CHIEF COMPLAINT: Hypercarbic Respiratory Failure

PRESENT ILLNESS: 64 yo male with PMH CAD (s/p CABG), AF (on coumadin), DM, HTN,
recent admission for presumed drug-induced
rhabdomyolysis/weakness resulting in hypercarbic respiratory
failure (s/p trach and PEG) and ARF presents with hypercarbic
respiratory failure.
.
Pt was recently admitted at [**Hospital1 18**] from [**Date range (1) 60244**] with elevated
LFTs, rhabdomyolysis with CK 13,000 and weakness presumed
secondary to a combination of zetia and avapro. Muscle biopsy
suggested a metabolic myopathy induced by toxic agents and drugs
(i.e cholesterol lowering agents). No evidence of inflammatory
myositis. Medications were held.
Hepatitis serologies negative. Pt developed hypercarbic
respiratory failure secondary to muscle weakness and was
intubated, then got trach and PEG for failure to extubate in
setting of persistently low NIFs. Course was complicated by
contrast nephropathy and was temporarily on HD; creatinine on
discharge was 1.0.
.
Recently, pt was being weaned off the vent: Trach was capped
during the day and put on Bipap at night. Per wife, pt was
having difficulty tolerating Bipap. PEG removed one week ago; pt
is eating by mouth. Per the pt's wife, pt expressed generalized
malaise for the past 3 days. On the morning of admission, pt was
noted to be less responsive and A&O x 1 (at baseline A&O x 3 and
appropriate). ABG was 7.15/117/65. Pt was given Lasix 200 IV x1,
put on mechanical ventilation, and transferred for further mgmt.
.
Of note, per wife, pt was coded two weeks ago. [**Month (only) 116**] have
preceding hypercarbic respiratory failure. He was pulseless and
received CPR without any shocks. Pt was admitted to [**Hospital 8**]
Hospital for one day. No neurologic complications.
.
ROS: [**Name (NI) 1094**] wife denies recent fever, GU sx. Pt has had some
secretion from trach. + nausea, abominal discomfort,
constipation. Denies vomiting, hematachezia, BRBPR, hematemesis.
.
In the [**Name (NI) **], pt was continued on AC 600/16/5/.4. ABG was
7.29/66/414.

MEDICAL HISTORY: Rhabdomyolosis (presumed [**2-26**] drug toxicity)
Respiratory Failure (s/p Trach and PEG)
ARF ([**2-26**] contrast nephropathy)
IDDM
HTN
AF on coumadin
Gout
Hypercholesterolemia
Arthritis
CAD (s/p CABG)
.
PSH:
s/p L 5th ray amputation [**2130**]
s/p R inguinal hernia repair [**2128**]
s/p cholecystectomy
s/p coronary artery by pass surgery x4 [**2127**]
s/p L TMA [**12/2131**]

MEDICATION ON ADMISSION: albuterol inh
Ascorbic acid 500mg qd
Citalopram 20mg qd
Lasix 140mg IV bid
Gabapentin 100mg qd
Hydralazine 20mg qid
Insulin ss
Metolazone 5mg qd
Lopressor 100mg [**Hospital1 **]
Miconazole powder
MVI qd
Olanzapine 2.5mg qd
Protonix 40mg qd
Papain/urea ointment
Warfarin qd
Zinc 220mg qd
Tylenol
ASA 325mg qd
Bisacodyl 10mg qd
ativan 0.5mg qhs
Nitroglycerin prn
Ondansetron 4mg q4h prn
Percocet prn

ALLERGIES: Avapro / Zetia / Heparin Agents

PHYSICAL EXAM: VS: t99.9, p72, 110/36, rr25, 95% AC 600/16/5/.4,
Gen: intubated, able to whisper
HEENT: clear OP, MMM
Neck: unable to assess JVP
CVS: irreg irreg, nl s1 s2, no m/g/r
Lungs: CTAB anteriorly
Abd: obese, soft, NT, ND, +BS
Ext: 3+ pitting edema of bilateral lower/upper extremities
Neuro: A&O x3, able to appropriately answer questions, [**3-1**]
bilateral upper extremities, unable to move bilateral lower
extremities

