CHIEF COMPLAINT: Tracheoesophageal fistula

PRESENT ILLNESS: 69F with hx of NSCLC s/p Right pneumonectomy, chemo&radiation
two years ago, admitted to OSH for LLL pneumonia on [**11-5**], found
to have tracheoesophageal fistula on barium swallow and
bronchoscopy, transerred to [**Hospital1 18**] intubated and sedated for
interventional pulmonology evaluation of tracheoesophageal
fistula.
.
Patient was initially admitted to [**Hospital 87965**] Hospital [**11-5**], where
she was treated for CAP with 10 days of levofloxacin, requiring
intubation from [**Date range (1) 87966**].  Her antibiotics were broadened
slowly first with aztreonam ([**11-9**]) then vancomycin ([**11-15**]).
She underwent bronchoscopy [**11-8**], which showed significant
inflammation in the left mainstem bronchus; culture showed rare
yeast. Post-extubation, she required continuous Bipap; she
required reintubation on [**11-15**] due to progressive hypercarbia.
She had been started on vasopressin prior to intubation and was
later started on dopamine as well.  At Midcoast, patient also
had a modified barium swallow which showed barium in the
trachea, but no obvious fistula.  Bronchoscopy confirmed
tracheoesophageal fistula 1cm TEF 5cm from the carina.  While at
Midcoast, she was also noted to have afib and aflutter, but no
known prior history.  An Echo on [**11-8**] showed pulmonary
hypertension and septal hypokinesis, but normal EF. She was
transfered to [**Hospital 1727**] Medical Center intubated on pressors
dopamine and vasopressin.
.
At [**Hospital 1727**] Medical Center, patient had a bronchoscopy with BAL
showing GPCs.  She underwent CT chest on [**11-16**] to rule out PE in
setting of mildly elevated CKMB and trop.  It appears that she
was afebrile throughout her stay at [**Hospital 1727**] Medical.  She was
started on IV doses of digoxin for her afib which helped keep
her rate-controlled and noted to be maintained in sinus rhythm.
Patient was on insulin drip at outside hospital for
hyperglycemia in the setting of TPN and high dose stress IV
steroids.  On transfer to [**Hospital1 18**], patient is on Vancomycin
(Day#4), Clindamycin (Day#3),  Aztreonam (Day#10), Fluconazole
(Day#2).
.
On arrival to the MICU at [**Hospital1 18**], patient is intermittently in
stable VT with SBPs in 180s, completely asymptomatic,
intermittently in rapid Afib with rates to 160s.  She was given
one dose of IV metoprolol 5mg while in Afib with RVR which
decreased her HRs and let her self-convert to NSR with rate 80s.

MEDICAL HISTORY: Non-Small Cell Lung Cancer, stage IIIB (T2N2M0), squamous cell
 - s/p Right pneumonectomy ~[**2125-6-24**]
 - s/p chemo ([**Doctor Last Name **]/taxol, fall [**2124**]) and radiation (5040 cGy
EBRT) at [**Hospital1 107**] [**Doctor Last Name **] Kettering
COPD, severe - not on home O2
HTN

MEDICATION ON ADMISSION: Tussionex
HCTZ
Spironolactone/HCTZ
Megace
Aspirin
Albuterol
Budesonide

ALLERGIES: Penicillin G

PHYSICAL EXAM: On admission to MICU:
itals: T: 97.1 BP: 157/82 P: 110 R: 18 O2: 98% on CMV FiO2 40%
General: intubated but can answer yes or no questions
appropriately and trying to communicate medical history while
intubated, no acute distress
HEENT: Sclera anicteric, MMM, NG tube with bloody aspirates
Neck: supple
Lungs: Diffuse rhonchi bilaterally with air movement only on
left
CV: Reg rhythm, rapid rate, no murmurs appreciated
Abdomen: soft, non-tender, mildly distended, hyperactive bowel
sounds, no rebound tenderness or guarding
GU: foley in place
Ext: warm, well perfused, 2+ pulses, [**11-25**]+ pitting edema of
bilateral lower extremities up to sacrum

