CHIEF COMPLAINT: Unresponsiveness

PRESENT ILLNESS: This is an 87 year old man with history of Diabetes Mellitus,
Hypertension, diverticulosis status post partial colectomy,
depression, CKD, vascular dementia, Parkinsonism, and status
post pacemaker who presented to the ED from [**Hospital 100**] Rehab for
unresponsiveness. At 6:45AM, patient was noted to be in
respiratory distress, O2 sat was 91%, and was placed on NRB. A
nurse walking by had noted that he was tachypneic and called a
code blue. Pulse was recorded as 81, BP 100/50, O2 sat 100% on
NRB. ABG: 7.21/101/92. Glucose 242. Received Lasix 60 mg IV.
.
In the ED: V/S afebrile, BP 110/50, RR 20s on NRB O2 sat 91%.
Patient was placed on BiPAP. Nitro gtt was started for CHF but
SBP in 80s so it was stopped. Given hypoxia, concern was for PE.
Bilateral LENIS were done which was negative. Pt received
vancomycin, ceftriaxone, and levaquin. Head CT was neg. for
bleed. Patient was then transferred to MICU for further
management. Patient was non-communicative at time of exam and
history was obtained from medical record and from family report.

MEDICAL HISTORY: 1. Type 2 DM
2. Thoracic pseudoaneursym of aorta, 4.3 cm in diameter
3. HTN
4. Diverticulosis, s/p partial colectomy
5. Depression
6. CRI (baseline Cr 1.3-1.7)
7. Parkinson's disease
8. Vascular dementia
9. Pacemaker c/b lead thrombus. Previously followed by Dr [**Last Name (STitle) **]

MEDICATION ON ADMISSION: Bupropion 75 mg [**Hospital1 **]
Calcium Carbonate 500 mg [**Hospital1 **]
Vitamin D3 400 DAILY
Citalopram 20 mg DAILY
Donepezil 10 mg PO HS
Ferrous Sulfate 325 mg DAILY
Pramipexole 0.25 mg PO TID
Docusate Sodium 100 mg [**Hospital1 **]
Bisacodyl 10 mg DAILY
Senna 8.6 mg [**Hospital1 **] PRN
Aspirin 325 mg DAILY
Glipizide 5 mg DAILY
Trazodone 25 mg qHS
Isosorbide Mononitrate 10 mg [**Hospital1 **]
Metoprolol Succinate 100 mg DAILY
Potassium Chloride 10 mEq PO MWF.
Cephalexin 500 mg Q24H
Iron 325 mg PO DAILY
Vitamin C 100 mg Daily
Vitamin B-12 1,000 mcg/mL SQ qMonthly
Melatonin 4 mg PO qHS.
Lasix 60 mg Daily

ALLERGIES: Bactrim / Procardia / Sulfa (Sulfonamides) / Sulfamethoxazole /
Trimethoprim

PHYSICAL EXAM: VS: T 96.0 ax, BP 126/62, HR 78, RR 24, O2 100% on BiPap 15/5
Gen: Unresponsive.
HEENT: NCAT. Sclera anicteric. Constricted pupils. MMM.
Neck: Supple with JVP of 7 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No murmurs noted.
Chest: No accessory muscle use. Decreased breath sounds
throughout, diffuse rhonchi. No crackles, wheezes.
Abd: Normoactive, soft, NT/ND, No HSM. No abdominial bruits.
Ext: No femoral bruits. Trace pedal edema bilaterally.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: Minimally responsive to sternal rub.
.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+
DP/PT
[**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+
DP/PT
.
.
On discharge exam not significantly changed except patient's
mental status has considerably improved.  Vital signs stable and
within normal limits (no further supplementary oxygen
requirement).  Alert and Oriented *2 (not to date) and
responding to some questions appropriately though confused with
others.  Conversational.  Lungs clear to auscultation
bilaterally.

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death.

