CHIEF COMPLAINT: SOB, dyspnea, asthma attack

PRESENT ILLNESS: 48F with past medical history of hypertension, obesity, and RVOT
ventricular tachycardia, status post ablation in [**2111-1-12**],
allergic rhinitis, sleep apnea,depression, and iron deficiency
anemia, severe asthma who presents with cough for 1 week and
chest tightness. She notes that she had a "cold", associated
with headache, chills, nasal congestion and sorethroat which
started ~ 1week ago. Most prominent has been a persistent dry
cough and worsening SOB and wheezing. No sputum production. Does
note vague left sided chest pain worsened with cough. Also notes
significant myalgias she attributes to her persistent coughing.
She has been using her nebs, flovent twice daily, Adavir diskus
and albuterol as needed. Her albuterol for the last 2 days she
has been using several times during the day/evening "too many to
count". She states that her PF this AM was around 120 and is
usually in the 200s. So this made her come to the hospital.
.
Of note, patient with history of difficult to control asthma.
She is followed by Dr. [**First Name (STitle) 437**] pulm and by Dr. [**First Name (STitle) **] from sleep.
She was last seen by pulm in [**2112-7-11**] and by sleep in [**2112-9-10**].
As per notes, she has difficulty with medication compliance and
at times get confused about her inhalers. There was also
recommendation that she gets ride of her indoor cats (3 cats)
and farrets, however she had not done so. She states that she
has mice in her house and the cats help keep the mice way. She
was getting Xolair injection for her allergies, but she has
developed dizziness during her last injection in [**2112-10-11**]. She
saw cards since then who does not think this is related to
arrythmia and recommended doing EKG during her next injection.
She states that she has not received any injections since then.

MEDICAL HISTORY: Asthma- last spirometry showed FEV1/FVC of 107% of predicted
value
-OSA on BiPAP at night
-Obesity
-Anxiety (was previously on Klonapin)
- RVOT ventricular tachycardia: [**2111-2-5**] - Successful Ablation
at [**Hospital1 18**], prior attempted ablation at [**Hospital3 **] in [**2109**] - Now
on Metop Succ 100mg QD
- Depression
- Hypertension

MEDICATION ON ADMISSION: Active Medication list as of [**2112-11-29**] (pt does not know all the
name of her medications)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission physical exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, becomes very anxious with increase WOB
when develops wheezing
HEENT: Sclera anicteric, MMdry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate tachy, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Expiratory wheezing through out, audible breath sounds
through out, increase WOB when having coughing spells leading to
worse wheezing- lasting 10-15 min. Then comfortable in between
Abdomen: soft, tender over the epigastric area, and right flank
area- pt with large scar from prior appendectomy and
cholecystectomy, non-distended, bowel sounds present, no
organomegaly
GU: foley with clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
Discharge physical exam:
Vitals: T 97.6 BP 168/87 (123-168/78-96) HR 87 (64-87) RR 20 O2
Sat 94% RA (94-98%)
General: Patient sitting up in bed in NAD. Able to complete full
sentences with no coughing fits this AM.
HEENT: EOMI. PERRL. MMM. OP without exudate.
CV: RRR. No M/R/G
LUNGS: No expiratory wheezes throughout, posteriorly. Mild
inspiratory rhonchorous breath sounds midway up the lung fields
bilaterally. Nml work of breathing. No accessory muscle use.
ABD: NABS+. Soft. NT/ND
EXT: WWP. No clubbing, cyanosis, or edema. 2+ raidal and DPs
bilaterally.