FAMILY HISTORY: [**Name (NI) **] Mother died of an MI at 79
Father with multiple myeloma

SOCIAL HISTORY: Married, Husband [**Name (NI) **]. Retired accountant.  Lives in [**State 1727**].
Tobacco: Quit, but smoked 20-40pack-yrs
ETOH: rare
Tracheoesophageal fistula,Acute respiratory failure,Pneumonia, organism unspecified,Hematemesis,Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Acidosis,Personal history of malignant neoplasm of bronchus and lung,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Personal history of irradiation, presenting hazards to health,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Rash and other nonspecific skin eruption,Pressure ulcer, lower back
Tracheoesophageal fstula,Acute respiratry failure,Pneumonia, organism NOS,Hematemesis,Parox ventric tachycard,Acute kidney failure NOS,Acidosis,Hx-bronchogenic malignan,Chr airway obstruct NEC,Hypertension NOS,Hx of irradiation,DMII wo cmp nt st uncntr,Nonspecif skin erupt NEC,Pressure ulcer, low back
Admission Date:  [**2131-11-19**]              Discharge Date:   [**2131-12-2**]

Date of Birth:  [**2062-8-16**]             Sex:   F

Service: CARDIOTHORACIC

Allergies:
Penicillin G

Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Tracheoesophageal fistula

Major Surgical or Invasive Procedure:
Bronchoscopy
Endoscopy

History of Present Illness:
69F with hx of NSCLC s/p Right pneumonectomy, chemo&radiation
two years ago, admitted to OSH for LLL pneumonia on [**11-5**], found
to have tracheoesophageal fistula on barium swallow and
bronchoscopy, transerred to [**Hospital1 18**] intubated and sedated for
interventional pulmonology evaluation of tracheoesophageal
fistula.
.
Patient was initially admitted to [**Hospital 87965**] Hospital [**11-5**], where
she was treated for CAP with 10 days of levofloxacin, requiring
intubation from [**Date range (1) 87966**].  Her antibiotics were broadened
slowly first with aztreonam ([**11-9**]) then vancomycin ([**11-15**]).
She underwent bronchoscopy [**11-8**], which showed significant
inflammation in the left mainstem bronchus; culture showed rare
yeast. Post-extubation, she required continuous Bipap; she
required reintubation on [**11-15**] due to progressive hypercarbia.
She had been started on vasopressin prior to intubation and was
later started on dopamine as well.  At Midcoast, patient also
had a modified barium swallow which showed barium in the
trachea, but no obvious fistula.  Bronchoscopy confirmed
tracheoesophageal fistula 1cm TEF 5cm from the carina.  While at
Midcoast, she was also noted to have afib and aflutter, but no
known prior history.  An Echo on [**11-8**] showed pulmonary
hypertension and septal hypokinesis, but normal EF. She was
transfered to [**Hospital 1727**] Medical Center intubated on pressors
dopamine and vasopressin.
.
At [**Hospital 1727**] Medical Center, patient had a bronchoscopy with BAL
showing GPCs.  She underwent CT chest on [**11-16**] to rule out PE in
setting of mildly elevated CKMB and trop.  It appears that she
was afebrile throughout her stay at [**Hospital 1727**] Medical.  She was
started on IV doses of digoxin for her afib which helped keep
her rate-controlled and noted to be maintained in sinus rhythm.
Patient was on insulin drip at outside hospital for
hyperglycemia in the setting of TPN and high dose stress IV
steroids.  On transfer to [**Hospital1 18**], patient is on Vancomycin
(Day#4), Clindamycin (Day#3),  Aztreonam (Day#10), Fluconazole
(Day#2).
.
On arrival to the MICU at [**Hospital1 18**], patient is intermittently in
stable VT with SBPs in 180s, completely asymptomatic,
intermittently in rapid Afib with rates to 160s.  She was given
one dose of IV metoprolol 5mg while in Afib with RVR which
decreased her HRs and let her self-convert to NSR with rate 80s.


