CHIEF COMPLAINT: transferred for evaluation of exertional dyspnea/acute CHF

PRESENT ILLNESS: This 64M with CAD s/p CABG in [**2162**] for a positive stress test
and hyperlipidemia who stopped taking all his cardiac
medications 8 months ago was traveling in [**State 350**] on
business began experiencing dyspnea and chest pressure after
walking 50-60 feet, which was new for him, four days prior to
admission to this hospital. Two days prior to admission, he was
dyspneic after just 20-25 feet, and presented to an OSH for
evaluation. He was found to be in CHF with marked volume
overload and also in rapid atrial fibrillation.
.
Diuresis was limited by acute renal failure (peak creatinine
1.8, up from 1.4 on admission). Control of atrial fibrillation
was attempted with diltiazem and he was loaded with digoxin.
Runs of NSVT were noted on telemetry. An echocardiogram showed
LVEF 10% and a dilated, hypokinetic RV. CXR showed mild
pulmonary edema. CTPA showed bilateral effusions but was
negative for PE.
.
.
On review of systems, he endorses cough productive of clear,
whitish sputum over the last three weeks. He denies orthopnea,
PND, or ankle edema. He reports a history of presyncope related
to uptitration of antihypertensives in the past and this is why
he self-discontinued beta blockers. He denies symptoms of stroke
or TIA. No history of bleeding problems.

MEDICAL HISTORY: # CAD s/p CABG [**2162**] @ [**State 4595**]; LIMA to midLAD,
SVG to midLCX, SVG to D2
# CHF (EF 10%)
- post-CABG EF 20-30%
# AF, noted at outpatient visit in [**2167**] in MN
# hypercholesterolemia
# ORIF of L tibial fracture, [**2160**]; hardware subsequently
removed, [**2161**]

MEDICATION ON ADMISSION: asa 325 mg daily
plavix 75 mg daily
heparin gtt
metoprolol 25 mg TID
Protonix 40 mg daily
Atorvastatin 40 mg daily
hydralazine 20 mg QID
spironolactone 25 mg daily
bumex 2 mg [**Hospital1 **]
digoxin 0.125 mg daily
dobutamine gtt

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: (on admission)
VS: T:97.6, BP:98/66, HR:111, RR:18, O2: 98% on 2L NC
Gen: obese middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 16 cm H2O.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, soft S1, paradoxically S2. No m/r/g. No thrills, lifts. No
S3 or S4.
Chest: Breathing with accessory muscles but able to speak in
sentences. Decreased breath sounds at both bases with R > L
crackles at the bases. Scattered wheezing. No rhonchi.
Abd: Obese, NTND. Pulsatile liver.
Groin: 2+ femoral pulses. No bruits
Ext: WWP. 1+ bilateral ankle edema. 2+ DP pulses.
Skin: Slight jaundice. No stasis dermatitis, ulcers, surgical
scar on L ankle, surgical scar along R leg c/w vein harvesting

FAMILY HISTORY: Brother died of sudden cardiac death during a plane flight at
age 62.

SOCIAL HISTORY: Lives with wife in [**State 3706**], works in [**Name (NI) 22441**] but travels
frequently to MA. Denies tobacco or illicit drug use. Drinks a
glass of wine with dinner 2-3 times per week.
Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Urinary tract infection, site not specified,Bacteremia,Coronary atherosclerosis of unspecified type of vessel, native or graft,Atrial fibrillation,Other and unspecified hyperlipidemia,Enlargement of lymph nodes,Aortocoronary bypass status,Personal history of noncompliance with medical treatment, presenting hazards to health
Ac on chr syst hrt fail,Acute kidney failure NOS,Prim cardiomyopathy NEC,Urin tract infection NOS,Bacteremia,Cor ath unsp vsl ntv/gft,Atrial fibrillation,Hyperlipidemia NEC/NOS,Enlargement lymph nodes,Aortocoronary bypass,Hx of past noncompliance
Admission Date:  [**2169-3-9**]              Discharge Date:   [**2169-3-16**]

