CHIEF COMPLAINT: Hypotension.

PRESENT ILLNESS: History of Present Illness: 64-year-old man with pancreatic
cancer s/p recent Whipple ([**2159-1-31**]) now on adjuvant
chemotherapy (last dose per patient was two weeks prior to
this), diabetes type II, sCHF with EF 30%, CAD s/p MI, and
atrial fibrillation on coumadin who presented to the ED from
home with progressive lower extremity swelling and "not feeling
well." Family members at home, furthermore, felt that he did not
look right and decided to bring him to the emergency room. Of
note, patient was recently discharged from [**Hospital3 3583**] to
home with diagnosis of pneumonia. It is not clear what
antibiotics he was treated with - patient cannot remember.
.
In the ED, initial vital signs were T 97.6, HR 111, BP 86/56, RR
12, satting 94% RA. Labs notable for hct 29 (at baseline), trop
of 0.21 with normal CK (in setting of acute on chronic renal
failure with creatinine 2.0 from baseline ~1.3), and glucose of
38. Lactate was 1.6. EKG showed atrial fibrillation (rate of
107) with RBBB and RAD. There were no significant changes from a
preoperative EKG in [**Month (only) 958**]. CXR showed RLL infiltrate consistent
with pneumonia. UA was negative. Blood and urine cultures were
sent. Patient was given aspirin 325 mg, levofloxacin 750 mg,
vancomycin 1gm, and one amp of D50. He was given 1.5L NS (given
h/o sCHF) and admitted to the intensive care unit for persistant
hypotension.
.
Review of Systems: currently patient denies pain, shortness of
breath, chest pain or pressure, headache, nausea or vomiting

MEDICAL HISTORY: Past Medical History:
- Type II DM
- CHF with an EF of 30%
- CAD s/p MI
- h/o atrial fibrillation on Coumadin
- Chronic Renal Insufficiency (baseline creatinine 1.3)
- Adenocarcinoma of the pancreas s/p Whipple in [**Month (only) **]/[**2158**] with
positive margins, currently undergoing adjuvant chemotherapy
with gemcitabine (about three cycles in); most recent
chemotherapy was two weeks ago, per patient
.
Past Surgical History:
- sinus surgery
- (L)LE bypass for nonhealing toe ulcer
- ERCP with stent placement
- Whipple procedure as above

MEDICATION ON ADMISSION: - toprol XL 50mg QD
- cozaar
- losartan 50mg PO daily
- lasix 20mg PO daily
- ecotrin 80mg PO daily
- lipitor 40mg PO daily
- protonix 30mg PO daily
- lantus 15 units qam
- levaquin 500mg PO daily X 5 days (just finished)
- coumadin 3mg PO daily

ALLERGIES: Penicillins

PHYSICAL EXAM: Vitals: SBP 90s, HR 100-110, sat mid 90s on RA
General: pale-appearing elderly gentleman in no acute distress
HEENT: PERRLA, non-icteric sclera
Neck: JVP to ear lobe at 30 degrees
Cardiovascular: irregularly irregular
Pulmonary: bilateral crackles half way up lung fields
Abdominal: soft, non-tender, normal bowel sounds
Extremities: cold distally, non-diaphoretic, 2+ pitting edema to
above the knees bilaterally
Neurological: AAOx3, moving all extremities

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Lives with his wife. Laid off from computer analyst position.
No tobacco. Occasional ETOH.
Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Malignant neoplasm of pancreas, part unspecified,Atrial fibrillation,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Anemia in chronic kidney disease,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled
Ac on chr syst hrt fail,Acute kidney failure NOS,Malig neo pancreas NOS,Atrial fibrillation,Chronic kidney dis NOS,Long-term use of insulin,Anemia in chr kidney dis,DMII oth nt st uncntrld
Admission Date:  [**2159-4-25**]              Discharge Date:   [**2159-4-30**]

Date of Birth:  [**2094-9-7**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Hypotension.

