CHIEF COMPLAINT: Dysphagia

PRESENT ILLNESS: 80F w hx Zenker's diverticulum s/p cricomyotomy/diverticulopexy
[**8-12**] and now with recurrent dysphagia.  Barium swallow was
consistent with recurrent Zenker's diverticulum and patient
presents now for surgical management.

MEDICAL HISTORY: PMH:  HTN, DM2, ^chol, OA/DJD, angioedema

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: ASA 81 QOD, Amlodipine - dose uncertain, HCTZ 25',
Lovastatin 40', Qvar 80mcg 2INH [**Hospital1 **], ICaps MV, fish oil,
Caltrate 600(1500)-400, Centrum silver MVI, metformin 1000mg [**Hospital1 **]

ALLERGIES: Lisinopril / anti-bacterial soap / Unasyn

PHYSICAL EXAM: Discharge P/E:
VS: T: 98.8  P: 93  BP: 140/88  RR: 18  O2sat: 95% 2L
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, +S1S2 w no M/R/G
PULM: CTA B/L w no W/R/R, normal excursion, no respiratory
distress
BACK: no vertebral tenderness, no CVAT
ABD: soft, NT, ND, no mass, no hernia
PELVIS: deferred
EXT: WWP, no CCE, no tenderness, 2+ B radial/DP/PT
NEURO: A&Ox3, no focal neurologic deficits
DERM: no rashes/lesions/ulcers

FAMILY HISTORY: No h/o DM. No other contrib fam hx

SOCIAL HISTORY: Occupation: retired
Drugs: none
Tobacco: 1ppd for 60 years
Alcohol: 1glass [**Doctor First Name **] or wine/night, no prev withdrawal
Other: Lives in senior community, retired, daughter [**Name (NI) **] [**Telephone/Fax (1) 63926**] next of [**Doctor First Name **]
Diverticulum of esophagus, acquired,Angioneurotic edema, not elsewhere classified,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified
Acq esophag diverticulum,Angioneurotic edema,Chr airway obstruct NEC,Hypertension NOS,DMII wo cmp nt st uncntr,Pure hypercholesterolem,Osteoarthros NOS-unspec
Admission Date:  [**2122-7-24**]              Discharge Date:   [**2122-8-3**]

Date of Birth:  [**2041-9-2**]             Sex:   F

Service: SURGERY

Allergies:
Lisinopril / anti-bacterial soap / Unasyn

Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Dysphagia

Major Surgical or Invasive Procedure:
[**2122-7-24**]:
Zenker's cricopharyngeal myotomy and diverticulotomy repair.


History of Present Illness:
80F w hx Zenker's diverticulum s/p cricomyotomy/diverticulopexy
[**8-12**] and now with recurrent dysphagia.  Barium swallow was
consistent with recurrent Zenker's diverticulum and patient
presents now for surgical management.

Past Medical History:
PMH:  HTN, DM2, ^chol, OA/DJD, angioedema

PSH:  Deviated septum repair and tonsillectomy, Zenker
Diverticulum s/p cricomyotomy and diverticulopexy ([**8-12**])

[**Last Name (un) 1724**]: ASA 81 QOD, Amlodipine - dose uncertain, HCTZ 25',
Lovastatin 40', Qvar 80mcg 2INH [**Hospital1 **], ICaps MV, fish oil,
Caltrate 600(1500)-400, Centrum silver MVI


Social History:
Occupation: retired
Drugs: none
Tobacco: 1ppd for 60 years
Alcohol: 1glass [**Doctor First Name **] or wine/night, no prev withdrawal
Other: Lives in senior community, retired, daughter [**Name (NI) **] [**Telephone/Fax (1) 63926**] next of [**Doctor First Name **]


Family History:
No h/o DM. No other contrib fam hx


Physical Exam:
Discharge P/E:
VS: T: 98.8  P: 93  BP: 140/88  RR: 18  O2sat: 95% 2L
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, +S1S2 w no M/R/G
PULM: CTA B/L w no W/R/R, normal excursion, no respiratory
distress
BACK: no vertebral tenderness, no CVAT
ABD: soft, NT, ND, no mass, no hernia
PELVIS: deferred
EXT: WWP, no CCE, no tenderness, 2+ B radial/DP/PT
NEURO: A&Ox3, no focal neurologic deficits
DERM: no rashes/lesions/ulcers


