CHIEF COMPLAINT: " there was an
alteraction, but I aint' gonna talk about that"

PRESENT ILLNESS: Patient is a 43 year old male with a  self reported history of
bipolar disorder and schizoaffective disorder, who was brought
to the ED by ambulance after his mother called 911 expressing
that her son was being aggressive and was concered for her
safety. Initially  upon presenation he denied any complaints to
ED doctor and reported that he wanted to be dishcarged. When
approaching
patient to interview, he reported he wanted to stay in the
hospital to focus on his "asthma and psych medications to calm
my nerves". He refused to elaborate on the incident that brought
him to the ED, becoming very hostile, but reported that "she is
trying to pull me down, get me to yell like a fool, but I ain't
gonna".  Patient was intially hostile to this interviewers,
saying " I ain't gonna slap that black pussy.. don't look at me,
write this down" He appeared to be responding to internal
stimuli and sporactically yelled " shut up" to what may have
been halucinations. WHile he denied AH or VH, at one point
during the
interview reported " that person is trying to make me crazy,
being adversarial, stop me from answering your questions" and
pointed to the corner of the room. He denied any SI, HI,
reported that his mood was good, that he was sleeping and eating
well and had not other complaints
.
Spoke with patient's  mother ([**Telephone/Fax (1) 103299**]) who reports she is
very concerned about her son. She reports that he has not been
acting like himself recently, has been talking to himself, gets
upset and angry very easily, and making accusations that she is
"going with a friend", telling her " to shut your mouth". She
also notes he has been acting this way on the streets and in
public. She expressed she is feeling threatened by him and
today, after he raised his voice, yelling for her to shut that,
that she called 911. She does not feel safe for him to return
home without psychiatric intervention and evaluation. She also
expresses concern that he may not have been taking his
medications and that while he denies substance use, is worried
that he may have been using.

MEDICAL HISTORY: -reports history of bipolar disorder/ schizophrenia diagnosed
when he was 17
- two hosptializations at [**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 103300**] and [**Last Name (LF) 42339**], [**First Name3 (LF) **]
mother, last [**Name2 (NI) 103301**] was 5 years ago see psychiatrist
Dr. [**First Name (STitle) 1169**] at [**Hospital1 2177**]
-Denies any suicide attempts in past

MEDICATION ON ADMISSION: per patient: Vanceil 84 mcq puff
 depakote 500 mg po qhs
HCTZ 25 mg po dialy
Lisinopril 10 mg po daily
Abilify 30 mg po dialy
Perphenazine 8 mg po dialy

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.8, P = 80, R = 19, 98% 02 sat, 150/76
MENTAL STATUS EXAM (USE FULL, DESCRIPTIVE SENTENCES WHERE
APPLICABLE)
APPEARANCE & FACIAL EXPRESSION: overweight male, with NC on
POSTURE: lying in bed
BEHAVIOR (NOTE ANY ABNORMAL MOVEMENTS):psychomotor agtiation
in terms of increased leg movement
ATTITUDE (E.G., COOPERATIVE, PROVOCATIVE): uncooperative,
hostile and at times almost threatening ( raised voice, used
fowl
language)
SPEECH (E.G., PRESSURED, SLOWED, DYSARTHRIC, APHASIC, ETC.):
normal in rate and rhytm
MOOD: " good"
AFFECT (NOTE RANGE, REACTIVITY, APPROPRIATENESS, ETC.):
irritable at times inapparopriate. Starting laughing at one
point, when asked why replied " I am thinking of something funny
that I can't remember now"
THOUGHT FORM (E.G., LOOSENED ASSOCIATIONS, TANGENTIALITY,
CIRCUMSTANTIALITY, FLIGHT OF IDEAS, ETC.): Tangential,
loosining of associations, very disorganized and difficult to
follow. Possible thought blocking.
THOUGHT CONTENT (E.G., PREOCCUPATIONS, OBSESSIONS,
DELUSIONS, ETC.): denied
ABNORMAL PERCEPTIONS (E.G., HALLUCINATIONS): denied, but
appeared to be responding to internal stimuli, seemded to be
talking and pointing to something in the corner of the room
NEUROVEGETATIVE SYMPTOMS (E.G., DISTURBANCES OF SLEEP,
APPETITE, ENERGY, LIBIDO): denied
SUICIDALITY/HOMICIDALITY (INCLUDE IDEATION, INTENT, PLAN):
denied
INSIGHT AND JUDGMENT: very poor
COGNITIVE ASSESSMENT:
SENSORIUM (E.G., ALERT, DROWSY, SOMNOLENT): alert
ORIENTATION: x 3
ATTENTION (DIGIT SPAN, SERIAL SEVENS, ETC.): DOMBI
MEMORY (SHORT- AND LONG-TERM): [**4-2**] registation [**3-4**]
recall
CALCULATIONS: 7 quarters in $1.75
FUND OF KNOWLEDGE (ESTIMATE INTELLIGENCE): fair
PROVERB INTERPRETATION: grass is greener: What you
think is greener sometimes is a little less green
SIMILARITIES/ANALOGIES:  table and chair: they both
have legs
.
Obese
HEENT: mmm
Pulm: decreased excursions and decreased breathing sounds
Cor: distant heart sounds, regular, no murmurs
Abd: obese, nl bs
Ext: no edema or ecchymoses

