CHIEF COMPLAINT: Shortness of Breath

PRESENT ILLNESS: Patient with a history of severe COPD secondary to longterm
smoking use although he quite smoking successfully 6 years ago.
Is on baseline oxygen at 2.5 liters per minute which he only
requires during the daytime and does not typically use at night.

MEDICAL HISTORY: COPD on home 2.5L O2
Descending aortic aneurysm 4.9cm on CT in [**8-21**], with mural
thrombi
AAA 3.9 cm at the infrarenal aorta, with mural thrombi
Inguinal hernia
Hypercholesterolemia
[**12-13**]+ TR, [**12-13**]+ MR, mild PA HTN (from TTE [**2105-8-10**])

MEDICATION ON ADMISSION: -Flovent HFA 110mcg, 2 puffs [**Hospital1 **]
-Proair 8.5g 2 puffs q4-6 prn shortness of breath
-Spiriva inhaler, 1 cap inhaled daily
-Lorazepam 0.5mg PO PRN anxiety
-Oxygen 2.5 lpm
-Prednisone 5mg PO every other day
-Barrier cream for skin rash, daily

ALLERGIES: Amoxicillin / Ciprofloxacin / Bactrim / Clindamycin / Citrucel

PHYSICAL EXAM: Admission Physical:
.
Vitals: per Metavision
General: Alert, oriented, uncomfortable in BiPAP mask
HEENT: Sclera anicteric, MMM, EOMI, PERRL, wearing BiPAP
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops,
bilateral peripheral IVs
Lungs: Bilateral rhonchi with scattered wheezes, retractions
throughout
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: moves all extremities spontaneously
Skin: multiple excoriations over the back
.
Discharge Physical
.
V/S:
Temp: 37 ??????C HR: 96 BP: 128/84 RR 20 95% 5L NC
General: Sleeping, easily arousable, alert and oriented once
awake
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops, bilateral
peripheral IVs
Lungs: B/L Rhonchi improved from yesterday, few scattered
wheezes, no retractions, diminished excursion b/l
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: moves all extremities spontaneously
Skin: multiple excoriations over the back

FAMILY HISTORY: Denies family history of COPD or lung cancer. Has family history
of diabetes. Denies family history of MI.

SOCIAL HISTORY: Former smoker. Quit 3-4 years ago. Started smoking at age 15.
Smoked up to 2 packs/day.  1 glass wine/night.  No drugs.
Lives with wife. Retired. Used to work as security officer for
Bank [**Location (un) 86**].
Obstructive chronic bronchitis with (acute) exacerbation,Other dependence on machines, supplemental oxygen,Personal history of tobacco use,Long-term (current) use of steroids,Thoracoabdominal aneurysm, without mention of rupture,Dermatophytosis of the body,Pure hypercholesterolemia,Diseases of tricuspid valve,Mitral valve disorders,Other chronic pulmonary heart diseases,Unqualified visual loss, both eyes,Do not resuscitate status
Obs chr bronc w(ac) exac,Depend-supplement oxygen,History of tobacco use,Long-term use steroids,Thracabd anurysm wo rupt,Dermatophytosis of body,Pure hypercholesterolem,Tricuspid valve disease,Mitral valve disorder,Chr pulmon heart dis NEC,Blindness NOS, both eyes,Do not resusctate status
Admission Date:  [**2107-5-22**]              Discharge Date:   [**2107-5-24**]

Date of Birth:  [**2022-12-8**]             Sex:   M

Service: MEDICINE

Allergies:
Amoxicillin / Ciprofloxacin / Bactrim / Clindamycin / Citrucel

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Shortness of Breath

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Patient with a history of severe COPD secondary to longterm
smoking use although he quite smoking successfully 6 years ago.
Is on baseline oxygen at 2.5 liters per minute which he only
requires during the daytime and does not typically use at night.

