CHIEF COMPLAINT: Chief Complaint: Wheezing/SOB

PRESENT ILLNESS: Mr. [**Known lastname **] is a 44-year-old man with a long history of
refractory asthma with > 100 hospitalization and 17 past
intubations now presenting with wheezing, SOB, with 1 week of
antecedent productive cough.

MEDICAL HISTORY: - Severe asthma with greater than 100 hospitalizations, multiple

MEDICATION ON ADMISSION: TIOTROPIUM BROMIDE - 18 mcg Capsule, puff Ih daily
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg Inh - 2 puffs Q4 PRN
FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - 6 puffs twice a
day
IPRATROPIUM-ALBUTEROL [DUONEB] - 1 Neb [**Month (only) **] PRN
SALMETEROL - 50 mcg 1 puff inh twice a day
MONTELUKAST [SINGULAIR] - 10 mg Tablet daily
PREDNISONE - 30mg daily, increase to 60mg with asthma flare
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1 Tablet
Qd
METFORMIN - 500 mg Tablet by mouth once a day
OMEPRAZOLE - 20 mg Capsule by mouth twice daily take 30 minutes
before eating or 2 hours after eating
AEROCHAMBER -  Spacer - AS DIRECTED
FLUTICASONE - 50 mcg Spray, Suspension - 1 Nasal Spray daily
Medications - OTC
GUAIFENESIN [MUCINEX] -  (Prescribed by Other Provider)
LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day PRN
NICOTINE (POLACRILEX) [COMMIT] - 4 mg Lozenge - 1 lozenge every
1-2 hours for first six weeks, then taper to q 2-4 hours x 2
weeks, then q 4-8 hours x 2 weeks. Max 20 pieces in 24 hours

ALLERGIES: Fish Product Derivatives / Shellfish Derived / Peanut / Grass
Pollen-Bermuda, Standard / Mold Extracts / Cat Hair Std Extract

PHYSICAL EXAM: Admission exam:
General: Alert, oriented, mild respiratory distress, some
accessory muscle use, lying on back
HEENT: Sclera anicteric, PERRL, continuous neb over face
Neck: supple
CV: tachy to 120s, no m/r/g
Lungs: poor air movement diffusely, diffuse fine exp wheezing
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&O x 3, no focal deficits

FAMILY HISTORY: Two children with asthma

SOCIAL HISTORY: Works as school bus driver. Lives with wife and one of his three
children. Still smoking. Has on average a bottle of wine/week.
Denies ilicits.
Asthma, unspecified type, with (acute) exacerbation,Acute bronchitis,Long-term (current) use of steroids,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tobacco use disorder,Obstructive sleep apnea (adult)(pediatric)
Asthma NOS w (ac) exac,Acute bronchitis,Long-term use steroids,DMII wo cmp nt st uncntr,Tobacco use disorder,Obstructive sleep apnea
Admission Date:  [**2178-5-16**]              Discharge Date:   [**2178-5-18**]

Date of Birth:  [**2133-6-10**]             Sex:   M

Service: MEDICINE

Allergies:
Fish Product Derivatives / Shellfish Derived / Peanut / Grass
Pollen-Bermuda, Standard / Mold Extracts / Cat Hair Std Extract

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Chief Complaint: Wheezing/SOB


Major Surgical or Invasive Procedure:
none.

History of Present Illness:
Mr. [**Known lastname **] is a 44-year-old man with a long history of
refractory asthma with > 100 hospitalization and 17 past
intubations now presenting with wheezing, SOB, with 1 week of
antecedent productive cough.

Roughly 1 week ago [**Known firstname **] developed a cough productive of
greenish sputum. No sick contacts, no fevers, chills, night
sweats. Did not feel more SOB than baseline and no wheezing over
baseline. Does endorse missing a dose or two of medications
(only pills, not inhalers) in the last week. This AM started
feeling "tight". Took 60mg Prednisone and 500mg Azithro and went
through whole albuterol inhaler. Worsened and came to the ER.

On ROS, (+) Per HPI. No significant weight changes, no chest
pain, no HA, no lightheadedness, no Abd pain, no diarrea, no
constipation, denies rash. No focal weakness.

Of note, he has been on multiple inhalers as well as very
high-dose oral steroids for the majority of the last several
years and has had multiple systemic complications as a result.
Has high Eos in past as well as midly elevated IgE levels. Has
been on Zolaire in the past and has been seen in allergy clinic
before. Saw Dr. [**Last Name (STitle) **] [**3-/2178**] but prior to that had been 15
months since pulmonary saw him.