FAMILY HISTORY: Mother died of liver cancer in her 70's

SOCIAL HISTORY: Retired postal worker, married, 4 children, no tobacco, no drugs
Acute respiratory failure,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Subendocardial infarction, initial episode of care,Pressure ulcer, buttock,Atrial fibrillation,Long-term (current) use of anticoagulants,Aortocoronary bypass status,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Tracheostomy status
Acute respiratry failure,Ac on chr diast hrt fail,Acute kidney failure NOS,DMII renl nt st uncntrld,Subendo infarct, initial,Pressure ulcer, buttock,Atrial fibrillation,Long-term use anticoagul,Aortocoronary bypass,Nephritis NOS in oth dis,Tracheostomy status
Admission Date:  [**2133-10-27**]              Discharge Date:   [**2133-10-29**]

Date of Birth:  [**2069-3-21**]             Sex:   M

Service: MEDICINE

Allergies:
Avapro / Zetia / Heparin Agents

Attending:[**First Name3 (LF) 8487**]
Chief Complaint:
Hypercarbic Respiratory Failure

Major Surgical or Invasive Procedure:
None

History of Present Illness:
64 yo male with PMH CAD (s/p CABG), AF (on coumadin), DM, HTN,
recent admission for presumed drug-induced
rhabdomyolysis/weakness resulting in hypercarbic respiratory
failure (s/p trach and PEG) and ARF presents with hypercarbic
respiratory failure.
.
Pt was recently admitted at [**Hospital1 18**] from [**Date range (1) 60244**] with elevated
LFTs, rhabdomyolysis with CK 13,000 and weakness presumed
secondary to a combination of zetia and avapro. Muscle biopsy
suggested a metabolic myopathy induced by toxic agents and drugs
(i.e cholesterol lowering agents). No evidence of inflammatory
myositis. Medications were held.
Hepatitis serologies negative. Pt developed hypercarbic
respiratory failure secondary to muscle weakness and was
intubated, then got trach and PEG for failure to extubate in
setting of persistently low NIFs. Course was complicated by
contrast nephropathy and was temporarily on HD; creatinine on
discharge was 1.0.
.
Recently, pt was being weaned off the vent: Trach was capped
during the day and put on Bipap at night. Per wife, pt was
having difficulty tolerating Bipap. PEG removed one week ago; pt
is eating by mouth. Per the pt's wife, pt expressed generalized
malaise for the past 3 days. On the morning of admission, pt was
noted to be less responsive and A&O x 1 (at baseline A&O x 3 and
appropriate). ABG was 7.15/117/65. Pt was given Lasix 200 IV x1,
put on mechanical ventilation, and transferred for further mgmt.
.
Of note, per wife, pt was coded two weeks ago. [**Month (only) 116**] have
preceding hypercarbic respiratory failure. He was pulseless and
received CPR without any shocks. Pt was admitted to [**Hospital 8**]
Hospital for one day. No neurologic complications.
.
ROS: [**Name (NI) 1094**] wife denies recent fever, GU sx. Pt has had some
secretion from trach. + nausea, abominal discomfort,
constipation. Denies vomiting, hematachezia, BRBPR, hematemesis.
.
In the [**Name (NI) **], pt was continued on AC 600/16/5/.4. ABG was
7.29/66/414.


Past Medical History:
Rhabdomyolosis (presumed [**2-26**] drug toxicity)
Respiratory Failure (s/p Trach and PEG)
ARF ([**2-26**] contrast nephropathy)
IDDM
HTN
AF on coumadin
Gout
Hypercholesterolemia
Arthritis
CAD (s/p CABG)
.
PSH:
s/p L 5th ray amputation [**2130**]
s/p R inguinal hernia repair [**2128**]
s/p cholecystectomy
s/p coronary artery by pass surgery x4 [**2127**]
s/p L TMA [**12/2131**]

