CHIEF COMPLAINT: Shortness of Breath and fall

PRESENT ILLNESS: 76 female with morbid obesity, obesity-hypoventilation syndrome,
OSA, non-compliant with home CPAP, pulmonary hypertension on
home oxygen therapy of 3L, Congestive Heart Failure secondary to
diastolic dysfunction, DM II who presented to [**Hospital1 18**] on [**10-10**]
after falling from a chair at home. Apparently, patient stood up
and fell forward after [**2-20**] steps. There was no reported loss of
consciousness or incontinence. Her emergency departement course
was notable for elective intubation to allow patient to lay flat
for CT scan. The CT scan was negative for pulmonary embolism,
but showed congestive heart failure.  Patient was admitted to
medicine service for diuresis for presumed congestive heart
failure and fall.

MEDICAL HISTORY: morbid obesity
obesity-hypoventilation syndrome
OSA
non-compliant with home CPAP
pulmonary hypertension on home oxygen therapy of 3L
Congestive Heart Failure secondary to diastolic dysfunction
Diabetes Mellitus 2
s/p Right CEA
Bilateral total knee replacements
Bronchomalacia
Chronic Low back pain

MEDICATION ON ADMISSION: aldotizide 25 mg po qd
neurontin 1200 mg po qd
oxycontin
diazepam
lisinopril 5 mg po qd
metformin 500 mg po bid
celexa 20 mg po qd
aspirin 325 mg po qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam on Admission to the MICU:
Vital Signs: Afebrile HR 60 BP 80/30
gen: prior to intubation awake, though somnolent, easily
arousable, oriented to person, placea nd following commands.
post intubation, lying flat in bed, intubated, sedated
CV: RRR, normal S1, loud S2, [**1-24**] HSM loudest at apex
Lungs: diffuse crackles anterolaterally (before intubation)
diffuse crackles bilaterally posteriorly. dullmess at bases R >
L.
Abd: soft, NT, ND. active bowel sounds. no HSM.
Extremities: 1+ pitting edema bilaterally
neuro: before intubation, CN II-XII appeared intact, non-focal
neuro exam, moving all extremities spontaneously

FAMILY HISTORY: Father: CVA

SOCIAL HISTORY: patient lives with daughter.
Denies tobacco, etoh.
Congestive heart failure, unspecified,Acute respiratory failure,Pneumonia, organism unspecified,Chronic airway obstruction, not elsewhere classified,Mitral valve disorders,Alkalosis,Cellulitis and abscess of unspecified sites,Unspecified protein-calorie malnutrition,Chronic pulmonary heart disease, unspecified,Morbid obesity,Hyperparathyroidism, unspecified,Other isolated or specific phobias,Other specified cardiac dysrhythmias,Anemia of other chronic disease,Enlargement of lymph nodes,Cervical spondylosis without myelopathy,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Personal history of noncompliance with medical treatment, presenting hazards to health,Unspecified fall
CHF NOS,Acute respiratry failure,Pneumonia, organism NOS,Chr airway obstruct NEC,Mitral valve disorder,Alkalosis,Cellulitis NOS,Protein-cal malnutr NOS,Chr pulmon heart dis NOS,Morbid obesity,Hyperparathyroidism NOS,Isolated/spec phobia NEC,Cardiac dysrhythmias NEC,Anemia-other chronic dis,Enlargement lymph nodes,Cervical spondylosis,DMII neuro nt st uncntrl,Neuropathy in diabetes,Hx of past noncompliance,Fall NOS
Admission Date:  [**2110-10-10**]              Discharge Date:   [**2110-10-22**]

Date of Birth:  [**2034-5-5**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 14385**]
Chief Complaint:
Shortness of Breath and fall

Major Surgical or Invasive Procedure:
tracheotomy
PICC line placement
post-pyloric Dobhoff tube placement


History of Present Illness:
76 female with morbid obesity, obesity-hypoventilation syndrome,
OSA, non-compliant with home CPAP, pulmonary hypertension on
home oxygen therapy of 3L, Congestive Heart Failure secondary to
diastolic dysfunction, DM II who presented to [**Hospital1 18**] on [**10-10**]
after falling from a chair at home. Apparently, patient stood up
and fell forward after [**2-20**] steps. There was no reported loss of
consciousness or incontinence. Her emergency departement course
was notable for elective intubation to allow patient to lay flat
for CT scan. The CT scan was negative for pulmonary embolism,
but showed congestive heart failure.  Patient was admitted to
medicine service for diuresis for presumed congestive heart
failure and fall.

