CHIEF COMPLAINT: Respiratory distress

PRESENT ILLNESS: 52M with h/o non-ischemic dilated cardiomyopathy (LVEF 20%),
COPD, who presents with shortness of breath, worsening acutely
today while at home, but getting progressively worse since [**2-13**].
 PT also reports malaise for the past couple of days, without
fevers but with chills, no nausea or vomiting.  He does report
some diffuse chest tightness in association with his acute
dyspnea.  The pain does not radiate and has resolved somewhat
with oxygen therapy.  He reports cough productive of yellowish
white sputum over the last three days.  There have been no other
upper respiratory symptoms.  Patient has history of similar
episodes of dyspnea, usually after smoking crack cocaine, but
reports that this time he was not.  His last reported crack
cocaine use was five days prior to admission (Thursday).  When
EMS found him, he was found to 70% on RA with SBPs in 120s,
respiratory rate about 40.  He was placed on a non-rebreather
and transported to [**Hospital1 18**].
.
Patient was recently admitted to [**Hospital1 18**] and discharged on [**2195-2-3**]
for acute respiratory decompensation and bilateral lung
opacifications requiring ICU admission, thought to be due to
acute crack inhalation lung injury.  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.
.
In the ED, initial VS were 99.0 116 123/66 40 96% nr. Patient
had JVD while sitting upright, and lung sounds with rales in
bases.  He was tachycardic to the 140-150, with O2 saturations
88% on NRB, with supraclavicular retractions.  ECG was
consistent with prior with no ST or T-wave changes.  CXR was
performed and significant for new alveolar opacities suspicious
for pulmonary edema.  He was placed on a nitro gtt and BIPAP,
and administered furosemide 40 mg IV x 1, urine output was not
recorded.  Labs were significant for initial venous blood gas of
7.29/53/45/27.  Troponin was 0.03.  BNP was measured at 8381.
There was leukocytosis with WBC count. 13.1 with 80%
neutrophils.  Arterial blood gas after being on BIPAP was
7.45/35/63/25.   On transfer, VS were 103, 118/66, rr34 100% on
50% CPAP 5+5, nitro gtt @ 0.667.  There are two 20g peripheral
IVs in place.  He has put out about 1.3 liters of urine after
receiving his dose of Lasix.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools.  He denies recent fevers or rigors.  He
does report some chills.  He denies exertional buttock or calf
pain.  All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

MEDICAL HISTORY: 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 30-35%, 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 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).

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T= 97.5 BP= 117/76 HR= 104 RR= 31 O2 sat= 100% on BIPAP
GENERAL: NAD. Oriented x3. Mood, affect appropriate.  Appears
uncomfortable.
HEENT: NCAT. Mask on face.  Sclera anicteric. PERRL, EOMI.
Conjunctiva are pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple with JVP of up to jaw line.
CARDIAC: Tachycardic, RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
are labored with supraclavicular retractions.  Rales are present
halfway up lung fields bilaterally, louder on right with
decreased BS on left.  No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Trace edema to 1/3 up shins bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.

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
Bronchitis and pneumonitis due to fumes and vapors,Acute respiratory failure,Acute on chronic systolic heart failure,Cocaine dependence, continuous,Other primary cardiomyopathies,Acute kidney failure, unspecified,Other and unspecified alcohol dependence, continuous,Chronic airway obstruction, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Adrenal cortical steroids causing adverse effects in therapeutic use,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified viral hepatitis C without hepatic coma,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Tobacco use disorder,Unspecified schizophrenia, unspecified,Anemia, unspecified
Fum/vapor bronc/pneumon,Acute respiratry failure,Ac on chr syst hrt fail,Cocaine depend-contin,Prim cardiomyopathy NEC,Acute kidney failure NOS,Alcoh dep NEC/NOS-contin,Chr airway obstruct NEC,DMII wo cmp uncntrld,Adv eff corticosteroids,Long-term use of insulin,Hyperlipidemia NEC/NOS,Hypertension NOS,Hpt C w/o hepat coma NOS,Meth resis Staph carrier,Tobacco use disorder,Schizophrenia NOS-unspec,Anemia NOS
Admission Date:  [**2196-2-15**]              Discharge Date:   [**2196-2-22**]

