CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: This is a 61 yo female with HIV on HAART (last CD4 1359 on
[**9-25**]) and asthma p/w 1 day of dyspnea and non-productive cough
with rhinorrhea. Denied fevers at home, did have sick contact
yesterday. [**Name2 (NI) **] po intake today [**1-8**] feeling unwell and cough.
Tried home flovent and albuterol without benefit.
.
Of note, pt was seen by PCP [**Last Name (NamePattern4) **] [**2132-11-20**] with increased blood
sugars due to changes in her med regimen, muscle aches, and
increase in her asthma sxs and increased use of inhalers. Before
that, she was seen in the ED on [**2132-9-20**] for a flu-like illness,
treated with oseltamivir, although flu swab came back negative.
.
En route to the ED, EMS gave 2 combivent nebs. In the ED,
initial VS were: 99.8 130 158/100 22 100%. Exam with wheezes and
rhonchi, 3rd combivent neb given, also 125mg IV
methylprednisolone and magnesium. Decompensated with hypoxia
requiring NRB, agitation and altered mental status. Given
midazolam, etomidate, succinylcholine and was intubated but
remained with sats in high 80s to low 90s on FiO2 1.0, so
increased PEEP to 12. CXR initially with diffuse opacity,
possible multifocal PNA. Given TMP-SMX and levofloxacin. Second
CXR with ?florid heart failure. Started on NTG drip. CTA chest
being done. Bedside U/S with hypodynamic LV. Access is 3 18g
PIVs. On propofol. Current VS: 130s 170s/90s 94-95% on 430x16,
12, 100%.
.
On the floor, patient is intubated and sedated, so further
history is not possible.
.

MEDICAL HISTORY: DMII
HCV
HIV (CD4 1359 [**9-14**], VL undetectable)
SUBARACHNOID HEMORRHAGE (L MCA aneurysm Left middle cerebral
aneursym ==> SAH s/p left pterional craniotomy and microsurgical
clipping of aneurysm and resection of incidental meningioma.
Current deficits: anosmia, agusia, dysarthria, dyscalcula,
dyslexia. CANT HAVE MRI D/T CLIPS)
HEADACHES
HYPERTENSION
PAROTID ENLARGEMENT
ASTHMA
GOITER [**2118**]
ELBOW FRACTURE [**2123-5-7**]
LLE SOFT TISSUE MASS
COLONIC POLYPS [**2128-9-2**]
Depression/anxiety

MEDICATION ON ADMISSION: ALBUTEROL - 90 mcg Aerosol - 2 puffs inhaler q4-6 hours
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled
q 6h as needed for shortness of breath
CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth once a day
DILTIAZEM HCL [DILT-XR] - 180 mg Capsule,Degradable Cnt Release
-
1 Capsule(s) by mouth once a day
FLUTICASONE - 50 mcg Spray, Suspension - 1 spray intranasal once
a day
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 1
inhalation(s) by mouth twice a day Rinse mouth after use
GLYBURIDE-METFORMIN [GLUCOVANCE] - 2.5 mg-500 mg Tablet - 1
Tablet(s) by mouth twice a day
HYDROCHLOROTHIAZIDE - 25 mg Tablet - [**12-8**] Tablet(s) by mouth once
a day
IBUPROFEN - 800 mg Tablet - 1 Tablet(s) by mouth every eight (8)
hours as needed for pain
LAMIVUDINE-ZIDOVUDINE [COMBIVIR] - 150 mg-300 mg Tablet - one
Tablet(s) by mouth twice a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
NEVIRAPINE - 200 mg Tablet - 1 Tablet(s) by mouth twice a day
OXYCODONE - 5 mg Tablet - [**12-8**] Tablet(s) by mouth twice a day as
needed for pain
ASCORBIC ACID - 1,000 mg Tablet - 1 Tablet(s) by mouth once a
day
ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a
day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM WITH VITAMIN D] - 600
mg-400 unit Tablet - 1 Tablet(s) by mouth three times a day
CETIRIZINE-PSEUDOEPHEDRINE - 5 mg-120 mg Tablet Sustained
Release
12 hr - 1 Tablet(s) by mouth twice a day as needed for sinus
symptoms
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] -   Tablet - ONE
Tablet(s) by mouth once a day
TERBINAFINE - 1 % Cream - apply to afected area twice a day

