CHIEF COMPLAINT: pneumonia

PRESENT ILLNESS: 56 year old female with a past medical history significant for
multiple sclerosis in a wheelchair, and DVT on coumadin who
presented with shortness of breath. [**Doctor Last Name 402**], her personal care
attendant, reports on Friday patient had some coughing, but no
shortness of breath. She got chest physical therapy and some
suctioning and felt better. On Saturday, she was slightly worse
with some cough, and shortness of breath, that improved
suctioning and pulmonary treatments. Today she had wheezing,
short of breath, and coughing. A neighbor was somehow notified
of shortness of breath and called EMS. EMS found patient 84 %,
placed on NRB then was 100%.

MEDICAL HISTORY: Multiple Sclerosis
DVT on coumadin, may years ago [**First Name8 (NamePattern2) **] [**Doctor Last Name 402**]
Depression

MEDICATION ON ADMISSION: Klonopin 0.5 mg QHS
Baclofen 10 mg 2 tabs at 8 am, 12 pm, 6pm and 1 tab at bedtime
Calcium Carbonate 600 mg daily
Vitamin C 500 mg [**Hospital1 **]
Clotrimazole 1% TID: rash: prn
Prozac solution 20 mg /5ml 7.5 ml daily
Hiprex 1 gm tabs [**Hospital1 **]
Prevacid 30 mg in apple juice [**Hospital1 **]
Colace 150 mg/15ml 10 ml daily
Senokot 8.6mg tabs [**Hospital1 **]
Bisacodyl 10 mg M/Wed/Fri
Reglan 5 mg/ml [**Hospital1 **]
Atrovent 0.03% solution neb [**Hospital1 **]
Pulmicort 0.25mg/2ml neb [**Hospital1 **]
Jevity 1.2 cal/cc 4 cans daily through g tube when upright in
wheelchair
BiPAP PEEP 5, inspiratory pressure 10 at night
ASA 81 mg daily
Lopressor 12.5 mg [**Hospital1 **]
Simvastatin 10 mg QHS
Cerovite (MVI) 15 ml daily
Coumadin unclear dosage
.
pills are crushed with pill crusher, mixed with water 50 cc and
given through g-tube with 50 cc flush. Liquid medicines are
given with 50 cc water, and flushed with 50 cc water.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ON ADMISSION
General: intubated, sedated, no acute distress
HEENT: Sclera anicteric, MMdry, oropharynx with dried blood,
blood in left posterior nares
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse rhonchi throughout
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, g- tube in
place
Ext: cool, slight mottling but cap refill < 3 secs. dopplerable
pulses, 1+ edema bilaterally. Arms with contractures at elbows
and hands.

FAMILY HISTORY: NC

SOCIAL HISTORY: lives alone, daily care health care aid- [**Doctor Last Name 402**] [**Telephone/Fax (1) 37057**].
Brothers and sisters, and two children. Divorced. Her daughter
[**Name (NI) **] primary health care proxy, and [**Name (NI) 402**] is secondary
health care proxy.
Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Cellulitis and abscess of leg, except foot,Urinary tract infection, site not specified,Candidiasis of mouth,Pneumonia, organism unspecified,Atrial fibrillation,Depressive disorder, not elsewhere classified,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Multiple sclerosis,Gastrostomy status,Other abnormal glucose
Food/vomit pneumonitis,Acute respiratry failure,Cellulitis of leg,Urin tract infection NOS,Thrush,Pneumonia, organism NOS,Atrial fibrillation,Depressive disorder NEC,Long-term use anticoagul,Hx-ven thrombosis/embols,Multiple sclerosis,Gastrostomy status,Abnormal glucose NEC
Admission Date:  [**2166-4-20**]              Discharge Date:   [**2166-5-2**]

Date of Birth:  [**2109-4-26**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
pneumonia

Major Surgical or Invasive Procedure:
Intubated on ventilator [**Date range (1) 13407**]
PICC line placed [**4-24**]


History of Present Illness:
56 year old female with a past medical history significant for
multiple sclerosis in a wheelchair, and DVT on coumadin who
presented with shortness of breath. [**Doctor Last Name 402**], her personal care
attendant, reports on Friday patient had some coughing, but no
shortness of breath. She got chest physical therapy and some
suctioning and felt better. On Saturday, she was slightly worse
with some cough, and shortness of breath, that improved
suctioning and pulmonary treatments. Today she had wheezing,
short of breath, and coughing. A neighbor was somehow notified
of shortness of breath and called EMS. EMS found patient 84 %,
placed on NRB then was 100%.

