CHIEF COMPLAINT: Throat swelling

PRESENT ILLNESS: 85 y.o. M with hx of HTN, AFib, GERD p/w with 1 wk hx of neck
swelling, dyspagia of solids and liquids, felt to have
supraglottitis, started on high dose steroids.  He initially was
started on steroids, but developed delirium and agitation,
requiring intubation for airway protection.  Steroids were
weaned off.  The cause of his supraglottitis was thought to be
angioedema [**1-24**] ACE-I, however pt states that he has been taking
his medicines for a long time.  Pt extubated, but had worsening
stridor, hypoxemia and reintubated electively.  He then
self-extubated on [**4-9**], but on [**4-12**] was found to be
unresponsive, hypercarbic and in PEA arrest, and reintubated.
Given atropine, epi and on pressors for 1 day.  Pt finally
extubated on [**4-16**], no respiratory problems since then.
Otherwise MICU course complicated by rapid AF requiring IV
lopressor, large amount of secretion, and sputum cx's with
e.coli and pseudomonas, started on Zosyn on [**4-15**] for sinusitis
by head CT on [**4-14**].  In addition, pt has required NGT for
nutrition given concern for aspiration, however pulled out
earlier today.  Video swallow study earlier today showed some
evidence of aspiration and assymetrical neck swelling.
On further hx pt admits to preceding subjective fever, denies
chills.  Also admits to lots of rhinorrhea, nasal congestion.  +
sick contacts with grandchildren.  He denies chills, diarrhea,
cough, shortness of breath, urinary sx's, rash, recent
medication changes.  He is followed at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**] VA.  He was
born in [**Male First Name (un) 1056**], moved to US in [**2060**], unclear status of
vaccinations.

MEDICAL HISTORY: chronic AFib-anticoagulation on coumadin s/p DCCV in 12/99
HTN
Borderline CAD - cath [**11/2109**]- 2. Selective coronary angiography
reveals a right dominant system with two vessel disease. The
left main tapers distally to a 40% stenosis. There is ostial
disease of all vessels at the trifurcation: LAD 60%, ramus
40-50%, LCX 50%. The RCA is small, but dominant, without focal
stenosis.
?CAD -s/p IMI
diabetes mellitus
COPD
BPH/Increased PSA
Hypercholesterol
OA- knees
-Possible Osggod Schlatter right knee
Syncope [**4-/2107**] - neg w/u (tilt, EP, DSE)
GI bleed [**10-24**]
-EGD: [**10-24**] - Single non-bleeding ulcer at antrum, single non-
bleeding superficial ulcer in duodenum
-Colonoscopy [**10-24**] - polyps (HP x 2, TA x 1)
[**8-/2114**]- ext hemorrhoids

MEDICATION ON ADMISSION: 1) ALBUTEROL 90/IPRATROP 18MCG 200D PO INHL INHALE 2 ACTIVE
PUFFS BY MOUTH FOUR TIMES A DAY
2) ASPIRIN 81MG EC TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE
DAY
3) ATENOLOL 100MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY ACTIVE
(S)
4) CAPSAICIN 0.075% CREAM APPLY THIN FILM TO SKIN TWICE ACTIVE
A DAY FOR LOCALIZED PAIN
5) CODEINE 30MG/ACETAMINOPHEN300MG TAB TAKE 1 TABLET BY ACTIVE
MOUTH THREE TIMES A DAY FOR PAIN
6) DIGOXIN (LANOXIN) 0.125MG TAB TAKE ONE TABLET BY ACTIVE
MOUTH EVERY DAY
7) DOCUSATE NA 100MG CAP TAKE ONE CAPSULE BY MOUTH TWICE ACTIVE
A DAY TO SOFTEN STOOL
8) FOSINOPRIL NA 20MG TAB TAKE TWO TABLETS BY MOUTH ACTIVE EVERY
MORNING AND TAKE ONE TABLET EVERY EVENING INCREASE IN DOSE
[**2113-6-27**]
9) HYDROCHLOROTHIAZIDE 25MG TAB TAKE ONE TABLET BY MOUTH ACTIVE
EVERY DAY
10) MENTHOL 10%/METHYL SALICYLATE 15% CREAM APPLY ACTIVE
MODERATE AMOUNT TO SKIN EVERY DAY AS NEEDED FOR
KNEE ARTHRITIS
11) NIFEDIPINE (ADALAT CC) 30MG SA TAB TAKE (DO NOT ACTIVE
CRUSH) ONE TABLET BY MOUTH EVERY DAY FOR HEART
12) OMEPRAZOLE 20MG SA CAP TAKE ONE CAPSULE BY MOUTH ACTIVE
EVERY MORNING 30 MINUTES BEFORE BREAKFAST
(REPLACES RABEPRAZOLE)
13) PSYLLIUM SF ORAL PWD TAKE 1 TABLESPOONFUL BY MOUTH ACTIVE
EVERY DAY (DISSOLVE IN 8OZ WATER/JUICE BEFORE
DRINKING)
14) SIMVASTATIN 80MG TAB TAKE ONE-HALF TABLET BY MOUTH AT ACTIVE
BEDTIME FOR REDUCING CHOLESTEROL
15) TERAZOSIN HCL 5MG CAP TAKE ONE CAPSULE BY MOUTH AT ACTIVE
BEDTIME
16) WARFARIN (COUMADIN) NA 2MG TAB TAKE ONE AND ONE-HALF ACTIVE
TABLETS BY MOUTH EVERY EVENING EXCEPT TAKE TWO TABLETS EVERY
MONDAY TO PREVENT BLOOD CLOTS(ANTICOAGULATION)

