CHIEF COMPLAINT: Hypercarbic respiratory failure

PRESENT ILLNESS: The pt is an 80 yo male with h/o severe OSA on 2L at home and
colon cancer s/p colectomy who presents with AMS, s/p 2 falls,
slurred speech, visual hallucinations, and worsening pco2. The
wife reports
he's been having hallucinations for 1.5 wks. Her husband
reported seeing people in the room who were not there and was
talking to these people. He also called 911 to ask the police to
remove these people from his house. He's also had slurred speech
for the past week. She reports he hit his head at 4am yesterday
with a resulting periorbital hematoma. He put his weight on a
table and the other end came up and hit him in the head. He then
fell again tonight which was unwitnessed but his wife thinks he
fell off the couch onto the rug. Over the last few days, his c02
has been rising at his PCPs office. Wife says these sx are
consistent with previous hypercarbic respiratory failure when he
needed to be admitted to [**Hospital1 2025**] 2 yrs ago.
.
Vitals on arrival to the ED were 98.2 100 142/83 16 96%. His ABG
showed pH 7.28 pCO2 78 pO260 and he was started on biPAP. CXR
was notable for mild pulm edema bilaterally. Blood cx was sent
but patient refused the 2nd of 2 blood cultures. The patient
refused a foley to obtain a UA. Labs in the ED were notable for
trop 0.04, lactate 1.2, WBC 8.5, k+ 6.3, BUN 26/creatinine 1.3,
glc 212, AST 81, ProBNP 1185. His legs were notable for a
cellulitis and he received vancomycin 1gram IV x1. The patient
refused CT head, chest, spine, abd/pelvis. Vitals prior to
transfer were 97.8 75 131/108 RR15 94% on BiPAP with 5 peep and
30% fi02.
.
On arrival to the floor the patient was agitated and wanting to
take off his c-collar. He was refusing to put on his CPAP
without administration of something for his anxiety. Meanwhile
he was satting 82% on 2L NC. He was given ativan 0.25mg IV. He
was placed on BiPAP and sats dropped as low as 69% and later
improvd to the 80s. He was intubated and started on propofol for
sedation.

MEDICAL HISTORY: Severe OSA on 2L at home
CPAP at night
Colon CA s/p colectomy [**2109**]
Diabetes

MEDICATION ON ADMISSION: -torsemide 20mg daily
-lisinopril 20mg daily
-allopurinol 300mg daily
-levothyroxine 175mcg daily
-diphenoxylate-atropine 2 tabs QUD prn diarrhea
-tamsulosin 0.4 2 tabs daily
-finasteride 5mg daily
-methylphenidate 10mg daily
-terbinafine 250mg daily

ALLERGIES: Amoxicillin

PHYSICAL EXAM: VS: BP: 152/63 HR:96 RR:19 O2sat 82% on NC
GEN: argumentative, A & O x3
HEENT: pupils equaal in size, generally can move eyes in all
directions, mildly dry mm
unable to appreciate JVD given body habitus
RESP: mildly decreased bs anteriorly
CV: RR, S1 and S2 wnl, no m/r/g
ABD: + echymossus in upper abdomem, obese, distended, + surgical
scars
EXT: + erythema and warmth of right leg, + chronic venous stasis
changes in LE bilaterally
SKIN: extensive [**Female First Name (un) **] in inguinal creases bilaterally
NEURO: AAOx3. Moving all extremities, pupils equal in size

