CHIEF COMPLAINT: Cardiac Arrest

PRESENT ILLNESS: 71M with hx of MI in [**2081**] medically managed, AFib on coumadin,
and IDDM2 who was headed to the gym when he felt dizzy in his
car. He got out and collapsed and was found by bystander. Denies
LOC (although family states he is a poor historian) ambulance
was called and he was found to be in monomorphic vtach with
pulse. Was shocked into polymorphic VT and got amiodarone, went
into vfib (although no strip evidence of this) and was shocked
again with return to NSR with prolonged PR and STE but was alert
and interactive. Was BIBA to our ED.
.
ED/Cath Lab Course: VS: HR 72, BP 142/84, O2 97%NRB
Per report, EKG in ED with RBBB and prolonged PR. Given ASA 325
and Plavix 600mg. Code STEMI and was transferred to cath lab,
found to have 60-70% occluded Mid LAD, total occlusion of RCA
and circumflex. No intervention taken as occlusions did not
appear to be acute. Received 4000 U of Heparin on table.
Transferred to CCU.
.
In unit, he is alert, oriented, interactive and asymptomatic. He
corroborates much of the above story. Denies chest pain, SOB,
lightheadedness, weakness, numbness, or tingling. He denies
recent illness, changes in health, prodromal syndromes, recent
syncope, pre-syncope or other symptoms of concern to him.
.
He additionally denies any prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. S/he denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

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

MEDICATION ON ADMISSION: - Coumadin 5mg PO daily
- Metoprolol succinate 100mg PO daily
- Diltiazem CD 120mg PO daily
- HCTZ 25mg PO daily
- Lisinopril 40mg PO daily
- Metformin SR 500mg X 2 PO daily
- Simvastatin 80mg PO daily
- Aspirin 81mg PO daily
- Insulin Aspart 70/30 38 units QAM and QDinner
- NTG 0.4mg SL PRN (hasn't taken in years)
- Elocon 0.1% cream once daily PRN itch

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
VS: T=95.4 BP= 126/70 HR= 70 RR= 14 O2 sat= 994LNC
GENERAL: NAD. AOx3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Dry MMM, no
xanthalesma.
NECK: Supple with JVP of 2 cm above sternal angle at 25 degrees.

FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: - Tobacco history:  30+ pack years, quit in [**2081**]
- ETOH: None
- Illicit drugs: None
Paroxysmal ventricular tachycardia,Acute systolic heart failure,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Old myocardial infarction,Personal history of tobacco use,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Mitral valve disorders,Leukocytosis, unspecified
Parox ventric tachycard,Ac systolic hrt failure,Acute kidney failure NOS,Crnry athrscl natve vssl,DMII renl nt st uncntrld,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Long-term use of insulin,Hyperlipidemia NEC/NOS,Old myocardial infarct,History of tobacco use,BPH w/o urinary obs/LUTS,Mitral valve disorder,Leukocytosis NOS
Admission Date:  [**2108-10-26**]              Discharge Date:   [**2108-11-2**]

Date of Birth:  [**2035-3-26**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Cardiac Arrest

Major Surgical or Invasive Procedure:
1. Left ventricle [**First Name3 (LF) 33362**]
2. Implanted cardiodefibrilator device (ICD) placement


History of Present Illness:
71M with hx of MI in [**2081**] medically managed, AFib on coumadin,
and IDDM2 who was headed to the gym when he felt dizzy in his
car. He got out and collapsed and was found by bystander. Denies
LOC (although family states he is a poor historian) ambulance
was called and he was found to be in monomorphic vtach with
pulse. Was shocked into polymorphic VT and got amiodarone, went
into vfib (although no strip evidence of this) and was shocked
again with return to NSR with prolonged PR and STE but was alert
and interactive. Was BIBA to our ED.
.
ED/Cath Lab Course: VS: HR 72, BP 142/84, O2 97%NRB
Per report, EKG in ED with RBBB and prolonged PR. Given ASA 325
and Plavix 600mg. Code STEMI and was transferred to cath lab,
found to have 60-70% occluded Mid LAD, total occlusion of RCA
and circumflex. No intervention taken as occlusions did not
appear to be acute. Received 4000 U of Heparin on table.
Transferred to CCU.
.
In unit, he is alert, oriented, interactive and asymptomatic. He
corroborates much of the above story. Denies chest pain, SOB,
lightheadedness, weakness, numbness, or tingling. He denies
recent illness, changes in health, prodromal syndromes, recent
syncope, pre-syncope or other symptoms of concern to him.
.
He additionally denies any prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. S/he denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

