CHIEF COMPLAINT: Dyspnea and cough

PRESENT ILLNESS: 43 year old obese woman with history of smoking (20 pack year),
asthma, bronchitis with multiple admissions since [**2130-9-18**]
for asthma flares. She has required hospitalization and steroids
in the past, but no intubations. She has been on Prednisone 20
mg PO for the past year. On [**9-28**], she presented with one day of
wheezing and cough, peak flows of 120 mL (baseline 250-300 mL).
In the ED, she was unresponsive to nebulizers, heliox, oral
prednisone and was hypoxemic to 87% on 6L NC. She was admitted
to the [**Hospital Unit Name 153**] for nebs q1hr, IV steroids and continuous
monitoring. Empiric CPAP at night was started in [**Hospital Unit Name 153**]. Of note,
pt was seen by Dermatology for rash x 2weeks and a biopsy was
negative for mites. She was discharged from the [**Hospital Unit Name 153**] with
improved oxygenation and ventilation with decreased frequency of
nebs to q3 hour.
ROS: Gained 60 pounds since [**9-21**] (when started steroids).
Endorses fatigue. No rhinorrhea, fever, chills. No N/V or
diarrhea. No chest pain, PND or palpitations. 2 pillow
orthopnea. Denies daytime sleepiness. Frequent bloody stools
with abdominal pain (missed several colonoscopy appointments
because of fatigue).

MEDICAL HISTORY: Asthma
Recurrent HAs
Hyperlipidemia
Depression
Obesity
Bronchitis
GERD/hiatal hernia
Anxiety
Rectal bleeding

MEDICATION ON ADMISSION: Transfer Meds:
Ipratropium Bromide MDI 2 PUFF IH QID
Ipratropium Bromide Neb [**1-19**] NEB IH Q3H
Albuterol Neb Soln [**1-19**] NEB IH Q3H
Albuterol 2 PUFF IH Q6H
Albuterol Neb Soln 15 NEB IH EVERY TWO HOURS
Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
Methylprednisolone Na Succ 125 mg IV Q8H
Montelukast Sodium 10 mg PO QD
Guaifenesin-Dextromethorphan 5 ml PO Q6H:PRN
Diphenhydramine HCl 25 mg PO Q6H:PRN
Levofloxacin 500 mg PO Q24H Duration: 5 Days (d1=[**2131-10-2**])
Atorvastatin 10 mg PO QD
Clonazepam 1 mg PO BID
Citalopram Hydrobromide 60 mg PO
Nicotine 14 mg TD QD
Pantoprazole 40 mg PO Q24H
Calcium Carbonate 500 mg PO TID W/MEALS
Vitamin D 400 UNIT PO QD
Sarna Lotion 1 Appl TP QID:PRN
Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
Heparin 5000 UNIT SC TID
Insulin SC  (per Insulin Flowsheet)
Acetaminophen 325-650 mg PO Q4-6H:PRN

ALLERGIES: Codeine

PHYSICAL EXAM: Vitals	T 97	P 74	BP 114/54	Resp	22
	O2 97% on 5L NC

FAMILY HISTORY: No IBD or early CAD.
Mom &#8211; died ovarian CA at 63
Dad- died of ?brain CA at 27

SOCIAL HISTORY: Lives adjacent to a pet store. Noticed that rash developed after
moving into new apartment. Has a dog and is going through
divorce. Lives with 13 and 27 yo sons. 1ppd x 2yrs after
quitting for 11yrs. No EtOH or IVDU.
Asthma, unspecified type, with status asthmaticus,Alkalosis,Other diseases of respiratory system, not elsewhere classified,Unspecified sleep apnea,Rash and other nonspecific skin eruption,Other specified infestations,Obesity, unspecified,Bronchitis, not specified as acute or chronic,Tobacco use disorder
Asthma w status asthmat,Alkalosis,Resp system disease NEC,Sleep apnea NOS,Nonspecif skin erupt NEC,Infestation NEC,Obesity NOS,Bronchitis NOS,Tobacco use disorder
Admission Date:  [**2131-9-28**]              Discharge Date:   [**2131-10-9**]