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: T 98.9 P 83 BP 128/47 RR 18 O2 96% RA, wt 88 kg complains of
mild sob when flat
Gen: no respiratory distress, no noticable gurgling, minimal
drooling
HEENT: EOMI, PERRLA, +trismus, erythema, difficult to visulize
tonsills, swelling R>L
LN: +submandibular lymph nodes right>L
Lungs: CTA x 2
Heart: s1 s2 no m/r/g
Abd: soft nt/nd +bs
Ext: no c/c/e
CN II-XII intact
AOx3

FAMILY HISTORY: NC

SOCIAL HISTORY: 110 pack year smoking hx, quit 3 years ago, occais etoh. Lives
alone, independent in all adl's
Supraglottitis unspecified, without obstruction,Other pulmonary insufficiency, not elsewhere classified,Atrial fibrillation,Drug-induced delirium,Chronic airway obstruction, not elsewhere classified,Acidosis,Acute kidney failure, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Edema of larynx,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Foreign body in other specified parts bronchus and lung,Esophageal reflux,Coronary atherosclerosis of native coronary artery,Other and unspecified special symptoms or syndromes, not elsewhere classified,Pure hypercholesterolemia,Abnormal coagulation profile,Unspecified sinusitis (chronic),Anemia of other chronic disease,Unspecified essential hypertension,Old myocardial infarction,Osteoarthrosis, unspecified whether generalized or localized, lower leg,Adrenal cortical steroids causing adverse effects in therapeutic use
Supraglottis w/o obs NOS,Other pulmonary insuff,Atrial fibrillation,Drug-induced delirium,Chr airway obstruct NEC,Acidosis,Acute kidney failure NOS,Chr blood loss anemia,Edema of larynx,BPH w urinary obs/LUTS,FB trach/bronch/lung NEC,Esophageal reflux,Crnry athrscl natve vssl,Special symptom NEC/NOS,Pure hypercholesterolem,Abnrml coagultion prfile,Chronic sinusitis NOS,Anemia-other chronic dis,Hypertension NOS,Old myocardial infarct,Osteoarthros NOS-l/leg,Adv eff corticosteroids
Admission Date:  [**2115-4-2**]              Discharge Date:   [**2115-4-30**]


Service: MEDICINE

Allergies:
Ace Inhibitors

Attending:[**First Name3 (LF) 2159**]
Chief Complaint:
Throat swelling

Major Surgical or Invasive Procedure:
Endotracheal intubation
Placement of central venous catheter
Placement of triple-lumen foley catheter


History of Present Illness:
85 y.o. M with hx of HTN, AFib, GERD p/w with 1 wk hx of neck
swelling, dyspagia of solids and liquids, felt to have
supraglottitis, started on high dose steroids.  He initially was
started on steroids, but developed delirium and agitation,
requiring intubation for airway protection.  Steroids were
weaned off.  The cause of his supraglottitis was thought to be
angioedema [**1-24**] ACE-I, however pt states that he has been taking
his medicines for a long time.  Pt extubated, but had worsening
stridor, hypoxemia and reintubated electively.  He then
self-extubated on [**4-9**], but on [**4-12**] was found to be
unresponsive, hypercarbic and in PEA arrest, and reintubated.
Given atropine, epi and on pressors for 1 day.  Pt finally
extubated on [**4-16**], no respiratory problems since then.
Otherwise MICU course complicated by rapid AF requiring IV
lopressor, large amount of secretion, and sputum cx's with
e.coli and pseudomonas, started on Zosyn on [**4-15**] for sinusitis
by head CT on [**4-14**].  In addition, pt has required NGT for
nutrition given concern for aspiration, however pulled out
earlier today.  Video swallow study earlier today showed some
evidence of aspiration and assymetrical neck swelling.
On further hx pt admits to preceding subjective fever, denies
chills.  Also admits to lots of rhinorrhea, nasal congestion.  +
sick contacts with grandchildren.  He denies chills, diarrhea,
cough, shortness of breath, urinary sx's, rash, recent
medication changes.  He is followed at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**] VA.  He was
born in [**Male First Name (un) 1056**], moved to US in [**2060**], unclear status of
vaccinations.


