CHIEF COMPLAINT: dyspnea

PRESENT ILLNESS: The patient is a 62-year-old
gentleman who has severe COPD was found have severe diffuse
tracheobronchomalacia.  He had marked improvement in dyspnea
with a silicone Y-stent, and presents for
tracheobronchoplasty.  He is using inhalers as prescribed
with some sx improvement and using oxygen at night. Without O2
he
is satting about 88-90%.

MEDICAL HISTORY: # Diabetes mellitus type 2
-- followed at [**Last Name (un) **], on Insulin and Victoza
-- last HgbA1c 9.2% on [**2202-12-14**]
# COPD -- former heavy smoker
-- good functional capacity
# Tracheobronchomalacia
-- severe on CT and bronchoscopy ([**8-/2202**])
-- excellent results with stent trial
-- considering tracheobronchoplasty
# Diastolic CHF
-- seen by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Cardiology
-- last echo ([**2200-9-19**]) with LVEF > 60%
-- stable on Furosemide 60 mg PO daily
-- mild lower extremity edema
# Osteoarthritis -- stable symptoms
# Narcotics Contract -- stable Percocet regimen
-- last renewed on [**2202-3-3**]
# Hypertension -- recently added Hydralazine
# GERD -- no symptoms recently
# Chronic kidney disease stage III
-- seen by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]
-- stable creatinine around 1.5
-- Calcitriol for elevated PTH

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 40 mg PO DAILY
2. Allopurinol 100 mg PO BID
3. Atenolol 50 mg PO BID
4. Amlodipine 10 mg PO DAILY
5. HydrALAzine 50 mg PO BID
6. Atorvastatin 80 mg PO DAILY
7. Humalog 75/25 80 Units Breakfast
Humalog 75/25 40 Units Lunch
Humalog 75/25 70 Units Dinner
8. Furosemide 60 mg PO DAILY
9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain
10. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
11. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >
12. Aspirin 81 mg PO DAILY
13. Tamsulosin 0.4 mg PO HS
14. Ipratropium Bromide MDI 2 PUFF IH QID
15. Calcitriol 0.25 mcg PO EVERY OTHER DAY
16. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)

ALLERGIES: Anacin

PHYSICAL EXAM: BP: 171/70. Heart Rate: 63. Weight: 251.8. BMI: 35.4.
Temperature: 95.7. O2 Saturation%: 90.

FAMILY HISTORY: # Mother -- died at age 58 from DM complications
# Father -- died at age 73 from "[**Last Name **] problem" but not MI

SOCIAL HISTORY: # Diet: He has had difficulty improving his diet. His weight
has remained fairly stable.
# Exercise: Walks approximately one mile each day and is fairly
Other diseases of trachea and bronchus,Acute respiratory failure following trauma and surgery,Ventilator associated pneumonia,Candidiasis of mouth,Acute kidney failure, unspecified,Chronic diastolic heart failure,Iatrogenic pneumothorax,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Chronic airway obstruction, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Esophageal reflux,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of tobacco use
Trachea & bronch dis NEC,Ac resp flr fol trma/srg,Ventltr assoc pneumonia,Thrush,Acute kidney failure NOS,Chr diastolic hrt fail,Iatrogenic pneumothorax,Oth gram negatv bacteria,Chr airway obstruct NEC,DMII wo cmp nt st uncntr,Long-term use of insulin,Hy kid NOS w cr kid I-IV,Chr kidney dis stage III,Esophageal reflux,Abn react-procedure NEC,History of tobacco use
Admission Date:  [**2203-8-3**]              Discharge Date:   [**2203-8-29**]

Date of Birth:  [**2140-12-30**]             Sex:   M

Service: CARDIOTHORACIC

Allergies:
Anacin

Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
dyspnea

Major Surgical or Invasive Procedure:
[**2203-8-3**]
Right thoracotomy and tracheoplasty with mesh,
right mainstem bronchus and bronchus intermedius
bronchoplasty with mesh, left mainstem bronchus bronchoplasty
with mesh, bronchoscopy with bronchoalveolar lavage.

[**2203-8-15**] -
tracheostomy

[**2203-8-25**]
Flexible bronchoscopy with bronchoalveolar lavage.


History of Present Illness:
The patient is a 62-year-old
gentleman who has severe COPD was found have severe diffuse
tracheobronchomalacia.  He had marked improvement in dyspnea
with a silicone Y-stent, and presents for
tracheobronchoplasty.  He is using inhalers as prescribed
with some sx improvement and using oxygen at night. Without O2
he
is satting about 88-90%.

