CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 47 yo male with hx of diastolic CHF, HTN, DM, and severe sleep
disordered breathing w chronic hypoxia on BiPAP presents from
his rehab facility for hypoxia. He reports increasing shortness
of breath and DOE for the past 3-4 days.  He was found to be
hypoxic to the 60s at his rehab facility so EMS was called and
he was placed on a NRB with sats at 92% on 10L in the field.
.
In the ED, initial VS were: 98.6 92 109/55 22 94% 10L NRB. On
exam he had poor air movement, mild exp wheezes right base,
sounded "tight". He was given an albuterol/ipratropium neb and
put on BiPAP with sats then 93%, dipping to high 80s on NRB.
Labs were notable for mildly elevated proBNP, pH 7.3 and pCO2 85
on ABG, mildly elevated lactate of 2.2.  CXR shows little change
from prior xrays, no evidence of infiltrates. He was given lasix
80mg IV but only put out 230cc urine while in the ED.  He was
then transferred to the ICU for hypoxia and worsening
respiratory status.
.
On arrival to the MICU, he is on BiPAP but is otherwise in no
distress.  He is able to speak in full sentences through the
mask and give the HPI.  He denies fevers, chills, or cough, but
does say he has been bringing up clear phlegm.  Reports
intermittent compliance with his BiPAP-- he is always using it
at night but not always during daytime naps.  Thinks his asthma
may be flaring a bit from the pollen, but was otherwise feeling
well.  Has been compliant with medications, has not noticed
significant swelling, but he admits some dietary indiscretions
and thinks his weight is up a little.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.

MEDICAL HISTORY: 1. Complex sleep disorder on bipap at night with severe
nocturnal and daytime hypoxia related to hypoventiliation
2. Schizophrenia
3. Bipolar disorder
4. CHF with diastolic dysfxn
5. Asthma
6. HTN
7. DM type 2, diet controlled
8. Erythrocythosis, thought secondary to hypoxia

MEDICATION ON ADMISSION: 1. doxepin 10 mg Capsule PO HS
2. metoprolol tartrate 25 mg 0.5 Tablet PO BID
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) PO DAILY
4. aspirin 81 mg Tablet, Chewable PO DAILY
5. risperidone 2 mg Tablet Two (2) Tablet PO BID
6. carbamazepine 200 mg Tablet One (1) Tablet PO QID
7. benztropine 0.5 mg Tablet One (1) Tablet PO DAILY PRN
dystonia.
8. furosemide 40 mg Tablet Two (2) Tablet PO BID
9. BiPap - Overnight BiPap settings of 20/18 with 10 liters of
supplemental oxygen
10. oxygen - 2-4 liters of continuous oxygen via nasal cannula.
Titrate for O2 saturations greater than 90%.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Alert, oriented, BiPAP mask
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

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

SOCIAL HISTORY: Has been living at [**Location 1268**] [**Hospital1 1501**] since [**2134-3-30**] for his
sleep apnea and BIPAP use. Sister is HCP
- [**Name (NI) 1139**]: none
- Alcohol: none
- Illicits: none
Acute and chronic respiratory failure,Acute kidney failure, unspecified,Acidosis,Chronic diastolic heart failure,Thrombocytopenia, unspecified,Obesity hypoventilation syndrome,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified schizophrenia, unspecified,Esophageal reflux
Acute & chronc resp fail,Acute kidney failure NOS,Acidosis,Chr diastolic hrt fail,Thrombocytopenia NOS,Obesity hypovent synd,Obstructive sleep apnea,Hypertension NOS,DMII wo cmp nt st uncntr,Schizophrenia NOS-unspec,Esophageal reflux
Admission Date:  [**2134-10-20**]              [**Month/Day/Year **] Date:   [**2134-10-21**]

