CHIEF COMPLAINT: Respiratory distress

PRESENT ILLNESS: 52 year old man with multiple admissions for inhaled
freebase-cocaine pneumonitis, non-ischemic dilated
cardiomyopathy with left ventricular ejection fraction of 20%,
and schizophrenia, who presents with respiratory distress.
Patient reports feeling short of breath since [**5-8**].  He reports
last smoking crack on [**5-6**].  Patient notes dyspnea on exertion
that has worsened over the course of three days, to the point
where he now has trouble ambulating from his bed to the
bathroom.  He reports no fever or night sweats, but does have
chills.  The patient also reports orthopnea and PND.  There is
chest tightness associated with his dyspnea.  He reports a dry
cough that has been present since he first started feeling short
of breath.  Patient reports being compliant with all of his
medications, and reports no specific dietary indiscretion.  He
does feel that his dose of furosemide does not seem to make him
urinate enough.
.
In the ED, initial VS were afebrile, HR 127, BP 123/79, RR 38,
O2 sat 99% on BIPAP.  Patient, in the field was 82% on RA, and
BIPAP was applied.  There was much improvement almost
immediately with this intervention, and patient reportedly
looked much improved upon arrival to the ED.  Lactate was
checked and was 1.7.  WBC count was 10.4K with 83% neutrophils,
no bands.  Sodium was 146, creatinine was 1.1.  Troponin was
noted to 0.05.  ProBNP was checked and was 4687.  UA was also
checked and was unremarkable.  Patient was administered
albuterol and ipratropium nebs x 2, methylprednisolone 125 mg IV
x 1, furosemide 100 mg IV x 1, lorazepam 2 mg IV x 1.  Urine
output in the ED was approximately 1 liter after furosemide
dosing.  Chest X-ray was performed and showed bibasilar
opacities similar to his previous imaging in 4/[**2195**].  Patient
was given vancomycin/cefepime for presumed HCAP.  Vitals on
transfer were pulse 120s, RR 30s, BP 121/64, 99-100% on BIPAP.

MEDICAL HISTORY: Crack pneumonitis
Type I Diabetes
Hyperlipidemia
HTN
Nonischemic dilated cardiomyopathy (EF 20% [**2-/2196**])
mild to moderate MR
moderate pHTN
Hepatitis C antibody positive
MRSA pneumonia (requiring trach)
COPD
Substance abuse (cocaine)
Tobacco abuse
Schizophrenia

MEDICATION ON ADMISSION: Medications:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 Solution(s) inhaled every six (6) hours
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2
puffs inhaled q4-6h as needed for shortness of breath, wheezing.
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth hs
-
No Substitution
CARVEDILOL -  (Prescribed by Other Provider) - 3.125 mg Tablet -
1 Tablet(s) by mouth twice a day
CLOTRIMAZOLE-BETAMETHASONE - 1 %-0.05 % Cream - apply to
affected
areas twice a day as needed for fungal skin infection use for 3
to 4 weeks
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff inhaled twice a day
FUROSEMIDE -  (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth twice a day
INSULIN ASPART [NOVOLOG] - 100 unit/mL Solution - As directed
per
sliding scale tid with meals
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 60 twice a
day
IPRATROPIUM BROMIDE - 0.2 mg/mL  (0.02 %) Solution - 1
Solution(s) inhaled every six (6) hours as needed for wheeze
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA
Aerosol
Inhaler - 1-2 puffs inhaled every six (6) hours as needed for
shortness of breath, wheezing
LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth once a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth twice a day
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for severe pain only

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:

FAMILY HISTORY: Father: pacemaker, deceased.  No family history of pulmonary
disease.

SOCIAL HISTORY: - history of multiple incarcerations (>6 months in [**2193**])
- lives with sister and [**Name2 (NI) 802**].  Collects disability for
shizophrenia.
- walks w/ cane due to right sided foot drop
- Tobacco history: current smoker, a few cig per day [**12-21**]
- ETOH: 2-3 beers three times per week
- Illicit drugs: last IVDU [**2166**], last crack cocaine [**2196-3-24**].
Used MJ [**2196-4-9**].
Acute on chronic systolic heart failure,Bronchitis and pneumonitis due to fumes and vapors,Other primary cardiomyopathies,Cocaine dependence, continuous,Other respiratory abnormalities,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Mitral valve disorders,Other chronic pulmonary heart diseases,Personal history of other infectious and parasitic diseases,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Chronic airway obstruction, not elsewhere classified,Tobacco use disorder,Unspecified schizophrenia, unspecified,Other acquired deformities of ankle and foot
Ac on chr syst hrt fail,Fum/vapor bronc/pneumon,Prim cardiomyopathy NEC,Cocaine depend-contin,Respiratory abnorm NEC,DMI wo cmp nt st uncntrl,Long-term use of insulin,Hyperlipidemia NEC/NOS,Hypertension NOS,Mitral valve disorder,Chr pulmon heart dis NEC,Prsnl hst oth nfct parst,Meth resis Staph carrier,Chr airway obstruct NEC,Tobacco use disorder,Schizophrenia NOS-unspec,Acq ankle-foot def NEC
Admission Date:  [**2196-5-10**]              Discharge Date:   [**2196-5-12**]

