CHIEF COMPLAINT: Respiratory Distress

PRESENT ILLNESS: The patient 71 year old female with a hx of breast cancer,
recent dx of esophageal cancer (SCCa) approx 1 month prior, TE
fistula s/p esophageal and Bronchus Y stent placement two weeks
ago, who is followed by Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Hospital3 **]. Please see
admission note for full details. Briefly, she had a recent
diagnosis of esophageal cancer. She presented to an OSH on [**7-17**]
w/ acute onset wheezing and underwent endoscopy that reavealed
large esophafeal mass and TE fistula. A esophageal and left main
stent were placed on [**7-26**] and she was stent was placed on [**7-26**]
and was intubated on [**2177-8-5**] for respiratory distress and left
main stem obstruction. It was thought she had an aspiration pna
and dislodgement of her bronchus stent. She was then transferred
to [**Hospital1 18**] on [**2177-8-6**]. On [**2177-8-7**] she underwent Rigid
bronchoscopy, flexible bronchoscopy, tumor destruction with
mechanical forceps,tumor destruction with cryotherapy, and
Y-stent placement. She was discharged home on tube feeds on
[**2177-8-11**] following stent placement. She presented to clinic on
[**8-19**] with severe nausea/ vomiting, treated with anti-emetics,
dexamethasone and IV fluids without significant effect, and
transferred to [**Hospital1 18**] for pallitative treatment.
.
Overnight she was having severe "retching" and was increasingly
agitated. At baseline she is oriented x3, but per nursing she
was confused, only oriented x1, and pulling and difficult to
settle. She remained tachycardic in the 130's, with HR as high
as 160's. She was given a total of ativan 0.25mg x2 and morphine
1mg this morning. She then triggered this AM for respiratory
distress with O2 sats as low as 75%. She remained tachy in the
130's and BP 160/100. The patient had was refusing secreations
and increasing agitated. The patient was spitting up clear
secreations and complaining of not getting enough air. She was
transferred to the [**Hospital Unit Name 153**] for emergent bronch to assess her
airway.
.
On arrive to the [**Hospital Unit Name 153**] she was 100% on RA, tachypneic with RR
30's, tachy to the 130's. She was initially calm, but escalated
with episodes of stridous breathing, increasing secreations and
agitation. She refused suction due to pain. She also states that
she "just want's to go home."
.
Spoke with the patient's husbnad over the phone and discuss her
situation at length. He said she had similar episodes in the
past when she is agitated and delerious that she will refuse
treatment. However, he emphasized that when she is mentating
clearly that she wanted everything performed including
intubation and other invasic procedures.

MEDICAL HISTORY: Stage II T2N0M0), left breast CA in [**2162**], s/p left mastectomy
and 4 cycles of chemo with adriamycin/cytoxan limited due to Gi
toxicity, and tamoxifen 20 mg for 5 years until [**2170**].
-Esophageal Cancer: dx [**2177-7-17**]. An endoscopy ([**7-21**]) and a CT
scan were performed and showed a large esophageal ulcerating
mass with TE fistula. Pathology revealed squamous cell
carcinoma. .
Depression.
Chronic back pain with opioid addiction (per prior notes)
GERD
Hypertension
Migraines
Hiatal hernia with severe reflux status post pyloroplasty.
palpitations
Status post hysterectomy, status post cholecystectomy and status

MEDICATION ON ADMISSION: 1. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for agitation or anxiety.
Disp:*30 Tablet(s)* Refills:*0*
2. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1)
Tab, Multiphasic Release 12 hr PO twice a day for 2 weeks.
Disp:*28 Tab, Multiphasic Release 12 hr(s)* Refills:*0*
3. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for cough for 2 weeks.
Disp:*60 Capsule(s)* Refills:*0*
4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1)  Transdermal
Q72H (every 72 hours).
5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1)  Transdermal once

ALLERGIES: Codeine / Bactrim / Erythromycin Base / Penicillins /
Prochlorperazine / Nalbuphine / Iodine / Phenothiazines /
Aspirin

