CHIEF COMPLAINT: Transfer from OSH for concerns with abdominal hematoma,
pancreatitis, ARF, hypovolemic shock,and Pulmonary Edema

PRESENT ILLNESS: 

MEDICAL HISTORY: PMH: HTN, dyslipidemia, hypothyroidism, diverticulitis, colon
Ca,
large ventral and parastomal hernias, chronic renal failure
(baseline Cr 1.6-1.8), gout, Nephrotic Syndrome ??
.
PSH: L breast Ca s/p lumpectomy '[**97**], now s/p needle guided
lumpectomy and SLNBx [**3-16**]; s/p appy, s/p cholecystectomy, s/p
hysterectomy, s/p tonsillectomy.  s/p L colectomy for colon Ca,
revision of colostomy, multiple ex laps for adhesions.

MEDICATION ON ADMISSION: Meds at OSH: Amlodipine 5', Temazepam 15-30 QHS, Synthroid 50',
Simethicone 80'''P, Tylenol PRN, Zofran PRN, Esomeprazole 40',
Morphine PRN, Lopressor 2.5-5 PRN
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon Discharge
Pale, obese female in NAD, A and O
VS:  97.9  82 136/62 24 96% TM
Anicteric, no JVD, pale conjunctiva, EOMi
RRR no m/r/g
CTAB (ant)
left breast well healed lumpectomy scar no sign infection
abd large midline scar, massive left abdominal hernia, soft
NT/ND + BS
stoma is clean, protudes above skin, + gas and stool in bag, no
signs infection, no parastomal hernias
no c/c/e
right first finger DIP swollen, blanching erythema, + TTP
right metatarsal 2nd/3rd + TTP , erythema
Neuro grossly intact, able to move all four extremities
Psych flattened affect

FAMILY HISTORY: N/C

SOCIAL HISTORY: SocHx: 30 pack year history but quit 30 yrs ago; 1 drink/week,
no
recreational drugs.  Lives at home with daughter
Acute kidney failure, unspecified,Acute pancreatitis,Pneumonia due to Klebsiella pneumoniae,Acute respiratory failure,Other shock without mention of trauma,Other colostomy and enterostomy complication,Nephrotic syndrome with unspecified pathological lesion in kidney,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of breast,Personal history of malignant neoplasm of large intestine,Congestive heart failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Nontraumatic hematoma of soft tissue,Anticoagulants causing adverse effects in therapeutic use,Accidents occurring in other specified places
Acute kidney failure NOS,Acute pancreatitis,K. pneumoniae pneumonia,Acute respiratry failure,Shock w/o trauma NEC,Colstmy/enteros comp NEC,Nephrotic syndrome NOS,Hypothyroidism NOS,Hx of breast malignancy,Hx of colonic malignancy,CHF NOS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Nontrauma hema soft tiss,Adv eff anticoagulants,Accident in place NEC
Admission Date:  [**2105-3-20**]              Discharge Date:   [**2105-4-3**]

Date of Birth:  [**2029-11-19**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Transfer from OSH for concerns with abdominal hematoma,
pancreatitis, ARF, hypovolemic shock,and Pulmonary Edema

Major Surgical or Invasive Procedure:
Percutaneous Tracheostomy Placement [**2105-3-31**]
(# 8 Portex, Cuffed, with Inner Cannula)


Past Medical History:
PMH: HTN, dyslipidemia, hypothyroidism, diverticulitis, colon
Ca,
large ventral and parastomal hernias, chronic renal failure
(baseline Cr 1.6-1.8), gout, Nephrotic Syndrome ??
.
PSH: L breast Ca s/p lumpectomy '[**97**], now s/p needle guided
lumpectomy and SLNBx [**3-16**]; s/p appy, s/p cholecystectomy, s/p
hysterectomy, s/p tonsillectomy.  s/p L colectomy for colon Ca,
revision of colostomy, multiple ex laps for adhesions.

