CHIEF COMPLAINT: Shortness of breath and hypoxia

PRESENT ILLNESS: Mr. [**Known lastname 732**] is a 47 year old male with h/o schizophrenia/bipolar
disorder, obesity, hypercholesterolemia, and severe complex
sleep disordered who comes in to from Reab facility with
increase in SOB and hypoxia. Pt has been on rehab, [**Location (un) 669**] West
since [**Month (only) 958**] of this year for his OSA since he lived in a group
home and was unable to care for himself. As per nursing staff at
the facility, he has been having increase in SOB and hypoxia for
the last 2 weeks for which he was tx with lasix with some
improvement. He had a recent 3 lbs wt gain in the last few days.
He is also non-complient with his diet and tends to drink "a lot
of soda". He is on lasix 80mg [**Hospital1 **], however there is no listing
of him having CHF. He denies missing any of his meds. He states
that he had increse in SOB today and his O2sat was 70s% on RA
and EMS was called. He denies having any fever, chills, sweats,
or cough, or LE edema. He sleep with "pillows".  He was then
brought to the ED for further eval.

MEDICAL HISTORY: PSYCHIATRIC HISTORY
- reports history of bipolar disorder/ schizophrenia diagnosed
when he was 17.
- two hosptializations at [**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) **] and [**Last Name (LF) 42339**], [**First Name3 (LF) **]
mother, last [**Name2 (NI) 103301**] was 5 years ago; sees [**Name2 (NI) 2447**]
Dr. [**First Name (STitle) 1169**] at [**Hospital1 2177**].
- Denies any suicide attempts in past.

MEDICATION ON ADMISSION: -Aripiprazole 20 mg PO/NG DAILY
-Aspirin 81 mg PO/NG DAILY
-Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
- Carbamazepine 200 mg PO/NG [**Hospital1 **]
-Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **]
-Doxepin HCl 10 mg PO/NG HS
-Omeprazole 20 mg PO DAILY
-Risperidone 3 mg PO BID

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION:
Vitals: T: 97.4, 110/35, 86, 20, 95% on mask
General: Alert, oriented, no acute distress. speaking in full
sentences. Talking to himself
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess given body habitus
Lungs: Decreased breath sounds bilaterally, no wheezes,
rales,ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Obese soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace edema on bil LE and and hands.
Neuro:  Alert and oriented X 3. able to recall medications and
sister's phone number. Gait not assessed.

FAMILY HISTORY: Mother with asthma, Several sibling all in good health. No
family history of cardiac dz or DM.

SOCIAL HISTORY: Currently lives at [**Location 1268**] [**Hospital1 1501**] for his sleep apnea and
BIPAP use. No smoking, no alcohol, no drug use. Sister is HCP
Acute respiratory failure,Acute diastolic heart failure,Atrial flutter,Obesity hypoventilation syndrome,Obstructive sleep apnea (adult)(pediatric),Unspecified schizophrenia, unspecified,Bipolar disorder, unspecified,Pure hypercholesterolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Polycythemia vera
Acute respiratry failure,Ac diastolic hrt failure,Atrial flutter,Obesity hypovent synd,Obstructive sleep apnea,Schizophrenia NOS-unspec,Bipolar disorder NOS,Pure hypercholesterolem,DMII wo cmp nt st uncntr,Polycythemia vera
Admission Date:  [**2134-9-1**]              [**Month/Day/Year **] Date:   [**2134-9-6**]

Date of Birth:  [**2087-8-23**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
Shortness of breath and hypoxia


