CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: Mr. [**Known lastname 10794**] is a 52yo male with a past medical history of
non-ischemic cardiomyopathy (LVEF 30%-35%), insulin-dependent
diabetes mellitus, hepatitis C infection, HTN, HLD,
schizophrenia and depression who is presenting in acute
respiratory distress after recent admission to the MICU/Gen med
([**Date range (1) 63644**]) for similar presentation. The patient reports that he
was smoking crack cocaine earlier 2 days ago began to have chest
pain and progressive shortness of breath over the past 2 days.
He also reports worsening of productive cough (white sputum)
which has been present since his discharge from the hospital on
[**1-21**]. He says that he felt that he never truly returned to his
baseline after his last hospitalization. He says that he has had
worsening orthopnea, with use of 3 pillows instead of his usual
2 last night. He denies edema, PND. He denies fevers/chills or
other URI sx, chest pain/pressure, pleuritic pain. He has had a
VNA and reports that his weight has decreased from 183 to 180,
he has avoided salt in his diet and he has been fully compliant
with this medications. He does think that the crack that he
smoked 2 days ago had "less baking soda in it." The patient also
does have a past medical history of MRSA pna requiring
tracheostomy.
.
He also had admission from [**2112-12-8**] in which he was intubated
and CT showed multifocal pneumonia. Because the radiographic
evidence of this pneumonia cleared quickly within 2 weeks, it
was felt that this was crack lung as opposed to infectious. He
was treated with broad spectrum abx and his respiratory status
returned to baseline. During his admission [**Date range (1) 63644**], the patient
was felt to have crack lung/hypersensitivity pneumonitis given
parenchymal abnormality seen on chest CT, he was treated with
one dose of methylprednisone 125mg but had hyperglycemia
requiring insulin gtt and was thus not treated with steroids. He
did not receive antibiotics. There may have been a component of
CHF during this presentation and the patient was treated with
lasix gtt during this prior admission.
.
In the ED, initial VS were:  RR 40s, O2 Sat: 75% on NRB. The
patient received nitro gtt, was placed on BiPap with dramatic
improvement. The patient was also treated with levofloxacin and
vancomycin. He received lasix 40mg IV x1, aspirin and tylenol
1000mg po. Blood cultures were obtained.
.
On arrival to the MICU, the patient is still tachypneic but
completing full sentences. He is alert, oriented and does not
appear in acute distress.
.
Review of systems:
(+) Per HPI. Endorses headaches. Endorses diarrhea which
resolved 2 days ago.
(-) Denies fever, chills, night sweats, recent weight gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Type II Diabetes, Hyperlipidemia, HTN
2. CARDIAC HISTORY:
3. OTHER PAST MEDICAL HISTORY:
- Nonischemic dilated cardiomyopathy ([**10/2195**]-LVEF 20%, LVD
6.4cm, 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: 1. 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.
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
.
Vitals: T: 98.6 BP: 98/61 P:95 R: 31 18 O2: 100%  CPAP with FiO2
100% and PEEP of 5
General: Alert, oriented, no acute distress with CPAP on
HEENT: Sclera anicteric, MMM, poor dentition, EOMI, PERRL
Neck: supple, JVP not able to be assessed, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops  appreciated
Lungs: diffuse dry crackles, no wheezes. Air movement
throughout. No use of accessory muscles with CPAP in place.
Abdomen: soft, minimal diffuse tenderness, mild distended, bowel
sounds present, obese
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
.
DISCHARGE EXAM:
.
VITALS: 98.8  98.7  115/68  100  20  94% 1L NC  BG: 77-239 mg/dL
I/Os: 1300 | 1000 + BRP (-0.5L LOS)
GENERAL: Appears in no acute distress. Alert and interactive.
Able to speak in full sentences.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD just above clavicle at
90-degrees.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Faint breath sounds bilaterally with inspiratory crackles
at bases; rhonchi in upper airways bilaterally. No wheezing.
Stable inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; no peripheral edema, 2+ peripheral
pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.

