CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 52 y/o male w/ PMHx nonischemic cardiomyopathy with EF 30%-35%,
Type 1 DM, Hep C who presents with shortness of breath and chest
pain.
.
Per patient, he was feeling in his usual state of health until
he smoked crack 2 days ago.  Since that time, he complains of
progressive shortness of breast, substernal chest pain similar
to prior episodes of heart failure. Denies any cough, wheezing,
fevers or other symptoms of systemic illness.  No peripheral
edema, weight gain, medication noncompliance or dietary
indescretion.
.
Of note, patient has had 2 similar episodes of dyspnea requiring
intubation, most recently on [**2112-12-8**] at [**Hospital1 18**].  On recent
hospital stay, he was initially diagnosed with CHF/ pulmonary
edema but CT chest showed multifocal PNA.  He was treated with
broad spectrum antibiotics and in less than 2 weeks, respiratory
status and CXR had returned to baseline.
.
On arrival to the ED, initial VS 101 126/76 25 100% NIPPV.  Labs
showed leukocytosis to 11.7, BNP of 4942 with mild troponin
elevation to 0.03.  EKG showed diffuse ST depressions, CXR with
patchy bilateral infiltrates.  Patient was treated for
presumptive CHF exacerbation with nitro gtt, lasix with
resultant 2L urine output.  Patient was able to be weaned
transiently from BiPAP to 6LNC but desaturated to mid 80%.
Placed back on NIPPV and transferred to the CCU for further
care.
.
On arrival to the CCU, patient dyspneic and unable to complete
full sentances.  He denies any current chest pain or cough.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Type I Diabetes, Hyperlipidemia, HTN
2. CARDIAC HISTORY:
3. OTHER PAST MEDICAL HISTORY:
- Nonischemic dilated cardiomyopathy ([**10/2195**]-LVEF 20%, LVD 6.4

MEDICATION ON ADMISSION: HOME MEDICATIONS:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2
puffs inhaled q4-6h as needed for shortness of breath, wheezing.
ATORVASTATIN [LIPITOR] - 20 mg Tablet daily
DOXEPIN - 10 mg Capsule - 2 Capsule(s) by mouth hs (not taking)
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk [**Hospital1 **]
FUROSEMIDE - 40 mg Tablet daily
INSULIN ASPART [NOVOLOG] - 100 unit/mL Solution - As directed
per
sliding scale tid with meals
INSULIN GLARGINE [LANTUS] - 40 units hs
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA
Aerosol
Inhaler - 1-2 puffs inhaled every six (6) hours as needed for
shortness of breath, wheezing
LISINOPRIL - 5 mg Tablet daily
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr
daily
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]
QUETIAPINE [SEROQUEL] - 100 mg Tablet - 1/2-1 Tablet(s) QHS
SERTRALINE [ZOLOFT] - 25 mg Tablet - 1 Tablet(s) by mouth qAM
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) daily
FERROUS SULFATE - 325 mg (65 mg Iron) Tablet [**Hospital1 **]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ON ADMISSION:
VS: T=98.1 BP=124/89 HR=110 RR=31 O2 sat=91% on BiPAP 8/5
GENERAL: A+O x3. Anxious, becomes dyspneic with mild exertion
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. BiPAP mask in place.

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 on chronic systolic heart failure,Cocaine dependence, continuous,Other primary cardiomyopathies,Other respiratory abnormalities,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified viral hepatitis C without hepatic coma,Tobacco use disorder,Unspecified schizophrenia, unspecified,Depressive disorder, not elsewhere classified,Other acquired deformities of ankle and foot,Personal history of noncompliance with medical treatment, presenting hazards to health
Obs chr bronc w(ac) exac,Ac on chr syst hrt fail,Cocaine depend-contin,Prim cardiomyopathy NEC,Respiratory abnorm NEC,DMI wo cmp nt st uncntrl,Long-term use of insulin,Hyperlipidemia NEC/NOS,Hypertension NOS,Hpt C w/o hepat coma NOS,Tobacco use disorder,Schizophrenia NOS-unspec,Depressive disorder NEC,Acq ankle-foot def NEC,Hx of past noncompliance
Admission Date:  [**2196-1-16**]              Discharge Date:   [**2196-1-21**]

