CHIEF COMPLAINT: Dyspnea on Exertion, inc edema

PRESENT ILLNESS: [**Age over 90 **] yo M with a h/o CAD (s/p 3 NSEMI's medically managed), RV
failure/pHTN with preserved LVEF 50-55%, diastolic dysfunction,
moderate MR and severe TR, HTN, HL, AFib on Coumadin, PVD (L
iliac thrombus s/p embolectomy, c/b dissection/stenting of L
common iliac/external iliac [**6-/2199**]), CKD, colon ca s/p resection
in the 80's and chronic GIB, who presented from cardiology
clinic today with increase in heart failure symptoms.
.
Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] have been uptitrating his outpt Lasix
regimen which the pt reports compliance with. He was recently on
Metolazone however this was stopped due to concern for rash and
increase in eosinophilia.
.
The pt endorses what sounds to be NYHA class IV heart failure
symptoms with SOB with very minimal exertion including getting
up to go to the bathroom. He is unable to walk at baseline and
only gets up from the bed to his wheelchair to get around. He
and his daughter endorse increased swelling everywhere in his
body including his abdomen, which he notes is distended more
than usual.
.
In the ED, he was noted to have increased WOB, tachypnic. 98.2
102   151/76   24   100%. Labs significant for Hct 27.9 (lower
than baseline), Cr 2.2 (baseline likely in the mid 1's but
appear to have been steadily rising over past year). BNP [**Numeric Identifier 78766**],
Trop 0.07 (CK and MB pending), lactate 2.4.
.
Was briefly started on BiPAP but is off by time he gets to the
CCU. Started on Nitro gtt, currently running. He got 40 mg IV
Lasix, ASA 325 PR x1.
.
No clear precipitant to this exacerbation, other than stopped
Metolazone recently. He endorses med compliance. No CP or pain
elsewhere. He describes baseline orthopnea and sleeps with a
couple pillows. Denies PND, but says he gets up a lot in the
middle of the night to go urinate. He has an off/on cough with
baseline phlegm production.
.
Otherwise, no f/c/ns, vision changes, n/v/d/c, abdominal pain,
dysuria, or any other symptoms for other organ systems.

MEDICAL HISTORY: 1. CHF / RV failure / diastolic dysfunction
--[**3-/2201**] echo with 50-55%, evidence of R overload, moderate MR,
severe TR
--EF 40-45% [**2199-4-26**] mild global HK, 2+MR, 3+TR, RA moderately
dilated, mild LVH, mod-severe pulm HTN
--repeat echo [**2199-5-2**] with EF 60%
Hypertension
Hypercholesterolemia
Atrial fibrillation, on warfarin
Chronic kidney disease
Iliac thrombus s/p embolectomy  (L iliac thrombus s/p
embolectomy, c/b dissection/stenting of L common iliac/external
iliac [**6-/2199**])
Chronic GIB
-negative colonoscopy [**2199-5-6**]
-negative EGD [**2199-4-26**]
-negative enteroscopy [**2199-4-30**]
-had capsule study [**5-7**] delayed transit from esophagus, capsule
did not reach esophagus
Duodenal ulcer
CAD
Colon CA s/p resection [**2171**]'s
Pleural effusion
Back Surgery

MEDICATION ON ADMISSION: clonidine 0.3mg patch q24hrs
ferrous sulfate 325 daily
hydralazine 20 mg tid
ISMN 30 mg daily
finasteride 5 mg a day
folic acid 1 mg a day
Lasix 60 mg QD
Toprol-XL 25 mg a day
omeprazole 20 mg a day
simvastatin 20 mg a day
warfarin as prescribed --> listed as 2mg daily
aspirin 81 mg a day
vitamin B12 [**2191**] mg a day
[metolazone on hold,?allerg reaction]

