CHIEF COMPLAINT: Hypercarbic respiratory failure.

PRESENT ILLNESS: This is a 63-year-old female
with a history of restrictive lung disease of unclear
etiology and [**Doctor Last Name 48516**] syndrome status post Whipple
in [**2113-1-7**].  She presents in hypercarbic respiratory
failure status post recent admission to the medical intensive
care unit in early [**2114-7-8**] following a syncopal episode and
similar hypercarbic respiratory failure.  On that admission,
arterial blood gas in the Emergency Department showed a pH of
7.14 and a PCO2 of 123.  The patient was admitted to the
Neonatal Intensive Care Unit for further treatment.  She was
briefly treated with noninvasive mask ventilation and her
ventilator status improved such that she was off noninvasive
mask ventilation within 24 hours.  On that admission she was
noted to chronically hypoventilate.  Chest x-ray at the time
showed left lower lobe atelectasis.  Pulmonary function tests
done in early [**Month (only) **] showed a restrictive pattern with an FEV1
of 45% of predicted, an FVC of 34% of predicted with a ratio
of 133% of predicted.  Additionally a TLC was 53% of
predicted, FRC was 70% of predicted, RV was 81% of predicted.
The RV to TLC ratio was 153% of predicted.  DSB (VA) was 46%
of predicted consistent with moderate reduction of diffusion
capacity suggesting the possibility of interstitial disease,
in addition to the likely neuromuscular disease that was
suggested by her lung volumes.  Electromyogram was performed
to assess for neurologic causes and showed no evidence for
disorder of neuromuscular transmission, though there was some
paraspinal denervation present acutely.  Additionally, an MRI
of the brain showed no lesions that might cause central
apnea.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Acute and chronic respiratory failure,Unspecified pleural effusion,Bacteremia,Myoneural disorders, unspecified,Abnormality of secretion of gastrin,Thoracic or lumbosacral neuritis or radiculitis, unspecified,Glycogenosis,Intestinal bypass or anastomosis status
Acute & chronc resp fail,Pleural effusion NOS,Bacteremia,Myoneural disorders NOS,Abnorm secretion gastrin,Lumbosacral neuritis NOS,Glycogenosis,Intestinal bypass status
Admission Date:  [**2114-8-2**]       Discharge Date:  [**2114-8-8**]

Date of Birth:   [**2052-6-26**]       Sex:  F

Service:  MICU

CHIEF COMPLAINT:  Hypercarbic respiratory failure.

HISTORY OF PRESENT ILLNESS:  This is a 63-year-old female
with a history of restrictive lung disease of unclear
etiology and [**Doctor Last Name 48516**] syndrome status post Whipple
in [**2113-1-7**].  She presents in hypercarbic respiratory
failure status post recent admission to the medical intensive
care unit in early [**2114-7-8**] following a syncopal episode and
similar hypercarbic respiratory failure.  On that admission,
arterial blood gas in the Emergency Department showed a pH of
7.14 and a PCO2 of 123.  The patient was admitted to the
Neonatal Intensive Care Unit for further treatment.  She was
briefly treated with noninvasive mask ventilation and her
ventilator status improved such that she was off noninvasive
mask ventilation within 24 hours.  On that admission she was
noted to chronically hypoventilate.  Chest x-ray at the time
showed left lower lobe atelectasis.  Pulmonary function tests
done in early [**Month (only) **] showed a restrictive pattern with an FEV1
of 45% of predicted, an FVC of 34% of predicted with a ratio
of 133% of predicted.  Additionally a TLC was 53% of
predicted, FRC was 70% of predicted, RV was 81% of predicted.
The RV to TLC ratio was 153% of predicted.  DSB (VA) was 46%
of predicted consistent with moderate reduction of diffusion
capacity suggesting the possibility of interstitial disease,
in addition to the likely neuromuscular disease that was
suggested by her lung volumes.  Electromyogram was performed
to assess for neurologic causes and showed no evidence for
disorder of neuromuscular transmission, though there was some
paraspinal denervation present acutely.  Additionally, an MRI
of the brain showed no lesions that might cause central
apnea.

Over the course of that hospitalization the acidosis resolved
without specific intervention and on discharge her blood
gases showed a pH of 7.4 and PCO2 of 71.  She was discharged
home on [**2114-7-14**].