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

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
None this hospitalization


History of Present Illness:
52 y/o male w/ PMHx nonischemic cardiomyopathy with EF 30%-35%,
Type 1 DM, Hep C who presents with shortness of breath and chest
pain.
.
Per patient, he was feeling in his usual state of health until
he smoked crack 2 days ago.  Since that time, he complains of
progressive shortness of breast, substernal chest pain similar
to prior episodes of heart failure. Denies any cough, wheezing,
fevers or other symptoms of systemic illness.  No peripheral
edema, weight gain, medication noncompliance or dietary
indescretion.
.
Of note, patient has had 2 similar episodes of dyspnea requiring
intubation, most recently on [**2112-12-8**] at [**Hospital1 18**].  On recent
hospital stay, he was initially diagnosed with CHF/ pulmonary
edema but CT chest showed multifocal PNA.  He was treated with
broad spectrum antibiotics and in less than 2 weeks, respiratory
status and CXR had returned to baseline.
.
On arrival to the ED, initial VS 101 126/76 25 100% NIPPV.  Labs
showed leukocytosis to 11.7, BNP of 4942 with mild troponin
elevation to 0.03.  EKG showed diffuse ST depressions, CXR with
patchy bilateral infiltrates.  Patient was treated for
presumptive CHF exacerbation with nitro gtt, lasix with
resultant 2L urine output.  Patient was able to be weaned
transiently from BiPAP to 6LNC but desaturated to mid 80%.
Placed back on NIPPV and transferred to the CCU for further
care.
.
On arrival to the CCU, patient dyspneic and unable to complete
full sentances.  He denies any current chest pain or cough.

.
On review of systems, he complains of chronic bilateral knee
pain.  He denies any prior history of stroke, TIA, deep venous
thrombosis, pulmonary embolism, bleeding at the time of surgery,
cough, hemoptysis, black stools or red stools. Denies recent
fevers, chills or rigors. He denies exertional buttock or calf
pain. All of the other review of systems were negative.


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

cm, 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:
ON ADMISSION:
VS: T=98.1 BP=124/89 HR=110 RR=31 O2 sat=91% on BiPAP 8/5
GENERAL: A+O x3. Anxious, becomes dyspneic with mild exertion
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. BiPAP mask in place.

