CHIEF COMPLAINT: Stridor

PRESENT ILLNESS: 54 yo male with a h/o Hep C, previously on pegasys, telaprevir
and ribavirin (started on [**2156-2-3**], stopped during prior
admission), HTN on lisinopril (stopped on last admission) and
CKD who was recently admitted to the MICU for angiodemema
believed to be from lisinopril who is now being readmitted for
stridor.

MEDICAL HISTORY: Hep C- currently being treated with telaprevir, peggylated
interferon and ribavirin ([**2156-2-3**])
Hypertension
CKD Stage III

MEDICATION ON ADMISSION: 1. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
2. prednisone 10 mg Tablet Sig: as directed Tablet PO once a day

ALLERGIES: Ace Inhibitors / [**Last Name (un) **]-Angiotensin Receptor Antagonist / Precedex

PHYSICAL EXAM: Admission Physical Exam:
General: Well appearing, breathing comfortably on RA, voice
mildly raspy, speaking mostly in full sentences but occasionally
stopping mid sentence to breath
HEENT: No swelling of the lips or tongue.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Mild stridourous breath sounds bilaterally, otherwise
CTAB.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE EXAM
VS - Temp 98.8 F, BP 147/77(147/77- 160/97), HR 69 , R 20 ,
O2-sat 98% RA
GENERAL - well-appearing man in NAD, comfortable
HEENT - NC/AT, PERRLA, EOMI, MMM, OP clear, tongue of normal
size
NECK -  no stridor
LUNGS - CTA bilat, no r/rh/wh, good air movement
HEART -  RRR, no MRG, nl S1-S2
ABDOMEN- no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

FAMILY HISTORY: No h/o liver dz or CA.  [**Name (NI) 1094**] Fatherr had an MI at age 62. Mother
and 8 sibs in good health. No history of significant allergic
reactions.

SOCIAL HISTORY: He lives in JP and is married. He worked as a personal care
attendant but is currenlty unemployed.  No ETOH, alcohol or
illicit drug use.  Pt. has 1 child with this partner, 2 others
with other partners.
Edema of larynx,Angioneurotic edema, not elsewhere classified,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Chronic hepatitis C without mention of hepatic coma,Anemia, unspecified,Anal fissure,Long-term (current) use of other medications,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Edema of larynx,Angioneurotic edema,Ben hy kid w cr kid I-IV,Chr kidney dis stage III,Chrnc hpt C wo hpat coma,Anemia NOS,Anal fissure,Long-term use meds NEC,Adv eff cardiovasc NEC,Abn react-procedure NEC
Admission Date:  [**2156-4-28**]              Discharge Date:   [**2156-5-4**]

Date of Birth:  [**2101-7-13**]             Sex:   M

Service: MEDICINE

Allergies:
Ace Inhibitors / [**Last Name (un) **]-Angiotensin Receptor Antagonist / Precedex

Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Stridor


Major Surgical or Invasive Procedure:
Fiberoptic bronchoscope at bedside

History of Present Illness:
54 yo male with a h/o Hep C, previously on pegasys, telaprevir
and ribavirin (started on [**2156-2-3**], stopped during prior
admission), HTN on lisinopril (stopped on last admission) and
CKD who was recently admitted to the MICU for angiodemema
believed to be from lisinopril who is now being readmitted for
stridor.

He was admitted from [**Date range (1) 30914**] for angioedema. At that time he
woke up with tongue swelling. He came to the ED where he was
intubated via fiber optic nasal scope and admitted to the MICU.
He was treated with solumedrol, vbenadryl and famotidine. He was
transitioned to po prednisone, benadryl and famotidine on the
day of transfer to the medical floor. On the floor he remained
stable, so was discharged with a prednisone taper and continued
on fexofenadine while on the taper. Benadryl was stopped due to
complaints of somnolence.

After discharge he went to see his PCP with complaints of
difficulty swallowing saying solids and liquids were irritating
and causing him to regurgitate. His PCP noted stridor and
referred him back to the ED. He denies any dyspnea, nor any of
the tongue swelling symptoms he had with prior presentation.
Initial vitals in the ED were: 100 140/82 16 100%. He was given
decadron, famotidine and benadryl. ENT was consulted who
performed a laryngoscopy which showed narrow airway, poor cord
movements, swelling diffusely around cords posterior > anterior.
They recommnded MICU for airway monitoring, plan re-scope at
11:00 AM. [**Month (only) 116**] have continued sequela of angioedema versus trauma
from intubation. also rec Protonix 40 IV. Admission Vitals: 85
159/90 18 98%

Upon arrival to the MICU initial vitals were 91 154/89 18 98%.
He was breathing comfortable and speaking in full sentences.

