CHIEF COMPLAINT: supraglottitis

PRESENT ILLNESS: patient is a 64 yo M with atrial fibrillation on coumadin, [**Hospital 2182**]
transferred from an OSH with respiratory distress due to
supraglottic edema. He initially presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
because he was 'spitting up blood' after eating a [**Location (un) 6002**] at
his rehab. He was found to have supraglottic edema both on exam
and in CT scan. He was transferred to [**Hospital1 18**] for airway
management. Surgery was called for respiratory distress in the
ED and performed an emergent crichothyroidotomy in the OR. ENT
was consulted and changed the crich to a tracheostomy. Admission
labs pertinent for Hct of 50 (down to 33 on transfer) and INR of
3.0 reversed with 6 [**Location 16678**] and 10 mg vitamin K (given at OSH)
down to 1.6.

MEDICAL HISTORY: - Atrial Fibrillation (on coumadin)
- s/p Pacer ([**Company 1543**] DDD)
- COPD
- Hypertension
- PVD s/p Aortobifemoral bypass
- Hyperlipidemia
- Chronic liver disease [**2-22**] EtOH (sober since [**2-/2146**])
- Anemia: h/o maroon stools
  colonoscopy in [**2146**] with hemorrhoids, colon polyps, adenoma
- h/o epistaxis
.

MEDICATION ON ADMISSION: Imdur 30 mg PO daily
Plavix 75 mg PO daily
Simvastatin 80 mg PO daily
Advair 250/50 1 puff [**Hospital1 **]
Viagra 50 mg PO daily (except Thursday)
Digoxin 0.125 mcg PO daily
Coumadin 7.5 mg PO daily
Lopressor 50 mg PO BID
ASA 325 mg PO daily
Albuterol 90 mcg INH 2 buffs [**Hospital1 **]
Florinef 1 mg PO daily
Famotidine 20 mg PO daily
KCL 20 mEq PO BID
Folic Acid 1 mg PO daily
Vitamin B12- 100 mc PO daily

ALLERGIES: Quetiapine

PHYSICAL EXAM: Vitals: 99 132/54 (90 non-invasive) 20 100% on trach collar.
General: elderly M with trach Alert NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs:  slight expiratory wheeze with otherwise clear breath
sounds
CV: distant HS, tachycardic, irregular, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, TTP in LUQ and LLQ, non-distended, bowel sounds
present, no rebound tenderness or guarding; bruises noted over
bilateral lower quadrants. no abdominal rash noted.
GU: no foley
Ext: limbs cool to touch BL with 1+ DPs, PTs bilaterally; hair
loss. Moving all lower and upper extremities to command.

FAMILY HISTORY: Family History:  father and mother both died of CAD

SOCIAL HISTORY: Social History:
- unemployed. Has a scooter at home. Short term rehab resident
at [**Hospital 70637**] Healthcare in [**Location (un) 32944**].  [**Hospital 1094**] health care proxy is
his friend [**Name (NI) 892**] [**Name (NI) 16471**],
(c) [**Telephone/Fax (1) 106834**], (h) [**Telephone/Fax (1) 106835**].
- Tobacco:  +1.5 ppd, no plans for quitting
- Alcohol:  per records, hx of heavy EtOH use but was abstaining
from EtOH since [**2146-6-10**].
- Illicits:  none
Acute and chronic respiratory failure,Acute epiglottitis with obstruction,Bronchopneumonia, organism unspecified,Hematemesis,Bacteremia,Delirium due to conditions classified elsewhere,Pathologic fracture of vertebrae,Chronic pulmonary embolism,Hyposmolality and/or hyponatremia,Atrial fibrillation,Acute gastritis, without mention of hemorrhage,Alcoholic cirrhosis of liver,Hematuria, unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Alcohol abuse, in remission,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Chronic airway obstruction, not elsewhere classified,Adrenal cortical steroids causing adverse effects in therapeutic use,Epistaxis,Dermatitis due to drugs and medicines taken internally,Unspecified drug or medicinal substance causing adverse effects in therapeutic use,Hypotension, unspecified,Other specified disorders of esophagus,Other diseases of trachea and bronchus
Acute & chronc resp fail,Ac epiglottitis w obstr,Bronchopneumonia org NOS,Hematemesis,Bacteremia,Delirium d/t other cond,Path fx vertebrae,Chr pulmonary embolism,Hyposmolality,Atrial fibrillation,Acute gastrtis w/o hmrhg,Alcohol cirrhosis liver,Hematuria NOS,Pseudomonas infect NOS,Alcohol abuse-in remiss,Long-term use anticoagul,Status cardiac pacemaker,Chr airway obstruct NEC,Adv eff corticosteroids,Epistaxis,Drug dermatitis NOS,Adv eff medicinal NOS,Hypotension NOS,Other dsrders esophagus,Trachea & bronch dis NEC
Admission Date:  [**2146-9-1**]              Discharge Date:   [**2146-9-14**]

