CHIEF COMPLAINT: Post tracheostomy and tracheal stenosis.

PRESENT ILLNESS: 59 y/o female with complicated medical history c/w morbid
obesity s/p Lap Gastric Bypass, sleep apnea, who has been
diagnosed with adult onset asthma 9 or 10 years ago. Her SOB has
been progressively getting worse over the years, although it
improved substantially after her bypass in [**2159**], when she was
able  to come off home O2 after loosing around 80lbs (from 280
to 201lbs currently). She was recently admitted to an OSH with
pneummonia and she required iv antibiotics and prednisone taper
for "asthma exacerbation". A CT scan of the chest was done and
was suggestive of tracheal stenosis and TBM. She was then
referred from Dr. [**Last Name (STitle) 64744**], her pulmonologist at [**Hospital3 **],
to Dr. [**Last Name (STitle) **] who performed a flexible bronchoscopy comfirming
an A shaped short tracheal stenosis with evidence of TBM. The pt
also reports occasional coughing with white phlegm, only yellow
when she has a concurrent pneumonia. She also reports mild
heartburn, but no fever, chills or recent weight loss. She
report a voice change since her thyroidectomy for [**Doctor Last Name 933**] disease
in [**2157**]. She currently is disabled, has SOB with mild exertion
such as walking, going up the stairs or attempting to do the
laundry. She has minimal SOB at rest, and cannot lay flat at
night (she has to use at least 2 pillows). She uses CPAP at
night for her sleep apnea as well. She was admitted for tracheal
resection and reconstruction for tracheal stenosis.

MEDICAL HISTORY: 1.  [**Doctor Last Name 933**] disease status post radioactive ablation with
subsequent thyroidectomy and hypothyroidism.
2.  T12-L1 disk herniation.
3.  Status post cholecystectomy.
4.  Right groin cyst removal
5.  History of gastric bypass.
6.  Diabetes mellitus type 2.
7.  Osteopenia
8.  Sleep apnea
9.  Pancreatitis
10. Silent MI
[**65**]. GERD
12. tracheostomy

MEDICATION ON ADMISSION: Norvasc 10mg po daily, Levoxyl 250 (5x/week), Prilosec 20'',
Lantus 52units qhs, Atenolol 50mg po daily, lisinopril 40 mg po
daily, Doxazocin 4mg po daily, Vit D, Albuterol prn, lasix 40 mg
po daily

ALLERGIES: Hydrochlorothiazide

PHYSICAL EXAM: Vital signs:
VS: T98.4, HR 74 SR, BP 124/70, RR 18, O2 sats 97% RA
Physical Exam:
Gen: pleasant, in NAD
Neck: incision healing without redness, purulence or drainage.
CV: RRR S1, S2, no MRG or JVD
Abd: soft, NT, ND
Ext: warm, no edema

FAMILY HISTORY: NC

SOCIAL HISTORY: Married with 3 children, quit smoking 15 years ago.
Mechanical complication of tracheostomy,Pulmonary collapse,Unspecified pleural effusion,Chronic pancreatitis,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Asthma, unspecified type, unspecified,Other specified cardiac dysrhythmias,Obstructive sleep apnea (adult)(pediatric),Morbid obesity,Bariatric surgery status,Other postablative hypothyroidism,Displacement of thoracic intervertebral disc without myelopathy,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Disorder of bone and cartilage, unspecified,Old myocardial infarction,Personal history of tobacco use
Tracheostomy - mech comp,Pulmonary collapse,Pleural effusion NOS,Chronic pancreatitis,Abn react-external stoma,Asthma NOS,Cardiac dysrhythmias NEC,Obstructive sleep apnea,Morbid obesity,Bariatric surgery status,Postablat hypothyr NEC,Thoracic disc displacmnt,DMII oth nt st uncntrld,Long-term use of insulin,Adv eff insulin/antidiab,Bone & cartilage dis NOS,Old myocardial infarct,History of tobacco use
Admission Date:  [**2165-4-26**]              Discharge Date:   [**2165-5-3**]

Date of Birth:  [**2105-4-28**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Hydrochlorothiazide

Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Post tracheostomy and tracheal stenosis.