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

2. CARDIAC HISTORY:  MI in [**2081**], no interventions
- CABG:  none
- PERCUTANEOUS CORONARY INTERVENTIONS: none
- PACING/ICD:  none
3. OTHER PAST MEDICAL HISTORY:
- Atrial fibrillation, on coumadin, INR 4.6 last week.
- IDDM type 2
- 30+ pack-year smoking
- BPH s/p TURP
- CKD (baseline Cr 1.4)

Social History:
- Tobacco history:  30+ pack years, quit in [**2081**]
- ETOH: None
- Illicit drugs: None

Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.

Physical Exam:
ADMISSION EXAM
VS: T=95.4 BP= 126/70 HR= 70 RR= 14 O2 sat= 994LNC
GENERAL: NAD. AOx3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Dry MMM, no
xanthalesma.
NECK: Supple with JVP of 2 cm above sternal angle at 25 degrees.

CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2 with physiologic split. No m/r/g. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Obese, Soft, NTND. No HSM or tenderness. No abdominial
bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Trace-1+ pitting edema
at ankles b/l
SKIN: Xerosis, onychomycosis, and chronic stasis changes at
shins bilaterally
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP [**1-1**]+ PT [**1-1**]+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP [**1-1**]+ PT [**1-1**]+
.
DISCHARGE EXAM:
VS: T=97.8 BP= 134/76 HR= 81 RR= 16 O2 sat= 99RA
GENERAL: NAD. AOx3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Dry MMM, no
xanthalesma.
NECK: Supple with JVP of 1 cm above sternal angle at 25 degrees.

CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2 with physiologic split. No m/r/g. No
thrills, lifts. No S3 or S4. Cannot appreciate MR found on ECHO
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Obese, Soft, NTND. No HSM or tenderness. No abdominial
bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Trace-1+ pitting edema
at ankles b/l
SKIN: Xerosis, onychomycosis, and chronic stasis changes at
shins bilaterally
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP [**1-1**]+ PT [**1-1**]+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP [**1-1**]+ PT [**1-1**]+

Pertinent Results:
ADMISSION LABS:
[**2108-10-26**] 10:58AM   WBC-15.0* RBC-5.25 HGB-15.7 HCT-46.0 MCV-88
MCH-29.9 MCHC-34.2 RDW-13.1
[**2108-10-26**] 10:58AM   NEUTS-66.8 LYMPHS-24.7 MONOS-5.1 EOS-3.1
BASOS-0.4
[**2108-10-26**] 10:58AM   PLT COUNT-264
[**2108-10-26**] 12:44PM   GLUCOSE-357* UREA N-20 CREAT-1.5* SODIUM-133
POTASSIUM-6.5* CHLORIDE-97 TOTAL CO2-24 ANION GAP-19
[**2108-10-26**] 12:44PM   CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-1.8
CHOLEST-134
[**2108-10-26**] 02:21PM   ALT(SGPT)-172* AST(SGOT)-181* LD(LDH)-312*
ALK PHOS-83 TOT BILI-1.3
[**2108-10-26**] 12:44PM   PT-30.5* PTT-42.8* INR(PT)-3.0*
.
PERTINENT LABS:
[**2108-10-26**] 02:21PM BLOOD CK-MB-5 cTropnT-0.05*
[**2108-10-27**] 05:45AM BLOOD CK-MB-4 cTropnT-0.03*
[**2108-10-26**] 12:44PM BLOOD %HbA1c-12.6* eAG-315*
.
DISCHARGE LABS:
[**2108-11-2**] 05:46AM BLOOD WBC-10.6 RBC-4.65 Hgb-13.6* Hct-40.3
MCV-87 MCH-29.1 MCHC-33.6 RDW-12.9 Plt Ct-206
[**2108-11-2**] 05:46AM BLOOD Glucose-182* UreaN-38* Creat-1.6* Na-135
K-4.5 Cl-99 HCO3-25 AnGap-16
.
CARDIAC CATH [**2108-10-26**]
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrates three vessel coronary artery disease. The left
atnerior
descending contains a 60-70% lesion in the mid-vessel. The right

