CHIEF COMPLAINT: Respiratory distress

PRESENT ILLNESS: Mr. [**Known lastname 10794**] is a 52M with h/o dilated CM (EF 30-35% on [**2195-12-10**]),
crack cocaine abuse c/b crack/toxic pneumonitis, h/o MRSA PNA,
COPD, and Type I DM who presents with dyspnea on exertion over
the last 36 hours. He noticed his dyspnea yesterday when he
noticed he could not walk more than [**2-21**] of one block without
stopping to catch his breath. This morning he was dyspneic in
bed while supine after waking up. Going to a sitting position
improved his dysnea somewhat. He walked back and forth to the
bathroom and became extremely short of breath prompting him to
call an ambulance. He had epigastric discomfort last night but
declines chest pressure. He declines fevers, chills, nausea,
vomiting, and diarrhea. Declines night sweats.
.
Of note, he has had multiple admissions for SOB and chest
tightness in the setting of crack cocaine use and attributed to
crack pneumonitis, most recently [**Date range (1) 35039**]/12 and [**2196-2-29**] -
[**2196-3-5**]. During his last admission from [**Date range (1) 63678**], he was
treated for with solumedrol, oxygen, and lasix for presumed
toxic pneumonitis and systolic CHF exacerbation. He was in the
MICU but not intubated and then transferred to the medicine
floor during that admission. He was initially treated with
antibiotics in the MICU, but these were discontinued on the
floor as there was no evidence of infection.
.
In the ED, initial VS were: 163/122 159 37 96% on NIPPV. H was
treated with ASA 300mg, nitro gtt, solumedrol 125mg iv once,
levofloxacin 750mg iv, ceftriaxone 1g iv, lasix 80mg iv. Stopped
Nitro gtt given bp 85/53 as of 0700.
.
On arrival to the MICU, the patient reported that his breathing
felt much better than it did when he arrived to the ED. TTE was
obtained which showed a decrease in LVEF to 20%. He was treated
agressively with steroids and lasix. His edema and shortness of
breath resolved within one day and he was subsequently
transferred to general medicine.

MEDICAL HISTORY: Crack pneumonitis
Type I Diabetes
Hyperlipidemia
HTN
Nonischemic dilated cardiomyopathy ([**10/2195**]-LVEF 30-35%, mild
RV dilation, borderline function, 1+ MR)
Hepatitis C antibody positive
MRSA pneumonia (requiring trach)
COPD
Substance abuse (cocaine)
Tobacco abuse
Schizophrenia

MEDICATION ON ADMISSION: -ipratropium bromide 0.02 % INH q6hrs prn
-albuterol sulfate 90 mcg INH 1-2 puffs q 4-6 hrs prn
-fluticasone-salmeterol 250-50 mcg/dose [**Hospital1 **]
-furosemide 40 mg daily
-carvedilol 6.25 mg PO BID
-lisinopril 5 mg daily
-omeprazole 20 mg daily
-aspirin 81 mg Tablet daily
-atorvastatin 20 mg daily
-quetiapine 100 mg qhs
-ferrous sulfate 300  mg daily
-nicotine 14 mg/24 hr Patch 24 hr Sig
-insulin glargine 50 units qhs
-Novolog sliding scale
-tramadol 50 mg q4-6hrs prn

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam on admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

FAMILY HISTORY: - Father: pacemaker, deceased

SOCIAL HISTORY: - history of multiple incarcerations (>6 months in [**2193**])
- lives with sister
- walks w/ cane due to right sided foot drop
- Tobacco history: current smoker, 1 cig per day
- ETOH: denies
- Illicit drugs: reports last use [**2167**] though evidence of use
prior
Acute on chronic systolic heart failure,Acute respiratory failure,Bronchitis and pneumonitis due to fumes and vapors,Cocaine dependence, continuous,Other primary cardiomyopathies,Long-term (current) use of steroids,Chronic airway obstruction, not elsewhere classified,Unspecified schizophrenia, unspecified,Diabetes with unspecified complication, type I [juvenile type], uncontrolled,Tobacco use disorder,Unspecified viral hepatitis C without hepatic coma,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus
Ac on chr syst hrt fail,Acute respiratry failure,Fum/vapor bronc/pneumon,Cocaine depend-contin,Prim cardiomyopathy NEC,Long-term use steroids,Chr airway obstruct NEC,Schizophrenia NOS-unspec,DMI unspf uncntrld,Tobacco use disorder,Hpt C w/o hepat coma NOS,Meth resis Staph carrier
Admission Date:  [**2196-3-9**]              Discharge Date:   [**2196-3-14**]

