CHIEF COMPLAINT: Chest Pain

PRESENT ILLNESS: This is a 68 y.o. male with past medical history of MI in [**2123**]
s/p PTCA at [**Hospital1 2177**] as well as aplastic anemia, DM, and PVD who
presented on the day of admission with approximately one hour of
chest pain.  This pain did not start with exertion as the
patient was just walking around his house when he noticed some
pain under his sternum.  At first, he thought this was most
likely heartburn so he took a couple of TUMs and then went to
lay down for a while.  Unfortunately, after about an hour he was
continuing to have this pain, which continued at a five out of
ten level and was beginning to radiate into his right shoulder.
He was not diaphoretic or short of breath at rest.  He described
this pain as very similar to his previous cardiac pain but less
severe.  When the pain did not go away after rest he became
concerned for a [**Last Name **] problem and called the ambulance to take
him to this hospital.

MEDICAL HISTORY: 1. Diabetes Mellitus type 2
2. Hypertension
3. Coronary Artery Disease s/p balloon angioplasty in [**2133**]
4. Peripheral Vascular Disease s/p R fem-[**Doctor Last Name **] bypass in [**Month (only) 216**],
[**2138**]
5. s/p right Carotid Endarterectomy in [**2135-1-26**]; left carotid
artery completely occluded but asymptomatic
6. s/p right 5th toe amputation in [**2137-6-25**]

MEDICATION ON ADMISSION: Folic Acid 1 mg PO daily
Metoprolol Tartrate 50 mg PO BID
Neooral 50 mg PO QAM and 25 mg PO QPM
Nifedipine ER 30 mg PO daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
VS: T 97.4, BP 144/87, HR 75, RR 22, O2 Sat 100% on 4L
Gen: This is a chronically ill appearing elderly male in NAD
HEENT: Sclerae anicteric, PERRL, oropharynx benign without
petechiae or bleeding
Neck: Supple, JVP at 1 cm above the clavicle, carotid bruit on
right side
CV: RRR, no M/R/G appreciated, nl S1 and S2
Pulm: CTAB w/ few crackles at the bases; no wheezes, rhonchi, or
rales
Abdomen: Soft, NT, ND, BS+, no masses or hepatosplenomegaly
appreciated
Extremities: Cold but not cyanotic with with trace edema
bilaterally
Pulses: dopplerable DP and PT pulses bilaterally, 1- radial
pulses, no palpable carotid pulses
Neuro: A&O *3, responds appropriately to queries, CNII-XII
grossly intact, strength 5/5 in all extremities

FAMILY HISTORY: His mother and sister have diabetes mellitus type two.  Many
members of his family have hyptertension.

SOCIAL HISTORY: He is retired.  He worked as a maintenance worker at [**Hospital1 2177**] for 25
yrs. He is widowed but has a son and daughter-in-law in town who
he stays in close touch with.  He lives by himself in poor
financial circumstances.  He has smoked one and a half packs of
cigarettes/day for at least 50 years. He denies alcohol or other
drugs.
Acute respiratory failure,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Congestive heart failure, unspecified,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Subendocardial infarction, initial episode of care,Paroxysmal ventricular tachycardia,Aplastic anemia, unspecified,Other primary cardiomyopathies
Acute respiratry failure,Acute kidney failure NOS,Hyposmolality,CHF NOS,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,DMII wo cmp nt st uncntr,Subendo infarct, initial,Parox ventric tachycard,Aplastic anemia NOS,Prim cardiomyopathy NEC
Admission Date:  [**2146-10-15**]              Discharge Date:   [**2146-10-22**]

Date of Birth:  [**2077-12-10**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Chest Pain

Major Surgical or Invasive Procedure:
-Attempted Ventricular Tachycardia Ablation
-Endotracheal Intubation