Pertinent Results:
LABORATORIES:

MICROBIOLOGY:
Bronchial washing [**7-26**]: 4000/ml commensural respiratory flora

PATHOLOGY: Pending

[**2122-7-31**] 07:40AM BLOOD WBC-8.8 RBC-4.81 Hgb-14.9 Hct-43.7 MCV-91
MCH-30.9 MCHC-34.1 RDW-14.2 Plt Ct-280
[**2122-7-31**] 07:40AM BLOOD Glucose-125* UreaN-13 Creat-0.5 Na-139
K-3.5 Cl-99 HCO3-28 AnGap-16

ESOPHAGEAL STUDY [**7-30**]
No evidence of obstruction or perforation. Prompt oral contrast
passage into the stomach

VIDEO OROPHARYNGEAL SWALLOW [**7-30**]
1. Mild penetration with thin barium, but no aspiration.
2. Persistent opacity posterior to the upper esophagus,
incompletely assessed in the current study.

Brief Hospital Course:
The patient was admitted to the [**Location 63928**] general surgery service
on [**2122-7-24**] and
had repair of a recurrent Zenker's diverticulum.  The patient
tolerated the procedure well and was brought to the PACU in
stable condition prior to transfer to CC6.

Neuro: Post-operatively, the patient received intermittent
morphine IV with good effect and adequate pain control.  When
intubated patient sedated with propofol which was weaned for
extubation.  Following extubation POD5 pt noted to have L facial
droop.  Neurology intensivist evaluated patient and felt that
this was related to the surgery and would likely be
self-limited. When tolerating oral intake, the patient was
transitioned to oral pain medications.

Electorlites: Patient electrolites were checked, requiring
potassium supplementation.

CV: Patient was placed on lopressor IV postop.  Home meds were
resumed; vital
signs were routinely monitored, they were stable during her
hospitalization in the floor.

Pulmonary: Patient had episode on tongue swelling temporally
associated with unasyn administration on POD1.  Benadryl IV was
given and tongue swelling returned to nearly baseline.  A second
dose of benadryl IV was given POD1 PM for minimal residual
tongue swelling.  On AM of POD2, patient became acutely short of
breath on ambulation from bathroom to bed.  Nurse called team to
bed and very quickly patient became unstable with increasing
peri-oral swelling and inability to effectively ventilate.  A
code was called just prior to arrival of house staff.  Code team
arrived and ACLS protocol engaged.  Epinephrine administered
given history of angioedema.  Patient emergently intubated via
awake fiber-optic intubation for inability to ventilate.
Patient was taken emergently to SICU.  Upon arrival,
bronchoscopy was performed which showed significant angioedema.
Steroids initiated POD2.  Persistent lack of cuff leak prompted
addition of benadryl POD3.  Steroids changed from dexamethasone
to methylprednisolone POD4.  Pt was extubated POD5.

Pulmonary toilet including incentive spirometry and early
ambulation were encouraged.  The patient was stable from a
pulmonary standpoint; vital signs were routinely monitored.

GI/GU: Post-operatively, the patient was kept NPO and given IV
fluids until tolerating oral intake.  Patient extubated POD5 and
pt evaluated by speech & swallow.  Given facial droop POD5, S&S
decided to perform video swallow study POD6 which showed.
Peri-incisional JP drain was removed.  Her diet was slowing
advanced to regular which was tolerated well.

ID: Post-operatively, the patient was kept on Unasyn given
nature of diverticulotomy/repair.  This was changed to
cipro/flagyl IV on POD1 per question of allergic reaction as
above.  Antibiotics were discontinued POD4. The patient's
temperature was closely watched for signs of infection.

Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.