Date of Birth:  [**2078-1-10**]             Sex:   M

Service: MEDICINE

Allergies:
Quetiapine

Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
 supraglottitis

Major Surgical or Invasive Procedure:
Emergent Cricothyroidotomy
Tracheostomy Placement
Mechanical Ventilation
PICC line placement


History of Present Illness:
patient is a 64 yo M with atrial fibrillation on coumadin, [**Hospital 2182**]
transferred from an OSH with respiratory distress due to
supraglottic edema. He initially presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
because he was 'spitting up blood' after eating a [**Location (un) 6002**] at
his rehab. He was found to have supraglottic edema both on exam
and in CT scan. He was transferred to [**Hospital1 18**] for airway
management. Surgery was called for respiratory distress in the
ED and performed an emergent crichothyroidotomy in the OR. ENT
was consulted and changed the crich to a tracheostomy. Admission
labs pertinent for Hct of 50 (down to 33 on transfer) and INR of
3.0 reversed with 6 [**Location 16678**] and 10 mg vitamin K (given at OSH)
down to 1.6.


Past Medical History:
- Atrial Fibrillation (on coumadin)
- s/p Pacer ([**Company 1543**] DDD)
- COPD
- Hypertension
- PVD s/p Aortobifemoral bypass
- Hyperlipidemia
- Chronic liver disease [**2-22**] EtOH (sober since [**2-/2146**])
- Anemia: h/o maroon stools
  colonoscopy in [**2146**] with hemorrhoids, colon polyps, adenoma
- h/o epistaxis
.

Social History:
Social History:
- unemployed. Has a scooter at home. Short term rehab resident
at [**Hospital 70637**] Healthcare in [**Location (un) 32944**].  [**Hospital 1094**] health care proxy is
his friend [**Name (NI) 892**] [**Name (NI) 16471**],
(c) [**Telephone/Fax (1) 106834**], (h) [**Telephone/Fax (1) 106835**].
- Tobacco:  +1.5 ppd, no plans for quitting
- Alcohol:  per records, hx of heavy EtOH use but was abstaining
from EtOH since [**2146-6-10**].
- Illicits:  none

Family History:
Family History:  father and mother both died of CAD

Physical Exam:
Vitals: 99 132/54 (90 non-invasive) 20 100% on trach collar.
General: elderly M with trach Alert NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs:  slight expiratory wheeze with otherwise clear breath
sounds
CV: distant HS, tachycardic, irregular, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, TTP in LUQ and LLQ, non-distended, bowel sounds
present, no rebound tenderness or guarding; bruises noted over
bilateral lower quadrants. no abdominal rash noted.
GU: no foley
Ext: limbs cool to touch BL with 1+ DPs, PTs bilaterally; hair
loss. Moving all lower and upper extremities to command.