History of Present Illness:
This is a 68 y.o. male with past medical history of MI in [**2123**]
s/p PTCA at [**Hospital1 2177**] as well as aplastic anemia, DM, and PVD who
presented on the day of admission with approximately one hour of
chest pain.  This pain did not start with exertion as the
patient was just walking around his house when he noticed some
pain under his sternum.  At first, he thought this was most
likely heartburn so he took a couple of TUMs and then went to
lay down for a while.  Unfortunately, after about an hour he was
continuing to have this pain, which continued at a five out of
ten level and was beginning to radiate into his right shoulder.
He was not diaphoretic or short of breath at rest.  He described
this pain as very similar to his previous cardiac pain but less
severe.  When the pain did not go away after rest he became
concerned for a [**Last Name **] problem and called the ambulance to take
him to this hospital.

In the ED initial vital signs were 75, 145/84, RR 15, O2 Sat of
96% on 4L.  He had an EKG which showed possible ST segment
elevations and T wave inversions in V3-V5 that remained stable
during his time in the ED.  Initial cardiac enzymes revealed a
troponin of 0.74 and CPK of 155 and MB of 6.  Other remarkable
lab values at the time included a Cr of 2.2 (up from his
baseline of 1.7) and a Platelet count of 101.  He was given
aspirin, clopidogrel, and started on NTG and heparin gtt.  His
pain resolved early in his ED course and did not recur.  The
cardiology fellow was consulted and felt though the patient was
most likely having an NSTEMI that he did not need urgent cath so
Mr. [**Known lastname 37430**] was admitted to the [**Hospital1 1516**] service for management with
early cathterization and revascularization planned in the next
24-48 hrs.  Epifibatide was initially held due to concern about
his thrombocytopenia and bleeding risk.

Past Medical History:
1. Diabetes Mellitus type 2
2. Hypertension
3. Coronary Artery Disease s/p balloon angioplasty in [**2133**]
4. Peripheral Vascular Disease s/p R fem-[**Doctor Last Name **] bypass in [**Month (only) 216**],
[**2138**]
5. s/p right Carotid Endarterectomy in [**2135-1-26**]; left carotid
artery completely occluded but asymptomatic
6. s/p right 5th toe amputation in [**2137-6-25**]


Social History:
He is retired.  He worked as a maintenance worker at [**Hospital1 2177**] for 25
yrs. He is widowed but has a son and daughter-in-law in town who
he stays in close touch with.  He lives by himself in poor
financial circumstances.  He has smoked one and a half packs of
cigarettes/day for at least 50 years. He denies alcohol or other
drugs.


Family History:
His mother and sister have diabetes mellitus type two.  Many
members of his family have hyptertension.

Physical Exam:
On admission:
VS: T 97.4, BP 144/87, HR 75, RR 22, O2 Sat 100% on 4L
Gen: This is a chronically ill appearing elderly male in NAD
HEENT: Sclerae anicteric, PERRL, oropharynx benign without
petechiae or bleeding
Neck: Supple, JVP at 1 cm above the clavicle, carotid bruit on
right side
CV: RRR, no M/R/G appreciated, nl S1 and S2
Pulm: CTAB w/ few crackles at the bases; no wheezes, rhonchi, or
rales
Abdomen: Soft, NT, ND, BS+, no masses or hepatosplenomegaly
appreciated
Extremities: Cold but not cyanotic with with trace edema
bilaterally
Pulses: dopplerable DP and PT pulses bilaterally, 1- radial
pulses, no palpable carotid pulses
Neuro: A&O *3, responds appropriately to queries, CNII-XII
grossly intact, strength 5/5 in all extremities

On discharge, exam not significantly changed from admission
except for in the following ways.  At discharge all vital signs
stable with oxygen saturation greater than 93% on room air.  No
JVD was appreciated.  Lung exam without crackles, wheezes,
rhonchi, or rales on auscultation.  No edema noted.