ALLERGIES: Levaquin

PHYSICAL EXAM: 95.7   146/78   62   34    100%NC
Pleasant elderly gentleman in no distress, speaking in full
sentences and able to relate history.
Sclera normal, no icterus, EOMI
Mouth moist, normal appearing, with dentures.
Bilateral external jugulars are distended and internal venous
pulsations are noted to above the earlobes with some minimal
hepatojugular reflux noted. Occlusion of the external jugular
with some refilling. Even the superficial veins going down to
his arms appear distended.
Tachypneic, slight rales at the bases but R base with marked
decreased BS's compared to L, with good air movement. Some
accessory muscle use, but does not appear in distress
Irregular rhythm, no murmurs or gallops but with variably split
S2. Radial pulses present bilaterally but DP's unable to palpate
due to edema. His PMI is soft but not overtly displaced.
Abd tight, distended, not tender. Hypertympanic at the apex,
with dullness just lateral to the midline. Shifting dullness not
assessed. BS positive.
Gross anasarca from BLE to thighs, abdomen with peau d'orange in
the RLQ. He even has gross anasarca from his bilateral elbows to
his hands.
CN 2-12 intact, no facial droop or dysarthria. Spontaneously
moving all four extremities without difficulty. No apparent
focal neuro lesions noted.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Retired [**Location (un) 86**] policeman.  Daughter lives upstairs.  Non-smoker.
 Rare EtOH (1-2 drinks/week).  Wife currently lives at [**Hospital 100**]
Rehab. His daughter helps with [**Name (NI) 4461**], but he performs all of his
ADLs.
Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Mitral valve disorders,Other chronic pulmonary heart diseases,Old myocardial infarction,Chronic kidney disease, unspecified,Long-term (current) use of anticoagulants,Atrial fibrillation,Diseases of tricuspid valve,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of large intestine,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified
Ac on chr diast hrt fail,Acute kidney failure NOS,Gastrointest hemorr NOS,Mitral valve disorder,Chr pulmon heart dis NEC,Old myocardial infarct,Chronic kidney dis NOS,Long-term use anticoagul,Atrial fibrillation,Tricuspid valve disease,Hyperlipidemia NEC/NOS,Hx of colonic malignancy,Hy kid NOS w cr kid I-IV
Admission Date:  [**2201-6-5**]              Discharge Date:   [**2201-6-12**]


Service: MEDICINE

Allergies:
Levaquin

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Dyspnea on Exertion, inc edema

Major Surgical or Invasive Procedure:
None

History of Present Illness:
[**Age over 90 **] yo M with a h/o CAD (s/p 3 NSEMI's medically managed), RV
failure/pHTN with preserved LVEF 50-55%, diastolic dysfunction,
moderate MR and severe TR, HTN, HL, AFib on Coumadin, PVD (L
iliac thrombus s/p embolectomy, c/b dissection/stenting of L
common iliac/external iliac [**6-/2199**]), CKD, colon ca s/p resection
in the 80's and chronic GIB, who presented from cardiology
clinic today with increase in heart failure symptoms.
.
Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] have been uptitrating his outpt Lasix
regimen which the pt reports compliance with. He was recently on
Metolazone however this was stopped due to concern for rash and
increase in eosinophilia.
.
The pt endorses what sounds to be NYHA class IV heart failure
symptoms with SOB with very minimal exertion including getting
up to go to the bathroom. He is unable to walk at baseline and
only gets up from the bed to his wheelchair to get around. He
and his daughter endorse increased swelling everywhere in his
body including his abdomen, which he notes is distended more
than usual.
.
In the ED, he was noted to have increased WOB, tachypnic. 98.2
102   151/76   24   100%. Labs significant for Hct 27.9 (lower
than baseline), Cr 2.2 (baseline likely in the mid 1's but
appear to have been steadily rising over past year). BNP [**Numeric Identifier 78766**],
Trop 0.07 (CK and MB pending), lactate 2.4.
.
Was briefly started on BiPAP but is off by time he gets to the
CCU. Started on Nitro gtt, currently running. He got 40 mg IV
Lasix, ASA 325 PR x1.
.
No clear precipitant to this exacerbation, other than stopped
Metolazone recently. He endorses med compliance. No CP or pain
elsewhere. He describes baseline orthopnea and sleeps with a
couple pillows. Denies PND, but says he gets up a lot in the
middle of the night to go urinate. He has an off/on cough with
baseline phlegm production.
.
Otherwise, no f/c/ns, vision changes, n/v/d/c, abdominal pain,
dysuria, or any other symptoms for other organ systems.