FAMILY HISTORY: mother with asthma, otherwise noncontributory

SOCIAL HISTORY: SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL
SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE): patient
denies
any substance use
.
SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL
ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL
HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.):
Patient was born in [**Location (un) **]. Did not graduated highschool but
made it until senior year. Has worked odd jobs but nothing
recnetly. Gets SSDI. Lives with his mother and sister, but
sister doesn't want them in her house any longer due to his
behavior. Reports he spends his time watching TV and grocery
shopping.
Acute and chronic respiratory failure,Obesity, unspecified,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Intestinal disaccharidase deficiencies and disaccharide malabsorption,Schizoaffective disorder, unspecified,Unspecified essential hypertension,Polycythemia, secondary,Other abnormal glucose
Acute & chronc resp fail,Obesity NOS,Asthma NOS,Obstructive sleep apnea,Disaccharidase def/malab,Schizoaffective dis NOS,Hypertension NOS,Secondary polycythemia,Abnormal glucose NEC
Admission Date:  [**2131-3-22**]              Discharge Date:   [**2131-3-26**]

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

Service: PSYCHIATRY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1678**]
Chief Complaint:
" there was an
alteraction, but I aint' gonna talk about that"


Major Surgical or Invasive Procedure:
none

History of Present Illness:
Patient is a 43 year old male with a  self reported history of
bipolar disorder and schizoaffective disorder, who was brought
to the ED by ambulance after his mother called 911 expressing
that her son was being aggressive and was concered for her
safety. Initially  upon presenation he denied any complaints to
ED doctor and reported that he wanted to be dishcarged. When
approaching
patient to interview, he reported he wanted to stay in the
hospital to focus on his "asthma and psych medications to calm
my nerves". He refused to elaborate on the incident that brought
him to the ED, becoming very hostile, but reported that "she is
trying to pull me down, get me to yell like a fool, but I ain't
gonna".  Patient was intially hostile to this interviewers,
saying " I ain't gonna slap that black pussy.. don't look at me,
write this down" He appeared to be responding to internal
stimuli and sporactically yelled " shut up" to what may have
been halucinations. WHile he denied AH or VH, at one point
during the
interview reported " that person is trying to make me crazy,
being adversarial, stop me from answering your questions" and
pointed to the corner of the room. He denied any SI, HI,
reported that his mood was good, that he was sleeping and eating
well and had not other complaints
.
Spoke with patient's  mother ([**Telephone/Fax (1) 103299**]) who reports she is
very concerned about her son. She reports that he has not been
acting like himself recently, has been talking to himself, gets
upset and angry very easily, and making accusations that she is
"going with a friend", telling her " to shut your mouth". She
also notes he has been acting this way on the streets and in
public. She expressed she is feeling threatened by him and
today, after he raised his voice, yelling for her to shut that,
that she called 911. She does not feel safe for him to return
home without psychiatric intervention and evaluation. She also
expresses concern that he may not have been taking his
medications and that while he denies substance use, is worried
that he may have been using.


Past Medical History:
-reports history of bipolar disorder/ schizophrenia diagnosed
when he was 17
- two hosptializations at [**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 103300**] and [**Last Name (LF) 42339**], [**First Name3 (LF) **]
mother, last [**Name2 (NI) 103301**] was 5 years ago see psychiatrist
Dr. [**First Name (STitle) 1169**] at [**Hospital1 2177**]
-Denies any suicide attempts in past

PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES,
OR OTHER NEUROLOGIC ILLNESS):
- severe complex sleep disordered breathing with severe
nocturnal
and daytime hyopixa related to hypventiliation, followed by Pulm
- secondary erytrocythosis, being following by Haem
- asthma
- hypertension


Social History:
SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL
SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE): patient
denies
any substance use
.
SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL
ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL
HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.):
Patient was born in [**Location (un) **]. Did not graduated highschool but
made it until senior year. Has worked odd jobs but nothing
recnetly. Gets SSDI. Lives with his mother and sister, but
sister doesn't want them in her house any longer due to his
behavior. Reports he spends his time watching TV and grocery
shopping.


