CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 59 yo M  homeless w/ PMH of COPD, alcohol dependence with recent
admission on [**6-19**] for COPD exacerbation, alcohol withdrawal who
left AMA presented today to the ED for shortness of breath. He
has a recent history of multiple admissions and ED evaluations
for shortness of breath. Of note he has been worked up for RML
collapse with concern of mass causing an obstruction s/p rigid
bronchoscopy in [**3-/2171**] with negative cytology.

MEDICAL HISTORY: COPD
PNA
Alcohol abuse
HTN
Multiple musculskeletal surgeries including facial
reconstruction
Splenectomy s/p [**Year (4 digits) 8751**] 10 years ago
Chronic pain on methadone
Hx hypercarbic respiratory failure

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Albuterol-Ipratropium 2 PUFF IH Q6H wheeze
3. Albuterol Inhaler 2 PUFF IH Q4H
4. Enalapril Maleate 10 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission Exam:
VS: 97.8, 97, 100/62, 13, 96%4L NC
General: Somnulent, nodding off mid sentence, older than stated
age male, thin with multiple areas of scab over, in no acute
distress. Mildly agitated when awakened but cooperative when
awake.
HEENT: Sclera anicteric,PEERL of 4mm and reactive. Unable to
perform EOM exam to assess for nystagmus. MMM, unable to open
mouth wide to assess oropharynx.
Neck: supple, JVP not elevated, no LAD, no retractions
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Moving good air bilaterally. Coughing with deep
inspiration, nonproductive. Wheezing inspiratory and expiratory
bilaterally. No dullness to percussion. Pt did not cooperate
with egophany
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ DP pulses bilaterally. no edema.
multipel areas of healing , no clubbing, cyanosis or edema
Neuro: limited neuro exam given his level of consciousness.
A+Ox1.5 (knew year but not date, did not know location and knew
name).  Unable to recall previous president.  Moving all
extremities. Tongue midline, symmetric smile. Finger to nose
deferred until sober

FAMILY HISTORY: unknown

SOCIAL HISTORY: Homeless, squatting on a floor in an old building. Smoking
currently (unclear amount), current alcohol use (does not recall
last drink). Denies other drugs
Obstructive chronic bronchitis with (acute) exacerbation,Acute alcoholic intoxication in alcoholism, continuous,Unspecified essential hypertension,Other chronic pain,Tobacco use disorder,Lack of housing,Other acquired absence of organ,Personal history of pneumonia (recurrent)
Obs chr bronc w(ac) exac,Ac alcohol intox-contin,Hypertension NOS,Chronic pain NEC,Tobacco use disorder,Lack of housing,Acq absence of organ NEC,Prsnl hx recur pneumonia
Admission Date:  [**2171-6-25**]              Discharge Date:   [**2171-6-26**]

Date of Birth:  [**2111-9-22**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
none

History of Present Illness:
59 yo M  homeless w/ PMH of COPD, alcohol dependence with recent
admission on [**6-19**] for COPD exacerbation, alcohol withdrawal who
left AMA presented today to the ED for shortness of breath. He
has a recent history of multiple admissions and ED evaluations
for shortness of breath. Of note he has been worked up for RML
collapse with concern of mass causing an obstruction s/p rigid
bronchoscopy in [**3-/2171**] with negative cytology.



On admission today, patient came in complaing of dyspnea.  Per
ED report, he was unable to explain more about why he was coming
in in the ED.  He denied alcohol intake however smelled of
alcohol and had an blood alcohol of 338. Denied chest pain,
denied fevers, chills, cough. Required sternal rub to wake up.
88% on RA and not moving good air bilaterally. His oxygenation
improved to 96% on 3L and a VBG on 3L was 7.40/49/122. CXR
showed RLL consolidation.  He received IV methylprednisolone
given his inability to take PO, 3 rounds of duonebs, and a dose
of IV levofloxacin. He was transferred to the unit due to his
altered mental status and poor respiratory status with this
depressed mental status however he was able to talk so it was
felt htat he did not require intubation for airway
protection/hypoxia.

On arrival to the MICU he complained of a knife like feeling in
his back that was worsened with deep breath but no change in his
cough or production of sputum. He denied any recent fevers or
chills. He could not recall why he was at the hospital or how he
got there.