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: crack cocaine three days ago
Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Other specified allergic alveolitis and pneumonitis,Cocaine dependence, continuous,Chronic systolic heart failure,Other primary cardiomyopathies,Poisoning by cocaine,Poisoning by other specified drugs and medicinal substances, undetermined whether accidentally or purposely inflicted,Tobacco use disorder,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified viral hepatitis C without hepatic coma
Obs chr bronc w(ac) exac,Acute respiratry failure,Allerg alveol/pneum NEC,Cocaine depend-contin,Chr systolic hrt failure,Prim cardiomyopathy NEC,Poisoning by cocaine,Undet pois-med agnt NEC,Tobacco use disorder,DMII wo cmp nt st uncntr,Long-term use of insulin,Hypertension NOS,Hyperlipidemia NEC/NOS,Hpt C w/o hepat coma NOS
Admission Date:  [**2196-1-28**]              Discharge Date:   [**2196-2-3**]

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

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 9160**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
None this hospitalization


History of Present Illness:
Mr. [**Known lastname 10794**] is a 52yo male with a past medical history of
non-ischemic cardiomyopathy (LVEF 30%-35%), insulin-dependent
diabetes mellitus, hepatitis C infection, HTN, HLD,
schizophrenia and depression who is presenting in acute
respiratory distress after recent admission to the MICU/Gen med
([**Date range (1) 63644**]) for similar presentation. The patient reports that he
was smoking crack cocaine earlier 2 days ago began to have chest
pain and progressive shortness of breath over the past 2 days.
He also reports worsening of productive cough (white sputum)
which has been present since his discharge from the hospital on
[**1-21**]. He says that he felt that he never truly returned to his
baseline after his last hospitalization. He says that he has had
worsening orthopnea, with use of 3 pillows instead of his usual
2 last night. He denies edema, PND. He denies fevers/chills or
other URI sx, chest pain/pressure, pleuritic pain. He has had a
VNA and reports that his weight has decreased from 183 to 180,
he has avoided salt in his diet and he has been fully compliant
with this medications. He does think that the crack that he
smoked 2 days ago had "less baking soda in it." The patient also
does have a past medical history of MRSA pna requiring
tracheostomy.
.
He also had admission from [**2112-12-8**] in which he was intubated
and CT showed multifocal pneumonia. Because the radiographic
evidence of this pneumonia cleared quickly within 2 weeks, it
was felt that this was crack lung as opposed to infectious. He
was treated with broad spectrum abx and his respiratory status
returned to baseline. During his admission [**Date range (1) 63644**], the patient
was felt to have crack lung/hypersensitivity pneumonitis given
parenchymal abnormality seen on chest CT, he was treated with
one dose of methylprednisone 125mg but had hyperglycemia
requiring insulin gtt and was thus not treated with steroids. He
did not receive antibiotics. There may have been a component of
CHF during this presentation and the patient was treated with
lasix gtt during this prior admission.
.
In the ED, initial VS were:  RR 40s, O2 Sat: 75% on NRB. The
patient received nitro gtt, was placed on BiPap with dramatic
improvement. The patient was also treated with levofloxacin and
vancomycin. He received lasix 40mg IV x1, aspirin and tylenol
1000mg po. Blood cultures were obtained.
.
On arrival to the MICU, the patient is still tachypneic but
completing full sentences. He is alert, oriented and does not
appear in acute distress.
.
Review of systems:
(+) Per HPI. Endorses headaches. Endorses diarrhea which
resolved 2 days ago.
(-) Denies fever, chills, night sweats, recent weight gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.


Past Medical History:
1. CARDIAC RISK FACTORS: Type II Diabetes, Hyperlipidemia, HTN
2. CARDIAC HISTORY:
3. OTHER PAST MEDICAL HISTORY:
- Nonischemic dilated cardiomyopathy ([**10/2195**]-LVEF 20%, LVD
6.4cm, 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: crack cocaine three days ago