Social History:
Retired postal worker, married, 4 children, no tobacco, no drugs

use, prior ETOH qweek, wife involved


Family History:
Mother died of liver cancer in her 70's

Physical Exam:
VS: t99.9, p72, 110/36, rr25, 95% AC 600/16/5/.4,
Gen: intubated, able to whisper
HEENT: clear OP, MMM
Neck: unable to assess JVP
CVS: irreg irreg, nl s1 s2, no m/g/r
Lungs: CTAB anteriorly
Abd: obese, soft, NT, ND, +BS
Ext: 3+ pitting edema of bilateral lower/upper extremities
Neuro: A&O x3, able to appropriately answer questions, [**3-1**]
bilateral upper extremities, unable to move bilateral lower
extremities


Pertinent Results:
Laboratory Data:
[**2133-10-27**] 08:15PM   CK(CPK)-744*
[**2133-10-27**] 08:15PM   CK-MB-32* MB INDX-4.3 cTropnT-2.35*
[**2133-10-27**] 03:29PM URINE  HOURS-RANDOM CREAT-48 TOT PROT-9
PROT/CREA-0.2
[**2133-10-27**] 01:28PM   CK(CPK)-734*
[**2133-10-27**] 01:28PM   CK-MB-31* MB INDX-4.2 cTropnT-2.03*
[**2133-10-27**] 10:11AM   TYPE-ART PO2-84* PCO2-44 PH-7.46* TOTAL
CO2-32* BASE XS-6
[**2133-10-27**] 10:11AM   freeCa-1.13
[**2133-10-27**] 09:48AM URINE  HOURS-RANDOM UREA N-365 CREAT-106
[**2133-10-27**] 05:00AM URINE  HOURS-RANDOM
[**2133-10-27**] 05:00AM URINE  GR HOLD-HOLD
[**2133-10-27**] 05:00AM URINE  COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2133-10-27**] 05:00AM URINE  BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-7.0 LEUK-MOD
[**2133-10-27**] 05:00AM URINE  RBC-[**3-29**]* WBC-[**7-4**]* BACTERIA-OCC
YEAST-NONE EPI-0
[**2133-10-27**] 05:00AM URINE  HYALINE-<1
[**2133-10-27**] 05:00AM URINE  AMORPH-OCC
[**2133-10-27**] 05:00AM URINE  EOS-NEGATIVE
[**2133-10-27**] 04:00AM   GLUCOSE-153* UREA N-65* CREAT-2.0* SODIUM-133
POTASSIUM-5.6* CHLORIDE-91* TOTAL CO2-31 ANION GAP-17
[**2133-10-27**] 04:00AM   ALT(SGPT)-89* AST(SGOT)-73* LD(LDH)-347*
CK(CPK)-892* ALK PHOS-98 TOT BILI-0.5
[**2133-10-27**] 04:00AM   CK-MB-63* MB INDX-7.1* cTropnT-1.29*
[**2133-10-27**] 04:00AM   ALBUMIN-3.8 PHOSPHATE-6.7*# IRON-57
[**2133-10-27**] 04:00AM   calTIBC-273 FERRITIN-91 TRF-210
[**2133-10-27**] 04:00AM   WBC-11.2* RBC-3.09*# HGB-9.8*# HCT-29.1*#
MCV-94 MCH-31.5 MCHC-33.5 RDW-16.3*
[**2133-10-27**] 04:00AM   NEUTS-88.7* LYMPHS-7.2* MONOS-3.8 EOS-0.1
BASOS-0.1
[**2133-10-27**] 04:00AM   HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+
[**2133-10-27**] 04:00AM   PLT COUNT-208
[**2133-10-27**] 04:00AM   RET AUT-4.6*
[**2133-10-27**] 03:17AM   TYPE-ART PO2-414* PCO2-66* PH-7.29* TOTAL
CO2-33* BASE XS-3
.
COMPLETE BLOOD COUNT   WBC   RBC    Hgb  Hct  MCV  MCH  MCHC RDW
 Plt Ct
[**2133-10-29**] 05:12AM    7.4   2.83*  9.0* 26.2*  93 31.8 34.4
15.8* 149*
[**2133-10-28**] 03:37AM    9.7   2.79*  8.9* 26.0*  93 32.0 34.4
16.1* 169
[**2133-10-27**] 04:00AM    11.2* 3.09*# 9.8* 29.1*# 94 31.5 33.5
16.3* 208
.
PT/PTT/INR: [**2133-10-29**]: 27.8/33/2.9
.
Retic Count: [**2133-10-27**]: 4.6
.
RENAL & GLUCOSE   Glucose UreaN Creat Na  K   Cl HCO3 AnGap