Past Medical History:
COPD
PNA
Alcohol abuse
HTN
Multiple musculskeletal surgeries including facial
reconstruction
Splenectomy s/p [**Year (4 digits) 8751**] 10 years ago
Chronic pain on methadone
Hx hypercarbic respiratory failure

Social History:
Homeless, squatting on a floor in an old building. Smoking
currently (unclear amount), current alcohol use (does not recall
last drink). Denies other drugs


Family History:
unknown

Physical Exam:
Admission Exam:
VS: 97.8, 97, 100/62, 13, 96%4L NC
General: Somnulent, nodding off mid sentence, older than stated
age male, thin with multiple areas of scab over, in no acute
distress. Mildly agitated when awakened but cooperative when
awake.
HEENT: Sclera anicteric,PEERL of 4mm and reactive. Unable to
perform EOM exam to assess for nystagmus. MMM, unable to open
mouth wide to assess oropharynx.
Neck: supple, JVP not elevated, no LAD, no retractions
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Moving good air bilaterally. Coughing with deep
inspiration, nonproductive. Wheezing inspiratory and expiratory
bilaterally. No dullness to percussion. Pt did not cooperate
with egophany
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ DP pulses bilaterally. no edema.
multipel areas of healing , no clubbing, cyanosis or edema
Neuro: limited neuro exam given his level of consciousness.
A+Ox1.5 (knew year but not date, did not know location and knew
name).  Unable to recall previous president.  Moving all
extremities. Tongue midline, symmetric smile. Finger to nose
deferred until sober


Pertinent Results:
Admission Labs:
[**2171-6-25**] 07:50PM BLOOD WBC-5.7 RBC-4.43* Hgb-14.3 Hct-44.4
MCV-100* MCH-32.2* MCHC-32.1 RDW-15.3 Plt Ct-157
[**2171-6-25**] 07:50PM BLOOD Neuts-26* Bands-0 Lymphs-55* Monos-7
Eos-10* Baso-1 Atyps-1* Metas-0 Myelos-0
[**2171-6-25**] 07:50PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2171-6-25**] 07:50PM BLOOD PT-10.2 PTT-31.6 INR(PT)-0.9
[**2171-6-25**] 07:50PM BLOOD Glucose-102* UreaN-11 Creat-0.8 Na-144
K-3.7 Cl-101 HCO3-31 AnGap-16
[**2171-6-25**] 07:50PM BLOOD ASA-NEG Ethanol-332* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2171-6-25**] 08:16PM BLOOD Type-[**Last Name (un) **] pO2-122* pCO2-49* pH-7.40
calTCO2-31* Base XS-4 Comment-GREEN

Micro
Blood culture [**2171-6-25**]- PENDING

Imaging:
CXR [**2171-6-25**]: Streaky airspace opacities within the lung bases,
slightly worse in the left lung base when compared to the prior
study.  These could reflect areas of bibasilar atelectasis but
infection particularly in the left lung base cannot be excluded.
 Emphysema.


Brief Hospital Course:
59 yo M w/ PMH of COPD (no PFTs in our system) and alcohol
intoxication presented intoxicated complaining of shortness of
breath and admitted to the ICU for altered mental status and
concern for pneumonia vs. COPD exacerbation.

#Hypoxia- patient has baseline COPD and it is unclear if he
takes his medications as an outpatient. he complained of some
shortness of breath on admission and was sating 89% on RA in no
respiratory distress. He received multiple rounds of nebulizers
with improvement in airmovement in his lungs.  His VBG on 3L of
NC was unremarkable.  He was admitted to the ICU for monitoring
of his respiratory status while he had altered mental status.
As his mental status improved, his respiratory status remained
stable with O2 sat 92 on Room Air, which appears to be his
baseline.

#Altered mental status- patient was intoxicated on admission
with a blood alcohol level of 332. The morning after admission
he was A+Ox3 with a nonfocal neurological exam.  Initially there
was concern that he may have had hypercarbia causing his AMS,
however as his EtOH intoxication decreased, his mental status
improved.

#Alcohol dependence-Patient has had many admissions/ED visits
for alcohol intoxication. He has no history of withdrawal
seizures but has had problems with respiratory depression in the
setting of preventing his withdrawal with diazepam.  On this
admission because of his inability to take in po, he was started
on IV ativan. over the first night he recieved 2 mg IV ativan
for agitation. Social work was consulted while he was here given
his frequent admissions for this. As he was able to take PO in
the morning, he was given a total of 15mg of Diazepam for CIWA
>10. Discharge to a detox facility was discussed, however Mr.
[**Known lastname 7710**] stated he did not want to quit drinking and would go back
to drinking after going to rehab.  Decision was made not to send
him to rehab and to discharge directly from ICU.