Social History:
SocHx: 30 pack year history but quit 30 yrs ago; 1 drink/week,
no
recreational drugs.  Lives at home with daughter

Family History:
N/C

Physical Exam:
Upon Discharge
Pale, obese female in NAD, A and O
VS:  97.9  82 136/62 24 96% TM
Anicteric, no JVD, pale conjunctiva, EOMi
RRR no m/r/g
CTAB (ant)
left breast well healed lumpectomy scar no sign infection
abd large midline scar, massive left abdominal hernia, soft
NT/ND + BS
stoma is clean, protudes above skin, + gas and stool in bag, no
signs infection, no parastomal hernias
no c/c/e
right first finger DIP swollen, blanching erythema, + TTP
right metatarsal 2nd/3rd + TTP , erythema
Neuro grossly intact, able to move all four extremities
Psych flattened affect

Pertinent Results:
[**2105-4-3**] 07:00AM BLOOD WBC-10.5 RBC-3.55* Hgb-10.1* Hct-31.1*
MCV-88 MCH-28.4 MCHC-32.4 RDW-14.0 Plt Ct-579*
[**2105-3-29**] 01:26PM BLOOD WBC-16.3*# RBC-3.34* Hgb-9.8* Hct-30.8*
MCV-92 MCH-29.2 MCHC-31.7 RDW-14.1 Plt Ct-606*
[**2105-3-30**] 02:00AM BLOOD WBC-12.9* RBC-3.28* Hgb-9.0* Hct-29.6*
MCV-90 MCH-27.5 MCHC-30.5* RDW-13.7 Plt Ct-570*
[**2105-3-31**] 03:28AM BLOOD WBC-12.0* RBC-3.28* Hgb-9.5* Hct-29.6*
MCV-90 MCH-29.0 MCHC-32.2 RDW-14.0 Plt Ct-517*
[**2105-3-20**] 02:52PM BLOOD WBC-10.3 RBC-3.47* Hgb-9.9* Hct-29.9*
MCV-86 MCH-28.5 MCHC-33.1 RDW-13.6 Plt Ct-327
[**2105-4-3**] 07:00AM BLOOD Glucose-118* UreaN-55* Creat-1.6* Na-140
K-3.8 Cl-106 HCO3-23 AnGap-15
[**2105-3-20**] 02:52PM BLOOD Glucose-126* UreaN-46* Creat-2.7* Na-137
K-5.5* Cl-108 HCO3-19* AnGap-16
[**2105-3-21**] 11:06AM BLOOD Glucose-89 UreaN-57* Creat-3.1* Na-139
K-4.4 Cl-109* HCO3-18* AnGap-16
[**2105-3-25**] 01:50AM BLOOD Glucose-146* UreaN-73* Creat-2.5* Na-146*
K-4.5 Cl-102 HCO3-33* AnGap-16
[**2105-3-29**] 02:33AM BLOOD Lipase-68*
[**2105-4-3**] 07:00AM BLOOD Calcium-9.3 Phos-4.2 Mg-2.5
[**2105-3-20**] 08:14PM BLOOD Triglyc-210*
[**2105-3-21**] 11:06AM BLOOD TSH-0.80
[**2105-3-21**] 11:06AM BLOOD Free T4-0.64*
[**2105-3-21**] 03:26PM BLOOD Cortsol-52.9*
[**2105-3-21**] 02:15PM BLOOD Cortsol-39.8*
[**2105-3-21**] 03:05PM BLOOD Cortsol-47.6*
[**2105-4-1**] 04:19AM BLOOD Type-ART Temp-37.7 pO2-99 pCO2-44 pH-7.40
calTCO2-28 Base XS-1
[**2105-3-24**] 03:02PM BLOOD Type-ART Temp-37.5 Rates-/20 Tidal V-423
PEEP-10 FiO2-50 pO2-78* pCO2-49* pH-7.47* calTCO2-37* Base XS-10
Intubat-INTUBATED Vent-SPONTANEOU
[**2105-3-24**] 08:33AM BLOOD Type-ART Temp-37.6 Rates-/21 Tidal V-474
PEEP-5 FiO2-50 pO2-60* pCO2-50* pH-7.46* calTCO2-37* Base XS-9
Intubat-INTUBATED Vent-SPONTANEOU
[**2105-3-30**] 05:31AM BLOOD Type-ART pO2-95 pCO2-53* pH-7.39
calTCO2-33* Base XS-5
[**2105-3-30**] 02:07AM BLOOD Type-ART pO2-105 pCO2-50* pH-7.41
calTCO2-33* Base XS-5
[**2105-3-26**] 01:57PM BLOOD Type-ART pO2-71* pCO2-45 pH-7.45
calTCO2-32* Base XS-6
[**2105-3-26**] 09:15AM BLOOD Type-ART pO2-67* pCO2-46* pH-7.45
calTCO2-33* Base XS-6
[**2105-3-24**] 03:02PM BLOOD Type-ART Temp-37.5 Rates-/20 Tidal V-423
PEEP-10 FiO2-50 pO2-78* pCO2-49* pH-7.47* calTCO2-37* Base XS-10
Intubat-INTUBATED Vent-SPONTANEOU
[**2105-3-24**] 02:40AM BLOOD Type-ART pO2-101 pCO2-46* pH-7.44
calTCO2-32* Base XS-5
[**2105-3-23**] 10:15PM BLOOD Type-ART pO2-100 pCO2-36 pH-7.48*
calTCO2-28 Base XS-3
[**2105-3-23**] 08:37PM BLOOD Type-ART pO2-74* pCO2-43 pH-7.48*
calTCO2-33* Base XS-7
[**2105-3-23**] 05:20PM BLOOD Type-ART pO2-74* pCO2-40 pH-7.49*
calTCO2-31* Base XS-6
[**2105-3-23**] 11:16AM BLOOD Type-ART Rates-/20 PEEP-10 FiO2-60
pO2-55* pCO2-40 pH-7.48* calTCO2-31* Base XS-5 Intubat-INTUBATED
Vent-SPONTANEOU
[**2105-3-23**] 03:13AM BLOOD Type-ART pO2-97 pCO2-39 pH-7.44
calTCO2-27 Base XS-1
[**2105-3-20**] 03:15PM BLOOD Type-ART pO2-95 pCO2-50* pH-7.21*
calTCO2-21 Base XS--8
[**2105-3-20**] 05:04PM BLOOD Type-ART pO2-53* pCO2-46* pH-7.21*
calTCO2-19* Base XS--9
[**2105-3-20**] 06:20PM BLOOD Type-ART pO2-69* pCO2-46* pH-7.23*
calTCO2-20* Base XS--8