Past Medical History:
chronic AFib-anticoagulation on coumadin s/p DCCV in 12/99
HTN
Borderline CAD - cath [**11/2109**]- 2. Selective coronary angiography
reveals a right dominant system with two vessel disease. The
left main tapers distally to a 40% stenosis. There is ostial
disease of all vessels at the trifurcation: LAD 60%, ramus
40-50%, LCX 50%. The RCA is small, but dominant, without focal
stenosis.
?CAD -s/p IMI
diabetes mellitus
COPD
BPH/Increased PSA
Hypercholesterol
OA- knees
-Possible Osggod Schlatter right knee
Syncope [**4-/2107**] - neg w/u (tilt, EP, DSE)
GI bleed [**10-24**]
-EGD: [**10-24**] - Single non-bleeding ulcer at antrum, single non-
bleeding superficial ulcer in duodenum
-Colonoscopy [**10-24**] - polyps (HP x 2, TA x 1)
[**8-/2114**]- ext hemorrhoids


Social History:
110 pack year smoking hx, quit 3 years ago, occais etoh. Lives
alone, independent in all adl's


Family History:
NC

Physical Exam:
T 98.9 P 83 BP 128/47 RR 18 O2 96% RA, wt 88 kg complains of
mild sob when flat
Gen: no respiratory distress, no noticable gurgling, minimal
drooling
HEENT: EOMI, PERRLA, +trismus, erythema, difficult to visulize
tonsills, swelling R>L
LN: +submandibular lymph nodes right>L
Lungs: CTA x 2
Heart: s1 s2 no m/r/g
Abd: soft nt/nd +bs
Ext: no c/c/e
CN II-XII intact
AOx3