[**2133-10-29**] 05:12AM    97   66* 1.9* 137 3.2* 92* 36* 12
[**2133-10-28**] 03:37AM    84   66* 2.0* 133 4.0  90* 31 16
[**2133-10-27**] 01:28PM         65* 2.0*     4.7
[**2133-10-27**] 04:00AM    153* 65* 2.0* 133 5.6* 91* 31 17
.
CPK ISOENZYMES       CK-MB   MB Indx cTropnT proBNP
[**2133-10-29**] 05:12AM    33*   3.4      1.77*1
[**2133-10-28**] 03:37AM    39*   4.0      2.75*1
[**2133-10-27**] 08:15PM    32*   4.3      2.35*1
[**2133-10-27**] 01:28PM    31*   4.2      2.03*1
[**2133-10-27**] 04:00AM    63*   7.1*     1.29*1
.
.
Imaging:
CXR: [**2133-10-27**]: INDICATION: 64-year-old male status post NG tube
placement.

COMPARISON: Comparison is made to radiograph performed in the
same day, approximately one hour earlier.

FINDINGS: There is interval placement of the NG tube with the
tip lying within the stomach. Otherwise, the appearance of the
chest is unchanged.
.
[**2133-10-27**]: EKG: AF @72, nl axis, nl QTc, low voltages, diffuse
TWF, 1mm STD in V2-4 (new)
.
[**2133-10-27**]: TTE ECHO:
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF>55%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. The
right ventricular cavity is moderately dilated. There is
hypokinesis of the basal half of the right ventricular free wall
preserved apical systolic function. There is abnormal systolic
septal motion/position consistent with right ventricular
pressure overload. The aortic root is mildly dilated. The aortic
valve leaflets (3) are moderately thickened. There is no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.


Compared with the prior study (images reviewed) of [**2133-8-28**], the
findings are similar. The prominent RV cavity enlargement and
free wall hypokinesis are similar and underestimated on the
prior study and suggestive of a primary pulmonary process
(pulmonary embolism, pneumonia, bronchospasm, etc.). The
estimated pulmonary artery systolic pressure is similar.
.



