CHIEF COMPLAINT: Hypoxia

PRESENT ILLNESS: 56M with T2DM, HTN, DL, previously admitted for Fournier's
gangrene c/b need for diverting colostomy and failure to wean
from vent, s/p tracheostomy now p/w respiratory distress from
[**Hospital3 **] hospital.
.
At rehab, in the PM of [**1-5**], began c/o of SOB/left chest pain.
On assessment, was AAOx3, 80% sat on 12 L O2 tracheostomy. His
BP ranged from 133/73-151/81, HR 100. Enroute 02 sat decreasd to
70s. Tracheostomy suctioned x4 enroute with improvement in
oxygenationation to 70's to 80s.
.
In the ED initial vitals, 97.8, 85, 160/75, 18, 86% on NRB.
Patient was uncomfortable in obvious distress. Unable to
ventilate through trach. ED team bronched patient and found an
obstructing 'mass'- fibrinous. Was given toradol when feeling
feverish and ativan for anxiety. Surgery was consulted and
replaced trach - patient desatted. ABG at this time 7.40/51/69.
Anesthesia was contact[**Name (NI) **] and patient was intubated (difficult
intubation). CXR with ET tube at 6.8 cm, bilateral patchy
infiltrates stable from prior, cardiomegaly with left lower lobe
opacity conerning for effusion vs infiltrate. Labs with white
count of 16.4 with left shift. Creatinine of 1.4. BNP of [**Numeric Identifier 87941**]
and Troponin T of 0.18. EKG with sinus tachycardia no evidence
of ischemia. Patient started on nitro drip and lasix 40mg IV x
one given concern for CHF. Also given Vanc/Zosyn for HAP.
Dysynchronous on vent so given propofol and patient became
hypotension. Vitals prior to transfer: HR 82, CMV 15/500/Fi02
100%, 136/75.
.
In the ICU, patient intubated and sedated, hemodynamically
stable.

MEDICAL HISTORY: -DM type 2
-gastroparesis
-MRSA infections
-kidney stones
-hypertension
-hypercholesterolemia
-Fournier's gangrene

MEDICATION ON ADMISSION: Norvasc 10 mg daily
Lasix 40 mg daily
Neurontin 300 mg [**Hospital1 **]
Amaryl 4 mg daily
lisinopril 5 mg daily
Reglan 10 mg QID
Lopressor 50 mg [**Hospital1 **]
Zocor 40 mg daily
DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Neb Solution INH Q6H PRN
Clonidine 0.3 mg/24 hr Transdermal Patch QSunday
Heparin (porcine) 5,000 unit SC TID
Aspirin 325 mg Tab daily
Hydromorphone 2-4 mg Tab Q4H PRN
Novolin N 12 units QAM at 0730 and 16 units QPM at 1700 SC
Hyoscyamine 0.25 mg Q6H PRN
Hexavitamin daily
Milk of Magnesia 30 mL QHS

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: Temp: Afebrile BP:133/72 HR:80 RR:14 O2sat 100
GEN: intubated, sedated
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: Diminished left base, good airmovement no
wheezing/rales/rhonchi
CV: RR, S1 and S2 wnl, no m/r/g
ABD: obese, nd, +b/s, soft, nt
EXT: 3+ lower extremity
SKIN: no rashes/no jaundice/no splinters - deep decubitus
ulceration perineum and left gluteus which appears stable.
NEURO: Sedated.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Former policeman. Was at rehab recovering from recent
hospitalization ([**Hospital3 7665**] in [**Hospital1 3597**], NH). HCP is brother
[**Name (NI) **] [**Name (NI) **].
Acute and chronic respiratory failure,Methicillin resistant pneumonia due to Staphylococcus aureus,Acute on chronic systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Urinary tract infection, site not specified,Mechanical complication of tracheostomy,Ventilator associated pneumonia,Other primary cardiomyopathies,Acute bronchitis,Gastroparesis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Pressure ulcer, buttock,Dysthymic disorder,Chronic kidney disease, unspecified,Vascular disorders of male genital organs,Anemia of other chronic disease,Pure hypercholesterolemia,Other constipation,Hyperpotassemia,Obstructive sleep apnea (adult)(pediatric),Long-term (current) use of insulin,Personal history of Methicillin resistant Staphylococcus aureus,Colostomy status
Acute & chronc resp fail,Meth res pneu d/t Staph,Ac on chr syst hrt fail,Ac kidny fail, tubr necr,Urin tract infection NOS,Tracheostomy - mech comp,Ventltr assoc pneumonia,Prim cardiomyopathy NEC,Acute bronchitis,Gastroparesis,Hy kid NOS w cr kid I-IV,DMII neuro nt st uncntrl,Pressure ulcer, buttock,Dysthymic disorder,Chronic kidney dis NOS,Male gen vascul dis NEC,Anemia-other chronic dis,Pure hypercholesterolem,Constipation NEC,Hyperpotassemia,Obstructive sleep apnea,Long-term use of insulin,Hx Methicln resist Staph,Colostomy status
Admission Date:  [**2178-1-6**]              Discharge Date:   [**2178-1-14**]