On [**10-14**], patient

Past Medical History:
morbid obesity
obesity-hypoventilation syndrome
OSA
non-compliant with home CPAP
pulmonary hypertension on home oxygen therapy of 3L
Congestive Heart Failure secondary to diastolic dysfunction
Diabetes Mellitus 2
s/p Right CEA
Bilateral total knee replacements
Bronchomalacia
Chronic Low back pain

Social History:
patient lives with daughter.
Denies tobacco, etoh.

Family History:
Father: CVA

Physical Exam:
Physical Exam on Admission to the MICU:
Vital Signs: Afebrile HR 60 BP 80/30
gen: prior to intubation awake, though somnolent, easily
arousable, oriented to person, placea nd following commands.
post intubation, lying flat in bed, intubated, sedated
CV: RRR, normal S1, loud S2, [**1-24**] HSM loudest at apex
Lungs: diffuse crackles anterolaterally (before intubation)
diffuse crackles bilaterally posteriorly. dullmess at bases R >
L.
Abd: soft, NT, ND. active bowel sounds. no HSM.
Extremities: 1+ pitting edema bilaterally
neuro: before intubation, CN II-XII appeared intact, non-focal
neuro exam, moving all extremities spontaneously

Pertinent Results:
[**2110-10-10**] 06:47AM   GLUCOSE-141* UREA N-15 CREAT-1.0 SODIUM-146*
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-42* ANION GAP-8
[**2110-10-10**] 06:47AM   ALT(SGPT)-12 AST(SGOT)-28 LD(LDH)-170
CK(CPK)-252* ALK PHOS-94 AMYLASE-79 TOT BILI-1.1
[**2110-10-10**] 06:47AM   TSH-0.72
[**2110-10-10**] 06:47AM   calTIBC-350 VIT B12-596 FOLATE-18.8
FERRITIN-84 TRF-269
[**2110-10-10**] 06:47AM   ALBUMIN-3.4 CALCIUM-9.5 PHOSPHATE-3.5
MAGNESIUM-1.8 IRON-56
[**2110-10-10**] 06:47AM   cTropnT-0.02*
[**2110-10-10**] 06:47AM   CK-MB-3
[**2110-10-10**] 12:45AM   CK(CPK)-249*
[**2110-10-10**] 12:45AM   CK-MB-3 cTropnT-0.02*
[**2110-10-9**] 02:25PM   CK(CPK)-148*
[**2110-10-9**] 02:25PM   CK-MB-3 cTropnT-0.01
[**2110-10-9**] 02:25PM   PT-15.4* PTT-26.1 INR(PT)-1.5

Brief Hospital Course:
Patient admitted to medicine service for diuresis.  Patient
initially responded well to diuresis, but then further lasix
held [**10-11**] to [**10-13**] due to metabolic alkalosis. Bicarbonate
increased to 44 ([**10-12**]), improving only slightly to 40 ([**10-14**]).
Lasix was restarted on [**10-13**] for increasing shortness of breath,
worsening failure by clinical exam. Patient was continued on her
Diamox.  Inermittently, the patient was noted to desaturate to
70-74% on RA.  On [**10-14**], patient noted to be increasingly
somnolent with decreasing systolic blood pressure in 90s.  ABG
at that time showed 7.16/53/120/ 83% O2 , improved to
7.20/66/111/ 90% O2 with BiPAP.  Lactate at this time was 0.8.
CXR at this time showed worsened congestive heart failure with
right greater than left pleural effusion.  An EKG obtained at
this time showed sinus bradycarida with TWF in II, aVF, V6.
Patient was transferred from floor to the ICU where she remained
bradycardic. She was given atropine 1 mg x 3 with increase in HR
to 60s but no improvement in blood pressure. A decision was then
made to electively intubate Ms. [**Known lastname 69742**].

1. Respiratory Failure:
Felt to be multifactorial secondary to CHF, OSA, pulmonary
hypertension, possible pneumonia, and possible right
diaphragmatic weakness.  The patient could not be weaned from
the ventilator and a tracheotomy was placed on [**2110-10-18**]. In the
ICU, the patient was weaned to pressure support ventilation with
setting of 15 pressure support and 5 PEEP. Patient did well on
this during daytime and was resting on Assist control during the
nightime. She was noted to have some thick brown secretions. A
NIF was obtained on [**10-20**] to evaluate her diaphragm strength.
The NIF score was negative 25. She was scheduled to have a
fluoroscopic SNIF on the day of discharge which they were unable
perform due to her compromised respiratory status.

