CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: 62 yo F with with a history of Stage III COPD (FEV1 27%) on
steroids and 3L oxygen, systolic CHF s/p ICD and ppm placement,
HTN, p/w shortness of breath to [**Hospital1 18**] on [**4-22**]. Please see
initial admit note for full history. She is transferred to the
ICU at this time for hypercarbia and increased work of
breathing. She was recently admitted on [**3-21**] for COPD
exacerbation for which she was treated with duonebs nebs, IV
steroids and required BiPAP and admission to the MICU. She was
discharged to rehab on a 2 week prednisone taper and instructed
to f/u with pulmonology and her PCP. [**Name10 (NameIs) **] her recent discharge
she has been able to titrate down her supplemental oxygen from
3L/min to 0.5 - 1 L/min.
.
On [**4-22**] she presented with increased shortness of breath and
lightheadedness with exertion since this morning. Patient stated
symptoms "feels like a normal COPD exacerbation". She also
complains of a productive cough that started that day, but
denied hematemesis, fevers, chills, n/v, chest pain, abdominal
pain, or leg swelling. She denies any known sick contacts but
has been residing in a rehab center since her discharge last
month. She reports she is up to date on her flu and pneumococcal
vaccines. She does admit to dietary indiscretions with increased
salt intake.
.
In ED VS were T 97.1 HR 110 BP 135/75 RR 20 SpO2 100%. She was
noted to have crackles at left lung base, but no acute process
on CXR. She had significant leukocytosis WBC 17.9. Troponin was
at baseline 0.02 and EKG showed sinus tach 108, LAD, NI, +TWI
V5-V6, <1mm V5-V6 (new from last admission). She recieved nebs
x2, levofloxacin 750 mg IV and solu-medrol 125 mg IV prior to
transfer to the medicine floor for presumed COPD exacerbation.
.
On the floor she was transitioned to oral prednisone 60 mg
daily, and treated with azithromycin and standing nebs. She was
continue on home diuretics and betablockers, with the assessment
that CHF was partially contributing the patients dyspnea, given
elevated BNP and crackles on exam.
.
At 1:30 pm today, patient felt sudden onset of worsening dyspnea
without chest pain. Patient was noted to have increased work of
breathing, with the use of ascessory muscles. She was saturating
94% on 2L but ABG showed CO2 of 60. She was given solumedrol,
nebs and lasix 80 mg IV x1, and morphine 2 mg IV.

MEDICAL HISTORY: 1) COPD on 3L home O2 with multiple hospitalizations; multiple
intubations
- FEV1 27% in [**12/2171**]
2) Systolic CHF with dual chamber pacemaker and AICD
-placed [**12/2171**]
-dilated cardiomyopathy with EF = 20-25% on TTE [**2183-3-17**]
3) TB - treated in [**2168**], had RUL wedge resection
4) paroxysmal afib
5) GERD
6) Anxiety
7) HL
8) OA
9) GI bleed [**3-12**] duodenal/gastric ulcer
10) Osteoporosis
11) Vtach s/p ICD
12) DM - type 2 in setting of high dose steroids
13) HTN
14) Macrocytic anemia
15) Chronic leukocytosis
16) s/p myomectomy in [**2166**]
17) s/p C-section
18) neuropathy of bilateral hands
19) facial burns related to fire while using supplemental oxygen

MEDICATION ON ADMISSION: 1. Calcium carbonate 500 mg po bid
2. Multivitamin po daily
3. Ferrous sulfate 325 mg po daily
4. Omeprazole 40 mg po bid
5. Docusate sodium 100 mg po bid prn
6. Senna 8.6 mg po bid prn constipation
8. Torsemide 20 mg po bid
9. Acetaminophen 1 g po tid prn pain
10. Lorazepam 0.5 mg q6h prn anxiety/pain (has not received
recently)
11. KCl 20 meq po daily
12. Vitamin D3 400 mg po daily
13. Fluticasone-salmeterol 500-50 mcg/dose inh [**Hospital1 **]
15. Bactrim DS po QMonWedFri
16. Prednisone 25 mg po daily
17. Oxycodone 5 mg po q4h prn pain
19. Metoprolol 100 mg ER daily
20. Albuterol neb q4h prn
21. Spiriva with HandiHaler 18 mcg daily
22. Cetirizine 10 mg daily

