CHIEF COMPLAINT: transfer from OSH for hypercapnic, hypoxic respiratory failure

PRESENT ILLNESS: 47 year old man with PMH significant for heart failure 4-5 years
previous without good medical follow up presented at [**Hospital3 **] in [**Location (un) 7661**] on [**2101-11-10**] with complaint of leg swelling
and shortness of breath over previous 4-5 days, although
according to his family these symptoms had been going on much
longer, greater than a month or two. He had no complaints of
fevers, chills, chest pain, or other symptoms at that time.
.
In their ED, he was found to be hypertensive and hypoxic with LE
edema, decreased breath sounds, and O2 sat of 71%. He was given
lasix with improvement in sat to 94%. He was admitted to the
floor, but was found to be in increasing respiratory distress
and was intubated for a PCO2 of 112 (7.18/112/72) and
transferred to the MICU. He was found to have an elevated
D-dimer, but was unable to have a CT scan due to his excessive
weight, so was empirically started on heparin. A TTE showed
pericardial effusions from 1-2.3 cm, and dilated pulmonary
artery. LV function appeared within normal limits. Leg
ultrasound showed no clots. He persistently had a large Aa
gradient and was ventilated on SIMV with 100% oxygen but ABG at
transfer was 7.42/41/64, so he was transferred to the [**Hospital1 18**] MICU
for further workup and treatment.

MEDICAL HISTORY: CHF, unknown EF but "LV function OK"
cocaine use
asthma as child
likely OSA per family, obseved to occasionally be apneic at
night

MEDICATION ON ADMISSION: MEDS AT HOME:
h/o lasix 4-5 years ago
.
MEDS ON TRANSFER:
ASA 81 QD
unasyn 3g IV Q8H
levoquin 750 IV Q24
pepcid 20 iv BID
solumedrol 60 mg IV Q6h
lasix 40 mg IV QD
NTG paste 1" to chest Q6H
ativan 1mg Q1h PRN
morphine 3-5 mg IV PRN
pavulon 3-5 mg IV PRN
Versed 1-2 mg IV prn
propafol 59 mcg/kg/min
heparin @ 1500/hour
traumacal tubefeeds 10 cc / hour

ALLERGIES: Levofloxacin/Dextrose 5%-Water

PHYSICAL EXAM: T98.2 130/70 82 18 95%
Ventilator: AC 700x18 100% PEEP 12 (ABG 7.45/44/85 lactate 2.7)
Gen: obese man in NAD
HEENT: NGT, ETT in place
Neck: obese, no appreciable JVD
Resp: diminished BS but generally clear
CV: RRR nl s1s2 no apprecible murmurs
Abd: obese soft NTND +BS
Ext: 1+ edema on legs. onchomycosis.
Neuro: intubated, sedated. pupils equal and reactive.
Skin: numerous tattoos, erythematous areas on chest.

FAMILY HISTORY: father had emphysema and type II diabetes. Mother had pneumonia
and MI at age 70. sister [**Name (NI) 56555**] OSA.

SOCIAL HISTORY: single but lives with partner of 24 years. Has 4 children with
previous partners, locations unknown. Occasional crack cocaine
use, last a few weeks ago. No tobacco or ETOH. No official
health care proxy at time of admission (default for medical
decision making is his group of siblings, primarily in contact
with [**Name (NI) **] [**Name (NI) 65140**], his sister, since pt's parents are deceased
and children are estranged)
Acute respiratory failure,Diastolic heart failure, unspecified,Cocaine abuse, unspecified,Acute sinusitis, unspecified,Obesity, unspecified,Obstructive sleep apnea (adult)(pediatric),Other specified diseases of hair and hair follicles,Dermatitis due to drugs and medicines taken internally,Other specified antibiotics causing adverse effects in therapeutic use
Acute respiratry failure,Diastolc hrt failure NOS,Cocaine abuse-unspec,Acute sinusitis NOS,Obesity NOS,Obstructive sleep apnea,Hair diseases NEC,Drug dermatitis NOS,Adv eff antibiotics NEC
Name:  [**Known lastname 11473**],[**Known firstname **]              Unit No:   [**Numeric Identifier 11474**]

Admission Date:  [**2101-11-13**]              Discharge Date:   [**2101-11-24**]

Date of Birth:  [**2053-12-7**]             Sex:   M

Service: MEDICINE

Allergies:
Levofloxacin/Dextrose 5%-Water

Attending:[**First Name3 (LF) 1225**]
Addendum:
Pt has no PCP. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11475**], MD, is now designated at PCP and
follow up phone number given for patient to call after
discharge.
Also, pt continued on SC heparin at the facility until he can
walk 100 feet twice a day.

Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Medical Center - [**Hospital1 2314**]

                             [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 1226**] MD [**Last Name (un) 1227**]

Completed by:[**2101-11-24**]

Admission Date:  [**2101-11-13**]              Discharge Date:   [**2101-11-24**]

Date of Birth:  [**2053-12-7**]             Sex:   M

Service: MEDICINE

Allergies:
Levofloxacin/Dextrose 5%-Water

Attending:[**First Name3 (LF) 297**]
Chief Complaint:
transfer from OSH for hypercapnic, hypoxic respiratory failure

Major Surgical or Invasive Procedure:
Intubation, Tracheostomy, G tube placement

History of Present Illness:
47 year old man with PMH significant for heart failure 4-5 years
previous without good medical follow up presented at [**Hospital3 **] in [**Location (un) 7661**] on [**2101-11-10**] with complaint of leg swelling
and shortness of breath over previous 4-5 days, although
according to his family these symptoms had been going on much
longer, greater than a month or two. He had no complaints of
fevers, chills, chest pain, or other symptoms at that time.
.
In their ED, he was found to be hypertensive and hypoxic with LE
edema, decreased breath sounds, and O2 sat of 71%. He was given
lasix with improvement in sat to 94%. He was admitted to the
floor, but was found to be in increasing respiratory distress
and was intubated for a PCO2 of 112 (7.18/112/72) and
transferred to the MICU. He was found to have an elevated
D-dimer, but was unable to have a CT scan due to his excessive
weight, so was empirically started on heparin. A TTE showed
pericardial effusions from 1-2.3 cm, and dilated pulmonary
artery. LV function appeared within normal limits. Leg
ultrasound showed no clots. He persistently had a large Aa
gradient and was ventilated on SIMV with 100% oxygen but ABG at
transfer was 7.42/41/64, so he was transferred to the [**Hospital1 18**] MICU
for further workup and treatment.


Past Medical History:
CHF, unknown EF but "LV function OK"
cocaine use
asthma as child
likely OSA per family, obseved to occasionally be apneic at
night


Social History:
single but lives with partner of 24 years. Has 4 children with
previous partners, locations unknown. Occasional crack cocaine
use, last a few weeks ago. No tobacco or ETOH. No official
health care proxy at time of admission (default for medical
decision making is his group of siblings, primarily in contact
with [**Name (NI) **] [**Name (NI) 65140**], his sister, since pt's parents are deceased
and children are estranged)


Family History:
father had emphysema and type II diabetes. Mother had pneumonia
and MI at age 70. sister [**Name (NI) 56555**] OSA.

Physical Exam:
T98.2 130/70 82 18 95%
Ventilator: AC 700x18 100% PEEP 12 (ABG 7.45/44/85 lactate 2.7)
Gen: obese man in NAD
HEENT: NGT, ETT in place
Neck: obese, no appreciable JVD
Resp: diminished BS but generally clear
CV: RRR nl s1s2 no apprecible murmurs
Abd: obese soft NTND +BS
Ext: 1+ edema on legs. onchomycosis.
Neuro: intubated, sedated. pupils equal and reactive.
Skin: numerous tattoos, erythematous areas on chest.

