CHIEF COMPLAINT: evaluation of tracheostomy

PRESENT ILLNESS: 75y/o M with a PMH of ESRD on HD, CAD, ischemic cardiomyopathy,
PAF, morbid obesity, COPD, OSA, and chronic tracheostomy
transferred to [**Hospital1 18**] for evaluation of tracheostomy. Per [**Hospital1 **]
reports there is concern for malfunctional tracheostomy as the
patient's peak pressures have been rising on ventilator. Per
respiratory therapy notes from [**Hospital1 **], prior to [**2150-9-9**] was on
AC 14/650/+5/50%, peak pressures rising over past week to mid
30s and 40s. RT has been unable to pass the inline catheter due
to resistance. Pt taken off vent to swith to 14 fr however
unable to pass airway. He was switched to SIMV 650/12/50%/ PEEP
5 with increased comfort.

MEDICAL HISTORY: # DM2
# CRI (baseline 2.5)- recently started on HD
# CHF - EF 50-55% [**3-24**]
# Trached and vent dependent [**1-17**] PNA in [**12-23**]
# PNA [**4-23**] with BAL growing stenotrophomonas (Bactrim sensitive)

MEDICATION ON ADMISSION: Fluconazole 100mg/50ml daily to end [**9-14**]
Levofloxacin 500mg IV Q24 (stop date [**9-14**])
Vancomycin 1gm IV
Epogen 20,000units QHD
Lispro SS
Heparin 5000U TID
Simvastatin 10mg daily
Docusate 100mg [**Hospital1 **]
Senna 2 tab [**Hospital1 **]
Famotidine 20mg daily
Warfarin 2mg daily
Renagel 800mg TID w/ meals
Tylenol 650mg Q6
Percocet 2 tab po Q4
Zofran 4mg IV Q6
Dulcolax 10mg po PRN constipation
Coumadin 2.5mg po daily
Metoprolol 12.5mg [**Hospital1 **]

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: 99.7   97.9   96/44   77   15   99% on vent
Alert and oriented with appropriate affect.
Trach in place.
Heart regular with no murmur.
Lungs with good air entry b/l and scattered crackles.
s/p right BKA, +1 edema in LE.
Obese with soft abdomen and bowel sounds present.
No rash, no asterixis.

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Used to live with wife, who is HCP. Now at [**Hospital1 **].
Chronic respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Methicillin susceptible pneumonia due to Staphylococcus aureus,Pressure ulcer, lower back,Chronic diastolic heart failure,Dependence on respirator, status,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Obstructive sleep apnea (adult)(pediatric),Chronic airway obstruction, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Infection with microorganisms resistant to penicillins,Tracheostomy status,Personal history, urinary (tract) infection,Below knee amputation status,Long-term (current) use of anticoagulants
Chronic respiratory fail,Hyp kid NOS w cr kid V,End stage renal disease,Meth sus pneum d/t Staph,Pressure ulcer, low back,Chr diastolic hrt fail,Respirator depend status,Crnry athrscl natve vssl,Atrial fibrillation,Obstructive sleep apnea,Chr airway obstruct NEC,DMII renl nt st uncntrld,Pure hypercholesterolem,Inf mcrg rstn pncllins,Tracheostomy status,Personal history UTI,Status amput below knee,Long-term use anticoagul
Admission Date:  [**2150-9-9**]              Discharge Date:   [**2150-9-10**]

Date of Birth:  [**2075-1-1**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
evaluation of tracheostomy

Major Surgical or Invasive Procedure:
bronchoscopy

History of Present Illness:
75y/o M with a PMH of ESRD on HD, CAD, ischemic cardiomyopathy,
PAF, morbid obesity, COPD, OSA, and chronic tracheostomy
transferred to [**Hospital1 18**] for evaluation of tracheostomy. Per [**Hospital1 **]
reports there is concern for malfunctional tracheostomy as the
patient's peak pressures have been rising on ventilator. Per
respiratory therapy notes from [**Hospital1 **], prior to [**2150-9-9**] was on
AC 14/650/+5/50%, peak pressures rising over past week to mid
30s and 40s. RT has been unable to pass the inline catheter due
to resistance. Pt taken off vent to swith to 14 fr however
unable to pass airway. He was switched to SIMV 650/12/50%/ PEEP
5 with increased comfort.