coronary artery is chronically occluded. The circumflex artery
is
calcified and stenosedin the second obtuse marginal to 50%. \

FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
.
ECHO [**2108-10-26**]
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is a
left ventricular aneurysm involving the basal inferior and
posterior walls. Overall left ventricular systolic function is
moderately depressed (LVEF= 35 %) secondary to extensive
inferior and posterior akinesis. Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
The right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with depressed free wall
contractility. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. The mitral valve leaflets do not
fully coapt secondary to posterior displacement of the papillary
muscles and consequent mitral leaflet tethering. Moderate to
severe (3+) mitral regurgitation is seen. There is no
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
.
ECHO [**2108-10-29**]
LV systolic function appears depressed. The right ventricle is
mildy dilated with normal free wall contractility. An eccentric
jet of mld to moderate ([**1-1**]+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is a
trivial/physiologic pericardial effusion. There is an anterior
space which most likely represents a prominent fat pad.
Compared with the prior study (images reviewed) of [**2108-10-26**],
findings are similar.
.
CXR [**2108-11-1**]
IMPRESSION: Appropriately placed pectoral ICD and leads.
Interval
improvement of the pulmonary vascular bed.

CARDIAC MR

1. Normal left ventricular cavity size with normal regional left
ventricular systolic function. The LVEF was moderately depressed
at 38%. CMR evidence of prior myocardial scarring/infarction, in
a right coronary artery distribution, with late gadolinium
contrast-enhanced CMR images demonstrating areas of
hyperenhancement as described above.
2. Normal right ventricular cavity size and systolic function.
The RVEF was mildly depressed at 47%.
3. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was normal.
4. Mild left atrial enlargement.
5. Mild pulmonic regurgitation.


Brief Hospital Course:
71M with hx of MI in [**2081**] medically managed, AFib on coumadin,
and poorly-controlled IDDM2 who collapsed in parking lot found
to be in monomorphic VT s/p amiodarone and defibrillator x 2
with significant MVD on cath without evidence of acute ischemia.

