CHIEF COMPLAINT: bleeding from tracheostomy

PRESENT ILLNESS: Mr [**Known lastname 3708**] is a 65 year old man with ALS since [**2129**] who has been at
[**Hospital1 **] after a complex medical stay at [**Hospital1 2025**] which resulted in
him being trached; prior to that he had been a long-time BiPAP
user. At [**Hospital1 **] he had been having some leaks around his trach
so doctors attempted to change out the trach tube for a larger
bore size. However he then had copious bleeding as well as some
shortness of breath.
.
When he came to the [**Hospital1 18**] he was seen by ENT who did a
fiberoptic exam and removed a large clot from inside the trach
tube. His prior feeling of difficulty breathing resolved with
this. They saw no evidence of tracheoinnominate fistula or large
bleed and the bleeding resolved. When he arrived on the floor of
the MICU he was once again having some fresh bleeding but this
resolved after suction and no further intervention.

MEDICAL HISTORY: ALS diagnosed in [**2129**]; stopped working in [**2130**]; had been power
wheelchair user in past but very difficult now due to almost no
hand strength
Hypercholesterolemia

MEDICATION ON ADMISSION: Ascorbic acid 1000 mg PO BID
Bacitracin ointment topical q shift
Coenzyme Q10, 30 mg PO BID
Dalteparin 5000 units sq daily
Miracle cream topical q shift
MVI daily
Prilosec 20 mg PO daily
Miralax daily
KCl 20 Meq daily
Seroquel 25 mg q8 hours
Rilutex 50 mg [**Hospital1 **]
Scopolamine patch 1.5 mg TD q72 hours
Vitamin E 100 Iu [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tmax: 35.8 ??????C (96.5 ??????F)
Tcurrent: 35.8 ??????C (96.5 ??????F)
HR: 69 (69 - 91) bpm
BP: 114/68(79) {114/68(79) - 147/81(99)} mmHg
RR: 14 (14 - 20) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)

FAMILY HISTORY: NC

SOCIAL HISTORY: Occupation: retired economic consultant
Drugs: denies
Tobacco: denies
Alcohol: denies
Other tracheostomy complications,Amyotrophic lateral sclerosis,Pulmonary collapse,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Hypotension, unspecified,Pure hypercholesterolemia,Anxiety state, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Paralysis, unspecified
Tracheostomy comp NEC,Amyotrophic sclerosis,Pulmonary collapse,Abn react-procedure NEC,Hypotension NOS,Pure hypercholesterolem,Anxiety state NOS,Chr blood loss anemia,Meth resis Staph carrier,Paralysis NOS
Admission Date:  [**2135-12-9**]              Discharge Date:   [**2135-12-13**]

Date of Birth:  [**2070-2-28**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
bleeding from tracheostomy

Major Surgical or Invasive Procedure:
ENT cautery with silver nitrate of trach site
Trach down-sized from size 8 to size 7

History of Present Illness:
Mr [**Known lastname 3708**] is a 65 year old man with ALS since [**2129**] who has been at
[**Hospital1 **] after a complex medical stay at [**Hospital1 2025**] which resulted in
him being trached; prior to that he had been a long-time BiPAP
user. At [**Hospital1 **] he had been having some leaks around his trach
so doctors attempted to change out the trach tube for a larger
bore size. However he then had copious bleeding as well as some
shortness of breath.
.
When he came to the [**Hospital1 18**] he was seen by ENT who did a
fiberoptic exam and removed a large clot from inside the trach
tube. His prior feeling of difficulty breathing resolved with
this. They saw no evidence of tracheoinnominate fistula or large
bleed and the bleeding resolved. When he arrived on the floor of
the MICU he was once again having some fresh bleeding but this
resolved after suction and no further intervention.


Past Medical History:
ALS diagnosed in [**2129**]; stopped working in [**2130**]; had been power
wheelchair user in past but very difficult now due to almost no
hand strength
Hypercholesterolemia


Social History:
Occupation: retired economic consultant
Drugs: denies
Tobacco: denies
Alcohol: denies


Family History:
NC

Physical Exam:
Tmax: 35.8 ??????C (96.5 ??????F)
Tcurrent: 35.8 ??????C (96.5 ??????F)
HR: 69 (69 - 91) bpm
BP: 114/68(79) {114/68(79) - 147/81(99)} mmHg
RR: 14 (14 - 20) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)

