Medical Text: Admission Date:  [**2199-12-3**]       Discharge Date:  [**2199-12-19**]

Date of Birth:                    Sex:  M

Service:

CHIEF COMPLAINT:  Hypoxia

HISTORY OF PRESENT ILLNESS:  This is a 33 year old male with
no significant past medical history who initially presented
to the [**Company 191**] Outpatient Clinic on [**11-27**] with four days of
high fevers (103 degrees F), nonproductive cough, malaise,
diffuse myalgias, mild resting dyspnea, no exposure to ill
contacts.  On [**2199-11-27**] his vital signs in the office
were temperature 99.5, blood pressure 120/85, heartrate 113
and respiratory rate 20, oxygen saturation 89% on room air.
Weight was 238 lbs.  Nonspecific pulmonary examination was
appreciated at the time.  He was prescribed Levaquin 500 mg
p.o. q.d. and discharged to home.  He represented to his
outpatient [**Hospital 191**] Clinic on [**2199-12-3**] complaining of
persistent fever to 102 degrees F, weakness, bilious emesis,
worsening dyspnea, and nonproductive cough.  Vital signs in
the office were temperature 97.3, blood pressure 108/70,
respiratory rate 20, heartrate 108, oxygen saturation 70% on
room air.  No wheezes were noted on examination.  He was
given 1 gm of Ceftriaxone and sent to the Emergency
Department where he received normal saline and 1 gm of
Vancomycin.  He denied pleuritic chest pain.  He has no risk
factors for human immunodeficiency virus.  He denies a
history of seizure disorder, alcohol use, recent somnolence,
or symptoms of gastroesophageal reflux disease.  He was
transferred to the Intensive Care Unit on arrival.

PAST MEDICAL HISTORY:  No significant past medical history or
surgical history.

ALLERGIES:  No known drug allergies.

MEDICATIONS ON ADMISSION:  Levofloxacin 500 mg p.o. q.d.

SOCIAL HISTORY:  Originally from [**Male First Name (un) 1056**].  A bus driver,
lives with his wife and daughter, no alcohol, no elicit drug
use.  Rare alcohol use.

FAMILY HISTORY:  Father had diabetes mellitus.

PHYSICAL EXAMINATION ON ADMISSION:  General, moderately
obese, sitting up in bed, no accessory muscle use.
Vital signs, temperature 99.0, heartrate 92, blood pressure
137/74, respiratory rate 16, oxygen saturation 100% on 100%
nonrebreather.
Head, eyes, ears, nose and throat, pupils equal, round and
reactive to light, extraocular muscles intact, anicteric,
oropharynx clear, fair dentition.
Neck, no lymphadenopathy.
Chest, rhonchi, right greater than left, no crackles, no
wheezes.  Normal I to E ratio, no egophony, no fremitus, no
dullness to percussion.
Cardiac, regular rate and rhythm, no murmurs, rubs or
gallops.
Abdomen, obese, normoactive bowel sounds, nontender,
nondistended, no masses.
Neurological, cranial nerves II through XII grossly intact.
Alert and oriented times three.  Conversant appropriately.
Strength 5/5 in all extremities.

LABORATORY DATA:  Laboratory findings on admission revealed
white blood cell count 8.4, 73% neutrophils, 0 bands, 19
lymphocytes, 6 monocytes, hematocrit 43.8, platelets 104, MCV
83, RDW 13.0, sodium 137, potassium 3.4, chloride 92,
bicarbonate 29, BUN 13, creatinine 0.8, glucose 129.
Arterial blood gases on 100% nonrebreather, PH 7.49, carbon
dioxide 39, oxygen 77.

Imaging:  [**2199-11-27**], chest x-ray, normal, no acute
cardiopulmonary process.  Chest x-ray [**2199-12-3**], (on
admission), patchy right upper lobe, right middle lobe
infiltrate and diffuse right greater than left interstitial
pattern, normal mediastinum, no effusion.