ALLERGIES: Codeine / Percodan

PHYSICAL EXAM: Physical exam on discharge:
VS: T:97.9, HR:87, BP:118/83, RR:18, O2sat:100%RA
Gen: alert, breathing normally, in NAD
Neck: JVP 10 cm at 30 degrees
CV: Regular rate and rhythm. No m/r/g.
Pulm: Dependent crackles on right with patient in R lateral
decubitus position.
Abd: +BS. S/NT/ND.
Ext: WWP, no edema.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Born [**Location (un) 86**], completed 2 years of college ==> 2 sons ([**2119**]: ages
27, 30) with 2 different fathers. H/o 30 pack-years tobacco;
quit [**2109**]. No ETOH or drugs per OMR. Lives at home per her son.
[**Name (NI) **] hospitalizations, [**Hospital1 1501**] admissions, or known recent abx per
son.
Acute respiratory failure,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Acute kidney failure, unspecified,Asthma, unspecified type, unspecified,Asymptomatic human immunodeficiency virus [HIV] infection status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified viral hepatitis C without hepatic coma,Dysthymic disorder,Unspecified essential hypertension,Hypoxemia,Other chronic pulmonary heart diseases,Mitral valve disorders
Acute respiratry failure,Ac on chr syst hrt fail,Prim cardiomyopathy NEC,Acute kidney failure NOS,Asthma NOS,Asymp hiv infectn status,DMII wo cmp nt st uncntr,Hpt C w/o hepat coma NOS,Dysthymic disorder,Hypertension NOS,Hypoxemia,Chr pulmon heart dis NEC,Mitral valve disorder
Admission Date:  [**2132-11-22**]              Discharge Date:   [**2132-11-27**]

Date of Birth:  [**2071-4-14**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine / Percodan

Attending:[**First Name3 (LF) 443**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
endotracheal intubation, bronchoscopy


History of Present Illness:
This is a 61 yo female with HIV on HAART (last CD4 1359 on
[**9-25**]) and asthma p/w 1 day of dyspnea and non-productive cough
with rhinorrhea. Denied fevers at home, did have sick contact
yesterday. [**Name2 (NI) **] po intake today [**1-8**] feeling unwell and cough.
Tried home flovent and albuterol without benefit.
.
Of note, pt was seen by PCP [**Last Name (NamePattern4) **] [**2132-11-20**] with increased blood
sugars due to changes in her med regimen, muscle aches, and
increase in her asthma sxs and increased use of inhalers. Before
that, she was seen in the ED on [**2132-9-20**] for a flu-like illness,
treated with oseltamivir, although flu swab came back negative.
.
En route to the ED, EMS gave 2 combivent nebs. In the ED,
initial VS were: 99.8 130 158/100 22 100%. Exam with wheezes and
rhonchi, 3rd combivent neb given, also 125mg IV
methylprednisolone and magnesium. Decompensated with hypoxia
requiring NRB, agitation and altered mental status. Given
midazolam, etomidate, succinylcholine and was intubated but
remained with sats in high 80s to low 90s on FiO2 1.0, so
increased PEEP to 12. CXR initially with diffuse opacity,
possible multifocal PNA. Given TMP-SMX and levofloxacin. Second
CXR with ?florid heart failure. Started on NTG drip. CTA chest
being done. Bedside U/S with hypodynamic LV. Access is 3 18g
PIVs. On propofol. Current VS: 130s 170s/90s 94-95% on 430x16,
12, 100%.
.
On the floor, patient is intubated and sedated, so further
history is not possible.
.


Past Medical History:
DMII
HCV
HIV (CD4 1359 [**9-14**], VL undetectable)
SUBARACHNOID HEMORRHAGE (L MCA aneurysm Left middle cerebral
aneursym ==> SAH s/p left pterional craniotomy and microsurgical
clipping of aneurysm and resection of incidental meningioma.
Current deficits: anosmia, agusia, dysarthria, dyscalcula,
dyslexia. CANT HAVE MRI D/T CLIPS)
HEADACHES
HYPERTENSION
PAROTID ENLARGEMENT
ASTHMA
GOITER [**2118**]
ELBOW FRACTURE [**2123-5-7**]
LLE SOFT TISSUE MASS
COLONIC POLYPS [**2128-9-2**]
Depression/anxiety

Social History:
Born [**Location (un) 86**], completed 2 years of college ==> 2 sons ([**2119**]: ages
27, 30) with 2 different fathers. H/o 30 pack-years tobacco;
quit [**2109**]. No ETOH or drugs per OMR. Lives at home per her son.
[**Name (NI) **] hospitalizations, [**Hospital1 1501**] admissions, or known recent abx per
son.