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
History of Present Illness: 64-year-old man with pancreatic
cancer s/p recent Whipple ([**2159-1-31**]) now on adjuvant
chemotherapy (last dose per patient was two weeks prior to
this), diabetes type II, sCHF with EF 30%, CAD s/p MI, and
atrial fibrillation on coumadin who presented to the ED from
home with progressive lower extremity swelling and "not feeling
well." Family members at home, furthermore, felt that he did not
look right and decided to bring him to the emergency room. Of
note, patient was recently discharged from [**Hospital3 3583**] to
home with diagnosis of pneumonia. It is not clear what
antibiotics he was treated with - patient cannot remember.
.
In the ED, initial vital signs were T 97.6, HR 111, BP 86/56, RR
12, satting 94% RA. Labs notable for hct 29 (at baseline), trop
of 0.21 with normal CK (in setting of acute on chronic renal
failure with creatinine 2.0 from baseline ~1.3), and glucose of
38. Lactate was 1.6. EKG showed atrial fibrillation (rate of
107) with RBBB and RAD. There were no significant changes from a
preoperative EKG in [**Month (only) 958**]. CXR showed RLL infiltrate consistent
with pneumonia. UA was negative. Blood and urine cultures were
sent. Patient was given aspirin 325 mg, levofloxacin 750 mg,
vancomycin 1gm, and one amp of D50. He was given 1.5L NS (given
h/o sCHF) and admitted to the intensive care unit for persistant
hypotension.
.
Review of Systems: currently patient denies pain, shortness of
breath, chest pain or pressure, headache, nausea or vomiting


Past Medical History:
Past Medical History:
- Type II DM
- CHF with an EF of 30%
- CAD s/p MI
- h/o atrial fibrillation on Coumadin
- Chronic Renal Insufficiency (baseline creatinine 1.3)
- Adenocarcinoma of the pancreas s/p Whipple in [**Month (only) **]/[**2158**] with
positive margins, currently undergoing adjuvant chemotherapy
with gemcitabine (about three cycles in); most recent
chemotherapy was two weeks ago, per patient
.
Past Surgical History:
- sinus surgery
- (L)LE bypass for nonhealing toe ulcer
- ERCP with stent placement
- Whipple procedure as above

Social History:
Lives with his wife. Laid off from computer analyst position.
No tobacco. Occasional ETOH.


Family History:
Non-contributory.

Physical Exam:
Vitals: SBP 90s, HR 100-110, sat mid 90s on RA
General: pale-appearing elderly gentleman in no acute distress
HEENT: PERRLA, non-icteric sclera
Neck: JVP to ear lobe at 30 degrees
Cardiovascular: irregularly irregular
Pulmonary: bilateral crackles half way up lung fields
Abdominal: soft, non-tender, normal bowel sounds
Extremities: cold distally, non-diaphoretic, 2+ pitting edema to
above the knees bilaterally
Neurological: AAOx3, moving all extremities


