CHIEF COMPLAINT: blood from trach

PRESENT ILLNESS: HPI: Ms. [**Known lastname **] is an 89 yo female with PMH notable for
Alzheimer's disease, depression, paroxysmal afib on coumadin and
recent admission to [**Hospital1 18**] MICU for MRSA pneumonia, Proteus
urosepsis and stenotrophomonas VAP who presents from her rehab
facility with bright red blood from her trach. On [**12-3**] at 1400,
the patient was noted to have blood-tinged secretions. At that
time, labs were obtained and heparin was held. Lasix was also
increased to 40 mg IV BID. At 1500, nurse [**First Name (Titles) 12883**] [**Last Name (Titles) **] blood from
trach. INR noted to be 5.4 with Hct 29.1. Later in the evening
(2300), her nurse [**First Name (Titles) 8706**] [**Last Name (Titles) 17577**] [**Last Name (Titles) **] hemoptysis with hct down
to 23.8; vent settings at that time AC 12X350, peep 5, fio2 40%
with oxygen saturation 93%. CXR showed worsening bilateral
infiltrates by report; she had a CT scan of the chest which
showed At midnight, she was seen by the ICU resident that she
had been treated with 2 U FFP and 5 mg vitamin K. ABG at that
time demonstrated pH 7.46 / pCO2 59 / pO2 77. Due to [**Last Name (Titles) 17577**]
hemoptysis, the patient was transferred back to the [**Hospital1 18**] ICU
for further evaluation and treatment.
.
On arrival to the CCU, the patient has [**Hospital1 **] blood secretions
from her ET tube. She opens eyes to voice and actively opposes
eye opening but otherwise is nonverbal at present.

MEDICAL HISTORY: Alzheimer's
Depression
Hypernatremia
Paroxymal Afib
h/o Urinary tract infections
Cholelithiasis
h/o Influenza A/b

MEDICATION ON ADMISSION: Meds:
coumadin 5 mg daily
bactrim 250 mg IV q8h (until [**12-7**])
lasix 40 mg IV Qam, 20 mg IV qnoon, 40 mg IV qpm
dulcolax 10 mg po daily
miralax 17 g daily
chlorhexidine mouth wash [**Hospital1 **]
colace 100 mg [**Hospital1 **]
ranitidine 150 mg daily
xopenex nebs q4h and q2h prn
atrovent nebs q4h & q2h prn
neutraphos 1 cap 4X/day X 3 days
K-phos 1 packet q6h X 3 days
vitamin K 5 mg PO X 1
aricept 10 mg daily
memantine 10 mg [**Hospital1 **]
vitamin E 800 U daily
hep sc tid
lactulose 15 ml po daily
ASA 325 mg po daily
miconazole powder [**Hospital1 **] prn
caltrate with vit D 600 U po bid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: vitals: T 98.9, HR 108, BP 171/88, RR 37, O2 100% on AC 12X400,
PEEP 5, FiO2 60%
gen: lying still with eyes closed, trach in place, no distress
heent: actively opposes eye opening, tongue slightly dry
neck: trach in place with mild bright red ooze surrounding
insertion site
pulm: coarse breath sounds bilaterally, expiratory wheeze R>L
cv: RRR, difficult to hear due to vent noise
abd: firm, no guarding or rebound, hypoactive bowel sounds, no
specific areas of palpation which elicit grimace, PEG tube in
place in LUQ with minimal surrounding erythema
extr: extremities warm, 3+ pitting edema to thighs, bruise on
right hand, R PICC in place
neuro: trached, opens eyes to sound occasionally, actively
opposes eye opening and does not follow other commands

FAMILY HISTORY: N/A

SOCIAL HISTORY: Permanent resident of [**Hospital3 **] Manor. Chinese speaking only,
Son and daughter active in her life and visit daily.
Unspecified septicemia,Acute and chronic respiratory failure,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Pneumonia due to escherichia coli [E. coli],Infection of gastrostomy,Cellulitis and abscess of trunk,Acute posthemorrhagic anemia,Other complications due to other vascular device, implant, and graft,Ventilator associated pneumonia,Severe sepsis,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Long-term (current) use of anticoagulants,Atrial fibrillation,Depressive disorder, not elsewhere classified,Tracheostomy status,Pressure ulcer, other site,Calculus of kidney
Septicemia NOS,Acute & chronc resp fail,Acute kidney failure NOS,Urin tract infection NOS,Hyperosmolality,Pneumonia e coli,Gastrostomy infection,Cellulitis of trunk,Ac posthemorrhag anemia,Comp-oth vasc dev/graft,Ventltr assoc pneumonia,Severe sepsis,Abnrml coagultion prfile,Adv eff anticoagulants,Alzheimer's disease,Dementia w/o behav dist,Long-term use anticoagul,Atrial fibrillation,Depressive disorder NEC,Tracheostomy status,Pressure ulcer, site NEC,Calculus of kidney
Admission Date:  [**2197-12-4**]              Discharge Date:   [**2197-12-14**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
blood from trach

