CHIEF COMPLAINT: Respiratory compromise with hypoxia and hypercarbia.

PRESENT ILLNESS: 46 year old man with a history of morbid obesity, OSA, COPD,
chronic trach, who was hospitalized in [**2134-4-3**] with VAP
(cultures + for acinetobacter and pseudomonas), who presents
with fever, hypoxia and multifocal pneumonia on CXR. He
initially traveled to [**Location (un) 620**] on [**2134-6-24**] with oxygen saturations
between 78-82% and somnolence. He was started on ceftazidime,
vancomycin, flagyl and levofloxacin. A femoral line was placed,
cultures drawn, and his trach was changed from a 6.0 Shily w/o
cuff to a 6.0 portex cuff trach.
He was transferred to [**Hospital1 18**] on [**2134-6-24**] with a temp of 101.3, HR
110, and BP 157/83. An ABG showed pH7.24 pCO2 81 pO2 76 on 100%
trach collar. He was then ventilated on PS 10/5. Repeat ABG was
pH 7.24 pCO2 79 pO2 88.
In the MICU, [**2-6**] blood cultures were positive for GPC, with
sputum and urine cultures still pending.  Wide spectrum
antibiotics were chnaged to ampicillin, although it remains
uncertain if the bacteria are, in fact, ampicillin sensitive,
despite clinical improvement.  Source remains uncertain.  He has
continued to tolerate the trach mask with high saturations on
venous blood gas.  He remains on 50% csm with saturations to the
high 90's and a respiratory rate in the teens.  Suction for the
trach has remained q3-4hrs.  Transferred to floor on [**6-27**].

MEDICAL HISTORY: -DM2 diagnosed [**2114**] with triopathy(retinopathy, nephropathy,
neuropathy): Cr has been as low as 1 in the past few months,
however widely fluctuant when hospitalized 1-2.5.
-COPD
-Multiple episodes of respiratory failure requiring intubation
in recent years (trach placed in [**12/2132**])
-Multiple VAP with resistent organisms:  pseudomonas, MRSA,
acinetobacter, citrobacter
-Acalculous cholecystitis requiring cholecystostomy tube
-G-tube
-OSA on CPAP
-VRE, S/p tracheostomy, as above in [**1-7**]
-HTN
-CHF
-Anemia of chronic disease (multiple transfusions in past)
-s/p BKA for chronic LE ulcer
-TIA in [**2125**]
-Difficult intubation; fiberoptic guidance in [**2131-10-3**].
-Urinary retention
-Osteoarthritis
-Depression
-C. Difficile in [**2129**]
-Hypogonadism
-Morbid obesity

MEDICATION ON ADMISSION: 

ALLERGIES: Cephalosporins / Morphine / Fentanyl

PHYSICAL EXAM: T 98.5 HR 68 BP 166/P  RR 20  O2sat: 100% on 50%cold steam mask
GENL: Obese male in NAD.  Slightly sleepy but attentive and
pleasant.
HEENT: +trach in place.  Slightly dry mucous membranes.  Unable
to palpate cervical nodes.
CV: RRR. Normal S1 and S2.  No murmur, rubs, or gallops.
Lungs: On ventral side, CTA bilaterally with no wheezes or
crackles.
Abd: Active bowel sounds.  Soft, obese, colostomy bag, midline
ovaloid scar.
Ext: Red brawny area on R lower leg, with no edema.  2+ right
dorsalis pedis pulse.  [**Male First Name (un) 28635**] lines in all ten fingernails.  L
BKA.

FAMILY HISTORY: Family History: Non contributory.