Family History:
- Father: pacemaker, deceased


Physical Exam:
ADMISSION EXAM:
.
Vitals: T: 98.6 BP: 98/61 P:95 R: 31 18 O2: 100%  CPAP with FiO2
100% and PEEP of 5
General: Alert, oriented, no acute distress with CPAP on
HEENT: Sclera anicteric, MMM, poor dentition, EOMI, PERRL
Neck: supple, JVP not able to be assessed, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops  appreciated
Lungs: diffuse dry crackles, no wheezes. Air movement
throughout. No use of accessory muscles with CPAP in place.
Abdomen: soft, minimal diffuse tenderness, mild distended, bowel
sounds present, obese
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
.
DISCHARGE EXAM:
.
VITALS: 98.8  98.7  115/68  100  20  94% 1L NC  BG: 77-239 mg/dL
I/Os: 1300 | 1000 + BRP (-0.5L LOS)
GENERAL: Appears in no acute distress. Alert and interactive.
Able to speak in full sentences.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD just above clavicle at
90-degrees.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Faint breath sounds bilaterally with inspiratory crackles
at bases; rhonchi in upper airways bilaterally. No wheezing.
Stable inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; no peripheral edema, 2+ peripheral
pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.

Pertinent Results:
ADMISSION LABS:
.
[**2196-1-28**] 09:30PM BLOOD WBC-13.6* RBC-4.20* Hgb-11.1* Hct-35.4*
MCV-84 MCH-26.4* MCHC-31.4 RDW-15.3 Plt Ct-333
[**2196-1-28**] 09:30PM BLOOD Neuts-74.1* Lymphs-18.8 Monos-2.5
Eos-4.2* Baso-0.4
[**2196-1-28**] 09:55PM BLOOD PT-11.4 PTT-35.1 INR(PT)-1.1
[**2196-1-28**] 09:30PM BLOOD Glucose-127* UreaN-12 Creat-0.9 Na-144
K-4.0 Cl-108 HCO3-26 AnGap-14
[**2196-1-29**] 03:06AM BLOOD ALT-19 AST-23 LD(LDH)-360* CK(CPK)-98
AlkPhos-65 TotBili-0.4
[**2196-1-29**] 03:06AM BLOOD Albumin-3.1* Calcium-8.5 Phos-3.9 Mg-1.4*
[**2196-1-28**] 09:30PM BLOOD ASA-NEG Ethanol-17* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2196-1-28**] 09:31PM BLOOD Lactate-2.2*
[**2196-1-28**] 10:35PM BLOOD Lactate-1.2
[**2196-1-29**] 05:07AM URINE cocaine-POS
.
DISCHARGE LABS:
.
[**2196-2-1**] 07:25AM BLOOD WBC-6.4 RBC-3.55* Hgb-9.2* Hct-30.1*
MCV-85 MCH-26.0* MCHC-30.7* RDW-15.1 Plt Ct-335
[**2196-1-29**] 03:06AM BLOOD PT-12.6* PTT-32.4 INR(PT)-1.2*
[**2196-2-3**] 06:55AM BLOOD Glucose-112* UreaN-9 Creat-0.8 Na-143
K-4.3 Cl-108 HCO3-29 AnGap-10
[**2196-2-3**] 06:55AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.8
.
MICROBIOLOGY DATA:
[**2196-1-28**] Blood culture (x 2) - pending
[**2196-1-29**] MRSA screen - negative
[**2196-1-29**] Urine legionella - negative
.
IMAGING:
[**2196-1-30**] CHEST (PORTABLE AP) - In addition to a severe
infiltrative abnormality, with probable confluence in the lung
bases, there are many small discrete nodular opacities, which
have grown appreciably since [**1-28**], probably entirely new
since [**1-18**]. Pattern strongly suggests widespread
infection, possibly septic emboli. Heart is moderately enlarged,
unchanged. At least small bilateral pleural
effusions are presumed.