FAMILY HISTORY: Cousin with possible MI in her 40s. Maternal grandmother had an

SOCIAL HISTORY: Patient lives with two of her three children - daughters
actively involved in her care. Unemployed. Patient denies
tobacco, alcohol or illicit drugs.
Bacterial pneumonia, unspecified,Acute respiratory failure,Asthma, unspecified type, with (acute) exacerbation,Paroxysmal ventricular tachycardia,Mixed acid-base balance disorder,Urinary tract infection, site not specified,Obesity, unspecified,Unspecified essential hypertension,Anxiety state, unspecified,Obstructive sleep apnea (adult)(pediatric),Bronchitis, not specified as acute or chronic,Unspecified disorder of kidney and ureter
Bacterial pneumonia NOS,Acute respiratry failure,Asthma NOS w (ac) exac,Parox ventric tachycard,Mixed acid-base bal dis,Urin tract infection NOS,Obesity NOS,Hypertension NOS,Anxiety state NOS,Obstructive sleep apnea,Bronchitis NOS,Renal & ureteral dis NOS
Admission Date:  [**2113-1-15**]              Discharge Date:   [**2113-1-20**]

Date of Birth:  [**2064-6-20**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
SOB, dyspnea, asthma attack

Major Surgical or Invasive Procedure:
None


History of Present Illness:
48F with past medical history of hypertension, obesity, and RVOT
ventricular tachycardia, status post ablation in [**2111-1-12**],
allergic rhinitis, sleep apnea,depression, and iron deficiency
anemia, severe asthma who presents with cough for 1 week and
chest tightness. She notes that she had a "cold", associated
with headache, chills, nasal congestion and sorethroat which
started ~ 1week ago. Most prominent has been a persistent dry
cough and worsening SOB and wheezing. No sputum production. Does
note vague left sided chest pain worsened with cough. Also notes
significant myalgias she attributes to her persistent coughing.
She has been using her nebs, flovent twice daily, Adavir diskus
and albuterol as needed. Her albuterol for the last 2 days she
has been using several times during the day/evening "too many to
count". She states that her PF this AM was around 120 and is
usually in the 200s. So this made her come to the hospital.
.
Of note, patient with history of difficult to control asthma.
She is followed by Dr. [**First Name (STitle) 437**] pulm and by Dr. [**First Name (STitle) **] from sleep.
She was last seen by pulm in [**2112-7-11**] and by sleep in [**2112-9-10**].
As per notes, she has difficulty with medication compliance and
at times get confused about her inhalers. There was also
recommendation that she gets ride of her indoor cats (3 cats)
and farrets, however she had not done so. She states that she
has mice in her house and the cats help keep the mice way. She
was getting Xolair injection for her allergies, but she has
developed dizziness during her last injection in [**2112-10-11**]. She
saw cards since then who does not think this is related to
arrythmia and recommended doing EKG during her next injection.
She states that she has not received any injections since then.

.
In the ED, initial VS were: 97.7 124 125/102 24 98% on 4L. Her
physical exam was notable for use of accessory muscles. Short
sentences. Tight chest with diffuse wheeze. She was given
albuterol and ipratropium nebs, Solumedrol 125mg. Patient
deveoloped worsening SOB and tightness following her 2nd neb tx.
Received Magnesium and started on continuous albuterol
nebulizer. Her initial lactate was 1.8, WBC 5.4 (N:70 Band:6
L:14 M:8 E:2 Bas:0), Hgb 12.9/ Hct 38.4, plats were not measured
due to clumping. She had ABG done after having worse SOB: pH
7.52 pCO2 25/ pO2 69/ HCO3 21/ Lactate:2.8. She also continued
to be tachycardic, her EKG was consistent with sinus tachy, no
ST changes. Her Cxray showed no acute cardiac or pulmonary
process, however soft tissue attenuation causes hazy
opacification over the mid to lower portions of both lungs. She
had blood cultures sent. No antibiotics were given. She was then
admitted to the ICU for close monitoring for asthma exacerbation
and tachycardia.
.
On arrival to the MICU, pt was coughing with exp wheezing, but
with + lung sounds through out. She was started on nebs. Post
neb, she states to be feeling "much better". Now able to speak
in full sentences. Wheezing improving. Her sats were 100% on 3L
N/C.