Date of Birth:  [**2121-12-28**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Hypoxia

Major Surgical or Invasive Procedure:
Tracheostomy replacement

History of Present Illness:
56M with T2DM, HTN, DL, previously admitted for Fournier's
gangrene c/b need for diverting colostomy and failure to wean
from vent, s/p tracheostomy now p/w respiratory distress from
[**Hospital3 **] hospital.
.
At rehab, in the PM of [**1-5**], began c/o of SOB/left chest pain.
On assessment, was AAOx3, 80% sat on 12 L O2 tracheostomy. His
BP ranged from 133/73-151/81, HR 100. Enroute 02 sat decreasd to
70s. Tracheostomy suctioned x4 enroute with improvement in
oxygenationation to 70's to 80s.
.
In the ED initial vitals, 97.8, 85, 160/75, 18, 86% on NRB.
Patient was uncomfortable in obvious distress. Unable to
ventilate through trach. ED team bronched patient and found an
obstructing 'mass'- fibrinous. Was given toradol when feeling
feverish and ativan for anxiety. Surgery was consulted and
replaced trach - patient desatted. ABG at this time 7.40/51/69.
Anesthesia was contact[**Name (NI) **] and patient was intubated (difficult
intubation). CXR with ET tube at 6.8 cm, bilateral patchy
infiltrates stable from prior, cardiomegaly with left lower lobe
opacity conerning for effusion vs infiltrate. Labs with white
count of 16.4 with left shift. Creatinine of 1.4. BNP of [**Numeric Identifier 87941**]
and Troponin T of 0.18. EKG with sinus tachycardia no evidence
of ischemia. Patient started on nitro drip and lasix 40mg IV x
one given concern for CHF. Also given Vanc/Zosyn for HAP.
Dysynchronous on vent so given propofol and patient became
hypotension. Vitals prior to transfer: HR 82, CMV 15/500/Fi02
100%, 136/75.
.
In the ICU, patient intubated and sedated, hemodynamically
stable.


Past Medical History:

-DM type 2
-gastroparesis
-MRSA infections
-kidney stones
-hypertension
-hypercholesterolemia
-Fournier's gangrene


Social History:
Former policeman. Was at rehab recovering from recent
hospitalization ([**Hospital3 7665**] in [**Hospital1 3597**], NH). HCP is brother
[**Name (NI) **] [**Name (NI) **].

Family History:
Noncontributory

Physical Exam:

VS: Temp: Afebrile BP:133/72 HR:80 RR:14 O2sat 100
GEN: intubated, sedated
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: Diminished left base, good airmovement no
wheezing/rales/rhonchi
CV: RR, S1 and S2 wnl, no m/r/g
ABD: obese, nd, +b/s, soft, nt
EXT: 3+ lower extremity
SKIN: no rashes/no jaundice/no splinters - deep decubitus
ulceration perineum and left gluteus which appears stable.
NEURO: Sedated.


Pertinent Results:
           **FINAL REPORT [**2178-1-9**]**

   GRAM STAIN (Final [**2178-1-6**]):
      >25 PMNs and <10 epithelial cells/100X field.
      NO MICROORGANISMS SEEN.

   RESPIRATORY CULTURE (Final [**2178-1-9**]):
      RARE GROWTH Commensal Respiratory Flora.
      Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
      workup will be performed appropriate to the isolates
recovered from
      this site.
      STAPH AUREUS COAG +.    SPARSE GROWTH.
         Staphylococcus species may develop resistance during
prolonged
         therapy with quinolones.   Therefore, isolates that are
initially
         susceptible may become resistant within three to four
days after
         initiation of therapy.  Testing of repeat isolates may
be
         warranted.  .
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
      YEAST.    SPARSE GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------   0.5 S
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------   <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S





Brief Hospital Course:
56M with T2DM, HTN, DL, previously admitted for Fournier's
gangrene c/b need for diverting colostomy and failure to wean
from vent, s/p tracheostomy now p/w respiratory distress from
[**Hospital3 **] hospital.
.
# Hypoxic Respiratory Failure: Patient intubated when unable to
effectively oxygenate through trach. Reports of "mass" seen with
bronchoscope in ED. CXR with similar bilateral patchy infiltrate
compared to prior though ? increased left lower lobe opacity.
Patient with elevated white count and left shift concerning for
infection and certainly raises the question of HAP. BNP elevated
to support the diagnosis of CHF though stable compared to one
prior measurement, further patient with 3+ lower extremity
edema. Initially on Vanc/Zosyn, zosyn changed to ceftriaxone
once urine grew Ecoli sensitive to CTX. Vancomycin and CTX
should be continued until [**1-15**]. Pt was extubated on day 2 on
admission and a new tracheostomy tube was placed by the surgical
service. On [**1-11**] trach was removed due to malfunctioning, and
pt was able to breathe comfortably on 2l NC oxygen. Diureses
during the admission was with 40 lasix IV bid which was
decreased to 40 lasix IV daily.  He was discharged on oral lasix
as below.