Pertinent Results:
[**2159-4-25**] 01:18AM BLOOD WBC-10.0 RBC-3.26* Hgb-9.6* Hct-29.0*
MCV-89 MCH-29.5# MCHC-33.2 RDW-21.6* Plt Ct-359#
[**2159-4-25**] 09:05AM BLOOD WBC-11.8* RBC-3.20* Hgb-9.4* Hct-29.5*
MCV-92 MCH-29.4 MCHC-31.8 RDW-21.7* Plt Ct-347
[**2159-4-26**] 04:15AM BLOOD WBC-11.2* RBC-3.32* Hgb-9.6* Hct-29.6*
MCV-89 MCH-28.8 MCHC-32.3 RDW-21.4* Plt Ct-475*
[**2159-4-27**] 05:20AM BLOOD WBC-11.8* RBC-3.28* Hgb-9.6* Hct-29.2*
MCV-89 MCH-29.1 MCHC-32.7 RDW-21.4* Plt Ct-476*
[**2159-4-25**] 01:18AM BLOOD Neuts-79.2* Lymphs-12.2* Monos-6.9
Eos-1.4 Baso-0.2
[**2159-4-25**] 09:10AM BLOOD PT-35.7* PTT-51.0* INR(PT)-3.7*
[**2159-4-26**] 04:15AM BLOOD PT-27.4* PTT-42.7* INR(PT)-2.7*
[**2159-4-27**] 05:20AM BLOOD PT-25.3* PTT-42.0* INR(PT)-2.4*
[**2159-4-28**] 06:10AM BLOOD PT-28.2* PTT-42.0* INR(PT)-2.8*
[**2159-4-25**] 01:18AM BLOOD Glucose-39* UreaN-41* Creat-2.0* Na-143
K-3.9 Cl-108 HCO3-25 AnGap-14
[**2159-4-25**] 12:15PM BLOOD Glucose-94 UreaN-35* Creat-1.8* Na-144
K-3.6 Cl-110* HCO3-24 AnGap-14
[**2159-4-25**] 09:30PM BLOOD Glucose-177* UreaN-38* Creat-2.1* Na-141
K-4.0 Cl-107 HCO3-26 AnGap-12
[**2159-4-26**] 04:15AM BLOOD Glucose-182* UreaN-38* Creat-1.9* Na-141
K-4.1 Cl-107 HCO3-25 AnGap-13
[**2159-4-26**] 05:05PM BLOOD Creat-2.0* Na-138 K-4.2 Cl-105
[**2159-4-27**] 05:20AM BLOOD Glucose-137* UreaN-38* Creat-1.9* Na-140
K-3.7 Cl-105 HCO3-27 AnGap-12
[**2159-4-28**] 06:10AM BLOOD Glucose-97 UreaN-31* Creat-1.6* Na-140
K-3.8 Cl-105 HCO3-29 AnGap-10
[**2159-4-25**] 12:15PM BLOOD ALT-22 AST-35 LD(LDH)-269* CK(CPK)-101
AlkPhos-114 TotBili-0.8
[**2159-4-25**] 01:18AM BLOOD cTropnT-0.21*
[**2159-4-25**] 09:10AM BLOOD CK-MB-2 cTropnT-0.05*
[**2159-4-25**] 12:15PM BLOOD CK-MB-3 cTropnT-0.14*
[**2159-4-25**] 01:18AM BLOOD CK-MB-4 proBNP-[**Numeric Identifier 24733**]*
[**2159-4-25**] 01:18AM BLOOD CK(CPK)-142
[**2159-4-25**] 12:15PM BLOOD Albumin-2.2* Calcium-6.5* Phos-3.3
Mg-1.3*
[**2159-4-25**] 09:30PM BLOOD Calcium-7.4* Phos-3.6 Mg-1.8
[**2159-4-26**] 04:15AM BLOOD Calcium-7.6* Phos-3.7 Mg-1.7
[**2159-4-27**] 05:20AM BLOOD Calcium-7.8* Phos-2.9 Mg-1.8
[**2159-4-28**] 06:10AM BLOOD Calcium-7.5* Phos-2.5* Mg-1.8
[**2159-4-25**] 09:10AM BLOOD Digoxin-<0.2*
[**2159-4-25**] 12:15PM BLOOD Digoxin-0.3*
[**2159-4-26**] 04:15AM BLOOD Digoxin-0.3*
[**2159-4-25**] 02:39AM BLOOD Lactate-1.6
[**2159-4-25**] 10:11AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
[**2159-4-25**] 04:25AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2159-4-25**] 10:11AM URINE Blood-TR Nitrite-NEG Protein-25
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2159-4-25**] 04:25AM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2159-4-25**] 10:11AM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2159-4-25**] 04:25AM URINE RBC-0 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2159-4-25**] 10:11AM URINE CastHy-[**1-26**]*
[**2159-4-25**] 10:11AM URINE Hours-RANDOM UreaN-831 Creat-116 Na-20

TTE [**2159-4-25**]:
The left atrium is mildly dilated. The right atrium is
moderately dilated. The right atrial pressure is indeterminate.
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. There is severe
regional left ventricular systolic dysfunction with akinesis of
the inferior and inferolateral walls and apex and hypokinesis of
the basal and mid anterior, anterolateral, and inferoseptal
segments. Overall left ventricular systolic function is severely
depressed (LVEF= 25-30 %). Right ventricular chamber size is
dilated and free wall motion is normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Moderate to severe (3+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is at least moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.

IMPRESSION: Severely depressed left ventricular systolic
function with akinesis of the inferior and inferolateral walls
and apex and hypokinesis of the basal and mid anterior,
anterolateral, and inferoseptal segments. Mild aortic root and
ascending aortic diliatation. Moderate to severe mitral
regurgitation. Moderate to severe tricuspid regurgitation.
Moderate pulmonary artery systolic hypertension.

Compared with the report of the prior study (images unavailable
for review) of [**2147-12-19**], the left ventricular ejection fraction
appears similar. The severity of mitral and tricuspid
regurgitation has increased.