Date of Birth:  [**2143-6-4**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Respiratory distress

Major Surgical or Invasive Procedure:
[**2196-5-10**]: Non-invasive positive pressure ventilation


History of Present Illness:
52 year old man with multiple admissions for inhaled
freebase-cocaine pneumonitis, non-ischemic dilated
cardiomyopathy with left ventricular ejection fraction of 20%,
and schizophrenia, who presents with respiratory distress.
Patient reports feeling short of breath since [**5-8**].  He reports
last smoking crack on [**5-6**].  Patient notes dyspnea on exertion
that has worsened over the course of three days, to the point
where he now has trouble ambulating from his bed to the
bathroom.  He reports no fever or night sweats, but does have
chills.  The patient also reports orthopnea and PND.  There is
chest tightness associated with his dyspnea.  He reports a dry
cough that has been present since he first started feeling short
of breath.  Patient reports being compliant with all of his
medications, and reports no specific dietary indiscretion.  He
does feel that his dose of furosemide does not seem to make him
urinate enough.
.
In the ED, initial VS were afebrile, HR 127, BP 123/79, RR 38,
O2 sat 99% on BIPAP.  Patient, in the field was 82% on RA, and
BIPAP was applied.  There was much improvement almost
immediately with this intervention, and patient reportedly
looked much improved upon arrival to the ED.  Lactate was
checked and was 1.7.  WBC count was 10.4K with 83% neutrophils,
no bands.  Sodium was 146, creatinine was 1.1.  Troponin was
noted to 0.05.  ProBNP was checked and was 4687.  UA was also
checked and was unremarkable.  Patient was administered
albuterol and ipratropium nebs x 2, methylprednisolone 125 mg IV
x 1, furosemide 100 mg IV x 1, lorazepam 2 mg IV x 1.  Urine
output in the ED was approximately 1 liter after furosemide
dosing.  Chest X-ray was performed and showed bibasilar
opacities similar to his previous imaging in 4/[**2195**].  Patient
was given vancomycin/cefepime for presumed HCAP.  Vitals on
transfer were pulse 120s, RR 30s, BP 121/64, 99-100% on BIPAP.

On arrival to the MICU, patient is noted to be tachypneic and
still on bipap, but reports feeling much better.

Past Medical History:
Crack pneumonitis
Type I Diabetes
Hyperlipidemia
HTN
Nonischemic dilated cardiomyopathy (EF 20% [**2-/2196**])
mild to moderate MR
moderate pHTN
Hepatitis C antibody positive
MRSA pneumonia (requiring trach)
COPD
Substance abuse (cocaine)
Tobacco abuse
Schizophrenia

Social History:
- history of multiple incarcerations (>6 months in [**2193**])
- lives with sister and [**Name2 (NI) 802**].  Collects disability for
shizophrenia.
- walks w/ cane due to right sided foot drop
- Tobacco history: current smoker, a few cig per day [**12-21**]
- ETOH: 2-3 beers three times per week
- Illicit drugs: last IVDU [**2166**], last crack cocaine [**2196-3-24**].
Used MJ [**2196-4-9**].


Family History:
Father: pacemaker, deceased.  No family history of pulmonary
disease.

Physical Exam:
Admission Physical Exam:

Vitals: T: 98.5 BP: 103/70 P: 117 R: 31 O2: 100% BIPAP
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, JVP difficult to assess, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops audible
Lungs: Insipiratory wheezes noted on anterior exam, scattered
dry crackles noted on posterior exam, good aeration
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3

Discharge Physical Exam:
Vitals: T: 98.2 BP: 99/69 (90's-120's/60's-80's) P: 102 (100's)
R: 20 O2: 99% on 2L, 96% on RA
BG [**5-11**]: 324 (Evening)
BG [**5-12**]: 365 (am)
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, JVP difficult to assess, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops audible
Lungs: Scattered wheezes and crackles bilaterally, no increased
respiratory effort
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3

