CHIEF COMPLAINT: Respiratory distress

PRESENT ILLNESS: 40yo female with a history of esophageal cancer s/p trach was
admitted from the ED with respiratory distress.
.
She has a tracheostomy in place due to esophageal cancer.
According to her family, she was exerting herself when she was
"air hungry." EMS presented and took the tracheostomy out and
noted a small plug in the tracheostomy itself. Upon arrival to
the ED, 97.9, HR 119, 111/82, RR 19, and pulse ox 99% on 12L
trach mask. Her exam was notable for tachycardia only. Her labs
were notable for elevated WBC to 12.9, and her imaging was
notable for CXR with left-sided pneumonia. She received
levofloxacin 750mg IV x 1, vancomycin 1g IV x 1, zosyn 4.5g IV x
1, potassium chloride 40mEq x 1, and morphine 4mg IV x 1. She
was evaluated by thoracics who replaced her tracheostomy and
they recommended further evaluation for her pneumonia.

MEDICAL HISTORY: - Metastatic esophageal Cancer
  ---> EGD - [**2130-6-1**] that was successful on the third attempt
and tissue biopsy at that time revealed an invasive squamous
cell carcinoma.
  ---> [**2130-7-13**] - started on Cetuximab with concurrent radiation.
She completed her radiation therapy on [**2130-8-24**] for a total of
6600 Gy. She also completed her Erbitux therapy at that time.
  ---> [**12-4**] She was admitted with nausea and vomiting and found
to have evidence of tracheal obstruction. In addition, she had a
CT of her neck, which was concerning for perforation. Thoracics
was consulted and felt that she would benefit from a
tracheostomy for airway protection, which was placed on
[**2130-12-8**]. She tolerated this well. She was noted to have a left
upper lobe cavitary lesion on the CT scan. She underwent a wedge
resection on [**2130-1-11**], which revealed carcinomatous plaques on
the pleural wall. This was confirmed to be a metastatic disease
on frozen section. In terms of her tracheostomy, she was
decannulated on [**2131-1-17**]. During the hospitalization she was
treated for pharyngeal abscess and had issues with tachycardia
as well as hypotension. She was discharged home on [**2131-1-19**].
  ---> [**2131-3-13**] - began a palliative chemotherapy regimen of 5-FU
and carboplatin on [**2131-3-13**].
- anemia.
- J tube placed by surgery via an open procedure in [**4-4**]
- constipation
- hypercalcemia
- tachycardia of unknown etiology
- tracheostomy
    ---->[**12-4**] - Tracheostomy placed due to supraglottic edema
in the setting of esophageal perforation
    ----> [**3-5**] - Tracheostomy placed due to vocal cord paralysis
and stridor

MEDICATION ON ADMISSION: 1. Oxygen - 35% continuous via tracheal mask with cool mist via
[**Last Name (un) **]
compressor.
2. Methadone 10 mg PO qhs / 5mg PO qAM
3. Lorazepam 0.5 - 1mg PO bid
4. Lactulose 20gm PO bid
5. Lansoprazole 30mg PO daily
6. Nortriptyline 10mg PO qhs prn insomnia
7. Compazine 25mg PR q6h prn nausea
8. Acetaminophen prn pain
9. Lidocaine patch q12h on and off
10. Guaifenesin prn
11. Morphine 10mg PO q4h prn pain

ALLERGIES: Roxicet

PHYSICAL EXAM: Gen: no acute distress, resting comfortably in bed, fatigued but
interacting appropriately
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD, trach in place without erythema,
tenderness, or discharge
CV: RR, tachycardic, NL S1, S2. No murmurs, rubs or gallops
LUNGS: decreased breath sounds at the left lower base
ABD: Soft, NT, ND. NL BS. No HSM. G tube in place without
erythema, drainage.
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: Maternal aunt - breast cancer.
Her mother and father are alive and healthy and siblings are all
alive and healthy.