Date of Birth:  [**2143-6-4**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Respiratory distress


Major Surgical or Invasive Procedure:
None


History of Present Illness:
Mr. [**Known lastname 10794**] is a 52M with h/o dilated CM (EF 30-35% on [**2195-12-10**]),
crack cocaine abuse c/b crack/toxic pneumonitis, h/o MRSA PNA,
COPD, and Type I DM who presents with dyspnea on exertion over
the last 36 hours. He noticed his dyspnea yesterday when he
noticed he could not walk more than [**2-21**] of one block without
stopping to catch his breath. This morning he was dyspneic in
bed while supine after waking up. Going to a sitting position
improved his dysnea somewhat. He walked back and forth to the
bathroom and became extremely short of breath prompting him to
call an ambulance. He had epigastric discomfort last night but
declines chest pressure. He declines fevers, chills, nausea,
vomiting, and diarrhea. Declines night sweats.
.
Of note, he has had multiple admissions for SOB and chest
tightness in the setting of crack cocaine use and attributed to
crack pneumonitis, most recently [**Date range (1) 35039**]/12 and [**2196-2-29**] -
[**2196-3-5**]. During his last admission from [**Date range (1) 63678**], he was
treated for with solumedrol, oxygen, and lasix for presumed
toxic pneumonitis and systolic CHF exacerbation. He was in the
MICU but not intubated and then transferred to the medicine
floor during that admission. He was initially treated with
antibiotics in the MICU, but these were discontinued on the
floor as there was no evidence of infection.
.
In the ED, initial VS were: 163/122 159 37 96% on NIPPV. H was
treated with ASA 300mg, nitro gtt, solumedrol 125mg iv once,
levofloxacin 750mg iv, ceftriaxone 1g iv, lasix 80mg iv. Stopped
Nitro gtt given bp 85/53 as of 0700.
.
On arrival to the MICU, the patient reported that his breathing
felt much better than it did when he arrived to the ED. TTE was
obtained which showed a decrease in LVEF to 20%. He was treated
agressively with steroids and lasix. His edema and shortness of
breath resolved within one day and he was subsequently
transferred to general medicine.


Past Medical History:
Crack pneumonitis
Type I Diabetes
Hyperlipidemia
HTN
Nonischemic dilated cardiomyopathy ([**10/2195**]-LVEF 30-35%, mild
RV dilation, borderline function, 1+ MR)
Hepatitis C antibody positive
MRSA pneumonia (requiring trach)
COPD
Substance abuse (cocaine)
Tobacco abuse
Schizophrenia


Social History:
- history of multiple incarcerations (>6 months in [**2193**])
- lives with sister
- walks w/ cane due to right sided foot drop
- Tobacco history: current smoker, 1 cig per day
- ETOH: denies
- Illicit drugs: reports last use [**2167**] though evidence of use
prior


Family History:
- Father: pacemaker, deceased

Physical Exam:
Physical Exam on admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

Physical Exam on discharge:

Vitals: 98.6, [ 100-131]/[ 65-81], HR 86-97, 96 RA FS
382,261,159.
GENERAL - well developed middle aged man in NAD, appears
anxious, animated
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS -  clear to ausculation b/l, no adventitious breath
sounds, I>E.No excess work of breathing.
HEART - tachy regular rythm, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e
SKIN - no rashes or lesions
LYMPH - no cervical or submandibular LAD
NEURO - awake, A&Ox3.

