CHIEF COMPLAINT: Shortness of breath.

PRESENT ILLNESS: This is a 54-year-old female,
with relapsing polychondritis, who presents for evaluation of
possible treatment of shortness of breath due to severe
subglottic stenosis.  The patient reports that her illness
began approximately four years ago, at which time she moved
to [**State 108**] and began to have "sinus problems."  The patient
was initially treated with three course of antibiotics
without improvement.  The patient also began to have severe
daily left-sided headaches.  At this time, the patient's
primary care physician recommended sinus surgery.  Following
surgery, the patient was stable for a few months, until
[**3-/2124**] or [**4-/2124**], at which time she lost her voice acutely.
The patient reports that her voice was very quiet and
extremely hoarse.  The patient also began to have joint and
muscle pain around this time.  On [**2124-10-5**], the patient
abruptly developed marked stridor and shortness of breath.
CT and bronchoscopy showed subglottic stenosis that was
moderately severe.  The patient was placed on prednisone 60
mg po qd with some improvement in her shortness of breath.
When the medication was decreased to 40 mg po qd, severe
shortness of breath recurred.  At this time, the patient was
diagnosed with polychondritis.  Labs on diagnosis showed an
ANCA which was negative, ESR 42 and 55, low positive
rheumatoid factor, and negative [**Doctor First Name **].

MEDICAL HISTORY: 1. Relapsing polychondritis per HPI.
2. Right ovary cyst removal.

MEDICATION ON ADMISSION: 

ALLERGIES: Nitrous oxide.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is divorced and lives in
[**State 108**].  Before she became ill, she worked in real estate
sales.  Smoked 30 years but quit 1 year ago.  Rare social
alcohol use.  Denies drug abuse.
Other disorders of bone and cartilage,Acute respiratory failure,Mechanical complication of tracheostomy,Stenosis of larynx,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Accidents occurring in residential institution,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Bone & cartilage dis NEC,Acute respiratry failure,Tracheostomy - mech comp,Stenosis of larynx,Pancreatic disorder NEC,Adv eff corticosteroids,Accid in resident instit,Abn react-external stoma
Admission Date:  [**2125-9-4**]       Discharge Date:  [**2125-9-14**]

Date of Birth:   [**2067-12-28**]       Sex:  F

Service:  [**Hospital1 **] & MEDICAL ICU GREEN TEAM

CHIEF COMPLAINT:  Shortness of breath.

HISTORY OF PRESENT ILLNESS:  This is a 54-year-old female,
with relapsing polychondritis, who presents for evaluation of
possible treatment of shortness of breath due to severe
subglottic stenosis.  The patient reports that her illness
began approximately four years ago, at which time she moved
to [**State 108**] and began to have "sinus problems."  The patient
was initially treated with three course of antibiotics
without improvement.  The patient also began to have severe
daily left-sided headaches.  At this time, the patient's
primary care physician recommended sinus surgery.  Following
surgery, the patient was stable for a few months, until
[**3-/2124**] or [**4-/2124**], at which time she lost her voice acutely.
The patient reports that her voice was very quiet and
extremely hoarse.  The patient also began to have joint and
muscle pain around this time.  On [**2124-10-5**], the patient
abruptly developed marked stridor and shortness of breath.
CT and bronchoscopy showed subglottic stenosis that was
moderately severe.  The patient was placed on prednisone 60
mg po qd with some improvement in her shortness of breath.
When the medication was decreased to 40 mg po qd, severe
shortness of breath recurred.  At this time, the patient was
diagnosed with polychondritis.  Labs on diagnosis showed an
ANCA which was negative, ESR 42 and 55, low positive
rheumatoid factor, and negative [**Doctor First Name **].

At this time, the patient came to [**Location (un) 86**] for a second opinion
from Dr. [**Last Name (STitle) 6426**].  Her polychondritis has been treated by
him since that time.  On [**2125-2-15**], CT of the trachea was
obtained to further evaluate her shortness of breath.  This
showed focal subglottic stenosis and minimal luminal airway
diameter of 5 mm x 6 mm.  The patient was admitted today for
repeat evaluation of her tracheomalacia and consideration of
treatment options.