# Hx of Fourneir's Gangrene: Evaluated by the surgical team in
the ED who felt there were no active surgical issues. Evaluated
by wound care team and recommmedations were provided and
followed.  Wound care recommendations include: His wounds are
clean and pink with granulation tissue and are draining
significant amount of serous drainage. The posterior wound is 10
x 11 with undermining of 2.5 cm in the area of  6 -11 o'clock
there is  a tunnel of 6 cm in the center of the wound. The other
woundis in the groin to the right of the scrotum it measures 6 x
4 cm with a tunnel  of 6 cm at 7 o'clock. Both wounds were
cleansed with commercial wound cleanser and patted dry. The
peri-wound skin was treated with Critic aid anti-fungal to
protect the skin and prevent yeast formation. The wounds were
packed with Kerlix making sure to wick into the tunnels and the
undermined areas. Have asked that Kerlix AMD be used to help
decrease the bio burden of the wound. do not pack the wound
tight
and change when wet [**Hospital1 **] and PRN.
.
3. Elevated Troponin: Mild elevation in troponin on admission.
EKG without evidence of MI. Ruled out MI with CE at 8 hours.
Continued Full Strength ASA
.
4. HTN: Home antihypertensives held initially and blood pressure
controlled with Labetelol PRN.   Home antihypertensives were
then started
.
5. Diabetes: He was managed with glargine 10 units and humalog
sliding scale insulin.
.
Code: FULL CODE



Medications on Admission:
Norvasc 10 mg daily
Lasix 40 mg daily
Neurontin 300 mg [**Hospital1 **]
Amaryl 4 mg daily
lisinopril 5 mg daily
Reglan 10 mg QID
Lopressor 50 mg [**Hospital1 **]
Zocor 40 mg daily
DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Neb Solution INH Q6H PRN
Clonidine 0.3 mg/24 hr Transdermal Patch QSunday
Heparin (porcine) 5,000 unit SC TID
Aspirin 325 mg Tab daily
Hydromorphone 2-4 mg Tab Q4H PRN
Novolin N 12 units QAM at 0730 and 16 units QPM at 1700 SC
Hyoscyamine 0.25 mg Q6H PRN
Hexavitamin daily
Milk of Magnesia 30 mL QHS


Discharge Medications:
1. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig:
One (1) g Intravenous Q24H (every 24 hours) for 1 days.
2. vancomycin 500 mg Recon Soln Sig: 1250 (1250) mg Intravenous
Q 12H (Every 12 Hours) for 1 days.
3. insulin glargine 100 unit/mL Cartridge Sig: Ten (10) units
Subcutaneous once a day.
4. Humalog 100 unit/mL Cartridge Sig: as directed  Subcutaneous
qachs: please give according to sliding scale.
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
9. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
10. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
13. Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
15. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1)  Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
16. multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
-Hypoxic Respiratory Failure: Felt in setting of suboptimal
tracheostomy placement, bilateral patchy infiltrates from volume
overload and left lower lobe pneumonia/tracheobronchitis (MRSA)
-Pneumonia
-Urinary tract infection
-Fournier's Gangrene

Anemia
hypertension
hyperlipidemia
diabetes
depression/anxiety


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 to [**Hospital1 69**] for
respiratory distress.  You were admitted to the intensive care
unit where your tracheostomy was removed.  You were treated with
antibiotics for pneumonia and for a urinary tract infection.

The following changes were made to your medications:
START Vancomycin 1250 mg intravenous every 12 hours for one more
day
START CeftriaXONE 1 gm intravenous once a day for one more day

STOP Amaryl
START Glargine 10 units once a day
START Humalog as directed by sliding scale insulin
STOP Novolin

STOP hydromorphone
STOP milk of magnesia
START Docusate twice a day

STOP Hyocyamine

Please continue your home medications.

Followup Instructions:
Please see your primary care doctor within two to four weeks.




