CHIEF COMPLAINT: SOB

PRESENT ILLNESS: 47yo male with asthma, dCHF, complex sleep disorder/OSA,
hypoventilation syndrome requiring 3-4L at baseline presenting
with increase work of breathing and SOB.
.
Patient recently hospitalized on [**10-20**] - [**10-21**] for similar
complaints of SOB. At that time patient was placed on home BiPAP
with improvement in symptoms. During that hospitalization
discussion re placement of a tracheostomy tube as a means of a
more effective therapy for his severe hypoventilation and
obstructive sleep apnea, however, entertained and patient
declined.  Upon [**Month/Year (2) **], his goal oxygen saturation was listed
as greater than 80% on oxygen supplementation with stipulation
to consider re-hospitalization only if oxygen saturations fall
below 80% or if patient symptomatic.
.
Per patient had been stable in the days following [**Month/Year (2) **] when
once again developed worsening SOB.
Pertinent +/-:
Denies associated CP, pleuritic pain, fevers, productive cough,
peipheral edema, orthopnea. Reports compliance with BiPAP
nightly.
.
Shortness of breath prompted presentation to ED. In the ED, 97.4
90 130/86 24 92% 15L and initially triggered for desats to 85%
on RA with sats improving on high flow as well as
non-rebreather. CXR with possible LLL PNA so given vanc
1gm/levoquin 750mg, combivent nebs x2. Labs notable for WBC
7.29, creatinine 1.4 (up from 0.9 on [**10-21**]), BNP ~1500, ABG
7.29/81/103. Patient received 500cc of NS. Due to concern that
patient may benefit from BiPAP decision made to transfer patient
to the MICU.
Prior to MICU transfer, VS: Afebrile, 93% on BiPAP FiO2 60
114-55 82 with appropriate mentation.
.
On the floor, patient oriented x3 with sats 88-92 on CPAP.
Reports improved breathing though not back to baseline.
.
Review of systems:
(+) Per HPI; reports increase in baseline cough in recent days
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.

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 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)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: BP: 120s/60s HR: 77 RR:16-18 88% on BiPAP 20/18 FiO260
General: Alert, oriented, no acute distress, on BiPAP
HEENT: Sclera anicteric, dry MM, oropharynx clear without
exudates or lesions
Neck: supple, JVP hard to discern, no LAD
Lungs: Anterior fields clear to auscultation bilaterally, no
audible wheezes, rales, ronchi thought overall moving minimal
air
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

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
Acute respiratory failure,Mixed acid-base balance disorder,Diastolic heart failure, unspecified,Obesity hypoventilation syndrome,Polycythemia, secondary,Obstructive sleep apnea (adult)(pediatric),Other sleep disturbances,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Unspecified schizophrenia, unspecified,Bipolar disorder, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Family history of asthma
Acute respiratry failure,Mixed acid-base bal dis,Diastolc hrt failure NOS,Obesity hypovent synd,Secondary polycythemia,Obstructive sleep apnea,Sleep disturbances NEC,Asthma NOS,Hypertension NOS,Schizophrenia NOS-unspec,Bipolar disorder NOS,DMII wo cmp nt st uncntr,Family hx-asthma
Admission Date:  [**2134-11-5**]              [**Month/Day/Year **] Date:   [**2134-11-7**]