He had a mild URI several months ago and fully recovered from
it.
He is able to walk several blocks w/o stopping; he is OK going
up
one flight of stairs but usually needs a break at the end.

He presents now for surgery.

Past Medical History:
# Diabetes mellitus type 2
-- followed at [**Last Name (un) **], on Insulin and Victoza
-- last HgbA1c 9.2% on [**2202-12-14**]
# COPD -- former heavy smoker
-- good functional capacity
# Tracheobronchomalacia
-- severe on CT and bronchoscopy ([**8-/2202**])
-- excellent results with stent trial
-- considering tracheobronchoplasty
# Diastolic CHF
-- seen by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Cardiology
-- last echo ([**2200-9-19**]) with LVEF > 60%
-- stable on Furosemide 60 mg PO daily
-- mild lower extremity edema
# Osteoarthritis -- stable symptoms
# Narcotics Contract -- stable Percocet regimen
-- last renewed on [**2202-3-3**]
# Hypertension -- recently added Hydralazine
# GERD -- no symptoms recently
# Chronic kidney disease stage III
-- seen by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]
-- stable creatinine around 1.5
-- Calcitriol for elevated PTH

Social History:
# Diet: He has had difficulty improving his diet. His weight
has remained fairly stable.
# Exercise: Walks approximately one mile each day and is fairly

physically active given his medical issues.
# Smoking: Quit approximately six years ago and previously
smoked 0.5-1 pack per day since the age of 12.
# Alcohol: No alcohol in 15 years, stopped after getting sick
from drinking too much wine at a party.
# Drugs: None


Family History:
# Mother -- died at age 58 from DM complications
# Father -- died at age 73 from "[**Last Name **] problem" but not MI


Physical Exam:
BP: 171/70. Heart Rate: 63. Weight: 251.8. BMI: 35.4.
Temperature: 95.7. O2 Saturation%: 90.

Alwake alert oriented
lungs clear w/o wheezing
heart regular
abd soft, not distended


Pertinent Results:
[**2203-8-3**] 11:20AM   HGB-15.1 calcHCT-45
[**2203-8-3**] 01:17PM   HGB-14.6 calcHCT-44 O2 SAT-97 MET HGB-0
[**2203-8-3**] 01:17PM   GLUCOSE-119* LACTATE-1.4 NA+-140 K+-3.7
CL--104 TCO2-27
[**2203-8-3**] 05:27PM   WBC-16.1*# RBC-5.43 HGB-14.5 HCT-45.6 MCV-84
MCH-26.6* MCHC-31.7 RDW-16.3*
[**2203-8-3**] 05:27PM   CALCIUM-7.9* PHOSPHATE-4.9*# MAGNESIUM-1.5*
[**2203-8-3**] 05:27PM   CK-MB-14* MB INDX-0.8
[**2203-8-3**] 05:27PM   CK(CPK)-1719*
[**2203-8-3**] 05:27PM   GLUCOSE-136* UREA N-18 CREAT-1.6* SODIUM-141
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-27 ANION GAP-11

[**2203-8-14**] Chest CT :
1. Status post tracheobronchoplasty. ET tube in place with fluid
within the distal trachea. Persistent narrowing of the central
airways.
2. Since [**2203-8-1**], new large right, and moderate left
loculated pleural effusions.
3. New diffuse bilateral ground glass opacities with prominent
pulmonary
vasculature, likely edema.
4. Bilateral lower lobe opacities, likely atelectasis, cannot
exclude
infection.
5. Emphysema.
6. Prior granulomatous disease.

[**2203-8-18**] Bilat lower ext duplex :
 No evidence of deep vein thrombosis in either leg.

[**2203-8-23**] Chest CT :
1.  Extensive bilateral diffuse ground-glass opacities with
associated
bibasilar severe atelectasis and small pleural effusions along
with the severe tracheobronchial stenosis suggest that a
combination of upper airway obstruction, pulmonary edema,
atelectasis, and likely a concurrent infectious process might be
contributing to the patient's difficulty to wean off the vent.
2.  Enlarged mediastinal lymph nodes, not significantly changed
compared with prior studies.

[**2203-8-29**] CXR :
In comparison with the study of [**8-27**], the monitoring and support

devices remain in place.  Continued enlargement of the cardiac
silhouette with indistinct pulmonary vessels and bilateral areas
of pulmonary opacification, consistent with pulmonary edema and
multifocal pneumonia.