Pertinent Results:
[**4-2**] Neck CT:
FINDINGS: A moderate amount of soft tissue swelling is seen
within the peritonsillar region with no definite focal
low-attenuation lesion to suggest abscess. A preponderance of
soft tissue swelling is seen within the supraglottic region. No
pathologically enlarged nodes are identified.
Of note, significant amount of ossification is seen within the
anterior cervical spine consistent with DISH. This region of
ossification is displacing soft tissue anteriorly.
IMPRESSION:
1. Soft tissue density within predominantly supraglottic region
with no definite evidence peritonsillar abscess.
2. No evidence of lymphadenopathy.
3. DISH causing anterior soft tissue displacement of the
pharynx.
.
[**4-3**] Head CT:
FINDINGS: There is no evidence of intracranial bleed, mass
effect, shift of normally midline structures. Within the left
cerebellum, there is a focal area of low density, likely
representing volume averaging. No major vascular territorial
infarct is seen. No evidence of hydrocephalus. Small air-fluid
levels are seen within the sphenoid sinuses and mucosal
thickening is present within the ethmoid sinuses. The maxillary
sinuses and ethmoid air cells are clear.
IMPRESSION: No evidence of intracranial hemorrhage.
Sinusitis
.
[**4-14**] Sinus CT:
NON-CONTRAST SINUS CT: Mucosal thickening is seen in the right
maxillary sinus. Minor mucosal thickening is seen in the ethmoid
air cells. Both sphenoid sinuses show air fluid levels and
mucosal thickening. There is scattered opacification of the
mastoid air cells. No bony destruction is seen. The patient has
a smallbore nasogastric feeding tube. A tiny focus of air is
seen between the dens and the anterior ring of C1; the
atlantoaxial interval is still within normal limits. The right
ostiomeatal unit is not patent, although the left is. The nasal
septum deviates to the right of midline. Anterior clinoid
processes are not pneumatized. The sphenoid sinus septum inserts
roughly on the midline.
IMPRESSION: Sinusitis, slightly worse compared to the CT scan of
[**2115-4-7**].
.
[**4-22**] Neck CT
FINDINGS: The patient is status post extubation. Previously
noted lobulated soft tissue swelling in the supraglottic region
is not identified in the present scan. Oropharynx and
hypopharynx are patent and symmetric. No significant
lymphadenopathy. Note is made of cervical spondylosis, as noted
previously. The visualized portions of the lung apices are
clear. No suspicious lytic or blastic lesions.
IMPRESSION: Previously noted supraglottic soft tissue swelling
is not identified. Cervical spondylosis.
.
TTE:
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *6.1 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.4 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *6.5 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.8 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 60% to 65% (nl >=55%)
Aorta - Valve Level: 3.1 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.6 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.4 m/sec
Mitral Valve - E Wave Deceleration Time: 132 msec
TR Gradient (+ RA = PASP): *40 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s)
Conclusions:
The left atrium is markedly dilated. The right atrium is
moderately dilated. The inferior vena cava is dilated (>2.5 cm).
There is mild symmetric left ventricular hypertrophy with normal
cavity size. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular systolic function is normal. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present.
Mild to moderate ([**12-24**]+) aortic regurgitation is seen. The mitral
valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a  restrictive filling
abnormality, with elevated left atrial pressure. The  tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
 artery systolic hypertension. The end-diastolic pulmonic
regurgitation  velocity is increased suggesting pulmonary artery
diastolic hypertension.  There is no pericardial effusion.
.
[**2115-4-2**] 02:00AM BLOOD WBC-11.5* RBC-4.60 Hgb-13.4* Hct-39.9*
MCV-87 MCH-29.2 MCHC-33.6 RDW-15.2 Plt Ct-223
[**2115-4-6**] 01:30AM BLOOD WBC-12.0* RBC-4.47* Hgb-12.8* Hct-38.7*
MCV-87 MCH-28.6 MCHC-33.0 RDW-15.3 Plt Ct-196
[**2115-4-13**] 04:11AM BLOOD WBC-11.9* RBC-3.58* Hgb-10.5* Hct-31.5*
MCV-88 MCH-29.4 MCHC-33.5 RDW-16.3* Plt Ct-240
[**2115-4-24**] 05:20AM BLOOD WBC-10.0 RBC-3.08* Hgb-9.4* Hct-28.4*
MCV-92 MCH-30.4 MCHC-33.0 RDW-19.2* Plt Ct-381
[**2115-4-2**] 02:00AM BLOOD Neuts-87.1* Lymphs-8.1* Monos-4.4 Eos-0.3
Baso-0.1
[**2115-4-7**] 02:30AM BLOOD Neuts-87.3* Lymphs-7.7* Monos-4.0 Eos-0.5
Baso-0.4
[**2115-4-14**] 04:30AM BLOOD Neuts-87.9* Lymphs-8.3* Monos-3.1 Eos-0.5
Baso-0.1
[**2115-4-2**] 03:20AM BLOOD PT-34.4* PTT-31.9 INR(PT)-3.7*
[**2115-4-4**] 01:35PM BLOOD PT-68.8* PTT-36.2* INR(PT)-8.8*
[**2115-4-5**] 03:00AM BLOOD PT-24.8* PTT-29.2 INR(PT)-2.5*
[**2115-4-24**] 05:20AM BLOOD PT-12.8 PTT-29.0 INR(PT)-1.1
[**2115-4-2**] 02:00AM BLOOD Glucose-154* UreaN-16 Creat-0.9 Na-137
K-3.5 Cl-100 HCO3-26 AnGap-15
[**2115-4-6**] 01:30AM BLOOD Glucose-148* UreaN-21* Creat-0.9 Na-143
K-3.4 Cl-108 HCO3-25 AnGap-13
[**2115-4-13**] 04:11AM BLOOD Glucose-161* UreaN-31* Creat-2.0* Na-150*
K-3.6 Cl-116* HCO3-25 AnGap-13
[**2115-4-24**] 05:20AM BLOOD Glucose-108* UreaN-12 Creat-1.0 Na-143
K-4.2 Cl-109* HCO3-22 AnGap-16
[**2115-4-3**] 10:00PM BLOOD ALT-22 AST-57* CK(CPK)-3122* AlkPhos-69
Amylase-338* TotBili-0.7
[**2115-4-5**] 03:00AM BLOOD ALT-25 AST-48* CK(CPK)-1270* AlkPhos-65
Amylase-384* TotBili-0.7
[**2115-4-19**] 05:00AM BLOOD ALT-23 AST-28 AlkPhos-68 TotBili-1.4
[**2115-4-13**] 04:11AM BLOOD CK(CPK)-69
[**2115-4-3**] 03:06AM BLOOD Lipase-23
[**2115-4-5**] 03:00AM BLOOD Lipase-21
[**2115-4-2**] 02:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2115-4-3**] 10:00PM BLOOD CK-MB-13* MB Indx-0.4 cTropnT-0.04*
[**2115-4-4**] 03:04AM BLOOD CK-MB-13* MB Indx-0.5 cTropnT-0.03*
[**2115-4-12**] 01:25PM BLOOD CK-MB-6 cTropnT-0.01
[**2115-4-2**] 05:55AM BLOOD Calcium-8.4 Phos-1.9* Mg-1.6
[**2115-4-19**] 05:00AM BLOOD calTIBC-192* TRF-148*
[**2115-4-3**] 03:06AM BLOOD VitB12-337 Folate-7.9
[**2115-4-3**] 03:06AM BLOOD TSH-0.25*
[**2115-4-4**] 03:04AM BLOOD Free T4-1.2
[**2115-4-5**] 03:00AM BLOOD C4-18
[**2115-4-24**] 05:20AM BLOOD C4-24
[**2115-4-2**] 02:00AM BLOOD Digoxin-0.5*
[**2115-4-2**] 02:10AM BLOOD Lactate-1.7

Urine
Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks
LG      NEG       TR    NEG    TR     NEG     NEG   5.0   TR
RBC WBC Bacteri Yeast Epi TransE RenalEp
>50 [**6-1**]* FEW    NONE 0-2
 CYTOLOGY ATYPICAL.
Rare atypical urothelial cells present singly and in loose
clusters.
Squamous cells, histiocytes, neutrophils and red blood cells.