The patient had been doing well at home although she had
complained of some fatigue over the last three weeks.
According to her sons she had two very active days just prior
to the day of admission.  At 7 AM on the day of admission her
sons left the house to go to work and reported that their
mother was awake although still in bed.  They returned home
at approximately 9 PM and found their mother still in her
pajamas, face down in the bed with decreased respirations.
They performed rescue breathing and the patient was brought
to the [**Hospital1 69**] Emergency
Department by EMS.  On arrival her blood gas showed a pH of
7.09, PCO2 of 119, PO2 of 198 and a bicarbonate of 38 with
lactate of 7.4 and she was initiated on BiPAP and transferred
to the medical intensive care unit for further management.

For past medical history, allergies, medications, social
history and family history, please refer to the admission
note from [**2114-8-2**].

PHYSICAL EXAMINATION:  The patient was resting on BiPAP and
did arouse to voice.  Vital signs were blood pressure 84/38,
heart rate 108, respiratory rate 14, saturating 100% on BiPAP
with pressure support of 12 and 10.  A repeat blood gas on
those settings showed improvement to 7.20, 91, 160 and 40.
Skin was warm and dry.  HEENT examination was normocephalic,
atraumatic, sclerae anicteric.  Neck was supple with no
lymphadenopathy and a jugular venous pressure of
approximately 8 cm.  Lungs had poor inspiratory effort with a
few scattered inspiratory squeaks.  Cardiovascularly she was
tachycardic, S1 and S2, no murmur.  Abdomen was soft and
nontender.  Extremities had no edema although cool hands and
feet.  On neurological examination the patient nodded to
simple questions but was poorly attentive though did follow
some simple commands.  Deep tendon reflexes were 3+/4 in the
bilateral upper extremities.

LABORATORY DATA:  For complete admission laboratory studies
please refer to the admission note from [**2114-8-2**].  Briefly,
pertinent laboratory studies included a chest x-ray that
showed low lung volumes but no infiltrates.  Electrolytes
were sodium 131, potassium 6.4, chloride 84, bicarbonate 28,
BUN 36, creatinine 1.2, glucose 352, with an anion gap of 19.
White blood cell count was 11.8.  Hemoglobin 12.2, hematocrit
41.1, platelet count 296.

HOSPITAL COURSE:  1. Respiratory failure:  After admission
the patient was placed on noninvasive mask ventilation and
overnight her pH normalized.  Her PCO2 improved.  She also
received 4?????? liters of normal saline with improvement of her
blood pressure.  Currently the patient is doing well on 1??????
liters nasal cannula oxygen when she is awake and BiPAP with
pressure support of 15 and 5, FIO2 of 0.3 when she is
sleeping.  Please note that the patient must be on BiPAP when
she is sleeping otherwise she hypoventilates and goes into
respiratory acidosis.  Her most recent blood gas showed a pH
of 7.4 and a PCO2 of 70.  The etiology of her lung disease
remains unclear at this point.  High-resolution chest CT
showed bilateral pleural effusions, small to moderate in
size, right greater than left, with some nodular plaques
along the pleura near the effusion.  However there was no
evidence of interstitial lung disease.  Right now it is
thought that the most likely etiology of her respiratory
failure is secondary to a neuromuscular process.  EMGs on the
last admission showed that it was not likely that there was a
problem with her synaptic transmission, thus putting
myasthenia [**Last Name (un) 2902**] and Lambert-Eaton syndrome as the
etiological causes low on the list.  Currently, neurology
believes that it is likely that the patient has a myopathy
and a muscle biopsy is planned.  Neurosurgery is aware of the
patient and two residents have been [**Name (NI) 653**], Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], pager #39-510, and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **]
#90-206.  They will be speaking with Dr. [**Last Name (STitle) 1132**], the
neurosurgery attending today to see if they can arrange for a
muscle biopsy this week for this patient.  We have spoken
with the neuropathologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 122**], who has
informed us that for technical reasons it is extremely
important that the pathologist be present in the operating
room when the muscle biopsy is taken in order for the muscle
to be properly preserved.  So once an OR day and time is set,
they need to be [**Last Name (NamePattern1) 653**] so that they can be present.
Neurology has said that based on the results of her EMGs and
on the fact that she has muscle weakness proximal greater
than distal, the right deltoid is the best site for biopsy
and neurosurgery has been so informed.

Additionally, the neurology and neuromuscular consultation
services have requested that antibodies to [**Doctor First Name **]-1, musk, and
voltage-gated calcium channels be tested for, so we have sent
those laboratory studies out.  If the muscle biopsy is
negative, neurology will consider repeating EMGs with nerve
conduction studies and possibly an MRI of the spine as well.
They will also consider doing a Tensilon test at that time.