Date of Birth:  [**2104-8-18**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
transferred for evaluation of exertional dyspnea/acute CHF

Major Surgical or Invasive Procedure:
None

History of Present Illness:
This 64M with CAD s/p CABG in [**2162**] for a positive stress test
and hyperlipidemia who stopped taking all his cardiac
medications 8 months ago was traveling in [**State 350**] on
business began experiencing dyspnea and chest pressure after
walking 50-60 feet, which was new for him, four days prior to
admission to this hospital. Two days prior to admission, he was
dyspneic after just 20-25 feet, and presented to an OSH for
evaluation. He was found to be in CHF with marked volume
overload and also in rapid atrial fibrillation.
.
Diuresis was limited by acute renal failure (peak creatinine
1.8, up from 1.4 on admission). Control of atrial fibrillation
was attempted with diltiazem and he was loaded with digoxin.
Runs of NSVT were noted on telemetry. An echocardiogram showed
LVEF 10% and a dilated, hypokinetic RV. CXR showed mild
pulmonary edema. CTPA showed bilateral effusions but was
negative for PE.
.
.
On review of systems, he endorses cough productive of clear,
whitish sputum over the last three weeks. He denies orthopnea,
PND, or ankle edema. He reports a history of presyncope related
to uptitration of antihypertensives in the past and this is why
he self-discontinued beta blockers. He denies symptoms of stroke
or TIA. No history of bleeding problems.


Past Medical History:
# CAD s/p CABG [**2162**] @ [**State 4595**]; LIMA to midLAD,
SVG to midLCX, SVG to D2
# CHF (EF 10%)
- post-CABG EF 20-30%
# AF, noted at outpatient visit in [**2167**] in MN
# hypercholesterolemia
# ORIF of L tibial fracture, [**2160**]; hardware subsequently
removed, [**2161**]

Social History:
Lives with wife in [**State 3706**], works in [**Name (NI) 22441**] but travels
frequently to MA. Denies tobacco or illicit drug use. Drinks a
glass of wine with dinner 2-3 times per week.


Family History:
Brother died of sudden cardiac death during a plane flight at
age 62.

Physical Exam:
(on admission)
VS: T:97.6, BP:98/66, HR:111, RR:18, O2: 98% on 2L NC
Gen: obese middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 16 cm H2O.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, soft S1, paradoxically S2. No m/r/g. No thrills, lifts. No
S3 or S4.
Chest: Breathing with accessory muscles but able to speak in
sentences. Decreased breath sounds at both bases with R > L
crackles at the bases. Scattered wheezing. No rhonchi.
Abd: Obese, NTND. Pulsatile liver.
Groin: 2+ femoral pulses. No bruits
Ext: WWP. 1+ bilateral ankle edema. 2+ DP pulses.
Skin: Slight jaundice. No stasis dermatitis, ulcers, surgical
scar on L ankle, surgical scar along R leg c/w vein harvesting