SOCIAL HISTORY: Home: Originally from [**Country 3587**] and Portuguese-Creole Speaking
only Lives at home with her cousin and husband who care for her.
Mechanical complication of tracheostomy,Bacterial pneumonia, unspecified,Malignant neoplasm of other specified part of esophagus,Secondary malignant neoplasm of lung,Mechanical complication of colostomy and enterostomy,Hypercalcemia,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Neoplasm related pain (acute) (chronic),Other constipation,Hypopotassemia,Anemia, unspecified,Other specified cardiac dysrhythmias,Anxiety state, unspecified
Tracheostomy - mech comp,Bacterial pneumonia NOS,Mal neo esophagus NEC,Secondary malig neo lung,Colosty/enter comp-mech,Hypercalcemia,Abn react-external stoma,Accident in place NEC,Neoplasm related pain,Constipation NEC,Hypopotassemia,Anemia NOS,Cardiac dysrhythmias NEC,Anxiety state NOS
Admission Date:  [**2131-5-2**]              Discharge Date:   [**2131-6-11**]

Date of Birth:  [**2090-5-18**]             Sex:   F

Service: MEDICINE

Allergies:
Roxicet

Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Respiratory distress

Major Surgical or Invasive Procedure:
J-tube replacement x 2.
2 blood transfusions


History of Present Illness:
40yo female with a history of esophageal cancer s/p trach was
admitted from the ED with respiratory distress.
.
She has a tracheostomy in place due to esophageal cancer.
According to her family, she was exerting herself when she was
"air hungry." EMS presented and took the tracheostomy out and
noted a small plug in the tracheostomy itself. Upon arrival to
the ED, 97.9, HR 119, 111/82, RR 19, and pulse ox 99% on 12L
trach mask. Her exam was notable for tachycardia only. Her labs
were notable for elevated WBC to 12.9, and her imaging was
notable for CXR with left-sided pneumonia. She received
levofloxacin 750mg IV x 1, vancomycin 1g IV x 1, zosyn 4.5g IV x
1, potassium chloride 40mEq x 1, and morphine 4mg IV x 1. She
was evaluated by thoracics who replaced her tracheostomy and
they recommended further evaluation for her pneumonia.

Past Medical History:
- Metastatic esophageal Cancer
  ---> EGD - [**2130-6-1**] that was successful on the third attempt
and tissue biopsy at that time revealed an invasive squamous
cell carcinoma.
  ---> [**2130-7-13**] - started on Cetuximab with concurrent radiation.
She completed her radiation therapy on [**2130-8-24**] for a total of
6600 Gy. She also completed her Erbitux therapy at that time.
  ---> [**12-4**] She was admitted with nausea and vomiting and found
to have evidence of tracheal obstruction. In addition, she had a
CT of her neck, which was concerning for perforation. Thoracics
was consulted and felt that she would benefit from a
tracheostomy for airway protection, which was placed on
[**2130-12-8**]. She tolerated this well. She was noted to have a left
upper lobe cavitary lesion on the CT scan. She underwent a wedge
resection on [**2130-1-11**], which revealed carcinomatous plaques on
the pleural wall. This was confirmed to be a metastatic disease
on frozen section. In terms of her tracheostomy, she was
decannulated on [**2131-1-17**]. During the hospitalization she was
treated for pharyngeal abscess and had issues with tachycardia
as well as hypotension. She was discharged home on [**2131-1-19**].
  ---> [**2131-3-13**] - began a palliative chemotherapy regimen of 5-FU
and carboplatin on [**2131-3-13**].
- anemia.
- J tube placed by surgery via an open procedure in [**4-4**]
- constipation
- hypercalcemia
- tachycardia of unknown etiology
- tracheostomy
    ---->[**12-4**] - Tracheostomy placed due to supraglottic edema
in the setting of esophageal perforation
    ----> [**3-5**] - Tracheostomy placed due to vocal cord paralysis
and stridor

Social History:
Home: Originally from [**Country 3587**] and Portuguese-Creole Speaking
only Lives at home with her cousin and husband who care for her.

EtOH: none
Tobacco: none
Drugs: none


Family History:
Maternal aunt - breast cancer.
Her mother and father are alive and healthy and siblings are all
alive and healthy.


