CHIEF COMPLAINT: trouble breathing

PRESENT ILLNESS: 47M h/o OSA, obestiy hypoventilation p/w dyspnea, hypercarbia
and lethargy. He is a poor historian. Per report, he did not
wear his bipap mask last night at his nursing home. He tells me
that he tripped and fell in the bathroom last night but did not
hit his head or lose consciousness. He was d/ced from [**Hospital1 18**] on
[**2134-2-6**] when he had a one night hospital course for hypoxemia. He
was treated with BiPAP at that time.  This morning he was picked
up by EMS who noticed an end tidal CO2 of 117.
.
In the ED, initial VS were:  [**Age over 90 **] F, HR 86, 131/65, RR 36, O2sat
96 on bipap. He came in on bipap and was kept on bipap in the
ED. Initial vbg showed 7.27/93/74 and CO2 worsened to 109
subsequently. He remained sleepy but arousable in the ED.
.
Upon transfer vitals were hr 86, 115/62, rr 18, O2 sat 96 bipap
[**11-4**].
.
On arrival to the MICU, he was arousable to loud verbal stimuli
and sternal rub. Half an hour later, he became somnolent and not
arousable to verbal stimuli or vigorous sternal rub. His CO2 had
risent to 125 at that point. He was immediately intubated and
mechanically ventilated. A right subclavian CVC was placed.
.
Review of systems:  per HPI, otherwise unable to obtain

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. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. metolazone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. risperidone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission PE: (to general medicine floor)
Vitals: afebrile 93/48 (57) 54 20 90% on 3L
General: obese gentleman, laying comfortable in bed watching
television, breathing comfortably on NC, NAD
HEENT: Sclera anicteric, dry mucous membranes
Neck: supple, could not assess for JVP given habitus
CV: distant heart sounds, RRR, S1, S2,  no murmurs/rubs/gallops
could be appreciated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, slighty distended, +BS
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: normal muscle strength and sensation throughout
..
[**Name (NI) **] PE:
Vitals: 97.9 74-114/33-68 61 20 85-93 on 2L
8h: -300/+240  24h: -950/+740
General: obese gentleman, sitting comfortably in chair, watching
television and eating breakfast, breathing comfortably on NC
HEENT: Sclera anicteric
Neck: supple, could not assess for JVP given habitus
CV: distant heart sounds, RRR, S1, S2,  no murmurs/rubs/gallops
could be appreciated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, slighty distended, +BS
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**] (RossCommons) since [**Month (only) 958**]
[**2134**] for his sleep apnea and BIPAP use. Sister is HCP
- [**Name (NI) 1139**]: none
- Alcohol: none
- Illicits: none
Acute respiratory failure,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Atrial flutter,Obstructive sleep apnea (adult)(pediatric),Localized adiposity,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypotension, unspecified,Polycythemia, secondary,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Bipolar disorder, unspecified,Schizoaffective disorder, unspecified
Acute respiratry failure,Ac on chr diast hrt fail,Acute kidney failure NOS,Atrial flutter,Obstructive sleep apnea,Localized adiposity,DMII wo cmp nt st uncntr,Hypotension NOS,Secondary polycythemia,Migrne unsp wo ntrc mgrn,Hypertension NOS,Asthma NOS,Bipolar disorder NOS,Schizoaffective dis NOS
Admission Date:  [**2135-2-8**]              [**Year/Month/Day **] Date:   [**2135-2-12**]

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

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 4358**]
Chief Complaint:
trouble breathing