FAMILY HISTORY: non contributory

SOCIAL HISTORY: no etoh, illicits, never smoker
Acute and chronic respiratory failure,Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Toxic encephalopathy,Cellulitis and abscess of leg, except foot,Obesity hypoventilation syndrome,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Obstructive chronic bronchitis with (acute) exacerbation,Obstructive sleep apnea (adult)(pediatric),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of large intestine,Right bundle branch block,Unspecified acquired hypothyroidism,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other chronic pulmonary heart diseases,Do not resuscitate status,Candidiasis of skin and nails,Dermatophytosis of nail,Conjunctivitis, unspecified,Malnutrition of moderate degree,Venous (peripheral) insufficiency, unspecified,History of fall
Acute & chronc resp fail,Ac on chr diast hrt fail,Pneumonia, organism NOS,Toxic encephalopathy,Cellulitis of leg,Obesity hypovent synd,Acute kidney failure NOS,Hyperosmolality,Obs chr bronc w(ac) exac,Obstructive sleep apnea,DMII wo cmp nt st uncntr,Hx of colonic malignancy,Rt bundle branch block,Hypothyroidism NOS,BPH w/o urinary obs/LUTS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Chr pulmon heart dis NEC,Do not resusctate status,Cutaneous candidiasis,Dermatophytosis of nail,Conjunctivitis NOS,Malnutrition mod degree,Venous insufficiency NOS,Personal history of fall
Admission Date:  [**2134-12-5**]              Discharge Date:   [**2134-12-30**]

Date of Birth:  [**2054-5-2**]             Sex:   M

Service: MEDICINE

Allergies:
Amoxicillin

Attending:[**Doctor First Name 2080**]
Chief Complaint:
Hypercarbic respiratory failure

Major Surgical or Invasive Procedure:
Intubation.
Central Venous Catheter Placement.

History of Present Illness:
The pt is an 80 yo male with h/o severe OSA on 2L at home and
colon cancer s/p colectomy who presents with AMS, s/p 2 falls,
slurred speech, visual hallucinations, and worsening pco2. The
wife reports
he's been having hallucinations for 1.5 wks. Her husband
reported seeing people in the room who were not there and was
talking to these people. He also called 911 to ask the police to
remove these people from his house. He's also had slurred speech
for the past week. She reports he hit his head at 4am yesterday
with a resulting periorbital hematoma. He put his weight on a
table and the other end came up and hit him in the head. He then
fell again tonight which was unwitnessed but his wife thinks he
fell off the couch onto the rug. Over the last few days, his c02
has been rising at his PCPs office. Wife says these sx are
consistent with previous hypercarbic respiratory failure when he
needed to be admitted to [**Hospital1 2025**] 2 yrs ago.
.
Vitals on arrival to the ED were 98.2 100 142/83 16 96%. His ABG
showed pH 7.28 pCO2 78 pO260 and he was started on biPAP. CXR
was notable for mild pulm edema bilaterally. Blood cx was sent
but patient refused the 2nd of 2 blood cultures. The patient
refused a foley to obtain a UA. Labs in the ED were notable for
trop 0.04, lactate 1.2, WBC 8.5, k+ 6.3, BUN 26/creatinine 1.3,
glc 212, AST 81, ProBNP 1185. His legs were notable for a
cellulitis and he received vancomycin 1gram IV x1. The patient
refused CT head, chest, spine, abd/pelvis. Vitals prior to
transfer were 97.8 75 131/108 RR15 94% on BiPAP with 5 peep and
30% fi02.
.
On arrival to the floor the patient was agitated and wanting to
take off his c-collar. He was refusing to put on his CPAP
without administration of something for his anxiety. Meanwhile
he was satting 82% on 2L NC. He was given ativan 0.25mg IV. He
was placed on BiPAP and sats dropped as low as 69% and later
improvd to the 80s. He was intubated and started on propofol for
sedation.


Past Medical History:
Severe OSA on 2L at home
CPAP at night
Colon CA s/p colectomy [**2109**]
Diabetes


Social History:
no etoh, illicits, never smoker

Family History:
non contributory

Physical Exam:
VS: BP: 152/63 HR:96 RR:19 O2sat 82% on NC
GEN: argumentative, A & O x3
HEENT: pupils equaal in size, generally can move eyes in all
directions, mildly dry mm
unable to appreciate JVD given body habitus
RESP: mildly decreased bs anteriorly
CV: RR, S1 and S2 wnl, no m/r/g
ABD: + echymossus in upper abdomem, obese, distended, + surgical
scars
EXT: + erythema and warmth of right leg, + chronic venous stasis
changes in LE bilaterally
SKIN: extensive [**Female First Name (un) **] in inguinal creases bilaterally
NEURO: AAOx3. Moving all extremities, pupils equal in size