Family History:
mother with asthma, otherwise noncontributory

Physical Exam:
VS: 98.8, P = 80, R = 19, 98% 02 sat, 150/76
MENTAL STATUS EXAM (USE FULL, DESCRIPTIVE SENTENCES WHERE
APPLICABLE)
APPEARANCE & FACIAL EXPRESSION: overweight male, with NC on
POSTURE: lying in bed
BEHAVIOR (NOTE ANY ABNORMAL MOVEMENTS):psychomotor agtiation
in terms of increased leg movement
ATTITUDE (E.G., COOPERATIVE, PROVOCATIVE): uncooperative,
hostile and at times almost threatening ( raised voice, used
fowl
language)
SPEECH (E.G., PRESSURED, SLOWED, DYSARTHRIC, APHASIC, ETC.):
normal in rate and rhytm
MOOD: " good"
AFFECT (NOTE RANGE, REACTIVITY, APPROPRIATENESS, ETC.):
irritable at times inapparopriate. Starting laughing at one
point, when asked why replied " I am thinking of something funny
that I can't remember now"
THOUGHT FORM (E.G., LOOSENED ASSOCIATIONS, TANGENTIALITY,
CIRCUMSTANTIALITY, FLIGHT OF IDEAS, ETC.): Tangential,
loosining of associations, very disorganized and difficult to
follow. Possible thought blocking.
THOUGHT CONTENT (E.G., PREOCCUPATIONS, OBSESSIONS,
DELUSIONS, ETC.): denied
ABNORMAL PERCEPTIONS (E.G., HALLUCINATIONS): denied, but
appeared to be responding to internal stimuli, seemded to be
talking and pointing to something in the corner of the room
NEUROVEGETATIVE SYMPTOMS (E.G., DISTURBANCES OF SLEEP,
APPETITE, ENERGY, LIBIDO): denied
SUICIDALITY/HOMICIDALITY (INCLUDE IDEATION, INTENT, PLAN):
denied
INSIGHT AND JUDGMENT: very poor
COGNITIVE ASSESSMENT:
SENSORIUM (E.G., ALERT, DROWSY, SOMNOLENT): alert
ORIENTATION: x 3
ATTENTION (DIGIT SPAN, SERIAL SEVENS, ETC.): DOMBI
MEMORY (SHORT- AND LONG-TERM): [**4-2**] registation [**3-4**]
recall
CALCULATIONS: 7 quarters in $1.75
FUND OF KNOWLEDGE (ESTIMATE INTELLIGENCE): fair
PROVERB INTERPRETATION: grass is greener: What you
think is greener sometimes is a little less green
SIMILARITIES/ANALOGIES:  table and chair: they both
have legs
.
Obese
HEENT: mmm
Pulm: decreased excursions and decreased breathing sounds
Cor: distant heart sounds, regular, no murmurs
Abd: obese, nl bs
Ext: no edema or ecchymoses


Pertinent Results:
[**2131-3-21**] 09:39AM URINE  HOURS-RANDOM
[**2131-3-21**] 09:39AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2131-3-21**] 04:30AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2131-3-21**] 12:15AM   estGFR-Using this
[**2131-3-21**] 12:15AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
[**2131-3-26**] 04:06PM BLOOD Type-ART Temp-36.7 pO2-55* pCO2-92*
pH-7.23* calTCO2-41* Base XS-7 Intubat-NOT INTUBA Comment-O2
DELIVER