PAST MEDICAL HISTORY:
1. Relapsing polychondritis per HPI.
2. Right ovary cyst removal.

ALLERGIES:  Nitrous oxide.

MEDICATIONS:
1. Remicade.
2. CellCept [**Pager number **] mg po bid.
3. Prednisone 35 mg po qd.
4. Albuterol nebs tid.
5. Effexor 37.5 qd.
6. Equate nasal spray.

SOCIAL HISTORY:  The patient is divorced and lives in
[**State 108**].  Before she became ill, she worked in real estate
sales.  Smoked 30 years but quit 1 year ago.  Rare social
alcohol use.  Denies drug abuse.

PHYSICAL EXAM ON ADMISSION:  Temperature 97.1, blood pressure
138/80, heart rate 76, respiratory rate 24.
GENERAL:  Pleasant lady in no acute distress.  Alert and
oriented x 3.  Must pause after 2 or 3 sentences for a deep
breath.
CARDIAC:  Regular rate and rhythm.
PULMONARY:  Diffuse inspiratory and expiratory wheezes
throughout all lung fields.  Bibasilar crackles.
ABDOMEN:  Soft, nontender, nondistended.  Positive bowel
sounds.
EXTREMITIES:  No clubbing or cyanosis.  1+ lower extremity
edema bilaterally, most severe around the ankles.  2+
dorsalis pedis pulses.
NEURO:  Cranial nerves II through XII intact.

STUDIES ON ADMISSION:  CT of the trachea [**2125-9-4**]:
Persistent subglottic stenosis with luminal narrowing to
approximately 5 mm in diameter.  Improved caliber of airways
in lower cervical trachea and intrathoracic trachea.
Persistent anterior wall thickening of the lower cervical and
intrathoracic trachea.  Extensive air-trapping.

SUMMARY OF HOSPITAL COURSE - 1) TRACHEOMALACIA WITH
SUBGLOTTIC STENOSIS:  This was due to the patient's relapsing
polychondritis.  On admission, it was evaluated by CT of the
trachea with results as above.  In addition, the patient
underwent bronchoscopy which showed her trachea to be
narrowed to 4 mm at the cricoid.  ENT and interventional
pulmonology consulted together to consider multidisciplinary
treatment approaches for her tracheomalacia and subglottic
stenosis.

On [**2125-9-5**], the patient underwent dilatation of her
trachea.  The patient initially tolerated the procedure well,
and her trachea was dilated to 12 mm.  However, following the
procedure, the patient developed stridor, and her oxygen
saturations dropped to 85% on room air.  At that time, the
patient required elective intubation.  It was determined that
the patient's respiratory distress was most likely due to
edema from the trauma of the procedure.  She was began on
stress dose steroids and ceftriaxone.

On [**2125-9-12**], the patient had a cuffless tracheostomy
placed.  She still had evidence of subglottic stenosis at
that time.  She will be continued on a slow dexamethasone
taper.  The ceftriaxone was discontinued on [**2125-9-13**].  The
patient has been oxygenating well with a trach mask since
that time.

2) DEPRESSION:  The patient with strong family support.
Support from nursing and medical team.  She was continued on
Effexor throughout admission.

3) RELAPSING POLYCHONDRITIS:  The patient was continued on
mycophenolate 100 mg po bid throughout the admission.  She
will receive a Remicade treatment on [**2125-9-14**] to maintain
her schedule.  Her PPI, diphosphonate and Vitamin D were all
continued throughout the admission, as the patient is on
chronic steroids.

4) ENDOCRINE:  The patient had fingersticks checked qid, and
sliding scale Insulin, for her steroid-induced hyperglycemia,
throughout the admission.

5) FLUIDS, ELECTROLYTE AND NUTRITION:  The patient underwent
a swallowing study, following placement of tracheostomy, on
[**2125-9-13**].  This showed that the patient had mildly reduced
bolus control resulting in premature spillover of liquids and
puree into the valleculae.  This material then spilled into
the laryngeal vestibule just as swallow was starting and
during the swallow.  However, the patient kept her vocal
cords closed and was able to strip the penetrating material
out of her laryngeal vestibule.  Aspiration never occurred.
The patient's diet has been advanced as tolerated, and she is
tolerating the diet at this time.  Electrolytes were replaced
as needed throughout the admission.