Pertinent Results:
OSH labs [**11-12**] (current labs below)
.
11.1\15.2/287
    /47.5\
85P 2B 6L 5M 2 meta
.
138  93  8
-------------< 160
3.8  38  1.0
Ca 8.5
.
T bil 1.0 d bil 0.2
AST 19 ALT 15
Alb 2.3
TP 5.3
B12 370
folate 11.4
.
Tox negative
BNP 75 (0-100)
.
EKG (OSH) NSR at 80, left axis deviation, poor R wve progression
in precords. TWI in III, V1-V3. No ST changes, no Q waves
.
CXR: bibalisar atelectasis vs infiltrate. cardiomegaly. wide
mediastinum/ dilated pulmonary arteries.
.
[**11-20**] Sputum cx:
Staph aureus
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
.
[**11-20**] urine cx negative
.
Blood cultures: multiple taken since admission, negative or no
growth to date at [**Hospital1 18**]. (1/2 bottles grew coag - staph from OSH
cultures)
.
[**2101-11-23**] 04:11AM BLOOD WBC-10.2 RBC-4.62 Hgb-13.2* Hct-41.2
MCV-89 MCH-28.6 MCHC-32.1 RDW-15.1 Plt Ct-373
[**2101-11-13**] 01:00AM BLOOD WBC-16.3* RBC-5.09 Hgb-15.0 Hct-46.5
MCV-91 MCH-29.6 MCHC-32.3 RDW-15.1 Plt Ct-274
[**2101-11-22**] 04:56AM BLOOD Neuts-79.0* Lymphs-12.6* Monos-4.8
Eos-3.1 Baso-0.6
[**2101-11-23**] 04:11AM BLOOD Plt Ct-373
[**2101-11-15**] 03:22AM BLOOD PT-13.0 PTT-23.8 INR(PT)-1.1
[**2101-11-14**] 12:30AM BLOOD PT-17.0* PTT-78.7* INR(PT)-2.0
[**2101-11-13**] 01:00AM BLOOD PT-13.6* PTT-41.3* INR(PT)-1.3
[**2101-11-23**] 04:11AM BLOOD Glucose-119* UreaN-12 Creat-0.6 Na-142
K-3.7 Cl-103 HCO3-27 AnGap-16
[**2101-11-22**] 04:56AM BLOOD Glucose-97 UreaN-11 Creat-0.7 Na-142
K-3.8 Cl-104 HCO3-28 AnGap-14
[**2101-11-21**] 04:10AM BLOOD Glucose-94 UreaN-11 Creat-0.7 Na-144
K-3.8 Cl-105 HCO3-31 AnGap-12
[**2101-11-13**] 01:00AM BLOOD Glucose-170* UreaN-16 Creat-1.0 Na-136
K-3.5 Cl-97 HCO3-29 AnGap-14
[**2101-11-20**] 04:17AM BLOOD CK(CPK)-267*
[**2101-11-13**] 01:00AM BLOOD ALT-12 AST-31 LD(LDH)-353* AlkPhos-64
Amylase-53 TotBili-0.5
[**2101-11-23**] 04:11AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.7
[**2101-11-22**] 04:56AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.8 Iron-34*
[**2101-11-13**] 01:00AM BLOOD Albumin-3.0* Calcium-8.6 Phos-3.1 Mg-1.6
[**2101-11-22**] 04:56AM BLOOD calTIBC-233* TRF-179*
[**2101-11-23**] 12:03PM BLOOD Type-ART Temp-37.3 Rates-/42 Tidal V-580
PEEP-10 FiO2-40 pO2-153* pCO2-32* pH-7.46* calHCO3-23 Base XS-0
Intubat-INTUBATED Vent-SPONTANEOU
[**2101-11-23**] 08:34AM BLOOD Type-ART Temp-37.3 Rates-/42 Tidal V-580
PEEP-10 FiO2-40 pO2-63* pCO2-40 pH-7.44 calHCO3-28 Base XS-2
Intubat-INTUBATED Vent-SPONTANEOU
[**2101-11-13**] 03:52AM BLOOD Type-ART Temp-36.7 Rates-18/ Tidal V-700
PEEP-15 FiO2-100 pO2-58* pCO2-45 pH-7.44 calHCO3-32* Base XS-5
AADO2-625 REQ O2-100 Intubat-INTUBATED
[**2101-11-16**] 06:31PM BLOOD O2 Sat-97
[**2101-11-16**] 10:11AM BLOOD freeCa-1.16
.
[**2101-11-13**] CXR: An element of fluid overload; smaller heart size
vs. prior.
.
[**2101-11-13**] CTA chest:
1. Limited examination for pulmonary embolism. There is no large
embolus within the main, right or left pulmonary arteries. No
definite filling defects are identified in other segmental and
subsegmental branches.
2. Moderate cardiomegaly, and a moderate pericardial effusion.
3. Bibasilar consolidation versus atelectasis.
4. Large main pulmonary artery, suggesting pulmonary arterial
hypertension.
.
[**2101-11-14**] Echo
Conclusions:
1.The left atrium is normal in size. An echo contrast study was
peformed at
rest only. While the study was limited and the images difficult
to interpret
confidently, no intracardiac shunt is seen.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity
size is normal. Overall left ventricular systolic function is
normal
(LVEF>55%).
3.The right ventricular free wall is hypertrophied. The right
ventricular
cavity is moderately dilated. Right ventricular systolic
function appears
depressed.
4.The aortic valve leaflets appear structurally normal with good
leaflet
excursion. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is
seen.
6. The pulmonary artery systolic pressure could not be
determined.
7.There is an anterior space . This is most likely represents a
fat pad,
though a loculated anterior pericardial effusion cannot be
excluded.
.
[**2101-11-18**] CXR
Small bilateral pleural effusions are unchanged. Heart size is
normal. Bilateral hilar enlargement has progressed since
[**11-14**] reflecting interval increase in pulmonary artery
pressure. Tracheostomy tube is in standard placement. Feeding
tube can be traced to the lower esophagus, the tip is indistinct
and the upper abdomen is not included on the study. Repeat
examination will be performed at no charge to the patient.
.
[**2101-11-21**] EKG
Sinus rhythm
Precordial/anterior T wave abnormalities - are nonspecific but
cannot exclude in part ischemia - clinical correlation is
suggested
Since previous tracing of [**2101-11-15**], no significant change

