CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: 24 yo female with PMH asthma, GERD presents with asthma
exacerbation. Pt states that she had a URI 3 weeks ago with sx
of congestion, sore throat, dry cough, with residual symptoms
over the past few weeks. Over the past 3 days, pt has developed
increasing SOB and increasing usage of albuterol nebs ~q1.5
hours. Her usually triggers are URIs, environmental triggers
such as pollen in the spring, and the winter season. She denies
any significant symptoms with exercise or exertion. She believes
her current trigger may have been the URI; she also went
outdoors 3 days ago. Denies recent sx of productive cough.
States a fever of 101 a few weeks ago. Her baseline peak flow is
350.
.
ROS: CP with coughing. Vomited x 1 yesterday. No abd pain,
dysuria.
.
In the ED her initial vitals were 98, p72, 135/81, rr30,
rr99%RA. Initial peak flow was 280. She was given frequent nebs,
prednisone 60mg x 1, magnesium 2gm over the course of 9am to
midnight. Peak flow improved to 330. In the evening around 10pm,
pt c/o feeling tired out and continued to have SOB and was
placed on continuous nebs and tx to the unit. CXR with
peribronchial cuffing, but no infiltrate. VBG was 7.45/35/38.
.
On admission to the [**Hospital Unit Name 153**], vitals were stable with O2 sat 100% on
RA and RR 15-20. During the first part of our conversation, pt
appearing to be breathing comfortably and able to complete full
sentences. Continuous nebs were removed briefly, after which pt
began to make erratic bilateral eye movements and c/o double
vision. then began to look increasingly SOB with use of
accessory muscles. ABG was 7.56/23/98 on RA. Pt was placed back
on continuous nebs and RR decreased to 14 and pt appeared more
comfortable. A repeat ABG on neb showed 7.47/32/286/24

MEDICAL HISTORY: Asthma
-2 ED visits/hospitalizations in [**2144**], last [**11/2144**]
-never been intubated
GERD

MEDICATION ON ADMISSION: Advair diskus
Albuterol in prn
Atrovent qid
Claritin

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: t95.3, p74, 144/88, rr20, 100%RA
Gen: see HPI above
HEENT: PERRL, clear OP
CVS: RRR, nl s1 s2, no m/g/r
Lungs: diffuse expiratory wheezing
Abd: soft, NT, ND, +BS
Ext: no edema
Neuro: difficulty with eye movements. [**5-29**] bilateral upper
extremity strength. Repeat exam revealed improved ability to
follow finger with eyes, CN o/w intact, 4+ bilateral LE
strength.

FAMILY HISTORY: First cousins with asthma.

SOCIAL HISTORY: Single mom of 3.5yo son. [**Name (NI) **] BF. Smokes 2pk/wk for past 10
years; quit 5 months ago. Works as medical assistant. Drinks 2-3
times a month. Denies drugs.
Asthma, unspecified type, with (acute) exacerbation,Acute respiratory failure,Myasthenia gravis with (acute) exacerbation,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acquired coagulation factor deficiency,Esophageal reflux,Infection with microorganisms resistant to penicillins,Hypopotassemia
Asthma NOS w (ac) exac,Acute respiratry failure,Myasthna gravs w ac exac,Meth sus pneum d/t Staph,Acq coagul factor defic,Esophageal reflux,Inf mcrg rstn pncllins,Hypopotassemia
Admission Date:  [**2145-5-18**]              Discharge Date:   [**2145-6-1**]

Date of Birth:  [**2120-12-21**]             Sex:   F

Service: NEUROLOGY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
Plasmapheresis
Central line placement
PICC line placement

