CHIEF COMPLAINT: hypoxia, somnolence

PRESENT ILLNESS: This is a 82 year-old female with a history of MDS, PE on
Lovenox, CAD, Crohn's who presents with increased O2
requirement.  At baseline, she uses approximately 2.5L of O2 at
home.  Her daughter noted that yesterday, she was satting in the
mid 80s, and increased her O2 to 3-4L.  The patient seemed more
somnolent and confused over the last day.  She brought her to
the ED for this. Of note, daughter states that patient has not
been eating much lately, and continues to have diarrhea.
.
In the ED, her initial VS were 96.7, 119/95,65,23, 95% 4L.  She
was noted to have bilateral crackles on exam.  CXR was
consistent with volume overload, left pleural effusion +/-
consolidation.  She was then noted to be hypotensive with BP
69/12.  She was given a 250 cc bolus with improvement to SBP
110.  She then was noted again to be hypotensive vitals  80/22,
62, 92% 4L.  She was to be given another 500 cc bolus when they
realized she had pulled out her IV.  They discussed with the
patients daughter, the HCP, about a [**Name (NI) 14938**], but the daughter
refused.  They placed another 18G and gave her another 500 cc
bolus.  She is on chronic prednisone (18 mg daily), so she was
given 10 mg decadron.  Also, she was given levofloxacin and
vancomycin in the ED as well as a combivent.  No ABG was done.
There was another lengthy discussion in the ED regarding goals
of care, which has been an issue in the past, and currently her
daughter reports that she is DNI, but not DNR.  Her last lovenox
dose was yesterday.
.
ROS: patient did not give ROS; per daughter, no fevers, nausea,
vomiting, chest pains.  She does report decreased UOP with
decreased PO intake and diarrhea recently.

MEDICAL HISTORY: #. Anemia, due to renal failure, anemia of chronic disease, and
myelodysplastic syndrome; previously on epo weekly and requiring

MEDICATION ON ADMISSION: 1) Albuterol 1-2 puffs Q4-6H PRN wheezing
2) Alendronate 70 mg qSat
3) Calcium carbonate 500 mg TID
4) Enoxaparin 70 mg Q24H
5) Epogen 40,000 units qweek
6) Folic acid 1 mg daily
7) Furosemide 10 mg QOD
8) Mesalamine 1200 mg daily
9) Toprol 25 mg daily
10) Omeprazole 20 mg [**Hospital1 **]
11) Prednisone 18 mg daily

ALLERGIES: Belladonna Alkaloids

PHYSICAL EXAM: Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Married; lives with her husband who is demented, her daughter
[**Name (NI) 108329**], [**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. Presently in
temporary housing while awaiting renovations on their [**Last Name (un) **]
which was damaged during a fire last winter. [**Last Name (un) 108329**] is the
caretaker for both of her parents. [**Last Name (un) 108329**] very stressed and
overwhelmed. Her mother-in-law in [**Name (NI) 4565**] died this past
month which required her husband to leave for [**Name (NI) 4565**]. She is
in the midst of trying to place her father in nursing care
facility and is quite guilty about this decision. Ms. [**Known lastname 108328**] [**Last Name (Titles) 108331**]y recieves near daily RN visits from Suburban Home Care.
[**Last Name (Titles) 108329**] is reliant on "sitters" to bring her mother to
appointments.
Acute on chronic diastolic heart failure,Acute respiratory failure,Pneumonia, organism unspecified,Chronic kidney disease, Stage IV (severe),Acute kidney failure, unspecified,Regional enteritis of unspecified site,Nontraumatic hematoma of soft tissue,Anticoagulants causing adverse effects in therapeutic use,Myelodysplastic syndrome, unspecified,Anemia in chronic kidney disease,Personal history of venous thrombosis and embolism,Other chronic pulmonary heart diseases,Obstructive sleep apnea (adult)(pediatric),Personal history of malignant neoplasm of breast,Volume depletion, unspecified,Long-term (current) use of anticoagulants
Ac on chr diast hrt fail,Acute respiratry failure,Pneumonia, organism NOS,Chr kidney dis stage IV,Acute kidney failure NOS,Regional enteritis NOS,Nontrauma hema soft tiss,Adv eff anticoagulants,Myelodysplastic synd NOS,Anemia in chr kidney dis,Hx-ven thrombosis/embols,Chr pulmon heart dis NEC,Obstructive sleep apnea,Hx of breast malignancy,Volume depletion NOS,Long-term use anticoagul
Admission Date:  [**2194-3-14**]              Discharge Date:   [**2194-3-22**]

