CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: 45 year old male with history of severe asthma requiring
numerous hospitalizations and intubations in the past, now
re-presenting with recurrent dyspnea and cough for 2 days.  His
productive cough started about 2 days ago, in the absence of any
other URI symptoms.  His shortness of breath began yesterday,
for which he usually tries his nebulizer and a Z-pack.  His
nebulizer machine was not working overnight, he actually went to
work the next day and he called [**Company 191**] in the morning to try to get
another script to replace it.  When this did not work, he drove
himself from work to the pharmacy to pick one up and then gave
himself a treatment on the way home.  Before he got a chance to
take his high-dose prednisone, he decided to come to the ED.  He
has been taking 50mg prednisone in a slow taper, but the goal
dose was 30mg every other day until he was able to get off
steroids entirely.
.
He was previously discharged from [**Hospital1 18**] after a similar
presentation and ICU admission, felt to be consistent with a
combination of asthma and COPD exacerbations.  He received
albuterol/ipratropium nebs q6h with clinical improvement in
wheezing, azithromycin for antibiotic coverage, and was
discharged on a prednisone taper to be determined by his
outpatient pulmonologist, Dr. [**Known firstname **] [**Last Name (NamePattern1) **].  Prior peak flows
were 350 on [**8-24**] and 300 on [**8-25**].  Prior admissions this year
have followed a similar pattern, none of which have required
intubations and have lasted 1-2 days.
.
In the ED, initial vitals were: 101.4, 137, 148/127, 92% on 4L
O2.  He received solumedrol 125mg IV, Magnesium 2g IV, Cefepime
1g IV, Levofloxacin 750mg IV, Combivent + albuterol nebs, and 1g
tylenol for fever.  Given his continued tachypnea and
tachycardia as well as his prior history of severe asthma, the
decision was made to admit him to the ICU for further
monitoring.  On transfer to the MICU, vitals were: Sats 91% RA,
RR 28, HR 120, BP 121/102 (151/96 prior).
.
On arrival to the MICU, he is still very wheezy, but comfortable
on RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.

MEDICAL HISTORY: - Severe asthma
--- [**2177**]: 6 hospitalizations since beginning of the year, all
lasting 1-2 days
--- More than 100 lifetime hospitalizations with multiple
intubations (17)
--- Most recent prolonged admission was in [**2169**], which was
complicated by MRSA and xanthomonas bronchitis
- OSA on CPAP at night
- GERD
- Avascular necrosis of the hip s/p left TKR [**6-/2175**] and shoulder
repair from prolonged steroid use
- L Achilles tendon rupture s/p repair

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Montelukast Sodium 10 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Loratadine *NF* 10 mg Oral daily allergies
7. Tiotropium Bromide 1 CAP IH DAILY
8. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
9. Fluticasone Propionate 110mcg 12 PUFF IH [**Hospital1 **]
home dose of 220mcg, 6 puffs [**Hospital1 **]
10. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation q4h SOB
11. Magnesium Oxide 400 mg PO DAILY
12. Guaifenesin ER 1200 mg PO Q12H
13. PredniSONE 50 mg PO DAILY
for the last 3 days.  Goal dose 30mg every other day for now,
until able to taper.

ALLERGIES: Fish Product Derivatives / Shellfish Derived / Peanut / Grass
Pollen-Bermuda, Standard / Mold Extracts / Cat Hair Std Extract

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: BP: 138/77 P: 93 R: 24 O2: 95% on RA
General: Alert, oriented, mild respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear but mildly
difficult to visualize, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: diffuse inspiratory and expiratory wheezing with
prolonged expiratory phase.  No crackles or rhonchi
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: nonfocal exam with CNII-XII grossly intact and full
strength and sensation bilaterally

FAMILY HISTORY: Maternal history of cancer and asthma.