History of Present Illness:
24 yo female with PMH asthma, GERD presents with asthma
exacerbation. Pt states that she had a URI 3 weeks ago with sx
of congestion, sore throat, dry cough, with residual symptoms
over the past few weeks. Over the past 3 days, pt has developed
increasing SOB and increasing usage of albuterol nebs ~q1.5
hours. Her usually triggers are URIs, environmental triggers
such as pollen in the spring, and the winter season. She denies
any significant symptoms with exercise or exertion. She believes
her current trigger may have been the URI; she also went
outdoors 3 days ago. Denies recent sx of productive cough.
States a fever of 101 a few weeks ago. Her baseline peak flow is
350.
.
ROS: CP with coughing. Vomited x 1 yesterday. No abd pain,
dysuria.
.
In the ED her initial vitals were 98, p72, 135/81, rr30,
rr99%RA. Initial peak flow was 280. She was given frequent nebs,
prednisone 60mg x 1, magnesium 2gm over the course of 9am to
midnight. Peak flow improved to 330. In the evening around 10pm,
pt c/o feeling tired out and continued to have SOB and was
placed on continuous nebs and tx to the unit. CXR with
peribronchial cuffing, but no infiltrate. VBG was 7.45/35/38.
.
On admission to the [**Hospital Unit Name 153**], vitals were stable with O2 sat 100% on
RA and RR 15-20. During the first part of our conversation, pt
appearing to be breathing comfortably and able to complete full
sentences. Continuous nebs were removed briefly, after which pt
began to make erratic bilateral eye movements and c/o double
vision. then began to look increasingly SOB with use of
accessory muscles. ABG was 7.56/23/98 on RA. Pt was placed back
on continuous nebs and RR decreased to 14 and pt appeared more
comfortable. A repeat ABG on neb showed 7.47/32/286/24


Past Medical History:
Asthma
-2 ED visits/hospitalizations in [**2144**], last [**11/2144**]
-never been intubated
GERD

Social History:
Single mom of 3.5yo son. [**Name (NI) **] BF. Smokes 2pk/wk for past 10
years; quit 5 months ago. Works as medical assistant. Drinks 2-3
times a month. Denies drugs.

Family History:
First cousins with asthma.

Physical Exam:
VS: t95.3, p74, 144/88, rr20, 100%RA
Gen: see HPI above
HEENT: PERRL, clear OP
CVS: RRR, nl s1 s2, no m/g/r
Lungs: diffuse expiratory wheezing
Abd: soft, NT, ND, +BS
Ext: no edema
Neuro: difficulty with eye movements. [**5-29**] bilateral upper
extremity strength. Repeat exam revealed improved ability to
follow finger with eyes, CN o/w intact, 4+ bilateral LE
strength.

Pertinent Results:
[**2145-5-18**] 09:40AM   WBC-5.6 RBC-4.86 HGB-14.7 HCT-42.5 MCV-88
MCH-30.3 MCHC-34.6 RDW-13.5
[**2145-5-18**] 09:40AM   NEUTS-56.4 LYMPHS-31.8 MONOS-4.0 EOS-5.5*
BASOS-2.4*
[**2145-5-18**] 11:01PM   freeCa-1.16
[**2145-5-18**] 11:01PM   TYPE-ART PO2-38* PCO2-35 PH-7.45 TOTAL CO2-25
BASE XS-0 COMMENTS-IONIZED CA
.
CXR: No focal infiltrates are identified.  There is mild
peribronchial cuffing noted bilaterally (left greater than
right).  No evidence of pneumothorax, pulmonary edema, or
pleural effusions.  Cardiomediastinal silhouette and hilar
contours are unremarkable. IMPRESSION: Mild bilateral
peribronchial cuffing may suggest underlying bronchitis with no
focal infiltrates or pneumothorax identified.
.
EMG ([**2145-5-20**]): Motor nerve conduction studies (NCSs) of the
right median and left tibial nerves were normal, including F
responses. Sensory NCSs of the right median and left sural
nerves were normal. Slow (3-Hz) repetitive nerve stimulation of
the right facial nerve produced an abnormal decrement of 11.5%
which was not reproduced on further testing of the right facial
nerve. Exercise testing was not possible due to the patient's
mental status. Concentric needle electromyography (EMG) of right
deltoid, biceps, and tibialis posterior was normal. EMG of right
vastus lateralis showed normal insertional activity and no motor
unit activity due to the patient's sedation. Single-fiber EMG
was not possible secondary to the patient's mental status.
IMPRESSION: Nondiagnostic study. Based on the studies performed,
a disorder of neuromuscular transmission (as in myasthenia
[**Last Name (un) 2902**] or botulism) or a demyelinating polyneuropathy cannot be
definitively excluded.
.
CT chest/abd/pelvis ([**2145-5-24**]): 1.  Multifocal pulmonary
opacities concerning for right upper lobe and left lower lobe
pneumonia or aspiration. The more mass-like 2.1 cm airspace
opacity in the left lower lobe has an atypical appearance for
infection and dedicated imaging following treatment to exclude
underlying mass is recommended. 2.  No acute intra-abdominal
process to explain the patient's pain.  The appendix is not
visualized, however there are no inflammatory changes in the
right lower quadrant. 3.  Incidentally noted malrotation of the
small bowel. 4.  Residual thymic tissue with no evidence of a
thymoma.
.

