CHIEF COMPLAINT: weight gain, shortness of breath, volume overload

PRESENT ILLNESS: Mr. [**Known lastname **] is a 68 yo M with Ischemic cardiomyopathy EF < 20%,
s/p CABG x2, s/p BIV ICD recently discharged on [**8-2**] for CHF
admitted with another acute on chronic CHF exacerbation.  During
his recent last hospitalization, we were able to remove several
liters of volume but diuresis was limited by advancing azotemia
and low blood pressure.  He was discharged from the hospital
after a minimal diuresis.  However, he claims to have felt less
bloated and less dyspneic after his treatment.  He states that
he was doing well after discharge until the last 48-72 hours
when he started gaining weight again and having increased
shortness of breath.  He reports gaining 6 pounds over the last
2 days and reports an increase in abdominal girth/firmness.  His
weight is 224 pounds currently with a dry weight on discharge
[**8-2**] of 216 pounds. He did not take any extra doses of Lasix at
home for this weight gain.  His shortness of breath at rest also
increased over this same time period.  He feels increased
dyspnea on exertion as well and as a result feels too weak to
walk.  He has been making a great effort to reduce the caloric
and sodium content in his diet and has come up with an elaborate
chart to document his intake.  His goal intake is 1200 mg or
less of sodium and fewer calories per day.  He continues to use
his BiPAP mask at night.  Otherwise he denies fevers, chills,
chest pain, nausea, vomiting, abdominal pain, diarrhea,
constipation, hematochezia, melena. He does report recent onset
of unsteady gait.
.
He was a direct admit from home and thus not seen in the ED.

MEDICAL HISTORY: # CAD
-s/p MI in [**2153**], CABG in [**2154**] and redo with porcine MVR4/17/07
-anatomy: LIMA to distal LAD, SVBG jump to LADD1 and D3, SVBG to
OM3
-[**2177-4-8**] Redo coronary artery bypass graft x2 (Saphenous vein
graft > right coronary artery, Saphenous vein graft >
interposition to Saphenous vein graft> obtuse marginal graft)
# CHF
-severe systolic dysfunction EF 25%
# h/o VT
-dx in [**2164**] -> had asx VT on tele while hospitalize for urologic
tx
-single lead ICD was placed
-had 2-3 episodes of appropriate ICD firing -> new lead placed
[**2167**]
-continued to have shocks -> tried betapace w/o relief
-started on amiodarone btw [**2167**]-[**2169**] w/ no further shocks
-had BiV ICD placed in [**2172**]
-attempted VT ablation in [**2174**] w/ reload of amiodarone
-last shocked:
-ICD last interrogated: [**4-/2177**]
# S/P Mitral Valve replacement (31mm [**Company 1543**] Mosaic Porcine
valve) [**3-/2177**]
# 3+ TR
# HTN
# CKD - baseline mid 2's
# DM
-insulin dependent
# Hypothyroidism
# Hyperparathyroidism
# Hypercalcemia
# Osteopenia
# Hypercholesterolemia
# Dyspepsia
# Sleep apnea
# Obesity
# LFT abnormalities attributed to NASH, possibly amio
# HIT

MEDICATION ON ADMISSION: Allopurinol 100 mg Tablet 1 (One) Tablet(s) by mouth once a day

ALLERGIES: Penicillins / Heparin Agents

PHYSICAL EXAM: VS: afebrile BP= 115/75  HR= 70 RR= 22 O2 sat= 96% on 2l o2.
GENERAL: Resting comfortably, mild respiratory distress but able
to speak in full sentences. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL left pupil slighty larger
than right, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa. No xanthalesma.
NECK: Supple, no LAD, +JVD below the angle of the mandible
sitting at 45 degrees.
CARDIAC: RRR, distal heart sounds, [**1-29**] holosystolic murmur most
notable in the sternal borders. No thrills, lifts.
LUNGS: well healed midline sternal scar. Resp were unlabored, no
accessory muscle use. Distant breath sounds, crackles at lung
bases, no wheezes.
ABDOMEN: Obese, distended, nontender, No HSM. Normoactive bowel
sounds.
EXTREMITIES: venous stasis dermatitis bilaterally; cool, dusky
extremities which are no different than his baseline.