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

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
none

History of Present Illness:
47 yo male with hx of diastolic CHF, HTN, DM, and severe sleep
disordered breathing w chronic hypoxia on BiPAP presents from
his rehab facility for hypoxia. He reports increasing shortness
of breath and DOE for the past 3-4 days.  He was found to be
hypoxic to the 60s at his rehab facility so EMS was called and
he was placed on a NRB with sats at 92% on 10L in the field.
.
In the ED, initial VS were: 98.6 92 109/55 22 94% 10L NRB. On
exam he had poor air movement, mild exp wheezes right base,
sounded "tight". He was given an albuterol/ipratropium neb and
put on BiPAP with sats then 93%, dipping to high 80s on NRB.
Labs were notable for mildly elevated proBNP, pH 7.3 and pCO2 85
on ABG, mildly elevated lactate of 2.2.  CXR shows little change
from prior xrays, no evidence of infiltrates. He was given lasix
80mg IV but only put out 230cc urine while in the ED.  He was
then transferred to the ICU for hypoxia and worsening
respiratory status.
.
On arrival to the MICU, he is on BiPAP but is otherwise in no
distress.  He is able to speak in full sentences through the
mask and give the HPI.  He denies fevers, chills, or cough, but
does say he has been bringing up clear phlegm.  Reports
intermittent compliance with his BiPAP-- he is always using it
at night but not always during daytime naps.  Thinks his asthma
may be flaring a bit from the pollen, but was otherwise feeling
well.  Has been compliant with medications, has not noticed
significant swelling, but he admits some dietary indiscretions
and thinks his weight is up a little.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.


Past Medical History:
1. Complex sleep disorder on bipap at night with severe
nocturnal and daytime hypoxia related to hypoventiliation
2. Schizophrenia
3. Bipolar disorder
4. CHF with diastolic dysfxn
5. Asthma
6. HTN
7. DM type 2, diet controlled
8. Erythrocythosis, thought secondary to hypoxia


Social History:
Has been living at [**Location 1268**] [**Hospital1 1501**] since [**2134-3-30**] for his
sleep apnea and BIPAP use. Sister is HCP
- [**Name (NI) 1139**]: none
- Alcohol: none
- Illicits: none


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


Physical Exam:
General: Alert, oriented, BiPAP mask
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
Labs upon admission:

[**2134-10-20**] 07:59PM BLOOD WBC-7.8 RBC-5.80 Hgb-15.6 Hct-50.9 MCV-88
MCH-26.8* MCHC-30.6* RDW-17.1* Plt Ct-191
[**2134-10-20**] 07:59PM BLOOD Neuts-65.8 Lymphs-22.7 Monos-8.4 Eos-2.6
Baso-0.5
[**2134-10-20**] 07:59PM BLOOD PT-14.0* PTT-24.0 INR(PT)-1.2*
[**2134-10-20**] 07:59PM BLOOD Glucose-159* UreaN-20 Creat-1.3* Na-139
K-4.4 Cl-90* HCO3-41* AnGap-12
[**2134-10-20**] 07:59PM BLOOD proBNP-1184*
[**2134-10-20**] 07:59PM BLOOD cTropnT-<0.01
[**2134-10-21**] 04:06AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.6
[**2134-10-20**] 08:59PM BLOOD Type-[**Last Name (un) **] pO2-82* pCO2-93* pH-7.26*
calTCO2-44* Base XS-10
[**2134-10-20**] 09:06PM BLOOD Glucose-135* Lactate-2.2* K-4.6
[**2134-10-21**] 12:46AM BLOOD Lactate-1.5
[**2134-10-20**] 08:59PM BLOOD Type-[**Last Name (un) **] pO2-82* pCO2-93* pH-7.26*
calTCO2-44* Base XS-10
[**2134-10-20**] 09:06PM BLOOD pO2-102 pCO2-85* pH-7.30* calTCO2-44*
Base XS-11

Labs upon [**Month/Day/Year **]:

[**2134-10-21**] 12:20PM BLOOD WBC-7.7 RBC-5.83 Hgb-15.1 Hct-49.8 MCV-85
MCH-26.0* MCHC-30.4* RDW-16.6* Plt Ct-205
[**2134-10-21**] 04:06AM BLOOD Glucose-116* UreaN-18 Creat-0.9 Na-141
K-4.1 Cl-92* HCO3-43* AnGap-10
[**2134-10-21**] 12:46AM BLOOD Type-ART pO2-76* pCO2-76* pH-7.38
calTCO2-47* Base XS-15
[**2134-10-21**] 12:46AM BLOOD Type-ART pO2-76* pCO2-76* pH-7.38
calTCO2-47* Base XS-15

Microbiology:

Blood cultures: pending at time of [**Month/Day/Year **] (currently no
growth to date)

Imaging:

CXR: IMPRESSION: Overall little interval change with no definite
acute pulmonary process noted. In particular, there is no focal
consolidation to suggest pneumonia or significant pulmonary
edema.


