CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: PCP: (notified by fax on admission)
Name: [**Last Name (LF) **],[**First Name3 (LF) 674**] B.
Location: CHILD HEALTH
Address: [**Last Name (un) 84539**], [**Hospital1 **],[**Numeric Identifier 84540**]
Phone: [**Telephone/Fax (1) 38488**]
Fax: [**Telephone/Fax (1) 84541**]

MEDICAL HISTORY: lactose intolerance
ovarian cyst
gallbladder dysfunction
broken nose
asthma
ppd neg

MEDICATION ON ADMISSION: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs(s) inhaled every 6-8 hours as needed for shortness of
breath
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inhaled twice a day rinse after use
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth
nightly
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once daily Take 15-30 minutes before breakfast.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 97.8 88 113/78 24 98RA
Gen: Well appearing, no acute distress, awake, alert,
appropriate, and oriented x 3
Skin: warm to touch, no apparent rashes.
HEENT: No conjunctival pallor, no scleral jaundice, OP clear, no
cervical LAD
CV: RRR no audible m/r/g, pulses 2+, no LE edema
Lungs: decreased air movement, mild scattered wheezing. no
crackles.
Abd: soft, NT, normal BS
Ext: No C/C/E
Neuro: strength and sensation intact bilaterally.

FAMILY HISTORY: Her mother and father are well.  There is no family history of
asthma.  She has 2 brothers and 2 [**Name2 (NI) 84542**], none of whom
have
asthma or other pulmonary related conditions

SOCIAL HISTORY: Pre-med student, - TOB, - ETOH, - IVDU
Other diseases of vocal cords,Bacterial pneumonia, unspecified,Asthma, unspecified type, with (acute) exacerbation,Esophageal reflux,Other and unspecified ovarian cyst,Leukocytosis, unspecified
Vocal cord disease NEC,Bacterial pneumonia NOS,Asthma NOS w (ac) exac,Esophageal reflux,Ovarian cyst NEC/NOS,Leukocytosis NOS
Admission Date:  [**2144-2-26**]              Discharge Date:   [**2144-2-29**]

Date of Birth:  [**2125-1-9**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
Direct Laryngoscopy


History of Present Illness:
PCP: (notified by fax on admission)
Name: [**Last Name (LF) **],[**First Name3 (LF) 674**] B.
Location: CHILD HEALTH
Address: [**Last Name (un) 84539**], [**Hospital1 **],[**Numeric Identifier 84540**]
Phone: [**Telephone/Fax (1) 38488**]
Fax: [**Telephone/Fax (1) 84541**]

Admission Date/Time:[**2144-2-27**] 0050

CC:shortness of breath

HPI:19F with h/o asthma who was recently treated with pred and
azithor for flare. She states that as soon as the prednisone
stopped, she started feeling short of breath again. Noticed
chest tightness, fever to 104, and increased wheezing. She
started having to use her albuterol 4+ times per day and was
waking at night with shortness of breath. her cough is
productive of green sputum. She also still c/o the night sweats
as she was having before. Denies any hemoptysis.

In ER: (Triage Vitals:) Noted to have mild increase in RR. PE-CT
with PNA. got 125 solumedrol, CTX/Azitho. 98.2 88 127/56 22
100RA

ROS:
-Constitutional: []WNL []Weight loss []Fatigue/Malaise [x]Fever
[]Chills/Rigors [x]Nightweats []Anorexia
-ENT: [x]WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose
[]Tinnitus []Sinus pain []Sore throat
-Cardiac: [x]WNL []Chest pain []Palpitations []LE edema
[]Orthopnea/PND []DOE
-Respiratory: see HPI
-Gastrointestinal: [x]WNL []Nausea []Vomiting []Abdominal pain
[]Abdominal Swelling []Diarrhea []Constipation []Hematemesis
[]Hematochezia []Melena
-GU: [x]WNL []Incontinence/Retention []Dysuria []Hematuria
[]Discharge []Menorrhagia
-Skin: [x]WNL []Rash []Pruritus
-Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain
-Neurological: [ xx]WNL []Numbness of extremities []Weakness of
extremities []Parasthesias []Dizziness/Lightheaded []Vertigo
[]Confusion []Headache