Pertinent Results:
Labs on admission:

[**2196-3-9**] 06:54AM [**Month/Day/Year 3143**] WBC-11.8* RBC-3.74* Hgb-9.9* Hct-32.8*
MCV-88 MCH-26.4* MCHC-30.1* RDW-17.2* Plt Ct-298
[**2196-3-9**] 06:54AM [**Month/Day/Year 3143**] Neuts-80.9* Bands-0 Lymphs-14.7*
Monos-2.6 Eos-1.5 Baso-0.2
[**2196-3-9**] 06:54AM [**Month/Day/Year 3143**] Hypochr-2+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Bite-OCCASIONAL
[**2196-3-9**] 06:54AM [**Month/Day/Year 3143**] PT-10.8 PTT-31.3 INR(PT)-1.0
[**2196-3-9**] 06:54AM [**Month/Day/Year 3143**] Glucose-316* UreaN-24* Creat-1.0 Na-139
K-4.8 Cl-106 HCO3-24 AnGap-14
[**2196-3-9**] 06:54AM [**Month/Day/Year 3143**] CK(CPK)-171
[**2196-3-9**] 06:54AM [**Month/Day/Year 3143**] CK-MB-6 proBNP-3025*
[**2196-3-9**] 06:54AM [**Month/Day/Year 3143**] cTropnT-0.02*
[**2196-3-9**] 01:14PM [**Month/Day/Year 3143**] cTropnT-0.02*
[**2196-3-9**] 06:54AM [**Month/Day/Year 3143**] Calcium-8.3* Phos-4.2 Mg-1.9
[**2196-3-9**] 06:54AM [**Month/Day/Year 3143**] ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2196-3-9**] 09:24AM [**Month/Day/Year 3143**] Type-ART pO2-106* pCO2-43 pH-7.40
calTCO2-28 Base XS-0
[**2196-3-9**] 07:12AM [**Month/Day/Year 3143**] Lactate-2.3*
[**2196-3-9**] 09:24AM [**Month/Day/Year 3143**] Lactate-1.2
[**2196-3-9**] 08:33AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.005
[**2196-3-9**] 08:33AM URINE [**Month/Day/Year **]-NEG Nitrite-NEG Protein-NEG
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2196-3-9**] 08:33AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG

[**Month/Day/Year **] cx [**3-9**] x 2: pending

Imaging:

Echo [**3-9**]:
The left atrium is moderately dilated. The left atrium is
elongated. The estimated right atrial pressure is 0-5 mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. Overall left ventricular systolic
function is severely depressed secondary to moderate-severe
global hypokinesis. The basal-mid infero-lateral segments
contract best. Quantitative (biplane) LVEF = 20 %. The right
ventricular cavity is moderately dilated with borderline normal
free wall function. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. Mild to moderate ([**12-21**]+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a very small circumferential
pericardial effusion without evidence of tamponade.

CXR on admission ([**3-9**]):
IMPRESSION: Increased asymmetric predominantly basilar diffuse
airspace
opacifications likely represent acute non-cardiac edema vs
pulmonary toxicity from inhaled substance.

Labs while on general medicine:

[**2196-3-14**] 07:55AM [**Month/Day/Year 3143**] WBC-8.4 RBC-3.72* Hgb-9.8* Hct-32.7*
MCV-88 MCH-26.2* MCHC-29.9* RDW-17.2* Plt Ct-236
[**2196-3-13**] 08:40AM [**Month/Day/Year 3143**] WBC-10.4 RBC-3.84* Hgb-9.8* Hct-34.0*
MCV-89 MCH-25.6* MCHC-28.9* RDW-16.9* Plt Ct-268
[**2196-3-12**] 07:50AM [**Month/Day/Year 3143**] WBC-10.7 RBC-3.66* Hgb-9.4* Hct-32.2*
MCV-88 MCH-25.8* MCHC-29.3* RDW-17.1* Plt Ct-271

[**2196-3-14**] 07:55AM [**Month/Day/Year 3143**] Glucose-352* UreaN-34* Creat-1.0 Na-138
K-3.8 Cl-100 HCO3-29 AnGap-13