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

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
SOB

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
with increase work of breathing and SOB.
.
Patient recently hospitalized on [**10-20**] - [**10-21**] for similar
complaints of SOB. At that time patient was placed on home BiPAP
with improvement in symptoms. During that hospitalization
discussion re placement of a tracheostomy tube as a means of a
more effective therapy for his severe hypoventilation and
obstructive sleep apnea, however, entertained and patient
declined.  Upon [**Month/Year (2) **], his goal oxygen saturation was listed
as greater than 80% on oxygen supplementation with stipulation
to consider re-hospitalization only if oxygen saturations fall
below 80% or if patient symptomatic.
.
Per patient had been stable in the days following [**Month/Year (2) **] when
once again developed worsening SOB.
Pertinent +/-:
Denies associated CP, pleuritic pain, fevers, productive cough,
peipheral edema, orthopnea. Reports compliance with BiPAP
nightly.
.
Shortness of breath prompted presentation to ED. In the ED, 97.4
90 130/86 24 92% 15L and initially triggered for desats to 85%
on RA with sats improving on high flow as well as
non-rebreather. CXR with possible LLL PNA so given vanc
1gm/levoquin 750mg, combivent nebs x2. Labs notable for WBC
7.29, creatinine 1.4 (up from 0.9 on [**10-21**]), BNP ~1500, ABG
7.29/81/103. Patient received 500cc of NS. Due to concern that
patient may benefit from BiPAP decision made to transfer patient
to the MICU.
Prior to MICU transfer, VS: Afebrile, 93% on BiPAP FiO2 60
114-55 82 with appropriate mentation.
.
On the floor, patient oriented x3 with sats 88-92 on CPAP.
Reports improved breathing though not back to baseline.
.
Review of systems:
(+) Per HPI; reports increase in baseline cough in recent days
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.


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:
Vitals: BP: 120s/60s HR: 77 RR:16-18 88% on BiPAP 20/18 FiO260
General: Alert, oriented, no acute distress, on BiPAP
HEENT: Sclera anicteric, dry MM, oropharynx clear without
exudates or lesions
Neck: supple, JVP hard to discern, no LAD
Lungs: Anterior fields clear to auscultation bilaterally, no
audible wheezes, rales, ronchi thought overall moving minimal
air
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema


Pertinent Results:
[**2134-11-5**] 07:46PM BLOOD WBC-7.5 RBC-6.20 Hgb-15.5 Hct-54.0*
MCV-87 MCH-25.0* MCHC-28.7* RDW-17.1* Plt Ct-194
[**2134-11-6**] 04:09AM BLOOD WBC-7.2 RBC-6.03 Hgb-15.4 Hct-52.9*
MCV-88 MCH-25.5* MCHC-29.1* RDW-17.1* Plt Ct-198
[**2134-11-5**] 07:46PM BLOOD Glucose-173* UreaN-34* Creat-1.4* Na-137
K-3.6 Cl-84* HCO3-44* AnGap-13
[**2134-11-6**] 04:09AM BLOOD Glucose-120* UreaN-29* Creat-1.0 Na-138
K-3.8 Cl-88* HCO3-41* AnGap-13
[**2134-11-5**] 07:46PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-1528*
[**2134-11-6**] 04:09AM BLOOD CK-MB-2 cTropnT-<0.01
[**2134-11-5**] 07:46PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.9
[**2134-11-6**] 04:09AM BLOOD Calcium-8.2* Phos-5.6* Mg-1.9
[**2134-11-5**] 07:46PM BLOOD D-Dimer-333
[**2134-11-5**] 07:45PM BLOOD pO2-72* pCO2-91* pH-7.33* calTCO2-50*
Base XS-16 Comment-GREEN TOP
[**2134-11-5**] 07:54PM BLOOD Type-ART pO2-81* pCO2-103* pH-7.29*
calTCO2-52* Base XS-17 Intubat-NOT INTUBA
[**2134-11-6**] 12:24AM BLOOD Type-ART pO2-80* pCO2-111* pH-7.28*
calTCO2-54* Base XS-19
[**2134-11-5**] 07:45PM BLOOD Lactate-3.2* K-3.7
[**2134-11-6**] 12:24AM BLOOD Lactate-1.3
.
Micro:
Blood cx: pending
Urine cx: pending
.
Images:
CXR:
Mild central congestion. Subtle opacity in the left lower lung
which could represent an early pneumonia in the correct clinical
setting.  Consider repeat with a more optimized technique to
clearly assess.


Brief Hospital Course:
47yo male with asthma, dCHF, complex sleep disorder, OSA,
hypoventilation syndrome requiring 3-4L daily and BiPAP nightly
presenting with increase work of breathing and SOB.