Pertinent Results:
Admission labs:
[**2134-12-5**] 01:00AM   WBC-8.5# RBC-4.20* HGB-12.8*# HCT-39.2*
MCV-93 MCH-30.4 MCHC-32.6 RDW-14.6
[**2134-12-5**] 01:00AM   NEUTS-77.5* LYMPHS-15.3* MONOS-4.8 EOS-1.5
BASOS-1.0
[**2134-12-5**] 01:00AM   GLUCOSE-212* UREA N-26* CREAT-1.3* SODIUM-136
POTASSIUM-6.3* CHLORIDE-98 TOTAL CO2-31 ANION GAP-13
[**2134-12-5**] 01:18AM   TYPE-ART O2 FLOW-2 PO2-60* PCO2-78* PH-7.28*
TOTAL CO2-38* BASE XS-6 INTUBATED-NOT INTUBA
.
Discharge Labs:
.
Microbiology:
Blood, Urine, Sputum Cultures Negative
RPR: Pending
.
[**2134-12-3**] CT head non contrast:
IMPRESSION: No evidence of acute intracranial pathological
process.
COMMENT: There is a suggestion of minimal bilateral proptosis,
without
extraocular muscle abnormalities to suggest Grave's disease.
Please correlate this observation clinically.
.
[**2134-12-3**] CT c-spine:
CT CHEST: The pulmonary arterial tree is well opacified, and
there is no
evidence of pulmonary embolism. The aorta is normal in caliber
without
evidence of acute aortic syndrome. Extensive calcifications of
the aorta and coronary arteries are seen.
Within the lung parenchyma, there is bibasilar atelectasis and
consolidation.
The airways are patent to the segmental level. No pericardial
effusion or
measurable pleural effusion is seen. No pathologically enlarged
lymph nodes are present. The patient is intubated with
endotracheal tube approximately 4.6 cm above the carina. A
nasogastric tube is in place with tip within the stomach.
CT ABDOMEN WITH CONTRAST: Within the abdomen, there is
cholelithiasis,
including a large stone measuring up to 5.5 x 5.3 cm within the
gallbladder fundus, which was present on the prior examination,
however, may be slightly increased in size. No evidence of
gallbladder wall edema is seen. No choledocholithiasis is
identified. The liver, kidneys, adrenal glands, spleen, and
pancreas appear grossly unremarkable. Loops of small and large
bowel are of normal size and caliber. There is diffuse anasarca
with some nonspecific diffuse stranding of the mesentery. Again
seen are extensive vascular calcifications. Several
retroperitoneal lymph nodes measuring up to 1.3 cm in short axis
(500b:77) are present however these are non-specific. No free
air is seen. The patient is status post right hemicolectomy.
CT PELVIS WITH CONTRAST: Again noted the patient is status post
right
hemicolectomy. There is diverticulosis of the sigmoid colon. The
bladder is collapsed around a urinary catheter. There are
prostatic calcifications.
Again noted is diffuse mild anasarca. No pelvic free air is
seen.
BONE WINDOWS: No concerning osseous lesion is seen. Bone islands
in the left iliac bone and within the ribs are stable.
IMPRESSION:
1. No evidence of pulmonary embolism. Bibasilar atelectasis and
possible
aspiration/consolidation.
2. Cholelithiasis without evidence of cholecystitis.
.
CTA chest [**2134-12-5**]:
CT CHEST: The pulmonary arterial tree is well opacified, and
there is no
evidence of pulmonary embolism. The aorta is normal in caliber
without
evidence of acute aortic syndrome. Extensive calcifications of
the aorta and coronary arteries are seen.
Within the lung parenchyma, there is bibasilar atelectasis and
consolidation.
The airways are patent to the segmental level. No pericardial
effusion or
measurable pleural effusion is seen. No pathologically enlarged
lymph nodes are present. The patient is intubated with
endotracheal tube approximately 4.6 cm above the carina. A
nasogastric tube is in place with tip within the stomach.