Past Medical History:
lactose intolerance
ovarian cyst
gallbladder dysfunction
broken nose
asthma
ppd neg

Social History:
Pre-med student, - TOB, - ETOH, - IVDU


Family History:
Her mother and father are well.  There is no family history of
asthma.  She has 2 brothers and 2 [**Name2 (NI) 84542**], none of whom
have
asthma or other pulmonary related conditions

Physical Exam:
VS: 97.8 88 113/78 24 98RA
Gen: Well appearing, no acute distress, awake, alert,
appropriate, and oriented x 3
Skin: warm to touch, no apparent rashes.
HEENT: No conjunctival pallor, no scleral jaundice, OP clear, no
cervical LAD
CV: RRR no audible m/r/g, pulses 2+, no LE edema
Lungs: decreased air movement, mild scattered wheezing. no
crackles.
Abd: soft, NT, normal BS
Ext: No C/C/E
Neuro: strength and sensation intact bilaterally.


Pertinent Results:
[**2144-2-26**] 07:13PM URINE  HOURS-RANDOM
[**2144-2-26**] 07:13PM URINE  HOURS-RANDOM
[**2144-2-26**] 07:13PM URINE  UCG-NEGATIVE
[**2144-2-26**] 07:13PM URINE  GR HOLD-HOLD
[**2144-2-26**] 07:13PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2144-2-26**] 07:13PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-NEG
[**2144-2-26**] 04:30PM   GLUCOSE-103* UREA N-9 CREAT-0.7 SODIUM-142
POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-25 ANION GAP-16
[**2144-2-26**] 04:30PM   estGFR-Using this
[**2144-2-26**] 04:30PM   CK(CPK)-49
[**2144-2-26**] 04:30PM   cTropnT-<0.01
[**2144-2-26**] 04:30PM   CK-MB-NotDone
[**2144-2-26**] 04:30PM   WBC-16.0*# RBC-4.62 HGB-13.6 HCT-40.4 MCV-88
MCH-29.4 MCHC-33.6 RDW-13.5
[**2144-2-26**] 04:30PM   NEUTS-83.6* LYMPHS-11.7* MONOS-4.0 EOS-0.4
BASOS-0.2
[**2144-2-26**] 04:30PM   PLT COUNT-237

PE-CT
1. Suboptimal IV bolus timing. No central or lobar PE.
2. No acute aortic pathology.
3. Right medial lung base opacity, ? aspiration or focal PNA.


Brief Hospital Course:
Summary

19F with repeated flares of presumed asthma presents with
recurrent event with drop in her peak flow from 400->250, cough,
fever, and multifocal infiltrate on CT. Patient was given a FQ
abx last time, but apparently did not improve. Was started on on
ceftriaxone, azithro and pulse dose steroids. She decompensated
with tachypnea to the 40's and violent, stridorous breathsounds.
In the [**Hospital Unit Name 153**], she underwent direct larygoscopy revealing vocal
cord dysfunction. She did well with anxiolytics and was
discharged to follow up outpatient

By Problem

Vocal Cord Dysfunction

     Clued to a diagnosis other than asthma by the lack of
wheezing and normal lung volumes, direct larygoscopy revealed
vocal cord dysfunction. This is a condition that likely exists
as part of a syndrome of anxiety and coping dysfunctions
manifested in her several diagnoses (eating disorders, sphincter
of oddi dysfunction, lactose intolerance) and is superimposed
upon her Asthma and GERD. She will need follow up for her voice
technique and management of her anxiety/coping.

Asthma

     review of PFTs were mild. continued home meds.