PHYSICAL EXAM: Vitals - T:97.9 BP:145/92 HR:124 RR:18 02 sat: 100%RA
GENERAL: extremely agitated and short shallow breathes. Episodes
of stridrous breath sounds and expectoring clear secreations. Pt
saying "I want to go home," thin frail appearing
SKIN: warm and well perfused, no rashes visible
HEENT: anicteric sclera, pink conjunctiva, patent nares, MMM
CARDIAC: tachycardic, regular rate, S1/S2, no mrg
LUNG: coarse rhonchi, episodes of stridorous upper airway sounds

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Married, lives in [**Location **], MA. Husband extremely supportive and
is primary caregiver. [**First Name (Titles) 1817**] [**Last Name (Titles) 1818**], quit [**2148**].
Malignant neoplasm of other specified part of esophagus,Tracheoesophageal fistula,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Foreign body in main bronchus,Drug-induced delirium,Alkalosis,Opioid type dependence, continuous,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Unilateral paralysis of vocal cords or larynx, partial,Unspecified essential hypertension,Dysthymic disorder,Personal history of malignant neoplasm of breast,Unspecified acquired hypothyroidism,Status of other artificial opening of gastrointestinal tract
Mal neo esophagus NEC,Tracheoesophageal fstula,Acute respiratry failure,Food/vomit pneumonitis,Foreign body bronchus,Drug-induced delirium,Alkalosis,Opioid dependence-contin,Adv eff analgesics NEC,Vocal paral unilat part,Hypertension NOS,Dysthymic disorder,Hx of breast malignancy,Hypothyroidism NOS,Enterostomy status NEC
Admission Date:  [**2177-8-20**]              Discharge Date:   [**2177-9-5**]

Date of Birth:  [**2106-3-12**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine / Bactrim / Erythromycin Base / Penicillins /
Prochlorperazine / Nalbuphine / Iodine / Phenothiazines /
Aspirin

Attending:[**First Name3 (LF) 31685**]
Chief Complaint:
Respiratory Distress

Major Surgical or Invasive Procedure:
flexible bronchoscopy

History of Present Illness:
The patient 71 year old female with a hx of breast cancer,
recent dx of esophageal cancer (SCCa) approx 1 month prior, TE
fistula s/p esophageal and Bronchus Y stent placement two weeks
ago, who is followed by Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Hospital3 **]. Please see
admission note for full details. Briefly, she had a recent
diagnosis of esophageal cancer. She presented to an OSH on [**7-17**]
w/ acute onset wheezing and underwent endoscopy that reavealed
large esophafeal mass and TE fistula. A esophageal and left main
stent were placed on [**7-26**] and she was stent was placed on [**7-26**]
and was intubated on [**2177-8-5**] for respiratory distress and left
main stem obstruction. It was thought she had an aspiration pna
and dislodgement of her bronchus stent. She was then transferred
to [**Hospital1 18**] on [**2177-8-6**]. On [**2177-8-7**] she underwent Rigid
bronchoscopy, flexible bronchoscopy, tumor destruction with
mechanical forceps,tumor destruction with cryotherapy, and
Y-stent placement. She was discharged home on tube feeds on
[**2177-8-11**] following stent placement. She presented to clinic on
[**8-19**] with severe nausea/ vomiting, treated with anti-emetics,
dexamethasone and IV fluids without significant effect, and
transferred to [**Hospital1 18**] for pallitative treatment.
.
Overnight she was having severe "retching" and was increasingly
agitated. At baseline she is oriented x3, but per nursing she
was confused, only oriented x1, and pulling and difficult to
settle. She remained tachycardic in the 130's, with HR as high
as 160's. She was given a total of ativan 0.25mg x2 and morphine
1mg this morning. She then triggered this AM for respiratory
distress with O2 sats as low as 75%. She remained tachy in the
130's and BP 160/100. The patient had was refusing secreations
and increasing agitated. The patient was spitting up clear
secreations and complaining of not getting enough air. She was
transferred to the [**Hospital Unit Name 153**] for emergent bronch to assess her
airway.
.
On arrive to the [**Hospital Unit Name 153**] she was 100% on RA, tachypneic with RR
30's, tachy to the 130's. She was initially calm, but escalated
with episodes of stridous breathing, increasing secreations and
agitation. She refused suction due to pain. She also states that
she "just want's to go home."
.
Spoke with the patient's husbnad over the phone and discuss her
situation at length. He said she had similar episodes in the
past when she is agitated and delerious that she will refuse
treatment. However, he emphasized that when she is mentating
clearly that she wanted everything performed including
intubation and other invasic procedures.