The patient underwent a recent R BKA on [**2150-8-27**]. He had episodes
of hypoxia related to mucous plugging and sputum grew MRSA and
was started on a short course of vancomycin. He has chronic
decubitous ulcers. He received a short course of linezolid,
aztreonam and flagyl during his post-op BKA course, all
discontinued on [**9-1**]. He is on dialysis for ESRD.

Past Medical History:
# DM2
# CRI (baseline 2.5)- recently started on HD
# CHF - EF 50-55% [**3-24**]
# Trached and vent dependent [**1-17**] PNA in [**12-23**]
# PNA [**4-23**] with BAL growing stenotrophomonas (Bactrim sensitive)

and acenitobacter ([**Last Name (un) 36**] to Unasyn, Gent and Tobra, resistant to
FQ, ceftaz, cefepime)
# ESBL Klebsiella UTI [**3-24**]
# Morbid obesity
# Afib on Coumadin
# Hypercholesterolemia
# Known coccyx ulcers

Allergies: Penicillin and sulfonamides

Social History:
Used to live with wife, who is HCP. Now at [**Hospital1 **].

Family History:
noncontributory

Physical Exam:
99.7   97.9   96/44   77   15   99% on vent
Alert and oriented with appropriate affect.
Trach in place.
Heart regular with no murmur.
Lungs with good air entry b/l and scattered crackles.
s/p right BKA, +1 edema in LE.
Obese with soft abdomen and bowel sounds present.
No rash, no asterixis.

Pertinent Results:
[**2150-9-9**] 08:49PM BLOOD WBC-7.5 RBC-2.90* Hgb-7.4* Hct-26.0*
MCV-90 MCH-25.6* MCHC-28.4* RDW-17.8* Plt Ct-202
[**2150-9-10**] 05:38AM BLOOD WBC-6.5 RBC-3.00* Hgb-7.6* Hct-25.8*
MCV-86 MCH-25.4* MCHC-29.5* RDW-19.3* Plt Ct-216
[**2150-9-9**] 08:49PM BLOOD PT-37.6* PTT-53.2* [**Month/Day/Year 263**](PT)-4.0*
[**2150-9-9**] 08:49PM BLOOD Glucose-149* UreaN-32* Creat-3.8* Na-140
K-3.8 Cl-104 HCO3-29 AnGap-11
[**2150-9-10**] 05:38AM BLOOD Glucose-109* UreaN-34* Creat-4.2* Na-139
K-3.7 Cl-103 HCO3-29 AnGap-11
[**2150-9-10**] 05:38AM BLOOD Albumin-2.4* Calcium-7.8* Phos-1.9*
Mg-2.7*

Micro:
[**2150-9-9**] 11:34 pm SPUTUM      Source: Endotracheal.

   GRAM STAIN (Final [**2150-9-10**]):
      >25 PMNs and <10 epithelial cells/100X field.
      4+   (>10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS.

   RESPIRATORY CULTURE (Preliminary):

BAL [**9-10**]:
      BRONCHIAL LAVAGE RIGHT MIDDLE LOBE.

   GRAM STAIN (Pending):

   RESPIRATORY CULTURE (Pending):

   FUNGAL CULTURE (Pending):

CXR [**2150-9-9**]:
In comparison with study of [**6-27**], there is little change in the
appearance of the tracheostomy tube. Dobbhoff tube is in place,
though the image ends above the diaphragm so the tip cannot be
seen. Central catheter tip similarly is difficult to evaluate
and appears to be in the right atrium.
Prominence of interstitial markings persists and there are
probable bilateral pleural effusions.

Brief Hospital Course:
75 y/o with chronic tracheostomy, HD-dependent ESRD, sacral/LE
ulcers, R [**Hospital 6024**] transferred to the MICU for evaluation of his
tracheostomy.