SOCIAL HISTORY: Social History: Lives in rehabilitation facility.  Health aide
comfortable with suctioning.
Acute respiratory failure,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Hyperpotassemia,Chronic airway obstruction, not elsewhere classified,Bacteremia,Hypoxemia,Bronchitis, not specified as acute or chronic,Unspecified essential hypertension,Anemia of other chronic disease,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Morbid obesity,Obstructive sleep apnea (adult)(pediatric),Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Other testicular hypofunction,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Depressive disorder, not elsewhere classified,Tracheostomy status,Personal history of other diseases of circulatory system,Below knee amputation status,Attention to colostomy
Acute respiratry failure,Pneumonia, organism NOS,CHF NOS,Hyperpotassemia,Chr airway obstruct NEC,Bacteremia,Hypoxemia,Bronchitis NOS,Hypertension NOS,Anemia-other chronic dis,DMII neuro nt st uncntrl,Neuropathy in diabetes,Nephritis NOS in oth dis,Diabetic retinopathy NOS,Morbid obesity,Obstructive sleep apnea,Enterococcus group d,Testicular hypofunc NEC,Osteoarthros NOS-unspec,Depressive disorder NEC,Tracheostomy status,Hx-circulatory dis NEC,Status amput below knee,Atten to colostomy
Admission Date:  [**2134-6-24**]              Discharge Date:   [**2134-7-2**]

Date of Birth:  [**2087-11-5**]             Sex:   M

Service: MEDICINE

Allergies:
Cephalosporins / Morphine / Fentanyl

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Respiratory compromise with hypoxia and hypercarbia.

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
46 year old man with a history of morbid obesity, OSA, COPD,
chronic trach, who was hospitalized in [**2134-4-3**] with VAP
(cultures + for acinetobacter and pseudomonas), who presents
with fever, hypoxia and multifocal pneumonia on CXR. He
initially traveled to [**Location (un) 620**] on [**2134-6-24**] with oxygen saturations
between 78-82% and somnolence. He was started on ceftazidime,
vancomycin, flagyl and levofloxacin. A femoral line was placed,
cultures drawn, and his trach was changed from a 6.0 Shily w/o
cuff to a 6.0 portex cuff trach.
He was transferred to [**Hospital1 18**] on [**2134-6-24**] with a temp of 101.3, HR
110, and BP 157/83. An ABG showed pH7.24 pCO2 81 pO2 76 on 100%
trach collar. He was then ventilated on PS 10/5. Repeat ABG was
pH 7.24 pCO2 79 pO2 88.
In the MICU, [**2-6**] blood cultures were positive for GPC, with
sputum and urine cultures still pending.  Wide spectrum
antibiotics were chnaged to ampicillin, although it remains
uncertain if the bacteria are, in fact, ampicillin sensitive,
despite clinical improvement.  Source remains uncertain.  He has
continued to tolerate the trach mask with high saturations on
venous blood gas.  He remains on 50% csm with saturations to the
high 90's and a respiratory rate in the teens.  Suction for the
trach has remained q3-4hrs.  Transferred to floor on [**6-27**].

Past Medical History:
-DM2 diagnosed [**2114**] with triopathy(retinopathy, nephropathy,
neuropathy): Cr has been as low as 1 in the past few months,
however widely fluctuant when hospitalized 1-2.5.
-COPD
-Multiple episodes of respiratory failure requiring intubation
in recent years (trach placed in [**12/2132**])
-Multiple VAP with resistent organisms:  pseudomonas, MRSA,
acinetobacter, citrobacter
-Acalculous cholecystitis requiring cholecystostomy tube
-G-tube
-OSA on CPAP
-VRE, S/p tracheostomy, as above in [**1-7**]
-HTN
-CHF
-Anemia of chronic disease (multiple transfusions in past)
-s/p BKA for chronic LE ulcer
-TIA in [**2125**]
-Difficult intubation; fiberoptic guidance in [**2131-10-3**].
-Urinary retention
-Osteoarthritis
-Depression
-C. Difficile in [**2129**]
-Hypogonadism
-Morbid obesity

Past Surgical History
Bilateral carpal tunnel release in [**2123**].
Hydrocele repair in [**2126-4-3**].
Quadriceps tendon repair in [**2127**].
Status post partial resection of transverse colon, end
transverse colostomy, mucus fistula, jejunostomy tube
Percutaneous tracheostomy on [**2132-12-16**].


Social History:
Social History: Lives in rehabilitation facility.  Health aide
comfortable with suctioning.


Family History:
Family History: Non contributory.


