CHIEF COMPLAINT: dyspnea on exertion, increased abdominal girth

PRESENT ILLNESS: Mr. [**Known lastname **] is a 68 yo M with Ischemic cardiomyopathy EF < 20%,
s/p CABG x2, s/p BIV ICD admitted with acute on chronic CHF
exacerbation admitted for diuresis.  He reports that over the
past two months he has had progressive dyspnea on exertion to
the point that he is now able to ambulate only about one block
on a flat surface.  He also reports increase in abdominal girth.
 His weight is 257 pounds with a dry weight of 210-220 pounds.
Otherwise he reports that he has been feeling well and denies
fevers, chills chest pain, PND, orthopnea, dyspnea at rest,
nausea, vomiting, abdominal pain, diarrhea, constipation,
hematochezia, melena.  He does endores imbalance with walking.

MEDICAL HISTORY: # CAD
- s/p MI in [**2153**], CABG in [**2154**] and redo with porcine MVR [**2177-4-8**]

MEDICATION ON ADMISSION: -allopurinol 100 mg daily,
-amiodarone 200 mg daily,
-Lipitor 20 mg daily,
-carvedilol 12.5 mg [**Hospital1 **]
-Sensipar 30 mg daily (rx is for [**Hospital1 **] but only taking one)
-folic acid daily,
-Lasix 160 mg twice a day
-metolazone 5 mg two times per week (th, sun)
-Neurontin two tabs daily
insulin daily,
-Imdur 30 mg daily,
-Levoxyl 175 mcg daily,
-lorazepam 1-2 mg every six hours as needed,
oxycodone as needed for pain,
-Protonix 40 mg daily,
-potassium 40 mEq three times a day with food,
-Zoloft 100 mg daily,
-spironolactone 25 mg twice a day,
-Ambien 10mg at bedtime,
-aspirin 81 mg daily,
-vitamin D 800 units daily.
-lisinopril 2.5mg (NOT TAKING)

ALLERGIES: Penicillins / Heparin Agents

PHYSICAL EXAM: VS: T=98.7 BP=126/75 HR=65 RR= 22 O2 sat= 95%RA
GENERAL: Resting comfortably, no acute distress, speaking 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 to the ear lobe sitting at 45
degrees.
CARDIAC: RRR, [**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. CTAB, fine bibasilar crackles, no wheezes.
ABDOMEN: Obese, distended, nontender, No HSM.  Normoactive bowel
sounds.
EXTREMITIES: venous stasis dermatitis bilaterally, cool
extremities, palpable pulses bilaterally.

FAMILY HISTORY: Mother died of SCD in her 40s, though the patient notes that she

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.
Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Coronary atherosclerosis of autologous vein bypass graft,Chronic kidney disease, Stage IV (severe),Automatic implantable cardiac defibrillator in situ,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diseases of tricuspid valve,Heart valve replaced by transplant,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Heparin-induced thrombocytopenia (HIT),Unspecified acquired hypothyroidism,Hyperparathyroidism, unspecified,Disorder of bone and cartilage, unspecified,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric),Obesity, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Gout, unspecified,Anxiety state, unspecified,Accidental fall from bed,Personal history of tobacco use
Ac on chr syst hrt fail,Acute kidney failure NOS,Prim cardiomyopathy NEC,Crn ath atlg vn bps grft,Chr kidney dis stage IV,Status autm crd dfbrltr,Hy kid NOS w cr kid I-IV,Tricuspid valve disease,Heart valve transplant,DMII wo cmp nt st uncntr,Long-term use of insulin,Heparin-indu thrombocyto,Hypothyroidism NOS,Hyperparathyroidism NOS,Bone & cartilage dis NOS,Pure hypercholesterolem,Obstructive sleep apnea,Obesity NOS,Elev transaminase/ldh,Gout NOS,Anxiety state NOS,Fall from bed,History of tobacco use
Admission Date:  [**2179-7-28**]              Discharge Date:   [**2179-8-2**]

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

Service: MEDICINE

Allergies:
Penicillins / Heparin Agents

Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
dyspnea on exertion, increased abdominal girth

Major Surgical or Invasive Procedure:
None


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 admitted with acute on chronic CHF
exacerbation admitted for diuresis.  He reports that over the
past two months he has had progressive dyspnea on exertion to
the point that he is now able to ambulate only about one block
on a flat surface.  He also reports increase in abdominal girth.
 His weight is 257 pounds with a dry weight of 210-220 pounds.
Otherwise he reports that he has been feeling well and denies
fevers, chills chest pain, PND, orthopnea, dyspnea at rest,
nausea, vomiting, abdominal pain, diarrhea, constipation,
hematochezia, melena.  He does endores imbalance with walking.