[**2196-3-13**] 08:40AM [**Month/Day/Year 3143**] Glucose-248* UreaN-31* Creat-0.9 Na-139
K-3.9 Cl-100 HCO3-32 AnGap-11
[**2196-3-12**] 07:50AM [**Month/Day/Year 3143**] Glucose-267* UreaN-31* Creat-0.9 Na-141
K-4.1 Cl-104 HCO3-30 AnGap-11
[**2196-3-11**] 05:39AM [**Month/Day/Year 3143**] Glucose-208* UreaN-33* Creat-1.0 Na-142
K-4.2 Cl-102 HCO3-30 AnGap-14
[**2196-3-10**] 01:59AM [**Month/Day/Year 3143**] Glucose-312* UreaN-34* Creat-1.3* Na-140
K-5.2* Cl-101 HCO3-25 AnGap-19

***PENDING LABS****
NEUMONITIS HYPERSENSITIVITY PROFILE	Results Pending

[**2196-3-12**] 07:50AM [**Month/Day/Year 3143**] PNEUMONITIS HYPERSENSITIVITY PROFILE-PND
.
[**2196-3-9**] 7:00 am [**Month/Day/Year 3143**] CULTURE

   [**Month/Day/Year **] Culture, Routine (Pending):


Brief Hospital Course:
Mr. [**Known lastname 10794**] is a 52M with dilated cardiomyopathy (EF 20%), crack
cocaine abuse c/b crack pneumonitis, COPD, and Type I DM who
presented to the ED with dyspnea on exertion for 36 hours. He
was admitted secondary to hypoxemia a combination of acute
systolic heart failure with an LVEF of 20% and hypersensitivity
pneumonitis secondary to extensive history of smoking
crack-cocaine and cigarettes.

Problems:
1. Acute respiratory distress secondary to acute on chronic
systolic heart failure
2. Hypoxemia secondary to hypersentivity pneumonitis secondary
to crack-cocaine exposure
3. Diabetes, type I uncontrolled with complications
4. Schizophrenia

     Mr. [**Known lastname 10794**] presented to the ED with acute respiratory
distress, hypoxemia, and extensive pitting lower extremity edema
several days after being discharged from [**Hospital1 18**] for a previous
episode of crack-cocaine induced pneumonitis. During this time,
he reports smoking the occasional cigarette but his dual
diagnosis rehab program noted that it was very unlikely that he
was actively abusing crack. Given the degree of his hypoxemia,
he had to be placed on NIPPV and was sent to the medical ICU for
close monitoring.

  Given his known history of non-ischemic dilated cardiomyopathy
with a depressed ejection fraction. An echo was obtained in the
MICU which showed a depressed LVEF of 20%. His carvedilol was
increased to 12.5mg [**Hospital1 **] and he was aggressively treated with
lasix. By hospital day 2, his lungs were clear to auscultation
bilaterally and he had no lower extremity edema. He was put on
Lasix 40mg po qd and remained euvolemic throughout the remained
of his hospital stay on a non fluid restricted diet. Dr. [**Last Name (STitle) **]
was made aware of his depressed ejection fraction and said that
Mr. [**Known lastname 10794**] could attend heart failure clinic, but Dr. [**Last Name (STitle) **]
expressed concerns that Mr. [**Known lastname 10794**] would be non-compliant. In
addition, Mr. [**Known lastname 10794**] has follow up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] cardiology for
possible placement for an AICD.

 Pulmonary medicine was consulted and they recommended that the
patient's respiratory distress was a direct result of reactive
inflammatory changes secondary to crack and other unknown
environmental triggers which resulted in a picture of
hypersentivity pneumonitis. Given the very low suspicion for
acute bacterial pneumonia his antibiotics were stopped after one
dose.