Admission Date:  [**2178-1-17**]              Discharge Date:   [**2178-2-3**]

Date of Birth:  [**2121-12-28**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
respiratory distress

Major Surgical or Invasive Procedure:
1. thoracentesis
2. chest tube placement
3. central venous line placement

History of Present Illness:
56 yo male with h/o Type II DM, HTN, HL, Fournier's gangrene and
recent admission for hypoxic respiratory failure thought
secondary to both systolic left heart failure and
tracheobronchitis presents with sudden onset dyspnea this
morning.  Patient was just discharged three days ago to rehab.
Reports waking this morning with sudden onset dyspnea, denies
any other associated symptoms; specifically denies fevers,
chills, chest pain, pre-syncope, and syncope.  Vitals at that
time were 188/103, HR 105, RR 32.  Patient reported feeling that
he "couldn't catch his breath", with O2 sat of 82%.  Patient
reports chronic cough, non-productive.  On call physician was
notified by rehab, and with complaint of shortness of breath at
[**Hospital6 **] at [**Hospital3 **], advised patient to be
transferred to [**Hospital1 18**] ED for further evaluation.  Vitals at OSH
([**Hospital3 **]) were 98.2  156/92  HR 109  96% on CPAP 10 cm/H2O.
Received furosemide 40 mg IV x 1, maintain on CPAP prior to
arrival at [**Hospital1 18**] ED, with improved symptoms.  On CPAP upon
arrival, no increased WOB.  Nitro gtt and lasix 40 IV x 2.
vanc, ceftriaxone and levaquin.  power picc.  HR 95  140/69  18.
.
In [**Hospital1 18**] ED, arrived on CPAP, vitals  97.2 84 156/92 18  96%
Other.  Received furosemide 40 mg IV x 1, kayexelate 30 cc PO x
1.  Nitro gtt was started for management of CHF.  Patient also
received vancomycin 1 gram, levofloxacin 750 mg, and ceftriaxone
1 gram all IV.  Power PICC in place.
.
Upon arrival to the ICU, patient reported improved breathing,
reported some chest discomfort that had improved since starting
this morning.  He had no other complaints.

Past Medical History:
-recent hypoxic resp failure, [**2-25**] sCHF and MRSA
tracheobronchitis
-DM type 2
-gastroparesis
-MRSA infections
-kidney stones
-hypertension
-hypercholesterolemia
-Fournier's gangrene

Social History:
Former policeman. Was at rehab recovering from recent
hospitalization ([**Hospital3 7665**] in [**Hospital1 3597**], NH).  HCP is brother
[**Name (NI) **] [**Name (NI) **].

Family History:
Noncontributory

Physical Exam:
On Admission:
VS: HR 86  135/79  93% 50% face mask
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, jvd to tragus of
ear, no carotid bruits, no thyromegaly or thyroid nodules
RESP: decreased breath sounds at bases, right > left, otherwise
CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g, no S3 noted
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: 2+ LE edema bilaterally
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated.  2+DTR's-patellar
and biceps
.
On Discharge:
Tm/c:97.7/97.7, BP: 144/76(120-165/50-76), HR: 77 (71-93), RR:
18, O2 95% 2LNC, I/O: 2172/1625
GA: AOx3, no pain from former chest tube site
HEENT:  MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: Crackles on right lower and mid-posterior lung fields,
chest tube site with dressing in place, no drainage. Abd: soft,
NT, +BS. Colostomy bag in place with air in the bag.
Posterior: Large perianal wound with purulent drainage and a
base with granulation tissue.
Extremities: trace lower extremity edema
Neuro/Psych: CNs II-XII intact.