Major Surgical or Invasive Procedure:
None


History of Present Illness:
Mr. [**Known lastname 732**] is a 47 year old male with h/o schizophrenia/bipolar
disorder, obesity, hypercholesterolemia, and severe complex
sleep disordered who comes in to from Reab facility with
increase in SOB and hypoxia. Pt has been on rehab, [**Location (un) 669**] West
since [**Month (only) 958**] of this year for his OSA since he lived in a group
home and was unable to care for himself. As per nursing staff at
the facility, he has been having increase in SOB and hypoxia for
the last 2 weeks for which he was tx with lasix with some
improvement. He had a recent 3 lbs wt gain in the last few days.
He is also non-complient with his diet and tends to drink "a lot
of soda". He is on lasix 80mg [**Hospital1 **], however there is no listing
of him having CHF. He denies missing any of his meds. He states
that he had increse in SOB today and his O2sat was 70s% on RA
and EMS was called. He denies having any fever, chills, sweats,
or cough, or LE edema. He sleep with "pillows".  He was then
brought to the ED for further eval.

In the ED, initial VS were: HR 80, 140/90, 25, 88-93% on BIPAP.
proBNP: 2129, WBC was 10.2 (N:74 Band:0 L:10 M:15 E:1
Bas:0),Trop-T: <0.01. UA negative. He had cxray which as per ED
report states continued evidence of left-sided pneumonia as well
as diffuse interstitial edema. He was given vanco, cefepime and
azithromycin for the concern of pneumonia. He also had a CTA
which did not show a PE or other acute lung process. He was then
given 80mg of IV lasix which he responded well with 900cc of
urine output in the ED and 300cc on arrival to the floor.

On arrival to the floor pt appears comfortable was sating at
100% on a non-rebreather. He denies having any complains of pain
or SOB. He states to feel "much better" than before.

As per his [**Hospital1 1501**], he did not have any recent pneumonia, infection
or complains of chest pain. He was planning to see a
cardiologist for concern of CHF.


Past Medical History:
PSYCHIATRIC HISTORY
- reports history of bipolar disorder/ schizophrenia diagnosed
when he was 17.
- two hosptializations at [**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) **] and [**Last Name (LF) 42339**], [**First Name3 (LF) **]
mother, last [**Name2 (NI) 103301**] was 5 years ago; sees [**Name2 (NI) 2447**]
Dr. [**First Name (STitle) 1169**] at [**Hospital1 2177**].
- Denies any suicide attempts in past.

PAST MEDICAL HISTORY:
- severe complex sleep disordered breathing with severe
nocturnal and daytime hypoxia related to hypoventiliation,
followed by Pulmonary service
- likely secondary erythrocythosis, being followed by Hematology

- moderately enlarged tonsils, followed by ENT
- asthma
- hypertension
- hyperlipidemia
- borderline DM


Social History:
Currently lives at [**Location 1268**] [**Hospital1 1501**] for his sleep apnea and
BIPAP use. No smoking, no alcohol, no drug use. Sister is HCP


Family History:
Mother with asthma, Several sibling all in good health. No
family history of cardiac dz or DM.

Physical Exam:
ADMISSION:
Vitals: T: 97.4, 110/35, 86, 20, 95% on mask
General: Alert, oriented, no acute distress. speaking in full
sentences. Talking to himself
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess given body habitus
Lungs: Decreased breath sounds bilaterally, no wheezes,
rales,ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Obese soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace edema on bil LE and and hands.
Neuro:  Alert and oriented X 3. able to recall medications and
sister's phone number. Gait not assessed.

[**Hospital1 894**]:
No signifcant changes. Stable on [**3-5**] L nasal cannula.

Pertinent Results:
Admission Labs:
[**2134-9-1**] 12:35PM BLOOD WBC-10.2 RBC-5.61 Hgb-16.4 Hct-51.2
MCV-91 MCH-29.2 MCHC-32.0 RDW-14.9 Plt Ct-220
[**2134-9-1**] 12:35PM BLOOD PT-15.8* PTT-25.3 INR(PT)-1.4*
[**2134-9-1**] 12:35PM BLOOD Glucose-152* UreaN-34* Creat-1.2 Na-136
K-5.2* Cl-90* HCO3-38* AnGap-13
[**2134-9-1**] 09:46PM BLOOD Calcium-8.1* Phos-4.6* Mg-2.0