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Patient resides at
[**Hospital 100**] Rehab.
Acute respiratory failure,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Acidosis,Obstructive sleep apnea (adult)(pediatric),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Thoracic aneurysm without mention of rupture,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Depressive disorder, not elsewhere classified,Paralysis agitans,Vascular dementia, uncomplicated,Diverticulosis of colon (without mention of hemorrhage),Cardiac pacemaker in situ
Acute respiratry failure,Ac on chr diast hrt fail,Acute kidney failure NOS,Acidosis,Obstructive sleep apnea,DMII wo cmp nt st uncntr,Thoracic aortic aneurysm,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Depressive disorder NEC,Paralysis agitans,Vascular dementia,uncomp,Dvrtclo colon w/o hmrhg,Status cardiac pacemaker
Admission Date:  [**2173-8-16**]              Discharge Date:   [**2173-8-21**]


Service: MEDICINE

Allergies:
Bactrim / Procardia / Sulfa (Sulfonamides) / Sulfamethoxazole /
Trimethoprim

Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Unresponsiveness

Major Surgical or Invasive Procedure:
Sleep Study
Fluoroscopic swallow study


History of Present Illness:
This is an 87 year old man with history of Diabetes Mellitus,
Hypertension, diverticulosis status post partial colectomy,
depression, CKD, vascular dementia, Parkinsonism, and status
post pacemaker who presented to the ED from [**Hospital 100**] Rehab for
unresponsiveness. At 6:45AM, patient was noted to be in
respiratory distress, O2 sat was 91%, and was placed on NRB. A
nurse walking by had noted that he was tachypneic and called a
code blue. Pulse was recorded as 81, BP 100/50, O2 sat 100% on
NRB. ABG: 7.21/101/92. Glucose 242. Received Lasix 60 mg IV.
.
In the ED: V/S afebrile, BP 110/50, RR 20s on NRB O2 sat 91%.
Patient was placed on BiPAP. Nitro gtt was started for CHF but
SBP in 80s so it was stopped. Given hypoxia, concern was for PE.
Bilateral LENIS were done which was negative. Pt received
vancomycin, ceftriaxone, and levaquin. Head CT was neg. for
bleed. Patient was then transferred to MICU for further
management. Patient was non-communicative at time of exam and
history was obtained from medical record and from family report.

.
Of note, patient was just discharged yesterday from [**Hospital1 18**] for
hypoxia/CHF exacerbation. Patient presented on that admission
with SpO2 76% on NRB and an arterial blood gas of 7.34/66/53. He
was started on BiPap (FiO2 60%, PEEP 5, PS 10) with improvement
of O2 sat to 90-100% which was weaned over several hours. PE was
on the differential during this last hospitalization as he has
history of RA thrombus so TTE was done which showed no thrombus,
LENIS were also negative. He was started on Lasix and was weaned
down to 4L NC on discharge.
.
On review of symptoms, family denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains,
hemoptysis, black stools or red stools. Denies recent fevers,
chills or rigors. He has a chronic raspy cough per the daughter.
[**Name (NI) **] of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
palpitations. Daughter is not aware of any dyspnea on exertion,
orthopnea. She has noted that he had ankle edema ("elephant
legs") in the late winter and early spring and had asked [**Hospital1 100**]
Senior Life to start the patient on Lasix. Daughter denies any
syncope or presyncope. He has poor functional capacity at
baseline.


Past Medical History:
1. Type 2 DM
2. Thoracic pseudoaneursym of aorta, 4.3 cm in diameter
3. HTN
4. Diverticulosis, s/p partial colectomy
5. Depression
6. CRI (baseline Cr 1.3-1.7)
7. Parkinson's disease
8. Vascular dementia
9. Pacemaker c/b lead thrombus. Previously followed by Dr [**Last Name (STitle) **]

for "episodic unreponsiveness." This resolved with pacemaker
adjustment. Recently seen by Dr. [**Last Name (STitle) **]/[**Doctor Last Name **] for
the thrombus, anticoagulation deferred for h/o falls, unsteady
gait, and confusion.
11. s/p hip fracture requiring ORIF in [**3-/2172**] with a
complicated medical course including hypoxic respiratory
failure.
12. Chronic diastolic dysfunction.


Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Patient resides at
[**Hospital 100**] Rehab.


Family History:
There is no family history of premature coronary artery disease
or sudden death.


Physical Exam:
VS: T 96.0 ax, BP 126/62, HR 78, RR 24, O2 100% on BiPap 15/5
Gen: Unresponsive.
HEENT: NCAT. Sclera anicteric. Constricted pupils. MMM.
Neck: Supple with JVP of 7 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No murmurs noted.
Chest: No accessory muscle use. Decreased breath sounds
throughout, diffuse rhonchi. No crackles, wheezes.
Abd: Normoactive, soft, NT/ND, No HSM. No abdominial bruits.
Ext: No femoral bruits. Trace pedal edema bilaterally.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: Minimally responsive to sternal rub.
.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+
DP/PT
[**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+
DP/PT
.
.
On discharge exam not significantly changed except patient's
mental status has considerably improved.  Vital signs stable and
within normal limits (no further supplementary oxygen
requirement).  Alert and Oriented *2 (not to date) and
responding to some questions appropriately though confused with
others.  Conversational.  Lungs clear to auscultation
bilaterally.