Past Medical History:
Asthma- last spirometry showed FEV1/FVC of 107% of predicted
value
-OSA on BiPAP at night
-Obesity
-Anxiety (was previously on Klonapin)
- RVOT ventricular tachycardia: [**2111-2-5**] - Successful Ablation
at [**Hospital1 18**], prior attempted ablation at [**Hospital3 **] in [**2109**] - Now
on Metop Succ 100mg QD
- Depression
- Hypertension


Social History:
Patient lives with two of her three children - daughters
actively involved in her care. Unemployed. Patient denies
tobacco, alcohol or illicit drugs.


Family History:
Cousin with possible MI in her 40s. Maternal grandmother had an

MI. [**Name (NI) **] sister has cancer, unknown. Nephrew with arrhythmia

vs. syncope.


Physical Exam:
Admission physical exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, becomes very anxious with increase WOB
when develops wheezing
HEENT: Sclera anicteric, MMdry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate tachy, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Expiratory wheezing through out, audible breath sounds
through out, increase WOB when having coughing spells leading to
worse wheezing- lasting 10-15 min. Then comfortable in between
Abdomen: soft, tender over the epigastric area, and right flank
area- pt with large scar from prior appendectomy and
cholecystectomy, non-distended, bowel sounds present, no
organomegaly
GU: foley with clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
Discharge physical exam:
Vitals: T 97.6 BP 168/87 (123-168/78-96) HR 87 (64-87) RR 20 O2
Sat 94% RA (94-98%)
General: Patient sitting up in bed in NAD. Able to complete full
sentences with no coughing fits this AM.
HEENT: EOMI. PERRL. MMM. OP without exudate.
CV: RRR. No M/R/G
LUNGS: No expiratory wheezes throughout, posteriorly. Mild
inspiratory rhonchorous breath sounds midway up the lung fields
bilaterally. Nml work of breathing. No accessory muscle use.
ABD: NABS+. Soft. NT/ND
EXT: WWP. No clubbing, cyanosis, or edema. 2+ raidal and DPs
bilaterally.