He does not use his nebulizer treatments routinely, but used 2
yesterday and 3 today without significant relief.  He was
maintaining his baseline until 2 days ago when he started
devloping a productive cough and progressive shortness of breath
- he directed his wife not to call 9-1-1 at that time; today his
breathing became acutely worse while trying to have dinner and
he told his wife he needed to go to the emergency department at
that time.

There has been no fever, no n/v/d.  No chest pain.  No extremity
pain or leg pain, no extremity swelling.  Wife confirms DNR/DNI.
 He has recently begun treatment with a wound care nurse for a
fungal infection of his skin complicated by excoriations.

In the ED, initial VS were: 100.1 ??????F (37.8 ??????C) (Temporal
Artery), Pulse: 124, RR: 38, BP: 147/101, O2Flow: 98.  He was
placed on BiPAP, started on antibiotics in the setting of a
low-grade fever and a productive cough.  He was loaded with
solumedrol, given ativan to improve bipap tolerance.  He was
then admitted to the MICU for BiPAP requirement, oxygen demand,
and work of breathing.

On arrival to the MICU, the patient appeared uncomfortable in
his BiPAP, but otherwise was saturating well, but tachypneic.
His wife was at his bedside with him.  He complains about the
discomfort of the mask, but denies any pain at this time.

Past Medical History:
COPD on home 2.5L O2
Descending aortic aneurysm 4.9cm on CT in [**8-21**], with mural
thrombi
AAA 3.9 cm at the infrarenal aorta, with mural thrombi
Inguinal hernia
Hypercholesterolemia
[**12-13**]+ TR, [**12-13**]+ MR, mild PA HTN (from TTE [**2105-8-10**])


Social History:
Former smoker. Quit 3-4 years ago. Started smoking at age 15.
Smoked up to 2 packs/day.  1 glass wine/night.  No drugs.
Lives with wife. Retired. Used to work as security officer for
Bank [**Location (un) 86**].


Family History:
Denies family history of COPD or lung cancer. Has family history
of diabetes. Denies family history of MI.


Physical Exam:
Admission Physical:
.
Vitals: per Metavision
General: Alert, oriented, uncomfortable in BiPAP mask
HEENT: Sclera anicteric, MMM, EOMI, PERRL, wearing BiPAP
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops,
bilateral peripheral IVs
Lungs: Bilateral rhonchi with scattered wheezes, retractions
throughout
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: moves all extremities spontaneously
Skin: multiple excoriations over the back
.
Discharge Physical
.
V/S:
Temp: 37 ??????C HR: 96 BP: 128/84 RR 20 95% 5L NC
General: Sleeping, easily arousable, alert and oriented once
awake
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops, bilateral
peripheral IVs
Lungs: B/L Rhonchi improved from yesterday, few scattered
wheezes, no retractions, diminished excursion b/l
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: moves all extremities spontaneously
Skin: multiple excoriations over the back

