CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: The patient is a 71 male with a history of coronary artery
disease s/p CABG ([**2186**] at [**Hospital1 112**] SVG to OM, SVG to RCA-RPL), PCI
[**2192**], [**2197**], [**2199-11-6**] (NSTEMI with DES of SVG to OM) as well as
hypertension, hyperlipidemia, and diabetes who presents from
cardiology clinic with worsening dyspnea. At baseline, he
ambulates slowly outside for about twenty minutes several times
per week. Several days ago, he was outside walking when he
developed dyspnea with limited ambulation. He returned home but
continued to feel short of breath with minimal exertion. He also
feels that his lower extremities were more swollen. He denies
chest pain, cough, fever, chills, syncope, diaphoresis. He
reports stable 2 pillow orthopnea. He endorses taking his
medications as prescribed. He monitors his blood pressure at
home with values typically 130s this past week. Today, he
presented to his cardiologist where he was found to have an
oxygen saturation of 91%. He was referred to the ED for further
evaluation of his dyspnea.
.
He was recently hospitalized ([**Date range (1) 25545**]) in the CCU for NSTEMI
(trop 2.45) with decompensated heart failure with a preserved
ejection fraction. Cath showed 90% distal stenosis with visible
thrombus of SVG-OM graft and he underwent successful PCI with
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**].  TTE showed ejection revealed that
regional/global systolic function were normal (>55%) with mild
to moderate mitral regurgitation. He was diuresed and was felt
to be euvolemic on discharge with O2 sats in mid to high 90s on
room air. His decompensation was felt to be due to IV fluids
received in the and acute ischemia. He was not discharged on a
diuretic.
.
In the ED, initial vitals were 97.7 54 132/65 18 94% 2L (78%RA).
On exam, patient appeared quite comfortable and minimally
symptomatic despite low oxygen saturation, crackles in lower
lung fields. Labs notable for creatinine 1.0 (baseline 1.2), BNP
of 2446 (was 985 in [**2196**]), troponin <0.01, d-dimer 910. ABG:
7.49/34/53 on 4L NC. EKG per report showed sinus bradycardia,
lateral Q waves, unchanged compared to prior. CT chest was
negative for pulmonary embolism but noted severe emphysema w/
right heart strain, interstitial pulmonary edema and small
bilateral pleural effusions. He was given albulterol and
ipratropium nebulizers. He was given lasix 40IV with 2.1L of
urine output in ED. Currenlty on 50% face tent satting mid-90s
and comfortable.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS
2. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.

ALLERGIES: Penicillins / Lisinopril / [**Last Name (un) **]-Angiotensin Receptor Antagonist

PHYSICAL EXAM: ADMISSION EXAM
VS: 100.1  127/62  HR:70  RR:20  92% 50%FM
GENERAL: NAD. Oriented x3. speaking in full sentences
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: -Father died in his 70s of heart disease.
-Brother died in his 70s of presumed heart disease.

SOCIAL HISTORY: - retired chemist
- married with one daughter
- [**Name (NI) 1139**] history:  smokes 1PPD x 55 years
- ETOH:  infrequent ETOH
- Illicit drugs:  denies
Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Other psoriasis,Chronic airway obstruction, not elsewhere classified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Coronary atherosclerosis of unspecified type of vessel, native or graft,Old myocardial infarction,Tobacco use disorder,Other specified counseling,Solitary pulmonary nodule,Family history of ischemic heart disease,Aortocoronary bypass status
Ac on chr diast hrt fail,Acute kidney failure NOS,Other psoriasis,Chr airway obstruct NEC,BPH w/o urinary obs/LUTS,DMII wo cmp nt st uncntr,Hypertension NOS,Hyperlipidemia NEC/NOS,Cor ath unsp vsl ntv/gft,Old myocardial infarct,Tobacco use disorder,Other specfd counseling,Solitary pulmonry nodule,Fam hx-ischem heart dis,Aortocoronary bypass
Admission Date:  [**2199-11-29**]              Discharge Date:   [**2199-12-3**]