Pertinent Results:
Images:
CXR ([**9-9**]) - FINDINGS: AP single view of the chest has been
obtained with patient in semi-upright position. Image field
directed towards upper abdomen on purpose so to identify
Dobbhoff line which is seen to be located in stomach pointing
towards pylorus and duodenum but not having passed of yet. No
other remarkable findings. This image has been obtained to
complement a previous chest examination obtained two hours
earlier.
.
CT neck (OSH on [**8-31**]):
Impression: Edema of the epiglottis, the R lateral oropharynx
and the hypopharynx. No discrete abscess. Mild narrowing of the
supraglottic airway.  Diffuse R maxillary sinusitis.
CT neck ([**9-6**])
IMPRESSION:
1. Significant decrease in right supraglottic edema since
[**2146-8-31**]. While no definite underlying mass is seen, a mass is
difficult to exclude.
2. Numerous lymph nodes at levels 1, 2 and 3, right greater than
left, not pathologically enlarged by CT size criteria. These may
be reactive.
3. Near-complete opacification of the paranasal sinuses, which
may be related to the known nasal packing.
4. 1 cm cystic lesion with wall calcifications in the left
vallecula.  Recommend direct visualization, when feasible.
  .
CT Chest ([**9-1**])
FINDINGS:
.
The patient is intubated through tracheostomy. For precise
evaluation of the neck and the area of the glottis, please
review CT of the neck obtained the same day and the
corresponding report. A central venous line terminates at the
cavoatrial junction. Pacemaker leads terminate in right atrium
and right ventricle. Aorta and pulmonary arteries are normal in
diameter. Heart size is normal. There is no pericardial
effusion. Extensive coronary calcifications are present.
.
The evaluation of the airways demonstrate patent trachea, right
and left main bronchi as well as the upper lung lobe and right
middle lobe bronchial tree.  Within the lower lobe, there are
bibasal consolidations, with air bronchogram on the right and
minimal air bronchogram on the left. Giving their relatively
high enhancement, they most likely represent areas of
atelectasis, but bibasilar infectious process cannot be excluded
and it is accompanied by small amount of pleural effusion. The
upper lungs are essentially clear. Severe emphysema is involving
the upper lobes, a combination of centrilobular and panlobular
type.
.
The imaged portion of the upper abdomen demonstrates small
degree of ascites.  Sludge within the gallbladder is noted, but
with no evidence of cholecystitis. The pancreatic duct is
dilated up to 9 mm, the reason is unclear, and the pancreas is
partially imaged. Significant lymphadenopathy is noted in the
area of the celiac trunk bifurcation up to 14 mm, and might
reflect both  neoplastic or infectious etiology. Adrenals,
imaged portion of the kidneys,
spleen, and imaged portion of the liver are unremarkable.
.
Extensive degenerative changes are present in the spine, but
there are no lytic or sclerotic lesions worrisome for neoplasm
or infection. Lateral view demonstrates wedge compression
fracture of upper lumbar vertebral body, chronicity
undetermined.
.
EGD ([**2146-9-9**]):
Findings: Esophagus:  Mucosa: Abnormal mucosa was noted
throughout the esophagus. There was 3 inches of circumferential
dark mucosa starting at the GE junction. Proximal to that in the
distal and mid esophagus there are patchy areas of dark mucosa.
This persists despite lavage. it has an ischemic appearance, and
most consistent with ischemic injury. There is also evidence of
punctate and patchy erythema consistent with esophagitis.
Stomach:  Mucosa: Patchy discontinuous erythema of the mucosa
with no bleeding was noted in the whole stomach. These findings
are compatible with gastritis.
Duodenum: Normal duodenum.
Impression: Abnormal mucosa in the esophagus
Erythema in the whole stomach compatible with gastritis
Otherwise normal EGD to third part of the duodenum
Recommendations: Would check H. Pylori serologies and treat if
positive.
Continue PPI [**Hospital1 **].

