CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: Patient is a 31 yo woman with h/o asthma, recent dx MS, [**Doctor First Name 919**]
syndrome, [**Last Name (un) 52372**] [**Doctor Last Name **] syndrome who presented to ED with CC of
cough/wheezing.  Pt states she was in her USOH until
approximately 5 days ago when developed increased wheezing, and
felt as though her asthma was flaring up.  She had run out of
her outpt advair at this time, and the pharmacy could not get it
for awhile, so she was not taking it over the past 5 days.  Over
the next couple of days, she continued to have SOB/wheezing, due
to her asthma, and then over the past 1-2 days developed
non-productive cough, mild rhinorrhea, chills, did not take temp
at home.  Also on night PTA, had onset of hives on her face and
tongue swelling, which she describes as similar to previous
allergic rxns to foods, but denies eating any new foods or foods
that she knows she has an allergy to.  Did eat from take-out on
friday night, but these sxs occurred saturday night.  Pt
otherwise denied any CP/pressure, heart palpitations, N/V, sore
throat, body aches.  States that her children and husband were
just sick with a viral URI.
To self treat her wheezing, cough at home, she states she has
been taking increased amounts of her home albuterol inhaler and
nebulizer treatment over past couple days to treat asthma and
compensate for no advair.  Notabley did albuterol neb treatment
on friday night, saturday night, and sunday morning prior to
presentation to ED.
In ED, initially felt asthma exacerbation and was given
prednisone 60mg PO x 1, levofloxacin 250mg x 1, along with
albuterol + atrovent nebulizer treatments.  CXR negative for
pneumonia.  Upon re-evaluation, pt was noted to be tachycardic
to 120's-130's, T 102, other VSS.  Labs notable for HCO3 19, AG
16, lactate 3.5.  EKG with diffusely flipped t waves, so concern
for pericarditis.  However, bedside U/S demonstrated no evidence
of pericardial effusion and pt CP free.  D dimer checked and was
nl.  Noted to be tremulous and have hyperreflexia on exam, so
concern for thyroid storm.  TSH sent, pending upon transfer to
MICU.  Endocrinology contact[**Name (NI) **] and aware of pt.  Pt given PTU
150mg x 1, hydroxyzine 25mg x 1, esmolol gtt.
Currently pt w/ continued cough, wheezing, but feels "ok".

MEDICAL HISTORY: - [**Doctor First Name 919**] syndrome: DS is a miswiring of the eye muscles that
causes some eye muscles to contract when they should not and
other eye muscles not to contract when they should. Often, when
the eye moves toward the nose, the eyeball also pulls into the
socket (ie, retraction), the eye opening narrows.
- [**Last Name (un) 52372**] [**Doctor Last Name **] syndrome: This autosomal dominant condition can
be
quite variable within families. The characteristics include lack
of an opening for the anus which must be repaired at birth,
abnormal bones of the hands or feet, kidney problems (usually
small, poorly formed kidneys), "lop" shaped ears, and mild
sensorineural hearing loss.  Single gene disorder (SALLI gene
mutation) encompasses many feature of both VATER association and
the [**Last Name (un) 52373**]-auriculo-vertebral malformation sequences.
- migraines : intense constant pain in back of her head which
wraps around in a band to the front, a/w nausea and occasionally
vomiting, photo- and phonophobia.  Last one 1 yr ago.  Has been
having daily [**2140-4-25**] severity either bifrontal or occipital
headaches with some associated left neck muscle aches in the
past
few days and on and off this summer.  Takes Tylenol PRN.
Headaches no not wake her from sleep.
- asthma
- anxiety

MEDICATION ON ADMISSION: Effexor XR 225 mg daily
Albuterol 90 mcg INH PRN
Albuterol Neb PRN
Advair Diskus INH daily

ALLERGIES: Nsaids / Aspirin / Claritin / Wheat Flour / Shellfish Derived

PHYSICAL EXAM: Vitals - T 98.2, HR 112, BP 109/77, RR 16, O2 95% on RA
Gen - awake, alert, NAD
HEENT - PERRL, EOMI, no nystagmus, no lid-lag, no exopthalmos
Neck - No thyromegaly appreciated on exam, thyroid non-tender to
palpation
CVS - tachycardic, regular, no noted m/r/g
Lungs - scattered inspiratory wheezes in UE b/l
Abd - soft, NT/ND, normoactive BS
Ext - No LE edema b/l
Neuro - A+Ox3, patellar reflexes and babinski reflexes notably
hyperreflexic w/ clonus

FAMILY HISTORY: asthma, seasonal allergies, CAD.  GM had stroke.  No h/o
migraines or headaches.