Physical Exam:
T 98.5 HR 68 BP 166/P  RR 20  O2sat: 100% on 50%cold steam mask
GENL: Obese male in NAD.  Slightly sleepy but attentive and
pleasant.
HEENT: +trach in place.  Slightly dry mucous membranes.  Unable
to palpate cervical nodes.
CV: RRR. Normal S1 and S2.  No murmur, rubs, or gallops.
Lungs: On ventral side, CTA bilaterally with no wheezes or
crackles.
Abd: Active bowel sounds.  Soft, obese, colostomy bag, midline
ovaloid scar.
Ext: Red brawny area on R lower leg, with no edema.  2+ right
dorsalis pedis pulse.  [**Male First Name (un) 28635**] lines in all ten fingernails.  L
BKA.


Pertinent Results:
[**2134-6-27**] 03:25AM BLOOD WBC-6.1 RBC-2.97* Hgb-9.2* Hct-26.3*
MCV-89 MCH-30.9 MCHC-34.9 RDW-15.5 Plt Ct-167
[**2134-6-24**] 10:30PM BLOOD WBC-11.0# RBC-3.46* Hgb-10.5* Hct-31.1*#
MCV-90 MCH-30.4 MCHC-33.8 RDW-15.7* Plt Ct-197
[**2134-6-25**] 01:27AM BLOOD Neuts-79.2* Bands-0 Lymphs-13.3*
Monos-3.7 Eos-3.3 Baso-0.5
[**2134-6-27**] 03:25AM BLOOD Plt Ct-167
[**2134-6-24**] 10:30PM BLOOD PT-12.9 PTT-27.7 INR(PT)-1.1
[**2134-6-27**] 03:25AM BLOOD Glucose-137* UreaN-25* Creat-1.2 Na-142
K-4.5 Cl-107 HCO3-29 AnGap-11
[**2134-6-24**] 10:30PM BLOOD Glucose-182* UreaN-34* Creat-1.7* Na-140
K-5.5* Cl-103 HCO3-32 AnGap-11
[**2134-6-24**] 10:30PM BLOOD ALT-14 AST-15 AlkPhos-44 Amylase-35
TotBili-0.4
[**2134-6-27**] 03:25AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.0
[**2134-6-24**] 10:30PM BLOOD Albumin-3.8 Calcium-9.1 Phos-4.4 Mg-1.9
[**2134-6-26**] 03:22PM BLOOD Type-[**Last Name (un) **] pO2-33* pCO2-59* pH-7.35
calHCO3-34* Base XS-4
[**2134-6-24**] 10:32PM BLOOD pO2-76* pCO2-81* pH-7.24* calHCO3-36*
Base XS-4
[**2134-6-25**] 07:07AM BLOOD Type-ART Temp-37.8 Rates-14/ PEEP-5
FiO2-50 pO2-105 pCO2-45 pH-7.44 calHCO3-32* Base XS-5
Intubat-INTUBATED Vent-CONTROLLED
[**2134-6-26**] 12:11PM BLOOD K-4.4
[**2134-6-24**] 10:32PM BLOOD Glucose-185* Lactate-1.3 Na-139 K-5.6*
Cl-102

[**2134-6-28**] ECHO - The left atrium is mildly dilated. There is
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve is not well seen. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. No mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion. No vegetation seen (cannot exclude).