Respiratory
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CMV/ASSIST/AutoFlow
Vt (Set): 400 (400 - 400) mL
RR (Set): 14
RR (Spontaneous): 7
PEEP: 5 cmH2O
FiO2: 50%
PIP: 18 cmH2O
Plateau: 16 cmH2O
Compliance: 36.4 cmH2O/mL
SpO2: 99%
Ve: 6.1 L/min

Physical Examination
General Appearance: Thin
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Trach tube; fresh blood visualized
through OP without any source of bleeding visualized
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Musculoskeletal: Muscle wasting, Unable to stand
Skin: Warm, No(t) Rash:
Neurologic: Attentive, Responds to: Not assessed, Movement: Not
assessed, Paralyzed, Tone: Decreased


Pertinent Results:
ON ADMISSION:
[**2135-12-8**] 10:00PM BLOOD WBC-10.2 RBC-3.64* Hgb-11.4* Hct-33.3*
MCV-91 MCH-31.2 MCHC-34.2 RDW-15.5 Plt Ct-271
[**2135-12-8**] 10:00PM BLOOD Neuts-84.3* Lymphs-8.4* Monos-5.4 Eos-1.7
Baso-0.2
[**2135-12-8**] 10:00PM BLOOD PT-14.4* PTT-29.8 INR(PT)-1.3*
[**2135-12-10**] 04:29AM BLOOD Glucose-81 UreaN-19 Creat-0.1* Na-141
K-3.7 Cl-103 HCO3-29 AnGap-13
[**2135-12-10**] 04:29AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.0
[**2135-12-11**] 04:33AM BLOOD Hapto-162
.
HEMATOCRIT TREND
[**2135-12-13**] 04:42AM BLOOD Hct-26.8*
[**2135-12-12**] 05:04PM BLOOD Hct-29.7*
[**2135-12-12**] 05:30AM BLOOD Hct-27.4*
[**2135-12-12**] 01:07AM BLOOD Hct-28.7*
[**2135-12-11**] 08:46PM BLOOD Hct-29.5*
[**2135-12-11**] 04:33AM BLOOD Hct-23.8*
[**2135-12-11**] 12:14AM BLOOD Hct-25.9*
[**2135-12-10**] 06:43PM BLOOD Hct-25.3*
[**2135-12-10**] 06:43PM BLOOD Hct-25.3*
[**2135-12-10**] 04:29AM BLOOD Hct-29.8*
[**2135-12-9**] 09:54PM BLOOD Hct-30.2*
[**2135-12-9**] 12:30PM BLOOD Hct-31.5*
[**2135-12-9**] 05:01AM BLOOD Hct-31.0*
[**2135-12-8**] 10:00PM BLOOD Hct-33.3*
.
STUDIES: CXRS
[**12-8**]: No evidence of pneumothorax, CHF, or pneumonia. Left-sided

pleural effusion and retrocardiac opacity likely represent left
lower lobe
collapse.
[**12-10**] Bleeding at trach site. Pigtail catheter is again seen
overlying
the left abdomen. Tracheostomy tube has been replaced with a new
tube. PICC line tip is in the SVC. There is improved aeration in
the left lower lobe.
[**12-11**]: New left upper lobe collapse, and mild atelectasis at the
left base recurred. Right lung clear. Heart size normal.
Drainage catheter projects over the left upper paramedian
[**12-12**]: There is resolution of the left upper lobe atelectasis but
worsening of the left lower lobe atelectasis with still present
left mediastinal shift. Small amount of pleural effusion is seen
on the left. The drainage catheter in the left upper abdomen is
unchanged in position.
The left PICC line tip is in mid SVC. No pneumothorax or overall
increase in pleural effusion is demonstrated.
[**12-13**]: The lateral aspect of the left hemithorax has been
excluded from
the image. The right lung remains clear. Left hemidiaphragm is
not well seen and there is some haziness on this side, raising
the possibility of layering effusion. Poor definition of the
medial aspect of the hemidiaphragm is consistent with volume
loss in the left lower lobe. Tracheostomy tube remains in good
position. Right PICC line extends to the
mid portion of the SVC
.
ON TRANSFER TO REHAB:
[**2135-12-13**] 04:42AM BLOOD WBC-9.1 RBC-3.01* Hgb-9.4* Hct-26.8*
MCV-89 MCH-31.4 MCHC-35.2* RDW-15.6* Plt Ct-207
[**2135-12-12**] 05:30AM BLOOD PT-14.8* PTT-30.6 INR(PT)-1.3*
[**2135-12-13**] 04:42AM BLOOD Glucose-91 UreaN-17 Creat-0.1* Na-143
K-3.6 Cl-109* HCO3-28 AnGap-10
.
URINE:
[**2135-12-11**] 03:16PM URINE Color-DkAmb Appear-Cloudy Sp [**Last Name (un) **]-1.025
[**2135-12-11**] 03:16PM URINE Blood-LG Nitrite-POS Protein->300
Glucose-NEG Ketone-TR Bilirub-MOD Urobiln-2* pH-5.5 Leuks-SM
[**2135-12-11**] 03:16PM URINE RBC->1000* WBC-707* Bacteri-MANY
Yeast-NONE Epi-0
[**2135-12-11**] 03:16PM URINE CaOxalX-OCC
[**2135-12-11**] 03:16PM URINE WBC Clm-FEW Mucous-MANY
.
Urine CX pending
Blood CX pending
[**2135-12-10**] 8:21 am SPUTUM      Source: Endotracheal.
.
   GRAM STAIN (Final [**2135-12-10**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE ROD(S).
      2+   (1-5 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN PAIRS AND CLUSTERS.
      1+    (<1 per 1000X FIELD):   GRAM POSITIVE COCCI.
                                    IN CHAINS.