SOCIAL HISTORY: lives w/husband 2 kids, still
breastfeeding.  Works as pre-K teacher, no tob, occ etoh.
Asthma, unspecified type, with (acute) exacerbation,Multiple sclerosis,Acidosis,Influenza with other respiratory manifestations,Duane's syndrome
Asthma NOS w (ac) exac,Multiple sclerosis,Acidosis,Flu w resp manifest NEC,Duane's syndrome
Admission Date:  [**2138-3-2**]              Discharge Date:   [**2138-3-6**]

Date of Birth:  [**2106-9-12**]             Sex:   F

Service: MEDICINE

Allergies:
Nsaids / Aspirin / Claritin / Wheat Flour / Shellfish Derived

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
none


History of Present Illness:
Patient is a 31 yo woman with h/o asthma, recent dx MS, [**Doctor First Name 919**]
syndrome, [**Last Name (un) 52372**] [**Doctor Last Name **] syndrome who presented to ED with CC of
cough/wheezing.  Pt states she was in her USOH until
approximately 5 days ago when developed increased wheezing, and
felt as though her asthma was flaring up.  She had run out of
her outpt advair at this time, and the pharmacy could not get it
for awhile, so she was not taking it over the past 5 days.  Over
the next couple of days, she continued to have SOB/wheezing, due
to her asthma, and then over the past 1-2 days developed
non-productive cough, mild rhinorrhea, chills, did not take temp
at home.  Also on night PTA, had onset of hives on her face and
tongue swelling, which she describes as similar to previous
allergic rxns to foods, but denies eating any new foods or foods
that she knows she has an allergy to.  Did eat from take-out on
friday night, but these sxs occurred saturday night.  Pt
otherwise denied any CP/pressure, heart palpitations, N/V, sore
throat, body aches.  States that her children and husband were
just sick with a viral URI.
To self treat her wheezing, cough at home, she states she has
been taking increased amounts of her home albuterol inhaler and
nebulizer treatment over past couple days to treat asthma and
compensate for no advair.  Notabley did albuterol neb treatment
on friday night, saturday night, and sunday morning prior to
presentation to ED.
In ED, initially felt asthma exacerbation and was given
prednisone 60mg PO x 1, levofloxacin 250mg x 1, along with
albuterol + atrovent nebulizer treatments.  CXR negative for
pneumonia.  Upon re-evaluation, pt was noted to be tachycardic
to 120's-130's, T 102, other VSS.  Labs notable for HCO3 19, AG
16, lactate 3.5.  EKG with diffusely flipped t waves, so concern
for pericarditis.  However, bedside U/S demonstrated no evidence
of pericardial effusion and pt CP free.  D dimer checked and was
nl.  Noted to be tremulous and have hyperreflexia on exam, so
concern for thyroid storm.  TSH sent, pending upon transfer to
MICU.  Endocrinology contact[**Name (NI) **] and aware of pt.  Pt given PTU
150mg x 1, hydroxyzine 25mg x 1, esmolol gtt.
Currently pt w/ continued cough, wheezing, but feels "ok".


Past Medical History:
- [**Doctor First Name 919**] syndrome: DS is a miswiring of the eye muscles that
causes some eye muscles to contract when they should not and
other eye muscles not to contract when they should. Often, when
the eye moves toward the nose, the eyeball also pulls into the
socket (ie, retraction), the eye opening narrows.
- [**Last Name (un) 52372**] [**Doctor Last Name **] syndrome: This autosomal dominant condition can
be
quite variable within families. The characteristics include lack
of an opening for the anus which must be repaired at birth,
abnormal bones of the hands or feet, kidney problems (usually
small, poorly formed kidneys), "lop" shaped ears, and mild
sensorineural hearing loss.  Single gene disorder (SALLI gene
mutation) encompasses many feature of both VATER association and
the [**Last Name (un) 52373**]-auriculo-vertebral malformation sequences.
- migraines : intense constant pain in back of her head which
wraps around in a band to the front, a/w nausea and occasionally
vomiting, photo- and phonophobia.  Last one 1 yr ago.  Has been
having daily [**2140-4-25**] severity either bifrontal or occipital
headaches with some associated left neck muscle aches in the
past
few days and on and off this summer.  Takes Tylenol PRN.
Headaches no not wake her from sleep.
- asthma
- anxiety


Social History:
lives w/husband 2 kids, still
breastfeeding.  Works as pre-K teacher, no tob, occ etoh.


