CHIEF COMPLAINT: tongue swelling

PRESENT ILLNESS: Ms. [**Known lastname 4886**] is a 77yoF with multiple medical problems including
HTN who was started on lisinopril approximately 6m ago who
presented to OSH with right facial swelling that started at 5am.
At the OSH, she was given Benadryl, solumedrol, and Pepcid. This
helped somewhat initially, but then left and tongue swelling
developed. He was transfered to the [**Hospital1 18**] ED. Initial ED vitals:
T 98.8, HR 58, BP 138/84, RR 18, 95% RA. In the [**Hospital1 18**] ED,
initially she got epinephrine, but was ultimately intubated to
protect airway after trying some epi.  She had some hypotension
on propofol, and so sedation was switched to vent/Versed.

MEDICAL HISTORY: G6PD deficiency
ERCP [**2191**]
HTN
diverticulitis (multiple hospitalizations per son)
GERD
asthma (well-controlled as of late per son)
hernia
Cataract
colon polyps
arthrits

MEDICATION ON ADMISSION: Protonix 40mg daily
HCTZ 25mg daily
budesonide 1 puff [**Hospital1 **]
KCl 20 meq daily
w-3 fatty acids 1200mg daily
MVI
cholystyramine 4g daily
albuterol q4 PRN
flonase 1 spray [**Hospital1 **]
fluocinonide 0.05% 4 drops OU daily PRN
oloatadine 0.1% 1 drop OU [**Hospital1 **]
vitamin D

ALLERGIES: NSAIDS / Flagyl / diltiazem / triazolam / Ciprofloxacin /
lisinopril / aspirin

PHYSICAL EXAM: Admission Physical Exam:
General: Intubated, sedated, responds to voice and follows sipme
commands
HEENT: Sclera anicteric, PERRL, tongue and neck swelling
Neck: edematous
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: hypoactive, BS, soft, non-tender, non-distended
Ext: warm, well perfused, no clubbing, cyanosis or edema
.
.
Physical Exam at Discharge:
Vitals: T: 98.0F   BP: 140/77   P: 74   R: 18   O2: 97%/RA
General: Alert and interactive with family conversations, NAD
HEENT: Sclera anicteric, PERRL, MMM , tongue with no edema
Neck: no longer edematous, no LAD, no JVD, supple
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: hypoactive, BS, soft, non-tender, non-distended
Ext: warm, well perfused, no clubbing, cyanosis or edema

FAMILY HISTORY: G6PD deficiency

SOCIAL HISTORY: - Tobacco: former
- Alcohol: none
- Illicits: none
Lives alone, retired. Son is HCP.
Angioneurotic edema, not elsewhere classified,Acute respiratory failure,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Accidents occurring in other specified places,Esophageal reflux,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Other iatrogenic hypotension
Angioneurotic edema,Acute respiratry failure,Adv eff cardiovasc NEC,Accident in place NEC,Esophageal reflux,Hypertension NOS,Asthma NOS,Iatrogenc hypotnsion NEC
Admission Date:  [**2195-9-5**]              Discharge Date:   [**2195-9-7**]

Date of Birth:  [**2118-4-25**]             Sex:   F

Service: MEDICINE

Allergies:
NSAIDS / Flagyl / diltiazem / triazolam / Ciprofloxacin /
lisinopril / aspirin

Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
tongue swelling


Major Surgical or Invasive Procedure:
Intubation

History of Present Illness:
Ms. [**Known lastname 4886**] is a 77yoF with multiple medical problems including
HTN who was started on lisinopril approximately 6m ago who
presented to OSH with right facial swelling that started at 5am.
At the OSH, she was given Benadryl, solumedrol, and Pepcid. This
helped somewhat initially, but then left and tongue swelling
developed. He was transfered to the [**Hospital1 18**] ED. Initial ED vitals:
T 98.8, HR 58, BP 138/84, RR 18, 95% RA. In the [**Hospital1 18**] ED,
initially she got epinephrine, but was ultimately intubated to
protect airway after trying some epi.  She had some hypotension
on propofol, and so sedation was switched to vent/Versed.