   RESPIRATORY CULTURE (Preliminary):
      SPARSE GROWTH OROPHARYNGEAL FLORA.
      STAPH AUREUS COAG +.    SPARSE GROWTH.

   LEGIONELLA CULTURE (Preliminary):    NO LEGIONELLA ISOLATED.

   FUNGAL CULTURE (Preliminary):    NO FUNGUS ISOLATED.


Brief Hospital Course:
BLEEDING IN THROAT/UPPER AIRWAY
Mr [**Known lastname 3708**] had distressing bleeding which was evidently from his
trach site and most likely associated with the attempt to resize
the tracheostomy tube. ENT service saw him on arrival, did
several fiberoptic exams, and followed him while here. They used
repeated applications of silver nitrate to stop bleeding around
the site and could identify no larger site of bleeding or
fistula. A bronchoscopy in the MICU did not show any bleeding in
the lung. His tracheostomy tube was sized down to Portex 7; he
had come in with a size 8 tube which was up from his prior 7. He
had some minor intermittent leaking around this site which did
not appear to compromise his tidal volumes. His tube should be
re-evaluated in follow-up with the ENT service, and follow-up
information is shown below.
.
ALS
Mr [**Known lastname 3708**] did complain of some air hunger during his visit and
appeared to especially appreciate being ambu-bagged. Based on
this we increased his tidal volumes to 500 and this could be
increased further for comfort since there is no sign of lung
injury. We continued Rilutek and Coenzyme Q10.
.
ANXIETY
Takes seroquel at home which he and his wife agree helps him
stay calm and breathe better. We continued this.
.
MRSA
At the end of his stay, a sputum came back positive for MRSA. He
does not have evidence of pneumonia but is likely
MRSA-colonized. He was sent back to a MRSA bed at rehab.
.
GOALS OF CARE
Patient appears to have not entirely intentionally ended up on
vent but did so originally with the hope of going back onto
BiPAP; he is OK with staying on the ventilator now but is firm
on his decision for a "do not resuscitate" status; this was
discussed and agreed-on with both the patient and his wife. [**Name (NI) 6419**]
the patient and his wife do appear to recognize the relentlessly
progressive nature of the disease.
 .
ICU CARE
NUTRITION
Usually gets Jevity 1.2 tube feeds with boluses at 0600, 0900,
1200, 1500, 1800 and 2100. Got [**Hospital1 18**] equivalent.
Glycemic Control: no issues
Lines:
-Midline - [**2135-12-9**] 04:22 AM
-18 Gauge - [**2135-12-9**] 04:24 AM
Prophylaxis:
DVT: Boots
Stress ulcer: PPI
.
Disposition: Return to [**Hospital **] Rehab


Medications on Admission:
Ascorbic acid 1000 mg PO BID
Bacitracin ointment topical q shift
Coenzyme Q10, 30 mg PO BID
Dalteparin 5000 units sq daily
Miracle cream topical q shift
MVI daily
Prilosec 20 mg PO daily
Miralax daily
KCl 20 Meq daily
Seroquel 25 mg q8 hours
Rilutex 50 mg [**Hospital1 **]
Scopolamine patch 1.5 mg TD q72 hours
Vitamin E 100 Iu [**Hospital1 **]

