CHIEF COMPLAINT: paradoxical vocal cord paralysis, inspiratory stridor

PRESENT ILLNESS: 34 y.o. W with history of questionably steroid-dependent asthma
presenting with chest tightness and dyspnea. The patient reports
worsening shortness of breath X 2 days. She was admitted to
[**Hospital1 18**] with asthma flare in [**4-26**] and treated with an 18-day
prednisone taper. The patient says this episode began as back
pain about two days ago, which then migrated to her chest and
abdomen. She began to feel SOB and tried to take nebs without
improvement. The chest pain is typical of her usual episodes of
SOB, and she describes it as a tight squeezing around her rib
cage. She has it chronically, off and on. This time the pain
persisted and so she came to the ED.
.
In the ED, patient has a CXR which was normal. Per report, she
had an ECG which may have had some new diffuse T-wave changes.
She refused ASA. She had a upper airway scope and per report had
paradoxical vocal cord movement. She was treated with 10 mg of
IV Valium with some relief. Given her history of multiple
intubations, and persistence of inspiratory stridor, she was
admitted to the MICU for close monitoring.
.
On arrival to the unit patient says that she is breathing
comfortably but complains of persistent chest and R back pain.
Denies any recent symptoms of illness - no cough, congestion,
urinary or bowel symptoms.

MEDICAL HISTORY: Asthma--intubated X 15 times, reports steroid dependence on 20
mg daily although no outpatient notes suggest this dose. Follows
with pulmonary at [**Hospital1 18**].
Seizure disorder
IDDM--since age 19
HTN-since age 16
Schizophrenia
Anxiety/Panic Attacks
DVT
CVA
Diverticulosis
Obstructive sleep apnea-10 cm H2O
pancreatitis

MEDICATION ON ADMISSION: per OMR:
Advair 500/50 [**Hospital1 **]
abilify 20 mg daily
Calcium 600 + D
Depakote 1000 daily
Colace 100 daily
Duoneb qid
flovent 2 [**Hospital1 **]
fluoxetine 60 mg daily
HCTZ 25 mg daily
NPH 26 u [**Hospital1 **]
lisinopril 30 mg dialy
montelukast 10 mg daily
dilantin 300 mg qam
Prilosec 40 mg daily
senna
Ziprasidone

ALLERGIES: Penicillins / Aspirin / Motrin / Tylenol

PHYSICAL EXAM: VS: T: 97 BP: 134/93 P: 85 RR: 19 O2 sat: 100% on RA
Gen: obese, no distress, speaking in complete sentences and
relates history without distress. No accessory muscle use.
HEENT: EOMI, no icterus, no injection, MMM, OP clear, neck
supple
Car: Tachycardic, no murmur
Resp: breath sounds distant, no abnormal sounds
Abd: soft, obese, diffusely tender to palpation, moves easily in
bed, + R CVA tenderness
Ext: no LE edema

FAMILY HISTORY: CAD, HTN

SOCIAL HISTORY: Lives alone, 3ppd X 15 years, quit 3 yrs ago), no etoh, no
drugs, works in "pathology".
Paralysis of vocal cords or larynx, unspecified,Asthma, unspecified type, with (acute) exacerbation,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified schizophrenia, unspecified,Adjustment disorder with depressed mood,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Other chest pain,Abdominal pain, unspecified site,Unspecified essential hypertension,Personal history of venous thrombosis and embolism,Personal history of other diseases of digestive system,Family history of ischemic heart disease
Vocal cord paralysis NOS,Asthma NOS w (ac) exac,Epilep NOS w/o intr epil,Schizophrenia NOS-unspec,Adjustmnt dis w depressn,DMI wo cmp nt st uncntrl,Chest pain NEC,Abdmnal pain unspcf site,Hypertension NOS,Hx-ven thrombosis/embols,Prsnl hst ot spf dgst ds,Fam hx-ischem heart dis
Admission Date:  [**2158-4-19**]              Discharge Date:   [**2158-4-22**]

Date of Birth:  [**2124-1-18**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Aspirin / Motrin / Tylenol

Attending:[**First Name3 (LF) 783**]
Chief Complaint:
paradoxical vocal cord paralysis, inspiratory stridor

