CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: Mr. [**Known lastname **] is a 72 year old male with history of mental
retardation, [**Known lastname **] (see below), who presented to [**Hospital1 18**] from his
adult day care center yesterday after having increasing dyspnea
and wheezing despite increased nebulizer use. Patient also noted
to have non-productive cough, no other URI symptoms. No
headache, myalgias, no known fevers at home. No known sick
contacts, but attends day program.
.
In ER, patient was uable to perform peak flow, and was given
continuous nebs, then peak flow=120. Was also febrile to T101.2
and tahcycardiac to 120-130's. O2 sats were in the 90's on nebs.
He was given heliox, Combivent, Solumedrol 125 mg, magnesium,
Ceftriaxone and Azithromycin. He was admitted to the [**Hospital Unit Name 153**]. He
was continued on continuous nebs overnight, and was started on
high dose steroids and an inhaled steroid as well. Antibiotics
were not felt to be warranted at this time. Patient was also
ruled out for flu.
.
Patient currently is c/o increased cough, non productive. Feels
that breathing has improved since admission, but is not at
baseline. Denies F/C/N/V, no chest pain or pleuritic pain. Per
family, patient has been using nebulizers at the day program up
to 3 times per day whether he needs them or not. Feel that
patient has been worse ever since going out in the cold Friday
night, ? trigger. Family also concerned b/c they feel patient
has lost significant amount of weight over this past year.

MEDICAL HISTORY: MR, estimated IQ 60-> HCP is nephew's wife [**Name (NI) **], who helps him
make medical decisions.
[**Name (NI) **] - several hospitalizations (3 this past year), on
multiple home meds, usually needing nebs Tid, no known
intubations. FEV1 72% predicted with a response of 20% to nebs
in 3/[**2189**].
GERD/PUD
BPH, s/p TURP
DJD
History of nasal polyps. No known asprin allergy.
Depression w/ psych features
Iron deficiency anemia
Hypercholesterolemia

MEDICATION ON ADMISSION: Albuterol nebs, Serevent, Flovent, Singulair, Prednisone,
Wellbutrin, Caralfate, Protonix, Lactulose, Niferex, Flocon

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GEN: NAD, lying in bed, awake, alert. Thin, with temporal
wasting and interosseus muscles
HEENT: no conjunctival injection, no scleral icterus, poor
dentition
NECK: no JVD, no lymphadenopathy
CHEST: no accessory muscle use, diffuse expiratory wheezes B/L,
no crackles, no conversational dyspnea
HEART: RRR, S1/S2 normal, no murmur
ABD: +BS, soft, NT/ND, no organomegaly
SKIN: diaphoretic, some excoriations and eczema on LE
EXT: multiple excoriated and eczematous areas on both lower
extremities. trace edema B/L. No clubbing, full DP pulses B/L
NEURO: CN II-XII intact no focal deficits, AAO x 3, appropriate
affect

FAMILY HISTORY: N/A

SOCIAL HISTORY: Lives with 73 year old brother and [**Name2 (NI) 802**]. Nonsmoker, no alcohol
use.
Obstructive chronic bronchitis with (acute) exacerbation,Pulmonary collapse,Esophageal reflux,Pure hypercholesterolemia,Depressive disorder, not elsewhere classified,Unspecified intellectual disabilities
Obs chr bronc w(ac) exac,Pulmonary collapse,Esophageal reflux,Pure hypercholesterolem,Depressive disorder NEC,Intellect disability NOS
Admission Date:  [**2192-1-17**]              Discharge Date:   [**2192-1-23**]

Date of Birth:  [**2120-1-7**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Mr. [**Known lastname **] is a 72 year old male with history of mental
retardation, [**Known lastname **] (see below), who presented to [**Hospital1 18**] from his
adult day care center yesterday after having increasing dyspnea
and wheezing despite increased nebulizer use. Patient also noted
to have non-productive cough, no other URI symptoms. No
headache, myalgias, no known fevers at home. No known sick
contacts, but attends day program.
.
In ER, patient was uable to perform peak flow, and was given
continuous nebs, then peak flow=120. Was also febrile to T101.2
and tahcycardiac to 120-130's. O2 sats were in the 90's on nebs.
He was given heliox, Combivent, Solumedrol 125 mg, magnesium,
Ceftriaxone and Azithromycin. He was admitted to the [**Hospital Unit Name 153**]. He
was continued on continuous nebs overnight, and was started on
high dose steroids and an inhaled steroid as well. Antibiotics
were not felt to be warranted at this time. Patient was also
ruled out for flu.
.
Patient currently is c/o increased cough, non productive. Feels
that breathing has improved since admission, but is not at
baseline. Denies F/C/N/V, no chest pain or pleuritic pain. Per
family, patient has been using nebulizers at the day program up
to 3 times per day whether he needs them or not. Feel that
patient has been worse ever since going out in the cold Friday
night, ? trigger. Family also concerned b/c they feel patient
has lost significant amount of weight over this past year.