Pertinent Results:
LABS:
.
CBC
[**2178-1-17**] 10:05AM BLOOD WBC-12.0* RBC-2.81* Hgb-8.5* Hct-25.4*
MCV-90 MCH-30.3 MCHC-33.5 RDW-16.0* Plt Ct-286
[**2178-1-19**] 04:03AM BLOOD WBC-8.9 RBC-2.84* Hgb-8.6* Hct-25.7*
MCV-91 MCH-30.2 MCHC-33.3 RDW-15.5 Plt Ct-303
[**2178-1-21**] 11:38AM BLOOD WBC-10.0 RBC-2.65* Hgb-8.3* Hct-22.9*
MCV-86 MCH-31.1 MCHC-36.0* RDW-15.5 Plt Ct-219
[**2178-1-22**] 04:14AM BLOOD WBC-9.4 RBC-3.43* Hgb-10.3* Hct-30.1*
MCV-88 MCH-30.0 MCHC-34.2 RDW-15.1 Plt Ct-199
[**2178-1-23**] 02:50AM BLOOD WBC-8.2 RBC-3.31* Hgb-10.1* Hct-29.2*
MCV-88 MCH-30.5 MCHC-34.6 RDW-14.9 Plt Ct-203
[**2178-1-28**] 05:04AM BLOOD WBC-10.8 RBC-3.46* Hgb-10.2* Hct-31.3*
MCV-91 MCH-29.6 MCHC-32.7 RDW-13.6 Plt Ct-296
[**2178-2-2**] 05:07AM BLOOD WBC-10.5 RBC-3.43* Hgb-10.2* Hct-30.6*
MCV-89 MCH-29.6 MCHC-33.2 RDW-13.5 Plt Ct-331
.
Coags
[**2178-1-17**] 10:25AM BLOOD PT-12.4 PTT-22.7 INR(PT)-1.0
[**2178-1-21**] 11:37PM BLOOD PT-13.5* INR(PT)-1.2*
[**2178-2-2**] 05:07AM BLOOD PT-13.1 PTT-23.2 INR(PT)-1.1
.
Fibrinogen
[**2178-1-21**] 11:37PM BLOOD Fibrino-450*#
.
BMP:
[**2178-1-17**] 10:05AM BLOOD Glucose-386* UreaN-39* Creat-2.4* Na-135
K-6.0* Cl-96 HCO3-32 AnGap-13
[**2178-1-18**] 02:16PM BLOOD Glucose-159* UreaN-39* Creat-2.8* Na-138
K-5.2* Cl-96 HCO3-33* AnGap-14
[**2178-1-20**] 03:51AM BLOOD Glucose-179* UreaN-46* Creat-3.1* Na-139
K-5.0 Cl-98 HCO3-34* AnGap-12
[**2178-1-22**] 04:14AM BLOOD Glucose-166* UreaN-46* Creat-3.2* Na-140
K-4.8 Cl-100 HCO3-33* AnGap-12
[**2178-1-24**] 03:58PM BLOOD Glucose-192* UreaN-39* Creat-2.8* Na-141
K-4.8 Cl-99 HCO3-38* AnGap-9
[**2178-2-2**] 05:07AM BLOOD Glucose-161* UreaN-38* Creat-2.3* Na-137
K-5.0 Cl-102 HCO3-28 AnGap-12
.
LFT
[**2178-1-23**] 11:12PM BLOOD ALT-6 AST-16 Amylase-19 TotBili-0.4
.
Troponin:
[**2178-1-17**] 10:05AM BLOOD cTropnT-0.33*
[**2178-1-18**] 02:16PM BLOOD CK-MB-5 cTropnT-0.54*
[**2178-1-19**] 04:03AM BLOOD CK-MB-5 cTropnT-0.46*
[**2178-1-20**] 03:51AM BLOOD CK-MB-4 cTropnT-0.42*
[**2178-1-21**] 03:12AM BLOOD CK-MB-4 cTropnT-0.36*
.
Pro-BNP
[**2178-1-17**] 10:05AM BLOOD proBNP-[**Numeric Identifier 87942**]*
.
electrolytes:
[**2178-1-17**] 04:19PM BLOOD Calcium-8.3* Phos-5.7*# Mg-1.9
[**2178-1-21**] 06:47PM BLOOD Calcium-8.2* Phos-6.8*
[**2178-1-23**] 04:59PM BLOOD Calcium-8.9 Phos-6.1* Mg-2.0
[**2178-1-25**] 04:49PM BLOOD Calcium-8.5 Phos-5.0* Mg-2.1
[**2178-2-2**] 05:07AM BLOOD Calcium-8.8 Phos-4.8* Mg-2.1
.
Lactate:
[**2178-1-17**] 10:19AM BLOOD Lactate-1.6
[**2178-1-17**] 01:17PM BLOOD Lactate-2.0
[**2178-1-20**] 05:18PM BLOOD Lactate-1.7
.
IMAGING:
[**2178-1-17**] CXR
FINDINGS: Previously noted malpositioned right approached PICC
is now
terminating within the right axilla. There are low lung volumes
with
bilateral lower lobe atelectasis/collapse. Bilateral lower lobe
opacification likely atelectasis/collapse. In addition, there is
worsening, now moderate to large right and stable moderate left
pleural effusions. There are increased pulmonary interstitial
markings, compatible with a component of interstitial pulmonary
edema. There are no new focal consolidations concerning for
pneumonia, though an underlying pneumonia particularly at the
bases cannot be excluded. The cardiomediastinal and hilar
contours are stable.

IMPRESSION: Worsening now moderate to large right and stable
moderate left
pleural effusion. Bilateral lateral lower lobe
collapse/atelectasis, though pneumonia cannot be excluded.
Moderate interstitial pulmonary edema
.
[**2178-1-20**] CXR
IMPRESSION: AP chest compared to [**1-9**] through 27:
Large right pleural effusion has worsened since [**1-19**].
Left lower lobe is severely consolidated, consistently since
[**1-9**], presumably
collapsed. Moderate left pleural effusion increased since
[**1-17**] is
stable since [**1-19**]. Upper lobe vasculature is engorged but
there is no good evidence for severe pulmonary edema. Left PIC
line ends at the junction of brachiocephalic veins.
Moderate-to-severe cardiomegaly is chronic. No pneumothorax.
.
[**2178-1-23**] CXR
FINDINGS: Study is limited due to technique and the lower lung
fields are cut off from the study. There is again seen increased
density surrounding the periphery of the right lung consistent
with known hemothorax. Bilateral pleural effusions and a left
retrocardiac opacity are again seen. There is a right IJ central
venous catheter with distal lead tip in the cavoatrial junction.