Brief Hospital Course:
OPERATIONS DURING ADMISSION
[**3-20**] CVL PLACEMENT
[**3-31**] PERCUTANEOUS TRACHEOSTOMY PLACEMENT (#8 Portex, Cuffed,
Inner Cannula)

CONSULTATIONS DURING ADMISSION
SICU [**3-20**] - [**4-2**]
Nephrology

PRINCIPAL DIAGNOSES
Acute on Chronic Renal Failure
Respiratory distress with Pulmonary Edema
Klebsiella Pneumonia
Abdominal Hematoma likely [**1-12**] heparin gtt at OSH
s/p left breast lumpectomy
s/p tracheostomy
Acute Gouty attacks (R DIP 1st finger, R 3rd MTP)

BRIEF HOSPITAL COURSE
The patient was transferred from OSH with concern for
pancreatitis, abdominal LUQ hematoma in the setting of
heparization for SOB in concern with PE (negative V/Q scan),
abdominal pain, and hypovolemic shock with acute on chronic
renal failure (chronic likely from possible Nephrotic Syndrome)
and paradoxically, respiratory distress with b/l large pulmonary
effusions.

[**3-20**] - [**3-21**] The patient was admitted on [**3-20**] in the late
evening.  She was intubated for respiratory distress and had an
A-line and CVL placed.  Her labs were significant for an
elevated creatinine of 3.1, and a bicarb of 19 concerning for
metabolic acidosis in the setting of ARF.  She did, however,
have a normal ALT, AST, Amylase, and Lipase, so we had very low
clinical concern for pancreatitis - oddly enough, the primary
reason for her transfer.  The patient underwent a renal consult
for her renal failure, who felt that she had oliguric ARF [**1-12**]
ATN from underesucitation in the setting of retroperitoneal
bleeding.  She was given 2 units of pRBC, a bicarbonate drip,
albumin, and multiple boluses of IVF, albumin, and her
creatinine eventually improved to 1.6 (near her baseline) on
[**3-31**].   Blood cultures throughout her stay have been negative
([**3-20**], [**3-23**], [**3-27**]).

She also underwent a hydrocortisol stress stim test to evaluate
her cortisol function, which was normal.

[**3-21**] -[**3-22**] The patient's UOP improved.  She underwent a CT scan
of the abdomen to further assess the question of peri-splenic
hematoma and her respiratory distress.  The CT scan was noteable
for a heterogeneous perisplenic hematoma that tracked into the
left anterior pararenal space and was slightly increased in size
when compared to the prior outside CT scan from [**Hospital3 25148**]
Center;  L > R mod b/l pleural effusions w/ atelectasis of post
R LL, complete atelectasis of LLL; worse from prior studies;
Left axillary and left breast hematomas measuring 4.2 cm and 3.2
cm; Stable midline infraumbilical and large left lower quadrant
parastomal hernias containing non- obstructed loops of bowel,
and extensive colonic diverticulosis.

