CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: 69 year old women with dyspnea on exertion and leg swelling x1
week. The pt has a history of COPD and is at home baseline at
2L.  The pt reports that for the past week she's been having
increasing shortness of breath particularly when walking, using
3 pillows at night to sleep and could not sleep laying flat, and
that her legs have been swelling up bilaterally.  The pt
reported the ED at [**Hospital1 **] where she was evaluated, and had
a CXR that showed "mild pulmonary edema", she had an elevated
BNP of 1400, and one negative troponin while there, with an ECG
NSR 95 NANI, no STTWc, but no comparison.  The pt was diuresed
1300ml there with IV Lasix 40, and was given SoluMedrol, and
then transferred to [**Hospital1 18**] due to full capacity there.  The
working diagnosis of her admission was COPD exacerbation versus
new onset CHF.  The pt endorsed headaches for the past week as
well.  The pt reportedly did not endorse fever or chills, nausea
or vomiting, productive cough, chest pain, rhinorrhea,
congestion, sore throat, diarrhea, constipation, BRBPR, melena,
dysuria or hematuria.

MEDICAL HISTORY: COPD, on home O2 (2L at baseline)
Anxiety
Chronic musculoskeletal pain

MEDICATION ON ADMISSION: Lorazepam 0.25mg [**Hospital1 **] (discontinued on evening of transfer)
Zofran 4mg IV x1
Senna daily
Colace 100mg [**Hospital1 **]
Lasix 40mg IV x1
Acetaminophen 325-650 mg Q6H prn pain/fever
Abuterol 0.083% nebs Q4H prn SOB
Ipratropium Bromide nebs Q6H prn SOB
ASA 81mg daily
Tiotropium Bromide 1 CAP inhaled daily
Heparin SC 5000 units TID

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
Vitals: p79 100/61, r16
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: with crackles diffusely
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, trace pitting edema
bilaterally

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives in [**Location 1411**] with daughter [**Name (NI) 803**], daughter [**Name (NI) **] lives next
door. Retired worker from WGBF station.
Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Congestive heart failure, unspecified,Other dependence on machines, supplemental oxygen,Iron deficiency anemia, unspecified,Myalgia and myositis, unspecified,Other constipation,Disorders of phosphorus metabolism
Obs chr bronc w(ac) exac,Acute respiratry failure,CHF NOS,Depend-supplement oxygen,Iron defic anemia NOS,Myalgia and myositis NOS,Constipation NEC,Dis phosphorus metabol
Admission Date:  [**2181-9-4**]              Discharge Date:   [**2181-9-10**]

Date of Birth:  [**2111-9-9**]             Sex:   F

Service: [**Year (4 digits) 662**]

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
none

History of Present Illness:
69 year old women with dyspnea on exertion and leg swelling x1
week. The pt has a history of COPD and is at home baseline at
2L.  The pt reports that for the past week she's been having
increasing shortness of breath particularly when walking, using
3 pillows at night to sleep and could not sleep laying flat, and
that her legs have been swelling up bilaterally.  The pt
reported the ED at [**Hospital1 **] where she was evaluated, and had
a CXR that showed "mild pulmonary edema", she had an elevated
BNP of 1400, and one negative troponin while there, with an ECG
NSR 95 NANI, no STTWc, but no comparison.  The pt was diuresed
1300ml there with IV Lasix 40, and was given SoluMedrol, and
then transferred to [**Hospital1 18**] due to full capacity there.  The
working diagnosis of her admission was COPD exacerbation versus
new onset CHF.  The pt endorsed headaches for the past week as
well.  The pt reportedly did not endorse fever or chills, nausea
or vomiting, productive cough, chest pain, rhinorrhea,
congestion, sore throat, diarrhea, constipation, BRBPR, melena,
dysuria or hematuria.