Major Surgical or Invasive Procedure:
ET intubation
right subclavian cvc

History of Present Illness:
47M h/o OSA, obestiy hypoventilation p/w dyspnea, hypercarbia
and lethargy. He is a poor historian. Per report, he did not
wear his bipap mask last night at his nursing home. He tells me
that he tripped and fell in the bathroom last night but did not
hit his head or lose consciousness. He was d/ced from [**Hospital1 18**] on
[**2134-2-6**] when he had a one night hospital course for hypoxemia. He
was treated with BiPAP at that time.  This morning he was picked
up by EMS who noticed an end tidal CO2 of 117.
.
In the ED, initial VS were:  [**Age over 90 **] F, HR 86, 131/65, RR 36, O2sat
96 on bipap. He came in on bipap and was kept on bipap in the
ED. Initial vbg showed 7.27/93/74 and CO2 worsened to 109
subsequently. He remained sleepy but arousable in the ED.
.
Upon transfer vitals were hr 86, 115/62, rr 18, O2 sat 96 bipap
[**11-4**].
.
On arrival to the MICU, he was arousable to loud verbal stimuli
and sternal rub. Half an hour later, he became somnolent and not
arousable to verbal stimuli or vigorous sternal rub. His CO2 had
risent to 125 at that point. He was immediately intubated and
mechanically ventilated. A right subclavian CVC was placed.
.
Review of systems:  per HPI, otherwise unable to obtain

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**] (RossCommons) since [**Month (only) 958**]
[**2134**] 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:
Admission PE: (to general medicine floor)
Vitals: afebrile 93/48 (57) 54 20 90% on 3L
General: obese gentleman, laying comfortable in bed watching
television, breathing comfortably on NC, NAD
HEENT: Sclera anicteric, dry mucous membranes
Neck: supple, could not assess for JVP given habitus
CV: distant heart sounds, RRR, S1, S2,  no murmurs/rubs/gallops
could be appreciated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, slighty distended, +BS
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: normal muscle strength and sensation throughout
..
[**Name (NI) **] PE:
Vitals: 97.9 74-114/33-68 61 20 85-93 on 2L
8h: -300/+240  24h: -950/+740
General: obese gentleman, sitting comfortably in chair, watching
television and eating breakfast, breathing comfortably on NC
HEENT: Sclera anicteric
Neck: supple, could not assess for JVP given habitus
CV: distant heart sounds, RRR, S1, S2,  no murmurs/rubs/gallops
could be appreciated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, slighty distended, +BS
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
Admission labs:
.
[**2135-2-8**] 10:25PM   TYPE-CENTRAL VE PO2-43* PCO2-66* PH-7.39
TOTAL CO2-41* BASE XS-11
[**2135-2-8**] 08:12PM   GLUCOSE-128* UREA N-43* CREAT-1.4* SODIUM-140
POTASSIUM-3.8 CHLORIDE-93* TOTAL CO2-39* ANION GAP-12
[**2135-2-8**] 08:12PM   CK(CPK)-72
[**2135-2-8**] 08:12PM   CK-MB-2 cTropnT-<0.01
[**2135-2-8**] 08:12PM   CALCIUM-8.2* PHOSPHATE-2.6*# MAGNESIUM-2.1
[**2135-2-8**] 08:12PM   WBC-9.1 RBC-5.51 HGB-15.3 HCT-48.3 MCV-88
MCH-27.7 MCHC-31.6 RDW-19.0*
[**2135-2-8**] 08:12PM   PLT SMR-NORMAL PLT COUNT-198
[**2135-2-8**] 04:11PM   TYPE-ART PO2-82* PCO2-84* PH-7.28* TOTAL
CO2-41* BASE XS-9
[**2135-2-8**] 02:43PM   TYPE-ART PO2-51* PCO2-125* PH-7.20* TOTAL
CO2-51* BASE XS-14 INTUBATED-NOT INTUBA
[**2135-2-8**] 12:20PM   PO2-85 PCO2-109* PH-7.23* TOTAL CO2-48* BASE
XS-12
[**2135-2-8**] 11:25AM   TYPE-[**Last Name (un) **] PO2-74* PCO2-93* PH-7.27* TOTAL
CO2-45* BASE XS-11 COMMENTS-GREEN TOP
[**2135-2-8**] 11:25AM   TYPE-[**Last Name (un) **] PO2-74* PCO2-93* PH-7.27* TOTAL
CO2-45* BASE XS-11 COMMENTS-GREEN TOP
[**2135-2-8**] 11:25AM   LACTATE-1.4 K+-4.6
[**2135-2-8**] 11:00AM   GLUCOSE-139* UREA N-45* CREAT-1.8* SODIUM-137
POTASSIUM-4.9 CHLORIDE-87* TOTAL CO2-38* ANION GAP-17
[**2135-2-8**] 11:00AM   proBNP-400*
[**2135-2-8**] 11:00AM   CALCIUM-8.0* PHOSPHATE-5.9* MAGNESIUM-2.2
[**2135-2-8**] 11:00AM   CARBAMZPN-5.9
[**2135-2-8**] 11:00AM   PT-11.0 PTT-30.3 INR(PT)-1.0
..
[**Year/Month/Day **] labs:

[**2135-2-11**] 03:22AM BLOOD WBC-8.2 RBC-5.46 Hgb-14.7 Hct-47.8 MCV-88
MCH-26.9* MCHC-30.7* RDW-19.1* Plt Ct-201
[**2135-2-12**] 07:00AM BLOOD WBC-9.9 RBC-5.54 Hgb-15.5 Hct-48.5 MCV-88
MCH-28.0 MCHC-32.0 RDW-19.2* Plt Ct-232
[**2135-2-11**] 03:22AM BLOOD Glucose-104* UreaN-37* Creat-1.5* Na-140
K-4.2 Cl-93* HCO3-38* AnGap-13
[**2135-2-12**] 07:00AM BLOOD Glucose-100 UreaN-26* Creat-0.9 Na-138
K-4.5 Cl-93* HCO3-34* AnGap-16
[**2135-2-11**] 03:22AM BLOOD Calcium-8.8 Phos-6.3*# Mg-2.1
[**2135-2-12**] 07:00AM BLOOD Calcium-8.9 Phos-3.7# Mg-2.1
[**2135-2-11**] 03:37AM BLOOD Lactate-1.7
.
Studies:
ECHO [**2135-2-11**]
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 60%). There is beat-to-beat variability of the left
ventricular ejection fraction due to an irregular rhythm. 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. There is no mitral valve prolapse.
There is no pericardial effusion. The pulmonary artery systolic
pressure could not be setermined due to inability to adequately
visualize the tricuspid valve and any tricuspid regurgitation
that might be present. The right ventricle was not
well-visualized but does not appear to be grossly dilated or
hypokinetic.

Compared with the findings of the prior study (images reviewed)
of [**2134-9-2**], the right ventricle is not well-visualized on
the present study. Right heart catheterization is recommended if
definitive knowledge of pulmonary artery pressure is required.
.
CXR [**2135-2-8**]
IMPRESSION: Trace bilateral pleural effusions with pulmonary
vascular
engorgement consistent with CHF exacerbation.
.
CXR [**2135-2-10**]
IMPRESSION: Improvement in the mild pulmonary edema and right
basilar opacity with a persistent retrocardiac opacity.


Brief Hospital Course:
Assessment and Plan:
Mr. [**Known lastname 732**] is a 47 yo male with obesity hypoventilation and
poorly controlled OSA admitted to the MICU from the [**Hospital1 18**] for
hypercarbic respiratory failure.
.
# Hypercarbic respiratory failure: The patient has had multiple
admissions for hypercarbic respiratory failure [**3-3**] to his OSA
and obesity ventilation syndrome in the context of not wearing
his CPAP at night.  The patient was initially admitted to the
MICU, and overnight, was found to be somnolent, with CO2 peaking
at 125 and was emergently intubated.  The patient remained
intubated for 48 hours, with O2 saturation goal>85% and CO2 at
his baseline, ~90s.  The patient was extubated and did well on
BIPAP overnight. He was called out to the floor on the following
day.
.
While on the medicine floor, the patient was instructed to
continue using BIPAP at night.  He was maintained on 3-4L NC
during the day, and maintaining O2 saturations >85%.
.
# Bradycardia and atrial flutter: While in the MICU, the patient
was found to have episodes of atrial flutter with intermittent
block.  There was concern for sick sinus syndrome, ans as per
report the patient's PCP was notified.  He was continued on his
aspirin and metoprolol (hold parameters were defined).
.
While on the general medicine floor, the patient's vital signs
were stable, with heart rates on the day of [**Month/Day (2) **] ~60s.
.
# Hypotension: While in the MICU, the patient was initially
hypotensive, which was attributed to hypovolemia in the setting
of sedative medications (midazolam and fentanyl).  There was a
low suscpicion for sepsis, adrenal insufficieny, and cardiac
event, as the patient was fluid responsive.
.
While on the medicine floor, the patient's blood pressures were
stable.
.
#Somnolence: While in the MICU, the patient was found to be
somnolent overnight, likely due to hypercarbia.  The patient was
ultimately intubated (see above), and upon extubation his mental
status remained at his baseline, without any further episodes of
somnolence.
.
#Obstructive Sleep Apnea: The patient has a long-standing
history of OSA, which has likely led to pulmonary hypertension.
The patient also has a history of being non-compliant with his
CPAP at night, which likely accounts for his repeat admissions
for hypercarbic respiratory failure.  The option of tracheostomy
has been discussed with the patient in the past, as well as
during this most recent admission; the patient continues to
decline this option.
.
#Acute Kidney Injury:  The patient's creat on admission was 1.8,
and trended down after getting hydrating, making prerenal
azotemia the likely cause of his acute kidney injury.  The
patient's creat bumped again after some diuresis.  Diuresis was
held, and the patient's creat was trending down upon [**Month/Day (2) **]
and his home diuretic regimen was restarted.