Pertinent Results:
Admission Labs:
[**2113-1-15**] 01:30PM BLOOD WBC-5.4 RBC-4.63 Hgb-12.9 Hct-38.4 MCV-83
MCH-27.9 MCHC-33.7 RDW-14.4 Plt Ct-UNABLE TO
[**2113-1-15**] 01:30PM BLOOD Neuts-70 Bands-6* Lymphs-14* Monos-8
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2113-1-15**] 01:30PM BLOOD Hypochr-1+ Anisocy-OCCASIONAL Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+
[**2113-1-15**] 01:30PM BLOOD PT-12.5 PTT-28.7 INR(PT)-1.2*
[**2113-1-15**] 01:30PM BLOOD Glucose-79 UreaN-9 Creat-1.2* Na-139
K-4.1 Cl-102 HCO3-24 AnGap-17
[**2113-1-15**] 08:45PM BLOOD ALT-10 AST-26 CK(CPK)-857* AlkPhos-95
TotBili-0.3
[**2113-1-15**] 01:30PM BLOOD Calcium-9.2 Phos-3.0 Mg-2.0
[**2113-1-15**] 10:25PM BLOOD %HbA1c-6.1* eAG-128*
[**2113-1-15**] 03:42PM BLOOD Type-ART pO2-69* pCO2-25* pH-7.52*
calTCO2-21 Base XS-0
[**2113-1-15**] 01:35PM BLOOD Glucose-83 Lactate-1.8 K-4.1
.
Imaging:
CTA of chest/CT of abdomen/pelvis:
FINDINGS: There is no significant axillary or mediastinal
adenopathy.
Subcentimeter mediastinal lymph nodes, the largest measuring 9
mm within the aortopulmonary window (3a:20). No evidence of
pulmonary embolus. The aorta is normal in appearance. The great
vessels opacify normally.
The trachea and bronchi are patent to the subsegmental level.
The esophagus is normal in appearance. There is a small hiatal
hernia. There is bibasilar atelectasis. No consolidation. No
pleural effusion. No pericardial effusion. Pulmonary nodules.
CT ABDOMEN WITH ORAL AND IV CONTRAST: The liver is normal in
attenuation. No focal liver lesion identified. There is no
intrahepatic duct dilation.
Previous cholecystectomy noted with surgical clips within the
gallbladder
fossa. The common duct measures 7.5 mm which is in keeping with
previous
cholecystectomy. The spleen, both adrenal glands, pancreas and
both kidneys are normal in appearance. The aorta is normal in
caliber throughout. The portal vein, splenic vein, superior
mesenteric vein and mesenteric vessels opacify normally. The
visualized small and large bowel are normal. There is no
significant retroperitoneal or mesenteric adenopathy. There is
no free fluid.
CT PELVIS: Intrauterine contraceptive device within the uterus.
The urinary bladder is normal in appearance with a Foley
catheter in situ. Air present within the urinary bladder is
likely due to recent instrumentation from Foley catheter
insertion. The rectum and sigmoid are normal in appearance. No
free fluid or free air. There is no inguinal or pelvic
adenopathy.
OSSEOUS STRUCTURES: No suspicious osseous sclerotic or lucent
lesion
identified.
IMPRESSION:
1. Bibasilar atelectasis.
2. Small hiatal hernia.
3. Small amount of air within the urinary bladder. suggest
correlation with history of recent instrumentation.
4. The remainder of the study is normal. No evidence of
perforation or acute process.
.
Chest x-ray:
FINDINGS: A single AP radiograph of the chest was acquired. Soft
tissue
attenuation causes hazy opacification over the mid to lower
portions of both lungs. No focal consolidations are seen. The
cardiac and mediastinal
contours are normal. No definite pleural effusions. No
pneumothorax is seen.
IMPRESSION: No definite acute intrathoracic process, although
this single AP radiograph is slightly limited due to body
habitus and technique. If there is persistent concern for an
infectious process, further evaluation with PA and lateral
radiographs could be performed.
.
Microbiology:
 Respiratory Viral Culture (Final [**2113-1-18**]):
      No respiratory viruses isolated.
      Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
      1,2 & 3, and Respiratory Syncytial Virus..
      Detection of viruses other than those listed above will
only be
      performed on specific request. Please call Virology at
[**Telephone/Fax (1) 6182**]
      within 1 week if additional testing is needed.

   Respiratory Viral Antigen Screen (Final [**2113-1-16**]):
      Negative for Respiratory Viral Antigen.
      Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
      and RSV by immunofluorescence.
      Refer to respiratory viral culture for further
information.

   Legionella Urinary Antigen  (Final [**2113-1-16**]):
      NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
           (Reference Range-Negative).
      Performed by Immunochromogenic assay.
      A negative result does not rule out infection due to other
L.
      pneumophila serogroups or other Legionella species.
Furthermore, in
      infected patients the excretion of antigen in urine may
vary.
.
[**2113-1-15**] 9:20 pm URINE      Source: Catheter.
                            **FINAL REPORT [**2113-1-17**]**
   URINE CULTURE (Final [**2113-1-17**]):    NO GROWTH.
.
URINE CULTURE (Final [**2113-1-18**]):    NO GROWTH.
.
[**2113-1-19**] 5:27 pm URINE      Source: CVS.
                            **FINAL REPORT [**2113-1-20**]**
   URINE CULTURE (Final [**2113-1-20**]):    <10,000 organisms/ml.
.
[**2113-1-15**] 1:10 pm BLOOD CULTURE
                            **FINAL REPORT [**2113-1-21**]**
   Blood Culture, Routine (Final [**2113-1-21**]):    NO GROWTH times 2
.
Discharge labs:
[**2113-1-20**] 07:50AM BLOOD WBC-8.1 RBC-4.49 Hgb-12.2 Hct-36.6 MCV-82
MCH-27.2 MCHC-33.4 RDW-14.5 Plt Ct-145*
[**2113-1-20**] 07:50AM BLOOD Glucose-85 UreaN-14 Creat-1.0 Na-139
K-3.5 Cl-105 HCO3-23 AnGap-15