Past Medical History:
1. CHF / RV failure / diastolic dysfunction
--[**3-/2201**] echo with 50-55%, evidence of R overload, moderate MR,
severe TR
--EF 40-45% [**2199-4-26**] mild global HK, 2+MR, 3+TR, RA moderately
dilated, mild LVH, mod-severe pulm HTN
--repeat echo [**2199-5-2**] with EF 60%
Hypertension
Hypercholesterolemia
Atrial fibrillation, on warfarin
Chronic kidney disease
Iliac thrombus s/p embolectomy  (L iliac thrombus s/p
embolectomy, c/b dissection/stenting of L common iliac/external
iliac [**6-/2199**])
Chronic GIB
-negative colonoscopy [**2199-5-6**]
-negative EGD [**2199-4-26**]
-negative enteroscopy [**2199-4-30**]
-had capsule study [**5-7**] delayed transit from esophagus, capsule
did not reach esophagus
Duodenal ulcer
CAD
Colon CA s/p resection [**2171**]'s
Pleural effusion
Back Surgery


Social History:
Retired [**Location (un) 86**] policeman.  Daughter lives upstairs.  Non-smoker.
 Rare EtOH (1-2 drinks/week).  Wife currently lives at [**Hospital 100**]
Rehab. His daughter helps with [**Name (NI) 4461**], but he performs all of his
ADLs.


Family History:
Non-contributory

Physical Exam:
95.7   146/78   62   34    100%NC
Pleasant elderly gentleman in no distress, speaking in full
sentences and able to relate history.
Sclera normal, no icterus, EOMI
Mouth moist, normal appearing, with dentures.
Bilateral external jugulars are distended and internal venous
pulsations are noted to above the earlobes with some minimal
hepatojugular reflux noted. Occlusion of the external jugular
with some refilling. Even the superficial veins going down to
his arms appear distended.
Tachypneic, slight rales at the bases but R base with marked
decreased BS's compared to L, with good air movement. Some
accessory muscle use, but does not appear in distress
Irregular rhythm, no murmurs or gallops but with variably split
S2. Radial pulses present bilaterally but DP's unable to palpate
due to edema. His PMI is soft but not overtly displaced.
Abd tight, distended, not tender. Hypertympanic at the apex,
with dullness just lateral to the midline. Shifting dullness not
assessed. BS positive.
Gross anasarca from BLE to thighs, abdomen with peau d'orange in
the RLQ. He even has gross anasarca from his bilateral elbows to
his hands.
CN 2-12 intact, no facial droop or dysarthria. Spontaneously
moving all four extremities without difficulty. No apparent
focal neuro lesions noted.


Pertinent Results:
CHEST (PA & LAT) Study Date of [**2201-6-5**] 1:16 PM
IMPRESSION: Bilateral pleural effusions, right greater than
left; underlying consolidation not excluded.

CBC
[**2201-6-7**] 03:01AM BLOOD WBC-8.2 RBC-2.94* Hgb-8.1* Hct-25.7*
MCV-87 MCH-27.3 MCHC-31.3 RDW-15.9* Plt Ct-198
[**2201-6-6**] 06:27AM BLOOD WBC-7.8 RBC-2.87* Hgb-7.7* Hct-24.7*
MCV-86 MCH-26.7* MCHC-31.1 RDW-15.9* Plt Ct-211
[**2201-6-5**] 12:30PM BLOOD WBC-7.2 RBC-3.19* Hgb-8.8* Hct-27.8*
MCV-87 MCH-27.4 MCHC-31.5 RDW-15.9* Plt Ct-221