The CT scan supports a diagnosis of actue on chronic renal
failure in the setting of underresuscitation for breast and
retroperitoneal hematomas [**1-12**] to heparinization for a
non-existent PE, though her V/Q scan was negative, complicated
by pulmonary effusions given her low albumin and proteinuria,
triglyceridemia, and hypertension likely from her Nephrotic
Syndrome.

[**3-23**] The patient was diuresed.  She remained intubated.  She was
also started on tube feeds via Dophoff given her normal LFTs and
need for nutrition.  She was seen by the ostomy nurse and her
colostomy tube changed regularly.

[**3-24**] - [**3-25**] The patient spiked a fever and was pan-cultured.
She remained hemodynamically stable without signs of sepsis.
Her diuresis was increased with lasix and diamox as repeat CXRs
remained with significant b/l effusions.  Her ventilatory
settings improved.

[**2014-3-25**] The patient was started on ciprofloxacin for a
pan-sensitive Klebsiella pneumoniae.  Given her improved vent
settings, the patient was extubated.  Unfortunately, the patient
later that morning became progressively short of breath with
inspiratory, and expiratory wheezes, tachypneic, and hypoxic,
and so she was reintubated without difficulty.  Her ABG at the
time was:  7.46/50/60/37.

[**3-27**] Given her failed extubation, the patient underwent an
echocardiogram to assess for cardiac dysfunction contributing to
her failued extubation.  The echo revealed
a mildly dilated LA, nl left ventricular wall thickness, cavity
size and regional/global systolic function (LVEF >55%), and
right ventricular chamber size and free wall motion, trace AR,
mild MR, and mild pulmonary artery systolic hypertension.

[**3-30**] - [**4-3**]  Given her continued need for ventilatory support,
the patient had a percutaneous tracheostomy tube placed on [**3-31**].
 She tolerated the procedure well.  Interestingly, only 1-2 days
later she was able to tolerate trach mask without need for
ventilation.

The patient remained hemodynamically stable, tolerating her tube
feeds, and so she was transferred to the floor on [**4-2**].  She
underwent placement of a passy-muir valve
on [**4-1**], which she has been tolerating well.  She also underwent
a swallow-study, that revealed dysphagia scale 4
(mild-moderate), She was noted to have "aspiration on large,
consecutive sips of thin liquids alone (x1) and after ground
solids as evidenced by a reflexive wet cough, though she
appeared to tolerate single sips of
thin liquid alternated with small bites of puree without overt
coughing." She was thus recommended to have a PO diet of thin
liquids and puree with supervision to ensure she is alternating
bites and single sips of liquids.

The patient walked out of bed to the chair with nursing.  She
was started back on her home medications.  Unfortunately, on
[**4-2**] the patient developed pain in her first right finger (DIP)
and midfoot on the right; XR of her foot revealed proximal 2nd,
3rd, 4th metatarsal chronic fractures (likely neuropathic), no
signs of acute fracture.  Given her history of gout she was
thought to have gouty attacks in the setting of stress, and was
started on renally dosed colchicine.  She also had some mild
peristomal pain but history and exam showed no evidence of
infection, parastomal hernia, or obstruction; she had no nausea,
vomiting, and there was plenty of gas and stool in her stoma
bag.

On [**4-3**] her CVL was removed.  Her Foley catheter is to be
removed after discharge.

On the time of discharge she is afebrile, tolerating her
dysphagia, diet, alert, oriented, and stable for discharge.  She
needs follow-up with her primary care doctor and Dr. [**Last Name (STitle) **].

Medications on Admission:
Meds at OSH: Amlodipine 5', Temazepam 15-30 QHS, Synthroid 50',
Simethicone 80'''P, Tylenol PRN, Zofran PRN, Esomeprazole 40',
Morphine PRN, Lopressor 2.5-5 PRN
.

Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Levothyroxine 25 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Esomeprazole Magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for wheeze, sob.
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days: for PNA.
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
13. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 5 days.
14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]

Discharge Diagnosis:
Acute on Chronic Renal Failure
Respiratory distress with Pulmonary Edema
Klebsiella Pneumonia
Abdominal Hematoma likely [**1-12**] heparin gtt at OSH
s/p left breast lumpectomy
s/p tracheostomy
Acute Gouty attacks (R DIP 1st finger, R 3rd MTP)

PMx: Nephrotic Syndrome, Gout, HTN, dyslipidemia,
hypothyroidism, diverticulitis, large ventral and parastomal
hernias, chronic renal failure (baseline Cr 1.6-1.8); L breast
Ca s/p lumpectomy '[**97**], now s/p needle guided lumpectomy and
SLNBx [**3-16**]; s/p appy, s/p cholecystectomy, s/p hysterectomy, s/p
tonsillectomy. s/p L colectomy for colon Ca, revision of
colostomy, multiple ex laps for adhesions.