Major Surgical or Invasive Procedure:
[**2165-4-26**]: Flexible bronchoscopy with bronchoalveolar lavage and
cervical tracheal resection and reconstruction.
[**2165-5-3**]: Bronchoscopy


History of Present Illness:
59 y/o female with complicated medical history c/w morbid
obesity s/p Lap Gastric Bypass, sleep apnea, who has been
diagnosed with adult onset asthma 9 or 10 years ago. Her SOB has
been progressively getting worse over the years, although it
improved substantially after her bypass in [**2159**], when she was
able  to come off home O2 after loosing around 80lbs (from 280
to 201lbs currently). She was recently admitted to an OSH with
pneummonia and she required iv antibiotics and prednisone taper
for "asthma exacerbation". A CT scan of the chest was done and
was suggestive of tracheal stenosis and TBM. She was then
referred from Dr. [**Last Name (STitle) 64744**], her pulmonologist at [**Hospital3 **],
to Dr. [**Last Name (STitle) **] who performed a flexible bronchoscopy comfirming
an A shaped short tracheal stenosis with evidence of TBM. The pt
also reports occasional coughing with white phlegm, only yellow
when she has a concurrent pneumonia. She also reports mild
heartburn, but no fever, chills or recent weight loss. She
report a voice change since her thyroidectomy for [**Doctor Last Name 933**] disease
in [**2157**]. She currently is disabled, has SOB with mild exertion
such as walking, going up the stairs or attempting to do the
laundry. She has minimal SOB at rest, and cannot lay flat at
night (she has to use at least 2 pillows). She uses CPAP at
night for her sleep apnea as well. She was admitted for tracheal
resection and reconstruction for tracheal stenosis.

Past Medical History:
1.  [**Doctor Last Name 933**] disease status post radioactive ablation with
subsequent thyroidectomy and hypothyroidism.
2.  T12-L1 disk herniation.
3.  Status post cholecystectomy.
4.  Right groin cyst removal
5.  History of gastric bypass.
6.  Diabetes mellitus type 2.
7.  Osteopenia
8.  Sleep apnea
9.  Pancreatitis
10. Silent MI
[**65**]. GERD
12. tracheostomy


Social History:
Married with 3 children, quit smoking 15 years ago.

Family History:
NC

Physical Exam:
Vital signs:
VS: T98.4, HR 74 SR, BP 124/70, RR 18, O2 sats 97% RA
Physical Exam:
Gen: pleasant, in NAD
Neck: incision healing without redness, purulence or drainage.
CV: RRR S1, S2, no MRG or JVD
Abd: soft, NT, ND
Ext: warm, no edema

Pertinent Results:
Pathology - Tracheal rings 1, 2, 3: Respiratory mucosa, squamous
metaplasia, and minor salivary gland. Tracheal cartilage.

CXR [**2165-4-28**]: Right mid lung atelectasis is unchanged otherwise
the lungs are grossly clear. Moderate-to-severe cardiomegaly is
stable. There is no evident pneumothorax. If any there is a
small right pleural effusion. A drain projects in the upper
mediastinum.

CXR [**2165-4-30**]: 1. Interval improvement in the atelectasis in the
right middle lobe. 2. Left mid lung linear atelectasis and small
left pleural effusion are unchanged.

[**2165-4-28**] 02:17AM BLOOD WBC-10.7 RBC-3.60* Hgb-10.2* Hct-32.0*
MCV-89 MCH-28.4 MCHC-32.0 RDW-15.5 Plt Ct-174
[**2165-5-3**] 07:20AM BLOOD Glucose-114* UreaN-15 Creat-1.2* Na-142
K-4.5 Cl-104 HCO3-29 AnGap-14

Brief Hospital Course:
The patient was taken to the Operating Room on [**2165-4-26**] by Dr.
[**Last Name (STitle) **] for flexible bronchoscopy with bronchoalveolar
lavage and cervical tracheal resection and reconstruction. There
were no complications to the procedure. Please see operative
report for more details. She was directly admitted to the
surgical ICU post-operatively and transferred to the floor POD3.
Her hospital course can be summmarized by the following review
of systems:

Neuro: Patient pain was controlled with a PCA of dilaudid. She
was transitioned to an oral regimen once tolerating diet. By
discharge, her pain was well-controlled on Roxicet. She had no
neurological deficits.