Physical Exam:
Gen: no acute distress, resting comfortably in bed, fatigued but
interacting appropriately
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD, trach in place without erythema,
tenderness, or discharge
CV: RR, tachycardic, NL S1, S2. No murmurs, rubs or gallops
LUNGS: decreased breath sounds at the left lower base
ABD: Soft, NT, ND. NL BS. No HSM. G tube in place without
erythema, drainage.
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant



Pertinent Results:
Admission labs
[**2131-5-2**] 08:10PM BLOOD WBC-12.9* RBC-3.98* Hgb-11.9* Hct-35.5*
MCV-89 MCH-29.9 MCHC-33.6 RDW-16.0* Plt Ct-514*
[**2131-5-2**] 08:10PM BLOOD Neuts-88.8* Lymphs-7.1* Monos-2.9 Eos-1.0
Baso-0.2
[**2131-5-2**] 08:10PM BLOOD PT-13.6* PTT-21.5* INR(PT)-1.2*
[**2131-5-2**] 08:10PM BLOOD Glucose-158* UreaN-19 Creat-0.7 Na-135
K-3.1* Cl-96 HCO3-31 AnGap-11
[**2131-5-2**] 08:10PM BLOOD CK(CPK)-35
[**2131-5-2**] 08:10PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2131-5-2**] 08:16PM BLOOD K-3.1*
[**2131-5-2**] 08:33PM BLOOD Lactate-2.0

[**2131-5-3**] 	SPUTUM 	GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
	
[**2131-5-3**] 	URINE 	Legionella Urinary Antigen -FINAL 	
[**2131-5-3**] 	MRSA SCREEN 	MRSA SCREEN-FINAL 	
[**2131-5-2**] 	BLOOD CULTURE 	Blood Culture, Routine-FINAL 	
[**2131-5-2**] 	BLOOD CULTURE 	Blood Culture, Routine-FINAL 	

[**2131-5-2**] CXR: 1. Left lower lobe pneumonia with subjacent
effusion.
2. No definite tracheostomy tube is seen. Recommend clinical
correlation.

[**2131-5-2**] CXR: Interval placement of a tracheostomy tube. Left
basilar effusion, pneumonia, unchanged.

[**2131-5-6**] CT C/A/P w contrast: 1. Interval increase in size of
left pleural effusion and associated atelectasis. 2. Increase in
size and number of cavitary masses in the lungs bilaterally,
consistent with progression of metastatic disease. 3. Distended
gallbladder without evidence of acute cholecystitis. 4. 2-mm
non-obstructing left renal calculus.

[**2131-5-7**] J-tube change:
IMPRESSION:
Uncomplicated replacement of jejunostomy tube via existing
tract. The
jejunostomy tube is ready to use.

[**2131-5-14**] LUE US:
IMPRESSION: No evidence of left upper extremity DVT.
Technically limited comparison of the right subclavian which
showed normal
color flow although venous waveform was not demonstrated.

[**2131-5-15**] CTA:
IMPRESSION:
1. Near complete venous obliteration at the level of the
junction of the left subclavian vein/left brachiocephalic vein,
by invasion of adjacent pleural mass. Please note that the
arterial structures including the left subclavian artery are
patent.
2. Interval worsening of left lung consolidation. Left lower
lobe bronchi is filled with secretion.
3. Edema of subcutaneous tissues of left chest.
4. No significant interval change in the thickness of
circumferential pleural mass with loculated pleural effusion.
5. No significant change in the focal consolidations and
cavitary lesions in the right lung.
6. Multiple osteolytic lesions in the left side ribs from local
invasion.

[**2131-5-23**]: J-tube change:
Uncomplicated J-tube exchange.

[**2131-5-26**]: J-tube check:
IMPRESSION: Jejunostomy tube terminates within the bowel with no
extravasation noted.