ALLERGIES: Captopril / Aspirin / Tetracycline / Erythromycin Base /
Penicillins / Motrin / Wellbutrin

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: T: 97.9 BP: 107/80 P: 100 R: 20 O2: 96% 2L
General: Alert, interactive
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Quiet BS, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, mild clubbing, no cyanosis
or edema

FAMILY HISTORY: HTN, Dementia

SOCIAL HISTORY: Retired LPN at [**Hospital3 **], LT care, substance abuse
facility. Before moving to [**Hospital3 **], lived at home with
daughter [**Name (NI) 97832**]. Ambulates with a walker. Occasionally needs
help with dressing, feeding. She has significant tobacco history
of 60 pack-years, and reports quiting after recent burn. History
of heavy EtOH, none since [**5-18**]. She denies use of illicit drugs.
Acute on chronic combined systolic and diastolic heart failure,Acute and chronic respiratory failure,Alkalosis,Other primary cardiomyopathies,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Leukocytosis, unspecified,Mononeuritis of upper limb, unspecified,Cachexia,Obstructive chronic bronchitis with (acute) exacerbation,Body Mass Index less than 19, adult,Anxiety state, unspecified,Mitral valve disorders,Esophageal reflux,Anemia of other chronic disease,Unspecified essential hypertension,Osteoporosis, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Other and unspecified hyperlipidemia,Other constipation,Cardiac pacemaker in situ,Long-term (current) use of steroids,Other dependence on machines, supplemental oxygen,Personal history of tuberculosis,Personal history of tobacco use,Encounter for palliative care,Other diuretics causing adverse effects in therapeutic use,Other iatrogenic hypotension
Ac/chr syst/dia hrt fail,Acute & chronc resp fail,Alkalosis,Prim cardiomyopathy NEC,DMII wo cmp nt st uncntr,Atrial fibrillation,Leukocytosis NOS,Mononeuritis arm NOS,Cachexia,Obs chr bronc w(ac) exac,BMI less than 19,adult,Anxiety state NOS,Mitral valve disorder,Esophageal reflux,Anemia-other chronic dis,Hypertension NOS,Osteoporosis NOS,Osteoarthros NOS-unspec,Hyperlipidemia NEC/NOS,Constipation NEC,Status cardiac pacemaker,Long-term use steroids,Depend-supplement oxygen,Prsnl hst tuberculosis,History of tobacco use,Encountr palliative care,Adv eff diuretics NEC,Iatrogenc hypotnsion NEC
Admission Date:  [**2183-4-22**]              Discharge Date:   [**2183-5-2**]

Date of Birth:  [**2120-12-7**]             Sex:   F

Service: MEDICINE

Allergies:
Captopril / Aspirin / Tetracycline / Erythromycin Base /
Penicillins / Motrin / Wellbutrin