In ED, patient was alert, able to nod head to questions. [**First Name8 (NamePattern2) **]
[**Doctor Last Name 402**] baseline is limited communication, mostly non-verbal.
Noted to have noisy upper respiratory sounds. Guaiac negative.
Underwent nasotracheal suctioning without significant
secretions, but with re-positioning appeared to throw up G-tube
feeds. Placed NGtube and suctioned tube feeds. Clinically felt
to aspirate. Portable CXR L basilar retrocardiac PNA. EKG sinus
tach at 118. Got Levoquin 750, flagyl, tylenol and toradol. Got
2.5 L fluid. Vitals Rectal 99.0, HR 106, BP 119/63, RR 18-20,
o2sat 96% 6 liters. Planned for unit transfer, then noted blood
in her airway, unclear source but suspected NG tube and got
intubated for airway protection. ED spoke with ENT, packed her
mouth and sent to ICU for further care.


Past Medical History:
Multiple Sclerosis
DVT on coumadin, may years ago [**First Name8 (NamePattern2) **] [**Doctor Last Name 402**]
Depression


Social History:
lives alone, daily care health care aid- [**Doctor Last Name 402**] [**Telephone/Fax (1) 37057**].
Brothers and sisters, and two children. Divorced. Her daughter
[**Name (NI) **] primary health care proxy, and [**Name (NI) 402**] is secondary
health care proxy.

Family History:
NC

Physical Exam:
ON ADMISSION
General: intubated, sedated, no acute distress
HEENT: Sclera anicteric, MMdry, oropharynx with dried blood,
blood in left posterior nares
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse rhonchi throughout
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, g- tube in
place
Ext: cool, slight mottling but cap refill < 3 secs. dopplerable
pulses, 1+ edema bilaterally. Arms with contractures at elbows
and hands.

ON DISCHARGE
General: no acute distress
HEENT: MMday, face tent humidified at 40% hiflow
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse breath sounds, moving air
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, g- tube in
place
Ext: warm, cap refill < 3 secs. dopplerable pulses,  trace edema
bilaterally. Arms with contractures at elbows and hands.

Pertinent Results:
ON ADMISSION:

CXR: Left basilar and retrocardiac opacity. Findings could
represent aspiration pneumonia. Minimal atelectasis of the right
base.

RESPIRATORY CULTURE (Final [**2166-4-24**]):
      Commensal Respiratory Flora Absent.
      YEAST.    RARE GROWTH.

CTA [**2166-4-22**]:
1)No pulmonary embolism or acute aortic pathology.
2)Partial collapse of the left upper lobe is contributing the
abnormal contour of the aortic knob on the recent chest
radiograph
3)Multifocal pneumonia with bilateral pleural effusions and
bibasilar
atelectasis.
4)Multilevel wedge compression fractures of indeterminate
chronicity.


[**2166-4-20**] 02:30PM BLOOD WBC-15.4* RBC-4.70 Hgb-14.8 Hct-43.2
MCV-92 MCH-31.6 MCHC-34.4 RDW-14.9 Plt Ct-255
[**2166-4-20**] 02:30PM BLOOD Neuts-89.2* Lymphs-5.3* Monos-4.9 Eos-0.1
Baso-0.6
[**2166-4-20**] 05:42PM BLOOD PT-19.4* PTT-40.9* INR(PT)-1.8*
[**2166-4-20**] 02:30PM BLOOD Glucose-138* UreaN-18 Creat-0.5 Na-136
K-4.0 Cl-97 HCO3-27 AnGap-16
[**2166-4-20**] 02:30PM BLOOD ALT-77* AST-69* AlkPhos-275* TotBili-0.3
[**2166-4-20**] 08:15PM BLOOD Calcium-8.1* Phos-2.0* Mg-1.4*
[**2166-4-20**] 09:04PM BLOOD Type-ART Rates-16/ PEEP-15 FiO2- O2
Flow-40 pO2-106* pCO2-40 pH-7.40 calTCO2-26 Base XS-0
-ASSIST/CON Intubat-INTUBATED
[**2166-4-20**] 02:54PM BLOOD Lactate-3.0*
[**2166-4-20**] 04:00PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2166-4-20**] 04:00PM URINE Blood-LG Nitrite-POS Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2166-4-20**] 04:00PM URINE RBC-[**5-29**]* WBC-[**5-29**]* Bacteri-MANY
Yeast-NONE Epi-[**2-21**] TransE-0-2