Pertinent Results:
<b>LABORATORY RESULTS<B>
=======================
Labs on Admission
WBC-7.2 RBC-4.27* Hgb-12.5* Hct-37.9* MCV-89 Plt Ct-130*
PT-13.0 PTT-28.5 INR(PT)-1.1
Glucose-198* UreaN-43* Creat-1.8* Na-144 K-3.8 Cl-99 HCO3-36*
AnGap-13
.
ABG on [**2173-8-16**]: ART Rates-/25 PEEP-5 FiO2-35 pO2-76* pCO2-78*
pH-7.30* calTCO2-40* Base XS-8 Intubat-NOT INTUBA
.
ABG on [**2173-8-18**]:ART pO2-76* pCO2-62* pH-7.41 calTCO2-41* Base
XS-11 Intubat-NOT INTUBA
.
Labs on Discharge
WBC-6.7 RBC-4.20* Hgb-12.1* Hct-38.2* MCV-91 Plt Ct-159
Glucose-205* UreaN-42* Creat-1.7* Na-145 K-4.3 Cl-100 HCO3-39*
AnGap-10
ALT-15 AST-15 LD(LDH)-107 AlkPhos-62 TotBili-0.3
Calcium-9.4 Phos-3.1 Mg-2.4
.
Cardiac Enzymes:
Trop: 0.03-0.02-0.02
CK-MB: [**3-19**]-ND
.
.
.
<b>RADIOLOGY<B>
===============
CT HEAD on [**2173-8-16**]
IMPRESSION:
No acute intracranial pathology. Atherosclerotic disease and old
lacunar-type infarcts as described above.
.
CT Chest on [**2173-8-18**]
IMPRESSION:
1. Technically limited CT due to submaximal inspiratory level
and respiratory motion. No substantial change in atelectasis
involving the majority of right lower lobe adjacent to an
elevated right hemidiaphragm. High-attenuation foci peripherally
could potentially represent aspirated barium if the patient has
had a prior oral contrast examination.
2. No short interval change in pseudoaneurysm since recent CTA.
.
.
<B>OTHER STUDIES<b>
Video Swallow Study [**2173-8-20**]:
SUMMARY:
Pt presents with mild-moderate oropharyngeal dysphagia as
described above.  There was premature spillage of liquids and
swallow initiation delay which resulted in silent aspiration of
thin liquids before and during the swallow and laryngeal
penetration of nectar thick liquids during the swallow.  Pt was
not sensate to aspiration and did not produce spontaneous cough.

Treatment techniques were not effective in reducing penetration
or aspiration.  Pt also presented with prolonged mastication of
solids.  This represents a decline in swallow function since
pt's
most recent videoswallow study, performed on [**2173-6-2**] while pt
was
at [**Hospital6 459**].

Based on these deficits, I recommend a PO diet of ground solids
and nectar thick liquids at this time.  Pt should have PO meds
whole in puree.  Pt is still at risk for intermittent aspiration
with nectar thick liquids due to laryngeal penetration, though
it
was not observed on our study.  However, I believe it is worth
trialing this diet in hopes that these restrictions will have a
positive effect on pt's respiratory symptoms.  If there is
continued concern for aspiration on this diet, repeat
videoswallow study is recommended with consideration of further
restricting pt's liquid intake.

This swallowing pattern correlates to a Dysphagia Outcome
Severity Scale (DOSS) rating of 4, mild-moderate dysphagia.

RECOMMENDATIONS:
1. PO diet: ground solids, nectar thick liquids
2. PO meds whole in puree
3. Supervision and assistance with meals as needed to maintain
standard aspiration precautions.
4. If there is continued concern for aspiration on this diet,
repeat videoswallow study is recommended with consideration of
further restricting pt's liquid intake.
.
Sleep Study from [**2173-8-20**]:
IMPRESSION:
This was an abnormal portable polysomnogram.  There was
presumptive evidence of significant nocturnal hypoventilation
and
hypoxemia in the form of persistently low oxygen saturations.
Moreover, there were evidence for severe chemoreflex-mediated
sleep-disordered breathing.
.
Suggest empiric trial of nocturnal BiPAP 12/6 with backup rate
of
8 breaths per minute and 2L/min of oxygen.  If he tolerates
this,
he can go home with this.