Brief Hospital Course:
#Intensive Care Unit Course: In the MICU, she was started on
steroids and given standing nebulizers with inhaled steroids.
She underwent CTA of the chest to rule out PE given the
patient's tachycardia, which was negative. She was empirically
treated for a PNA/bronchitis with ceftriaxone and levofloxacin
initially. Lactate was initially elevated, and this was felt to
be due to her increased work of breathing. She received IV
fluids and with treatment of her symptoms, and her lactate
improved. The patient was on room air during her ICU course and
never required intubation. Because of persistent tachycardia and
right-sided abdominal pain, the patient underwent CTA of the
chest and CT of the abdomen/pelvis. Patient was found not to
have a pulmonary embolism, and there was no finding on CT of the
abdomen/pelvis to suggest a cause for her right-sided abdominal
pain. She was transferred to the general medicine floor for
further management of her asthma exacerbation (general medicine
floor hospital course outlined below).
.
GENERAL [**Hospital 662**] HOSPITAL COURSE
.
# Asthma exacerbation with presumed bacterial pneumonia: Patient
presented in respiratory distress. Asthma exacerbation most
likely secondary to viral URI/ possible flu-like symptoms with
myalgias. In the MICU, the patient received IV solumedrol and
was then transitioned to oral prednisone. She was receiving
albuterol and ipratropium nebulizers every 4 hours, with
abluterol nebulizer available every 2 hours as needed for
shortness of breath. Upon arrival to the medicine floor from the
MICU, the patient was very wheezy on exam, but with air
movement. Patient was transitioned to oral levofloxacin for
treatment of bronchitis. Oral prednisone 40mg daily was
continued on the floor, and the patient's scheduled nebulizer
treatments were increased to every 6 hours from every 4 hours.
The patient's home inhaler regimen and montelukast were
continued through her hospitalization. The patient's exam
improved with no wheezing appreciated on day of discharge. On
day of discharge, the patient was started on a long-steroid
taper, beginning with 30mg of oral prednisone for 3 days.
   OUTPATIENT ISSUES: Patient has scheduled follow-up with her
pulmonologist following this hospitalization. Continuation of
scheduled nebulizer treatments every 6 hours. Continuation of
home inhaler regimen. Continuation of Levofloxacin for treatment
of bronchitis.  Continuation of oral prednisone taper: Starting
[**2113-1-21**], take 30mg prednisone by mouth for 3 days. Starting
[**2113-1-24**], take 20mg of prednisone by mouth for 3 days. Starting
[**2113-1-27**], take 10mg of prednisone by mouth for 5 days. Starting
[**2113-2-1**], take 5mg of prednisone by mouth for 5 days and then
stop.
.
# Elevated CK, in setting of lactic acidosis: In the MICU,
patient was noted to have an elevated CK. CK was trended through
the patient's admission on the general medicine service.
Overall, patient had a downtrending CK: 857 --> 1272 --> 1416
--> 1150 --> 682. CK-MB and troponin were within normal limits.
Patient described myalgias as part of her illness that
precipitated her asthma exacerbation, which was thought to
explain the elevated CK. Serum creatinine was monitored and
trended to baseline upon day of discharge.
.
# Renal function, mild renal insufficiency, resolved: Upon
intial presentation, patient had elevated serum creatinine
(baseline 1.1). Patient appeared dry on exam secondary to poor
oral intake with cough. Anti-hypertensives were initially held
and patient received IV fluids. Lactate trended down with IV
fluids. Patient's serum creatinine also trended to baseline; on
day of discharge, patient's serum creatinine was 1.0.
.
# Urinary tract infection: Patient complained of dysuria and
hematuria with WBC elevated at 16.2 without bands on
differential. Urine analysis was remarkable to WBC and large
amount of blood. First urine culture was negative, and the
second urine culture had less than 10,000 organisms. The patient
was continued on levofloxacin until [**2113-1-24**] for treatment of a
complicated UTI given that the patient had a Foley catheter in
place while in the ICU.
  OUTPATIENT ISSUES: Continuation of Levofloxacin until
[**2113-1-24**] for treatment of a complicated UTI.
.
# Respiratory alkalosis: Resolved. Respiratory alkalosis was
likely due to tachypnea related to asthma exacerbation and
possibly some anxiety.
.
# Hypertension: Anti-hypertensives initially held but were
restarted in MICU. The patient was discharged on her [**Last Name (un) **] regimen
of amlodipine and lisinopril
.
# OSA: On BiPAP at night at home. Patient has been maintained on
CPAP autoset as an inpatient.
   OUTPATIENT ISSUES: Continuation of BiPAP at night as an
outpatient.
.
# Anxiety: On no anxiolytic agents as an outpatient. Was started
on lorazepam as needed in MICU, which was continued on the
floor.
.
# RVOT ventricular tachycardia: Patient was continued on
metoprolol as noted above through ICU course and through her
admission on the general medicine floor.



