CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 53 y/o M s/p self-inflicted gunshot injury to face in [**2187**] with
resulting tracheostomy, who presented to [**Hospital6 14576**]
in [**Location (un) 8973**] [**6-6**] c/o increased secretions from tracheostomy.
They were yellowish, and this had been going on x 3 weeks. He
reportedly didn't feel his breathing was worse than usual. He
denied fevers or chills. He had been seen in the ED one day
prior to this with the same complaint and was sent home with
Levaquin. He continued to require more frequent suctioning and
so returned to the OSH ED the next day. He also was having
coffee-grounds aspirate from G tube, and BRBPR. At that time, he
was afebrile, bp 140/80, RR 20, and O2 sat 95% on 40% trach
mask. He was felt to have bronchospasm, and begun on frequent
nebulizers, steroid taper, and IV levofloxacin. GI felt that his
GI bleeding was [**3-4**] gastritis and hemorrhoids.  On HD1 at the
OSH, he was noted to be in resp distress and tube feeds were
suctioned from his lungs. His ABG was 7.22/78/64 and he was
transferred to the ICU. He was tachypneic in the 30s and c/o
respiratory fatigue so was placed on the vent in the early
morning [**6-7**]. In the ICU, his uncuffed trach was changed to a
cuffed trach with a fair amount of difficulty. He was placed on
PCV due to high peak pressures. He was emergently bronchoscoped
which revealed severe hemorrhagic bronchitis but was difficult
because the bronchoscope that was used was unable to suction. He
was changed to Zosyn upon arrival in the ICU, and was also
placed on flagyl when he developed a distended abdomen with a
lot of gas on the RUQ (CDiff pending). He also was begun on
vancomycin when staph grew from his sputum. He had a neck CT
done to evaluate the degree of his tracheal stenosis, which was
severe. At this point he was transferred to [**Hospital1 18**] for further
management of his tracheal stenosis, for IP procedure. In the
MICU patient initially put on ventilator and was switched to
trach mask the following day.

MEDICAL HISTORY: -bronchiectasis s/p R pneumonectomy [**2180**]
-seizure [**2182**] with anoxic encephalopathy
-gunshot wound to face [**2187**] requiring multiple facial
reconstructions, trach/G tube
-gastritis
-gastric ulcer
-esophagitis

MEDICATION ON ADMISSION: prevacid 30 mg per G tube [**Hospital1 **]
Sucralfate 1 mg per G tube 4x/day
zoloft 50 mg daily
albuterol 25 mg with atrovent [**Age over 90 **]m g nebs q4hours
decadron 10 IV bid
xopenex neb 0.63 mg tid
colace
zosyn 3.37 g IV q8h (day 1= [**6-7**])
Humulin sliding scale
reglan 10 mg IV q8h
flagyl 500 mg IV q8h (day 1= [**6-10**])
vancomycin 1 gm IV q12h (day 1= [**6-11**])
versed 2-4 mg IV q1h

ALLERGIES: Tylenol / Penicillins

PHYSICAL EXAM: Upon transfer to the floor:
PE: T 96.3 HR 85 BP 135-164/80-87 RR 23 O2sat 100%
Gen: NAD, with trach mask
Heent: Disfigured mouth, PERRL, OP clear
Lungs: Upper airway sound b/L, diffuse rhonchi
Cardiac: RRR S1/S2 no murmurs
Abd: soft, distended, NABS, tender to palpation diffuse, no
guarding or rebound
Ext: no edema
Neuro: AAOx3

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives with wife, from [**Name (NI) 6257**] originally.
Remote tobacco history. Denies etoh.
Other tracheostomy complications,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Embolism and thrombosis of other specified artery,Intestinal infection due to Clostridium difficile,Other complications due to other vascular device, implant, and graft,Chronic airway obstruction, not elsewhere classified,Pneumonitis due to inhalation of food or vomitus,Anoxic brain damage,Other gastrostomy complications,Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other abnormal granulation tissue,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Infection with microorganisms resistant to penicillins,Aneurysm of other visceral artery,Vascular disorders of kidney,Depressive disorder, not elsewhere classified,Late effect of intracranial injury without mention of skull fracture,Late effects of self-inflicted injury,Accidents occurring in unspecified place,Other specified cardiac dysrhythmias
Tracheostomy comp NEC,Acute respiratry failure,Meth sus pneum d/t Staph,Arterial embolism NEC,Int inf clstrdium dfcile,Comp-oth vasc dev/graft,Chr airway obstruct NEC,Food/vomit pneumonitis,Anoxic brain damage,Gastrostomy comp NEC,Chr stomach ulc w hem,Abn react-procedure NEC,Abnormal granulation NEC,Other staphylococcus,Inf mcrg rstn pncllins,Visceral aneurysm NEC,Renal vascular disorder,Depressive disorder NEC,Lt eff intracranial inj,Late eff of self-injury,Accident in place NOS,Cardiac dysrhythmias NEC
Admission Date:  [**2195-6-11**]              Discharge Date:   [**2195-7-10**]