Pertinent Results:
<b><u>LABORATORY RESULTS</B></U>
On Admission:
WBC-4.8 RBC-2.53* Hgb-9.2* Hct-27.1* MCV-107* Plt Ct-101*
----------Neuts-40.7* Lymphs-54.1* Monos-3.1 Eos-1.9 Baso-0.3
PT-14.0* PTT-28.8 INR(PT)-1.2*
Glucose-226* UreaN-34* Creat-2.2* Na-132* K-3.9 Cl-95* HCO3-20*
AnGap-21*

On Discharge:
WBC-3.2* RBC-2.60* Hgb-8.8* Hct-25.9* MCV-100* Plt Ct-100*
PT-13.4 PTT-35.3* INR(PT)-1.1
Glucose-96 UreaN-33* Creat-1.9* Na-137 K-4.2 Cl-105 HCO3-22
AnGap-14

Cardiac Enzymes (CK-MB-TropT)
[**2146-10-15**] 06:55PM 155-6-0.75
[**2146-10-16**] 01:18AM 158-9.7- 0.98
[**2146-10-16**] 06:35AM 172-8- 1.29
[**2146-10-16**] 11:57AM 158-7-1.19
[**2146-10-17**] 06:32AM 119-5-1.06

<b><u>OTHER STUDIES</b></u>
EKG on [**2146-10-15**]:
Sinus rhythm with Q waves in leads II, III and aVF consistent
with inferior
myocardial infarction of indeterminate age. ST segment coving in
leads V3- with associated T wave inversions consistent with
evolving anterior injury
pattern. Multiple ventricular premature beats. No previous
tracing available for comparison.

CXR on [**2146-10-15**]:
IMPRESSION: There is diffuse pulmonary edema. There is likely a
right
pleural effusion possibly a small left pleural effusion. A more
consolidative process in the right lung base cannot be excluded.
The heart appears relatively enlarged even accounting for
patient and technical factors which would represent an acute
change. Repeat radiography following appropriate diuresis is
recommended to assess for underlying infection.

Echocardiogram on [**2146-10-16**]:
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is an inferolateral basal left
ventricular aneurysm. There is severe regional left ventricular
systolic dysfunction with akinesis of the mid to distal anterior
septum, basal inferior and inferolateral segments, severe
hypokinesis of the remaining segments with sparing of the basal
septum. Overall left ventricular systolic function is severely
depressed (LVEF= 15-20 %). Right ventricular chamber size is
normal. with depressed free wall contractility. The aortic root
is mildly dilated at the sinus level. 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. Mild (1+) mitral regurgitation is seen. There
is an anterior space which most likely represents a fat pad.

IMPRESSION: Moderately dilated left ventricle with severe
regional dysfunction consistent with ischemic heart disease
(multivessel).


Brief Hospital Course:
68 year old gentleman with history of coronary artery disease
s/p MI as well as diabetes mellitus, peripheral vascular
disease, and aplastic anemia presenting with chest pain.

1) NSTEMI/CAD: Given the patient's multiple risk factors and EKG
changes he was diagnosed with presumptive ACS on arrival to the
ED and thus was almost immediately given aspirin and beta
blocker and started on nitroglycerine.  His pain resolved after
receiving NTG and never recurred.  He was also started on
heparin.  After his first set of cardiac enzymes returned
positive the on-call cardiology fellow was contact[**Name (NI) **] and made
aware of the patient.  S/he recommended against epifibatide
given the patient's thrombocytopenia and indicated that the
patient did not need urgent cathterization.  The patient was
admitted to the cardiology service with plan for cardiac
catheterization in the next 24-48 hours. The patient was then
transferred to CCU for sustained VT (see below).  Repeat cardiac
enzymes continued to show flat CK's and echo showed significant
wall motion abnormalities suggesting this was a subacute
presentation of a myocardial infarction.  This indicated less
benefit from immediate catheterization and given development of
decompensated heart failure and need for intubation (see below)
as well as acute renal failure the decision was made to postpone
catheterization until after kidney function had normalized.  The
patient will also have stress perfusion study prior to
catheterization as echocardiogram findings are consistent with
diffuse CAD and this testing could suggest minimal benefit from
PTCA and drive management toward a surgical strategy.  The
[**Hospital 228**] medical regimen for CAD was optimized during this
hospitalization with addition of aspirin, clopidogrel, and
statin.  The dose of statin was modified for concurrent
cyclosporine use.  He will follow up with Dr. [**Last Name (STitle) 911**] in
cardiology clinic.