[**Month/Day/Year **]:
[**2134-9-6**] 04:37AM BLOOD WBC-7.7 RBC-5.27 Hgb-14.6 Hct-46.6 MCV-88
MCH-27.8 MCHC-31.4 RDW-14.8 Plt Ct-198
[**2134-9-6**] 04:37AM BLOOD Glucose-115* UreaN-17 Creat-0.7 Na-140
K-3.9 Cl-92* HCO3-40* AnGap-12
[**2134-9-6**] 04:37AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.8

Cardiac Biomarkers:
[**2134-9-1**] 12:35PM BLOOD cTropnT-<0.01
[**2134-9-1**] 09:46PM BLOOD CK-MB-2 cTropnT-<0.01
[**2134-9-2**] 02:54AM BLOOD CK-MB-1 cTropnT-<0.01
[**2134-9-6**] 04:37AM BLOOD CK-MB-1 cTropnT-<0.01
[**2134-9-1**] 12:35PM BLOOD proBNP-2129*

STUDIES:

CT OF THE CHEST WITH AND WITHOUT INTRAVENOUS CONTRAST:
There is no evidence of pulmonary embolism to the subsegmental
level. Note is made of a bovine configuration of the aortic
arch. The thoracic aorta is unremarkable with no evidence of
acute aortic pathology. There is cardiomegaly. The right
ventricle is mildly enlarged which could relate to component of
right heart failure. There is no evidence of pericardial
effusion. There is no axillary, hilar, or mediastinal
lymphadenopathy.

The tracheobronchial tree is patent to the subsegmental level.
There is bibasilar atelectasis. There are no pleural effusions
or pneumothorax. There are no focal consolidations concerning
for pneumonia.

This examination is not tailored for subdiaphragmatic
evaluation. Note is made of diffuse fatty infiltration of the
liver. Visualized upper abdomen is otherwise unremarkable.

BONE WINDOWS: There are no suspicious lytic or sclerotic foci.
There are multilevel degenerative changes of the thoracic spine
as manifested by marginal osteophytic formation.

IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Cardiomegaly. Mildly enlarged right ventricle which could
relate to
component of right heart failure.
3. Bibasilar atelectasis.

Portable TTE (Complete) Done [**2134-9-2**] at 10:50:10 AM   FINAL
Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is an anterior space which most likely
represents a prominent fat pad.

IMPRESSION: Mildly dilated right ventricle with normal global
and regional biventricular systolic function. Normal estimated
pulmonary pressures.

Compared with the prior study (images reviewed) of [**2131-3-27**],
the findings are similar.

CHEST (PORTABLE AP) Study Date of [**2134-9-2**] 3:21 AM
FINDINGS: As compared to the previous radiograph, there is
almost unchanged evidence of moderate pulmonary edema. No major
pleural effusions but cardiomegaly and distention of pulmonary
vessels as well as the presence of interstitial thickening. Mild
retrocardiac atelectasis but no evidence of pneumonia. No other
relevant changes.


Brief Hospital Course:
Pt is a 47 yo male with significant psychiatric of bipolar and
schizophrenia with hx significant hx of severe complex sleep
disordered breathing with severe nocturnal and daytime hypoxia
who now presented with hypoxia.

# Hypoxia: pt with significant hx of severe complex sleep
disordered breathing with severe nocturnal and daytime hypoxia
related to hypoventiliation. He has required increased pressures
at night with high O2 flow which has improved his saturation
overnight. His O2 sats have remained stable in the low 90%s on
BIPAP of 20/18 with 10L of O2. During the day he uses 2-4 L of
O2 N/C to maintain his sats >90%. He states to feel much better,
more rested. He will need to continue to follow-up with pulm and
we have discussed importance of wt management, although this may
be difficult given his psych issues and living situation (in
nursing home).
- BiPAP settings of 20/18 with 10L of O2 at night and when pt
naps during the day
- will need new home order for BIPAP
- F/u with pulm/ sleep specialist