Brief Hospital Course:
The patient is an 87 year old man with a history of Diabetes,
Hypertension, diastolic CHF, status post pacemaker, CKD,
Parkinson's, and vascular dementia who presented for
unresponsiveness and was found to be in hypercarbic respiratory
failure.
.
# Acute mental status changes: On arrival the patient was
minimally responsive to sternal rub and did not withdraw
extremities to pain. Given the ABG obtained at the outside
facility the likely cause of his unresponsiveness was
hypercarbic respiratory failure. Urine tox for opiates was
negative and a head CT showed no acute process.  There were no
signs of infection as the patient was afebrile, had no
localizing symptoms, and had no leukocytosis. BiPAP was started
and patient's mental status resolved with improving ABG's over
the next two to three days so that on day of discharge he was at
his baseline mental status.
.
# Respiratory failure: Pt was in hypercarbic respiratory failure
at [**Hospital1 100**]. There was strong suspicion he is a CO2 retainer at
baseline as also had elevated CO2's during last hospitalization.
 The cause of this was difficult to elucidate.  Initially, we
screened for pharmacologic causes of altered mental status, but
the urine tox screen was negative.  Pramipexole and Trazodone
were both potentially sedating medications so trazodone was
stopped and pramipexole dose was halved. Other etiologies of
potential respiratory failure were also pursued.  Pulmonary was
consulted and the general pulmonary team didn't think there was
a primary pulmonary process for this problem, especially with
negative chest CT.  Concern was also raised for aspiration, as
patient seemed to be choking on thin liquids.  Speech and
swallow performed a fluoroscopic swallow evaluation and did did
document dysphagia, but patient was already on aspiration
precautions as an outpatient so an acute aspiration episode was
considered a less likely cause of respiratory failure.  Another
etiology pursued was sleep apnea as the patient had a history of
snoring.  Sleep consult was obtained and inpatient sleep study
showed central sleep apnea pattern and recommended BiPAP.
Finally, to screen for possible causes of central sleep apnea,
neurology was consulted and said Parkinsonism or vascular
dementia are possible but unlikely causes of central apnea.
Patient was thus treated empirically with BiPAP and discharged
with prescription for this therapy.
.
# Pump: Patient has history of diastolic dysfunction and
inadequate control of his diastolic heart failure was considered
one possible contributing factor to his respiratory failure.
Thus, over the course of the hospitalization we worked to
optimize heart failure therapy titrating the patient's diuretic
and beta blocker as well as adding an ACE inhibitor for better
control of blood.  Patient was initially diuresed about one and
a half liters then kept at relatively neutral fluid balance
therafter.
.
# CAD/Ischemia: EKG showed possible new T wave inversions at
admission but cardiac enzymes flat and never significant.  ACS
considered extremely unlikely as cause for acute respiratory
decompensation and no further work-up was pursued.
.
# Rhythm: Patient was in NSR throughout hospitalization but
bizarre wide complex rhythm obtained from pacemaker recording.
EP evaluated and thought unlikely to be afib and was probably an
unusual sinus rhythm.  The patient was followed on telemetry
throughout his hospitalization and had no clinically significant
dysrhythmias.
.
# Diabetes Mellitus Type II: The patient was maintained on
sliding scale insulin and was reasonably well controlled in the
hospital.
.
# Chronic Kidney Disease (baseline Cr 1.3-1.7): Patient remained
at stable Cr throughout addition of ACEi and other modifications
to HTN regimen.  No acute issues.
.
# Parkinson's disease/Vascular Dementia/Depression: Very unclear
history of the exact etiologies of these processes.  Unclear if
Parkinson's disease vs Parkinsonism as consequence of vascular
dementia.  Patient's Pramipexole initially weaned down due to
fear of sedation but neurology said this could worsen dysphagia
so he was returned to his admission dose.  Psychiatric
medications continued at home doses.
.
The patient was NPO initially but as his mental status cleared
he was allowed to eat.  Liquids were thickened and he had ground
solids per Speech and Swallow reccs.  he was maintained on SC
heparin for DVT prophylaxis.  He was DNR but 1 shock was
allowed, which was confirmed by the [**Hospital 228**] health care
proxies.  He was discharged to [**Hospital 100**] Rehab MACU after
stabilized on new medication regimen and probable cause of
hypercarbic episodes was discovered.

