CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: 45M with past medical history significant for severe asthma with
>100 hospitalizations & 17 intubations who presents with
shortness of breath, wheezing, and cough for the past few days,
consistent with an asthma exacerbation.
  Patient says he was in his usual state of health until a few
nights ago when he felt incresing shortness of breath.  He was
also noticing some increasing cough with sputum.  No
fevers/chills.  No sick contacts.
  [**Name (NI) **] was recently admitted from [**Date range (1) 93487**] for similar
symptoms, thought to be [**1-29**] COPD exacerbation and was dc'd on a
5 day course of azithromycin.  He followed up with his
pulmonologist a week later who encouraged smoking cessation but
did not make and changes to his medications.
  He is very knowledgeable with regards to his asthma and
triggers, feels they are brought on by weather changes as well
as seasonally.  He self increased his dose of prednisone from 30
mg to 50 mg PO this morning.  Since his symptoms were not
improving, he decided to go to the ED.

MEDICAL HISTORY: - Severe asthma with >100 hospitalizations, multiple intubations
(17), most recent prolonged admission was in [**2169**], which was
complicated by MRSA and xanthomonas bronchitis
- OSA on CPAP at night
- Avascular necrosis of the hip s/p left TKR [**6-/2175**] and shoulder
from prolonged steroid use
- GERD
- H/o L Achilles tendon rupture s/p repair

MEDICATION ON ADMISSION: ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
Aerosol Inhaler 2 puffs inh every 4 hours prn wheezing

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

PHYSICAL EXAM: ADMISSION EXAM:
95  126/84   99   21  94% RA

FAMILY HISTORY: Maternal history of cancer and asthma.

SOCIAL HISTORY: Smokes five cigarettes a day, ~30 pack-year history. Drinks ~1
bottle of wine per week. Occasionally uses marijuana. He is
currently living with his wife and young daughter in his
mother's house in [**Location (un) 583**]. Currently has a lot of social
stressors; his house in [**Location (un) 5503**] is being foreclosed.  He
lost his job as a school bus driver in [**Month (only) **], and his
unemployment benefit is about to run out. He is taking classes
at [**Location (un) 6188**] Community College hoping to eventually work as a
compliance officer or as a hazmat official. He is married, has
three children (two daughters ages 19 & 4, one son age 17).
Chronic obstructive asthma with (acute) exacerbation,Acidosis,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder,Long-term (current) use of steroids,Leukocytosis, unspecified,Esophageal reflux,Anxiety state, unspecified,Hip joint replacement
Ch obst asth w (ac) exac,Acidosis,Obstructive sleep apnea,Tobacco use disorder,Long-term use steroids,Leukocytosis NOS,Esophageal reflux,Anxiety state NOS,Joint replaced hip
Admission Date:  [**2178-8-24**]              Discharge Date:   [**2178-8-26**]

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

Service: MEDICINE

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

Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
None

History of Present Illness:
45M with past medical history significant for severe asthma with
>100 hospitalizations & 17 intubations who presents with
shortness of breath, wheezing, and cough for the past few days,
consistent with an asthma exacerbation.
  Patient says he was in his usual state of health until a few
nights ago when he felt incresing shortness of breath.  He was
also noticing some increasing cough with sputum.  No
fevers/chills.  No sick contacts.
  [**Name (NI) **] was recently admitted from [**Date range (1) 93487**] for similar
symptoms, thought to be [**1-29**] COPD exacerbation and was dc'd on a
5 day course of azithromycin.  He followed up with his
pulmonologist a week later who encouraged smoking cessation but
did not make and changes to his medications.
  He is very knowledgeable with regards to his asthma and
triggers, feels they are brought on by weather changes as well
as seasonally.  He self increased his dose of prednisone from 30
mg to 50 mg PO this morning.  Since his symptoms were not
improving, he decided to go to the ED.