SOCIAL HISTORY: Smokes five cigarettes a day, ~30 pack-year history. Drinks ~1
bottle of wine per week. Occasionally uses marijuana. He is
currently living with his wife and young daughter in his
mother's house in [**Location (un) 583**], previously in [**Location (un) 5503**]. Currently
has a lot of social stressors; his house in [**Location (un) 5503**] is being
foreclosed.  He lost his job as a Volkswagen car mechanic due to
his asthma and has been a bus driver since then. He is married,
has three children
Chronic obstructive asthma with (acute) exacerbation,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder,Tachycardia, unspecified,Anxiety state, unspecified,Nonspecific abnormal electrocardiogram [ECG] [EKG],Knee joint replacement
Ch obst asth w (ac) exac,Esophageal reflux,Obstructive sleep apnea,Tobacco use disorder,Tachycardia NOS,Anxiety state NOS,Abnorm electrocardiogram,Joint replaced knee
Admission Date:  [**2178-9-2**]              Discharge Date:   [**2178-9-8**]

Date of Birth:  [**2133-6-10**]             Sex:   M

Service: MEDICINE

Allergies:
Fish Product Derivatives / Shellfish Derived / Peanut / Grass
Pollen-Bermuda, Standard / Mold Extracts / Cat Hair Std Extract

Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
none

History of Present Illness:
45 year old male with history of severe asthma requiring
numerous hospitalizations and intubations in the past, now
re-presenting with recurrent dyspnea and cough for 2 days.  His
productive cough started about 2 days ago, in the absence of any
other URI symptoms.  His shortness of breath began yesterday,
for which he usually tries his nebulizer and a Z-pack.  His
nebulizer machine was not working overnight, he actually went to
work the next day and he called [**Company 191**] in the morning to try to get
another script to replace it.  When this did not work, he drove
himself from work to the pharmacy to pick one up and then gave
himself a treatment on the way home.  Before he got a chance to
take his high-dose prednisone, he decided to come to the ED.  He
has been taking 50mg prednisone in a slow taper, but the goal
dose was 30mg every other day until he was able to get off
steroids entirely.
.
He was previously discharged from [**Hospital1 18**] after a similar
presentation and ICU admission, felt to be consistent with a
combination of asthma and COPD exacerbations.  He received
albuterol/ipratropium nebs q6h with clinical improvement in
wheezing, azithromycin for antibiotic coverage, and was
discharged on a prednisone taper to be determined by his
outpatient pulmonologist, Dr. [**Known firstname **] [**Last Name (NamePattern1) **].  Prior peak flows
were 350 on [**8-24**] and 300 on [**8-25**].  Prior admissions this year
have followed a similar pattern, none of which have required
intubations and have lasted 1-2 days.
.
In the ED, initial vitals were: 101.4, 137, 148/127, 92% on 4L
O2.  He received solumedrol 125mg IV, Magnesium 2g IV, Cefepime
1g IV, Levofloxacin 750mg IV, Combivent + albuterol nebs, and 1g
tylenol for fever.  Given his continued tachypnea and
tachycardia as well as his prior history of severe asthma, the
decision was made to admit him to the ICU for further
monitoring.  On transfer to the MICU, vitals were: Sats 91% RA,
RR 28, HR 120, BP 121/102 (151/96 prior).
.
On arrival to the MICU, he is still very wheezy, but comfortable
on RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.

Past Medical History:
- Severe asthma
--- [**2177**]: 6 hospitalizations since beginning of the year, all
lasting 1-2 days
--- More than 100 lifetime hospitalizations with multiple
intubations (17)
--- Most recent prolonged admission was in [**2169**], which was
complicated by MRSA and xanthomonas bronchitis
- OSA on CPAP at night
- GERD
- Avascular necrosis of the hip s/p left TKR [**6-/2175**] and shoulder
repair from prolonged steroid use
- L Achilles tendon rupture s/p repair

Social History:
Smokes five cigarettes a day, ~30 pack-year history. Drinks ~1
bottle of wine per week. Occasionally uses marijuana. He is
currently living with his wife and young daughter in his
mother's house in [**Location (un) 583**], previously in [**Location (un) 5503**]. Currently
has a lot of social stressors; his house in [**Location (un) 5503**] is being
foreclosed.  He lost his job as a Volkswagen car mechanic due to
his asthma and has been a bus driver since then. He is married,
has three children

Family History:
Maternal history of cancer and asthma.