NECK: R EJ PIV in place, JVP difficult to assess
CARDIAC: tachycardia S1 split S2
LUNGS: diffuse crackles throughout, predominantly at bases
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
AT DISCHARGE:
VITALS: 98.7  97.5  106/62  96  20  96% 1L NC  (-1.5L LOS from
MICU)
WEIGHT: 83.5 kg   BG: 198-485 mg/dL
I/Os: 2070 | 1625 + BRP
GENERAL: Appears in no acute distress. Alert and interactive.
Speaking in full sentences.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD 2-3 cm above the
clavicle at 30-degrees.
CVS: Regular rate and rhythm, 2/6 systolic murmur at RLSB, no
rubs or gallops. S1 and S2 normal.
RESP: Diffusely coarse breath sounds, worse at bases (R > L)
bilaterally. No wheezing; but faint inspiratory crackles. Stable
inspiratory effort.
ABD: soft, non-tender, non-distended, with normoactive bowel
sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or 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:
.
[**2196-1-16**] 03:16AM BLOOD WBC-11.7*# RBC-3.98* Hgb-10.5* Hct-32.2*
MCV-81* MCH-26.3* MCHC-32.5 RDW-15.4 Plt Ct-410
[**2196-1-16**] 03:16AM BLOOD Neuts-86.4* Lymphs-9.2* Monos-2.6 Eos-1.3
Baso-0.4
[**2196-1-16**] 03:16AM BLOOD PT-12.8* PTT-35.1 INR(PT)-1.2*
[**2196-1-16**] 03:16AM BLOOD Glucose-236* UreaN-12 Creat-0.9 Na-139
K-3.3 Cl-103 HCO3-23 AnGap-16
[**2196-1-16**] 03:16AM BLOOD CK-MB-7 cTropnT-0.03* proBNP-4942*
[**2196-1-16**] 07:05PM BLOOD Calcium-8.4 Phos-3.5 Mg-1.2*
.
DISCHARGE LABS:
.
[**2196-1-21**] 06:17AM BLOOD WBC-6.1 RBC-3.82* Hgb-10.0* Hct-31.9*
MCV-84 MCH-26.1* MCHC-31.2 RDW-15.2 Plt Ct-342
[**2196-1-20**] 05:02AM BLOOD Neuts-49.1* Lymphs-41.8 Monos-5.3 Eos-3.3
Baso-0.5
[**2196-1-17**] 02:36AM BLOOD PT-13.8* PTT-36.6* INR(PT)-1.3*
[**2196-1-21**] 08:25AM BLOOD Na-145 K-3.8 Cl-105
[**2196-1-19**] 04:36AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.8
.
MICROBIOLOGIC DATA:
[**2196-1-10**] BAL bronchial fluid - negative AFB, negative culture,
PCP negative, Legionella negative
[**2196-1-16**] MRSA screen - negative
.
IMAGING:
[**2196-1-16**] CHEST (PORTABLE AP) - Diffuse bilateral severe
parenchymal opacities, similar to that seen previously in
[**2195-11-19**] with multifocal pneumonia. These findings are more
consistent with multifocal pneumonia, supperimposed pulmonary
edema is possible.
.
[**2196-1-16**] CT CHEST W/O CONTRAST - Diffuse bilateral airspace
opacities, predominantly of ground-glass pattern, with areas of
more confluent consolidations. The distribution of disease is
nearly identical to the prior CT; however, it is noted that
there was interval resolution of these abnormalities (see chest
radiograph [**2195-12-30**]). Based on these findings, the
pulmonary parenchymal abnormality is felt likely to reflect
re-exposure an [**Doctor Last Name 360**] causing a reactive hypersensitivity
pneumonitis or possibly an eosinophilic pneumonitis. Pulmonary
edema is not considered likely given the distribution. Atypical
infection such as PCP cannot be excluded. Bulky mediastinal
lymphadenopathy is unchanged when compared to the prior study
and is likely reactive. Small bilateral pleural effusions,
similar in appearance to the prior study. Small pericardial
effusion.