CT ABDOMEN WITH CONTRAST: Within the abdomen, there is
cholelithiasis,
including a large stone measuring up to 5.5 x 5.3 cm within the
gallbladder fundus, which was present on the prior examination,
however, may be slightly increased in size. No evidence of
gallbladder wall edema is seen. No choledocholithiasis is
identified. The liver, kidneys, adrenal glands, spleen, and
pancreas appear grossly unremarkable. Loops of small and large
bowel are of normal size and caliber. There is diffuse anasarca
with some nonspecific diffuse stranding of the mesentery. Again
seen are extensive vascular calcifications. Several
retroperitoneal lymph nodes measuring up to 1.3 cm in short axis
(500b:77) are present however these are non-specific. No free
air is seen. The patient is status post right hemicolectomy.
CT PELVIS WITH CONTRAST: Again noted the patient is status post
right
hemicolectomy. There is diverticulosis of the sigmoid colon. The
bladder is collapsed around a urinary catheter. There are
prostatic calcifications.  Again noted is diffuse mild anasarca.
No pelvic free air is seen.
BONE WINDOWS: No concerning osseous lesion is seen. Bone islands
in the left iliac bone and within the ribs are stable.
IMPRESSION:
1. No evidence of pulmonary embolism. Bibasilar atelectasis and
possible
aspiration/consolidation.
2. Cholelithiasis without evidence of cholecystitis.
.
Echo [**2134-12-6**]: The left atrium is elongated. No atrial septal
defect is seen by 2D or color Doppler. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is normal (LVEF>55%). There
is no ventricular septal defect. with normal free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. There is no aortic valve stenosis.
No aortic regurgitation is seen. The mitral valve leaflets are
not well seen. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
.
Renal Ultrasound ([**2134-12-15**]): Unremarkable renal ultrasound,
without hydronephrosis or evidence of obstruction. Bladder not
evaluated.
.
CT Head ([**12-20**]):. No evidence for hemorrhage or other acute
intracranial process.  2. Interval resolution of ethmoidal and
left sphenoid air cell fluid, with residual sphenoid air cell
mucosal thickening.