.
ACTIVE ISSUES:
# Spontaneous monomorphic VT/Out-of-Hospital Cardiac Arrest:
First time event for this patient, requiring defibrillation in
the field. Cardiac cath showed three vessel disease but no
evidence of active ischemia. Cardiac enzymes were elevated but
likely from defib x 2. Likely related to scarring from remote
posterior RCA-distribution MI as well as MR. [**First Name (Titles) **] [**Last Name (Titles) 33362**] and
ablation was attempted bhowever the focus was not found and no
ablation was performed. An ICD was succesfully placed.
.
#MR/ Systolic CHF: EF 40% with moderate MR. [**First Name (Titles) **] [**Last Name (Titles) **] overloaded
during this admission and was diuresed with IV lasix. His
metoprolol, diltiazem, and hctz were stopped and carvedilol,
lisinopril, spironolactone and furosemide were started.
.
# Acute Kidney Injury on CKD: He had a briew creatinine
elevation from his baseline ~1.4 to 1.9 likely from diuresis and
contrast from catheterization. His creatinine decreased to 1.6
on discharge. His metformin was discontinued to avoid lactic
acidosis given his elevated creatinine.
.
# IDDM2: HbA1c 12.6 on admission which indicates average BSL of
~370. Hi shome regimen included insulin 70/30 and metformin.
Sugars  under better control in the hospital on same insulin
without metformin. This suggest poor medication or diet
compliance outside of hospital.
.
#Atrial fibrilation: CHADS score of 4. His coumadin was held for
his ICD placement and then restarted at his home dose. On
discharge his INR was 1.4
.
#CAD: S/p cardaic cath [**10-26**]. Chronic-appearing occlusions of
RCA, 60-70% mid LAD occlusion, and branch off of circumflex. No
intervention done. No evidence of acute ischemia. On carvedilol,
lisinopril and aspirin
.
#HTN: His metoprolol, diltiazem, and hctz were stopped and
carvedilol, lisinopril, spironolactone and furosemide were
started.
.
# HLD: Total chol 153, HDL 45, LDL 81 in 8/[**2107**]. Simvastatin was
decreased to 40mg based on recent FDA warning and possibility of
requiring amiodarone which would interact with simvastatin.
.
TRANSITIONAL ISSUES:
.
#HbA1c: His HbA1c on admission was 12.6 which indicates an
average daily blood sugar level in the 300's. There is concern
regarding his access to medcations/insulin (he denies
significant issues but this is unclear) and his medication
compliance. His sugars have been in the mid-100 to mid 200's
range in-house on his home insulin regimen. He will need
especially close follow-up for this issue.
.
#ICD Placement: He has a new ICD device placed. He has been set
up with follow-up with the [**Hospital1 18**] device clinic.
.
#Afib on Coumadin: Pt has been on coumadin as an outpatient. He
will need continued close follow-up of his INR levels
.
#Transaminitis: Pt found to have transaminitis around his
cardiac arrest. Believed to be related to poor forward flow
during the resuscitative effort. Would continue to trend these
in clinic and conduct a workup if they do not normalize.
.
#Creatinine and Metformin: Pt has an elevated Cr of 1.6 at the
time of discharge (it seems his baseline in ~1.4). We would
recommend following his Cr and re-starting his metformin when it
returns to his baseline

Medications on Admission:
- Coumadin 5mg PO daily
- Metoprolol succinate 100mg PO daily
- Diltiazem CD 120mg PO daily
- HCTZ 25mg PO daily
- Lisinopril 40mg PO daily
- Metformin SR 500mg X 2 PO daily
- Simvastatin 80mg PO daily
- Aspirin 81mg PO daily
- Insulin Aspart 70/30 38 units QAM and QDinner
- NTG 0.4mg SL PRN (hasn't taken in years)
- Elocon 0.1% cream once daily PRN itch

Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Elocon 0.1 % Cream Sig: One (1)  Topical once a day as needed
for itching.
7. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual PRN as needed for pain: x3 as needed for chest pain.

8. Insulin 70/30
38 units at breakfast and 38 units at dinner
9. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. simvastatin 80 mg Tablet Sig: 0.5 Tablet PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnoses:
Ventricular tachycardia
Implanted cardiodefibrilator placement
Hypertension
Systolic congestive heart failure

Secondary Diagnoses:
Diabetes
Coronary artery disease
Atrial fibrilation
Hyperlipidemia
Chronic kidney disease


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


Discharge Instructions:
Dear Mr [**Known lastname **],
Thank you for coming to the [**Hospital1 1170**]. It was a pleasure taking care of you. You were in the
hospital because you had a dangerous, irregular heart rhythm.
The cardiologist placed an ICD device that will prevent your
heart from going in to this rhythm. We also made a few changes
in your medications.

Medication summary:
Please stop Diltiazem
Please stop metoprolol
please stop hydrochlorothiazide
please stop metformin
Please start carvedilol 25 mg twice a day
Please start furosemide 20 mg daily
please start spironolactone 25 mg daily
please decrease simvastatin to 40 mg daily
please continue taking all other medications as you have been

It was a pleasure taking part in your medical care.