Brief Hospital Course:
47 year old man with hypoxic, hypercapnic respiratory failure
likely secondary to obesity hypoventilation syndrome transferred
to [**Hospital1 18**] for intensive care.
.
# Hypoxic/hypercapnic respiratory failure
Pt initially had wide A-a gradient c/w shunt physiology such as
intracardiac shunt, or PE. Those diagnoses were ruled out with
echo and CTA chest (ruled out significant PE). The pt's course
coupled with those labs was consistent with obesity
hypoventilation syndrome. P:F ratio now improved. LENIs
negative. PS and PEEP weaned to the point that the pt could talk
while on trach collar without his Passy Muir valve in place as
the cuff leak was significant. Since this meant he was
preserving little to no PEEP, his progress was deemed to be
significant from last week requiring PEEP in 20s.
.
#. Fever
Differential included bleeding vs. infection. The pt's hct was
stable and rectal was negative and his clinical stability
collectively offered evidence against a source of bleeding.
Infectious sources were pursued and he was empirically treated
with a 7 day course of vancomycin and ceftazidime for nosocomial
sinusitis well into his hospital course. On day 3 of those
antibiotics his fever resolved and his nasal discharge was
significantly reduced.
Prior to that, there was concern for pneumonia on admission, for
which he was treated with levofloxcacin initially. He developed
a rash which was characterized as a drug rash by dermatology on
day 1 of levofloxacin. He was transitioned to ceftriaxone, which
was ultimately stopped after a 7 day course w/ a relatively
unremarkable CXR. He had a mild folliculitis that resolved w/
topical clindamycin. His urine was free of bacteria and his line
cultures were unremarkable. When nearing discharge he was
afebrile and showed no clinical indication of having a
significant infection.
.
# Neurologic status
Pt was noted to have disconjugate gaze a few days in a row when
he was deeply sedated with midazolam and fentanyl. The gaze was
variable in its presentation and would resolve sporadically. As
the pt's sedation was weaned, he was not found to have this on
subsequent exam. This was thought to be toxic/metabolic rather
than neurologic given the variable presentation and the
resolution w/ resolution of the mental status. Doll's eyes
negative.
.
# congestive heart failure
The pt's echo showed EF >55% and pt did well with diuresis
without more help than his home diuresis regimen.
.
#. Hct change, approximately 10 initially, now stable
He has no evidence of bleeding and his hematocrit has been
stable for over one week in the low 40s. No evidence of GIB,
hematoma, or any other source.
.
# FEN
The pt is getting screened for further PO intake as he failed
his initial swallow evaluation. Pt has a G tube and has been
tolerating tube feeds well.
.
# [**Name (NI) **]
The pt received heparing subcutaneous, a bowel regimen, and a
PPI
.
# code
The patient was full code throughout the hospitalization.
.
# Communication/Social issues
The pt's official medical decision maker is his sister, [**Name (NI) **]
[**Name (NI) 65141**] (lives in [**State 5887**], [**Telephone/Fax (1) 65142**]) in conjunction with
the other siblings. The pt's parents are deceased and the
children are estranged. The pt's partner of 24 years was upset
with her lack up input, but did show up to the family meeting
and there was apparently little disagreement between her and the
pt's siblings. The topic of health care proxy was broached but
not resolved.

Patient received flu vaccine and pnemovax before discharge.
Sputum culture before discharge came back positive for MRSA and
the pt was continued on vancomycin for a seven day course, which
was originally started for nosocomial sinusitis.

Medications on Admission:
MEDS AT HOME:
h/o lasix 4-5 years ago
.
MEDS ON TRANSFER:
ASA 81 QD
unasyn 3g IV Q8H
levoquin 750 IV Q24
pepcid 20 iv BID
solumedrol 60 mg IV Q6h
lasix 40 mg IV QD
NTG paste 1" to chest Q6H
ativan 1mg Q1h PRN
morphine 3-5 mg IV PRN
pavulon 3-5 mg IV PRN
Versed 1-2 mg IV prn
propafol 59 mcg/kg/min
heparin @ 1500/hour
traumacal tubefeeds 10 cc / hour


Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed.
4. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1)  PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: Do not take more than 12 pills in 24
hours.
6. Clindamycin Phosphate 1 % Solution Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) for 10 days: End date: [**2101-12-4**].
7. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical  [**Hospital1 **]
(2 times a day) for 10 days: End date: [**2101-12-4**].
8. Senna 8.6 mg Tablet Sig: 0-4 Tablets PO BID (2 times a day):
Titrate to [**12-13**] BM/day (give 4 tabs if 0 BM; reduce to 0 if >4
BM/day).
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation: Hold if 1 or more BM per
day.
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for oral thrush for 7 days.
11. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution Sig: Two (2)  PO Q8H (every 8 hours) for 2 days:
End date: [**2101-11-26**].
12. Sodium Chloride 0.9 % Parenteral Solution Sig: Three (3) ML
Intravenous  DAILY (Daily) as needed: to keep line open.
13. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
 every twelve (12) hours for 2 days: End date: [**2101-11-26**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]

Discharge Diagnosis:
Obesity hypoventilation syndrome
congestive heart failure (diastolic heart failure)
nosocomial sinusitis
MRSA (source: sputum)


Discharge Condition:
stable. Vaccinated with Flu vaccine and pneumovax.