Past Medical History:
MR, estimated IQ 60-> HCP is nephew's wife [**Name (NI) **], who helps him
make medical decisions.
[**Name (NI) **] - several hospitalizations (3 this past year), on
multiple home meds, usually needing nebs Tid, no known
intubations. FEV1 72% predicted with a response of 20% to nebs
in 3/[**2189**].
GERD/PUD
BPH, s/p TURP
DJD
History of nasal polyps. No known asprin allergy.
Depression w/ psych features
Iron deficiency anemia
Hypercholesterolemia


Social History:
Lives with 73 year old brother and [**Name2 (NI) 802**]. Nonsmoker, no alcohol
use.


Family History:
N/A

Physical Exam:
GEN: NAD, lying in bed, awake, alert. Thin, with temporal
wasting and interosseus muscles
HEENT: no conjunctival injection, no scleral icterus, poor
dentition
NECK: no JVD, no lymphadenopathy
CHEST: no accessory muscle use, diffuse expiratory wheezes B/L,
no crackles, no conversational dyspnea
HEART: RRR, S1/S2 normal, no murmur
ABD: +BS, soft, NT/ND, no organomegaly
SKIN: diaphoretic, some excoriations and eczema on LE
EXT: multiple excoriated and eczematous areas on both lower
extremities. trace edema B/L. No clubbing, full DP pulses B/L
NEURO: CN II-XII intact no focal deficits, AAO x 3, appropriate
affect


Pertinent Results:
admission CXR: increased right pulmonary artery and opacity of
the left lung vascularity - findings which may represent
pulmonary emboli.
No evidence of congestive heart failure or pleural effusion.
.
CTA OF THE CHEST: The heart, pericardium, and great vessels
appear unremarkable. Note is made of coronary artery
calcifications. No filling defects are identified within the
central or segmental pulmonary arteries to suggest embolism.
There is no axillary, mediastinal, or hilar lymphadenopathy.
There is complete collapse of the right middle lobe and total
opacification of the right middle lobe bronchus. The remaining
lung demonstrates stable scarring at the apices bilaterally. No
lung nodules or masses are identified. There is thickening of
the bronchial walls, most notably in the lower lobes
bilaterally, which appears slightly worse than on the prior CT
from [**2189**].
The osseous structures demonstrate degenerative changes of the
spine.
IMPRESSION:
1. Complete right middle lobe collapse. Bronchoscopy is
suggested to evaluate for obstructing endoluminal lesion.
2. Thickening of the bronchial walls, most notably in the lower
lobe is slightly worse since [**2189**] and is consistent with chronic
airway inflammation.
3. No evidence of central or segmental pulmonary emboli.
.
Compared to the film from the prior day, there has been no
significant interval change. The cardiac and mediastinal
silhouette is normal. The pulmonary vasculature is normal. The
right middle lobe collapse is better visualized on the lateral
view. Again seen is blunting of the right costophrenic angle.
IMPRESSION: No significant change in right middle lobe collapse.
.
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2192-1-17**]):
      Negative for Influenza A viral antigen.

   DIRECT INFLUENZA B ANTIGEN TEST (Final [**2192-1-17**]):
      NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.

[**2192-1-17**] 10:47AM BLOOD WBC-8.9 RBC-5.54 Hgb-16.3 Hct-46.0 MCV-83
MCH-29.5 MCHC-35.5* RDW-14.0 Plt Ct-195
[**2192-1-22**] 06:55AM BLOOD WBC-6.7 RBC-5.18 Hgb-15.2 Hct-45.3 MCV-87
MCH-29.3 MCHC-33.5 RDW-14.3 Plt Ct-209
[**2192-1-17**] 10:47AM BLOOD Neuts-70.7* Lymphs-14.9* Monos-3.7
Eos-9.5* Baso-1.1
[**2192-1-22**] 06:55AM BLOOD Neuts-69.2 Lymphs-22.8 Monos-6.7 Eos-1.0
Baso-0.2
[**2192-1-19**] 10:56AM BLOOD Type-ART pO2-108* pCO2-40 pH-7.39
calHCO3-25 Base XS-0
[**2192-1-18**] 11:30AM BLOOD Lactate-2.6*
[**2192-1-19**] 10:56AM BLOOD Lactate-2.1*