Discharge Condition:
Stable


Discharge Instructions:
1.  ***Consider changing to a un-cuffed tracheostomy tube, and
then down-sizing, and eventual decannulization as patient
tolerates ***
2.  Please remove the patient's Foley catheter upon arrival.
3.  Please call your doctor or nurse practitioner or return to
the Emergency  Department for any of the following:

*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons.  Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours.  Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.

4. Please resume all regular home medications , unless
specifically advised not to take a particular medication.  Also,
please take any new medications as prescribed.
5. Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
6. Please take the colchicine for five days for your gouty
attacks.  Your XR did not show any acute fractures of your right
foot, though you do have chronic fractures in that foot.

Followup Instructions:
1.  Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a follow-up
appointment for your gout, your pulmonary issues, and your renal
failure.  If your foot pain does not improve, consider orthodics
or follow-up with a podiatrist as you likely have chronic
fractures in your foot.
2.  Please call Dr.[**Name (NI) 2829**] office at [**Telephone/Fax (1) 62570**] for a
follow-up appointment in [**1-13**] weeks.
3.  Consider downsizing, uncuffing the tracheostomy tube and
then eventual decannulation pending improvement of your
respiratory status with supervision of a doctor.



Completed by:[**2105-4-3**]
{'Acute kidney failure, unspecified,Acute pancreatitis,Pneumonia due to Klebsiella pneumoniae,Acute respiratory failure,Other shock without mention of trauma,Other colostomy and enterostomy complication,Nephrotic syndrome with unspecified pathological lesion in kidney,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of breast,Personal history of malignant neoplasm of large intestine,Congestive heart failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Nontraumatic hematoma of soft tissue,Anticoagulants causing adverse effects in therapeutic use,Accidents occurring in other specified places'}


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: Transfer from OSH for concerns with abdominal hematoma,
pancreatitis, ARF, hypovolemic shock,and Pulmonary Edema

PRESENT ILLNESS: 

MEDICAL HISTORY: PMH: HTN, dyslipidemia, hypothyroidism, diverticulitis, colon
Ca,
large ventral and parastomal hernias, chronic renal failure
(baseline Cr 1.6-1.8), gout, Nephrotic Syndrome ??
.
PSH: L breast Ca s/p lumpectomy '[**97**], now s/p needle guided
lumpectomy and SLNBx [**3-16**]; s/p appy, s/p cholecystectomy, s/p
hysterectomy, s/p tonsillectomy.  s/p L colectomy for colon Ca,
revision of colostomy, multiple ex laps for adhesions.

MEDICATION ON ADMISSION: Meds at OSH: Amlodipine 5', Temazepam 15-30 QHS, Synthroid 50',
Simethicone 80'''P, Tylenol PRN, Zofran PRN, Esomeprazole 40',
Morphine PRN, Lopressor 2.5-5 PRN
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon Discharge
Pale, obese female in NAD, A and O
VS:  97.9  82 136/62 24 96% TM
Anicteric, no JVD, pale conjunctiva, EOMi
RRR no m/r/g
CTAB (ant)
left breast well healed lumpectomy scar no sign infection
abd large midline scar, massive left abdominal hernia, soft
NT/ND + BS
stoma is clean, protudes above skin, + gas and stool in bag, no
signs infection, no parastomal hernias
no c/c/e
right first finger DIP swollen, blanching erythema, + TTP
right metatarsal 2nd/3rd + TTP , erythema
Neuro grossly intact, able to move all four extremities
Psych flattened affect

FAMILY HISTORY: N/C

SOCIAL HISTORY: SocHx: 30 pack year history but quit 30 yrs ago; 1 drink/week,
no
recreational drugs.  Lives at home with daughter 

### Response:
{'Acute kidney failure, unspecified,Acute pancreatitis,Pneumonia due to Klebsiella pneumoniae,Acute respiratory failure,Other shock without mention of trauma,Other colostomy and enterostomy complication,Nephrotic syndrome with unspecified pathological lesion in kidney,Unspecified acquired hypothyroidism,Personal history of malignant neoplasm of breast,Personal history of malignant neoplasm of large intestine,Congestive heart failure, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Nontraumatic hematoma of soft tissue,Anticoagulants causing adverse effects in therapeutic use,Accidents occurring in other specified places'}