Discharge Instructions:
Most of the tracheostomy care will be taken care of by the vent
weaning facility. Make sure to call or come back with any
questions or concerns that you might have. See the instructions
below for care and emergency procedures in relation to you
tracheostomy care.
Also, come back for chest pain, shortness of breath, trouble
breathing, unexplained sweating.
Do not drink alcohol, do not smoke, and do not use any drugs,
including cocaine. Cocaine can damage your lungs and heart very
seriously, which will make it more difficult to heal and breath
well.

TRACHEOSTOMY CARE
WHAT YOU SHOULD KNOW:

A tracheostomy (tra-[**Doctor First Name **]-AH-stuh-[**Last Name (un) **]) or "trach" is a tube to
help you breathe. It is put into a small opening in your neck
called a stoma, then into your trachea. The trachea is also
called the windpipe. The outer cannula of your trach tube fits
into your stoma. The inner cannula fits inside the outer
cannula. The inner cannula may be locked so that when you cough
it does not [**Doctor Last Name **] out.
You do trach care so you can breathe easily. There are two parts
to trach care:
Suctioning. Suctioning is done using a long, thin, tube
(catheter) with a hole to control when and how long you suction.
The tube is attached to a machine that makes the suction.
Suctioning removes [**Doctor Last Name 65143**] that build up in the throat. If the
[**Doctor Last Name 65143**] get too thick to be coughed out, they must be suctioned.
Cleaning. Cleaning keeps the cannula path open.

AFTER YOU LEAVE:

How do I instill sterile salt water into my trach? Caregivers
may show you how to instill sterile salt water into your trach.
If your caregivers have told you to instill sterile salt water
into your trach, follow the steps listed below.

Gather the items you will need:
A 5 or 10 mL syringe or a spray.
Sterile salt water.
4 x 4 gauze pads to catch the fluid you cough up.
Wash your hands carefully and dry them completely before and
after instilling sterile salt water.
If you are using a syringe, draw up the sterile saline into the
syringe. If you are using a spray, unscrew the top.
While breathing in, slowly squirt (or spray) [**1-15**] mL's of the
sterile salt water solution into the trach tube. You need enough
sterile salt water to loosen [**Month/Day (1) 65143**], but not so much that it
makes you cough as it goes in.
When you cough up [**Month/Day (1) 65143**], it should not be tiring. The fluid
should be loose or thin enough to cough out easily.

How do I suction my trach? When you suction your trach, the
catheter ( long, thin tube) should not go into the trach further
than the end of the trach tube. Your caregivers will [**Name2 (NI) **] the
safe place on the catheter to not insert the catheter beyond
while suctioning. Make sure you [**Name2 (NI) **] the correct place on each
new catheter you use.
Gather the things you will need before you start:
Suction machine with suction tubing.
Small bowl.
Sterile salt water.
Suction catheter with safety [**Name2 (NI) **].
Gloves.

Turn on the suction machine. Set the dial between -80 and -120
mmHg. Attach suction tubing to the suction machine.

Fill the small bowl with some of the sterile salt water. Put the
sterile lid back on the jar of sterile salt water. Do not touch
the inside of either the jar or lid. Set the small bowl to the
side of your work table.
Wash your hands with soap and water. Dry your hands and put on
gloves.

Take the suction catheter out of its package. Hook it to the
suction tubing on the suction machine. Dip the catheter tip into
the sterile salt water. This will make the catheter easier to
put into your trach.

Take a few deep breaths. Gently put the wet catheter into your
trach tube or stoma. Put the catheter in to the marked place. Do
not cover the catheters control valve while you are putting the
catheter into your trachea. Covering the valve will start the
suction. The control valve is the small hole near the end that
is in your hand.
Slowly pull the catheter out of your trach tube. As you pull it
out, use your thumb to cover and uncover the catheters control
valve. This will start and stop the suction. Do this several
times. Do not keep the control valve covered all the time. Also,
roll the catheter between your thumb and fingers as you pull it
out of your trachea. Suction no longer than 10 seconds. If you
suction longer than that, the amount of oxygen in your lungs may
fall too low.
Put the tip of the catheter into the sterile salt water in the
bowl. Put your thumb over the control valve to clear the suction
catheter and tubing. Turn off the suction machine and remove the
catheter from the suction tubing. Throw the catheter into a
trash can. Rinse the small bowl and the collection bottle from
your suction machine with soap and water.
How do I clean my inner cannula?