Brief Hospital Course:
72 yo with h/o MR [**First Name (Titles) **] [**Last Name (Titles) **] transferred from [**Hospital Unit Name 153**] after
presenting with signs and symptoms suggestive of mild to
moderate [**Hospital Unit Name **] exacerbation.  While in the [**Hospital Unit Name 153**], the patient
improved with 24 hours of continuous nebulizers and IV steroid.
No intubation was required, no antibiotics were started.  His
hospital course is discussed by problem.
.
# [**Hospital Unit Name **]: The exact trigger for his exacerbation was unclear,
possibly cold exposure w/ viral infection vs. poor medication
compliance with control meds, as patient had not been taking his
inhaled steroid on a regular basis, but rather relying solely on
nebulizers multiple times throughout the day (administered at
the group home).  He was ruled out for influenza, and although
her was febrile initially, he remained afebrile for the
remainder of his hospitalization.  He was continued on high dose
oral steroids with a slow taper.  His PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6431**], was
[**Name (NI) 653**], and explained the patient was supposed to be on 10mg
of prednisone daily.  He was provided with standing albuterol
and Atrovent nebulizers.  Although his oxygen saturation
remained stable, the patient persistently complained of
difficulty breathing on a daily basis.  A chest CTA was done
given the findings of the initial CXR, and although PE was ruled
out, the patient was found to have a RML collapse from most
likely a mucous plug.  The patient was provided with a flutter
valve, expectorants, fluid hydration, and chest PT to help clear
the plug.  The pulmonary service was [**Name (NI) 653**] and felt that
bronchoscopy would be unnecessary given his hemodynamic
stability, and to increased his inhaled steroid in addition to
the afore mentioned measures.  The patient's lung exam continued
to improve despite no interval change by CXR.  The patient was
eventually weaned off oxygen and remained stable at rest and
with ambulation.  It was suspected that his complaints of
dyspnea may have been associated with anxiety as well, as the
patient appeared quite comfortable when watched from afar, but
appeared anxious while being interviewed/ examined.  On the day
of discharge, the pulm service suggested pursuing a
bronchoscopy, but it was felt that this may cause the patient
more harm than benefit at this time given the stability of his
oxygen requirements and his improvement on exam and by symptoms.
 The patient was scheduled with an earlier appointment to see
his PCP within two weeks of discharge, and will need a follow-up
CXR at that time to assess if he has cleared the plug.  In
addition, his [**Name (NI) 802**] was instructed to return to the hospital if
he developed a fever or new cough to be evaluated for pneumonia.

.
# GERD: He was continued on Protonix, and it was thought that
this may be a possible cause of exacerbation as well.
.
# Depression: His affect appeared stable, and more anxious than
depressed.  His psychiatrist, Dr. [**Last Name (STitle) **] was [**Last Name (STitle) 653**] and it
was recommended that Remeron be started as an inpatient in
addition to his Wellbutrin and Zyprexa.  Dr. [**Last Name (STitle) **] also
explained that the patient had a significant component of
psychomotor agitation, which may explain his appearing anxious
during exam.  He has an appointment to see Dr. [**Last Name (STitle) **] within
one week of discharge.
.
# Eczema on bilateral lower legs: He was provided Hydrocerin to
increase moisturization.
.
Although the family noted the patient had weight loss over the
past year, he had underwent a abdominal CT in the past without
significant findings.  The chest CT done here did not suggest
any significant LAD or suspicious lesions.  The patient's
albumin was within normal limits which suggested adequate
nourishment.  The patient was discharged home with a
prescription for a steroid taper, and will see Dr. [**Last Name (STitle) 6431**] within
two weeks.

Medications on Admission:
Albuterol nebs, Serevent, Flovent, Singulair, Prednisone,
Wellbutrin, Caralfate, Protonix, Lactulose, Niferex, Flocon

Discharge Medications:
1. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for depression.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for hypercholesterolemia.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) as
needed for GERD/PUD.
4. White Petrolatum-Mineral Oil     Cream Sig: One (1) Appl
Topical  TID (3 times a day) as needed for dry skin.
Disp:*qs * Refills:*0*
5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
6. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*0*
8. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
9. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day
for 3 days: Please take 4 tablets for the next three days.  On
[**2192-1-27**], take three tablets a day for four days.  On [**2192-1-31**]
take two tablets a day for three days, and on [**2-3**] start taking
one tablet a day everyday until you see Dr. [**Last Name (STitle) 6431**].
Disp:*50 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary: [**Last Name (STitle) **] exacerbation
.
Secondary: GERD, hypercholesterolemia, depression