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
None

History of Present Illness:
62 yo F with with a history of Stage III COPD (FEV1 27%) on
steroids and 3L oxygen, systolic CHF s/p ICD and ppm placement,
HTN, p/w shortness of breath to [**Hospital1 18**] on [**4-22**]. Please see
initial admit note for full history. She is transferred to the
ICU at this time for hypercarbia and increased work of
breathing. She was recently admitted on [**3-21**] for COPD
exacerbation for which she was treated with duonebs nebs, IV
steroids and required BiPAP and admission to the MICU. She was
discharged to rehab on a 2 week prednisone taper and instructed
to f/u with pulmonology and her PCP. [**Name10 (NameIs) **] her recent discharge
she has been able to titrate down her supplemental oxygen from
3L/min to 0.5 - 1 L/min.
.
On [**4-22**] she presented with increased shortness of breath and
lightheadedness with exertion since this morning. Patient stated
symptoms "feels like a normal COPD exacerbation". She also
complains of a productive cough that started that day, but
denied hematemesis, fevers, chills, n/v, chest pain, abdominal
pain, or leg swelling. She denies any known sick contacts but
has been residing in a rehab center since her discharge last
month. She reports she is up to date on her flu and pneumococcal
vaccines. She does admit to dietary indiscretions with increased
salt intake.
.
In ED VS were T 97.1 HR 110 BP 135/75 RR 20 SpO2 100%. She was
noted to have crackles at left lung base, but no acute process
on CXR. She had significant leukocytosis WBC 17.9. Troponin was
at baseline 0.02 and EKG showed sinus tach 108, LAD, NI, +TWI
V5-V6, <1mm V5-V6 (new from last admission). She recieved nebs
x2, levofloxacin 750 mg IV and solu-medrol 125 mg IV prior to
transfer to the medicine floor for presumed COPD exacerbation.
.
On the floor she was transitioned to oral prednisone 60 mg
daily, and treated with azithromycin and standing nebs. She was
continue on home diuretics and betablockers, with the assessment
that CHF was partially contributing the patients dyspnea, given
elevated BNP and crackles on exam.
.
At 1:30 pm today, patient felt sudden onset of worsening dyspnea
without chest pain. Patient was noted to have increased work of
breathing, with the use of ascessory muscles. She was saturating
94% on 2L but ABG showed CO2 of 60. She was given solumedrol,
nebs and lasix 80 mg IV x1, and morphine 2 mg IV.

Past Medical History:
1) COPD on 3L home O2 with multiple hospitalizations; multiple
intubations
- FEV1 27% in [**12/2171**]
2) Systolic CHF with dual chamber pacemaker and AICD
-placed [**12/2171**]
-dilated cardiomyopathy with EF = 20-25% on TTE [**2183-3-17**]
3) TB - treated in [**2168**], had RUL wedge resection
4) paroxysmal afib
5) GERD
6) Anxiety
7) HL
8) OA
9) GI bleed [**3-12**] duodenal/gastric ulcer
10) Osteoporosis
11) Vtach s/p ICD
12) DM - type 2 in setting of high dose steroids
13) HTN
14) Macrocytic anemia
15) Chronic leukocytosis
16) s/p myomectomy in [**2166**]
17) s/p C-section
18) neuropathy of bilateral hands
19) facial burns related to fire while using supplemental oxygen

Social History:
Retired LPN at [**Hospital3 **], LT care, substance abuse
facility. Before moving to [**Hospital3 **], lived at home with
daughter [**Name (NI) 97832**]. Ambulates with a walker. Occasionally needs
help with dressing, feeding. She has significant tobacco history
of 60 pack-years, and reports quiting after recent burn. History
of heavy EtOH, none since [**5-18**]. She denies use of illicit drugs.



Family History:
HTN, Dementia


Physical Exam:
ADMISSION EXAM:
Vitals: T: 97.9 BP: 107/80 P: 100 R: 20 O2: 96% 2L
General: Alert, interactive
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Quiet BS, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, mild clubbing, no cyanosis
or edema


Pertinent Results:
ADMISSION LABS:
[**2183-4-22**] 04:42PM BLOOD WBC-17.9*# RBC-3.39* Hgb-10.2* Hct-32.8*
MCV-97 MCH-30.0 MCHC-31.0 RDW-14.4 Plt Ct-361
[**2183-4-22**] 04:42PM BLOOD Neuts-94.5* Lymphs-3.9* Monos-1.1*
Eos-0.3 Baso-0.2
[**2183-4-22**] 04:42PM BLOOD Glucose-172* UreaN-19 Creat-0.7 Na-137
K-4.6 Cl-93* HCO3-35* AnGap-14
.
PERTINENT LABS:
[**2183-4-22**] 04:42PM BLOOD proBNP-4638*
[**2183-4-22**] 04:42PM BLOOD cTropnT-0.02*
[**2183-4-23**] 05:48AM BLOOD CK-MB-5 cTropnT-<0.01
[**2183-4-25**] 02:00PM BLOOD CK-MB-3 cTropnT-0.01
[**2183-4-23**] 05:48AM BLOOD CK(CPK)-60
[**2183-4-25**] 02:00PM BLOOD CK(CPK)-26*
[**2183-4-22**] 04:56PM BLOOD Lactate-2.0
[**2183-4-23**] 02:04PM BLOOD Lactate-2.3*
[**2183-4-23**] 06:16PM BLOOD Lactate-1.4
[**2183-4-25**] 09:40AM BLOOD calTIBC-345 Ferritn-46 TRF-265
[**2183-4-25**] 09:40AM BLOOD Ret Aut-2.4
.
DISCHARGE LABS:
................................................................
MICROBIOLOGY:
[**2183-4-24**] Urine Legionella Ag: negative
[**2183-4-24**] Respiratory Viral Screen/Cx: negative
[**2183-4-25**] MRSA Screen: negative
[**2183-4-26**] Stool: negative for C. diff
................................................................
IMAGING:
[**2183-4-22**] CXR: Minimal bibasilar atelectasis. COPD. No
radiographic evidence for pneumonia or congestive heart failure.