Micro:
Blood cultures 4/11, [**4-11**], [**4-12**]: No growth.
Blood culture [**4-14**]: Presumptive PROPIONIBACTERIUM ACNES [**12-26**]
bottles
[**4-2**]: Monospot negative
[**4-2**] Throat Culture: Beta-hemolytic, non group-A strep, sparse
growth
[**4-2**]: Respiratory virus screen negative on nasopharyngeal
aspirate
[**4-3**] Urine culture negative
[**4-7**] Sputum: No growth
[**4-11**] Sputum:
                             ESCHERICHIA COLI
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------     8 S
CEFEPIME--------------   <=1 S       16 I
CEFTAZIDIME-----------   <=1 S     =>64 R
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------    16 I
CIPROFLOXACIN---------   0.5 S      =>4 R
GENTAMICIN------------   <=1 S        4 S
IMIPENEM--------------   <=1 S          I
LEVOFLOXACIN----------     1 S
MEROPENEM-------------<=0.25 S        8 I
PIPERACILLIN---------- =>128 R    =>128 R
PIPERACILLIN/TAZO-----   <=4 S       64 S
TOBRAMYCIN------------   <=1 S      <=1 S
TRIMETHOPRIM/SULFA----  =>16 R
.
[**4-11**] Stool: C. diff negative
[**4-14**] RPR nonreactive
[**4-14**] Sputum: E. Coli and P. aeruginosa
.
[**4-18**] Video Swallow:
VIDEO OROPHARYNGEAL SWALLOW EXAMINATION: An oral and pharyngeal
video fluoroscopy swallowing study was performed in
collaboration with the Speech and Language Pathology division.
Various consistencies of barium including thin liquid,
nectar-thickened liquid and puree consistencies were
administered.
A single spot fluoroscopic image again demonstrates ossification
of the anterior longitudinal ligament of the cervical spine,
which is unchanged from recent neck CTs on [**4-2**] and [**4-7**], [**2114**].
The oral phase of the study was notable for mild impairment of
bolus formation and control without premature spillover. The
pharyngeal phase was notable for moderate-to-severely impaired
laryngeal elevation and valve closure. There was absent
epiglottic deflection. Following swallow, mild residue remained
in the pharynx and spilled into the airway after the swallow.
In the AP position, bilateral vocal fold adduction was observed.
Left pharyngeal swelling was noted with the left piriform sinus
nearly completely effaced. There was penetration into the
laryngeal vestibule with all consistencies before and after
swallowing. There was aspiration of small amounts of all
consistencies following the swallow due to spillage of material
from the laryngeal vestibule and piriform sinuses. There was a
spontaneous cough upon aspiration.
IMPRESSION: Moderate pharyngeal dysphagia with aspiration of
small amounts of all consistencies after the swallow. A
combination of left pharyngeal swelling and chronic ossification
of the anterior longitudinal spinal ligament contributes to the
swallowing difficulty.
.
[**4-22**] Video Swallow:
An oral and pharyngeal swallowing videofluoroscopy was performed
today in collaboration with the speech and language pathology
division. Various consistencies of barium including thin liquid,
nectar-thickened liquid, puree, and ground cookies and pudding
were administered.
The oral phase was notable for mildly impaired bolus formation
control and anterior to posterior tongue movement. There was
premature spillover of thin and nectar-thickened liquids into
the pharynx prior to initiation of the swallow.
The pharyngeal phase was notable for mild delay in the
pharyngeal swallow. There was moderate-to-severe impairment of
laryngeal elevation and valve closure. Epiglottic deflection was
not demonstrated. Mild-to-moderate amounts of puree and ground
consistencies were retained in the valleculae to a greater
extent than in the piriform sinuses.
In the anterior to posterior position swelling of the left
pharynx was again demonstrated, but improved compared to prior
study last week.
There was penetration of thin and nectar-thickened liquids into
the laryngeal vestibule before and during the swallow. There was
aspiration of thin and nectar-thickened liquids before and after
the swallow. There was a spontaneous cough upon aspiration.
IMPRESSION: Overall improved oropharyngeal swallowing function
compared to [**2115-4-18**] but continued aspiration of thin and
nectar-thickened liquids before and after the swallow.
Improvement in left pharyngeal swelling.