Date of Birth:  [**2112-2-19**]             Sex:   F

Service: MEDICINE

Allergies:
Belladonna Alkaloids

Attending:[**First Name3 (LF) 8104**]
Chief Complaint:
hypoxia, somnolence

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is a 82 year-old female with a history of MDS, PE on
Lovenox, CAD, Crohn's who presents with increased O2
requirement.  At baseline, she uses approximately 2.5L of O2 at
home.  Her daughter noted that yesterday, she was satting in the
mid 80s, and increased her O2 to 3-4L.  The patient seemed more
somnolent and confused over the last day.  She brought her to
the ED for this. Of note, daughter states that patient has not
been eating much lately, and continues to have diarrhea.
.
In the ED, her initial VS were 96.7, 119/95,65,23, 95% 4L.  She
was noted to have bilateral crackles on exam.  CXR was
consistent with volume overload, left pleural effusion +/-
consolidation.  She was then noted to be hypotensive with BP
69/12.  She was given a 250 cc bolus with improvement to SBP
110.  She then was noted again to be hypotensive vitals  80/22,
62, 92% 4L.  She was to be given another 500 cc bolus when they
realized she had pulled out her IV.  They discussed with the
patients daughter, the HCP, about a [**Name (NI) 14938**], but the daughter
refused.  They placed another 18G and gave her another 500 cc
bolus.  She is on chronic prednisone (18 mg daily), so she was
given 10 mg decadron.  Also, she was given levofloxacin and
vancomycin in the ED as well as a combivent.  No ABG was done.
There was another lengthy discussion in the ED regarding goals
of care, which has been an issue in the past, and currently her
daughter reports that she is DNI, but not DNR.  Her last lovenox
dose was yesterday.
.
ROS: patient did not give ROS; per daughter, no fevers, nausea,
vomiting, chest pains.  She does report decreased UOP with
decreased PO intake and diarrhea recently.


Past Medical History:
#. Anemia, due to renal failure, anemia of chronic disease, and
myelodysplastic syndrome; previously on epo weekly and requiring

regular transfusions, multiple positive anti-RBC antibodies.
#. Chronic bilat LE edema
#. Crohn's disease
#. breast CA s/p s/p R lumpectomy and XRT 13 yrs ago
#. GERD
#. CAD s/p NSTEMI '[**89**]
#. s/p CCY 10 yrs ago
#. HTN (does not appear to be on home meds)
#. hx of bilateral DVTs and saddle embolus in [**2190**], had been on
warfarin.
#. CRI, baseline cr 1.5-1.8
#. MVA 20 years ago with intracranial bleed


Social History:
Married; lives with her husband who is demented, her daughter
[**Name (NI) 108329**], [**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. Presently in
temporary housing while awaiting renovations on their [**Last Name (un) **]
which was damaged during a fire last winter. [**Last Name (un) 108329**] is the
caretaker for both of her parents. [**Last Name (un) 108329**] very stressed and
overwhelmed. Her mother-in-law in [**Name (NI) 4565**] died this past
month which required her husband to leave for [**Name (NI) 4565**]. She is
in the midst of trying to place her father in nursing care
facility and is quite guilty about this decision. Ms. [**Known lastname 108328**] [**Last Name (Titles) 108331**]y recieves near daily RN visits from Suburban Home Care.
[**Last Name (Titles) 108329**] is reliant on "sitters" to bring her mother to
appointments.

Family History:
non-contributory

Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.



Pertinent Results:
[**2194-3-14**] 04:25PM BLOOD WBC-5.2 RBC-2.83* Hgb-10.2* Hct-32.7*
MCV-116* MCH-36.3* MCHC-31.3 RDW-19.0* Plt Ct-219
[**2194-3-14**] 04:25PM BLOOD Neuts-60.7 Lymphs-31.2 Monos-6.7 Eos-1.0
Baso-0.4
[**2194-3-14**] 03:10PM BLOOD PT-11.0 PTT-20.7* INR(PT)-0.9
[**2194-3-14**] 03:10PM BLOOD Glucose-88 UreaN-27* Creat-2.3* Na-138
K-5.2* Cl-101 HCO3-30 AnGap-12
[**2194-3-14**] 03:10PM BLOOD ALT-5 AST-15
[**2194-3-14**] 03:10PM BLOOD Lipase-39
[**2194-3-14**] 03:10PM BLOOD Albumin-3.5 Phos-4.0 Mg-2.0
[**2194-3-14**] 03:10PM BLOOD GreenHd-HOLD
[**2194-3-14**] 08:40PM BLOOD Type-ART pO2-68* pCO2-74* pH-7.23*
calTCO2-33* Base XS-0
[**2194-3-14**] 08:40PM BLOOD Lactate-0.6