1. HYPERCAPNEIC RESPIRATORY FAILURE:  Patient with repeat
admissions for hypercapnic respiratory failure most likely due
to his obesity hypoventilation syndrome and complex sleep
disorder.  Additional work-up notable for negative Ddimer and
BNP elevated but roughly at baseline. The pt's metolazole was
held, he was given 1L IVF, started on home BiPAP settings.
Serial ABGs were checked showing stable oxygenation with
[**Month/Day/Year 103306**] with C02 to ~100.  He maintained goal sats ~88-92,
and he had clear mental status, able to interact, A&Ox3.
Standing nebs for bronchodilation. Additional Abx were held
given low clinical suspicion for PNA.  He developed severe
somnolence overnight with minimal responsiveness to sternal rub
accompanied by hypotension to the 70s-80s sytolic.  ABG again
was reassuring at that time at pO269* pCO2102 pH7.30  Bicarb 52.
 He awoke a few minutes later without residual AMS, and
normalization of his BP.  His underlying obesity hypoventilation
seems likely.  We stopped metolazone due to fears that a
mounting alkalosis was driving [**Month/Day/Year 103306**] and triggering his
respiratory failure.  Otherwise, his home BiPAP levels were
maintained.   Tracheostomy discussions were again initiated for
proper ventilation particualrly during nighttime hours, though
patient remains disinterested currently.  Followup with his
pulmonologist/sleep doctor Dr. [**Last Name (STitle) 95746**] at [**Hospital1 18**] is important
to continue these discussions as well as managing his BiPAP.

2. [**Last Name (un) **]. Creatinine 1.4, up from 0.9 on previous d/c. Additional
labs c/w hemoconcentration making pre-renal azotemia most likely
cause to acute bump. Patient received 500cc of IVF in ED and
another 500cc in the MICU. He maintained good UOP and cr later
normalized to 0.9.

3. Atrial Dysarrhytmia with h/o afib/aflutter. Seen by
cardiology at last admission for eval of prolonged QTc. At that
time rec re arrhythmias was daily anticoagulation with ASA
325mg. Underlying cause that to be worsening pulm function.

4. dCHF. No signs of decompensation per HPI, labs or imaging.
BNP ~1500 within recent baseline. His diuretics were briefly
held due to concern for hypovolemia.  Lasix restarted, but held
metolazone for fear of exacerbating [**Last Name (un) 103306**].

5. Schizophrenia: continued home medications

PENDING TESTS AT [**Last Name (un) 894**]:
-blood cultures 10/7 x 2 not finalized but NGTD

TRANSITIONAL CARE ISSUES:
-stopped metolazone to prevent further [**Last Name (LF) 103306**], [**First Name3 (LF) **] need
volume monitoring and management of diuretics
-will need sleep/pulmonology followup at [**Hospital1 18**]
-ongoing tracheostomy discussions due to worsening complex sleep
disorder/obesity-hypoventilation syndromes


Medications on Admission:
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 325 mg Tablet, Chewable Sig: One (1) Tablet, Chewable

PO DAILY (Daily).
5. risperidone 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. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
10. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation

Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
11. Potassium supplementation 40mg daily
12. Metalozone 2.5mg PO, 30minutes prior to lasix M, W, F
.
** Per record home bipap settings: 20/18 with 10 liters of
supplemental oxygen


[**Hospital1 **] Medications:
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 **] Disposition:
Extended Care

Facility:
Roscommon on the Parkway - [**Location 1268**]

[**Location **] Diagnosis:
hypercarbic respiratory failure due to obesity/hypventilation
syndrome and OSA


[**Location **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


[**Location **] Instructions:
Dear Mr. [**Known lastname 732**],

You were admitted to [**Hospital1 18**] due to complaints of worsening
shortness of breath and fatigue.  After numerous blood tests and
xrays, we did not find any evidence of pneumonia, asthma, or
heart failure to explain your decompensation.  These symptoms
were likely related to your obstructive sleep apena and complex
sleep disorder.  You remained on your breathing machine and felt
better with a little intravenous fluid.  We stopped one of your
diuretics because you were dehydrated on admission.  It is very
important to see your lung [**Hospital1 21334**] after [**Name5 (PTitle) **] leave the hospital.