Brief Hospital Course:
Patient is a 43 year old male with a self reported history of
bipolar disorder and schizoaffective disorder, who was brought
to the ED by ambulance after his mother called 911 expressing
that her son was being aggressive and was concered for her
safety. Pt initially wanted to be discharged, but eventually
agreed to admission to have his "meds evaluated" as they are
making him "rambunctious". The patient continued to indicate
that his medications are not working. He signed CV upon
admission.
 .
Abilify and perhenazine were discontinued, VPA was increased to
500BID and he was started on geodon at 60BID. He became somewhat
less agitated, but appeared to continue to respond to internal
stimuli. There were no outburst of violence. The plan was to
increase to geodon to 80BID, but due to respiratory
decompenstation (see below) his dose was kept at 60mg [**Hospital1 **]. For
the same reason, VPA was held. A DMH application was submitted,
as he is longer able to live with his sister, and his mother has
no place to live herself.
.
With respect to his medical problems, he has severe
hypoventilation syndrome, followed by Pulmonary (dr [**Last Name (STitle) 15371**]).
For polycythemia (baseline Hct of 62) he had been seen by Dr
[**Last Name (STitle) 2455**]. Both services were contact[**Name (NI) **] this admission. Asthma
medications and antihypertensives were continued, a statin was
added for hyperlipidemia.
At home, Mr [**Known lastname 732**] in on 2L NC O2 during the day, and is
supposed to wear BiPAP at night. Per his mom, there may be
non-compliance with BiPAP and he often walks around with an
empty O2 tank. On [**3-26**], Mr [**Known lastname 732**] became very somnulent and was
hard to arouse. He denied any shortness or breath or chest pain,
and did not have a fever. An ABG was obtained, showing severe
hypercarbic respiratory failure. A pulmonary consult was called,
and Mr [**Known lastname 732**] was transferred to the ICU for close monitoring
and titration of CPAP/O2. In retrospect, the underlying cause
may have been that Mr [**Known lastname 732**] received too much O2. The events
were discussed with his mother.
.
The plan is for Mr [**Known lastname 732**] to return to [**Hospital1 **] 4 when medically
cleared.


Medications on Admission:
per patient: Vanceil 84 mcq puff
 depakote 500 mg po qhs
HCTZ 25 mg po dialy
Lisinopril 10 mg po daily
Abilify 30 mg po dialy
Perphenazine 8 mg po dialy


Discharge Medications:
HCTZ 25 mg po dialy
Lisinopril 10 mg po daily
simvastatin 20mg PO daily
Albuterol INH
Ipratropium INH
geodon 60mg [**Hospital1 **] PO
depakote 500mg [**Hospital1 **] PO on hold

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 22160**] transfer to ICU

Discharge Diagnosis:
schizoaffective disorder, psychosis, mania
hypoventilation syndrome
morbid obesity
asthma
hyperlipidemia

Discharge Condition:
respiratory failure, guarded

Discharge Instructions:
discharge to ICU

Followup Instructions:
discharged to ICU


Completed by:[**2131-3-29**]

Admission Date:  [**2131-3-26**]              Discharge Date:   [**2131-3-29**]

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

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 6780**]
Chief Complaint:
Hypoxia, Hypersomnolence, Hypercapnea

Major Surgical or Invasive Procedure:
none

History of Present Illness:
PCP: [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **], MD ([**Hospital **] Community Health Center)
.
HPI: 43 y.o. M with obesity hypoventilation syndrome, bipolar
disease, and asthma admitted on [**2131-3-23**] to Psychiatry after an
episode of mania after an argument with his mother. [**Name (NI) **]
wanted to be evaluated for medication change. Per report in the
ED, he was irritable and responding to internal stimuli, but
denies AH and VH. ED VS: 98.9 HR 80 BP 150/76 RR 19 and 95% RA.
While on the Pyschiatry service, he slowly improved with his
psychiatric medications. On the day of transfer to the MICU
team, at 4:50 PM, he was noted to be difficult to be aroused and
required sternal rub to awaken. An ABG was drawn that showed
respiratory acidosis (7.23/92/55/41). The patient was on 4 L O2
via NC with O2 sat of 83%. Bipap was initiated, and his O2 sat
was 93%. He denied SOB or pain at that time. Of note, PC02 at
baseline is 55-60. At home his Bipap is 16/12 @ 4L O2 at night
with 2 L O2 during the day.
.
On the psych floor patient was switched from 2L o2 to 4L because
patient was thought to be hypoxic. This led to patient becoming
hypercapneic and lethargic ABG : 7.23/92/55/41. Pt was
transferred to the MICU place on BiPap where his gas improved to
7.36/74/54. This is near his baseline per pulm notes.
.
Pulm notes state that patient is supposed to be on 4L oxygen at
home. He states that he wears 2L oxygen at home and that he has
not been wearing his bipap at home, because his mask recently
broke.
.
Allergies: NKDA


Past Medical History:
Past Medical History:
1. Obesity hypoventilation syndrome
2. Secondary erythrocytosis
3. Asthma
4. Bipolar disease with ?schizoaffective/schizophrenia disorder

5. Hypertension

Psych:
1.reports history of bipolar disorder/ schizophrenia diagnosed
when he was 17
2.two hosptializations at [**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 103300**] and [**Last Name (LF) 42339**], [**First Name3 (LF) **]
mother, last [**Name2 (NI) 103301**] was 5 years ago see psychiatrist
Dr. [**First Name (STitle) 1169**] at [**Hospital1 2177**]
3.Denies any suicide attempts in past


Social History:
Social History: No smoking, occasional alcohol, no drug use. He
is single and lives with his mom and sister. [**Name (NI) **] [**Name2 (NI) 68562**] out of
high school during his senior year. He states that he would
eventually like to get his GED. The only job he has held in the
past is [**Last Name (un) 6058**]. He is now on disability.
.