Date of Birth:  [**2141-8-28**]             Sex:   M

Service: MEDICINE

Allergies:
Tylenol / Penicillins

Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
Rigid Bronchoscopy
Upper Endoscopy
Endoscopic ultrasound


History of Present Illness:
53 y/o M s/p self-inflicted gunshot injury to face in [**2187**] with
resulting tracheostomy, who presented to [**Hospital6 14576**]
in [**Location (un) 8973**] [**6-6**] c/o increased secretions from tracheostomy.
They were yellowish, and this had been going on x 3 weeks. He
reportedly didn't feel his breathing was worse than usual. He
denied fevers or chills. He had been seen in the ED one day
prior to this with the same complaint and was sent home with
Levaquin. He continued to require more frequent suctioning and
so returned to the OSH ED the next day. He also was having
coffee-grounds aspirate from G tube, and BRBPR. At that time, he
was afebrile, bp 140/80, RR 20, and O2 sat 95% on 40% trach
mask. He was felt to have bronchospasm, and begun on frequent
nebulizers, steroid taper, and IV levofloxacin. GI felt that his
GI bleeding was [**3-4**] gastritis and hemorrhoids.  On HD1 at the
OSH, he was noted to be in resp distress and tube feeds were
suctioned from his lungs. His ABG was 7.22/78/64 and he was
transferred to the ICU. He was tachypneic in the 30s and c/o
respiratory fatigue so was placed on the vent in the early
morning [**6-7**]. In the ICU, his uncuffed trach was changed to a
cuffed trach with a fair amount of difficulty. He was placed on
PCV due to high peak pressures. He was emergently bronchoscoped
which revealed severe hemorrhagic bronchitis but was difficult
because the bronchoscope that was used was unable to suction. He
was changed to Zosyn upon arrival in the ICU, and was also
placed on flagyl when he developed a distended abdomen with a
lot of gas on the RUQ (CDiff pending). He also was begun on
vancomycin when staph grew from his sputum. He had a neck CT
done to evaluate the degree of his tracheal stenosis, which was
severe. At this point he was transferred to [**Hospital1 18**] for further
management of his tracheal stenosis, for IP procedure. In the
MICU patient initially put on ventilator and was switched to
trach mask the following day.

Past Medical History:
-bronchiectasis s/p R pneumonectomy [**2180**]
-seizure [**2182**] with anoxic encephalopathy
-gunshot wound to face [**2187**] requiring multiple facial
reconstructions, trach/G tube
-gastritis
-gastric ulcer
-esophagitis


Social History:
Lives with wife, from [**Name (NI) 6257**] originally.
Remote tobacco history. Denies etoh.

Family History:
Noncontributory

Physical Exam:
Upon transfer to the floor:
PE: T 96.3 HR 85 BP 135-164/80-87 RR 23 O2sat 100%
Gen: NAD, with trach mask
Heent: Disfigured mouth, PERRL, OP clear
Lungs: Upper airway sound b/L, diffuse rhonchi
Cardiac: RRR S1/S2 no murmurs
Abd: soft, distended, NABS, tender to palpation diffuse, no
guarding or rebound
Ext: no edema
Neuro: AAOx3

Pertinent Results:
Micro:
[**2195-7-7**] BLOOD CULTURE INPATIENT Pending
[**2195-7-6**] STOOL INPATIENT toxin A negative
[**2195-7-6**] BLOOD CULTURE INPATIENT Pending
[**2195-7-6**] URINE INPATIENT <10,000 organisms/ml
[**2195-7-6**] BLOOD CULTURE INPATIENT Pending
[**2195-7-2**] CATHETER TIP-IV INPATIENT no growth
[**2195-7-2**] BLOOD CULTURE INPATIENT no growth
[**2195-7-2**] SEROLOGY/BLOOD INPATIENT RPR nonreactive
[**2195-7-2**] BLOOD CULTURE INPATIENT no growth
[**2195-6-27**] BLOOD CULTURE INPATIENT no growth
[**2195-6-27**] BLOOD CULTURE INPATIENT no growth
[**2195-6-26**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) INPATIENT
Pending
[**2195-6-24**] SEROLOGY/BLOOD INPATIENT H. pylori Ab negative
[**2195-6-21**] BLOOD CULTURE INPATIENT no growth
[**2195-6-21**] BLOOD CULTURE INPATIENT no growth
[**2195-6-19**] BLOOD CULTURE INPATIENT no growth
[**2195-6-19**] BLOOD CULTURE INPATIENT no growth
[**2195-6-19**] STOOL INPATIENT toxin A negative

