CHIEF COMPLAINT: Oxygen desaturation at nursing facility

PRESENT ILLNESS: 47yo male with asthma, dCHF, complex sleep disorder/OSA,
hypoventilation syndrome requiring 3-4L at baseline presenting
from respiratory rehab with sats in the 70s on room air coming
up to 85% with nasal cannula. Pt is at mental baseline.  Denies
chest pain fever leg swelling, pleuritic chest pain. He has
shortness of breath which has improved upon presentation to the
emergency department.  Per pt this AM on floor, he woke up
yesterday "feeling bad."  His symptoms included nausea,
vomiting, "feeling asthmatic" (wheezing, SOB), and cough
productive of yellow sputum.  He says these symptoms all began
yest when we awoke.  He noticed a little dark red blood in the
vomit.  He has no h/o GI bleeding.  Denies F/C/S.  No diarrhea -
last BM a few days ago.  Pt admits to pain in chest "at first"
but it has since resolved.  Denies mucles aches, joint pains,
other pain, dysuria, runny nose, or sore throat.
.
Of note, pt has had multiple recent hospitalizations for similar
symptoms, most recently on [**2134-11-5**].  At that time, his
symptoms were attributed to hypercapnic respiratory failure
secondary to obesity hypoventilation syndrome and complex sleep
disorder.  He had several ABG's throughout that admission that
[**Last Name (un) 22975**] stable oxygenation in the setting of [**Last Name (un) 103306**] with CO2
to ~100. During that admission he developed severe somnolence
overnight, was minimally responsive to sternal rub, and
developed hypotension to SBP 70-80s, but despite this still had
stable PO2 of 69, CO2 102, and no residual AMS with
normalization of BP upon waking.  His baseline pulse ox is high
80s at rest while awake.  He was recommended tracheostomy to
stabilize breathing but refused.
.
In the ED, he was 86%on 2L, and 90% on 4L.  CXR showed possible
pneumonia at the left base, so he was started on vanc/levo and
given nebs.  still tachypneic.

MEDICAL HISTORY: 1. Complex sleep disorder on bipap at night with severe
nocturnal and daytime hypoxia related to hypoventiliation
2. Schizophrenia
3. Bipolar disorder
4. CHF with diastolic dysfxn
5. Asthma
6. HTN
7. DM type 2, diet controlled
8. Erythrocythosis, thought secondary to hypoxia

MEDICATION ON ADMISSION: 1. doxepin 10 mg Capsule Sig: One (1) Capsule PO 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 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Risperdal 4 mg Tablet Sig: One (1) Tablet PO twice 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 once a day
as needed for dystonia.
8. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Alert, oriented, no acute distress, obese
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, extensive soft tissue surrounding neck, could not
assess JVD, no LAD
Lungs: poor air movement with shallow BS.  Coarse crackles
diffusely but no wheezing or focal area of consolidation
CV: faint heart sounds
Abdomen: soft, obese, distended, hypoactive bowel sounds,
non-tender, no guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN 2-12 intact, strength 5/5 UE, [**5-4**] LE hip flexors but
otherwise [**6-3**] in LE

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

SOCIAL HISTORY: Has been living at [**Location 1268**] [**Hospital1 1501**] since [**2134-3-30**] for his
sleep apnea and BIPAP use. Sister is HCP
- [**Name (NI) 1139**]: none
- Alcohol: none
- Illicits: none
Chronic diastolic heart failure,Obesity hypoventilation syndrome,Chronic respiratory failure,Schizophrenic disorders, residual type, chronic,Hypoxemia,Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Polycythemia, secondary
Chr diastolic hrt fail,Obesity hypovent synd,Chronic respiratory fail,Schizophr dis resid-chr,Hypoxemia,Asthma NOS,DMII wo cmp nt st uncntr,Hypertension NOS,Obstructive sleep apnea,Secondary polycythemia
Admission Date:  [**2134-11-25**]              [**Month/Day/Year **] Date:   [**2134-11-29**]

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

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Oxygen desaturation at nursing facility