.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

Past Medical History:
# CAD
- s/p MI in [**2153**], CABG in [**2154**] and redo with porcine MVR [**2177-4-8**]

- 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". 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: T=98.7 BP=126/75 HR=65 RR= 22 O2 sat= 95%RA
GENERAL: Resting comfortably, no acute distress, speaking 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 to the ear lobe sitting at 45
degrees.
CARDIAC: RRR, [**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. CTAB, fine bibasilar crackles, no wheezes.
ABDOMEN: Obese, distended, nontender, No HSM.  Normoactive bowel
sounds.
EXTREMITIES: venous stasis dermatitis bilaterally, cool
extremities, palpable pulses bilaterally.


Pertinent Results:
[**2179-7-28**] 12:36PM   WBC-9.5 RBC-4.77 HGB-15.9 HCT-45.4 MCV-95
MCH-33.4*# MCHC-35.1* RDW-16.2*
[**2179-7-28**] 12:36PM   NEUTS-81.6* LYMPHS-11.5* MONOS-5.3 EOS-1.2
BASOS-0.4
[**2179-7-28**] 12:36PM   PLT COUNT-101*
[**2179-7-28**] 12:36PM   PT-13.2 PTT-25.1 INR(PT)-1.1
[**2179-7-28**] 12:36PM   CALCIUM-8.9 PHOSPHATE-3.8 MAGNESIUM-1.8

Abdominal ultrasound [**7-30**]:
FINDINGS: A limited study of the four quadrants of the abdomen
was performed and no ascites was identified.
IMPRESSION: No ascites seen in the abdomen.

CXR [**8-2**]:
FINDINGS: Persistent marked cardiomegaly but no evidence of
congestive heart failure. ICD with biventricular pacing lead
remains in place, and there is evidence of prior sternotomy.

[**2178-3-2**] 2D-ECHOCARDIOGRAM: LVEF 20%, Severe left ventricular
cavity dilation with severe global hypokinesis. Well-seated
mitral valve bioprosthesis with slightly increased transvalvular
gradients. Mild RV cavity dilation with normal function.
Moderate pulmonary hypertension.
.
[**2176-11-8**] Persantine MIBI:
1. Unchanged pattern of moderate-to-severe myocardial perfusion
defects, primarily involving the left anterior descending
coronary artery territory.
2. Similar left ventricular dysfunction, with an ejection
fraction of only 20%.
.
CARDIAC CATH:  [**2177-3-10**]
1. Three vessel coronary artery disease.
2. Severe systolic and diastolic ventricular dysfunction.
(RVEDP 22mmHg and LVEDP of 34mmHg, respectively) with moderate
pulmonary hypertension (49/34mmHg).
.
(LMCA with 30% stenosis, LAD complete occlusion after 1st
septal, LCX occluded after mid segment, RCA with diffuse disease
occluded after mid segment.  LIMA widely patent, SVG to OM with
proximal 30% stenosis, SVG jump graft to D1 and distal diag
patent)


