CHIEF COMPLAINT: SOB

PRESENT ILLNESS: Mr. [**Known lastname 86057**] is a 60 year old male w/ h/o COPD who presented with
sore throat for several days and stridor for 3 hours. No
vomiting, no CP, no abd pain. + Fever, chills.
.
In ED, vitals were, Temp:102.8 HR:90 BP:1421/P Resp:26-28
O(2)Sat:98 normal. Pt was dyspneic and noted to have biphasic
stridor.  ENT was consulted was who upon examination of the
patients oropharynx with fiberoptic scope, noted significant
supraglottic and epiglottic swelling with a 2 mm airway.
Preparations were made for emergent transfer to the OR. The pt
received IV ceftriaxone and unasyn as well as 10 mg IV
dexamethasone and nebulized racemic epi as a temporizing measure
in the ED.  The patient was noted to have increasing respiratory
distress on arrival to the OR.  Fiberoptic intubation was
attempted but unable to visualize arytenoids or pass a bougie.
Perc cric was then attempted with puncture of the airway through
the thyroid cartilage.  The patients sats dropped to 70s,
unclear if pt aspirated while in extremis. A temporary airway
was established and then converted to a formal tracheostomy.
The pt was then transferred to the MICU.

MEDICAL HISTORY: COPD
GERD
Frequent URI's

MEDICATION ON ADMISSION: azithromycin 500 mg x1 dose yest. am
advair prn
albuterol prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE AFTER ADMISION TO THE FLOOR:
Vitals: 99.5, 144/80, 57, 18, 95% on 2L NC
Gen: Well appearing male in NAD, speaking in full senteces
CV: RRR, no murmurs
LUngs: diminished BS at bases, ronchi on upper airway clearing
with cough. NO SOB, trach is capped.
ABD: soft, NT/ND, + BS x 4 quads. NG tube with feeds.
Ext: no edema and + pulses
Neuro: A+Ox3

FAMILY HISTORY: NC

SOCIAL HISTORY: - Tobacco: ++, [**3-5**] ppd x45 yrs, currently at 2 ppd
- Alcohol:
- Illicits:
High school teacher lives with wife who is a nurse.
Acute epiglottitis with obstruction,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Esophageal reflux,Tobacco use disorder,Chronic airway obstruction, not elsewhere classified
Ac epiglottitis w obstr,Acute respiratry failure,Food/vomit pneumonitis,Esophageal reflux,Tobacco use disorder,Chr airway obstruct NEC
Admission Date:  [**2194-5-30**]              Discharge Date:   [**2194-6-6**]

Date of Birth:  [**2133-10-11**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
SOB

Major Surgical or Invasive Procedure:
S/p emergent tracheostomy


History of Present Illness:
Mr. [**Known lastname 86057**] is a 60 year old male w/ h/o COPD who presented with
sore throat for several days and stridor for 3 hours. No
vomiting, no CP, no abd pain. + Fever, chills.
.
In ED, vitals were, Temp:102.8 HR:90 BP:1421/P Resp:26-28
O(2)Sat:98 normal. Pt was dyspneic and noted to have biphasic
stridor.  ENT was consulted was who upon examination of the
patients oropharynx with fiberoptic scope, noted significant
supraglottic and epiglottic swelling with a 2 mm airway.
Preparations were made for emergent transfer to the OR. The pt
received IV ceftriaxone and unasyn as well as 10 mg IV
dexamethasone and nebulized racemic epi as a temporizing measure
in the ED.  The patient was noted to have increasing respiratory
distress on arrival to the OR.  Fiberoptic intubation was
attempted but unable to visualize arytenoids or pass a bougie.
Perc cric was then attempted with puncture of the airway through
the thyroid cartilage.  The patients sats dropped to 70s,
unclear if pt aspirated while in extremis. A temporary airway
was established and then converted to a formal tracheostomy.
The pt was then transferred to the MICU.


Past Medical History:
COPD
GERD
Frequent URI's

Social History:
- Tobacco: ++, [**3-5**] ppd x45 yrs, currently at 2 ppd
- Alcohol:
- Illicits:
High school teacher lives with wife who is a nurse.