Coag
[**2201-6-7**] 03:01AM BLOOD PT-26.4* PTT-30.9 INR(PT)-2.6*
[**2201-6-6**] 06:27AM BLOOD PT-23.0* PTT-30.5 INR(PT)-2.2*
[**2201-6-5**] 12:30PM BLOOD PT-22.2* PTT-28.5 INR(PT)-2.1*

Chemistry
[**2201-6-7**] 04:36PM BLOOD Glucose-125* UreaN-53* Creat-2.1* Na-140
K-3.6 Cl-99 HCO3-31 AnGap-14
[**2201-6-7**] 03:01AM BLOOD Glucose-118* UreaN-55* Creat-2.1* Na-139
K-3.5 Cl-99 HCO3-27 AnGap-17
[**2201-6-6**] 03:58PM BLOOD Glucose-109* UreaN-58* Creat-2.3* Na-138
K-3.7 Cl-98 HCO3-28 AnGap-16
[**2201-6-6**] 06:27AM BLOOD Glucose-120* UreaN-60* Creat-2.3* Na-140
K-3.4 Cl-100 HCO3-29 AnGap-14
[**2201-6-5**] 12:30PM BLOOD Glucose-96 UreaN-62* Creat-2.2* Na-140
K-4.0 Cl-98 HCO3-26 AnGap-20
[**2201-6-7**] 04:36PM BLOOD Calcium-8.6 Phos-3.0 Mg-1.9
[**2201-6-7**] 03:01AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0
[**2201-6-6**] 03:58PM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0
[**2201-6-6**] 06:27AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.2
[**2201-6-5**] 12:30PM BLOOD Albumin-3.9 Calcium-9.1 Phos-3.5 Mg-2.1

Brief Hospital Course:
[**Age over 90 **] yo M with a h/o CAD (s/p 3 NSEMI's medically managed), RV
failure/pHTN with preserved LVEF 50-55%, diastolic dysfunction,
moderate MR and severe TR, HTN, HL, AFib on Coumadin, PVD (L
iliac thrombus s/p embolectomy, c/b dissection/stenting of L
common iliac/external iliac [**6-/2199**]), CKD, colon ca s/p resection
in the 80's and chronic GIB, who presented from cardiology
clinic today with increase in heart failure symptoms.
.
1. Acute on chronic diastolic heart failure: Pt with low-normal
EF 50-55% on last echo [**3-/2201**] with evidence of R sided heart
failure and moderate MR, severe TR, and moderate-severe pulm
HTN. His heart failure is likely multifactorial from valvular
disease, diastolic impairment, and possibly a component of
primary pulmonary disease/HTN. Atrial fibrillation also likely
contributing.
.
Patient was started on Lasix gtt and aldactone.  He diuresed
well. He was continued on hydral/nitrate for afterload
reduction.  His home metoprolol was switched to carvedilol and
clonidine patch changed to po.  Lasix and aldactone were
subsequently transitioned to po torsemide and patient was near
euvolemic on discharge.
.
2. Chronic renal failure: Creatine remained stable between
2.1-2.5.
.
3. AFib: Patient remained rate controlled and continued on his
Coumadin.
.
4. CAD: He was continued on his statin, hydral, imdur, and
aspirin.  His clonidine patch was switched to po to be ultimated
titrated down, and metoprolol switched to carvedilol.
.
5. Anemia: Patient's hct slowly trended down from 27 to 23.  He
has a history of GI bleed, and on admission was guaic positive.
He was transfused one unit pRBC.  Patient will need to follow up
with GI.

Medications on Admission:
clonidine 0.3mg patch q24hrs
ferrous sulfate 325 daily
hydralazine 20 mg tid
ISMN 30 mg daily
finasteride 5 mg a day
folic acid 1 mg a day
Lasix 60 mg QD
Toprol-XL 25 mg a day
omeprazole 20 mg a day
simvastatin 20 mg a day
warfarin as prescribed --> listed as 2mg daily
aspirin 81 mg a day
vitamin B12 [**2191**] mg a day
[metolazone on hold,?allerg reaction]


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Capsule, Sustained Release PO once a day.
6. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
7. Vitamin B-12 2,000 mcg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Hold on [**2201-6-12**].
10. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.

