CHIEF COMPLAINT: SOB w/ exertion

PRESENT ILLNESS: 62F with h/o COPD on 3L home O2, sCHF s/p ICD/Ppm, HTN, DM2
presents from [**Hospital3 2558**] with worsening SOB with exertion x
2 days.
.
Of note, the patient was recently admitted to [**Hospital1 112**] from [**2-21**] to
[**2-27**] for a facial burn sustained when she tried to smoke a
cigarette while on oxygen via nasal cannula. She was initially
on BiPap in the ED, was given high-dose steroids. Bronchoscopy
showed no airway edema or soot. On [**2-22**], she had flash pulmonary
edema and was treated with 40 mg IV Lasix. She was discharged on
her home meds and Prednisone taper.
.
She notes that yesterday she tried to be more active and was
getting up and moving around more and noticed that she felt more
short of breath doing activities - felt she couldn't catch her
breath. She was on her usual 3L nc at that time and didn't try
to increase the rate. She took a Duoneb inhaler yesterday, which
helped her SOB. Then this morning, she noticed that she again
had trouble catching her breath with activity. Duoneb inhaler
was given without improvement. She was given 40 mg Prednisone
(takes 20 mg chronically) and was brought to the ED.
.
In the ED, initial vitals 97.0  128 (sinus)  144/93  20  100% on
2L (home requirement is 3L). Exam was notable for absence of
wheezing, absence of significant crackles, and no LE edema. Labs
revealed Cr 0.5, WBC 17.1, Hct 27.5. CT-A was performed and
showed no PE; did reveal emphysema and a 7 mm LLL pulmonary
nodule. CXR showed COPD, dual-chamber Ppm/AICD, flat diaphragms,
and large cardiac silhouette - no infiltrate or edema. She was
given 1L NS, Solumedrol 125 mg, 5 mg Oxycodone for face/hand
pain, and Levaquin 750 mg IV. She was then transferred to the
floor.
.
Currently, VS are 115  159/83  18  99% on 3L. The patient
generally appears to be breathing comfortably and is in no
apparent distress. She speaks in full sentences. She denies
recent cough. Denies fevers/chills, no chest pain, no n/v,
dysuria, no recent illness. She did have her flu vaccine this
year. ROS is positive for diarrhea for a few days that resolved
one week ago, recent PND - was been waking up more often feeling
SOB, orthopnea - 1 pillow chronically, has gained [**4-11**] pounds
over 1.5 months.

MEDICAL HISTORY: COPD on 3L home O2 with multiple hospitalizations; was in ICU
for COPD exacerbation in [**1-17**]
- FEV1 27% in [**12/2171**]
systolic CHF with dual chamber pacemaker and AICD
-placed [**12/2171**]
-dilated cardiomyopathy with EF = 20-25% from ?year
TB - treated in [**2168**], had RUL wedge resection
paroxysmal Afib?
GERD
Anxiety
HL
OA
GI bleed [**3-12**] duodenal/gastric ulcer
Osteoporosis
Vtach
Gastric ulcer
DM - type 2
HTN
Macrocytic anemia
Chronic leukocytosis
s/p myomectomy in [**2166**]
s/p C-section

MEDICATION ON ADMISSION: Toprol XL 100 mg qday
Multivitamin 1 tab qday
Oxycodone 5 mg q4h prn
Ultram 25 mg q6h prn
Tylenol 650 mg TID prn
Calcium Carbonate 1 tab [**Hospital1 **]
Colace
Ferrous Sulfate 325 mg qday
Potassium Chloride 20 Meq qday
Omeprazole 40 mg [**Hospital1 **]
Prednisone 20 mg qday (chronic home dose)
Lactulose 30 mg QID prn constipation
Senna 8.6 mg [**Hospital1 **] prn
Bactrim DS - 1 tab M,W,F
Insulin sliding scale
Duoneb q6h prn
Spiriva 18 mcg qday
Torsemide 20 mg [**Hospital1 **]
Albuterol neb prn
Bacitracin/Neosporin/Polymixin ointment
Advair 250/50 [**Hospital1 **]
Caltrate 600/400 [**Hospital1 **]
Lorazepam 0.5 mg q8h prn
Vit D3 400 U qday