Medications on Admission:
Bupropion 75 mg [**Hospital1 **]
Calcium Carbonate 500 mg [**Hospital1 **]
Vitamin D3 400 DAILY
Citalopram 20 mg DAILY
Donepezil 10 mg PO HS
Ferrous Sulfate 325 mg DAILY
Pramipexole 0.25 mg PO TID
Docusate Sodium 100 mg [**Hospital1 **]
Bisacodyl 10 mg DAILY
Senna 8.6 mg [**Hospital1 **] PRN
Aspirin 325 mg DAILY
Glipizide 5 mg DAILY
Trazodone 25 mg qHS
Isosorbide Mononitrate 10 mg [**Hospital1 **]
Metoprolol Succinate 100 mg DAILY
Potassium Chloride 10 mEq PO MWF.
Cephalexin 500 mg Q24H
Iron 325 mg PO DAILY
Vitamin C 100 mg Daily
Vitamin B-12 1,000 mcg/mL SQ qMonthly
Melatonin 4 mg PO qHS.
Lasix 60 mg Daily


Discharge Medications:
1. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Cholecalciferol (Vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
7. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q24H (every
24 hours).
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1)  Injection
once a month.
12. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. Nitrostat 0.4 mg Tablet, Sublingual Sig: One (1)  Sublingual
q 5 minutes x3 as needed for chest pain.
14. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
15. Acetaminophen 325 mg Tablet Sig: Three (3) Tablet PO every
six (6) hours.
16. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO once a
day.
17. Melatonin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
18. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
19. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
20. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO twice a day.
21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
22. BiPAP
Nasal CPAP w/PSV (BIPAP) Inspiratory pressure: 12 cm/h2o
Expiratory pressure: 6 cm/h2o Backup rate: 8 bth/min Supp O2: 2
L/min


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Primary Diagnoses:
===================
Sleep Apnea
Diastolic Heart Failure
.
Secondary Diagnoses:
====================
1. Diabetes Mellitus, type 2
2. Thoracic pseudoaneursym of aorta, 4.3 cm in diameter
3. Hypertension
4. Diverticulosis, s/p partial colectomy
5. Depression
6. Chronic Kidney Disease (baseline Cr 1.3-1.7)
7. Parkinson's disease
8. Vascular dementia
9. Pacemaker placed for "episodic unreponsiveness," which
resolved with pacemaker adjustment
10. s/p hip fracture requiring ORIF in [**3-/2172**] with a
complicated medical course including hypoxic respiratory
failure.


Discharge Condition:
Comfortable, not requiring O2, tolerating P.O.'s


Discharge Instructions:
You were admitted to the hospital because you were confused and
not thinking well.  We believe this was due to you having low
oxygen in your blood and high carbon dioxide due to not
breathing adequately.  This was most likely due to the fact that
 you stop breathing when you sleep in addition to a bit a bit of
a worsening of your heart failure.
.
Your medications have been changed.  You have been started on
LISINOPRIL, a medication to help control your blood pressure.
Your METOPROLOL XL dose was also increased to better control
your blood pressure.  Your FUROSEMIDE (LASIX) dose has been
decreased in order to protect you from the combined affect of it
and LISINOPRIL on your kidneys.  Your TRAZODONE has been stopped
as this medication might worsen your breathing at night.
.
You have also been started on BiPAP, a treatment to help your
breathing at night.  This intervention should help you continue
to breathe adequately throughout the night and prevent episodes
of low oxygen and high carbon dioxide in the blood such as those
that brought you into the hospital.
.
Please keep all scheduled appointments as these are important to
maintain your health.
.
Please adher to a 2 gm sodium/day diet.  Please call your doctor
or report to the ED if you have chest pain, shortness of breath,
Fever to 101 F, increased swelling of your legs, or any other
disturbing changes to your health.
Fluid Restriction:

Followup Instructions:
Gastroenterology:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2173-12-2**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2173-12-2**] 1:45
.
Cardiology:
You have a follow up scheduled for Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] on [**9-20**] at 11am on [**Hospital Ward Name 23**] 7.  His office can be reached at
[**Telephone/Fax (1) 62**]
.
You will need to follow up in sleep clinic in four to six weeks
to talk about how you're doing on BiPAP.  Sleep clinic can be
reached at([**Telephone/Fax (1) 9525**].
{'Acute respiratory failure,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Acidosis,Obstructive sleep apnea (adult)(pediatric),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Thoracic aneurysm without mention of rupture,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Depressive disorder, not elsewhere classified,Paralysis agitans,Vascular dementia, uncomplicated,Diverticulosis of colon (without mention of hemorrhage),Cardiac pacemaker in situ'}