Major Surgical or Invasive Procedure:
none


History of Present Illness:
34 y.o. W with history of questionably steroid-dependent asthma
presenting with chest tightness and dyspnea. The patient reports
worsening shortness of breath X 2 days. She was admitted to
[**Hospital1 18**] with asthma flare in [**4-26**] and treated with an 18-day
prednisone taper. The patient says this episode began as back
pain about two days ago, which then migrated to her chest and
abdomen. She began to feel SOB and tried to take nebs without
improvement. The chest pain is typical of her usual episodes of
SOB, and she describes it as a tight squeezing around her rib
cage. She has it chronically, off and on. This time the pain
persisted and so she came to the ED.
.
In the ED, patient has a CXR which was normal. Per report, she
had an ECG which may have had some new diffuse T-wave changes.
She refused ASA. She had a upper airway scope and per report had
paradoxical vocal cord movement. She was treated with 10 mg of
IV Valium with some relief. Given her history of multiple
intubations, and persistence of inspiratory stridor, she was
admitted to the MICU for close monitoring.
.
On arrival to the unit patient says that she is breathing
comfortably but complains of persistent chest and R back pain.
Denies any recent symptoms of illness - no cough, congestion,
urinary or bowel symptoms.


Past Medical History:
Asthma--intubated X 15 times, reports steroid dependence on 20
mg daily although no outpatient notes suggest this dose. Follows
with pulmonary at [**Hospital1 18**].
Seizure disorder
IDDM--since age 19
HTN-since age 16
Schizophrenia
Anxiety/Panic Attacks
DVT
CVA
Diverticulosis
Obstructive sleep apnea-10 cm H2O
pancreatitis


Social History:
 Lives alone, 3ppd X 15 years, quit 3 yrs ago), no etoh, no
drugs, works in "pathology".

Family History:
CAD, HTN

Physical Exam:
VS: T: 97 BP: 134/93 P: 85 RR: 19 O2 sat: 100% on RA
Gen: obese, no distress, speaking in complete sentences and
relates history without distress. No accessory muscle use.
HEENT: EOMI, no icterus, no injection, MMM, OP clear, neck
supple
Car: Tachycardic, no murmur
Resp: breath sounds distant, no abnormal sounds
Abd: soft, obese, diffusely tender to palpation, moves easily in
bed, + R CVA tenderness
Ext: no LE edema


Pertinent Results:
Admission labs:
[**Age over 90 **]|105|11
-----------<103
5.0|26 |0.9
Comments: K: Hemolysis Falsely Elevates K
estGFR: 72 / >75
CK: 176  MB: 3  Trop-T: <0.01
Ca: 9.2 Mg: 2.3 P: 3.2
ALT: 13 AP: 60
AST: 33 LDH: 448
[**Doctor First Name **]: 59 Lip: 71
Phenytoin: <0.6 Valproate: <3.0
  13.2
6.5>-<178
  39.6
N:49.4 L:44.1 M:4.3 E:0.7 Bas:1.4
.
CXR: SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: Technically
limited study due to underpenetration and soft tissue scatter.
Low lung volumes are noted. Within these limitations, no focal
pulmonary opacities. There is no pleural effusion. Linear
subsegmental atelectasis at the left lung base is noted.
Cardiomediastinal silhouette is normal. Pulmonary vasculature is
within normal limits. There is no pneumothorax.



