CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: 52 year-old paramedic who has a history of subglottic stenosis
and
tracheobronchomalacia who presents to [**Hospital1 190**] for evaluation for her airway disease for
possible surgical management. The patient has a history of 7
intubations for elective surgical procedures beginning in
[**2120**] with the most recent intubation in [**2125**] when the patient
underwent a VATS biopsy of her right lung for pleural
effusions with a final diagnosis of sarcoidosis. The patient
developed significant shortness of breath in [**2125-11-18**] and
pn [**2125-12-10**] was diagnosed with tracheal stenosis. The
patient had a silicone tracheal stent placed in [**2126-1-16**] by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**State 2690**]. Patient had the stent replaced a
month later with a longer stent after which she developed
some malacia of the trachea distal to the stent.

MEDICAL HISTORY: tracheal stenosis, trachealbronchomalacia, diagnosis of
sarcoidosis and multiple endotracheal intubations (7 total)for
various surgical procedures
PMHX: sarcoidosis, OSA-CPAP at home, Asthma, hypothyroid, DJD
PSHX: bilat TKR, CCY, VATS right lung bx, hiatal
hernia/fundoplication

MEDICATION ON ADMISSION: MEDS: wellbutrin 300'/150', klonopin .5/.5/1mg, cymbalta
60qam/30hs, protonix 40', lasix 40", potassium 40", zyrtec',
advair, singular 10', synthroid 75', flexeril 10prn, prednisone
2.5 qod.

ALLERGIES: Erythromycin Base

PHYSICAL EXAM: General- obese middle age female lying on bed in NAD
HEENT- PERRLA, Oral- pink, neck-ROM intact, no JVD, mild insp
stridor
REsp-CTA
Cor-RRR
Abd- + BS, NT, ND, obese
Ext-no edema

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: lives in [**State 2690**] with husband- here at hotel while pt in hospital
Occupation- paramedic
+ smoker x9 years- quit
Sarcoidosis,Lung involvement in other diseases classified elsewhere,Stenosis of larynx,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified acquired hypothyroidism,Knee joint replacement,Long-term (current) use of steroids,Anemia, unspecified
Sarcoidosis,Lung involv in oth dis,Stenosis of larynx,Asthma NOS,Obstructive sleep apnea,Hypothyroidism NOS,Joint replaced knee,Long-term use steroids,Anemia NOS
Admission Date:  [**2126-7-25**]              Discharge Date:   [**2126-8-7**]

Date of Birth:  [**2074-5-13**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Erythromycin Base

Attending:[**Last Name (NamePattern1) 1561**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
s/p trachealplasty, tracheal resection.[**2126-7-31**]
rigid [**Month/Day/Year **]- tracheal stent placement-[**2126-7-25**]
rigid [**Month/Day/Year **]- tracheal stent removal-
flexible [**Month/Day/Year **] -9/11/06;9/14/06;9/15/06;[**2126-8-7**].


History of Present Illness:
 52 year-old paramedic who has a history of subglottic stenosis
and
tracheobronchomalacia who presents to [**Hospital1 190**] for evaluation for her airway disease for
possible surgical management. The patient has a history of 7
intubations for elective surgical procedures beginning in
[**2120**] with the most recent intubation in [**2125**] when the patient
underwent a VATS biopsy of her right lung for pleural
effusions with a final diagnosis of sarcoidosis. The patient
developed significant shortness of breath in [**2125-11-18**] and
pn [**2125-12-10**] was diagnosed with tracheal stenosis. The
patient had a silicone tracheal stent placed in [**2126-1-16**] by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**State 2690**]. Patient had the stent replaced a
month later with a longer stent after which she developed
some malacia of the trachea distal to the stent.


