CHIEF COMPLAINT: Hemoptysis/Tracheal bleed, Hypoxia

PRESENT ILLNESS: 70F with DM, asthma, chronic respiratory failure [**1-19**] PNA/asthma
(? vented at night with chronic trach x ? 3 months) CVA, CAD,
s/p recent tracheal bleed and trach change [**2106-7-4**] transferred
from OSH with recurrent tracheal bleed for IP eval and
bronchoscopy. Oxygen saturations 80% on 50% FiO2 in IP suite so
she was admitted to MICU for bronchoscopy and evaluation.
Patient's prior bronch in [**Month (only) 205**] revealed subglottic stenosis,
granulation tissue at stoma, plaque like lesions on main carina
and rigth bronchus intermedius (bx-no malignancy), polypoid
lesions main carina. No evidence of TM and trach replaced with
new cuffless #6 trach tube. There was ? HSV but biopsies were
negative.
.
In IP suite, initial vs were: T97.6 P68 BP121/57 R20 O2 sat92%
on 35%. Patient was transferred to ICU for assessment and plan
for flexible bronch in afternoon and rigid bronchoscopy
tomorrow.
.
On the floor, her only complaint is left arm pain which has been
treated with neurontin. She states this "just started" but
unclear when. reports "a little SOB", but improved now on vent.
Denies further bleeding from trach site, wheezing, chest pain,
cough, abdominal pain, LH, dizziness. States she had fevers and
chills 6 days prior but none since then.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.

MEDICAL HISTORY: IDDM2
Asthma
Chronic resp failure ([**1-19**] asthma and PNA) s/p trach and PEG ? 3
months ago (? on ventilator at night)
s/p bronch [**7-8**], [**7-6**], cuffless trach replacement to cuffed
catheter in ED [**7-4**]
CVA (L weakness)
CAD
HTN
DJD
GERD
h/o AFB in sputum felt to be colonizer
Polypoid lesion trachea
? hypothyroidism
? hyperlipidemia

MEDICATION ON ADMISSION: Tylenol 650 q4 prn
Dulcolax 10mg Po daily prn
Levothyroxine 0.1 mg PO daily
Lexapro 20mg daily per PEG
ferrous sulfate 320mg PO BID
Neurontin 300mg PO TID
HCTZ 12.5mg PO daily
Novolog sliding scale
Levimere 25mg SC BID
Lactobacillus 1 tab PO TID
Lorazepam 0.5mg PO q6 prn
Milk of magnesia 30ml PEG prn
Oxycodone IR 10 mg PO q4h prn
Pantoprazole 40 mg IV daily
Seroquel 25mg PO BID
Ropinirole 2mg PEG qhs
Zocor 20mg PEG daily
Ambien 5mg PO qhs prn
omeprazole 20mg via PEG [**Hospital1 **]
zantac 30 mg via PEG QHS
Ventolin 2.5 mg INH q 2 hours prn