11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily):
Hold SBP < 90.
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
13. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-10**] Sprays Nasal
QID (4 times a day) as needed for dry nose.
14. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

15. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Outpatient Lab Work
Please check CBC, INR and chem 7 on Monday [**6-15**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Acute on Chronic Diastolic Congestive Heart Failure
Acute on Chronic Kidney Disease
Coronary Artery Disease
Atrial Fibrillation on coumadin
Peripheral [**Hospital6 **] Disease
Chronic GI Bleed on Fe supplements


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted with an exacerbation of your congestive heart
failure. We changed some of your medicines to help your heart
work better and your condition seems to be optimized at a weight
of 80 kg (176 pounds). Your kidneys are also not working as well
as they should, we expect this will improve gradually as your
heart functions better. We made the following changes to your
medicines:
1. Stop Clonidine
2. change Lasix to Torsemide
3. Increase Omeprazole to 40 mg twice daily
4. Start Nasal spray daily for your dry nose
5. change Toprol to Carvedilol for your heart rate and blood
pressure.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day or 6 pounds in 3 days.

Followup Instructions:
Cardiology:
[**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone: [**Telephone/Fax (1) 62**] Date/Time: Office will call
your daughter with an appt in [**1-10**] weeks.
.
[**Date Range **]:
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2201-6-25**]
9:30
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2201-6-25**]
10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**]
Date/Time:[**2201-6-25**] 11:00
.
Gastroenterology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2643**] Phone: ([**Telephone/Fax (1) 2306**] Date/time: Friday [**6-19**] at 2:30pm
[**Last Name (NamePattern1) 439**], [**Location (un) 858**], [**Location (un) 86**].
.
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] L. Phone: [**Telephone/Fax (1) 250**] Please make an appt to see him
after you get out of rehabilitation



Completed by:[**2201-6-12**]
{'Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Mitral valve disorders,Other chronic pulmonary heart diseases,Old myocardial infarction,Chronic kidney disease, unspecified,Long-term (current) use of anticoagulants,Atrial fibrillation,Diseases of tricuspid valve,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of large intestine,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}


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 on Exertion, inc edema

PRESENT ILLNESS: [**Age over 90 **] yo M with a h/o CAD (s/p 3 NSEMI's medically managed), RV
failure/pHTN with preserved LVEF 50-55%, diastolic dysfunction,
moderate MR and severe TR, HTN, HL, AFib on Coumadin, PVD (L
iliac thrombus s/p embolectomy, c/b dissection/stenting of L
common iliac/external iliac [**6-/2199**]), CKD, colon ca s/p resection
in the 80's and chronic GIB, who presented from cardiology
clinic today with increase in heart failure symptoms.
.
Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] have been uptitrating his outpt Lasix
regimen which the pt reports compliance with. He was recently on
Metolazone however this was stopped due to concern for rash and
increase in eosinophilia.
.
The pt endorses what sounds to be NYHA class IV heart failure
symptoms with SOB with very minimal exertion including getting
up to go to the bathroom. He is unable to walk at baseline and
only gets up from the bed to his wheelchair to get around. He
and his daughter endorse increased swelling everywhere in his
body including his abdomen, which he notes is distended more
than usual.
.
In the ED, he was noted to have increased WOB, tachypnic. 98.2
102   151/76   24   100%. Labs significant for Hct 27.9 (lower
than baseline), Cr 2.2 (baseline likely in the mid 1's but
appear to have been steadily rising over past year). BNP [**Numeric Identifier 78766**],
Trop 0.07 (CK and MB pending), lactate 2.4.
.
Was briefly started on BiPAP but is off by time he gets to the
CCU. Started on Nitro gtt, currently running. He got 40 mg IV
Lasix, ASA 325 PR x1.
.
No clear precipitant to this exacerbation, other than stopped
Metolazone recently. He endorses med compliance. No CP or pain
elsewhere. He describes baseline orthopnea and sleeps with a
couple pillows. Denies PND, but says he gets up a lot in the
middle of the night to go urinate. He has an off/on cough with
baseline phlegm production.
.
Otherwise, no f/c/ns, vision changes, n/v/d/c, abdominal pain,
dysuria, or any other symptoms for other organ systems.