.
[**2178-1-24**] CXR
FINDINGS: Comparison is made to previous study from [**2178-1-23**].
There is again seen increased density along the periphery of the
right chest. This has decreased since previous likely
representing improvement of the hemothorax. There is unchanged
cardiomegaly. There is a left-sided pleural effusion and left
retrocardiac opacity, which appears stable. There is some mild
pulmonary vascular congestion, stable. The right IJ central
venous catheter has the distal lead tip in the cavoatrial
junction and is unchanged.
.
[**2178-1-28**] CXR
IMPRESSION: AP chest compared to [**1-20**] through [**1-25**]:
The volume of the right pleural abnormality surrounding the
right lung has
decreased slightly, but now air has appeared in the apical
region of the right hemithorax. There is no fluid level to
suggest a readily drainable fluid.
Previous mild pulmonary edema, as best evaluated in the left
lung has
improved. Right pleural tube unchanged in position. One reason
for
unreliable function of the right pleural tube may be that it is
fissural, and has been since at least [**1-22**].
.
[**2178-1-30**] CXR
IMPRESSION: AP chest compared to [**1-23**] through [**1-30**]:
Moderate right hemopneumothorax continues to increase both in
the volume of air which is largely apical and fluid which is
costal and dependent. Small left pleural effusion has been
present without much change.
Moderate-to-severe cardiac enlargement unchanged. Left PIC line
curving
medially beyond the level of the carina, is separated by such a
distance from the right lateral wall of the cardiac silhouette
that it suggests persistence of pericardial effusion.
.
[**2178-1-31**] CXR
IMPRESSION: AP chest compared to [**1-23**] through [**1-30**]:

Moderate right hemopneumothorax continues to increase both in
the volume of air which is largely apical and fluid which is
costal and dependent. Small left pleural effusion has been
present without much change.
Moderate-to-severe cardiac enlargement unchanged. Left PIC line
curving
medially beyond the level of the carina, is separated by such a
distance from the right lateral wall of the cardiac silhouette
that it suggests persistence of pericardial effusion.
.........................................................
[**2178-1-18**] Left Upper Extremity Doppler venous U/S
A tiny non-obstructive thrombus is seen within the left basilic
vein. The
proximal portion of the cephalic vein appears diminutive, and an
underlying nonocclusive thrombus cannot be excluded. There is
patent flow seen more distally.

IMPRESSION:
1. No DVT.
2. Small non-occlusive thrombus within the left basilic vein.
3. Diminutive caliber of the proximal portion of the left
cephalic vein. A
small thrombus in this area cannot be excluded.
.
[**2178-1-19**] ECHO
The left atrium is mildly dilated. The estimated right atrial
pressure is 10-15mmHg. Left ventricular wall thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic dysfunction with severe hypokinesis of the distal
septum and low normal contraction of the remaining segments
(LVEF = 45-50 %). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (?#) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild to
moderate ([**1-25**]+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is a small
circumferential pericardial effusion without echocardiographic
signs of tamponade.

IMPRESSION: Normal left ventricular cavity size with mild
regional systolic dysfunction suggestive of CAD (distal LAD
distribution). Mild-moderate mitral regurgitation. Mild
pulmonary artery systolic hypertension. Dilated ascending aorta.
 Compared with the prior study (images reviewed) of [**2177-12-11**],
the left ventricular systolic function is less vigorous with
suggestion of regionality and the severity of mitral
regurgitation is slightly greater. The pericardial effusion is
similar.
.
[**2178-1-19**] renal U/S:
FINDINGS: Suboptimal scan due to patient positioning. The right
kidney
measures 12.7 cm. Left kidney measures 11 cm. There is no
evidence of
hydronephrosis. The 2-mm non-obstructive stone seen on recent CT
in the lower pole of the left kidney is not clearly visualized.
The urinary bladder is collapsed, containing a Foley catheter.
There is right pleural effusion as seen on recent CXR.

IMPRESSION: No hydronephrosis.
.
[**2178-1-19**]: CT chest w/o contrast:
FINDINGS: The superior segment of the left lower lobe is
minimally aerated.  Otherwise, both lower lobes are still
collapsed. Aeration in both upper lobes is intact except for
residual atelectasis in the posterior segment of the right upper
lobe. There are no findings to suggest pneumonia or persistent
edema. Small pericardial effusion has decreased; there is no
indication of tamponade. Moderate to large, nonhemorrhagic
layering pleural effusions are stable and the pleural surfaces
remain smooth. Atherosclerotic calcification is present in left
main and its anterior descending and circumflex branches.
IMPRESSION: Severe, mildly improved bilateral lower lobe
atelectasis.
Improved right upper lobe atelectasis. Stable moderate layering
bilateral
pleural effusion. No edema or pneumonia.
.
[**2178-1-22**] CT Chest w/o contrast
CT CHEST WITHOUT IV CONTRAST: A right internal jugular line
terminates in the distal SVC and a left PICC terminates at the
cavoatrial junction. The
moderate posterior dependent right pleural effusion is smaller
and now
contains large, hyperdense clots. The circumferential hemothorax
in the right upper chest, new since the prior chest CT is
comparable in extent to the pleural rind on subsequent chest
radiographs. There is new atelectasis of the posterior segment
of the right upper lobe (2:13). Although there is minimal
reexpansion of the anterior basal segment, the remainder of the
right lower lobe is collapsed. On the left, the moderate
layering nonhemorrhagic pleural effusion is not appreciably
changed and causes persistent left lower lobe collapse. A low
density small pericardial effusion is stable, and there are no
radiographic findings of tamponade. The right chest tube is
unchanged in position, terminating at the superior aspect of the
right major fissure.
There is no mediastinal, axillary or supraclavicular
lymphadenopathy. Dense coronary calcifications appear unchanged.
The upper abdomen is partially imaged and appears unremarkable.
IMPRESSION:
1. New partially layering and partially loculated right
hemothorax.
2. New collapse of the posterior segment of right upper lobe;
persistent
near-collapse right lower lobe.
3. No change in moderate layering nonhemorrhagic left pleural
effusion and
left lower lobe collapse.