Family History:
Noncontributory

Physical Exam:
Physical exam on discharge:
VS: T:97.9, HR:87, BP:118/83, RR:18, O2sat:100%RA
Gen: alert, breathing normally, in NAD
Neck: JVP 10 cm at 30 degrees
CV: Regular rate and rhythm. No m/r/g.
Pulm: Dependent crackles on right with patient in R lateral
decubitus position.
Abd: +BS. S/NT/ND.
Ext: WWP, no edema.

Pertinent Results:
I. Labs

A. Admission
[**2132-11-22**] 09:15PM BLOOD WBC-8.1 RBC-3.14* Hgb-12.7 Hct-37.0
MCV-118* MCH-40.3* MCHC-34.2 RDW-14.9 Plt Ct-323
[**2132-11-22**] 09:15PM BLOOD Neuts-67.2 Lymphs-26.8 Monos-4.2 Eos-0.7
Baso-1.1
[**2132-11-22**] 09:15PM BLOOD Plt Ct-323
[**2132-11-22**] 09:15PM BLOOD Glucose-167* UreaN-22* Creat-1.0 Na-138
K-3.8 Cl-104 HCO3-22 AnGap-16
[**2132-11-22**] 09:15PM BLOOD ALT-68* AST-56* CK(CPK)-795* AlkPhos-61
TotBili-0.5
[**2132-11-23**] 11:03AM BLOOD Albumin-3.7 Calcium-9.5 Phos-5.4* Mg-1.6
[**2132-11-22**] 09:15PM BLOOD TSH-0.78
[**2132-11-22**] 09:15PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2132-11-23**] 01:20AM BLOOD Type-ART Temp-37.1 pO2-327* pCO2-55*
pH-7.16* calTCO2-21 Base XS--9
[**2132-11-22**] 10:09PM BLOOD Lactate-3.0*
[**2132-11-23**] 01:20AM BLOOD freeCa-1.31

B. Cardiac
[**2132-11-23**] 11:03AM BLOOD CK-MB-4 cTropnT-<0.01
[**2132-11-22**] 09:15PM BLOOD CK-MB-5 cTropnT-<0.01 proBNP-3382*

C. Urine
[**2132-11-22**] 10:25PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013
[**2132-11-22**] 10:25PM URINE Blood-SM Nitrite-NEG Protein-75
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2132-11-22**] 10:25PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-1
[**2132-11-23**] 02:17PM URINE Hours-RANDOM UreaN-800 Creat-155 Na-22
K-84 Cl-13
[**2132-11-23**] 02:17PM URINE Osmolal-612

D. Discharge
CBC: wbc 6.7, hct 33.3, plt 281
Chem 7: Na 138, L 4.5, Cl 105, HCO3 25, BUN 31, Cr 0.9, Glu 177
Ca 8.7, Mg 1.9, Phos 3.2
.
II. Microbiology
[**2132-11-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-11-23**] Rapid Respiratory Viral Screen & Culture
Respiratory Viral Culture-PRELIMINARY; Respiratory Viral Antigen
Screen-FINAL INPATIENT
[**2132-11-23**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL;
RESPIRATORY CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY;
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-FINAL INPATIENT
[**2132-11-23**] URINE URINE CULTURE-FINAL INPATIENT
[**2132-11-23**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2132-11-23**] Influenza A/B by DFA DIRECT INFLUENZA A
ANTIGEN TEST-FINAL; DIRECT INFLUENZA B ANTIGEN TEST-FINAL
INPATIENT
[**2132-11-23**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
.
III. Imaging
.
A. CXR ([**2132-11-22**])
IMPRESSION:ETT and NGT positioned appropriately. Diffuse
pulmonary ground
glass opacities, more confluent at the bases, may represent
atypical infection
such as PCP versus pulmonary edema. Please refer to subsequent
CTA chest for
further details.
.
B. CTA Chest ([**2132-11-22**])
IMPRESSION:
1. Patchy ground-glass opacities distributed across the lung
parenchyma, with associated septal thickening, most compatible
with moderate-to-severe pulmonary edema.
2. Moderate-sized bilateral pleural effusions.
3. Bibasilar consolidations, concerning for pneumonia.
Aspiration is also on the differential given the rapid onset of
symptoms.
4. No pulmonary embolism detected to the subsegmental levels.
5. No dissection.
.
IV. Cardiology
A. EKG
Probable sinus tachycardia. Non-specific ST-T wave changes.
Compared to the previous tracing of [**2132-4-14**] the ventricular rate
is faster. ST-T wave changes are new.
.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
141 0 78 [**Telephone/Fax (2) 100033**]8
.
B. ECHO
The left atrium is mildly dilated. The right atrial pressure is
indeterminate. Left ventricular wall thicknesses and cavity size
are normal. There is severe global left ventricular hypokinesis
(LVEF = 25%). Systolic function of apical segments is relatively
preserved. No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size is normal with mild global free
wall hypokinesis. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a very small pericardial
effusion primarily around the right atrium.
.
IMPRESSION: Normal left ventricular cavity size with severe
global hypokinesis c/w diffuse process (toxin, metabolic, etc. -
cannot fully exclude multivessel CAD). Pulmonary artery systolic
hypertension. Mild-moderate mitral regurgitation.
Compared with the report of the prior study (images unavailable
for review) of [**2126-6-28**], the findings are new.
.
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or [**Last Name (un) **].
Based on [**2128**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
Pending cultures (to be followed by PCP):
- blood culture [**2132-11-23**], [**2132-11-24**]: pending