ALLERGIES: Captopril / Aspirin / Tetracycline / Erythromycin Base /
Penicillins / Motrin / Wellbutrin

PHYSICAL EXAM: On admission:
VS -  AF  115  159/83   18   99% on 3L
GENERAL - elderly AAF appears older than state age, breathing
comfortably in NAD, pleasant, a&ox3
HEENT - face with obvious burn on upper lip and tip of nose,
PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - poor air movement throughout, few bibasilar crackles, no
wheezing, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2, ?additional heart sound vs. split
S1
ABDOMEN - C-section scar, soft/NT/ND, NABS, no masses or HSM, no
rebound/guarding
EXTREMITIES - thin, WWP, no c/c/e, 2+ peripheral pulses
(radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-13**] throughout but equal bilaterally, sensation grossly intact
throughout, gait deferred

FAMILY HISTORY: HTN, Dementia

SOCIAL HISTORY: Retired LPN - worked at [**Hospital3 **], LT care, substance
abuse facility.
Before going to [**Hospital3 **], lived at home with daughter
[**Name (NI) 97832**].
Ambulates with a walker. Occasionally needs help with dressing,
feeding.
+ tob - 60 pack-year history, states she quit after recent burn
History of heavy EtOH, none since [**5-18**]
No drugs
Obstructive chronic bronchitis with (acute) exacerbation,Acute and chronic respiratory failure,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Unspecified protein-calorie malnutrition,Body Mass Index less than 19, adult,Anxiety state, unspecified,Leukocytosis, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Burn of unspecified degree of face and head, unspecified site,Anemia, unspecified,Esophageal reflux,Osteoporosis, unspecified,Unspecified essential hypertension,Tachycardia, unspecified,Chest pain, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Volume depletion, unspecified,Personal history of tuberculosis,Personal history of tobacco use,Other dependence on machines, supplemental oxygen,Long-term (current) use of steroids,Automatic implantable cardiac defibrillator in situ,Accident caused by unspecified fire
Obs chr bronc w(ac) exac,Acute & chronc resp fail,Ac on chr syst hrt fail,Prim cardiomyopathy NEC,Protein-cal malnutr NOS,BMI less than 19,adult,Anxiety state NOS,Leukocytosis NOS,DMII wo cmp nt st uncntr,Burn NOS head-unspec,Anemia NOS,Esophageal reflux,Osteoporosis NOS,Hypertension NOS,Tachycardia NOS,Chest pain NOS,Osteoarthros NOS-unspec,Volume depletion NOS,Prsnl hst tuberculosis,History of tobacco use,Depend-supplement oxygen,Long-term use steroids,Status autm crd dfbrltr,Fire accident NOS
Admission Date:  [**2183-3-14**]              Discharge Date:   [**2183-3-21**]

Date of Birth:  [**2120-12-7**]             Sex:   F

Service: MEDICINE

Allergies:
Captopril / Aspirin / Tetracycline / Erythromycin Base /
Penicillins / Motrin / Wellbutrin

Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
SOB w/ exertion

Major Surgical or Invasive Procedure:
...