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

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Respiratory distress

Major Surgical or Invasive Procedure:
none

History of Present Illness:
52M with h/o non-ischemic dilated cardiomyopathy (LVEF 20%),
COPD, who presents with shortness of breath, worsening acutely
today while at home, but getting progressively worse since [**2-13**].
 PT also reports malaise for the past couple of days, without
fevers but with chills, no nausea or vomiting.  He does report
some diffuse chest tightness in association with his acute
dyspnea.  The pain does not radiate and has resolved somewhat
with oxygen therapy.  He reports cough productive of yellowish
white sputum over the last three days.  There have been no other
upper respiratory symptoms.  Patient has history of similar
episodes of dyspnea, usually after smoking crack cocaine, but
reports that this time he was not.  His last reported crack
cocaine use was five days prior to admission (Thursday).  When
EMS found him, he was found to 70% on RA with SBPs in 120s,
respiratory rate about 40.  He was placed on a non-rebreather
and transported to [**Hospital1 18**].
.
Patient was recently admitted to [**Hospital1 18**] and discharged on [**2195-2-3**]
for acute respiratory decompensation and bilateral lung
opacifications requiring ICU admission, thought to be due to
acute crack inhalation lung injury.  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.
.
In the ED, initial VS were 99.0 116 123/66 40 96% nr. Patient
had JVD while sitting upright, and lung sounds with rales in
bases.  He was tachycardic to the 140-150, with O2 saturations
88% on NRB, with supraclavicular retractions.  ECG was
consistent with prior with no ST or T-wave changes.  CXR was
performed and significant for new alveolar opacities suspicious
for pulmonary edema.  He was placed on a nitro gtt and BIPAP,
and administered furosemide 40 mg IV x 1, urine output was not
recorded.  Labs were significant for initial venous blood gas of
7.29/53/45/27.  Troponin was 0.03.  BNP was measured at 8381.
There was leukocytosis with WBC count. 13.1 with 80%
neutrophils.  Arterial blood gas after being on BIPAP was
7.45/35/63/25.   On transfer, VS were 103, 118/66, rr34 100% on
50% CPAP 5+5, nitro gtt @ 0.667.  There are two 20g peripheral
IVs in place.  He has put out about 1.3 liters of urine after
receiving his dose of Lasix.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools.  He denies recent fevers or rigors.  He
does report some chills.  He denies exertional buttock or calf
pain.  All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.


Past Medical History:
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 30-35%, 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:
VS: T= 97.5 BP= 117/76 HR= 104 RR= 31 O2 sat= 100% on BIPAP
GENERAL: NAD. Oriented x3. Mood, affect appropriate.  Appears
uncomfortable.
HEENT: NCAT. Mask on face.  Sclera anicteric. PERRL, EOMI.
Conjunctiva are pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple with JVP of up to jaw line.
CARDIAC: Tachycardic, RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
are labored with supraclavicular retractions.  Rales are present
halfway up lung fields bilaterally, louder on right with
decreased BS on left.  No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Trace edema to 1/3 up shins bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.

Pertinent Results:
On Admission:

[**2196-2-15**] 03:40AM BLOOD WBC-13.1*# RBC-3.76* Hgb-10.1* Hct-30.8*
MCV-82 MCH-26.9* MCHC-32.8 RDW-16.5* Plt Ct-346
[**2196-2-15**] 03:40AM BLOOD Neuts-80.8* Lymphs-12.0* Monos-2.5
Eos-4.1* Baso-0.6
[**2196-2-15**] 03:40AM BLOOD PT-12.8* PTT-37.2* INR(PT)-1.2*
[**2196-2-15**] 03:40AM BLOOD Glucose-66* UreaN-13 Creat-1.1 Na-142
K-5.0 Cl-106 HCO3-24 AnGap-17
[**2196-2-15**] 03:40AM BLOOD CK-MB-5 cTropnT-0.03* proBNP-8381*
[**2196-2-15**] 06:39AM BLOOD CK-MB-5 cTropnT-0.04*
[**2196-2-15**] 03:00PM BLOOD CK-MB-5 cTropnT-0.05*
[**2196-2-15**] 03:40AM BLOOD CK(CPK)-259
[**2196-2-15**] 06:39AM BLOOD ALT-15 AST-29 LD(LDH)-464* AlkPhos-73
TotBili-0.5
[**2196-2-15**] 06:39AM BLOOD Calcium-8.3* Phos-4.6* Mg-1.3*
[**2196-2-15**] 03:49AM BLOOD Type-[**Last Name (un) **] pO2-45* pCO2-53* pH-7.29*
calTCO2-27 Base XS--1 Comment-GREEN TOP
[**2196-2-15**] 04:58AM BLOOD Type-ART Temp-36.4 FiO2-50 pO2-63*
pCO2-35 pH-7.45 calTCO2-25 Base XS-0 Intubat-NOT INTUBA
Comment-CPAP

IMAGING:
PLEASE ADD FINAL REPORT OF CT

Brief Hospital Course:
52M with h/o non-ischemic dilated cardiomyopathy (LVEF 20%),
COPD, presenting with acute respiratory decompensation.