Brief Hospital Course:
61-year-old female with HIV on HAART (last CD4 1359 on [**9-25**])
and asthma presented with one day of dyspnea and non-productive
cough, intubated for hypoxic respiratory failure likely
secondary to pulmonary edema in setting of new cardiomyopathy.

# Hypoxic respiratory failure:
Patient had large component of pulmonary edema on CXR.
Precipitant unclear as cardiac biomarkers negative not
suggestive of ischemia but ECHO showing severe global
hypokinesis consistent with diffuse process with pulmonary
artery systolic hypertension, and mild-moderate regurgitation.
Co-existing infection thought to be less likely with pneumonia
not favored given no fever, leukocytosis; however, a
retrocardiac opacity was noted on CXR. Influenza testing
negative in setting of myalgias, malaise, upper respiratory
systems. Patient was empirically covered for CAP with
ceftriaxone and levofloxacin for empiric infection, which was
subsequently discontinued. She underwent bronchoscopy, which was
grossly unremarkable with bronchial culture and rapid
respiratory viral screen/culture, fungal culture, and PCP were
all negative.
.
She also underwent diuresis with a nitro gtt in the initial
stages.  Asthma exacerbation not suggested. Patient underwent
endotracheal intubation with approximately 1-day of respiratory
support and subsequently extubated without issue.
At the time of discharge, patient was on room air with 100%
oxygen saturation
.
# Dilated cardiomyopathy with systolic heart failure: Etiology
of cardiomyopathy considered included toxic metabolic, viral,
and ischemic. Based on EKG, patient does not have overt signs of
ischemic disease. Patient had stress testing in [**2127**] and last
ECHO in [**2125**] not suggestive of above abnormalities.
Echocardiogram demonstrated dilated cariomyopathy with LVEF of
25%. Patient was started on aspirin, carvedilol, and lasix.
Follow-up with heart failure clinic/cardiomyopathy clinic was
made prior to discharge.
.
# HIV: Patient has well-controlled HIV with persistent CD4 > 500
and undetectable VL. She was continued on HAART.
.
# DM: She was continued on SSI in house.
.
# Asthma: She was continued on fluticasone with prn nebs.
.
# Depression/anxiety: She was continued on citalopram.


