CHIEF COMPLAINT: Hydrothorax

PRESENT ILLNESS: Ms. [**Known lastname 1692**] is a 54 F with a history of decompensated hepatitis C
cirrhosis, recently admitted [**2111-2-11**] for dyspnea and found to
have left-sided hydrothorax, who presents now with a 4-day
history of poor appetite, nausea, vomiting and malaise. She
states that she began feeling nauseous and vomiting
(occasionally bile, occasionally mucous/sputum) shortly after
her last admission, though symptoms had initially improved some
and have recurred over the past few days. She has cough with
sputum, occasional blood streaks but no gross blood. She had one
episode of watery diarrhea yesterday evening, no recurrence. Has
noticed decreased UOP last 2 days. Also reports increased
abdominal fullness (epigastric) and chest pressure.

MEDICAL HISTORY: - HCV cirrhosis
- hypothyroidism
- depression/ anxiety
- MSSA spinal osteomyelitis/ discitis/ epidural
abscess/paravertebral abscess and cord compression s/p C2-C3
laminectomy in [**2107**] with resultant disability and "paralysis"
- prior IV cocaine use of short duration
- negative PPD several years ago

MEDICATION ON ADMISSION: - furosemide 40 mg PO BID
- lactulose 10 gram/15 mL 30 ML PO TID
- spironolactone 100 mg 1.5 Tablets PO DAILY
- tramadol 50 mg PO twice a day as needed for pain (patient not
taking)
- omeprazole 20 mg PO BID (prescribed; patient not taking)
- multivitamin 1 tab PO DAILY

ALLERGIES: Penicillins

PHYSICAL EXAM: ADMISSION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Mother with HTN and DM. Father unknown. Sister passed away from
pancreatic cancer. Grandmother with lung cancer.

SOCIAL HISTORY: On disability since her epidural abscess s/p laminectomy in
[**2107**]. Prior to that was a nurses aid, teacher, crossing guard.
Ambulates minimally with a rolling walker, but mostly confined
to wheelchair. Lives at home with her children, 19 and 21 years
old. Quit smoking in [**2110**]. Formerly smoked [**1-4**] ppd x 5 years;
quit [**2110-6-3**]. Denies current ETOH or IVDA. Used to use
cocaine.
Other specified forms of effusion, except tuberculous,Other ascites,Acute kidney failure, unspecified,Acute cystitis,Cirrhosis of liver without mention of alcohol,Chronic hepatitis C without mention of hepatic coma,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Dysthymic disorder
Effusion NEC exc tb,Ascites NEC,Acute kidney failure NOS,Acute cystitis,Cirrhosis of liver NOS,Chrnc hpt C wo hpat coma,Gstr/ddnts NOS w/o hmrhg,Dysthymic disorder
Admission Date:  [**2111-3-14**]              Discharge Date:   [**2111-3-18**]

Date of Birth:  [**2056-9-29**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
Hydrothorax

Major Surgical or Invasive Procedure:
Diagnostic and therapeutic thoracentesis
Diagnostic Esophagogastroduodenoscopy


History of Present Illness:
Ms. [**Known lastname 1692**] is a 54 F with a history of decompensated hepatitis C
cirrhosis, recently admitted [**2111-2-11**] for dyspnea and found to
have left-sided hydrothorax, who presents now with a 4-day
history of poor appetite, nausea, vomiting and malaise. She
states that she began feeling nauseous and vomiting
(occasionally bile, occasionally mucous/sputum) shortly after
her last admission, though symptoms had initially improved some
and have recurred over the past few days. She has cough with
sputum, occasional blood streaks but no gross blood. She had one
episode of watery diarrhea yesterday evening, no recurrence. Has
noticed decreased UOP last 2 days. Also reports increased
abdominal fullness (epigastric) and chest pressure.

On her last admission, she underwent thoracentesis with 1.1 L of
fluid removed which was terminated early due to coughing, then
had a repeat procedure the following day with 800 cc removed.
She had no significant ascites on RUQ ultrasound during that
admission. This fluid was expected to reaccumulate and she was
planned for follow up in liver clinic to address the need for
further titration of medications or additional thoracentesis;
however, she did not attend her appointment. She states that she
takes her medications as prescribed but is unable to provide
details.