Physical Exam:
Admission Physical Exam:
Vitals: T: BP: 138/77 P: 93 R: 24 O2: 95% on RA
General: Alert, oriented, mild respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear but mildly
difficult to visualize, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: diffuse inspiratory and expiratory wheezing with
prolonged expiratory phase.  No crackles or rhonchi
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: nonfocal exam with CNII-XII grossly intact and full
strength and sensation bilaterally

Discharge Physical Exam:
VS - 97, 131/88 (to to 160s systolic), 87 (up to 130s), 22, 96RA

GENERAL - sleeping with CPAP
HEENT - EOMI, sclerae anicteric, MMM, OP clear
HEART - RR, nl S1-S2, no MRG
LUNGS - Diffuse inspiratory and expiratory wheezes with
prolonged I/E ratio, improved from yesterday. no rales. Speaking
in full sentences. No accessory muscle use.
ABDOMEN - NABS, soft and adipose/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

SKIN - no rashes or lesions
MSK - Full ROM throughout.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle and
sensation grossly intact throughout


Pertinent Results:
ADMISSION LABS:
[**2178-9-2**] 11:20PM   GLUCOSE-185* UREA N-11 CREAT-0.8 SODIUM-140
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
[**2178-9-2**] 11:20PM   CK(CPK)-166
[**2178-9-2**] 11:20PM   CK-MB-4 cTropnT-<0.01
[**2178-9-2**] 11:20PM   CALCIUM-8.5 PHOSPHATE-2.5* MAGNESIUM-2.4
[**2178-9-2**] 11:20PM   WBC-15.5* RBC-5.09 HGB-15.3 HCT-46.1 MCV-91
MCH-30.1 MCHC-33.2 RDW-13.1
[**2178-9-2**] 11:20PM   NEUTS-94.0* LYMPHS-3.9* MONOS-1.2* EOS-0.8
BASOS-0.2
[**2178-9-2**] 11:20PM   PLT COUNT-282
[**2178-9-2**] 11:20PM   PT-12.8* PTT-32.4 INR(PT)-1.2*
[**2178-9-2**] 06:54PM   LACTATE-1.4
[**2178-9-2**] 06:40PM   GLUCOSE-102* UREA N-12 CREAT-0.9 SODIUM-141
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13
[**2178-9-2**] 06:40PM   estGFR-Using this
[**2178-9-2**] 06:40PM   WBC-13.2* RBC-5.43 HGB-16.5 HCT-48.9 MCV-90
MCH-30.5 MCHC-33.8 RDW-13.0
[**2178-9-2**] 06:40PM   NEUTS-73.3* LYMPHS-11.8* MONOS-10.0 EOS-4.4*
BASOS-0.5
[**2178-9-2**] 06:40PM   PLT COUNT-329

CBC
[**2178-9-2**] 11:20PM BLOOD WBC-15.5* RBC-5.09 Hgb-15.3 Hct-46.1
MCV-91 MCH-30.1 MCHC-33.2 RDW-13.1 Plt Ct-282
[**2178-9-4**] 06:40AM BLOOD WBC-21.6* RBC-4.51* Hgb-13.5* Hct-41.4
MCV-92 MCH-30.1 MCHC-32.7 RDW-13.2 Plt Ct-265
[**2178-9-5**] 07:50AM BLOOD WBC-13.6* RBC-4.44* Hgb-13.5* Hct-41.0
MCV-92 MCH-30.5 MCHC-33.0 RDW-13.3 Plt Ct-267
[**2178-9-6**] 08:21AM BLOOD WBC-17.4* RBC-4.68 Hgb-14.6 Hct-42.4
MCV-91 MCH-31.2 MCHC-34.4 RDW-13.4 Plt Ct-283
[**2178-9-7**] 07:05AM BLOOD WBC-16.9* RBC-4.45* Hgb-13.7* Hct-40.1
MCV-90 MCH-30.8 MCHC-34.2 RDW-13.4 Plt Ct-264
[**2178-9-2**] 11:20PM BLOOD Neuts-94.0* Lymphs-3.9* Monos-1.2*
Eos-0.8 Baso-0.2

CHEMISTRY:
[**2178-9-2**] 11:20PM BLOOD Glucose-185* UreaN-11 Creat-0.8 Na-140
K-4.3 Cl-105 HCO3-23 AnGap-16
[**2178-9-4**] 06:40AM BLOOD Glucose-102* UreaN-18 Creat-0.8 Na-142
K-3.9 Cl-110* HCO3-26 AnGap-10
[**2178-9-5**] 07:50AM BLOOD Glucose-131* UreaN-15 Creat-0.8 Na-146*
K-3.4 Cl-112* HCO3-26 AnGap-11
[**2178-9-6**] 08:21AM BLOOD Glucose-81 UreaN-14 Creat-0.8 Na-145
K-3.5 Cl-108 HCO3-27 AnGap-14
[**2178-9-7**] 07:05AM BLOOD Glucose-81 UreaN-19 Creat-0.8 Na-146*
K-3.4 Cl-107 HCO3-29 AnGap-13
[**2178-9-4**] 06:40AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.2
[**2178-9-5**] 07:50AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.9
[**2178-9-6**] 08:21AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.9
[**2178-9-7**] 07:05AM BLOOD Calcium-9.0 Phos-4.9* Mg-2.0