Family History:
asthma, seasonal allergies, CAD.  GM had stroke.  No h/o
migraines or headaches.

Physical Exam:
Vitals - T 98.2, HR 112, BP 109/77, RR 16, O2 95% on RA
Gen - awake, alert, NAD
HEENT - PERRL, EOMI, no nystagmus, no lid-lag, no exopthalmos
Neck - No thyromegaly appreciated on exam, thyroid non-tender to
palpation
CVS - tachycardic, regular, no noted m/r/g
Lungs - scattered inspiratory wheezes in UE b/l
Abd - soft, NT/ND, normoactive BS
Ext - No LE edema b/l
Neuro - A+Ox3, patellar reflexes and babinski reflexes notably
hyperreflexic w/ clonus


Pertinent Results:
[**2138-3-2**] 08:45PM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2138-3-2**] 08:45PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2138-3-2**] 01:11PM   ALT(SGPT)-18 AST(SGOT)-25 LD(LDH)-216
CK(CPK)-88 ALK PHOS-124* AMYLASE-56 TOT BILI-0.2
[**2138-3-2**] 01:11PM   LIPASE-47
[**2138-3-2**] 01:11PM   CK-MB-NotDone cTropnT-<0.01
[**2138-3-2**] 01:11PM   ALBUMIN-4.5 URIC ACID-4.8
[**2138-3-2**] 01:11PM   TSH-0.76
[**2138-3-2**] 01:11PM   T4-5.4 T3-92
[**2138-3-2**] 01:11PM   HCG-<5
[**2138-3-2**] 01:11PM   WBC-8.9# RBC-4.58 HGB-14.2 HCT-39.9 MCV-87
MCH-31.1 MCHC-35.7* RDW-13.6
[**2138-3-2**] 01:11PM   NEUTS-90.3* BANDS-0 LYMPHS-5.5* MONOS-1.5*
EOS-2.1 BASOS-0.7
[**2138-3-2**] 01:11PM   PLT COUNT-259
[**2138-3-2**] 01:11PM   D-DIMER-310
[**2138-3-2**] 01:10PM   LACTATE-3.6*

CHEST (PORTABLE AP)  [**2138-3-4**] 7:18 AM
SINGLE VIEW, CHEST: There are no focal areas of consolidation,
pneumothorax, pleural effusion, or infiltration. Pulmonary
vasculature is within normal limits without evidence of
interstitial edema. Hilar contours are normal without evidence
of hilar adenopathy. The cardiomediastinal contour is unusual
despite absence of gastric distension as present on previous
study. Similar unusual configuration of the cardiomediastinal
contour was also noted on [**2137-8-21**] and has since been
unchanged. There is no evidence of cardiomegaly.

IMPRESSION: Unusual cardiac contour unchanged since [**2137-8-21**].
No pneumonia or acute cardiopulmonary process.

Echo [**3-3**]
The left atrium is normal in size. The estimated right atrial
pressure is 10-20mmHg. Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets appear structurally normal with good
leaflet excursion. No aortic stenosis or aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.

IMPRESSION: Normal biventricular cavity sizes with preserved
global biventricular systolic function. Mildly dilated ascending
aorta.

CLINICAL IMPLICATIONS:
Based on [**2137**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.

CTA CHEST W&W/O C&RECONS, NON-CORONARY  [**2138-3-3**] 3:43 PM

IMPRESSIONS:

1. Lower lobe and lingular subsegmental atelectasis, without
evidence of pulmonary embolus.

2. Incidentally noted duplicated superior vena cava.


Brief Hospital Course:
Assessment/Plan:  Pt is a 31 yo woman w/ h/o asthma, recently dx
MS who p/w asthma exacerbation, fevers, tachycardia w/ initial
concern for thyroid storm, but TFTs nl.
.
# Hypoxia/resp status:  Pt presented w/ c/o "asthma
exacerbation" w/ noted wheezing on initial exam.  Evaluated w/
CXR which was unremarkable.  However, after o/n treatment w/
nebulizer treatments and steroids, pt with increased vs
decreased O2 requirement.  CTA chest was done to r/o PE (even
though d dimer < 500), neg for PE or parenchymal consolidation.
DFA done on [**3-3**] returned positive for influenza.  Plan to:
- steroid burst - pred 60mg x 5 days (started [**3-2**])
- albuterol nebs PRN
- continue outpt advair
- continue tamiflu x 5 days (started [**3-3**])
- continue azithro x 5 days (started [**3-2**])
The patient was transferred to the floor with quick improvement
of her respiratory status. She did not require nebs the last 24
hours of her hospital stay, and sats were normal and stable upon
discharge.
.
# Elevated lactate/AG acidosis:  Pt w/ elevated lactate 3.5 in
ED, rechecked, and elevated to 4.5.  Also w/ noted decreased
HCO3 to 19, with AG 16 on admission.  Pt appeared to be well
perfused, nl renal fxn, nl LFTs.  Received IVF.  Concern for
influenza given prior presentations for increased lactate.  As
above, DFA positive.  Plan to:
- mangagement as above
- moniter HCO3
The patient's anion gap acidosis resolved prior to discharge.
.
# Fever:  Presumabley [**2-22**] flu.  Afebrile here.

# Sinus tachycardia:  Initially felt due to possible thyroid
storm, maintained on esmolol gtt.  Now TFTs returned nl, esmolol
gtt d/ced.  PE r/o w/ CTA chest.  ECHO unremarkable for etiology
of tachycardia.  Now resolving w/ treatment of resp status.  Pt
had a stable HR around 90 upon discharge, which has been
attributed to her virus and albuterol treatments. She was chest
pain free and without pleuritic pain or shortness of breath/DOE
at discharge and will follow up with her PCP regarding this.

# H/O MS:  Not on any meds. No sx while here.
.
# Depression: Continue effexor. No Sx while here.

Pt remained stable while on the floor without any issues. She
took good PO and remained on appropriate prophylaxis throughout
her hospital stay. She was discharged in good condition with
prescriptions to complete tamiflu, prednisone and Advair tx. She
was sent with masks and instructions to wear x 4 more days.

She was advised to discard breastmilk for two days while she is
on tamiflu.


Medications on Admission:
Effexor XR 225 mg daily
Albuterol 90 mcg INH PRN
Albuterol Neb PRN
Advair Diskus INH daily


Discharge Medications:
1. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs Disk with Device(s)* Refills:*0*
3. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily) for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
4. Oseltamivir Phosphate 75 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day) for 2 days.
Disp:*4 Capsule(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Influenza A
Asthma exacerbation


Discharge Condition:
good


Discharge Instructions:
You were evaluated and found to have an asthma exacerbation and
influenza A. You were admitted to the intensive care unit
because of the level of respiratory distress you had. In the
ICU, you received nebulizer medication that helped resolve your
breathing difficulty. You were started on an antiviral and a
z-pack. Your evaluation, including xray, heart ultrasound and
chest CT scan were all negative for any underlying problems.

Finish your medication as directed

Please call your doctor or come to the emergency room if you
experience any of the following: Fever, chills, increased pain,
increased cough, nausea, vomiting, abdominal pain, shortness of
breath, chest pain or any other symptoms that are worrisome to
you.

Followup Instructions:
1. Please follow up with your primary care doctor as needed for
further evaluation and treatent.
-you should discuss your continued fast heart rate with you
doctor. [**First Name (Titles) **] [**Last Name (Titles) 37566**] in the hospital has been negative for any
serious underlying issue and due to the virus and medicine, but
this should be followed up.


