CHIEF COMPLAINT: Evaluation for lung bleb resection

PRESENT ILLNESS: CC: Respiratory monitoring and evaluation by thoracics service,
s/p intubation for hypercarbic respiratory arrest at OSH now
extubated.
.
HPI: This is a 55 year old man with long smoking history and
severe COPD,
pulmonary HTN who was admitted to [**Hospital6 1597**] from
[**Date range (1) **] with initial complaints of feeling poorly 2 days prior
to admission with increasing cough and diaphoresis but no chest
pain or fevers. Despite increasing his prednisone from 40 to
60mg daily 1 day prior to admission, patient began to have
increasing shortness of breath and went to [**Hospital3 2568**] ED on [**5-25**].
In the ED, he was noted to be somnolent and had an ABG of
7.18/104/412. He was subsequently intubated for acute
hypercarbic respiratory failure. He was started on azithromycin
and ceftriaxone on [**5-25**] and solumedrol. CXR showed no evidence
of pulmonary edema and BNP was 70. An ECHO per notes showed an
EF 50%, PASP 37 mm HG. Patient was extubated on [**5-26**] after
treatment with inhalers/solumedrol/antibiotics and then placed
on bipap during the nighttime. His solumedrol was changed to
prednisone and his sputum culture on [**5-25**] grew streptococcus
pneumoniae. His antibiotic regimen of ceftriaxone and
azithromycin was continued and was restarted on his daily home
dose of lasix.
.
He was transferred to [**Hospital1 18**] for thoracics evaluation of right
upper lung blebs for possible lung reduction surgery. On the
surgical service, he had a CXR which showed emphysematous
changes, particularly in right lung apex and a chest CT which
reveal severe emphysematous changes with a large bulla occupying
most of the right upper lobe, centrilobular nodular opacities in
left lower lobe may represent aspiration or [**Doctor First Name **] infection and
right middle lobe and left lower lobe bronchiectasis. He was
evaluated by the IP service for which they stated he was not
currently an EBV candidate because he must be smoke free for 4
months. Patient reports smoking cigarettes just prior to
presentation at the outside hospital.
.
Patient states that his COPD has been relatively well controlled
over the past year with intermittent steroid tapers and
antibiotics and hasn't required hospitalization for about 1
year. He has been intubated x 2 before for his COPD. He states
that his best oxygen level is about upper 80's at home and only
uses 2L NC at home at nighttime. He also is able to do his own
ADLs, works 7 days a week, can walk up a flight of stairs
without SOB.

MEDICAL HISTORY: - Emphysema - steroid dependent, intubated x 2, on home O2,
baseline CO2 60-70
- Hyperlipidemia
- Pulmonary HTN
- Heavy tobacco abuse
- GERD

MEDICATION ON ADMISSION: prednisone 4mg po qd
Protonix 40 mg po qd
Lasix 40 mg daily
Calcium prn
doxycycline
albuterol
advair
combivent
.
Transferred on azithro/levofloxacin
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tm 98.0, Tc 98.0, HR 97 (79-102), BP 112/75 (95-130/60-80), RR
17, 84% (84%-96%) on 5L NC, overnight on BiPAP 12/8 with 6LPM
O2.
GEN - lying flat in bed in NAD, AAOx3, speaks [**3-18**] words before
stopping
Neck - no JVD appreciated
HEENT - EOMI, anicteric, PERRL
CV- tachycardic, nl S1/S2, no M
CHEST - barrel chested, decreased breath sounds at bases, no
audible wheezes currently,
ABD - soft, NT/ND, +BS
EXT - tr pedal edema bilaterally, + clubbing

FAMILY HISTORY: His father died of MI around age 52.

SOCIAL HISTORY: Patient is married, smokes 10 cigarretes daily (70 PYHx), no
EtOH, owns a video store, does own ADLs.
Emphysematous bleb,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Congestive heart failure, unspecified,Tobacco use disorder,Surgical or other procedure not carried out because of contraindication,Personal history of noncompliance with medical treatment, presenting hazards to health,Other chronic pulmonary heart diseases,Esophageal reflux,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Accidents occurring in other specified places
Emphysematous bleb,Pneumococcal pneumonia,CHF NOS,Tobacco use disorder,No proc/contraindication,Hx of past noncompliance,Chr pulmon heart dis NEC,Esophageal reflux,Pancreatic disorder NEC,Adv eff corticosteroids,Accident in place NEC
Admission Date:  [**2186-5-31**]              Discharge Date:   [**2186-6-5**]

Date of Birth:  [**2130-11-5**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
Evaluation for lung bleb resection