.
[**2183-4-25**] CTA:
1. No pulmonary embolism or acute pathology. No pneumonia or
pulmonary edema. Minimal bibasilar subsegmental atelectasis.
Minimal right pleural effusion.
2. Stable appearance of right upper lobe wedge resection. Severe
emphysema with upper lobe predominance. Similar severe
cardiomegaly.
3. 10 x 8 mm rounded left lower lobe nodule, increased from 7 x
7 mm on [**2183-3-14**]. The apparent growing size in a short
interval favors infectious or inflammatory in etiology, but
neoplasm remains high in the differential given the [**Hospital 228**]
medical history. A three-month followup must be performed per
recommendation from the prior study.
.
[**2183-4-28**] CXR: Previous left lower lobe atelectasis or
consolidation has improved. Lungs are severely emphysematous but
clear of any focal abnormality. There is no vascular engorgement
or appreciable pleural effusion. Heart size is top normal,
improved since the earlier examinations. Transvenous right
atrial pacer and right ventricular pacer defibrillator leads
follow their expected courses. Chain suture suggests prior wedge
resection from the right upper lobe.

Brief Hospital Course:
62 year old woman with with a history of Stage III COPD (FEV1
27%) on steroids and 3L oxygen, systolic CHF s/p ICD and
pacemaker placement, HTN, who p/w shortness of breath and was
transferred to the MICU for hypercarbia and worsening dyspnea.
.
# Hypercarbic respiratory failure: Patient admitted with
dyspnea, initially felt to be secondary to a COPD exacerbation.
She was first admitted to general medicine floor and had been
started on steroids, azithromycin, and nebs. Was transferred to
MICU on [**4-23**] (HD #1) given concern that she was tiring on the
floor and might require BiPAP. Trigger for COPD exacerbation
unclear. Respiratory viral screen negative, urine legionella
antigen negative, and no evidence of pneumonia on CXR or CT.
Patient was continued on steroid taper, azithromycin x5 days,
and albuterol/ipratropium nebs. As patient on long term
steroids, continued Bactrim for PCP [**Name Initial (PRE) **]. Patient trialed briefly
on BiPAP on several occasions in ICU, though did not tolerate
well. Serial ABGs revealed pCO2 in 60s-70s, likely close to
patient's baseline. Was also some concern for systolic CHF
exacerbation contributing to respiratory distress. Patient
endorsed dietary indiscretion and had elevated BNP, though
imaging was not suggestive of significant pulmonary edema. Given
known mod-severe MR [**First Name (Titles) **] [**Last Name (Titles) **] 20-25%, patient was diuresed with
subsequent improvement in dyspnea (see CHF discussion below).
Had CTA chest [**4-25**] which did not demonstrate PE. She was called
out from the MICU on [**2183-4-29**] and maintained O2 saturations on
nasal canula. Her home steroid dose was continued.
.
# Systolic CHF: Ms. [**Known lastname **] has a history of dilated cardiomyopathy
with EF 20-25%, as well as mod-severe MR. CXR without
overwhelming pulmonary edema on transfer to ICU, and she had
minimal hypoxia. She was continued on beta blocker, and diuresed
with lasix IV. Patient had some improvement in dyspnea with
diuresis, suggesting pulmonary edema was likely contributing to
respiratory distress as above. In setting of aggressive
diuresis, patient developed contraction alkalosis. Started on
acetazolamide [**4-26**]. Restarted torsemide [**4-26**], though dose
increased from home dose of 20mg [**Hospital1 **] to 60mg daily, and also
added valsartan for afterload reduction. In setting of adding
[**Last Name (un) **] to regimen, patient developed hypotension to 70s but was
mentating well throughout episode. Holding parameters for
antihypertensive regimen were adjusted, and patient's BP
improved with boluses of NS 250cc x2. The [**Last Name (un) **] was discontinued.
On return to the general medicine floor, the patient was
maintained on home dose of torsemide 20 mg [**Hospital1 **] with a I/O goal