Upon arrival to the ED vitals were: T 98.6, HR 88, BP 117/69, RR
20, 98% 15L NRB. She did not receive any fluids or medications.
She was admitted to the MICU for thoracentesis. Vitals prior to
transfer to the MICU were: afebrile, HR 92, BP 123/74, 96% on
6L.

On arrival to the floor, patient is very anxious, reporting that
she does not want thoracentesis because it hurt her too much the
last time. Most of review of systems is positive which seems to
reflect patient's anxiety over questions about these symptoms to
some degree.

REVIEW OF SYSTEMS:
(+)ve:
(-)ve: fever, chills, night sweats, loss of appetite, fatigue,
chest pain, palpitations, rhinorrhea, nasal congestion, cough,
sputum production, hemoptysis, dyspnea, orthopnea, paroxysmal
nocturnal dyspnea, diarrhea, constipation, hematochezia, melena,
dysuria, urinary frequency, urinary urgency, focal numbness,
focal weakness, myalgias, arthralgias

Past Medical History:
- HCV cirrhosis
- hypothyroidism
- depression/ anxiety
- MSSA spinal osteomyelitis/ discitis/ epidural
abscess/paravertebral abscess and cord compression s/p C2-C3
laminectomy in [**2107**] with resultant disability and "paralysis"
- prior IV cocaine use of short duration
- negative PPD several years ago


Social History:
On disability since her epidural abscess s/p laminectomy in
[**2107**]. Prior to that was a nurses aid, teacher, crossing guard.
Ambulates minimally with a rolling walker, but mostly confined
to wheelchair. Lives at home with her children, 19 and 21 years
old. Quit smoking in [**2110**]. Formerly smoked [**1-4**] ppd x 5 years;
quit [**2110-6-3**]. Denies current ETOH or IVDA. Used to use
cocaine.


Family History:
Mother with HTN and DM. Father unknown. Sister passed away from
pancreatic cancer. Grandmother with lung cancer.


Physical Exam:
ADMISSION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema


Pertinent Results:
Labs on admission:
[**2111-3-14**] 01:55PM   WBC-7.0 RBC-4.09* HGB-12.9 HCT-38.0 MCV-93
MCH-31.4 MCHC-33.9 RDW-16.6*
[**2111-3-14**] 01:55PM   NEUTS-57.8 LYMPHS-30.0 MONOS-7.4 EOS-4.0
BASOS-0.9
[**2111-3-14**] 01:55PM   PLT COUNT-62*
[**2111-3-14**] 01:55PM   PT-17.1* PTT-32.6 INR(PT)-1.5*
[**2111-3-14**] 01:55PM   GLUCOSE-109* UREA N-24* CREAT-1.2* SODIUM-135
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-21* ANION GAP-12
[**2111-3-14**] 01:55PM   ALT(SGPT)-146* AST(SGOT)-205* ALK PHOS-184*
TOT BILI-3.3*
[**2111-3-14**] 01:55PM   ALBUMIN-3.2* CALCIUM-9.1 PHOSPHATE-3.7
MAGNESIUM-2.0
[**2111-3-14**] 01:55PM   AMMONIA-66*
[**2111-3-14**] 02:06PM   LACTATE-2.3*
[**2111-3-14**] 04:55PM   LACTATE-1.6
[**2111-3-14**] 05:20PM URINE  COLOR-DkAmb APPEAR-Hazy SP [**Last Name (un) 155**]-1.034
[**2111-3-14**] 05:20PM URINE  BLOOD-NEG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-8* PH-6.0 LEUK-NEG
[**2111-3-14**] 05:20PM URINE  RBC-0 WBC-1 BACTERIA-MOD YEAST-NONE
EPI-6
[**2111-3-14**] 05:20PM URINE  HYALINE-33*

ECG [**2111-3-14**]: Sinus rhythm. Early R wave progression. Since the
previous tracing of [**2111-2-11**] probably no significant change.

CXR [**2111-3-14**]: FINDINGS: Single AP portable upright chest
radiograph was obtained. There is a new large left pleural
effusion, with associated collapse of the entire left lower
lobe. The aerated portion of the left upper lobe is
unremarkable. The right lung is well expanded and clear, without
focal consolidation, pleural effusion, or pneumothorax. There is
mild shift of the trachea and mediastinum to the right. No acute
osseous abnormality is detected. IMPRESSION: Large left pleural
effusion with associated collapse of the left lower lobe.