Medications on Admission:
Active Medication list as of [**2112-11-29**] (pt does not know all the
name of her medications)

Medications - Prescription
-ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for
Nebulization - 1 ampule four times a day as needed for PRN
-ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler -
[**12-12**]
puffs(s) inhaled four times a day
-AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
-CLONAZEPAM [KLONOPIN] - 1 mg Tablet - 1 Tablet(s) by mouth
daily (not currently taking this)
-EPINEPHRINE [EPIPEN] - 0.3 mg/0.3 mL (1:1,000) Pen Injector -
IM
PRN anaphylaxis as needed please dispense 2-pack
-ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 40 mg Capsule, Delayed
Release(E.C.) - 1 Capsule(s) by mouth once a day
-FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 2 puffs
intranasal once a day
-FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
twice daily with spacer- in addition to Advair
-FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose
Disk
with Device - 1 puff(s) inhaled twice a day
-LISINOPRIL - 20 mg Tablet - 2 Tablet(s) by mouth daily
-LORATADINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
-METOPROLOL SUCCINATE - 100 mg Tablet Extended Release 24 hr - 1

Tablet(s) by mouth twice a day
-MONTELUKAST [SINGULAIR] - 10 mg Tablet - 1 Tablet(s) by mouth
once a day
-NYSTATIN - 100,000 unit/mL Suspension - 1 by mouth 5 times
daily
-OMALIZUMAB [XOLAIR] - (Not Taking as Prescribed: on hold a s of

[**2112-10-20**]) - 150 mg Recon Soln - 300mg sub Q every two weeks4
-TRIAMTERENE-HYDROCHLOROTHIAZID - 37.5 mg-25 mg Capsule - 1
Capsule(s) by mouth daily
-CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] - 315 mg-200 unit
Tablet - 2 Tablet(s) by mouth twice daily
-DOCUSATE SODIUM - 100 mg Capsule - 1 Capsule(s) by mouth twice
a
day hold medication if experiencing diarrhea
-SENNOSIDES [SENNA] - 8.6 mg Capsule - 1 Capsule(s) by mouth
daily
as needed for constipation
-SODIUM CHLORIDE [SALINE NASAL] - (OTC) - 0.65 % Aerosol, Spray
-
1 spray intranasal once a day Can use more often if helpful


Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation .
3. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-12**] Sprays Nasal
TID (3 times a day).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
6. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal twice a day.
7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*0*
8. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours).
Disp:*16 nebulizer* Refills:*0*
11. ipratropium bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
Disp:*16 nebulizer* Refills:*0*
12. 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.
Disp:*1 inhaler* Refills:*0*
13. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) pen injector
Intramuscular PRN as needed for Anaphylasix.
14. nystatin 100,000 unit/mL Suspension Sig: Five (5) mL PO four
times a day.
Disp:*250 mL* Refills:*0*
15. Citracal + D 315-200 mg-unit Tablet Sig: Two (2) Tablet PO
once a day.
16. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
17. prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 3 days: Start date [**2113-1-21**]
Stop date [**2113-1-23**].
Disp:*9 Tablet(s)* Refills:*0*
18. prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day
for 3 days: Start date [**2113-1-24**]
Stop date [**2113-1-26**].
Disp:*6 Tablet(s)* Refills:*0*
19. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days: Start date [**2113-1-27**]
Stop date [**2113-2-1**].
Disp:*5 Tablet(s)* Refills:*0*
20. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day for
5 days: Start date [**2113-2-2**]
Stop date [**2113-2-5**].
Disp:*5 Tablet(s)* Refills:*0*
21. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
22. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*0*
23. Flovent HFA 110 mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Disp:*1 inhaler* Refills:*0*
24. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO twice a day.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
Multicultural VNA

Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Asthma exacerbation

SECONDARY DIAGNOSIS:
Bronchitis
Hypertension
Obstructive sleep apnea
Elevated creatinine kinase


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


Discharge Instructions:
Dear Ms. [**Known lastname 1004**],

It was a pleasure taking care of you during your hospitalization
at [**Hospital1 69**].

You were hospitalized with an asthma exacerbation thought to be
due to a bronchitis. You required monitoring in the intensive
care unit. However, you did well and did not require any
invasive procedures. You were then trasnfered to the floor for
further management of your asthma exacerbation, where oral
steroids, antibiotics, nebulizer treatments, and your home
asthma inhaler regimen were continued.

Upon discharge, you will continue asthma exacerbation treatment
with oral steroids, oral antibiotics, nebulizers, and your home
asthma inhaler regimen.

During this admission, you also developed a urinary tract
infection, which the antibiotics that you are on for treatment
of bronchitis will also cover for your urinary tract infection.

Please take all medications as instructed. It is *ABSOLUTELY*
important that you take your asthma medications as instructed as
this will prevent future hospitalizations for asthma
exacerbations.

Please note the following medication changes:
1. *NEW* Levofloxacin 750mg, 1 pill each day for another 4 days
to complete a full course of treatment for bronchitis and
urinary tract infection
2. *NEW* Prednisone taper: Starting [**2113-1-21**], take 30mg
prednisone by mouth for 3 days. Starting [**2113-1-24**], take 20mg of
prednisone by mouth for 3 days. Starting [**2113-1-27**], take 10mg of
prednisone by mouth for 5 days. Starting [**2113-2-1**], take 5mg of
prednisone by mouth for 5 days and then stop.
3. Please note that you are also being prescribed for the
inhalers that you regularly use at home.

Please keep all follow-up appointments; your up-coming follow-up
appointments are listed below.

Followup Instructions:
Department: MEDICAL SPECIALTIES
When: MONDAY [**2113-1-23**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: GASTROENTEROLOGY
When: WEDNESDAY [**2113-1-25**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18307**], MD [**Telephone/Fax (1) 1983**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: [**Hospital3 249**]
When: THURSDAY [**2113-1-26**] at 3:20 PM
With: Dr. [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] South [**Hospital **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
This appointment is with a hospital-based doctor as part of your
transition from the hospital back to your primary care provider.
[**Name10 (NameIs) 616**] this visit, you will see your              regular primary
care doctor in follow up.

Department: PULMONARY FUNCTION LAB
When: MONDAY [**2113-2-6**] at 10:40 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES-Pulmonary
When: MONDAY [**2113-2-6**] at 11:00 AM
With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Bacterial pneumonia, unspecified,Acute respiratory failure,Asthma, unspecified type, with (acute) exacerbation,Paroxysmal ventricular tachycardia,Mixed acid-base balance disorder,Urinary tract infection, site not specified,Obesity, unspecified,Unspecified essential hypertension,Anxiety state, unspecified,Obstructive sleep apnea (adult)(pediatric),Bronchitis, not specified as acute or chronic,Unspecified disorder of kidney and ureter'}


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: SOB, dyspnea, asthma attack