[**2146-9-1**] 09:29PM   WBC-15.8* RBC-3.92* HGB-12.4* HCT-37.2*
MCV-95 MCH-31.7 MCHC-33.4 RDW-15.7*
[**2146-9-1**] 09:29PM   PLT COUNT-228
[**2146-9-1**] 09:29PM   PT-21.3* PTT-35.7* INR(PT)-2.0*
[**2146-9-1**] 04:54PM   HCT-33.0*
[**2146-9-1**] 04:54PM   PT-21.8* PTT-37.3* INR(PT)-2.0*
[**2146-9-1**] 11:19AM   PLT COUNT-238
[**2146-9-1**] 11:19AM   PT-24.6* PTT-39.4* INR(PT)-2.4*
[**2146-9-1**] 06:17AM   TYPE-ART PO2-105 PCO2-37 PH-7.41 TOTAL CO2-24
BASE XS-0
[**2146-9-1**] 05:25AM URINE  COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.047*
[**2146-9-1**] 05:25AM URINE  RBC->50 WBC-[**3-25**] BACTERIA-MOD YEAST-NONE
EPI-0
[**2146-9-1**] 05:24AM   DIGOXIN-0.8*
[**2146-9-1**] 02:49AM   TYPE-ART PO2-112* PCO2-53* PH-7.37 TOTAL
CO2-32* BASE XS-4
[**2146-9-1**] 02:31AM   GLUCOSE-137* UREA N-23* CREAT-1.0 SODIUM-135
POTASSIUM-5.3* CHLORIDE-102 TOTAL CO2-26 ANION GAP-12
[**2146-9-1**] 02:31AM   CALCIUM-8.8 PHOSPHATE-4.1 MAGNESIUM-2.0
[**2146-9-1**] 02:31AM   WBC-21.2*# RBC-4.68 HGB-14.6 HCT-44.7 MCV-96
MCH-31.3 MCHC-32.7 RDW-15.6*
[**2146-9-1**] 02:31AM   PLT COUNT-226
[**2146-9-1**] 02:31AM   PT-26.6* PTT-40.8* INR(PT)-2.6*
[**2146-9-1**] 12:13AM   UREA N-24* CREAT-1.0
[**2146-9-1**] 12:13AM   estGFR-Using this
[**2146-9-1**] 12:13AM   LIPASE-71*
[**2146-9-1**] 12:13AM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2146-9-1**] 12:13AM   WBC-11.3* RBC-5.38 HGB-16.8 HCT-50.9 MCV-95
MCH-31.3 MCHC-33.1 RDW-16.0*
[**2146-9-1**] 12:13AM   PLT COUNT-216
[**2146-9-1**] 12:13AM   PT-30.4* PTT-35.9* INR(PT)-3.0*
[**2146-9-1**] 12:13AM   FIBRINOGE-550*

Brief Hospital Course:
Hospital Course: He has remained in the SICU and was co-managed
by ENT for the past week. ENT has performed upper airway
endoscopy and found no obvious upper airway source of bleeding
and deemed that his supraglottic edema has resolved on [**9-6**] neck
CT compared to OSH CT. All oropharyngeal packing removed on
[**9-5**]. Sputum cultures noted to have M. cattarhalis. He was
initially treated with Vancomycin/Unasyn but developed a rash on
his abdomen. He is currently being treated with Cipro/Flagyl
(Vancomycin d/c-ed) and has received 7 days of antibiotic
treatment to date. No signs of deep space neck infection on CT
scans. He has been weaned to trach collar and tolerated it for
12 hours prior to being put on PS 5/5 last night for tachycardia
and hypertension in the setting of agitation/delerium.  He has
been guiac positive for several days. His Hct has been stable
between 33 and 37 without requiring any blood transfusions.
Pacer interrogated by EP on [**9-6**], functioning well. He was
started on a heparin gtt yesterday by the SICU team for atrial
fibrillation. Dobhoff was placed yesterday, was not migrated
post-pyloric but TFs were started anyway. There is a note of
history of PE on ENT/surgery admission notes, but this is not
confirmed in his PCP [**Name Initial (PRE) 14453**] (PCP has been called for further
confirmation).
.
The morning of transfer, the patient was noted to have 700 ccs
of coffee ground emesis. When he vomited this morning, the
Dobhoff came out was replaced with TFs.  Overnight he was also
noted to be slightly hypertensive and tachycardic and was
transferred back from trach collar to pressure support. His
stools were guiac positive.  NG was placed, and lavage performed
demonstrated 240 ccs of bilious fluid with specks of brown, no
pink tinge or blood noted. GI was consulted and plan to perform
an upper endoscopy today. He was slightly hypotensive to SBPs of
90s, but was urinating and mentating well. Responded well to 500
cc NS bolus x1. He was transferred to the MICU for management of
possible upper GI bleed.