Past Medical History:
Stage II T2N0M0), left breast CA in [**2162**], s/p left mastectomy
and 4 cycles of chemo with adriamycin/cytoxan limited due to Gi
toxicity, and tamoxifen 20 mg for 5 years until [**2170**].
-Esophageal Cancer: dx [**2177-7-17**]. An endoscopy ([**7-21**]) and a CT
scan were performed and showed a large esophageal ulcerating
mass with TE fistula. Pathology revealed squamous cell
carcinoma. .
Depression.
Chronic back pain with opioid addiction (per prior notes)
GERD
Hypertension
Migraines
Hiatal hernia with severe reflux status post pyloroplasty.
palpitations
Status post hysterectomy, status post cholecystectomy and status

post left mastectomy.


Social History:
Married, lives in [**Location **], MA. Husband extremely supportive and
is primary caregiver. [**First Name (Titles) 1817**] [**Last Name (Titles) 1818**], quit [**2148**].

Family History:
non-contributory

Physical Exam:
Vitals - T:97.9 BP:145/92 HR:124 RR:18 02 sat: 100%RA
GENERAL: extremely agitated and short shallow breathes. Episodes
of stridrous breath sounds and expectoring clear secreations. Pt
saying "I want to go home," thin frail appearing
SKIN: warm and well perfused, no rashes visible
HEENT: anicteric sclera, pink conjunctiva, patent nares, MMM
CARDIAC: tachycardic, regular rate, S1/S2, no mrg
LUNG: coarse rhonchi, episodes of stridorous upper airway sounds

ABDOMEN: nondistended, +BS, diffusely tender, no
rebound/guarding, midline staples and j tube in place.
M/S: no cyanosis, clubbing or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: pupils equal round and reactive, patient unable to
cooperated with neuro exam. Moving all ext spontaneously. No
obvious focal deficits.


Pertinent Results:
[**2177-8-22**] 03:57AM BLOOD WBC-17.0* RBC-4.21 Hgb-11.7* Hct-36.1
MCV-86 MCH-27.8 MCHC-32.5 RDW-14.7 Plt Ct-587*
[**2177-8-21**] 12:41AM BLOOD WBC-14.2* RBC-3.85* Hgb-10.8* Hct-33.1*
MCV-86 MCH-28.0 MCHC-32.6 RDW-14.7 Plt Ct-553*
[**2177-8-20**] 07:30PM BLOOD WBC-15.7* RBC-4.06* Hgb-11.2* Hct-34.9*
MCV-86 MCH-27.5 MCHC-32.1 RDW-14.3 Plt Ct-570*
[**2177-8-22**] 03:57AM BLOOD Neuts-84.0* Lymphs-10.1* Monos-5.4
Eos-0.3 Baso-0.2
[**2177-8-20**] 07:30PM BLOOD Neuts-78.2* Lymphs-14.0* Monos-6.8
Eos-0.8 Baso-0.2
[**2177-8-22**] 03:57AM BLOOD PT-13.4 PTT-52.5* INR(PT)-1.1
[**2177-8-22**] 03:57AM BLOOD Glucose-162* UreaN-4* Creat-0.4 Na-140
K-2.8* Cl-99 HCO3-29 AnGap-15
[**2177-8-21**] 12:41AM BLOOD Glucose-113* UreaN-7 Creat-0.5 Na-141
K-3.1* Cl-101 HCO3-32 AnGap-11
[**2177-8-20**] 07:30PM BLOOD Glucose-100 UreaN-7 Creat-0.5 Na-141
K-3.2* Cl-102 HCO3-31 AnGap-11
[**2177-8-20**] 07:30PM BLOOD ALT-13 AST-18 AlkPhos-83 TotBili-0.2
[**2177-8-22**] 03:57AM BLOOD Calcium-10.0 Phos-2.4* Mg-1.7
[**2177-8-21**] 12:41AM BLOOD Calcium-9.6 Phos-2.6* Mg-1.9
[**2177-8-20**] 07:30PM BLOOD Albumin-3.2* Calcium-10.0 Phos-2.5*
Mg-2.0
[**2177-8-21**] 02:40PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2177-8-21**] 02:40PM URINE Blood-SM  Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
[**2177-8-21**] 02:40PM URINE RBC-15* WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
[**2177-8-21**] 02:40PM URINE Mucous-RARE
.
.
Cx Pending: neg to date
[**2177-8-22**] BLOOD CULTURE Blood Culture, No growth
[**2177-8-21**] BLOOD CULTURE Blood Culture, No growth
[**2177-8-21**] URINE URINE CULTURE, No growth
.
.
CT