Pertinent Results:
LABORATORY DATA from OSH:
Troponin I 0.18-->0.22
Cr 1.5-->1.87-->1.37
BNP 1164
.
Admission Labs:
[**2169-3-9**] 10:35PM   GLUCOSE-106* UREA N-33* CREAT-1.4* SODIUM-134
POTASSIUM-3.7 CHLORIDE-92* TOTAL CO2-34* ANION GAP-12
[**2169-3-9**] 10:35PM   ALT(SGPT)-748* AST(SGOT)-227* LD(LDH)-242 ALK
PHOS-72 TOT BILI-1.2
[**2169-3-9**] 10:35PM   proBNP-5719*
[**2169-3-9**] 10:35PM   WBC-12.3* RBC-4.58* HGB-14.3 HCT-41.2 MCV-90
MCH-31.2 MCHC-34.7 RDW-15.5
[**2169-3-9**] 10:35PM   PT-15.0* PTT-41.0* INR(PT)-1.3*
.
Admission ECG: atrial fibrillation with PVCs vs aberrancy, LBBB;
similar to tracings from [**Hospital3 2737**] dated [**3-7**] and [**3-8**], no
older tracings available
.
Admission CXR (AP) ([**2169-3-10**]): The patient has had median
sternotomy.  The heart is mildly enlarged.  Right lung is clear.
 Left lower lung is opacified, and there may be a small left
pleural effusion.  In the absence of prior imaging, I cannot
ascribe the left lower lobe to benign post-surgical atelectasis
and there is the suggestion of a left hilar mass.  Chest CT
imaging is recommended unless the explanation for the abnormal
left lower lung is known.
.
Echo ([**2169-3-10**]): The left atrium is markedly dilated. The right
atrium is markedly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is severe global left ventricular
hypokinesis (LVEF = 20 %). A left ventricular apical
mass/thrombus cannot be excluded. There is no ventricular septal
defect. The right ventricular cavity is mildly dilated with
depressed free wall contractility. The ascending aorta is
moderately dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**12-28**]+) mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. The end-diastolic
pulmonic regurgitation velocity is increased suggesting
pulmonary artery diastolic hypertension. There is no pericardial
effusion.
.
CT ([**2169-3-10**]): 1.  Mild pulmonary edema.  Moderate right pleural
effusion. No evidence of pneumonia. 2.  The appearance on chest
radiograph is likely secondary to a combination of the
moderate-sized loculated left pleural effusion, left lower lobe
and lingular atelectasis and cardiomegaly.  3.  6-mm right upper
lobe nodule.  In a high-risk patient (history of smoking
or known malignancy), followup is recommended in six months.
Otherwise, 12-
month followup is recommended.
.
PVR at the time of d/c 193
.
Discharge weight 110.7kg