   He was treated with high dose steroids which dramatically
improved his breathing. He was started on a 20 day course of
tapered prednisone starting at 60mg x5 days, 40mg x5 day, 20mg x
5 days, and 10mg x 5 days. He his breathing showed daily
improvement while on steroids. On the day of discharge he no
longer required supplemental oxygen and could ambulate with Sa02
in the 90's on room air. A hypersensitivity panel was sent off
and the results of these tests are still pending. The patient
has follow up with Dr. [**Last Name (STitle) **] for PFTs and further pulmonary
work-up in [**Month (only) 547**].

  A complication of his high dose steroids was very high [**Month (only) **]
glucose levels. Despite 80mg of lantus with an aggressive
humalog sliding scale, his finger sticks would be as high as
400. During his hospitalization, he never became ketotic nor did
he become hypoglycemic. He was discharged on lantus 60mg [**Hospital1 **] and
a novolog sliding scale. This will have to be closely monitored
as his steroid taper decreases.

 His schizophrenia is currently well controlled on seroquel. He
shows no signs of paranoid, delusional, or disorganized
thinking.

 Upon discharge, he was able to go live at home with his sister.
In addition, he will continue to attend the [**Hospital1 1680**] dual
diagnosis program as the patient is committed to quitting crack
cocaine. He also has a prescription for cardiopulmonary
rehabilitation at [**Hospital1 2025**].

**Medication Changes****
1. Carvedilol increased to 12.5mg [**Hospital1 **]
2. Predisone taper as listed above
3. Lantus 60mg [**Hospital1 **] (same novolog SSI).

***Transitional Issues***
1. Pending labs: [**Hospital1 **] Cultures from [**2196-3-9**].
2. Hypersensitivity Pneumonitis Work Up: Labs Pending.
Appointment with Dr. [**Last Name (STitle) **] for PFT's and follow up labs in
[**3-22**]. Dilated cardiomyopathy: patient has an appointment with Dr.
[**Last Name (STitle) **] [**Last Name (STitle) **] evaluation for AICD for prevention of sudden cardiac
death. In addition, if the patient and PCP agree he is welcome
to attend heart failure clinic.
4. Steroid taper causing hyperglycemia: Mr. [**Known lastname 10794**] [**Last Name (Titles) **] sugar is
very difficult to control while on corticosteroids. Per
recommendations of Pulmonary medicine, he is on a large dose of
prednisone with a long taper. As a result, his [**Last Name (Titles) **] glucose
will need to be vigilantly monitored and insulin regimen
customized to reflect his steroid taper.

Medications on Admission:
-ipratropium bromide 0.02 % INH q6hrs prn
-albuterol sulfate 90 mcg INH 1-2 puffs q 4-6 hrs prn
-fluticasone-salmeterol 250-50 mcg/dose [**Hospital1 **]
-furosemide 40 mg daily
-carvedilol 6.25 mg PO BID
-lisinopril 5 mg daily
-omeprazole 20 mg daily
-aspirin 81 mg Tablet daily
-atorvastatin 20 mg daily
-quetiapine 100 mg qhs
-ferrous sulfate 300  mg daily
-nicotine 14 mg/24 hr Patch 24 hr Sig
-insulin glargine 50 units qhs
-Novolog sliding scale
-tramadol 50 mg q4-6hrs prn


Discharge Medications:
1. ipratropium bromide 0.02 % Solution Sig: One (1) unit
Inhalation every six (6) hours as needed for sob/wheezing.
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*2*
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. quetiapine 50 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
12. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
14. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever/pain: do not drink alcohol
when taking. Take less than 4gm per day. .
15. insulin glargine 100 unit/mL Solution Sig: Sixty (60) Units
Subcutaneous twice a day: Please take at breakfast and bedtime.
.
Disp:*3000 Units* Refills:*2*
16. Novolog 100 unit/mL Solution Sig: As directed Units
Subcutaneous with meals : As directed by sliding scale .
17. prednisone 10 mg Tablet Sig: 1-6 Tablets PO once a day for
17 days: Take 6 tabs for 2 days, then 4 tabs for 5 days, then 2
tabs for 5 days, then 1 tab for 5 days.
Disp:*47 Tablet(s)* Refills:*0*
18. Outpatient Physical Therapy
[**Hospital **] rehabilitation
19. Glucometer
Please provide patient with Glucometer
20. Glucometer Test Strips
Please provide patient with glucometer test stripe