Family History:
NC

Physical Exam:
PE AFTER ADMISION TO THE FLOOR:
Vitals: 99.5, 144/80, 57, 18, 95% on 2L NC
Gen: Well appearing male in NAD, speaking in full senteces
CV: RRR, no murmurs
LUngs: diminished BS at bases, ronchi on upper airway clearing
with cough. NO SOB, trach is capped.
ABD: soft, NT/ND, + BS x 4 quads. NG tube with feeds.
Ext: no edema and + pulses
Neuro: A+Ox3

Pertinent Results:
ADMISSION LABS:
===============
[**2194-5-29**] 11:45PM BLOOD WBC-20.1* RBC-5.78 Hgb-17.3 Hct-52.3*
MCV-90 MCH-29.9 MCHC-33.1 RDW-14.3 Plt Ct-239
[**2194-5-29**] 11:45PM BLOOD PT-12.3 PTT-25.3 INR(PT)-1.0
[**2194-5-29**] 11:45PM BLOOD Glucose-110* UreaN-12 Creat-0.9 Na-138
K-4.0 Cl-101 HCO3-28 AnGap-13
[**2194-5-30**] 04:22AM BLOOD Calcium-7.2* Phos-3.5 Mg-1.9
[**2194-5-30**] 04:40AM BLOOD Type-ART Temp-37.4 PEEP-8 O2 Flow-100
pO2-109* pCO2-53* pH-7.28* calTCO2-26 Base XS--2
Intubat-INTUBATED
[**2194-5-29**] 11:53PM BLOOD Lactate-1.2 K-3.7
[**2194-5-30**] 10:19PM BLOOD freeCa-1.10*

MICROBIOLOGY:
.
[**2194-5-30**] 8:56 am BLOOD CULTURE      Source: Line-tlcl.
   Blood Culture, Routine (Final [**2194-6-5**]):    NO GROWTH.
.
[**2194-5-30**] 8:57 am SPUTUM      Source: Endotracheal.
GRAM STAIN (Final [**2194-5-30**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2194-6-1**]):
      RARE GROWTH Commensal Respiratory Flora.
.
[**2194-5-30**] 8:57 am URINE      Source: Catheter.
URINE CULTURE (Final [**2194-5-31**]):    NO GROWTH.
.
[**2194-5-29**] 11:45 pm BLOOD CULTURE
Blood Culture, Routine (Final [**2194-6-4**]):    NO GROWTH.

DISCHARGE LABS:
================
[**2194-6-6**] 05:50AM BLOOD WBC-11.4* RBC-4.80 Hgb-14.0 Hct-41.7
MCV-87 MCH-29.2 MCHC-33.6 RDW-13.7 Plt Ct-295
[**2194-6-6**] 05:50AM BLOOD Glucose-94 UreaN-13 Creat-0.6 Na-142
K-4.1 Cl-105 HCO3-27 AnGap-14
[**2194-6-6**] 05:50AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.2

IMAGING/STUDIES:
# ECG ON [**2194-5-29**]:
Baseline artifact. Sinus rhythm. Left axis deviation. Late R
wave
progression. No previous tracing available for comparison.
TRACING #1
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
91 152 94 352/406 71 -43 28
.
# CXRAY [**2194-5-29**]:
SINGLE FRONTAL VIEW OF THE CHEST: Vascular engorgement and
minimal basal
interstitial abnormality could be due to cardiac decompensation,
although
heart size is only top normal. No pneumonia.

The laryngeal and subglottic airway looks diffusely narrowed and
should be
evaluated with conventional or CT radiography. Leftward
displacement of normal calibre trachea below the thoracic inlet
could be due to tortuous vasculature.

IMPRESSION:
1. Possible narrowing larnyngeal and subglottic airway should be
imaged
further.
2. Borderline cardiac decompensation.
.

#NECK SOFT TISSUE [**2194-5-29**]:
PORTABLE SINGLE LATERAL VIEW OF THE NECK: Only C1 through C4 is
visualized on this lateral view. The visualized prevertebral
soft tissues are within normal limits. The epiglottis is largely
obscured by overlying patient's shoulders. Degenerative changes
are noted throughout the visualized cervical spine.

IMPRESSION: Limited evaluation. Apparent soft tissue swelling of
the
anterior neck.
.

#PATHOLOGY Tracheal cartilage:
Respiratory mucosa with mild acute and chronic inflammation,
bone, and cartilage.
Clinical: Acute epiglottitis.
Gross:

The specimen is received fresh in a container labeled the
patient's name, "[**Known lastname 86057**], [**Known firstname **]", the medical record number and
"tracheal cartilage". It consists of two fragments of pink-tan
cartilage measuring 1.5 x 0.7 x 0.7 cm in aggregate. The
specimen is entirely submitted in cassette A.

#CXRAY ON [**2194-6-1**]:
One portable view. Comparison with [**2194-5-31**]. There is persistent
asymmetric
density at the right lung base suspicious for pneumonia. The
left lung
appears relatively clear on the current study. The heart and
mediastinal
structures are unchanged. A right subclavian catheter,
tracheostomy tube and nasogastric tube remain in place.

