CHIEF COMPLAINT: obstruction beneath trachea

PRESENT ILLNESS: 59-year-old female transferred from [**First Name8 (NamePattern2) **] [**Hospital3 6783**] Hospital with a
history of a tracheostomy placement on [**2120-10-17**] due to
seizures, respiratory failure and vocal cord edema. According to
the patient she underwent an early decannulation for less than
24
hrs and they had to recannulate and left the trach tube. She was
doing well on a rehab, but on [**2121-1-15**] she presented again to
[**Hospital2 **]
[**Hospital3 6783**] Hospital  with fevers to 101.9 and an hypoxic episode
with Sats down to the 60's. She was worked up and had a
bronchoscopy on [**1-16**] and was noted to have a tracheostomy tube
completely occluded by a tissue mass - ?granulation tissue. The
bronchoscope could not advance past the mass, so the trach tube
was pulled back slightly and the mass was better visualized. The
mass was washed with saline but not biopsied. Respiratory status
was stable after repositioning. She is now being transferred to
[**Hospital1 18**] for evaluation of the mass and possible resection.

MEDICAL HISTORY: HTN, DM2, Hyperlipidemia, PVD, OM with MRSA, OA,
retinopathy, neuropathy, nephropathy, ARF, obesity, seizures,
aspiration PNA, failed bedside swallow - pureed honey thick diet

MEDICATION ON ADMISSION: Gabapentin 300''', Levetiracetam 500'', Zinc 200'', Insulin
aspart SS, Albuterol/Ipratropium q4, Heparin 5000''', Morphine
2prn, Lopressor 50'', Vit D 400, Silver cream to R knee, Zinc
220'', Ferrous Sulfate 325', Cyanocobalamin 500', Pantoprazole
40', ASA 325', HCTZ 25'

ALLERGIES: Vicodin

PHYSICAL EXAM: VS: T 99.7, 89reg, 128/75, RR 20, 92% RA
Physical Exam:
Gen: pleasant in NAD, lying in hospital bed.
Lungs: rhonchi t/o bilaterally
CV: RRR, S1, S2, no MRG or JVD
Abd: soft, NT, ND
Right BKA with intact wound vac to suction
left leg warm, no edema

FAMILY HISTORY: n/c

SOCIAL HISTORY: ex-smoker, married.
Other tracheostomy complications,Accidental puncture or laceration during a procedure, not elsewhere classified,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Epilepsy, unspecified, without mention of intractable epilepsy,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Polyneuropathy in diabetes,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Below knee amputation status
Tracheostomy comp NEC,Accidental op laceration,Acc cut in med care NEC,Epilep NOS w/o intr epil,DMII renl nt st uncntrld,Nephritis NOS in oth dis,Diabetic retinopathy NOS,Neuropathy in diabetes,Hypertension NOS,Hyperlipidemia NEC/NOS,Status amput below knee
Admission Date:  [**2121-1-21**]              Discharge Date:   [**2121-1-27**]

Date of Birth:  [**2061-3-20**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Vicodin

Attending:[**First Name3 (LF) 281**]
Chief Complaint:
obstruction beneath trachea

Major Surgical or Invasive Procedure:
[**2121-1-22**] flexible bronchoscopy with tracheal decannulation
[**2121-1-27**] flexible bronchoscopy


History of Present Illness:
59-year-old female transferred from [**First Name8 (NamePattern2) **] [**Hospital3 6783**] Hospital with a
history of a tracheostomy placement on [**2120-10-17**] due to
seizures, respiratory failure and vocal cord edema. According to
the patient she underwent an early decannulation for less than
24
hrs and they had to recannulate and left the trach tube. She was
doing well on a rehab, but on [**2121-1-15**] she presented again to
[**Hospital2 **]
[**Hospital3 6783**] Hospital  with fevers to 101.9 and an hypoxic episode
with Sats down to the 60's. She was worked up and had a
bronchoscopy on [**1-16**] and was noted to have a tracheostomy tube
completely occluded by a tissue mass - ?granulation tissue. The
bronchoscope could not advance past the mass, so the trach tube
was pulled back slightly and the mass was better visualized. The
mass was washed with saline but not biopsied. Respiratory status
was stable after repositioning. She is now being transferred to
[**Hospital1 18**] for evaluation of the mass and possible resection.