Past Medical History:
Non-Small Cell Lung Cancer, stage IIIB (T2N2M0), squamous cell
 - s/p Right pneumonectomy ~[**2125-6-24**]
 - s/p chemo ([**Doctor Last Name **]/taxol, fall [**2124**]) and radiation (5040 cGy
EBRT) at [**Hospital1 107**] [**Doctor Last Name **] Kettering
COPD, severe - not on home O2
HTN

Social History:
Married, Husband [**Name (NI) **]. Retired accountant.  Lives in [**State 1727**].
Tobacco: Quit, but smoked 20-40pack-yrs
ETOH: rare

Family History:
[**Name (NI) **] Mother died of an MI at 79
Father with multiple myeloma

Physical Exam:
On admission to MICU:
itals: T: 97.1 BP: 157/82 P: 110 R: 18 O2: 98% on CMV FiO2 40%
General: intubated but can answer yes or no questions
appropriately and trying to communicate medical history while
intubated, no acute distress
HEENT: Sclera anicteric, MMM, NG tube with bloody aspirates
Neck: supple
Lungs: Diffuse rhonchi bilaterally with air movement only on
left
CV: Reg rhythm, rapid rate, no murmurs appreciated
Abdomen: soft, non-tender, mildly distended, hyperactive bowel
sounds, no rebound tenderness or guarding
GU: foley in place
Ext: warm, well perfused, 2+ pulses, [**11-25**]+ pitting edema of
bilateral lower extremities up to sacrum

Pertinent Results:
On admission:
.
[**2131-11-19**] 07:25PM BLOOD WBC-27.4* RBC-4.16* Hgb-11.3* Hct-33.6*
MCV-81* MCH-27.0 MCHC-33.5 RDW-13.9 Plt Ct-460*
[**2131-11-19**] 07:25PM BLOOD PT-11.5 PTT-26.2 INR(PT)-1.0
[**2131-11-19**] 07:25PM BLOOD Glucose-76 UreaN-33* Creat-0.3* Na-143
K-5.3* Cl-101 HCO3-35* AnGap-12
[**2131-11-19**] 07:25PM BLOOD ALT-33 AST-47* LD(LDH)-739* CK(CPK)-60
AlkPhos-49 TotBili-0.4
[**2131-11-20**] 04:15AM BLOOD ALT-22 AST-16 LD(LDH)-198 AlkPhos-40
TotBili-0.5
[**2131-11-19**] 07:25PM BLOOD Albumin-3.0* Calcium-8.5 Phos-3.3 Mg-1.8
[**2131-11-20**] 04:24AM BLOOD Type-[**Last Name (un) **] Temp-36.0 Rates-18/2 Tidal V-300
PEEP-5 FiO2-40 pO2-43* pCO2-63* pH-7.43 calTCO2-43* Base XS-13
-ASSIST/CON Intubat-INTUBATED
.
[**11-18**]: Blood cx: NG
.
OSH: [**2131-11-9**] - TTE showed normal EF, septal hypokinesis,
pulmonary hypertension
.
CXR [**2131-11-19**] - Right lung [**Last Name (un) 57454**] out with tracheal deviation to
the right; right-sided PICC line tip in distal subclavian; LLL
infiltrate mixed with barium
.
EKG:
- [**2131-11-19**] - 19:06 - wide complex tachycardia, rate 143,
evidence of p-waves though diff morphologies and not necessarily
conducting; a capture beat
- [**2131-11-19**] - 19:28 - Afib w RVR, rate 130s; narrow complex;
T-wave inversions in inferior leads II, III, avF and precordial
leads V1-V6
- [**2131-11-19**] - 19:33 - NSR rate 80s, inverted T waves in inferior
leads II, III, avF and in V1-V4; flattened T waves in lateral
leads
.
[**11-18**] CXR:
Rightward mediastinal shift and opacification of the right
hemithorax is
consistent with prior pneumonectomy. There is no gas in the
right
pneumonectomy space. Heterogeneous opacification at the base of
the left lung
could be dependent edema or pneumonia, including aspiration. A
2-cm wide
elliptical opacity projecting over the left mid lung could be a
nodule or
fissural pleural fluid since there is pleural fluid, more
inferiorly.
Mediastinum shifted into the opacified right hemithorax cannot
be assessed.
ET tube in standard placement. Nasogastric tube should be
advanced at least 4
cm to move all the side ports well beyond the gastroesophageal
junction
.
CT Torso:
IMPRESSION:

1. Right pneumonectomy, with no evidence of cancer recurrence.

2. Left lower lobe consolidation, with high-attenuation material
suspicious
for prior aspiration of enteric contrast material.