Brief Hospital Course:
47 year old man with diastolic congestive heart failure,
hypertension, pre-diabetes, obesity hypoventilation syndrome and
severe obstructive sleep apnea, presented from his skilled
nursing facility for hypoxia.  CXR showed no significant
interval change from prior films, and there was no radiographic
or clinical evidence of worsening pulmonary edema (note BNP was
1184 which is improved prior levels) or pneumonia.  His hypoxia
appears to be at baseline, and there was no clear evidence of an
acute exacerbating process.  ABG showed 7.3/76/76/47 which is
consistent with chronic respiratory acidosis with appropriate
metabolic compensation.  He was given albuterol and ipratropium
nebulizer treatments for possible bronchospasm (he may have
underlying obstructive component, possibly asthma, although
recent pulmonary function tests would be needed to confirm
this), 80mg IV lasix, and was placed on his home Bipap settings
overnight. He reported improvement in his shortness of breath on
the day of [**Month/Day/Year **] and was at baseline for his oxygen
requirements and saturations.  We discussed placement of a
tracheostomy tube as a means of a more effective therapy for his
severe hypoventilation and obstructive sleep apnea, however, the
patient declined.  Upon [**Month/Day/Year **], his goal oxygen saturation is
greater than 80% on oxygen supplementation.  Please consider
re-hospitalization if oxygen saturations fall below 80%.

Of note, he had mild acute renal injury with elevated creatinine
1.3 upon admission, which was attributed to pre-renal azotemia
(supported by FeUrea 32%).  His renal function normalized on the
day of [**Month/Day/Year **] to 0.9.  Initially lactate was elevated at 2.0,
but this normalized on the day of [**Month/Day/Year **] as well.

The patient was full code for this admission.


Medications on Admission:
1. doxepin 10 mg Capsule PO HS
2. metoprolol tartrate 25 mg 0.5 Tablet PO BID
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) PO DAILY
4. aspirin 81 mg Tablet, Chewable PO DAILY
5. risperidone 2 mg Tablet Two (2) Tablet PO BID
6. carbamazepine 200 mg Tablet One (1) Tablet PO QID
7. benztropine 0.5 mg Tablet One (1) Tablet PO DAILY PRN
dystonia.
8. furosemide 40 mg Tablet Two (2) Tablet PO BID
9. BiPap - Overnight BiPap settings of 20/18 with 10 liters of
supplemental oxygen
10. oxygen - 2-4 liters of continuous oxygen via nasal cannula.
Titrate for O2 saturations greater than 90%.


[**Month/Day/Year **] Medications:
1. doxepin 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. risperidone 4 mg Tablet Sig: One (1) Tablet PO twice a day.
6. carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
7. benztropine 0.5 mg Tablet Sig: One (1) Tablet PO once a day
as needed for dystonia.
8. furosemide 40 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
10. ipratropium bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.


[**Month/Day/Year **] Disposition:
Extended Care

Facility:
Roscommon [**Hospital 1268**] Extended Care Center

[**Hospital **] Diagnosis:
Chronic obstructive sleep apnea and obesity hypoventilation
syndrome
Diastolic congestive heart failure
Hypertension
Pre-diabetes
Schizophrenia
Bipolar disorder


[**Hospital **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Uses walker


[**Hospital **] Instructions:
Dear. Mr. [**Known lastname 732**],

You came to the hospital because of shortness of breath and low
oxygen levels.  You received a chest x-ray and laboratory tests
which were reassuring.  We believe your shortness of breath is
due to your chronic obstructive sleep apnea.  We discussed
placement of a tracheostomy which would be an effective
intervention for your shortness of breath, however you declined.
We recommend you follow a low salt diet, continue with your home
medications, and if possible, try to lose weight.