a. CHF: Pt has EF 60% with known diastolic dysfunction. Patient
was followed by the congestive heart failure service in the
hospital.  She was diuresed several liters and improved, but
then developed contraction alkalosis.  Therefore, diuresis was
held.  Pt then gained several pounds and was noted to have
episodic desaturations. It was felt patient was again volume
overloaded. Since elective intubation on [**10-14**], patient's CHF
has stabilized. She was started on lisinopril for afterload
reduction.  CVP ranged 12-14 suggesting euvolemia. Goals have
been to keep patient's ins and outs even.
b. Obstructive Sleep Apnea: Pt non-tolerant of home CPAP mask.
She clearly has a weight-related obstructive sleep apnea.  She
will need to be weaned from vent and then evaluated for tracheal
CPAP while she sleeps.  She will need outpatient sleep follow up
on discharge from rehab.
c. Pulmonary hypertension secondary to obesity- hypoventilation
syndrome: Pt is on home 3 L nasal canula. She will likely need
to resume this once she is weaned from the ventilator
d. Right upper lobe pneumonia: Pt treated with vancomycin and
zosyn for 7 day course. will complete final doses at rehab.

2. Fall: was felt to be mechanical in nature. There was no
suggestion of cardiac, metabolic or neurolgical cause. She was
ruled out for ischemia. An echo was obtained which showed 3+ MR.
2+ TR, worsened oulmonary hypertension, as well as an echodense
mass in left ventricle apex, likely thickened, calcified chordal
structure.  Patient was monitored on telemetry and was noted to
have bradycardia which was not associated with hypotension. Her
fall was not felt to be from her bradycardia. Patient will need
physical therapy to clear patient for home safety evaluation.

3. Pathologically enlarged lymph nodes:
Pt noted to have some increase in size of paratrachial lymph
nodes since [**3-22**]. Pt was seen by pulmonary who recommended no
intervention at this time but follow up CT scan in 6 months when
heart failure compensated. It was felt that given the absence of
mass, the enlarged lymph nodes were unlikely to be secondary to
malignancy.

4. Metabolic Alkalosis: Some element of chronic increased CO2
from OSA.  Pt developed contraction alkalosis from over-diuresis
for CHF.

5. Sinus Bradycarida: Pt was evaluated by electrophysiology on
[**10-21**] for bradycardia to 30s with stable blood pressure. They
felt this was likely secondary to obesity hypoventilation
syndrome and that it was not consistent with sick sinus
syndrome. Given stable hemodynamics, EP felt there was no
indication for pacemaker.

6. Anemia: Evaluated while inpatient. Likely anemia of chronic
disease. B12 and folate both normal. Should monitor weekly while
at rehab.

7. Diabetes Mellitus complicated by neuropathy: Patient was
monitored with fingersticks QID. She was kept on an insulin
sliding scale with good control of her blood sugars. She should
be transitioned back to home diabetic medications.

8. FEN: patient tolerating tube feeds well on discharge. She was
evaluated by speech and swallow who felt we should permit
patient to have pureed solids and thin liquids for comfort when
the Passy-Muir valve is connected. She can advance as tolerated
and will need to be re-evaluated by speech and swallow before
advanced to full po diet. A post-pyloric Dobhoff tube was placed
on [**10-21**] under fluoroscopy.

9. Code : Full per pateint.

10. Acces: Patient had PICC placed under fluoroscopy guidance.

Medications on Admission:
aldotizide 25 mg po qd
neurontin 1200 mg po qd
oxycontin
diazepam
lisinopril 5 mg po qd
metformin 500 mg po bid
celexa 20 mg po qd
aspirin 325 mg po qd

Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD ().
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD ().
3. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection
 Injection TID (3 times a day).
4. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): per sliding scale:
FS 0-150, no insulin
150-200, 2 U insulin
201-250, 4 U insulin
251-300, 6 U insulin
301-350, 8 U insulin
351-400, 10 U insulin
> 401, please [**Name8 (MD) 138**] MD
. injection
5. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal PRN (as
needed).
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One [**Age over 90 1230**]y
(150) mg PO BID (2 times a day) as needed for constipation.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty
(30) mg PO once a day: per dobhoff.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  TID
(3 times a day) as needed.
10. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed for gas.
11. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): per dobhoff if needed.
12. Acetaminophen 160 mg/5 mL Elixir Sig: 160-320 mg PO Q4-6H
(every 4 to 6 hours) as needed.
13. Piperacillin-Tazobactam 4-0.5 g Recon Soln Sig: One (1)
Recon Soln Intravenous  Q8H (every 8 hours) for 2 doses.
14. Vancomycin HCl 10 g Recon Soln Sig: One (1) gram Intravenous
 Q24H (every 24 hours) for 1 doses.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 86**]

Discharge Diagnosis:
Primary
Hypercarbic respiratory failure
Congestive heart failure
Fall
Secondary:
Obesity Hypoventilation syndrome
pulmonary hypertension
Diabetes mellitus
bronchomalacia
Congestive Heart Failure, diastolic
Peripheral neuropathy
Cervical spondylosis
Hyperparathyroidism


Discharge Condition:
stable. pt doing well on PSV trials during daytime.