# Respiratory failure:
Mr. [**Known lastname 77792**] has a history of hypercarbic/hypoxic respiratory
failure and is s/p trachostomy earlier in [**2149**].  He was noted to
have increasing peak pressures with difficulty in passing a
catheter due to resistance and was transferred for further
evaluation of his trach.  IP was consulted and performed
bronchoscopy on [**9-10**].  He was found to have diffuse airway edema
consistent with volume overload.  There were no significant
secretions and a full survey of the airways reveals all airways
were patent without any endobronchial lesions.  His trach was
felt to be in appropriate position without any obstruction.
There was no tracheobronchomalacia.

He should be continued on vancomycin for treatment of MRSA
pneumonia.

Please note that the findings of the sputum culture and BAL were
pending at the time of discharge.

# ESRD:
Related to diabetic nephropathy.  Patient did not receive HD at
[**Hospital1 18**] as he will be receiving it upon return to [**Hospital1 **].
Continued renagel.

# Atrial Fibrillation:
Continued metoprolol.  Coumadin was held for supratherapeutic
[**Hospital1 263**] of 4.  Please dose coumadin as needed to maintain [**Hospital1 263**] of
[**1-18**].

Please note that coumadin is not on the current medication list
as it should be held given that his [**Month/Day (3) 263**] is elevated. This is
most likely due to the interaction of coumadin with his current
antibiotics (levofloxacin and fluconazole). Please restart
coumadin cautiously once his [**Month/Day (3) 263**] is < 2.5 to maintain an [**Month/Day (3) 263**]
between 2 and 3.

Also note that subcutaneous heparin was stopped during your
hospital stay.

# Type II DM: continued sliding scale insulin and Lantus.

# R BKA with Sacral and leg ulcers:
Continued current wound care, no signs of active infection

# Plasma cell dyscrasia:
Found to have IgA kappa on serum electrophoresis with an
imbalance in the free kappa:lambda light chain ratio. BM biopsy
showed 5-10% plasma cells.  During his work up the hematology
team felt he likely had MGUS and ordered a retroperitoneal
biopsy of a mass that was noted on his abd CT scan. His FNA was
non-diagnostic and a needle core biopsy showed fragments of
lymphoid tissue with quiescent appearing germinal centers.
Continued outpatient follow up

# Nutrition: NPO; tube feeds continued.

# Access - mid-line

# Code- full

Medications on Admission:
Fluconazole 100mg/50ml daily to end [**9-14**]
Levofloxacin 500mg IV Q24 (stop date [**9-14**])
Vancomycin 1gm IV
Epogen 20,000units QHD
Lispro SS
Heparin 5000U TID
Simvastatin 10mg daily
Docusate 100mg [**Hospital1 **]
Senna 2 tab [**Hospital1 **]
Famotidine 20mg daily
Warfarin 2mg daily
Renagel 800mg TID w/ meals
Tylenol 650mg Q6
Percocet 2 tab po Q4
Zofran 4mg IV Q6
Dulcolax 10mg po PRN constipation
Coumadin 2.5mg po daily
Metoprolol 12.5mg [**Hospital1 **]

Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
5. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: hold if sedated.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Fluconazole 10 mg/mL Suspension for Reconstitution Sig: One
Hundred (100) mg PO once a day for 4 days: Last dose 9/29.
9. Levofloxacin 25 mg/mL Solution Sig: Five Hundred (500) mg
Intravenous once a day for 4 days: last day = [**9-14**].
10. Vancomycin 1,000 mg Recon Soln Sig: One (1) g Intravenous
with dialysis for as directed days: per treatment course as
directed by physicians at [**Hospital1 **].
11. Epogen 20,000 unit/mL Solution Sig: 20,000 units Injection
with dialysis.
12. Insulin
Please continue insulin according to the regimen you were on
prior to transfer to [**Hospital1 18**].
13. Zofran 2 mg/mL Solution Sig: Four (4) mg Intravenous every
six (6) hours as needed for nausea.
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day: hold for sbp < 90 or hr < 55.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]

Discharge Diagnosis:
Primary Diagnosis:  Respiratory failure
Secondary Diagnoses:  Pneumonia, End stage renal disease, Sacral
and leg ulcers, diabetes, Chronic diastolic heart failure,
Atrial fibrillation on coumadin


Discharge Condition:
On mechanical ventilation via trach.  Afebrile with HR in
70s-80s and BP 98/40.