Brief Hospital Course:
IMPRESSION: 52M with a PMH significant for non-ischemic
cardiomyopathy (LVEF 30%-35%), insulin-dependent diabetes
mellitus, hepatitis C infection, HTN, HLD, schizophrenia and
depression with recent hospitalization for crack lung, who
presented with acute hypoxic respiratory distress found to have
bilaterally diffuse airspace opacification with suspected
component of CHF exacerbation, in the setting of recent illicit
substance use.
.
# DIFFUSE, BILATERAL LUNG OPACIFICATION AND ACUTE RESPIRATORY
DECOMPENSATION - Consistent with his prior hospitalizations, Mr.
[**Known lastname 10794**] was admitted with acute hypoxic respiratory failure
requiring NIPPV in the setting of recent crack cocaine use,
attributed to acute crack inhalation lung injury. In [**Month (only) 1096**]
[**2194**], he presented with a picture concerning for multifocal
pneumonia, although his rapid resolution of symptoms without
antibiotics was more consistent with hypersensitivity
pneumonitis or crack lung. Three days preceding admission, he
notes crack cocaine use. He was admitted to the MICU for
respiratory monitoring and required a period of BiPAP use with
improvement with symptomatic treatment, namely nebulizers and
agressive respiratory therapy. He was not intubated during this
admission. While he received a single dose of IV Vancomycin in
the ED, these were discontinued, and steroids were deferred
given his similar presentation with rapid improvement in the
past despite minimal intervention. His admitting CXR showed
bilateral opacifications, despite a normal WBC and no fevers. A
chest CT on prior admission showed marked diffuse bilateral
airspace opacities, ground-glass in appearance, with confluent
consolidation -- but subsequent CXRs noted rapid improvement
despite limited therapy, supporting a crack lung or
hypersensitivity etiology. Over several days, his supplemental
oxygen was weaned and he ambulated 100 feet without
destaurations, maintaining his oxygen saturations in the 92-94%
range on room air (which is his baseline). He had no cough or
respiratory symptoms and he resumed all of his home medications.
.
# INSULIN-DEPENDENT DIABETES MELLITUS - Patient previously
managed with Lantus dosing (taking 40 units at home) -
intermittently checks his glucose at home, has been under the
200 mg/dL range per the patient. Last HbA1c 7.4% in 11/[**2194**]. No
evidence of retinopathy, renal failure (baseline creatinine
0.9-1.1) or neuropathy. We titrated his Lantus to 50 units SC at
nighttime for tighter glucose control.
.
# NON-ISCHEMIC CARDIOMYOPATHY / CHRONIC SYSTOLIC HEART FAILURE -
Patient with known moderate global left ventricular hypokinesis
(LVEF = 30-35%), LVD 6.4-cm, mild RV dilation, borderline
function, 1+ MR on 2D-Echo from 12/[**2194**]. His respiratory
decompensation was attributed to a pulmonary source
predominantly. He was tolerating his home PO Lasix, and returned
to room air with adequate oxygen saturations prior to discharge.
We continued his Lisinopril 10 mg PO daily, Metoprolol succinate
XL 100 mg PO daily, maintained his home dose of Furosemide 40 mg
PO daily and kept him on a fluid restriction of 1500 mL daily.
He was monitored with daily weights, monitored I/Os, and his
goal for diuresis was 0.5-1L daily.
.
# HYPERTENSION - Managed as an outpatient with ACEI,
beta-blocker. Discharged on home regimen without changes.
.
# HYPERLIPIDEMIA - We continued Atorvastatin 20 mg PO QHS.
.
# SUBSTANCE, TOBACCO ABUSE HISTORY - He has multiple prior
episodes of relapse with resulting hospitalizations; patient
notes mostly crack-cocaine use (2-3 days prior to admission) in
lieu of alcohol use. Lives with sister who is supportive and is
a probation officer. We offered him a nicotine patch for tobacco
use and provided smoking cessation counseling. Social work
consultation was provided and motivational support was offered;
he may benefit from outpatient addiction program assistance,
which he is strongly considering. He does not qualify for dual
diagnosis admission since his psychiatric illness is
compensated.
.
# HEPATITIS C INFECTION - He has a history of positive HCV
antibody documented in [**2188**]. No evidence of sequelae of chronic
liver disease. Liver synthetic function appears maintained (plt
424, albumin 2.8). LFTs: AST 29 and ALT 13 with T-bili 0.4 from
prior lab studies. HIV negative, AMA and smooth negative in
[**2190**]. Abdominal U/S in [**2189**] was normal. HCV viral load
20,101,696 IU/mL in 11/[**2194**]. Will need follow-up as outpatient
for AFP, serial ultrasounds, candidacy for possible anti-viral
therapy
(likely poor candidate) given his hepatitis C infection.
.
TRANSITION OF CARE ISSUES:
1. Social work consultation was provided and motivational
support was offered; he may benefit from outpatient addiction
program assistance given his substance abuse history.
2. Has outpatient follow-up with primary care physician and
Pulmonology scheduled.
3. Will need follow-up as outpatient for AFP, serial
ultrasounds, candidacy for possible anti-viral therapy (likely
poor candidate) given his hepatitis C infection.
4. Will also need outpatient PFTs and Pulmonology follow-up to
evaluate for other underlying lung disease.