Pertinent Results:
Admission Labs:
.
[**2107-5-22**] 05:40PM BLOOD WBC-11.0# RBC-4.54* Hgb-14.3 Hct-43.9
MCV-97 MCH-31.4 MCHC-32.5 RDW-13.6 Plt Ct-280
[**2107-5-22**] 05:40PM BLOOD Neuts-89.4* Lymphs-5.0* Monos-3.4 Eos-1.7
Baso-0.5
[**2107-5-22**] 05:40PM BLOOD PT-10.4 PTT-27.3 INR(PT)-1.0
[**2107-5-22**] 05:40PM BLOOD Plt Ct-280
[**2107-5-22**] 05:40PM BLOOD Glucose-133* UreaN-21* Creat-1.0 Na-138
K-4.6 Cl-95* HCO3-34* AnGap-14
[**2107-5-22**] 05:40PM BLOOD ALT-15 AST-30 AlkPhos-75 TotBili-0.6
[**2107-5-22**] 05:40PM BLOOD cTropnT-<0.01
[**2107-5-22**] 05:40PM BLOOD Lipase-15
[**2107-5-22**] 05:40PM BLOOD Albumin-4.4 Phos-3.7 Mg-2.2
[**2107-5-22**] 07:53PM BLOOD Type-[**Last Name (un) **] Temp-38.2 Rates-/31 Tidal V-500
PEEP-5 FiO2-60 pO2-43* pCO2-67* pH-7.29* calTCO2-34* Base XS-2
Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NIPPV
[**2107-5-22**] 05:48PM BLOOD Lactate-1.9
.
Discharge Labs:
.
[**2107-5-24**] 05:32AM BLOOD WBC-14.8*# RBC-3.87* Hgb-12.2* Hct-37.5*
MCV-97 MCH-31.6 MCHC-32.6 RDW-13.8 Plt Ct-210
[**2107-5-24**] 05:32AM BLOOD Plt Ct-210
[**2107-5-24**] 05:32AM BLOOD Glucose-142* UreaN-41* Creat-0.8 Na-133
K-5.0 Cl-96 HCO3-26 AnGap-16
[**2107-5-24**] 05:32AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.5
.
Pertinent Imaging:
CXR [**5-22**]:
Portable AP radiograph of the chest was reviewed in comparison
to [**2107-5-22**] at 5:43 p.m.
.
Heart size is normal.  Aneurysmal descending thoracic aorta is
redemonstrated. Bilateral enlargement of pulmonary arteries,
most likely consistent with pulmonary hypertension is
redemonstrated.  Severe emphysema involving upper and mid lung
zones and to some extent lower lobes is redemonstrated.  No
pneumothorax is seen.  The patient might potentially have small
hiatal hernia.
No pneumothorax is seen.  Minimal bibasilar atelectasis is
present.  Overall, no abnormality has developed in the interim
to explain patient's symptoms since the prior radiograph.

Brief Hospital Course:
84 y/o male with history of COPD presenting with 2 days of
worsening shortness of breath and a productive cough, needing
BiPAP, admitted for increased work of breathing.
.
#COPD Exacerbation: likely due to wife having respiratory
illness in the last 2 weeks, less likely is PE which was
considered in the face of this patient population having
increased risk of PE, but with a good source and response to
COPD therapies COPD exacerbation is the most likely diagnosis.
-continue NC & high flow, tolerated better than BiPAP
-continuous vs stacked nebs
-continue prednisone at 40mg today, start [**Year (4 digits) 15123**] tomorrow
-hold home spiriva at this time
-morphine for air hunger
-DNI/DNR
-CM for LTAC
**ICU Course**
The patient was quickly transitioned off BiPAP his first night
in the unit and did well with nebulizers and nasal cannula, but
intermittently required high-flow oxygen with corresponding
tachypnea to maintain O2 saturations in the mid 90's; he quickly
recovered once that therapy was initiated, howevever.  He has
been stable on 5L via nasal cannula for the last day.  He
received 4 doses of IV methylpred, and was started on a steroid
[**Last Name (LF) 15123**], [**First Name3 (LF) **] far has received 40mg [**Hospital1 **] of prednisone, will be
slowly tapered over the next 2 weeks then he should continue his
5mg regimen [**Hospital1 **].  He has been receiving scheduled nebs, this
should continue.
.
#PNA/Bronchitis: low grade fever, unlikely pneumonia on CXR,
will narrow coverage to levo in the face of this; if spikes or
deteriorates low threshold for advancing to MRSA coverage with
vanc for cefepime.
-levo 750mg q48, next dose 6/12 AM
-airway management as above
-follow cultures
**ICU Course**
The patient had low-grade temps, but is being treated for
pneumonia given his increased risk having COPD and a productive
cough.  Due to his creatinine clearance he was dosed 750mg q48,
he has received 1 dose and will need to receive a dose at 10pm
tonight and then his last dose at 10pm on [**5-26**].
.
#Vision Changes: patient with several months of worsening
vision, unable to get to eye doctor due to financial
constraints, wife is asking that this be looked into.
**ICU Course**
No emergent need to address this in the ICU, should be
evaluated/facilitated in the outpatient setting.
.
# FEN: No IVF, replete electrolytes, regular diet
# Prophylaxis: Subcutaneous heparin
# Access: peripherals
# Communication: Patient, Wife [**Name (NI) **] HCP
# Code: DNR/DNI (confirmed by Wife and HCP [**Doctor First Name **]
# Disposition: LTAC
.
Transitional Care Issues:
-continue levofloxacin x2 doses (next dose today at 10pm, then
[**5-26**] at 10pm)
[**Hospital **] rehab
-continued oxygen demand
-likely need palliative care for eval of end-stage COPD
-steroid [**Hospital 15123**], then resume his current 5mg every other day of
prednisone
-ophthomology evaluation of the patients eye complaints