6) REHABILITATION:  The patient has been evaluated by
physical therapy.  She will be continued to be followed by
them throughout the rest of her hospitalization.  She will
benefit from outpatient rehabilitation stay in a physical and
pulmonary rehabilitation center.

7) PROPHYLAXIS:  The patient was continued on a proton pump
inhibitor, subcu heparin, and sliding scale Insulin
throughout the admission.

8) CODE STATUS:  The patient is full code.

CONDITION ON DISCHARGE:  Stable using a tracheostomy mask
with oxygen.  The patient will be discharged to a
rehabilitation center for physical and pulmonary
rehabilitation.

DISCHARGE DIAGNOSES:
1. Tracheomalacia with subglottic stenosis.
2. Acute respiratory failure.
3. Relapsing polychondritis.
4. Depression.
5. Steroid-induced hyperglycemia.

DISCHARGE MEDICATIONS:
1. Acetaminophen 325 mg 1-2 tabs po q 4-6 h prn.
2. Ambien 5 mg 1 tab po q hs prn for sleeplessness.
3. Mycophenolate 1,000 mg po bid.
4. Albuterol nebs q 8 h.
5. Sodium chloride nasal spray [**11-23**] sprays tid prn.
6. Venlafaxine XR 112.5 mg po qd.
7. Risedronate 35 mg 1 tab po q Sunday.
8. Albuterol MDI 1-2 puffs inhaled q 4 h prn.
9. Ipratropium bromide 118 mcg 2 puffs inhaled q 4-6 h prn.
10.Calcium carbonate 500 mg 1 tab po tid.
11.Vitamin D 400 U po qd.
12.Milk of magnesia prn.
13.Lansoprazole 30 mg po qd.
14.Sliding scale Insulin.
15.Percocet 1-2 tabs po q 4-6 h prn pain for tracheostomy
site.
16.Ativan 0.5, 2 mg po q 4-6 h prn for anxiety.
17.Dexamethasone taper.

FOLLOW-UP PLANS:
1. The patient will follow-up with Dr. [**Last Name (STitle) 6426**] as needed at
her convenience.
2. The patient will follow-up with Dr. [**Last Name (STitle) **] per his
recommendations which will be determined prior to discharge.




                            [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 2506**]

Dictated By:[**Name8 (MD) 315**]
MEDQUIST36

D:  [**2125-9-14**]  12:11
T:  [**2125-9-14**]  12:17
JOB#:  [**Job Number 47066**]


UPDATE PENDING [**2125-9-17**]


Admission Date:  [**2125-9-4**]       Discharge Date:  [**2125-9-24**]

Date of Birth:   [**2067-12-28**]       Sex:  F

Service:  BLOOMGARD

HISTORY OF PRESENT ILLNESS:  The patient is a 57-year-old
female with a four year history of relapsing polychondritis
complicated by subglottic stenosis managed with steroids
prior to admission.  The patient presented on [**9-4**] with
complaints of shortness of breath and she was admitted for
evaluation for tracheomalacia and consideration of further
treatment options.

PAST MEDICAL HISTORY:
1.  Relapsing polychondritis times four years managed with
prednisone 60 mg q. day, Remicade, CellCept and albuterol
p.r.n.
2.  Right ovary removed.
3.  Depression managed with Effexor.

SOCIAL HISTORY:  The patient is divorced.  Lives in [**State 108**].
Worked in real estate.  She smoked for 30 years but quit one
year ago.

ALLERGIES:  Allergic to nitrous oxide which gives her a rash.