IMPRESSION: Persistent asymmetric density at the right base
suspicious for
pneumonia.
.
#UGI SGL CONTRAST W/ KUB Study Date of [**2194-6-5**] 4:25 PM
FINDINGS: The initial scout radiograph of mediastinal area was
performed.
Limited visualization of the lung bases. However, the previously
noted
asymmetric opacity in the right lung base is improved. No
pneumothorax or
subcutaneous emphysema is identified in the lower neck and
chest.

A barium swallow study was performed with thin liquid barium. On

administration of thin liquid barium, there was normal free
passage of barium through the oropharynx and the esophagus. No
definite leak is identified in the oropharynx or the esophagus.
There is no evidence of obstruction with contrast passing freely
into the stomach. Detailed evaluation of the motility of the
esophagus was not performed at this time.

IMPRESSION: Limited upper GI study, did not reveal contrast leak
from the
oropharynx or the esophagus.


Brief Hospital Course:
60 yo M w/ h/o COPD here with ST for several days, fever,
stridor with epiglottitis seen on fiberoptic scope s/p emergent
trach in OR prior to transfer to the MICU.
.
# Epiglottitis- Confirmed by fiberoptic scope by ENT in the ED
then again during emergent trach in the OR.  The trach was left
in place, with the balloon inflated x5d post admission for
airway protection while supraglottic and glottic edema resolved.
 The patient received high dose dexamethasone in the first 24
hours in the ICU to speed improvement in the airway edema.  He
was given IV unasyn x5d as well as IV vancomycin x4d (for
presumed aspiration during emergent airway procedure)  with plan
to transition to orals once pt passed barium swallow.  The
oropharynx was visualized again on HD6 with moderate but
resolving supraglottic edema seen. His antibiotics were changed
to Augmentin 875mg twice daily for total of 14 days (Day 1 was
on [**2194-6-4**]). On [**2194-6-5**] he had oropharynx was visualized and
supraglottic edema was improved. He had both tracheotosmy and NG
tube removed. Patient had Barium swallow study wich showed no
aspiration and no leakage. He was advanced to regular soft diet
which he tolerated well, he no difficulty swallowing. Patient
denies having any shortness of breath and his o2 sats have been
in mid 90s% while walking and while resting. Patient and family
wanted to leave today and drive to [**Location (un) 7349**]. He was given instruction
to follow-up with a ENT doctor early next week. His wife is a
nursse and is trying to arrange the appointment.
.
#Hypotension- The patient was hypotensive with SBPs in the 70s
initially on arrival to the ICU.  DDX included volume depletion
vs. sepsis [**3-4**] epiglottitis or aspiration pneumonitis.  The pt
required dopamine then levophed gtts initially in addition to
IVF resuscitation to support BPs but were weaned within the
first 24 hours.  BP was stable in the normal range since.
.
#Tracheostomy, crash airway- Pt converted to formal trach in OR.
Reportedly the thyroid cartilage was punctured during the
emergent procedure, which required ENT to be more cautious with
trach removal.  Cuff was left inflated for 5 days then deflated
by ENT, the trach was downsized on HD6 and it was decannulazed
on the following day.  The pt was advanced to po's once he
passed a barium swallow study demonstrating no persistent injury
to the hypopharynx caused by the crash procedure.
.
#COPD- Albuterol and ipratropium MDIs given per trach q6h
scheduled for pts known COPD. He denies having any shortness of
breath and was sating in mid 90s% at time of discharge.
.
GERD- IV PPI daily.
.
# FEN: tolerating soft diet well with no complains and no
difficulty swallowing.
# Prophylaxis: He was given Subcutaneous heparin
# Access: peripherals.
# Communication: Patient.
# Code: Full
# Disposition: going home to [**Location (un) 7349**]

Medications on Admission:
azithromycin 500 mg x1 dose yest. am
advair prn
albuterol prn

Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
[**Last Name (STitle) **]:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0*
2. Nicotine 14 mg/24 hr Patch 24 hr [**Last Name (STitle) **]: One (1) Patch 24 hr
Transdermal DAILY (Daily): You should use the 14mg patch for a
total of 6 weeks then change to 7mg for 2 weeks and then stop.
You will need to follow-up with your primary care doctor.
[**Last Name (Titles) **]:*30 Patch 24 hr(s)* Refills:*0*
3. Fluticasone 110 mcg/Actuation Aerosol [**Last Name (Titles) **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
[**Hospital1 **]:*2 Inhalers* Refills:*1*
4. Amoxicillin-Pot Clavulanate 250-62.5 mg/5 mL Suspension for
Reconstitution [**Hospital1 **]: One (1)  PO BID (2 times a day) for 10 days.
[**Hospital1 **]:*20 Tablets* Refills:*0*
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing, SOB.
[**Hospital1 **]:*2 inhalers* Refills:*1*
6. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
Two (2) Puff Inhalation Q6H (every 6 hours).
[**Hospital1 **]:*2 inhalers* Refills:*1*
7. Oxycodone 5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every four (4)
hours as needed for pain: This medication may cause drowsiness.
You should not drive,operate heavy machenary or do anything that
may require allertness while taking this medication.
[**Hospital1 **]:*10 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
Epiglotitis, s/p emergent tracheostomy