Brief Hospital Course:
The patient is a 46 yo M with h/o morbid obesity, OSA, COPD,
chronic trach, recent hospitalization in [**4-/2134**] with VAP with
cultures + for acinetobacter and pseudomonas who presented to
[**Location (un) 620**] on [**6-24**] with O2 sats of 78-82% and somnolence. He was
given ceftazidime, vancomycin, flagyl and levofloxacin. Cultures
were drawn. His trach was changed from a 6.0 Shily w/o cuff to a
6.0 portex cuff trach. He was transferred to [**Hospital1 18**] where he was
febrile to 101 and his ABG was notable for pH 7.24 pCO2 81 pO2
76 on 100% trach collar. He was then ventilated on PS 10/5.
Repeat ABG was pH 7.24 pCO2 79 pO2 88. He was started on
vanco/gent. While in the MICU, his respiratory status improved
and his blood cultures were notable for [**2-6**] Enterococcus so his
abx were changed to ampicillin and he defervesced (he will need
to complete a 14 day course of amp - to be completed on [**2134-7-9**]).
He was transferred to the floor on [**6-27**]. He did well until pm of
[**6-29**] when he became tachypneic. The tachypnea improved with
suctioning. On [**6-30**], he again became tachypneic to RR 40s and O2
sats decreased to 79% on 40% trach mask.  Respiratory therapy
got little mucus return with suctioning so they bagged him with
improvement in O2 sats to 99%. He was changed to 100% trach mask
with O2 sats 97-99% but continued tachpnea in 30s so he was
transferred to the ICU team for PS o/n.  The patient was
supported on pressure support ventilation and his setting were
weaned down.  He did well with a trach mask on [**2134-7-2**].  His
blood pressure continued to be elevated.  He was restarted on
his home labetalol and clonidine.  He was started on captopril
which was titrated up during the course of admission.  If his BP
remains elevated at rehab, his clonidine dose can be increased.

Regarding the patients chronic back pain, he was given PO
dilaudid PRN which was sufficient for pain control.  Increasing
his pain medication should be avoided.

The patient was hypoglycemic at times during his MICU course.
His home insulin regimen was Insulin Glargine 50 units [**Hospital1 **] and
Humalog SS.  His glargine was cut in half to 25 units [**Hospital1 **].  If
his sugars are elevated while at rehab, his lantus can be
increased back to his home regimen.

Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed.
2. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000)
units Injection TID (3 times a day).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Paroxetine HCl 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. Trazodone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime) as needed.
7. Olanzapine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a
day) as needed.
8. Clonidine 0.1 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a
day).
9. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3
times a day).
10. Clonazepam 1 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a
day).
11. Hydrocodone-Acetaminophen 5-500 mg Tablet [**Hospital1 **]: 1-2 Tablets
PO Q4-6H (every 4 to 6 hours) as needed.
12. Docusate Sodium 100 mg Capsule [**Hospital1 **]: Two (2) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
14. Ampicillin Sodium 2 g Recon Soln [**Hospital1 **]: Two (2) g Injection
Q6H (every 6 hours) for 7 days: last day should be [**2134-7-9**].
15. Tramadol 50 mg Tablet [**Month/Day/Year **]: Two (2) Tablet PO QID (4 times a
day).
16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day/Year **]:
One (1) Adhesive Patch, Medicated Topical  DAILY (Daily): apply
to left shoulder.
17. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
18. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Last Name (STitle) **]: [**6-10**]
Puffs Inhalation Q4H (every 4 hours).
19. Fluticasone 110 mcg/Actuation Aerosol [**Month/Day (3) **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
20. Lorazepam 0.5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
21. Labetalol 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times
a day).
22. Captopril 25 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a
day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]

Discharge Diagnosis:
Congestive heart failure
Edema
Enterococcus Bacteremia


Discharge Condition:
Good.  Blood pressure slightly elevated.  Will need to continue
to titrate up medications at rehab.


Discharge Instructions:
If you develop any shortness of breath, difficulty breathing,
heart palpitations, worsening leg edema, or any other concerning
symptoms, please call your doctor or go to an emergency
department.
Continue on a low sodium diet (2 gm sodium diet).


Followup Instructions:
--Please make as appointment to see Dr. [**Last Name (STitle) 22882**] ([**Telephone/Fax (1) 28634**])
within the next 1 week for blood work and a follow up
appointment.
{'Acute respiratory failure,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Hyperpotassemia,Chronic airway obstruction, not elsewhere classified,Bacteremia,Hypoxemia,Bronchitis, not specified as acute or chronic,Unspecified essential hypertension,Anemia of other chronic disease,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Morbid obesity,Obstructive sleep apnea (adult)(pediatric),Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Other testicular hypofunction,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Depressive disorder, not elsewhere classified,Tracheostomy status,Personal history of other diseases of circulatory system,Below knee amputation status,Attention to colostomy'}


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: Respiratory compromise with hypoxia and hypercarbia.

