CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: 78 y.o. female with h/o CHF EF = 15-20%, active tobacco use,
0.5-1.5 ppd who presents with acute onset of shortness of breath
and black stool one day prior to admission.  She was in her
general state of chronic health, sleeping on 3 pillows and sob
with walking short distances until the night prior to admission
when she experienced bilateral lower quadrant cramping and then
had a moderate amount of black stool. She then awoke later with
shortness of breath. She denies cp, diphoresis, nausea or
vomiting, or palpitations.  Denies NSAID use. She called her
PCP's office who checked labs and then advised her to go to the
[**Hospital1 18**] emergency room. In the ED an NGT was placed which did not
clear after 500 cc. It was on intermittent suction until d/c'ed
at the rest of GI. She was given 150 cc NS.
.
On review of systems, the pt. denied recent fever or chills.
Reported a 3 pound wt loss. No change in chronic cough
productive of white sputum.  Increased lower extremity swelling.
C/o chronic aches and pains including back pain.
.
In MICU pt received FFP to reverse INR until bleeding resolved.
Received 4 units PRBC with HCT 20-->31.

MEDICAL HISTORY: 1. anemia with hx GI bleed, baseline Hct 30-35, Hct 35 last week
- last EGD [**2131-1-29**] with 1 cm angioectasia cauterized, no major
GIB since
- last C-scope [**8-18**] with diverticulosis, int hemorrhoids
2. type II DM
3. CHF ef 15-20%, last echo [**8-19**] with severely depressed EF
15-20%, severe global LV HK, mod 2+MR
4. MVR -St. [**Male First Name (un) 1525**] mechanical valve placed [**2122**] secondary to
rheumatic heart dz, on coumadin
5. hyperparathyroid
6. h/o PUD
7. HTN
8. hx NSVT
9. afib s/p cardioversion [**2130**], on amiodarone
10. hx TIA
11. high cholesterol

MEDICATION ON ADMISSION: On Admission:
1. Carvedilol 3.125 mg PO BID
2. Gemfibrozil 600 mg PO BID
3. Ferrous Sulfate 325mg PO DAILY
4. Amiodarone 200 mg  PO QAM
5. MagOx 400 mg PO twice a day.
6. Albuterol 90 mcg: 1-2 Puffs Inhalation Q4-6H
7. Ipratropium Bromide 18 mcg Two (2) QID.
8. Lasix 20 mg PO QOD.
9. Vitamin D 400 IU
10. Calcium Vit D [**Hospital1 **]

ALLERGIES: Erythromycin Base

PHYSICAL EXAM: VS T 97.2, P 82 BP 86/44 RR 22 O2Sat 96%
GENERAL: Elderly female sitting upright in chair, able to speak
in full sentence.
HEENT: NC/AT, PERRL, no scleral icterus noted, dry MMM, no
lesions noted in OP
Neck: supple, JVD elevated to the mandible
Pulmonary: Lungs with difuse wheeze and rhonchi.
Cardiac:irreg, irreg, no murmur appreciated.
Abdomen: soft, NT/ND, normoactive bowel sounds, mild diffuse
tenderness,
RECTAL: black stool on guiac in ED
Extremities: 2+ pitting edema to the shin with 1+ DPP
bilaterally
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Widowed [**2110**], independent in all her ADLs and IADLs.  Lives
alone in [**Location (un) **] Corner.  Children live in the area.  no EtOH
and +tob (1 ppd x 60 yrs, still smoking),no IVDA.
Acute kidney failure with lesion of tubular necrosis,Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute on chronic systolic heart failure,Diseases of tricuspid valve,Atrial fibrillation,Urinary tract infection, site not specified,Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Hypovolemia,Abnormal coagulation profile,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Unspecified essential hypertension,Hyperparathyroidism, unspecified,Long-term (current) use of anticoagulants,Heart valve replaced by other means
Ac kidny fail, tubr necr,Chr stomach ulc w hem,Ac on chr syst hrt fail,Tricuspid valve disease,Atrial fibrillation,Urin tract infection NOS,Acute respiratry failure,Obs chr bronc w(ac) exac,Hypovolemia,Abnrml coagultion prfile,DMII wo cmp nt st uncntr,Pure hypercholesterolem,Hypertension NOS,Hyperparathyroidism NOS,Long-term use anticoagul,Heart valve replac NEC
Admission Date:  [**2133-3-4**]              Discharge Date:   [**2133-3-12**]

Date of Birth:  [**2055-2-8**]             Sex:   F

Service: MEDICINE

Allergies:
Erythromycin Base

Attending:[**First Name3 (LF) 297**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
NGT placement, PICC line placement.
s/p intubation