Date of Birth:  [**2087-10-15**]             Sex:   F

Service: MED

Allergies:
Codeine

Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
Dyspnea and cough

Major Surgical or Invasive Procedure:
None

History of Present Illness:
43 year old obese woman with history of smoking (20 pack year),
asthma, bronchitis with multiple admissions since [**2130-9-18**]
for asthma flares. She has required hospitalization and steroids
in the past, but no intubations. She has been on Prednisone 20
mg PO for the past year. On [**9-28**], she presented with one day of
wheezing and cough, peak flows of 120 mL (baseline 250-300 mL).
In the ED, she was unresponsive to nebulizers, heliox, oral
prednisone and was hypoxemic to 87% on 6L NC. She was admitted
to the [**Hospital Unit Name 153**] for nebs q1hr, IV steroids and continuous
monitoring. Empiric CPAP at night was started in [**Hospital Unit Name 153**]. Of note,
pt was seen by Dermatology for rash x 2weeks and a biopsy was
negative for mites. She was discharged from the [**Hospital Unit Name 153**] with
improved oxygenation and ventilation with decreased frequency of
nebs to q3 hour.
ROS: Gained 60 pounds since [**9-21**] (when started steroids).
Endorses fatigue. No rhinorrhea, fever, chills. No N/V or
diarrhea. No chest pain, PND or palpitations. 2 pillow
orthopnea. Denies daytime sleepiness. Frequent bloody stools
with abdominal pain (missed several colonoscopy appointments
because of fatigue).

Past Medical History:
Asthma
Recurrent HAs
Hyperlipidemia
Depression
Obesity
Bronchitis
GERD/hiatal hernia
Anxiety
Rectal bleeding

Social History:
Lives adjacent to a pet store. Noticed that rash developed after
moving into new apartment. Has a dog and is going through
divorce. Lives with 13 and 27 yo sons. 1ppd x 2yrs after
quitting for 11yrs. No EtOH or IVDU.

Family History:
No IBD or early CAD.
Mom &#8211; died ovarian CA at 63
Dad- died of ?brain CA at 27

Physical Exam:
Vitals	T 97	P 74	BP 114/54	Resp	22
	O2 97% on 5L NC

Gen	A+Ox3.Slight resp distress. Not toxic.
HEENT	No JVD. OP clear w/o exudates. No LAD. EOMI.
Neck	Thyroid difficult to assess, but no discrete nodules
palpated. No carotid bruits.
Thorax	Diffuse I & E wheezes throughout both lungs. Coarse
rhonchi throughout.
CV	Distant heart sounds. NSR. No m/r/g.
Abd     Obese. Normoactive BS. No tenderness. No ascites,
masses.
Skin	Diffuse macular rash with varying sized lesions on abdomen,
arms and quadriceps.
Ext	1+ pitting edema. Warm. Radial and PT 2+ bilaterally. DP 1+
bilat.
Neuro	CN II-XII intact. Strength 5/5 in UE & LE. Sensation to
touch intact. Babinski-upgoing toes bilat.

Pertinent Results:
[**2131-9-28**] 08:06PM   TYPE-ART PO2-115* PCO2-46* PH-7.37 TOTAL
CO2-28 BASE XS-1
[**2131-9-28**] 08:06PM   O2 SAT-97
[**2131-9-28**] 11:15AM   WBC-12.4* RBC-4.64 HGB-12.7 HCT-38.3 MCV-83
MCH-27.5 MCHC-33.3 RDW-15.7*
[**2131-9-28**] 11:15AM   NEUTS-82* BANDS-1 LYMPHS-12* MONOS-3 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2131-9-28**] 11:15AM   HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
STIPPLED-OCCASIONAL
[**2131-9-28**] 11:15AM   PLT COUNT-303

CXRs:
([**2131-9-28**]) - IMPRESSION: No evidence of an acute cardiopulmonary
abnormality.
([**2131-9-30**]) - IMPRESSION: There is no evidence of active disease
in the lungs or heart. No significant changes since the prior
study.
([**2131-10-1**]) - IMPRESSION: Improving left heart failure.

Sputum Culture ([**2131-9-30**]): GRAM STAIN - <10 PMNs and >10
epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE
ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA.

CXR:
[**10-3**] Bilateral lungs are clear.  No evidence of active lung
disease. There is minimal plate-like atelectasis in the left
lower lobe (prelim report)
[**10-1**] Cephalization of pulmonary vasculature persists, although
improved since the last exam.
[**9-30**] No cardiomegaly.  The lungs are clear of an active
congestion or infiltration.  No evidence of pleural effusion or
pneumothorax.