Brief Hospital Course:
# s/p PEA arrest - unclear etiology. Likely secondary to
hypoxia, hypercarbic respiratory acidosis, copious secretions.
Became temporarily hypotensive on pressors with CEs negative.
Pressors quickly weaned without difficulty. Treated with
aggressive suctioning, albuterol/atrovent/flovent.
.
# Supraglottitis - Treated initially with Unasyn. Resolved over
span of [**10-5**] days. Etiology remains unclear. Throat culture
grew sparse B-hemolytic, non-Group-A strep. EBV, blood cultures,
nasopharyngeal aspirate for respiratory viruses all negative.
Possibly angioedema secondary to ACEI, which was immediately
d/c'ed on admission.  On [**4-3**], pt became acutely agitated,
thought to be [**1-24**] steroid psychosis. Intubated for airway
protection in setting of increased need for sedation.  Patient
extubated uneventfully on [**4-5**]. D/c'd Unasyn and Decadron on
[**4-5**] as unclear that these interventions were adding any
benefit. ENT re-eval on [**4-6**] without signs of edema. On [**4-6**],
again became increasingly stridorous, acidotic, hypoxic after
ativan/haldol for agitation and re-intubated. Self-extubated on
[**4-9**].  Reintubated after PEA arrest, as above. Serial neck CTs
demonstrated gradual resolution of soft tissue edema, but did
demonstrate diffuse ossification of the anterior longitudinal
ligament, which likely limits functional reserve, predisposing
Mr. [**Known lastname 66593**] to respiratory distress with small amount of
soft tissue swelling. Speech and swallow evaluation from [**4-7**]
and [**4-18**] demonstrated evidence of aspiration, and Mr.
[**Known lastname 66593**] was kept NPO with NGT in place. As mental status
cleared, repeat S&S evaluation done on [**4-23**], which demonstrated
improvement. Was placed back on carefully observed PO diet, with
repeated teaching regarding safe PO intake. On [**4-23**], consulted
Allergy, who thought it would be safe to restart low-dose [**Last Name (un) **],
as a) possible infectious etiology, and b) relatively small
cross-over effect in likelihood between ACEI and [**Last Name (un) **].
Experienced episode of relative hypotension to SBP 80 after two
doses [**Last Name (un) **], and was d/c'ed prior to d/c. However, did not
experience any resporatory compromise; therefore, should
ACEI/[**Last Name (un) **] become important to Mr. [**Doctor Last Name 66594**] future
medical management, it should be reasonably safe.
.
# Delirium/Psychosis: Probable ICU psychosis vs. steroid
psychosis. Also with positive sputum cultures and leukocytosis,
possible constributing infection component.  Received high doses
Haldol in ICU, QTc remained stable.  Head CT neg [**4-3**], [**4-7**],
[**4-14**].  Psychiatry followed and left recommendations regarding
sedating meds for agitation.  Mental status improved around
[**4-22**], scheduled Haldol d/c'ed, with continued options for prn
Haldol and Seroquel.
.
# CAD: H/o IMI. Cath [**2108**] with 2VD - LAD 60%, LCX 50%. PMIBI at
VA [**11-26**] without ischemic changes. CE neative after PEA arrest.
Maintained on ASA, titrated up BB, reinstituted [**Last Name (un) **] on [**4-23**],
but d/c'ed after episode of hypotension to SBP 80.
.
# HTN- Home regimen includes fosinopril, atenolol, hctz,
terazosin, nifedipine.
Held antihypertensives given hypotension in ICU. Also
experienced episode of relative hypotension to 80/palp on [**4-25**]
after reintroduction of [**Last Name (un) **] to regimen of metoprolol, terazosin,
and [**Last Name (un) **] d/c'ed.
.
# Afib- remains in chronic A fib.  Held coumadin in setting of
supratherapeutic INR, held lopressor/dilt/digoxin in acute
setting. Achieved rate control once reintroducing metoprolol.
Restarted coumadin [**4-26**]. Will need to have INR monitored and
coumadin adjusted to goal INR [**1-25**].
.
# Urinary retention/hematuria - Experienced gross hematuria,
initially in setting of supratherapeutic INR. Experienced
concommitant urinary retention, likely [**1-24**] to clots. Had 24
french 3 way catheter with continuous bladder irrigation in ICU,
d/c'd [**4-12**] as urine cleared. Gross hematuria returned once
called out to floor, with persistent clots despite flushing and
changing foley. Reinstituted 3-way CBI, with urology
consultation. Urine cytology demonstrated atypical cells. Will
need close f/u by urology for outpatient cystoscopy for possible
bladder CA. He will need to renew his application for Freecare
before an outpatient appointment can be made.
.
# FEN -  While NPO, fed via Dobhoff w/ TF's - Promote with
fiber, free water flushes. After POs reinstituted, maintained on
pureed solids, nectar-thick liquids, with closely observed
feeding. Aspiration precautions instituted.

#Code- Full Code


Medications on Admission:
1) ALBUTEROL 90/IPRATROP 18MCG 200D PO INHL INHALE 2 ACTIVE
PUFFS BY MOUTH FOUR TIMES A DAY
2) ASPIRIN 81MG EC TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE
DAY
3) ATENOLOL 100MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY ACTIVE
(S)
4) CAPSAICIN 0.075% CREAM APPLY THIN FILM TO SKIN TWICE ACTIVE
A DAY FOR LOCALIZED PAIN
5) CODEINE 30MG/ACETAMINOPHEN300MG TAB TAKE 1 TABLET BY ACTIVE
MOUTH THREE TIMES A DAY FOR PAIN
6) DIGOXIN (LANOXIN) 0.125MG TAB TAKE ONE TABLET BY ACTIVE
MOUTH EVERY DAY
7) DOCUSATE NA 100MG CAP TAKE ONE CAPSULE BY MOUTH TWICE ACTIVE
A DAY TO SOFTEN STOOL
8) FOSINOPRIL NA 20MG TAB TAKE TWO TABLETS BY MOUTH ACTIVE EVERY
MORNING AND TAKE ONE TABLET EVERY EVENING INCREASE IN DOSE
[**2113-6-27**]
9) HYDROCHLOROTHIAZIDE 25MG TAB TAKE ONE TABLET BY MOUTH ACTIVE
EVERY DAY
10) MENTHOL 10%/METHYL SALICYLATE 15% CREAM APPLY ACTIVE
MODERATE AMOUNT TO SKIN EVERY DAY AS NEEDED FOR
KNEE ARTHRITIS
11) NIFEDIPINE (ADALAT CC) 30MG SA TAB TAKE (DO NOT ACTIVE
CRUSH) ONE TABLET BY MOUTH EVERY DAY FOR HEART
12) OMEPRAZOLE 20MG SA CAP TAKE ONE CAPSULE BY MOUTH ACTIVE
EVERY MORNING 30 MINUTES BEFORE BREAKFAST
(REPLACES RABEPRAZOLE)
13) PSYLLIUM SF ORAL PWD TAKE 1 TABLESPOONFUL BY MOUTH ACTIVE
EVERY DAY (DISSOLVE IN 8OZ WATER/JUICE BEFORE
DRINKING)
14) SIMVASTATIN 80MG TAB TAKE ONE-HALF TABLET BY MOUTH AT ACTIVE
BEDTIME FOR REDUCING CHOLESTEROL
15) TERAZOSIN HCL 5MG CAP TAKE ONE CAPSULE BY MOUTH AT ACTIVE
BEDTIME
16) WARFARIN (COUMADIN) NA 2MG TAB TAKE ONE AND ONE-HALF ACTIVE
TABLETS BY MOUTH EVERY EVENING EXCEPT TAKE TWO TABLETS EVERY
MONDAY TO PREVENT BLOOD CLOTS(ANTICOAGULATION)


Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Disp:*30 Suppository(s)* Refills:*2*
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray
Nasal [**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO HS (at bedtime):
Restarted coumadin [**4-26**] - will need INR checked [**5-2**].
Disp:*120 Tablet(s)* Refills:*2*
8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation prn as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*2*
9. Atrovent 18 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
Disp:*1 inhaler* Refills:*2*
10. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: Two (2) Tablet Sustained Release 24HR PO once a day.
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Supraglottitis
Hematuria


Discharge Condition:
Stable


Discharge Instructions:
You were admitted with supraglottitis, and were intubated in the
ICU. Your swelling has resolved. You were also treated for blood
in your urine, and it is very important that you follow up with
urology. .
You also need to have your coumadin level checked on Thursday,
[**5-2**].

Followup Instructions:
It is important that you follow up at urology clinic with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**]. You will need to finalize your Freecare renewal
before an appointment can be made, but when this is done, you
should call [**Telephone/Fax (1) 5727**] for an appointment.
.
If you have trouble arranging urology follow-up with Dr.
[**Last Name (STitle) 770**], you should try to arrange this through the [**Location 1268**]
system.
{'Supraglottitis unspecified, without obstruction,Other pulmonary insufficiency, not elsewhere classified,Atrial fibrillation,Drug-induced delirium,Chronic airway obstruction, not elsewhere classified,Acidosis,Acute kidney failure, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Edema of larynx,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Foreign body in other specified parts bronchus and lung,Esophageal reflux,Coronary atherosclerosis of native coronary artery,Other and unspecified special symptoms or syndromes, not elsewhere classified,Pure hypercholesterolemia,Abnormal coagulation profile,Unspecified sinusitis (chronic),Anemia of other chronic disease,Unspecified essential hypertension,Old myocardial infarction,Osteoarthrosis, unspecified whether generalized or localized, lower leg,Adrenal cortical steroids causing adverse effects in therapeutic 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: Throat swelling

PRESENT ILLNESS: 85 y.o. M with hx of HTN, AFib, GERD p/w with 1 wk hx of neck
swelling, dyspagia of solids and liquids, felt to have
supraglottitis, started on high dose steroids.  He initially was
started on steroids, but developed delirium and agitation,
requiring intubation for airway protection.  Steroids were
weaned off.  The cause of his supraglottitis was thought to be
angioedema [**1-24**] ACE-I, however pt states that he has been taking
his medicines for a long time.  Pt extubated, but had worsening
stridor, hypoxemia and reintubated electively.  He then
self-extubated on [**4-9**], but on [**4-12**] was found to be
unresponsive, hypercarbic and in PEA arrest, and reintubated.
Given atropine, epi and on pressors for 1 day.  Pt finally
extubated on [**4-16**], no respiratory problems since then.
Otherwise MICU course complicated by rapid AF requiring IV
lopressor, large amount of secretion, and sputum cx's with
e.coli and pseudomonas, started on Zosyn on [**4-15**] for sinusitis
by head CT on [**4-14**].  In addition, pt has required NGT for
nutrition given concern for aspiration, however pulled out
earlier today.  Video swallow study earlier today showed some
evidence of aspiration and assymetrical neck swelling.
On further hx pt admits to preceding subjective fever, denies
chills.  Also admits to lots of rhinorrhea, nasal congestion.  +
sick contacts with grandchildren.  He denies chills, diarrhea,
cough, shortness of breath, urinary sx's, rash, recent
medication changes.  He is followed at [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 669**] VA.  He was
born in [**Male First Name (un) 1056**], moved to US in [**2060**], unclear status of
vaccinations.