Past Medical History:
Hep C- currently being treated with telaprevir, peggylated
interferon and ribavirin ([**2156-2-3**])
Hypertension
CKD Stage III


Social History:
He lives in JP and is married. He worked as a personal care
attendant but is currenlty unemployed.  No ETOH, alcohol or
illicit drug use.  Pt. has 1 child with this partner, 2 others
with other partners.


Family History:
No h/o liver dz or CA.  [**Name (NI) 1094**] Fatherr had an MI at age 62. Mother
and 8 sibs in good health. No history of significant allergic
reactions.


Physical Exam:
Admission Physical Exam:
General: Well appearing, breathing comfortably on RA, voice
mildly raspy, speaking mostly in full sentences but occasionally
stopping mid sentence to breath
HEENT: No swelling of the lips or tongue.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Mild stridourous breath sounds bilaterally, otherwise
CTAB.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE EXAM
VS - Temp 98.8 F, BP 147/77(147/77- 160/97), HR 69 , R 20 ,
O2-sat 98% RA
GENERAL - well-appearing man in NAD, comfortable
HEENT - NC/AT, PERRLA, EOMI, MMM, OP clear, tongue of normal
size
NECK -  no stridor
LUNGS - CTA bilat, no r/rh/wh, good air movement
HEART -  RRR, no MRG, nl S1-S2
ABDOMEN- no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact.
LABS: See below.

Pertinent Results:
ADMISSION LABS
[**2156-4-28**] 08:00PM   PT-12.1 PTT-24.8* INR(PT)-1.1
[**2156-4-28**] 08:00PM   PLT COUNT-245
[**2156-4-28**] 08:00PM   PLT COUNT-245
[**2156-4-28**] 08:00PM   WBC-7.0# RBC-2.78* HGB-9.1* HCT-28.1*
MCV-101* MCH-32.8* MCHC-32.4 RDW-15.2
[**2156-4-28**] 08:00PM   WBC-7.0# RBC-2.78* HGB-9.1* HCT-28.1*
MCV-101* MCH-32.8* MCHC-32.4 RDW-15.2
[**2156-4-28**] 08:00PM   GLUCOSE-143* UREA N-27* CREAT-1.8*
SODIUM-131* POTASSIUM-4.6 CHLORIDE-92* TOTAL CO2-25 ANION GAP-19
[**2156-4-28**] 08:20PM   LACTATE-1.6
[**2156-4-28**] 08:20PM   TYPE-[**Last Name (un) **]
.
DISCHARGE LABS
[**2156-5-4**] 06:10AM BLOOD WBC-4.7 RBC-2.79* Hgb-9.3* Hct-29.0*
MCV-104* MCH-33.4* MCHC-32.1 RDW-14.8 Plt Ct-246
[**2156-5-4**] 06:10AM BLOOD Glucose-216* UreaN-24* Creat-1.1 Na-134
K-4.6 Cl-95* HCO3-28 AnGap-16
[**2156-5-4**] 06:10AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.9
.
CHEST (PORTABLE AP) Study Date of [**2156-4-28**] 7:45 PM
IMPRESSION: Suboptimal evaluation of the lower lungs which in
this patient
with recent right lower lobe pneumonia renders this exam
incomplete.
Recommend dedicated PA and lateral views to more clearly the
lung bases.

CHEST (PA & LAT) Study Date of [**2156-4-29**] 12:17 AM
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Normal lung volumes, no evidence of pleural effusions or

pneumothorax. Tortuosity of the thoracic aorta. Normal
appearance of the
lung parenchyma, no pulmonary edema. No focal parenchymal
opacities.

 CT CHEST W/O CONTRAST Study Date of [**2156-4-29**] 3:42 PM
IMPRESSION:
1. Normal caliber intrathoracic trachea without evidence for
wall thickening
or stenosis.
2. Multiple small foci of ground-glass opacity in the right
lower lobe, most
likely reflecting subclinical aspiration. Early or resolving
infection are
also possible in the appropriate clinical setting.
3. Please see separately dictated CT neck for evaluation of the
vocal
cords/larynx.


CT NECK W/O CONTRAST (EG: PAROTIDS) Study Date of [**2156-4-29**] 3:42
PM
IMPRESSION: Study limited due to non-contrast technique.
Symmetric
thickening of the vocal cords with marked narrowing of the
larynx. Soft
tissue along the posterior commissure is likely related to
post-intubation
scarring. Please correlate with direct laryngoscopy.
Fullness in the piriform sinuses- correlate with direct ENT
examination.
Consider MRI for better assessment if not CI, if clinically
necessary.