Discharge Condition:
Good- patient weaned off oxygen, hemodynamically stable


Discharge Instructions:
Please continue to take the steroids as instructed over the next
few days.  We have increased your dose of fluticasone/salmeterol
inhaler.  We have also started a new medication to help with
your anxiety, Remeron, at the advice of Dr. [**Last Name (STitle) **], your
psychiatrist.
.
Please call your doctor if you develop fever, chills, chest
pain, or severe difficulty breathing

Followup Instructions:
Provider: [**Name10 (NameIs) 9611**],[**Name11 (NameIs) **] PSYCHIATRY OPD Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2192-1-24**] 10:00
Provider: [**Name10 (NameIs) 9611**],[**Name11 (NameIs) **] PSYCHIATRY OPD Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2192-1-31**] 10:00
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 9612**] MEDICINE (PRIVATE)
Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2192-2-6**] 10:20
{'Obstructive chronic bronchitis with (acute) exacerbation,Pulmonary collapse,Esophageal reflux,Pure hypercholesterolemia,Depressive disorder, not elsewhere classified,Unspecified intellectual disabilities'}


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: Mr. [**Known lastname **] is a 72 year old male with history of mental
retardation, [**Known lastname **] (see below), who presented to [**Hospital1 18**] from his
adult day care center yesterday after having increasing dyspnea
and wheezing despite increased nebulizer use. Patient also noted
to have non-productive cough, no other URI symptoms. No
headache, myalgias, no known fevers at home. No known sick
contacts, but attends day program.
.
In ER, patient was uable to perform peak flow, and was given
continuous nebs, then peak flow=120. Was also febrile to T101.2
and tahcycardiac to 120-130's. O2 sats were in the 90's on nebs.
He was given heliox, Combivent, Solumedrol 125 mg, magnesium,
Ceftriaxone and Azithromycin. He was admitted to the [**Hospital Unit Name 153**]. He
was continued on continuous nebs overnight, and was started on
high dose steroids and an inhaled steroid as well. Antibiotics
were not felt to be warranted at this time. Patient was also
ruled out for flu.
.
Patient currently is c/o increased cough, non productive. Feels
that breathing has improved since admission, but is not at
baseline. Denies F/C/N/V, no chest pain or pleuritic pain. Per
family, patient has been using nebulizers at the day program up
to 3 times per day whether he needs them or not. Feel that
patient has been worse ever since going out in the cold Friday
night, ? trigger. Family also concerned b/c they feel patient
has lost significant amount of weight over this past year.

MEDICAL HISTORY: MR, estimated IQ 60-> HCP is nephew's wife [**Name (NI) **], who helps him
make medical decisions.
[**Name (NI) **] - several hospitalizations (3 this past year), on
multiple home meds, usually needing nebs Tid, no known
intubations. FEV1 72% predicted with a response of 20% to nebs
in 3/[**2189**].
GERD/PUD
BPH, s/p TURP
DJD
History of nasal polyps. No known asprin allergy.
Depression w/ psych features
Iron deficiency anemia
Hypercholesterolemia

MEDICATION ON ADMISSION: Albuterol nebs, Serevent, Flovent, Singulair, Prednisone,
Wellbutrin, Caralfate, Protonix, Lactulose, Niferex, Flocon

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: GEN: NAD, lying in bed, awake, alert. Thin, with temporal
wasting and interosseus muscles
HEENT: no conjunctival injection, no scleral icterus, poor
dentition
NECK: no JVD, no lymphadenopathy
CHEST: no accessory muscle use, diffuse expiratory wheezes B/L,
no crackles, no conversational dyspnea
HEART: RRR, S1/S2 normal, no murmur
ABD: +BS, soft, NT/ND, no organomegaly
SKIN: diaphoretic, some excoriations and eczema on LE
EXT: multiple excoriated and eczematous areas on both lower
extremities. trace edema B/L. No clubbing, full DP pulses B/L
NEURO: CN II-XII intact no focal deficits, AAO x 3, appropriate
affect

FAMILY HISTORY: N/A

SOCIAL HISTORY: Lives with 73 year old brother and [**Name2 (NI) 802**]. Nonsmoker, no alcohol
use. 

### Response:
{'Obstructive chronic bronchitis with (acute) exacerbation,Pulmonary collapse,Esophageal reflux,Pure hypercholesterolemia,Depressive disorder, not elsewhere classified,Unspecified intellectual disabilities'}