Major Surgical or Invasive Procedure:
Bronchoscopy (bedside): small area of injury at main carina
without active bleeding.  Blood seen in all segments and cleared
fully.  Upon re-inspection return of blood seen and with BAL
progressive bloody return seen.


History of Present Illness:
HPI: Ms. [**Known lastname **] is an 89 yo female with PMH notable for
Alzheimer's disease, depression, paroxysmal afib on coumadin and
recent admission to [**Hospital1 18**] MICU for MRSA pneumonia, Proteus
urosepsis and stenotrophomonas VAP who presents from her rehab
facility with bright red blood from her trach. On [**12-3**] at 1400,
the patient was noted to have blood-tinged secretions. At that
time, labs were obtained and heparin was held. Lasix was also
increased to 40 mg IV BID. At 1500, nurse [**First Name (Titles) 12883**] [**Last Name (Titles) **] blood from
trach. INR noted to be 5.4 with Hct 29.1. Later in the evening
(2300), her nurse [**First Name (Titles) 8706**] [**Last Name (Titles) 17577**] [**Last Name (Titles) **] hemoptysis with hct down
to 23.8; vent settings at that time AC 12X350, peep 5, fio2 40%
with oxygen saturation 93%. CXR showed worsening bilateral
infiltrates by report; she had a CT scan of the chest which
showed At midnight, she was seen by the ICU resident that she
had been treated with 2 U FFP and 5 mg vitamin K. ABG at that
time demonstrated pH 7.46 / pCO2 59 / pO2 77. Due to [**Last Name (Titles) 17577**]
hemoptysis, the patient was transferred back to the [**Hospital1 18**] ICU
for further evaluation and treatment.
.
On arrival to the CCU, the patient has [**Hospital1 **] blood secretions
from her ET tube. She opens eyes to voice and actively opposes
eye opening but otherwise is nonverbal at present.

Past Medical History:
Alzheimer's
Depression
Hypernatremia
Paroxymal Afib
h/o Urinary tract infections
Cholelithiasis
h/o Influenza A/b


Social History:
Permanent resident of [**Hospital3 **] Manor. Chinese speaking only,
Son and daughter active in her life and visit daily.


Family History:
N/A

Physical Exam:
vitals: T 98.9, HR 108, BP 171/88, RR 37, O2 100% on AC 12X400,
PEEP 5, FiO2 60%
gen: lying still with eyes closed, trach in place, no distress
heent: actively opposes eye opening, tongue slightly dry
neck: trach in place with mild bright red ooze surrounding
insertion site
pulm: coarse breath sounds bilaterally, expiratory wheeze R>L
cv: RRR, difficult to hear due to vent noise
abd: firm, no guarding or rebound, hypoactive bowel sounds, no
specific areas of palpation which elicit grimace, PEG tube in
place in LUQ with minimal surrounding erythema
extr: extremities warm, 3+ pitting edema to thighs, bruise on
right hand, R PICC in place
neuro: trached, opens eyes to sound occasionally, actively
opposes eye opening and does not follow other commands