The study and the report were reviewed by the staff radiologist.



Brief Hospital Course:
PRIMARY REASON FOR ADMISSION
Pt is a 54 yo male with a h/o Hep C, previously on pegasys,
telaprevir and ribavirin (started on [**2156-2-3**], stopped during
prior admission), HTN on lisinopril (stopped on last admission)
and CKD who was recently admitted to the MICU for angiodemema
believed to be from lisinopril who is now being readmitted for
stridor and concern for airway edema.

#Laryngeal/airway edema:
His current edema may be from continued/recurrent angioedema
versus trauma from intubation. Reflux may also be playing some
component. He is no longer having his previous swelling of his
tongue or lips. His angioedema was initially believed to be from
lisinopril. He has not taken lisinopril since prior to his last
admission. If his angioedema has recurred this could be from the
natural course of edema or tapering steroids and stopping
Benadryl. Alternately there may be another inciting factor
separate from the lisinopril. Other potential causes of
angioedema include Hepatitis C treatment though he has also not
been taking these medications since his prior admission, food
ingestion, C1-inhibitor deficiency.  Patient was given Decadron
10 mg q8h, famotidine 20 mg IV bid, Protonix 40mg IV BID and
benadryl 50 mg q8h. A repeat laryngoscopy showed improved edema,
however patient did have inability to relax vocal cords leading
to a suboptimal exam. Allergy was consulted and gave medication
recommendations. Initially a suture lateralization was
recommended by ENT, but he was serially reexamined by ENT and
his vocal cord immobility improved throughout his MICU stay and
he was transferred to the floor after his airway improved.  He
was transitioned to oral decadron 6 mg PO TID, and PO benadryl.
He will continue on this dose for 7 more days and then be slowly
tapered over 2 weeks.  This dose was to be continued for 7 days
and then tapered slowly. The patient will follow-up with ENT. He
will also have allergy testing as an outpatient.

STABLE ISSUES
# Benign Hypertension:
Patient was initially managed with IV labetalol but was
transitioned back to PO hypertension medications after taking
POs. His home HCTZ was held given concern that this medication
was contributing to the edema. He was discharged on a regimen of
amlodipine and labetalol.

#Hepatitis C:
Previously treated with triple therapy but stopped on previous
admission.  We held triple therapy per liver recommendations

#Anemia:
Above his recent baseline. Seems to have been caused by HCV
therapy and is now improving.

#CKD:
At baseline. Medications were renally dosed and electrolytes
were trended.
.
TRANSITIONAL ISSUES
- Full code
- Patient with follow-up with ENT, allergy, and his PCP

Medications on Admission:
1. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
2. prednisone 10 mg Tablet Sig: as directed Tablet PO once a day

for 8 days: TAPER instructions: 4 tabs on [**4-27**]; 3 tabs on [**4-28**];
2 tabs on [**5-7**]; 1 tab on [**4-14**]; then stop.
3. fexofenadine 180 mg Tablet Sig: One (1) Tablet PO once a day
for 8 days: take while on steroids; can stop after steroid taper

is complete.
4. labetalol 100 mg Tablet Sig: One (1) Tablet PO TID
.
Medications prior to last admission:
HYDROCHLOROTHIAZIDE - 25 mg Tablet - 1 Tablet(s) by mouth once a
day - No Substitution
LISINOPRIL - 30 mg Tablet - 1 Tablet(s) by mouth once a day
Ribavirin 600 mg [**Hospital1 **]
Telaprevir 750 mg tid
Pegasys 180 mcg weekly injections
.


Discharge Medications:
1. labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
every eight (8) hours: do not drive while taking this medication
as it can make you tired .
Disp:*63 Capsule(s)* Refills:*0*
4. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day for 21 days: take
while on steroids .
Disp:*21 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. dexamethasone 2 mg Tablet Sig: see below  Tablet PO three
times a day: 3 tabs three times a day x 7 days  then 2 tabs
three times a day x 3 days then two tabs twice a day x 3 days
then two tabs once daily x 3 days then one tab daily x 3 days .
Disp:*102 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary diagnosis
Laryngeal edema (swelling of the airway)

Secondary Diagnosis
Hypertension (High blood pressure)
Hepatitis C


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
Dear Mr. [**Known lastname 634**],

You were admitted to [**Hospital1 69**] for
concerns of stridor (difficulty breathing). We gave you
anti-inflammatory medications. Our ENT doctors saw [**Name5 (PTitle) **].  They
looked at you airway with a scope which showed swelling of your
airway. You were given IV steroids with improvement in the
swelling. You were transitioned to oral steroids which you need
to continue for 3 more weeks. Swelling was likely caused by both
inflammation related to the lisinopril you were previously
taking in addition to trauma from your recent intubation.  It
will be important that you follow-up with allergy to see if the
swelling was caused by a medication allergy.