Of note, she ate scallops and clams for dinner last night. Her
son does not recall any issues with shelfish in the past,
although she does not eat it terribly frequently because these
foods are often too [**Doctor First Name **] for her. She has a number of medicaion
allergies, although no recent exposure to any of these meds. She
has never had a reaction that has caused throat swelling before
that her son is aware of. She may have had hives before, but her
medication allergies all happened a number of years ago.
.
.
Vitals prior to transfer: T 97, HR 88, BP 146/88, RR 15, 100% on
CMV with FiO2 100%
.
On the floor, she is intubated and sedated. She responds to
voice and is able to follow simple commands.


Past Medical History:
G6PD deficiency
ERCP [**2191**]
HTN
diverticulitis (multiple hospitalizations per son)
GERD
asthma (well-controlled as of late per son)
hernia
Cataract
colon polyps
arthrits


Social History:
- Tobacco: former
- Alcohol: none
- Illicits: none
Lives alone, retired. Son is HCP.


Family History:
G6PD deficiency

Physical Exam:
Admission Physical Exam:
General: Intubated, sedated, responds to voice and follows sipme
commands
HEENT: Sclera anicteric, PERRL, tongue and neck swelling
Neck: edematous
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: hypoactive, BS, soft, non-tender, non-distended
Ext: warm, well perfused, no clubbing, cyanosis or edema
.
.
Physical Exam at Discharge:
Vitals: T: 98.0F   BP: 140/77   P: 74   R: 18   O2: 97%/RA
General: Alert and interactive with family conversations, NAD
HEENT: Sclera anicteric, PERRL, MMM , tongue with no edema
Neck: no longer edematous, no LAD, no JVD, supple
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: hypoactive, BS, soft, non-tender, non-distended
Ext: warm, well perfused, no clubbing, cyanosis or edema


Pertinent Results:
Admission Labs:
[**2195-9-5**] 04:50PM BLOOD WBC-8.7 RBC-4.30 Hgb-14.1 Hct-39.5 MCV-92
MCH-32.8* MCHC-35.7* RDW-14.0 Plt Ct-141*
[**2195-9-5**] 12:55PM BLOOD PT-11.7 PTT-24.9 INR(PT)-1.0
[**2195-9-5**] 12:55PM BLOOD UreaN-13 Creat-0.9
[**2195-9-6**] 01:31AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.5*
[**2195-9-5**] 01:48PM BLOOD Type-ART Rates-14/ Tidal V-450 PEEP-5
FiO2-100 pO2-515* pCO2-33* pH-7.45 calTCO2-24 Base XS-0
AADO2-182 REQ O2-39 Intubat-INTUBATED
[**2195-9-5**] 01:06PM BLOOD Glucose-107* Lactate-2.5* Na-142 K-3.5
Cl-95* calHCO3-25
[**2195-9-5**] 01:06PM BLOOD Hgb-15.8 calcHCT-47 O2 Sat-90 COHgb-4
MetHgb-0

CHEST (PORTABLE AP) Study Date of [**2195-9-5**] 1:25 PM
The lungs are low in volume. There is minimal atelectasis in the
left lung
base. Remainder of the lungs are clear. The cardiac silhouette
is normal. The mediastinal silhouette shows a tortuous aortic
knob. The hilar contours are normal. There may be a small left
pleural effusion. No pneumothorax is present. An ET tube
terminates with its tip 3 cm above the carina. Multiple clips
are noted in the right upper quadrant of the abdomen.
IMPRESSION:
Possible small left effusion and left basilar mild atelectasis.
ET tube is appropriate.
.
.


Brief Hospital Course:
77 yo F with asthma, HTN, and recurrent episodes of
diverticulitis who presented to OSH with tongue swelling and
despite steroids, histaime blockade, and epi, requried
intubation for airway protections gien worsening angioedema.