Past Medical History:
tracheal stenosis, trachealbronchomalacia, diagnosis of
sarcoidosis and multiple endotracheal intubations (7 total)for
various surgical procedures
PMHX: sarcoidosis, OSA-CPAP at home, Asthma, hypothyroid, DJD
PSHX: bilat TKR, CCY, VATS right lung bx, hiatal
hernia/fundoplication

Social History:
lives in [**State 2690**] with husband- here at hotel while pt in hospital
Occupation- paramedic
+ smoker x9 years- quit

Family History:
non-contributory

Physical Exam:
General- obese middle age female lying on bed in NAD
HEENT- PERRLA, Oral- pink, neck-ROM intact, no JVD, mild insp
stridor
REsp-CTA
Cor-RRR
Abd- + BS, NT, ND, obese
Ext-no edema

Pertinent Results:
Hematology
  COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2126-8-7**] 06:00AM    7.7 3.38* 9.1* 27.4* 81* 26.9* 33.1 18.6*
394
  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2126-8-7**] 06:00AM        394
[**2126-8-7**] 06:00AM    12.3 25.5   1.1

Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2126-8-7**] 06:00AM    100 15 1.0 142 3.9 100 33* 13
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2126-7-24**] 01:50PM    18 19     96 32 0.4
CPK ISOENZYMES proBNP
[**2126-7-26**] 08:15PM    221*1

  CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
[**2126-8-7**] 06:00AM          9.2 4.2 2.4
LIPID/CHOLESTEROL Cholest Triglyc HDL CHOL/HD LDLcalc
[**2126-7-27**] 05:33AM    [**Telephone/Fax (1) 69233**] 45


[**2126-7-25**] 09:30PM   GLUCOSE-118* UREA N-9 CREAT-0.9 SODIUM-141
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-30 ANION GAP-14
[**2126-7-25**] 09:30PM   CALCIUM-9.2 PHOSPHATE-3.8 MAGNESIUM-2.2
[**2126-7-24**] 01:50PM   GLUCOSE-99 UREA N-14 CREAT-1.0 SODIUM-142
POTASSIUM-3.3 CHLORIDE-103 TOTAL CO2-26 ANION GAP-16
[**2126-7-24**] 01:50PM   ALT(SGPT)-18 AST(SGOT)-19 ALK PHOS-96
AMYLASE-32 TOT BILI-0.4
[**2126-7-24**] 01:50PM   TOT PROT-7.1 ALBUMIN-4.1 GLOBULIN-3.0
[**2126-7-24**] 01:50PM   WBC-14.3* RBC-4.05* HGB-10.7* HCT-32.9*
MCV-81* MCH-26.4* MCHC-32.5 RDW-19.0*
[**2126-7-24**] 01:50PM   PLT COUNT-373
[**2126-7-24**] 01:50PM   PT-12.3 PTT-27.4 INR(PT)-1.1
RADIOLOGY  Final Report

CHEST (PORTABLE AP)  [**2126-8-1**] 7:58 AM
Reason: r/o pneumo

[**Hospital 93**] MEDICAL CONDITION:
52 year old woman s/p traceal resection, s/p tracheoplasty
HISTORY: Status post tracheoplasty. Rule out pneumonia.
IMPRESSION: AP chest compared to postoperative film from
[**7-31**] and preoperative films from [**7-29**]:

Mild interstitial pulmonary edema has improved though lung
volumes remain quite small. Tip of the endotracheal tube is
approximately a cm beyond the carina in the right bronchus.
Consolidation of the base of the left lung is probably
atelectasis. The mandible obscures the upper mediastinum but the
cardiomediastinal silhouette reflecting mild cardiomegaly, is
unchanged. Lung apices are similarly obscured. There is no
pneumothorax seen along the more clearly delineated pleural
surfaces.
OPERATIVE REPORT
 Surgeon:  [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 17274**]
ASSISTANT:  [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D.

PREOPERATIVE DIAGNOSES:  Postintubation tracheal stenosis,
diffuse tracheobronchomalacia, status post tracheal resection
and reconstruction, and modified tracheoplasty.