PRESENT ILLNESS: 48F with past medical history of hypertension, obesity, and RVOT
ventricular tachycardia, status post ablation in [**2111-1-12**],
allergic rhinitis, sleep apnea,depression, and iron deficiency
anemia, severe asthma who presents with cough for 1 week and
chest tightness. She notes that she had a "cold", associated
with headache, chills, nasal congestion and sorethroat which
started ~ 1week ago. Most prominent has been a persistent dry
cough and worsening SOB and wheezing. No sputum production. Does
note vague left sided chest pain worsened with cough. Also notes
significant myalgias she attributes to her persistent coughing.
She has been using her nebs, flovent twice daily, Adavir diskus
and albuterol as needed. Her albuterol for the last 2 days she
has been using several times during the day/evening "too many to
count". She states that her PF this AM was around 120 and is
usually in the 200s. So this made her come to the hospital.
.
Of note, patient with history of difficult to control asthma.
She is followed by Dr. [**First Name (STitle) 437**] pulm and by Dr. [**First Name (STitle) **] from sleep.
She was last seen by pulm in [**2112-7-11**] and by sleep in [**2112-9-10**].
As per notes, she has difficulty with medication compliance and
at times get confused about her inhalers. There was also
recommendation that she gets ride of her indoor cats (3 cats)
and farrets, however she had not done so. She states that she
has mice in her house and the cats help keep the mice way. She
was getting Xolair injection for her allergies, but she has
developed dizziness during her last injection in [**2112-10-11**]. She
saw cards since then who does not think this is related to
arrythmia and recommended doing EKG during her next injection.
She states that she has not received any injections since then.

MEDICAL HISTORY: Asthma- last spirometry showed FEV1/FVC of 107% of predicted
value
-OSA on BiPAP at night
-Obesity
-Anxiety (was previously on Klonapin)
- RVOT ventricular tachycardia: [**2111-2-5**] - Successful Ablation
at [**Hospital1 18**], prior attempted ablation at [**Hospital3 **] in [**2109**] - Now
on Metop Succ 100mg QD
- Depression
- Hypertension

MEDICATION ON ADMISSION: Active Medication list as of [**2112-11-29**] (pt does not know all the
name of her medications)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission physical exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, becomes very anxious with increase WOB
when develops wheezing
HEENT: Sclera anicteric, MMdry, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate tachy, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Expiratory wheezing through out, audible breath sounds
through out, increase WOB when having coughing spells leading to
worse wheezing- lasting 10-15 min. Then comfortable in between
Abdomen: soft, tender over the epigastric area, and right flank
area- pt with large scar from prior appendectomy and
cholecystectomy, non-distended, bowel sounds present, no
organomegaly
GU: foley with clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
Discharge physical exam:
Vitals: T 97.6 BP 168/87 (123-168/78-96) HR 87 (64-87) RR 20 O2
Sat 94% RA (94-98%)
General: Patient sitting up in bed in NAD. Able to complete full
sentences with no coughing fits this AM.
HEENT: EOMI. PERRL. MMM. OP without exudate.
CV: RRR. No M/R/G
LUNGS: No expiratory wheezes throughout, posteriorly. Mild
inspiratory rhonchorous breath sounds midway up the lung fields
bilaterally. Nml work of breathing. No accessory muscle use.
ABD: NABS+. Soft. NT/ND
EXT: WWP. No clubbing, cyanosis, or edema. 2+ raidal and DPs
bilaterally.

FAMILY HISTORY: Cousin with possible MI in her 40s. Maternal grandmother had an

SOCIAL HISTORY: Patient lives with two of her three children - daughters
actively involved in her care. Unemployed. Patient denies
tobacco, alcohol or illicit drugs. 

### Response:
{'Bacterial pneumonia, unspecified,Acute respiratory failure,Asthma, unspecified type, with (acute) exacerbation,Paroxysmal ventricular tachycardia,Mixed acid-base balance disorder,Urinary tract infection, site not specified,Obesity, unspecified,Unspecified essential hypertension,Anxiety state, unspecified,Obstructive sleep apnea (adult)(pediatric),Bronchitis, not specified as acute or chronic,Unspecified disorder of kidney and ureter'}