2) Dysrrthymia:  During his first night in the hospital the
patient had a run of sustained ventricular tachycardia while
resting comfortably and being monitored on telemetery.  His
blood pressure decreased from SBP's in the 140's to SBP's in the
110's, but Mr [**Known lastname 37430**] remained completely asymptomatic during
this episode.  Given concern this was possibly ischemia related
VT, he was started on a lidocaine drip with resolution of his VT
to NSR in a matter of one to two minutes.  He was then
transferred to the CCU for further management.  In the CCU the
patient was monitored on telemetry and stayed primarily in NSR
with occasional incidents of NSVT that decreased in frequency
over the course of his hospital stay.  He was seen by EP, who
thought given this was monomorphic VT with history of MI and
hypo/akinetic apex this was most likely scar mediated VT.  The
plan was made to do a VT ablation at the same time of cardiac
catheterization for revascularization.  Cardiac cathterization
was canceled for the reasons described above but the
electrophysiology service decided to proceed with the ablation
and took the patient to the cath lab.  Unfortunately, during
this procedure after receiving blood products and put in a
supine position he became quite short of breath and hypoxic and
was electively intubated for respiratory ditress.  The VT
ablation was unsuccessful and the patient was managed medically
from that point forward.  Given the decreased incidence of NSVT
over the course of his hospitalization the electrophysiology
service did not recommend continuing anti-arrythmic therapy with
anything but beta blocker.

3) Acute Systolic Heart Failure: At the time of presentation the
patient had crackles to auscultation of his lung bases
bilaterally and an oxygen requirement. Given presumption of MI
it was assumed he was in some degree of acute, decompensated
heart failure and he had a brisk diuresis to a single dose of
furosemide.  Early in the morning following admission the
patient had an echocardiogram showing severe LV dysfunction with
an EF of 15-20%. Despite this, the patient had a stable
respiratory status over the following day.  He received one unit
of blood with furosemide given at the same time and continued to
have good oxygen saturations on a few liters of oxygen by nasal
cannula.  Unfortunately, the following day after receiving two
liters of blood in the cath lab and being put in a recumbent
position the patient had an acutely worsened respiratory status
and had to be intubated due to respiratory compromise.  He also
became hypotensive briefly and returned to the CCU from the cath
lab on small doses of dopamine, which were weaned off over the
following hours without recurrence of hypotension.  While he was
intubated he was diuresed approximately two liters, which
required a furosemide drip after an inadequate response to bolus
furosemide doses.  After this diuresis he was s extubated
without incident and continued to self diurese another liter
without further diuretic therapy.  He maintained approximate
euvolemia after this without further need for diuretics.
Regarding chronic medical management of his heart failure, the
patient was continued on his beta blocker.  ACE inhibitor
therapy was considered but held due to the patient's acute renal
failure.  He was started on Hydralazine and Isosorbide as a
substitute regimen for afterload reduction with plan to start
ACE inhibitor as an outpatient after renal function has improved
to baseline.  On discharge the patient has chronic heart failure
given known reduced EF but was compensated without clinical
signs of volume overload.

4) Acute renal failure on Chronic Kidney Disease: On
presentation the patient's Cr was elevated to 2.2 from baseline
of 1.6.  Consideration was given to ATN versus poor perfusion
due to acute decompensated heart failure versus cyclosporine
toxicity.  Cyclosporine level was found to be undetectable, but
the first two diagnostic possibilities remained under
consideration particularly as kidney function did not improve
with initial heart failure management.  Thus, the nephrology
service was consulted.  They examined the urinary sediment and
found no granular casts suggesting ATN.  This led to a
presumptive diagnosis of prerenal failure due to poor systolic
function and inadequate perfusion.  As the patient's heart
failure improved his Cr improved as well and after peaking at
2.6 it had fallen back to 1.9 at discharge.