Brief Hospital Course:
8o yo male with h/o hypercarbic respiratory failure and OSA who
presents with hallucination
.
# Hypercarbic respiratory failure: Likely secondary to OSA,
Obesity Hypoventilation Syndrome, and Altered Mental Status. Gas
in the ED just after put on 2L was pH 7.28 pCO2 78 pO2 60. On
arrival his 02 sat was as low as 69% on BiPAP.  He was intubated
and maintained on AC ventilation.  He was diuresed, and sedation
was slowly weaned but his mental status remained a barrier to
extubation (i.e. he was agitatated when awake enough not to be
apneic). He was on a Precedex drip for several days, but this
did not seem to affect his mental status.  His sedation was
weaned, and eventually he was extubated.  Upon extubation, he
was mildly hypoxic and CO2 in the 60s. CXR showed possible
pneumonia.  He was started on levofloxacin and vancomycin on
[**12-14**] (also covering cellulitis, as below). Throughout the
course of his hospitalization he intermittently required BiPAP.
Diuresis continued and eventually the patient only required
BiPAP overnight with stability of blood gases during the day.
After several family meetings, it was decided that pt would be
DNR/DNI and [**Month/Year (2) 3225**]. He can continue night time CPAP with BIPAP mode
(PSV) at rate of: [**12-27**] (insp pressure=12 and exp pressure=6). Pt
may refuse this if he choses.
.
# AMS: Combination of hypercarbic respiratory failure,
infection, and s/p fall with trauma to the head. Pt with
hallucinations and slurred speech per his wife.  CT of the head
was unremarkable for an acute process.  CT c-spine showed only
cervical spondylosis and spinal stenosis. He was maintained in
his c-collar while intubated and sedated.  Mental status became
a barrier to extubation, so Precedex was tried for several days
but did not affect his mental status.  Haldol also did nothing
to calm him.  He continued to require Versed boluses.
Eventually this was weaned and he was extubated.  Psychiatry
consultants recommended Haldol while not taking PO and seroquel
when taking PO. Eventually the patient had seroquel DC'd given
concerns that it was effecting his mental status and was
ultimately switched to zyprexa standing and prn. He continued to
be delirious. CT of head was repeated without acute intracranial
process. Neurology was consulted and felt that this presentation
was consistent with toxic metabolic encephelopathy. They
recommended checking folate, b12, RPR, all of which were wnl. On
the days prior to discharge, pt was made [**Month/Day (4) 3225**] and all
medications, tubes, lines were stopped. He then improved and
became more lucid, conversant, would answer questions
appropriately. At time of discharge he was given zyprexa qhs as
well as PRN zyprexa and haldol as needed for agitation. He was
also given thiamine in the event that his AMS was contributed by
a thiamine deficiency. In summary, his AMS throughout
hospitalization was thought to be due to multiple problems:
hypercarbic resp encephalopathy, ICU and Hospital delerium,
infection. He started to clear prior to discharge after lines,
tubes, meds were d/c-ed.
.
# Cellulitis:  He was treated with vancomycin IV and
levofloxacin.  His cellulitis resolved but he still has chronic
venous stasis changes in the lower legs.  He completed a 7-day
course.  On [**12-14**], he was noted to have new lower extremity
erythema. Vancomycin and levofloxacin were restarted with
resolution of cellulitis.
.
# Goals of care:  Given his tenuous respiratory status prior to
extubuation multiple family meetings were held to clarify the
patient and family's wishes about contingencies post-extubation.
 The final decision, agreed upon by the patient's wife and
daughter, was that the patient would not want further aggressive
measures including no re-intubation and no tracheostomy.  He
values his independence highly. Later in the hospital course the
decision was made that the patient would be discharged to rehab
with hospice care and plan on not returning to the hospital. Pt
was made DNR/DNI/DNH/[**Month/Year (2) 3225**].
*pt is DNR/DNI
*Pt is "do not return to hospital"
*Pt is [**Name (NI) 3225**]
*[**Month (only) 116**] give night-time BIPAP (as above) if pt agrees but he may
refuse.
.
# Pulm edema: pro BNP was as high as 1185. His echo showed an EF
of 70-75%, moderate symmetric left ventricular hypertrophy, and
they were unable to measure degree of pulm HTN. He was diuresed
with lasix gtt during the admission.
.
# New right bundle: This is compared to EKG 5 yrs ago. His
enzymes were cycled and he was ruled out for a MI.
.
#DM:  He was placed on an insulin sliding scale.
.
# Renal failure: His feNa was <0.5% suggesting a prerenal
etiology. Urine eos were negative. His medications were renally
dosed.  His creatinine returned to baseline 1.0.  Later, he
again developed acute renal failure in the context of aggressive
diuresis.  Creatinine continued to trend up after diuresis was
stopped. It was observed that with higher MAPs the patient
tended to have improved urine output. He was given a trial of
levophed to determine if higher MAPs improved renal function.
With levophed the patient's creatinine improved. Levophed was
stopped and creatinine remained stable. Renal was consulted and
felt that the patient pre renal etiology to explain his poor
renal function. At time of discharge his Cr ranged from 2.1-2.3
(baseline appears to be 1.0-1.3).
.
#Cardiac/HTN: Pt's lisinopril and torsemide were held towards
the end of hospitalization when pt made [**Month (only) 3225**]. They may be resumed
at rehab if pt's mental status continues to improve and he
agrees to take them. He was on torsemide 20mg daily and
lisinopril 20mg daily.
.
# Hypothyroidism:  His CT of the head showed minimal bilateral
proptosis and his TSH was normal. He was continued on his home
levothyroxine 175mcg daily.
.
# BPH: He was continued on his tamsulosin and finasteride.
.
#. Psych history: Per his PCP he was taking extra
methylphenidate while at home as well as a sedative. His
methylphenidate was discontinued.
.
# Onchycomycosis:  His terbinafine 250mg daily was hled given
his elevated ASTs.
.
# [**Female First Name (un) 564**] in groin folds: He was treated with miconazole and his
[**Female First Name (un) **] improved significantly.