FAMILY HISTORY: Mother died of SCD in her 40s, though the patient notes that she
also suffered from a severe depression at the time and "had lost
the will to live". His father died of an MI in his mid 60s. He
also has 2 older brothers who have CAD and are post-MIs. + HTN,
but no stroke/TIA, no cancer and no DM.

SOCIAL HISTORY: Reports 20 year smoking history of about 1 PPD, quit 30 years
ago. Very rare EtOH use. He is trained as an
attorney but works in purchasing companies, predominantly
telecommunications and sports teams. Married. Has 2 adopted
boys, aged 18 and 20.
Congestive heart failure, unspecified,Acute kidney failure, unspecified,Other specified forms of chronic ischemic heart disease,Hypopotassemia,Anxiety state, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric),Heart valve replaced by transplant,Long-term (current) use of insulin,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ
CHF NOS,Acute kidney failure NOS,Chr ischemic hrt dis NEC,Hypopotassemia,Anxiety state NOS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,DMII wo cmp nt st uncntr,Hypothyroidism NOS,Pure hypercholesterolem,Obstructive sleep apnea,Heart valve transplant,Long-term use of insulin,Aortocoronary bypass,Status autm crd dfbrltr
Admission Date:  [**2179-8-11**]              Discharge Date:   [**2179-8-22**]

Date of Birth:  [**2111-6-10**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Heparin Agents

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
weight gain, shortness of breath, volume overload

Major Surgical or Invasive Procedure:
Right sided CVL
CVVH via femoral line

History of Present Illness:
Mr. [**Known lastname **] is a 68 yo M with Ischemic cardiomyopathy EF < 20%,
s/p CABG x2, s/p BIV ICD recently discharged on [**8-2**] for CHF
admitted with another acute on chronic CHF exacerbation.  During
his recent last hospitalization, we were able to remove several
liters of volume but diuresis was limited by advancing azotemia
and low blood pressure.  He was discharged from the hospital
after a minimal diuresis.  However, he claims to have felt less
bloated and less dyspneic after his treatment.  He states that
he was doing well after discharge until the last 48-72 hours
when he started gaining weight again and having increased
shortness of breath.  He reports gaining 6 pounds over the last
2 days and reports an increase in abdominal girth/firmness.  His
weight is 224 pounds currently with a dry weight on discharge
[**8-2**] of 216 pounds. He did not take any extra doses of Lasix at
home for this weight gain.  His shortness of breath at rest also
increased over this same time period.  He feels increased
dyspnea on exertion as well and as a result feels too weak to
walk.  He has been making a great effort to reduce the caloric
and sodium content in his diet and has come up with an elaborate
chart to document his intake.  His goal intake is 1200 mg or
less of sodium and fewer calories per day.  He continues to use
his BiPAP mask at night.  Otherwise he denies fevers, chills,
chest pain, nausea, vomiting, abdominal pain, diarrhea,
constipation, hematochezia, melena. He does report recent onset
of unsteady gait.
.
He was a direct admit from home and thus not seen in the ED.

Past Medical History:
# CAD
-s/p MI in [**2153**], CABG in [**2154**] and redo with porcine MVR4/17/07
-anatomy: LIMA to distal LAD, SVBG jump to LADD1 and D3, SVBG to
OM3
-[**2177-4-8**] Redo coronary artery bypass graft x2 (Saphenous vein
graft > right coronary artery, Saphenous vein graft >
interposition to Saphenous vein graft> obtuse marginal graft)
# CHF
-severe systolic dysfunction EF 25%
# h/o VT
-dx in [**2164**] -> had asx VT on tele while hospitalize for urologic
tx
-single lead ICD was placed
-had 2-3 episodes of appropriate ICD firing -> new lead placed
[**2167**]
-continued to have shocks -> tried betapace w/o relief
-started on amiodarone btw [**2167**]-[**2169**] w/ no further shocks
-had BiV ICD placed in [**2172**]
-attempted VT ablation in [**2174**] w/ reload of amiodarone
-last shocked:
-ICD last interrogated: [**4-/2177**]
# S/P Mitral Valve replacement (31mm [**Company 1543**] Mosaic Porcine
valve) [**3-/2177**]
# 3+ TR
# HTN
# CKD - baseline mid 2's
# DM
-insulin dependent
# Hypothyroidism
# Hyperparathyroidism
# Hypercalcemia
# Osteopenia
# Hypercholesterolemia
# Dyspepsia
# Sleep apnea
# Obesity
# LFT abnormalities attributed to NASH, possibly amio
# HIT

Social History:
Reports 20 year smoking history of about 1 PPD, quit 30 years
ago. Very rare EtOH use. He is trained as an
attorney but works in purchasing companies, predominantly
telecommunications and sports teams. Married. Has 2 adopted
boys, aged 18 and 20.