Major Surgical or Invasive Procedure:
None

History of Present Illness:
47yo male with asthma, dCHF, complex sleep disorder/OSA,
hypoventilation syndrome requiring 3-4L at baseline presenting
from respiratory rehab with sats in the 70s on room air coming
up to 85% with nasal cannula. Pt is at mental baseline.  Denies
chest pain fever leg swelling, pleuritic chest pain. He has
shortness of breath which has improved upon presentation to the
emergency department.  Per pt this AM on floor, he woke up
yesterday "feeling bad."  His symptoms included nausea,
vomiting, "feeling asthmatic" (wheezing, SOB), and cough
productive of yellow sputum.  He says these symptoms all began
yest when we awoke.  He noticed a little dark red blood in the
vomit.  He has no h/o GI bleeding.  Denies F/C/S.  No diarrhea -
last BM a few days ago.  Pt admits to pain in chest "at first"
but it has since resolved.  Denies mucles aches, joint pains,
other pain, dysuria, runny nose, or sore throat.
.
Of note, pt has had multiple recent hospitalizations for similar
symptoms, most recently on [**2134-11-5**].  At that time, his
symptoms were attributed to hypercapnic respiratory failure
secondary to obesity hypoventilation syndrome and complex sleep
disorder.  He had several ABG's throughout that admission that
[**Last Name (un) 22975**] stable oxygenation in the setting of [**Last Name (un) 103306**] with CO2
to ~100. During that admission he developed severe somnolence
overnight, was minimally responsive to sternal rub, and
developed hypotension to SBP 70-80s, but despite this still had
stable PO2 of 69, CO2 102, and no residual AMS with
normalization of BP upon waking.  His baseline pulse ox is high
80s at rest while awake.  He was recommended tracheostomy to
stabilize breathing but refused.
.
In the ED, he was 86%on 2L, and 90% on 4L.  CXR showed possible
pneumonia at the left base, so he was started on vanc/levo and
given nebs.  still tachypneic.


Past Medical History:
1. Complex sleep disorder on bipap at night with severe
nocturnal and daytime hypoxia related to hypoventiliation
2. Schizophrenia
3. Bipolar disorder
4. CHF with diastolic dysfxn
5. Asthma
6. HTN
7. DM type 2, diet controlled
8. Erythrocythosis, thought secondary to hypoxia


Social History:
Has been living at [**Location 1268**] [**Hospital1 1501**] since [**2134-3-30**] for his
sleep apnea and BIPAP use. Sister is HCP
- [**Name (NI) 1139**]: none
- Alcohol: none
- Illicits: none


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


Physical Exam:
General: Alert, oriented, no acute distress, obese
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, extensive soft tissue surrounding neck, could not
assess JVD, no LAD
Lungs: poor air movement with shallow BS.  Coarse crackles
diffusely but no wheezing or focal area of consolidation
CV: faint heart sounds
Abdomen: soft, obese, distended, hypoactive bowel sounds,
non-tender, no guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN 2-12 intact, strength 5/5 UE, [**5-4**] LE hip flexors but
otherwise [**6-3**] in LE


Pertinent Results:
On Admission:
[**2134-11-25**] 12:04AM BLOOD WBC-7.0 RBC-6.87* Hgb-16.8 Hct-58.4*
MCV-85 MCH-24.4* MCHC-28.7* RDW-18.1* Plt Ct-245#
[**2134-11-25**] 12:04AM BLOOD Glucose-135* UreaN-18 Creat-0.9 Na-140
K-4.5 Cl-90* HCO3-36* AnGap-19
[**2134-11-25**] 09:00AM BLOOD Calcium-8.5 Phos-5.6* Mg-1.9

On [**Month/Day/Year **]:
[**2134-11-28**] 04:34AM BLOOD WBC-6.0 RBC-6.07 Hgb-15.1 Hct-51.2 MCV-85
MCH-24.9* MCHC-29.5* RDW-17.6* Plt Ct-223
[**2134-11-27**] 04:40AM BLOOD PT-13.1 PTT-28.1 INR(PT)-1.1
[**2134-11-28**] 04:31PM BLOOD Glucose-111* UreaN-16 Creat-0.6 Na-140
K-3.9 Cl-89* HCO3-44* AnGap-11
[**2134-11-28**] 04:31PM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8

Studies:

CXR [**2134-11-25**] - IMPRESSION: Mild interstitial pulmonary edema
improved since [**2134-11-6**].