OTHER LABS:
[**2178-9-2**] 11:20PM BLOOD CK-MB-4 cTropnT-<0.01
[**2178-9-2**] 11:20PM BLOOD CK(CPK)-166
[**2178-9-2**] 11:20PM BLOOD PT-12.8* PTT-32.4 INR(PT)-1.2*

MICRO:
Blood cultures [**2178-9-8**]: no growth

IMAGING:
CXR [**2178-9-2**]: IMPRESSION:  No acute cardiopulmonary pathology.

ECHO [**2178-9-3**]: The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Left ventricular systolic function is
hyperdynamic (EF 75%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.


Brief Hospital Course:
CHIEF COMPLAINT: SOB

REASON FOR ADMISSION: 45 year old male with multiple prior
hospitalizations requiring intubation for asthma exacerbation
and ?additional pulmonary disease, re-presenting with acute
onset dyspnea consistent with an asthma exacerbation after a
recent discharge for the same.

# Asthma exacerbation: Exacerbating factors for this
presentation include broken nebulizer machine, life stressors,
smoking, weather, and URI. Outpatient management of this
patient's asthma has been extremely difficult, as he has
required 6 hospitalizations this year despite back-up plans of
high-dose prednisone as needed and very high doses of inhaled
glucocorticoids and controller meds. During his ICU course he
received standing albuterol and ipratropium q2h nebs, prednisone
60mg, azithromycin and continued his home regimen of
flovent,singulair and salmeterol. On the medicine floor, he
completed a 5 day azithromycin course. His PCP prophylaxis with
bactrim was continued, and calcium/vitamin D given chronic
intermittent high dose steroid use. Outpatient consideration for
thermoplasty and consideration of therapy with zolair was
discussed in emails with outpatient providers. After spacing of
his nebulizers, he was discharged on a prednisone taper starting
at 60mg daily x7 days, then to 40mg until followup with his PCP.
 [**Name10 (NameIs) **] has an appointment with his pulmonologist Dr. [**Last Name (STitle) **] in
[**Month (only) 1096**], but he was encouraged to make an earlier appointment
if possible.

# Anxiety: Patient cited multiple life stressors, including
marital discord, which are likely contributing to his frequent
asthma exacerbations. Was seen by social work who recommended
outpatient resources. He was given ativan 1mg prn to help with
anxiety, which he will continue on discharge.

# Smoking cessation: Patient reports interest in smoking
cessation. He used nicotine lozenges during admission and also
expressed interest in discussing Chantix with his PCP.

# OSA on CPAP: Patient was on home CPAP at night, with the
exception of the night spent in the ICU for more frequent
nebulizer therapy.

# GERD: Likely secondary to chronic steroid use, continued his
home dose PPI.

TRANSITIONAL ISSUES:
Asthma exacerbation - He is on a steroid taper with close
outpatient followup
Life stressors - He was given a list of outpatient resources by
SW
Smoking cessation - He was given lozenges, and expressed
interest in discussing Chantix with outpatient providers.

MEDICATION CHANGES:
START nicotine lozenges
START calcium and vitamin D
START prednisone taper at 60mg daily x7days, then to 40mg daily
until following up with PCP
START lorazepam for anxiety

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Montelukast Sodium 10 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Loratadine *NF* 10 mg Oral daily allergies
7. Tiotropium Bromide 1 CAP IH DAILY
8. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
9. Fluticasone Propionate 110mcg 12 PUFF IH [**Hospital1 **]
home dose of 220mcg, 6 puffs [**Hospital1 **]
10. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation q4h SOB
11. Magnesium Oxide 400 mg PO DAILY
12. Guaifenesin ER 1200 mg PO Q12H
13. PredniSONE 50 mg PO DAILY
for the last 3 days.  Goal dose 30mg every other day for now,
until able to taper.