ALLERGIES: Penicillins

PHYSICAL EXAM: General: Alert, intermittently falling asleep during exam,
oriented to city and state, date, not month, no acute distress,
able to communicate by whispering in full sentences
HEENT: Sclera anicteric, MMM with thrush, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse breath sounds with exp wheezes bilaterally. No
crackles or rhonchi
CV: Regular rate and rhythm, normal S1 + S2 with 2/6 systolic
murmur LUSB, no rubs or gallops
Abdomen: soft, obese, non-tender, multiple ecchymoses,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. LUE with mild nonpitting edema
Neuro: AAOx2-3 as above. CN 2-12 intact. 5/5 strength RUE and
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/L. LUE contracted with inability to uncle[**Name (NI) **] fist.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Resident at [**Hospital1 **] Commons. Has 3 sons. [**Name (NI) 87235**] worked as
manager of group home.
- Tobacco:  Denies
- Alcohol:  rare
- Illicits:  None
Mechanical complication of tracheostomy,Acute and chronic respiratory failure,Urinary tract infection, site not specified,Candidiasis of mouth,Hematemesis,Other vascular complications of medical care, not elsewhere classified,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Morbid obesity,Unspecified essential hypertension,Esophageal reflux,Leukocytosis, unspecified,Other late effects of cerebrovascular disease,Muscle weakness (generalized),Anxiety state, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Gastrostomy status,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Tracheostomy - mech comp,Acute & chronc resp fail,Urin tract infection NOS,Thrush,Hematemesis,Vasc comp med care NEC,Phlbts sprfc vn up extrm,Klebsiella pneumoniae,DMII wo cmp nt st uncntr,Asthma NOS,Crnry athrscl natve vssl,Hypothyroidism NOS,Hyperlipidemia NEC/NOS,Morbid obesity,Hypertension NOS,Esophageal reflux,Leukocytosis NOS,Late effect CV dis NEC,Muscle weakness-general,Anxiety state NOS,Idio periph neurpthy NOS,Osteoarthros NOS-unspec,Gastrostomy status,Abn react-procedure NEC
Admission Date:  [**2106-8-26**]              Discharge Date:   [**2106-8-31**]

Date of Birth:  [**2035-11-14**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Hemoptysis/Tracheal bleed, Hypoxia

Major Surgical or Invasive Procedure:
Rigid bronchoscopy with debridement of granulation tissue and
trach size change

History of Present Illness:
70F with DM, asthma, chronic respiratory failure [**1-19**] PNA/asthma
(? vented at night with chronic trach x ? 3 months) CVA, CAD,
s/p recent tracheal bleed and trach change [**2106-7-4**] transferred
from OSH with recurrent tracheal bleed for IP eval and
bronchoscopy. Oxygen saturations 80% on 50% FiO2 in IP suite so
she was admitted to MICU for bronchoscopy and evaluation.
Patient's prior bronch in [**Month (only) 205**] revealed subglottic stenosis,
granulation tissue at stoma, plaque like lesions on main carina
and rigth bronchus intermedius (bx-no malignancy), polypoid
lesions main carina. No evidence of TM and trach replaced with
new cuffless #6 trach tube. There was ? HSV but biopsies were
negative.
.
In IP suite, initial vs were: T97.6 P68 BP121/57 R20 O2 sat92%
on 35%. Patient was transferred to ICU for assessment and plan
for flexible bronch in afternoon and rigid bronchoscopy
tomorrow.
.
On the floor, her only complaint is left arm pain which has been
treated with neurontin. She states this "just started" but
unclear when. reports "a little SOB", but improved now on vent.
Denies further bleeding from trach site, wheezing, chest pain,
cough, abdominal pain, LH, dizziness. States she had fevers and
chills 6 days prior but none since then.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.

Past Medical History:
IDDM2
Asthma
Chronic resp failure ([**1-19**] asthma and PNA) s/p trach and PEG ? 3
months ago (? on ventilator at night)
s/p bronch [**7-8**], [**7-6**], cuffless trach replacement to cuffed
catheter in ED [**7-4**]
CVA (L weakness)
CAD
HTN
DJD
GERD
h/o AFB in sputum felt to be colonizer
Polypoid lesion trachea
? hypothyroidism
? hyperlipidemia

Social History:
Resident at [**Hospital1 **] Commons. Has 3 sons. [**Name (NI) 87235**] worked as
manager of group home.
- Tobacco:  Denies
- Alcohol:  rare
- Illicits:  None

Family History:
non-contributory

Physical Exam:
General: Alert, intermittently falling asleep during exam,
oriented to city and state, date, not month, no acute distress,
able to communicate by whispering in full sentences
HEENT: Sclera anicteric, MMM with thrush, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse breath sounds with exp wheezes bilaterally. No
crackles or rhonchi
CV: Regular rate and rhythm, normal S1 + S2 with 2/6 systolic
murmur LUSB, no rubs or gallops
Abdomen: soft, obese, non-tender, multiple ecchymoses,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. LUE with mild nonpitting edema
Neuro: AAOx2-3 as above. CN 2-12 intact. 5/5 strength RUE and
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/L. LUE contracted with inability to uncle[**Name (NI) **] fist.