Medications on Admission:
ALBUTEROL - 90 mcg Aerosol - 2 puffs inhaler q4-6 hours
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled
q 6h as needed for shortness of breath
CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth once a day
DILTIAZEM HCL [DILT-XR] - 180 mg Capsule,Degradable Cnt Release
-
1 Capsule(s) by mouth once a day
FLUTICASONE - 50 mcg Spray, Suspension - 1 spray intranasal once
a day
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 1
inhalation(s) by mouth twice a day Rinse mouth after use
GLYBURIDE-METFORMIN [GLUCOVANCE] - 2.5 mg-500 mg Tablet - 1
Tablet(s) by mouth twice a day
HYDROCHLOROTHIAZIDE - 25 mg Tablet - [**12-8**] Tablet(s) by mouth once
a day
IBUPROFEN - 800 mg Tablet - 1 Tablet(s) by mouth every eight (8)
hours as needed for pain
LAMIVUDINE-ZIDOVUDINE [COMBIVIR] - 150 mg-300 mg Tablet - one
Tablet(s) by mouth twice a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
NEVIRAPINE - 200 mg Tablet - 1 Tablet(s) by mouth twice a day
OXYCODONE - 5 mg Tablet - [**12-8**] Tablet(s) by mouth twice a day as
needed for pain
ASCORBIC ACID - 1,000 mg Tablet - 1 Tablet(s) by mouth once a
day
ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a
day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM WITH VITAMIN D] - 600
mg-400 unit Tablet - 1 Tablet(s) by mouth three times a day
CETIRIZINE-PSEUDOEPHEDRINE - 5 mg-120 mg Tablet Sustained
Release
12 hr - 1 Tablet(s) by mouth twice a day as needed for sinus
symptoms
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] -   Tablet - ONE
Tablet(s) by mouth once a day
TERBINAFINE - 1 % Cream - apply to afected area twice a day


Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every 4-6 hours as needed for shortness
of breath or wheezing.
Disp:*3 inhalers* Refills:*2*
2. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO once a day.
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*2 inhalers* Refills:*2*
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
spray Nasal once a day.
Disp:*2 bottle* Refills:*2*
6. glyburide-metformin 2.5-500 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
7. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Combivir 150-300 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
9. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. nevirapine 200 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
11. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
16. Calcium 600 with Vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: One (1) Capsule PO three times a day.
Disp:*90 Capsule(s)* Refills:*2*
17. Lancets,Thin     Misc Sig: One (1)  Miscellaneous four times
a day.
Disp:*1 pack* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] VNA

Discharge Diagnosis:
Dilated cardiomyapathy
Congestive heart failure
HIV
Hepatitis C
Asthma


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


Discharge Instructions:
Ms. [**Known lastname 24642**], you were admitted to the [**Hospital1 827**] because you were having difficulty breathing. We
had had to briefly put a breathing tube in you but you got
better and we removed it. You were found to have severe dilated
cardiomyopathy, which means your heart is large and does not
pump well. We gave you medication to get rid of extra fluids in
your body. At the time of discharge, you are able to walk around
and had no trouble breathing.
.
We made the following changes to your medications:
ADDED-
1. Furosemide 20 mg by mouth per day
2. Aspirin 81 mg by mouth per day
3. Carvedilol 12.5 mg by mouth twice a day

Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2132-12-3**] at 9:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: INFECTIOUS DISEASE
When: THURSDAY [**2132-12-18**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 568**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: [**Hospital3 249**]
When: THURSDAY [**2133-1-1**] at 9:20 AM
With: [**Name6 (MD) **] [**Name8 (MD) 13532**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2132-11-27**]
{'Acute respiratory failure,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Acute kidney failure, unspecified,Asthma, unspecified type, unspecified,Asymptomatic human immunodeficiency virus [HIV] infection status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified viral hepatitis C without hepatic coma,Dysthymic disorder,Unspecified essential hypertension,Hypoxemia,Other chronic pulmonary heart diseases,Mitral valve disorders'}


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: This is a 61 yo female with HIV on HAART (last CD4 1359 on
[**9-25**]) and asthma p/w 1 day of dyspnea and non-productive cough
with rhinorrhea. Denied fevers at home, did have sick contact
yesterday. [**Name2 (NI) **] po intake today [**1-8**] feeling unwell and cough.
Tried home flovent and albuterol without benefit.
.
Of note, pt was seen by PCP [**Last Name (NamePattern4) **] [**2132-11-20**] with increased blood
sugars due to changes in her med regimen, muscle aches, and
increase in her asthma sxs and increased use of inhalers. Before
that, she was seen in the ED on [**2132-9-20**] for a flu-like illness,
treated with oseltamivir, although flu swab came back negative.
.
En route to the ED, EMS gave 2 combivent nebs. In the ED,
initial VS were: 99.8 130 158/100 22 100%. Exam with wheezes and
rhonchi, 3rd combivent neb given, also 125mg IV
methylprednisolone and magnesium. Decompensated with hypoxia
requiring NRB, agitation and altered mental status. Given
midazolam, etomidate, succinylcholine and was intubated but
remained with sats in high 80s to low 90s on FiO2 1.0, so
increased PEEP to 12. CXR initially with diffuse opacity,
possible multifocal PNA. Given TMP-SMX and levofloxacin. Second
CXR with ?florid heart failure. Started on NTG drip. CTA chest
being done. Bedside U/S with hypodynamic LV. Access is 3 18g
PIVs. On propofol. Current VS: 130s 170s/90s 94-95% on 430x16,
12, 100%.
.
On the floor, patient is intubated and sedated, so further
history is not possible.
.