POSTOPERATIVE DIAGNOSES:  Postintubation tracheal stenosis,
diffuse tracheobronchomalacia, status post tracheal resection
and reconstruction, and modified tracheoplasty.
PROCEDURE:  Flexible [**Name8 (MD) **].
INDICATIONS FOR PROCEDURE:  Assessment of airway patency.
DESCRIPTION OF PROCEDURE:  After informed consent was
obtained, Ms. [**Known lastname 69234**] was in the CSRU where she was prepped
using 1% lidocaine applied to the posterior oropharynx.
Through the oral route, we advanced a flexible bronchoscope
to the oropharynx and larynx with visualization of the vocal
cords and arytenoids which were normal. The bronchoscope was
advanced into the trachea. We could appreciate at 2 cm from
the vocal cords a circumferential area of edema and erythema
at the site of tracheal resection. There was a 2-cm vertical
incision in the posterior membranous wall with edema and
erythema with moderate malacia at this site. There was severe
mid distal tracheal malacia as well as severe right
bronchomalacia. There were minimal secretions overall.
COMPLICATIONS:  None.
IMPRESSION:  Tracheobronchomalacia and postintubation
tracheal stenosis, status post tracheal resection and
modified tracheoplasty with a moderate amount of edema and
erythema at the surgical site.
-----------------
CT TRACHEA W/C & W/3D REND  [**2126-7-30**] 12:17 PM
Reason: Dynamic study, eval tracheomalacia/stenosis after stent
[**Last Name (un) **]
Contrast: [**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with h/o recurrent PNA w/ tracheomalacia
pre-op for OR
REASON FOR THIS EXAMINATION:
Dynamic study, eval tracheomalacia/stenosis after stent removal.
Scheduled for OR [**7-31**]
CONTRAINDICATIONS for IV CONTRAST: None.
REASON FOR EXAM: Stent removal, tracheal stenosis, and
tracheomalacia.
Comparison is made with prior study [**2126-7-23**].
TECHNIQUE: Multidetector CT through the chest without oral or IV
contrast per CT trachea protocol was performed during
inspiration, dynamic breathing and during coughing. Multiple 3D
reformatted images were also provided and reviewed.

FINDINGS: The tracheal stent has been removed. Where the
tracheal stent was, starting 2cm from the vocal cords and
extending inferiorly for 3.5cm, there is tracheal stenosis and
the tracheal wall has irregular, almost polypoid, thickening.
Below it, there is diffuse tracheal wall thickening to the level
of the aortic arch. The narrowest dimensions of the trachea at
the thoracic inlet are 10 x 6 mm (20 x 7mm when the stent was in
place). Below the stenosis, the tracheal dimensions are 14 x 16.

In dynamic sequences, there is narrowing of the trachea with
almost complete obliteration of the tracheal lumen from the
thoracic inlet to the aortic arch. More diistally, there is
moderate to severe collapse of the trachea and right mainstem
bronchus.

Widespread ground glass opacity and peribronchial infiltration
developed between [**7-23**] and [**7-24**], and is stable
since then. Scarring or atelectasis involves the right upper
lobe, and right middle lobe. Multiple calcified granulomas are
present. A small right pleural effusion is new. There is no
pneumothorax or left pleural effusion. Multiple enlarged
mediastinal lymph nodes are stable measuring up to 16 mm in the
right lower paratracheal station. The LAD is mildly calcified,
otherwise, the heart and great vessels are unremarkable.
Small hiatal hernia is unchanged.
Patient is post cholecystectomy, otherwise the upper abdomen is
unremarkable. Retrocrural lymph nodes are not enlarged and are
stable.

IMPRESSION: Upper tracheal stenosis at site of previous
stenting. Severe tracheobronchomalacia with complete
obliteration of the supra-aortic trachea.
Stable mediastinal lymphadenopathy.
Procedure date     Tissue received     Report Date    Diagnosed
by
[**2126-7-31**] [**2126-7-31**] [**2126-8-5**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/tk??????
Previous biopsies:    [**-4/3518**]  STENT (1).
DIAGNOSIS:

Trachea, excision:
A. Trachea with squamous metaplasia, focal mucosal ulceration,
fibrosis, and chronic inflammation.
B. Cartilage with chronic inflammation, degenerative and
reactive change and focal ossification. See note.