Past Medical History:
HTN, DM2, Hyperlipidemia, PVD, OM with MRSA, OA,
retinopathy, neuropathy, nephropathy, ARF, obesity, seizures,
aspiration PNA, failed bedside swallow - pureed honey thick diet

[**2-25**] R CEA
[**9-25**] R BKA
[**10-25**] Tracheostomy [**2-18**] seizure, PEA arrest and vocal cord edema


Social History:
ex-smoker, married.


Family History:
n/c

Physical Exam:
VS: T 99.7, 89reg, 128/75, RR 20, 92% RA
Physical Exam:
Gen: pleasant in NAD, lying in hospital bed.
Lungs: rhonchi t/o bilaterally
CV: RRR, S1, S2, no MRG or JVD
Abd: soft, NT, ND
Right BKA with intact wound vac to suction
left leg warm, no edema

Pertinent Results:
[**2121-1-27**] 06:05AM BLOOD WBC-7.0 RBC-3.34* Hgb-9.9* Hct-30.1*
MCV-90 MCH-29.5 MCHC-32.7 RDW-13.5 Plt Ct-380
[**2121-1-27**] 06:05AM BLOOD Plt Ct-380
[**2121-1-27**] 06:05AM BLOOD Glucose-168* UreaN-13 Creat-0.8 Na-142
K-4.3 Cl-100 HCO3-35* AnGap-11
[**2121-1-27**] 06:05AM BLOOD Calcium-8.3* Phos-4.2 Mg-2.4
[**2121-1-26**] 07:35AM BLOOD Vanco-20.8*

[**2121-1-23**]
Right femoropopliteal duplex was performed at the bedside.

FINDINGS: The inflow right common femoral waveform is monophasic
with a
velocity of 72 cm/sec. The SFA is patent to the mid thigh with
monophasic
waveforms and velocities of 39, 115 cm/sec. The distal SFA and
above-knee
popliteal artery appear to be occluded. The mid popliteal artery
is
reconstituted with monophasic waveforms and velocities of 36
cm/sec.

The profunda femoris was not seen due to obesity.

IMPRESSION: Monophasic common femoral waveform with monophasic
flow in the
proximal SFA with mid SFA occlusion and reconstitution of the
popliteal
artery

[**2121-1-23**] Venous duplex:
FINDINGS: RIGHT: The right greater saphenous vein is occluded.
It is
possible that this represents an occluded right lower extremity
bypass graft
given the overlying surgical scar.

LEFT: The left greater saphenous is patent with diameters from
ankle to knee
of 2.3, 1.8, 2.4, 3.1 mm. The diameters from knee to groin are
4.0, 4 2, 4.8,
4.8.

IMPRESSION: Occluded right greater saphenous vein versus
occluded bypass.
Patent left greater saphenous vein with good diameters to the
proximal calf.

[**2121-1-22**] 3:39 pm SWAB      Source: right BKA.

   GRAM STAIN (Final [**2121-1-22**]):
      2+   (1-5 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      1+    (<1 per 1000X FIELD):   GRAM NEGATIVE ROD(S).

   WOUND CULTURE (Preliminary):
      PSEUDOMONAS AERUGINOSA.    MODERATE GROWTH.
         COLISTIN REQUESTED PER DR [**Last Name (NamePattern4) 83919**] [**2121-1-26**].
         ISOLATE SENT TO [**Known lastname 4534**] FOR COLISTIN SENSITIVITY TESTING
[**2121-1-27**].
      PSEUDOMONAS AERUGINOSA.    MODERATE GROWTH.  SECOND
STRAIN.
         COLISTIN REQUESTED PER DR [**Last Name (NamePattern4) 83919**] [**2121-1-26**].
         ISOLATE SENT TO [**Known lastname 4534**] FOR COLISTIN SENSITIVITY TESTING
[**2121-1-27**].
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    RARE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |          PSEUDOMONAS AERUGINOSA
                             |          |
CEFEPIME--------------    32 R       32 R
CEFTAZIDIME-----------  =>64 R     =>64 R
CIPROFLOXACIN---------   =>4 R      =>4 R
GENTAMICIN------------     2 S        4 S
MEROPENEM-------------  =>16 R     =>16 R
PIPERACILLIN/TAZO----- =>128 R    =>128 R
TOBRAMYCIN------------   <=1 S      <=1 S