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: Unresponsiveness

PRESENT ILLNESS: This is an 87 year old man with history of Diabetes Mellitus,
Hypertension, diverticulosis status post partial colectomy,
depression, CKD, vascular dementia, Parkinsonism, and status
post pacemaker who presented to the ED from [**Hospital 100**] Rehab for
unresponsiveness. At 6:45AM, patient was noted to be in
respiratory distress, O2 sat was 91%, and was placed on NRB. A
nurse walking by had noted that he was tachypneic and called a
code blue. Pulse was recorded as 81, BP 100/50, O2 sat 100% on
NRB. ABG: 7.21/101/92. Glucose 242. Received Lasix 60 mg IV.
.
In the ED: V/S afebrile, BP 110/50, RR 20s on NRB O2 sat 91%.
Patient was placed on BiPAP. Nitro gtt was started for CHF but
SBP in 80s so it was stopped. Given hypoxia, concern was for PE.
Bilateral LENIS were done which was negative. Pt received
vancomycin, ceftriaxone, and levaquin. Head CT was neg. for
bleed. Patient was then transferred to MICU for further
management. Patient was non-communicative at time of exam and
history was obtained from medical record and from family report.

MEDICAL HISTORY: 1. Type 2 DM
2. Thoracic pseudoaneursym of aorta, 4.3 cm in diameter
3. HTN
4. Diverticulosis, s/p partial colectomy
5. Depression
6. CRI (baseline Cr 1.3-1.7)
7. Parkinson's disease
8. Vascular dementia
9. Pacemaker c/b lead thrombus. Previously followed by Dr [**Last Name (STitle) **]

MEDICATION ON ADMISSION: Bupropion 75 mg [**Hospital1 **]
Calcium Carbonate 500 mg [**Hospital1 **]
Vitamin D3 400 DAILY
Citalopram 20 mg DAILY
Donepezil 10 mg PO HS
Ferrous Sulfate 325 mg DAILY
Pramipexole 0.25 mg PO TID
Docusate Sodium 100 mg [**Hospital1 **]
Bisacodyl 10 mg DAILY
Senna 8.6 mg [**Hospital1 **] PRN
Aspirin 325 mg DAILY
Glipizide 5 mg DAILY
Trazodone 25 mg qHS
Isosorbide Mononitrate 10 mg [**Hospital1 **]
Metoprolol Succinate 100 mg DAILY
Potassium Chloride 10 mEq PO MWF.
Cephalexin 500 mg Q24H
Iron 325 mg PO DAILY
Vitamin C 100 mg Daily
Vitamin B-12 1,000 mcg/mL SQ qMonthly
Melatonin 4 mg PO qHS.
Lasix 60 mg Daily

ALLERGIES: Bactrim / Procardia / Sulfa (Sulfonamides) / Sulfamethoxazole /
Trimethoprim

PHYSICAL EXAM: VS: T 96.0 ax, BP 126/62, HR 78, RR 24, O2 100% on BiPap 15/5
Gen: Unresponsive.
HEENT: NCAT. Sclera anicteric. Constricted pupils. MMM.
Neck: Supple with JVP of 7 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No murmurs noted.
Chest: No accessory muscle use. Decreased breath sounds
throughout, diffuse rhonchi. No crackles, wheezes.
Abd: Normoactive, soft, NT/ND, No HSM. No abdominial bruits.
Ext: No femoral bruits. Trace pedal edema bilaterally.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: Minimally responsive to sternal rub.
.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+
DP/PT
[**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+
DP/PT
.
.
On discharge exam not significantly changed except patient's
mental status has considerably improved.  Vital signs stable and
within normal limits (no further supplementary oxygen
requirement).  Alert and Oriented *2 (not to date) and
responding to some questions appropriately though confused with
others.  Conversational.  Lungs clear to auscultation
bilaterally.

FAMILY HISTORY: There is no family history of premature coronary artery disease
or sudden death.

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. Patient resides at
[**Hospital 100**] Rehab. 

### Response:
{'Acute respiratory failure,Acute on chronic diastolic heart failure,Acute kidney failure, unspecified,Acidosis,Obstructive sleep apnea (adult)(pediatric),Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Thoracic aneurysm without mention of rupture,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Depressive disorder, not elsewhere classified,Paralysis agitans,Vascular dementia, uncomplicated,Diverticulosis of colon (without mention of hemorrhage),Cardiac pacemaker in situ'}