Medications on Admission:
-torsemide 20mg daily
-lisinopril 20mg daily
-allopurinol 300mg daily
-levothyroxine 175mcg daily
-diphenoxylate-atropine 2 tabs QUD prn diarrhea
-tamsulosin 0.4 2 tabs daily
-finasteride 5mg daily
-methylphenidate 10mg daily
-terbinafine 250mg daily

Discharge Medications:
1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for rash.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
4. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation: PRN.
5. budesonide 0.5 mg/2 mL Suspension for Nebulization Sig: One
(1) ML Inhalation [**Hospital1 **] (2 times a day).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q4H (every 4 hours) as
needed for SOB, wheezing.
7. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
Q4H (every 4 hours) as needed for SOB, wheezing.
8. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
9. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation:
PRN.
10. haloperidol lactate 5 mg/mL Solution Sig: One (1)  Injection
[**Hospital1 **] (2 times a day) as needed for agitation: PRN (first try
zyprexa).
11. insulin lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
12. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO once a
day.
13. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO once a day.
14. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
15. thiamine HCl 250 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: start on [**2134-12-31**].
16. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day: Start on [**2135-1-5**].


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 582**] Of [**Location (un) 5176**]

Discharge Diagnosis:
Altered mental status
Hypercarbic respiratory failure
[**Hospital **]
hospital acquired pneumonia


Discharge Condition:
Mental Status: Confused - always. (occasionally has lucid
moments)
[**Name2 (NI) **] of Consciousness: [**Name (NI) **] and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
It was a pleasure providing care for your during your
hospitalization. You were admitted to the hospital for
confusion. The confusion was thought to be due to breathing
difficulties (hypercarbic respiratory distress from your sleep
apnea). You also likely had hospital induced and ICU induced
delerium.

The following changes were made to your medications:

Your heart and blood pressure medications were temporarily
STOPPED. You may resume them at rehab if your confusion
continues to improve:
-torsemide 20mg daily
-lisinopril 20mg daily

Your thyroid medication was continued.
-Levothyroxine 175mcg per day

Your Diphenoxylate-atropine was STOPPED

For your Prostate, the following meds were continued
-Tamsulosin 0.4mg 2 tabs daily
-finasteride 5mg daily

Methylphenidate 10mg daily was STOPPED.

Terbinafine 250mg daily was also STOPPED.

(all of the above medications that were held may be resumed as
your mental status improves)

Please start:
-Thiamine. Take 250mg once a day for the next 5 days. Then take
100mg once a day thereafter
-Zyprexa at night

If you agree, we also reccomend you continue your CPAP at night:
nasal BIPAP with PSV mode of [**12-27**].


Followup Instructions:
Should follow up with your primary care doctor after you leave
rehab.
{'Acute and chronic respiratory failure,Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Toxic encephalopathy,Cellulitis and abscess of leg, except foot,Obesity hypoventilation syndrome,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Obstructive chronic bronchitis with (acute) exacerbation,Obstructive sleep apnea (adult)(pediatric),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of large intestine,Right bundle branch block,Unspecified acquired hypothyroidism,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other chronic pulmonary heart diseases,Do not resuscitate status,Candidiasis of skin and nails,Dermatophytosis of nail,Conjunctivitis, unspecified,Malnutrition of moderate degree,Venous (peripheral) insufficiency, unspecified,History of 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: Hypercarbic respiratory failure