Date of Birth:  [**2127-12-1**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Lisinopril / [**Last Name (un) **]-Angiotensin Receptor Antagonist

Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
none

History of Present Illness:
The patient is a 71 male with a history of coronary artery
disease s/p CABG ([**2186**] at [**Hospital1 112**] SVG to OM, SVG to RCA-RPL), PCI
[**2192**], [**2197**], [**2199-11-6**] (NSTEMI with DES of SVG to OM) as well as
hypertension, hyperlipidemia, and diabetes who presents from
cardiology clinic with worsening dyspnea. At baseline, he
ambulates slowly outside for about twenty minutes several times
per week. Several days ago, he was outside walking when he
developed dyspnea with limited ambulation. He returned home but
continued to feel short of breath with minimal exertion. He also
feels that his lower extremities were more swollen. He denies
chest pain, cough, fever, chills, syncope, diaphoresis. He
reports stable 2 pillow orthopnea. He endorses taking his
medications as prescribed. He monitors his blood pressure at
home with values typically 130s this past week. Today, he
presented to his cardiologist where he was found to have an
oxygen saturation of 91%. He was referred to the ED for further
evaluation of his dyspnea.
.
He was recently hospitalized ([**Date range (1) 25545**]) in the CCU for NSTEMI
(trop 2.45) with decompensated heart failure with a preserved
ejection fraction. Cath showed 90% distal stenosis with visible
thrombus of SVG-OM graft and he underwent successful PCI with
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**].  TTE showed ejection revealed that
regional/global systolic function were normal (>55%) with mild
to moderate mitral regurgitation. He was diuresed and was felt
to be euvolemic on discharge with O2 sats in mid to high 90s on
room air. His decompensation was felt to be due to IV fluids
received in the and acute ischemia. He was not discharged on a
diuretic.
.
In the ED, initial vitals were 97.7 54 132/65 18 94% 2L (78%RA).
On exam, patient appeared quite comfortable and minimally
symptomatic despite low oxygen saturation, crackles in lower
lung fields. Labs notable for creatinine 1.0 (baseline 1.2), BNP
of 2446 (was 985 in [**2196**]), troponin <0.01, d-dimer 910. ABG:
7.49/34/53 on 4L NC. EKG per report showed sinus bradycardia,
lateral Q waves, unchanged compared to prior. CT chest was
negative for pulmonary embolism but noted severe emphysema w/
right heart strain, interstitial pulmonary edema and small
bilateral pleural effusions. He was given albulterol and
ipratropium nebulizers. He was given lasix 40IV with 2.1L of
urine output in ED. Currenlty on 50% face tent satting mid-90s
and comfortable.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.


Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension

2. CARDIAC HISTORY:
- CABG: [**2186**]
- PERCUTANEOUS CORONARY INTERVENTIONS: PTCA [**2192**], Stent [**2197**],
[**2198**]
- PACING/ICD: none
- h/o multifocal atrial tachycardia
3. OTHER PAST MEDICAL HISTORY:
- BPH
- COPD
- Diabetes

Social History:
- retired chemist
- married with one daughter
- [**Name (NI) 1139**] history:  smokes 1PPD x 55 years
- ETOH:  infrequent ETOH
- Illicit drugs:  denies

Family History:
-Father died in his 70s of heart disease.
-Brother died in his 70s of presumed heart disease.

Physical Exam:
ADMISSION EXAM
VS: 100.1  127/62  HR:70  RR:20  92% 50%FM
GENERAL: NAD. Oriented x3. speaking in full sentences
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

NECK: Supple with JVP of 8cm.
CARDIAC: healed sternotomy incision, PMI located in 5th
intercostal space, midclavicular line. regular rhythm, normal
rate, S1, S2
LUNGS: mildly labored respirations, crackles 1/3 up from bases
bilaterally R>L, no wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+