KUB [**2111-3-15**]: Current study demonstrates diffuse spread of the
bowel gas within the abdomen, with no evidence of obstruction.
Decubitus view demonstrates no evidence of free air or
pathologic air-fluid levels.

US:
CLINICAL HISTORY: 54-year-old female with hepatitis C. Assess
for portal
vein thrombosis.

TECHNIQUE: Grayscale and limited Doppler ultrasound of the
abdomen was
performed, with Doppler interrogation of the portal venous
system.

COMPARISON STUDY: Abdominal ultrasound from [**2111-1-7**].

FINDINGS:

Hepatic echotexture is diffusely heterogeneous with a nodular
contour,
findings compatible with cirrhosis. No focal liver lesions are
identified.
There is no intra- or extra-hepatic biliary duct dilation. The
common bile
duct measures 5 mm in thickness. The gallbladder is not
visualized and may be
completely contracted. The main, right, and left portal venous
branches are
widely patent with normal direction of flow.

A small left pleural effusion is noted. There is no abdominal
ascites. The
spleen is enlarged, measuring 13.4 cm. Included portions of the
pancreatic
body and head are unremarkable. The tail of the pancreas is
excluded.
Included portions of the abdominal aorta and IVC are
unremarkable.

IMPRESSION:

1. Patency of the portal venous system.
2. Hepatic cirrhosis without focal lesion identified.
3. Small left pleural effusion.
4. Nonvisualization of the gallbladder, which may be due to
contraction.

CXR on [**2111-3-17**]
COMPARISON: Radiographs dating back to [**2111-3-14**] and most recently
[**2111-3-15**].

FINDINGS: The left pleural effusion has significantly reduced in
size and has
not re-accumulated, a small left pleural effusion remains. The
right lung is
normal in appearance. The cardiac size is at the upper limits of
normal.
Heterogenous focal opacity in the left upper lobe was not
present on the
radiograph of [**2111-3-15**] and may represent evolving consolidation,
meriting
further surveillance radiographs.

IMPRESSION:
1. Interval resolution of large left pleural effusion, only
residual small
effusion remains.
2. Heterogenous opacity in the left upper lobe may represent
evolving
consolidation and merits radiographic surveillance.

Discharge labs:
[**2111-3-18**] 04:40AM BLOOD WBC-3.0* RBC-3.29* Hgb-10.3* Hct-30.7*
MCV-93 MCH-31.3 MCHC-33.6 RDW-16.4* Plt Ct-47*
[**2111-3-18**] 04:40AM BLOOD Glucose-74 UreaN-24* Creat-1.3* Na-140
K-4.3 Cl-108 HCO3-26 AnGap-10
[**2111-3-18**] 04:40AM BLOOD ALT-88* AST-132* AlkPhos-118*
TotBili-2.1*
[**2111-3-18**] 04:40AM BLOOD Albumin-3.4* Mg-2.4
.

[**2111-3-14**] 5:20 pm URINE     Site: CLEAN CATCH

                            **FINAL REPORT [**2111-3-18**]**

   URINE CULTURE (Final [**2111-3-18**]):
      ESCHERICHIA COLI.    >100,000 ORGANISMS/ML..
         PRESUMPTIVE IDENTIFICATION.  OF TWO COLONIAL
MORPHOLOGIES.
         Piperacillin/tazobactam sensitivity testing available
on request.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S


Brief Hospital Course:
Ms. [**Known lastname 1692**] is a 54 F with a history of decompensated hepatitis C
cirrhosis, recently admitted [**2111-2-11**] for dyspnea and found to
have left-sided hydrothorax, who re-presented with a hydrothorax
in addition to a UTI and found to have epigastric pain without
evidence of portal vein clot which was thought to be secondary
to  Gastritis after an EGD.
.
ACTIVE ISSUES:

# HEPATIC HYDROTHORAX:
This is the patient's second presentation for this issue in
approximately one month. The hydrothorax is most likely
secondary to liver cirrhosis, which explains the reaccumulation
of fluid over a short interval. She had increases to her
diurectic regimen at her last admission, but although she states
that she has been compliant with her medication, she is unable
to name the medicines, describe the dose changes or explain how
she has been taking the medications at this time. She reports
that the bottle of the "small pill" (? furosemide) has recently
run out. She was supposed to have a follow up appointment in
liver clinic on [**2111-2-26**] to assess for fluid reaccumulation but
did not attend this appointment.  Therefore, non-compliance may
also play a role in this presentation. She underwent bedside
thoracentesis which showed 1L of clear fluid. Repeat CXR showed
a decrease in her effusion.
.
# Decompensated HCV CIRRHOSIS with Mild Enecephalopathy: Patient
noted to have transaminases elevated but slightly lower than
recent baseline, TB elevated to 3.3 (highest recent value), and
INR of 1.5 (similar to prior), consistent with MELD of 17. She
is not currently on the liver transplant list. She was oriented
but reported frequently feeling confused at home and requiring
help from her sisters to run her household and manage her
illness consistent with mild/low grade encephaopathy. Ammonia
level was 66 on arrival to ED. She reports taking her lactulose
but does not have multiple BM daily, rather reports constipation
generally. She is not currently on the transplant list though
reports that Dr. [**Last Name (STitle) **] has raised this possibility in the past.
 Due to her low grade enecephalopathy, she was started on a more
aggressive bowel regiment with miralax in addition to lactulose.
,
# LOW URINE OUTPUT: The patient reported dysuria and low UOP x 2
days on arrival. She was noted to have dark, concentrated urine
on arrival with bacteria and + nitrites, though only 1 WBC and
negative LE. Cutlure grew out E. coli.  On arrival to the MICU,
UOP was < 50 cc/hr. She was given a dose of 40 mg IV furosemide
and UOP increased to > 100 cc/hr.
.
#UTI: Upon admission you had a urine culture sent which grew out
E. Coli you were started on Bactrim to complete a 7 day course.
.
# ACUTE RENAL FAILURE: Creatinine was elevated to 1.2 on
admission from baseline 0.8-1.0. Over the course of this
admission, creatinine remained stably elevated above her
baseline.  She was instructed to hold her diurectic until five
days after discharge.
.
# NAUSEA, VOMITING: Patient complained of nausea/vomiting on and
off since her last discharge. However, on arrival to the MICU
she stated that she was not nauseous but rather hungry. Clear
liquid diet was suggested but patient strongly preferred regular
diet and felt she would tolerate. Had episode of vomiting in the
morning after admission following breakfast of undigested food.
Of note, she was not taking her prescribed PPI because she
believed she may have had a reaction (rash) to "a medicine
prescribed after EGD" in the past. However, she is unable to
provide clear history regarding which medication this was, and
she received omeprazole during her last admision with no
apparent reaction. Omeprazole was therefore restarted.  Of note,
she continued to be nauseous throughout her hospital stay
without resolution of her symptoms.  It was thought, therefore,
that her nausea was multifactorial given her UTI, gastritis,
.
# Epigastric Pain: Unclear etiology, she had a slow drift down
in her Hgb but no evidence of acute blood loss. She also has not
had a bowel movement since friday, making a brisk UGIB unlikely.
She underwent an EGD which showed minimal erythema in the
antrum, but was otherwise unremarkable.  An US of the portal
venous system did not demonstrate a clot.  Therefore, her
epigastric pain was attributed to a mild form of gastritis and
her PPI was increased and she was started on sucralfate.
.
INACTIVE ISSUES
.
# HYPOTHYROISISM: TSH noted to be increased in the past to < 10,
never treated. Recommend follow up with PCP to trend TSH as
outpatient. Hypothyroidism may contribute to her chronic
constipation.

Discharge: Home
Transiation of care: Patient will need careful follow up
regarding her medication prescriptions

Medications on Admission:
- furosemide 40 mg PO BID
- lactulose 10 gram/15 mL 30 ML PO TID
- spironolactone 100 mg 1.5 Tablets PO DAILY
- tramadol 50 mg PO twice a day as needed for pain (patient not
taking)
- omeprazole 20 mg PO BID (prescribed; patient not taking)
- multivitamin 1 tab PO DAILY


Discharge Medications:
1. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
Disp:*7 Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever pain: do not exceed 2grams (2000mg)
in 24 hrs.
3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
6. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily): dissolved in fluid daily, hold for
loose stools.
Disp:*1 bottle* Refills:*2*
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day:
Do not restart until [**2111-3-23**].
10. spironolactone 50 mg Tablet Sig: Three (3) Tablet PO once a
day: do not restart until [**2111-3-23**].