#Diastolic Heart Failure: Pt appeared fluid overloaded on
presentation w/ elevated BNP.  He had an Echo on [**9-2**] which
showed mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
The right ventricular cavity is mildly dilated with normal free
wall contractility.   Pt was restarted on his home dose of lasix
80mg [**Hospital1 **]. Breathing comfortable with no signs of fluid over
load. Continue to monitor for fluid status.
-Continue on 80mg of lasix [**Hospital1 **]
-continue metoprolol and aspirin 81

# Schizophrenia: Pt was very agitated, with pressure speech and
very tangentional at presentation. Talked in the room initially
with periods of easy aggravation/agitation becoming at times
almost combative. We called psychiatry consult which recommended
increasing dose of carbamazepime and risperidone. Pt has become
more calm  and less tangetional. His increase in sleep due to
better controlled hypoxia may also have contributed to his
improving symtoms.
- continue carbamazepime, risperidone, and benztropine
- He will need to have close monitoring and follow-up with
psychiatry for titration of medications.

# Atrial arrhythmia: Past EKGs with A-fib/A-flutter which
recurred while on tele in the ICU. He was rate controlled below
100 BPMs. He was listed previously on warfarin up to a few
months ago as per nurse [**First Name (Titles) **] [**Last Name (Titles) 1501**]. This was switched to ASA. He was
maintained on aspirin while inpatient. Consider starting
warfarin if follow-up and monitoring is considered possible. If
not, aspirin and Plavix would be deemed the best option.
- Currently on metoprolol 12.5mg [**Hospital1 **] and ASA 81mg daily as well
as plavix 75mg daily.
- EKG weekly while for QT prolongation until stabilized on psych
med regimen

# DM II: as per notes most of his gluc has been in the low to
mid 100s. His last  A1C in our system is from [**2133**]  and is
elevated to meeting criteria for DM 7.2. Encouraged a diabetic
diet and should f/u with his PCP for further management.

# Polycythemia: Hct lower than prior in the mid 40s%, pt had
work up in the past by hemeonc, thought to be secondary
polycythemia. Stable at this  time.

# Hypertension: controlled with home BP meds.


Medications on Admission:
-Aripiprazole 20 mg PO/NG DAILY
-Aspirin 81 mg PO/NG DAILY
-Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
- Carbamazepine 200 mg PO/NG [**Hospital1 **]
-Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **]
-Doxepin HCl 10 mg PO/NG HS
-Omeprazole 20 mg PO DAILY
-Risperidone 3 mg PO BID


[**Hospital1 **] Medications:
1. doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. risperidone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
7. benztropine 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for dystonia.
8. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. BiPap
Overnight BiPap settings of 20/18 with 10 liters of supplemental
oxygen
10. oxygen
2-4 liters of continuous oxygen via nasal cannula. Titrate for
O2 saturations greater than 90%.


[**Hospital1 **] Disposition:
Extended Care

Facility:
Roscommon [**Hospital 1268**] Extended Care Center

[**Hospital **] Diagnosis:
Primary:
Severe complex sleep disordered breathing with severe
nocturnal and daytime hypoxia related to hypoventiliation
Bipolar disorder
Atrial flutter


[**Hospital **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


[**Hospital **] Instructions:
Mr. [**Known lastname 732**],

It was a pleasure taking part in your care. You were admitted to
[**Hospital1 18**] for increase in shortness of breath and low oxygen levels.
You were admitted to the intensive care unit to help manage your
low oxygen level. Your BiPap (sleep mask) settings were
increased to keep your oxygen level above 90%. Your new settings
are 20/18 with 10 liters of supplemental oxygen.

You also were noted to have an arrhythmia which you have had in
the past. The electrophysiologists were consulted and
recommended....

Psychiatry was involved in your care, and made changes to some
of your medications to help with your bipolar disorder (as
listed below).