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 who presented with acute hypoxic respiratory distress
found to have bilaterally diffuse airspace opacities with
ground-glass appearance on CT chest imaging with suspected
component of CHF exacerbation, in the setting of recent illicit
substance use.
.
# DIFFUSE, BILATERAL LUNG OPACIFICATION AND ACUTE RESPIRATORY
DECOMPENSATION - His initial presentation was concerning for
pulmonary edema vs. multifocal pneumonia vs. hypersensitivity
pneumonitis. He had a similar presentation in [**2195-11-19**]
thought to be secondary to multifocal pneumonia, although rapid
radiographic resolution in less than 2-weeks at that time was
more consistent with crack lung. Per the ED, he improved
symptomatically on BiPAP, Nitroglycerin gtt and a Lasix gtt
which made a component of decompensated non-ischemic
cardiomyopathy a likely superimposed diagnosis. He diuresed
roughly 2L on transfer from the cardiac and medical ICUs to the
floor which marked improvement in oxygenation status. He was
weaned from a non-rebreather to 1L of oxygen via nasal cannula -
ultimately on room air upon discharge. A CT chest was obtained
showing diffuse bilateral airspace opacities, predominantly of
ground-glass pattern, with areas of more confluent
consolidations. The pulmonary parenchymal abnormality was felt
likely to reflect re-exposure to an [**Doctor Last Name 360**] causing a reactive
hypersensitivity pneumonitis or possibly an eosinophilic
pneumonitis, although no peripheral eosinophilia was noted.
Crack lung was also considered, given his substance use 3-days
prior to arrival. He was treated with Methylprednisolone 125 mg
IV x 1 with resultant hyperglycemia, and was therefore managed
without steroids thereafter. Antibiotics were also deferred
given his rapid clinical improvement. We continued his nebulizer
treatments, encouraged incentive spirometry and made no changes
to his home medications.
.
# INSULIN-DEPENDENT DIABETES MELLITUS - Patient previously
managed with Lantus dosing (taking 40 units at home, 15 units
per previous discharge paperwork) - 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. Did
receive pulse steroids for hypersensitivity pneumonitis concerns
(as noted above), with resulting hyperglycemia, requiring an
insulin gtt briefly. He was quickly weaned to his home Lantus
regimen without concern. [**Last Name (un) **] diabetes was consulted during
her insulin gtt period, and agreed with return to his home
regimen.
.
# NON-ISCHEMIC CARDIOMYOPATHY - 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**]. Admitted with some chest discomfort, EKG changes with
non-specific ST changes and Troponin elevation to 0.05-0.06 with
flat CK-MBs x 2. BNP was 4924. He was admitted to the CCU
initially and started on a Nitroglycerin gtt with Lasix gtt for
presumed volume overload in the setting of dietary indiscretion
and poor compliance with diuretics, leading to CHF exacerbation
component (as noted above). Diuresed -2.7L with [**Location 10226**]2L fluid
balance prior to floor transfer. 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 dishcarge. 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 [**2183**] 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 - requiring Nitro gtt on admission briefly.
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-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.
.
# 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 this
admission. 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. Will need outpatient follow-up with primary care physician
[**Name Initial (PRE) 1988**].
3. No culture data, radiologic studies or laboratory studies
pending at discharge.
4. Will need follow-up as outpatient for AFP, serial
ultrasounds, candidacy for possible anti-viral therapy (likely
poor candidate) given his hepatitis C infection.


Medications on Admission:
HOME MEDICATIONS:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2
puffs inhaled q4-6h as needed for shortness of breath, wheezing.
ATORVASTATIN [LIPITOR] - 20 mg Tablet daily
DOXEPIN - 10 mg Capsule - 2 Capsule(s) by mouth hs (not taking)
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk [**Hospital1 **]
FUROSEMIDE - 40 mg Tablet daily
INSULIN ASPART [NOVOLOG] - 100 unit/mL Solution - As directed
per
sliding scale tid with meals
INSULIN GLARGINE [LANTUS] - 40 units hs
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA
Aerosol
Inhaler - 1-2 puffs inhaled every six (6) hours as needed for
shortness of breath, wheezing
LISINOPRIL - 5 mg Tablet daily
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr
daily
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]
QUETIAPINE [SEROQUEL] - 100 mg Tablet - 1/2-1 Tablet(s) QHS
SERTRALINE [ZOLOFT] - 25 mg Tablet - 1 Tablet(s) by mouth qAM
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) daily
FERROUS SULFATE - 325 mg (65 mg Iron) Tablet [**Hospital1 **]

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 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.
16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
17. melatonin 3 mg Tablet Sig: One (1) Tablet PO 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
cardiac 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
.
* 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: CARDIAC SERVICES
When: FRIDAY [**2196-1-22**] at 2:20 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: MONDAY [**2196-2-1**] at 3:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: TUESDAY [**2196-2-9**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22387**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute on chronic systolic heart failure,Cocaine dependence, continuous,Other primary cardiomyopathies,Other respiratory abnormalities,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified viral hepatitis C without hepatic coma,Tobacco use disorder,Unspecified schizophrenia, unspecified,Depressive disorder, not elsewhere classified,Other acquired deformities of ankle and foot,Personal history of noncompliance with medical treatment, presenting hazards to health'}