The inner cannula of your trach is very important. [**Name2 (NI) **] from
your throat can thicken in your inner cannula. Thickening [**Name2 (NI) 65143**]
will make the hole in the cannula get smaller. As the hole gets
smaller, it will be harder for you to breathe. The inner cannula
can easily be removed for cleaning. Do not use just the outer
cannula to breathe through. If you do not use the inner cannula,
you may have an emergency if the outer cannula builds up [**Name2 (NI) 65143**].

Some caregivers will want you to remove and replace the inner
cannula with another disposable inner cannula. Other caregivers
will want you to clean your reusable inner cannula. Clean or
replace your inner cannula often, at at least twice a day. If
you have a new trach, you will need to clean or replace the
inner cannula about every 4 hours. You should have two inner
cannulas available. This way, as you use one, you may clean the
other. Gather the things you will need to clean your inner
cannula:
A clean inner cannula.
A small bowl.
Water that was boiled for 20 minutes then cooled to room
temperature.
3 percent hydrogen peroxide.
Pipe cleaners for cleaning the inside and a small brush for
cleaning the outside of the cannula.
A cotton cloth.
Put about 2 ounces of the boiled water and 2 ounces of hydrogen
peroxide into the small bowl.
Place a mirror in front of you so that you can see your face and
throat.
Wash your hands with soap and water carefully, and dry them
completely.
Unlock the inner cannula. Use the hand you do not write with to
keep the outer cannula from moving. Using the hand that you do
write with, remove the inner cannula. The inner cannula comes
out easily if you pull out and down at the same time.
Put a clean, moistened, inner cannula inside the outer cannula.
Lock the inner cannula in place.
Clean the dirty cannula by soaking it in peroxide and water. As
the hydrogen peroxide works, it will bubble. When the bubbling
stops, clean the outside of the cannula with the brush, and the
inside with pipe cleaners.
Rinse the inner cannula under running water. Make sure all the
hydrogen peroxide has been rinsed off.
Dry the inner cannula with the cotton cloth. Store the clean
cannula where it will stay clean and easy to reach. A small,
plastic, snack-type storage bag works well.

How do I change my trach tube? You may have been shown how to
change your trach tube by your caregiver. If you have, follow
the steps below to change your trach tube at home:
Gather the things you need before you start:
A clean trach tube.
Twill or velcro trach tube ties.
Scissors.
Two small bowls.
Sterile saline solution.
3 percent hydrogen peroxide.
Tap water.
Trach bib (optional).
Cotton-tipped applicators.
A trash container.
Trach tube one size smaller than the one you are using.
Mirror.
Good lighting.
Adjust your mirror and light so you can see your trach area
clearly.
Mix about 2 ounces of peroxide with 2 ounces of tap water in one
of the small bowls.
Pour some sterile saline into the second bowl.
Remove your trach bib if you have one and throw it away where
children and pets cannot get to it.
Wash your hands carefully and dry them completely.
Remove the inner cannula and put the obturator into the outer
cannula.
Put new ties on the trach tube you will put in.
Remove or cut the trach ties on the trach tube in your throat.
Remove your trach tube by pulling out and down.
Using the cotton-tipped applicators clean the area around the
stoma by working from the stoma to the skin. Be careful not to
allow any of the [**Name2 (NI) 65144**] [**Name2 (NI) 65143**] into the stoma. Cotton-tipped
applicators dipped in the peroxide solution can be rolled over
areas where there are [**Name2 (NI) 65144**] [**Name2 (NI) 65143**]. The area will foam. It will
loosen the [**Name2 (NI) 65144**] [**Name2 (NI) 65143**] so they can be gently rolled away from
the stoma and removed.
Look at the area around the stoma for redness, hardness, or pus.
If you see any of these things, call your caregivers when you
are finished changing your trach and let them know.
Put the end of the trach tube into the sterile saline. It is
easier to insert the clean trach if it is wet. Insert the new
trach tube in and down with the obturator in place. Do not force
the trach tube. When the trach tube is in, quickly remove the
obturator. If you are having trouble getting the trach tube in,
try to ease it by gently turning it from side to side.
If you cannot get the trach tube in, use the smaller one. If you
still cannot get the trach tube in, call 911 for help. Your
stoma will not close suddenly. Stay calm and wait for help to
arrive.
Secure your trach ties.
Put the inner cannula into the outer cannula and lock it in
place.
If you use a trach bib, place it under the trach faceplate.
How do I care for my trach faceplate and stoma? It is important
to look at and clean your stoma at least once a day. If you have
a new trach you will have to clean the stoma several times a
day. Look for redness, hardness, pus, and any [**Name2 (NI) 65143**] that may be
stuck on or around the stoma. If you notice any redness,
hardness or pus, call your caregiver. [**First Name (Titles) **] [**Last Name (Titles) 65143**] need to be
removed carefully and as completely as possible. Gather the
items you will need to clean your stoma:
Cotton-tipped applicators.
Tap water.
3 percent hydrogen peroxide.
A small clean bowl.
A trash container.
Wash your hands carefully and dry them completely. When cleaning
the stoma, work from the stoma toward skin. Be careful as you
work under the faceplate of the trach tube. [**Last Name (Titles) **] [**Last Name (Titles) 65143**] or any
other matter should not go into the stoma opening.
Pour some hydrogen peroxide into the bowl. Pour an equal amount
of water into the bowl.