  In the ED, initial VS were T 98.8, HR 127, BP 151/107, RR 18,
SpO2 99% RA. Labs were notable for lactate 4.0. Preliminary read
of CXR showed no acute cardiopulmonary process. EKG was sinus
tachycardia @ 122 bpm, consistent with prior. Patient received 2
Duo-Nebs (albuterol/ipratropium), 2 additional albuterol nebs,
magnesium sulfate 2g, and solu-medrol 80mg IV (pt requested only
80mg because he takes prednisone at home and has a h/o avascular
necrosis) with significant improvement in his symptoms. VS on
transfer were T 97.4, HR 106, BP 146/88, RR 16, 96%RA.

On arrival to the MICU, patient says he is breathing "at or
near" his baseline.  His VS were: 95  126/84   99   21  94% RA

Review of systems:
(+) Per HPI, shortness of breath, non-productive cough, dyspnea,
wheezing
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.

Past Medical History:
- Severe asthma with >100 hospitalizations, multiple intubations
(17), most recent prolonged admission was in [**2169**], which was
complicated by MRSA and xanthomonas bronchitis
- OSA on CPAP at night
- Avascular necrosis of the hip s/p left TKR [**6-/2175**] and shoulder
from prolonged steroid use
- GERD
- H/o L Achilles tendon rupture s/p repair


Social History:
Smokes five cigarettes a day, ~30 pack-year history. Drinks ~1
bottle of wine per week. Occasionally uses marijuana. He is
currently living with his wife and young daughter in his
mother's house in [**Location (un) 583**]. Currently has a lot of social
stressors; his house in [**Location (un) 5503**] is being foreclosed.  He
lost his job as a school bus driver in [**Month (only) **], and his
unemployment benefit is about to run out. He is taking classes
at [**Location (un) 6188**] Community College hoping to eventually work as a
compliance officer or as a hazmat official. He is married, has
three children (two daughters ages 19 & 4, one son age 17).


Family History:
Maternal history of cancer and asthma.


Physical Exam:
ADMISSION EXAM:
95  126/84   99   21  94% RA

General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: end expiratory wheezing heard throughout posterior lung
fields, diminished air entry at bases, no crackles/rhonchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

GU: no foley
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.

Discharge Exam:
Vitals: T 97.9, BP 142/73, HR 78, RR 16, SpO2 95%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: no increaesed work of breathing or accessory muscle use.
scant scattered expiratory wheezing heard throughout posterior
lung fields, good air exchange throughout all lung fields, no
crackles/rhonchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

GU: no foley
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, normal gait.

Pertinent Results:
ADMISSION LABS:

[**2178-8-24**] 09:45AM BLOOD WBC-8.8 RBC-5.19 Hgb-15.7 Hct-46.4 MCV-90
MCH-30.4 MCHC-33.9 RDW-13.3 Plt Ct-265
[**2178-8-24**] 09:45AM BLOOD Neuts-84.2* Lymphs-9.1* Monos-2.5 Eos-3.6
Baso-0.7
[**2178-8-24**] 09:45AM BLOOD Plt Ct-265
[**2178-8-24**] 09:45AM BLOOD Glucose-169* UreaN-12 Creat-0.9 Na-141
K-3.5 Cl-105 HCO3-23 AnGap-17
[**2178-8-24**] 09:45AM BLOOD Albumin-4.6 Calcium-9.2 Phos-1.6*# Mg-2.1
[**2178-8-24**] 10:08AM BLOOD Lactate-4.0*

Discharge Labs:

[**2178-8-26**] 01:51AM BLOOD WBC-26.4* RBC-4.66 Hgb-14.2 Hct-42.8
MCV-92 MCH-30.4 MCHC-33.1 RDW-13.5 Plt Ct-283
[**2178-8-26**] 01:51AM BLOOD Neuts-93.8* Lymphs-2.7* Monos-3.3 Eos-0.1
Baso-0.1
[**2178-8-26**] 01:51AM BLOOD Glucose-136* UreaN-19 Creat-1.0 Na-143
K-4.3 Cl-110* HCO3-20* AnGap-17
[**2178-8-26**] 01:51AM BLOOD Calcium-9.5 Phos-2.9 Mg-2.3
[**2178-8-25**] 08:24AM BLOOD Lactate-2.6*
[**2178-8-24**] 08:34PM BLOOD Type-[**Last Name (un) **] pO2-57* pCO2-35 pH-7.45
calTCO2-25 Base XS-0

Microbiology:
[**2178-8-24**] 9:50 am BLOOD CULTURE: Pending. No growth to date.