Brief Hospital Course:
Mrs. [**Known lastname **] was admitted on [**2121-1-21**]. On [**2121-1-22**] she went to the CDC
where she had bronchoscopy revealing a false passage in the
pretracheal area. She also has a tracheal laceration that
measured approximately 1 cm in length. The patient also has some
necrotic areas of cartilage just proximal to the tracheal
defect. She was intubated and trach decannulated, and sent to
the ICU for overnight observation. CT neck and chest were done
revealing a 3-cm long, subcutaneous, pretracheal, low cervical
tract, without clear intrathoracic extension or abscess, and
multifocal atelectasis, less likely pneumonia.  No subcutaneous
emphysema, adventitious gas or gas- or fluid-containing tract in
the anterior cervical soft tissues to specifically suggest
persistent "false channel" communicating with the cervical
trachea. The patient was transfused 2 units PRBC for hct of
around 22, and extubated [**2121-1-23**]. She had vascular surgery
consult for her nonhealing right BKA, who placed a wound vac,
and started her on cipro/vanc. Cultures grew out pseudomonas
only sensitive to tobra and gent. ID was consulted for further
help in antibiotic management on [**2121-1-27**]. They recommended
colisitin sensitivities. In the meantime another right BKA wound
culture was sent on [**2121-1-27**], and recommendations were made to
stop all antibiotics, and when the patient underwent future
vascular surgery for her stump, she should be treated with
antibiotics. A wound vac was applied to the stump. The patient
underwent bronchoscopy on [**2121-1-27**] showing trauma to posterior
wall. Dr. [**Last Name (STitle) **] deemed the patient safe for discharge to
[**Hospital1 1559**] [**Hospital1 **] with follow up in two weeks. The patient
states she would like to follow up with [**Hospital1 18**] vascular surgery,
therefore a follow up appointment was made for two weeks.

We have sent off another culture of the right BKA today, and
will follow this as an outpatient.


Medications on Admission:
Gabapentin 300''', Levetiracetam 500'', Zinc 200'', Insulin
aspart SS, Albuterol/Ipratropium q4, Heparin 5000''', Morphine
2prn, Lopressor 50'', Vit D 400, Silver cream to R knee, Zinc
220'', Ferrous Sulfate 325', Cyanocobalamin 500', Pantoprazole
40', ASA 325', HCTZ 25'


Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) mL PO BID (2
times a day).
3. Hydrochlorothiazide 12.5 mg Capsule [**Hospital1 **]: One (1) Capsule PO
DAILY (Daily).
4. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
6. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO Q8H (every
8 hours).
7. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO every six
(6) hours as needed for pain.
8. Glucagon (Human Recombinant) 1 mg Recon Soln [**Hospital1 **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
9. Levetiracetam 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1) ml
Injection TID (3 times a day).
12. Collagenase 250 unit/g Ointment [**Last Name (STitle) **]: One (1) Appl Topical
DAILY (Daily): to right pressure sore above the knee.
13. insulin
Insulin SC Sliding Scale
  Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70   mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-159   mg/dL 0   Units 0   Units 0   Units 0   Units
160-179   mg/dL 2   Units 2   Units 2   Units 2   Units
180-199   mg/dL 3   Units 3   Units 3   Units 3   Units
200-219   mg/dL 4   Units 4   Units 4   Units 4   Units
220-239   mg/dL 5   Units 5   Units 5   Units 5   Units
240-259   mg/dL 6   Units 6   Units 6   Units 6   Units
260-279   mg/dL 7   Units 7   Units 7   Units 7   Units
280-299   mg/dL 8   Units 8   Units 8   Units 8   Units
300-319   mg/dL 9   Units 9   Units 9   Units 9   Units
320-339   mg/dL 10   Units 10   Units 10   Units 10   Units
340-359   mg/dL 11   Units 11   Units 11   Units 11   Units
360-379   mg/dL 12   Units 12   Units 12   Units 12   Units
380-399   mg/dL 13   Units 13   Units 13   Units 13   Units
  Instructons for NPO Patients: Evening Prior to
Surgery/Procedure: If on glargine or detemir: give 80% of usual
dose; If on NPH: give 100% usual dose. Morning of
Surgery/Procedure: If on glargine or detemir: give 80% of usual
dose; If on NPH: give 50% of usual dose; If on premix insulin
(e.g. 70/30, 75/25): take total number of AM units ordered,
divide by 3, and give that many units as NPH; If on sliding
scale of short acting insulin: administer according to HS
schedule. Hold all oral antidiabetic medications, and consider
sliding scale coverage; If appropriate, give IVF with dextrose
to prevent hypoglycemia.