Brief Hospital Course:
This is a 64 yo male with recent drug induced
rhabdomyolosis/hepatitis complicated by respiratory failure (s/p
Trach/PEG) and ARF who is re-admitted with hypercarbic
respiratory failure.
.
Hypercarbic respiratory failure: On initial presentation, this
was most likely of mutifactorial etiology. Possibilites included
secondary to recent weaning off vent, continued respiratory
muscle weakness, increased abdominal girth (compressing
diaphragm), and standing sedating medications. Also, pt has RLL
opacity on CXR which may be aspiration pneumonitis vs. early
pneumonia. We held all sedating medications, diuresed the
patient and maintained him on standing nebulizers. 24 hours into
his admission, the patient's mentation and respiratory status
improved substantially. His vent was changed from AC to PS and
then taken off. His ABG improved from
His ABG improved from 7.29/66/414 to 7.46/44/84 as him mentation
improved. He was not empirically started on antibitics because
of lack of fever or increased WBC count. Pt was on trach mask
during the day and bipap at night. Diuresis was achieved with
10mg zaroxolyn followed by 140mg IV lasix. On day of discharge,
pt was started on Diamox, given his rising bicarb from 31 to 36.
Pt should be continued on 2 more days of diamox.
.
# Anasarca: Most likely secondary to right heart failure. Urine
protein to creatinine ratio was 0.2 with a serum albumin of 3.8
- no evidence for nephrotic syndrome. Echo showed worsened RV
function. Pt was diuresed with lasix and zaroxyln.
.
# RH failure: Unknown etiology. Most likely secondary to
pulmonary disease - DDx includes intermittent pulmonary
vasoconstriction 2/2 episodes of apnea, chronic thromboembolic
disease, pulmonary edema. Less likely secondary to LV
dysfunction, given disproportionate RV dysfunction on echo. Pt
needs a right heart cath at some point, once his renal function
improves and is stable. [**Month (only) 116**] also benefit from a Chest CT with
contrast.
.
# Elevated Tn: Pt had a Tn of 1.3 on admission, which increased
to 2.75. CK MB index was negative. This is most likely secondary
to demand ischemia (more likely RV than LV). Pt needs to be
aggressively diuresed. He may benefit from pMIBI and potential
cardiac cath as an outpatient.
.
# ARF: Most likely secondary to pre-renal state from being
intravascularly dry and underlying diabetic nephropathy. Pt's Fe
Urea was 11%, which is consistent with pre-renal status. Urine
eosinophils were negative. Creatinine remained stable with
diuresis. Pt should have his creatinine and lytes followed
daily.
.
# Anemia: Most likely dilutional in setting of significant total
body overload. No evidence of active bleeding; guiac negative.
Iron studies suggestive of iron deficiency anemia. Pt was
started on iron supplementation. Pt needs continued outpt w/u of
anemia.
.
#. Afib: Pt was continued on BB for rate control. Coumadin was
held in setting of supratherapeutic INR. INR on discharge was
2.9. Coumadin should be restarted tomorrow.
.
# DM: ISS
.
# HTN: continue hydralazine and lopressor
.
# CAD: continue asa, bb
.
# Depression: continue citalopram

Medications on Admission:
albuterol inh
Ascorbic acid 500mg qd
Citalopram 20mg qd
Lasix 140mg IV bid
Gabapentin 100mg qd
Hydralazine 20mg qid
Insulin ss
Metolazone 5mg qd
Lopressor 100mg [**Hospital1 **]
Miconazole powder
MVI qd
Olanzapine 2.5mg qd
Protonix 40mg qd
Papain/urea ointment
Warfarin qd
Zinc 220mg qd
Tylenol
ASA 325mg qd
Bisacodyl 10mg qd
ativan 0.5mg qhs
Nitroglycerin prn
Ondansetron 4mg q4h prn
Percocet prn

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff
Inhalation Q6H (every 6 hours) as needed.
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Hydralazine 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6
hours).
8. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  QID
(4 times a day) as needed.
11. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
12. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

14. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6)
Puff Inhalation QID (4 times a day).
15. Metolazone 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. Furosemide 10 mg/mL Cartridge Sig: One [**Age over 90 11578**]y (180)
mg Injection twice a day: please give 30 minutes after zaroxyln.

19. Acetazolamide Sodium 500 mg Recon Soln Sig: Two Hundred
Fifty (250) mg Injection once a day for 2 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Hypercarbic respiratory failure
Anasarca
RH Failure
ARF
Demand ischemia vs. NSTEMI
Anemia


Discharge Condition:
Stable respiratory status.


Discharge Instructions:
Please return to the ED if you develop altered mental status or
respiratory distress.

Please follow up with your PCP.

Please continue all of your medications.

Followup Instructions:
Follow up with your primary care doctor as needed.

Follow up with cardiology within 1 month. Call ([**Telephone/Fax (1) 2037**] to
schedule an appointment.
{'Acute respiratory failure,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Subendocardial infarction, initial episode of care,Pressure ulcer, buttock,Atrial fibrillation,Long-term (current) use of anticoagulants,Aortocoronary bypass status,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Tracheostomy 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: Hypercarbic Respiratory Failure