Family History:
Mother died of SCD in her 40s, though the patient notes that she
also suffered from a severe depression at the time and "had lost
the will to live". His father died of an MI in his mid 60s. He
also has 2 older brothers who have CAD and are post-MIs. + HTN,
but no stroke/TIA, no cancer and no DM.


Physical Exam:
VS: afebrile BP= 115/75  HR= 70 RR= 22 O2 sat= 96% on 2l o2.
GENERAL: Resting comfortably, mild respiratory distress but able
to speak in full sentences. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL left pupil slighty larger
than right, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa. No xanthalesma.
NECK: Supple, no LAD, +JVD below the angle of the mandible
sitting at 45 degrees.
CARDIAC: RRR, distal heart sounds, [**1-29**] holosystolic murmur most
notable in the sternal borders. No thrills, lifts.
LUNGS: well healed midline sternal scar. Resp were unlabored, no
accessory muscle use. Distant breath sounds, crackles at lung
bases, no wheezes.
ABDOMEN: Obese, distended, nontender, No HSM. Normoactive bowel
sounds.
EXTREMITIES: venous stasis dermatitis bilaterally; cool, dusky
extremities which are no different than his baseline.

Pertinent Results:
Renal US [**2179-8-12**]:
IMPRESSION: No hydronephrosis. Bilateral simple renal cysts. No
obstructing renal stones identified.
.
IR guided CVL placement [**2179-8-12**]:
IMPRESSION: Placement of temporary hemodialysis catheter via the
right common femoral vein access with the tip of the catheter at
the lower IVC and the catheter is ready to use.
.
Unilat upper extremity vein [**2179-8-14**]:
IMPRESSION: No evidence for left upper extremity DVT.
.
Labs on discharge:
[**2179-8-22**] 05:45AM BLOOD WBC-8.3 RBC-4.22* Hgb-12.8* Hct-39.1*
MCV-93 MCH-30.4 MCHC-32.8 RDW-17.3* Plt Ct-175
[**2179-8-22**] 05:45AM BLOOD Glucose-112* UreaN-77* Creat-2.5* Na-138
K-4.2 Cl-97 HCO3-31 AnGap-14
.
Labs on admission:
[**2179-8-11**] 05:35PM BLOOD WBC-10.3 RBC-4.94 Hgb-14.9 Hct-46.3
MCV-94 MCH-30.3 MCHC-32.3 RDW-16.2* Plt Ct-111*
[**2179-8-11**] 05:35PM BLOOD Glucose-205* UreaN-125* Creat-4.4*
Na-130* K-6.1* Cl-93* HCO3-25 AnGap-18