The following changes were made to your medications:
- STOPPED Aripiprazole
- INCREASED Risperidone to 4mg by mouth two times a day
- INCREASED Carbamazepine to 200mg by mouth four times a day
- STARTED benztropine mesylate 0.5mg once a day as needed for
abnormal muscle movements

Please take all medications as prescribed, and follow-up with
psychiatry, cardiology, and your sleep [**Hospital1 21334**] [**First Name (Titles) **] [**Last Name (Titles) **]
from rehab.

Followup Instructions:
Please follow-up with your [**Last Name (Titles) 2447**], pulmonary, cardiology,
and primary care [**Last Name (Titles) 21334**] [**First Name (Titles) **] [**Last Name (Titles) **] from rehab.



Completed by:[**2134-9-6**]
{'Acute respiratory failure,Acute diastolic heart failure,Atrial flutter,Obesity hypoventilation syndrome,Obstructive sleep apnea (adult)(pediatric),Unspecified schizophrenia, unspecified,Bipolar disorder, unspecified,Pure hypercholesterolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Polycythemia vera'}


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 and hypoxia

PRESENT ILLNESS: Mr. [**Known lastname 732**] is a 47 year old male with h/o schizophrenia/bipolar
disorder, obesity, hypercholesterolemia, and severe complex
sleep disordered who comes in to from Reab facility with
increase in SOB and hypoxia. Pt has been on rehab, [**Location (un) 669**] West
since [**Month (only) 958**] of this year for his OSA since he lived in a group
home and was unable to care for himself. As per nursing staff at
the facility, he has been having increase in SOB and hypoxia for
the last 2 weeks for which he was tx with lasix with some
improvement. He had a recent 3 lbs wt gain in the last few days.
He is also non-complient with his diet and tends to drink "a lot
of soda". He is on lasix 80mg [**Hospital1 **], however there is no listing
of him having CHF. He denies missing any of his meds. He states
that he had increse in SOB today and his O2sat was 70s% on RA
and EMS was called. He denies having any fever, chills, sweats,
or cough, or LE edema. He sleep with "pillows".  He was then
brought to the ED for further eval.

MEDICAL HISTORY: PSYCHIATRIC HISTORY
- reports history of bipolar disorder/ schizophrenia diagnosed
when he was 17.
- two hosptializations at [**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) **] and [**Last Name (LF) 42339**], [**First Name3 (LF) **]
mother, last [**Name2 (NI) 103301**] was 5 years ago; sees [**Name2 (NI) 2447**]
Dr. [**First Name (STitle) 1169**] at [**Hospital1 2177**].
- Denies any suicide attempts in past.

MEDICATION ON ADMISSION: -Aripiprazole 20 mg PO/NG DAILY
-Aspirin 81 mg PO/NG DAILY
-Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
- Carbamazepine 200 mg PO/NG [**Hospital1 **]
-Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **]
-Doxepin HCl 10 mg PO/NG HS
-Omeprazole 20 mg PO DAILY
-Risperidone 3 mg PO BID

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION:
Vitals: T: 97.4, 110/35, 86, 20, 95% on mask
General: Alert, oriented, no acute distress. speaking in full
sentences. Talking to himself
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP difficult to assess given body habitus
Lungs: Decreased breath sounds bilaterally, no wheezes,
rales,ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Obese soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
Trace edema on bil LE and and hands.
Neuro:  Alert and oriented X 3. able to recall medications and
sister's phone number. Gait not assessed.

FAMILY HISTORY: Mother with asthma, Several sibling all in good health. No
family history of cardiac dz or DM.

SOCIAL HISTORY: Currently lives at [**Location 1268**] [**Hospital1 1501**] for his sleep apnea and
BIPAP use. No smoking, no alcohol, no drug use. Sister is HCP 

### Response:
{'Acute respiratory failure,Acute diastolic heart failure,Atrial flutter,Obesity hypoventilation syndrome,Obstructive sleep apnea (adult)(pediatric),Unspecified schizophrenia, unspecified,Bipolar disorder, unspecified,Pure hypercholesterolemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Polycythemia vera'}