Pertinent Results:
ADMISSION LABS
.
[**2199-11-29**] 02:50PM BLOOD WBC-5.9 RBC-3.89* Hgb-11.8* Hct-34.6*
MCV-89 MCH-30.3 MCHC-34.1 RDW-16.3* Plt Ct-273
[**2199-11-29**] 02:50PM BLOOD Neuts-69.6 Lymphs-20.7 Monos-4.5 Eos-4.9*
Baso-0.2
[**2199-11-29**] 02:50PM BLOOD PT-12.3 PTT-29.7 INR(PT)-1.1
[**2199-11-29**] 02:50PM BLOOD Glucose-195* UreaN-17 Creat-1.0 Na-140
K-4.7 Cl-108 HCO3-23 AnGap-14
[**2199-11-29**] 02:50PM BLOOD ALT-16 AST-15 LD(LDH)-183 CK(CPK)-61
AlkPhos-130 TotBili-0.3
[**2199-11-29**] 02:50PM BLOOD Albumin-3.7 Calcium-8.7 Phos-3.3 Mg-1.8
.
PERTINENT LABS AND STUDIES
[**2199-11-29**] 09:31PM BLOOD Type-ART pO2-53* pCO2-34* pH-7.49*
calTCO2-27 Base XS-2
[**2199-11-30**] 01:07AM BLOOD TSH-0.82
[**2199-11-29**] 04:40PM BLOOD D-Dimer-910*
[**2199-11-29**] 02:50PM BLOOD CK-MB-2 proBNP-2446*
[**2199-11-29**] 02:50PM BLOOD cTropnT-<0.01
[**2199-11-30**] 01:07AM BLOOD CK-MB-2 cTropnT-<0.01
.
CXR [**2199-11-29**] Mild-to-moderate interstitial pulmonary edema with
small
bilateral pleural effusions and bibasilar airspace opacities,
likely
atelectasis.
.
CT CHEST WITH AND WITHOUT CONTRAST [**2199-11-29**] 1. No pulmonary
embolus or acute intrathoracic process.
2. Mild pulmonary edema and bilateral pleural effusions.
3. Severe emphysema with early fibrosis.
4. Pulmonary nodules up to 1.0 cm, for which PET-CT or
three-month follow-up chest CT recommended.
5. Prominent mediastinal lymph nodes, non-specific
.
ECHO [**2199-11-30**] The left atrium is elongated. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with mild hypokinesis of
the inferior wall. The remaining segments contract normally
(LVEF = 50 %). There is no ventricular septal defect (limited
views). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. IMPRESSION: Normal left ventricular cavity size with
mild regional systolic dysfunction c/w CAD. No significant
mitral regurgitation or definite VSD identified. Compared with
the prior study (images reviewed) of [**2199-11-3**], inferior left
ventricular hypokinesis is more clearly defined.