Family History:
Family History:
Mother with asthma, Several sibling all in good health. No
family history of cardiac dz or DM.

Physical Exam:
Physical Exam:
VS: Temp: 97.9 BP: 117/98 HR: 80s RR: 28 O2sat 88% on 2L NC
GEN: obese AA male on BiPAP - conversant
HEENT: anicteric, OP - not assessed as on BiPAP
NECK: thick, short, no LAD appreciated
OP: enlarged tonsils and adenoids
RESP: CTAB, no w/r/r appreciated No crackles at bases
CV: distant heart sounds, RRR, no m/r/g
ABD: NDNT, soft, obese
EXT: no c/c/e, 2+ DP pulses
SKIN: no rashes, ecchymosis, petechiae noted
NEURO: arousable, A&O x 3


Pertinent Results:
ADMISSION LABS:
[**2131-3-26**] 10:30PM BLOOD WBC-8.8 RBC-6.39* Hgb-19.3* Hct-61.7*
MCV-97 MCH-30.2 MCHC-31.2 RDW-13.7 Plt Ct-202
[**2131-3-26**] 10:30PM BLOOD Neuts-70.1* Lymphs-21.3 Monos-5.9 Eos-2.0
Baso-0.7
[**2131-3-26**] 10:30PM BLOOD PT-14.3* PTT-28.4 INR(PT)-1.2*
[**2131-3-26**] 10:30PM BLOOD Glucose-112* UreaN-8 Creat-0.8 Na-139
K-4.9 Cl-90* HCO3-40* AnGap-14
[**2131-3-26**] 10:30PM BLOOD Calcium-8.9 Phos-4.0 Mg-1.9
[**2131-3-26**] 10:30PM BLOOD TSH-1.3
[**2131-3-26**] 10:33PM BLOOD Lactate-2.4*
[**2131-3-26**] 10:33PM BLOOD freeCa-1.18
[**2131-3-29**] 06:30AM BLOOD %HbA1c-6.9*

CARDIAC ENZYMES
[**2131-3-26**] 10:30PM BLOOD CK(CPK)-74
[**2131-3-26**] 10:30PM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-55
[**2131-3-27**] 05:01PM BLOOD CK-MB-NotDone cTropnT-<0.01
.

ARTERIAL BLOOD GASES
[**2131-3-26**] 04:06PM BLOOD Type-ART Temp-36.7 pO2-55* pCO2-92*
pH-7.23* calTCO2-41* Base XS-7 Intubat-NOT INTUBA Comment-O2
DELIVER
[**2131-3-26**] 07:36PM BLOOD Type-ART pO2-46* pCO2-80* pH-7.29*
calTCO2-40* Base XS-7 Intubat-NOT INTUBA Comment-O2 DELIVER
[**2131-3-26**] 10:33PM BLOOD Type-ART PEEP-5 pO2-61* pCO2-75* pH-7.37
calTCO2-45* Base XS-13 Intubat-NOT INTUBA
[**2131-3-27**] 07:02AM BLOOD Type-ART pO2-54* pCO2-74* pH-7.36
calTCO2-44* Base XS-11

CXR: [**3-26**]:
IMPRESSION: Although smaller lung volumes exaggerate heart size
and pulmonary vascular crowding, since [**1-26**] there has
been an increase in moderate cardiomegaly, and vascular
congestion in both the lungs and mediastinum just to the point
of interstitial edema. There is no appreciable pleural effusion.

[**2131-3-27**]: ECHO
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) Right ventricular chamber size and free wall
motion are normal. The number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function
PFT [**2131-3-1**]
Dx: Dyspnea. Good test quality and fair reproducibility.
Medications:
Flovent, Atrovent.
Mechanics: The FVC and FEV1 are moderately reduced. The FEV1/FVC
ratio is normal.
Flow-Volume Loop: Restrictive contour.
.
Impression: Results are consistent with a restrictive
ventilatory defect, which is confirmed by the reduced TLC
measured on [**2129-10-10**]. Compared to the prior study of [**2131-1-25**]
the FVC has increased by 0.56 L (37%) and the FEV1 has increased
by 0.24 L (18%).