Brief Hospital Course:
64M with CAD s/p CABG in [**2162**], also hyperlipidemia, self-d/c'd
all cardiac medications 8 months ago, now with acute on chronic
systolic heart failure and rapid atrial rhythm.
.
#  Acute on chronic systolic heart failure, LVEF 20%
Pt was admitted with NYHA Class IV symptoms, acutely over the
week prior to presentation but had been off all cardiac
medications for the past 8 months (aside from lasix) as he
wanted to be on herbal medications instead. Acute decompensation
was most likely related to worsening of her cardiomyopathy [**1-28**]
rapid heart rate over time, in the setting of no meds. On
transfer, he was dyspneic at rest with 2L O2 requirement despite
some diuresis at OSH, and on dobutamine for low blood pressure.
He diuresed 1300cc overnight on lasix drip with dobutamine and
SOB improved. Dobutamine was weaned off in the am the following
day.
The etiology of the acute HF was thought to be hypertension for
stopping the meds (increased afterload and work on heart) +/-
[**1-28**] paroxysmal afib with RVR.
Pt was digoxin loaded at the OSH to control HR, and when seen in
the CCU here was continued at 0.25 (given hr into 110-120s
despite load.  BB was also added for rate control once tolerated
from BP standpoint.
Lasix gtt was continued and 3-4L was taken off the following 2
days.   Echo was done demonstrating severe global left
ventricular hypokinesis with an LVEF = 20 % as previously known.
Over the following days we continued lasix with boluses IV for
diuresis, and the pt diuresed another 3-4 L prior to discharge
and the dry weight at the time of discharge was 110.7kg.  he was
discharged on 40mg po lasix to maintain this dry weight.
On day #4, afterload reduction was added in the form of [**First Name8 (NamePattern2) **] [**Last Name (un) **]
(given hx of cough with ACEi) once bp tolerated.  Also,
aldactone was started for class IV heart failure.
On the echo, a left ventricular apical mass/thrombus could not
be excluded.  The plan for this was to have pt anticoagulated
for at least one month prior to possible DCCV in order to
prevent possibly dislodging a thrombus from the LV.
.
# CAD: s/p CABG
Pt was not currently taking any anti-ischemic therapy at the
time of admission. ASA, plavix, simvastatin 40mg was started
empirically and continued throught d/c.  Lipid profile included
a very low HDL and niacin and/or fibrates were considered.
However, the thinking was that the cholesterol panel may be
falsely low due peri-MI.  Therefore, the recommendation was to
recheck as an outpt and to consider niacin or fibrate if low. We
also recommended exercise as this may raise HDL. Ischemic insult
was felt very unlikely as a cause of HF and more likely related
to medication noncompliance. BB and [**Last Name (un) **] were started as above.
.
# Rhythm: Atrial fibrillation
Digoxin and BB for rate control as mentioned above as well as
heparin gtt.  DCCV was considered (although given the size of
the atria will have have high risk of recurrence) but given that
possible LV thrombus would not be better visualized with TEE
than TTE the decisiton was made to have pt be anticoagulated for
at least one month prior to possible DCCV in order to prevent
possibly dislodging a thrombus from the LV.  The pt was
therefore started on coumadin with the heparin bridge although
the heparin had to be held tha day prior to discharge.  At this
time the INR was 1.5.  Since 3 days had passed after starting
5mg coumadin the dose was increased to 7.5 mg on [**3-15**].  At the
time of discharge INR was still 1.5.  He was instructed to have
his INR checked on [**3-20**] in [**State **] and given a script for a
lab draw.
.
# E.Coli UTI and bacteremia, pan-sensitive
Pt was found to have positive UA on routine UA taken on
admission and therefore ciprofloxacin was started on day#2.  The
urine culture grew out pan-sensitive E.Coli.  Blood cultures
taken at the same time (for hypotension) had 1/4 bottles
positive for E.Coli as well.  Pt continued to be HD stable and
without s/s of sepsis and the abx regiment was therefore not
changed and cipro was continued in hospital and at the time of
discharge for a total of 14 days for complicated UTI.  Pt did
not have any lines in when blood culture was found to be
positive, and foley was removed prior to this as well.  Repeat
cultures for clearing of blood were negative.
.
# Persistent Hematuria
Started after placing foley on admission and thought likely [**1-28**]
traumatic foley + anticoagulation + UTI.  Pt slowly had clearing
of his urine with treatment of UTI, but then on HOD#5 had
recurrence of dark hematuria (no clots) likely [**1-28**]
supratherapeutic PTT of 106.8. Urology were consulted and
agreed.  No imaging was recommended given no smoking hx and
other liekly etiology.  When heparin was held the hematuria
resolved and was not present at the time of discharge. Pt
probably had some underlying BPH but no meds were started since
the prostate was probably a bit enlarged due to the foley
trauma.  If the pt continues to have sx's of retention when
returning home he should be seen by a urologist.  His PVR at the
time of d/c was 193.
.
# Loculated L pleural effusion
Pulm was initially conslted for a diagnostic tap but were they
not able to given small effusions and it was almost completely
resolved with diuresis. There was no reason to tap since
remained afebrile without another reason for infection.  teh
most likely etiology we thought was  scar tissue from CABG plus
pulm edema.
.
# Multiple prominent mediastinal lymph nodes.
Largest node in the prevascular space measures 22 x 12 mm. Pt
had left lower lobe and lingular atelectasis that resolved but
radiology recommended followup in six months.
.
# Abnml LFTs: Trended down after admission with diuresis and
almost certainly [**1-28**] congestive hepatopathy from CHF.
.
# Contact: with patient, also wife [**Name (NI) **] [**Name (NI) 21628**] [**Telephone/Fax (1) 77971**]
***FAX this summary to [**Hospital3 14659**] at [**Telephone/Fax (1) 77972**] (ATTN:
[**Doctor First Name 5638**]) at the time of discharge**** Phone [**Telephone/Fax (1) 77973**]

Medications on Admission:
asa 325 mg daily
plavix 75 mg daily
heparin gtt
metoprolol 25 mg TID
Protonix 40 mg daily
Atorvastatin 40 mg daily
hydralazine 20 mg QID
spironolactone 25 mg daily
bumex 2 mg [**Hospital1 **]
digoxin 0.125 mg daily
dobutamine gtt