The following changes were made to your medications:
STOP METOLAZONE

Please continue your other medications


Followup Instructions:
You have the following [**Name5 (PTitle) 648**]:
Department: CARDIAC SERVICES
When: [**Name5 (PTitle) **] [**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

It is very important that you schedule an [**Hospital Ward Name 648**] with your
lung doctor, Dr.[**Last Name (STitle) **].  You can reach her office at  ([**Telephone/Fax (1) 514**]
{'Acute respiratory failure,Mixed acid-base balance disorder,Diastolic heart failure, unspecified,Obesity hypoventilation syndrome,Polycythemia, secondary,Obstructive sleep apnea (adult)(pediatric),Other sleep disturbances,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Unspecified schizophrenia, unspecified,Bipolar disorder, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Family history of asthma'}


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: SOB

PRESENT ILLNESS: 47yo male with asthma, dCHF, complex sleep disorder/OSA,
hypoventilation syndrome requiring 3-4L at baseline presenting
with increase work of breathing and SOB.
.
Patient recently hospitalized on [**10-20**] - [**10-21**] for similar
complaints of SOB. At that time patient was placed on home BiPAP
with improvement in symptoms. During that hospitalization
discussion re placement of a tracheostomy tube as a means of a
more effective therapy for his severe hypoventilation and
obstructive sleep apnea, however, entertained and patient
declined.  Upon [**Month/Year (2) **], his goal oxygen saturation was listed
as greater than 80% on oxygen supplementation with stipulation
to consider re-hospitalization only if oxygen saturations fall
below 80% or if patient symptomatic.
.
Per patient had been stable in the days following [**Month/Year (2) **] when
once again developed worsening SOB.
Pertinent +/-:
Denies associated CP, pleuritic pain, fevers, productive cough,
peipheral edema, orthopnea. Reports compliance with BiPAP
nightly.
.
Shortness of breath prompted presentation to ED. In the ED, 97.4
90 130/86 24 92% 15L and initially triggered for desats to 85%
on RA with sats improving on high flow as well as
non-rebreather. CXR with possible LLL PNA so given vanc
1gm/levoquin 750mg, combivent nebs x2. Labs notable for WBC
7.29, creatinine 1.4 (up from 0.9 on [**10-21**]), BNP ~1500, ABG
7.29/81/103. Patient received 500cc of NS. Due to concern that
patient may benefit from BiPAP decision made to transfer patient
to the MICU.
Prior to MICU transfer, VS: Afebrile, 93% on BiPAP FiO2 60
114-55 82 with appropriate mentation.
.
On the floor, patient oriented x3 with sats 88-92 on CPAP.
Reports improved breathing though not back to baseline.
.
Review of systems:
(+) Per HPI; reports increase in baseline cough in recent days
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.

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 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)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: BP: 120s/60s HR: 77 RR:16-18 88% on BiPAP 20/18 FiO260
General: Alert, oriented, no acute distress, on BiPAP
HEENT: Sclera anicteric, dry MM, oropharynx clear without
exudates or lesions
Neck: supple, JVP hard to discern, no LAD
Lungs: Anterior fields clear to auscultation bilaterally, no
audible wheezes, rales, ronchi thought overall moving minimal
air
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

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:
{'Acute respiratory failure,Mixed acid-base balance disorder,Diastolic heart failure, unspecified,Obesity hypoventilation syndrome,Polycythemia, secondary,Obstructive sleep apnea (adult)(pediatric),Other sleep disturbances,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Unspecified schizophrenia, unspecified,Bipolar disorder, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Family history of asthma'}