History of Present Illness:
 78 y.o. female with h/o CHF EF = 15-20%, active tobacco use,
0.5-1.5 ppd who presents with acute onset of shortness of breath
and black stool one day prior to admission.  She was in her
general state of chronic health, sleeping on 3 pillows and sob
with walking short distances until the night prior to admission
when she experienced bilateral lower quadrant cramping and then
had a moderate amount of black stool. She then awoke later with
shortness of breath. She denies cp, diphoresis, nausea or
vomiting, or palpitations.  Denies NSAID use. She called her
PCP's office who checked labs and then advised her to go to the
[**Hospital1 18**] emergency room. In the ED an NGT was placed which did not
clear after 500 cc. It was on intermittent suction until d/c'ed
at the rest of GI. She was given 150 cc NS.
.
On review of systems, the pt. denied recent fever or chills.
Reported a 3 pound wt loss. No change in chronic cough
productive of white sputum.  Increased lower extremity swelling.
C/o chronic aches and pains including back pain.
.
In MICU pt received FFP to reverse INR until bleeding resolved.
Received 4 units PRBC with HCT 20-->31.


Past Medical History:
1. anemia with hx GI bleed, baseline Hct 30-35, Hct 35 last week
- last EGD [**2131-1-29**] with 1 cm angioectasia cauterized, no major
GIB since
- last C-scope [**8-18**] with diverticulosis, int hemorrhoids
2. type II DM
3. CHF ef 15-20%, last echo [**8-19**] with severely depressed EF
15-20%, severe global LV HK, mod 2+MR
4. MVR -St. [**Male First Name (un) 1525**] mechanical valve placed [**2122**] secondary to
rheumatic heart dz, on coumadin
5. hyperparathyroid
6. h/o PUD
7. HTN
8. hx NSVT
9. afib s/p cardioversion [**2130**], on amiodarone
10. hx TIA
11. high cholesterol


Social History:
Widowed [**2110**], independent in all her ADLs and IADLs.  Lives
alone in [**Location (un) **] Corner.  Children live in the area.  no EtOH
and +tob (1 ppd x 60 yrs, still smoking),no IVDA.


Family History:
non-contributory

Physical Exam:
VS T 97.2, P 82 BP 86/44 RR 22 O2Sat 96%
GENERAL: Elderly female sitting upright in chair, able to speak
in full sentence.
HEENT: NC/AT, PERRL, no scleral icterus noted, dry MMM, no
lesions noted in OP
Neck: supple, JVD elevated to the mandible
Pulmonary: Lungs with difuse wheeze and rhonchi.
Cardiac:irreg, irreg, no murmur appreciated.
Abdomen: soft, NT/ND, normoactive bowel sounds, mild diffuse
tenderness,
RECTAL: black stool on guiac in ED
Extremities: 2+ pitting edema to the shin with 1+ DPP
bilaterally
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.


Pertinent Results:
[**2133-3-4**] 10:51PM   HCT-20.4*
[**2133-3-4**] 06:58PM   HGB-6.5* calcHCT-20
[**2133-3-4**] 06:47PM   HGB-7.1* calcHCT-21
[**2133-3-4**] 06:30PM   GLUCOSE-61* UREA N-117* CREAT-4.0*#
SODIUM-136 POTASSIUM-4.9 CHLORIDE-93* TOTAL CO2-23 ANION GAP-25*
[**2133-3-4**] 06:30PM   ALT(SGPT)-7 AST(SGOT)-19 LD(LDH)-186
CK(CPK)-66 ALK PHOS-32* AMYLASE-92 TOT BILI-0.2
[**2133-3-4**] 06:30PM   LIPASE-47
[**2133-3-4**] 06:30PM   CK-MB-NotDone cTropnT-0.07*
[**2133-3-4**] 06:30PM   ALBUMIN-3.8
[**2133-3-4**] 06:30PM   WBC-6.4 RBC-2.19*# HGB-6.9*# HCT-20.3*#
MCV-93 MCH-31.4 MCHC-33.9 RDW-15.6*
[**2133-3-4**] 06:30PM   PLT COUNT-155
[**2133-3-4**] 06:30PM   PT-47.6* PTT-44.0* INR(PT)-5.6*
.
ON TRANSFER:

[**2133-3-7**] 04:00AM BLOOD WBC-7.5 RBC-3.35* Hgb-10.1* Hct-29.7*
MCV-89 MCH-30.2 MCHC-34.1 RDW-16.5* Plt Ct-UNABLE TO
[**2133-3-7**] 06:00AM BLOOD Plt Ct-102*
[**2133-3-7**] 04:00AM BLOOD Glucose-100 UreaN-107* Creat-3.2* Na-144
K-3.8 Cl-102 HCO3-25 AnGap-21*
[**2133-3-7**] 04:00AM BLOOD Calcium-9.5 Phos-3.5 Mg-2.5
.
SPEP: negative
UPEP: negative
.
EKG ([**2133-3-7**]): Atrial fibrillation @ 108. Intraventricular
conduction delay with left axis deviation which is probably
atypical left bundle-branch block. ST-T wave abnormalities may
be secondary to intraventricular conduction delay
.
Imaging:
CXR ([**2133-3-4**]): 1. Stable mild congestive heart failure.
2. Possible left small pleural effusion versus pleural
thickening.
.
Renal ultrasound ([**2133-3-5**]):
1. No evidence of hydronephrosis. Slightly echogenic kidneys
consistent with chronic parenchymal disease.
2. Small amount of ascites.
.
Echocardiogram ([**2133-3-5**]):
1. The left atrium is moderately dilated. The right atrium is
moderately
dilated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular
cavity is moderately dilated. There is severe global left
ventricular
hypokinesis. Overall left ventricular systolic function is
severely depressed.
3. The right ventricular cavity is dilated. There is severe
global right
ventricular free wall hypokinesis.
4. The aortic valve leaflets are mildly thickened.
5. A bileaflet mitral valve prosthesis is present. Moderate [2+]
tricuspid
regurgitation is seen.
6. There is mild pulmonary artery systolic hypertension.
7. Compared with the findings of the prior study (images
reviewed) of
[**2132-9-1**], there has been no significant change.
.
CT head ([**2133-3-6**]): 1. Curvilinear hyperdensity bilaterally in
temporal horns of the ventricle, somewhat more prominent on the
left, probably representing calcified and prominent choroid,
given the absence of other abnormal density in the ventricle. In
this patient with anticoagulation, if the symptom persists or
worsens, please consider short-term followup by CT scan or MRI.
2. Sinusitis.
.
CXR: [**2133-3-7**]: IMPRESSION: Worsening patchy opacities at the lung
bases, most likely representing worsening atelectasis. Pneumonia
cannot be fully excluded
.
KUB ([**2133-3-7**]):
The air is identified throughout the small bowel and colon
probably indicating mild ileus. The pelvis is not completely
included in the radiograph. If clinically indicated, please
evaluate with repeated supine and erect AP radiographs of the
abdomen.
.
The patient has prior MVR and median sternotomy. Temporary pacer
wire is identified.
.
CXR ([**2133-3-10**]):
Tip of the right PIC catheter projects over the right
brachiocephalic vein at the level of the upper margin of the
manubrium. ET tube in standard placement. Nasogastric tube
passes below the diaphragm and out of view. Moderate
cardiomegaly stable. Pulmonary vascular engorgement is mild but
there is no pulmonary edema or appreciable pleural effusion.
Patient has had median sternotomy and mitral valve replacement.
.