CT Chest/Abdomen/Pelvis [**8-25**]:
1. Mediastinal mass with locules of air suggesting erosion
outside the
esophageal stent. Also noted compression of the subglottic
trachea just above the tracheobronchial Y stent.  .
2. Subpleural nodularity, pleural thickening and irregularity,
part of which could reflect rounded atelectasis; however, in the
setting of malignancy, Metastatic involvement cannot be excluded
and attention on followup is recommended. Alternatively may
relate to radiation sequelae, correlation with history is
recommended.
3. Loculated right oblique fissure fluid.
4. Incidental note of aberrant right subclavian artery.
.
Bone scan [**8-29**]: No findings of bony metastatic disease.

Brief Hospital Course:
Brief Hospital Course:
The patient is a 71-year-old female with a remote history of
breast cancer, recent diagnosis of esophageal CA s/p esophageal
and bronchial Y stent in [**2177-6-30**], who was admitted to OSH with
persistent nausea and vomiting.  She was transferred to [**Hospital1 18**]
for chemotherapy and radiation, but soon after admission was
sent to the [**Hospital Unit Name 153**] for an urgent brochoscopy because of
respiratory distress and difficulty clearing secretions.  The
bronchoscopy showed that the patient's Y stent was patent, and
thick secretions were suctioned.  She was then transferred back
to the floor and received daily chemotherapy with 5FU and
Cisplatin.  She was initiated on XRT on [**2176-9-5**].  She tolerated
the procedure well and was discharged to her outpatient
appointment with Dr. [**Last Name (STitle) **].
.
#. Respiratory Distress: The patient had a patent Y stent on
bronchoscopy, but intermittent evidence of upper airway
obstruction on physical examination, concerning for mucous
plugging.  She was treated with albuterol, atrovent and
acetylcisteine neubulizers and mucinex.  She also completed a 14
day course of moxifloxacin on [**2177-8-25**].
.
#Agitation/Anxiety: The patient had intermittent agitation,
responsive to haldol.  She was also treated with Remeron at
night.  During her admission, benzos were avoided because of a
history of paradoxical reaction to ativan in the past (per
husband).
.
# Esophageal Ca: The patient was treated with daily chemotherapy
while an inpatient, initiated XRT, with a plan to XRT  and
chemotherapy as an outpatient.  She tolerated chemotherapy well,
with moderated nausea and vomiting responsive to zofran and
compazine.
.
# pain management: The patient has a long history of chronic
pain and opioid use.  While inpatient she was continued on her
home dose of methadone 20mg TID, but her fentanyl patch was
decreased from 120 mcg to 75 mcg q72 hrs.
.
#HTN: Nifedipine was changed to amlodipine for administration
through j tube.
.
#Hypothyroidism: Continued on home dose of synthroid
.
#FEN/GI: The patient had a recent swallow study showing moderate
oropharyngeal dysphagia and aspiration of thin liquids.
Consequently, she was placed on strict aspiration precautions
with head of bed at 45 degrees at all times and tube feeds were
only administered while sitting up.