Medications on Admission:
1. 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.
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.

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. insulin lispro 100 unit/mL Solution Sig: [**12-21**] units
Subcutaneous per sliding scale.
6. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
7. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:

1-2 puffs Inhalation every six (6) hours as needed for shortness

of breath or wheezing.
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)

Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. sertraline 50 mg Tablet Sig: 0.5 Tablet PO once a day.
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable

PO DAILY (Daily).
13. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO twice a day.
14. codeine sulfate 30 mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for pain.
15. Seroquel 100 mg Tablet Sig: 0.5-1 Tablet PO at bedtime.

Discharge Medications:
1. 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.
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
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. Novolog 100 unit/mL Solution Sig: [**12-21**] units Subcutaneous once
a day: per insulin sliding scale.
6. Lantus 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous at bedtime.
7. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
11. sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. codeine sulfate 30 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. quetiapine 100 mg Tablet Sig: 0.5-1 Tablet PO HS (at
bedtime).


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Primary Diagnoses:
1. Acute pulmonary syndrome (presumably related to crack-cocaine

use)
2. Acute on chronic exacerbation of non-ischemic cardiomyopathy
.
Secondary Diagnoses:
1. History of polysubstance abuse
2. Insulin-dependent diabetes mellitus
3. Hypertension
4. Hyperlipidemia
5. Positive Hepatitis C antibody
6. Chronic obstructive pulmonary disease


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


Discharge Instructions:
Patient Discharge Instructions:
.
You were admitted to the Internal Medicine service at [**Hospital1 1535**] on CC7 regarding management of
your acute respiratory issues. You were first admitted to the
medical intensive care unit given concern for worsening heart
failure in the setting of your illicit substance use, but this
resolved with supportive therapy. You should AVOID ALL ILLICIT
SUBSTANCE USE in the future and take all necessary steps to
obtain motivational assistance and substance abuse program
assistance to promote healthy living.
.
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
.
CHANGES IN YOUR MEDICATION RECONCILIATION:
.
* Upon admission, we ADDED: NONE
.
* Upon admission, we CHANGED:
We CHANGED: Lantus from 40 to 50 units subcutaneously in the
evenings for better glucose control
.
* The following medications were DISCONTINUED on admission and
you should NOT resume: NONE
.
* You should continue all of your other home medications as
prescribed, unless otherwise directed above.

Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2196-2-11**] at 9:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2196-2-11**] at 9:30 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: PFT
When: THURSDAY [**2196-2-11**] at 9:30 AM
** Please contact our registration department at [**Telephone/Fax (1) 10676**] to
update your information.**
.
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: FRIDAY [**2196-2-12**] at 10:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 63642**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 9162**]
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Other specified allergic alveolitis and pneumonitis,Cocaine dependence, continuous,Chronic systolic heart failure,Other primary cardiomyopathies,Poisoning by cocaine,Poisoning by other specified drugs and medicinal substances, undetermined whether accidentally or purposely inflicted,Tobacco use disorder,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified viral hepatitis C without hepatic coma'}