Dip a cotton-tipped applicator into the hydrogen peroxide and
water mixture.

Lightly roll the applicator along the [**Last Name (Titles) 65144**] fluid areas. The
peroxide solution ill foam.

Using a new applicator each time, continue to put the peroxide
solution on areas where there are [**Last Name (Titles) 65144**] [**Last Name (Titles) 65143**].

The [**Last Name (Titles) 65144**] [**Last Name (Titles) 65143**] will loosen. Remove them with applicators,
throwing away applicators after each contact. Peroxide will not
foam when the area is clean.

How do I change my trach bib? Your caregivers may want you to
use a trach bib. A trach bib is used to catch any [**Last Name (Titles) 65143**] that
come from your stoma. This will help keep the skin around the
stoma from getting sore. You may use a pre-cut non-raveling
(does not make loose threads) bib, or make one. If you make or
use a bib, follow the steps in this section.

Wash your hands carefully and dry them completely.

To make a trach bib, use a 4-inch by 4-inch non-raveling pad.
Cut a slit from the edge to the center of the pad.

Slide the two sides under the faceplate and up and around the
stoma.

How do I make sterile (germ-free) salt water? You will need
sterile salt water if you instill it into your trach tube before
suctioning. You will also need sterile salt water for your
suctioning catheter. To make sterile salt water:

You will add 1 teaspoon of salt to a quart of water. Gather the
things you will need:
Saucepan.
Metal tongs.
Clean 1 quart glass jar with lid.
1 teaspoon of regular cooking salt.
Tap water.
Place the jar, lid, and metal tongs in the saucepan. Allow the
handle of the tongs to stick out from the saucepan.
Fill the pan with tap water to cover the jar.
Boil the water for 30 minutes.
After boiling for 30 minutes, allow the water to cool until you
can touch the tongs.
Pick up the jar with the tongs and place it right side up on a
table.
Fill the jar with the boiled water from the saucepan.
Measure one teaspoon of salt and place it in the jar.
Put the lid on the jar using the tongs.
Tighten the lid and shake the solution to mix thoroughly.
Store the solution in the refrigerator and use for up to 3 days.
Discard unused sterile salt water after three days.

How do I change the ties on my trach? You will need another
person to help you when you change the ties on your trach. When
the ties are not on, one person needs to hold the trach in place
until the new ties are on. Without the ties, you may cough out
the trach tube by accident. A trach tie is usually made of some
kind of twill. A tie may also have a velcro close. Some people
with permanent trachs have their jeweler make them a trach tie.
Follow these steps to change twill ties:
While one person is holding the trach faceplate in place, cut
your old tie. Remove the tie carefully from each of the holes in
your faceplate.

Thread the new tie through the hole on one side of the
faceplate, and around the back of your neck. Thread the end of
the tie through the hole in the other side of the faceplate.
Bring the two ends of the tie together.

Tie the ends using a square knot. Make sure that the knot is
secure, but not too tight. You should be able to put one finger
under the tie easily. The knot should not loosen if pulled.

How can I add humidity to keep [**Last Name (Titles) 65143**] thin? Thin [**Last Name (Titles) 65143**] are
easier to cough out and to suction. There are two ways to help
keep your [**Last Name (Titles) 65143**] thin: add humidity where you live, and drink
plenty of liquids.

Humidifier. A [**8-20**] gallon humidifier in the area where you spend
your day will help keep your [**Month/Year (2) 65143**] thin. Also, keep a
humidifier going in your bedroom at night. You may use warm or
cold humidifiers. Clean the humidifiers daily to stop germs from
growing.
Drink plenty of liquids. Drink at least six to eight (8-ounce)
cups of liquid during the day, unless your caregiver tells you
not to. Drinking enough liquid will help keep the [**Month/Year (2) 65143**] in your
throat thin and easy to cough up.
What should I do when I go outside?
Cover your trach. It is important to protect your throat and
lungs from germs, foreign bodies like hair and dust, and dry
air. Your mouth and nose usually do this for you. Tie a scarf
below your chin and let it cover your trach. Do not use silk or
any material that may cling to the trach as you breathe in.
Water is a [**Doctor Last Name 13205**]. Golfing, gardening, walking are encouraged.
Avoid boating, swimming, and fishing. If you are under water
there is no way to hold your breath. Water will be able to enter
your lungs and you may drown.