Medications on Admission:
1. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for agitation or anxiety.
Disp:*30 Tablet(s)* Refills:*0*
2. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1)
Tab, Multiphasic Release 12 hr PO twice a day for 2 weeks.
Disp:*28 Tab, Multiphasic Release 12 hr(s)* Refills:*0*
3. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for cough for 2 weeks.
Disp:*60 Capsule(s)* Refills:*0*
4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1)  Transdermal
Q72H (every 72 hours).
5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1)  Transdermal once

a day: total 125 mcg/hr .
6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheezes or SOB.
7. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO TID (3 times a day).
8. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Moxifloxacin 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) as needed for Esophageal fistula for 2 weeks.
Disp:*12 Tablet(s)* Refills:*0*
10. Senna 8.8 mg/5 mL Syrup Sig: 1-2 Tablets PO BID (2 times a
day).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2

times a day).
12. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Acetylcysteine 10 % (100 mg/mL) Solution Sig: Three (3) mL
Miscellaneous twice a day: for Y stent patency
Mix w/albuterol to prevent bronchospasm.
Disp:*180 mL* Refills:*2*
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation twice a day: mix
w/mucomyst.
15. Procardia 10 mg [**Hospital1 **]

Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Acetylcysteine 20 % (200 mg/mL) Solution Sig: Three (3) ML
Miscellaneous TID (3 times a day).
Disp:*270 ML(s)* Refills:*2*
3. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: 2.5 mg Inhalation Q6H (every 6 hours) as
needed for shortness of breath. mg
6. Guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q6H
(every 6 hours).
7. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) teaspoons PO
twice a day.
8. Senna 8.8 mg/5 mL Syrup Sig: One (1) teaspoon PO BID (2 times
a day) as needed for constipation.
9. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for agitation.
Disp:*60 Tablet(s)* Refills:*0*
10. Methadone 10 mg/5 mL Solution Sig: Ten (10) cc PO TID (3
times a day).
Disp:*1 bottle (100cc)* Refills:*0*
11. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
Disp:*2 0* Refills:*0*
15. Mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
16. Prilosec 10 mg Susp,Delayed Release for Recon Sig: Twenty
(20) mg PO once a day.
Disp:*1 bottle (300cc)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
primary: esophageal cancer
secondary: hypertension, depression, anxiety


Discharge Condition:
stable, afebrile.  Right side catheter with access in place.


Discharge Instructions:
You were admitted to [**Hospital1 18**] on [**2177-8-20**] for nausea and vomiting.
We treated you for your esophageal cancer with chemo and
radiation therapy.  You developed an episode of severe shortness
of breath and an emergent bronchoscopy was performed in the ICU
and the stent that you have in place in your lungs was suctioned
to clear secretions.  You returned to the oncology floor for
daily chemotherapy.  Radiation therapy was initiated while
inpatient and will continue as outpatient.

A number of your medications have changed during your hospital
Please see attached sheet for new medication regimen.

Please return to the emergency room if you experience any
shortness of breath, chest pain, severe headaches, severe nausea
and vomiting.


Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] at 12:30pm on Friday [**2177-9-6**].

Your next treatment with radiation oncology is scheduled for
Monday. Please call [**Telephone/Fax (1) 9710**] for date and time.



Completed by:[**2177-9-7**]
{'Malignant neoplasm of other specified part of esophagus,Tracheoesophageal fistula,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Foreign body in main bronchus,Drug-induced delirium,Alkalosis,Opioid type dependence, continuous,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Unilateral paralysis of vocal cords or larynx, partial,Unspecified essential hypertension,Dysthymic disorder,Personal history of malignant neoplasm of breast,Unspecified acquired hypothyroidism,Status of other artificial opening of gastrointestinal tract'}


