HPI:
A 60 year old African American female with known seizure disorder, CAD, HTN, CHF (EF 15%) and history of CABG presents to the ED with a chief complaint of shortness of breath and lower abdominal pain for over a week. She describes the abdominal pain as "dull" and "difficult to pinpoint." No radiation to the back. Onset of the pain was insidious, and the pain has been constant and unrelenting. She denies alleviating or aggravating factors. Review of systems is negative for chest pain, dysuria, constipation, diarrhea, syncopal events, seizure, anuria.

PMHx:
Multivessel CABG 1992
CAD
CHF with EF 10-15%
Restricitve Lung Disease
Seizure Disorder
HTN
Tobacco Abuse

Social Hx: 1 ppd smoker, remote etoh, drug use. Has not worked in years secondary to her medical problems.

Meds: Dilantin, Keppra, Insulin, Aspirin, Lisinopril, Lopressor, Lanoxin

Exam

VS: 98.4, 108, 26, 151/94, pulse ox 97% on room air
GEN: Nontoxic appearance, alert and oriented x 3, unlabored respirations
LUNGS: Bilateral Rales, no ronchi or wheeze present
CV: RRR, +S3 gallop, no S4, no murmur present
ABD: nondistended, no rebound or guarding, but tender in the periumbilical area.
EXT: pitting edema bilaterally to the knees
SKIN: Warm, dry. No acute or chronic rashes present.

Significant Labs:

BNP 4600
Hb 15.1
Plt 107
Chem 7 normal
CXR Pulmonary edema
EKG Chronic changes, no specific ST/T wave changes

What is your initial plan?

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