Discharge Disposition:
Home

Discharge Diagnosis:
1. Respiratory failure (hypersensitivity pneumonitis)
2. Insulin dependent diabetes mellitus with complications
3. Compensated Systolic heart failure with an ejection fraction
of 20%
4. Schizophrenia


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


Discharge Instructions:
Dear Mr. [**Known lastname 10794**],

You were admitted for respiratory failure and pulmonary edema
caused by lung irritation secondary to former crack cocaine and
cigarette smoking. Also, you have heart failure which means your
heart does not pump [**Known lastname **] as well as it should, so fluid can
accumulate in your lungs. Going forward you should return to
your dual diagnosis partial hospital program at [**Hospital 1680**] Hospital
in [**Location (un) 18293**]. At this program, they will help you with your
addiction to crack cocaine. You also have a previous
perscription to [**Hospital 63676**] rehab. Please attend this
program as it will your ability to perform day-to-day activities
without becoming short of breath. Since you are going to the
[**Hospital1 1680**] program VNA will not be able to visit you while you are
at this program. Please discuss resuming home VNA with your PCP
after you complete the program.

Your previous history of smoking has caused significant damage
to your lungs. We are discharging you on a steroid taper. It is
important that you take this medication specifically as
directed. Also it is important to know that this medication can
cause your [**Hospital1 **] sugar to be higher than normal so it is
important that you pay close attention to what you eat and
monitoring your [**Hospital1 **] sugar closely. Also prednisone can cause
agitation and insomnia. If you are having difficult side effects
from prednisone please talk to Dr. [**First Name (STitle) 31365**]. If your [**First Name (STitle) **] sugar is
consistently above 400, please call your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **].
[**Telephone/Fax (1) 7976**] for help controlling your [**Telephone/Fax (1) **] sugar.

Please resume your normal home medications. We have made some
changes as listed below.

We are STARTING you on the following medication:
1. Start oral Prednisone taper as directed for the next 17 days:
Prednisone taper as follows: 60 mg by mouth daily for 2 days,
then 40 mg by mouth daily for 5 days, then 20 mg by mouth daily
for 5 days, then 10 mg by mouth daily for 5 days.

We are increasing your insulin glargine:
2. Please take Lantus (insulin glargine) 50units TWICE a day.
Once at breakfast and once at 10pm.

We are increasing your carvedilol.
3. Carvedilol 12.5mg tab by mouth TWICE a day.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs. If you experience any of the danger symptoms below,
please call your primary care doctor and go to the nearest
emergency department.

Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: MONDAY [**2196-3-21**] at 6:00 PM
With: [**First Name11 (Name Pattern1) 2801**] [**Last Name (NamePattern4) 14773**], NP [**Telephone/Fax (1) 7976**], NP[**MD Number(3) 12768**] with Dr.
[**First Name (STitle) 31365**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site

Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: TUESDAY [**2196-3-22**] at 2:20 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22387**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site
=
Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: TUESDAY [**2196-3-22**] at 3:30 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12898**], DPM [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site

Department: CARDIAC SERVICES
When: FRIDAY [**2196-4-1**] at 12:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: PULMONARY FUNCTION LAB
When: MONDAY [**2196-4-25**] at 4:10 PM
With: Dr. [**Last Name (STitle) **] @ PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Acute on chronic systolic heart failure,Acute respiratory failure,Bronchitis and pneumonitis due to fumes and vapors,Cocaine dependence, continuous,Other primary cardiomyopathies,Long-term (current) use of steroids,Chronic airway obstruction, not elsewhere classified,Unspecified schizophrenia, unspecified,Diabetes with unspecified complication, type I [juvenile type], uncontrolled,Tobacco use disorder,Unspecified viral hepatitis C without hepatic coma,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus'}