History of Present Illness:
62F with h/o COPD on 3L home O2, sCHF s/p ICD/Ppm, HTN, DM2
presents from [**Hospital3 2558**] with worsening SOB with exertion x
2 days.
.
Of note, the patient was recently admitted to [**Hospital1 112**] from [**2-21**] to
[**2-27**] for a facial burn sustained when she tried to smoke a
cigarette while on oxygen via nasal cannula. She was initially
on BiPap in the ED, was given high-dose steroids. Bronchoscopy
showed no airway edema or soot. On [**2-22**], she had flash pulmonary
edema and was treated with 40 mg IV Lasix. She was discharged on
her home meds and Prednisone taper.
.
She notes that yesterday she tried to be more active and was
getting up and moving around more and noticed that she felt more
short of breath doing activities - felt she couldn't catch her
breath. She was on her usual 3L nc at that time and didn't try
to increase the rate. She took a Duoneb inhaler yesterday, which
helped her SOB. Then this morning, she noticed that she again
had trouble catching her breath with activity. Duoneb inhaler
was given without improvement. She was given 40 mg Prednisone
(takes 20 mg chronically) and was brought to the ED.
.
In the ED, initial vitals 97.0  128 (sinus)  144/93  20  100% on
2L (home requirement is 3L). Exam was notable for absence of
wheezing, absence of significant crackles, and no LE edema. Labs
revealed Cr 0.5, WBC 17.1, Hct 27.5. CT-A was performed and
showed no PE; did reveal emphysema and a 7 mm LLL pulmonary
nodule. CXR showed COPD, dual-chamber Ppm/AICD, flat diaphragms,
and large cardiac silhouette - no infiltrate or edema. She was
given 1L NS, Solumedrol 125 mg, 5 mg Oxycodone for face/hand
pain, and Levaquin 750 mg IV. She was then transferred to the
floor.
.
Currently, VS are 115  159/83  18  99% on 3L. The patient
generally appears to be breathing comfortably and is in no
apparent distress. She speaks in full sentences. She denies
recent cough. Denies fevers/chills, no chest pain, no n/v,
dysuria, no recent illness. She did have her flu vaccine this
year. ROS is positive for diarrhea for a few days that resolved
one week ago, recent PND - was been waking up more often feeling
SOB, orthopnea - 1 pillow chronically, has gained [**4-11**] pounds
over 1.5 months.


Past Medical History:
COPD on 3L home O2 with multiple hospitalizations; was in ICU
for COPD exacerbation in [**1-17**]
- FEV1 27% in [**12/2171**]
systolic CHF with dual chamber pacemaker and AICD
-placed [**12/2171**]
-dilated cardiomyopathy with EF = 20-25% from ?year
TB - treated in [**2168**], had RUL wedge resection
paroxysmal Afib?
GERD
Anxiety
HL
OA
GI bleed [**3-12**] duodenal/gastric ulcer
Osteoporosis
Vtach
Gastric ulcer
DM - type 2
HTN
Macrocytic anemia
Chronic leukocytosis
s/p myomectomy in [**2166**]
s/p C-section


Social History:
Retired LPN - worked at [**Hospital3 **], LT care, substance
abuse facility.
Before going to [**Hospital3 **], lived at home with daughter
[**Name (NI) 97832**].
Ambulates with a walker. Occasionally needs help with dressing,
feeding.
+ tob - 60 pack-year history, states she quit after recent burn
History of heavy EtOH, none since [**5-18**]
No drugs


Family History:
HTN, Dementia


Physical Exam:
On admission:
VS -  AF  115  159/83   18   99% on 3L
GENERAL - elderly AAF appears older than state age, breathing
comfortably in NAD, pleasant, a&ox3
HEENT - face with obvious burn on upper lip and tip of nose,
PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - poor air movement throughout, few bibasilar crackles, no
wheezing, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2, ?additional heart sound vs. split
S1
ABDOMEN - C-section scar, soft/NT/ND, NABS, no masses or HSM, no
rebound/guarding
EXTREMITIES - thin, WWP, no c/c/e, 2+ peripheral pulses
(radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-13**] throughout but equal bilaterally, sensation grossly intact
throughout, gait deferred