Brief Hospital Course:
Mr. [**Known lastname **] is a 68 yo M with Ischemic cardiomyopathy, EF 20%, s/p
CABG x 2, s/p BIV ICD recently discharged on [**8-2**] for CHF,
directly admitted from home with an acute on chronic CHF
exacerbation for aggressive diuresis.
.
# PUMP: Patient has history of acute on chronic systolic heart
failure [**1-25**] ischemic cardiomyopathy, EF 20%. He is s/p mitral
valve repair in [**2176**] with improvement in cardiac function since.
Now coming in approximately [**10-7**] kg above his dry weight. In
the CCU, patient was continued on lasix bolus and gtt, along
with milrinone bolus and gtt.  He was continued on metolazone 5
mg [**Hospital1 **].  CVVH was started via R femoral line and continued for
several days until it clotted off.  Through this time, patient
was continued on low dose neosynephrine as needed to support
blood pressure with goal MAP of 55.  When CVVH line clotted off
([**2179-8-17**]), patient was re-initiated on lasix gtt and metolazone
with good UOP of 100-200 cc/hr.  Patient was net -15 L fluid
removal on discharge.  Patient was continued on BB to prevent
ectopy. EP was contact[**Name (NI) **] about the possibility of LV pacing, as
patient has severe LV/RV dysynchrony on echo. It was felt that
given his NYHA class IV status as well as prior use of LV pacing
which was not very successful, the risks outweighed the
benefits.  However, patient's pacemaker HR was increased to 90
to improve forward flow.  Patient approached new dry weight of
110kg (came in at 121 kg). His K+ goal was kept near 5-5.5 with
aggressive supplementation.  On discharge, patient told to stop
his lasix (160 mg [**Hospital1 **]) and carvedilol (25 mg [**Hospital1 **]).  Instead, he
will take torsemide (80 mg [**Hospital1 **]) and metoprolol succinate (50 mg
daily in AM). He was also discharged on potassium supplements 40
meq tid.  Patient was informed to check his weights on a daily
basis, nutrition care was discussed with patient as well.  If
patient starts gaining weight (i.e. [**1-26**] lbs), he is to take
metolazone 5 mg tablet and call [**Hospital 1902**] clinic.  He has f/u with
[**Doctor First Name **] on [**2179-9-1**] in [**Hospital 1902**] clinic.
.
# CORONARIES: Extensive history of CAD s/p CABG x 2, last cath
in [**2176**] with LIMA widely patent, SVG to OM with proximal 30%
stenosis, SVG jump graft to D1 and distal diag patent. No acute
issues.  Patient was continued on asa 81, lipitor 20.  No ACEi
given acute on chronic renal failure.
.
# RHYTHM: Currently in NSR on admission, has BIV PPM/ICD. Does
have h/o VT with ICD firing provoked by K <4.8.  Monitored on
telemetry without events, continued on BB to prevent ectopy, and
continued on amiodarone. BiV ICD rate was increased to 90 to
increase forward flow, as noted above.
.
# Acute on chronic renal failure - likely [**1-25**] combination of
chronic systolic heart failure and poorly controlled DM,
baseline creatinine 2.4-2.9.  On discharge, Cr was 2.5.  As
above, pt was continued on CVVH for diuresis via R femoral line.
Renal US showed no obstructive cause for elevated Cr.
Lisinopril and aldactone were held in setting of ARF on CKD.
.
# Hypokalemia - Potassium 6.1 on admission, but for most of
admission potassium level was repleted with approximately
100-150 meq per day, given aggressive diuresis. His goal K+ was
between 5 and 5.5.  On discharge, patient to take 40 meq
potassium tid.
.
# Type II DM - HbA1C 3/09=7.5, 8/09=9.2; followed by Dr. [**Last Name (STitle) **] of
the [**Last Name (un) **] but not recently. Patient was continued on outpatient
regimen of 75/25 45 units qam, 50 units qpm with NPH 45 units at
bedtime, with good control.
.
# Hypothyroidism - continued on home dose levothyroxine
.
# OSA - patient kept on his CPAP at night.  His settings were
adjusted and he transitioned to a full face CPAP, as per
respiratory therapy.
.
# Anxiety - continued home dose ativan prn and ambien for sleep.

.
# Left hand swelling - one episode of left hand swelling,
resolved the next day. LUE US was negative for DVT.



Medications on Admission:
Allopurinol 100 mg Tablet 1 (One) Tablet(s) by mouth once a day

Amiodarone 200 mg Tablet 1 Tablet(s) by mouth daily
Atorvastatin [Lipitor] 20 mg Tablet 1 Tablet(s) by mouth daily

Carvedilol [Coreg] 12.5 mg Tablet 1 Tablet(s) by mouth twice
daily    Cinacalcet [Sensipar] 30 mg Tablet 1 (One) Tablet(s) by
mouth daily
Digoxin 125 mcg Tablet one Tablet(s) by mouth every other day on
hold as of [**2179-8-9**]
Folic Acid 1 mg Tablet one Tablet(s) by mouth daily
Furosemide [Lasix] 80 mg Tablet two Tablet(s) by mouth twice a
day on hold asof8/18/09
Gabapentin 300 mg Capsule 1 Capsule(s) by mouth daily
Insulin Lispro Protam & Lispro [Humalog Mix 75-25] Dosage
uncertain
Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr 1
Tablet(s) by mouth once a day
Levothyroxine [Levoxyl] 175 mcg Tablet 1 Tablet(s) by mouth once
a day
Lorazepam [Ativan] 0.5 mg Tablet 1 Tablet(s) by mouth Q6 as
needed for anxiety
Metolazone 5 mg Tablet 1 Tablet(s) by mouth three times per week
on hold as of [**2179-8-10**]
Nitroglycerin 0.4 mg Tablet, Sublingual 1 to 2 Tablet(s)
sublingually as needed
Oxycodone-Acetaminophen 5 mg-325 mg Tablet one or two Tablet(s)
by mouth every 6 hours as needed for pain
Pantoprazole [Protonix] 40 mg Tablet, Delayed Release (E.C.) 1
(One) Tablet(s) by mouth once a day
Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal 4
Tab(s) by mouth three times a day for severe low K+ on hold as
of [**2179-8-10**]
Sertraline [Zoloft] 100 mg Tablet 1 Tablet(s) by mouth once a
day    Spironolactone 25 mg Tablet 1 Tablet(s) by mouth twice a
day
Zolpidem [Ambien] 10 mg Tablet one Tablet(s) by mouth hs

