ED 11/16, transferred to another hospital, 3 days in the hospital, discharged on 11/19.  Returned to the clinic on 11/23, then transferred to ED.  Is currently on a Life vest.   11/23/21 clinic provider note: 43yr old male in for a follow-up from hospitalization. He was hospitalized 4 days ago for acute CHF.  He was treated with transfer and has life vest on with defibrillator and told to follow-up with us at this time.  He felt fine walking into clinic and then he got lightheaded, color pale and skin moist and passed out.  Laid down on table.  felet better.  Did sit him him up and gave him some water.  Was feeling better and then he said here it comes again.  Taken to ER per gurney.  BP was 90/60   I have reviewed the patient's medical history in detail and updated the computerized patient record. 11/23/21 ED nurse note: 43yr old male who present from clinic for c/o syncope. Patient states he was in ER and then sent to another hospital with Heart Failure. They are lowering his blood pressure and getting rid of fluid. He was suppose to follow-up today and went to the clinic and started to feel dizzy, couldn't hear and couldn't see. He currently is wearing a life vest.       11/16/21: 43yr old male presents from clinic with complaints of shortness of breathe for "couple weeks"/ Patient states "feels tight in chest on both sides when I take a deep breathe", rates tightness 3/10. Reports he took Pepto at home think it was his stomache acting up.  Pt presented to the clinic with constipation and abd pressure, chest pain. Pt has not had a BM for 1 week. Sent to ED. Weakness and diaphoretic. EKG shows T wave changes, abn, looks like ischemia. Pt hasn't taken BP meds for long time. Anxious. BP 183/120 initial. NTG x 1 SL. ASA given. Pending d-dimer. Will send via ground EMS.    Dr. adv concern for cardiac enlargement Recommendations given for pain management. Will accept. ED STOP. Patient is sent to ER due to SOB, tachycardia, 'chest pressure'.    Referred for sleep apnea evaluation. Patient was recently hospitalized for shortness of breath and hypoxemia with findings of uncontrolled hypertension, non-STEMI and acute systolic cardiomyopathy.  Echocardiogram showed LVEF of 20 to 25% with RVSP of 49.  Diagnostic angiography revealed noncritical CAD .  He is currently improving with medical management especially diuresis.  During this hospitalization, nursing staff reported snoring and apnea as low as 50%, requiring oxygen only during sleep.  No one has reported periodic breathing or Cheyne-Stokes respiration.  Untreated OSA is suspected and may be contributing to the above problems.  He reported his girlfriend acknowledged longstanding snoring and apnea as well as his 2 brothers who are present today.  His weight has increased over the years.  He is a non-smoker and works as a mechanic.  The rest of the review system is negative.  Covid vaccination has been completed.  EKG was done which showed some nonspecific changes such as T wave inversion however no ST elevation.  He was given an aspirin and nitroglycerin.  Initially his blood pressure was 134/84 but he did become more anxious and blood pressure spiked up to 180/124.  Repeat manual shows 164/94.  Troponin has come back positive mildly.  They would like to transfer for further further work-up and treatment.  Patient does have family history of early coronary artery disease.   Vital Signs:             B/P 164/94               pulse 101           RR 20             O2 Sat 98% room air   Physical Exam Findings Relayed From Outlying Provider: As above   Diagnostic Studies: Chest x-ray appears to show cardiomegaly no formal read back yet.  No history of this per provider.  Abdominal x-ray does show moderate stool.  Labs in ED:  D-Dimer; EKG, CBC with diff, BMP, TSH, COVID, chest xray  FINDINGS:  Liver: Left hepatic lobe hemangioma again noted  Gallbladder and bile ducts: Prominent gallbladder wall thickening. No calcified  gallstones  Pancreas: Normal. No ductal dilation.  Spleen: Normal. No splenomegaly.  Adrenal glands: Normal. No mass.  Kidneys and ureters: Normal. No hydronephrosis.  Stomach and bowel: There are scattered diverticuli in the distal colon.  Pericolonic fat planes are preserved. Bowel gas pattern is nonobstructive.  Appendix: No evidence of appendicitis.  Colonic diverticulosis.  stress test, cmp, echocardiogram, cardiac catheterization, troponin, CT abdomen pelvis, CTA chest     Acute heart failure with reduced ejection fraction and diastolic dysfunction Active Problems:   Acute heart failure with reduced ejection fraction and diastolic dysfunction Resolved Problems:   * No resolved hospital problems. *  Plan: New acute heart failure with reduced EF-mild coronary artery disease, nonobstructive -Euvolemic currently, aspirin, statin, beta-blocker, will also need lisinopril Uncontrolled hypertension-improved, continue current meds Elevated troponin-likely demand ischemia CKD 3, hydrate, stable Constipation-stable, continue home meds Full code Estimated Discharge Date: 2 days  Discharge summary: Hospital Course >> This is a 43-year-old male who was admitted to the hospitalist service with new heart failure and fluid retention and upon work up was found to have low  EF of 35%. He underwent angiogram revealing  mild coronary artery disease.  He has been diuresed and treated with optimization of his fluid status and blood pressure and is now discharged home with LifeVest and will follow up with cardiology clinic as, outpatient . He also has probable severe OSA and been dropping his So2 to 50% at night while asleep. Overnight oximetry been done and he will be going home with oxygen and then follow up with pulmonary clinic as out patient for formal sleep study. Patient is discharged home in a much better and stable condition and has the following F/U appointment noted below.