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: Respiratory distress

PRESENT ILLNESS: Mr. [**Known lastname 10794**] is a 52M with h/o dilated CM (EF 30-35% on [**2195-12-10**]),
crack cocaine abuse c/b crack/toxic pneumonitis, h/o MRSA PNA,
COPD, and Type I DM who presents with dyspnea on exertion over
the last 36 hours. He noticed his dyspnea yesterday when he
noticed he could not walk more than [**2-21**] of one block without
stopping to catch his breath. This morning he was dyspneic in
bed while supine after waking up. Going to a sitting position
improved his dysnea somewhat. He walked back and forth to the
bathroom and became extremely short of breath prompting him to
call an ambulance. He had epigastric discomfort last night but
declines chest pressure. He declines fevers, chills, nausea,
vomiting, and diarrhea. Declines night sweats.
.
Of note, he has had multiple admissions for SOB and chest
tightness in the setting of crack cocaine use and attributed to
crack pneumonitis, most recently [**Date range (1) 35039**]/12 and [**2196-2-29**] -
[**2196-3-5**]. During his last admission from [**Date range (1) 63678**], he was
treated for with solumedrol, oxygen, and lasix for presumed
toxic pneumonitis and systolic CHF exacerbation. He was in the
MICU but not intubated and then transferred to the medicine
floor during that admission. He was initially treated with
antibiotics in the MICU, but these were discontinued on the
floor as there was no evidence of infection.
.
In the ED, initial VS were: 163/122 159 37 96% on NIPPV. H was
treated with ASA 300mg, nitro gtt, solumedrol 125mg iv once,
levofloxacin 750mg iv, ceftriaxone 1g iv, lasix 80mg iv. Stopped
Nitro gtt given bp 85/53 as of 0700.
.
On arrival to the MICU, the patient reported that his breathing
felt much better than it did when he arrived to the ED. TTE was
obtained which showed a decrease in LVEF to 20%. He was treated
agressively with steroids and lasix. His edema and shortness of
breath resolved within one day and he was subsequently
transferred to general medicine.

MEDICAL HISTORY: Crack pneumonitis
Type I Diabetes
Hyperlipidemia
HTN
Nonischemic dilated cardiomyopathy ([**10/2195**]-LVEF 30-35%, mild
RV dilation, borderline function, 1+ MR)
Hepatitis C antibody positive
MRSA pneumonia (requiring trach)
COPD
Substance abuse (cocaine)
Tobacco abuse
Schizophrenia

MEDICATION ON ADMISSION: -ipratropium bromide 0.02 % INH q6hrs prn
-albuterol sulfate 90 mcg INH 1-2 puffs q 4-6 hrs prn
-fluticasone-salmeterol 250-50 mcg/dose [**Hospital1 **]
-furosemide 40 mg daily
-carvedilol 6.25 mg PO BID
-lisinopril 5 mg daily
-omeprazole 20 mg daily
-aspirin 81 mg Tablet daily
-atorvastatin 20 mg daily
-quetiapine 100 mg qhs
-ferrous sulfate 300  mg daily
-nicotine 14 mg/24 hr Patch 24 hr Sig
-insulin glargine 50 units qhs
-Novolog sliding scale
-tramadol 50 mg q4-6hrs prn

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam on admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

FAMILY HISTORY: - Father: pacemaker, deceased

SOCIAL HISTORY: - history of multiple incarcerations (>6 months in [**2193**])
- lives with sister
- walks w/ cane due to right sided foot drop
- Tobacco history: current smoker, 1 cig per day
- ETOH: denies
- Illicit drugs: reports last use [**2167**] though evidence of use
prior 

### Response:
{'Acute on chronic systolic heart failure,Acute respiratory failure,Bronchitis and pneumonitis due to fumes and vapors,Cocaine dependence, continuous,Other primary cardiomyopathies,Long-term (current) use of steroids,Chronic airway obstruction, not elsewhere classified,Unspecified schizophrenia, unspecified,Diabetes with unspecified complication, type I [juvenile type], uncontrolled,Tobacco use disorder,Unspecified viral hepatitis C without hepatic coma,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus'}