Pneumonia

     In light of her multifocal infiltrates and dyspnea, patient
was treated with cfx/azithro and discharged on azithro for 5 day
course

GERD - continue omeprazole

Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs(s) inhaled every 6-8 hours as needed for shortness of
breath
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inhaled twice a day rinse after use
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth
nightly
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once daily Take 15-30 minutes before breakfast.

Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: Start on Sunday.
Disp:*2 Tablet(s)* Refills:*0*
4. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 6-8 hours as needed for shortness of
breath or wheezing.


Discharge Disposition:
Home

Discharge Diagnosis:
Vocal Cord Dysfunction - paradoxical vocal cord adduction
GERD
Asthma


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


Discharge Instructions:
You were admitted to the ICU with severe difficulty breathing.
You had two major problems: a mild pneumonia that may have
triggered your asthma and, above all, a condition called vocal
cord dysfunction. This was diagnosed by direct laryngoscopy. The
cause of this condition is often associated with stressors in
life and it can be treated by specialized techniques to help
relax your vocal cords and also by working on the stress
response and anxiety in general.

Please finish your course of AZITHROMYCIN - an antibiotic for
your pneumonia to completa a 5 day course total.


Followup Instructions:
You have an appointment on Tuesday, 9:30am [**2144-3-3**] in the [**Hospital1 **] [**Hospital Ward Name 121**] building - Span 106 for videostriposcopy.
[**Telephone/Fax (1) 3731**] is the number at which you can reach them

Provider: [**Known firstname **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 3731**] Date/Time:[**2144-3-3**] 9:30
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2144-4-6**] 3:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2144-4-6**] 4:00

Please also follow up with the physicians at [**Hospital **] Healthcare
Center. You can get an appointment at [**Telephone/Fax (1) 84543**].

If you breathing worsens, you notice wheezing, shortness of
breath please call 911 and go to the closest emergency room. You
can use your albuterol inhaler in the mean time and try to
relax.


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Completed by:[**2144-2-29**]
{'Other diseases of vocal cords,Bacterial pneumonia, unspecified,Asthma, unspecified type, with (acute) exacerbation,Esophageal reflux,Other and unspecified ovarian cyst,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: shortness of breath

PRESENT ILLNESS: PCP: (notified by fax on admission)
Name: [**Last Name (LF) **],[**First Name3 (LF) 674**] B.
Location: CHILD HEALTH
Address: [**Last Name (un) 84539**], [**Hospital1 **],[**Numeric Identifier 84540**]
Phone: [**Telephone/Fax (1) 38488**]
Fax: [**Telephone/Fax (1) 84541**]

MEDICAL HISTORY: lactose intolerance
ovarian cyst
gallbladder dysfunction
broken nose
asthma
ppd neg

MEDICATION ON ADMISSION: ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs(s) inhaled every 6-8 hours as needed for shortness of
breath
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inhaled twice a day rinse after use
MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth
nightly
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once daily Take 15-30 minutes before breakfast.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 97.8 88 113/78 24 98RA
Gen: Well appearing, no acute distress, awake, alert,
appropriate, and oriented x 3
Skin: warm to touch, no apparent rashes.
HEENT: No conjunctival pallor, no scleral jaundice, OP clear, no
cervical LAD
CV: RRR no audible m/r/g, pulses 2+, no LE edema
Lungs: decreased air movement, mild scattered wheezing. no
crackles.
Abd: soft, NT, normal BS
Ext: No C/C/E
Neuro: strength and sensation intact bilaterally.

FAMILY HISTORY: Her mother and father are well.  There is no family history of
asthma.  She has 2 brothers and 2 [**Name2 (NI) 84542**], none of whom
have
asthma or other pulmonary related conditions

SOCIAL HISTORY: Pre-med student, - TOB, - ETOH, - IVDU 

### Response:
{'Other diseases of vocal cords,Bacterial pneumonia, unspecified,Asthma, unspecified type, with (acute) exacerbation,Esophageal reflux,Other and unspecified ovarian cyst,Leukocytosis, unspecified'}