Pertinent Results:
On admission:
137  92  14
------------< 121
4.8  35  0.5
.
17.1>---< 299
     27.5
Diff: 79N, 14L, 4M, 3E
.
proBNP 4125
.
PT 11.8  PTT 25
.
U/A neg
.
[**3-14**] Urine and blood cultures: pending
.
CT-A: (wet read)
-no PE
-emphysema
- 7 mm LLL pulmonary nodule
.
Admit CXR: (wet read)
- COPD, ?lung reduction surgery, dual chamber Ppm and AICD, flat
diaphragms, enlarged cardiac silhouette
.
EKG: Sinus tach, rate 121; LAD, ?LA enlargement, < 2mm STE in
V2, V3, lead V4-V6 difficult to interpret [**3-12**] baseline artifact
.


Brief Hospital Course:
62F with h/o COPD on 3L home O2, sCHF s/p ICD/Ppm, HTN, DM2
presents from [**Hospital3 2558**] with worsening SOB with exertion x
2 days
.
# SOB: On presentation to the ED, the patient appeared to be
breathing comfortably; she was satting 99% on her home O2
requirement of 3L. CXR showed no infiltrate or evidence of
edema. CT-A was negative for PE. Exam revealed no wheezing or
significant crackles. She had been given 40 mg Prednisone at
[**Hospital3 2558**]. She received an additional 125 mg of Solumedrol
in ED and a dose of 750 mg IV Levaquin. On the floor, she
appeared comfortable. Antibiotics were discontinued. Nebulizers
were administered prn. On [**3-15**] AM, the patient became acutely SOB
after getting up to go to the bathroom. O2 sats were 95% on 2L.
CXR showed acutely worsened vascular congestion. She was given
80 mg IV Lasix with some improvement but still appeared to be in
significant respiratory distress. She was transferred to the
ICU.  In the MICU, she diuresed approximately 1.5 L from one
dose of Lasix 80 mg IV.  She was noted to be tachypneic with
minimal movements but did not desaturate, so she was eventually
transferred back to the floor on [**2183-3-16**].  Please see COPD
section for remainder hospital course.
.
# COPD: FEV1 listed as 27% in 11/[**2171**]. States that she hasn't
seen pulmonologist in a while but thinks she needs to see one
given multiple recent admits to [**Hospital1 112**]. 125 mg IV Solumedrol was
given initially in the ED. Bactrim DS 1 tab M/W/F was continued.
Home inhalers - Advair, Spiriva were continued.  On transfer to
the ICU, patient started on Levofloxacin daily for COPD
exacerbation, as patient has significant allergies to PCNs and
macrolides. Continued Prednisone 60 mg PO daily with a 2-week
taper. Attempted to use BiPAP but patient did not tolerate well
due to facial burns.  She was noted to be tachypneic with
minimal movements but did not desaturate, so she was eventually
transferred back to the floor on [**2183-3-16**].  On the floor, she
developed increased work of breathing and tachycardia.  Her O2
saturation at this time was noted to be 100% on 3L.  She had an
ABG on this O2 saturation, which demonstrated pH 7.32, pCO2 of
71, and pO2 of 132.  Given that her hypercarbia was felt
secondary to high O2 administration in the setting of COPD, her
oxygen was titrated down to 1 L, with resulting desaturation to
85 %; she was then tried on CPAP, which she failed to tolerate,
and she was then restarted on 3 L NC with improvement back up to
100%.  As she was thought to be dry on physical exam, she was
given 250 cc NS.  Her EKG was unchanged.  She was given Morphine
2 mg IV and was transferred back to the MICU on [**2183-3-17**] for
increasing nursing demand.  Over the next several days in the
ICU, her ABGs continued to improve.  Her Advair was increased to
500/50.  Her respiratory improved to the point that she was
called out to the floor for several days but a bed was not
available.  Anxiety and pain were thought to be a large
contribution to her dyspnea; her symptoms much improved with
Ativan and Morphine as needed.  She worked with physical therapy
daily to help maintain her strength.  On [**2183-3-21**], a bed became
available at the [**Hospital3 2558**] so she was discharged directly
from the MICU.
.
She will need repeat CT chest in 6 months for pulm nodule and
outpatient pulmonologist follow up for repeat PFTs.
.
# Chronic sCHF with dilated CM (EF 20-25%) from ?year. On
initial presentation, did not appear overloaded on exam. She was
given gentle IVF in the ED and on the floor our of concern for
history of recent diarrhea and sinus tachycardia. As above, on
[**3-15**], the patient had a likely episode of flash PE when getting
up to go to the bathroom. In the MICU, she diuresed
approximately 1.5 L from one dose of Lasix 80 mg IV.  Her home
Torsemide was restarted and she diuresed appropriately.
Baseline BPs were 80-90s systolic while maintaining normal
mental status and making good urine.
.
# Chest pain:  The patient states that she has [**6-17**] substernal
chest pain, which started earlier this afternoon.  EKG showed
TWIs in V4-V6, which appear to be changed from her EKGs on
[**2183-3-14**].  Her chest pain is relieved with Morphine 2 mg IV. She
was monitored on telemetry; serial cardiac enzymes remained flat
and no new EKG changes over several days.  Thought to be most
likely anxiety is setting of respiratory distress. Resolved.
.
# Tachycardia: Sinus tachycardia on admission. Was intially
given gentle IVF, which were stopped after the flash PE event.
After improvement of COPD exacerbation, patient's tachycardia
resolved.
.
# Facial burn:
- Bacitracin/Neosporin/Polymixin ointment
.
# HTN: Monitor closely given h/o flash PE. 159/83 currently.
- cont. Toprol 100 mg qday
.
# Osteoporosis:
- cont Ca and Vit D
.
# GERD:
- cont. Omeprazole 40 mg [**Hospital1 **]
.
# Anemia: MCV = 93. Hct =  25.9 in [**7-18**].7 on [**2183-3-7**].
Appears to be at baseline.
- cont. to trend
.
# DM:
- diabetic diet
- ISS
.
# Leukocytosis: Likely [**3-12**] chronic steroids. Listed as chronic
medical issue in OSH records.
.
# LLL nodule:
- repeat CT scan in [**4-13**] months
.
# Anxiety: Ativan 0.5 mg q8h prn as per home regimen
.
## CODE STATUS: Full code
# CONTACT:  [**Name (NI) 97832**] [**Known lastname **] ([**Telephone/Fax (1) 97833**]