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: Mr. [**Known lastname 10794**] is a 52yo male with a past medical history of
non-ischemic cardiomyopathy (LVEF 30%-35%), insulin-dependent
diabetes mellitus, hepatitis C infection, HTN, HLD,
schizophrenia and depression who is presenting in acute
respiratory distress after recent admission to the MICU/Gen med
([**Date range (1) 63644**]) for similar presentation. The patient reports that he
was smoking crack cocaine earlier 2 days ago began to have chest
pain and progressive shortness of breath over the past 2 days.
He also reports worsening of productive cough (white sputum)
which has been present since his discharge from the hospital on
[**1-21**]. He says that he felt that he never truly returned to his
baseline after his last hospitalization. He says that he has had
worsening orthopnea, with use of 3 pillows instead of his usual
2 last night. He denies edema, PND. He denies fevers/chills or
other URI sx, chest pain/pressure, pleuritic pain. He has had a
VNA and reports that his weight has decreased from 183 to 180,
he has avoided salt in his diet and he has been fully compliant
with this medications. He does think that the crack that he
smoked 2 days ago had "less baking soda in it." The patient also
does have a past medical history of MRSA pna requiring
tracheostomy.
.
He also had admission from [**2112-12-8**] in which he was intubated
and CT showed multifocal pneumonia. Because the radiographic
evidence of this pneumonia cleared quickly within 2 weeks, it
was felt that this was crack lung as opposed to infectious. He
was treated with broad spectrum abx and his respiratory status
returned to baseline. During his admission [**Date range (1) 63644**], the patient
was felt to have crack lung/hypersensitivity pneumonitis given
parenchymal abnormality seen on chest CT, he was treated with
one dose of methylprednisone 125mg but had hyperglycemia
requiring insulin gtt and was thus not treated with steroids. He
did not receive antibiotics. There may have been a component of
CHF during this presentation and the patient was treated with
lasix gtt during this prior admission.
.
In the ED, initial VS were:  RR 40s, O2 Sat: 75% on NRB. The
patient received nitro gtt, was placed on BiPap with dramatic
improvement. The patient was also treated with levofloxacin and
vancomycin. He received lasix 40mg IV x1, aspirin and tylenol
1000mg po. Blood cultures were obtained.
.
On arrival to the MICU, the patient is still tachypneic but
completing full sentences. He is alert, oriented and does not
appear in acute distress.
.
Review of systems:
(+) Per HPI. Endorses headaches. Endorses diarrhea which
resolved 2 days ago.
(-) Denies fever, chills, night sweats, recent weight gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Type II Diabetes, Hyperlipidemia, HTN
2. CARDIAC HISTORY:
3. OTHER PAST MEDICAL HISTORY:
- Nonischemic dilated cardiomyopathy ([**10/2195**]-LVEF 20%, LVD
6.4cm, 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: 1. 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.
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
.
Vitals: T: 98.6 BP: 98/61 P:95 R: 31 18 O2: 100%  CPAP with FiO2
100% and PEEP of 5
General: Alert, oriented, no acute distress with CPAP on
HEENT: Sclera anicteric, MMM, poor dentition, EOMI, PERRL
Neck: supple, JVP not able to be assessed, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops  appreciated
Lungs: diffuse dry crackles, no wheezes. Air movement
throughout. No use of accessory muscles with CPAP in place.
Abdomen: soft, minimal diffuse tenderness, mild distended, bowel
sounds present, obese
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
.
DISCHARGE EXAM:
.
VITALS: 98.8  98.7  115/68  100  20  94% 1L NC  BG: 77-239 mg/dL
I/Os: 1300 | 1000 + BRP (-0.5L LOS)
GENERAL: Appears in no acute distress. Alert and interactive.
Able to speak in full sentences.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD just above clavicle at
90-degrees.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Faint breath sounds bilaterally with inspiratory crackles
at bases; rhonchi in upper airways bilaterally. No wheezing.
Stable inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing; no peripheral edema, 2+ peripheral
pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.

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: crack cocaine three days ago 

### Response:
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Other specified allergic alveolitis and pneumonitis,Cocaine dependence, continuous,Chronic systolic heart failure,Other primary cardiomyopathies,Poisoning by cocaine,Poisoning by other specified drugs and medicinal substances, undetermined whether accidentally or purposely inflicted,Tobacco use disorder,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified viral hepatitis C without hepatic coma'}