Abdominal Skin Biopsy ([**2131-9-30**]): The presence of acanthosis and
subepidermal fibrin is most consistentwith irritation or trauma
to the site (as would be seen with excoriations). The typical
histologic findings of dermatitis herpetiformis or pemphigus
foliaceous are not seen.

Axillary biopsy ([**2131-10-6**]): Right upper arm.  Dermal
hypersensitivity reaction
Note: Sections show an unremarkable epidermis.  The dermis
demonstrates a superficial and deep perivascular lymphocytic
infiltrate with eosinophils. The findings are consistent with a
dermal hypersensitivity reaction, such as to an arthropod
assault.

Brief Hospital Course:
43 year old obese woman with history of asthma, 20 pack year
smoking, bronchitis with multiple admissions since [**9-21**] for
asthma flares requiring hospitalization and steroids. Her
hospital course is discussed by problem.

1) Asthma-
On transfer to the medical floor, she was placed on q3:prn nebs
with albuterol and ipratropium. She also received combivent q4
standing, prednisone 60 mg PO, serevent, flovent and singulair.
During her hospital course, she tolerated the weaning frequency
of neb treatment to q3-q4:prn, as well as a decrease in her O2
requirement from an initial 5 L/ min to room air. During this
transition from O2 via nasal cannula to room air, her O2
saturation was between 92-97%. Also, her daily peak flows
gradually increased to 250-300, which is at the patient's
baseline.  Notably, the patient's O2 on ambulation was 97% on
her discharge date. Smoking cessation was encouraged during her
hospital stay. She was sent home on Wellbutrin and a nicotine
patch.

2) Rash	- Patient reported rash on torso, upper thigh and arms
was pruritic and developed when she moved into her apartment,
which is adjacent to a pet store. She was given clobetasol,
benadryl and hydroxyzine with some relief. Initial biopsy
demonstrated nonspecific inflammation (see results sections).
After her discharge, it was noted that the rebiopsy of new
axillary lesion demonstrated many eosinophil consistent with
arthropod infestation.

3) Obstructive sleep apnea (OSA)
Patient complained of difficulty sleep and apneic episodes. She
noted a decreased in her symptomatology once she started using
CPAP. Patient's obesity, reported symptoms and improvement on
empiric CPAP was thought to be suggestive of OSA. Patient will
follow up with sleep lab for a sleep study.

4) Bronchitis
Patient completed 5 day course on empiric Levaquin for atypical
coverage and a cough characterized by scant white/yellow sputum.

5)Metabolic alkalosis-
Patient's HCO3 was persistently 34 fro a few days, and then
decreased to 29 on her discharge date.  This elevated HCO3 was
thought to be due to large consumption of Diet Pepsi (>6 jugs 24
oz/day).

6) Leukocytosis
WBC count between 19 and 25. This was thought to be due to
steroids(chronically on prednisone 20 for over a year, and now
on prednisone 60 mg PO). However, because patient was on
steroids, it was not felt that she would mount  a febrile
response if infected, thus, to rule out an infection cultures
were sent. Urine cultures and analysis were negative.  Blood
cultures pending upon discharge.

7) Diabetes mellitus
Patient was managed on insulin sliding scale and glucose was
checked qid.

8) Anxiety
Celexa and Klonopin were continued, per outpatient regimen.

9) GERD-
Patient complained of emesis while asleep. CT scan demonstrated
a large hiatal hernia, which was thought to contribute to her
symptoms of GERD and worsening asthma from aspiration. She was
started on a proton pump inhibitor. Also, an appointment with
Dr. [**Last Name (STitle) 57300**] from General Surgery was scheduled for the
patient.

Patient was stable upon discharge to home. She has transferred
all of her medical care to the [**Hospital1 18**].

Medications on Admission:
Transfer Meds:
Ipratropium Bromide MDI 2 PUFF IH QID
Ipratropium Bromide Neb [**1-19**] NEB IH Q3H
Albuterol Neb Soln [**1-19**] NEB IH Q3H
Albuterol 2 PUFF IH Q6H
Albuterol Neb Soln 15 NEB IH EVERY TWO HOURS
Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
Methylprednisolone Na Succ 125 mg IV Q8H
Montelukast Sodium 10 mg PO QD
Guaifenesin-Dextromethorphan 5 ml PO Q6H:PRN
Diphenhydramine HCl 25 mg PO Q6H:PRN
Levofloxacin 500 mg PO Q24H Duration: 5 Days (d1=[**2131-10-2**])
Atorvastatin 10 mg PO QD
Clonazepam 1 mg PO BID
Citalopram Hydrobromide 60 mg PO
Nicotine 14 mg TD QD
Pantoprazole 40 mg PO Q24H
Calcium Carbonate 500 mg PO TID W/MEALS
Vitamin D 400 UNIT PO QD
Sarna Lotion 1 Appl TP QID:PRN
Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
Heparin 5000 UNIT SC TID
Insulin SC  (per Insulin Flowsheet)
Acetaminophen 325-650 mg PO Q4-6H:PRN