MEDICAL HISTORY: chronic AFib-anticoagulation on coumadin s/p DCCV in 12/99
HTN
Borderline CAD - cath [**11/2109**]- 2. Selective coronary angiography
reveals a right dominant system with two vessel disease. The
left main tapers distally to a 40% stenosis. There is ostial
disease of all vessels at the trifurcation: LAD 60%, ramus
40-50%, LCX 50%. The RCA is small, but dominant, without focal
stenosis.
?CAD -s/p IMI
diabetes mellitus
COPD
BPH/Increased PSA
Hypercholesterol
OA- knees
-Possible Osggod Schlatter right knee
Syncope [**4-/2107**] - neg w/u (tilt, EP, DSE)
GI bleed [**10-24**]
-EGD: [**10-24**] - Single non-bleeding ulcer at antrum, single non-
bleeding superficial ulcer in duodenum
-Colonoscopy [**10-24**] - polyps (HP x 2, TA x 1)
[**8-/2114**]- ext hemorrhoids

MEDICATION ON ADMISSION: 1) ALBUTEROL 90/IPRATROP 18MCG 200D PO INHL INHALE 2 ACTIVE
PUFFS BY MOUTH FOUR TIMES A DAY
2) ASPIRIN 81MG EC TAB TAKE ONE TABLET BY MOUTH EVERY ACTIVE
DAY
3) ATENOLOL 100MG TAB TAKE ONE TABLET BY MOUTH EVERY DAY ACTIVE
(S)
4) CAPSAICIN 0.075% CREAM APPLY THIN FILM TO SKIN TWICE ACTIVE
A DAY FOR LOCALIZED PAIN
5) CODEINE 30MG/ACETAMINOPHEN300MG TAB TAKE 1 TABLET BY ACTIVE
MOUTH THREE TIMES A DAY FOR PAIN
6) DIGOXIN (LANOXIN) 0.125MG TAB TAKE ONE TABLET BY ACTIVE
MOUTH EVERY DAY
7) DOCUSATE NA 100MG CAP TAKE ONE CAPSULE BY MOUTH TWICE ACTIVE
A DAY TO SOFTEN STOOL
8) FOSINOPRIL NA 20MG TAB TAKE TWO TABLETS BY MOUTH ACTIVE EVERY
MORNING AND TAKE ONE TABLET EVERY EVENING INCREASE IN DOSE
[**2113-6-27**]
9) HYDROCHLOROTHIAZIDE 25MG TAB TAKE ONE TABLET BY MOUTH ACTIVE
EVERY DAY
10) MENTHOL 10%/METHYL SALICYLATE 15% CREAM APPLY ACTIVE
MODERATE AMOUNT TO SKIN EVERY DAY AS NEEDED FOR
KNEE ARTHRITIS
11) NIFEDIPINE (ADALAT CC) 30MG SA TAB TAKE (DO NOT ACTIVE
CRUSH) ONE TABLET BY MOUTH EVERY DAY FOR HEART
12) OMEPRAZOLE 20MG SA CAP TAKE ONE CAPSULE BY MOUTH ACTIVE
EVERY MORNING 30 MINUTES BEFORE BREAKFAST
(REPLACES RABEPRAZOLE)
13) PSYLLIUM SF ORAL PWD TAKE 1 TABLESPOONFUL BY MOUTH ACTIVE
EVERY DAY (DISSOLVE IN 8OZ WATER/JUICE BEFORE
DRINKING)
14) SIMVASTATIN 80MG TAB TAKE ONE-HALF TABLET BY MOUTH AT ACTIVE
BEDTIME FOR REDUCING CHOLESTEROL
15) TERAZOSIN HCL 5MG CAP TAKE ONE CAPSULE BY MOUTH AT ACTIVE
BEDTIME
16) WARFARIN (COUMADIN) NA 2MG TAB TAKE ONE AND ONE-HALF ACTIVE
TABLETS BY MOUTH EVERY EVENING EXCEPT TAKE TWO TABLETS EVERY
MONDAY TO PREVENT BLOOD CLOTS(ANTICOAGULATION)

ALLERGIES: Ace Inhibitors

PHYSICAL EXAM: T 98.9 P 83 BP 128/47 RR 18 O2 96% RA, wt 88 kg complains of
mild sob when flat
Gen: no respiratory distress, no noticable gurgling, minimal
drooling
HEENT: EOMI, PERRLA, +trismus, erythema, difficult to visulize
tonsills, swelling R>L
LN: +submandibular lymph nodes right>L
Lungs: CTA x 2
Heart: s1 s2 no m/r/g
Abd: soft nt/nd +bs
Ext: no c/c/e
CN II-XII intact
AOx3

FAMILY HISTORY: NC

SOCIAL HISTORY: 110 pack year smoking hx, quit 3 years ago, occais etoh. Lives
alone, independent in all adl's 

### Response:
{'Supraglottitis unspecified, without obstruction,Other pulmonary insufficiency, not elsewhere classified,Atrial fibrillation,Drug-induced delirium,Chronic airway obstruction, not elsewhere classified,Acidosis,Acute kidney failure, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Edema of larynx,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Foreign body in other specified parts bronchus and lung,Esophageal reflux,Coronary atherosclerosis of native coronary artery,Other and unspecified special symptoms or syndromes, not elsewhere classified,Pure hypercholesterolemia,Abnormal coagulation profile,Unspecified sinusitis (chronic),Anemia of other chronic disease,Unspecified essential hypertension,Old myocardial infarction,Osteoarthrosis, unspecified whether generalized or localized, lower leg,Adrenal cortical steroids causing adverse effects in therapeutic use'}