ON DISCHARGE:

[**2166-5-2**] 03:21AM BLOOD WBC-8.6 RBC-2.84* Hgb-9.3* Hct-27.1*
MCV-96 MCH-32.6* MCHC-34.1 RDW-14.5 Plt Ct-806*
[**2166-4-27**] 04:33AM BLOOD Neuts-67.0 Lymphs-21.8 Monos-10.8 Eos-0.2
Baso-0.2
[**2166-5-2**] 03:21AM BLOOD Glucose-99 UreaN-13 Creat-0.3* Na-141
K-4.3 Cl-103 HCO3-28 AnGap-14
[**2166-4-22**] 03:32AM BLOOD ALT-40 AST-27 AlkPhos-175* TotBili-0.4
[**2166-5-2**] 03:21AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.1

Brief Hospital Course:
This is a 56 year old female with advanced multiple sclerosis
admitted for pneumonia.

1. Respiratory Failure: The patient required intubation related
to her underlying PNA.  She also developed lobar collapse versus
segmental atelectasis on imaging when she was initially weaned
to pressure support.  Sedation was weaned off but extubation was
problem[**Name (NI) 115**] due to weakened gag reflex, underlying muscle
weakness secondary to advanced multiple sclerosis, volume
overload, copious oral secretions, and lack of cuff leak.  She
received a course of dexamethasone given her absence of cuff
leak.  Further diuresis was attempted but was limited by the
patient developing hypotension.  She was extubated on [**4-28**] after
a 4 day trial of PSV.  After exutbation, she still had a high
oxygen requirement and need for frequent suctioning of oral
secretions. Her saturation would improve with repositioning,
chest PT, and suctioning which suggested that she may have had
intermittent mucous plugging.  She also had some pleural
effusions on imaging.  The patient confirmed that she would not
want to be re-intubated and her code status was changed to
DNR/DNI.  She required aggressive chest PT, scopolamine patches
as needed to reduce oral secretions, as well as ipratropium,
albuterol, Mucomyst, and fluticasone MDIs to improve her
pulmonary status.  An insufflator/exsufflator was also initiated
to stimulate cough to further help to bring up secretions.  She
was also continued on her home biPAP of [**9-23**] at night.  Her
fluticasone MDI was discontinued prior to discharge given the
association of steroids with increased incidence of pneumonia.
She may benefit from intermittent scopolamine patches to help
decrease her oral secretions.

2. PNA:  Most likely community acquired with an aspiration
component given her altered gag reflex and observation in the ED
of tube feeds in her mouth.  She was orginally on levofloxacin,
ceftiaxone, and flagyl.  Ceftriaxone was discontinued [**4-23**].
Flagyl was changed to clindamycin to cover for celllulitis as
detailed below.  She completed a 7 days course of levofloxacin
and was continued clindamycin to treat both her cellulitis and
aspiration.

3. Leukocytosis/Fevers:  The patient developed leukocytosis on
[**4-29**] in addition to some low-grade fevers.  She has had no other
localizing sources of infection other than her PNA and improving
cellulitis.  Her fevers may possibly be due to atelectasis, but
C. diff was also ruled out given the administration of
antibiotics.  Her PICC was placed on [**4-24**].  She has not had any
fevers for a few days prior to discharge and her leukocytosis
has also resolved.

4. RLE Erythema:  She was noted to have a rash on [**4-25**] which was
concerning for cellulitis.  Flagyl was changed to clindamycin on
[**4-25**] with improvement of the demarcated border of erythema.  She
completed a 7 day course of clindamycin on [**5-2**].  Clindamycin
was picked because it will cover both possible MRSA and
aspiration PNA.

5. Atrial Fibrillation: The etiology is likely secondary to
pneumonia. Her CHADS score is 1.  She was started on diltiazem
30mg PO q6 which worked well for rate control initially but had
to be discontinued given her hypotension.  She was on metoprolol
at home as well which was also discontinued due to hypotension.
Aspirin was originally held given OP bleeding but was restarted
on [**4-25**].  Her home Coumadin was not restarted. She was in sinus
with tachycardia in low 100s and hemodynamically stable at time
of discharge.