We made the following changes to your medications
1. START
-Decadron 6 mg (3 tabs) three times a day for 7 days until
[**2156-5-11**]
-then 4 mg (2 tabs) three times a day for 3 days until [**2156-5-14**]
-then 4 mg (two tabs) twice a day for 3 days until [**2156-5-17**]
-then 4 mg (two tabs) once daily for 3 days until [**2156-5-20**]
-then 2 mg daily for 3 days until [**2156-5-23**]
2. STOP HCTZ as this medication might be causing the swelling
3. START benadryl 25 mg three times a day while on steroids
4. START omeprazole 40 mg daily while on steroids

Please continue to take all other medications as instructed.
Please feel free to call with any questions or concerns.

Followup Instructions:
Department: [**Hospital1 7975**] INTERNAL MEDICINE
When: THURSDAY [**2156-5-6**] at 9:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site

Department: LIVER CENTER
When: MONDAY [**2156-5-10**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 30913**], PA [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage

Department: DIV OF ALLERGY AND INFLAM
When: TUESDAY [**2156-5-11**] at 11:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 9316**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) 895**]
Campus: OFF CAMPUS     Best Parking: Parking on Site

Department: OTOLARYNGOLOGY-AUDIOLOGY
When: THURSDAY [**2156-5-13**] at 10:00 AM
With: [**Name6 (MD) 15040**] [**Last Name (NamePattern4) 15041**], MD [**Telephone/Fax (1) 41**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 895**]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
{'Edema of larynx,Angioneurotic edema, not elsewhere classified,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Chronic hepatitis C without mention of hepatic coma,Anemia, unspecified,Anal fissure,Long-term (current) use of other medications,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: Stridor

PRESENT ILLNESS: 54 yo male with a h/o Hep C, previously on pegasys, telaprevir
and ribavirin (started on [**2156-2-3**], stopped during prior
admission), HTN on lisinopril (stopped on last admission) and
CKD who was recently admitted to the MICU for angiodemema
believed to be from lisinopril who is now being readmitted for
stridor.

MEDICAL HISTORY: Hep C- currently being treated with telaprevir, peggylated
interferon and ribavirin ([**2156-2-3**])
Hypertension
CKD Stage III

MEDICATION ON ADMISSION: 1. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
2. prednisone 10 mg Tablet Sig: as directed Tablet PO once a day

ALLERGIES: Ace Inhibitors / [**Last Name (un) **]-Angiotensin Receptor Antagonist / Precedex

PHYSICAL EXAM: Admission Physical Exam:
General: Well appearing, breathing comfortably on RA, voice
mildly raspy, speaking mostly in full sentences but occasionally
stopping mid sentence to breath
HEENT: No swelling of the lips or tongue.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Mild stridourous breath sounds bilaterally, otherwise
CTAB.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE EXAM
VS - Temp 98.8 F, BP 147/77(147/77- 160/97), HR 69 , R 20 ,
O2-sat 98% RA
GENERAL - well-appearing man in NAD, comfortable
HEENT - NC/AT, PERRLA, EOMI, MMM, OP clear, tongue of normal
size
NECK -  no stridor
LUNGS - CTA bilat, no r/rh/wh, good air movement
HEART -  RRR, no MRG, nl S1-S2
ABDOMEN- no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)

FAMILY HISTORY: No h/o liver dz or CA.  [**Name (NI) 1094**] Fatherr had an MI at age 62. Mother
and 8 sibs in good health. No history of significant allergic
reactions.

SOCIAL HISTORY: He lives in JP and is married. He worked as a personal care
attendant but is currenlty unemployed.  No ETOH, alcohol or
illicit drug use.  Pt. has 1 child with this partner, 2 others
with other partners. 

### Response:
{'Edema of larynx,Angioneurotic edema, not elsewhere classified,Hypertensive chronic kidney disease, benign, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Chronic hepatitis C without mention of hepatic coma,Anemia, unspecified,Anal fissure,Long-term (current) use of other medications,Other and unspecified agents primarily affecting the cardiovascular system causing adverse effects in therapeutic use,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