Finally, a diaphragmatic excursion test at the bedside was
performed on [**2114-8-3**] and was grossly normal.

2. Bacteremia:  On the night of [**8-4**] to [**8-5**] the patient
spiked a fever to 103 and cultures drawn at that time showed
E. coli present in [**6-11**] bottles.  The patient was initially
started on empiric therapy of ceftriaxone, Flagyl, and
levofloxacin.  Sensitivities of E. coli showed that it was in
fact sensitive to levofloxacin so that has been continued for
a total of a 10-day course and the ceftriaxone and Flagyl
have been discontinued.  Since then the patient has been
afebrile for 72 hours now.  Cultures drawn on [**2114-8-6**] and
[**2114-8-7**] have shown no growth to date.  The source of the E.
coli is presently unclear.  Urine cultures and urinalysis
were negative for urinary tract infection.  Abdominal CT was
negative for an intrahepatic abscess.  There had been concern
for this because the patient has intermittently increased her
liver function tests.  The pleural effusion on the patient's
right side was tapped on [**2114-8-5**] and the results were
consistent with an exudate.  Currently, cultures are pending.
The Gram stain showed PMNs but no bacteria.  Cytology on the
pleural fluid is also pending.

3. Increased liver function tests:  On admission the patient
had increased liver function tests that were at the time
thought to be secondary to her respiratory failure and poor
oxygenation status on admission.  They initially were
trending down but bumped up on [**2114-8-5**].  They are again
trending down.  Ultrasound and hepatitis serologies were all
negative.  Ultrasound and abdominal CT showed no evidence of
biliary disease although ultrasound can miss the majority of
retained stones.  If she bumps her liver function tests
again, we will obtain a magnetic resonance
cholangiopancreatography.

4. Anemia:  Over the course of the hospitalization as we have
fluid resuscitated the patient, her blood counts have been
trending down, currently with a hemoglobin of 7.8 and an
hematocrit of 26.7.  Studies revealed an iron of 18, ferritin
of 46, and a calculated TIBC of 230 consistent with iron
deficiency anemia and we have started the patient on iron.

5. Zollinger-[**Doctor Last Name 9480**] syndrome:  The patient is status post
Whipple antrectomy and vagotomy in [**2113-1-7**].  Despite
that procedure the patient has continued to have high gastrin
levels and we have maintained her on Protonix 40 mg p.o.
t.i.d.

6. Diabetes mellitus:  The patient was noted on her last
admission to have high sugars and we have continued her on a
sliding scale.  She will likely need to be started on an oral
hypoglycemic [**Doctor Last Name 360**].

7. Access:  The patient had a left subclavian line placed on
[**2114-8-5**].

8. Code status:  The patient is full code.

CONDITION ON DISCHARGE:  The patient's respiratory status has
improved greatly since admission, although we still do not
have an etiology for this problem.  Currently she is stable
enough to go to the floor, though she needs to remain
hospitalized until a diagnostic work-up has been completed
and home health has been arranged for her to get training on
the BiPAP machine.





                            [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.  [**MD Number(1) 7585**]

Dictated By:[**Last Name (NamePattern1) 8978**]
MEDQUIST36

D:  [**2114-8-8**]  11:49
T:  [**2114-8-8**]  12:06
JOB#:  [**Job Number 48517**]


Name:  [**Known lastname 8948**], [**Known firstname 300**]                     Unit No:  [**Numeric Identifier 8949**]

Admission Date:  [**2114-8-2**]     Discharge Date:  [**2114-8-14**]

Date of Birth:   [**2052-6-26**]     Sex:  F

Service:

CONTINUATION OF HOSPITAL COURSE:
1. Respiratory failure:  Patient's deltoid biopsy revealed
rare degenerating-regenerating myofibrils, increased
internalized nuclei and scattered nuclear knot, but there was
no significant inflammation or vacuolization.  Patient was
followed closely for Neurology throughout her admission and
had a full spinal MRI as well to rule out spondylosis.  There
were degenerative changes of the spine, but no impressive
changes of cervical spondylosis on the MRI.

Neurology also performed a tensilon test at bedside with
patient which was unrevealing.  A second EMG was set-up for
the day of discharge on [**8-14**] in Neurology on [**Hospital Ward Name 600**].
The patient continued to do well, and was discharged with
home BiPAP and oxygen with pulse oximetry.