Discharge Medications:
1. Outpatient Lab Work
please obtain PT q3d as pt. on coumadin
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 8 days.
Disp:*16 Tablet(s)* Refills:*0*
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
Disp:*20 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*15 Tablet(s)* Refills:*2*
10. Losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
# Acute on chronic systolic heart failure, LVEF 20%
# CAD s/p CABG
- [**2162**] @ [**State 4595**]; LIMA to midLAD, SVG to midLCX,
SVG to D2
# Atrial fibrillation with RVR
- digoxin and BB started for rate control
- consider DCCV after antiacoag x1mo
- first noted in [**2167**] but not on coumadin before
# E.Coli UTI and bacteremia, pan-sensitive
- cipro was continued for 14 days
# Multiple prominent mediastinal lymph nodes
- largest node in the prevascular space measures 22 x 12 mm
- left lower lobe and lingular atelectasis; given hx history of
smoking followup is recommended in six
# Persistent Hematuria
- likely [**1-28**] traumatic foley + anticoagulation + UTI -->
resolved by time of d/c
.
Secondary Diagnosis:
# Hypercholesterolemia
# ORIF of L tibial fracture, [**2160**]; hardware subsequently
removed, [**2161**]


Discharge Condition:
Stable


Discharge Instructions:
You were admitted and treated for acute on chronic congestive
heart failure and atrial fibrillation which was making your
heart contract too quickly.
.
If you develop fever greater than 101F, chest pain, shortness of
breath, or if you at any time become concerned about your health
please contact your PCP, [**Name10 (NameIs) 18**] at [**Telephone/Fax (3) **] or present to the
nearest ED.
.
Please take your medications as prescribed.  Not taking your
prescribed heart failure medications likely played a large role
in putting you in acute heart failure.
.
- The cardiology department at [**Hospital3 **] has been contact[**Name (NI) **] by
us on your request and all you have to do is to call and give
them your insurance info and shcedule a time to be seen within 2
weeks.  There are times available but you have to call to make
this appointment.
- Please schedule an appointment to be seen by your primary care
provider [**Name Initial (PRE) 176**] 1-2 weeks.
- It is very important that you go to your doctors office and
have a lab draw on Monday [**3-20**] to have your INR checked and your
coumadin dose adjusted
- If you have recurrence of hematuria or continue to have
difficulty initiating urination, have a stream or frequesnt
visits to the bathroom at night you should set up an appointment
with a urologist.
.
Please weigh yourself daily and call your PCP if you gain >3lbs.
 Please adhere to a diet with <2g sodium day.

Followup Instructions:
- The cardiology department at [**Hospital3 **] has been contact[**Name (NI) **] by
us on your request and all you have to do is to call and give
them your insurance info and shcedule a time to be seen within 2
weeks.  There are times available but you have to call to make
this appointment.
- Please schedule an appointment to be seen by your primary care
provider [**Name Initial (PRE) 176**] 1-2 weeks.
- It is very important that you go to your doctors office and
have a lab draw on Monday [**3-20**] to have your INR checked and your
coumadin dose adjusted
- If you have recurrence of hematuria or continue to have
difficulty initiating urination, have a stream or frequesnt
visits to the bathroom at night you should set up an appointment
with a urologist.





Name:  [**Known lastname 12594**],[**Known firstname 12595**] J                 Unit No:   [**Numeric Identifier 12596**]

Admission Date:  [**2169-3-9**]              Discharge Date:   [**2169-3-16**]

Date of Birth:  [**2104-8-18**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 713**]
Addendum:
The following instructions were added to the discharge
instructions:
- It is very important that you go to your PCP's office (Dr.
[**Last Name (STitle) 12597**]and have a lab draw on Monday [**3-20**] to have your INR checked
and your coumadin dose adjusted. You have an appointment for
this at 3pm.
- You have an appointment to be seen by Dr. [**Last Name (STitle) 12597**] at 10am on
tuesday [**3-21**]. Please make sure to go to this.