[**2203-8-12**] 4:20 pm SPUTUM      SPUTUM.

                            **FINAL REPORT [**2203-8-15**]**

   GRAM STAIN (Final [**2203-8-12**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2203-8-15**]):
      Commensal Respiratory Flora Absent.
      PSEUDOMONAS AERUGINOSA.    SPARSE GROWTH.
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].
      SERRATIA MARCESCENS.    SPARSE GROWTH.
         This organism may develop resistance to third
generation
         cephalosporins during prolonged therapy. Therefore,
isolates that
         are initially susceptible may become resistant within
three to
         four days after initiation of therapy.  For serious
infections,
         repeat culture and sensitivity testing may therefore be
warranted
         if third generation cephalosporins were used.
         Piperacillin/tazobactam sensitivity testing available
on request.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |          SERRATIA MARCESCENS
                             |          |
CEFEPIME--------------     2 S      <=1 S
CEFTAZIDIME-----------     4 S      <=1 S
CEFTRIAXONE-----------              <=1 S
CIPROFLOXACIN---------<=0.25 S   <=0.25 S
GENTAMICIN------------   <=1 S      <=1 S
MEROPENEM-------------<=0.25 S   <=0.25 S
PIPERACILLIN/TAZO-----       S
TOBRAMYCIN------------   <=1 S        4 S
TRIMETHOPRIM/SULFA----              <=1 S

 [**2203-8-18**] 11:42 am BRONCHOALVEOLAR LAVAGE

                            **FINAL REPORT [**2203-8-22**]**

   GRAM STAIN (Final [**2203-8-18**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2203-8-22**]):
      Commensal Respiratory Flora Absent.
      PSEUDOMONAS AERUGINOSA.
         >100,000 ORGANISMS/ML. OF TWO COLONIAL MORPHOLOGIES.
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].
      SERRATIA MARCESCENS.    10,000-100,000 ORGANISMS/ML..
         This organism may develop resistance to third
generation
         cephalosporins during prolonged therapy. Therefore,
isolates that
         are initially susceptible may become resistant within
three to
         four days after initiation of therapy.  For serious
infections,
         repeat culture and sensitivity testing may therefore be
warranted
         if third generation cephalosporins were used.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |          SERRATIA MARCESCENS
                             |          |
CEFEPIME--------------     4 S      <=1 S
CEFTAZIDIME-----------     4 S      <=1 S
CEFTRIAXONE-----------              <=1 S
CIPROFLOXACIN---------   0.5 I   <=0.25 S
GENTAMICIN------------   <=1 S      <=1 S
MEROPENEM-------------     1 S   <=0.25 S
PIPERACILLIN/TAZO-----       S
TOBRAMYCIN------------   <=1 S        8 I
TRIMETHOPRIM/SULFA----              <=1 S

[**2203-8-25**] 12:37 pm BRONCHOALVEOLAR LAVAGE

   GRAM STAIN (Final [**2203-8-25**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      2+   (1-5 per 1000X FIELD):   BUDDING YEAST WITH
PSEUDOHYPHAE.

   RESPIRATORY CULTURE (Final [**2203-8-27**]):
      Commensal Respiratory Flora Absent.
      YEAST.    10,000-100,000 ORGANISMS/ML..
      GRAM NEGATIVE ROD(S).    ~[**2191**]/ML.  FURTHER WORKUP ON
REQUEST ONLY.
         Isolates are considered potential pathogens in amounts
>=10,000
         cfu/ml.

   FUNGAL CULTURE (Preliminary):
      YEAST.






Brief Hospital Course:
Mr. [**Known lastname 108993**] is a 62 year old admitted for tracheobronchomalacia
on whom we performed tracheobronchoplasty with posterior
splinting on [**2203-8-3**].  The procedure went without
complications.  Post-operatively in the PACU he failed to
extubate and was transferred to the trauma ICU.  A chest xray at
the time showed that the endotracheal tube ended 3.9cm above
carina.  The right chest tube was in place. There was only mild
pulmonary edema, no pneumothorax, and bibasilar atelectasis.  At
the time he developed low urine output and received a 500 mL
bolus.  He was found to have persistent metabolic acidosis.

On POD1, his chest tube was set to waterseal.  A second attempt
was made to extubate.  He became hypoxic with oxygen saturations
at 88%, so he was placed to CPAP.  Due to respiratory distress,
however, he required reintubation.  At the time, a chest xray
revealed subcutaneous emphysema tracking along the anterior
chest wall and a pneumothorax.  The chest tube was placed back
onto -20 cm H2O suction.