# Hypoxia secondary to crack pneumonitis: Patient presents with
acute respiratory decompensation, over the course of hours,
associated with hypoxemia, with bilateral opacifications in the
bilateral lung fields consistent with likely pulmonary edema and
pneumonitis/pneumonia.  In the past, patient has had similar
presentations, usually following crack cocaine use, thought to
be due to acute crack lung inhalation injury.  His most recent
reported crack cocaine use was five days prior to admission, and
his symptoms of dyspnea started 3 days prior to admission, which
is consistent with crack cocaine pneumonitis.  Patient also had
elevated JVP, rales on lung exam, and imaging suggestive of
fluid overload, making CHF exacerbation a likely diagnosis.  The
patient was aggresively diuresis 4.5 litter over the next 36
hours until his creatinine bumped and he was at his dry weight.
His respiratory status did NOT marketly improved  with diuresis
(continue to require 50-100% O2 by face mask) and pulmonary was
consulted.  Per pulmonary, the patient's clinical presentation
was most consistent with crack cocaine pneumonitis, but an
atypical penumonia could not be ruled out.  He was started on
levofloxacin on [**2-16**] for a 7 day course.  He was also started on
solumedrol 60mg q6 hours and was tappered to oral prednisone and
stopped 2 days prior to discharge.  The patient's oxygen
requirement decreased and was weaned off oxygen. A repeat chest
x-ray showed marked improvement in his lung fields. Patient was
discharged with a normal ambulatory oxygen saturation.

# Acute systolic congestive heart failure, non-ischemic dilated
cardiomyopathy: The patient has a history of LVEF 20%.  Despite
his clinical presentation (see above), the patient reported
taking his medication faithfully without dietary indiscretions.
Given his clinical presenation, the patient was given lasix 40mg
IV and started on an lasix gtt.  The patient was aggresively
diuresis 4.5 litter over the next 36 hours until his creatinine
bumped and he was at his dry weight.  His home medications were
intially held.  He was initally started on Captopril 6.25 mg
TID.  On the floor the patient was euvolemic and additional
doses of IV lasix were held. Patient was transitioned to
carvedilol and discontinued the metoprolol as he is at risk for
continued cocaine abuse. He remained euvolemic during his stay
and was discharged without oxygen requirement.

# Diabetes mellitus: it is unclear whether patient actually has
type 1 or type 2 diabetes but he has been able to go extended
periods of time without medications making it more likely he has
type 2 diabetes. Due to his high steriod dosing patient had
significant increases in his insulin requirements. [**Last Name (un) **]
diabetes consult was placed and assisted in dosing insulin.
There was no evidence of DKA while he was inpatient. Eventually
after he came off of steriods he was able to be transitioned
back to his home insulin regimen.

# Hyperlipidemia: continue home atorvastatin dose

# COPD: patient with history of COPD.  He was started on
albuterol and ipratropium nebulizers. His home
fluticasone-salmeterol was held and he was started on
Fluticasone [**Hospital1 **].

# Acute on chronic normocytic anemia: patient hematocrit around
baseline.

# Substance abuse: Patient with history or cocaine use and
tobacco use. Patient was counseled on risks of continued cocaine
abuse including readmission and even death. He was also
discharged for prescription for nicotine replacement therapy and
he seemed agreeable to stopping both the tobacco use and cocaine
abuse.

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 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 Medications:
1. ipratropium bromide 0.02 % Solution Sig: One (1) unit
Inhalation Q6H (every 6 hours) as needed for wheeze.
Disp:*QS for 30 days unit* Refills:*0*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation twice a day.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) unit Inhalation Q6H (every 6 hours).
Disp:*QS for 30 days unit* Refills:*0*
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily): use 1 patch daily for 2 weeks then
one patch every other day for one week then stop.
Disp:*30 Patch 24 hr(s)* Refills:*0*
10. quetiapine 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Nebulizer
Please dispense 1 nebulizer machine
13. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
14. insulin glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous at bedtime.
15. Novolog 100 unit/mL Solution Sig: As directed per sliding
scale units Subcutaneous three times a day: Please resume usual
sliding scale with meals.
16. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
You can also take [**12-21**] of your 10mg tablet if it is scored.
Disp:*30 Tablet(s)* Refills:*1*


Discharge Disposition:
Home With Service

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

Discharge Diagnosis:
Pneumonitis
Acute on chronic systolic heart failure
Diabetes
Substance abuse (cocaine)

Chronic conditions:
COPD
Schizophrenia


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


Discharge Instructions:

Mr. [**Known lastname 10794**], you were admitted to the hospital for pneumonitis,
which is inflammation of your lung tissue secondary to your use
of crack cocaine. This caused you to be very short of breath and
to require oxygen for a short period of time. It is important
that you stop smoking crack cocaine as this is the cause of your
lung inflammation.