6. Multiple Sclerosis: She was continued on her home regimen of
clonazepam, baclofen, and reglan.  It was noted that she had
some increased sedation which improved with halving her
clonzepam dose to 0.25mg TID.

7. Elevated LFTs: Her transaminitis was likely related to her
statin.  It resolved off of simvastatin and her statin was not
re-initiated on discharge.

8. h/o DVT: Her home Coumadin and aspirin were initially stopped
secondary to oropharyngeal bleeding noted on admission.  She was
restarted on aspirin but not Coumadin.  DVT prophylaxis was
maintained with heparin SC and pneumoboots.

9. Depression: She was continued on her home dose of fluoxetine.

10. Hyperglycemia: She did not have a diagnosis of diabetes
prior to admission.  It may be that her sugars have been
elevated in the setting of acute illness.  She was maintained on
a Humalog ISS, but it was discontinued on discharge as she has
not had any appreciable insulin requirement in several days.

10. Code: Confirmed DNR/DNI.


Medications on Admission:
Klonopin 0.5 mg QHS
Baclofen 10 mg 2 tabs at 8 am, 12 pm, 6pm and 1 tab at bedtime
Calcium Carbonate 600 mg daily
Vitamin C 500 mg [**Hospital1 **]
Clotrimazole 1% TID: rash: prn
Prozac solution 20 mg /5ml 7.5 ml daily
Hiprex 1 gm tabs [**Hospital1 **]
Prevacid 30 mg in apple juice [**Hospital1 **]
Colace 150 mg/15ml 10 ml daily
Senokot 8.6mg tabs [**Hospital1 **]
Bisacodyl 10 mg M/Wed/Fri
Reglan 5 mg/ml [**Hospital1 **]
Atrovent 0.03% solution neb [**Hospital1 **]
Pulmicort 0.25mg/2ml neb [**Hospital1 **]
Jevity 1.2 cal/cc 4 cans daily through g tube when upright in
wheelchair
BiPAP PEEP 5, inspiratory pressure 10 at night
ASA 81 mg daily
Lopressor 12.5 mg [**Hospital1 **]
Simvastatin 10 mg QHS
Cerovite (MVI) 15 ml daily
Coumadin unclear dosage
.
pills are crushed with pill crusher, mixed with water 50 cc and
given through g-tube with 50 cc flush. Liquid medicines are
given with 50 cc water, and flushed with 50 cc water.


Discharge Medications:
1. Baclofen 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO 8 AM, 12 PM AND
6 PM ().
2. Baclofen 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS (once a day
(at bedtime)).
3. Metoclopramide 10 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a
day).
4. Fluoxetine 20 mg Tablet [**Hospital1 **]: 1.5 Tablets PO DAILY (Daily).
5. Therapeutic Multivitamin     Liquid [**Hospital1 **]: Five (5) ML PO DAILY
(Daily).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] twice a day.
7. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ML PO BID (2
times a day).
8. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO QMOWEFR (Monday
-Wednesday-Friday).
10. Ascorbic Acid 500 mg/5 mL Syrup [**Last Name (STitle) **]: Five (5) ML PO twice a
day.
11. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Acetaminophen 650 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever, pain.
13. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed for affected areas.
14. Ibuprofen 600 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain/fever.
15. Acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (STitle) **]: Five (5) ML
Miscellaneous Q4H (every 4 hours) as needed for chest
congestion.
16. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) ampule
Inhalation Q6H (every 6 hours).
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) ampule Inhalation every four (4) hours
as needed for shortness of breath or wheezing.
18. Clonazepam 0.5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO TID (3 times a
day).
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
20. Calcium Carbonate 600 mg (1,500 mg) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO once a day.
21. Hiprex 1 gram Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]

Discharge Diagnosis:
Primary Diagnosis: Community acquired pneumonia with element of
aspiration requiring intubation
Primary Diagnosis: new onset atrial fibrillation

Secondary diagnoses:
Advanced Multiple Sclerosis
History of DVT many years ago
Depression


Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Mental Status: Clear and coherent.
SBP: 90s-100s, HR 100s, stable


Discharge Instructions:
You were admitted to [**Hospital1 69**] for
evaluation of shortness of breath.  You were noted to have a
pneumonia that required intubation. You have slowly recovered,
but continue to have trouble coughing up phelgm and are going to
a rehabilitation facility to help regain your strength.