On POD2, his creatinine was elevated to 2.6.  A FeNa was 0.2%
and FeUrea was 31.8%.  The patient was on furosemide at the
time, so intrinsic renal failure was suspected given the FeUrea
as FeNa is unreliable in patients on furosemide.  He was put on
D5 normal saline, and tube feeds were started via an orogastric
tube.  A chest xray at the time reveals a stable pneumothorax.
A PICC line was placed for additional access.

On POD3, the pleurovac was found to have a systems leak and was
replaced.  Tube feeds were advanced every 6 hours.  FeUrea was
43.3, a non-diagnostic value.  Creatinine was stable at 2.  A
sputum culture from POD1 grew our rare gram negative rods.

On POD4, to optimize respiratory status, furosemide was
continued and a 60mg IV dose administered.  Mr. [**Known lastname 108993**] was
started on levofloxacin and piperacillin/tazobactam at this time
too because of the cultures.  He was also having hypertension,
and his metoprolol was increased from twice daily to thrice
daily.  We felt at this time the chest tube was working against
the patient's ability to exhale efficiently, so we removed the
chest tube.  He developed a fever or 102.7 and so cultures were
drawn.

On POD5, the sputum cultures grew out pansensitive pseudomonas
aeruginosa.  Because of persistent hypertension with systolic
blood pressures reaching the 190s, a labetalol drip was started
and hydralazine started, which achieved better control.  His
FiO2 was increased from 40% to 60% due to low saturations of
80%.

On POD6, he pass a spontaneous breathing trial on 0 and 5
inspiratory pressure support settings; however, after an
extubation trial he became hypoxic at 5 minutes, desatting to
70%.  He also became tachypnic and so he was reintubated.  To
optimize his ventilatory status, a fluid deficit was desired.
To achieve it, his drips were concentrated.  His cumulative
balance that day was -500 mL.

On POD7, a new left subclavian line was placed to begin a
furosemide drip.  Inhaled steroids were also added in an effort
to optimize respiratory status.

On POD8, sensitivities came back on the pseudomonas cultures,
and vancomycin was discontinued.  Ciprofloxacin was changed to
PO.  Fluid balance was -1.6L.

On POD9, copious secretions were noted and repeat sputum
cultures obtained.  Fluid balance was -2.4L.

On POD10, he developed a WBC of 18 and low grade temperatures,
so he was pan-cultured.  To double cover pseudomonas,
piperacillin/tazobactam was started.  The U/A was not conclusive
for infection.

On POD 11, WBC continued to rise to 21.  A CT of the chest was
performed to search a source that was potentially drainable.  A
large right pleural effusion was found as well as a smaller,
left-sided loculated effusion.  His PICC was draining purulent
materal, and a PICC culture was sent but ultimately grew out
nothing (final).  His bronchoalveolar lavage culture was 2+PMNs,
and grew out pseudomonas again.

On POD12/0, a tracheostomy was performed in the OR.  The
operation went without complications, and post-operatively the
patient was transferred directly to the trauma ICU.  A Dobhoff
tube was placed, and a thoracentesis of the pleural effusion was
performed with cultures sent.  No organisms were isolated.

On POD13/1, loose stools prompted a C. diff toxin assay, which
was negative.  He had increased hypertension, so labetalol IV
was given.  His sedation medication, lorazepam, was switched to
propofol in an effort to reduce his hypertension.  A blood gas
revealed respiratory alkalosis.

On POD14/2, patient was foudn to have increased abdominal
distention, and a KUB showed ileus.  NGT was placed to low
continuous suction, tube feeds held.  Methylnaltrexone, a
mu-opioid antagonist, was trialed with no effect.  He was found
also on CXR to have a R>L pleural effusion, for which
interventional pulmonology was consulted for pigtail placement.
 He continued to be diuresed, receiving 40 mg furosemide IV.  He
was also febrile to 101.3 and so he was pan-cultured.  Although
the urine, pleural fluid, and blood cultures were negative, the
sputum culture grew out serratia marcesens and pseudomonal
aeruginosa.

On POD15/3, bronchoscopy was performed for respiratory
secretions.  He was hypertensive and started on a labetalol
drip.  Based on ID recommendations, he was switched to cefepime.
 At this time, the source of leukocytosis was unclear but it was
suggested the mesh may be colonized with pseudomonas aeruginosa.
 The pulmonology team, who had been consulted for failure to
extubate, felt a wise course would be to permit lung rest on the
ventilator and allow the pneumonia to pass prior to subsequent
extubation attempts.  So, he remained on the ventilator on
POD16/4, and that day was otherwise unremarkable.