CALL  IF:
You still have trouble breathing after coughing or suctioning.
Your stoma is swollen, red, or has pus coming out of it or from
around it. This may mean it is infected.
You get a temperature over 100.5 degrees.
You have questions or concerns about your tracheostomy or
medicine.

SEEK CARE IMMEDIATELY IF:
You are very short of breath and coughing or suctioning does not
help.
Your trach falls out. Call 911 or 0 (operator) to get to the
nearest hospital or clinic. Do not drive yourself!

Followup Instructions:
Call your primary care doctor from the ventilator weaning
facility and make an appointment. If you do not have a primary
care doctor, call the [**Company 191**] ([**Hospital6 733**]) at
[**Telephone/Fax (1) 250**] and explain that you need a new primary care
doctor.
{'Acute respiratory failure,Diastolic heart failure, unspecified,Cocaine abuse, unspecified,Acute sinusitis, unspecified,Obesity, unspecified,Obstructive sleep apnea (adult)(pediatric),Other specified diseases of hair and hair follicles,Dermatitis due to drugs and medicines taken internally,Other specified antibiotics causing adverse effects in therapeutic use'}


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: transfer from OSH for hypercapnic, hypoxic respiratory failure

PRESENT ILLNESS: 47 year old man with PMH significant for heart failure 4-5 years
previous without good medical follow up presented at [**Hospital3 **] in [**Location (un) 7661**] on [**2101-11-10**] with complaint of leg swelling
and shortness of breath over previous 4-5 days, although
according to his family these symptoms had been going on much
longer, greater than a month or two. He had no complaints of
fevers, chills, chest pain, or other symptoms at that time.
.
In their ED, he was found to be hypertensive and hypoxic with LE
edema, decreased breath sounds, and O2 sat of 71%. He was given
lasix with improvement in sat to 94%. He was admitted to the
floor, but was found to be in increasing respiratory distress
and was intubated for a PCO2 of 112 (7.18/112/72) and
transferred to the MICU. He was found to have an elevated
D-dimer, but was unable to have a CT scan due to his excessive
weight, so was empirically started on heparin. A TTE showed
pericardial effusions from 1-2.3 cm, and dilated pulmonary
artery. LV function appeared within normal limits. Leg
ultrasound showed no clots. He persistently had a large Aa
gradient and was ventilated on SIMV with 100% oxygen but ABG at
transfer was 7.42/41/64, so he was transferred to the [**Hospital1 18**] MICU
for further workup and treatment.

MEDICAL HISTORY: CHF, unknown EF but "LV function OK"
cocaine use
asthma as child
likely OSA per family, obseved to occasionally be apneic at
night

MEDICATION ON ADMISSION: MEDS AT HOME:
h/o lasix 4-5 years ago
.
MEDS ON TRANSFER:
ASA 81 QD
unasyn 3g IV Q8H
levoquin 750 IV Q24
pepcid 20 iv BID
solumedrol 60 mg IV Q6h
lasix 40 mg IV QD
NTG paste 1" to chest Q6H
ativan 1mg Q1h PRN
morphine 3-5 mg IV PRN
pavulon 3-5 mg IV PRN
Versed 1-2 mg IV prn
propafol 59 mcg/kg/min
heparin @ 1500/hour
traumacal tubefeeds 10 cc / hour

ALLERGIES: Levofloxacin/Dextrose 5%-Water

PHYSICAL EXAM: T98.2 130/70 82 18 95%
Ventilator: AC 700x18 100% PEEP 12 (ABG 7.45/44/85 lactate 2.7)
Gen: obese man in NAD
HEENT: NGT, ETT in place
Neck: obese, no appreciable JVD
Resp: diminished BS but generally clear
CV: RRR nl s1s2 no apprecible murmurs
Abd: obese soft NTND +BS
Ext: 1+ edema on legs. onchomycosis.
Neuro: intubated, sedated. pupils equal and reactive.
Skin: numerous tattoos, erythematous areas on chest.

FAMILY HISTORY: father had emphysema and type II diabetes. Mother had pneumonia
and MI at age 70. sister [**Name (NI) 56555**] OSA.

SOCIAL HISTORY: single but lives with partner of 24 years. Has 4 children with
previous partners, locations unknown. Occasional crack cocaine
use, last a few weeks ago. No tobacco or ETOH. No official
health care proxy at time of admission (default for medical
decision making is his group of siblings, primarily in contact
with [**Name (NI) **] [**Name (NI) 65140**], his sister, since pt's parents are deceased
and children are estranged) 

### Response:
{'Acute respiratory failure,Diastolic heart failure, unspecified,Cocaine abuse, unspecified,Acute sinusitis, unspecified,Obesity, unspecified,Obstructive sleep apnea (adult)(pediatric),Other specified diseases of hair and hair follicles,Dermatitis due to drugs and medicines taken internally,Other specified antibiotics causing adverse effects in therapeutic use'}