Past Medical History:
COPD, on home O2 (2L at baseline)
Anxiety
Chronic musculoskeletal pain


Social History:
Lives in [**Location 1411**] with daughter [**Name (NI) 803**], daughter [**Name (NI) **] lives next
door. Retired worker from WGBF station.

Family History:
Non-contributory


Physical Exam:
ADMISSION EXAM
Vitals: p79 100/61, r16
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: with crackles diffusely
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, trace pitting edema
bilaterally

On DISCHARGE:
T 97.2 BP 114/56 HR 82 RR 18 O2Sat 97% on 2L NC
Lungs with some crackles remaining diffusely, particularly at
lower bases
no pedal edema


Pertinent Results:
[**2181-9-4**] 01:00AM BLOOD WBC-11.6* RBC-4.90 Hgb-10.4* Hct-35.7*
MCV-73* MCH-21.1* MCHC-29.0* RDW-16.6* Plt Ct-303
[**2181-9-10**] 06:40AM BLOOD WBC-8.3 RBC-4.37 Hgb-9.2* Hct-34.0*
MCV-78*# MCH-21.0* MCHC-27.0* RDW-17.8* Plt Ct-298
[**2181-9-4**] 01:00AM BLOOD Neuts-95.6* Lymphs-3.6* Monos-0.6*
Eos-0.1 Baso-0.1
[**2181-9-4**] 01:00AM BLOOD PT-14.3* PTT-26.4 INR(PT)-1.2*
[**2181-9-4**] 01:00AM BLOOD Glucose-138* UreaN-16 Creat-0.7 Na-136
K-4.2 Cl-93* HCO3-38* AnGap-9
[**2181-9-10**] 06:40AM BLOOD Glucose-83 UreaN-12 Creat-0.7 Na-140
K-3.7 Cl-96 HCO3-37* AnGap-11
[**2181-9-4**] 05:55AM BLOOD CK(CPK)-26*
[**2181-9-5**] 03:48AM BLOOD ALT-14 AST-15 CK(CPK)-22* AlkPhos-88
Amylase-20 TotBili-0.3
[**2181-9-5**] 03:48AM BLOOD CK(CPK)-23*
[**2181-9-4**] 01:00AM BLOOD cTropnT-<0.01
[**2181-9-4**] 05:55AM BLOOD CK-MB-2 cTropnT-<0.01
[**2181-9-5**] 03:48AM BLOOD CK-MB-2 cTropnT-<0.01
[**2181-9-5**] 03:48AM BLOOD CK-MB-2 cTropnT-<0.01
[**2181-9-5**] 11:50AM BLOOD cTropnT-<0.01
[**2181-9-6**] 03:34AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.0
[**2181-9-10**] 06:40AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.3
[**2181-9-4**] 12:20PM BLOOD Calcium-8.5 Phos-3.3 Mg-2.3 Iron-21*
[**2181-9-4**] 12:20PM BLOOD calTIBC-502* Ferritn-4.2* TRF-386*
[**2181-9-4**] 12:20PM BLOOD TSH-1.5
[**2181-9-5**] 04:02AM BLOOD Type-ART pO2-118* pCO2-174* pH-7.11*
calTCO2-59* Base XS-17 Intubat-NOT INTUBA
[**2181-9-5**] 04:54AM BLOOD Type-ART Temp-36.8 Tidal V-500 PEEP-5
pO2-448* pCO2-81* pH-7.36 calTCO2-48* Base XS-16
Intubat-INTUBATED Vent-CONTROLLED
[**2181-9-5**] 12:06PM BLOOD Type-ART Rates-10/0 Tidal V-500 PEEP-5
FiO2-30 pO2-185* pCO2-76* pH-7.37 calTCO2-46* Base XS-14
Intubat-INTUBATED Vent-CONTROLLED
[**2181-9-6**] 01:02PM BLOOD Type-ART pO2-63* pCO2-76* pH-7.38
calTCO2-47* Base XS-15 Intubat-NOT INTUBA
[**2181-9-5**] 04:06AM BLOOD Lactate-0.7
[**2181-9-5**] 08:03AM BLOOD Lactate-1.0
[**2181-9-5**] 12:06PM BLOOD Lactate-0.8
[**2181-9-5**] 04:06AM BLOOD freeCa-1.13
[**2181-9-5**] 08:03AM BLOOD freeCa-1.04*
[**2181-9-5**] 12:06PM BLOOD freeCa-1.19
[**2181-9-5**] 12:04PM BLOOD O2 Sat-75