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
-Decompensated Hepatitis C Cirrhosis complicated by hepatic
hydrothorax and acute kidney injury
-Gastritis
-Acute bacterial cystitis

Secondary Diagnoses:
-Hypothyroidism
-Depression/Anxiety


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted for difficulty breathing and abdominal pain.
Your difficulty with breathing improved after getting fluid
drained off your lungs.  We think your abdominal pain was due to
inflammation of the lining of your stomach, which we are
treating with acid blocking medications.  You also had a urinary
tract infection, which we are treating with antibiotics.

Your medications have been changed.  You have been started on
sucralfate (Carafate) and your dose of omeprazole (PRILOSEC) has
been increased in order to help your stomach heal.

You have also been started on a medication called
TRIMETHOPRIM-SULFAMETHAXASOLE (BACTRIM) for your urinary tract
infection.  You will need to take another three days of this
medication.

Finally, we have started you on a more intenvsive bowel regimen
with polyethylene glycol (MIRALAX) and senna to help you keep
your bowels moving, which is  important to avoid confusion from
your liver disease.

Your other medications have not been changed but you will hold
your diuretics (water pills) for an additional five days and
restart them on Monday, [**3-23**].  It will be important for
you to take these medications as previously to prevent
reaccumulation of the fluids around your lung.

Followup Instructions:
Name:  [**Last Name (LF) 94105**], [**Name8 (MD) **], NP.
Location: [**Location (un) **] COMMUNITY HEALTH CENTER
Address: [**State **], [**Location (un) **],[**Numeric Identifier 5138**]
Phone: [**0-0-**]
When: TUESDAY, [**3-24**], 2:45PM

Department: LIVER CENTER
When: FRIDAY [**2111-3-20**] at 10:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: TRANSPLANT
When: THURSDAY [**2111-5-7**] at 2:20 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]

Completed by:[**2111-6-4**]
{'Other specified forms of effusion, except tuberculous,Other ascites,Acute kidney failure, unspecified,Acute cystitis,Cirrhosis of liver without mention of alcohol,Chronic hepatitis C without mention of hepatic coma,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Dysthymic disorder'}


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: Hydrothorax

PRESENT ILLNESS: Ms. [**Known lastname 1692**] is a 54 F with a history of decompensated hepatitis C
cirrhosis, recently admitted [**2111-2-11**] for dyspnea and found to
have left-sided hydrothorax, who presents now with a 4-day
history of poor appetite, nausea, vomiting and malaise. She
states that she began feeling nauseous and vomiting
(occasionally bile, occasionally mucous/sputum) shortly after
her last admission, though symptoms had initially improved some
and have recurred over the past few days. She has cough with
sputum, occasional blood streaks but no gross blood. She had one
episode of watery diarrhea yesterday evening, no recurrence. Has
noticed decreased UOP last 2 days. Also reports increased
abdominal fullness (epigastric) and chest pressure.

MEDICAL HISTORY: - HCV cirrhosis
- hypothyroidism
- depression/ anxiety
- MSSA spinal osteomyelitis/ discitis/ epidural
abscess/paravertebral abscess and cord compression s/p C2-C3
laminectomy in [**2107**] with resultant disability and "paralysis"
- prior IV cocaine use of short duration
- negative PPD several years ago

MEDICATION ON ADMISSION: - furosemide 40 mg PO BID
- lactulose 10 gram/15 mL 30 ML PO TID
- spironolactone 100 mg 1.5 Tablets PO DAILY
- tramadol 50 mg PO twice a day as needed for pain (patient not
taking)
- omeprazole 20 mg PO BID (prescribed; patient not taking)
- multivitamin 1 tab PO DAILY

ALLERGIES: Penicillins

PHYSICAL EXAM: ADMISSION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
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
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Mother with HTN and DM. Father unknown. Sister passed away from
pancreatic cancer. Grandmother with lung cancer.

SOCIAL HISTORY: On disability since her epidural abscess s/p laminectomy in
[**2107**]. Prior to that was a nurses aid, teacher, crossing guard.
Ambulates minimally with a rolling walker, but mostly confined
to wheelchair. Lives at home with her children, 19 and 21 years
old. Quit smoking in [**2110**]. Formerly smoked [**1-4**] ppd x 5 years;
quit [**2110-6-3**]. Denies current ETOH or IVDA. Used to use
cocaine. 

### Response:
{'Other specified forms of effusion, except tuberculous,Other ascites,Acute kidney failure, unspecified,Acute cystitis,Cirrhosis of liver without mention of alcohol,Chronic hepatitis C without mention of hepatic coma,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage,Dysthymic disorder'}