Discharge Medications:
1. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit [**Unit Number **] tablet(s) by mouth
twice daily Disp #*120 Tablet Refills:*0
2. Nicotine Lozenge 4 mg PO Q2H:PRN desire to smoke
RX *nicotine (polacrilex) 4 mg 1 lozenge every two hours as
needed Disp #*60 Lozenge Refills:*0
3. Calcium Carbonate 500 mg PO BID
RX *calcium carbonate [Calcium 600] 600 mg (1,500 mg) 1
tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. fluticasone *NF* 220 mcg/actuation INHALATION 12 PUFFS  [**Hospital1 **]
7. Magnesium Oxide 400 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation q4h SOB
10. Guaifenesin ER 1200 mg PO Q12H
11. Loratadine *NF* 10 mg Oral daily allergies
12. Montelukast Sodium 10 mg PO DAILY
13. Omeprazole 20 mg PO BID
14. PredniSONE 60 mg PO DAILY Duration: 7 Days
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*21 Tablet
Refills:*0
15. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
17. Lorazepam 1 mg PO BID:PRN anxiety
RX *lorazepam 1 mg 1 tablet by mouth twice daily Disp #*14
Tablet Refills:*0
18. PredniSONE 40 mg PO DAILY
Start taking after finishing 7 days of prednisone 60mg.
Continue this dose until otherwise directed by your doctor.
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0


Discharge Disposition:
Home

Discharge Diagnosis:
PRIMARY:
Asthma exacerbation
Tachycardia
Anxiety
Tobacco use


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


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

It was a pleasure to be a part of your care at [**Hospital1 18**]. You were
admitted for increasing shortness of breath. Your symptoms were
consistent with an asthma exacerbation. You were treated with
nebulizers, systemic and inhaled steroids, and your home
medications. You will be on a prednisone taper for several
weeks. Given the side effects of steroids, you were given
calcium and vitamin D in the hospital, which you should continue
at home.

Your heart rate was very fast during hospitalization. Causes of
your elevated heart rate include some of the medications that
you were on, as well as anxiety. You were given low dose
benzodiazepines to help with anxiety and were seen by the
hospital social worker to discuss coping mechanisms and
outpatient therapy resources. It is strongly suggested that you
pursue out patient counseling as well as psychiatry to help
address your anxiety which is likely contributing to your asthma
exacerbations. You can continue to take the low dose
anti-anxiolytic as an outpatient, but must not drink or operate
machinery on the medication.

You were counseled on smoking cessation during your stay. You
were given nicotine lozenges to help with cravings during
hospitalization. We strongly encourage continued smoking
cessation in the outpatient setting, as smoking is contributing
to your frequent asthma exacerbations. You are being sent home
with lozenges and should talk to your primary care doctor about
a prescription medicine called Chantix.

Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2178-9-16**] at 11:10 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2178-9-16**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14290**], OD [**Telephone/Fax (1) 253**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2178-9-16**] at 3:00 PM
With:  BONE DENSITY TESTING [**Telephone/Fax (1) 4586**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

** Pulmonary follow up**
Your next appointment with Dr. [**Last Name (STitle) **] is scheduled for [**2178-12-16**]
at 8:30 AM.  Please call his office at ([**Telephone/Fax (1) 513**] to try to
have an earlier appointment scheduled.

It is strongly suggested that you pursue out patient counseling
as well as psychiatry to help address your anxiety which is
likely contributing to your asthma exacerbations.  Below are a
list of agencies you can contact:

[**Location (un) 577**]-[**Location (un) 583**] Mental Health
[**First Name8 (NamePattern2) **]
[**Location (un) 583**], [**Numeric Identifier 994**]
[**0-0-**]

[**Hospital **] [**Hospital 4189**] Health Center
[**Street Address(2) 93488**]
[**Location (un) **], [**Numeric Identifier 822**]
[**Telephone/Fax (1) 93489**]

If you need assistance with this upon discharge, please contact
the social worker you saw while you were here, [**Name (NI) 636**] [**Last Name (NamePattern1) 12471**], at
[**Telephone/Fax (1) 57081**].