Pertinent Results:
[**2106-8-26**] 05:40PM BLOOD WBC-13.3* RBC-3.69* Hgb-10.0* Hct-30.4*
MCV-83 MCH-27.1 MCHC-32.8 RDW-16.4* Plt Ct-410
[**2106-8-30**] 03:50AM BLOOD WBC-10.3 RBC-3.29* Hgb-9.0* Hct-28.3*
MCV-86 MCH-27.3 MCHC-31.7 RDW-16.3* Plt Ct-371
[**2106-8-26**] 05:40PM BLOOD Neuts-65 Bands-0 Lymphs-23 Monos-4 Eos-8*
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2106-8-26**] 05:40PM BLOOD PT-12.7 PTT-23.9 INR(PT)-1.1
[**2106-8-26**] 05:40PM BLOOD Glucose-148* UreaN-30* Creat-1.0 Na-138
K-4.8 Cl-95* HCO3-36* AnGap-12
[**2106-8-30**] 03:50AM BLOOD Glucose-92 UreaN-26* Creat-0.9 Na-137
K-5.0 Cl-100 HCO3-27 AnGap-15
[**2106-8-26**] 05:40PM BLOOD Calcium-9.3 Phos-4.6* Mg-2.3
[**2106-8-29**] 04:47AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.2

[**2106-8-29**] 01:35PM URINE Blood-MOD Nitrite-POS Protein-25
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2106-8-29**] 01:35PM URINE RBC-0 WBC->50 Bacteri-MANY Yeast-NONE
Epi-[**2-19**] TransE-0-2

[**2106-8-27**] 8:36 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2106-8-31**]**

   URINE CULTURE (Final [**2106-8-31**]):
      KLEBSIELLA PNEUMONIAE.    >100,000 ORGANISMS/ML..
         WARNING! This isolate is an extended-spectrum
beta-lactamase
         (ESBL) producer and should be considered resistant to
all
         penicillins, cephalosporins, and aztreonam. Consider
Infectious
         Disease consultation for serious infections caused by
         ESBL-producing species.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             KLEBSIELLA PNEUMONIAE
                             |
AMPICILLIN/SULBACTAM--    16 I
CEFAZOLIN-------------  =>64 R
CEFEPIME--------------       R
CEFTAZIDIME-----------  =>64 R
CEFTRIAXONE-----------       R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------     4 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------   256 R
PIPERACILLIN/TAZO-----     8 S
TOBRAMYCIN------------  =>16 R
TRIMETHOPRIM/SULFA----  =>16 R

[**8-26**], [**8-27**] Blood Cx pending, NGTD

[**8-26**] CXR:  Low lung volumes. Minimal bilateral atelectasis

[**8-27**] CT Trachea:
1. Extensive abnormal soft tissue thickening in the supraglottic
and
infraglottic regions and surrounding the tracheostomy, likely
reflecting
granulation tissue. Severe stenosis at the level of the cricoid
cartilage. The tracheostomy appears patent.
2. Limited evaluation of the lungs due to respiratory motion. No
large
pulmonary nodules or areas of consolidation.

[**8-30**] CXR: Worsening left mid lung zone opacity concerning for
infection or
worsening atelectasis.