Pertinent Results:
[**2197-12-4**] 02:37AM BLOOD WBC-10.8# RBC-2.09* Hgb-7.2* Hct-20.9*
MCV-100* MCH-34.6* MCHC-34.6 RDW-18.2* Plt Ct-271
[**2197-12-4**] 03:54PM BLOOD Hct-25.4*
[**2197-12-5**] 04:00AM BLOOD WBC-8.9 RBC-2.49* Hgb-8.1* Hct-23.5*
MCV-94 MCH-32.3* MCHC-34.3 RDW-19.5* Plt Ct-228
[**2197-12-5**] 10:53AM BLOOD Hct-22.8*
[**2197-12-5**] 10:53AM BLOOD Hct-22.8*
[**2197-12-5**] 10:00PM BLOOD Hct-25.4*
[**2197-12-6**] 03:32AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.5* Hct-24.0*
MCV-91 MCH-32.0 MCHC-35.4* RDW-18.4* Plt Ct-207
[**2197-12-6**] 03:32AM BLOOD WBC-8.7 RBC-2.65* Hgb-8.5* Hct-24.0*
MCV-91 MCH-32.0 MCHC-35.4* RDW-18.4* Plt Ct-207
[**2197-12-7**] 03:34AM BLOOD WBC-13.5* RBC-2.80* Hgb-9.0* Hct-26.6*
MCV-95 MCH-32.0 MCHC-33.7 RDW-18.3* Plt Ct-280
[**2197-12-8**] 03:56AM BLOOD WBC-11.6* RBC-2.28* Hgb-7.5* Hct-21.6*
MCV-95 MCH-33.1* MCHC-35.0 RDW-18.1* Plt Ct-249
[**2197-12-8**] 05:23AM BLOOD Hct-20.7*
[**2197-12-8**] 03:19PM BLOOD WBC-11.0 RBC-2.83* Hgb-9.1* Hct-25.4*
MCV-90 MCH-32.0 MCHC-35.7* RDW-18.7* Plt Ct-198
[**2197-12-10**] 03:35AM BLOOD WBC-11.8* RBC-3.38* Hgb-10.5* Hct-30.4*
MCV-90 MCH-31.0 MCHC-34.5 RDW-17.4* Plt Ct-192
[**2197-12-4**] 02:37AM BLOOD Neuts-91.5* Lymphs-2.6* Monos-4.2 Eos-1.5
Baso-0.2
[**2197-12-4**] 02:37AM BLOOD PT-23.6* PTT-41.5* INR(PT)-2.3*
[**2197-12-4**] 03:54PM BLOOD PT-16.7* INR(PT)-1.5*
[**2197-12-5**] 04:00AM BLOOD PT-16.1* PTT-34.5 INR(PT)-1.4*
[**2197-12-6**] 03:32AM BLOOD PT-20.9* PTT-35.8* INR(PT)-2.0*
[**2197-12-7**] 03:34AM BLOOD PT-25.3* PTT-32.2 INR(PT)-2.5*
[**2197-12-8**] 03:56AM BLOOD PT-16.4* PTT-28.8 INR(PT)-1.5*
[**2197-12-9**] 03:54AM BLOOD PT-15.5* PTT-30.1 INR(PT)-1.4*
[**2197-12-10**] 03:35AM BLOOD PT-16.5* PTT-28.4 INR(PT)-1.5*
[**2197-12-8**] 05:23AM BLOOD Ret Aut-2.4
[**2197-12-4**] 02:37AM BLOOD Glucose-161* UreaN-32* Creat-1.4* Na-134
K-4.6 Cl-90* HCO3-40* AnGap-9
[**2197-12-5**] 04:00AM BLOOD Glucose-76 UreaN-34* Creat-1.4* Na-136
K-4.8 Cl-91* HCO3-39* AnGap-11
[**2197-12-7**] 03:34AM BLOOD Glucose-132* UreaN-38* Creat-1.9* Na-134
K-5.0 Cl-89* HCO3-42* AnGap-8
[**2197-12-8**] 03:56AM BLOOD Glucose-71 UreaN-43* Creat-2.0* Na-134
K-4.6 Cl-90* HCO3-38* AnGap-11
[**2197-12-10**] 03:35AM BLOOD Glucose-120* UreaN-44* Creat-1.8* Na-137
K-4.0 Cl-93* HCO3-38* AnGap-10
[**2197-12-10**] 06:55PM BLOOD Glucose-133* UreaN-44* Creat-1.7* Na-140
K-4.2 Cl-97 HCO3-40* AnGap-7*
[**2197-12-4**] 02:37AM BLOOD ALT-18 AST-25 LD(LDH)-209 AlkPhos-88
TotBili-0.2