[**2195-6-15**] BRONCHOALVEOLAR LAVAGE INPATIENT
GRAM STAIN (Final [**2195-6-15**]):
      3+  (5-10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      3+  (5-10 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   RESPIRATORY CULTURE (Final [**2195-6-19**]):
      10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
      STAPH AUREUS COAG +.    10,000-100,000 ORGANISMS/ML..
         OF THREE COLONIAL MORPHOLOGIES.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   =>8 R
OXACILLIN-------------   =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
VANCOMYCIN------------   <=1 S

[**2195-6-13**] STOOL INPATIENT toxin A negative
[**2195-6-12**] STOOL INPATIENT toxin A negative

Pertinent reports:
[**2195-7-6**] Radiology CTA ABD PELVIS
IMPRESSION:
1) No new pseudoaneurysms identified.
2) No significant change in soft tissue mass surrounding the
hepatic artery branches, though the proper hepatic artery is now
somewhat attenuated when compared with the prior study, though
still patent.
3) Slightly decreased size of retrogastric soft tissue density.

[**2195-7-3**] Cardiology STRESS INTERPRETATION: 53 year old male with
IDDM and vascular aneurysms presents to the laboratory for
evaluation of coronary artery disease. The patient received
0.142 mg/kg/min of dipyridamole over three minutes. No anginal
symptoms were reported by the patient. The dipyridamole was
reversed with 125 mg of amiophylline IV. No significant ST
segment changes during the procedure. Rhythm was sinus with rare
APBs.
Hemodynamic response was appropriate. IMPRESSION: No ischemic
ECG changes or anginal symptoms. Nuclear report sent separately.


[**2195-7-3**] Radiology PERSANTINE MIBI
IMPRESSION: 1.Normal myocardial perfusion study. 2. Normal left
ventricular
size and function.

[**2195-7-2**] Cardiology ECG Sinus rhythm Poor R wave progression -
is nonspecific and may be within normal limits but clinical
correlation is suggested Since previous tracing of [**2195-6-24**], no
significant change

[**2195-7-2**] Cardiology ECHO Conclusions:
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. A small, mobile echodensity (about 5 mm) is attached
to a catheter seen in the right atrium (probable thrombus). No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with  maneuvers. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Right ventricular chamber size and free
wall motion are  normal. The aortic valve leaflets (3) appear
structurally normal with good  leaflet excursion and no aortic
regurgitation. No masses or vegetations are  seen on the aortic
valve. The mitral valve leaflets are structurally normal.  No
mass or vegetation is seen on the mitral valve. No mitral
regurgitation is  seen. There is no pericardial effusion.
Impression:  1. No cardiac source for systemic embolization
seen.  2. A small, mobile echodensity is seen on the tip of a
catheter in the right atrium. This likely represents a small
catheter-associated thrombus.

[**2195-7-2**] Radiology CHEST (PORTABLE AP)  IMPRESSION:
1) Right subclavian central venous catheter is seen with the tip
extending into the right IJ, beyond the image margin. The
results were discussed with Dr. [**Last Name (STitle) **] at 10:15 a.m. on
[**2195-7-3**].
2) Stable post pneumonectomy changes are again noted.

[**2195-7-1**] EGD/EUS
Impression: Abnormal splenic artery
At the level of the celiac axis a 17x17mm soft tissue mass
identified
Normal pancreas, CBD and PD.
Using the radial and linear echoendoscopes the pancreas,
mesenteric vessels and surrounding structures were examined in
real time. The celiac axis was identified and the proximal take
off appeared normal. Splenic artery however had markedly
thickened walls with pronounced peri-arterial soft tissue and
possible small thrombus. The pancreatic head, body and tail
appeared normal and the CBD and PD were also normal without
dilatation or filling defects. At the level of the celiac axis
take-off a soft tissue mass 17 x 17 mm was identified. This may
relate to a lymph node. It was irregular in outline with a tiny
cystic component but otherwise solid throughout. It was 4 mm
from the celiac axis on EUS.

[**2195-6-30**] Cardiology ECHO Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. Due to suboptimal technical quality, a
focal wall
motion abnormality cannot be fully excluded. Overall systolic
function is
mild-moderately depressed (LVEF ~35%). The right ventricular
cavity size is normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is no pericardial effusion.  If clinically indicated, a
radionuclide study may be better able to define biventricular
systolic function.

[**2195-6-30**] Radiology CTA ABD PELVIS IMPRESSION:
1) Interval presumed thrombosis of the previously noted
aneurysms nvolving the splenic artery and hepatic arteries, with
stable gastroduodenal artery aneurysm and 2 new tiny
intrahepatic aneurysms within the right lobe. No evidence of
arterial occlusion. Stable peri-arterial soft tissue densities
as described.
2) New infarcts within the left kidney as described. Given the
normal renal arteries, this raises the possibility of embolic
etiology, for example, from a cardiac source. Clinical
correlation is advised.
3) Stable retrogastric soft tissue density.