# Angioedema: DDx - allergic reaction to shellfish vs ACEi.
ACEi-associated angioedema can happen any time while on the
medication. However, timing is suspicious for allergic etiology.
Pt does appear to have atopic tendencies given asthma and
multiple medication allergies. Lisinopril was added to her
allergy list, and she was told to avoid shellfish. She was
intubated in the ED secondary to severe angioedema. He was
started on 80mg q8 x 24H. She received Benadryl 25mg Q6H, for
the first 24 hours, then had it stopped. Morning after her
admission, her tongue swelling resolved and she was extubated
successfully, started on PO prednisone taper. Patient satting
well on RA and eating a regular diet. She will need follow-up
with allergy to flesh out her reaction, but likely to ace
inhibitors given that shellfish didn't give her trouble in past
and that rxn happened the next morning after a dinner meal.
Also, if her angioedema was secondary to a mast-cell mediated
anaphylactic reaction, we would have expected her to respond to
epinephrine, which she did not.

# asthma: Pt did not require intubation for any intrinsic
pulmonary process. Prior to transfer to the floor she was
satting well on room air. Continue her inhalers with budesonide.

# HTN: Pt was hypotensive in the setting of propofol. H/H in ED
looked hemoconcentrated, improved after 1L NS in ED. Pressures
120s-130s in the unit, but she had low UOP overnight and was
given 2L NS. Her HCTZ was held initially.

# GERD: Pantoprazole IV while intubated. Changed to PO after
extubation.

# s/p ERCP: Held cholestyramine while NPO.

# Cataracts: Her son brought her eye drops in and she used her
own medications while in house.
.
.
Pending Tests: none.
.
.
Transitional Issues:
Patient will have follow up appt with allergist/pcp. [**Name10 (NameIs) **] stop
ace inhibitors indefintiely.

Medications on Admission:
Protonix 40mg daily
HCTZ 25mg daily
budesonide 1 puff [**Hospital1 **]
KCl 20 meq daily
w-3 fatty acids 1200mg daily
MVI
cholystyramine 4g daily
albuterol q4 PRN
flonase 1 spray [**Hospital1 **]
fluocinonide 0.05% 4 drops OU daily PRN
oloatadine 0.1% 1 drop OU [**Hospital1 **]
vitamin D


Discharge Medications:
1. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
2. prednisone 10 mg Tablet Sig: Two (2) Tablet PO ONCE (Once)
for 1 doses: Please take 2 pills for a total of 20 mg tomorrow,
[**2195-9-8**].
Disp:*2 Tablet(s)* Refills:*0*
3. prednisone 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: please take 1 pill for a total of 5mg on [**2195-9-10**]. then
stop all prednisone.
Disp:*1 Tablet(s)* Refills:*0*
4. prednisone 10 mg Tablet Sig: One (1) Tablet PO once for 1
doses: Please take one pill on [**2195-9-9**] for a total of 10mg.
Disp:*1 Tablet(s)* Refills:*0*
5. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
DAILY (Daily).
6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
8. olopatadine 0.1 % Drops Sig: One (1) drop Ophthalmic [**Hospital1 **] (2
times a day): to both eyes.
9. fluocinolone-shower cap 0.01 % Oil Sig: One (1) drops Topical
four times a day: to both eyes.
10. Vitamin D  Oral
11. KCl  Sig: Twenty (20) meq  once a day.
12. w-3 fatty acids 1200mg daily  Sig: One (1) pill  once a day.

13. M-Vit  Oral
14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
15. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal twice a day.
16. epinephrine 1 mg/mL (1:1,000) (1mL) Solution Sig: One (1)
injection Injection prn as needed for anaphylaxis: Use Epi Pen
if feeling throat, tongue swelling, shortness of breath. Please
call 911 after administering this drug.
Disp:*1 pen* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Angioedema, likely [**2-25**] to ace inhibitor


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 at the [**Hospital1 771**]. You presented to the hospital with an
allergic reaction, tongue and throat swelling, and was admitted
to the hospital. While you were here, we provided you with
supportive care, which included intubating you to help you
breathe. Once you were stable, the breathing tube was removed
and you have been stable since.

At this time, we believe the reaction is to your lisinopril, an
ACE inhibitor. Please throw the rest of these medications away
and don't take them again until further notice.

The following changes have been made to your medications:
--Stop lisinopril
--Stop budesonide 1 puff [**Hospital1 **]

--START fluticasone inhaler 2 puffs [**Hospital1 **] to replace your
budesonide inhaler.