Medications on Admission:
Toprol XL 100 mg qday
Multivitamin 1 tab qday
Oxycodone 5 mg q4h prn
Ultram 25 mg q6h prn
Tylenol 650 mg TID prn
Calcium Carbonate 1 tab [**Hospital1 **]
Colace
Ferrous Sulfate 325 mg qday
Potassium Chloride 20 Meq qday
Omeprazole 40 mg [**Hospital1 **]
Prednisone 20 mg qday (chronic home dose)
Lactulose 30 mg QID prn constipation
Senna 8.6 mg [**Hospital1 **] prn
Bactrim DS - 1 tab M,W,F
Insulin sliding scale
Duoneb q6h prn
Spiriva 18 mcg qday
Torsemide 20 mg [**Hospital1 **]
Albuterol neb prn
Bacitracin/Neosporin/Polymixin ointment
Advair 250/50 [**Hospital1 **]
Caltrate 600/400 [**Hospital1 **]
Lorazepam 0.5 mg q8h prn
Vit D3 400 U qday


Discharge Medications:
1. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
2. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. ferrous sulfate 300  mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. bacitracin-polymyxin B     Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for upper lip burn.
8. torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain, anxiety.
11. potassium chloride 20 mEq Packet Sig: One (1)  PO once a
day.
12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. Ultram 50 mg Tablet Sig: 0.5 Tablet PO every six (6) hours
as needed for pain.
15. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
16. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 4 days: Started [**2183-3-20**]. total course 5 days. Last dose
[**2183-3-24**]. .
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
18. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
19. Toprol XL 100 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day: hold for SBP <90.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
20. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
21. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1)  Inhalation once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
COPD exacerbation
Systolic heart failure


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted to the hospital for your shortness of breath
and were treated for a COPD exacerbation.  You were given
steroids and antibiotics to help improve your lung function.