[**2195-6-26**] Cardiology ECG Sinus rhythm. Since the previous tracing
of [**2195-6-26**] the rate has slowed and atrial ectopy is no longer
seen. The tracing is now normal.

[**2195-6-26**] Cardiology ECG Sinus tachycardia with premature
supraventricular beats. Compared to the previous tracing of
[**2195-6-23**] premature beats are now present.

[**2195-6-25**] Radiology CTA ABD PELVIS
CTA Abdomen [**6-25**]: The patient is status post right pneumonectomy
with an unchanged appearance. The left lung base is clear. The
liver and gallbladder appear normal. The pancreas appears
normal. However, adjacent to the pancreas, in the lesser sac,
but not definitely associated with either the stomach or the
pancreas, is an area of soft tissue density with minimal if any
enhancement of unclear etiology. The spleen has a similar
appearance with an area of peripheral hypodensity likely
representing an infarct. The kidneys and adrenal glands are
within normal limits. The appearance of the gastrostomy tube in
the stomach and the small and large bowel are within normal
limits. There is no retroperitoneal or mesenteric
lymphadenopathy or free fluid. Again noted on the arterial phase
images is extensive wall thickening of the entire celiac axis
with multiple regions of contrast collection which may represent
ulcerations into the surrounding soft tissue density. The
appearance is not significantly changed since the prior study.
The splenic artery may be somewhat stenotic as before but is
opacified. More inferior images are available on this CT and
these demonstrate a separate small focus over about 1 cm of
mural thickening of a major branch of the superior mesenteric
artery, although contrast again appears to pass distally. The
major mesenteric veins appear open.  IMPRESSION: Vascular
process involving the celiac axis and its branches (Splenic,
hepatic to intrahepatic branches and GDA) and at least one right
branch (ileocolic) of the SMA, associated with splenic infarct
and soft tissue retrogastric density. These findings are new,
developed after [**6-14**]. Mural hematoma vs dissection is
considered. Focal gastric perforation with secondary vascular
changes is less likely. Finally pancreatitis is unlikely due to
otherwise normal pancreas.

[**2195-6-23**] Cardiology ECG Sinus tachycardia
Normal for tracing except for rate
Since previous tracing of [**2195-6-22**], no atrial premature complex

[**2195-6-23**] EGD
Impression: Erosion in the stomach body (opposite the peg tube)
PEG tube noted in body
Otherwise normal egd to second part of the duodenum
Recommendations: PPI therapy
Serological H pylori testing. Treat if positive

[**2195-6-23**] Radiology CTA CHEST IMPRESSION:
1) Status post right pneumonectomy.
2) No evidence of pulmonary embolism.
3) Patchy parenchymal densities in the left lung, suggesting
atypical pneumonia or inflammatory changes.
4) New peripancreatic fluid, raising a question of pancreatitis.
5) EXTENSIVE Soft tissue density or edema tracking along the
entire celiac axis, and ivolving the hepatic artery, including
the intrahepatic branches and the splenic artery. Although this
appearance could represent sequelae of pancreatitis, a primary
vasculitis is felt more likely.
6) New splenic infarct.

[**2195-6-22**] Cardiology ECG Sinus tachycardia. Atrial premature
beats. Probable right atrial abnormality. Since the previous
tracing of [**2189-4-6**] atrial ectopy is present and the sinus
tachycardia rate has increased.

[**2195-6-20**] Radiology CHEST (PORTABLE AP)   PORTABLE CHEST:
Comparison is made to prior film dated [**2195-6-16**]. Previously
noted PICC catheter and tracheostomy tube remain in place,
without significant change. Changes of prior right pneumonectomy
are again identified. There is associated rightward shift of
midline structures. There is stable pleural based density in the
left apex. No acute changes are seen within the parenchyma of
the left lung. IMPRESSION: No acute change.

[**2195-6-19**] Radiology ABDOMEN (SUPINE ONLY) IMPRESSION: No evidence
of bowel obstruction or significant ileus.

[**2195-6-16**] Radiology CHEST (PORTABLE AP) IMPRESSION: PICC tip in
the lower SVC.

[**2195-6-14**] Radiology CT ABDOMEN PELVIS
CT abdomen/pelvis [**2195-6-14**]:IMPRESSION:
1) No CT evidence of colitis or other intraabdominal source for
the patient's abdominal pain.
2) Pulmonary parenchymal opacity within the left lower lobe,
raising the question of aspiration or other
infectious/inflammatory processes in this patient status post
right-sided pneumonectomy.