Imaging:
[**2178-8-24**] EKG: Sinus tachycardia. Probable left atrial
abnormality. Compared to the previous tracing of [**2178-5-16**] sinus
tachycardia persists but heart rate is slower.

[**2178-8-24**] CXR:
IMPRESSION:  No acute cardiopulmonary process.

Brief Hospital Course:
Brief Course:
Mr. [**Known lastname **] is a 45M with past medical history significant for
severe asthma with >100 hospitalizations & 17 intubations who
presents with shortness of breath, wheezing, and cough for the
past few days, consistent with an asthma exacerbation. He was
admitted to the ICU and treated with duonebs, magnesium sulfate,
steroids, and azithromycin for possible concominant COPD
exacerbation. He never required intubation and was weaned off
nasal cannula and returned to baseline. He was discharged to
home from the ICU.

Active Issues:
# Asthma/COPD exacerbation: Patient has h/o severe asthma with
>100 hospitalizations and multiple intubations and presented
with 2-3 days worsening dyspnea, wheezing and productive cough.
Pt's respiratory distress is likely secondary to asthma
exacerbation and probable COPD exacerbation given his h/o severe
persistent asthma on chronic steroids with continued tobacco
abuse. Environmental allergies, stress, tobacco are all likely
factors in acute exacerbation. CXR was negative for any focal
process/pneumonia, blood cultures are pending, and pt has
remained afebrile. Dyspnea improved w/ Duo-Nebs, Magnesium
sulfate and solumedrol 80mg IV in ED. In the MICU, pt received
albuterol/ipratropium nebs q6h with clinical improvement in
wheezing. He received solumedrol 60mg q6h on day of admission
and transitioned to prednisone po 60mg q6h on [**2178-8-25**]. Pt was
started on 4 day course of azithromycin (500mg on day 1, 250mg
day 2,3,4) to be completed on [**2178-8-27**], given suspected COPD
exacerbation. Peak flows were 350 on [**8-24**] and 300 on [**8-25**]. Pt
continued to improve clinically with diminished wheezing on
physical exam and no dyspnea even while ambulating. He felt that
he was back at his baseline. His prednisone was tapered to 60 mg
[**Hospital1 **] on the day of discharge which he will take on [**8-26**] and [**8-27**],
then taper further to 60 mg daily which he will continue until
he follows up with his pulmonologist Dr. [**Last Name (STitle) **].

# Lactic acidosis: Had elevated lactate 4.0 on day of admission,
likely type b lactic acidosis due to local hypoxia from muscle
fatigue and toxin induced from albuterol. Lactate was
down-trending to 2.6 upon discharge from the MICU.

# Leukocytosis: Pt had leukocytosis of 19.8 with 90.3% neut and
6.3% lymph on [**8-25**]. This is likely from steroids. Infection,
particularly pneumonia, was not suspected as patient's chest
x-ray was negative and he clinically improved with steroid and
nebulizer treatments.

Chronic Issues:
# Obstructive sleep apnea: pt was continued on nocturnal CPAP.

# Gerd: Pt contnued home omeprazole.

# Tobacco use: Patient was counseled on the importance of
smoking cessation especially in the setting of his asthma and
frequent exacerabtions.