MEDICAL HISTORY: 1. CHF / RV failure / diastolic dysfunction
--[**3-/2201**] echo with 50-55%, evidence of R overload, moderate MR,
severe TR
--EF 40-45% [**2199-4-26**] mild global HK, 2+MR, 3+TR, RA moderately
dilated, mild LVH, mod-severe pulm HTN
--repeat echo [**2199-5-2**] with EF 60%
Hypertension
Hypercholesterolemia
Atrial fibrillation, on warfarin
Chronic kidney disease
Iliac thrombus s/p embolectomy  (L iliac thrombus s/p
embolectomy, c/b dissection/stenting of L common iliac/external
iliac [**6-/2199**])
Chronic GIB
-negative colonoscopy [**2199-5-6**]
-negative EGD [**2199-4-26**]
-negative enteroscopy [**2199-4-30**]
-had capsule study [**5-7**] delayed transit from esophagus, capsule
did not reach esophagus
Duodenal ulcer
CAD
Colon CA s/p resection [**2171**]'s
Pleural effusion
Back Surgery

MEDICATION ON ADMISSION: clonidine 0.3mg patch q24hrs
ferrous sulfate 325 daily
hydralazine 20 mg tid
ISMN 30 mg daily
finasteride 5 mg a day
folic acid 1 mg a day
Lasix 60 mg QD
Toprol-XL 25 mg a day
omeprazole 20 mg a day
simvastatin 20 mg a day
warfarin as prescribed --> listed as 2mg daily
aspirin 81 mg a day
vitamin B12 [**2191**] mg a day
[metolazone on hold,?allerg reaction]

ALLERGIES: Levaquin

PHYSICAL EXAM: 95.7   146/78   62   34    100%NC
Pleasant elderly gentleman in no distress, speaking in full
sentences and able to relate history.
Sclera normal, no icterus, EOMI
Mouth moist, normal appearing, with dentures.
Bilateral external jugulars are distended and internal venous
pulsations are noted to above the earlobes with some minimal
hepatojugular reflux noted. Occlusion of the external jugular
with some refilling. Even the superficial veins going down to
his arms appear distended.
Tachypneic, slight rales at the bases but R base with marked
decreased BS's compared to L, with good air movement. Some
accessory muscle use, but does not appear in distress
Irregular rhythm, no murmurs or gallops but with variably split
S2. Radial pulses present bilaterally but DP's unable to palpate
due to edema. His PMI is soft but not overtly displaced.
Abd tight, distended, not tender. Hypertympanic at the apex,
with dullness just lateral to the midline. Shifting dullness not
assessed. BS positive.
Gross anasarca from BLE to thighs, abdomen with peau d'orange in
the RLQ. He even has gross anasarca from his bilateral elbows to
his hands.
CN 2-12 intact, no facial droop or dysarthria. Spontaneously
moving all four extremities without difficulty. No apparent
focal neuro lesions noted.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Retired [**Location (un) 86**] policeman.  Daughter lives upstairs.  Non-smoker.
 Rare EtOH (1-2 drinks/week).  Wife currently lives at [**Hospital 100**]
Rehab. His daughter helps with [**Name (NI) 4461**], but he performs all of his
ADLs. 

### Response:
{'Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Hemorrhage of gastrointestinal tract, unspecified,Mitral valve disorders,Other chronic pulmonary heart diseases,Old myocardial infarction,Chronic kidney disease, unspecified,Long-term (current) use of anticoagulants,Atrial fibrillation,Diseases of tricuspid valve,Other and unspecified hyperlipidemia,Personal history of malignant neoplasm of large intestine,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}