Rigid [**Last Name (un) **] Findings [**2195-6-15**]:
The right side was absent surgically. The stoma seems to be very
clean. The left main stem was patent. The left lower lobe showed
evidence of some very thick, greenish mucous secretions.
Bronchoalveolar lavage was done at that side. At that moment, a
rigid bronchoscope was retrieved to the subglottic area. Under
direct visualization, tumor excision with the use microdebrider
was done to the granulation tissue. At that moment, a 6 Portex,
cuffless, nonfenestrated tracheostomy was placed under direct
visualization.  There were no complications. The patient
tolerated the procedure well, and he was transferred to
recovery.

[**2195-6-12**] Radiology CHEST (PORTABLE AP)   IMPRESSION:
Status post right pneumonectomy. Suggestion of bronchiectasis at
the left lung base. No pneumonia

[**2195-6-12**] Radiology ABDOMEN (SUPINE ONLY) IMPRESSION: No evidence
of obstruction and no free air. Prominent loop of large bowel in
the right mid/upper abdomen, which appears to represent a
prominent cecum. If clinical symptoms continue, repeat KUB or CT
may be helpful.

Pertinent labs:
[**2195-7-9**] 06:16AM BLOOD WBC-11.0 RBC-4.05* Hgb-12.3* Hct-36.9*
MCV-91 MCH-30.2 MCHC-33.2 RDW-13.1 Plt Ct-400
[**2195-6-12**] 12:56AM BLOOD WBC-9.8# RBC-4.72# Hgb-14.4# Hct-43.6#
MCV-92 MCH-30.6 MCHC-33.1 RDW-12.3 Plt Ct-181
[**2195-6-12**] 12:56AM BLOOD Neuts-90.0* Lymphs-6.2* Monos-3.7 Eos-0.1
Baso-0
[**2195-7-6**] 01:03PM BLOOD Neuts-90.8* Lymphs-5.4* Monos-3.7 Eos-0
Baso-0.1
[**2195-7-7**] 06:01AM BLOOD PT-13.4* PTT-89.6* INR(PT)-1.2
[**2195-6-24**] 05:45AM BLOOD ESR-65*
[**2195-6-29**] 08:42AM BLOOD ESR-60*
[**2195-6-12**] 12:56AM BLOOD Glucose-89 UreaN-24* Creat-0.6 Na-141
K-4.3 Cl-101 HCO3-35* AnGap-9
[**2195-7-9**] 06:16AM BLOOD Glucose-112* UreaN-21* Creat-0.5 Na-137
K-3.9 Cl-98 HCO3-34* AnGap-9
[**2195-6-12**] 12:56AM BLOOD ALT-32 AST-32 AlkPhos-48 Amylase-72
TotBili-0.6
[**2195-6-24**] 05:45AM BLOOD ALT-22 AST-16 LD(LDH)-255* AlkPhos-76
Amylase-56 TotBili-0.6
[**2195-6-12**] 12:56AM BLOOD Calcium-8.3* Phos-3.9# Mg-2.1
[**2195-7-9**] 06:16AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.9
[**2195-6-19**] 04:47AM BLOOD Albumin-3.5
[**2195-7-2**] 06:06AM BLOOD Cryoglb-NO CRYOGLO
[**2195-6-26**] 05:48AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2195-6-24**] 05:45AM BLOOD ANCA-NEGATIVE B
[**2195-7-1**] 06:19AM BLOOD PSA-4.8*
[**2195-6-29**] 08:42AM BLOOD CRP-3.46*
[**2195-6-26**] 05:48AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2195-6-26**] 05:48AM BLOOD RheuFac-5
[**2195-6-26**] 05:48AM BLOOD C3-164 C4-49*
[**2195-7-9**] 11:57AM BLOOD HIV Ab-PND
[**2195-7-8**] 10:14PM BLOOD Vanco-10.7*
[**2195-6-19**] 10:00PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2195-6-19**] 10:00PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2195-7-6**] 06:15PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.050*
[**2195-7-6**] 06:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG

Brief Hospital Course:
## Tracheal Stenosis: Based on CT results patient has severe
tracheal stenosis. Patient underwent rigid bronch with excision
of granulation tissue and change of cuff.  No residual problems
throughout rest of hospital course.
.
## Hemoptysis: Pt initially transferred to [**Hospital1 18**] MICU. Had rigid
bronch to assess tracheomalacia. HD stable and weaned off vent.
He was transferred to the floor [**6-12**]. On the night of [**6-13**], he
began to have episodes of hemoptysis, necessitating emergent
[**Last Name (un) 1066**] and transfer back to the MICU. Bronch revealed that pt was
bleeding from granulation tissue on upper stoma. Anticoagulation
was stopped and his bleeding resolved. Pt was HD stable and was
transferred back to the floor for further management.  While on
floor patient continued to have minimal bleeding from trach and
bronch was performed again and trach cuff was changed. No
further bleeding from trach site.
.
## Respiratory Failure:  Initially on transfer patient felt to
possbily have aspiration PNA.  In the ICU he was kept on a
ventilator overnight and was quickly extubated the following day
put on trach mask.  Patient continued to have many secretions so
given 7 day course of Zosyn which was completed in the hospital.
 The OSH reported that sputum aspirate showed MRSA and patient
was started on IV vanco.  Patient underwent BAL during fisrt
bronch which came back possitive for MRSA which was consistant
with results from OSH. Treated with IV vancomycin total 14 days.
Once on floor, secretions decreased, had no further episodes of
respiratory distress.
.
## Abdominal Pain - While in the ICU, patient complained of
abdominal pain.  A KUB was done which came back normal.  When
transferred to the floor patient still had abdominal pain so
underwent a CT abdomen which was negative.  Patient was started
on Flagyl for presumed C diff which was stopped after 4 days
when patient's diarrhea and abdominal pain resolved and first
set on C. diff toxin came back negative.  After a few days being
pain free, diarrhea and abdominal pain returned along with
increased WBC.  Patient was started on PO vancomycin for C. diff
colitis.  Another set of C. diff toxins were sent which again
came back negative however felt that 14 day PO vancomycin course
should be completed.  Patients abdominal pain and diarrhea
resolved.  Patient put on PPI [**Hospital1 **]. GI saw patient in ICU for
blood in PEG, which was felt to be secondary to hemoptysis.
While on the floor patient found to have blood mixed with tube
feeds (bright red, no clots); Hct stable but EGD was done to
rule out active bleeding.  EGD showed no active bleeding and
mild gastritis opposite PEG site.  On CTA of abdomen to further
eval the multiple aneurysms discovered on CTA chest, a
retrogastric mass as well as a splenic infart was found, which
was thought to possibly be the cause of the patient's pain. The
pain resolved over 2d after transfer to the floor.
.
## Abdominal aneurysms - On a chest CTA done to r/o PE, multiple
abdominal aneurysms were seen along celiac trunk, and a 2x2cm
retrogastric mass was noted. Patient had CTA abdomen which
revealed what appears to be a vasculitis picture affecting the
hepatic artery, splenic artery, gastroduodenal artery, with
multiple aneurysms. Rheumatology was consulted and sent HepB and
HepC, Rh factor, complement, [**Doctor First Name **]. Rh factor and C3, C4 WNL.
Patient ESR slightly elevated and ANCA neagative. Consulted GI
who performed EUS with intention of getting FNA of soft tissue
mass, but given proximity (4mm away) of celiac artery this was
deferred. Vascular was also consulted who felt aneurysms were
likely infectious in etiology given the rapid time course of
onset, as they were not seen on the abd CT [**2195-6-14**].  ID felt
that there was unlikely to be an infectious cause of the
aneurysms. Multiple mycotic and bacterial blood cultures were
sent with no growth.  Patient also had a TTE and then TEE to r/o
embolic cause of splenic and renal infarct, especially as there
was no aneursym or thrombosis proximal to the L kidney which had
an infarct. A 4mm clot vs. bacterial growth was found off the
end of the pt's PICC line, which was subsequently removed and
cultured without growth. Double lumen PICC placed thereafter.
.
A second CTA of abd/pelv showed thromboses of aneurysms, two new
small intrahepatic aneurysms, new renal infarcts. Steroids were
started in case of PAN or similar vasculitis, and repeat CTA
(#3) showed stabilization/improvement of the aneurysms. Vasc rec
no anticoag, cont abx x 6 week course, f/u CTA and clinic appt
in 6 mths. Rheum recommended high dose prednisone, f/u CTA in 2
wks and appt with Dr. [**First Name4 (NamePattern1) 16931**] [**Last Name (NamePattern1) 16932**] in 3 weeks, as well as
Bactrim, calcium, Vit D, Fosamax, HIV test which is pending.
Presumptive diagnosis is vasculitis, likely PAN however
consensus among multiple consultants was that empiric six weeks
of antibiotics given the lack of biospy proven diagnosis and the
rare chance of an infectious etiology which could prove fatal if
treated with steroids alone.
.
## Retrogastric mass - Was initially 17mm x 17mm per EUS. FNA
was felt to be too risky given proximity to celiac axis. Gen
[**Doctor First Name **] was consulted for possible lap bx. Pt had repeat CTA after
abx/steroids that showed mass had shrunk. Gen [**Doctor First Name **] holding off
on lap bx at this time, want to re-evaluate mass by CT in 2
weeks
.
## Sinus tachycardia - After patient returned to floor from ICU
for the second time he was found to be tachycardic.  Felt that
tachycardia was due to aggressive albuterol nebulizer
treatments.  A CTA of the chest was done to make sure
tachycardia was not secondary to pulmonary embolism, which was
ruled out. Tachycardia went away after nebs decreased.
.
## Depression - maintained on Zoloft, mood fluctuated but was
overall appropriate
.
## Diarrhea - while on abx and steroids near the end of
hospitalization for vasculitis, developed multiple loose stools
with no pain but increased WBC count that seemed to far out from
initiation of steroids to be from demargination; had no fever; C
diff toxin A negative, toxin B sent but still pending; did not
restart Flagyl or PO Vanc; likely from abx themselves, with WBC
elev from steroids.
His diarrhea improved spontaneously.