Brief Hospital Course:
Acute Hypoxemic on Chronic Respiratory Failure - This was
thought to be due to  granulation tissue seen around the area of
her tracheostomy and subglottic stenosis.  She had a rigid
bronchoscopy by IP which showed diffuse granulation tissue
around her stoma and her trach, as well as subglottic stenosis.
This was debrided and a larger size (#7 non-fenestrated) trach
tube was inserted.  She tolerated the procedure well without
difficulty.  The patient had hemoptysis at an OSH that was
initially thought to be HSV tracheitis, however biopsies were
negative.  The hemoptysis was thought to be due to the
granulation tissue.  Per IP recs, started omeprazole and
ranitidine.  Hct remained stable during admission.  WBC trended
down to 10.3.  PSV overnight, required peak 10 PEEP 5 overnight
night of [**8-29**].  Trach mask trial successful during day.

UTI: Patient with cloudy, foul smelling urine.  U/A showed
evidence of UTI with many bacteria.  Started on Cipro.  On day 3
of antibiotics, culture results became available, showing
Klebsiella sensitive only to Zosyn, gentamycin, and meropenem.
Patient had a PICC line placed by IR as the PICC team could not
at bedside.  She was discharged on meropenem as she had a
previous reaction to zosyn.

Diabetes: On detemir and humalog sliding scale.  Hypoglycemic to
60s during afternoon and overnight, so decreased detemir from 25
[**Hospital1 **] to 20 [**Hospital1 **].

Anxiety:  Ativan prn.

Yeast infection:  Noted white discharge and foul odor.  Received
Fluconazole 200mg x1.

Asthma: Continued home albuterol.

Thrush: Nystatin oral suspension.

LUE pain: Pt reports LUE pain with unclear chronicity on
neurontin. [**Month (only) 116**] be secondary to CVA vs DVT, chronic neuropathic
pain. Continued neurontin and used oxycodone prn.

CAD and s/p CVA: Held ASA for procedure.  Prior to discharge,
ASA was restarted with agreement from Interventional
Pulmonology.

Hyperlipdemia: Continued statin.

Hypothyroidism: Continued levothyroxine.

Medications on Admission:
Tylenol 650 q4 prn
Dulcolax 10mg Po daily prn
Levothyroxine 0.1 mg PO daily
Lexapro 20mg daily per PEG
ferrous sulfate 320mg PO BID
Neurontin 300mg PO TID
HCTZ 12.5mg PO daily
Novolog sliding scale
Levimere 25mg SC BID
Lactobacillus 1 tab PO TID
Lorazepam 0.5mg PO q6 prn
Milk of magnesia 30ml PEG prn
Oxycodone IR 10 mg PO q4h prn
Pantoprazole 40 mg IV daily
Seroquel 25mg PO BID
Ropinirole 2mg PEG qhs
Zocor 20mg PEG daily
Ambien 5mg PO qhs prn
omeprazole 20mg via PEG [**Hospital1 **]
zantac 30 mg via PEG QHS
Ventolin 2.5 mg INH q 2 hours prn

Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
4. Acetaminophen 650 mg/20.3 mL Solution Sig: One (1)  PO Q6H
(every 6 hours) as needed for pain.
5. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
9. Oxycodone 5 mg/5 mL Solution Sig: Five (5) ml PO Q4H (every 4
hours) as needed for pain.
Disp:*150 ml* Refills:*0*
10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Ropinirole 1 mg Tablet Sig: Two (2) Tablet PO QPM (once a
day (in the evening)).
12. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
14. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q2H (every 2 hours) as needed for .
15. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
16. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
17. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
18. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
19. Levemir 100 unit/mL Solution Sig: 25  units  Subcutaneous
twice a day.
Disp:*50 * Refills:*2*
20. Novolog 100 unit/mL Solution Sig: ASDIR  Subcutaneous QACHS:
per sliding scale .
21. General Care
Please keep the head of the bed elevated to 60 degrees at all
times.
22. Meropenem 1 gram Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 7 days.
Disp:*21 Recon Soln(s)* Refills:*0*
23. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).



Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] Commons

Discharge Diagnosis:
hemoptysis, subglottic stenosis, granulation tissue around stoma


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.