Brief Hospital Course:
# GIB: 78 y.o. female with h/o gastric angioetasia, CHF with EF
= 15-20%, s/p MVR on coumadin p/w maroon red OGT output and
black stool with 10 point HCT drop and shortness of breath in
the setting of a supra-therapeutic INR. Pt was given FFP to
reverse coagulopathy. Initially given 4 units of blood with
increase in hct from 20 to 30. Most likely felt to be UGIB, with
initial ddx including AVM, ulcer, malignancy, gastritis. Pt was
intermittently hypotensive initially, so GI held off on EGD
given hypotension and risk of further BP drop with sedation. Pt
was then intubated for respiratory distress (see below). EGD was
performed on [**2133-3-9**] which showed gastric ulcer with evidence of
recent bleeding, clean based pyloric ulcer, and petechiae and
erosions in esophagus and stomach secondary to NG trauma. Most
likely source of bleeding is gastric ulcer. [**Hospital1 **] hct checks were
continued and pt was given an additional 2 units of blood for
slight drops in hct. Pt didn't have any further episodes of
bloody stool. Pt was initially maintained on IV bid protonix,
which was switched to po BID protonix after resolution of GIB.
Pt needs a repeat EGD in [**4-23**] weeks to document resolution of
gastric ulcer and for possible biopsy.
.
# DYSPNEA: On HD5 ([**3-8**]), pt was intubated secondary to
respiratory failure. Respiratory failure was felt to be likely
multifactorial [**12-18**] to COPD exacerbation and CHF. Sputum cx grew
Pseudomonas, but there was no evidence of pna on CXR. Pt was
treated for COPD with around the clock nebulizer treatments. She
received intermittent IV lasix for clinical evidence of volume
overload. Pt was successfully extubated on [**3-10**]. Pt was started
on IV solumedrol on [**3-11**] for wheezing and dyspnea. Pt will need
to transition to po steroid with a taper.
.
# HYPOTENSION: Pt was hypotensive on admission to MICU.
Hypotension was thought to be secondary to hypovolemia and
underlying severe CHF. Pt has a low BP at baseline. Pt was
afebrile without leukocytosis thus sepsis unlikely.  She
initially responded to IVF and PRBC. However, she transiently
required pressors. Pt was initially on Levophed, but was noted
to have intermitten rapid AF (110-120s) and was switched to Neo
which was titrated off.  BP meds were held. Pt's BP subsequently
stabilized.
.
# CHF - Pt has severe systolic dysfunction with EF <20%
(confirmed by TTE this admission). Pt diuresed with intermittent
IV lasix for CHF. Pt was started on digoxin for AF, which will
help with inotropy.
.
# A FIB: Pt has known afib. She is s/p DCCV at last admission.
Beta-blocker was held secondary to hypotension. Amiodarone was
held on admission, then restarted. Pt was started on digoxin in
the setting of rapid HR in 110-120s. Coumadin was initially
held. Pt was on heparin bridge.
.
# MVR: coumadin was initially held. Pt was maintained on heparin
gtt for goal PTT 60-80. Coumadin was restarted prior to
discharge: goal INR is 2.5-3.5.
.
# ARF: Pt's baseline cr is 1.4. Creatinine on admission was 3.9,
and decreased/stabilized at 2.5. The etiology of ARF is likely
ATN due to pre-renal state [**12-18**] GIB.  FeNa=8.3% and FeBUN=37%,
c/w ATN. Renal U/S was negative for hydro. U eos negative. Pt
continued to have good UOP.
.
# HTN: Antihypertensives were held
.
# DM:Continued on RISS
.
# Hypercholesteremia - Gembibrozil held during admission
.
# UTI: Pt was found to have +UA on admission. Urine cx grew pan
sensitive proteus
Pt was treated with cipro for 5/7 days.
.
# Headache: Likely tension/migraine. Head CT [**3-6**] with likely
calcified choroid plexus on the left and sinusitis. given
tylenol prn.
.
# Pain: Pt c/o mild diffuse pain, requiring prn IV morphine. Pt
was started on fentanyl 25mcg qd.
.
# CODE status: Per discussion with pt's HCP, pt was made
DNR/DNI.


Medications on Admission:
On Admission:
1. Carvedilol 3.125 mg PO BID
2. Gemfibrozil 600 mg PO BID
3. Ferrous Sulfate 325mg PO DAILY
4. Amiodarone 200 mg  PO QAM
5. MagOx 400 mg PO twice a day.
6. Albuterol 90 mcg: 1-2 Puffs Inhalation Q4-6H
7. Ipratropium Bromide 18 mcg Two (2) QID.
8. Lasix 20 mg PO QOD.
9. Vitamin D 400 IU
10. Calcium Vit D [**Hospital1 **]


Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical  QD ().
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1)  Transdermal Q72H
(every 72 hours).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
13. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q4H (every 4 hours).
14. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q2H (every 2 hours) as needed.
15. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
17. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
18. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: One (1)  Intravenous  ASDIR (AS DIRECTED): please continue
heparin bridge until INR is 2.5-3.5.
19. Methylprednisolone Sodium Succ 40 mg Recon Soln Sig: Two (2)
Recon Soln Injection Q8H (every 8 hours): 80mg tid.
20. Ciprofloxacin in D5W 400 mg/200 mL Piggyback Sig: One (1)
Intravenous  Q24H (every 24 hours) for 2 days.
21. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a
day.
22. FerrouSul 325 (65) mg Tablet Sig: One (1) Tablet PO once a
day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 86**]

Discharge Diagnosis:
Primary diagnoses:
GIB
Respiratory failure (requring intubation)
CHF
COPD
Hypotension
ARF ([**12-18**] ATN)
UTI
.
Secondary diagnoses:
AF
s/p MVR
HTN
DM
hyperlipidemia


Discharge Condition:
stable


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet

Call your doctor or return to the ED if you develop fevers,
chills, chest pain, difficulty breathing, lightheadedness,
bloody stools, or any other concerningn symptoms.