2. Bacteremia:  Patient's surveillance cultures remained
negative.  She was continued on her po Levaquin dose
throughout her admission and was sent home to complete a 14
total day course.  She remained afebrile without elevation in
her white count.

3. Elevated LFTs:  Patient's transaminases continued to trend
down except for her alkaline phosphatase, which remained
elevated throughout admission.  Ultrasound while in Intensive
Care was unrevealing for common bile duct dilatation or
gallstones.  This will be followed up as an outpatient.  The
patient never complained about abdominal pain.

4. Anemia:  Patient's anemia remained stable.  The etiology
of this is unclear.  She will need a colonoscopy upon
outpatient.

5. Zollinger-[**Doctor Last Name 6764**] syndrome:  The patient experienced
several episodes of diarrhea while in-house.  She was
continued on her regimen of Viokase four tablets tid with
meals and Protonix 40 mg tid as well as Reglan 10 mg [**Hospital1 **].
This was her home regimen and worked well for the patient.

6. Diabetes mellitus:  The patient was on sliding scale
throughout admission and maintained sugars from the 100's to
low 200's.  It was thought that patient would need insulin
upon discharge, so she was given a trial of metformin 500 mg
[**Hospital1 **] which was increased during admission to 850 mg [**Hospital1 **] to
control her sugars.  Patient was given diabetes teaching in
order to check her own fingersticks at home qid.  She was
discharged on metformin.

Patient continued to do well throughout her admission, and
was discharged to home with her sons with several follow-up
appointments including pulmonary sleep studies, Neurology
EMG, and Neurosurgery, as well as following up with me, her
new primary care physician in the [**Name9 (PRE) 112**] Clinic.  The patient
will be followed closely by all of these departments because
the etiology of her respiratory status remains unclear.  It
is thought that this is very likely neuromuscular, however, a
specific diagnosis has not been made.  The patient was setup
with VNA home services, as well as her home BiPAP, and
diabetes education, and she was discharged in stable
condition.

DISCHARGE DIAGNOSES:
1. Hypercapnia respiratory failure of unclear etiology.
2. Resolved E. coli bacteremia.
3. Transaminitis resolved.
4. Anemia.
5. Zollinger-[**Doctor Last Name 6764**] syndrome.
6. Diabetes mellitus.

DISCHARGE MEDICATIONS:
1. Metformin 850 mg [**Hospital1 **].
2. Protonix 40 mg tid.
3. Viokase four tablets with meals tid.
4. Reglan 10 mg [**Hospital1 **].
5. Levaquin 500 mg po q day for 14 days.
6. Home O2 and BiPAP.

FOLLOW-UP PLANS:  She was discharged by ambulance straight to
[**Hospital Ward Name 600**] for her Neurology appointment in the [**Hospital 8950**] Clinic.
On [**8-20**], she has an appointment with Dr. [**Last Name (STitle) **] [**Name (STitle) **] in
the Sleep Unit at 1 pm.  On [**9-4**], she has an appointment
with Neurology, Dr. [**Doctor Last Name 8951**] at 8:30, and she will see
me, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 2:30 on [**9-4**] at the [**Hospital 112**]
Clinic.  She will see Neurosurgery, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24**] at 1 pm on
[**9-14**].




                          [**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D.  [**MD Number(1) 522**]

Dictated By:[**Last Name (NamePattern1) 1791**]

MEDQUIST36

D:  [**2114-8-15**]  19:58
T:  [**2114-8-16**]  05:23
JOB#:  [**Job Number 8952**]


Name:  [**Known lastname 8948**], [**Known firstname 300**]                     Unit No:  [**Numeric Identifier 8949**]

Admission Date:  [**2114-8-2**]     Discharge Date:  [**2114-8-14**]

Date of Birth:   [**2052-6-26**]     Sex:  F

Service:  MEDICINE-[**Hospital1 248**]

This is and addendum to the discharge summary per Dr.
[**Name (NI) 781**] on [**2114-8-8**].

HISTORY OF PRESENT ILLNESS:  Patient is a 63-year-old lady
with Zollinger-[**Doctor Last Name 6764**] syndrome and history of hypercapnia
with respiratory failure, who is transferred out of the
Intensive Care Unit on [**2114-8-8**].