Brief Hospital Course:
40F ([**Location 7972**] Portuguese speaking only) with metastatic
esophageal cancer c/b respiratory failure requiring trach
admitted initially with respiratory distress due to mucous
plugging as well as hypercalcemia. Her course was complicated by
progressive lung mets on the left resulting in
subclavian/brachiocephalic venous obstrution causing left facial
edema. She was made DNR. She receeved treatment for HAP with
persistent hypercalcemia and worsening facial edema due to
compression of vessels by her tumor. She worsened clinically and
goals of care ultimately were focused on her comfort. She passed
away with her family at her bedside after several days of
progressive cognitive and respiratory decline.
.
#. Esophageal Cancer: Per her primary oncologist, Dr. [**Last Name (STitle) **], she
would not benefit from further chemo. [**Hospital **] hospice care as an
inpatient with Abx, feedings, and steroids as appropriate.
Palliative care consulted actively in her care. Patient made
DNR/DNI after discussion held on [**5-25**] between Dr. [**First Name (STitle) **] from
palliative care and the patient's husband. Pt pulled out Jtube
[**2131-5-31**]. A 14Fr foley was placed in the Jtube tract as a bridge
to repeat Jtube placement at IR. Jtube replaced [**2131-6-4**] at IR.
.
# Enteric - vesicular fistula: After Jtube replacement on [**2131-6-5**]
Pt developed bilious output from her vagina. Concern for
entero-vaginal fistula so injected methylene blue into the Jtube
at 0945AM on [**2131-6-7**]. Seems to be having blue urine consisent
enteric-vesicular fistula. Jtube feeds were held thereafter.
.
# Pleural mass/Left-sided swelling: CTA of her chest on [**5-15**]
showed near obliteration at the left subclavian vein and left
brachiocephalic vein by a pleural mass. Per rad-onc consult the
patient has had radiation in the area which would need to be
irradiated earlier in her disease and the risks of radiating her
again would outweigh the questionable benefit it could given
her. Symptomatic treatment with pain control. Steroids as needed
to decrease inflammation. This treatment had to be used
judiciously as she became agitated with steroids and suffered a
fall.
.
# Respiratory Distress: Occasionally has respiratory distress
secondary to mucous plugging which improves with suctioning. She
had completed a 7 day course of vanc/zosyn on [**5-9**]. Chest CTA on
[**5-15**] showed interval worsening of left lung consolidation.
Continued on humidified air via trach mask, suctioning per
nursing to decrease mucous plugging. Atrovent nebs q6h with
xopenex nebs prn. Steroids as above.
.
# Chronic Pain: The patient suffered chronic pain under her left
arm near a previous scar which continued to cause her pain. Also
had local invasion of her left ribs which contributed to her
pain. received standing tylenol 1000 mg po tid, and a lidocaine
patch, morphine 4-8 mg IV for breakthrough pain, Methadone 6 mg
IV Q8H. Palliative care guided her pain management.
.
#. Hypercalcemia: Received palmidronate in the beggining of [**Month (only) 116**].
As her calcium remained elevated despite hydration, she was
given zolendrenic acid on [**5-12**]. Calcium had decreased to the
normal range since getting zolendrenic acid, but then rose
again. PTHrP returned negative and imaging showed multiple
osteolytic lesions in the left ribs from local invasion. Given
this, bony mets are likely the cause of her hypercalcemia. She
received another dose of pamidronate 90 mg IV on [**5-21**]. Her
calcium was refractory to intervention.

Medications on Admission:
1. Oxygen - 35% continuous via tracheal mask with cool mist via
[**Last Name (un) **]
compressor.
2. Methadone 10 mg PO qhs / 5mg PO qAM
3. Lorazepam 0.5 - 1mg PO bid
4. Lactulose 20gm PO bid
5. Lansoprazole 30mg PO daily
6. Nortriptyline 10mg PO qhs prn insomnia
7. Compazine 25mg PR q6h prn nausea
8. Acetaminophen prn pain
9. Lidocaine patch q12h on and off
10. Guaifenesin prn
11. Morphine 10mg PO q4h prn pain

Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
Primary:
Hypoxia secondary mucous plugging in tracheostomy
Hypercalcemia of malignancy
Metastatic esophageal cancer
Compression multiple blood vessels causing left upper extremity
and left facial swelling
Chronic anemia
Chronic pain
Anxiety
Pneumonia


Discharge Condition:
death

Discharge Instructions:
death

Followup Instructions:
none


Completed by:[**2131-9-17**]
{'Mechanical complication of tracheostomy,Bacterial pneumonia, unspecified,Malignant neoplasm of other specified part of esophagus,Secondary malignant neoplasm of lung,Mechanical complication of colostomy and enterostomy,Hypercalcemia,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Neoplasm related pain (acute) (chronic),Other constipation,Hypopotassemia,Anemia, unspecified,Other specified cardiac dysrhythmias,Anxiety state, unspecified'}


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: Respiratory distress

PRESENT ILLNESS: 40yo female with a history of esophageal cancer s/p trach was
admitted from the ED with respiratory distress.
.
She has a tracheostomy in place due to esophageal cancer.
According to her family, she was exerting herself when she was
"air hungry." EMS presented and took the tracheostomy out and
noted a small plug in the tracheostomy itself. Upon arrival to
the ED, 97.9, HR 119, 111/82, RR 19, and pulse ox 99% on 12L
trach mask. Her exam was notable for tachycardia only. Her labs
were notable for elevated WBC to 12.9, and her imaging was
notable for CXR with left-sided pneumonia. She received
levofloxacin 750mg IV x 1, vancomycin 1g IV x 1, zosyn 4.5g IV x
1, potassium chloride 40mEq x 1, and morphine 4mg IV x 1. She
was evaluated by thoracics who replaced her tracheostomy and
they recommended further evaluation for her pneumonia.

