CHIEF COMPLAINT: SOB

PRESENT ILLNESS: Briefly 57 yo F w/ COPD on home O2 and prednisone and
tracheobronchial malacia p/w inability to wean vent. Initially
presented to [**Hospital 1562**] hospital with SOB on [**11-4**] and was
intubated on [**11-5**] for COPD exacerbation/PNA got 11 day course
of zosyn and diflucan. She was trached on [**11-9**]. She was
bronched and diagnosed with tracheobronchial malacia at OSH and
transferred to [**Hospital1 18**] on the TSICU service. TSICU team had been
trying to wean her off of propofol but she repeatedly became
very anxious and dropped her O2 sats. She was started on
quetiapine and her propofol was stopped this am. She has failed
trials with PM valve several times. TSICU team has been
attempting to diurese her but she has continued to run positive.
Her Aline was replaced yesterday. She has been getting nutren
TFs. She is transferred to the MICU for further weaning of her
PEEP and possible stenting of her tracheobronchial malacia.
.

MEDICAL HISTORY: -Advanced COPD, on supplemental O2 (6-7L) and prednisone, last
PFTs in [**2168**], last hospitalization in [**2178-4-16**]
-Asthma
-HTN
-Hyperlipidemia
-Obesity
-Anemia
-Osteoporosis

MEDICATION ON ADMISSION: -Prednisone 5mg qday
-Diovan 80 mg qday
-Spiriva 18mcg inh qday
-[**Doctor First Name **] 180mg qday
-Singulair 10mg qday
-Lipitor 10mg qday
-Lasix 20mg qday
-Boniva qmonth
-Foradil 12mcg inh [**Hospital1 **]
-Combivent 2puffs QID PRN
-Calcium carbonate/Vit D1 qday
-ASA 81 qday
-Albuterol 2.5mg neb q4 PRN

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Keflex / Levaquin / Actonel

PHYSICAL EXAM: Vitals - BP: 145/69 HR: 70 RR: 16 02 sat:  97
GENERAL:  A/oX3, unable to speak [**1-18**] trach, answering yes/no
appropriately
HEENT: Trach, unable to assess JVD [**1-18**] habitus. Oral thrush
CARDIAC:  RRR, Distant heart sounds
LUNG:  Distant lung sounds
ABDOMEN:  Massively obese, soft, NT
EXT:  trace pitting edema bilaterally, 2+ DP/PT pulses

FAMILY HISTORY: NC

SOCIAL HISTORY: hx of tobacco but quit [**2163**], denies ETOH
Acute respiratory failure,Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Hyperosmolality and/or hypernatremia,Candidiasis of mouth,Anxiety state, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other diseases of trachea and bronchus,Other and unspecified hyperlipidemia,Personal history of tobacco use,Osteoporosis, unspecified,Obesity, unspecified
Acute respiratry failure,Pneumonia, organism NOS,Obs chr bronc w(ac) exac,Hyperosmolality,Thrush,Anxiety state NOS,DMII wo cmp nt st uncntr,Hypertension NOS,Trachea & bronch dis NEC,Hyperlipidemia NEC/NOS,History of tobacco use,Osteoporosis NOS,Obesity NOS
Admission Date:  [**2179-11-15**]              Discharge Date:   [**2179-11-23**]

Date of Birth:  [**2121-11-27**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamide Antibiotics) / Keflex / Levaquin / Actonel

Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
Bronchoscopy x2

History of Present Illness:
Briefly 57 yo F w/ COPD on home O2 and prednisone and
tracheobronchial malacia p/w inability to wean vent. Initially
presented to [**Hospital 1562**] hospital with SOB on [**11-4**] and was
intubated on [**11-5**] for COPD exacerbation/PNA got 11 day course
of zosyn and diflucan. She was trached on [**11-9**]. She was
bronched and diagnosed with tracheobronchial malacia at OSH and
transferred to [**Hospital1 18**] on the TSICU service. TSICU team had been
trying to wean her off of propofol but she repeatedly became
very anxious and dropped her O2 sats. She was started on
quetiapine and her propofol was stopped this am. She has failed
trials with PM valve several times. TSICU team has been
attempting to diurese her but she has continued to run positive.
Her Aline was replaced yesterday. She has been getting nutren
TFs. She is transferred to the MICU for further weaning of her
PEEP and possible stenting of her tracheobronchial malacia.
.

.
Currently, she complains of pain in the back left of her mouth.
.
ROS unobtainable [**1-18**] trach.