STUDIES:

CXR
SINGLE AP PORTABLE VIEW OF THE CHEST

REASON FOR EXAM: Assess ET tube.

CXXR [**2181-9-5**]
ET tube tip is in the right main bronchus, should be pulled back
4-5 cm to
standard position. NG tube tip is out of view below the
diaphragm. Cardiac
size is top normal. There is no evident pneumothorax or pleural
effusion.
The patient has known COPD. Mild right apical thickening is of
unknown
chronicity. Right lower lobe opacity is new could be due to
atelectasis, but aspiration cannot be excluded and attention in
followup study is recommended

CXR  9/29/1
FINDINGS: Removal of right internal jugular vascular catheter
with no visible pneumothorax. Standard position of endotracheal
tube, nasogastric tube terminates in the stomach. Heart size
remains normal. No focal areas of consolidation are evident
within the lungs. Mild elevation of left
hemidiaphragm is unchanged.


Brief Hospital Course:
Pt is a 69 y/o woman with PMHx significant for COPD requiring 2L
oxygen at home and anxiety presenting with COPD exacerbation and
?mild CHF.

COPD/Hypercapneic Respiratory Failure: Pt found to have FEV1 of
19%, putting her in the very severe staging of Gold's criteria
and was gently diuresed.   Pt was started on azithromycin 500 mg
X1 and then 250 mg daily.  On hospital day #1 she became
increasingly somnolent and found to have a PCO2 of 179. She was
transferred to the ICU. Unclear etiology of patients respiratory
failure. Potential etiology included ativan use in the setting
of COPD, however this was an extremely small dose and the
patient had been taking it routinely in the evening at home.
Recent respiratory infection as a trigger could not be ruled
out.  Cardiac cause has also been entertained, but pt had
negative troponin X3 and no EKG changes suggestive of STEMI.
Additionally her TTE was normal.  Infectious workup has been
negative.  Pt was intubated upon transfer to MICU. Her
antiobiotcs and steroids were continued. Pt was successfully
extubated on 2nd day of MICU. She continued to maintain good O2
sats on floor.

Prednisone was started at 40 mg, with a plan to taper 10 mg
every 2 days.  Pt was also treated with albuterol and
ipratropium neb.  After return to the floor
salmeterol-fluticasone was initiated. Pt needs a pulmonologist,
has never previously seen one. We scheduled an appointment for
her in the [**Hospital 2182**] clinic here at [**Hospital1 18**]. She will be discharged and
go to outpatient pulmonary rehab.

#. Altered Mental Status: Initially on the floor pt was very
stable, with no trouble breathing or complaints otherwise.
Laughing and conversing with the team. That evening, there was
concerned for her behavior.  The team reported that she was
acting "normal" when she was admitted but became increasingly
more confused.  The floor team did not report that the pt was
aphasic or had clear neurological deficit with any laterality or
focality, but was somnolent appearing.  ABG done on the pt on
the floor showed pCO2 of 179, and in the setting of her
worsening mental status and increased work of breathing, a
trigger was called and the pt intubated on the floor then
transfered to the unit.  On arrival to the MICU the pt was
comfortably sedated, hemodynamically stable.  Hypercarbia or
hypoxia seem like a reasonable diagnoses.  Her mental status
resolved upon the resolution of hypercarbia and extubation. Pt
did not exhibit any signs or symptoms of worsening
hypoxia/hypercapnia when she returned to the floor.