ECG [**2159-5-2**]:
Atrial fibrillation with ventricular rate of 107. Complete right
bundle-branch block with QRS duration of 136 milliseconds. Q
waves in leads II, III and aVF. Poor R wave progression
laterally. Right axis deviation at plus 117 degrees. Compared to
the previous tracing of [**2159-2-6**] no diagnostic interval change.
     Intervals      Axes
Rate PR QRS QT/QTc  P QRS T
107  0  136 348/430 0 117 -18

CXR:
Cardiac size is top normal. There has been reaccumulation of
bilateral
pleural effusions , more conspicuous in the current exam could
be due to
difference in positioning of the patient. Bibasilar
consolidations are
grossly unchanged. Right Port-A-Cath remains in place in
standard position.
There is no evidence of pneumothorax.


Brief Hospital Course:
64-year-old man with history of pancreatic cancer s/p Whipple on
chemotherapy, DM II, CAD, PVD, and sCHF now presents with
hypotension, and progressive lower extremity edema.
.
# Hypotension: Likely secondary to decompensated heart failure
with unclear trigger.  [**Month (only) 116**] also have been secondary to poorly
controlled atrial fibrillation with RVR as patient had not been
taking his digoxin.  Required short course of pressors and IV
fluids.  Losartan was held. Digoxin and metoprolol were
initially held, but with stabilization of blood pressures,
digoxin was loaded and metoprolol was added on [**4-27**] with good
rate control.  Now symptomatically improved with stable vital
signs.
.
# Acute on chronic sCHF: Likely secondary to ischemic
cardiomyopathy. On admission, patient had 3+ lower extremity
edema to the hip, and a BNP > [**Numeric Identifier 15362**].  His weight on admission
was 200#, up from his dry weight of 180#. He was intially
treated with lasix gtt with good urine output.  On discharge he
was transitioned to furosemide 40mg IV bid.  Weight on discharge
was 192#.  He had improved, but persistent LE edema on
discharge.  He will require continued diuresis and monitoring of
his edema. He was continued on aspirin, beta-blocker, statin.
.
# Acute on chronic renal failure: likely prerenal azotemia -
unclear if secondary to hypovolemia versus poor forward flow
from decompensated CHF. His creatinine gradually improved.
.
# Atrial fibrillation:  Loaded with digoxin and restarted
metoprolol at 12.5mcg PO BID.  He remained in atrial
fibrillation. He was continued on his home coumadin, and INR was
checked daily.
.
# Pneumonia:  Treated at OSH. Afebrile while here with no new
respiratory complaints.  Antibiotics were discontinued on [**4-25**].
Urine legionella negative.
.
# Pancreatic cancer s/p Whipple: patient is currently undergoing
adjuvant chemotherapy and work-up for possible cyberknife
therapy, both at outside centers closer to his home.  Spoke with
Dr. [**First Name (STitle) 3443**] ([**Hospital3 **] Oncology), she will see him in clinic next
week to further plan his cancer treatment.
.
# Anemia: Stable and at recent baseline. Normal MCV suggests
anemia of chronic inflammation.
.
# Type II diabetes: on insulin as outpatient.  His long-acting
insulin was held given renal failure and low sugars in ED.  He
was covered with a humalog sliding scale, and restarted on his
home lantus 15 units PO daily on discharge.

Medications on Admission:
- toprol XL 50mg QD
- cozaar
- losartan 50mg PO daily
- lasix 20mg PO daily
- ecotrin 80mg PO daily
- lipitor 40mg PO daily
- protonix 30mg PO daily
- lantus 15 units qam
- levaquin 500mg PO daily X 5 days (just finished)
- coumadin 3mg PO daily

Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
6. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for stomach pain.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection
twice a day.
14. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous once a day.
15. Furosemide
Patient's dry weight is 180 lbs, weight on discharge 192 lbs.
Please perform daily weights.  Obtain serum Na, K, Cl,
Bicarbonate, BUN, Creatinine, Glucose twice weekly and send to
rehab MD.  Titrate down furosemide dose as lower extremity edema
resolves, and patient approaches dry weight.  Goal dose of
furosemide is 40mg PO bid.
16. Electrolytes
Please replete K to 4.0, magnesium to 2.0.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Acute on Chronic Systolic Heart Failure
Pancreatic Cancer


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


Discharge Instructions:
You were admitted for worsening of your heart failure.  You were
treated with the diuretic furosemide, and your urine output
increased.  You were restarted on digoxin for your atrial
fibrillation.