MICU stay:
68 yo M with AF on coumadin p/w respiratory distress, found to
have supraglottic edema currently s/p tracheostomy. Transferred
to MICU service with question of upper GI bleed.
.
# GI Bleed: Patient transferred to MICU service for evaluation
of possible upper GI bleed given history of hemetemesis on
admission, anticoagulation with heparin gtt, and coffee ground
emesis. NG lavage without frank blood or pink tinge. Possible
patient had upper GI bleed in setting of recent Dobhoff
placement (not passed post-pyloric, but was receiving TFs) and
recent heparin gtt being restarted vs old blood passing from
recent upper airway bleeding. Also with hx of EtOH abuse in the
past. Colonoscopy in [**2146**] with history of polyps/adenomas per
PCP [**Name Initial (PRE) 14453**]. Endoscopy performed by GI confirms gastritis but
with no active bleeding or varices noted.
Throughout MICU stay, HCT has been stable without the need for
transfusions. Pt has PICC for access. H. pylori was negative. On
[**9-11**] pt did have a leak from his trach and had a bronchoscopy
done. His trach was pushed in about 1 cm and the leak resolve.


# Pseudomonas bacteremia: Patient with rising temperature on
transfer to 100. Also with increased secretions around trach.
Treated for 7 days with Cipro/Flagyl.  Cultures grew Pseudomonas
from sputum, catheter tip, and blood, sensitive to cefepime.
Rash to unasyn, on cefepime .  Cefepime day [**6-3**].

# Hematuria on [**9-14**]: Likely traumatic. Resolving.

# Supraglottic edema/ Respiratory distress: Could have occurred
in setting of upper airway infection (possibly M. cattarhalis
PNA, common in patients with COPD). Other etiologies include a
viral illness given evidence of abdominal and cervical LAD on
imaging. No evidence of abscesses noted. He has received 7 days
of antibiotics.  Supraglottic edema appears resolved on [**9-6**] .CT
scan and all oropharyngeal packing has been removed. Pt is on
sildenafil for pulmonary htn. On [**9-14**] his trach was downsized.
He tolerated this well.

# MCAT in sputum: Received 7 days of abx with Vanc/Cipro/Flagyl.


# Delirium: Patient noted to be agitated at night while on trach
collar alone requiring placement back on PS overnight initially.
[**Month (only) 116**] be in setting of prolonged hospitalization vs underlying
infection. Patient appears alert and oriented today,
communicating with team. Restraints are off. Pt did pull out his
dobhoff 2-3 times, but not in the last few days. 2 mg of Haldol
and ativan prn was used for his agitation. This regimen has
worked well.

# Atrial fibrillation/wide complex: CHADS2 score is 1 (at
minimum). coumadin held for now.  Evaluate need for
anti-coagulation with Coumadin given CHADS2 score.
Increased metoprolol to 50 mg tid.

# COPD: Unknown severity but with emphysema on CT scan. MCAT
growing in sputum which is common organism found in PNA patients
also with underlying COPD. Received 7 days of Vancomycin/
Ciprofloxacin/ Flagyl. continue home inhalers.