Aspirin [Enteric Coated Aspirin] 81 mg Tablet, Delayed Release
(E.C.) one Tablet(s) by mouth daily
Cholecalciferol (Vitamin D3) [Vitamin D-3] 400 unit Capsule 2
Capsule(s) by mouth once a day


Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for sleep.
Disp:*30 Tablet(s)* Refills:*0*
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
14. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
17. Metolazone 5 mg Tablet Sig: One (1) Tablet PO once a day as
medication.
Disp:*30 Tablet(s)* Refills:*0*
18. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
19. Insulin Lispro Protam & Lispro 100 unit/mL (75-25)
Suspension Sig: 45 units at breakfast, 50 units at dinner units
Subcutaneous once a day.
20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 25
units at bedtime units Subcutaneous once a day.
21. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO three times a
day: please take 40 meq potassium supplements three times a day.

22. Torsemide 20 mg Tablet Sig: Four (4) Tablet PO twice a day.
Disp:*240 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
acute on chronic congestive heart failure


Discharge Condition:
Stable, ambulatory


Discharge Instructions:
You were admitted to the [**Hospital1 **] Hospital for
fluid overload due to your known congestive heart failure.  You
underwent aggressive diuresis in the CCU and were able to put
out a total of 15 liters of fluid.  Diuresis was stopped when
you reached your new dry weight of 110 kg. Please weigh yourself
every morning and call your doctor if your weight increases by
more than 3 lbs.  Adhere to a 2 gm sodium diet and try to
restrict your fluids.
.
MEDICATION CHANGES:
1. Take potassium supplements 40 mEQ three times a day
2. STOP carvedilol (coreg)
3. STOP lasix
4. START metoprolol succinate 50 mg daily
5. START torsemide 80 mg twice a day
6. Take metolazone 5 mg if your weight starts to increase (for
example, if your weight goes up by [**1-26**] lbs, take 5 mg metolazone
and call the [**Hospital 1902**] clinic).
.
Please seek medical attention for increasing shortness of
breath, chest pain, abdominal pain, increasing weight (as noted
above), or any other concerns.

Followup Instructions:
Please follow-up with the appointments listed below:
.
Provider [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
Date/Time:[**2179-9-1**] 10:30
.
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. Date/Time:[**2179-11-9**] 12:10



Completed by:[**2179-8-22**]
{'Congestive heart failure, unspecified,Acute kidney failure, unspecified,Other specified forms of chronic ischemic heart disease,Hypopotassemia,Anxiety state, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric),Heart valve replaced by transplant,Long-term (current) use of insulin,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ'}


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: weight gain, shortness of breath, volume overload

PRESENT ILLNESS: Mr. [**Known lastname **] is a 68 yo M with Ischemic cardiomyopathy EF < 20%,
s/p CABG x2, s/p BIV ICD recently discharged on [**8-2**] for CHF
admitted with another acute on chronic CHF exacerbation.  During
his recent last hospitalization, we were able to remove several
liters of volume but diuresis was limited by advancing azotemia
and low blood pressure.  He was discharged from the hospital
after a minimal diuresis.  However, he claims to have felt less
bloated and less dyspneic after his treatment.  He states that
he was doing well after discharge until the last 48-72 hours
when he started gaining weight again and having increased
shortness of breath.  He reports gaining 6 pounds over the last
2 days and reports an increase in abdominal girth/firmness.  His
weight is 224 pounds currently with a dry weight on discharge
[**8-2**] of 216 pounds. He did not take any extra doses of Lasix at
home for this weight gain.  His shortness of breath at rest also
increased over this same time period.  He feels increased
dyspnea on exertion as well and as a result feels too weak to
walk.  He has been making a great effort to reduce the caloric
and sodium content in his diet and has come up with an elaborate
chart to document his intake.  His goal intake is 1200 mg or
less of sodium and fewer calories per day.  He continues to use
his BiPAP mask at night.  Otherwise he denies fevers, chills,
chest pain, nausea, vomiting, abdominal pain, diarrhea,
constipation, hematochezia, melena. He does report recent onset
of unsteady gait.
.
He was a direct admit from home and thus not seen in the ED.