Major Surgical or Invasive Procedure:
none


History of Present Illness:
CC: Respiratory monitoring and evaluation by thoracics service,
s/p intubation for hypercarbic respiratory arrest at OSH now
extubated.
.
HPI: This is a 55 year old man with long smoking history and
severe COPD,
pulmonary HTN who was admitted to [**Hospital6 1597**] from
[**Date range (1) **] with initial complaints of feeling poorly 2 days prior
to admission with increasing cough and diaphoresis but no chest
pain or fevers. Despite increasing his prednisone from 40 to
60mg daily 1 day prior to admission, patient began to have
increasing shortness of breath and went to [**Hospital3 2568**] ED on [**5-25**].
In the ED, he was noted to be somnolent and had an ABG of
7.18/104/412. He was subsequently intubated for acute
hypercarbic respiratory failure. He was started on azithromycin
and ceftriaxone on [**5-25**] and solumedrol. CXR showed no evidence
of pulmonary edema and BNP was 70. An ECHO per notes showed an
EF 50%, PASP 37 mm HG. Patient was extubated on [**5-26**] after
treatment with inhalers/solumedrol/antibiotics and then placed
on bipap during the nighttime. His solumedrol was changed to
prednisone and his sputum culture on [**5-25**] grew streptococcus
pneumoniae. His antibiotic regimen of ceftriaxone and
azithromycin was continued and was restarted on his daily home
dose of lasix.
.
He was transferred to [**Hospital1 18**] for thoracics evaluation of right
upper lung blebs for possible lung reduction surgery. On the
surgical service, he had a CXR which showed emphysematous
changes, particularly in right lung apex and a chest CT which
reveal severe emphysematous changes with a large bulla occupying
most of the right upper lobe, centrilobular nodular opacities in
left lower lobe may represent aspiration or [**Doctor First Name **] infection and
right middle lobe and left lower lobe bronchiectasis. He was
evaluated by the IP service for which they stated he was not
currently an EBV candidate because he must be smoke free for 4
months. Patient reports smoking cigarettes just prior to
presentation at the outside hospital.
.
Patient states that his COPD has been relatively well controlled
over the past year with intermittent steroid tapers and
antibiotics and hasn't required hospitalization for about 1
year. He has been intubated x 2 before for his COPD. He states
that his best oxygen level is about upper 80's at home and only
uses 2L NC at home at nighttime. He also is able to do his own
ADLs, works 7 days a week, can walk up a flight of stairs
without SOB.


Past Medical History:
- Emphysema - steroid dependent, intubated x 2, on home O2,
baseline CO2 60-70
- Hyperlipidemia
- Pulmonary HTN
- Heavy tobacco abuse
- GERD


Social History:
Patient is married, smokes 10 cigarretes daily (70 PYHx), no
EtOH, owns a video store, does own ADLs.

Family History:
His father died of MI around age 52.

Physical Exam:
Tm 98.0, Tc 98.0, HR 97 (79-102), BP 112/75 (95-130/60-80), RR
17, 84% (84%-96%) on 5L NC, overnight on BiPAP 12/8 with 6LPM
O2.
GEN - lying flat in bed in NAD, AAOx3, speaks [**3-18**] words before
stopping
Neck - no JVD appreciated
HEENT - EOMI, anicteric, PERRL
CV- tachycardic, nl S1/S2, no M
CHEST - barrel chested, decreased breath sounds at bases, no
audible wheezes currently,
ABD - soft, NT/ND, +BS
EXT - tr pedal edema bilaterally, + clubbing

Pertinent Results:
OSH pertinent labs:
CBC - [**2186-5-25**]- 8/47/135, UA negative, BNP 70, TSH 0.81, B12 456,
Folate >20,

Labs on admission:
WBC-8.5 RBC-4.41* Hgb-14.4 Hct-42.4 MCV-96 MCH-32.6* MCHC-33.9
RDW-14.4 Plt Ct-154
PT-11.0 PTT-27.4 INR(PT)-0.9
Glucose-495* UreaN-15 Creat-0.7 Na-134 K-4.3 Cl-91* HCO3-37*
AnGap-10 Calcium-7.6* Phos-3.5 Mg-1.8 TSH-1.4
[**2186-5-31**] 10:42PM BLOOD Type-ART Temp-36.7 Rates-0/20 PEEP-8
pO2-52* pCO2-79* pH-7.36 calHCO3-46* Base XS-14 Intubat-NOT
INTUBA Vent-SPONTANEOU
ALPHA-1-ANTITRYPSIN-wnl
.
Studies:
.
[**5-31**] CXR - Emphysematous changes, particularly in right lung
apex.
.
EKG - NSR @ 97, RAD, RBBB, no ST-T wve changes, RAA, LAA
.
Chest CT - 1. Severe emphysematous changes with a large bulla
occupying most of the right upper lobe. 2. Centrilobular nodular
opacities in left lower lobe may represent aspiration or [**Doctor First Name **]
infection. 3. Right middle lobe and left lower lobe
bronchiectasis.
.
ECHO [**6-2**] - 1. A tiny patent foramen ovale is present. A
right-to-left shunt across the interatrial septum is seen at
rest. 2. The left ventricular cavity size is normal. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). 3. The right ventricular
cavity is moderately dilated. There is severe global
right ventricular free wall hypokinesis. 4. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. 5. Moderate [2+] tricuspid regurgitation is seen. There
is mild pulmonary artery systolic hypertension.
.
Trachea CT [**6-3**] - 1. Prominent narrowing in the coronal diameter
of the trachea giving it the saber-sheath appearance which is
even more emphasized during expiration. 2. Prominent narrowing
of the left main bronchus to less than 25% of the diameter. 3.
Marked secretion in the trachea and main bronchus is most
probably due to bronchitis exacerbation.
4. Severe emphysematous changes in the left upper lobe and large
right apical bulla and right upper lobe panlobular emphysema.