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
{'Chronic obstructive asthma with (acute) exacerbation,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder,Tachycardia, unspecified,Anxiety state, unspecified,Nonspecific abnormal electrocardiogram [ECG] [EKG],Knee joint replacement'}


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: Shortness of breath

PRESENT ILLNESS: 45 year old male with history of severe asthma requiring
numerous hospitalizations and intubations in the past, now
re-presenting with recurrent dyspnea and cough for 2 days.  His
productive cough started about 2 days ago, in the absence of any
other URI symptoms.  His shortness of breath began yesterday,
for which he usually tries his nebulizer and a Z-pack.  His
nebulizer machine was not working overnight, he actually went to
work the next day and he called [**Company 191**] in the morning to try to get
another script to replace it.  When this did not work, he drove
himself from work to the pharmacy to pick one up and then gave
himself a treatment on the way home.  Before he got a chance to
take his high-dose prednisone, he decided to come to the ED.  He
has been taking 50mg prednisone in a slow taper, but the goal
dose was 30mg every other day until he was able to get off
steroids entirely.
.
He was previously discharged from [**Hospital1 18**] after a similar
presentation and ICU admission, felt to be consistent with a
combination of asthma and COPD exacerbations.  He received
albuterol/ipratropium nebs q6h with clinical improvement in
wheezing, azithromycin for antibiotic coverage, and was
discharged on a prednisone taper to be determined by his
outpatient pulmonologist, Dr. [**Known firstname **] [**Last Name (NamePattern1) **].  Prior peak flows
were 350 on [**8-24**] and 300 on [**8-25**].  Prior admissions this year
have followed a similar pattern, none of which have required
intubations and have lasted 1-2 days.
.
In the ED, initial vitals were: 101.4, 137, 148/127, 92% on 4L
O2.  He received solumedrol 125mg IV, Magnesium 2g IV, Cefepime
1g IV, Levofloxacin 750mg IV, Combivent + albuterol nebs, and 1g
tylenol for fever.  Given his continued tachypnea and
tachycardia as well as his prior history of severe asthma, the
decision was made to admit him to the ICU for further
monitoring.  On transfer to the MICU, vitals were: Sats 91% RA,
RR 28, HR 120, BP 121/102 (151/96 prior).
.
On arrival to the MICU, he is still very wheezy, but comfortable
on RA.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.

MEDICAL HISTORY: - Severe asthma
--- [**2177**]: 6 hospitalizations since beginning of the year, all
lasting 1-2 days
--- More than 100 lifetime hospitalizations with multiple
intubations (17)
--- Most recent prolonged admission was in [**2169**], which was
complicated by MRSA and xanthomonas bronchitis
- OSA on CPAP at night
- GERD
- Avascular necrosis of the hip s/p left TKR [**6-/2175**] and shoulder
repair from prolonged steroid use
- L Achilles tendon rupture s/p repair

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Montelukast Sodium 10 mg PO DAILY
3. Omeprazole 20 mg PO BID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Loratadine *NF* 10 mg Oral daily allergies
7. Tiotropium Bromide 1 CAP IH DAILY
8. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
9. Fluticasone Propionate 110mcg 12 PUFF IH [**Hospital1 **]
home dose of 220mcg, 6 puffs [**Hospital1 **]
10. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation q4h SOB
11. Magnesium Oxide 400 mg PO DAILY
12. Guaifenesin ER 1200 mg PO Q12H
13. PredniSONE 50 mg PO DAILY
for the last 3 days.  Goal dose 30mg every other day for now,
until able to taper.

ALLERGIES: Fish Product Derivatives / Shellfish Derived / Peanut / Grass
Pollen-Bermuda, Standard / Mold Extracts / Cat Hair Std Extract

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T: BP: 138/77 P: 93 R: 24 O2: 95% on RA
General: Alert, oriented, mild respiratory distress
HEENT: Sclera anicteric, MMM, oropharynx clear but mildly
difficult to visualize, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: diffuse inspiratory and expiratory wheezing with
prolonged expiratory phase.  No crackles or rhonchi
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: nonfocal exam with CNII-XII grossly intact and full
strength and sensation bilaterally

FAMILY HISTORY: Maternal history of cancer and asthma.

SOCIAL HISTORY: Smokes five cigarettes a day, ~30 pack-year history. Drinks ~1
bottle of wine per week. Occasionally uses marijuana. He is
currently living with his wife and young daughter in his
mother's house in [**Location (un) 583**], previously in [**Location (un) 5503**]. Currently
has a lot of social stressors; his house in [**Location (un) 5503**] is being
foreclosed.  He lost his job as a Volkswagen car mechanic due to
his asthma and has been a bus driver since then. He is married,
has three children 

### Response:
{'Chronic obstructive asthma with (acute) exacerbation,Esophageal reflux,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder,Tachycardia, unspecified,Anxiety state, unspecified,Nonspecific abnormal electrocardiogram [ECG] [EKG],Knee joint replacement'}