Brief Hospital Course:
HOSPITAL COURSE:
.
Mr. [**Known lastname 732**] is a 43 y/o AAM w/ schizoaffective d/o, sleep apnea,
asthma, obesity hypoventilation syndrome, on home o2 of 2L,
bipap at night, w/ polycythemia likely [**3-3**] to hypoxemia,
originally admitted for mania, transferred to micu for
hypercapneic resp failure, transferred to general medicine wards
for further management of pulm issues.
.
PROBLEMS:
.
# Hypercarbic Respiratory Failure: Per pulmonary, most likely
secondary to either decreased resp drive from increasing patient
supplemental oxygen to quickly suppressing his respiratory drive
or secondary to lack of proper bipap settings. Patient had
desaturated down to 70s while in inpatient psych facility. ACS
was ruled out as a cause of resp failure. Patients baseline
saturations on high 80s on 2L/NC on home o2. Patient was seen by
the sleep consultants who felt that his bipap should be set as
follows. Baseline sat 78-85 on RA per OMR.
--Bipap used every night and w/ daytime naps, setting 16/12 w/
Oxygen 2L, titrated to sats above 85-90%.
--Keep oxygen saturations between 85 and 90%.
--During the day patient should be on n/c oxygen 2-4L titrate
again sats btw 85-90%.
--Avoid given supplement oxygen above 4L n/c, if needed while in
house please reconsult pulmonary medicine and check ABG.
--cont albuterol and ipratroprium standing nebulizers q6H. [**Month (only) 116**]
switch back to inhalers as desired.
--cont fluticasone as prescribed.
.
# Asthma( see above)
.
# Obstructive Sleep Apnea: (See above) Patient needs follow up
with Dr. [**First Name (STitle) **] in sleep clinic. He was evaluated by ENT for
tonisellectomy. ENT felt tonsillectomy was not necessary at this
time, but that pt may benefit from procedure at a later date.
Sleep team felt that amphetamines or stimulants for daytime
sleepiness were not indicated at this time.
.
# Secondary Polycythemia: Seen by heme consult service in
[**2131-1-29**] and again on [**2131-3-28**]. They felt polycythemia likely
secondary to hypoxia, despite his epo being low in the past. He
does not have the JAK2-V617F mutation, ,making a primary
polycythemia less likely. No therapeutic indications for
phlebotomy at this time.
Heme did NOT think that hypoxia was secondary to sludging of
RBCs in pulmonary vasculature.
-Signs and symptoms to be aware of for sludging include
headache, chest pain, and neurological or stroke like symptoms,
numbness, weakness, sensory deficits,

# Hypertension: Patient was normotensive during his hospital
stay would continue.
-continue lisinopril 10mg , HCTZ 25mg
.
# Hyperglycemia: No history of DM 2, however glucoses in 200s on
the floor. Maybe secondary to atypical antipsychotic. No
evidence of DM HgA1C 6.9
-cont insulin sliding scale okay to d/c if sugars normalize
.
# Bipolar disorder: Defer to psychiatry team. While on the
medicine floor he was responding to active internal stimuli. He
was noted to have full conversation with himself while alone in
his room. He stated that he did not want to discuss who he was
talking to. He was followed by liason service while in house. He
was discharged on the following medications.
- geodon 80mg [**Hospital1 **]
- valproic acid 250mg [**Hospital1 **]
.
# Hypercholesterolemia:
-continue simvastatin 20mg daily.
.
# Patient needs follow up with Hematology, repeat sleep study
and then appointment with Dr. [**First Name (STitle) **], and Dr. [**Last Name (STitle) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8952**] [**MD Number(1) 8953**]

Medications on Admission:
Medications on Admission:
HCTZ 25 mg po daily
Lisinopril 10 mg po daily
Abilify 30 mg po daily
Depakote EC 500 mg daily
Perphenazine 8 mg po daily
.
Medications on Transfer to MICU:
Fluticasone Proprionate 110 mcg 2 puffs INH [**Hospital1 **]
Ziprasidone 80 mg po BID (?60)
Lisniopril 10 mg po daily
HCTZ 25 mg po daily
Divalproez Sodium 500 mg po BID
Simvastatin 20 mg po daily
Ipratroprium Bromide MDI 2 puffs INH QID
Beclomethasone Dipropionate 80 mcg IN daily
Acetaminophen 650 mg po q4 hours prn
Aluminum-MgOH-Simethicone 30 ml po q4 hours prn
MOM 30 ml po q8 hours prn
Senna 1 tab po BID prn
Docusate 100 mg po BID prn
Albuterol 2 puffs INH q6 hours prn
.
Meds on Txfer from MICU to Floor:
Fluticasone Proprionate 110 mcg 2 puffs INH [**Hospital1 **]
Ziprasidone 80 mg po BID
Lisniopril 10 mg po daily
HCTZ 25 mg po daily
Simvastatin 20 mg po daily
Albuterol  q6H neb
Ipratropium  q6H neb
SC Heparin


Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1)  Inhalation Q2H (every 2 hours) as needed for SOB/
wheeze.
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Ziprasidone HCl 40 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. Valproic Acid 250 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection ASDIR (AS DIRECTED).
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day: Hold if SBP below 90.