[**2194-3-15**]  	Radiology	CT CHEST W/O CONTRAST
IMPRESSION:
1. Slightly increased right pleural effusion which is now
moderate, and
unchanged small left pleural effusion. Minimal residual opacity
in the
posterior left upper lobe from previously seen consolidation.
2. Thickening of the mid to distal esophagus with fatty
infiltration in the
distal esophageal wall, suggesting esophagitis, which may relate
to the
patient's moderate-sized axial hiatal hernia.
3. Unchanged hypoattenuating left thyroid lesion, for which
ultrasound is
recommended.

[**2194-3-19**]  	Radiology	CHEST (PA & LAT)
IMPRESSION: Unchanged appearance of mild pulmonary edema and
bilateral
pleural effusions.


Brief Hospital Course:
82 year-old female with a history of PE, MDS, CKD, anemia, CAD
who presents with hypoxia and hypotension.

# Hypoxic/hypercapnic respiratory failure:  Patient presented
with acute on chronic hypoxia, as she has an oxygen requirement
at home of 2.5L.  A CXR on admission demonstrated pneumonia and
a chest CT confirmed the presence of an infiltrate and also
demonstrated bilateral pleural effusions, right greater than
left.  Patient's hypoxia was thought to be secondary to
pneumonia, pleural effusions, and diastolic heart failure, and
her hypercapnia was thought to be secondary to muscular weakness
and possibly obstructive sleep apnea (does not carry this
diagnosis).  She was continued on levofloxacin (day 1=[**3-14**]) and
vancomycin (day 1=[**3-15**]).  She will likely require BiPAP qhs
chronically. Vancomycin was d/c'd prior to transfer out of the
ICU [**3-17**]. Patient remained stable following transfer to floor.
She was continued on a 10day course of levofloxacin.  She did
not tolerate increased doses of lasix. However, she was
continued on 10mg daily (up from home dose qod) and she had
marked improvement of her anasarca.  Given the severity of
right-sided heart failure/diastolic heart failure, and expected
recurrent exacerbations the CHF service was consulted and
recommend continued diuresis with lasix qod/prn, with dosing
until blood pressure decreases or Cr increases. She was also
continued on metoprolol 12.5. Her weight at time of discharge
was 126.5lbs. She electively did not use BiPAP on the floor.

# Pneumonia:  Patient was continued on levofloxacin. Vancomycin
d/c'd after 2 days on [**3-17**].

# Hypotension:  Patient was hypotensive at presentation with a
SBP in the 80s and was thought to be relatively volume deplete
in the setting of diarrhea and poor po intake.  Her SBP improved
to the 100s after IVF administration in the ED and arrival to
the ICU. Her blood pressure remained stable during this
hospitalization.

# Altered mental status:  There was some concern initially that
patient's mental status was altered and a head CT was negative
for an acute process. Her mental status was at baseline per her
daughter and this remained stable.

# DVT and PE: Patient has a history of DVT/PE and is on lovenox
at home, with LMW heparin levels checked regularly (last checked
on [**2194-3-4**], LMW hep = 1.04).  She was continued on her lovenox
dose of 70 mg daily.

# CRI:  Patient's creatinine was at it's baseline (1.8-2.3) and
medications were renally dosed. Her Cr did increase slightly to
2.5 with extra lasix and was 2.4 at day of discharge.

#Hemorrhagic bullous s/p rupture: Wound healing nicely and large
blood clot was debrided by plastic surgery. Healthy tissue was
seen underneath the clot. She will have home wound care and f/up
with plastic surgery.

# MDS:  Followed by Dr. [**Last Name (STitle) **] of [**Hospital1 18**].  Has received multiple
blood transfusions in past.