--START prednisone by mouth (a steroid that we started you on
here, treats severe allergic reactions). We are tapering you off
of them. Tomorrow, on [**9-8**], you will need to take 20mg by mouth.
On [**9-9**], take 10mg, and on [**9-10**], take 5mg. Then stop.

Please continue to take all of your other medications as
previously prescribed.

Followup Instructions:
You have the following appointments:

Name: PA [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16542**]
Location: [**Location (un) **] PHYSICIANS
Address: 100 [**Last Name (un) **] WAY, [**Location (un) 10068**],[**Numeric Identifier 10069**]
Phone: [**Telephone/Fax (1) 49260**]
Appointment: Friday [**2195-9-11**] 11:00am
*This is a follow up appointment of your hospitalization. You
will be reconnected with your primary care physician after this
visit.

Department: DIV OF ALLERGY AND INFLAM
When: THURSDAY [**2195-9-17**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) 71988**], MD [**Telephone/Fax (1) 9316**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) 895**]
Campus: OFF CAMPUS     Best Parking: Parking on Site
**You have also been placed on a waitlist for this appointment.
The office will call you at home if a sooner appointment becomes
available.
{'Angioneurotic edema, not elsewhere classified,Acute respiratory failure,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Accidents occurring in other specified places,Esophageal reflux,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Other iatrogenic hypotension'}


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: tongue swelling

PRESENT ILLNESS: Ms. [**Known lastname 4886**] is a 77yoF with multiple medical problems including
HTN who was started on lisinopril approximately 6m ago who
presented to OSH with right facial swelling that started at 5am.
At the OSH, she was given Benadryl, solumedrol, and Pepcid. This
helped somewhat initially, but then left and tongue swelling
developed. He was transfered to the [**Hospital1 18**] ED. Initial ED vitals:
T 98.8, HR 58, BP 138/84, RR 18, 95% RA. In the [**Hospital1 18**] ED,
initially she got epinephrine, but was ultimately intubated to
protect airway after trying some epi.  She had some hypotension
on propofol, and so sedation was switched to vent/Versed.

MEDICAL HISTORY: G6PD deficiency
ERCP [**2191**]
HTN
diverticulitis (multiple hospitalizations per son)
GERD
asthma (well-controlled as of late per son)
hernia
Cataract
colon polyps
arthrits

MEDICATION ON ADMISSION: Protonix 40mg daily
HCTZ 25mg daily
budesonide 1 puff [**Hospital1 **]
KCl 20 meq daily
w-3 fatty acids 1200mg daily
MVI
cholystyramine 4g daily
albuterol q4 PRN
flonase 1 spray [**Hospital1 **]
fluocinonide 0.05% 4 drops OU daily PRN
oloatadine 0.1% 1 drop OU [**Hospital1 **]
vitamin D

ALLERGIES: NSAIDS / Flagyl / diltiazem / triazolam / Ciprofloxacin /
lisinopril / aspirin

PHYSICAL EXAM: Admission Physical Exam:
General: Intubated, sedated, responds to voice and follows sipme
commands
HEENT: Sclera anicteric, PERRL, tongue and neck swelling
Neck: edematous
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: hypoactive, BS, soft, non-tender, non-distended
Ext: warm, well perfused, no clubbing, cyanosis or edema
.
.
Physical Exam at Discharge:
Vitals: T: 98.0F   BP: 140/77   P: 74   R: 18   O2: 97%/RA
General: Alert and interactive with family conversations, NAD
HEENT: Sclera anicteric, PERRL, MMM , tongue with no edema
Neck: no longer edematous, no LAD, no JVD, supple
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: hypoactive, BS, soft, non-tender, non-distended
Ext: warm, well perfused, no clubbing, cyanosis or edema

FAMILY HISTORY: G6PD deficiency

SOCIAL HISTORY: - Tobacco: former
- Alcohol: none
- Illicits: none
Lives alone, retired. Son is HCP. 

### Response:
{'Angioneurotic edema, not elsewhere classified,Acute respiratory failure,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Accidents occurring in other specified places,Esophageal reflux,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Other iatrogenic hypotension'}