##UTI- Patient had a urinalysis with trace leukocytes, 35 WBC
and few bacteria performed yesterday, UCx pending. Patient has
no complaints of urinary urgency/frequency or dysuria but had a
foley in place during MICU stay.Pt started on cipro for UA
showing whites and bacteria and leukesterase, but culture came
back with ~[**2169**] units and cipro was DCd due to this minimal
bacterial burden.

#. Borderline Iron Deficiency Anemia: We started PO iron after
pt came out of the MICU. There is concern for GI
malignancy/other pathology in a postmenopausal woman with such
significant level of Fe deficiency (ferritin was 4). we would
suggest increasing her iron dosing further to TID on discharge,
now limited by constipation. She will likely need to have a
virtual colonoscopy as it would  be ill-advised for her to
undergo the amount of sedation required for a colonoscopy.

#.Home 02 - pt has difficulty wearing home O2 at night due to
loud noise of machine. We have contact[**Name (NI) **] the company to assess
this.

#. Anxiety: This is not an active issue insofar as she normally
takes lorazepam 0.5mg [**Hospital1 **].  We discontinued this medication.

#. Chronic MSK Pain: at baseline.

Pt was maintained as full code during the entire
hospitalization.

TRANSITIONAL ISSUES:
Iron deficiency anemia - pt needs to have colonoscopy, likely
needs virtual as her respiratory issues make it so she would
have difficulty tolerating sedation.


Medications on Admission:
Lorazepam 0.25mg [**Hospital1 **] (discontinued on evening of transfer)
Zofran 4mg IV x1
Senna daily
Colace 100mg [**Hospital1 **]
Lasix 40mg IV x1
Acetaminophen 325-650 mg Q6H prn pain/fever
Abuterol 0.083% nebs Q4H prn SOB
Ipratropium Bromide nebs Q6H prn SOB
ASA 81mg daily
Tiotropium Bromide 1 CAP inhaled daily
Heparin SC 5000 units TID


Discharge Medications:
1. services
Patient needs hospital bed. Diagnosis: COPD and CHF. Patient has
to sleep with bed elevated.
2. pulmonary rehabilitation
Outpatient pulmonary rehabilitation
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily). Tablet, Chewable(s)
4. docusate sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
Disp:*30 * Refills:*2*
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
Disp:*QS * Refills:*0*
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1)  Inhalation once a day.
Disp:*30 * Refills:*0*
7. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*QS * Refills:*0*
8. 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*
9. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. prednisone 10 mg Tablet Sig: follow taper directions Tablet
PO once a day for 16 days: - [**9-11**] - 8: 30 mg (3 tabs of 10
mg) daily
- [**9-16**] - 12: 20 mg (2 tabs of 10 mg) daily
- [**9-20**] - 16: 10 mg (1 tab of 10 mg) daily
.
Disp:*30 Tablet(s)* Refills:*0*
11. simethicone 80 mg Tablet, Chewable Sig: 0.5 Tablet, Chewable
PO twice a day as needed for gas.
Disp:*40 Tablet, Chewable(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
no services

Discharge Diagnosis:
PRIMARY:
COPD exacerbation


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


Discharge Instructions:
It was a pleasure taking care of you during your
hospitalization. You came in with shortness of breath, and your
difficulty breathing progressed to the point where you were not
responsive, so you were intubated and taken to the ICU. We
treated you for a COPD exacerbation with steroids and
antibiotics, and your breathing improved so you came back to the
floor, where you continued to improve. Also, we found that you
have very low iron in your blood and low red blood cell count.
This could represent blood loss from the GI tract, so it is
important to discuss this with your primary care doctor and
possibly see a gastroenterologist.