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 Distress

PRESENT ILLNESS: The patient 71 year old female with a hx of breast cancer,
recent dx of esophageal cancer (SCCa) approx 1 month prior, TE
fistula s/p esophageal and Bronchus Y stent placement two weeks
ago, who is followed by Dr. [**First Name (STitle) **] [**Name (STitle) **] at [**Hospital3 **]. Please see
admission note for full details. Briefly, she had a recent
diagnosis of esophageal cancer. She presented to an OSH on [**7-17**]
w/ acute onset wheezing and underwent endoscopy that reavealed
large esophafeal mass and TE fistula. A esophageal and left main
stent were placed on [**7-26**] and she was stent was placed on [**7-26**]
and was intubated on [**2177-8-5**] for respiratory distress and left
main stem obstruction. It was thought she had an aspiration pna
and dislodgement of her bronchus stent. She was then transferred
to [**Hospital1 18**] on [**2177-8-6**]. On [**2177-8-7**] she underwent Rigid
bronchoscopy, flexible bronchoscopy, tumor destruction with
mechanical forceps,tumor destruction with cryotherapy, and
Y-stent placement. She was discharged home on tube feeds on
[**2177-8-11**] following stent placement. She presented to clinic on
[**8-19**] with severe nausea/ vomiting, treated with anti-emetics,
dexamethasone and IV fluids without significant effect, and
transferred to [**Hospital1 18**] for pallitative treatment.
.
Overnight she was having severe "retching" and was increasingly
agitated. At baseline she is oriented x3, but per nursing she
was confused, only oriented x1, and pulling and difficult to
settle. She remained tachycardic in the 130's, with HR as high
as 160's. She was given a total of ativan 0.25mg x2 and morphine
1mg this morning. She then triggered this AM for respiratory
distress with O2 sats as low as 75%. She remained tachy in the
130's and BP 160/100. The patient had was refusing secreations
and increasing agitated. The patient was spitting up clear
secreations and complaining of not getting enough air. She was
transferred to the [**Hospital Unit Name 153**] for emergent bronch to assess her
airway.
.
On arrive to the [**Hospital Unit Name 153**] she was 100% on RA, tachypneic with RR
30's, tachy to the 130's. She was initially calm, but escalated
with episodes of stridous breathing, increasing secreations and
agitation. She refused suction due to pain. She also states that
she "just want's to go home."
.
Spoke with the patient's husbnad over the phone and discuss her
situation at length. He said she had similar episodes in the
past when she is agitated and delerious that she will refuse
treatment. However, he emphasized that when she is mentating
clearly that she wanted everything performed including
intubation and other invasic procedures.

MEDICAL HISTORY: Stage II T2N0M0), left breast CA in [**2162**], s/p left mastectomy
and 4 cycles of chemo with adriamycin/cytoxan limited due to Gi
toxicity, and tamoxifen 20 mg for 5 years until [**2170**].
-Esophageal Cancer: dx [**2177-7-17**]. An endoscopy ([**7-21**]) and a CT
scan were performed and showed a large esophageal ulcerating
mass with TE fistula. Pathology revealed squamous cell
carcinoma. .
Depression.
Chronic back pain with opioid addiction (per prior notes)
GERD
Hypertension
Migraines
Hiatal hernia with severe reflux status post pyloroplasty.
palpitations
Status post hysterectomy, status post cholecystectomy and status

MEDICATION ON ADMISSION: 1. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for agitation or anxiety.
Disp:*30 Tablet(s)* Refills:*0*
2. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1)
Tab, Multiphasic Release 12 hr PO twice a day for 2 weeks.
Disp:*28 Tab, Multiphasic Release 12 hr(s)* Refills:*0*
3. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for cough for 2 weeks.
Disp:*60 Capsule(s)* Refills:*0*
4. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1)  Transdermal
Q72H (every 72 hours).
5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1)  Transdermal once

ALLERGIES: Codeine / Bactrim / Erythromycin Base / Penicillins /
Prochlorperazine / Nalbuphine / Iodine / Phenothiazines /
Aspirin

PHYSICAL EXAM: Vitals - T:97.9 BP:145/92 HR:124 RR:18 02 sat: 100%RA
GENERAL: extremely agitated and short shallow breathes. Episodes
of stridrous breath sounds and expectoring clear secreations. Pt
saying "I want to go home," thin frail appearing
SKIN: warm and well perfused, no rashes visible
HEENT: anicteric sclera, pink conjunctiva, patent nares, MMM
CARDIAC: tachycardic, regular rate, S1/S2, no mrg
LUNG: coarse rhonchi, episodes of stridorous upper airway sounds

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Married, lives in [**Location **], MA. Husband extremely supportive and
is primary caregiver. [**First Name (Titles) 1817**] [**Last Name (Titles) 1818**], quit [**2148**]. 

### Response:
{'Malignant neoplasm of other specified part of esophagus,Tracheoesophageal fistula,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Foreign body in main bronchus,Drug-induced delirium,Alkalosis,Opioid type dependence, continuous,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Unilateral paralysis of vocal cords or larynx, partial,Unspecified essential hypertension,Dysthymic disorder,Personal history of malignant neoplasm of breast,Unspecified acquired hypothyroidism,Status of other artificial opening of gastrointestinal tract'}