[**2197-12-4**] 02:37AM BLOOD Lipase-54
[**2197-12-4**] 02:37AM BLOOD Albumin-2.6* Calcium-8.5 Phos-4.0# Mg-2.5
[**2197-12-8**] 03:56AM BLOOD Hapto-142
[**2197-12-4**] 03:54PM BLOOD ANCA-NEGATIVE B
[**2197-12-8**] 06:29PM BLOOD Vanco-15.0
[**2197-12-7**] 06:06PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.0 Leuks-MOD
[**2197-12-7**] 06:06PM URINE RBC-21-50* WBC-[**6-13**]* Bacteri-MOD
Yeast-NONE Epi-0-2 RenalEp-1
[**2197-12-7**] 06:06PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017
[**2197-12-7**] 06:06PM URINE CastHy-<1
[**2197-12-7**] 03:02PM URINE Eos-POSITIVE
[**2197-12-7**] 10:27AM URINE Hours-RANDOM UreaN-440 Creat-64 Na-18
Cl-LESS THAN  Uric Ac-23.9
[**2197-12-7**] 10:27AM URINE Osmolal-336
.
Micro data:
[**2197-12-4**] 3:56 am BRONCHIAL WASHINGS
                            **FINAL REPORT [**2197-12-6**]**
   GRAM STAIN (Final [**2197-12-4**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.
   RESPIRATORY CULTURE (Final [**2197-12-6**]):    ~[**2189**]/ML
OROPHARYNGEAL FLORA.
.
[**2197-12-5**] 9:57 pm CATHETER TIP-IV      Source: R arm PICC.
                            **FINAL REPORT [**2197-12-8**]**
   WOUND CULTURE (Final [**2197-12-8**]):    No significant growth.
.
[**2197-12-7**] 2:51 pm STOOL     CONSISTENCY: NOT APPLICABLE
      Source: Stool.
                            **FINAL REPORT [**2197-12-8**]**
   CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2197-12-8**]):
      Feces negative for C.difficile toxin A & B by EIA.
           (Reference Range-Negative).
.
Radiographic studies:
[**12-4**] CXR:
IMPRESSION:
1. Developing right upper lobe infiltrate.
2. Continued bilateral pleural effusions with bibasilar
atelectasis.
3. Findings concerning for mild congestive failure.
.
[**12-8**] CT:
IMPRESSION:
1. Migration of gastric tube into the rectus sheath. There is a
clear
connection, however, into the stomach and no evidence for free
air or free
fluid. Repositioning of tube is recommended.
2. No radiographic explanation for falling hematocrit.
3. Multiple incidental findings including right staghorn
calculus, porcelain gallbladder, anasarca, bilateral pleural
effusions with associated atelectasis, and severe
atherosclerotic disease.
.
[**12-9**] CXR:
Compared to the study from the prior day, there is increased
vascular
congestion and increased volume loss in both lower [**Known lastname **]s. An
underlying
infectious infiltrate cannot be excluded. Diffuse alveolar
opacities are
again seen.
.


