Medical Text: Admission Date:  [**2188-5-24**]              Discharge Date:   [**2188-5-30**]

Date of Birth:  [**2132-11-19**]             Sex:   M

Service: MEDICINE

Allergies:
Ampicillin / Thorazine

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Respiratory Failure

Major Surgical or Invasive Procedure:
Trach change
Mechanical ventilation


History of Present Illness:
Mr. [**Known lastname 89172**] is a 55 yo man with PMH significant for Downs
Syndrome, MRSA pneumonia and respiratory failure in [**10/2187**]
resulting in tracheostomy which was reversed [**2188-5-13**], who is
transferred from s/p intubation at [**Hospital1 **] in [**Location (un) 1110**] today.
Patient had been predominantly in rehab since developing MRSA
pneumonia in [**10/2187**] (first [**Last Name (un) **] and then [**Hospital 5279**] Rehab
Centers) and presented to [**Hospital1 **] from rehab for respiratory
distress.  He had been started on Rocephin [**5-22**] for presumed
pneumonia at Rehab in setting of labored breathing.  Patient was
intubated at [**Hospital1 **] for labored breathing, accessory muscle
use.  Per report, there may have been some failed attempt in OSH
ED to re-open his tracheostomy prior to intubation.
.
At OSH, patient received, levoquin 750mg @ 03:25, Vancomycin 1g
@ 5:09 for pneumonia.  He was ordered for 4L NS and received at
least 2.5L. CXR and CT Chest appeared to show some fluid
overload.  Patient was difficult to maintain on sedation; blood
pressure dropped on propofol, so patient was briefly on dopamine
until sedation was switched to versed boluses prn, which he
tolerated well.  Trach site had some serosanguinous fluid
leakage, so it was covered with guaze and tegaderm.  Respiratory
therapist in ED confirmed no air leakage while on the
ventilator.  Patient was transfered to [**Hospital1 18**] for further
management.
.
In ED, initial VS were as follows: 99.9 (Rectal temp) 101
174/100 22 98% on ventilator with 100%FiO2.  He was given 1amp
D50 for a blood sugar of 69.  He also received 250cc of IVF and
2.5mg bolus of IV versed for sedation while ventilated. EKG
showed sinus tach with rate 103.  CXR showed fluid overload with
possible consolidation, so CTA of chest was done to further
characterize ?consolidation and rule out PE.  CTA showed no
signs of PE and confirmed RUL and RML pneumonia, as well as
fluid filled esophagus, suggesting aspiration. CT also showed
moderate left and small right effusions, but no pulmonary edema.
 Vitals in ED prior to transfer to ICU were as follows: 99.8F HR
91  BP 92/53  RR 16  O2sat100% cpap FIO2 60%, PS 10, PEEP 5.
.
On arrival to the unit, patient is mechanically ventilated and
appears comfortable.  He is accompanied by his sister who was
able to corroborate the above story. Of note, the patient is
non-verbal at baseline but does make some signs, only eats
icecream and [**Last Name (un) **] tea by mouth (for pleasure) and is otherwise
fed through tube feeds.
.


Past Medical History:
- Downs Syndrome
- MRSA Pneumonia complicated by tracheostomy [**10/2187**]
  - reversed [**2188-5-13**]
- C Diff Colitis - [**2188**]
- Pseudomonas Colitis - [**2188**] - dx by colonoscopy, tx w cipro
through G-tube
- Adrenal Insufficiency
- Seizure History, per sister this [**Name2 (NI) 89173**] with
hospitalization in [**11-3**] - on keppra
- Hx transaminitis - presumed to be secondary to antiepileptics
- Hx of HBV
- Membranoproliferative Glomerulonephritis


Social History:
Lives at Group Home, but has spent significant amount of time at
Rehab since [**10/2187**] and presented from [**First Name4 (NamePattern1) 5279**] [**Last Name (NamePattern1) **].  [**Last Name (NamePattern1) 6961**]
are his guardians, but his sister [**Name (NI) **] is also very involved in
his care and finances.


Family History:
NC

Physical Exam:
ADMISSION EXAM:
GEN: Comfortable appearing, opens eyes to command
HEENT: ETT in place.
NECK: Tegaderm placed over anterior neck; difficult to assess
opening in skin. No drainage or erythema.
CV: RRR, no murmur
LUNGS: Rhonchi anteriorly R>L, CTAB laterally on both sides
ABD: Soft, non-tender but distended. Central G-tube covered with
gauze with tube feeds draining around opening. Ostomy
erythematous, raw. No erythema on surrounding skin.
EXT: LE cachectic, No LE edema.