PRESENT ILLNESS: 64 yo male with PMH CAD (s/p CABG), AF (on coumadin), DM, HTN,
recent admission for presumed drug-induced
rhabdomyolysis/weakness resulting in hypercarbic respiratory
failure (s/p trach and PEG) and ARF presents with hypercarbic
respiratory failure.
.
Pt was recently admitted at [**Hospital1 18**] from [**Date range (1) 60244**] with elevated
LFTs, rhabdomyolysis with CK 13,000 and weakness presumed
secondary to a combination of zetia and avapro. Muscle biopsy
suggested a metabolic myopathy induced by toxic agents and drugs
(i.e cholesterol lowering agents). No evidence of inflammatory
myositis. Medications were held.
Hepatitis serologies negative. Pt developed hypercarbic
respiratory failure secondary to muscle weakness and was
intubated, then got trach and PEG for failure to extubate in
setting of persistently low NIFs. Course was complicated by
contrast nephropathy and was temporarily on HD; creatinine on
discharge was 1.0.
.
Recently, pt was being weaned off the vent: Trach was capped
during the day and put on Bipap at night. Per wife, pt was
having difficulty tolerating Bipap. PEG removed one week ago; pt
is eating by mouth. Per the pt's wife, pt expressed generalized
malaise for the past 3 days. On the morning of admission, pt was
noted to be less responsive and A&O x 1 (at baseline A&O x 3 and
appropriate). ABG was 7.15/117/65. Pt was given Lasix 200 IV x1,
put on mechanical ventilation, and transferred for further mgmt.
.
Of note, per wife, pt was coded two weeks ago. [**Month (only) 116**] have
preceding hypercarbic respiratory failure. He was pulseless and
received CPR without any shocks. Pt was admitted to [**Hospital 8**]
Hospital for one day. No neurologic complications.
.
ROS: [**Name (NI) 1094**] wife denies recent fever, GU sx. Pt has had some
secretion from trach. + nausea, abominal discomfort,
constipation. Denies vomiting, hematachezia, BRBPR, hematemesis.
.
In the [**Name (NI) **], pt was continued on AC 600/16/5/.4. ABG was
7.29/66/414.

MEDICAL HISTORY: Rhabdomyolosis (presumed [**2-26**] drug toxicity)
Respiratory Failure (s/p Trach and PEG)
ARF ([**2-26**] contrast nephropathy)
IDDM
HTN
AF on coumadin
Gout
Hypercholesterolemia
Arthritis
CAD (s/p CABG)
.
PSH:
s/p L 5th ray amputation [**2130**]
s/p R inguinal hernia repair [**2128**]
s/p cholecystectomy
s/p coronary artery by pass surgery x4 [**2127**]
s/p L TMA [**12/2131**]

MEDICATION ON ADMISSION: albuterol inh
Ascorbic acid 500mg qd
Citalopram 20mg qd
Lasix 140mg IV bid
Gabapentin 100mg qd
Hydralazine 20mg qid
Insulin ss
Metolazone 5mg qd
Lopressor 100mg [**Hospital1 **]
Miconazole powder
MVI qd
Olanzapine 2.5mg qd
Protonix 40mg qd
Papain/urea ointment
Warfarin qd
Zinc 220mg qd
Tylenol
ASA 325mg qd
Bisacodyl 10mg qd
ativan 0.5mg qhs
Nitroglycerin prn
Ondansetron 4mg q4h prn
Percocet prn

ALLERGIES: Avapro / Zetia / Heparin Agents

PHYSICAL EXAM: VS: t99.9, p72, 110/36, rr25, 95% AC 600/16/5/.4,
Gen: intubated, able to whisper
HEENT: clear OP, MMM
Neck: unable to assess JVP
CVS: irreg irreg, nl s1 s2, no m/g/r
Lungs: CTAB anteriorly
Abd: obese, soft, NT, ND, +BS
Ext: 3+ pitting edema of bilateral lower/upper extremities
Neuro: A&O x3, able to appropriately answer questions, [**3-1**]
bilateral upper extremities, unable to move bilateral lower
extremities

FAMILY HISTORY: Mother died of liver cancer in her 70's

SOCIAL HISTORY: Retired postal worker, married, 4 children, no tobacco, no drugs 

### Response:
{'Acute respiratory failure,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Subendocardial infarction, initial episode of care,Pressure ulcer, buttock,Atrial fibrillation,Long-term (current) use of anticoagulants,Aortocoronary bypass status,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Tracheostomy status'}