Transitions of care:
1. Full Code
2. Contact: Wife [**Name (NI) 93485**] [**Telephone/Fax (1) 93486**]
3. Pending labs: [**8-24**] Blood Cultures (no growth to date)
4. Follow up:
-Dr. [**Last Name (STitle) **] [**Name (STitle) **] (transition from hospital to PCP)
-Dr. [**Known firstname **] [**Last Name (NamePattern1) **] (pulmonologist)
[**Hospital 26283**] clinic for OSA
5. Medication Changes:
-Continue azithromycin 250 mg through [**2178-8-27**] (1 more day after
discharge)
-Continue prednisone 60 mg [**Hospital1 **] for [**2178-8-26**] and [**2178-8-27**], then
decrease to 60 mg daily until patient sees Dr. [**Last Name (STitle) **]


Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
Aerosol Inhaler 2 puffs inh every 4 hours prn wheezing

FLUTICASONE - fluticasone 50 mcg/actuation Nasal Spray, Susp 1
spray intranasal twice a day

FLUTICASONE [FLOVENT HFA] - Flovent HFA 220 mcg/actuation
Aerosol Inhaler 6 puffs twice a day

IPRATROPIUM-ALBUTEROL [DUONEB] - DuoNeb 0.5 mg-3 mg(2.5 mg
base)/3 mL Neb Solution 1 inhalation four times a day as needed
for prn

MONTELUKAST [SINGULAIR] - Singulair 10 mg tablet 1 Tablet by
mouth once a day every day

PREDNISONE - prednisone 10 mg tablet 3 Tablets by mouth once a
day; increase to 6 tabs a day with asthma flare with usual
taper.

SALMETEROL [SEREVENT DISKUS] - Serevent Diskus 50 mcg/dose for
Inhalation 1 puff inh twice a day

SULFAMETHOXAZOLE-TRIMETHOPRIM - sulfamethoxazole-trimethoprim
400 mg-80 mg tablet 1 Tablet(s) by mouth once a day for pcp
prophylaxis TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] -
Spiriva with HandiHaler 18 mcg & inhalation capsules 1 puff Inh
daily

OMEPRAZOLE - omeprazole 20 mg capsule, delayed release 1 Capsule
by mouth twice daily

GUAIFENESIN [MUCINEX]

LORATADINE - loratadine 10 mg tablet 1 Tablet by mouth once a
day as needed for allergy symptoms

MAGNESIUM OXIDE - magnesium oxide 400 mg capsule 1 capsule by
mouth daily

ERGOCALCIFEROL (VITAMIN D2) - ergocalciferol (vitamin D2) 50,000
unit capsule 1 Capsule(s) by mouth twice a week x 4 weeks

NICOTINE [NICOTROL NS] - Nicotrol NS 10 mg/mL Nasal Spray [**12-29**]
sprays(s) nasal per hour as needed for craving [**12-29**] sprays/hour;
no more than 5 doses (10 sprays) per hour, no more than 4
doses/day

NICOTINE (POLACRILEX) [COMMIT] - Commit 4 mg Buccal Lozenge 1
lozenge every 1-2 hours for first six weeks, then taper to q2-4
hours x 2 weeks, then q 4-8 hours x 2 weeks. Max 20 pieces in 24
hours

Discharge Medications:
1. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
2. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Montelukast Sodium 10 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Nicotine Lozenge 4 mg PO Q4H:PRN craving
9. PredniSONE 60 mg PO BID
Tapered dose - DOWN
RX *prednisone 20 mg 3 tablet(s) by mouth twice daily Disp #*60
Tablet Refills:*0
10. Vitamin D 50,000 UNIT PO 1X/WEEK (MO) Duration: 4 Weeks
11. Magnesium Oxide 400 mg PO ONCE Duration: 1 Doses
12. Loratadine *NF* 10 mg Oral daily allergies
13. Tiotropium Bromide 1 CAP IH DAILY
14. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
15. ipratropium bromide *NF* 0.02 % Inhalation [**Hospital1 **] wheezing


Discharge Disposition:
Home

Discharge Diagnosis:
Primary: Asthma exacerbation

Secondary: Obstructive sleep apnea, Tobacco abuse


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


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

You were admitted to the ICU with an asthma exacerbation.  We
treated you with nebulizer treatments, magnesium, and steroids,
and your breathing improved.