We also treated you for worsening congestive heart failure. You
required IV medications to remove fluid from your lungs. Your
symptoms improved after a few days.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

The following changes were made to your medications:
ADD carvedilol 6.25 mg by mouth twice a day
STOP metoprolol 100mg daily
DECREASE Lisinopril to 5mg

Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2196-4-25**] at 4:10 PM
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: MONDAY [**2196-4-25**] at 4:30 PM
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: MONDAY [**2196-4-25**] at 4:30 PM

Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: FRIDAY [**2196-2-26**] 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
{'Bronchitis and pneumonitis due to fumes and vapors,Acute respiratory failure,Acute on chronic systolic heart failure,Cocaine dependence, continuous,Other primary cardiomyopathies,Acute kidney failure, unspecified,Other and unspecified alcohol dependence, continuous,Chronic airway obstruction, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Adrenal cortical steroids causing adverse effects in therapeutic use,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified viral hepatitis C without hepatic coma,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Tobacco use disorder,Unspecified schizophrenia, unspecified,Anemia, unspecified'}


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: Respiratory distress

PRESENT ILLNESS: 52M with h/o non-ischemic dilated cardiomyopathy (LVEF 20%),
COPD, who presents with shortness of breath, worsening acutely
today while at home, but getting progressively worse since [**2-13**].
 PT also reports malaise for the past couple of days, without
fevers but with chills, no nausea or vomiting.  He does report
some diffuse chest tightness in association with his acute
dyspnea.  The pain does not radiate and has resolved somewhat
with oxygen therapy.  He reports cough productive of yellowish
white sputum over the last three days.  There have been no other
upper respiratory symptoms.  Patient has history of similar
episodes of dyspnea, usually after smoking crack cocaine, but
reports that this time he was not.  His last reported crack
cocaine use was five days prior to admission (Thursday).  When
EMS found him, he was found to 70% on RA with SBPs in 120s,
respiratory rate about 40.  He was placed on a non-rebreather
and transported to [**Hospital1 18**].
.
Patient was recently admitted to [**Hospital1 18**] and discharged on [**2195-2-3**]
for acute respiratory decompensation and bilateral lung
opacifications requiring ICU admission, thought to be due to
acute crack inhalation lung injury.  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.
.
In the ED, initial VS were 99.0 116 123/66 40 96% nr. Patient
had JVD while sitting upright, and lung sounds with rales in
bases.  He was tachycardic to the 140-150, with O2 saturations
88% on NRB, with supraclavicular retractions.  ECG was
consistent with prior with no ST or T-wave changes.  CXR was
performed and significant for new alveolar opacities suspicious
for pulmonary edema.  He was placed on a nitro gtt and BIPAP,
and administered furosemide 40 mg IV x 1, urine output was not
recorded.  Labs were significant for initial venous blood gas of
7.29/53/45/27.  Troponin was 0.03.  BNP was measured at 8381.
There was leukocytosis with WBC count. 13.1 with 80%
neutrophils.  Arterial blood gas after being on BIPAP was
7.45/35/63/25.   On transfer, VS were 103, 118/66, rr34 100% on
50% CPAP 5+5, nitro gtt @ 0.667.  There are two 20g peripheral
IVs in place.  He has put out about 1.3 liters of urine after
receiving his dose of Lasix.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools.  He denies recent fevers or rigors.  He
does report some chills.  He denies exertional buttock or calf
pain.  All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.

MEDICAL HISTORY: 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 30-35%, 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 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).

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: T= 97.5 BP= 117/76 HR= 104 RR= 31 O2 sat= 100% on BIPAP
GENERAL: NAD. Oriented x3. Mood, affect appropriate.  Appears
uncomfortable.
HEENT: NCAT. Mask on face.  Sclera anicteric. PERRL, EOMI.
Conjunctiva are pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple with JVP of up to jaw line.
CARDIAC: Tachycardic, RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
are labored with supraclavicular retractions.  Rales are present
halfway up lung fields bilaterally, louder on right with
decreased BS on left.  No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Trace edema to 1/3 up shins bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.

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:
{'Bronchitis and pneumonitis due to fumes and vapors,Acute respiratory failure,Acute on chronic systolic heart failure,Cocaine dependence, continuous,Other primary cardiomyopathies,Acute kidney failure, unspecified,Other and unspecified alcohol dependence, continuous,Chronic airway obstruction, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled,Adrenal cortical steroids causing adverse effects in therapeutic use,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Unspecified viral hepatitis C without hepatic coma,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Tobacco use disorder,Unspecified schizophrenia, unspecified,Anemia, unspecified'}