In the ED, initial VS were: 146 197/90 28 95%. Patient reported
to have increased WOB, able to speak only in 1 word answers,
coughing up phlegm, tripoding intermittently. Wheezy and tight
on evam. Given 2mg mag, 60mg solumedrol, tons of nebs. No
improvement and actually said went from [**6-7**] asthma to [**9-7**]
asthma. Was placed on continuous nebs and started to stabilize.
Tachy to 120s with this, RR down to high 20s, sats in high 90s.
BPs okay. WBC elevated at 19.6. Admitted to the ICU over concern
that he would tire out and need intubation.

On arrival to the MICU, slightly improved. Able to speak in full
sentences and comfortably while lying on back.

Past Medical History:
- Severe asthma with greater than 100 hospitalizations, multiple

intubations (17), followed by Dr. [**Last Name (STitle) **] in pulm, plan to refer
to
Dr. [**First Name (STitle) **] at [**Hospital1 112**]
- OSA on CPAP at night
- Avascular necrosis of the hip and shoulder from prolonged
steroid use, status post hip replacement ([**2173**])
- GERD
- H/o L Achilles tendon rupture s/p repair


Social History:
Works as school bus driver. Lives with wife and one of his three
children. Still smoking. Has on average a bottle of wine/week.
Denies ilicits.


Family History:
Two children with asthma


Physical Exam:
Admission exam:
General: Alert, oriented, mild respiratory distress, some
accessory muscle use, lying on back
HEENT: Sclera anicteric, PERRL, continuous neb over face
Neck: supple
CV: tachy to 120s, no m/r/g
Lungs: poor air movement diffusely, diffuse fine exp wheezing
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&O x 3, no focal deficits

Discharge PE:
VS: 97.9 Tm 98 148/86 (140-141/86-91) 102 (91-102) 18 95RA
General: well appearing middle aged gentleman, NAD, laying
comfortably in bed talking on telephone
HEENT: Sclera anicteric, PERRL, EOMI
Neck: supple
CV: RRR S1, S2 no murmurs/rubs/gallops
Lungs: diffuse inspiratory and expiratory wheezing throughout,
however unlabored respirations
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&O x 3, CN 2-12 grossly intact, normal muscle strength
and sensation throught


Pertinent Results:
Admission labs:

[**2178-5-16**] 05:15PM BLOOD WBC-19.6*# RBC-5.45 Hgb-16.3 Hct-49.9
MCV-91 MCH-30.0 MCHC-32.8 RDW-13.2 Plt Ct-297
[**2178-5-16**] 05:15PM BLOOD Neuts-83.6* Lymphs-8.4* Monos-5.3 Eos-2.4
Baso-0.3
[**2178-5-17**] 05:23AM BLOOD PT-12.8* PTT-29.9 INR(PT)-1.2*
[**2178-5-16**] 05:15PM BLOOD Glucose-134* UreaN-16 Creat-1.0 Na-143
K-3.8 Cl-104 HCO3-23 AnGap-20
[**2178-5-16**] 05:15PM BLOOD Calcium-9.3 Phos-2.3* Mg-2.0
[**2178-5-16**] 05:20PM BLOOD Type-[**Last Name (un) **] pO2-61* pCO2-41 pH-7.40
calTCO2-26 Base XS-0 Comment-GREEN TOP

CXR Pa/Lat ([**5-16**]):
CHEST, AP:  There is increased subsegmental atelectasis in the
lower lobes. No focal consolidation.  Heart size is normal.
There are no significant pleural effusions, pneumothorax, or
pneumomediastinum.
IMPRESSION:  Subsegmental atelectasis.  No focal consolidation.

EKG: sinus tachy to 140s, no significant ST changes, normal
intervals

Discharge labs:

[**2178-5-18**] 06:30AM BLOOD WBC-29.8* RBC-4.96 Hgb-14.7 Hct-46.2
MCV-93 MCH-29.7 MCHC-31.9 RDW-13.5 Plt Ct-294
[**2178-5-18**] 06:30AM BLOOD Glucose-91 UreaN-24* Creat-0.9 Na-143
K-4.1 Cl-107 HCO3-23 AnGap-17
[**2178-5-18**] 06:30AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.3

Brief Hospital Course:
44 yr/o M with severe refractory asthma presenting with
significant SOB and wheezing with increased WOB in the ER
requiring continuous nebs and raising concern for possible
decompensation to intubation.