Brief Hospital Course:
56 yo male with history of HTN, Type II DM,, and Fournier's
gangrene presented with hypoxemic respiratory failure and [**Last Name (un) **]
thought to be secondary to flash pulm edema whose course was
complicated by hydrothorax, now improving with stable Hct and
decreased O2 requirement.

# Hypoxemic respiratory failure/Acute on chronic systolic heart
failure: Patient likely awoke with PND, and subsequent
sympathetic drive likely led to flash pulm edema given history
(not catching breath) and initial vitals of 180s/100s and HR
100s.  Recent TTE showed LVH and diastolic dysfunction with some
regional systolic dysfunction.  Patient denied medication
non-compliance, and did not report heavy salt load.  Patient was
discharged three days prior to admission with furosemide 40 mg
daily, and was clearly overloaded on exam on admission.

He had improvement in his dyspnea with diuresis, positive airway
pressure, and hypertensive control.   He was initially diuresed
with a lasix drip.  He underwent a chest CT which showed pleural
effusions so IP was consulted for a therapeutic thoracentesis
which removed 1900 cc serous fluid.  His thoracentesis was
complicated by a hemothorax, requiring chest tube placement.

He was ruled out for MI with serial cardiac biomarkers.  His
metoprolol was increased to 50 mg tid.  He had a repeat echo
which showed slightly increased distal septum hypokinesis, but
no other changes from prior (EF 40%).  Pt was transferred to the
floor and auto-diuresed remaining negative 800-1800cc/day.  On
the day prior to discharge he was positive 500cc and so his home
lasix dose was restarted.  Pt had excellent oxygen saturations
on 2L NC.
.
# Fluid overload - Of note, the patient had over 17L diuresed
both with a lasix drip and auto-diuresis.  It is important to
monitor the patient's fluid status and fluid restrict him to
less than 2L/day and make sure his I/O's are even on a daily
basis.  If there is any weight gain greater than 5lbs, or
noticeable swelling of his lower extremities or other signs of
dependent edema, his lasix dose should be adjusted to ensure he
remains evolemic.
.
#  Hemo/pneumothorax: Initial post-[**Female First Name (un) 576**] film showed no
pneumothorax, however shortly afterwards he developed
right-sided pleuritic chest pain, became diaphoretic and
hypotensive, and syncopized.  He was found on repeat CXR to have
a right [**Last Name (un) **] lung hemothorax.  Thoracics was consulted and placed
a posterior right-sided chest tube which drained bloody fluid.
His Hct acutely dropped and he was transfused a total of 10
units of PRBC over several days (last transfusion was [**1-22**]).  A
repeat chest CT showed no change in the moderate right dependent
effusion or loculated hemothorax component.  His tube was on
wall suction at the time he was transferred to the floor.  Mr.
[**Known lastname **] had severe pain at the chest tube insertion site.  The site
was non-infected and his pain was controlled with Morphine
Q4H:PRN.  The patient continued to drain serosanguinous fluid
from his chest tube, but his Hct remained stable.  He was
monitored by thoracics and they pulled his chest tube on [**2178-1-29**].
 Follow up CXR initially showed some increase in pleural fluid
on the right, but it then stabilized on serial CXR.  Pt chest
tube site was non-tender at time of discharge and his
respiratory status is stable.  He will continued to be
moniotored at Rehab and we will continue to keep the patient
overall fluid negative.  Pt has follow up CXR on [**2178-2-8**] and
follow up appt with thoracic surgery on [**2178-2-18**]

# [**Last Name (un) **]/Chronic kidney disease - Thought to be initially secondary
to poor forward flow from acute systolic heart failure, however
it worsened with diuresis so renal was consulted.  Renal felt it
was consistent with ATN.  Improved somewhat with diuresis, but
not yet back to his recent baseline.  His creatinine during this
hospitalization never dipped below 2.3, which is still above his
recent baseline.  After speaking with renal it may be that this
is his new baseline as his kidneys may not fully recover from
this insult.  Also, he may just have prolonged recovery and his
creatinine may continue to trend down in the coming 8 weeks.  He
will need follow up labs to further assess his renal function.
His lisinopril was also held in the setting of acute renal
failure and will be held for 3-4 weeks and then restarted at a
home dose of 5mg PO Daily.