# Code: DNR/DNI- confirmed with daughter

#Social: Multiple discussion were had with the patient and her
daughter throughout this hospitalization regarding goals of care
and prognosis.  The patient and daughter seemed to be in
agreement about continued medical care, with avoiding aggressive
interventions, such as cardiopulmonary resuscitation and other
procedures. Given the severity  of her right heart failure and
delicate fluid balance (preload dependence/diastolic CHF), and
hence likely course of continued CHF exacerbations and frequent
hospitalizations, the patient was seen by the palliative care
service to introduce the services offered by additional
programs/home hospice, The family was not interested in hospice
services at this time,but will continue with a visiting nurse
and other services as needed.


Medications on Admission:
1) Albuterol 1-2 puffs Q4-6H PRN wheezing
2) Alendronate 70 mg qSat
3) Calcium carbonate 500 mg TID
4) Enoxaparin 70 mg Q24H
5) Epogen 40,000 units qweek
6) Folic acid 1 mg daily
7) Furosemide 10 mg QOD
8) Mesalamine 1200 mg daily
9) Toprol 25 mg daily
10) Omeprazole 20 mg [**Hospital1 **]
11) Prednisone 18 mg daily


Discharge Medications:
1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed.
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QSAT (every
Saturday).
Disp:*12 Tablet(s)* Refills:*2*
7. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
8. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 doses.
Disp:*1 Tablet(s)* Refills:*0*
13. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*60 Tablet(s)* Refills:*2*
14. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) units
Subcutaneous Q24H (every 24 hours).
15. Prednisone 10 mg Tablet Sig: Eighteen (18) mg PO DAILY
(Daily).
16. Epoetin Alfa 10,000 unit/mL Solution Sig: 40,000 units
Injection once a week.
17. Outpatient Lab Work
Outpatient Lab Work
Please have your sodium, potassium, bicarbonate, chloride, BUN,
creatinine, calcium, magnesium, and phosphate next Wednesday
[**3-26**]. Please have results sent to attention Dr. [**Last Name (STitle) 3357**] Phone
[**Telephone/Fax (1) 4606**]

18. Home Oxygen
Diagnosis: congestive heart failure
Please start nasal cannula 2 L/min to keep sats >94%


Discharge Disposition:
Home With Service

Facility:
[**Hospital6 1952**], [**Location (un) 86**]

Discharge Diagnosis:
1)Acute on chronic diastolic and right-sided heart failure
2)Hypercarbia
3)Pneumonia
4)Chronic Kidney Disease


Discharge Condition:
Stable; on 2L NC; Weight 126lbs in the hospital


Discharge Instructions:
You were hospitalized with low oxygen levels and hypercarbia
(high carbon dioxide).  This was likely due to congestive heart
failure, possible pneumonia, and weakness.
.
You were given lasix to try and get rid of some of the fluid in
your
lungs and the swelling of your arms and legs. Please take all
your medications as prescribed.
.
You should weigh yourself when you arrive home today and be
weighed everyday. On day of discharge you weighed 126.5 pounds.
If you gain more than 3 pounds you should take an extra dose of
you lasix. Also, you should not eat more than 2 grams of salt in
your diet a day. You should also drink less than 1200 ml of
fluid a day .
.
You have one more day of an antibiotic treatment.
.
Regarding your prednisone, you should see Dr.[**Last Name (STitle) 3708**] to discuss
decreasing the dose of this. It can be detrimental to be on high

doses of steroids for an extended period of time.
.
Please have your labs drawn to check your electrolytes and
hematocrit this week. Enclosed is a prescription for a lab draw.
You should have your kidney function monitored every two weeks.
.
Call your primary physician with concerns or questions, and
return to the emergency department if you have fever greater
than 101, low oxygen, shortness of breath, bleeding, increased
pain, or other alarming symptoms.



Followup Instructions:
Please call the plastic surgery [**Telephone/Fax (1) 4652**] for a follow-up
appointment on [**4-4**]. You should tell them that you were
seen in the hospital and instructed to go to that clinic.
.
Please call Dr. [**Last Name (STitle) 3357**] for close follow up on discharge.