Brief Hospital Course:
A/P: 89 yo with PMH of alzheimer's dementia, hypernatremia, UTI
presents with AMS, sepsis physiology, UTI, and impressive
hypernatremia.
.
# Blood from trach: Seems from clinical history provided by
rehab that patient's secretions initially were "blood tinged"
and progressed to frankly blood over the course of the day on
[**12-3**]. Her hematocrit in the same time period has decreased from
29-->23.8. Bronchoscopy on arrival to the ICU demonstrated
bloody secretions which did not clear but became progressively
bloodier making diffuse alveolar hemorrhage most likely
diagnosis. However, could also represent lesion near trach
insertion but this is less likely given bronch findings. Was
given 2U PRBC x1 at initial presentation. Held aspirin and
coumadin, reversed INR with FFP, Vitamin K PO, and then Vitamin
K IV for refractory elevated INR.  Once INR reversed trach
oozing stoped. ANCA negative, anti-GBM negative.
.
# Anemia: Hct drop x3 since admission. Transfused 3x with 2U of
blood. Initial drop explained by DAH. Hct did not bump
appropriately, found to have melena x1 and repeatedly giauac pos
stool. Melena explained by the PEG gastric wall erosion.
Hemolysis labs negative.  Enlarging hematoma in L arm, axilla,
and anterior chest, but likely source of  Hct drop.  CT showed
no intraperitoneal or retroperitoneal hemorrhage. Hct has been
stable as of [**12-10**].
.
# Respiratory failure: Initial decompensation likely due to
diffuse alveolar hemorrhage, although contribution of underlying
pneumonia, fluid overload, and baseline [**Known lastname **] disease (?) likely
contribute.  Of note, during prior admission patient was
unsuccessfully extubated twice and could not be weaned off the
vent after several attempts due to high RISBIs  and acidemia.
The patient continued to be ventilator dependent at her rehab
facility and has failed trach mask and low pressure support
ventilation during this admission b/c of very low tidal volumes
(down to 130??????s) which improved after pressure support was
increased from 10 to 20. Patient??????s air movement also did improve
after albuterol nebulizer treatment as per nursing staff.  Lasix
boluses initially attempted without much improvement in UOP and
stopped because of rising Cr.  Stenotrophomonis pneumonia
treatment course completed. 3+GNR in sputum stain, sputum
culture growing ceftriaxone-sensitive E.coli. Ecoli also
isolated for PEG site culture and Urine culture. Her antibiotic
regimen was adjusted. Lasix drip was again attempted later in
the hospital course with good response in urine output but not
significant improvement in respiratory status. Lasix converted
to IV 60mg TID. Cr and fluid status should continue to be
monitored.
.
# Acute renal failure: Likely related to volume depletion
secondary to blood loss and up titration of lasix at rehab and
in MICU as creatinine has trended up over the past week per
their records Higher bicarbonate level and FeUREA of 34% would
support volume depletion as well.  UA w/few eos, rare hyaline
casts reported.  Did have hematuria, but difficult to interpret
in setting of indwelling foley, elevated INR. On urine culture
grew ceftriaxone-sensitive E.coli and antibiotic regimen was
adjusted to cover. Last day of ceftriaxone treatment should be
[**2197-12-25**]. Could also represent component of systemic process if
DAH associated with Goodpasture's or Wegener's (however anti-GBM
negative). Staghorn R kidney stone noted on CT could be
contributing. Urine has been progressively more clear and her
urine output has improved on lasix drip. With improved urine
output, lasix drip was stopped and she was started on lasix PO
60mg tid.
.
#UTI: Ecoli with same sensitivity profile as the PEG swab
culture and sputum isolated in urine. Treatment with ceftriaxone
as above. VRE colonized in urine as well.
.
# PEG complications:  Erythema/ Pus around peg likely
combination of dermatitis/skin breakdown from pressure of PEG on
skin w/some cellulitic component. Initially improved after 3
days on vanco and after padded bandage placed between PEG and
skin but has worsened over last 48 hours with increasingly
purulent exudate around the tube. Patient also with erosion of
gastric wall around PEG site. Endoscopy by IP showed that peg
balloon still in stomach, was re-positioned to decrease pressure
on wall to better allow for healing. No free intraperitoneal air
was noted on CT. [**12-11**] repeat  EGD showed dobbhoff still post
pyloric. Erosion around peg greatly improved. PEG ballon in
place. No stiches needed. Cultures of discharge shown to be
E.coli, also sensitive to ceftriaxone. Vanco was continued to
treat cellulitis- last day [**12-14**] for 10 day course. As per IP
recommendations, PEG to low intermittent suction.  CT confirmed
PEG placement, dobhoff placement and r/o free air (final read
pending). Per IP PEG tip is 2cm from stomach wall and should not
be moved for 3 weeks. Tube feeds were restarted via PEG and
well-tolerated.
.
# Paroxysmal afib: The patient was recently started on coumadin
at the rehab facility with INR now > 5 on coumadin 5 mg daily.
CHADs-2 score by my calculation only 1 due to age-not clear that
patient has h/o hypertension or CHF and no documented h/o stroke
or DM. Aspirin and coumadin were held. She has not been on
anti-arrhythmic medications and maintained a good heart rate.
Futher anticoagulation should be avoided
.
# Abdominal distension: NTTP.  Has been intermittently present
since admission. Usually resolves with bowel movement.  LFTs and
lipase normal. CT w/PEG findings discussed above and porcelain
gallbladder, but no evidence of intraperitoneal bleed or other
intraabdominal process. Further work up of porcelian gallbladder
as outpatient as this is often associated with adenocarcinoma.
.
# Recent Stenotrophomonas VAP: Treated with Bactrim 250 mg IV
q8h, stop date 12/5 per prior d/c summary.
.
# Alzheimer's: cont home meds when using PEG tube. During
admission pt mouths words but will not follow commands. Pt
non-english speaking.
.
# PPx: PPI, heparin SQ& pneumoboots, bowel regimen prn
.
# FEN: TF via PEG.
.
# Code: DNR/DNI, confirmed with son [**Name (NI) **] [**Name (NI) **] who is HCP
.
# Access: Right-sided PICC (placed at [**Hospital1 18**] during previous
admission)
.
# Communication: With patient and son [**Name (NI) **] [**Known lastname 17578**]([**Telephone/Fax (1) 17579**]
cell
.
# Dispo: ICU level care given vent requirement