Medications on Admission:
prevacid 30 mg per G tube [**Hospital1 **]
Sucralfate 1 mg per G tube 4x/day
zoloft 50 mg daily
albuterol 25 mg with atrovent [**Age over 90 **]m g nebs q4hours
decadron 10 IV bid
xopenex neb 0.63 mg tid
colace
zosyn 3.37 g IV q8h (day 1= [**6-7**])
Humulin sliding scale
reglan 10 mg IV q8h
flagyl 500 mg IV q8h (day 1= [**6-10**])
vancomycin 1 gm IV q12h (day 1= [**6-11**])
versed 2-4 mg IV q1h


Discharge Medications:
1. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day) as needed.
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-1**]
Puffs Inhalation every six (6) hours.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
6. Flovent 44 mcg/Actuation Aerosol Sig: Two (2)  Inhalation
twice a day.
7. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1)
injection Intravenous  Q24H (every 24 hours) for 27 days.
8. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: One (1)
injection Intravenous  Q 12H (Every 12 Hours) for 27 days.
9. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
10. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): continue at current dose until pt sees Rheumatologist
on [**2195-7-29**].
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): per sliding scale,
while on steroids.
12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO DAILY (Daily).
13. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO
QDAY ().
14. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Alendronate Sodium 10 mg Tablet Sig: One (1) Tablet PO QSAT
(every Saturday).
16. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day:
cont while on steroids.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 5503**] Rehab

Discharge Diagnosis:
Respiratory Failure
Tracheal stenosis
MRSA pneumonia
Abdominal aneurysms: hepatic, splenic, gastroduodenal arteries
Associated arterial thromboses
Splenic and renal infarcts
Retrogastric mass of unclear etiology
PICC line clot
C diff colitis
Depression


Discharge Condition:
Patient breathing well on trach mask, hemodynamically stable, no
abdominal or chest pain, no shortness of breath

Discharge Instructions:
Please continue to take all medications as directed and follow
up with your doctors.  Inform your doctors if [**Name5 (PTitle) **] have bleeding
from trach site, abdominal pain, chest pain, shortness of
breath, increased secretions or any other concerning symptoms.

Followup Instructions:
Please follow up with the following appointments:

1. Please have the following lab values checked each week for
the next 6 weeks while you are at the rehab facility: CBC, Chem
10, Vanc trough. You should have a physician view the results
each week and adjust your medications accordingly.

2. You have a repeat CT scan of your abdomen scheduled as well.
Provider: [**Name10 (NameIs) **] SCAN Where: [**Hospital6 29**] RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2195-7-24**] 9:00

3. You have the following Rheumatology appt scheduled:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 16933**]
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2195-7-29**] 11:00

4. Vascular Surgery follow up: please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
office in the next several days to set up a follow up
appointment after your CT scan. Her office # is [**Telephone/Fax (1) 2395**].





Name:  [**Known lastname 2687**],[**Known firstname **]                 Unit No:   [**Numeric Identifier 2688**]

Admission Date:  [**2195-6-11**]              Discharge Date:   [**2195-7-10**]

Date of Birth:  [**2141-8-28**]             Sex:   M

Service: MEDICINE

Allergies:
Tylenol / Penicillins

Attending:[**First Name3 (LF) 1513**]
Addendum:
Update:

[**First Name3 (LF) **] Surgery follow up: Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) 798**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 282**]
SURGERY Where: [**Last Name (NamePattern4) 282**] SURGERY Date/Time:[**2195-8-19**] 1:15pm

Alendronate 10mg po qd (not qweek as originally written)

Discharge Disposition:
Extended Care

Facility:
[**Hospital 2653**] Rehab

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1514**] MD [**MD Number(2) 1515**]