On POD17/5, the pigtail catheter was removed; however, due to
high PEEP requirements, the trauma ICU was unable to attempt
trach mask.  In an effort for further diuresis, on POD18/6 the
tube feeds were concentrated.  Also he was switched to D5 1/2NS
for hypernatremia.  Despite having been found to have persistent
copious secretions, Mr. [**Known lastname 108993**] was able to be weaned to CPAP
[**1-16**].  He self-discontinued his arterial line, which was
replaced.

On POD19/7, his mental status continued to improve, and bowel
sounds were noted.  Tube feeds were continued at goal.

On POD20/8, his mental status continued to improve and he was
able to answer questions.  Despite SaO2>95%, he was having
episodes of agitation, which improved with lorazepam.  He was
started on inhaled tobramycin for double-coverage of
pseudomonas.  A repeat CT chest did not show an appreciable
drainable effusion.  He was switched back to assist control for
increased tachypnea despite normal oxygen saturations.

On POD21/9 he had a J tube placed and tube feedings were
continued which were well tolerated.  His insulin requirements
were graduaklly decreasing as his infection was controlled and
his insulin was adjusted appropriately.

Over the last few days his WBC had decreased nicely to the 14
range and he remains afebrile on Cefepine ( started [**2203-8-19**]) and
inhaled Tobra (started [**2203-8-23**]). His antibiotics should continue
thru [**2203-9-14**]. His secretions have decreased since his last
bronchoscopy on [**2203-8-25**].  There was no exposed mesh or purulence
noted.  He has been weaning better with good CPAP trials and
remains on O2 at 50% with IPS and PEEP both at 8 cm.

He also has been evaluated by the Physical Therapy service
closely and he needs continued encouragement and maximum
assistance to increase his mobility and evantually be more
independent.  After a long, complicated course, he was
discharged to rehab of [**2203-8-29**] and will follow up with Dr.
[**Last Name (STitle) **] in 2 weeks.


Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 40 mg PO DAILY
2. Allopurinol 100 mg PO BID
3. Atenolol 50 mg PO BID
4. Amlodipine 10 mg PO DAILY
5. HydrALAzine 50 mg PO BID
6. Atorvastatin 80 mg PO DAILY
7. Humalog 75/25 80 Units Breakfast
Humalog 75/25 40 Units Lunch
Humalog 75/25 70 Units Dinner
8. Furosemide 60 mg PO DAILY
9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain
10. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
11. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >
12. Aspirin 81 mg PO DAILY
13. Tamsulosin 0.4 mg PO HS
14. Ipratropium Bromide MDI 2 PUFF IH QID
15. Calcitriol 0.25 mcg PO EVERY OTHER DAY
16. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)


Discharge Medications:
1. Furosemide 40 mg PO DAILY
2. NPH 35 Units Breakfast
NPH 25 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
3. HydrALAzine 50 mg PO BID
4. Albuterol Inhaler 6 PUFF IH Q2H:PRN Wheeze
5. Albuterol-Ipratropium 6 PUFFS IH Q6H
6. Bisacodyl 10 mg PO/PR [**Hospital1 **]
7. CefePIME 2 g IV Q8H
thru [**2203-9-14**]
8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation.
9. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QWED
10. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
11. Docusate Sodium 100 mg PO BID
12. Famotidine 20 mg PO BID
13. Fluconazole 100 mg PO Q24H Duration: 7 Days
thru [**2203-9-5**]
14. Heparin 5000 UNIT SC TID
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. HYDROmorphone (Dilaudid) 0.5-2 mg IV Q3H:PRN pain
17. Labetalol 300 mg PO TID HTN
Hold for SBP<120, HR<50.
18. Lorazepam 1-2 mg IV Q4H:PRN agitation
19. Maalox/Diphenhydramine/Lidocaine 15-30 mL PO TID:PRN mouth
sores
20. Metoclopramide 5 mg PO QIDACHS
21. Ondansetron 4 mg IV Q8H:PRN nausea
22. Senna 1 TAB PO BID
23. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
24. Tobramycin Inhalation Soln 300 mg NEB [**Hospital1 **]
thru [**2203-9-14**]
25. Atorvastatin 80 mg PO DAILY


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - MACU

Discharge Diagnosis:
Tracheobronchomalacia
Pseudomonas and serratia pneumonia
Respiratory insufficiency
Thrush


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
* You were admitted to the hospital for surgery to improve your
airway.  Unfortunately you had difficulty breathing on your own
and you required a tracheostomy along with help from a
respirator.
* You are slowly improving and will need time to get stronger
and totally wean from the respirator.
* You are4 being fed through a feeding tube in your stomach but
in time you should be able to swallow and eat regular food.
* You will need to participate in Physical Therapy to get strong
and begin to walk again.
* Dr. [**Last Name (STitle) **] will continue to follow you in the Clinic.