Pertinent Results:
Admission Labs:

[**2196-5-10**] 08:30AM [**Month/Day/Year 3143**] WBC-10.4# RBC-4.66 Hgb-11.9* Hct-40.0
MCV-86 MCH-25.5* MCHC-29.6* RDW-15.7* Plt Ct-245
[**2196-5-10**] 08:30AM [**Month/Day/Year 3143**] Neuts-82.7* Lymphs-11.5* Monos-2.7
Eos-2.6 Baso-0.5
[**2196-5-10**] 08:30AM [**Month/Day/Year 3143**] PT-11.5 PTT-36.0 INR(PT)-1.1
[**2196-5-10**] 08:30AM [**Month/Day/Year 3143**] Plt Ct-245
[**2196-5-10**] 08:30AM [**Month/Day/Year 3143**] Glucose-69* UreaN-18 Creat-1.1 Na-146*
K-4.0 Cl-109* HCO3-24 AnGap-17
[**2196-5-10**] 08:30AM [**Month/Day/Year 3143**] CK(CPK)-253
[**2196-5-10**] 08:30AM [**Month/Day/Year 3143**] proBNP-4687*
[**2196-5-10**] 08:30AM [**Month/Day/Year 3143**] CK-MB-6 cTropnT-0.05*
[**2196-5-10**] 04:22PM [**Month/Day/Year 3143**] CK-MB-4 cTropnT-0.03*
[**2196-5-10**] 10:12PM [**Month/Day/Year 3143**] CK-MB-4 cTropnT-0.02*
[**2196-5-10**] 04:22PM [**Month/Day/Year 3143**] Mg-1.6
[**2196-5-10**] 08:39AM [**Month/Day/Year 3143**] Lactate-1.7

Radiography:

[**5-10**] AP Chest:
IMPRESSION:  Bilateral airspace opacities, slightly increased
from prior.
Differential includes pneumonitis, asymmetric pulmonary edema or
infection.

Discharge labs:

[**2196-5-12**] 05:50AM [**Month/Day/Year 3143**] WBC-8.5 RBC-4.42* Hgb-11.5* Hct-38.2*
MCV-86 MCH-26.0* MCHC-30.1* RDW-15.4 Plt Ct-256
[**2196-5-12**] 05:50AM [**Month/Day/Year 3143**] Glucose-173* UreaN-28* Creat-1.2 Na-144
K-4.6 Cl-105 HCO3-26 AnGap-18
[**2196-5-12**] 05:50AM [**Month/Day/Year 3143**] Mg-1.8

Brief Hospital Course:
52 year old man with schizophrenia, multiple admissions for
inhaled freebase-cocaine pneumonitis, non-ischemic dilated
cardiomyopathy with left ventricular ejection fraction of 20%
who presented with respiratory distress, most consistent with an
acute on chronic systolic CHF exacerbation.

Active Issues:

# Actue on chronic Systolic CHF exacerbation: Patient presented
with respiratory distress, noted to be tachypneic with O2
saturation of 82% on room air initially, which improved back to
baseline with diuresis (lasix gtt). He had a history of crack
pneumonitis and systolic congestive heart failure, as well as a
diagnosis of COPD. Possible etiologies of the patient's
exacerbation included pneumonitis from continued crack use,
heart failure exacerbation or COPD exacerbation.  Given his
orthopnea, PND, and possible underdosing of his furosemide, pt
was diuresed with a lasix gtt with a large symptomatic
improvement.  His breathing appeared back to baseline after
agressive diuresis with lasix gtt in the ICU.  After being
called out to them edical floor pt was restarted on his home
dose of po lasix 40 mg [**Hospital1 **].  He was also continued on his
ipratropium and albuterol nebs, as well as
fluticasone/salmeterol.  He was also continued on carvidelol and
lisinopril for sCHF.

# Type I Diabetes:  Pt's BG's were in the 400's initially in the
ICU, likely [**1-21**] to the high dose steroids he received in the ED.
 Once on the medical floor his BG's remained in the low 200's
before discharge.  He will follow up with his PCP for further
titration of his insulin.

# Schizophrenia: Patient was not currently on antipsychotics and
was scheduled to see a psychiatrist this week. He reports
continuously hearing voices, oftentimes telling him to hurt
himself. He has never acted on these voices, and has no current
suicidal or homicidal ideation. Psychiatry was consulted and
recommended outpt follow up.