Discharge Instructions:
Dear Ms. [**Known lastname **],

It was a pleasure taking care of you during your
hospitalization.
You were admitted to the hospital for bleeding coming from your
tracheostomy.  You underwent a rigid bronchoscopy during which
you had granulation tissue removed and your trach was replaced.
You tolerated this procedure and then had a trial with your
trach mask which you did well with. You were found to have a
urinary tract infection caused by a bacteria called Klebsiella
while in the hospital and we started you on a medication called
meropenem which you will take for 7 days.  You had a chest x-ray
that was concerning for pneumonia, however you had no cough or
increasing oxygen requirement that made us concerned for
pneumonia at this time.  You should be monitored closely for
fevers and worsening respiratory status that could signal a
pneumonia.

Medication changes:
- Please take nystatin oral suspension 5 ml orally four times a
day as needed for thrush.
- Started meropenem 1000 mg IV every 8 hours for 7 days
- Started ranitidine 300 mg orally in the evening
- Started oxycodone 5mg/5ml Q4H for pain
- Increased omeprazole to 40 mg orally twice a day
- Decreased acetaminophen 650 mg orally every 6 hours for pain

Please make sure the head of your bed is always elevated to 60
degrees.

Note: Attempted to contact family to inform them of Ms. [**Known lastname 87236**]
transfer back to [**Hospital1 **].  Tried calling listed numbers for
HCP [**Name (NI) **] ([**Telephone/Fax (1) 87237**]) and alternate [**Doctor Last Name **] [**Telephone/Fax (1) 87238**].  Both
numbers out of service.  Only other number listed in our system
is for [**Hospital1 **].  Pt states that she does not know the new
phone numbers, but has them written down at home.  She states
that she does not mind if we do not contact her family, as she
plans to call them when she returns to [**Hospital1 **].  Contact[**Name (NI) **]
[**Name2 (NI) **], and neither the admissions coordinator [**Doctor Last Name 11923**], nor
the staff on her unit were able to locate any other phone
numbers.  Checked with case manager [**First Name8 (NamePattern2) 19267**] [**Last Name (NamePattern1) 87239**], who also did
not have any other phone number.  Spoke with SW who recommended
contacting PCP.  [**Name10 (NameIs) **] listed PCP??????s office; they could not
locate any records for pt.

Followup Instructions:
Please follow up with IP with Dr. [**Last Name (STitle) **] in 2 weeks. - Dr [**Last Name (STitle) **]
([**Telephone/Fax (1) 3020**])
Provider: [**Name10 (NameIs) **] INTAKE,ONE [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2106-9-15**] 7:30
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2106-9-15**]
8:00
Provider: [**Name10 (NameIs) **] ROOM TWO Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2106-9-15**]
8:00


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
{"Mechanical complication of tracheostomy,Acute and chronic respiratory failure,Urinary tract infection, site not specified,Candidiasis of mouth,Hematemesis,Other vascular complications of medical care, not elsewhere classified,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Morbid obesity,Unspecified essential hypertension,Esophageal reflux,Leukocytosis, unspecified,Other late effects of cerebrovascular disease,Muscle weakness (generalized),Anxiety state, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Gastrostomy status,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: Hemoptysis/Tracheal bleed, Hypoxia