3. No CT evidence of tracheoesophageal fistula. Please note that
this
examination was not a dedicated trachea study but no
spontaneously patent wall
defect is appreciated.

4. Volume overload as evidenced by pleural effusions, mesenteric
edema,
ascites, and anasarca.
.
MRI Brain:
IMPRESSIONS:

1. No intracranial metastases.

2. Small amount of fluid in right mastoid air cells.

3. Mild chronic small vessel ischemic change.


Brief Hospital Course:
69F with hx NSCLC s/p right pneumonectomy/chemo/radiation who
presented to OSH with LLL pneumonia on [**11-5**], found to have
tracheoesophageal fistula by bronchoscopy, transferred to [**Hospital1 18**]
for further management of TEF.
.
# Hypercarbic and Hypoxemic Respiratory Failure: Pt was
transferred from OSH s/p intubation and antibiotic course for
pneumonia. She was transferred after discovery of TE fistula. Pt
remained intubated in the MICU for malignancy w/u and IP
evaluation of the TE fistual. She was taken to the OR on [**11-20**]
for rigid bronch, and while they were there the ET tube was
changed due to cuffleak with resulting ABG showing improvement
in oxygenation and a decrease in her previously elevated CO2.
.
# LLL Pneumonia: CXR showed LLL process; pt had completed 10
days of antibiotics for pneumonia. Vancomycin was continued for
a recent OSH sputum culture that had grown GPCs.  On HD#3,
bilious contents were aspirated from the patient's ET tube. She
was taken to the OR by interventional pulmonology for the
fistula on [**11-20**] (see below for results).  As she was
hemodynamically unstable after the procedure, antibiotics were
broadened on [**11-20**] to vancomycin, aztreonam, and levofloxacin.
.
# TE Fistula: The patient had an initial bronchoscopy in the ICU
on HD#2 that showed a well-demarcated fistula. This was thought
to be [**12-26**] trauma from prior intubation or cancer recurrence.
Malignancy w/u was initiated. CT Torso and MRI brain were
negative for evidence of cancer. On HD#3, pt was taken to the OR
for rigid bronch which showed large incision-shaped TEF in trach
into esophagus (thought to be from an intubation through
necrotic tissue); tracheal stent was placed to seal TEF from
tracheal side, but she will need an esophageal stent as well to
be placed by GI. She was transferred to the [**Hospital Unit Name 153**] on [**11-20**] for
the esophageal stent to be placed.  EGD was attempted on [**11-21**]
at which point she became hypotensive after propofol induction
and the procedure was stopped.  EGD was delayed until [**11-24**] at
which point the TEF was deemed to be too large and a stent
seemed futile.
.
# Wide Complex Tachycardia: On arrival, pt was in stable VT with
rates in the 140s-150s. Potentially may also have represented
SVT with aberancy, though cards was informally c/s'd and agreed
the rhythm appeared to be stable VT. The patient was given 5 mg
IV metoprolol with conversion into sinus rhythm. An EKG showed
worsening TWI. Cards recs did not feel it was ischemic and that
her persistent narrow complex tachycarida was likely MAT. Her
Lopressor was increased to 5IV q4h on [**11-19**].
.
# Coffee Ground Material in NG tube: On transfer, there was
coffee ground material in the NG tube. Aspirate was guaiac
positive. GI bleed was thought to be [**12-26**] high dose steroids at
OSH. She was maintained on [**Hospital1 **] PPI. Hematocrit remained stable
and no other coffee ground material was seen.
.
# Afib with RVR: Pt was intermittently in Afib with RVR and MAT
along with the wide-complex rhythm discussed above. Metoprolol
was increased to 5 mg IV q4h with good effect. She was
maintained on subQ heparin for DVT prophylaxis.