Brief Hospital Course:
Briefly, 55M with significant tobacco history with ends stage
COPD/emphysema who was intubated for hypercarbic respiratory
arrest at OSH now extubated since [**5-26**] who was transferred here
for possible surgical vs. IP intervention who is no longer a
candidate (d/t recent smoking hx) and now started on nighttime
BiPAP therapy.
.
.
#. Severe COPD/emphysema - Patient has significant smoking
history and is currently interested in quitting now. Patient is
not a candidate for EBV given his current smoking status.
Patient was continued on BiPAP overnight and arrangements were
made for him at home to continue nighttime BiPAP after discharge
from hospital. Patient was continued on
albuterol/ipratropium/fluticasone. Continuted PO lasix QD and
mucinex [**Hospital1 **]. Prednisone was slowly tapered from 60mg daily with
decreasing dosing changes every week by an increment of 10mg.
Patient completed a 10 day course of ceftriaxone and
azithromycin. Patient sat'ing well on 4L NC. Thyroid function
and anti-trypsin level were wnl. Trachea 3D CT scan and
pulmonary function tests were performed as part of the
pre-procedural workup for possible lung reduction surgery in the
future. Patient will follow-up with thoracic surgery as an
outpatient.
.
#. HTN - continued diltiazem
.
#. Hyperlipidemia - continued statin
.
#. GERD- continued PPI therapy.
.
#. Hyperglycemia - likely secondary to prednisone as no prior
history of diabetes. Continued RISS. Patient not requiring much
coverage per sliding scale given tapering of steroids and so was
not discharged on insulin.
.
#. FEN - tolerating po diabetic diet, no need for IVF
.
#. PPX - on PPI for GERD, SC heparin TID
.
#. FULL CODE

Medications on Admission:
prednisone 4mg po qd
Protonix 40 mg po qd
Lasix 40 mg daily
Calcium prn
doxycycline
albuterol
advair
combivent
.
Transferred on azithro/levofloxacin
.


Discharge Medications:
1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-16**]
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
Disp:*1 month* Refills:*2*
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 month* Refills:*2*
4. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: take 60 mg (6 tablets) 2 more days (until [**6-7**]), then 50 mg
(5 tablets) for 7 days, then 40 mg for 7 days, 30 mg x 7 days,
20 mg x 7 days, 10 mg x 7 days, 5 mg (half tablet) x 7 days,
then off.
Disp:*150 Tablet(s)* Refills:*1*
5. BIPAP therapy
Mask Ventilation: Nasal CPAP w/ PSV (BIPAP) Inspiratory
pressure: 12 cm/h2o Expiratory pressure: 8 cm/h2o Supp O2: 6
L/min
6. Continuous O2 nasal cannula
Continuous O2 by nasal cannula at 4L or keeping O2 sat>90.
7. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
8. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO q12hrs () as needed for difficulty
bringing up phlegm.
Disp:*1 month* Refills:*2*
9. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
11. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnoses:
1.  COPD
2.  Pneumonia
3.  Respiratory failure
Secondary Diagnosis:
1.  Tachycardia


Discharge Condition:
good, sat'ing in 94% on 4L nasal cannula


Discharge Instructions:
1.  Please take all your medications exactly as prescribed and
described in this discharge paperwork. Make sure to continue
using the BIPAP machine overnight daily and use oxygen nasal
cannula at 4L.

2.  Please follow up as described below.

3.  Please call your PCP if you are experiencing chest pain,
shortness of breath, fever, chills, or any other concerning
symptoms
.
4.  You would benefit from chest physical therapy. Please
discuss with you primary care physician who can make
arrangements.