Medications on Admission:
Meds:
coumadin 5 mg daily
bactrim 250 mg IV q8h (until [**12-7**])
lasix 40 mg IV Qam, 20 mg IV qnoon, 40 mg IV qpm
dulcolax 10 mg po daily
miralax 17 g daily
chlorhexidine mouth wash [**Hospital1 **]
colace 100 mg [**Hospital1 **]
ranitidine 150 mg daily
xopenex nebs q4h and q2h prn
atrovent nebs q4h & q2h prn
neutraphos 1 cap 4X/day X 3 days
K-phos 1 packet q6h X 3 days
vitamin K 5 mg PO X 1
aricept 10 mg daily
memantine 10 mg [**Hospital1 **]
vitamin E 800 U daily
hep sc tid
lactulose 15 ml po daily
ASA 325 mg po daily
miconazole powder [**Hospital1 **] prn
caltrate with vit D 600 U po bid

Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: Six (6)
Puff Inhalation Q6H (every 6 hours).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2)  PO BID (2
times a day) as needed.
6. Polyethylene Glycol 3350 100 % Powder [**Hospital1 **]: Seventeen (17) g
PO DAILY (Daily) as needed.
7. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed for wheezing.
8. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H
(every 8 hours) as needed.
9. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
10. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) 5000
unit dose Injection TID (3 times a day).
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Metoclopramide 5 mg IV Q6H:PRN
13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
14. CeftriaXONE 1 g IV Q24H
day 1 [**12-12**]
15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
16. Furosemide 60 mg IV Q8H
17. Insulin Lispro 100 unit/mL Solution [**Month/Day (4) **]: 2-10 units
Subcutaneous ASDIR (AS DIRECTED): per humalog isulin sliding
scale.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]

Discharge Diagnosis:
diffuse aveolar hemmorrhage
acute on chronic respiratory failure
Acute renal failure
Gastric erosion secondary to PEG tube
Ecoli Pneumonia
Ecoli UTI
Abdominal cellulitis
End stage dementia
Anemia

paroxysmal Atrial fibrillation


Discharge Condition:
stable, Vent dependent.


Discharge Instructions:
You were admitted to the hospital for bleeding from your
tracheotomy tube. You were found to have diffuse [**Known lastname **] injury
termed diffuse aveolar hemmorhage. The bleeding in your [**Known lastname **]s
was stoped with reversing your coumadin. You were given blood
for your anemia. We have not been able to wean you off the
ventilator.
.
You had acute renal failure from overdiuresis and blood loss. It
has gradually improved. We are now trying to take fluid off with
diuretics.
.
You PEG tube was found to be eroding through your stomach wall.
The tube was repositioned and the erossion has improved. Tube
feeds were resumed.
.
You were found to have E. coli present in your [**Known lastname 17580**], over the
PEG, and in the urine. You are being treated with antibiotics
for the infection.
.
The following pertinent changes were made to your medications.
Coumadin was stoped.
Bactrim course was completed
You were started on Ceftriaxone
.
Please follow up with your doctor as detailed below
.
If you develop presistant fever, return of bloody secretions
from your [**Known lastname 17580**], abdominal pain or return of pus from around the
PEG site, dirrhea, please seek urgent medical attention.


Followup Instructions:
Please call your PCP for follow up within 1-2 weeks after
discharge from rehab.


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Completed by:[**2197-12-14**]
{"Unspecified septicemia,Acute and chronic respiratory failure,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Pneumonia due to escherichia coli [E. coli],Infection of gastrostomy,Cellulitis and abscess of trunk,Acute posthemorrhagic anemia,Other complications due to other vascular device, implant, and graft,Ventilator associated pneumonia,Severe sepsis,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Long-term (current) use of anticoagulants,Atrial fibrillation,Depressive disorder, not elsewhere classified,Tracheostomy status,Pressure ulcer, other site,Calculus of kidney"}


