Erythromycin Ethylsuccinate
/ Zithromax / Zofran

PHYSICAL EXAM: VS: T 100.6F, HR 111, BP 141/75, RR 18, O2 sat 93% on 2.5L NC.
GEN: pale elderly female, pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
Neck: No supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits, no thyromegaly or thyroid nodules. Right IJ in
place
RESP: CTA b/l with good air movement throughout
CV: irregular rate, S1 and S2 wnl, no m/r/g
ABD/GU: Right flank TTP, normoactive bowel sounds, soft, no
masses or hepatosplenomegaly, mild suprapubic pain with
palpation
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
RECTAL: deferred

FAMILY HISTORY: mother with breast and ovarian cancer in older age, maternal GF:
 lung cancer (smoker), maternal GM: unknown malignancy. Father
h/o MI, all paternal uncles with heart disease.
Brother with MI at 58.

SOCIAL HISTORY: Lives at home with husband who is her primary care giver.
Wheelchair bound. Quit smoking 15 years ago, ~50 pack year
history
Has three children and a whole group of grandchildren. 

### Response:
{'Unspecified septicemia,Septic shock,Hydronephrosis,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side,Calculus of kidney,Severe sepsis,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hematuria, unspecified,Depressive disorder, not elsewhere classified,Epilepsy, unspecified, without mention of intractable epilepsy,Other dependence on machines, supplemental oxygen,Long-term (current) use of anticoagulants'}