Brief Hospital Course:
The patient is a 71 male with a history of coronary artery
disease s/p CABG ([**2186**] at [**Hospital1 112**] SVG to OM, SVG to RCA-RPL), PCI
[**2192**], [**2197**], [**2199-11-6**] (NSTEMI with DES of SVG to OM) as well as
hypertension, hyperlipidemia, and diabetes who presents from
home with worsening dyspnea found to be in hypoxic respiratory
distress
.
ACUTE CARE:
# HYPOXIA: He likely has a low pulmonary reserve from
obstructive airway disease, as although he does not carry a
diagnosis of COPD his chest imaging findings in the setting of
significant smoking history are highly suggestive. His acute
decompensation with hypoxic respiratory distress with a
significant A-a gradient is likely due to worsening  V/Q
mismatch from pulmonary edema and pleural effusion from
decompensated heart failure. There is no evidence of pulmonary
embolism on chest CT. Pneumonia considered but lower suspicion
given that he is afebrile, without leukocytosis and absence of
focal  consolidation on chest CT. COPD exacerbation considered
but does not meet GOLD criteria as no change in sputum frequency
or amount so will defer steroids and antibiotics at this time.
The patient was diuresed aggressively and required 6L initially,
but was weaned progressively to room air without issue.
.
# CORONARY ARTERY DISEASE: Patient with a history of coronary
artery disease s/p CABG, multiple PCI and recent hospitalization
for NSTEMI with non-occlusive thrombus in SVG supplying LCX
territory. Patient without chest pain, unchanged EKG, and
negative biomarkers. Continue clopidogrel 75 mg daily, aspirin
325 mg dialy, carvedilol twice daily, atorvastatin 80 mg daily.
.
# ACUTE ON CHRONIC HEART FAILURE WITH PRESERVED EJECTION
FRACTION: Patient with most clinical (crackles bilaterally), lab
(elevated BNP) and imaging (pulmonary edema) evidence suggestive
of decompensated heart failure. The etiology of the
decompensation is not clear but is likely diet noncompliance.
Mechanical complications following myocardial infarction are
considered, in particular worsening valvular function, but there
is no evidence of acute mitral regurgitation or VSD on
trans-thoracic echocardiogram. Arrhythmia considered but remains
in sinus rhythm on telemetry. Calcium channel blockers can
worsen heart failure and he was recently restarted on
nifedipine. Uncontrolled hypertension considered but patient
reports reasonable control at home. He was diuresed with lasix.
.
CHRONIC CARE
# HYPERTENSION: nifedipine, carvedilol
.
# HYPERLIDEMIA: Continue atorvastatin
.
# DIABETES: Held metformin and glyburide, treated with sliding
scale insulin
.
# TOBACCO ABUSE: Pre-contemplative at this time regarding
quitting. The pt was counseled about the benefits of quitting
smoking and he declined a nicotine patch.
.
# PULMONARY NODULE: Patient with significant smoking history
found to have enlarged lymph node and pulmonary nodules. He will
need repeat CT or PET in 3 months to follow nodules.
.
? COPD: Patient will likely require outpatient tiotropium and
PFTs.
.
# BPH: Continue doxazosin
.
ISSUES OF TRANSITIONS IN CARE:
1. We started Furosemide daily to promote diuresis.
2. We started Spiriva to help with his emphysema.
3. Repeat CT chest or PET in 3-months to follow nodules seen on
CT chest done [**2199-11-29**].
4. Patient needs outpatient PFTs for lung disease assessment in
the future.

Medications on Admission:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS
2. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.

3. glyburide-metformin 2.5-500 mg Tablet  [**Hospital1 **]
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
8. doxazosin 4 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
9. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
10. nifedipine CR 90mg daily

Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. glyburide-metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO
twice a day.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. doxazosin 4 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
9. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
10. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 capsules* Refills:*2*
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Outpatient Lab Work
Please check Chem-7 on Thursday [**2199-12-5**] with results to Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 171**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP[**MD Number(3) **]: [**Telephone/Fax (1) 62**] or fax
[**Telephone/Fax (1) 19842**]


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Acute on Chronic Diastolic congestive Heart failure
Acute Kidney Injury
Coronary artery disease
Hypertension
Hyperlipidemia
Chronic Obstructive Pulmonary Disease


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted because of extra fluid that had accumulated in
your lungs and legs, making it hard for you to breathe. You
received intravenous lasix to remove the fluid and you are now
on lasix pills. You will need to watch yourself very closely to
make sure the fluid does not return. Weigh yourself every
morning, call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP if weight goes up more than 3
lbs in 1 day or 5 pounds in 3 days. Please also call [**Doctor First Name **] if
your legs swell or if you have trouble breathing.
It is very important that you avoid salt in your diet.
.
There were some nodules seen on your CT scan that are
concerning, you will need to have another CT scan checked in 3
months.
.
We made the following changes to your medicines:
1. START taking furosemide daily to prevent fluid from
accumulating in your legs and lungs
2. START taking Spiriva to help with your emphysema. It is
extremely important that you quit smoking to prevent lung cancer
and the need for oxygen permanantly.