Followup Instructions:
1.  Please follow up with Dr. [**Last Name (STitle) 68158**] [**Name (STitle) 27106**] your primary care
physician.
[**Name Initial (NameIs) 2897**]/Time: [**2186-6-7**] 2:45pm
Phone: [**Telephone/Fax (1) 68159**] Fax: [**Telephone/Fax (1) 68160**]
.
2.  Please follow up with Dr. [**Last Name (STitle) 952**] (Cardiothoracic surgery)
for further management/surgery
Date/Time: [**2186-6-25**] 9:30am
Phone: [**Telephone/Fax (1) 170**]


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]

Completed by:[**2186-6-7**]
{'Emphysematous bleb,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Congestive heart failure, unspecified,Tobacco use disorder,Surgical or other procedure not carried out because of contraindication,Personal history of noncompliance with medical treatment, presenting hazards to health,Other chronic pulmonary heart diseases,Esophageal reflux,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Accidents occurring in other specified places'}


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: Evaluation for lung bleb resection

PRESENT ILLNESS: CC: Respiratory monitoring and evaluation by thoracics service,
s/p intubation for hypercarbic respiratory arrest at OSH now
extubated.
.
HPI: This is a 55 year old man with long smoking history and
severe COPD,
pulmonary HTN who was admitted to [**Hospital6 1597**] from
[**Date range (1) **] with initial complaints of feeling poorly 2 days prior
to admission with increasing cough and diaphoresis but no chest
pain or fevers. Despite increasing his prednisone from 40 to
60mg daily 1 day prior to admission, patient began to have
increasing shortness of breath and went to [**Hospital3 2568**] ED on [**5-25**].
In the ED, he was noted to be somnolent and had an ABG of
7.18/104/412. He was subsequently intubated for acute
hypercarbic respiratory failure. He was started on azithromycin
and ceftriaxone on [**5-25**] and solumedrol. CXR showed no evidence
of pulmonary edema and BNP was 70. An ECHO per notes showed an
EF 50%, PASP 37 mm HG. Patient was extubated on [**5-26**] after
treatment with inhalers/solumedrol/antibiotics and then placed
on bipap during the nighttime. His solumedrol was changed to
prednisone and his sputum culture on [**5-25**] grew streptococcus
pneumoniae. His antibiotic regimen of ceftriaxone and
azithromycin was continued and was restarted on his daily home
dose of lasix.
.
He was transferred to [**Hospital1 18**] for thoracics evaluation of right
upper lung blebs for possible lung reduction surgery. On the
surgical service, he had a CXR which showed emphysematous
changes, particularly in right lung apex and a chest CT which
reveal severe emphysematous changes with a large bulla occupying
most of the right upper lobe, centrilobular nodular opacities in
left lower lobe may represent aspiration or [**Doctor First Name **] infection and
right middle lobe and left lower lobe bronchiectasis. He was
evaluated by the IP service for which they stated he was not
currently an EBV candidate because he must be smoke free for 4
months. Patient reports smoking cigarettes just prior to
presentation at the outside hospital.
.
Patient states that his COPD has been relatively well controlled
over the past year with intermittent steroid tapers and
antibiotics and hasn't required hospitalization for about 1
year. He has been intubated x 2 before for his COPD. He states
that his best oxygen level is about upper 80's at home and only
uses 2L NC at home at nighttime. He also is able to do his own
ADLs, works 7 days a week, can walk up a flight of stairs
without SOB.

MEDICAL HISTORY: - Emphysema - steroid dependent, intubated x 2, on home O2,
baseline CO2 60-70
- Hyperlipidemia
- Pulmonary HTN
- Heavy tobacco abuse
- GERD

MEDICATION ON ADMISSION: prednisone 4mg po qd
Protonix 40 mg po qd
Lasix 40 mg daily
Calcium prn
doxycycline
albuterol
advair
combivent
.
Transferred on azithro/levofloxacin
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tm 98.0, Tc 98.0, HR 97 (79-102), BP 112/75 (95-130/60-80), RR
17, 84% (84%-96%) on 5L NC, overnight on BiPAP 12/8 with 6LPM
O2.
GEN - lying flat in bed in NAD, AAOx3, speaks [**3-18**] words before
stopping
Neck - no JVD appreciated
HEENT - EOMI, anicteric, PERRL
CV- tachycardic, nl S1/S2, no M
CHEST - barrel chested, decreased breath sounds at bases, no
audible wheezes currently,
ABD - soft, NT/ND, +BS
EXT - tr pedal edema bilaterally, + clubbing

FAMILY HISTORY: His father died of MI around age 52.

SOCIAL HISTORY: Patient is married, smokes 10 cigarretes daily (70 PYHx), no
EtOH, owns a video store, does own ADLs. 

### Response:
{'Emphysematous bleb,Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia],Congestive heart failure, unspecified,Tobacco use disorder,Surgical or other procedure not carried out because of contraindication,Personal history of noncompliance with medical treatment, presenting hazards to health,Other chronic pulmonary heart diseases,Esophageal reflux,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Accidents occurring in other specified places'}