Followup Instructions:
You will need to be seen by Dr. [**Last Name (STitle) **] in the Thoracic
Surgery Clinic on [**2203-9-13**].  His secretary will call the
rehab to arrange a time. ([**Telephone/Fax (1) 16996**])
Please report 30 minutes prior to your appointment to the
Radiology Department on the [**Location (un) 470**] of the [**Location (un) 40900**] for a chest xray.



Completed by:[**2203-8-29**]
{'Other diseases of trachea and bronchus,Acute respiratory failure following trauma and surgery,Ventilator associated pneumonia,Candidiasis of mouth,Acute kidney failure, unspecified,Chronic diastolic heart failure,Iatrogenic pneumothorax,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Chronic airway obstruction, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Esophageal reflux,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,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: dyspnea

PRESENT ILLNESS: The patient is a 62-year-old
gentleman who has severe COPD was found have severe diffuse
tracheobronchomalacia.  He had marked improvement in dyspnea
with a silicone Y-stent, and presents for
tracheobronchoplasty.  He is using inhalers as prescribed
with some sx improvement and using oxygen at night. Without O2
he
is satting about 88-90%.

MEDICAL HISTORY: # Diabetes mellitus type 2
-- followed at [**Last Name (un) **], on Insulin and Victoza
-- last HgbA1c 9.2% on [**2202-12-14**]
# COPD -- former heavy smoker
-- good functional capacity
# Tracheobronchomalacia
-- severe on CT and bronchoscopy ([**8-/2202**])
-- excellent results with stent trial
-- considering tracheobronchoplasty
# Diastolic CHF
-- seen by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in Cardiology
-- last echo ([**2200-9-19**]) with LVEF > 60%
-- stable on Furosemide 60 mg PO daily
-- mild lower extremity edema
# Osteoarthritis -- stable symptoms
# Narcotics Contract -- stable Percocet regimen
-- last renewed on [**2202-3-3**]
# Hypertension -- recently added Hydralazine
# GERD -- no symptoms recently
# Chronic kidney disease stage III
-- seen by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]
-- stable creatinine around 1.5
-- Calcitriol for elevated PTH

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Lisinopril 40 mg PO DAILY
2. Allopurinol 100 mg PO BID
3. Atenolol 50 mg PO BID
4. Amlodipine 10 mg PO DAILY
5. HydrALAzine 50 mg PO BID
6. Atorvastatin 80 mg PO DAILY
7. Humalog 75/25 80 Units Breakfast
Humalog 75/25 40 Units Lunch
Humalog 75/25 70 Units Dinner
8. Furosemide 60 mg PO DAILY
9. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO TID:PRN pain
10. Fluticasone-Salmeterol Diskus (250/50)  1 INH IH [**Hospital1 **]
11. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours
Hold for K >
12. Aspirin 81 mg PO DAILY
13. Tamsulosin 0.4 mg PO HS
14. Ipratropium Bromide MDI 2 PUFF IH QID
15. Calcitriol 0.25 mcg PO EVERY OTHER DAY
16. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)

ALLERGIES: Anacin

PHYSICAL EXAM: BP: 171/70. Heart Rate: 63. Weight: 251.8. BMI: 35.4.
Temperature: 95.7. O2 Saturation%: 90.

FAMILY HISTORY: # Mother -- died at age 58 from DM complications
# Father -- died at age 73 from "[**Last Name **] problem" but not MI

SOCIAL HISTORY: # Diet: He has had difficulty improving his diet. His weight
has remained fairly stable.
# Exercise: Walks approximately one mile each day and is fairly 

### Response:
{'Other diseases of trachea and bronchus,Acute respiratory failure following trauma and surgery,Ventilator associated pneumonia,Candidiasis of mouth,Acute kidney failure, unspecified,Chronic diastolic heart failure,Iatrogenic pneumothorax,Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other gram-negative organisms,Chronic airway obstruction, not elsewhere classified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Long-term (current) use of insulin,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, Stage III (moderate),Esophageal reflux,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Personal history of tobacco use'}