MEDICAL HISTORY: - Metastatic esophageal Cancer
  ---> EGD - [**2130-6-1**] that was successful on the third attempt
and tissue biopsy at that time revealed an invasive squamous
cell carcinoma.
  ---> [**2130-7-13**] - started on Cetuximab with concurrent radiation.
She completed her radiation therapy on [**2130-8-24**] for a total of
6600 Gy. She also completed her Erbitux therapy at that time.
  ---> [**12-4**] She was admitted with nausea and vomiting and found
to have evidence of tracheal obstruction. In addition, she had a
CT of her neck, which was concerning for perforation. Thoracics
was consulted and felt that she would benefit from a
tracheostomy for airway protection, which was placed on
[**2130-12-8**]. She tolerated this well. She was noted to have a left
upper lobe cavitary lesion on the CT scan. She underwent a wedge
resection on [**2130-1-11**], which revealed carcinomatous plaques on
the pleural wall. This was confirmed to be a metastatic disease
on frozen section. In terms of her tracheostomy, she was
decannulated on [**2131-1-17**]. During the hospitalization she was
treated for pharyngeal abscess and had issues with tachycardia
as well as hypotension. She was discharged home on [**2131-1-19**].
  ---> [**2131-3-13**] - began a palliative chemotherapy regimen of 5-FU
and carboplatin on [**2131-3-13**].
- anemia.
- J tube placed by surgery via an open procedure in [**4-4**]
- constipation
- hypercalcemia
- tachycardia of unknown etiology
- tracheostomy
    ---->[**12-4**] - Tracheostomy placed due to supraglottic edema
in the setting of esophageal perforation
    ----> [**3-5**] - Tracheostomy placed due to vocal cord paralysis
and stridor

MEDICATION ON ADMISSION: 1. Oxygen - 35% continuous via tracheal mask with cool mist via
[**Last Name (un) **]
compressor.
2. Methadone 10 mg PO qhs / 5mg PO qAM
3. Lorazepam 0.5 - 1mg PO bid
4. Lactulose 20gm PO bid
5. Lansoprazole 30mg PO daily
6. Nortriptyline 10mg PO qhs prn insomnia
7. Compazine 25mg PR q6h prn nausea
8. Acetaminophen prn pain
9. Lidocaine patch q12h on and off
10. Guaifenesin prn
11. Morphine 10mg PO q4h prn pain

ALLERGIES: Roxicet

PHYSICAL EXAM: Gen: no acute distress, resting comfortably in bed, fatigued but
interacting appropriately
HEENT: Clear OP, MMM
NECK: Supple, No LAD, No JVD, trach in place without erythema,
tenderness, or discharge
CV: RR, tachycardic, NL S1, S2. No murmurs, rubs or gallops
LUNGS: decreased breath sounds at the left lower base
ABD: Soft, NT, ND. NL BS. No HSM. G tube in place without
erythema, drainage.
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. Normal
coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: Maternal aunt - breast cancer.
Her mother and father are alive and healthy and siblings are all
alive and healthy.

SOCIAL HISTORY: Home: Originally from [**Country 3587**] and Portuguese-Creole Speaking
only Lives at home with her cousin and husband who care for her. 

### Response:
{'Mechanical complication of tracheostomy,Bacterial pneumonia, unspecified,Malignant neoplasm of other specified part of esophagus,Secondary malignant neoplasm of lung,Mechanical complication of colostomy and enterostomy,Hypercalcemia,Surgical operation with formation of external stoma causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in other specified places,Neoplasm related pain (acute) (chronic),Other constipation,Hypopotassemia,Anemia, unspecified,Other specified cardiac dysrhythmias,Anxiety state, unspecified'}