of net 0. A small dose of metoprolol, 6.25mg [**Hospital1 **] was added
[**2183-4-30**] to help with tachycardia. Ms. [**Known lastname **] PCP was [**Name (NI) 653**]
regarding her history of allergy to ACEI. She had angioedema
with captopril in the [**2162**], but has tolerated irbesartan in the
past. We contemplated starting irbasartan at a miniscule dose to
decrease afterload and improve her forward cardiac output in the
setting of severe mitral regurgitation.  However, in the end it
was decided that her hemodynamic status was too fragile to
antihypertensives and since she had been stable for the last
three days on the floor this medication was not started.
.
# Neuropathic pain: Continued tylenol and oxycodone prn pain.
.
# Anemia: HCT was stable in the 30s.
.
# Code Status: Full Code. Per discussion with patient and her
daughter, who is also her HCP, patient has been intubated 5
times and has been extubated successfully.  Therefore, at this
time they would still want her to be intubated if medically
necessary, and daughter would decide when to withdraw care after
a few days if prognosis was poor. Palliative care was consulted
for help with a goals of care discussion after Ms. [**Known lastname **] got back
to the floor. She maintained that she would like to be full code
and continue aggressive medical therapy. She had worked with
[**Hospital 3005**] hospice in the past and graduated from her benefits.
Palliative care moderated the discussion of returning to rehab
or going home with hospice care. It was decided that the patient
would return to rehab and apply for re-enrollment in hospice
with a goal of eventually transitioning to her daughter's home.
.
# Leukocytosis: Patient with chronic leukocytosis (WBC [**11-26**]);
may be related to her steroid use or chronic inflammatory state.
This was montiored and reached a high of 15.9, but no localizing
symptoms or fevers occurred.
.
# Anemia: Given [**Hospital 228**] medical history and normal MCV she
likely has anemia of chronic disease. A daily ferrous sulfate
supplement was continued.
.
#Communication: [**First Name9 (NamePattern2) 97832**] [**Known lastname **] (daughter) [**Telephone/Fax (1) 97834**]


Medications on Admission:
1. Calcium carbonate 500 mg po bid
2. Multivitamin po daily
3. Ferrous sulfate 325 mg po daily
4. Omeprazole 40 mg po bid
5. Docusate sodium 100 mg po bid prn
6. Senna 8.6 mg po bid prn constipation
8. Torsemide 20 mg po bid
9. Acetaminophen 1 g po tid prn pain
10. Lorazepam 0.5 mg q6h prn anxiety/pain (has not received
recently)
11. KCl 20 meq po daily
12. Vitamin D3 400 mg po daily
13. Fluticasone-salmeterol 500-50 mcg/dose inh [**Hospital1 **]
15. Bactrim DS po QMonWedFri
16. Prednisone 25 mg po daily
17. Oxycodone 5 mg po q4h prn pain
19. Metoprolol 100 mg ER daily
20. Albuterol neb q4h prn
21. Spiriva with HandiHaler 18 mcg daily
22. Cetirizine 10 mg daily

Discharge Medications:
1. torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
3. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day.
4. ferrous sulfate 300  mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times a
day as needed for pain.
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety .
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
13. prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation every four (4) hours as
needed for sob, wheezing.
15. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1)  Inhalation once a day.
16. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day.
17. potassium chloride 25 mEq Packet Sig: One (1)  PO once a
day.
18. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO 3 hrs as needed for
pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
COPD exacerbation
CHF


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


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

It was a pleasure taking care of you during your recent
admission for COPD exacerbation.