# Hypertension:  continued home carvedilol, restarted lisinopril
before discharge as [**Last Name (un) **] was resolved.

Inactive Issues:

# Hyperlipidemia: continued home atorvastatin 20 mg daily

# Pain control: restarted tramadol 50 mg [**Hospital1 **] prn pain

Transitional Issues:

-Pt will f/u with PCP on [**Name9 (PRE) 2974**] [**5-13**]

Medications on Admission:
Medications:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 Solution(s) inhaled every six (6) hours
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2
puffs inhaled q4-6h as needed for shortness of breath, wheezing.
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth hs
-
No Substitution
CARVEDILOL -  (Prescribed by Other Provider) - 3.125 mg Tablet -
1 Tablet(s) by mouth twice a day
CLOTRIMAZOLE-BETAMETHASONE - 1 %-0.05 % Cream - apply to
affected
areas twice a day as needed for fungal skin infection use for 3
to 4 weeks
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff inhaled twice a day
FUROSEMIDE -  (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth twice a day
INSULIN ASPART [NOVOLOG] - 100 unit/mL Solution - As directed
per
sliding scale tid with meals
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 60 twice a
day
IPRATROPIUM BROMIDE - 0.2 mg/mL  (0.02 %) Solution - 1
Solution(s) inhaled every six (6) hours as needed for wheeze
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA
Aerosol
Inhaler - 1-2 puffs inhaled every six (6) hours as needed for
shortness of breath, wheezing
LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth once a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth twice a day
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for severe pain only

Medications - OTC
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 (One)
Tablet(s) by mouth once a day
[**Name9 (PRE) 3143**] SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] -   Strip - Check
[**Name9 (PRE) **] sugar three times a day
FERROUS SULFATE - 325 mg (65 mg Iron) Tablet - 1 Tablet(s) by
mouth twice a day
INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE] - 1 mL 25 X
[**4-26**]" Syringe - use twice daily twice a day
LANCETS [LANCETS,ULTRA THIN] -     Misc - use tid three times a
day
NICOTINE -  (Not Taking as Prescribed) - 14 mg/24 hour Patch 24
hr - Apply 1 patch to skin daily
NICOTINE -  (Not Taking as Prescribed) - 7 mg/24 hour Patch 24
hr
- Apply 1 patch to skin daily start after 14mg patch.

Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) solution Inhalation Q6H (every 6
hours) as needed for shortness of breath or wheezing.
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
3. atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. clotrimazole-betamethasone 1-0.05 % Cream Sig: One (1)
Topical twice a day: apply to affected
areas twice a day as needed for fungal skin infection use for 3

to 4 weeks
.
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. insulin aspart 100 unit/mL Solution Sig: One (1)
Subcutaneous three times a day: as directed tid with meals.
9. insulin glargine 100 unit/mL Solution Sig: Sixty (60) units
Subcutaneous twice a day.
10. ipratropium bromide 0.02 % Solution Sig: One (1) solution
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
11. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler
Sig: [**12-21**]  Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
12. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
14. tramadol 50 mg Tablet Sig: One (1) Tablet PO twice a day.
15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. ferrous sulfate 300  mg (60 mg iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
17. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Acute on chronic systolic heart failure

Secondary:
Diabetes Mellitus type 2


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


Discharge Instructions:
  Dear Mr. [**Known lastname 10794**],
       It was a pleasure taking care of you during your
hospitalization at [**Hospital1 69**].  You
were admitted with worsening shortness of breath, which we feel
is secondary to a heart failure exacerbation.  You improved with
a medication called lasix that removed fluid from your body.
    You are now safe for discharge home.

PLEASE NOTE THE FOLLOWING MEDICATION CHANGES:
NONE

Followup Instructions:
When: FRIDAY [**2196-5-13**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 63642**], MD [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site

Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: MONDAY [**2196-5-23**] at 11:00 AM
With: [**Name (NI) **] [**Name (NI) 12853**], PT [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site

Department: LIVER CENTER
When: TUESDAY [**2196-7-19**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
{'Acute on chronic systolic heart failure,Bronchitis and pneumonitis due to fumes and vapors,Other primary cardiomyopathies,Cocaine dependence, continuous,Other respiratory abnormalities,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Mitral valve disorders,Other chronic pulmonary heart diseases,Personal history of other infectious and parasitic diseases,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Chronic airway obstruction, not elsewhere classified,Tobacco use disorder,Unspecified schizophrenia, unspecified,Other acquired deformities of ankle and foot'}