# diastolic CHF: The patient has diastolic CHF, with most recent
EF 60% in [**2135-2-11**].  The patient was initially thought to be
hypovolemia and prerenal and was hydrated.  He was then
diuresed, as CXRs showed evidence of pulmonary congestion.
.
On transfer from the MICU to the general medicine floor, the
patient had a creat bump to 1.5, likely from being diuresed.
Diuresis was held for one day, and the patient's creat
normalized.  At this point, he was restarted on his home
diuretic regimen of Lasix 100 mg [**Hospital1 **] and metolazone 2.5 mg
daily.  The patient was continued on metoprolol 12.5 mg [**Hospital1 **],
lisinopril 2.5 mg daily (which was initially held during times
of acute kidney injury), and ASA 325 mg.
.
# schizoaffective disoder:  The patient was continued on his
home regimen of doxepin 10 mg qhs, risperidone 4 mg [**Hospital1 **], and
benztropine 0.5 mg daily.
.
#DMII, diet controlled:  While in the hospital the patient was
placed on insulin sliding scale, with fingersticks being check
with meals and before bed.
.
#Erythrocytosis: Likely due to his chronic hypoxia from his OSA
and hypoventilatory disorder.  His crits were monitored while in
the hospital.
.
# HTN: The patient was continued on metoprolol 12.5 mg [**Hospital1 **],
Lisinopril 2.5 mg daily, as well as his Lasix and metolazone.
.
#Migraine Headaches:  The patient was continued on
carbamazepime.
.
Transitional Issues:
- It was reemphasized that the patient MUST use his CPAP at
night.
- TSH elevated to 6.1 with normal T4, likely sick euthyroid in
the setting of MICU stay.  The patient will have to have this
followed up as an outpatient.

Medications on Admission:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. metolazone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. risperidone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a

day).
8. ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times

a day).
9. furosemide 40 mg Tablet Sig: 2.5 Tablets PO BID (2 times a
day).
10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. benztropine 0.5 mg Tablet Sig: One (1) Tablet PO once a day.

12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:

Three (3) Tablet, ER Particles/Crystals PO once a day.
13. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1) spray Inhalation every six (6) hours as needed for shortness

of breath or wheezing.
14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.


[**Hospital1 **] Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
2. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. risperidone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
8. benztropine 1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: One
(1)  Inhalation q6h:PRN as needed for shortness of breath or
wheezing.
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-31**]  Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
11. Lasix 40 mg Tablet Sig: 2.5 Tablets PO twice a day: 100 mg
[**Hospital1 **].
12. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day.

13. ketoconazole 2 % Cream Sig: One (1)  Topical twice a day.
14. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Three (3) Tablet, ER Particles/Crystals PO once a day.