Followup Instructions:
Follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks of discharge. [**Last Name (LF) **],[**First Name3 (LF) **]
D. [**Telephone/Fax (1) 2936**]



Follow up with Dr. [**First Name (STitle) 450**] [**Doctor Last Name **] for repeat EGD in [**4-23**] weeks.
Call ([**Telephone/Fax (1) 21742**] to schedule an appointment.
{'Acute kidney failure with lesion of tubular necrosis,Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute on chronic systolic heart failure,Diseases of tricuspid valve,Atrial fibrillation,Urinary tract infection, site not specified,Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Hypovolemia,Abnormal coagulation profile,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Unspecified essential hypertension,Hyperparathyroidism, unspecified,Long-term (current) use of anticoagulants,Heart valve replaced by other means'}


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: Dyspnea

PRESENT ILLNESS: 78 y.o. female with h/o CHF EF = 15-20%, active tobacco use,
0.5-1.5 ppd who presents with acute onset of shortness of breath
and black stool one day prior to admission.  She was in her
general state of chronic health, sleeping on 3 pillows and sob
with walking short distances until the night prior to admission
when she experienced bilateral lower quadrant cramping and then
had a moderate amount of black stool. She then awoke later with
shortness of breath. She denies cp, diphoresis, nausea or
vomiting, or palpitations.  Denies NSAID use. She called her
PCP's office who checked labs and then advised her to go to the
[**Hospital1 18**] emergency room. In the ED an NGT was placed which did not
clear after 500 cc. It was on intermittent suction until d/c'ed
at the rest of GI. She was given 150 cc NS.
.
On review of systems, the pt. denied recent fever or chills.
Reported a 3 pound wt loss. No change in chronic cough
productive of white sputum.  Increased lower extremity swelling.
C/o chronic aches and pains including back pain.
.
In MICU pt received FFP to reverse INR until bleeding resolved.
Received 4 units PRBC with HCT 20-->31.

MEDICAL HISTORY: 1. anemia with hx GI bleed, baseline Hct 30-35, Hct 35 last week
- last EGD [**2131-1-29**] with 1 cm angioectasia cauterized, no major
GIB since
- last C-scope [**8-18**] with diverticulosis, int hemorrhoids
2. type II DM
3. CHF ef 15-20%, last echo [**8-19**] with severely depressed EF
15-20%, severe global LV HK, mod 2+MR
4. MVR -St. [**Male First Name (un) 1525**] mechanical valve placed [**2122**] secondary to
rheumatic heart dz, on coumadin
5. hyperparathyroid
6. h/o PUD
7. HTN
8. hx NSVT
9. afib s/p cardioversion [**2130**], on amiodarone
10. hx TIA
11. high cholesterol

MEDICATION ON ADMISSION: On Admission:
1. Carvedilol 3.125 mg PO BID
2. Gemfibrozil 600 mg PO BID
3. Ferrous Sulfate 325mg PO DAILY
4. Amiodarone 200 mg  PO QAM
5. MagOx 400 mg PO twice a day.
6. Albuterol 90 mcg: 1-2 Puffs Inhalation Q4-6H
7. Ipratropium Bromide 18 mcg Two (2) QID.
8. Lasix 20 mg PO QOD.
9. Vitamin D 400 IU
10. Calcium Vit D [**Hospital1 **]

ALLERGIES: Erythromycin Base

PHYSICAL EXAM: VS T 97.2, P 82 BP 86/44 RR 22 O2Sat 96%
GENERAL: Elderly female sitting upright in chair, able to speak
in full sentence.
HEENT: NC/AT, PERRL, no scleral icterus noted, dry MMM, no
lesions noted in OP
Neck: supple, JVD elevated to the mandible
Pulmonary: Lungs with difuse wheeze and rhonchi.
Cardiac:irreg, irreg, no murmur appreciated.
Abdomen: soft, NT/ND, normoactive bowel sounds, mild diffuse
tenderness,
RECTAL: black stool on guiac in ED
Extremities: 2+ pitting edema to the shin with 1+ DPP
bilaterally
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Widowed [**2110**], independent in all her ADLs and IADLs.  Lives
alone in [**Location (un) **] Corner.  Children live in the area.  no EtOH
and +tob (1 ppd x 60 yrs, still smoking),no IVDA. 

### Response:
{'Acute kidney failure with lesion of tubular necrosis,Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Acute on chronic systolic heart failure,Diseases of tricuspid valve,Atrial fibrillation,Urinary tract infection, site not specified,Acute respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Hypovolemia,Abnormal coagulation profile,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Unspecified essential hypertension,Hyperparathyroidism, unspecified,Long-term (current) use of anticoagulants,Heart valve replaced by other means'}