Brief Hospital Course:
52 year-old paramedic who has a history of subglottic stenosis
and
tracheobronchomalacia who presents  and admitted to [**Hospital1 69235**] [**2126-7-25**] for evaluation for her airway disease for
possible surgical management. S/p Stent placement in
[**Location (un) 18296**],[**State 2690**]- referral by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD.
The patient developed sudden shortness of breath in [**Month (only) 205**] of
this year and [**Month (only) **] revealed distal migration of the
stent. The stent was repositioned to an area of stenosis and
her symptoms resolved.
Apparently the patient reports production of foul smelling
and foul smelling purulent secretions when she coughs. She
has had no recent fevers or chills. She has had no chest
pain. She has had no hemoptysis.
HD#1-9/7/06- To OR for rigid [**Month (only) **] for tracheal stent-
tolerated well, no complications. Oral mass found on bronch. ENT
consulted. Thoracic Surgery consulted for operative evaluation.
REgulart meds resumed. Lytes monitored.
PPD#1/HD#2-Pt tolerated stent removal well. Cardiology
evaluation pre-op- recs of beta blocker started, i/o monitoring,
abx prophylaxis, echo done.
HD#[**1-20**]- Ongoing discussion w/ Cardiology and Thoracic Surgery
re: surgical plan. Old stress records obtained.
HD#5- Bronch- flexible for eval tracheal s/p stent removal-
subglottic stenosis- mild, severe TBM
HD#6 [**2126-7-30**]- pt pre-op for surgery in [**11-19**] days. CT trachea
done.
Hd#7- Rigid and flexible [**Date Range **] pre-op for final eval
prior to surgery- To OR for tracheal resection and
trachealplasty. Tolerated well. Pt transferred to ICU intubated
overnight, good airway movement.  STress dose steroids 100 mg x2
given. Close monitoring overnight.
HD#8/POD#1--extubated w/o complication, CXRY  no significant
worsening. REsp greatlyh improved per patient. Agressive
pulmonary toilet, guardian [**Name (NI) 69236**] in place, antibiotics- Ancef
x5-7 days. Tapered dose stress dose steroids x1 given. Plan for
regular dose Prednisone 2.5 mg qod start POD#2.
POD#2- Close monitoring and managament of resp/ pulmonary toilet
status. Physical Therapy consulted. Flexible bronch done for
post-op eval of trachea.- minimal secretions. ICU care. Po diet
resumed
POD#3-9/15/06- [**Name (NI) **] for eval- minimal secretions. Doing
well- ICU care.
POD#4- Transfer to floor- pul toilet, PT/IS/OOB- ambulation.
POD#[**3-23**]- MOnitoring i/o, lytes. Pul toilet. Ambulating
independently- resp status greatly improved. O2 sat96% RA.
[**Month/Day (3) 16689**] done [**8-7**](HD#6) [**Doctor Last Name **] present - Anastamosis intact
w/ min granulation tissue in prox trachea improved, resection
and reconstruction site - patent trachea s/ improved malacia.
Guardian stitch removed, cervical incision staples removed w/o
complication. Local area of reddness w/o discharge at incision
site, presumed fungal in setting of neck flexion x1 week, rx
mycostatin powder topically.
Disposition plan- Discharge in stable/good condition in company
of husband to local hotel. F/U [**8-13**] for [**Month/Year (2) **] and
Thoracic Surgery post-op eval. Plan to fly to [**Location (un) 18296**], [**State 2690**]
[**2126-8-14**] pending no issues seen on [**Month/Day/Year 16689**]/post-op eval.


Medications on Admission:
MEDS: wellbutrin 300'/150', klonopin .5/.5/1mg, cymbalta
60qam/30hs, protonix 40', lasix 40", potassium 40", zyrtec',
advair, singular 10', synthroid 75', flexeril 10prn, prednisone
2.5 qod.

Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours).
Disp:*1 box* Refills:*2*
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
Disp:*1 box* Refills:*2*
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disk
with Device(s)
4. Prednisone 5 mg Tablet Sig: 0.5 Tablet PO QOD ().
Disp:*15 Tablet(s)* Refills:*2*
5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed.
Disp:*60 Tablet(s)* Refills:*0*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
11. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO QAM (once a day (in the
morning)).
12. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)).

13. Bupropion 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QHS (once a day (at bedtime)).
14. Bupropion 150 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO QAM (once a day (in the morning)).
15. Miconazole     Powder Sig: One (1) Appl Miscell.  [**Hospital1 **] (2
times a day) as needed.
Disp:*90 gram* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
tracheal stenosis, trachealbronchomalacia- s/p trachealplasty,
tracheal resection.
sarcoidosis, obstructive sleep apnea- on CPAP breathing machine
at night; asthma, degerative joint disease, hypothyroidism.
bilateral knee replacements, chlolycystectomy, VATS rightlung
biopsy, hiatal hernia s/p fundoplication.