# Asthma - Severe refractory: Currently with flare that started
the morning of admission and was not able to turn around at home
by starting prednisone/Azithro. [**Month (only) 116**] have been triggered by
bronchitis with 1 week of productive cough and clear CXR. Has
multiple past admissions and intubations raising likelihood that
he may not be able to turn around with just nebs. Had elevated
Eos at times in the past as well as mildly elevated IgE levels.
Abnormal RAST testing in past. Multiple negative aspergillus Abs
in the past. PFTs in [**March 2178**] showing severe obstructive
defect.

Patient was initially on continuous nebs, which were spaced out
to Q1H then to Q2H then to Q4H.  Patient was started on IV
solumedrol 60mg IV Q8hrs.  Also started azithro 250mg Q24 for
total of 5 day course.  Patient continued on home inhalers.  His
breathing improved and he was called out to medicine floor.
While on the floor, the patient was continued on his home
medications; he was also transitioned from IV solumedrol to
prednisone 60 mg daily.  He was saturating well on room air,
breathing comfortably.  A peak flow prior to discharge was 370,
which is near his baseline.  The patient was discharged on a
prednisone taper (60 mg x5 days, 50 mg x5days, 40 mg x5days),
and then was instructed to continue his home dose of 30 mg
prednisone daily.  He was also discharged on another two days of
azithromycin to complete a total five day course.

# Diabetes: Last A1C in [**Month (only) **] was 5.9 on only 500mg daily of
metformin. Gets lots of steroids for his lung disease which is
probably why is DM/Pre-DM. Continued metformin 500mg daily.

# Allergies:  The patient was continued on all of his home
allergy medications, including fluticasone, loratidine, and
montelukast.

# smoking cessation:  The patient was counseled re: the
importance of smoking cessation, especially in the setting of
his refractory asthma.  He was give nicotine lozenges.

# OSA:  The patient was continued on CPAP while in house.

Transitional Issues:
- The patient was discharged on prednisone taper (60 mg x5 days,
50 mg x5days, 40 mg x5days), and then was instructed to continue
his home dose of 30 mg prednisone daily.

Medications on Admission:
TIOTROPIUM BROMIDE - 18 mcg Capsule, puff Ih daily
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg Inh - 2 puffs Q4 PRN
FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - 6 puffs twice a
day
IPRATROPIUM-ALBUTEROL [DUONEB] - 1 Neb [**Month (only) **] PRN
SALMETEROL - 50 mcg 1 puff inh twice a day
MONTELUKAST [SINGULAIR] - 10 mg Tablet daily
PREDNISONE - 30mg daily, increase to 60mg with asthma flare
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1 Tablet
Qd
METFORMIN - 500 mg Tablet by mouth once a day
OMEPRAZOLE - 20 mg Capsule by mouth twice daily take 30 minutes
before eating or 2 hours after eating
AEROCHAMBER -  Spacer - AS DIRECTED
FLUTICASONE - 50 mcg Spray, Suspension - 1 Nasal Spray daily
Medications - OTC
GUAIFENESIN [MUCINEX] -  (Prescribed by Other Provider)
LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day PRN
NICOTINE (POLACRILEX) [COMMIT] - 4 mg Lozenge - 1 lozenge every
1-2 hours for first six weeks, then taper to q 2-4 hours x 2
weeks, then q 4-8 hours x 2 weeks. Max 20 pieces in 24 hours


Discharge Medications:
1. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal twice a day.
2. metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1)  Inhalation once a day.
7. Flovent HFA 220 mcg/actuation Aerosol Sig: Six (6) puffs
Inhalation twice a day.
8. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1)  Inhalation every four (4) hours as
needed for shortness of breath or wheezing.
9. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
10. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2)
puffs Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
12. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.

13. nicotine (polacrilex) 2 mg Lozenge Sig: One (1) Lozenge
Buccal Q2H (every 2 hours) as needed for cravings.
14. prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: START prednisone 60 mg (6 pills) by mouth daily for another
3 days (LAST DAY [**5-21**])

START prednisone 50 mg (5 pills) by mouth daily for 5 days
([**Date range (1) 88300**])

START prednisone 40 mg (4 pills) by mouth daily for 5 days
([**Date range (1) 78269**])

Then after [**5-31**], continue on your daily prednisone 30 mg daily
.
Disp:*63 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
primary diagnosis:
acute asthma excacerbation


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


Discharge Instructions:
Dear Mr. [**Known lastname **],

It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**].  You were admitted to the hospital because you had an
asthma attack; you initially went to the intensive care unit
because of your severe condition.  Your breathing improved after
getting continuous nebulizer treatments.