THE FOLLOWING CHANGES WERE MADE TO YOUR MEDICATIONS:
.
Advair was increased to 500/50
.
Prednisone 40mg daily for next 4 days, then continue your normal
20mg daily dose
.
OxycoDONE (Immediate Release) 5 mg by mouth every 4 hours as
needed for pain

Followup Instructions:
Please follow up with Pulmonology for a repeat CT chest in 6
months and for repeat pulmonary function tests.  Dr [**First Name (STitle) **]
should be able to help you set this up.

You have a follow up appointment with your PCP Dr [**First Name (STitle) **] on
Thursday [**2184-3-26**]:20.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute and chronic respiratory failure,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Unspecified protein-calorie malnutrition,Body Mass Index less than 19, adult,Anxiety state, unspecified,Leukocytosis, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Burn of unspecified degree of face and head, unspecified site,Anemia, unspecified,Esophageal reflux,Osteoporosis, unspecified,Unspecified essential hypertension,Tachycardia, unspecified,Chest pain, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Volume depletion, unspecified,Personal history of tuberculosis,Personal history of tobacco use,Other dependence on machines, supplemental oxygen,Long-term (current) use of steroids,Automatic implantable cardiac defibrillator in situ,Accident caused by unspecified fire'}


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: SOB w/ exertion

PRESENT ILLNESS: 62F with h/o COPD on 3L home O2, sCHF s/p ICD/Ppm, HTN, DM2
presents from [**Hospital3 2558**] with worsening SOB with exertion x
2 days.
.
Of note, the patient was recently admitted to [**Hospital1 112**] from [**2-21**] to
[**2-27**] for a facial burn sustained when she tried to smoke a
cigarette while on oxygen via nasal cannula. She was initially
on BiPap in the ED, was given high-dose steroids. Bronchoscopy
showed no airway edema or soot. On [**2-22**], she had flash pulmonary
edema and was treated with 40 mg IV Lasix. She was discharged on
her home meds and Prednisone taper.
.
She notes that yesterday she tried to be more active and was
getting up and moving around more and noticed that she felt more
short of breath doing activities - felt she couldn't catch her
breath. She was on her usual 3L nc at that time and didn't try
to increase the rate. She took a Duoneb inhaler yesterday, which
helped her SOB. Then this morning, she noticed that she again
had trouble catching her breath with activity. Duoneb inhaler
was given without improvement. She was given 40 mg Prednisone
(takes 20 mg chronically) and was brought to the ED.
.
In the ED, initial vitals 97.0  128 (sinus)  144/93  20  100% on
2L (home requirement is 3L). Exam was notable for absence of
wheezing, absence of significant crackles, and no LE edema. Labs
revealed Cr 0.5, WBC 17.1, Hct 27.5. CT-A was performed and
showed no PE; did reveal emphysema and a 7 mm LLL pulmonary
nodule. CXR showed COPD, dual-chamber Ppm/AICD, flat diaphragms,
and large cardiac silhouette - no infiltrate or edema. She was
given 1L NS, Solumedrol 125 mg, 5 mg Oxycodone for face/hand
pain, and Levaquin 750 mg IV. She was then transferred to the
floor.
.
Currently, VS are 115  159/83  18  99% on 3L. The patient
generally appears to be breathing comfortably and is in no
apparent distress. She speaks in full sentences. She denies
recent cough. Denies fevers/chills, no chest pain, no n/v,
dysuria, no recent illness. She did have her flu vaccine this
year. ROS is positive for diarrhea for a few days that resolved
one week ago, recent PND - was been waking up more often feeling
SOB, orthopnea - 1 pillow chronically, has gained [**4-11**] pounds
over 1.5 months.