5) Aplastic Anemia: On presentation the patient's hematocrit was
approximately 27, which is his baseline.  Over the next day,
however, he fell to 25 and was given three units of blood in the
hospital due to concern for anemia in the context of inadequate
coronary perfusion.  After these transfusions his hematocrit
increased appropriately to 29 but then began to fall to around
his baseline value of 26 at the time of discharge.  The patient
was also thrombocytopenic with relatively stable platelet counts
of 70 to 100 during his hospitalization.  His cyclosporine was
held in the hospital due to concerns over his acute renal
failure but restarted at the time of discharge.  He will follow
up with his regular hematologist, Dr. [**Last Name (STitle) 6944**].

6) Diabetes Mellitus: The patient was maintained on sliding
scale insulin in the hospital with reasonable control of his
blood glucose.

7) Peripheral Vascular Disease: The patient is status post
multiple peripheral vascular interventions with multiple bruits
appreciated on physical exam. Following his attempted
percutaneous VT ablation he was found to have a cold, pulseless
left foot that became mottled during the period there was a
sheath in place.  This exam improved with better color following
sheath removal but pulses could still not be found with doppler.
 Vascular surgery was consulted and chose to monitor given no
signs of active ischemia and over the next day pulse returned
and at discharge patient's foot at baseline with dopplerable but
not palpable pulses.  During this hospitalization Mr. [**Known lastname 37430**] was
started on aspirin, clopidogrel, and statin therapy for his CAD,
but these medical measures should also help manage his PVD.

Mr. [**Known lastname 37430**] was fed a cardiac, heart healthy diet in the
hospital.  He was kept on subcutaneous heparin for DVT
prophylaxis.  He was full code.

Medications on Admission:
Folic Acid 1 mg PO daily
Metoprolol Tartrate 50 mg PO BID
Neooral 50 mg PO QAM and 25 mg PO QPM
Nifedipine ER 30 mg PO daily

Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Isosorbide Dinitrate 20 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
6. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours.
Disp:*90 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Neoral 25 mg Capsule Sig: Three (3) Capsule PO once a day:
Please take two tablets each morning and one tablet each
afternoon. .
Disp:*90 Capsule(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Acute Systolic Congestive Heart Failure
Acute Kidney Injury on Chronic Kidney Disease
Hypertension
Ventricular tachycardia
Aplastic Anemia


Discharge Condition:
Good, pain free, adequate O2 Sats on room air


Discharge Instructions:
You had strain on your heart and an irregular heart rhythm
called ventricular tachycardia. You had a procedure to try to
prevent the ventricular tachycardia but had an acute episode of
congestive heart failure during the procedure. You were
intubated and on a ventilator to help you breathe. Your kidneys
were not working well because of your heart but now are getting
better. Your heart is weak and not pumping as well as it should.
Please weigh yourself every day in the morning before eating and
call Dr. [**Last Name (STitle) 911**] is you have a weight gain of more than 3 pounds
in 1 day or 6 pounds in 3 days. Please also avoid salt in your
diet, you should not eat more than 2000mg per day.
.
You need to have a stress test in 2 weeks and see Dr. [**Last Name (STitle) 911**] in 6
weeks.  The cardiovascular clinic will call you about setting up
this appointment with Dr. [**Last Name (STitle) 911**].  You also should have cardiac
rehabilitation that will help your heart be as strong as it can
be.
.
Please stop smoking. Information was given to you on admission
regarding smoking cessation.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5717**], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2146-11-23**] 1:30. [**Hospital Ward Name 23**] Clinical
Center
.
Cardiology:
Stress Test:
Date/Time: Tuesday [**11-8**] at 9:50am. [**Hospital Ward Name 23**] Building [**Location (un) **] radiology department.
No caffeine 12 hours before, no food or drink after midnight on
[**11-7**].
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:
[**12-2**] at 11:20am. You should call the office after you are
home and they have promised to get you an earlier appt.
.
Please follow up with podiatry, call for an appointment
[**Telephone/Fax (1) 67765**]