Discharge Condition:
good

Discharge Instructions:
Call Dr.[**Doctor Last Name **]/ Thoracic Surgery office for any issues
related to surgery. [**Telephone/Fax (1) 170**].
Call Dr. [**Last Name (STitle) **] for specific airway issues not related to surgery
or your primary Pulmonologist if necessary.
Take medications as directed and stated on discharge instruction
sheet.  Prescriptions given for new medications.
Gentle neck range of motion exercises [**1-19**] time/day as instructed
by Nurse.
[**First Name (Titles) 16689**] [**Last Name (Titles) 3816**], [**2126-8-13**] at 12:30 pm in
Interventional Pulmonary Suite- [**Hospital1 **] 2, next door to [**Hospital Ward Name 121**]
2.
[**Telephone/Fax (1) 3020**] for any issues. Dr. [**Last Name (STitle) 952**] and Dr. [**Last Name (STitle) **] to review
and add to discharge instructions as appropriate.

Followup Instructions:
[**Last Name (STitle) 16689**] [**Last Name (STitle) 3816**], [**2126-8-13**] at 12:30 pm in
Interventional Pulmonary Suite- [**Hospital1 **] 2, next door to [**Hospital Ward Name 121**]
2.
Please report to Surgical Day Care [**Hospital Ward Name 121**] 8 at 11:30 am on
[**2126-8-13**].
[**Telephone/Fax (1) 3020**] for any issues.
Provider: [**Name10 (NameIs) 454**],NINE DAY CARE [**Hospital Ward Name **] 8 Date/Time:[**2126-8-13**] 11:30
Provider: [**Name10 (NameIs) **],IP PROC IP PROCEDURES Date/Time:[**2126-8-13**]
12:30
Provider: [**Name10 (NameIs) **],ROOM ONE IP ROOMS Date/Time:[**2126-8-13**] 12:30



Completed by:[**2126-8-7**]
{'Sarcoidosis,Lung involvement in other diseases classified elsewhere,Stenosis of larynx,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified acquired hypothyroidism,Knee joint replacement,Long-term (current) use of steroids,Anemia, 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: shortness of breath

PRESENT ILLNESS: 52 year-old paramedic who has a history of subglottic stenosis
and
tracheobronchomalacia who presents to [**Hospital1 190**] for evaluation for her airway disease for
possible surgical management. The patient has a history of 7
intubations for elective surgical procedures beginning in
[**2120**] with the most recent intubation in [**2125**] when the patient
underwent a VATS biopsy of her right lung for pleural
effusions with a final diagnosis of sarcoidosis. The patient
developed significant shortness of breath in [**2125-11-18**] and
pn [**2125-12-10**] was diagnosed with tracheal stenosis. The
patient had a silicone tracheal stent placed in [**2126-1-16**] by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**State 2690**]. Patient had the stent replaced a
month later with a longer stent after which she developed
some malacia of the trachea distal to the stent.

MEDICAL HISTORY: tracheal stenosis, trachealbronchomalacia, diagnosis of
sarcoidosis and multiple endotracheal intubations (7 total)for
various surgical procedures
PMHX: sarcoidosis, OSA-CPAP at home, Asthma, hypothyroid, DJD
PSHX: bilat TKR, CCY, VATS right lung bx, hiatal
hernia/fundoplication

MEDICATION ON ADMISSION: MEDS: wellbutrin 300'/150', klonopin .5/.5/1mg, cymbalta
60qam/30hs, protonix 40', lasix 40", potassium 40", zyrtec',
advair, singular 10', synthroid 75', flexeril 10prn, prednisone
2.5 qod.

ALLERGIES: Erythromycin Base

PHYSICAL EXAM: General- obese middle age female lying on bed in NAD
HEENT- PERRLA, Oral- pink, neck-ROM intact, no JVD, mild insp
stridor
REsp-CTA
Cor-RRR
Abd- + BS, NT, ND, obese
Ext-no edema

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: lives in [**State 2690**] with husband- here at hotel while pt in hospital
Occupation- paramedic
+ smoker x9 years- quit 

### Response:
{'Sarcoidosis,Lung involvement in other diseases classified elsewhere,Stenosis of larynx,Asthma, unspecified type, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified acquired hypothyroidism,Knee joint replacement,Long-term (current) use of steroids,Anemia, unspecified'}