You were treated with steroids, nebulizer treatments, nasal
oxygen, and azithromycin. Your care required admission to the
ICU. There, you were treated with Bipap and diuretics. On
[**2183-4-29**], you were transferred back to the floor. You
maintained your oxygen saturation with nasal oxygen. Your hand
pain was controlled with home oxycodone. We held your home doses
of metoprolol and hydralazine because you had periods where your
blood pressure was too low.  We then restarted the metoprolol at
a lower dose, 6.25mg [**Hospital1 **].

You need to continue omeprazole, bactrim, calcium and vitamin D
because you take steroids daily.

In summary,
We decreased your metoprolol to 6.25mg [**Hospital1 **].

Followup Instructions:
Please follow-up with your primary care physician. [**Name10 (NameIs) **] should
discuss being referred to a pulmonologist with her.

Name: [**Last Name (LF) **],[**First Name3 (LF) **] N.
Location: [**Hospital1 641**]
Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**]
Phone: [**Telephone/Fax (1) 644**]
****Please discuss with the staff at the facility a follow up
appointment with your PCP in the next 1 to 2 weeks or when you
are ready for discharge****

Name: [**Last Name (LF) 9303**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appt: We are working on an appt for you in the next month.  The
office will call you at home with an appt.  If you dont hear
from them by Monday afternoon, please call them directly with an
appt.
{'Acute on chronic combined systolic and diastolic heart failure,Acute and chronic respiratory failure,Alkalosis,Other primary cardiomyopathies,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Leukocytosis, unspecified,Mononeuritis of upper limb, unspecified,Cachexia,Obstructive chronic bronchitis with (acute) exacerbation,Body Mass Index less than 19, adult,Anxiety state, unspecified,Mitral valve disorders,Esophageal reflux,Anemia of other chronic disease,Unspecified essential hypertension,Osteoporosis, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Other and unspecified hyperlipidemia,Other constipation,Cardiac pacemaker in situ,Long-term (current) use of steroids,Other dependence on machines, supplemental oxygen,Personal history of tuberculosis,Personal history of tobacco use,Encounter for palliative care,Other diuretics causing adverse effects in therapeutic use,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: Dyspnea

PRESENT ILLNESS: 62 yo F with with a history of Stage III COPD (FEV1 27%) on
steroids and 3L oxygen, systolic CHF s/p ICD and ppm placement,
HTN, p/w shortness of breath to [**Hospital1 18**] on [**4-22**]. Please see
initial admit note for full history. She is transferred to the
ICU at this time for hypercarbia and increased work of
breathing. She was recently admitted on [**3-21**] for COPD
exacerbation for which she was treated with duonebs nebs, IV
steroids and required BiPAP and admission to the MICU. She was
discharged to rehab on a 2 week prednisone taper and instructed
to f/u with pulmonology and her PCP. [**Name10 (NameIs) **] her recent discharge
she has been able to titrate down her supplemental oxygen from
3L/min to 0.5 - 1 L/min.
.
On [**4-22**] she presented with increased shortness of breath and
lightheadedness with exertion since this morning. Patient stated
symptoms "feels like a normal COPD exacerbation". She also
complains of a productive cough that started that day, but
denied hematemesis, fevers, chills, n/v, chest pain, abdominal
pain, or leg swelling. She denies any known sick contacts but
has been residing in a rehab center since her discharge last
month. She reports she is up to date on her flu and pneumococcal
vaccines. She does admit to dietary indiscretions with increased
salt intake.
.
In ED VS were T 97.1 HR 110 BP 135/75 RR 20 SpO2 100%. She was
noted to have crackles at left lung base, but no acute process
on CXR. She had significant leukocytosis WBC 17.9. Troponin was
at baseline 0.02 and EKG showed sinus tach 108, LAD, NI, +TWI
V5-V6, <1mm V5-V6 (new from last admission). She recieved nebs
x2, levofloxacin 750 mg IV and solu-medrol 125 mg IV prior to
transfer to the medicine floor for presumed COPD exacerbation.
.
On the floor she was transitioned to oral prednisone 60 mg
daily, and treated with azithromycin and standing nebs. She was
continue on home diuretics and betablockers, with the assessment
that CHF was partially contributing the patients dyspnea, given
elevated BNP and crackles on exam.
.
At 1:30 pm today, patient felt sudden onset of worsening dyspnea
without chest pain. Patient was noted to have increased work of
breathing, with the use of ascessory muscles. She was saturating
94% on 2L but ABG showed CO2 of 60. She was given solumedrol,
nebs and lasix 80 mg IV x1, and morphine 2 mg IV.