Brief Hospital Course:
Mr. [**Known lastname 732**] is a 47 year-old man with complex sleep disorder/OSA,
hypoventilation syndrome requiring 3-4L O2 at baseline who was
sent to the emergency department after an oxygen desaturation at
his nursing facility.
.
#. Respiratory Distress ?????? The patient was at respiratory rehab
due to a history of complex sleep disorder and frequent
desaturations into the 80% range. He has had multiple admissions
for respiratory failure in the past. On arrival to the ED here,
the patient's O2 sat was initially 86% on 2L and improved to 90%
on 4L. CXR showed possible pneumonia at the left base, and he
was started on vanc/levo. Admitted to the [**Hospital Unit Name 153**]. In the unit, the
patient was stable and afebrile. Antibiotics were not continued.
He was actively diuresed with good UOP response. The patient was
placed on BiPap. Overnight, Mr. [**Name14 (STitle) 103307**] had frequent
desaturations into the 70s on a setting of 20/18. The patient's
BiPap settings were titrated to 22/18 and he was diuresed
further with a lasix drip.  On the night prior to [**Name14 (STitle) **], the
patient was stable with only intermittent desats to the 80s.  He
tolerated BiPap well.  He will be discharged directly from the
[**Hospital Unit Name 153**] back to rehab with plans to continue BiPap and continuous
O2 supplementation.
.
#.  Erythrocytosis - The patient's initial laboratory studies
revealed a Hct of 58.4.  The patient has a h/o eryhthrocytosis
which has been attributed to chronic hypoxia.  His Hct remained
relatively stable over his hospital stay.
.
#. Schizophrenia - Continued on home medication regimen of
risperidal, doxepin and carbamazepine.  Also conitnued on
benztropine.
.
#. dCHF - Diuresed as above. Also continued on home metorpolol,
ASA. Will be discharged on 80mg [**Hospital1 **] furosemide and 2.5mg
metolazone.
.
#. Asthma - Continued on home albuterol and ipratropium nebs
.
Transitional Issues:
1) Follow-up with nursing facility to ensure patient is
receiving continuous O2 supplementation and BiPap appropriately.
2) Sleep medicine consult
3) Pulmonary medicine [**Hospital1 648**]

Medications on Admission:
1. doxepin 10 mg Capsule Sig: One (1) Capsule PO 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 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Risperdal 4 mg Tablet Sig: One (1) Tablet PO twice 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 once a day
as needed for dystonia.
8. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a

day).
9. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
11. potassium chloride 20 mEq Packet Sig: Two (2)  PO once a
day.


[**Hospital1 **] Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours).
2. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
3. doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. risperidone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
9. benztropine 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for dystonia.
10. furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
Please have a chemistry panel drawn withing 3 days of [**Hospital1 **]
and have results faxed to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 7022**].
13. BiPap Setting
Please continue BiPap ventilation whenever sleeping at a setting
of 22/18. Please attend your scheduled sleep consult [**Telephone/Fax (1) 648**]
on [**2135-3-12**] for further changes to this setting.


[**Year (4 digits) **] Disposition:
Extended Care

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

[**Hospital **] Diagnosis:
Primary: Hypoxia
Secondary: Obesity Hypoventilation Syndrome, Congestive Heart
Failure


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


[**Hospital **] Instructions:
It was a pleasure taking care of you at [**Hospital1 18**]!

You were admitted due to the hospital due to a low level of
blood oxygen. In the hospital we gave you additional oxygen
through a nasal cannula and placed you on a BiPap machine. The
settings of your BiPap machine were modified so that you would
be more comfortable and have fewer episodes of low blood oxygen.
Additionally, we removed a lot of fluid from your body which
should also help you breather better.

See below for changes to your home medication regimen:
1) Please CHANGE your Lasix dosing from 40mg to 80mg twice daily
2) Please START Metolazone 2.5mg daily
3) Please weigh yourself every morning and call your PCP if your
weight goes up more than 3 lbs
.
See below for instructions regarding follow-up care:

Followup Instructions:
Department: MEDICAL SPECIALTIES- Mask Fitting
When: Wednesday [**2134-12-1**] at 1:00PM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 612**]
Building: KSB 23, [**Hospital Ward Name 860**] basement
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES- Sleep Medicine
When: THURSDAY [**2134-12-2**] at 10:00 AM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5533**] ([**Telephone/Fax (1) 3581**])
WHEN: FRIDAY [**12-3**] 2:00PM
[**Last Name (un) 103308**], [**Numeric Identifier 18406**]

Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2134-12-30**] at 3:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES
When: THURSDAY [**2134-12-30**] at 4:00 PM
With: DR. [**Last Name (STitle) **]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: CARDIAC SERVICES
When: [**Hospital Ward Name **] [**2135-4-11**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.