# PVD: history of on ASA/plavix at home. h/o aortobifemoral
bypass.  Holding all anticoagulation now in setting of possible
bleed. Restarted ASA 81 mg

# Abdominal/Cervical LAD: sub-pathologic LAD noted in cervical
area and also around celiac trunk. Likely infectious given
patient's recent supraglottic edema. Other etiology includes
neoplasm.  f/u CT scanning is needed in [**4-26**] weeks.

# Wedge fractures - Noted in lumbar region on CT scan. Likely in
setting of previous prednisone use from COPD. has hx of colon
adenomas, but no known history of lung, thyroid, renal, or
prostate cancer which can metastazize to bone -> pathologic
fracture. Neurologic exam intact in lower extremities.  calcium
500 mg PO TID, vitamin D 1000 U daily. vitamin D levels need to
bechecked as outpatient.

# HTN: metoprolol to 50 mg tid

#Right arm [**Date Range **]: U/S with no evidence of DVT


Medications on Admission:
Imdur 30 mg PO daily
Plavix 75 mg PO daily
Simvastatin 80 mg PO daily
Advair 250/50 1 puff [**Hospital1 **]
Viagra 50 mg PO daily (except Thursday)
Digoxin 0.125 mcg PO daily
Coumadin 7.5 mg PO daily
Lopressor 50 mg PO BID
ASA 325 mg PO daily
Albuterol 90 mcg INH 2 buffs [**Hospital1 **]
Florinef 1 mg PO daily
Famotidine 20 mg PO daily
KCL 20 mEq PO BID
Folic Acid 1 mg PO daily
Vitamin B12- 100 mc PO daily

Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO BID (2 times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Sildenafil 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q4H (every 4 hours) as
needed for wheezing, sob.
10. Haloperidol 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
12. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
13. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
14. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours).
15. Lorazepam 2 mg/mL Syringe Sig: One (1)  Injection Q6H (every
6 hours) as needed for agitation.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]

Discharge Diagnosis:
Supraglottic Edema
Hypoxic Respiratory Distress
Upper Gastrointenstinal Bleed
Pseudomonas Bacteremia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
You were admitted with [**Location (un) **] in your throat that was
compromising your breathing. You had an emergent breathing tube
placed in your neck known as a tracheostomy, placed by Ear,
Nose, and Throat Doctors. [**First Name (Titles) **] [**Last Name (Titles) **] improved and you have
been weaned from the ventilator. You also had a possible GI
bleed and had an endoscopy by our GI doctors which did not show
any active bleeding or need for intervention.

Please start the following medications:

Please stop the following medications:

Followup Instructions:
Please follow up with Dr. [**First Name4 (NamePattern1) 10827**] [**Last Name (NamePattern1) **] on Thursday [**2146-8-29**] at 10:30 am. Please bring your insurance card and a photo
ID. Phone Number -- ([**Telephone/Fax (1) 7767**] Office Location: [**Location (un) **], [**Location (un) 55**], [**Numeric Identifier **] Division:



Completed by:[**2146-9-20**]
{'Acute and chronic respiratory failure,Acute epiglottitis with obstruction,Bronchopneumonia, organism unspecified,Hematemesis,Bacteremia,Delirium due to conditions classified elsewhere,Pathologic fracture of vertebrae,Chronic pulmonary embolism,Hyposmolality and/or hyponatremia,Atrial fibrillation,Acute gastritis, without mention of hemorrhage,Alcoholic cirrhosis of liver,Hematuria, unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Alcohol abuse, in remission,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Chronic airway obstruction, not elsewhere classified,Adrenal cortical steroids causing adverse effects in therapeutic use,Epistaxis,Dermatitis due to drugs and medicines taken internally,Unspecified drug or medicinal substance causing adverse effects in therapeutic use,Hypotension, unspecified,Other specified disorders of esophagus,Other diseases of trachea and bronchus'}


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: supraglottitis

PRESENT ILLNESS: patient is a 64 yo M with atrial fibrillation on coumadin, [**Hospital 2182**]
transferred from an OSH with respiratory distress due to
supraglottic edema. He initially presented to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
because he was 'spitting up blood' after eating a [**Location (un) 6002**] at
his rehab. He was found to have supraglottic edema both on exam
and in CT scan. He was transferred to [**Hospital1 18**] for airway
management. Surgery was called for respiratory distress in the
ED and performed an emergent crichothyroidotomy in the OR. ENT
was consulted and changed the crich to a tracheostomy. Admission
labs pertinent for Hct of 50 (down to 33 on transfer) and INR of
3.0 reversed with 6 [**Location 16678**] and 10 mg vitamin K (given at OSH)
down to 1.6.