Brief Hospital Course:
A/P: 34 y.o. W with history of questionably steroid-dependent
asthma presenting with chest tightness and dyspnea.
.
# Paradoxical vocal cord dysfunction: The patient was initially
admitted to the intensive care unit due to feelings of acute
shortness of breath and stridor. A chest X-ray showed no acute
abnormalities and EKG was within normal limites without evidence
of ischemia. By report, visualization of the vocal cords
displayed evidence of abnormal vocal cord movement. She was
treated convervatively. She was not intubated, she was given
frequent albuterol nebulizer treatments and continued on her
maintanence asthma medications. She had no evidence of airway
compromise or O2 desaturations. She was seen by speech and
swallow and felt that she would benefit from speech therapy
(note in chart). She should also have ENT follow-up for further
management.
.
# Epigastric pain: This resolved upon admission without
intervention and she was continued on a diabetic diet.
.
# Chest pain: She intermittently had discomfort, but pt reported
that this was baseline for her. Her pain improved with nebulizer
treatments and as above had normal EKG and cardiac enzymes were
normal.
.
# Right flank pain: She was started on a lidocaine patch for her
chronic R flank pain. She had no evidence of UTI.
.
# DMII: She was continued on NPH, though pm dose transiently
lowered due to relative am hypoglycemia. She was discharged on
usual dose.
.
# HTN: Stable, continued on home medications of lisinopril and
HCTZ
.
# Schizophrenia/mood: The patient was seen by psychiatry and
felt to have a personality disorder vs cyclothymia vs bipolar
disorder, needing further evaluation given short stay and prior
history of polysubstance abuse. She was seen previously at [**Hospital1 112**]
but wants to transfer her care here. She recently learned that
her brother died suddenly and did express the urge to cut
herself when she is sad. She endorsed that she would not do this
and would be safe at her mother's house. Please see Dr. [**Name (NI) 93743**] note for details. All outpatient depression and mood
stabilizing medications were held.
.
# Seizure disorder: Held depakote or dilantin given no
documentation of seizure disorder and levels of these meds zero
on admission suggesting that she was not taking them.


Medications on Admission:
per OMR:
Advair 500/50 [**Hospital1 **]
abilify 20 mg daily
Calcium 600 + D
Depakote 1000 daily
Colace 100 daily
Duoneb qid
flovent 2 [**Hospital1 **]
fluoxetine 60 mg daily
HCTZ 25 mg daily
NPH 26 u [**Hospital1 **]
lisinopril 30 mg dialy
montelukast 10 mg daily
dilantin 300 mg qam
Prilosec 40 mg daily
senna
Ziprasidone


Discharge Medications:
1. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One (1)
nebulizer treatment Inhalation every six (6) hours.
2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. CALCIUM 500+D  Oral
4. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
6. Flovent Diskus 50 mcg/Actuation Disk with Device Sig: One (1)
puff Inhalation twice a day.
7. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
8. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty
Six (26) units Subcutaneous twice a day: at breakfast and
dinner.
9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO once a day.
11. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge
Mucous membrane every six (6) hours as needed.
Disp:*30 Lozenge(s)* Refills:*0*
12. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): place
patch on for 12 hours, then off for 12 hours.
Disp:*7 Adhesive Patch, Medicated(s)* Refills:*4*
15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.


Discharge Disposition:
Home

Discharge Diagnosis:
1) Paroxysmal vocal cord dysfunction
2) Asthma exacerbation
3) Chronic chest and right flank pain


Discharge Condition:
afebrile, displaying normal vital signs, and tolerating a
regular diet


Discharge Instructions:
You were admitted to the hospital with wheezing, shortness of
breath and chest tightness. This improved with nebulizer
treatments and continued inhalers for your asthma. You were also
started on a lidocaine patch to help with the pain in your hip.
You were evaluated by the psychiatry service while you were in
the hospital and several of your depression medications were
discontinued including Prozac, Abilify and Ziprasidone. It is
very important that you follow-up with psychiatry soon after
discharge. You will need to see your primary care provider to
get [**Name Initial (PRE) **] psychiatry appointment set-up at [**Hospital3 **], since you
will be a new patient.
.
Also, your seizure medications were discontinued including
depakote and dilantin since you had no history of recent
seizures. You should talk to your doctor [**First Name (Titles) 5001**] [**Last Name (Titles) 9533**] these
medications.
.
You were started on a lidocaine patch to help with the pain in
your right side. You should talk to your primary care provider
about this pain regimen.
.
If you feel unsafe in any way, feel that you would hurt yourself
or others, call 911 or seek immediate medical attention.
.
If you feel throat tightening, trouble breathing, new or
worsening chest pain, abdominal pain, nausea, vomiting,
confusion, worsening mood, or new uncontrolled movement of any
body part concerning for a seizure seek immediate medical
attention.