Cardio: She was hemodynamically stable. Her beta-blockade was
resumed immediately post-operatively. Her oral regimen was
maintained and adjusted to lower dosing of atenolol 25mg po
daily. She had sinus bradycardia in the mid 40's occasionally
but was assymptomatic. She had no other issues. Her lisinopril
and norvasc dosed were also halved due to excellent blood
pressure.

Pulm: S/p tracheal resection with reconstruction. She was taken
directly to the surgical ICU post-operatively and extubated
later that evening. She maintained her airway with no
respiratory distress. Her Lasix was resumed on POD6 due to
slight shortness of breath and pedal edema. She did not require
any oxygen on discharge. Bronchoscopy performed POD 7 showed
intact anastomosis and patent airway. Sutures were cut.

GI: Patient was kept NPO for 3 days for aspiration precautions.
She was then advanced to a soft regular diet. PPI was resumed.
No other issues.

FEN/Renal: As she is on daily lasix, her fluid status was
closely monitored. She made adequate urine t/o this hospital
stay. Lasix was resumed on POD6. No other issues.

Heme: She was started on SQH and had no other issues.

ID: Pre-operative antibiotics of ancef. No infectious issues or
concerns.

Endo: Blood sugars were watched closely, and the patient was
placed on lantus 10 units which kept her sugars controlled below
130 mostly. She will followup with outpatient endocrinologist
for further uptitration of her lantus insulin if her glucoses
are >150, as she was discharged well below her home dose of 52
units qhs. She was also resumed on her metformin.

Dispo: The patient was deemed safe by Dr. [**Last Name (STitle) **] for
discharge home today. VNA was ordered to visit her once.


Medications on Admission:
Norvasc 10mg po daily, Levoxyl 250 (5x/week), Prilosec 20'',
Lantus 52units qhs, Atenolol 50mg po daily, lisinopril 40 mg po
daily, Doxazocin 4mg po daily, Vit D, Albuterol prn, lasix 40 mg
po daily

Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for sob,
wheeze.
3. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: check
electrolytes in one week with your PCP.
4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

5. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*500 ML(s)* Refills:*0*
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
NOTE DOSE CHANGE.
7. Levothyroxine 100 mcg Tablet Sig: 2.5 Tablets PO 5X/WEEK
(MO,TU,WE,TH,FR).
8. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
NOTE DOSE CHANGE.
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
NOTE DOSE CHANGE.
10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
13. Calcium 500 mg Tablet Oral
14. Ergocalciferol (Vitamin D2)  Oral
15. Lantus 100 unit/mL Solution Sig: Ten (10) units Subcutaneous
at bedtime: if blood sugars >150 consistently discuss increasing
lantus with your endocrinologist.


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
Post tracheostomy, tracheal stenosis.
[**Doctor Last Name 933**] disease status post radioactive ablation with subsequent
thyroidectomy and hypothyroidism.
T12-L1 disk herniation.
Diabetes mellitus type 2 on insulin
Osteopenia
Sleep apnea
Pancreatitis
Silent MI
GERD

PSH: History of gastric bypass. Status post cholecystectomy.
Right groin cyst removal


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


Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Hoarsness or difficulty breathing
-You may shower.  No swimming or bathing
-No driving while taking narcotics

- NOTE YOU ARE ON DIFFERENT MEDICATION DOSING COMPARED WITH
ADMISSION MEDICATIONS: PLEASE TAKE NEW MEDICATIONS WITH DOSING.
CALL IF ?'S.


Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**5-21**] at 9:00 am in the [**Hospital Ward Name 121**]
Building Chest Disease Center [**Hospital1 **] 116
Chest X-Ray [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiolgoy 30
minutes before your appointment.

Follow up with your endocrinologist regarding your lantus
dosing. If blood glucose greater than 150 you will need to have
lantus dose adjusted.