Discharge Medications:
1. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal QD (once a day).
Disp:*30 Patch 24HR(s)* Refills:*2*
2. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day
for 3 days: Stop on [**10-11**].
Disp:*9 Tablet(s)* Refills:*0*
3. Prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day for
6 days: Start [**10-12**]; stop [**10-17**].
Disp:*6 Tablet(s)* Refills:*0*
4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
6 days: Start [**10-18**]; stop [**10-23**].
Disp:*12 Tablet(s)* Refills:*0*
5. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 6 days: start [**10-24**]; stop [**10-29**].
Disp:*18 Tablet(s)* Refills:*0*
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for
6 days: start [**10-30**]; stop [**11-4**].
Disp:*6 Tablet(s)* Refills:*0*
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
start [**11-5**] and continue every day.
Disp:*30 Tablet(s)* Refills:*2*
8. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning))
for 1 days.
Disp:*1 Tablet Sustained Release(s)* Refills:*0*
9. Wellbutrin XL 300 mg Tablet Sustained Release 24HR Sig: One
(1) Tablet Sustained Release 24HR PO once a day.
Disp:*21 Tablet Sustained Release 24HR(s)* Refills:*2*
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*42 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*21 Tablet(s)* Refills:*2*
12. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*21 Tablet(s)* Refills:*2*
13. Fluticasone Propionate 220 mcg/Actuation Aerosol Sig: 4
puffs  Inhalation twice a day.
Disp:*3 * Refills:*2*
14. Citalopram Hydrobromide 20 mg Tablet Sig: Three (3) Tablet
PO QD (once a day).
Disp:*63 Tablet(s)* Refills:*2*
15. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q3-4H () as needed for shortness of breath or wheezing.
Disp:*3 units* Refills:*0*
16. Albuterol Sulfate 5 mg/mL Nebu Soln Sig: [**1-19**]  Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*21 amps* Refills:*0*
17. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
Disp:*42 Disk with Device(s)* Refills:*2*
18. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for itching.
Disp:*100 Tablet(s)* Refills:*0*
19. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
Disp:*100 Capsule(s)* Refills:*0*
20. Clobetasol Propionate 0.05 % Ointment Sig: One (1) Appl
Topical  [**Hospital1 **] (2 times a day) as needed for itching: Avoid on
face. .
Disp:*2 tube* Refills:*0*
21. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*2 tube* Refills:*0*
22. Spacer
Please obtain spacer at pharmacy.

Discharge Disposition:
Home

Discharge Diagnosis:
Asthma
Obstructive sleep apnea
Obesity
Rash
Hypoxemia
Hypoventilation
Metabolic alkalosis
Bronchitis
Hyperlipidemia
Gastroesophageal reflux disese
Anxiety
Depression


Discharge Condition:
Stable

Discharge Instructions:
* Call your primary care physician if you develop chest pain,
worsening shortness of breath, lightheadedness or any other
concerning symptoms.

* Take all medications as prescribed.

* Follow up with all appointments.

* Taper prednisone slowly to 10 mg/day over one month. Started
50 mg PO on [**2131-10-10**]. Will take 50 mg PO for 6 days, and then
take 40 mg PO for 6 days, etc.

* Per Dermatology, please request that PCP check tissue
transglutaminase (TTG) for celiac sprue.

* Remind PCP to call insurance company to request a reclining
chair.

* Speak with PCP about home environment evaluation.


Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2131-10-18**] 2:00

Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **]/DR. [**First Name (STitle) **] Where: [**Hospital6 29**] NEUROLOGY
Phone:[**Telephone/Fax (1) 6856**] Date/Time:[**2131-10-12**] 11:00

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Where: LM [**Hospital Unit Name 41726**] ASSOCIATES Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2131-10-22**] 2:30

Provider: [**First Name11 (Name Pattern1) 306**] [**Last Name (NamePattern4) 7907**], MD Where: [**Hospital6 29**]
DERMATOLOGY Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2131-11-19**] 11:00



Completed by:[**2131-10-10**]
{'Asthma, unspecified type, with status asthmaticus,Alkalosis,Other diseases of respiratory system, not elsewhere classified,Unspecified sleep apnea,Rash and other nonspecific skin eruption,Other specified infestations,Obesity, unspecified,Bronchitis, not specified as acute or chronic,Tobacco use disorder'}


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: Dyspnea and cough

PRESENT ILLNESS: 43 year old obese woman with history of smoking (20 pack year),
asthma, bronchitis with multiple admissions since [**2130-9-18**]
for asthma flares. She has required hospitalization and steroids
in the past, but no intubations. She has been on Prednisone 20
mg PO for the past year. On [**9-28**], she presented with one day of
wheezing and cough, peak flows of 120 mL (baseline 250-300 mL).
In the ED, she was unresponsive to nebulizers, heliox, oral
prednisone and was hypoxemic to 87% on 6L NC. She was admitted
to the [**Hospital Unit Name 153**] for nebs q1hr, IV steroids and continuous
monitoring. Empiric CPAP at night was started in [**Hospital Unit Name 153**]. Of note,
pt was seen by Dermatology for rash x 2weeks and a biopsy was
negative for mites. She was discharged from the [**Hospital Unit Name 153**] with
improved oxygenation and ventilation with decreased frequency of
nebs to q3 hour.
ROS: Gained 60 pounds since [**9-21**] (when started steroids).
Endorses fatigue. No rhinorrhea, fever, chills. No N/V or
diarrhea. No chest pain, PND or palpitations. 2 pillow
orthopnea. Denies daytime sleepiness. Frequent bloody stools
with abdominal pain (missed several colonoscopy appointments
because of fatigue).

MEDICAL HISTORY: Asthma
Recurrent HAs
Hyperlipidemia
Depression
Obesity
Bronchitis
GERD/hiatal hernia
Anxiety
Rectal bleeding

MEDICATION ON ADMISSION: Transfer Meds:
Ipratropium Bromide MDI 2 PUFF IH QID
Ipratropium Bromide Neb [**1-19**] NEB IH Q3H
Albuterol Neb Soln [**1-19**] NEB IH Q3H
Albuterol 2 PUFF IH Q6H
Albuterol Neb Soln 15 NEB IH EVERY TWO HOURS
Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
Methylprednisolone Na Succ 125 mg IV Q8H
Montelukast Sodium 10 mg PO QD
Guaifenesin-Dextromethorphan 5 ml PO Q6H:PRN
Diphenhydramine HCl 25 mg PO Q6H:PRN
Levofloxacin 500 mg PO Q24H Duration: 5 Days (d1=[**2131-10-2**])
Atorvastatin 10 mg PO QD
Clonazepam 1 mg PO BID
Citalopram Hydrobromide 60 mg PO
Nicotine 14 mg TD QD
Pantoprazole 40 mg PO Q24H
Calcium Carbonate 500 mg PO TID W/MEALS
Vitamin D 400 UNIT PO QD
Sarna Lotion 1 Appl TP QID:PRN
Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
Heparin 5000 UNIT SC TID
Insulin SC  (per Insulin Flowsheet)
Acetaminophen 325-650 mg PO Q4-6H:PRN

ALLERGIES: Codeine

PHYSICAL EXAM: Vitals	T 97	P 74	BP 114/54	Resp	22
	O2 97% on 5L NC

FAMILY HISTORY: No IBD or early CAD.
Mom &#8211; died ovarian CA at 63
Dad- died of ?brain CA at 27

SOCIAL HISTORY: Lives adjacent to a pet store. Noticed that rash developed after
moving into new apartment. Has a dog and is going through
divorce. Lives with 13 and 27 yo sons. 1ppd x 2yrs after
quitting for 11yrs. No EtOH or IVDU. 

### Response:
{'Asthma, unspecified type, with status asthmaticus,Alkalosis,Other diseases of respiratory system, not elsewhere classified,Unspecified sleep apnea,Rash and other nonspecific skin eruption,Other specified infestations,Obesity, unspecified,Bronchitis, not specified as acute or chronic,Tobacco use disorder'}