Brief Hospital Course:
Mr. [**Known lastname **] is a 68 yo male with ischemic cardiomyopathy with an
EF=20%, s/p CABG x2, s/p BIV ICD admitted with acute on chronic
CHF exacerbation.
.
# CHF: The patient was admitted for diuresis after an
approximate 40 pound weight gain and history of increasing
dyspnea on exertion.  It was felt that this weight gain was
secondary to fluid overload as he has systolic heart failure
secondary to ischemic cardiomyopathy with an EF=20%.  He was
started on a milrinone drip which was titrated up to
0.5mg/kg/min as well as a Lasix drip at 20mg/hr.  In addition,
he was given metolazone 5mg [**Hospital1 **].  His home carvedilol was
switched to metoprolol to give more blood pressure room for
diuresis.  We also increased the rate of his pacer from 60 to 70
to increase his cardiac output and therefore facilitate
diuresis.  He put out about 4 liters on this regimen.  The plan
was to stop diuresis if his creatinine raised above 3.5 or if
his abdominal ultrasound did not show any ascites.  Both of
these criteria were met after about 3 days of diuresis on the
above regimen.  Diuresis was then stopped and his home regimen
of diuretics were instituted.  He will be discharged on all of
his previous home medications except for spironolactone.  He
will follow-up with Dr. [**First Name (STitle) 437**] in cardiology clinic in one week
where any further changes to his home medication regimen will be
discussed.
.
# CORONARIES: Extensive history of CAD s/p CABG x2, last cath in
[**2176**] with LIMA widely patent, SVG to OM with proximal 30%
stenosis, SVG jump graft to D1 and distal diag patent.  There
were no acute issues from a coronary perfusion standpoint during
this admission.  He was continued on his home imdur, aspirin 81
mg, and Lipitor 20 mg.
.
# RHYTHM: He was in NSR on admission and has a BIV PPM/ICD.
Does have h/o VT with ICD firing provoked by K<4.8.  He was
monitored on telemetry throughout his admission.  Metoprolol was
given to decrease ectopy on milronone.  His home dose of
amiodarone was continued.
.
# Chronic renal failure - Followed by Dr. [**Last Name (STitle) 4090**] as an
outpatient. His chronic renal failure is likely secondary to a
combination of chronic systolic heart failure and poorly
controlled DM.  His baseline creatinine ranges from 2.4-2.9 and
was 2.9 on admission.  His spironolactone and ACE inhibitor were
held.  His electrolytes were repleted to maintain a goal
potassium of [**4-27**].5 because the patient has a history of VT/ICD
firing for K <4.8.  Vitamin D and cinacalcet were continued.
His creatinine prior to discharge was 3.5.
.
# Type II DM - His HbA1C on [**3-1**] was 7.5.  He is followed by Dr.
[**Last Name (STitle) **] of [**Last Name (un) **].  We originally continued his outpatient regimen
of Humalog 75/25 40 units qam and 50 units qpm with NPH 35 units
at bedtime.  However, his sugars were up to the 300s on this
regimen.  A hemoglobin A1C was rechecked and was 9.2.  His
insulin regimen was increased accordingly and his sugars were
maintained mostly in the 70s to 150s with one episode of
hypoglycemia to the 50s.
.
# Oxygen requirement - The patient required 2 liters of oxygen
via nasal cannula throughout his hospital admission.  He is not
on oxygen at home and his chest x-rays did not show any signs of
heart failure or pneumonia.  It is felt that his home baseline
sats may be in the low 90s secondary to obesity hypoventilation
syndrome.  His ambulatory sats were in the low 90s and he was
discharged home without any supplemental oxygen.
.
# Hypothyroidism - His home dose of levothyroxine was continued.
.
# OSA - The patient brought his home CPAP and that was continued
during his hospitalization.
.
# Gout - Renally dosed allopurinol was continued.
.
# Anxiety - His home dose ativan and ambien were continued for
sleep.

Medications on Admission:
-allopurinol 100 mg daily,
-amiodarone 200 mg daily,
-Lipitor 20 mg daily,
-carvedilol 12.5 mg [**Hospital1 **]
-Sensipar 30 mg daily (rx is for [**Hospital1 **] but only taking one)
-folic acid daily,
-Lasix 160 mg twice a day
-metolazone 5 mg two times per week (th, sun)
-Neurontin two tabs daily
insulin daily,
-Imdur 30 mg daily,
-Levoxyl 175 mcg daily,
-lorazepam 1-2 mg every six hours as needed,
oxycodone as needed for pain,
-Protonix 40 mg daily,
-potassium 40 mEq three times a day with food,
-Zoloft 100 mg daily,
-spironolactone 25 mg twice a day,
-Ambien 10mg at bedtime,
-aspirin 81 mg daily,
-vitamin D 800 units daily.
-lisinopril 2.5mg (NOT TAKING)

Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Carvedilol 6.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
5. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

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

7. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Metolazone 5 mg Tablet Sig: One (1) Tablet PO twice weekly
(Sunday and Thursday).
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
11. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO TID (3 times a
day).
14. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
17. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
18. Insulin
Continue home insulin regimen with humalog 75/25 and NPH.
Please check your sugars more frequently at home and dose your
insulin accordingly.


Discharge Disposition:
Home

Discharge Diagnosis:
acute on chronic congestive heart failure

Secondary diagnoses:
# CAD
- s/p MI in [**2153**], CABG in [**2154**] and redo with porcine MVR [**2177-4-8**]

- 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 Cr mid 2's
# DM
- insulin dependent
# Hypothyroidism
# Hyperparathyroidism
# Hypercalcemia
# Osteopenia
# Hypercholesterolemia
# Dyspepsia
# Sleep apnea
# Obesity
# LFT abnormalities attributed to NASH, possibly amio
# HIT


Discharge Condition:
Stable, afebrile, 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 about 4 liters of fluid.  Diuresis was stopped when your
creatinine went above 3.5 and when we found out via ultrasound
that you did not have excess fluid in your abdomen.  Please
avoid eating a fourth meal in the future as it appears that this
has contributed the most to your recent weight gain. 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.