Discharge Disposition:
Home

                             [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 714**] MD [**MD Number(1) 715**]

Completed by:[**2169-3-16**]
{'Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Urinary tract infection, site not specified,Bacteremia,Coronary atherosclerosis of unspecified type of vessel, native or graft,Atrial fibrillation,Other and unspecified hyperlipidemia,Enlargement of lymph nodes,Aortocoronary bypass status,Personal history of noncompliance with medical treatment, presenting hazards to health'}


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: transferred for evaluation of exertional dyspnea/acute CHF

PRESENT ILLNESS: This 64M with CAD s/p CABG in [**2162**] for a positive stress test
and hyperlipidemia who stopped taking all his cardiac
medications 8 months ago was traveling in [**State 350**] on
business began experiencing dyspnea and chest pressure after
walking 50-60 feet, which was new for him, four days prior to
admission to this hospital. Two days prior to admission, he was
dyspneic after just 20-25 feet, and presented to an OSH for
evaluation. He was found to be in CHF with marked volume
overload and also in rapid atrial fibrillation.
.
Diuresis was limited by acute renal failure (peak creatinine
1.8, up from 1.4 on admission). Control of atrial fibrillation
was attempted with diltiazem and he was loaded with digoxin.
Runs of NSVT were noted on telemetry. An echocardiogram showed
LVEF 10% and a dilated, hypokinetic RV. CXR showed mild
pulmonary edema. CTPA showed bilateral effusions but was
negative for PE.
.
.
On review of systems, he endorses cough productive of clear,
whitish sputum over the last three weeks. He denies orthopnea,
PND, or ankle edema. He reports a history of presyncope related
to uptitration of antihypertensives in the past and this is why
he self-discontinued beta blockers. He denies symptoms of stroke
or TIA. No history of bleeding problems.

MEDICAL HISTORY: # CAD s/p CABG [**2162**] @ [**State 4595**]; LIMA to midLAD,
SVG to midLCX, SVG to D2
# CHF (EF 10%)
- post-CABG EF 20-30%
# AF, noted at outpatient visit in [**2167**] in MN
# hypercholesterolemia
# ORIF of L tibial fracture, [**2160**]; hardware subsequently
removed, [**2161**]

MEDICATION ON ADMISSION: asa 325 mg daily
plavix 75 mg daily
heparin gtt
metoprolol 25 mg TID
Protonix 40 mg daily
Atorvastatin 40 mg daily
hydralazine 20 mg QID
spironolactone 25 mg daily
bumex 2 mg [**Hospital1 **]
digoxin 0.125 mg daily
dobutamine gtt

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: (on admission)
VS: T:97.6, BP:98/66, HR:111, RR:18, O2: 98% on 2L NC
Gen: obese middle aged male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 16 cm H2O.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, soft S1, paradoxically S2. No m/r/g. No thrills, lifts. No
S3 or S4.
Chest: Breathing with accessory muscles but able to speak in
sentences. Decreased breath sounds at both bases with R > L
crackles at the bases. Scattered wheezing. No rhonchi.
Abd: Obese, NTND. Pulsatile liver.
Groin: 2+ femoral pulses. No bruits
Ext: WWP. 1+ bilateral ankle edema. 2+ DP pulses.
Skin: Slight jaundice. No stasis dermatitis, ulcers, surgical
scar on L ankle, surgical scar along R leg c/w vein harvesting

FAMILY HISTORY: Brother died of sudden cardiac death during a plane flight at
age 62.

SOCIAL HISTORY: Lives with wife in [**State 3706**], works in [**Name (NI) 22441**] but travels
frequently to MA. Denies tobacco or illicit drug use. Drinks a
glass of wine with dinner 2-3 times per week. 

### Response:
{'Acute on chronic systolic heart failure,Acute kidney failure, unspecified,Other primary cardiomyopathies,Urinary tract infection, site not specified,Bacteremia,Coronary atherosclerosis of unspecified type of vessel, native or graft,Atrial fibrillation,Other and unspecified hyperlipidemia,Enlargement of lymph nodes,Aortocoronary bypass status,Personal history of noncompliance with medical treatment, presenting hazards to health'}