Swallowing: Esophageal barium study was perform, no evidence of
obstruction or perforation. Prompt oral contrast passage into
the stomach. Speach and swallow evaluated the patient, they
recommended soft solids and nectar thick liquids which she
tolerated  very well. A swallowing study was repeated on [**8-3**],
it showed penetration of thin and nectar thick liquids during
the swallow as well as backflow
of liquids and purees from the esophagus into the airway after
the swallow, Full liquid diet was recommended. Nutrition consult
for patient education was given to the patient. She understand
the risk of aspiration. She will follow up with speach and
swallow if any concer. She will be d/c with VNA Swallowing
therapy and Physical Therapy. Her daughter was informed of this
risk of aspiration.

Physical teraphy worked with her during her hospitalization, she
is able to walk with walker. Patient was d/c with physical
therapy services at home and continue O2 suplementation.

At the time of discharge on POD 10 the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.


Medications on Admission:
[**Last Name (un) 1724**]: ASA 81 QOD, Amlodipine - dose uncertain, HCTZ 25',
Lovastatin 40', Qvar 80mcg 2INH [**Hospital1 **], ICaps MV, fish oil,
Caltrate 600(1500)-400, Centrum silver MVI, metformin 1000mg [**Hospital1 **]


Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
3. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day) as needed for COPD.

4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
7. lovastatin 20 mg Tablet Sig: Two (2) Tablet PO daily ().
8. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
10. Caltrate 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
once a day.


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 932**] Area VNA

Discharge Diagnosis:
1. Zenker's diverticulum
2. Angioedema
3. Chronic obstructive pulmonary disease


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the [**Location 63928**] general surgery service for
surgical management of your recurrent Zenker's diverticulum.

General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication.  Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed.  You
may not drive or heavy machinery while taking narcotic analgesic
medications.  You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids.  Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions.  Please also
follow-up with your primary care physician.

Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water.  Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.


Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2819**] in approximately two
weeks.   Call ([**Telephone/Fax (1) 10058**] for an appointment or with any
questions/concerns.

Please call [**Telephone/Fax (1) 3731**] for speach and swallow out patient
follow up if any questions or concerns.
{'Diverticulum of esophagus, acquired,Angioneurotic edema, not elsewhere classified,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Osteoarthrosis, unspecified whether generalized or localized, site 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: Dysphagia

PRESENT ILLNESS: 80F w hx Zenker's diverticulum s/p cricomyotomy/diverticulopexy
[**8-12**] and now with recurrent dysphagia.  Barium swallow was
consistent with recurrent Zenker's diverticulum and patient
presents now for surgical management.

MEDICAL HISTORY: PMH:  HTN, DM2, ^chol, OA/DJD, angioedema

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: ASA 81 QOD, Amlodipine - dose uncertain, HCTZ 25',
Lovastatin 40', Qvar 80mcg 2INH [**Hospital1 **], ICaps MV, fish oil,
Caltrate 600(1500)-400, Centrum silver MVI, metformin 1000mg [**Hospital1 **]

ALLERGIES: Lisinopril / anti-bacterial soap / Unasyn

PHYSICAL EXAM: Discharge P/E:
VS: T: 98.8  P: 93  BP: 140/88  RR: 18  O2sat: 95% 2L
GEN: WD, WN in NAD
HEENT: NCAT, EOMI, anicteric
CV: RRR, +S1S2 w no M/R/G
PULM: CTA B/L w no W/R/R, normal excursion, no respiratory
distress
BACK: no vertebral tenderness, no CVAT
ABD: soft, NT, ND, no mass, no hernia
PELVIS: deferred
EXT: WWP, no CCE, no tenderness, 2+ B radial/DP/PT
NEURO: A&Ox3, no focal neurologic deficits
DERM: no rashes/lesions/ulcers

FAMILY HISTORY: No h/o DM. No other contrib fam hx

SOCIAL HISTORY: Occupation: retired
Drugs: none
Tobacco: 1ppd for 60 years
Alcohol: 1glass [**Doctor First Name **] or wine/night, no prev withdrawal
Other: Lives in senior community, retired, daughter [**Name (NI) **] [**Telephone/Fax (1) 63926**] next of [**Doctor First Name **] 

### Response:
{'Diverticulum of esophagus, acquired,Angioneurotic edema, not elsewhere classified,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pure hypercholesterolemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified'}