PRESENT ILLNESS: 46 year old man with a history of morbid obesity, OSA, COPD,
chronic trach, who was hospitalized in [**2134-4-3**] with VAP
(cultures + for acinetobacter and pseudomonas), who presents
with fever, hypoxia and multifocal pneumonia on CXR. He
initially traveled to [**Location (un) 620**] on [**2134-6-24**] with oxygen saturations
between 78-82% and somnolence. He was started on ceftazidime,
vancomycin, flagyl and levofloxacin. A femoral line was placed,
cultures drawn, and his trach was changed from a 6.0 Shily w/o
cuff to a 6.0 portex cuff trach.
He was transferred to [**Hospital1 18**] on [**2134-6-24**] with a temp of 101.3, HR
110, and BP 157/83. An ABG showed pH7.24 pCO2 81 pO2 76 on 100%
trach collar. He was then ventilated on PS 10/5. Repeat ABG was
pH 7.24 pCO2 79 pO2 88.
In the MICU, [**2-6**] blood cultures were positive for GPC, with
sputum and urine cultures still pending.  Wide spectrum
antibiotics were chnaged to ampicillin, although it remains
uncertain if the bacteria are, in fact, ampicillin sensitive,
despite clinical improvement.  Source remains uncertain.  He has
continued to tolerate the trach mask with high saturations on
venous blood gas.  He remains on 50% csm with saturations to the
high 90's and a respiratory rate in the teens.  Suction for the
trach has remained q3-4hrs.  Transferred to floor on [**6-27**].

MEDICAL HISTORY: -DM2 diagnosed [**2114**] with triopathy(retinopathy, nephropathy,
neuropathy): Cr has been as low as 1 in the past few months,
however widely fluctuant when hospitalized 1-2.5.
-COPD
-Multiple episodes of respiratory failure requiring intubation
in recent years (trach placed in [**12/2132**])
-Multiple VAP with resistent organisms:  pseudomonas, MRSA,
acinetobacter, citrobacter
-Acalculous cholecystitis requiring cholecystostomy tube
-G-tube
-OSA on CPAP
-VRE, S/p tracheostomy, as above in [**1-7**]
-HTN
-CHF
-Anemia of chronic disease (multiple transfusions in past)
-s/p BKA for chronic LE ulcer
-TIA in [**2125**]
-Difficult intubation; fiberoptic guidance in [**2131-10-3**].
-Urinary retention
-Osteoarthritis
-Depression
-C. Difficile in [**2129**]
-Hypogonadism
-Morbid obesity

MEDICATION ON ADMISSION: 

ALLERGIES: Cephalosporins / Morphine / Fentanyl

PHYSICAL EXAM: T 98.5 HR 68 BP 166/P  RR 20  O2sat: 100% on 50%cold steam mask
GENL: Obese male in NAD.  Slightly sleepy but attentive and
pleasant.
HEENT: +trach in place.  Slightly dry mucous membranes.  Unable
to palpate cervical nodes.
CV: RRR. Normal S1 and S2.  No murmur, rubs, or gallops.
Lungs: On ventral side, CTA bilaterally with no wheezes or
crackles.
Abd: Active bowel sounds.  Soft, obese, colostomy bag, midline
ovaloid scar.
Ext: Red brawny area on R lower leg, with no edema.  2+ right
dorsalis pedis pulse.  [**Male First Name (un) 28635**] lines in all ten fingernails.  L
BKA.

FAMILY HISTORY: Family History: Non contributory.

SOCIAL HISTORY: Social History: Lives in rehabilitation facility.  Health aide
comfortable with suctioning. 

### Response:
{'Acute respiratory failure,Pneumonia, organism unspecified,Congestive heart failure, unspecified,Hyperpotassemia,Chronic airway obstruction, not elsewhere classified,Bacteremia,Hypoxemia,Bronchitis, not specified as acute or chronic,Unspecified essential hypertension,Anemia of other chronic disease,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Morbid obesity,Obstructive sleep apnea (adult)(pediatric),Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Other testicular hypofunction,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Depressive disorder, not elsewhere classified,Tracheostomy status,Personal history of other diseases of circulatory system,Below knee amputation status,Attention to colostomy'}