Medications on Admission:
-Flovent HFA 110mcg, 2 puffs [**Hospital1 **]
-Proair 8.5g 2 puffs q4-6 prn shortness of breath
-Spiriva inhaler, 1 cap inhaled daily
-Lorazepam 0.5mg PO PRN anxiety
-Oxygen 2.5 lpm
-Prednisone 5mg PO every other day
-Barrier cream for skin rash, daily

Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H
2. Docusate Sodium (Liquid) 100 mg PO BID
3. Ipratropium Bromide Neb 1 NEB IH Q4H
4. Levofloxacin 750 mg PO Q48H Duration: 2 Doses
One dose at 10pm today ([**5-24**]) and then one dose at 10pm on [**5-26**]
5. Morphine Sulfate (Oral Soln.) 5 mg PO Q4H:PRN dyspnea
hold for rr<10, sedation
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Senna 1 TAB PO BID Constipation
8. Lorazepam 0.5 mg PO BID
once in the morning, once at night
9. Tiotropium Bromide 1 CAP IH DAILY
10. PredniSONE 35 mg PO daily Duration: 2 Days Start: In am
Continue the 5mg every other day as an ongoing dose
11. PredniSONE 30 mg PO daily Duration: 2 Days Start: After 35
mg tapered dose.
Continue the 5mg every other day as an ongoing dose
12. PredniSONE 25 mg PO daily Duration: 2 Days Start: After 30
mg tapered dose.
Continue the 5mg every other day as an ongoing dose
13. PredniSONE 20 mg PO daily Duration: 2 Days Start: After 25
mg tapered dose.
Continue the 5mg every other day as an ongoing dose
14. PredniSONE 15 mg PO daily Duration: 2 Days Start: After 20
mg tapered dose.
Continue the 5mg every other day as an ongoing dose
15. PredniSONE 10 mg PO daily Duration: 2 Days Start: After 15
mg tapered dose.
Continue the 5mg every other day as an ongoing dose
16. PredniSONE 5 mg PO daily Duration: 2 Days Start: After 10 mg
tapered dose.
Continue the 5mg every other day as an ongoing dose
17. PredniSONE 5 mg PO every other day Duration: 99 Doses Start:
After 5 mg tapered dose.
Continue the 5mg every other day as an ongoing dose
18. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
19. Albuterol Inhaler 2 PUFF IH Q6H:PRN shortness of breath
20. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath
start PRN after 1 week of standing nebulizer treatments
21. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of breath

Start this after 1 week of standing nebulizer treatments


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 86**]

Discharge Diagnosis:
COPD Exacerbation


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


Discharge Instructions:
You presented to the emergency department for shortness of
breath.  You stayed in the intensive care unit for stabilization
of your breathing, improving to the point where you can be
safely sent to rehab to further treat and rehabilitate your
severe lung disease.
.
The following medication changes were made:
CONTINUE ALL HOME MEDS
START prednisone [**Location (un) 15123**]:
30mg x2 days, 25mg x2 days, 20mg x2 days, 15mg x2 days, 10mg x2
days, 5mg x2 days, THEN resume your 5mg every other day
START levofloxacin (antibiotic) 750mg for 2 doses, these doses
will be at 10pm on [**5-24**] (today) and 10pm on [**5-26**] (Thursday)
START ipratropium bromide nebulizer every 4 hours for 1 week,
then every 4 hours as needed
START albuterol nebulizer every 4 hours for 1 week, then every 4
hours as needed
START morphine sulfate (liquid) 5mg every 4 hours as needed for
shortness of breath