Followup Instructions:
.
Department: CARDIAC SERVICES
When: MONDAY [**2200-2-10**] at 9:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: TUESDAY [**2199-12-10**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: PRIMARY CARE
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 588**]
Phone: [**Telephone/Fax (1) 4606**]
Appointment: [**12-26**] at 12:45 PM
{'Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Other psoriasis,Chronic airway obstruction, not elsewhere classified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Coronary atherosclerosis of unspecified type of vessel, native or graft,Old myocardial infarction,Tobacco use disorder,Other specified counseling,Solitary pulmonary nodule,Family history of ischemic heart disease,Aortocoronary bypass status'}


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: The patient is a 71 male with a history of coronary artery
disease s/p CABG ([**2186**] at [**Hospital1 112**] SVG to OM, SVG to RCA-RPL), PCI
[**2192**], [**2197**], [**2199-11-6**] (NSTEMI with DES of SVG to OM) as well as
hypertension, hyperlipidemia, and diabetes who presents from
cardiology clinic with worsening dyspnea. At baseline, he
ambulates slowly outside for about twenty minutes several times
per week. Several days ago, he was outside walking when he
developed dyspnea with limited ambulation. He returned home but
continued to feel short of breath with minimal exertion. He also
feels that his lower extremities were more swollen. He denies
chest pain, cough, fever, chills, syncope, diaphoresis. He
reports stable 2 pillow orthopnea. He endorses taking his
medications as prescribed. He monitors his blood pressure at
home with values typically 130s this past week. Today, he
presented to his cardiologist where he was found to have an
oxygen saturation of 91%. He was referred to the ED for further
evaluation of his dyspnea.
.
He was recently hospitalized ([**Date range (1) 25545**]) in the CCU for NSTEMI
(trop 2.45) with decompensated heart failure with a preserved
ejection fraction. Cath showed 90% distal stenosis with visible
thrombus of SVG-OM graft and he underwent successful PCI with
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5175**].  TTE showed ejection revealed that
regional/global systolic function were normal (>55%) with mild
to moderate mitral regurgitation. He was diuresed and was felt
to be euvolemic on discharge with O2 sats in mid to high 90s on
room air. His decompensation was felt to be due to IV fluids
received in the and acute ischemia. He was not discharged on a
diuretic.
.
In the ED, initial vitals were 97.7 54 132/65 18 94% 2L (78%RA).
On exam, patient appeared quite comfortable and minimally
symptomatic despite low oxygen saturation, crackles in lower
lung fields. Labs notable for creatinine 1.0 (baseline 1.2), BNP
of 2446 (was 985 in [**2196**]), troponin <0.01, d-dimer 910. ABG:
7.49/34/53 on 4L NC. EKG per report showed sinus bradycardia,
lateral Q waves, unchanged compared to prior. CT chest was
negative for pulmonary embolism but noted severe emphysema w/
right heart strain, interstitial pulmonary edema and small
bilateral pleural effusions. He was given albulterol and
ipratropium nebulizers. He was given lasix 40IV with 2.1L of
urine output in ED. Currenlty on 50% face tent satting mid-90s
and comfortable.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension

MEDICATION ON ADMISSION: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS
2. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.

ALLERGIES: Penicillins / Lisinopril / [**Last Name (un) **]-Angiotensin Receptor Antagonist

PHYSICAL EXAM: ADMISSION EXAM
VS: 100.1  127/62  HR:70  RR:20  92% 50%FM
GENERAL: NAD. Oriented x3. speaking in full sentences
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.

FAMILY HISTORY: -Father died in his 70s of heart disease.
-Brother died in his 70s of presumed heart disease.

SOCIAL HISTORY: - retired chemist
- married with one daughter
- [**Name (NI) 1139**] history:  smokes 1PPD x 55 years
- ETOH:  infrequent ETOH
- Illicit drugs:  denies 

### Response:
{'Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Other psoriasis,Chronic airway obstruction, not elsewhere classified,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Coronary atherosclerosis of unspecified type of vessel, native or graft,Old myocardial infarction,Tobacco use disorder,Other specified counseling,Solitary pulmonary nodule,Family history of ischemic heart disease,Aortocoronary bypass status'}