[**Hospital1 **] Disposition:
Extended Care

Facility:
Roscommon - [**Location 1268**]

[**Location **] Diagnosis:
primary diagnosis:
hypercarbic respiratory failure
obstructive sleep apnea
obesity hypoventilaton syndrome
.
secondary diagnosis:
diabetes mellitus
hypertension


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


[**Location **] Instructions:
Dear Mr. [**Known lastname 732**],
.
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**].  You were admitted because you were having difficulty
breathing.  You had to go to the intensive care unit and your
breathing was so bad that they ultimately had to put a tube into
your windpipe to help breath for you.  We were able to remove
the breathing tube and you were then breathing comfortably on
the same amount of oxygen you use at home.
.
We think that the reason this keeps happening is because you do
not use your CPAP at home.  It is VERY important that you use
your CPAP at home.  If you do not use your CPAP at home, you
will continue to not breath properly and keep returning to the
hospital.
.
We did not make any changes to your home medications.
.
It is very important that you keep all of your follow up
appointments as an outpatient (please see below)

Followup Instructions:
PCP [**Name Initial (PRE) 648**]: Thursday, [**2-17**] at 9:30am
With:Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]( Dr. [**First Name (STitle) **] works with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
who is unavailable to see you next week)
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**]
.
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2135-3-31**] 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
****We are working on a sooner follow up appt with DR. [**Last Name (STitle) **]
for you to be seen with in 2 weeks from your [**Last Name (STitle) **]. If you
have not heard by next Thursday the 19th  from her office or
have questions, please call the above number.



Completed by:[**2135-2-12**]
{'Acute respiratory failure,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Atrial flutter,Obstructive sleep apnea (adult)(pediatric),Localized adiposity,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypotension, unspecified,Polycythemia, secondary,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Bipolar disorder, unspecified,Schizoaffective disorder, unspecified'}


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: trouble breathing

PRESENT ILLNESS: 47M h/o OSA, obestiy hypoventilation p/w dyspnea, hypercarbia
and lethargy. He is a poor historian. Per report, he did not
wear his bipap mask last night at his nursing home. He tells me
that he tripped and fell in the bathroom last night but did not
hit his head or lose consciousness. He was d/ced from [**Hospital1 18**] on
[**2134-2-6**] when he had a one night hospital course for hypoxemia. He
was treated with BiPAP at that time.  This morning he was picked
up by EMS who noticed an end tidal CO2 of 117.
.
In the ED, initial VS were:  [**Age over 90 **] F, HR 86, 131/65, RR 36, O2sat
96 on bipap. He came in on bipap and was kept on bipap in the
ED. Initial vbg showed 7.27/93/74 and CO2 worsened to 109
subsequently. He remained sleepy but arousable in the ED.
.
Upon transfer vitals were hr 86, 115/62, rr 18, O2 sat 96 bipap
[**11-4**].
.
On arrival to the MICU, he was arousable to loud verbal stimuli
and sternal rub. Half an hour later, he became somnolent and not
arousable to verbal stimuli or vigorous sternal rub. His CO2 had
risent to 125 at that point. He was immediately intubated and
mechanically ventilated. A right subclavian CVC was placed.
.
Review of systems:  per HPI, otherwise unable to obtain

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. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. metolazone 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. risperidone 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission PE: (to general medicine floor)
Vitals: afebrile 93/48 (57) 54 20 90% on 3L
General: obese gentleman, laying comfortable in bed watching
television, breathing comfortably on NC, NAD
HEENT: Sclera anicteric, dry mucous membranes
Neck: supple, could not assess for JVP given habitus
CV: distant heart sounds, RRR, S1, S2,  no murmurs/rubs/gallops
could be appreciated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, slighty distended, +BS
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: normal muscle strength and sensation throughout
..
[**Name (NI) **] PE:
Vitals: 97.9 74-114/33-68 61 20 85-93 on 2L
8h: -300/+240  24h: -950/+740
General: obese gentleman, sitting comfortably in chair, watching
television and eating breakfast, breathing comfortably on NC
HEENT: Sclera anicteric
Neck: supple, could not assess for JVP given habitus
CV: distant heart sounds, RRR, S1, S2,  no murmurs/rubs/gallops
could be appreciated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, obese, non-tender, slighty distended, +BS
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**] (RossCommons) since [**Month (only) 958**]
[**2134**] for his sleep apnea and BIPAP use. Sister is HCP
- [**Name (NI) 1139**]: none
- Alcohol: none
- Illicits: none 

### Response:
{'Acute respiratory failure,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Atrial flutter,Obstructive sleep apnea (adult)(pediatric),Localized adiposity,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypotension, unspecified,Polycythemia, secondary,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Unspecified essential hypertension,Asthma, unspecified type, unspecified,Bipolar disorder, unspecified,Schizoaffective disorder, unspecified'}