Followup Instructions:
You have a follow-up appointment at [**Hospital3 **] ([**Hospital Ward Name 5074**] of [**Hospital1 **]) on the [**Location (un) **] of the [**Hospital Ward Name 23**]
Building on [**4-26**] at 2pm with Dr. [**First Name (STitle) **].
.
Provider: [**First Name4 (NamePattern1) 488**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2158-4-26**]
2:00
.
It is important that you arrange follow-up with the psychiatry
department at that time.


                             [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
{'Paralysis of vocal cords or larynx, unspecified,Asthma, unspecified type, with (acute) exacerbation,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified schizophrenia, unspecified,Adjustment disorder with depressed mood,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Other chest pain,Abdominal pain, unspecified site,Unspecified essential hypertension,Personal history of venous thrombosis and embolism,Personal history of other diseases of digestive system,Family history of ischemic heart disease'}


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: paradoxical vocal cord paralysis, inspiratory stridor

PRESENT ILLNESS: 34 y.o. W with history of questionably steroid-dependent asthma
presenting with chest tightness and dyspnea. The patient reports
worsening shortness of breath X 2 days. She was admitted to
[**Hospital1 18**] with asthma flare in [**4-26**] and treated with an 18-day
prednisone taper. The patient says this episode began as back
pain about two days ago, which then migrated to her chest and
abdomen. She began to feel SOB and tried to take nebs without
improvement. The chest pain is typical of her usual episodes of
SOB, and she describes it as a tight squeezing around her rib
cage. She has it chronically, off and on. This time the pain
persisted and so she came to the ED.
.
In the ED, patient has a CXR which was normal. Per report, she
had an ECG which may have had some new diffuse T-wave changes.
She refused ASA. She had a upper airway scope and per report had
paradoxical vocal cord movement. She was treated with 10 mg of
IV Valium with some relief. Given her history of multiple
intubations, and persistence of inspiratory stridor, she was
admitted to the MICU for close monitoring.
.
On arrival to the unit patient says that she is breathing
comfortably but complains of persistent chest and R back pain.
Denies any recent symptoms of illness - no cough, congestion,
urinary or bowel symptoms.

MEDICAL HISTORY: Asthma--intubated X 15 times, reports steroid dependence on 20
mg daily although no outpatient notes suggest this dose. Follows
with pulmonary at [**Hospital1 18**].
Seizure disorder
IDDM--since age 19
HTN-since age 16
Schizophrenia
Anxiety/Panic Attacks
DVT
CVA
Diverticulosis
Obstructive sleep apnea-10 cm H2O
pancreatitis

MEDICATION ON ADMISSION: per OMR:
Advair 500/50 [**Hospital1 **]
abilify 20 mg daily
Calcium 600 + D
Depakote 1000 daily
Colace 100 daily
Duoneb qid
flovent 2 [**Hospital1 **]
fluoxetine 60 mg daily
HCTZ 25 mg daily
NPH 26 u [**Hospital1 **]
lisinopril 30 mg dialy
montelukast 10 mg daily
dilantin 300 mg qam
Prilosec 40 mg daily
senna
Ziprasidone

ALLERGIES: Penicillins / Aspirin / Motrin / Tylenol

PHYSICAL EXAM: VS: T: 97 BP: 134/93 P: 85 RR: 19 O2 sat: 100% on RA
Gen: obese, no distress, speaking in complete sentences and
relates history without distress. No accessory muscle use.
HEENT: EOMI, no icterus, no injection, MMM, OP clear, neck
supple
Car: Tachycardic, no murmur
Resp: breath sounds distant, no abnormal sounds
Abd: soft, obese, diffusely tender to palpation, moves easily in
bed, + R CVA tenderness
Ext: no LE edema

FAMILY HISTORY: CAD, HTN

SOCIAL HISTORY: Lives alone, 3ppd X 15 years, quit 3 yrs ago), no etoh, no
drugs, works in "pathology". 

### Response:
{'Paralysis of vocal cords or larynx, unspecified,Asthma, unspecified type, with (acute) exacerbation,Epilepsy, unspecified, without mention of intractable epilepsy,Unspecified schizophrenia, unspecified,Adjustment disorder with depressed mood,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Other chest pain,Abdominal pain, unspecified site,Unspecified essential hypertension,Personal history of venous thrombosis and embolism,Personal history of other diseases of digestive system,Family history of ischemic heart disease'}