MEDICAL HISTORY: DMII
HCV
HIV (CD4 1359 [**9-14**], VL undetectable)
SUBARACHNOID HEMORRHAGE (L MCA aneurysm Left middle cerebral
aneursym ==> SAH s/p left pterional craniotomy and microsurgical
clipping of aneurysm and resection of incidental meningioma.
Current deficits: anosmia, agusia, dysarthria, dyscalcula,
dyslexia. CANT HAVE MRI D/T CLIPS)
HEADACHES
HYPERTENSION
PAROTID ENLARGEMENT
ASTHMA
GOITER [**2118**]
ELBOW FRACTURE [**2123-5-7**]
LLE SOFT TISSUE MASS
COLONIC POLYPS [**2128-9-2**]
Depression/anxiety

MEDICATION ON ADMISSION: ALBUTEROL - 90 mcg Aerosol - 2 puffs inhaler q4-6 hours
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled
q 6h as needed for shortness of breath
CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth once a day
DILTIAZEM HCL [DILT-XR] - 180 mg Capsule,Degradable Cnt Release
-
1 Capsule(s) by mouth once a day
FLUTICASONE - 50 mcg Spray, Suspension - 1 spray intranasal once
a day
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 1
inhalation(s) by mouth twice a day Rinse mouth after use
GLYBURIDE-METFORMIN [GLUCOVANCE] - 2.5 mg-500 mg Tablet - 1
Tablet(s) by mouth twice a day
HYDROCHLOROTHIAZIDE - 25 mg Tablet - [**12-8**] Tablet(s) by mouth once
a day
IBUPROFEN - 800 mg Tablet - 1 Tablet(s) by mouth every eight (8)
hours as needed for pain
LAMIVUDINE-ZIDOVUDINE [COMBIVIR] - 150 mg-300 mg Tablet - one
Tablet(s) by mouth twice a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
NEVIRAPINE - 200 mg Tablet - 1 Tablet(s) by mouth twice a day
OXYCODONE - 5 mg Tablet - [**12-8**] Tablet(s) by mouth twice a day as
needed for pain
ASCORBIC ACID - 1,000 mg Tablet - 1 Tablet(s) by mouth once a
day
ASPIRIN - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth once a
day
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM WITH VITAMIN D] - 600
mg-400 unit Tablet - 1 Tablet(s) by mouth three times a day
CETIRIZINE-PSEUDOEPHEDRINE - 5 mg-120 mg Tablet Sustained
Release
12 hr - 1 Tablet(s) by mouth twice a day as needed for sinus
symptoms
MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] -   Tablet - ONE
Tablet(s) by mouth once a day
TERBINAFINE - 1 % Cream - apply to afected area twice a day

ALLERGIES: Codeine / Percodan

PHYSICAL EXAM: Physical exam on discharge:
VS: T:97.9, HR:87, BP:118/83, RR:18, O2sat:100%RA
Gen: alert, breathing normally, in NAD
Neck: JVP 10 cm at 30 degrees
CV: Regular rate and rhythm. No m/r/g.
Pulm: Dependent crackles on right with patient in R lateral
decubitus position.
Abd: +BS. S/NT/ND.
Ext: WWP, no edema.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Born [**Location (un) 86**], completed 2 years of college ==> 2 sons ([**2119**]: ages
27, 30) with 2 different fathers. H/o 30 pack-years tobacco;
quit [**2109**]. No ETOH or drugs per OMR. Lives at home per her son.
[**Name (NI) **] hospitalizations, [**Hospital1 1501**] admissions, or known recent abx per
son. 

### Response:
{'Acute respiratory failure,Acute on chronic systolic heart failure,Other primary cardiomyopathies,Acute kidney failure, unspecified,Asthma, unspecified type, unspecified,Asymptomatic human immunodeficiency virus [HIV] infection status,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified viral hepatitis C without hepatic coma,Dysthymic disorder,Unspecified essential hypertension,Hypoxemia,Other chronic pulmonary heart diseases,Mitral valve disorders'}