Brief Hospital Course:
The patient was admitted with apparent complaints of an asthma
exacerbation, incluidng shortness of breath and decreased peak
flow. The patient was started on nebulizers and oral steroids
with some improvement in peak flow. The patient had persistent
shortness of breath with complaints of fatigue including
clinical signs of respiratory distress, including use of
accessory muscles. On ABG she was found to have hypoxemia. The
patient had no signs of an acute infiltrate on chest x-ray.
The ICU team noted that the patient had diplopia, extraocular
muscle paresis in addition to the respiratory weakness and
called a neurology consult.  She was clinically diagnosed with
myasthenia [**Last Name (un) 2902**] on the day after admission.

Two days after admission, the patient developed myasthenic
crisis with respiratory failure requiring intubation and
plasmapheresis. The patient had a nondiagnositc EMG revealing a
disorder of neuromuscular transmission (differential of
myasthenia vs. botulinum) or a demyelinating polyneuropathy.
AchR Ab and modulating Ab were negative. Botulinum toxin was
negative.  The patient underwent plasmapheresis every other day
x10 days (5 total treatments) with good response. The patient
was successfully extubated on [**2145-5-28**]. She was started on
pyridostigmine 60mg q8h and called out to the general neurology
service.
.
The patient's ICU course was complicated by a ventilator
associated pneumonia with growth of MSSA and H. Flu beta
lactamase positive in the sputum. The patient will complete a 14
day total course of MSSA coverage. She was started on vanco (day
1: [**2145-5-26**]) though she was then switched to a 14 day course
with bactrim once sensitivities returned, given her history of
allergy to penicillin. The patient's MSSA coverage will complete
on [**2145-6-8**]. The patient will complete a 10 day total course of
azithromycin for the H. Flu (day 1: [**2145-5-26**], to be completed on
[**2145-6-4**]). The patient will complete a longer than usual course
of both antibiotics given recent plasmapheresis and possible
complication of underdosing due to drug removal with pheresis.
.
She was also found to have an lung nodule discovered
incidentally on CT scan.  Patient needs to have f/u CT scan in 6
months to follow R lung nodule.
.
The patient remained stable on the floor, although her
neurological exam still showed evidence of mild residual
fatiguability.  Thymectomy was discussed with the patient at
length, as was the seriousness of her medical condition.  She
was started of Prednisone 20 mg PO QOD and Mycophenolate Mofetil
500 mg PO BID, in addition to the pyridostigmine 60mg q8h.  She
was discharged in stable condition, on these medications,along
with her usual home meds (advair, ranitidine, albuterol) and her
remaining antibiotics (bactrim and azithromycin) with scheduled
appointments with neurology and pulmonary.


Medications on Admission:
Advair diskus
Albuterol in prn
Atrovent qid
Claritin

Discharge Medications:
1. Mycophenolate Mofetil 250 mg Capsule Sig: Two (2) Capsule PO
BID (2 times a day).
Disp:*120 Capsule(s)* Refills:*0*
2. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
Disp:*2 Capsule(s)* Refills:*0*
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*14 Tablet(s)* Refills:*0*
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*0*
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours).
Disp:*90 Tablet(s)* Refills:*0*
7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*0*
8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) inhaler
Inhalation four times a day as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
myasthenia [**Last Name (un) 2902**]
pneumonia
asthma


Discharge Condition:
stable


Discharge Instructions:
You have myasthenia [**Last Name (un) 2902**]. You need to follow up with your
primary care doctor and your neurologist. In addition, you have
a nodule on your chest CT. This may represent an infection or a
cancer. You need to have a follow up CT scan in 6 months. Please
work with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] this study.

Take all medications EXACTLY as prescribed.  You must finish all
of your antibiotics even if you are feeling better.  Not taking
all of your antibiotics can lead to a relapse.

You are on three medications for your myasthenia [**Last Name (un) 2902**]:
prednisone, mycophenolate mofetil. and pyridostigmine.  You must
take these medications as they are prescribed.  If you stop
taking these medications or miss too many doses, you are at high
risk of having a relapse which could lead to needing to be
brought back to the hospital.