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
{'Acute respiratory failure,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Congestive heart failure, unspecified,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Subendocardial infarction, initial episode of care,Paroxysmal ventricular tachycardia,Aplastic anemia, unspecified,Other primary cardiomyopathies'}


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: Chest Pain

PRESENT ILLNESS: This is a 68 y.o. male with past medical history of MI in [**2123**]
s/p PTCA at [**Hospital1 2177**] as well as aplastic anemia, DM, and PVD who
presented on the day of admission with approximately one hour of
chest pain.  This pain did not start with exertion as the
patient was just walking around his house when he noticed some
pain under his sternum.  At first, he thought this was most
likely heartburn so he took a couple of TUMs and then went to
lay down for a while.  Unfortunately, after about an hour he was
continuing to have this pain, which continued at a five out of
ten level and was beginning to radiate into his right shoulder.
He was not diaphoretic or short of breath at rest.  He described
this pain as very similar to his previous cardiac pain but less
severe.  When the pain did not go away after rest he became
concerned for a [**Last Name **] problem and called the ambulance to take
him to this hospital.

MEDICAL HISTORY: 1. Diabetes Mellitus type 2
2. Hypertension
3. Coronary Artery Disease s/p balloon angioplasty in [**2133**]
4. Peripheral Vascular Disease s/p R fem-[**Doctor Last Name **] bypass in [**Month (only) 216**],
[**2138**]
5. s/p right Carotid Endarterectomy in [**2135-1-26**]; left carotid
artery completely occluded but asymptomatic
6. s/p right 5th toe amputation in [**2137-6-25**]

MEDICATION ON ADMISSION: Folic Acid 1 mg PO daily
Metoprolol Tartrate 50 mg PO BID
Neooral 50 mg PO QAM and 25 mg PO QPM
Nifedipine ER 30 mg PO daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On admission:
VS: T 97.4, BP 144/87, HR 75, RR 22, O2 Sat 100% on 4L
Gen: This is a chronically ill appearing elderly male in NAD
HEENT: Sclerae anicteric, PERRL, oropharynx benign without
petechiae or bleeding
Neck: Supple, JVP at 1 cm above the clavicle, carotid bruit on
right side
CV: RRR, no M/R/G appreciated, nl S1 and S2
Pulm: CTAB w/ few crackles at the bases; no wheezes, rhonchi, or
rales
Abdomen: Soft, NT, ND, BS+, no masses or hepatosplenomegaly
appreciated
Extremities: Cold but not cyanotic with with trace edema
bilaterally
Pulses: dopplerable DP and PT pulses bilaterally, 1- radial
pulses, no palpable carotid pulses
Neuro: A&O *3, responds appropriately to queries, CNII-XII
grossly intact, strength 5/5 in all extremities

FAMILY HISTORY: His mother and sister have diabetes mellitus type two.  Many
members of his family have hyptertension.

SOCIAL HISTORY: He is retired.  He worked as a maintenance worker at [**Hospital1 2177**] for 25
yrs. He is widowed but has a son and daughter-in-law in town who
he stays in close touch with.  He lives by himself in poor
financial circumstances.  He has smoked one and a half packs of
cigarettes/day for at least 50 years. He denies alcohol or other
drugs. 

### Response:
{'Acute respiratory failure,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Congestive heart failure, unspecified,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Subendocardial infarction, initial episode of care,Paroxysmal ventricular tachycardia,Aplastic anemia, unspecified,Other primary cardiomyopathies'}