MEDICAL HISTORY: - Atrial Fibrillation (on coumadin)
- s/p Pacer ([**Company 1543**] DDD)
- COPD
- Hypertension
- PVD s/p Aortobifemoral bypass
- Hyperlipidemia
- Chronic liver disease [**2-22**] EtOH (sober since [**2-/2146**])
- Anemia: h/o maroon stools
  colonoscopy in [**2146**] with hemorrhoids, colon polyps, adenoma
- h/o epistaxis
.

MEDICATION ON ADMISSION: Imdur 30 mg PO daily
Plavix 75 mg PO daily
Simvastatin 80 mg PO daily
Advair 250/50 1 puff [**Hospital1 **]
Viagra 50 mg PO daily (except Thursday)
Digoxin 0.125 mcg PO daily
Coumadin 7.5 mg PO daily
Lopressor 50 mg PO BID
ASA 325 mg PO daily
Albuterol 90 mcg INH 2 buffs [**Hospital1 **]
Florinef 1 mg PO daily
Famotidine 20 mg PO daily
KCL 20 mEq PO BID
Folic Acid 1 mg PO daily
Vitamin B12- 100 mc PO daily

ALLERGIES: Quetiapine

PHYSICAL EXAM: Vitals: 99 132/54 (90 non-invasive) 20 100% on trach collar.
General: elderly M with trach Alert NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs:  slight expiratory wheeze with otherwise clear breath
sounds
CV: distant HS, tachycardic, irregular, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: soft, TTP in LUQ and LLQ, non-distended, bowel sounds
present, no rebound tenderness or guarding; bruises noted over
bilateral lower quadrants. no abdominal rash noted.
GU: no foley
Ext: limbs cool to touch BL with 1+ DPs, PTs bilaterally; hair
loss. Moving all lower and upper extremities to command.

FAMILY HISTORY: Family History:  father and mother both died of CAD

SOCIAL HISTORY: Social History:
- unemployed. Has a scooter at home. Short term rehab resident
at [**Hospital 70637**] Healthcare in [**Location (un) 32944**].  [**Hospital 1094**] health care proxy is
his friend [**Name (NI) 892**] [**Name (NI) 16471**],
(c) [**Telephone/Fax (1) 106834**], (h) [**Telephone/Fax (1) 106835**].
- Tobacco:  +1.5 ppd, no plans for quitting
- Alcohol:  per records, hx of heavy EtOH use but was abstaining
from EtOH since [**2146-6-10**].
- Illicits:  none 

### Response:
{'Acute and chronic respiratory failure,Acute epiglottitis with obstruction,Bronchopneumonia, organism unspecified,Hematemesis,Bacteremia,Delirium due to conditions classified elsewhere,Pathologic fracture of vertebrae,Chronic pulmonary embolism,Hyposmolality and/or hyponatremia,Atrial fibrillation,Acute gastritis, without mention of hemorrhage,Alcoholic cirrhosis of liver,Hematuria, unspecified,Pseudomonas infection in conditions classified elsewhere and of unspecified site,Alcohol abuse, in remission,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Chronic airway obstruction, not elsewhere classified,Adrenal cortical steroids causing adverse effects in therapeutic use,Epistaxis,Dermatitis due to drugs and medicines taken internally,Unspecified drug or medicinal substance causing adverse effects in therapeutic use,Hypotension, unspecified,Other specified disorders of esophagus,Other diseases of trachea and bronchus'}