The following changes have been made to your home medication
regimen:
- You should stop your home Pulmicort
- You should stop your home Coumadin
- You should stop your home simvastatin
- You should stop your home metoprolol
- You should decrease your home clonazepam dose to 0.25mg three
times daily

Followup Instructions:
Please follow up with the physicians at your long term care
facility.

Please contact your primary care practice, [**Name (NI) **] Community
Medical Group,  to update them on your progress. [**First Name4 (NamePattern1) 1743**]
[**Last Name (NamePattern1) 37058**], NP [**Telephone/Fax (1) 37059**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 37060**] [**Telephone/Fax (1) 8454**]. They
can also help you transition home when you are ready.


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Cellulitis and abscess of leg, except foot,Urinary tract infection, site not specified,Candidiasis of mouth,Pneumonia, organism unspecified,Atrial fibrillation,Depressive disorder, not elsewhere classified,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Multiple sclerosis,Gastrostomy status,Other abnormal glucose'}


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: pneumonia

PRESENT ILLNESS: 56 year old female with a past medical history significant for
multiple sclerosis in a wheelchair, and DVT on coumadin who
presented with shortness of breath. [**Doctor Last Name 402**], her personal care
attendant, reports on Friday patient had some coughing, but no
shortness of breath. She got chest physical therapy and some
suctioning and felt better. On Saturday, she was slightly worse
with some cough, and shortness of breath, that improved
suctioning and pulmonary treatments. Today she had wheezing,
short of breath, and coughing. A neighbor was somehow notified
of shortness of breath and called EMS. EMS found patient 84 %,
placed on NRB then was 100%.

MEDICAL HISTORY: Multiple Sclerosis
DVT on coumadin, may years ago [**First Name8 (NamePattern2) **] [**Doctor Last Name 402**]
Depression

MEDICATION ON ADMISSION: Klonopin 0.5 mg QHS
Baclofen 10 mg 2 tabs at 8 am, 12 pm, 6pm and 1 tab at bedtime
Calcium Carbonate 600 mg daily
Vitamin C 500 mg [**Hospital1 **]
Clotrimazole 1% TID: rash: prn
Prozac solution 20 mg /5ml 7.5 ml daily
Hiprex 1 gm tabs [**Hospital1 **]
Prevacid 30 mg in apple juice [**Hospital1 **]
Colace 150 mg/15ml 10 ml daily
Senokot 8.6mg tabs [**Hospital1 **]
Bisacodyl 10 mg M/Wed/Fri
Reglan 5 mg/ml [**Hospital1 **]
Atrovent 0.03% solution neb [**Hospital1 **]
Pulmicort 0.25mg/2ml neb [**Hospital1 **]
Jevity 1.2 cal/cc 4 cans daily through g tube when upright in
wheelchair
BiPAP PEEP 5, inspiratory pressure 10 at night
ASA 81 mg daily
Lopressor 12.5 mg [**Hospital1 **]
Simvastatin 10 mg QHS
Cerovite (MVI) 15 ml daily
Coumadin unclear dosage
.
pills are crushed with pill crusher, mixed with water 50 cc and
given through g-tube with 50 cc flush. Liquid medicines are
given with 50 cc water, and flushed with 50 cc water.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ON ADMISSION
General: intubated, sedated, no acute distress
HEENT: Sclera anicteric, MMdry, oropharynx with dried blood,
blood in left posterior nares
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse rhonchi throughout
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, g- tube in
place
Ext: cool, slight mottling but cap refill < 3 secs. dopplerable
pulses, 1+ edema bilaterally. Arms with contractures at elbows
and hands.

FAMILY HISTORY: NC

SOCIAL HISTORY: lives alone, daily care health care aid- [**Doctor Last Name 402**] [**Telephone/Fax (1) 37057**].
Brothers and sisters, and two children. Divorced. Her daughter
[**Name (NI) **] primary health care proxy, and [**Name (NI) 402**] is secondary
health care proxy. 

### Response:
{'Pneumonitis due to inhalation of food or vomitus,Acute respiratory failure,Cellulitis and abscess of leg, except foot,Urinary tract infection, site not specified,Candidiasis of mouth,Pneumonia, organism unspecified,Atrial fibrillation,Depressive disorder, not elsewhere classified,Long-term (current) use of anticoagulants,Personal history of venous thrombosis and embolism,Multiple sclerosis,Gastrostomy status,Other abnormal glucose'}