Followup Instructions:
To be arranged from your extended care facility, but should
include pulmonology, primary care, and ophthomology


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Completed by:[**2107-5-24**]
{'Obstructive chronic bronchitis with (acute) exacerbation,Other dependence on machines, supplemental oxygen,Personal history of tobacco use,Long-term (current) use of steroids,Thoracoabdominal aneurysm, without mention of rupture,Dermatophytosis of the body,Pure hypercholesterolemia,Diseases of tricuspid valve,Mitral valve disorders,Other chronic pulmonary heart diseases,Unqualified visual loss, both eyes,Do not resuscitate status'}


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: Patient with a history of severe COPD secondary to longterm
smoking use although he quite smoking successfully 6 years ago.
Is on baseline oxygen at 2.5 liters per minute which he only
requires during the daytime and does not typically use at night.

MEDICAL HISTORY: COPD on home 2.5L O2
Descending aortic aneurysm 4.9cm on CT in [**8-21**], with mural
thrombi
AAA 3.9 cm at the infrarenal aorta, with mural thrombi
Inguinal hernia
Hypercholesterolemia
[**12-13**]+ TR, [**12-13**]+ MR, mild PA HTN (from TTE [**2105-8-10**])

MEDICATION ON ADMISSION: -Flovent HFA 110mcg, 2 puffs [**Hospital1 **]
-Proair 8.5g 2 puffs q4-6 prn shortness of breath
-Spiriva inhaler, 1 cap inhaled daily
-Lorazepam 0.5mg PO PRN anxiety
-Oxygen 2.5 lpm
-Prednisone 5mg PO every other day
-Barrier cream for skin rash, daily

ALLERGIES: Amoxicillin / Ciprofloxacin / Bactrim / Clindamycin / Citrucel

PHYSICAL EXAM: Admission Physical:
.
Vitals: per Metavision
General: Alert, oriented, uncomfortable in BiPAP mask
HEENT: Sclera anicteric, MMM, EOMI, PERRL, wearing BiPAP
Neck: supple, JVP not elevated, no LAD
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops,
bilateral peripheral IVs
Lungs: Bilateral rhonchi with scattered wheezes, retractions
throughout
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: moves all extremities spontaneously
Skin: multiple excoriations over the back
.
Discharge Physical
.
V/S:
Temp: 37 ??????C HR: 96 BP: 128/84 RR 20 95% 5L NC
General: Sleeping, easily arousable, alert and oriented once
awake
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops, bilateral
peripheral IVs
Lungs: B/L Rhonchi improved from yesterday, few scattered
wheezes, no retractions, diminished excursion b/l
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: moves all extremities spontaneously
Skin: multiple excoriations over the back

FAMILY HISTORY: Denies family history of COPD or lung cancer. Has family history
of diabetes. Denies family history of MI.

SOCIAL HISTORY: Former smoker. Quit 3-4 years ago. Started smoking at age 15.
Smoked up to 2 packs/day.  1 glass wine/night.  No drugs.
Lives with wife. Retired. Used to work as security officer for
Bank [**Location (un) 86**]. 

### Response:
{'Obstructive chronic bronchitis with (acute) exacerbation,Other dependence on machines, supplemental oxygen,Personal history of tobacco use,Long-term (current) use of steroids,Thoracoabdominal aneurysm, without mention of rupture,Dermatophytosis of the body,Pure hypercholesterolemia,Diseases of tricuspid valve,Mitral valve disorders,Other chronic pulmonary heart diseases,Unqualified visual loss, both eyes,Do not resuscitate status'}