MEDICATIONS:  Include:
1.  Acetylcysteine 20%, 10 mL q. 4-6h.
2.  Ibuprofen 600 mg p.o. q. 8h. p.r.n.
3.  Prednisone 30 mg p.o. q. day.
4.  Cephalexin 500 mg p.o. q. 6h.
5.  Lorazepam 0.5 to 2 mg IV q. 4h. p.r.n. anxiety.
6.  Albuterol one to two puffs IH q. 4h. p.r.n.
7.  Ipratropium bromide MDI two puffs IH q. 4-6h.
8.  Mycophenolate mofetil 1000 mg p.o. b.i.d.
9.  Venlafaxine XR 112.5 mg p.o. q. day.
10. Calcium carbonate 500 mg p.o. t.i.d.
11. Vitamin D 400 units p.o. q. day.
12. Lansoprazole 30 mg p.o. q. day.
13. Milk of magnesia 30 mL p.o. q. 6h.
14. Alendronate sodium 35 mg p.o. every Sunday.
15. Aluminum magnesium hydroxide 15-30 mL p.o. q.i.d. p.r.n.
16. Acyclovir ointment 5% one application t.p. q.i.d.
17. Zolpidem tartrate 5 mg p.o. q. hs. p.r.n.

PHYSICAL EXAMINATION ON ADMISSION:  Examination on admission
[**9-4**] was significant for a respiratory rate of 24.  She
was in no apparent distress but required a pause between
sentences to take a breath.  Respiratory examination was
significant for diffuse inspiratory and expiratory wheezes
through all lung fields.  She had bibasilar crackles.  Her
extremities showed 1+ edema in the lower extremities with 2+
pulses.

LABORATORY ON ADMISSION:  Normal.

RADIOLOGY:  CT trachea showed persistent subglottic stenosis
with luminal narrowing to 5 mm diameter with extensive air
trapping.

HOSPITAL COURSE:
1.  Respiratory/subglottic stenosis:  Description of the
patient's course from [**9-5**] to [**9-14**] is described
in the discharge note by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47067**].  Briefly, on
[**9-5**] patient underwent subglottic dilation to 12 mm.
This was complicated by severe airway edema requiring
emergent intubation.  In Medical Intensive Care Unit she was
placed on stress dose steroids 60 mg q. 4h. with sedation,
nebs and ceftriaxone prophylaxis.  On [**9-12**] she had a
cuffless trach placed and was transferred to the Medical
floor on [**9-14**] stable with mild throat pain, 98% with
trach mask.  Ambulating and tolerating p.o.'s.

On [**9-16**] the patient began complaining of shortness of
breath even with nebulizers.  She was seen by Cardiothoracic
Surgery for evaluation of subcutaneous air.  Cardiothoracic
Surgery removed the deep suture around her trach to allow for
air removal and her shortness of breath was treated with
racemic epinephrine with some improvement.  On [**9-17**] at
6:00 a.m. the patient in acute respiratory distress with
hypoxia in the 60's secondary to trach dislodgement.  A
respiratory code was called for acute respiratory failure.
The patient received nasotracheal tube with improvement of
sats to the mid 90's.  She was transferred back to the
Medical Intensive Care Unit.  On [**9-17**] the patient went
back to the Operating Room to have her trach replaced.
Cefazolin was started due to mild erythema around the stoma.

On [**9-18**] she was transferred back to the floor stable on
trach mask, 94% on room air.  The patient was ambulating,
tolerating p.o.'s.  On [**9-21**] the patient went back to
the Operating Room to have a custom made #7 Portex cuffless
trach with extra long arm placement.  This was done without
complications.  She has remained stable since this procedure
satting 98% on room air.  She received nebulizers and
Mucomyst for increased pulmonary secretions on [**9-24**].
She is to return to the hospital on [**10-1**] to have her
trach downsized.

2.  Relapsing polychondritis:  The patient was continued on
mycophenolate 1000 mg b.i.d. and Remicade 100 mg once which
was received on [**2125-9-14**].  Steroids were tapered from
dexamethasone 4 mg q. 4h. to prednisone 7.5 mg q. day.  Two
days after the taper patient began complaining of paratibial
pain and some calf pain similar to previous RPC flare-ups.
Her prednisone was increased to 30 mg q. day with resolution
of symptoms.  She continued to receive proton pump
inhibitors, diphosphate and vitamin B for prophylaxis.