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary Diagnosis:
1. Obesity hypoventilation Syndrome
2. Acute on Chronic Hypercapneic Respiratory Failure
3. Asthma
4. Obstructive Sleep Apnea
5. Glucose Intolerance
6. Schizoaffective disorder
7. Mania
8. Psychosis
9. Hypertension
10. Secondary Polythycemia


Discharge Condition:
Section 12 for psychosis, tranfer to inpatient psychiaty at
[**Hospital1 **]-4 [**Hospital1 18**].


Discharge Instructions:
Mr. [**Known lastname 732**] you were tranferred to the [**Hospital1 18**] psychiatry facility
to the ICU at [**Hospital1 18**], because of abnormalities in your breathing.
You were found to have low oxygen levels in your blood and high
CO2 levels in your blood. We believe this was because your bipap
settings were not maximized.
.
During your hospital stay you had a study of your heart done
called an echocardiogram which was normal. You had a chest x-ray
which was also normal.
.
You were seen by the pulmonary [**Hospital1 21334**] and [**Name5 (PTitle) **] [**Name5 (PTitle) 21334**] who
recommended that you continue using BiPap at night with a
setting of 17/12 on 2-4L of oxygen titrating your pulse oximetry
up to above 85%. During the day you should be on 2-4L of oxygen
by nasal canula. This should be titrated to keep your oxygen
sats above 85%. Please continue to use all of your nebulizers
and inhalers.
.
If you

Followup Instructions:
Please schedule a follow up with Dr. [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **] once you are
discharged from the hospital [**Telephone/Fax (1) 3581**].

Please follow up with Dr. [**First Name8 (NamePattern2) 3688**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] from the
department of pulmonary medicine on the [**Location (un) 436**] of the [**Hospital Ward Name **] of [**Hospital1 18**] [**Location (un) 436**] on [**2131-4-25**] at 10:00AM
.
Please schedule a follow up appointment with Dr. [**First Name (STitle) **] at the
sleep unit. The phone number there is [**Telephone/Fax (1) 6856**].
.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2805**] from hematology for your
polythycemia. You can call [**Telephone/Fax (1) 103302**]  to make an appointment.
{'Acute and chronic respiratory failure,Obesity, unspecified,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Intestinal disaccharidase deficiencies and disaccharide malabsorption,Schizoaffective disorder, unspecified,Unspecified essential hypertension,Polycythemia, secondary,Other abnormal glucose'}


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: " there was an
alteraction, but I aint' gonna talk about that"

PRESENT ILLNESS: Patient is a 43 year old male with a  self reported history of
bipolar disorder and schizoaffective disorder, who was brought
to the ED by ambulance after his mother called 911 expressing
that her son was being aggressive and was concered for her
safety. Initially  upon presenation he denied any complaints to
ED doctor and reported that he wanted to be dishcarged. When
approaching
patient to interview, he reported he wanted to stay in the
hospital to focus on his "asthma and psych medications to calm
my nerves". He refused to elaborate on the incident that brought
him to the ED, becoming very hostile, but reported that "she is
trying to pull me down, get me to yell like a fool, but I ain't
gonna".  Patient was intially hostile to this interviewers,
saying " I ain't gonna slap that black pussy.. don't look at me,
write this down" He appeared to be responding to internal
stimuli and sporactically yelled " shut up" to what may have
been halucinations. WHile he denied AH or VH, at one point
during the
interview reported " that person is trying to make me crazy,
being adversarial, stop me from answering your questions" and
pointed to the corner of the room. He denied any SI, HI,
reported that his mood was good, that he was sleeping and eating
well and had not other complaints
.
Spoke with patient's  mother ([**Telephone/Fax (1) 103299**]) who reports she is
very concerned about her son. She reports that he has not been
acting like himself recently, has been talking to himself, gets
upset and angry very easily, and making accusations that she is
"going with a friend", telling her " to shut your mouth". She
also notes he has been acting this way on the streets and in
public. She expressed she is feeling threatened by him and
today, after he raised his voice, yelling for her to shut that,
that she called 911. She does not feel safe for him to return
home without psychiatric intervention and evaluation. She also
expresses concern that he may not have been taking his
medications and that while he denies substance use, is worried
that he may have been using.