The following changes have been made to your home medication
regimen:
-You will stop taking spironolactone until further notice from
Dr. [**First Name (STitle) 437**]

Please follow-up with all of your outpatient medical
appointments listed below.

Please seek medical care if you experience any concerning
symptoms such as chest pain, increased shortness of breath,
diaphoresis

Followup Instructions:
Please follow-up with all of your outpatient medical
appointments listed below:

1. Cardiology:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2179-8-9**]
2:30

2. Primary Care:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. Date/Time:[**2179-11-9**] 12:10

Please follow-up with [**Last Name (un) **] concerning your blood sugar
control.
{'Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Coronary atherosclerosis of autologous vein bypass graft,Chronic kidney disease, Stage IV (severe),Automatic implantable cardiac defibrillator in situ,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diseases of tricuspid valve,Heart valve replaced by transplant,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Heparin-induced thrombocytopenia (HIT),Unspecified acquired hypothyroidism,Hyperparathyroidism, unspecified,Disorder of bone and cartilage, unspecified,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric),Obesity, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Gout, unspecified,Anxiety state, unspecified,Accidental fall from bed,Personal history of tobacco use'}


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, increased abdominal girth

PRESENT ILLNESS: Mr. [**Known lastname **] is a 68 yo M with Ischemic cardiomyopathy EF < 20%,
s/p CABG x2, s/p BIV ICD admitted with acute on chronic CHF
exacerbation admitted for diuresis.  He reports that over the
past two months he has had progressive dyspnea on exertion to
the point that he is now able to ambulate only about one block
on a flat surface.  He also reports increase in abdominal girth.
 His weight is 257 pounds with a dry weight of 210-220 pounds.
Otherwise he reports that he has been feeling well and denies
fevers, chills chest pain, PND, orthopnea, dyspnea at rest,
nausea, vomiting, abdominal pain, diarrhea, constipation,
hematochezia, melena.  He does endores imbalance with walking.

MEDICAL HISTORY: # CAD
- s/p MI in [**2153**], CABG in [**2154**] and redo with porcine MVR [**2177-4-8**]

MEDICATION ON ADMISSION: -allopurinol 100 mg daily,
-amiodarone 200 mg daily,
-Lipitor 20 mg daily,
-carvedilol 12.5 mg [**Hospital1 **]
-Sensipar 30 mg daily (rx is for [**Hospital1 **] but only taking one)
-folic acid daily,
-Lasix 160 mg twice a day
-metolazone 5 mg two times per week (th, sun)
-Neurontin two tabs daily
insulin daily,
-Imdur 30 mg daily,
-Levoxyl 175 mcg daily,
-lorazepam 1-2 mg every six hours as needed,
oxycodone as needed for pain,
-Protonix 40 mg daily,
-potassium 40 mEq three times a day with food,
-Zoloft 100 mg daily,
-spironolactone 25 mg twice a day,
-Ambien 10mg at bedtime,
-aspirin 81 mg daily,
-vitamin D 800 units daily.
-lisinopril 2.5mg (NOT TAKING)

ALLERGIES: Penicillins / Heparin Agents

PHYSICAL EXAM: VS: T=98.7 BP=126/75 HR=65 RR= 22 O2 sat= 95%RA
GENERAL: Resting comfortably, no acute distress, speaking 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 to the ear lobe sitting at 45
degrees.
CARDIAC: RRR, [**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. CTAB, fine bibasilar crackles, no wheezes.
ABDOMEN: Obese, distended, nontender, No HSM.  Normoactive bowel
sounds.
EXTREMITIES: venous stasis dermatitis bilaterally, cool
extremities, palpable pulses bilaterally.

FAMILY HISTORY: Mother died of SCD in her 40s, though the patient notes that she

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:
{'Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Coronary atherosclerosis of autologous vein bypass graft,Chronic kidney disease, Stage IV (severe),Automatic implantable cardiac defibrillator in situ,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diseases of tricuspid valve,Heart valve replaced by transplant,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Heparin-induced thrombocytopenia (HIT),Unspecified acquired hypothyroidism,Hyperparathyroidism, unspecified,Disorder of bone and cartilage, unspecified,Pure hypercholesterolemia,Obstructive sleep apnea (adult)(pediatric),Obesity, unspecified,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH],Gout, unspecified,Anxiety state, unspecified,Accidental fall from bed,Personal history of tobacco use'}