The following changes were made in your medications:
Your dose of furosemide was increased, and will be slowly
decreased while in rehab.
We stopped your Cozaar (losartan).
We restarted digoxin.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Please arrange to see your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge
from rehab.

Dr. [**First Name (STitle) 3443**]
[**Hospital3 **] Oncology
Tuesday [**2159-5-8**] 12:00 pm


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
{'Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Malignant neoplasm of pancreas, part unspecified,Atrial fibrillation,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Anemia in chronic kidney disease,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled'}


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: Hypotension.

PRESENT ILLNESS: History of Present Illness: 64-year-old man with pancreatic
cancer s/p recent Whipple ([**2159-1-31**]) now on adjuvant
chemotherapy (last dose per patient was two weeks prior to
this), diabetes type II, sCHF with EF 30%, CAD s/p MI, and
atrial fibrillation on coumadin who presented to the ED from
home with progressive lower extremity swelling and "not feeling
well." Family members at home, furthermore, felt that he did not
look right and decided to bring him to the emergency room. Of
note, patient was recently discharged from [**Hospital3 3583**] to
home with diagnosis of pneumonia. It is not clear what
antibiotics he was treated with - patient cannot remember.
.
In the ED, initial vital signs were T 97.6, HR 111, BP 86/56, RR
12, satting 94% RA. Labs notable for hct 29 (at baseline), trop
of 0.21 with normal CK (in setting of acute on chronic renal
failure with creatinine 2.0 from baseline ~1.3), and glucose of
38. Lactate was 1.6. EKG showed atrial fibrillation (rate of
107) with RBBB and RAD. There were no significant changes from a
preoperative EKG in [**Month (only) 958**]. CXR showed RLL infiltrate consistent
with pneumonia. UA was negative. Blood and urine cultures were
sent. Patient was given aspirin 325 mg, levofloxacin 750 mg,
vancomycin 1gm, and one amp of D50. He was given 1.5L NS (given
h/o sCHF) and admitted to the intensive care unit for persistant
hypotension.
.
Review of Systems: currently patient denies pain, shortness of
breath, chest pain or pressure, headache, nausea or vomiting

MEDICAL HISTORY: Past Medical History:
- Type II DM
- CHF with an EF of 30%
- CAD s/p MI
- h/o atrial fibrillation on Coumadin
- Chronic Renal Insufficiency (baseline creatinine 1.3)
- Adenocarcinoma of the pancreas s/p Whipple in [**Month (only) **]/[**2158**] with
positive margins, currently undergoing adjuvant chemotherapy
with gemcitabine (about three cycles in); most recent
chemotherapy was two weeks ago, per patient
.
Past Surgical History:
- sinus surgery
- (L)LE bypass for nonhealing toe ulcer
- ERCP with stent placement
- Whipple procedure as above

MEDICATION ON ADMISSION: - toprol XL 50mg QD
- cozaar
- losartan 50mg PO daily
- lasix 20mg PO daily
- ecotrin 80mg PO daily
- lipitor 40mg PO daily
- protonix 30mg PO daily
- lantus 15 units qam
- levaquin 500mg PO daily X 5 days (just finished)
- coumadin 3mg PO daily

ALLERGIES: Penicillins

PHYSICAL EXAM: Vitals: SBP 90s, HR 100-110, sat mid 90s on RA
General: pale-appearing elderly gentleman in no acute distress
HEENT: PERRLA, non-icteric sclera
Neck: JVP to ear lobe at 30 degrees
Cardiovascular: irregularly irregular
Pulmonary: bilateral crackles half way up lung fields
Abdominal: soft, non-tender, normal bowel sounds
Extremities: cold distally, non-diaphoretic, 2+ pitting edema to
above the knees bilaterally
Neurological: AAOx3, moving all extremities

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Lives with his wife. Laid off from computer analyst position.
No tobacco. Occasional ETOH. 

### Response:
{'Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Malignant neoplasm of pancreas, part unspecified,Atrial fibrillation,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Anemia in chronic kidney disease,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled'}