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: 52 y/o male w/ PMHx nonischemic cardiomyopathy with EF 30%-35%,
Type 1 DM, Hep C who presents with shortness of breath and chest
pain.
.
Per patient, he was feeling in his usual state of health until
he smoked crack 2 days ago.  Since that time, he complains of
progressive shortness of breast, substernal chest pain similar
to prior episodes of heart failure. Denies any cough, wheezing,
fevers or other symptoms of systemic illness.  No peripheral
edema, weight gain, medication noncompliance or dietary
indescretion.
.
Of note, patient has had 2 similar episodes of dyspnea requiring
intubation, most recently on [**2112-12-8**] at [**Hospital1 18**].  On recent
hospital stay, he was initially diagnosed with CHF/ pulmonary
edema but CT chest showed multifocal PNA.  He was treated with
broad spectrum antibiotics and in less than 2 weeks, respiratory
status and CXR had returned to baseline.
.
On arrival to the ED, initial VS 101 126/76 25 100% NIPPV.  Labs
showed leukocytosis to 11.7, BNP of 4942 with mild troponin
elevation to 0.03.  EKG showed diffuse ST depressions, CXR with
patchy bilateral infiltrates.  Patient was treated for
presumptive CHF exacerbation with nitro gtt, lasix with
resultant 2L urine output.  Patient was able to be weaned
transiently from BiPAP to 6LNC but desaturated to mid 80%.
Placed back on NIPPV and transferred to the CCU for further
care.
.
On arrival to the CCU, patient dyspneic and unable to complete
full sentances.  He denies any current chest pain or cough.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Type I Diabetes, Hyperlipidemia, HTN
2. CARDIAC HISTORY:
3. OTHER PAST MEDICAL HISTORY:
- Nonischemic dilated cardiomyopathy ([**10/2195**]-LVEF 20%, LVD 6.4

MEDICATION ON ADMISSION: HOME MEDICATIONS:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2
puffs inhaled q4-6h as needed for shortness of breath, wheezing.
ATORVASTATIN [LIPITOR] - 20 mg Tablet daily
DOXEPIN - 10 mg Capsule - 2 Capsule(s) by mouth hs (not taking)
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk [**Hospital1 **]
FUROSEMIDE - 40 mg Tablet daily
INSULIN ASPART [NOVOLOG] - 100 unit/mL Solution - As directed
per
sliding scale tid with meals
INSULIN GLARGINE [LANTUS] - 40 units hs
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA
Aerosol
Inhaler - 1-2 puffs inhaled every six (6) hours as needed for
shortness of breath, wheezing
LISINOPRIL - 5 mg Tablet daily
METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr
daily
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]
QUETIAPINE [SEROQUEL] - 100 mg Tablet - 1/2-1 Tablet(s) QHS
SERTRALINE [ZOLOFT] - 25 mg Tablet - 1 Tablet(s) by mouth qAM
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) daily
FERROUS SULFATE - 325 mg (65 mg Iron) Tablet [**Hospital1 **]

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ON ADMISSION:
VS: T=98.1 BP=124/89 HR=110 RR=31 O2 sat=91% on BiPAP 8/5
GENERAL: A+O x3. Anxious, becomes dyspneic with mild exertion
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. BiPAP mask in place.

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 on chronic systolic heart failure,Cocaine dependence, continuous,Other primary cardiomyopathies,Other respiratory abnormalities,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified viral hepatitis C without hepatic coma,Tobacco use disorder,Unspecified schizophrenia, unspecified,Depressive disorder, not elsewhere classified,Other acquired deformities of ankle and foot,Personal history of noncompliance with medical treatment, presenting hazards to health'}