14. oxygen
2LNasal cannula. Wean to keep o2 sats >92%
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for SOB, dyspnea.
16. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
17. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
18. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
19. Zinc Sulfate 220 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a
day.
20. Cyanocobalamin 500 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day.
21. Vitamin D 400 unit Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.



Discharge Disposition:
Extended Care

Facility:
[**Location (un) 32674**] - [**Location (un) **]

Discharge Diagnosis:
Tracheal decannulation after false tracheal cannulation at
outside hospital
PMH:
HTN, DM2, Hyperlipidemia, PVD, OM with MRSA, OA, retinopathy,
neuropathy, nephropathy, ARF, obesity, seizures, aspiration PNA,
failed bedside swallow - pureed honey thick diet


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:
-Out of bed three times a day with physical therapy
-wound vac to right stump to low continuous suction. change
3x/week.
-Call Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 10084**] if you have questions
-accuchecks prior to meals and at bedtime. Administer insulin as
written.


Followup Instructions:
1. Follow up with Dr. [**Last Name (STitle) **] of interventional pulmonology
Tuesday [**2121-2-11**] at 9am, in [**Hospital1 **] 116 ([**Hospital Ward Name **]). Do not eat
after midnight the night before because you will get a
bronchoscopy at 10am to evaluate your airway. ([**Telephone/Fax (1) 73295**]
2. Follow up with Dr. [**Last Name (STitle) 1391**] of Vascular Surgery [**Telephone/Fax (1) 1393**]
on [**2120-2-13**] AT 1130, in [**Hospital Unit Name **] 110 [**Doctor First Name **] room 5C.


                             [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**]

Completed by:[**2121-1-27**]
{'Other tracheostomy complications,Accidental puncture or laceration during a procedure, not elsewhere classified,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Epilepsy, unspecified, without mention of intractable epilepsy,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Polyneuropathy in diabetes,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Below knee amputation status'}


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: obstruction beneath trachea

PRESENT ILLNESS: 59-year-old female transferred from [**First Name8 (NamePattern2) **] [**Hospital3 6783**] Hospital with a
history of a tracheostomy placement on [**2120-10-17**] due to
seizures, respiratory failure and vocal cord edema. According to
the patient she underwent an early decannulation for less than
24
hrs and they had to recannulate and left the trach tube. She was
doing well on a rehab, but on [**2121-1-15**] she presented again to
[**Hospital2 **]
[**Hospital3 6783**] Hospital  with fevers to 101.9 and an hypoxic episode
with Sats down to the 60's. She was worked up and had a
bronchoscopy on [**1-16**] and was noted to have a tracheostomy tube
completely occluded by a tissue mass - ?granulation tissue. The
bronchoscope could not advance past the mass, so the trach tube
was pulled back slightly and the mass was better visualized. The
mass was washed with saline but not biopsied. Respiratory status
was stable after repositioning. She is now being transferred to
[**Hospital1 18**] for evaluation of the mass and possible resection.

MEDICAL HISTORY: HTN, DM2, Hyperlipidemia, PVD, OM with MRSA, OA,
retinopathy, neuropathy, nephropathy, ARF, obesity, seizures,
aspiration PNA, failed bedside swallow - pureed honey thick diet

MEDICATION ON ADMISSION: Gabapentin 300''', Levetiracetam 500'', Zinc 200'', Insulin
aspart SS, Albuterol/Ipratropium q4, Heparin 5000''', Morphine
2prn, Lopressor 50'', Vit D 400, Silver cream to R knee, Zinc
220'', Ferrous Sulfate 325', Cyanocobalamin 500', Pantoprazole
40', ASA 325', HCTZ 25'

ALLERGIES: Vicodin

PHYSICAL EXAM: VS: T 99.7, 89reg, 128/75, RR 20, 92% RA
Physical Exam:
Gen: pleasant in NAD, lying in hospital bed.
Lungs: rhonchi t/o bilaterally
CV: RRR, S1, S2, no MRG or JVD
Abd: soft, NT, ND
Right BKA with intact wound vac to suction
left leg warm, no edema

FAMILY HISTORY: n/c

SOCIAL HISTORY: ex-smoker, married. 

### Response:
{'Other tracheostomy complications,Accidental puncture or laceration during a procedure, not elsewhere classified,Accidental cut, puncture, perforation or hemorrhage during other specified medical care,Epilepsy, unspecified, without mention of intractable epilepsy,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere,Background diabetic retinopathy,Polyneuropathy in diabetes,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Below knee amputation status'}