# Non-Small Cell Lung Cancer: The patient is s/p Right
pneumonectomy ~[**2125-6-24**]
 - s/p chemo ([**Doctor Last Name **]/taxol, fall [**2124**]) and radiation (5040 cGy
EBRT) at [**Hospital1 107**] [**Doctor Last Name **] Kettering. The patient was taken to the
OR on [**11-20**] for TE fistula and biopsies were taken in OR of
tracheal and esophageal sides; necrotic tissue seen in right
bronch stump; biopsy from tracheal side preliminarily shows
possible SCC recurrence, but biopsy from GI side sent in
formalin will take longer to come back
.
# Pt was on pneumoboots and later subQ heparin for DVT
prophylaxis. Communication was with the patient and her husband
[**Name (NI) **] ([**Telephone/Fax (1) 87967**] (home) and ([**Telephone/Fax (1) 87968**] (cell). She remained
full code during this admission.

Trauma ICU Course:
EVENTS:
- [**11-25**]: Transfered to TSICU pre-op for diversion of TEF, SVT to
180's; rate controlled with diltiazem, transiently hypotensive
to 70's but resolved.
- [**11-26**]: OR for TEF diversion c/b migration of stent, interval
enlargement of TEF, drains placed x 3. Respiratory acidosis
resolved with increasing PEEP/rate. Received lasix 10mg for
pulmonary edema.
- [**11-27**]: 2uPRBC's w/ 20 IV lasix between. Weaning vent.
Respiratory distress (on CPAP [**6-30**]) after 1 unit of blood
improved with the lasix. 40 IV lasix total. Increased alkalosis
holding diuresis as FeUrea is high. SVT (130's) at 3 AM, rate
controlled with 10 IV lopressor, increased dilt PO to 60 QID.
- [**11-28**]: 20 lasix, dropped HR to 40s on [**3-27**] CPAP. Placed on 100%
FiO2, [**7-2**]- resolved. diamox given, monitoring diuresis
- [**11-29**]: CPAP 5/0 in AM, 15 minutes, tachycardic, went into a. fib
responsive to IV diltiazem, increased CPAP [**7-4**] throughout day.
Met with family briefly.
- [**11-30**]: family meeting - continue care/full code.
- [**12-1**]: TF's started, continuing TPN until TFs at goal. Metabolic
alkalosis largely resolved, likely contraction alkalosis from
diuresis in setting of baseline compensatory alkalosis; dc'd
diamox and started [**Hospital1 **] lasix. Good diuresis but pt hypotensive -
albumin 12.5g x 2 with improvement. Family requests palliative
care consult. Decreased insulin in TPN given episodes of AM
hypoglycemia
- [**12-2**]: D/c'd lasix for weight < preadmission. Patient made CMO
after extensive conversation with patient, family, palliative
care, nursing; ICU attending present.

The patient expired thereafter.


Medications on Admission:
Tussionex
HCTZ
Spironolactone/HCTZ
Megace
Aspirin
Albuterol
Budesonide

Discharge Medications:
expired

Discharge Disposition:
Expired

Discharge Diagnosis:
expired

Discharge Condition:
expired

Discharge Instructions:
expired

Followup Instructions:
expired
{'Tracheoesophageal fistula,Acute respiratory failure,Pneumonia, organism unspecified,Hematemesis,Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Acidosis,Personal history of malignant neoplasm of bronchus and lung,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Personal history of irradiation, presenting hazards to health,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Rash and other nonspecific skin eruption,Pressure ulcer, lower back'}