Check you blood pressure sporadically and if it is staying
higher than 130/80 please discuss increasing some of your blood
pressure medications with your primary care physician.



Completed by:[**2165-5-3**]
{'Mechanical complication of tracheostomy,Pulmonary collapse,Unspecified pleural effusion,Chronic pancreatitis,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Asthma, unspecified type, unspecified,Other specified cardiac dysrhythmias,Obstructive sleep apnea (adult)(pediatric),Morbid obesity,Bariatric surgery status,Other postablative hypothyroidism,Displacement of thoracic intervertebral disc without myelopathy,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Disorder of bone and cartilage, unspecified,Old myocardial infarction,Personal history of tobacco use'}


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: Post tracheostomy and tracheal stenosis.

PRESENT ILLNESS: 59 y/o female with complicated medical history c/w morbid
obesity s/p Lap Gastric Bypass, sleep apnea, who has been
diagnosed with adult onset asthma 9 or 10 years ago. Her SOB has
been progressively getting worse over the years, although it
improved substantially after her bypass in [**2159**], when she was
able  to come off home O2 after loosing around 80lbs (from 280
to 201lbs currently). She was recently admitted to an OSH with
pneummonia and she required iv antibiotics and prednisone taper
for "asthma exacerbation". A CT scan of the chest was done and
was suggestive of tracheal stenosis and TBM. She was then
referred from Dr. [**Last Name (STitle) 64744**], her pulmonologist at [**Hospital3 **],
to Dr. [**Last Name (STitle) **] who performed a flexible bronchoscopy comfirming
an A shaped short tracheal stenosis with evidence of TBM. The pt
also reports occasional coughing with white phlegm, only yellow
when she has a concurrent pneumonia. She also reports mild
heartburn, but no fever, chills or recent weight loss. She
report a voice change since her thyroidectomy for [**Doctor Last Name 933**] disease
in [**2157**]. She currently is disabled, has SOB with mild exertion
such as walking, going up the stairs or attempting to do the
laundry. She has minimal SOB at rest, and cannot lay flat at
night (she has to use at least 2 pillows). She uses CPAP at
night for her sleep apnea as well. She was admitted for tracheal
resection and reconstruction for tracheal stenosis.

MEDICAL HISTORY: 1.  [**Doctor Last Name 933**] disease status post radioactive ablation with
subsequent thyroidectomy and hypothyroidism.
2.  T12-L1 disk herniation.
3.  Status post cholecystectomy.
4.  Right groin cyst removal
5.  History of gastric bypass.
6.  Diabetes mellitus type 2.
7.  Osteopenia
8.  Sleep apnea
9.  Pancreatitis
10. Silent MI
[**65**]. GERD
12. tracheostomy

MEDICATION ON ADMISSION: Norvasc 10mg po daily, Levoxyl 250 (5x/week), Prilosec 20'',
Lantus 52units qhs, Atenolol 50mg po daily, lisinopril 40 mg po
daily, Doxazocin 4mg po daily, Vit D, Albuterol prn, lasix 40 mg
po daily

ALLERGIES: Hydrochlorothiazide

PHYSICAL EXAM: Vital signs:
VS: T98.4, HR 74 SR, BP 124/70, RR 18, O2 sats 97% RA
Physical Exam:
Gen: pleasant, in NAD
Neck: incision healing without redness, purulence or drainage.
CV: RRR S1, S2, no MRG or JVD
Abd: soft, NT, ND
Ext: warm, no edema

FAMILY HISTORY: NC

SOCIAL HISTORY: Married with 3 children, quit smoking 15 years ago. 

### Response:
{'Mechanical complication of tracheostomy,Pulmonary collapse,Unspecified pleural effusion,Chronic pancreatitis,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Asthma, unspecified type, unspecified,Other specified cardiac dysrhythmias,Obstructive sleep apnea (adult)(pediatric),Morbid obesity,Bariatric surgery status,Other postablative hypothyroidism,Displacement of thoracic intervertebral disc without myelopathy,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Insulins and antidiabetic agents causing adverse effects in therapeutic use,Disorder of bone and cartilage, unspecified,Old myocardial infarction,Personal history of tobacco use'}