You should continue taking steroids 60 mg twice a day for [**8-26**]
and [**8-27**] then switch to 60 mg daily until you see your
pulmonologist Dr. [**Last Name (STitle) **].  His office will call you to schedule
an appointment in the next 1-2 weeks.  If you don't hear from
them in 2 days you should call at [**Telephone/Fax (1) 612**] to schedule an
appointment.

You should also continue taking azithromycin through [**8-27**]
It is extremely important that you stop smoking.  Continuing to
smoke will lead to recurrent asthma exacerbations and can cause
permanent damage to your lungs.  We strongly encourage you to
quit smoking.

Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2178-9-3**] at 9:30 AM
With: Dr. [**Last Name (STitle) **] [**Name (STitle) **]
Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**]
Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] North [**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.

We are working on a follow up appointment for your
hospitalization in Pulmonary and Sleep with Dr. [**Known firstname **] [**Last Name (NamePattern1) **] as
well as Sleep Specialist. They are scheduled in the same office.
It is recommended you be seen within 2 weeks of discharge with
Dr. [**Last Name (STitle) **] and within 1 month for Sleep. The office will
contact you at home with both appointment information. If you
have not heard within 2 business days please call the office at
[**Telephone/Fax (1) 612**].



Completed by:[**2178-8-27**]
{'Chronic obstructive asthma with (acute) exacerbation,Acidosis,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder,Long-term (current) use of steroids,Leukocytosis, unspecified,Esophageal reflux,Anxiety state, unspecified,Hip joint replacement'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: 45M with past medical history significant for severe asthma with
>100 hospitalizations & 17 intubations who presents with
shortness of breath, wheezing, and cough for the past few days,
consistent with an asthma exacerbation.
  Patient says he was in his usual state of health until a few
nights ago when he felt incresing shortness of breath.  He was
also noticing some increasing cough with sputum.  No
fevers/chills.  No sick contacts.
  [**Name (NI) **] was recently admitted from [**Date range (1) 93487**] for similar
symptoms, thought to be [**1-29**] COPD exacerbation and was dc'd on a
5 day course of azithromycin.  He followed up with his
pulmonologist a week later who encouraged smoking cessation but
did not make and changes to his medications.
  He is very knowledgeable with regards to his asthma and
triggers, feels they are brought on by weather changes as well
as seasonally.  He self increased his dose of prednisone from 30
mg to 50 mg PO this morning.  Since his symptoms were not
improving, he decided to go to the ED.

MEDICAL HISTORY: - Severe asthma with >100 hospitalizations, multiple intubations
(17), most recent prolonged admission was in [**2169**], which was
complicated by MRSA and xanthomonas bronchitis
- OSA on CPAP at night
- Avascular necrosis of the hip s/p left TKR [**6-/2175**] and shoulder
from prolonged steroid use
- GERD
- H/o L Achilles tendon rupture s/p repair

MEDICATION ON ADMISSION: ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation
Aerosol Inhaler 2 puffs inh every 4 hours prn wheezing

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

PHYSICAL EXAM: ADMISSION EXAM:
95  126/84   99   21  94% RA

FAMILY HISTORY: Maternal history of cancer and asthma.

SOCIAL HISTORY: Smokes five cigarettes a day, ~30 pack-year history. Drinks ~1
bottle of wine per week. Occasionally uses marijuana. He is
currently living with his wife and young daughter in his
mother's house in [**Location (un) 583**]. Currently has a lot of social
stressors; his house in [**Location (un) 5503**] is being foreclosed.  He
lost his job as a school bus driver in [**Month (only) **], and his
unemployment benefit is about to run out. He is taking classes
at [**Location (un) 6188**] Community College hoping to eventually work as a
compliance officer or as a hazmat official. He is married, has
three children (two daughters ages 19 & 4, one son age 17). 

### Response:
{'Chronic obstructive asthma with (acute) exacerbation,Acidosis,Obstructive sleep apnea (adult)(pediatric),Tobacco use disorder,Long-term (current) use of steroids,Leukocytosis, unspecified,Esophageal reflux,Anxiety state, unspecified,Hip joint replacement'}