Past Medical History:
-Advanced COPD, on supplemental O2 (6-7L) and prednisone, last
PFTs in [**2168**], last hospitalization in [**2178-4-16**]
-Asthma
-HTN
-Hyperlipidemia
-Obesity
-Anemia
-Osteoporosis


Social History:
hx of tobacco but quit [**2163**], denies ETOH

Family History:
NC

Physical Exam:
Vitals - BP: 145/69 HR: 70 RR: 16 02 sat:  97
GENERAL:  A/oX3, unable to speak [**1-18**] trach, answering yes/no
appropriately
HEENT: Trach, unable to assess JVD [**1-18**] habitus. Oral thrush
CARDIAC:  RRR, Distant heart sounds
LUNG:  Distant lung sounds
ABDOMEN:  Massively obese, soft, NT
EXT:  trace pitting edema bilaterally, 2+ DP/PT pulses


Pertinent Results:
[**2179-11-15**] 11:06PM BLOOD WBC-14.0* RBC-3.70* Hgb-10.5* Hct-34.0*
MCV-92 MCH-28.3 MCHC-30.8* RDW-15.4 Plt Ct-533*
[**2179-11-22**] 04:00AM BLOOD WBC-7.8 RBC-3.66* Hgb-10.7* Hct-33.9*
MCV-93 MCH-29.2 MCHC-31.5 RDW-15.5 Plt Ct-327
[**2179-11-22**] 04:00AM BLOOD PT-12.4 PTT-21.7* INR(PT)-1.0
[**2179-11-22**] 04:00AM BLOOD Glucose-122* UreaN-14 Creat-0.6 Na-145
K-4.2 Cl-98 HCO3-40* AnGap-11
[**2179-11-15**] 11:06PM BLOOD Glucose-104 UreaN-15 Creat-0.7 Na-146*
K-3.9 Cl-104 HCO3-34* AnGap-12
[**2179-11-22**] 04:00AM BLOOD Calcium-9.7 Phos-4.3 Mg-2.1
[**2179-11-20**] 10:32AM BLOOD Type-ART Temp-37.1 Rates-/25 PEEP-5
FiO2-40 pO2-77* pCO2-65* pH-7.36 calTCO2-38* Base XS-7
Intubat-INTUBATED Vent-SPONTANEOU
[**2179-11-19**] 04:53AM BLOOD Type-ART pO2-91 pCO2-67* pH-7.37
calTCO2-40* Base XS-9
[**2179-11-20**] 10:32AM BLOOD Lactate-0.7

CXR [**11-18**]:
Tracheostomy tube is in standard position. NG tube tip is out of
view below the diaphragm. Cardiac size is normal. The lungs are
hyperinflated Small right pleural effusion is unchanged from
prior. Of note the left lateral CP angle was not included on the
film. Minimal atelectasis is noted in the left lower lobe. There
is no pneumothorax.

Bronchoscopy [**11-22**]:
Proximal: mild tracheomalacia
Mid: moderate tracheomalacia
Distal: severe tracheomalacia
Airways: Severe right mainstem, bronchus intermedius, left
main-stem bromchomalacia.
Plan: Discharge to rehab, f/u in a few months when recovered.


Brief Hospital Course:
ASSESSMENT & PLAN:  57 yo F w/ COPD, morbid obesity, TBM and
failure to wean vent.

#  Failure to wean/COPD/TBM: Appears chronic retainer. A large
component of her difficulty with weening was anxiety related.
Upon arrival at the MICU, she was gently diuresed and her
anxiety was controlled with PRN ativan. She was able to be
weened to PS 14/10 and she is able to tolerate PS 8/5 for a
short time, enough to try a Passy Muir valve for some time.
However, she feels much more comfortable with a PEEP of 10. She
does have some significant respiratory muscle weakness with a
NIF of 23, likely due to her extended ventilator exposure, with
no signs of peripheral muscle weakness. However, other
etiologies for respiratory muscle weakness should be considered
if she continues to have difficulty weening. After her PEEP was
weened down to 5 for some time, she was rebronched by the
Interventional Pulmonary service who did see some distal
tracheobronchial malacia but nothing proximal that they felt
placing a stent in would assist in her weening. She may follow
up with the IP service in several months after she has been
weened for further evaluation and treatment. She is continued on
her home dose of prednisone, combivent inhalers, and PO lasix.
Due to her ventilated status, she could not receive her home
Spriva or Foradil but these should be restarted after weening.

#Anxiety: Well controlled with Low dose PRN ativan.
.
#DMII: Blood sugars were noted to be elevated, likely
representing underlying type 2 diabetes worsened by steroids and
stress. Well controlled with an insulin sliding scale in
hospital but should be switched to PO agents at a later time
before returning home.
.
#Trach pain: Uncomfortable at the site of her tracheostomy. Well
controlled with small doses of PO dilaudid and tylenol, with
chloraseptic PRN.

#HTN: Well controlled on valsartan and diltiazem.
.
# PPX: famotidine, heparin SQ, bowel regimen
# ACCESS: PICC
# CODE:  Full
# CONTACT:  [**Name (NI) 4906**] [**Name (NI) **] [**Telephone/Fax (1) 84055**] (cell) [**Telephone/Fax (1) 84056**]
(home); Son [**Name (NI) **] [**Telephone/Fax (1) 84057**] (cell)


Medications on Admission:
-Prednisone 5mg qday
-Diovan 80 mg qday
-Spiriva 18mcg inh qday
-[**Doctor First Name **] 180mg qday
-Singulair 10mg qday
-Lipitor 10mg qday
-Lasix 20mg qday
-Boniva qmonth
-Foradil 12mcg inh [**Hospital1 **]
-Combivent 2puffs QID PRN
-Calcium carbonate/Vit D1 qday
-ASA 81 qday
-Albuterol 2.5mg neb q4 PRN


Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: Please see
attached scale  Injection ASDIR (AS DIRECTED).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day). mL
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Fluticasone 110 mcg/Actuation Aerosol Sig: Eight (8) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for anxiety/pain.
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**4-21**]
Puffs Inhalation Q4H (every 4 hours).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO BID
(2 times a day) as needed for thrush.
9. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for anxiety.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
11. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous
membrane Q4H (every 4 hours) as needed for sore throat.
12. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
17. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
18. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
20. Diltia XT 120 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
21. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).



Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] [**Location (un) 686**]

Discharge Diagnosis:
Community Acquired Pneumonia
COPD exacerbation
Hypertension
Type 2 Diabetes


Discharge Condition:
Non-ambulatory, on PS [**2180-11-28**], comfortable on vent and
communicative. All vital signs stable. Alert and oriented x 3


Discharge Instructions:
You were admitted after a pneumonia and a COPD exacerbation to
continue weening you off the ventilator and evaluate whether
your airways showed any signs of collapse, known as
tracheobronchomalacia, that could be helped by a stent placed to
keep them open. The Interventional Pulmonary service evaluated
you and found that while you did have some collapse of your
small airways, there was no major collapse of the large airways
that would be helped with a stent.

Followup Instructions:
Provider: [**Name10 (NameIs) 12554**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2180-2-15**] 10:00
Provider: [**Name10 (NameIs) **] INTAKE,ONE [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2180-2-15**] 10:30
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5072**] Date/Time:[**2180-2-15**]
11:00

Please follow up with PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 84058**],
after discharge from rehab.



Completed by:[**2179-11-26**]
{'Acute respiratory failure,Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Hyperosmolality and/or hypernatremia,Candidiasis of mouth,Anxiety state, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other diseases of trachea and bronchus,Other and unspecified hyperlipidemia,Personal history of tobacco use,Osteoporosis, unspecified,Obesity, 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: SOB

PRESENT ILLNESS: Briefly 57 yo F w/ COPD on home O2 and prednisone and
tracheobronchial malacia p/w inability to wean vent. Initially
presented to [**Hospital 1562**] hospital with SOB on [**11-4**] and was
intubated on [**11-5**] for COPD exacerbation/PNA got 11 day course
of zosyn and diflucan. She was trached on [**11-9**]. She was
bronched and diagnosed with tracheobronchial malacia at OSH and
transferred to [**Hospital1 18**] on the TSICU service. TSICU team had been
trying to wean her off of propofol but she repeatedly became
very anxious and dropped her O2 sats. She was started on
quetiapine and her propofol was stopped this am. She has failed
trials with PM valve several times. TSICU team has been
attempting to diurese her but she has continued to run positive.
Her Aline was replaced yesterday. She has been getting nutren
TFs. She is transferred to the MICU for further weaning of her
PEEP and possible stenting of her tracheobronchial malacia.
.

MEDICAL HISTORY: -Advanced COPD, on supplemental O2 (6-7L) and prednisone, last
PFTs in [**2168**], last hospitalization in [**2178-4-16**]
-Asthma
-HTN
-Hyperlipidemia
-Obesity
-Anemia
-Osteoporosis

MEDICATION ON ADMISSION: -Prednisone 5mg qday
-Diovan 80 mg qday
-Spiriva 18mcg inh qday
-[**Doctor First Name **] 180mg qday
-Singulair 10mg qday
-Lipitor 10mg qday
-Lasix 20mg qday
-Boniva qmonth
-Foradil 12mcg inh [**Hospital1 **]
-Combivent 2puffs QID PRN
-Calcium carbonate/Vit D1 qday
-ASA 81 qday
-Albuterol 2.5mg neb q4 PRN

ALLERGIES: Sulfa (Sulfonamide Antibiotics) / Keflex / Levaquin / Actonel

PHYSICAL EXAM: Vitals - BP: 145/69 HR: 70 RR: 16 02 sat:  97
GENERAL:  A/oX3, unable to speak [**1-18**] trach, answering yes/no
appropriately
HEENT: Trach, unable to assess JVD [**1-18**] habitus. Oral thrush
CARDIAC:  RRR, Distant heart sounds
LUNG:  Distant lung sounds
ABDOMEN:  Massively obese, soft, NT
EXT:  trace pitting edema bilaterally, 2+ DP/PT pulses

FAMILY HISTORY: NC

SOCIAL HISTORY: hx of tobacco but quit [**2163**], denies ETOH 

### Response:
{'Acute respiratory failure,Pneumonia, organism unspecified,Obstructive chronic bronchitis with (acute) exacerbation,Hyperosmolality and/or hypernatremia,Candidiasis of mouth,Anxiety state, unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other diseases of trachea and bronchus,Other and unspecified hyperlipidemia,Personal history of tobacco use,Osteoporosis, unspecified,Obesity, unspecified'}