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

Completed by:[**2138-3-6**]
{"Asthma, unspecified type, with (acute) exacerbation,Multiple sclerosis,Acidosis,Influenza with other respiratory manifestations,Duane's syndrome"}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: Patient is a 31 yo woman with h/o asthma, recent dx MS, [**Doctor First Name 919**]
syndrome, [**Last Name (un) 52372**] [**Doctor Last Name **] syndrome who presented to ED with CC of
cough/wheezing.  Pt states she was in her USOH until
approximately 5 days ago when developed increased wheezing, and
felt as though her asthma was flaring up.  She had run out of
her outpt advair at this time, and the pharmacy could not get it
for awhile, so she was not taking it over the past 5 days.  Over
the next couple of days, she continued to have SOB/wheezing, due
to her asthma, and then over the past 1-2 days developed
non-productive cough, mild rhinorrhea, chills, did not take temp
at home.  Also on night PTA, had onset of hives on her face and
tongue swelling, which she describes as similar to previous
allergic rxns to foods, but denies eating any new foods or foods
that she knows she has an allergy to.  Did eat from take-out on
friday night, but these sxs occurred saturday night.  Pt
otherwise denied any CP/pressure, heart palpitations, N/V, sore
throat, body aches.  States that her children and husband were
just sick with a viral URI.
To self treat her wheezing, cough at home, she states she has
been taking increased amounts of her home albuterol inhaler and
nebulizer treatment over past couple days to treat asthma and
compensate for no advair.  Notabley did albuterol neb treatment
on friday night, saturday night, and sunday morning prior to
presentation to ED.
In ED, initially felt asthma exacerbation and was given
prednisone 60mg PO x 1, levofloxacin 250mg x 1, along with
albuterol + atrovent nebulizer treatments.  CXR negative for
pneumonia.  Upon re-evaluation, pt was noted to be tachycardic
to 120's-130's, T 102, other VSS.  Labs notable for HCO3 19, AG
16, lactate 3.5.  EKG with diffusely flipped t waves, so concern
for pericarditis.  However, bedside U/S demonstrated no evidence
of pericardial effusion and pt CP free.  D dimer checked and was
nl.  Noted to be tremulous and have hyperreflexia on exam, so
concern for thyroid storm.  TSH sent, pending upon transfer to
MICU.  Endocrinology contact[**Name (NI) **] and aware of pt.  Pt given PTU
150mg x 1, hydroxyzine 25mg x 1, esmolol gtt.
Currently pt w/ continued cough, wheezing, but feels "ok".

MEDICAL HISTORY: - [**Doctor First Name 919**] syndrome: DS is a miswiring of the eye muscles that
causes some eye muscles to contract when they should not and
other eye muscles not to contract when they should. Often, when
the eye moves toward the nose, the eyeball also pulls into the
socket (ie, retraction), the eye opening narrows.
- [**Last Name (un) 52372**] [**Doctor Last Name **] syndrome: This autosomal dominant condition can
be
quite variable within families. The characteristics include lack
of an opening for the anus which must be repaired at birth,
abnormal bones of the hands or feet, kidney problems (usually
small, poorly formed kidneys), "lop" shaped ears, and mild
sensorineural hearing loss.  Single gene disorder (SALLI gene
mutation) encompasses many feature of both VATER association and
the [**Last Name (un) 52373**]-auriculo-vertebral malformation sequences.
- migraines : intense constant pain in back of her head which
wraps around in a band to the front, a/w nausea and occasionally
vomiting, photo- and phonophobia.  Last one 1 yr ago.  Has been
having daily [**2140-4-25**] severity either bifrontal or occipital
headaches with some associated left neck muscle aches in the
past
few days and on and off this summer.  Takes Tylenol PRN.
Headaches no not wake her from sleep.
- asthma
- anxiety

MEDICATION ON ADMISSION: Effexor XR 225 mg daily
Albuterol 90 mcg INH PRN
Albuterol Neb PRN
Advair Diskus INH daily

ALLERGIES: Nsaids / Aspirin / Claritin / Wheat Flour / Shellfish Derived

PHYSICAL EXAM: Vitals - T 98.2, HR 112, BP 109/77, RR 16, O2 95% on RA
Gen - awake, alert, NAD
HEENT - PERRL, EOMI, no nystagmus, no lid-lag, no exopthalmos
Neck - No thyromegaly appreciated on exam, thyroid non-tender to
palpation
CVS - tachycardic, regular, no noted m/r/g
Lungs - scattered inspiratory wheezes in UE b/l
Abd - soft, NT/ND, normoactive BS
Ext - No LE edema b/l
Neuro - A+Ox3, patellar reflexes and babinski reflexes notably
hyperreflexic w/ clonus

FAMILY HISTORY: asthma, seasonal allergies, CAD.  GM had stroke.  No h/o
migraines or headaches.

SOCIAL HISTORY: lives w/husband 2 kids, still
breastfeeding.  Works as pre-K teacher, no tob, occ etoh. 

### Response:
{"Asthma, unspecified type, with (acute) exacerbation,Multiple sclerosis,Acidosis,Influenza with other respiratory manifestations,Duane's syndrome"}