If you have any fevers, chills, worsening weakness, or any other
concerning symptoms, either call your doctor or come to the
emergency room.

Followup Instructions:
1. PULMONARY:
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2145-7-1**] 7:40 on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] building
followed immediately by...
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2145-7-1**] 8:00

2. PRIMARY CARE: please call to make a follow appointment with
your primary care doctor in [**3-28**] weeks.  At that visit you should
discuss this hospitalization.  Please take these papers with you
to the visit.
- CT chest in 6 months to evaluate progression of right lung
nodule.

3. Neurology
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2145-6-15**] 8:00


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
{'Asthma, unspecified type, with (acute) exacerbation,Acute respiratory failure,Myasthenia gravis with (acute) exacerbation,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acquired coagulation factor deficiency,Esophageal reflux,Infection with microorganisms resistant to penicillins,Hypopotassemia'}


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: Shortness of breath

PRESENT ILLNESS: 24 yo female with PMH asthma, GERD presents with asthma
exacerbation. Pt states that she had a URI 3 weeks ago with sx
of congestion, sore throat, dry cough, with residual symptoms
over the past few weeks. Over the past 3 days, pt has developed
increasing SOB and increasing usage of albuterol nebs ~q1.5
hours. Her usually triggers are URIs, environmental triggers
such as pollen in the spring, and the winter season. She denies
any significant symptoms with exercise or exertion. She believes
her current trigger may have been the URI; she also went
outdoors 3 days ago. Denies recent sx of productive cough.
States a fever of 101 a few weeks ago. Her baseline peak flow is
350.
.
ROS: CP with coughing. Vomited x 1 yesterday. No abd pain,
dysuria.
.
In the ED her initial vitals were 98, p72, 135/81, rr30,
rr99%RA. Initial peak flow was 280. She was given frequent nebs,
prednisone 60mg x 1, magnesium 2gm over the course of 9am to
midnight. Peak flow improved to 330. In the evening around 10pm,
pt c/o feeling tired out and continued to have SOB and was
placed on continuous nebs and tx to the unit. CXR with
peribronchial cuffing, but no infiltrate. VBG was 7.45/35/38.
.
On admission to the [**Hospital Unit Name 153**], vitals were stable with O2 sat 100% on
RA and RR 15-20. During the first part of our conversation, pt
appearing to be breathing comfortably and able to complete full
sentences. Continuous nebs were removed briefly, after which pt
began to make erratic bilateral eye movements and c/o double
vision. then began to look increasingly SOB with use of
accessory muscles. ABG was 7.56/23/98 on RA. Pt was placed back
on continuous nebs and RR decreased to 14 and pt appeared more
comfortable. A repeat ABG on neb showed 7.47/32/286/24

MEDICAL HISTORY: Asthma
-2 ED visits/hospitalizations in [**2144**], last [**11/2144**]
-never been intubated
GERD

MEDICATION ON ADMISSION: Advair diskus
Albuterol in prn
Atrovent qid
Claritin

ALLERGIES: Penicillins

PHYSICAL EXAM: VS: t95.3, p74, 144/88, rr20, 100%RA
Gen: see HPI above
HEENT: PERRL, clear OP
CVS: RRR, nl s1 s2, no m/g/r
Lungs: diffuse expiratory wheezing
Abd: soft, NT, ND, +BS
Ext: no edema
Neuro: difficulty with eye movements. [**5-29**] bilateral upper
extremity strength. Repeat exam revealed improved ability to
follow finger with eyes, CN o/w intact, 4+ bilateral LE
strength.

FAMILY HISTORY: First cousins with asthma.

SOCIAL HISTORY: Single mom of 3.5yo son. [**Name (NI) **] BF. Smokes 2pk/wk for past 10
years; quit 5 months ago. Works as medical assistant. Drinks 2-3
times a month. Denies drugs. 

### Response:
{'Asthma, unspecified type, with (acute) exacerbation,Acute respiratory failure,Myasthenia gravis with (acute) exacerbation,Methicillin susceptible pneumonia due to Staphylococcus aureus,Acquired coagulation factor deficiency,Esophageal reflux,Infection with microorganisms resistant to penicillins,Hypopotassemia'}