Discharge Instructions:
You were admitted for evaluation of your tracheostomy.  A
bronchoscopy was performed and showed that your trach tube was
in the correct position without any obstruction.

1. Please attend all follow-up appointments as recommended by
your normal providers.

2. Please continue all medications as instructed.  We stopped
your subcutaneous heparin during your stay.  We also would like
you to dose coumadin carefully as the [**Hospital1 263**] is currently elevated
at 4.  This is most likely from the interaction of coumadin with
fluconazole and levofloxacin.

3. Please return to the hospital if you develop fevers,
worsening respiratory status, or any other concerning symptom.

4. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet

Followup Instructions:
Please continue to see your normal providers through [**Hospital **]
Health Care.



Completed by:[**2150-9-10**]
{'Chronic respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Methicillin susceptible pneumonia due to Staphylococcus aureus,Pressure ulcer, lower back,Chronic diastolic heart failure,Dependence on respirator, status,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Obstructive sleep apnea (adult)(pediatric),Chronic airway obstruction, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Infection with microorganisms resistant to penicillins,Tracheostomy status,Personal history, urinary (tract) infection,Below knee amputation status,Long-term (current) use of anticoagulants'}


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: evaluation of tracheostomy

PRESENT ILLNESS: 75y/o M with a PMH of ESRD on HD, CAD, ischemic cardiomyopathy,
PAF, morbid obesity, COPD, OSA, and chronic tracheostomy
transferred to [**Hospital1 18**] for evaluation of tracheostomy. Per [**Hospital1 **]
reports there is concern for malfunctional tracheostomy as the
patient's peak pressures have been rising on ventilator. Per
respiratory therapy notes from [**Hospital1 **], prior to [**2150-9-9**] was on
AC 14/650/+5/50%, peak pressures rising over past week to mid
30s and 40s. RT has been unable to pass the inline catheter due
to resistance. Pt taken off vent to swith to 14 fr however
unable to pass airway. He was switched to SIMV 650/12/50%/ PEEP
5 with increased comfort.

MEDICAL HISTORY: # DM2
# CRI (baseline 2.5)- recently started on HD
# CHF - EF 50-55% [**3-24**]
# Trached and vent dependent [**1-17**] PNA in [**12-23**]
# PNA [**4-23**] with BAL growing stenotrophomonas (Bactrim sensitive)

MEDICATION ON ADMISSION: Fluconazole 100mg/50ml daily to end [**9-14**]
Levofloxacin 500mg IV Q24 (stop date [**9-14**])
Vancomycin 1gm IV
Epogen 20,000units QHD
Lispro SS
Heparin 5000U TID
Simvastatin 10mg daily
Docusate 100mg [**Hospital1 **]
Senna 2 tab [**Hospital1 **]
Famotidine 20mg daily
Warfarin 2mg daily
Renagel 800mg TID w/ meals
Tylenol 650mg Q6
Percocet 2 tab po Q4
Zofran 4mg IV Q6
Dulcolax 10mg po PRN constipation
Coumadin 2.5mg po daily
Metoprolol 12.5mg [**Hospital1 **]

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: 99.7   97.9   96/44   77   15   99% on vent
Alert and oriented with appropriate affect.
Trach in place.
Heart regular with no murmur.
Lungs with good air entry b/l and scattered crackles.
s/p right BKA, +1 edema in LE.
Obese with soft abdomen and bowel sounds present.
No rash, no asterixis.

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Used to live with wife, who is HCP. Now at [**Hospital1 **]. 

### Response:
{'Chronic respiratory failure,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,End stage renal disease,Methicillin susceptible pneumonia due to Staphylococcus aureus,Pressure ulcer, lower back,Chronic diastolic heart failure,Dependence on respirator, status,Coronary atherosclerosis of native coronary artery,Atrial fibrillation,Obstructive sleep apnea (adult)(pediatric),Chronic airway obstruction, not elsewhere classified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Infection with microorganisms resistant to penicillins,Tracheostomy status,Personal history, urinary (tract) infection,Below knee amputation status,Long-term (current) use of anticoagulants'}