PRESENT ILLNESS: The pt is an 80 yo male with h/o severe OSA on 2L at home and
colon cancer s/p colectomy who presents with AMS, s/p 2 falls,
slurred speech, visual hallucinations, and worsening pco2. The
wife reports
he's been having hallucinations for 1.5 wks. Her husband
reported seeing people in the room who were not there and was
talking to these people. He also called 911 to ask the police to
remove these people from his house. He's also had slurred speech
for the past week. She reports he hit his head at 4am yesterday
with a resulting periorbital hematoma. He put his weight on a
table and the other end came up and hit him in the head. He then
fell again tonight which was unwitnessed but his wife thinks he
fell off the couch onto the rug. Over the last few days, his c02
has been rising at his PCPs office. Wife says these sx are
consistent with previous hypercarbic respiratory failure when he
needed to be admitted to [**Hospital1 2025**] 2 yrs ago.
.
Vitals on arrival to the ED were 98.2 100 142/83 16 96%. His ABG
showed pH 7.28 pCO2 78 pO260 and he was started on biPAP. CXR
was notable for mild pulm edema bilaterally. Blood cx was sent
but patient refused the 2nd of 2 blood cultures. The patient
refused a foley to obtain a UA. Labs in the ED were notable for
trop 0.04, lactate 1.2, WBC 8.5, k+ 6.3, BUN 26/creatinine 1.3,
glc 212, AST 81, ProBNP 1185. His legs were notable for a
cellulitis and he received vancomycin 1gram IV x1. The patient
refused CT head, chest, spine, abd/pelvis. Vitals prior to
transfer were 97.8 75 131/108 RR15 94% on BiPAP with 5 peep and
30% fi02.
.
On arrival to the floor the patient was agitated and wanting to
take off his c-collar. He was refusing to put on his CPAP
without administration of something for his anxiety. Meanwhile
he was satting 82% on 2L NC. He was given ativan 0.25mg IV. He
was placed on BiPAP and sats dropped as low as 69% and later
improvd to the 80s. He was intubated and started on propofol for
sedation.

MEDICAL HISTORY: Severe OSA on 2L at home
CPAP at night
Colon CA s/p colectomy [**2109**]
Diabetes

MEDICATION ON ADMISSION: -torsemide 20mg daily
-lisinopril 20mg daily
-allopurinol 300mg daily
-levothyroxine 175mcg daily
-diphenoxylate-atropine 2 tabs QUD prn diarrhea
-tamsulosin 0.4 2 tabs daily
-finasteride 5mg daily
-methylphenidate 10mg daily
-terbinafine 250mg daily

ALLERGIES: Amoxicillin

PHYSICAL EXAM: VS: BP: 152/63 HR:96 RR:19 O2sat 82% on NC
GEN: argumentative, A & O x3
HEENT: pupils equaal in size, generally can move eyes in all
directions, mildly dry mm
unable to appreciate JVD given body habitus
RESP: mildly decreased bs anteriorly
CV: RR, S1 and S2 wnl, no m/r/g
ABD: + echymossus in upper abdomem, obese, distended, + surgical
scars
EXT: + erythema and warmth of right leg, + chronic venous stasis
changes in LE bilaterally
SKIN: extensive [**Female First Name (un) **] in inguinal creases bilaterally
NEURO: AAOx3. Moving all extremities, pupils equal in size

FAMILY HISTORY: non contributory

SOCIAL HISTORY: no etoh, illicits, never smoker 

### Response:
{'Acute and chronic respiratory failure,Acute on chronic diastolic heart failure,Pneumonia, organism unspecified,Toxic encephalopathy,Cellulitis and abscess of leg, except foot,Obesity hypoventilation syndrome,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Obstructive chronic bronchitis with (acute) exacerbation,Obstructive sleep apnea (adult)(pediatric),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of large intestine,Right bundle branch block,Unspecified acquired hypothyroidism,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Other chronic pulmonary heart diseases,Do not resuscitate status,Candidiasis of skin and nails,Dermatophytosis of nail,Conjunctivitis, unspecified,Malnutrition of moderate degree,Venous (peripheral) insufficiency, unspecified,History of fall'}