Followup Instructions:
Please attend the following appointments:

Name: [**Last Name (LF) 41433**],[**First Name3 (LF) **]
Location: [**University/College **] PRIMARY CARE MEDICINE
Address: [**Street Address(2) **], [**University/College **],[**Numeric Identifier 3471**]
Phone: [**Telephone/Fax (1) 41434**]
Appointment: TUESDAY [**11-6**] AT 9:40AM

Department: CARDIAC SERVICES
When: THURSDAY [**2108-11-8**] at 10:00 AM
With:  DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Name: SHEFTEL,[**Name6 (MD) **] L MD
Specialty: CARDIOLOGY
Address: [**2108**], STE#562, [**Location (un) **],[**Numeric Identifier 8934**]
Phone: [**Telephone/Fax (1) 18278**]
Appointment: MONDAY [**12-3**] AT 1:20PM

Department: CARDIAC SERVICES
When: FRIDAY [**2108-12-7**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Paroxysmal ventricular tachycardia,Acute systolic heart failure,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Old myocardial infarction,Personal history of tobacco use,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Mitral valve disorders,Leukocytosis, 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: Cardiac Arrest

PRESENT ILLNESS: 71M with hx of MI in [**2081**] medically managed, AFib on coumadin,
and IDDM2 who was headed to the gym when he felt dizzy in his
car. He got out and collapsed and was found by bystander. Denies
LOC (although family states he is a poor historian) ambulance
was called and he was found to be in monomorphic vtach with
pulse. Was shocked into polymorphic VT and got amiodarone, went
into vfib (although no strip evidence of this) and was shocked
again with return to NSR with prolonged PR and STE but was alert
and interactive. Was BIBA to our ED.
.
ED/Cath Lab Course: VS: HR 72, BP 142/84, O2 97%NRB
Per report, EKG in ED with RBBB and prolonged PR. Given ASA 325
and Plavix 600mg. Code STEMI and was transferred to cath lab,
found to have 60-70% occluded Mid LAD, total occlusion of RCA
and circumflex. No intervention taken as occlusions did not
appear to be acute. Received 4000 U of Heparin on table.
Transferred to CCU.
.
In unit, he is alert, oriented, interactive and asymptomatic. He
corroborates much of the above story. Denies chest pain, SOB,
lightheadedness, weakness, numbness, or tingling. He denies
recent illness, changes in health, prodromal syndromes, recent
syncope, pre-syncope or other symptoms of concern to him.
.
He additionally denies any prior history of stroke, TIA, deep
venous thrombosis, pulmonary embolism, bleeding at the time of
surgery, myalgias, joint pains, cough, hemoptysis, black stools
or red stools. S/he denies recent fevers, chills or rigors. S/he
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

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

MEDICATION ON ADMISSION: - Coumadin 5mg PO daily
- Metoprolol succinate 100mg PO daily
- Diltiazem CD 120mg PO daily
- HCTZ 25mg PO daily
- Lisinopril 40mg PO daily
- Metformin SR 500mg X 2 PO daily
- Simvastatin 80mg PO daily
- Aspirin 81mg PO daily
- Insulin Aspart 70/30 38 units QAM and QDinner
- NTG 0.4mg SL PRN (hasn't taken in years)
- Elocon 0.1% cream once daily PRN itch

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
VS: T=95.4 BP= 126/70 HR= 70 RR= 14 O2 sat= 994LNC
GENERAL: NAD. AOx3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Dry MMM, no
xanthalesma.
NECK: Supple with JVP of 2 cm above sternal angle at 25 degrees.

FAMILY HISTORY: - No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: - Tobacco history:  30+ pack years, quit in [**2081**]
- ETOH: None
- Illicit drugs: None 

### Response:
{'Paroxysmal ventricular tachycardia,Acute systolic heart failure,Acute kidney failure, unspecified,Coronary atherosclerosis of native coronary artery,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Old myocardial infarction,Personal history of tobacco use,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Mitral valve disorders,Leukocytosis, unspecified'}