It is VERY important that you stop smoking.  Smoking will only
worsen your asthma and increase not only the frequency, but also
the severity of your attacks.  Please continue to try and quit
smoking.

We made the following changes to your medications:
START Azithromycin 250 mg by mouth daily for another 2 days
START prednisone 60 mg by mouth daily for another 3 days (LAST
DAY [**5-21**])
START prednisone 50 mg by mouth daily for 5 days ([**Date range (1) 88300**])
START prednisone 40 mg by mouth daily for 5 days ([**Date range (1) 78269**])
Then after [**5-31**], continue on your daily prednisone 30 mg daily


Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2178-5-22**] at 10:10 AM
With: Dr. [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Central [**Hospital **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your              regular primary
care doctor in follow up.

We are working on a follow up appointment for your
hospitalization in Pulmonary with Dr. [**Known firstname **] [**Last Name (NamePattern1) **]. You need to
be seen within 2 weeks of discharge. The office will contact you
at home with an appointment. If you have not heard within 2
business days or have any questions please call the office at
[**Telephone/Fax (1) 612**].

Department: MEDICAL SPECIALTIES
When: FRIDAY [**2178-6-5**] at 2:00 PM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 249**]
When: WEDNESDAY [**2178-6-17**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1879**], M.D. [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2178-5-21**]
{'Asthma, unspecified type, with (acute) exacerbation,Acute bronchitis,Long-term (current) use of steroids,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tobacco use disorder,Obstructive sleep apnea (adult)(pediatric)'}


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: Chief Complaint: Wheezing/SOB

PRESENT ILLNESS: Mr. [**Known lastname **] is a 44-year-old man with a long history of
refractory asthma with > 100 hospitalization and 17 past
intubations now presenting with wheezing, SOB, with 1 week of
antecedent productive cough.

MEDICAL HISTORY: - Severe asthma with greater than 100 hospitalizations, multiple

MEDICATION ON ADMISSION: TIOTROPIUM BROMIDE - 18 mcg Capsule, puff Ih daily
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg Inh - 2 puffs Q4 PRN
FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - 6 puffs twice a
day
IPRATROPIUM-ALBUTEROL [DUONEB] - 1 Neb [**Month (only) **] PRN
SALMETEROL - 50 mcg 1 puff inh twice a day
MONTELUKAST [SINGULAIR] - 10 mg Tablet daily
PREDNISONE - 30mg daily, increase to 60mg with asthma flare
SULFAMETHOXAZOLE-TRIMETHOPRIM - 400 mg-80 mg Tablet - 1 Tablet
Qd
METFORMIN - 500 mg Tablet by mouth once a day
OMEPRAZOLE - 20 mg Capsule by mouth twice daily take 30 minutes
before eating or 2 hours after eating
AEROCHAMBER -  Spacer - AS DIRECTED
FLUTICASONE - 50 mcg Spray, Suspension - 1 Nasal Spray daily
Medications - OTC
GUAIFENESIN [MUCINEX] -  (Prescribed by Other Provider)
LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day PRN
NICOTINE (POLACRILEX) [COMMIT] - 4 mg Lozenge - 1 lozenge every
1-2 hours for first six weeks, then taper to q 2-4 hours x 2
weeks, then q 4-8 hours x 2 weeks. Max 20 pieces in 24 hours

ALLERGIES: Fish Product Derivatives / Shellfish Derived / Peanut / Grass
Pollen-Bermuda, Standard / Mold Extracts / Cat Hair Std Extract

PHYSICAL EXAM: Admission exam:
General: Alert, oriented, mild respiratory distress, some
accessory muscle use, lying on back
HEENT: Sclera anicteric, PERRL, continuous neb over face
Neck: supple
CV: tachy to 120s, no m/r/g
Lungs: poor air movement diffusely, diffuse fine exp wheezing
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&O x 3, no focal deficits

FAMILY HISTORY: Two children with asthma

SOCIAL HISTORY: Works as school bus driver. Lives with wife and one of his three
children. Still smoking. Has on average a bottle of wine/week.
Denies ilicits. 

### Response:
{'Asthma, unspecified type, with (acute) exacerbation,Acute bronchitis,Long-term (current) use of steroids,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Tobacco use disorder,Obstructive sleep apnea (adult)(pediatric)'}