PRESENT ILLNESS: 70F with DM, asthma, chronic respiratory failure [**1-19**] PNA/asthma
(? vented at night with chronic trach x ? 3 months) CVA, CAD,
s/p recent tracheal bleed and trach change [**2106-7-4**] transferred
from OSH with recurrent tracheal bleed for IP eval and
bronchoscopy. Oxygen saturations 80% on 50% FiO2 in IP suite so
she was admitted to MICU for bronchoscopy and evaluation.
Patient's prior bronch in [**Month (only) 205**] revealed subglottic stenosis,
granulation tissue at stoma, plaque like lesions on main carina
and rigth bronchus intermedius (bx-no malignancy), polypoid
lesions main carina. No evidence of TM and trach replaced with
new cuffless #6 trach tube. There was ? HSV but biopsies were
negative.
.
In IP suite, initial vs were: T97.6 P68 BP121/57 R20 O2 sat92%
on 35%. Patient was transferred to ICU for assessment and plan
for flexible bronch in afternoon and rigid bronchoscopy
tomorrow.
.
On the floor, her only complaint is left arm pain which has been
treated with neurontin. She states this "just started" but
unclear when. reports "a little SOB", but improved now on vent.
Denies further bleeding from trach site, wheezing, chest pain,
cough, abdominal pain, LH, dizziness. States she had fevers and
chills 6 days prior but none since then.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
chest pain, chest pressure, palpitations, or weakness. Denies
nausea, vomiting, diarrhea, constipation, abdominal pain, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Denies arthralgias or myalgias. Denies rashes or skin changes.

MEDICAL HISTORY: IDDM2
Asthma
Chronic resp failure ([**1-19**] asthma and PNA) s/p trach and PEG ? 3
months ago (? on ventilator at night)
s/p bronch [**7-8**], [**7-6**], cuffless trach replacement to cuffed
catheter in ED [**7-4**]
CVA (L weakness)
CAD
HTN
DJD
GERD
h/o AFB in sputum felt to be colonizer
Polypoid lesion trachea
? hypothyroidism
? hyperlipidemia

MEDICATION ON ADMISSION: Tylenol 650 q4 prn
Dulcolax 10mg Po daily prn
Levothyroxine 0.1 mg PO daily
Lexapro 20mg daily per PEG
ferrous sulfate 320mg PO BID
Neurontin 300mg PO TID
HCTZ 12.5mg PO daily
Novolog sliding scale
Levimere 25mg SC BID
Lactobacillus 1 tab PO TID
Lorazepam 0.5mg PO q6 prn
Milk of magnesia 30ml PEG prn
Oxycodone IR 10 mg PO q4h prn
Pantoprazole 40 mg IV daily
Seroquel 25mg PO BID
Ropinirole 2mg PEG qhs
Zocor 20mg PEG daily
Ambien 5mg PO qhs prn
omeprazole 20mg via PEG [**Hospital1 **]
zantac 30 mg via PEG QHS
Ventolin 2.5 mg INH q 2 hours prn

ALLERGIES: Penicillins

PHYSICAL EXAM: General: Alert, intermittently falling asleep during exam,
oriented to city and state, date, not month, no acute distress,
able to communicate by whispering in full sentences
HEENT: Sclera anicteric, MMM with thrush, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Coarse breath sounds with exp wheezes bilaterally. No
crackles or rhonchi
CV: Regular rate and rhythm, normal S1 + S2 with 2/6 systolic
murmur LUSB, no rubs or gallops
Abdomen: soft, obese, non-tender, multiple ecchymoses,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. LUE with mild nonpitting edema
Neuro: AAOx2-3 as above. CN 2-12 intact. 5/5 strength RUE and
[**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]/L. LUE contracted with inability to uncle[**Name (NI) **] fist.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Resident at [**Hospital1 **] Commons. Has 3 sons. [**Name (NI) 87235**] worked as
manager of group home.
- Tobacco:  Denies
- Alcohol:  rare
- Illicits:  None 

### Response:
{"Mechanical complication of tracheostomy,Acute and chronic respiratory failure,Urinary tract infection, site not specified,Candidiasis of mouth,Hematemesis,Other vascular complications of medical care, not elsewhere classified,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asthma, unspecified type, unspecified,Coronary atherosclerosis of native coronary artery,Unspecified acquired hypothyroidism,Other and unspecified hyperlipidemia,Morbid obesity,Unspecified essential hypertension,Esophageal reflux,Leukocytosis, unspecified,Other late effects of cerebrovascular disease,Muscle weakness (generalized),Anxiety state, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Gastrostomy status,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure"}