Discharge Instructions:
Please give patient all medications. Pt will need to follow up
with Dr. [**Last Name (STitle) **] on discharge from rehab facility.

Followup Instructions:
Call Dr. [**Last Name (STitle) **] to schedule follow up appointment for patient
prior to discharge from rehab at [**Telephone/Fax (1) 14825**].

Pt should also follow up with Dr. [**Last Name (STitle) **] in pulmonary clinic on
discharge from rehab.
{'Congestive heart failure, unspecified,Acute respiratory failure,Pneumonia, organism unspecified,Chronic airway obstruction, not elsewhere classified,Mitral valve disorders,Alkalosis,Cellulitis and abscess of unspecified sites,Unspecified protein-calorie malnutrition,Chronic pulmonary heart disease, unspecified,Morbid obesity,Hyperparathyroidism, unspecified,Other isolated or specific phobias,Other specified cardiac dysrhythmias,Anemia of other chronic disease,Enlargement of lymph nodes,Cervical spondylosis without myelopathy,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Personal history of noncompliance with medical treatment, presenting hazards to health,Unspecified fall'}


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 fall

PRESENT ILLNESS: 76 female with morbid obesity, obesity-hypoventilation syndrome,
OSA, non-compliant with home CPAP, pulmonary hypertension on
home oxygen therapy of 3L, Congestive Heart Failure secondary to
diastolic dysfunction, DM II who presented to [**Hospital1 18**] on [**10-10**]
after falling from a chair at home. Apparently, patient stood up
and fell forward after [**2-20**] steps. There was no reported loss of
consciousness or incontinence. Her emergency departement course
was notable for elective intubation to allow patient to lay flat
for CT scan. The CT scan was negative for pulmonary embolism,
but showed congestive heart failure.  Patient was admitted to
medicine service for diuresis for presumed congestive heart
failure and fall.

MEDICAL HISTORY: morbid obesity
obesity-hypoventilation syndrome
OSA
non-compliant with home CPAP
pulmonary hypertension on home oxygen therapy of 3L
Congestive Heart Failure secondary to diastolic dysfunction
Diabetes Mellitus 2
s/p Right CEA
Bilateral total knee replacements
Bronchomalacia
Chronic Low back pain

MEDICATION ON ADMISSION: aldotizide 25 mg po qd
neurontin 1200 mg po qd
oxycontin
diazepam
lisinopril 5 mg po qd
metformin 500 mg po bid
celexa 20 mg po qd
aspirin 325 mg po qd

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam on Admission to the MICU:
Vital Signs: Afebrile HR 60 BP 80/30
gen: prior to intubation awake, though somnolent, easily
arousable, oriented to person, placea nd following commands.
post intubation, lying flat in bed, intubated, sedated
CV: RRR, normal S1, loud S2, [**1-24**] HSM loudest at apex
Lungs: diffuse crackles anterolaterally (before intubation)
diffuse crackles bilaterally posteriorly. dullmess at bases R >
L.
Abd: soft, NT, ND. active bowel sounds. no HSM.
Extremities: 1+ pitting edema bilaterally
neuro: before intubation, CN II-XII appeared intact, non-focal
neuro exam, moving all extremities spontaneously

FAMILY HISTORY: Father: CVA

SOCIAL HISTORY: patient lives with daughter.
Denies tobacco, etoh. 

### Response:
{'Congestive heart failure, unspecified,Acute respiratory failure,Pneumonia, organism unspecified,Chronic airway obstruction, not elsewhere classified,Mitral valve disorders,Alkalosis,Cellulitis and abscess of unspecified sites,Unspecified protein-calorie malnutrition,Chronic pulmonary heart disease, unspecified,Morbid obesity,Hyperparathyroidism, unspecified,Other isolated or specific phobias,Other specified cardiac dysrhythmias,Anemia of other chronic disease,Enlargement of lymph nodes,Cervical spondylosis without myelopathy,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Personal history of noncompliance with medical treatment, presenting hazards to health,Unspecified fall'}