Completed by:[**2195-7-10**]
{'Other tracheostomy complications,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Embolism and thrombosis of other specified artery,Intestinal infection due to Clostridium difficile,Other complications due to other vascular device, implant, and graft,Chronic airway obstruction, not elsewhere classified,Pneumonitis due to inhalation of food or vomitus,Anoxic brain damage,Other gastrostomy complications,Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other abnormal granulation tissue,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Infection with microorganisms resistant to penicillins,Aneurysm of other visceral artery,Vascular disorders of kidney,Depressive disorder, not elsewhere classified,Late effect of intracranial injury without mention of skull fracture,Late effects of self-inflicted injury,Accidents occurring in unspecified place,Other specified cardiac dysrhythmias'}


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: shortness of breath

PRESENT ILLNESS: 53 y/o M s/p self-inflicted gunshot injury to face in [**2187**] with
resulting tracheostomy, who presented to [**Hospital6 14576**]
in [**Location (un) 8973**] [**6-6**] c/o increased secretions from tracheostomy.
They were yellowish, and this had been going on x 3 weeks. He
reportedly didn't feel his breathing was worse than usual. He
denied fevers or chills. He had been seen in the ED one day
prior to this with the same complaint and was sent home with
Levaquin. He continued to require more frequent suctioning and
so returned to the OSH ED the next day. He also was having
coffee-grounds aspirate from G tube, and BRBPR. At that time, he
was afebrile, bp 140/80, RR 20, and O2 sat 95% on 40% trach
mask. He was felt to have bronchospasm, and begun on frequent
nebulizers, steroid taper, and IV levofloxacin. GI felt that his
GI bleeding was [**3-4**] gastritis and hemorrhoids.  On HD1 at the
OSH, he was noted to be in resp distress and tube feeds were
suctioned from his lungs. His ABG was 7.22/78/64 and he was
transferred to the ICU. He was tachypneic in the 30s and c/o
respiratory fatigue so was placed on the vent in the early
morning [**6-7**]. In the ICU, his uncuffed trach was changed to a
cuffed trach with a fair amount of difficulty. He was placed on
PCV due to high peak pressures. He was emergently bronchoscoped
which revealed severe hemorrhagic bronchitis but was difficult
because the bronchoscope that was used was unable to suction. He
was changed to Zosyn upon arrival in the ICU, and was also
placed on flagyl when he developed a distended abdomen with a
lot of gas on the RUQ (CDiff pending). He also was begun on
vancomycin when staph grew from his sputum. He had a neck CT
done to evaluate the degree of his tracheal stenosis, which was
severe. At this point he was transferred to [**Hospital1 18**] for further
management of his tracheal stenosis, for IP procedure. In the
MICU patient initially put on ventilator and was switched to
trach mask the following day.

MEDICAL HISTORY: -bronchiectasis s/p R pneumonectomy [**2180**]
-seizure [**2182**] with anoxic encephalopathy
-gunshot wound to face [**2187**] requiring multiple facial
reconstructions, trach/G tube
-gastritis
-gastric ulcer
-esophagitis

MEDICATION ON ADMISSION: prevacid 30 mg per G tube [**Hospital1 **]
Sucralfate 1 mg per G tube 4x/day
zoloft 50 mg daily
albuterol 25 mg with atrovent [**Age over 90 **]m g nebs q4hours
decadron 10 IV bid
xopenex neb 0.63 mg tid
colace
zosyn 3.37 g IV q8h (day 1= [**6-7**])
Humulin sliding scale
reglan 10 mg IV q8h
flagyl 500 mg IV q8h (day 1= [**6-10**])
vancomycin 1 gm IV q12h (day 1= [**6-11**])
versed 2-4 mg IV q1h

ALLERGIES: Tylenol / Penicillins

PHYSICAL EXAM: Upon transfer to the floor:
PE: T 96.3 HR 85 BP 135-164/80-87 RR 23 O2sat 100%
Gen: NAD, with trach mask
Heent: Disfigured mouth, PERRL, OP clear
Lungs: Upper airway sound b/L, diffuse rhonchi
Cardiac: RRR S1/S2 no murmurs
Abd: soft, distended, NABS, tender to palpation diffuse, no
guarding or rebound
Ext: no edema
Neuro: AAOx3

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Lives with wife, from [**Name (NI) 6257**] originally.
Remote tobacco history. Denies etoh. 

### Response:
{'Other tracheostomy complications,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Embolism and thrombosis of other specified artery,Intestinal infection due to Clostridium difficile,Other complications due to other vascular device, implant, and graft,Chronic airway obstruction, not elsewhere classified,Pneumonitis due to inhalation of food or vomitus,Anoxic brain damage,Other gastrostomy complications,Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other abnormal granulation tissue,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Infection with microorganisms resistant to penicillins,Aneurysm of other visceral artery,Vascular disorders of kidney,Depressive disorder, not elsewhere classified,Late effect of intracranial injury without mention of skull fracture,Late effects of self-inflicted injury,Accidents occurring in unspecified place,Other specified cardiac dysrhythmias'}