HOSPITAL COURSE:  A 33 year old male with no past medical
history originally admitted to the Intensive Care Unit with
hypoxia, bilateral pneumonia, received Ceftriaxone and
Azithromycin, and then Doxycycline was added since he had a
parakeet at home (he also has rats at home).  He underwent a
bronchoscopy and had a computed tomographic angiography of
the thorax which demonstrated right middle lobe and right
lower lobe pulmonary emboli with a question of infarction.
He was subsequently heparinized.  His human immunodeficiency
virus test was negative.  He received Bactrim and steroids
for a few days but were stopped when his human
immunodeficiency virus test came back negative.  A
hypercoagulability workup was pending when he arrived on the
floor in stable condition.  On arrival to the floor he was
clinically improving on the heparin drip, Ceftriaxone,
Azithromycin, and Doxycycline.  The further studies that were
obtained while in the Intensive Care Unit included [**First Name8 (NamePattern2) **] [**Doctor First Name **]
which was negative, an ANCA which was negative, hepatitis
panel which was negative.  LENIS demonstrated no deep vein
thrombosis, a thrombosis of the right lesser saphenous vein,
echocardiogram was obtained as well on [**12-6**], that
demonstrated an ejection fraction of 50%, a mildly dilated
right ventricle and mild tricuspid regurgitation.  The chest
computerized tomography scan mentioned above was on [**12-4**] and that demonstrated multiple small pulmonary emboli
(right lower lobe and right middle lobe) and bilateral
atypical pneumonias.  Workup for the organism of said
pneumonia was undertaken.  He had negative viral culture,
negative Chlamydia, negative leptospirosis, negative C.
Psittaci and negative mycoplasmas.  Blood cultures were
negative as well.  He was maintained on Azithromycin and
completed a 14 day course for his pneumonia.  The Doxycycline
was withdrawn.  He completed a ten day course of Ceftriaxone.
Regarding the pulmonary emboli, he remained hemodynamically
stable on a heparin drip throughout his admission.  A repeat
computerized tomography scan of the thorax demonstrated
bilateral expanded heterogenous soft tissue densities within
the rectus abdominis muscle ? hematomas, partial resolution
of bilateral perihilar ground-glass opacities, left SVC,
however, no pulmonary emboli.  Given the discrepancy between
the [**12-4**] and [**12-11**], computerized tomography
scans, it would be very difficult to prove that there were no
pulmonary emboli on the [**12-4**] film.  The decision to
anticoagulate him for three to six months and then to pursue
further evaluation was made.  Regarding his anticoagulation
workup, the patient had a positive anticardiolipin IgM
(46.9).  This is an intermediate range value.  The IgG
anticardiolipin value was 1.6.  The patient had a normal PTT
on admission.  While we can not make the diagnosis of
anticardiolipin syndrome on a single value, the finding
stands as nonspecific, however, the anticardiolipin panel
will have to be repeated in six weeks.  The patient was
subsequently continued on anticoagulation for pulmonary
emboli.  His heparin drip was discontinued by discharge where
he was bridged to Coumadin with Lovenox.  Regarding the
rectus hematomas noted on computerized axial tomography scan,
this finding is commonly seen in the setting of
anticoagulation.  The patient concurrently had fevers
maximally to 101 degrees F.  There was concern perhaps the
fevers may be attributable to the hematoma or a local
infection thereabouts.  He was started on Clindamycin in
conjunction with the Infectious Disease Consult Service's
recommendations.  He completed a ten day course of
Clindamycin.

Finally, the patient was noted to have a drop in his
hematocrit during his anticoagulation.  He was guaiac
negative.  There was no other source for bleed identified.
It is likely he bled into the abdominal hematoma attributing
for the drop in hematocrit.  The patient was also
intermittently hyponatremic during his stay, likely secondary
to syndrome of inappropriate antidiuretic hormone secondary
to the thoracic processes (namely bilateral pneumonia,
pulmonary embolisms) on this admission.

DISCHARGE DIAGNOSIS:
1.  Bilobar pneumonia with atypical fevers
2.  Pulmonary embolus
3.  Rectus hematoma
4.  Anticardiolipin antibody IgM positive
5.  Hyponatremia
6.  Anemia

FOLLOW UP:  The patient will follow up with his primary
provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] the week following discharge.

MEDICATIONS ON DISCHARGE:  He will be discharged on Lovenox
bridge to Coumadin.  He was also discharged on Clindamycin to
complete his ten day course.



                            [**Name6 (MD) 251**] [**Name8 (MD) **], M.D.  [**MD Number(1) 1197**]

Dictated By:[**Name8 (MD) 17844**]
MEDQUIST36

D:  [**2200-5-7**]  17:14
T:  [**2200-5-7**]  19:08
JOB#:  [**Job Number **]

ICD9 Codes: 486, 2761, 2859