MEDICAL HISTORY: COPD on 3L home O2 with multiple hospitalizations; was in ICU
for COPD exacerbation in [**1-17**]
- FEV1 27% in [**12/2171**]
systolic CHF with dual chamber pacemaker and AICD
-placed [**12/2171**]
-dilated cardiomyopathy with EF = 20-25% from ?year
TB - treated in [**2168**], had RUL wedge resection
paroxysmal Afib?
GERD
Anxiety
HL
OA
GI bleed [**3-12**] duodenal/gastric ulcer
Osteoporosis
Vtach
Gastric ulcer
DM - type 2
HTN
Macrocytic anemia
Chronic leukocytosis
s/p myomectomy in [**2166**]
s/p C-section

MEDICATION ON ADMISSION: Toprol XL 100 mg qday
Multivitamin 1 tab qday
Oxycodone 5 mg q4h prn
Ultram 25 mg q6h prn
Tylenol 650 mg TID prn
Calcium Carbonate 1 tab [**Hospital1 **]
Colace
Ferrous Sulfate 325 mg qday
Potassium Chloride 20 Meq qday
Omeprazole 40 mg [**Hospital1 **]
Prednisone 20 mg qday (chronic home dose)
Lactulose 30 mg QID prn constipation
Senna 8.6 mg [**Hospital1 **] prn
Bactrim DS - 1 tab M,W,F
Insulin sliding scale
Duoneb q6h prn
Spiriva 18 mcg qday
Torsemide 20 mg [**Hospital1 **]
Albuterol neb prn
Bacitracin/Neosporin/Polymixin ointment
Advair 250/50 [**Hospital1 **]
Caltrate 600/400 [**Hospital1 **]
Lorazepam 0.5 mg q8h prn
Vit D3 400 U qday

ALLERGIES: Captopril / Aspirin / Tetracycline / Erythromycin Base /
Penicillins / Motrin / Wellbutrin

PHYSICAL EXAM: On admission:
VS -  AF  115  159/83   18   99% on 3L
GENERAL - elderly AAF appears older than state age, breathing
comfortably in NAD, pleasant, a&ox3
HEENT - face with obvious burn on upper lip and tip of nose,
PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - poor air movement throughout, few bibasilar crackles, no
wheezing, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2, ?additional heart sound vs. split
S1
ABDOMEN - C-section scar, soft/NT/ND, NABS, no masses or HSM, no
rebound/guarding
EXTREMITIES - thin, WWP, no c/c/e, 2+ peripheral pulses
(radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**5-13**] throughout but equal bilaterally, sensation grossly intact
throughout, gait deferred

FAMILY HISTORY: HTN, Dementia

SOCIAL HISTORY: Retired LPN - worked at [**Hospital3 **], LT care, substance
abuse facility.
Before going to [**Hospital3 **], lived at home with daughter
[**Name (NI) 97832**].
Ambulates with a walker. Occasionally needs help with dressing,
feeding.
+ tob - 60 pack-year history, states she quit after recent burn
History of heavy EtOH, none since [**5-18**]
No drugs 

### Response:
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute and chronic respiratory failure,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Unspecified protein-calorie malnutrition,Body Mass Index less than 19, adult,Anxiety state, unspecified,Leukocytosis, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Burn of unspecified degree of face and head, unspecified site,Anemia, unspecified,Esophageal reflux,Osteoporosis, unspecified,Unspecified essential hypertension,Tachycardia, unspecified,Chest pain, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Volume depletion, unspecified,Personal history of tuberculosis,Personal history of tobacco use,Other dependence on machines, supplemental oxygen,Long-term (current) use of steroids,Automatic implantable cardiac defibrillator in situ,Accident caused by unspecified fire'}