MEDICAL HISTORY: # CAD
-s/p MI in [**2153**], CABG in [**2154**] and redo with porcine MVR4/17/07
-anatomy: LIMA to distal LAD, SVBG jump to LADD1 and D3, SVBG to
OM3
-[**2177-4-8**] Redo coronary artery bypass graft x2 (Saphenous vein
graft > right coronary artery, Saphenous vein graft >
interposition to Saphenous vein graft> obtuse marginal graft)
# CHF
-severe systolic dysfunction EF 25%
# h/o VT
-dx in [**2164**] -> had asx VT on tele while hospitalize for urologic
tx
-single lead ICD was placed
-had 2-3 episodes of appropriate ICD firing -> new lead placed
[**2167**]
-continued to have shocks -> tried betapace w/o relief
-started on amiodarone btw [**2167**]-[**2169**] w/ no further shocks
-had BiV ICD placed in [**2172**]
-attempted VT ablation in [**2174**] w/ reload of amiodarone
-last shocked:
-ICD last interrogated: [**4-/2177**]
# S/P Mitral Valve replacement (31mm [**Company 1543**] Mosaic Porcine
valve) [**3-/2177**]
# 3+ TR
# HTN
# CKD - baseline mid 2's
# DM
-insulin dependent
# Hypothyroidism
# Hyperparathyroidism
# Hypercalcemia
# Osteopenia
# Hypercholesterolemia
# Dyspepsia
# Sleep apnea
# Obesity
# LFT abnormalities attributed to NASH, possibly amio
# HIT

MEDICATION ON ADMISSION: Allopurinol 100 mg Tablet 1 (One) Tablet(s) by mouth once a day

ALLERGIES: Penicillins / Heparin Agents

PHYSICAL EXAM: VS: afebrile BP= 115/75  HR= 70 RR= 22 O2 sat= 96% on 2l o2.
GENERAL: Resting comfortably, mild respiratory distress but able
to speak in full sentences. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL left pupil slighty larger
than right, EOMI. Conjunctiva were pink, no pallor or cyanosis
of the oral mucosa. No xanthalesma.
NECK: Supple, no LAD, +JVD below the angle of the mandible
sitting at 45 degrees.
CARDIAC: RRR, distal heart sounds, [**1-29**] holosystolic murmur most
notable in the sternal borders. No thrills, lifts.
LUNGS: well healed midline sternal scar. Resp were unlabored, no
accessory muscle use. Distant breath sounds, crackles at lung
bases, no wheezes.
ABDOMEN: Obese, distended, nontender, No HSM. Normoactive bowel
sounds.
EXTREMITIES: venous stasis dermatitis bilaterally; cool, dusky
extremities which are no different than his baseline.

FAMILY HISTORY: Mother died of SCD in her 40s, though the patient notes that she
also suffered from a severe depression at the time and "had lost
the will to live". His father died of an MI in his mid 60s. He
also has 2 older brothers who have CAD and are post-MIs. + HTN,
but no stroke/TIA, no cancer and no DM.

SOCIAL HISTORY: Reports 20 year smoking history of about 1 PPD, quit 30 years
ago. Very rare EtOH use. He is trained as an
attorney but works in purchasing companies, predominantly
telecommunications and sports teams. Married. Has 2 adopted
boys, aged 18 and 20. 

### Response:
{'Congestive heart failure, unspecified,Acute kidney failure, unspecified,Other specified forms of chronic ischemic heart disease,Hypopotassemia,Anxiety state, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric),Heart valve replaced by transplant,Long-term (current) use of insulin,Aortocoronary bypass status,Automatic implantable cardiac defibrillator in situ'}