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: Tracheoesophageal fistula

PRESENT ILLNESS: 69F with hx of NSCLC s/p Right pneumonectomy, chemo&radiation
two years ago, admitted to OSH for LLL pneumonia on [**11-5**], found
to have tracheoesophageal fistula on barium swallow and
bronchoscopy, transerred to [**Hospital1 18**] intubated and sedated for
interventional pulmonology evaluation of tracheoesophageal
fistula.
.
Patient was initially admitted to [**Hospital 87965**] Hospital [**11-5**], where
she was treated for CAP with 10 days of levofloxacin, requiring
intubation from [**Date range (1) 87966**].  Her antibiotics were broadened
slowly first with aztreonam ([**11-9**]) then vancomycin ([**11-15**]).
She underwent bronchoscopy [**11-8**], which showed significant
inflammation in the left mainstem bronchus; culture showed rare
yeast. Post-extubation, she required continuous Bipap; she
required reintubation on [**11-15**] due to progressive hypercarbia.
She had been started on vasopressin prior to intubation and was
later started on dopamine as well.  At Midcoast, patient also
had a modified barium swallow which showed barium in the
trachea, but no obvious fistula.  Bronchoscopy confirmed
tracheoesophageal fistula 1cm TEF 5cm from the carina.  While at
Midcoast, she was also noted to have afib and aflutter, but no
known prior history.  An Echo on [**11-8**] showed pulmonary
hypertension and septal hypokinesis, but normal EF. She was
transfered to [**Hospital 1727**] Medical Center intubated on pressors
dopamine and vasopressin.
.
At [**Hospital 1727**] Medical Center, patient had a bronchoscopy with BAL
showing GPCs.  She underwent CT chest on [**11-16**] to rule out PE in
setting of mildly elevated CKMB and trop.  It appears that she
was afebrile throughout her stay at [**Hospital 1727**] Medical.  She was
started on IV doses of digoxin for her afib which helped keep
her rate-controlled and noted to be maintained in sinus rhythm.
Patient was on insulin drip at outside hospital for
hyperglycemia in the setting of TPN and high dose stress IV
steroids.  On transfer to [**Hospital1 18**], patient is on Vancomycin
(Day#4), Clindamycin (Day#3),  Aztreonam (Day#10), Fluconazole
(Day#2).
.
On arrival to the MICU at [**Hospital1 18**], patient is intermittently in
stable VT with SBPs in 180s, completely asymptomatic,
intermittently in rapid Afib with rates to 160s.  She was given
one dose of IV metoprolol 5mg while in Afib with RVR which
decreased her HRs and let her self-convert to NSR with rate 80s.

MEDICAL HISTORY: Non-Small Cell Lung Cancer, stage IIIB (T2N2M0), squamous cell
 - s/p Right pneumonectomy ~[**2125-6-24**]
 - s/p chemo ([**Doctor Last Name **]/taxol, fall [**2124**]) and radiation (5040 cGy
EBRT) at [**Hospital1 107**] [**Doctor Last Name **] Kettering
COPD, severe - not on home O2
HTN

MEDICATION ON ADMISSION: Tussionex
HCTZ
Spironolactone/HCTZ
Megace
Aspirin
Albuterol
Budesonide

ALLERGIES: Penicillin G

PHYSICAL EXAM: On admission to MICU:
itals: T: 97.1 BP: 157/82 P: 110 R: 18 O2: 98% on CMV FiO2 40%
General: intubated but can answer yes or no questions
appropriately and trying to communicate medical history while
intubated, no acute distress
HEENT: Sclera anicteric, MMM, NG tube with bloody aspirates
Neck: supple
Lungs: Diffuse rhonchi bilaterally with air movement only on
left
CV: Reg rhythm, rapid rate, no murmurs appreciated
Abdomen: soft, non-tender, mildly distended, hyperactive bowel
sounds, no rebound tenderness or guarding
GU: foley in place
Ext: warm, well perfused, 2+ pulses, [**11-25**]+ pitting edema of
bilateral lower extremities up to sacrum

FAMILY HISTORY: [**Name (NI) **] Mother died of an MI at 79
Father with multiple myeloma

SOCIAL HISTORY: Married, Husband [**Name (NI) **]. Retired accountant.  Lives in [**State 1727**].
Tobacco: Quit, but smoked 20-40pack-yrs
ETOH: rare 

### Response:
{'Tracheoesophageal fistula,Acute respiratory failure,Pneumonia, organism unspecified,Hematemesis,Paroxysmal ventricular tachycardia,Acute kidney failure, unspecified,Acidosis,Personal history of malignant neoplasm of bronchus and lung,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Personal history of irradiation, presenting hazards to health,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Rash and other nonspecific skin eruption,Pressure ulcer, lower back'}