MEDICAL HISTORY: 1) COPD on 3L home O2 with multiple hospitalizations; multiple
intubations
- FEV1 27% in [**12/2171**]
2) Systolic CHF with dual chamber pacemaker and AICD
-placed [**12/2171**]
-dilated cardiomyopathy with EF = 20-25% on TTE [**2183-3-17**]
3) TB - treated in [**2168**], had RUL wedge resection
4) paroxysmal afib
5) GERD
6) Anxiety
7) HL
8) OA
9) GI bleed [**3-12**] duodenal/gastric ulcer
10) Osteoporosis
11) Vtach s/p ICD
12) DM - type 2 in setting of high dose steroids
13) HTN
14) Macrocytic anemia
15) Chronic leukocytosis
16) s/p myomectomy in [**2166**]
17) s/p C-section
18) neuropathy of bilateral hands
19) facial burns related to fire while using supplemental oxygen

MEDICATION ON ADMISSION: 1. Calcium carbonate 500 mg po bid
2. Multivitamin po daily
3. Ferrous sulfate 325 mg po daily
4. Omeprazole 40 mg po bid
5. Docusate sodium 100 mg po bid prn
6. Senna 8.6 mg po bid prn constipation
8. Torsemide 20 mg po bid
9. Acetaminophen 1 g po tid prn pain
10. Lorazepam 0.5 mg q6h prn anxiety/pain (has not received
recently)
11. KCl 20 meq po daily
12. Vitamin D3 400 mg po daily
13. Fluticasone-salmeterol 500-50 mcg/dose inh [**Hospital1 **]
15. Bactrim DS po QMonWedFri
16. Prednisone 25 mg po daily
17. Oxycodone 5 mg po q4h prn pain
19. Metoprolol 100 mg ER daily
20. Albuterol neb q4h prn
21. Spiriva with HandiHaler 18 mcg daily
22. Cetirizine 10 mg daily

ALLERGIES: Captopril / Aspirin / Tetracycline / Erythromycin Base /
Penicillins / Motrin / Wellbutrin

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: T: 97.9 BP: 107/80 P: 100 R: 20 O2: 96% 2L
General: Alert, interactive
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Quiet BS, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, mild clubbing, no cyanosis
or edema

FAMILY HISTORY: HTN, Dementia

SOCIAL HISTORY: Retired LPN at [**Hospital3 **], LT care, substance abuse
facility. Before moving to [**Hospital3 **], lived at home with
daughter [**Name (NI) 97832**]. Ambulates with a walker. Occasionally needs
help with dressing, feeding. She has significant tobacco history
of 60 pack-years, and reports quiting after recent burn. History
of heavy EtOH, none since [**5-18**]. She denies use of illicit drugs. 

### Response:
{'Acute on chronic combined systolic and diastolic heart failure,Acute and chronic respiratory failure,Alkalosis,Other primary cardiomyopathies,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Atrial fibrillation,Leukocytosis, unspecified,Mononeuritis of upper limb, unspecified,Cachexia,Obstructive chronic bronchitis with (acute) exacerbation,Body Mass Index less than 19, adult,Anxiety state, unspecified,Mitral valve disorders,Esophageal reflux,Anemia of other chronic disease,Unspecified essential hypertension,Osteoporosis, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Other and unspecified hyperlipidemia,Other constipation,Cardiac pacemaker in situ,Long-term (current) use of steroids,Other dependence on machines, supplemental oxygen,Personal history of tuberculosis,Personal history of tobacco use,Encounter for palliative care,Other diuretics causing adverse effects in therapeutic use,Other iatrogenic hypotension'}