Physical examination upon arrival to the floor:  Temperature
was 98.9, blood pressure 127/56, pulse 80, respirations 19.
Patient was sating 98% on 2 liters.  Fingerstick was 156.
Generally, the patient was sitting in chair, comfortable with
nasal cannula.  HEENT:  Pupils are equal, round, and reactive
to light and accommodation.  Extraocular movements are
intact.  Mucous membranes were moist.  Nasal cannula was in
place.  Oropharynx clear, no erythema.  Neck:  No cervical
nodes, no jugular venous distention, no thyromegaly, supple.
Chest:  Bilaterally clear to auscultation in apices.
Decreased breath sounds at bilateral bases with dullness to
percussion at bases bilaterally, no wheezing or crackles.
Cardiovascular:  Regular, rate, and rhythm.  Abdomen is soft,
nontender, nondistended, no masses.  Extremities:
Bilaterally upper extremity edema, nonpitting, bilateral
lower extremity mild nonpitting edema, 2+ pulses, diminished
patellar reflexes bilaterally.  Neurologic:  Cranial nerves
II through XII intact bilaterally.  Strength is [**5-12**] grossly
in bilateral lower extremities, alert and oriented times
three.  Patient is a good historian.

LABORATORIES UPON TRANSFER TO FLOOR:  White blood cells 8.2,
hematocrit 26.7, platelets 158.  Sodium 135, potassium 3.6,
chloride 96, bicarbonate 40, BUN 7, creatinine 0.3, glucose
179, calcium 8.2, magnesium 1.8, phosphorus 2.3, ALT 192, AST
53, alkaline phosphatase 267.

CONTINUED HOSPITAL COURSE FROM INTENSIVE CARE UNIT ADMISSION:
1. Respiratory failure:  Patient was stable on [**2-8**] liters
throughout entire admission.  She received BiPAP therapy each
night to prevent her apneic episodes.  Respiratory therapy
visited patient each night to ensure adequate oxygenation.
The patient did not have any episodes of oxygen desaturation
throughout her admission, and was off of her nasal cannula
throughout the day and her last three days of admission.  To
followup with the neuromuscular workup, a deltoid biopsy was
performed on [**8-9**] without complications.




                          [**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D.  [**MD Number(1) 522**]

Dictated By:[**Last Name (NamePattern1) 1791**]

MEDQUIST36

D:  [**2114-8-15**]  19:40
T:  [**2114-8-16**]  05:13
JOB#:  [**Job Number 8953**]
{'Acute and chronic respiratory failure,Unspecified pleural effusion,Bacteremia,Myoneural disorders, unspecified,Abnormality of secretion of gastrin,Thoracic or lumbosacral neuritis or radiculitis, unspecified,Glycogenosis,Intestinal bypass or anastomosis status'}


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: Hypercarbic respiratory failure.

PRESENT ILLNESS: This is a 63-year-old female
with a history of restrictive lung disease of unclear
etiology and [**Doctor Last Name 48516**] syndrome status post Whipple
in [**2113-1-7**].  She presents in hypercarbic respiratory
failure status post recent admission to the medical intensive
care unit in early [**2114-7-8**] following a syncopal episode and
similar hypercarbic respiratory failure.  On that admission,
arterial blood gas in the Emergency Department showed a pH of
7.14 and a PCO2 of 123.  The patient was admitted to the
Neonatal Intensive Care Unit for further treatment.  She was
briefly treated with noninvasive mask ventilation and her
ventilator status improved such that she was off noninvasive
mask ventilation within 24 hours.  On that admission she was
noted to chronically hypoventilate.  Chest x-ray at the time
showed left lower lobe atelectasis.  Pulmonary function tests
done in early [**Month (only) **] showed a restrictive pattern with an FEV1
of 45% of predicted, an FVC of 34% of predicted with a ratio
of 133% of predicted.  Additionally a TLC was 53% of
predicted, FRC was 70% of predicted, RV was 81% of predicted.
The RV to TLC ratio was 153% of predicted.  DSB (VA) was 46%
of predicted consistent with moderate reduction of diffusion
capacity suggesting the possibility of interstitial disease,
in addition to the likely neuromuscular disease that was
suggested by her lung volumes.  Electromyogram was performed
to assess for neurologic causes and showed no evidence for
disorder of neuromuscular transmission, though there was some
paraspinal denervation present acutely.  Additionally, an MRI
of the brain showed no lesions that might cause central
apnea.

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Acute and chronic respiratory failure,Unspecified pleural effusion,Bacteremia,Myoneural disorders, unspecified,Abnormality of secretion of gastrin,Thoracic or lumbosacral neuritis or radiculitis, unspecified,Glycogenosis,Intestinal bypass or anastomosis status'}