PRN
acetaminophen
albuterol inhaler
dulcolax
docusate
lidocaine jelly
epinephrine (for bronchospasm)
lactulose 20 gm daily prn
simethicone 80 mg tablet prn

Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Ascorbic Acid 90 mg/mL Drops [**Hospital1 **]: 1008 (1008) mg PO BID (2
times a day).
4. Bacitracin Zinc 500 unit/g Ointment [**Hospital1 **]: One (1) Appl Topical
TID (3 times a day).
5. Polyethylene Glycol 3350 100 % Powder [**Hospital1 **]: Seventeen (17) gm
gm PO DAILY (Daily) as needed.
6. Quetiapine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H (every 8
hours).
7. Riluzole 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO daily ().
8. Scopolamine Base 1.5 mg Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
9. Therapeutic Multivitamin     Liquid [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Albuterol 90 mcg/Actuation Aerosol [**Last Name (STitle) **]: 6-10 Puffs
Inhalation Q4H (every 4 hours) as needed for shortness of breath
or wheezing.
12. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.

[**Month (only) 116**] resume prior meds for symptom control/bowel regimen etc as
appropriate.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary:
Bleeding from tracheostomy site

Secondary:
ALS
Anxiety


Discharge Condition:
Afebrile, vital signs stable


Discharge Instructions:
Follow up with ENT for ongoing trach care and consideration of
new trach tube.

Followup Instructions:
Follow-up with Otorhinolaryngology - Dr. [**First Name (STitle) **] [**2135-12-27**] 9:45am.
Please arrive 15-20 minutes prior.  The office is located at
[**Street Address(2) 28470**]., [**Location (un) 55**].
{'Other tracheostomy complications,Amyotrophic lateral sclerosis,Pulmonary collapse,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Hypotension, unspecified,Pure hypercholesterolemia,Anxiety state, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Paralysis, 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: bleeding from tracheostomy

PRESENT ILLNESS: Mr [**Known lastname 3708**] is a 65 year old man with ALS since [**2129**] who has been at
[**Hospital1 **] after a complex medical stay at [**Hospital1 2025**] which resulted in
him being trached; prior to that he had been a long-time BiPAP
user. At [**Hospital1 **] he had been having some leaks around his trach
so doctors attempted to change out the trach tube for a larger
bore size. However he then had copious bleeding as well as some
shortness of breath.
.
When he came to the [**Hospital1 18**] he was seen by ENT who did a
fiberoptic exam and removed a large clot from inside the trach
tube. His prior feeling of difficulty breathing resolved with
this. They saw no evidence of tracheoinnominate fistula or large
bleed and the bleeding resolved. When he arrived on the floor of
the MICU he was once again having some fresh bleeding but this
resolved after suction and no further intervention.

MEDICAL HISTORY: ALS diagnosed in [**2129**]; stopped working in [**2130**]; had been power
wheelchair user in past but very difficult now due to almost no
hand strength
Hypercholesterolemia

MEDICATION ON ADMISSION: Ascorbic acid 1000 mg PO BID
Bacitracin ointment topical q shift
Coenzyme Q10, 30 mg PO BID
Dalteparin 5000 units sq daily
Miracle cream topical q shift
MVI daily
Prilosec 20 mg PO daily
Miralax daily
KCl 20 Meq daily
Seroquel 25 mg q8 hours
Rilutex 50 mg [**Hospital1 **]
Scopolamine patch 1.5 mg TD q72 hours
Vitamin E 100 Iu [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Tmax: 35.8 ??????C (96.5 ??????F)
Tcurrent: 35.8 ??????C (96.5 ??????F)
HR: 69 (69 - 91) bpm
BP: 114/68(79) {114/68(79) - 147/81(99)} mmHg
RR: 14 (14 - 20) insp/min
SpO2: 99%
Heart rhythm: SR (Sinus Rhythm)

FAMILY HISTORY: NC

SOCIAL HISTORY: Occupation: retired economic consultant
Drugs: denies
Tobacco: denies
Alcohol: denies 

### Response:
{'Other tracheostomy complications,Amyotrophic lateral sclerosis,Pulmonary collapse,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Hypotension, unspecified,Pure hypercholesterolemia,Anxiety state, unspecified,Iron deficiency anemia secondary to blood loss (chronic),Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus,Paralysis, unspecified'}