Please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**Last Name (STitle) **] for follow up of you MDS.
.
You should follow up with Dr [**Last Name (STitle) 3708**] of GI and discuss tapering
your prednisone down.
{'Acute on chronic diastolic heart failure,Acute respiratory failure,Pneumonia, organism unspecified,Chronic kidney disease, Stage IV (severe),Acute kidney failure, unspecified,Regional enteritis of unspecified site,Nontraumatic hematoma of soft tissue,Anticoagulants causing adverse effects in therapeutic use,Myelodysplastic syndrome, unspecified,Anemia in chronic kidney disease,Personal history of venous thrombosis and embolism,Other chronic pulmonary heart diseases,Obstructive sleep apnea (adult)(pediatric),Personal history of malignant neoplasm of breast,Volume depletion, unspecified,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: hypoxia, somnolence

PRESENT ILLNESS: This is a 82 year-old female with a history of MDS, PE on
Lovenox, CAD, Crohn's who presents with increased O2
requirement.  At baseline, she uses approximately 2.5L of O2 at
home.  Her daughter noted that yesterday, she was satting in the
mid 80s, and increased her O2 to 3-4L.  The patient seemed more
somnolent and confused over the last day.  She brought her to
the ED for this. Of note, daughter states that patient has not
been eating much lately, and continues to have diarrhea.
.
In the ED, her initial VS were 96.7, 119/95,65,23, 95% 4L.  She
was noted to have bilateral crackles on exam.  CXR was
consistent with volume overload, left pleural effusion +/-
consolidation.  She was then noted to be hypotensive with BP
69/12.  She was given a 250 cc bolus with improvement to SBP
110.  She then was noted again to be hypotensive vitals  80/22,
62, 92% 4L.  She was to be given another 500 cc bolus when they
realized she had pulled out her IV.  They discussed with the
patients daughter, the HCP, about a [**Name (NI) 14938**], but the daughter
refused.  They placed another 18G and gave her another 500 cc
bolus.  She is on chronic prednisone (18 mg daily), so she was
given 10 mg decadron.  Also, she was given levofloxacin and
vancomycin in the ED as well as a combivent.  No ABG was done.
There was another lengthy discussion in the ED regarding goals
of care, which has been an issue in the past, and currently her
daughter reports that she is DNI, but not DNR.  Her last lovenox
dose was yesterday.
.
ROS: patient did not give ROS; per daughter, no fevers, nausea,
vomiting, chest pains.  She does report decreased UOP with
decreased PO intake and diarrhea recently.

MEDICAL HISTORY: #. Anemia, due to renal failure, anemia of chronic disease, and
myelodysplastic syndrome; previously on epo weekly and requiring

MEDICATION ON ADMISSION: 1) Albuterol 1-2 puffs Q4-6H PRN wheezing
2) Alendronate 70 mg qSat
3) Calcium carbonate 500 mg TID
4) Enoxaparin 70 mg Q24H
5) Epogen 40,000 units qweek
6) Folic acid 1 mg daily
7) Furosemide 10 mg QOD
8) Mesalamine 1200 mg daily
9) Toprol 25 mg daily
10) Omeprazole 20 mg [**Hospital1 **]
11) Prednisone 18 mg daily

ALLERGIES: Belladonna Alkaloids

PHYSICAL EXAM: Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Married; lives with her husband who is demented, her daughter
[**Name (NI) 108329**], [**Name2 (NI) 108330**] husband and 6 [**Name2 (NI) **] granddaughter. Presently in
temporary housing while awaiting renovations on their [**Last Name (un) **]
which was damaged during a fire last winter. [**Last Name (un) 108329**] is the
caretaker for both of her parents. [**Last Name (un) 108329**] very stressed and
overwhelmed. Her mother-in-law in [**Name (NI) 4565**] died this past
month which required her husband to leave for [**Name (NI) 4565**]. She is
in the midst of trying to place her father in nursing care
facility and is quite guilty about this decision. Ms. [**Known lastname 108328**] [**Last Name (Titles) 108331**]y recieves near daily RN visits from Suburban Home Care.
[**Last Name (Titles) 108329**] is reliant on "sitters" to bring her mother to
appointments. 

### Response:
{'Acute on chronic diastolic heart failure,Acute respiratory failure,Pneumonia, organism unspecified,Chronic kidney disease, Stage IV (severe),Acute kidney failure, unspecified,Regional enteritis of unspecified site,Nontraumatic hematoma of soft tissue,Anticoagulants causing adverse effects in therapeutic use,Myelodysplastic syndrome, unspecified,Anemia in chronic kidney disease,Personal history of venous thrombosis and embolism,Other chronic pulmonary heart diseases,Obstructive sleep apnea (adult)(pediatric),Personal history of malignant neoplasm of breast,Volume depletion, unspecified,Long-term (current) use of anticoagulants'}