Please make the following changes to your medications:
1. STARTED prednisone:
- [**9-11**] - 8: 30 mg (3 tabs of 10 mg) daily
- [**9-16**] - 12: 20 mg (2 tabs of 10 mg) daily
- [**9-20**] - 16: 10 mg (1 tab of 10 mg) daily
2.  STARTED advair inhaler 1 inh [**Hospital1 **]. Please use this every day.
3.  STARTED simethicone for gas pain. You can take this up to 4
times a day as needed for gas pain
4. STARTED docusate twice a day as needed for constipation.
5. STARTED iron (ferrous sulfate) twice daily for your anemia.

Inhalers:
1. CONTINUED your home tiotropium.
2. ADDED albuterol inhaler every 6 hours as needed for shortness
of breath or wheezing
3. STARTED albuterol nebulizer treatment every 6 hours for
shortness of breath or wheezing
4. STARTED ipratropium nebulizer treatment every 6 hours for
shortness of breath or wheezing


Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2181-9-12**] at 10:10 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: PFT
When: WEDNESDAY [**2181-9-12**] at 10:30 AM

Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2181-9-12**] at 10:30 AM
With: DR. [**Last Name (STitle) 91**] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Name:[**First Name8 (NamePattern2) 8826**] [**First Name8 (NamePattern2) 19115**] [**Last Name (NamePattern1) **],MD
Specialty: Primary Care
Location: [**Hospital1 **] [**First Name (Titles) 3860**] [**Last Name (Titles) 662**] CENTER
Address: [**Street Address(2) 3861**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 3858**]
When: Friday, [**9-14**] at 10:15am
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Congestive heart failure, unspecified,Other dependence on machines, supplemental oxygen,Iron deficiency anemia, unspecified,Myalgia and myositis, unspecified,Other constipation,Disorders of phosphorus metabolism'}


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: 69 year old women with dyspnea on exertion and leg swelling x1
week. The pt has a history of COPD and is at home baseline at
2L.  The pt reports that for the past week she's been having
increasing shortness of breath particularly when walking, using
3 pillows at night to sleep and could not sleep laying flat, and
that her legs have been swelling up bilaterally.  The pt
reported the ED at [**Hospital1 **] where she was evaluated, and had
a CXR that showed "mild pulmonary edema", she had an elevated
BNP of 1400, and one negative troponin while there, with an ECG
NSR 95 NANI, no STTWc, but no comparison.  The pt was diuresed
1300ml there with IV Lasix 40, and was given SoluMedrol, and
then transferred to [**Hospital1 18**] due to full capacity there.  The
working diagnosis of her admission was COPD exacerbation versus
new onset CHF.  The pt endorsed headaches for the past week as
well.  The pt reportedly did not endorse fever or chills, nausea
or vomiting, productive cough, chest pain, rhinorrhea,
congestion, sore throat, diarrhea, constipation, BRBPR, melena,
dysuria or hematuria.

MEDICAL HISTORY: COPD, on home O2 (2L at baseline)
Anxiety
Chronic musculoskeletal pain

MEDICATION ON ADMISSION: Lorazepam 0.25mg [**Hospital1 **] (discontinued on evening of transfer)
Zofran 4mg IV x1
Senna daily
Colace 100mg [**Hospital1 **]
Lasix 40mg IV x1
Acetaminophen 325-650 mg Q6H prn pain/fever
Abuterol 0.083% nebs Q4H prn SOB
Ipratropium Bromide nebs Q6H prn SOB
ASA 81mg daily
Tiotropium Bromide 1 CAP inhaled daily
Heparin SC 5000 units TID

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
Vitals: p79 100/61, r16
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: with crackles diffusely
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, trace pitting edema
bilaterally

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives in [**Location 1411**] with daughter [**Name (NI) 803**], daughter [**Name (NI) **] lives next
door. Retired worker from WGBF station. 

### Response:
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute respiratory failure,Congestive heart failure, unspecified,Other dependence on machines, supplemental oxygen,Iron deficiency anemia, unspecified,Myalgia and myositis, unspecified,Other constipation,Disorders of phosphorus metabolism'}