DISCHARGE EXAM:
GEN: Comfortable appearing, opens eyes to command, not in
distress
HEENT/Neck: EOMI, trach in place with sputum surrounding, mild
erythema around site
CV: RRR, no murmur
LUNGS: Rhonchi anteriorly, CTAB laterally on both sides
ABD: Soft, non-tender but distended. Central G-tube covered with
gauze. Mildly erythematous around opening.
EXT: LE cachectic, No LE edema.


Pertinent Results:
ADMISSION LABS:
.
[**2188-5-24**] 11:50AM   PT-18.8* PTT-31.4 INR(PT)-1.7*
[**2188-5-24**] 11:50AM URINE  RBC-28* WBC-7* BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
[**2188-5-24**] 11:50AM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
[**2188-5-24**] 11:50AM   WBC-11.7* RBC-2.84* HGB-10.5* HCT-31.6*
MCV-111* MCH-37.1* MCHC-33.4 RDW-18.9*
[**2188-5-24**] 11:50AM   GLUCOSE-69* UREA N-54* CREAT-1.0 SODIUM-136
POTASSIUM-5.0 CHLORIDE-107 TOTAL CO2-24 ANION GAP-10
[**2188-5-24**] 12:00PM   LACTATE-2.0
.
DISCHARGE LABS:
.
[**2188-5-30**] 03:56AM BLOOD WBC-8.1 RBC-2.32* Hgb-8.9* Hct-26.7*
MCV-115* MCH-38.5* MCHC-33.5 RDW-17.4* Plt Ct-130*
[**2188-5-30**] 03:56AM BLOOD Glucose-83 UreaN-29* Creat-1.1 Na-135
K-3.7 Cl-108 HCO3-24 AnGap-7*
[**2188-5-30**] 03:56AM BLOOD Calcium-7.3* Phos-2.5* Mg-1.5*
[**2188-5-30**] 03:56AM BLOOD Vanco-25.0*
.
MICRO:
C. diff negative
Urine culture - no growth
Blood culture x2 - no growth to date

IMAGING:
CXR [**2188-5-24**]:
1. Endotracheal tube terminating at the carina.
2. Mild pulmonary interstitial edema.
3. Right upper zone opacity may reflect aspiration pneumonitis
or developing
pneumonia.

CT-A [**2188-5-24**]:
IMPRESSION:
1. RUL and RML pneumonia, possible due to aspiration since the
esophagus is fluid filled and dilated.
2. No PE.
3. Moderate left and small right effusions, but no pulmonary
edema.
4. Mediastinal lymphadenopathy
5. Acute left 7th rib fracture.

G/GJ/GI TUBE CHECK
FINDINGS: Supine radiographs demonstrate jejunostomy tube with
tip at the
junction of the distal duodenum or proximal jejunum. Contrast is
seen passing distally in the jejunum without evidence of leak.
Bowel gas pattern is normal without evidence of leak. Imaged
portion of the lungs are clear. Surgical clips are noted
overlying the base of the heart.
IMPRESSION: Jejunostomy tube in appropriate position with normal
passage of contrast without evidence of leak.