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

Completed by:[**2134-11-29**]
{'Chronic diastolic heart failure,Obesity hypoventilation syndrome,Chronic respiratory failure,Schizophrenic disorders, residual type, chronic,Hypoxemia,Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Polycythemia, secondary'}


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: Oxygen desaturation at nursing facility

PRESENT ILLNESS: 47yo male with asthma, dCHF, complex sleep disorder/OSA,
hypoventilation syndrome requiring 3-4L at baseline presenting
from respiratory rehab with sats in the 70s on room air coming
up to 85% with nasal cannula. Pt is at mental baseline.  Denies
chest pain fever leg swelling, pleuritic chest pain. He has
shortness of breath which has improved upon presentation to the
emergency department.  Per pt this AM on floor, he woke up
yesterday "feeling bad."  His symptoms included nausea,
vomiting, "feeling asthmatic" (wheezing, SOB), and cough
productive of yellow sputum.  He says these symptoms all began
yest when we awoke.  He noticed a little dark red blood in the
vomit.  He has no h/o GI bleeding.  Denies F/C/S.  No diarrhea -
last BM a few days ago.  Pt admits to pain in chest "at first"
but it has since resolved.  Denies mucles aches, joint pains,
other pain, dysuria, runny nose, or sore throat.
.
Of note, pt has had multiple recent hospitalizations for similar
symptoms, most recently on [**2134-11-5**].  At that time, his
symptoms were attributed to hypercapnic respiratory failure
secondary to obesity hypoventilation syndrome and complex sleep
disorder.  He had several ABG's throughout that admission that
[**Last Name (un) 22975**] stable oxygenation in the setting of [**Last Name (un) 103306**] with CO2
to ~100. During that admission he developed severe somnolence
overnight, was minimally responsive to sternal rub, and
developed hypotension to SBP 70-80s, but despite this still had
stable PO2 of 69, CO2 102, and no residual AMS with
normalization of BP upon waking.  His baseline pulse ox is high
80s at rest while awake.  He was recommended tracheostomy to
stabilize breathing but refused.
.
In the ED, he was 86%on 2L, and 90% on 4L.  CXR showed possible
pneumonia at the left base, so he was started on vanc/levo and
given nebs.  still tachypneic.

MEDICAL HISTORY: 1. Complex sleep disorder on bipap at night with severe
nocturnal and daytime hypoxia related to hypoventiliation
2. Schizophrenia
3. Bipolar disorder
4. CHF with diastolic dysfxn
5. Asthma
6. HTN
7. DM type 2, diet controlled
8. Erythrocythosis, thought secondary to hypoxia

MEDICATION ON ADMISSION: 1. doxepin 10 mg Capsule Sig: One (1) Capsule PO 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 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Risperdal 4 mg Tablet Sig: One (1) Tablet PO twice 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 once a day
as needed for dystonia.
8. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Alert, oriented, no acute distress, obese
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, extensive soft tissue surrounding neck, could not
assess JVD, no LAD
Lungs: poor air movement with shallow BS.  Coarse crackles
diffusely but no wheezing or focal area of consolidation
CV: faint heart sounds
Abdomen: soft, obese, distended, hypoactive bowel sounds,
non-tender, no guarding
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN 2-12 intact, strength 5/5 UE, [**5-4**] LE hip flexors but
otherwise [**6-3**] in LE

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

SOCIAL HISTORY: Has been living at [**Location 1268**] [**Hospital1 1501**] since [**2134-3-30**] for his
sleep apnea and BIPAP use. Sister is HCP
- [**Name (NI) 1139**]: none
- Alcohol: none
- Illicits: none 

### Response:
{'Chronic diastolic heart failure,Obesity hypoventilation syndrome,Chronic respiratory failure,Schizophrenic disorders, residual type, chronic,Hypoxemia,Asthma, unspecified type, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Obstructive sleep apnea (adult)(pediatric),Polycythemia, secondary'}