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: blood from trach

PRESENT ILLNESS: HPI: Ms. [**Known lastname **] is an 89 yo female with PMH notable for
Alzheimer's disease, depression, paroxysmal afib on coumadin and
recent admission to [**Hospital1 18**] MICU for MRSA pneumonia, Proteus
urosepsis and stenotrophomonas VAP who presents from her rehab
facility with bright red blood from her trach. On [**12-3**] at 1400,
the patient was noted to have blood-tinged secretions. At that
time, labs were obtained and heparin was held. Lasix was also
increased to 40 mg IV BID. At 1500, nurse [**First Name (Titles) 12883**] [**Last Name (Titles) **] blood from
trach. INR noted to be 5.4 with Hct 29.1. Later in the evening
(2300), her nurse [**First Name (Titles) 8706**] [**Last Name (Titles) 17577**] [**Last Name (Titles) **] hemoptysis with hct down
to 23.8; vent settings at that time AC 12X350, peep 5, fio2 40%
with oxygen saturation 93%. CXR showed worsening bilateral
infiltrates by report; she had a CT scan of the chest which
showed At midnight, she was seen by the ICU resident that she
had been treated with 2 U FFP and 5 mg vitamin K. ABG at that
time demonstrated pH 7.46 / pCO2 59 / pO2 77. Due to [**Last Name (Titles) 17577**]
hemoptysis, the patient was transferred back to the [**Hospital1 18**] ICU
for further evaluation and treatment.
.
On arrival to the CCU, the patient has [**Hospital1 **] blood secretions
from her ET tube. She opens eyes to voice and actively opposes
eye opening but otherwise is nonverbal at present.

MEDICAL HISTORY: Alzheimer's
Depression
Hypernatremia
Paroxymal Afib
h/o Urinary tract infections
Cholelithiasis
h/o Influenza A/b

MEDICATION ON ADMISSION: Meds:
coumadin 5 mg daily
bactrim 250 mg IV q8h (until [**12-7**])
lasix 40 mg IV Qam, 20 mg IV qnoon, 40 mg IV qpm
dulcolax 10 mg po daily
miralax 17 g daily
chlorhexidine mouth wash [**Hospital1 **]
colace 100 mg [**Hospital1 **]
ranitidine 150 mg daily
xopenex nebs q4h and q2h prn
atrovent nebs q4h & q2h prn
neutraphos 1 cap 4X/day X 3 days
K-phos 1 packet q6h X 3 days
vitamin K 5 mg PO X 1
aricept 10 mg daily
memantine 10 mg [**Hospital1 **]
vitamin E 800 U daily
hep sc tid
lactulose 15 ml po daily
ASA 325 mg po daily
miconazole powder [**Hospital1 **] prn
caltrate with vit D 600 U po bid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: vitals: T 98.9, HR 108, BP 171/88, RR 37, O2 100% on AC 12X400,
PEEP 5, FiO2 60%
gen: lying still with eyes closed, trach in place, no distress
heent: actively opposes eye opening, tongue slightly dry
neck: trach in place with mild bright red ooze surrounding
insertion site
pulm: coarse breath sounds bilaterally, expiratory wheeze R>L
cv: RRR, difficult to hear due to vent noise
abd: firm, no guarding or rebound, hypoactive bowel sounds, no
specific areas of palpation which elicit grimace, PEG tube in
place in LUQ with minimal surrounding erythema
extr: extremities warm, 3+ pitting edema to thighs, bruise on
right hand, R PICC in place
neuro: trached, opens eyes to sound occasionally, actively
opposes eye opening and does not follow other commands

FAMILY HISTORY: N/A

SOCIAL HISTORY: Permanent resident of [**Hospital3 **] Manor. Chinese speaking only,
Son and daughter active in her life and visit daily. 

### Response:
{"Unspecified septicemia,Acute and chronic respiratory failure,Acute kidney failure, unspecified,Urinary tract infection, site not specified,Hyperosmolality and/or hypernatremia,Pneumonia due to escherichia coli [E. coli],Infection of gastrostomy,Cellulitis and abscess of trunk,Acute posthemorrhagic anemia,Other complications due to other vascular device, implant, and graft,Ventilator associated pneumonia,Severe sepsis,Abnormal coagulation profile,Anticoagulants causing adverse effects in therapeutic use,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Long-term (current) use of anticoagulants,Atrial fibrillation,Depressive disorder, not elsewhere classified,Tracheostomy status,Pressure ulcer, other site,Calculus of kidney"}