MEDICAL HISTORY: -reports history of bipolar disorder/ schizophrenia diagnosed
when he was 17
- two hosptializations at [**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 103300**] and [**Last Name (LF) 42339**], [**First Name3 (LF) **]
mother, last [**Name2 (NI) 103301**] was 5 years ago see psychiatrist
Dr. [**First Name (STitle) 1169**] at [**Hospital1 2177**]
-Denies any suicide attempts in past

MEDICATION ON ADMISSION: per patient: Vanceil 84 mcq puff
 depakote 500 mg po qhs
HCTZ 25 mg po dialy
Lisinopril 10 mg po daily
Abilify 30 mg po dialy
Perphenazine 8 mg po dialy

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 98.8, P = 80, R = 19, 98% 02 sat, 150/76
MENTAL STATUS EXAM (USE FULL, DESCRIPTIVE SENTENCES WHERE
APPLICABLE)
APPEARANCE & FACIAL EXPRESSION: overweight male, with NC on
POSTURE: lying in bed
BEHAVIOR (NOTE ANY ABNORMAL MOVEMENTS):psychomotor agtiation
in terms of increased leg movement
ATTITUDE (E.G., COOPERATIVE, PROVOCATIVE): uncooperative,
hostile and at times almost threatening ( raised voice, used
fowl
language)
SPEECH (E.G., PRESSURED, SLOWED, DYSARTHRIC, APHASIC, ETC.):
normal in rate and rhytm
MOOD: " good"
AFFECT (NOTE RANGE, REACTIVITY, APPROPRIATENESS, ETC.):
irritable at times inapparopriate. Starting laughing at one
point, when asked why replied " I am thinking of something funny
that I can't remember now"
THOUGHT FORM (E.G., LOOSENED ASSOCIATIONS, TANGENTIALITY,
CIRCUMSTANTIALITY, FLIGHT OF IDEAS, ETC.): Tangential,
loosining of associations, very disorganized and difficult to
follow. Possible thought blocking.
THOUGHT CONTENT (E.G., PREOCCUPATIONS, OBSESSIONS,
DELUSIONS, ETC.): denied
ABNORMAL PERCEPTIONS (E.G., HALLUCINATIONS): denied, but
appeared to be responding to internal stimuli, seemded to be
talking and pointing to something in the corner of the room
NEUROVEGETATIVE SYMPTOMS (E.G., DISTURBANCES OF SLEEP,
APPETITE, ENERGY, LIBIDO): denied
SUICIDALITY/HOMICIDALITY (INCLUDE IDEATION, INTENT, PLAN):
denied
INSIGHT AND JUDGMENT: very poor
COGNITIVE ASSESSMENT:
SENSORIUM (E.G., ALERT, DROWSY, SOMNOLENT): alert
ORIENTATION: x 3
ATTENTION (DIGIT SPAN, SERIAL SEVENS, ETC.): DOMBI
MEMORY (SHORT- AND LONG-TERM): [**4-2**] registation [**3-4**]
recall
CALCULATIONS: 7 quarters in $1.75
FUND OF KNOWLEDGE (ESTIMATE INTELLIGENCE): fair
PROVERB INTERPRETATION: grass is greener: What you
think is greener sometimes is a little less green
SIMILARITIES/ANALOGIES:  table and chair: they both
have legs
.
Obese
HEENT: mmm
Pulm: decreased excursions and decreased breathing sounds
Cor: distant heart sounds, regular, no murmurs
Abd: obese, nl bs
Ext: no edema or ecchymoses

FAMILY HISTORY: mother with asthma, otherwise noncontributory

SOCIAL HISTORY: SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL
SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE): patient
denies
any substance use
.
SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL
ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL
HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.):
Patient was born in [**Location (un) **]. Did not graduated highschool but
made it until senior year. Has worked odd jobs but nothing
recnetly. Gets SSDI. Lives with his mother and sister, but
sister doesn't want them in her house any longer due to his
behavior. Reports he spends his time watching TV and grocery
shopping. 

### Response:
{'Acute and chronic respiratory failure,Obesity, unspecified,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Intestinal disaccharidase deficiencies and disaccharide malabsorption,Schizoaffective disorder, unspecified,Unspecified essential hypertension,Polycythemia, secondary,Other abnormal glucose'}