3.  Endocrine:  The patient has steroid-induced diabetes.
She received q.i.d. fingersticks with sliding scale insulin.

DISCHARGE MEDICATIONS:
1.  Acetylcysteine [**12-1**] mL nebulizer q. 4-6h. p.r.n.
2.  Ibuprofen 600 mg p.o. q. 8h. p.r.n.
3.  Prednisone 30 mg p.o. q. day.
4.  Cephalexin 500 mg p.o. q. 6h.
5.  Lorazepam 0.5 to 2 mg IV q. 4h. p.r.n. anxiety.
6.  Albuterol one to two puffs IH q. 4h. p.r.n. wheezing.
7.  Ipratropium bromide MDI two puffs IH q. 4-6h. p.r.n.
wheezing.
8.  Insulin sliding scale as described.
9.  Epinephrine inhalation 0.5 mL IH q. 6h. p.r.n. shortness
of breath.
10. Mycophenolate mofetil 1000 mg p.o. b.i.d.
11. Venlafaxine XR 112.5 mg p.o. q.i.d.
12. Calcium carbonate 500 mg p.o. t.i.d.
13. Vitamin D 400 units p.o. q. day.
14. Alenzoprazole 30 mg p.o. q. day.
15. Milk of magnesia30 mL p.o. q. 6h. p.r.n. for
gastrointestinal upset.
16. Alendronate sodium 35 mg p.o. every Sunday.
17. Acyclovir ointment 5% one application topical q.i.d.
18. Zolpidem tartrate 5 mg p.o.

CODE STATUS:  Full code.

DISPOSITION:  To pulmonary rehabilitation.

CONDITION AT DISCHARGE:  Stable.

DISCHARGE DIAGNOSES:
1.  Relapsing polychondritis with subglottic stenosis.
2.  Acute renal failure.

FOLLOW-UP INSTRUCTIONS:
1.  Patient to follow up with Dr. [**Last Name (STitle) **] on [**10-1**] for
downsizing of trach.
2.  Should not use Muir valve until 24 hours after refitting.
3.  Follow up with Dr. [**Last Name (STitle) 47068**] as necessary.




                      DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-986

Dictated By:[**Last Name (NamePattern1) 47069**]
MEDQUIST36

D:  [**2125-9-25**]  13:52
T:  [**2125-9-25**]  14:18
JOB#:  [**Job Number 47070**]
{'Other disorders of bone and cartilage,Acute respiratory failure,Mechanical complication of tracheostomy,Stenosis of larynx,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Accidents occurring in residential institution,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: This is a 54-year-old female,
with relapsing polychondritis, who presents for evaluation of
possible treatment of shortness of breath due to severe
subglottic stenosis.  The patient reports that her illness
began approximately four years ago, at which time she moved
to [**State 108**] and began to have "sinus problems."  The patient
was initially treated with three course of antibiotics
without improvement.  The patient also began to have severe
daily left-sided headaches.  At this time, the patient's
primary care physician recommended sinus surgery.  Following
surgery, the patient was stable for a few months, until
[**3-/2124**] or [**4-/2124**], at which time she lost her voice acutely.
The patient reports that her voice was very quiet and
extremely hoarse.  The patient also began to have joint and
muscle pain around this time.  On [**2124-10-5**], the patient
abruptly developed marked stridor and shortness of breath.
CT and bronchoscopy showed subglottic stenosis that was
moderately severe.  The patient was placed on prednisone 60
mg po qd with some improvement in her shortness of breath.
When the medication was decreased to 40 mg po qd, severe
shortness of breath recurred.  At this time, the patient was
diagnosed with polychondritis.  Labs on diagnosis showed an
ANCA which was negative, ESR 42 and 55, low positive
rheumatoid factor, and negative [**Doctor First Name **].

MEDICAL HISTORY: 1. Relapsing polychondritis per HPI.
2. Right ovary cyst removal.

MEDICATION ON ADMISSION: 

ALLERGIES: Nitrous oxide.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is divorced and lives in
[**State 108**].  Before she became ill, she worked in real estate
sales.  Smoked 30 years but quit 1 year ago.  Rare social
alcohol use.  Denies drug abuse. 

### Response:
{'Other disorders of bone and cartilage,Acute respiratory failure,Mechanical complication of tracheostomy,Stenosis of larynx,Other specified disorders of pancreatic internal secretion,Adrenal cortical steroids causing adverse effects in therapeutic use,Accidents occurring in residential institution,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