Brief Hospital Course:
55M with hx of Downs Syndrome, MRSA pneumonia c/b respiratory
failure and tracheostomy, s/p tracheostomy reversal 10d prior to
admission, transferred to [**Hospital1 18**] for hypoxic respiratory failure
[**2-27**] RUL/RML aspiration PNA
.
# Aspiration PNA/respiratory distress: PE was ruled out as
potential cause of respiratory distress.  Imaging demonstrated
RUL/RML pneumonia secondary to aspiration, as well as airway
narrowing at site of prior tracheostomy.  Likely secondary to
aspiration, as patient was also noted to have fluid filled
esophagus on CT scan.  Patient was treated with hospital
acquired and community acquired pneumonia with Vancomycin,
Levoquin and Cefepime (8-day course). Cultures of urine and
blood from OSH showed no growth. Aspiration may have been
related to overflow at g-tube site.  Tube feeds were initially
held, and G tube study was ordered which showed jejunostomy tube
in appropriate position with normal passage of contrast without
evidence of leak. Patient on steroids at home for adrenal
insufficiency, was not on PCP prophylaxis at home so bactrim
daily was started.  Patient was arranged to be transferred to
[**Hospital Ward Name 517**] ICU service for extubation and potential IP
intervention at site of airway narrowing. IP found an 0.8 cm
focal area of stenosis with dynamic collapse at 2nd tracheal
ring.  The granulation tissue was debrided and IP replaced
percutaneous trach through existing stoma.  Patient will need
evaluation for tracheal resection/reconstruction at IP o/p f/u
in 2 weeks. Post-procedure CXR showed multifocal PNA, unchanged
bilateral effusions, trach in appropriate position.  Patient
remained stable with new trach in place and did well prior to
discharge. His last day of levaquin and cefepime will be on
[**2188-5-31**].
.
# Recent history of colitis: Reported recent history of both
C.diff and Pseudomembranous colitis.  Patient with with several
episodes of lose stool. C. diff was checked and was negative.
.
# Down syndrome/Anxiety: At baseline, pt nonverbal.  Pt was
restarted on home dose of ativan given evidence of anxiety and
aggitation w/groups of people while intubated.
.
# Adrenal Insufficiency: History unclear but patient currently
on prednisone 20 daily - patient has not had outpatient
endocrine evaluation. As per [**Hospital 228**] rehab facility steroids
were started to treat low sodium.  Patient currently with normal
blood pressures. Steroid dose tapered to 10mg daily for 1 week
with outpatient follow up of electrolytes. Patient started on
PCP prophylaxis, which he should remain on if he is going to
continue steroids long term. Patient will follow-up with
endocrinology for further work-up of possible renal
insufficiency. OSH records were faxed to endocrinology
department when appointment was made.
.
# Hx of seizure disorder: Reportedly first seizure [**11-3**] at time
of hospitalization with MRSA pneumonia.  Continued home dose of
Keppra.
.
#FEN: Concern for leaking at J tube site.  Tube feeds were held
as concern for leaking at feeding tube.  Surgery was consulted
and sutured the tube in place with clamp. Dressing in place over
tube site.
.
# Prophylaxis: SubQ heparin, Famotidine
.
# Contact:  [**Name (NI) 6961**] = guardians, [**Name (NI) 449**] and [**Name (NI) **]
([**0-0-**]), Sister [**Name (NI) **] [**Telephone/Fax (1) 89174**].
.
# Code Status: FULL CODE (Confirmed with family)


Medications on Admission:
Prednisone 20mg daily
Omeprazole 20mg [**Hospital1 **]
Keppra 500mg [**Hospital1 **] (do not crush)
Ativan 0.25-0.5mg via PEG Q8h PRN (for moderate to severe
anxiety)
Duonebs prn wheezing
oxycodone
Zinc
Bacitracin ointment
Bowel Regimen prn


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Healthcare Center - [**Location (un) 1110**]

Discharge Diagnosis:
Primary diagnosis:
Subglottic stenosis
Hosptial acquired pneumonia
.
Secondary diagnoses:
? Adrenal insufficiency
Down's syndrome
Seizure disorder


Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Mental Status: Confused - sometimes. (baseline)


Discharge Instructions:
It was a pleasure to participate in your care Mr. [**Known lastname 89172**].  You
were admitted to [**Hospital1 18**] for evaluation of respiratory failure.
You were found to have narrowing of your trachea.  You were
taken to the OR to have a procedure to replace tracheostomy.
You were also treated for a pneumonia.
.
There was concern for your G tube not working appropriately.
Surgery evaluated you and fixed your J tube.
.
You were started on steroids at your outpatient facility as you
had low sodium.  We decreased your dose of steroid and started
you on Bactrim to prevent a type of lung infection called PCP.
[**Name10 (NameIs) **] will have you follow-up with endocrinology here to further
evaluate if you need to take steroids.
.
MEDICATION CHANGES:
START Cefepime 2gm Q24 for one more day
START Levofloxacin 750mg daily for one more day
START Bactrim SS daily for prophylaxis for PCP
DECREASE Prednisone to 10mg daily


Followup Instructions:
Department: Thoracic Multi [**Hospital 4094**] Clinic
When: TUESDAY [**2188-6-10**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: Thoracic Multi [**Hospital 4094**] Clinic
When: TUESDAY [**2188-6-10**] at 3:00 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES - Endocrinology
When: WEDNESDAY [**2188-6-11**] at 3:15 PM
With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2188-6-10**] at 2:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2188-6-10**] at 3:00 PM
With: [**Name6 (MD) 1532**] [**Name8 (MD) 1533**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2188-6-11**] at 3:15 PM
With: MALA [**Last Name (NamePattern4) 16956**], MD [**Telephone/Fax (1) 1803**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


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

Completed by:[**2188-5-30**]
ICD9 Codes: 5070