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: Respiratory distress

PRESENT ILLNESS: 52 year old man with multiple admissions for inhaled
freebase-cocaine pneumonitis, non-ischemic dilated
cardiomyopathy with left ventricular ejection fraction of 20%,
and schizophrenia, who presents with respiratory distress.
Patient reports feeling short of breath since [**5-8**].  He reports
last smoking crack on [**5-6**].  Patient notes dyspnea on exertion
that has worsened over the course of three days, to the point
where he now has trouble ambulating from his bed to the
bathroom.  He reports no fever or night sweats, but does have
chills.  The patient also reports orthopnea and PND.  There is
chest tightness associated with his dyspnea.  He reports a dry
cough that has been present since he first started feeling short
of breath.  Patient reports being compliant with all of his
medications, and reports no specific dietary indiscretion.  He
does feel that his dose of furosemide does not seem to make him
urinate enough.
.
In the ED, initial VS were afebrile, HR 127, BP 123/79, RR 38,
O2 sat 99% on BIPAP.  Patient, in the field was 82% on RA, and
BIPAP was applied.  There was much improvement almost
immediately with this intervention, and patient reportedly
looked much improved upon arrival to the ED.  Lactate was
checked and was 1.7.  WBC count was 10.4K with 83% neutrophils,
no bands.  Sodium was 146, creatinine was 1.1.  Troponin was
noted to 0.05.  ProBNP was checked and was 4687.  UA was also
checked and was unremarkable.  Patient was administered
albuterol and ipratropium nebs x 2, methylprednisolone 125 mg IV
x 1, furosemide 100 mg IV x 1, lorazepam 2 mg IV x 1.  Urine
output in the ED was approximately 1 liter after furosemide
dosing.  Chest X-ray was performed and showed bibasilar
opacities similar to his previous imaging in 4/[**2195**].  Patient
was given vancomycin/cefepime for presumed HCAP.  Vitals on
transfer were pulse 120s, RR 30s, BP 121/64, 99-100% on BIPAP.

MEDICAL HISTORY: Crack pneumonitis
Type I Diabetes
Hyperlipidemia
HTN
Nonischemic dilated cardiomyopathy (EF 20% [**2-/2196**])
mild to moderate MR
moderate pHTN
Hepatitis C antibody positive
MRSA pneumonia (requiring trach)
COPD
Substance abuse (cocaine)
Tobacco abuse
Schizophrenia

MEDICATION ON ADMISSION: Medications:
ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 Solution(s) inhaled every six (6) hours
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
1-2
puffs inhaled q4-6h as needed for shortness of breath, wheezing.
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth hs
-
No Substitution
CARVEDILOL -  (Prescribed by Other Provider) - 3.125 mg Tablet -
1 Tablet(s) by mouth twice a day
CLOTRIMAZOLE-BETAMETHASONE - 1 %-0.05 % Cream - apply to
affected
areas twice a day as needed for fungal skin infection use for 3
to 4 weeks
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff inhaled twice a day
FUROSEMIDE -  (Prescribed by Other Provider) - 40 mg Tablet - 1
(One) Tablet(s) by mouth twice a day
INSULIN ASPART [NOVOLOG] - 100 unit/mL Solution - As directed
per
sliding scale tid with meals
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 60 twice a
day
IPRATROPIUM BROMIDE - 0.2 mg/mL  (0.02 %) Solution - 1
Solution(s) inhaled every six (6) hours as needed for wheeze
IPRATROPIUM BROMIDE [ATROVENT HFA] - 17 mcg/Actuation HFA
Aerosol
Inhaler - 1-2 puffs inhaled every six (6) hours as needed for
shortness of breath, wheezing
LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth once a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth twice a day
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for severe pain only

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:

FAMILY HISTORY: Father: pacemaker, deceased.  No family history of pulmonary
disease.

SOCIAL HISTORY: - history of multiple incarcerations (>6 months in [**2193**])
- lives with sister and [**Name2 (NI) 802**].  Collects disability for
shizophrenia.
- walks w/ cane due to right sided foot drop
- Tobacco history: current smoker, a few cig per day [**12-21**]
- ETOH: 2-3 beers three times per week
- Illicit drugs: last IVDU [**2166**], last crack cocaine [**2196-3-24**].
Used MJ [**2196-4-9**]. 

### Response:
{'Acute on chronic systolic heart failure,Bronchitis and pneumonitis due to fumes and vapors,Other primary cardiomyopathies,Cocaine dependence, continuous,Other respiratory abnormalities,Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled,Long-term (current) use of insulin,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Mitral valve disorders,Other chronic pulmonary heart diseases,Personal history of other infectious and parasitic diseases,Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Chronic airway obstruction, not elsewhere classified,Tobacco use disorder,Unspecified schizophrenia, unspecified,Other acquired deformities of ankle and foot'}