#Hypertension- patient has a history of hypertension however on
admission his BPs ranged in the low 100s.  He was unable to
verify his home regimen and his antihypertensives were held.
While in the MICU, his SBP ranged from 100-140s.  No anti
hypertensives were started.

TRANSITIONAL ISSUES
-Pt. was counseled on alcohol cessation, he should continue to
be encouraged to quit drinking.
-Pt. should be further counseled to take his COPD medications
-Pt. would benefit from social work assistance


Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Albuterol-Ipratropium 2 PUFF IH Q6H wheeze
3. Albuterol Inhaler 2 PUFF IH Q4H
4. Enalapril Maleate 10 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID


Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
2. Albuterol-Ipratropium 2 PUFF IH Q6H wheeze
3. Albuterol Inhaler 2 PUFF IH Q4H
4. Enalapril Maleate 10 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID


Discharge Disposition:
Home

Discharge Diagnosis:
EtOH intoxication
COPD


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


Discharge Instructions:
Dear Mr. [**Known lastname 7710**],
You were treated at [**Hospital1 18**] for intoxication and difficulty
breathing.  As you became more sober, your difficulty breathing
was improved.  We strongly recommend you enter a detoxification
program and stop drinking.  We also recommend that you take your
medications that are prescribed to you.

Followup Instructions:
Please see your PCP [**Last Name (NamePattern4) **] [**1-28**] days
Please enter an alcohol detox program


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

Completed by:[**2171-6-26**]
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute alcoholic intoxication in alcoholism, continuous,Unspecified essential hypertension,Other chronic pain,Tobacco use disorder,Lack of housing,Other acquired absence of organ,Personal history of pneumonia (recurrent)'}


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: 59 yo M  homeless w/ PMH of COPD, alcohol dependence with recent
admission on [**6-19**] for COPD exacerbation, alcohol withdrawal who
left AMA presented today to the ED for shortness of breath. He
has a recent history of multiple admissions and ED evaluations
for shortness of breath. Of note he has been worked up for RML
collapse with concern of mass causing an obstruction s/p rigid
bronchoscopy in [**3-/2171**] with negative cytology.

MEDICAL HISTORY: COPD
PNA
Alcohol abuse
HTN
Multiple musculskeletal surgeries including facial
reconstruction
Splenectomy s/p [**Year (4 digits) 8751**] 10 years ago
Chronic pain on methadone
Hx hypercarbic respiratory failure

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Albuterol-Ipratropium 2 PUFF IH Q6H wheeze
3. Albuterol Inhaler 2 PUFF IH Q4H
4. Enalapril Maleate 10 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission Exam:
VS: 97.8, 97, 100/62, 13, 96%4L NC
General: Somnulent, nodding off mid sentence, older than stated
age male, thin with multiple areas of scab over, in no acute
distress. Mildly agitated when awakened but cooperative when
awake.
HEENT: Sclera anicteric,PEERL of 4mm and reactive. Unable to
perform EOM exam to assess for nystagmus. MMM, unable to open
mouth wide to assess oropharynx.
Neck: supple, JVP not elevated, no LAD, no retractions
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Moving good air bilaterally. Coughing with deep
inspiration, nonproductive. Wheezing inspiratory and expiratory
bilaterally. No dullness to percussion. Pt did not cooperate
with egophany
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ DP pulses bilaterally. no edema.
multipel areas of healing , no clubbing, cyanosis or edema
Neuro: limited neuro exam given his level of consciousness.
A+Ox1.5 (knew year but not date, did not know location and knew
name).  Unable to recall previous president.  Moving all
extremities. Tongue midline, symmetric smile. Finger to nose
deferred until sober

FAMILY HISTORY: unknown

SOCIAL HISTORY: Homeless, squatting on a floor in an old building. Smoking
currently (unclear amount), current alcohol use (does not recall
last drink). Denies other drugs 

### Response:
{'Obstructive chronic bronchitis with (acute) exacerbation,Acute alcoholic intoxication in alcoholism, continuous,Unspecified essential hypertension,Other chronic pain,Tobacco use disorder,Lack of housing,Other acquired absence of organ,Personal history of pneumonia (recurrent)'}