We made the following changes to your medications:
- Please start albuterol and ipratropium nebulizer treatments
every 6 hours as needed for shortness of breath or wheezing

It was a pleasure caring for you.  We wish you a speedy
recovery.

Followup Instructions:
Department: CARDIAC SERVICES
When: [**Known lastname **] [**2135-4-11**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2134-10-22**]
{'Acute and chronic respiratory failure,Acute kidney failure, unspecified,Acidosis,Chronic diastolic heart failure,Thrombocytopenia, unspecified,Obesity hypoventilation syndrome,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified schizophrenia, unspecified,Esophageal reflux'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 47 yo male with hx of diastolic CHF, HTN, DM, and severe sleep
disordered breathing w chronic hypoxia on BiPAP presents from
his rehab facility for hypoxia. He reports increasing shortness
of breath and DOE for the past 3-4 days.  He was found to be
hypoxic to the 60s at his rehab facility so EMS was called and
he was placed on a NRB with sats at 92% on 10L in the field.
.
In the ED, initial VS were: 98.6 92 109/55 22 94% 10L NRB. On
exam he had poor air movement, mild exp wheezes right base,
sounded "tight". He was given an albuterol/ipratropium neb and
put on BiPAP with sats then 93%, dipping to high 80s on NRB.
Labs were notable for mildly elevated proBNP, pH 7.3 and pCO2 85
on ABG, mildly elevated lactate of 2.2.  CXR shows little change
from prior xrays, no evidence of infiltrates. He was given lasix
80mg IV but only put out 230cc urine while in the ED.  He was
then transferred to the ICU for hypoxia and worsening
respiratory status.
.
On arrival to the MICU, he is on BiPAP but is otherwise in no
distress.  He is able to speak in full sentences through the
mask and give the HPI.  He denies fevers, chills, or cough, but
does say he has been bringing up clear phlegm.  Reports
intermittent compliance with his BiPAP-- he is always using it
at night but not always during daytime naps.  Thinks his asthma
may be flaring a bit from the pollen, but was otherwise feeling
well.  Has been compliant with medications, has not noticed
significant swelling, but he admits some dietary indiscretions
and thinks his weight is up a little.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.

MEDICAL HISTORY: 1. Complex sleep disorder on bipap at night with severe
nocturnal and daytime hypoxia related to hypoventiliation
2. Schizophrenia
3. Bipolar disorder
4. CHF with diastolic dysfxn
5. Asthma
6. HTN
7. DM type 2, diet controlled
8. Erythrocythosis, thought secondary to hypoxia

MEDICATION ON ADMISSION: 1. doxepin 10 mg Capsule PO HS
2. metoprolol tartrate 25 mg 0.5 Tablet PO BID
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) PO DAILY
4. aspirin 81 mg Tablet, Chewable PO DAILY
5. risperidone 2 mg Tablet Two (2) Tablet PO BID
6. carbamazepine 200 mg Tablet One (1) Tablet PO QID
7. benztropine 0.5 mg Tablet One (1) Tablet PO DAILY PRN
dystonia.
8. furosemide 40 mg Tablet Two (2) Tablet PO BID
9. BiPap - Overnight BiPap settings of 20/18 with 10 liters of
supplemental oxygen
10. oxygen - 2-4 liters of continuous oxygen via nasal cannula.
Titrate for O2 saturations greater than 90%.

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Alert, oriented, BiPAP mask
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

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

SOCIAL HISTORY: Has been living at [**Location 1268**] [**Hospital1 1501**] since [**2134-3-30**] for his
sleep apnea and BIPAP use. Sister is HCP
- [**Name (NI) 1139**]: none
- Alcohol: none
- Illicits: none 

### Response:
{'Acute and chronic respiratory failure,Acute kidney failure, unspecified,Acidosis,Chronic diastolic heart failure,Thrombocytopenia, unspecified,Obesity hypoventilation syndrome,Obstructive sleep apnea (adult)(pediatric),Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified schizophrenia, unspecified,Esophageal reflux'}