Secondary:
COPD
GERD


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


Discharge Instructions:
You were admitted to the [**Hospital1 18**] for shortness of breath. You were
found to have epiglotitis, swelling and infection of your
throat. Unfortunately your throat closed completely and you
needed to have an emergent tracheostomy. You were then taken to
the ICU and you have overall improved. Your tracheostomy was
removed and you have done very well. You had a swallow
evaluation and you have been eating soft diet without any
difficulty. You will need to follow-up with an ENT (Ear, Nose
and Throat) doctor [**First Name (Titles) **] [**Last Name (Titles) **] early next week. Please let us know if
you have any difficulty in arranging for this appointment.

We have added the following medications to your regimen:
- Augumentin 875 mg twice per day for another 10 more days. It
is very important that you take this medication as prescribed
and do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**].
- Albuterol 2 puffs every 4 hours as need for SOB and wheezing
- Fluticasone Propionate 110mcg 2 PUFF twice daily
- Ipratropium Bromide MDI 2 PUFFs every 6 hours
- Nicotine Patch 14 mg TD DAILY
- Prevacid disintergrating tablets daily (gastric reflux)
- Oxycodone 5mg 1-2 tablets as needed every 6 hours for pain.
This medication may cause drowsiness and you should not drive,
operate heavy machenary or do anything that requires alertness
while taking this medication


Followup Instructions:
You wife is arranging an appointment with an ENT doctor in [**Location (un) 5426**]. You should see someone early next week or sooner if you
have any other concerns. Please call Dr. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]
at [**Telephone/Fax (1) 2756**] and ask operator to page [**Numeric Identifier 86058**] if you have any
questions or concerns or if you can't get an ENT doctor.


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
{'Acute epiglottitis with obstruction,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Esophageal reflux,Tobacco use disorder,Chronic airway obstruction, not elsewhere classified'}


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: Mr. [**Known lastname 86057**] is a 60 year old male w/ h/o COPD who presented with
sore throat for several days and stridor for 3 hours. No
vomiting, no CP, no abd pain. + Fever, chills.
.
In ED, vitals were, Temp:102.8 HR:90 BP:1421/P Resp:26-28
O(2)Sat:98 normal. Pt was dyspneic and noted to have biphasic
stridor.  ENT was consulted was who upon examination of the
patients oropharynx with fiberoptic scope, noted significant
supraglottic and epiglottic swelling with a 2 mm airway.
Preparations were made for emergent transfer to the OR. The pt
received IV ceftriaxone and unasyn as well as 10 mg IV
dexamethasone and nebulized racemic epi as a temporizing measure
in the ED.  The patient was noted to have increasing respiratory
distress on arrival to the OR.  Fiberoptic intubation was
attempted but unable to visualize arytenoids or pass a bougie.
Perc cric was then attempted with puncture of the airway through
the thyroid cartilage.  The patients sats dropped to 70s,
unclear if pt aspirated while in extremis. A temporary airway
was established and then converted to a formal tracheostomy.
The pt was then transferred to the MICU.

MEDICAL HISTORY: COPD
GERD
Frequent URI's

MEDICATION ON ADMISSION: azithromycin 500 mg x1 dose yest. am
advair prn
albuterol prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE AFTER ADMISION TO THE FLOOR:
Vitals: 99.5, 144/80, 57, 18, 95% on 2L NC
Gen: Well appearing male in NAD, speaking in full senteces
CV: RRR, no murmurs
LUngs: diminished BS at bases, ronchi on upper airway clearing
with cough. NO SOB, trach is capped.
ABD: soft, NT/ND, + BS x 4 quads. NG tube with feeds.
Ext: no edema and + pulses
Neuro: A+Ox3

FAMILY HISTORY: NC

SOCIAL HISTORY: - Tobacco: ++, [**3-5**] ppd x45 yrs, currently at 2 ppd
- Alcohol:
- Illicits:
High school teacher lives with wife who is a nurse. 

### Response:
{'Acute epiglottitis with obstruction,Acute respiratory failure,Pneumonitis due to inhalation of food or vomitus,Esophageal reflux,Tobacco use disorder,Chronic airway obstruction, not elsewhere classified'}