# Type II DM- He was initially treated with an insulin drip and
transitioned to basal/bolus a regimen.  He was continued on ASA.
 His insulin regiment was adjusted throughout the course of his
hospital stay as he had difficult to control finger sticks.
.
# HTN- He was continued on the metoprolol as above, clonidine,
and amlodipine.  The patient was hypertensive on arrival to the
floor in the setting of holding his lisinopril because of ARF.
His amlodipine was increased to 10mg PO Daily and his BP was
better controlled.  His amlodipine should be continued at 10mg
PO daily for now, but may need to be reduced back to 5mg when
his lisinopril is restarted on [**2178-2-24**].
.
# constipation:  The patient had intermittent episodes on left
sided abdominal pain, nausea and vomiting that resolved when he
had bowel movements.  While on the floor he would have one day
with large bowel movements and then would not have a bowel
movement for 2 days.  During these episodes of constipation, he
would develop nausea/vomiting and left sided pain.  These
symptoms were well controlled with zofran and increasing his
bowel regiment.  At the time of discharge all of his bowel meds
were standing and to be held if he had loose stools.  He will be
followed at rehab where they can further adjust his meds if
necessary.

# Fourniers gangrene- His dressings are changed daily and
according to wound care orders.  His wound has remained stable
and well granulated.

#  Staph epi bactermia:  Blood cultures from the OHS returned
during this hospitalization with 1/4 showing staph epi.  It was
thought to be a contaminant, however he was treated with 1 week
of vancomycin.  Pt has been afebrile and cultures have all been
negative at [**Hospital1 18**].

# HL- He was continued on his statin.  This was not an active
issue during the course of his hospital stay.

Code:  full


Medications on Admission:
insulin glargine 100 unit/mL Cartridge Sig: Ten (10) units daily
Humalog 100 unit/mL Cartridge Sig: as directed  QACHS SS
amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY
aspirin 325 mg Tablet Sig:
lisinopril 5 mg Tablet (has not received since discharge)
clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day
Zocor 40 mg Tablet Sig: One (1) Tablet PO once a day.
heparin (porcine) 5,000 unit/mL Solution
DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Neb Q6H PRN wheezing.
multivitamin daily
docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID


Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QFRI (every Friday).
4. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice
a day.
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1)  Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
9. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

10. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
11. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML
PO Q6H (every 6 hours): Hold for loose stools.
12. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily): Hold for loose stools.
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily): Hold for loose
stools.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): Hold for loose stools.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime):
Hold for loose stools.
16. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
17. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
18. gabapentin 300 mg Capsule Sig: One (1) Capsule PO every
twelve (12) hours.
19. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
20. insulin glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous QHS.
21. insulin lispro 100 unit/mL Solution Sig: Six (6) Units
Subcutaneous before meals (breakfast, lunch, Dinner).
22. insulin lispro 100 unit/mL Solution Sig: As per sliding
scale  Subcutaneous QAC and hs: 101-150: 2 units
151-200: 4 Units
201-250: 6 Units
251-300: 8 units
301-350: 10 Units
351-400: 12 Units
>400: 14 units and notify MD.
23. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
Primary Diagnosis:
Fluid overload
.
Secondary diagnosis:
-recent hypoxic resp failure, [**2-25**] sCHF and MRSA
tracheobronchitis
-DM type 2
-gastroparesis
-MRSA infections
-kidney stones
-hypertension
-hypercholesterolemia
-Fournier's gangrene


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You are being discharged from [**Hospital1 **].  It was a pleasure taking care of you during your
hospital stay.  You were admitted to the hospital on [**2178-1-17**]
for excessive fluid in your body and shortness of breath because
a lot of the fluid was in your lungs.  You were transferred here
from Rehab and you were admitted to the ICU.  In the ICU you
required oxygen support and we agressively removed fluid from
your body.  It was hard to get fluid off and you were still very
short of breath.  The intensive care unit thought it would be
best to drain the fluid from the right lung and evaluate it.  A
thoracentesis was done and it was complicated by blood building
up in the space between your lungs and the chest wall.  A chest
tube was placed to drain the blood.  During your ICU stay, over
15L of fluid was removed from your body with diuretics and
drainage from the chest tube.  Your oxygen requirement decreased
and you were transferred to the floor for further management.
On the floor you were continued to be monitored and you
continued to improve.  The chest tube was removed a few days
prior to discharge.  You did well and follow up CXR showed
stable lung fields with minimal to no accumulation of blood or
other fluid.  During your stay you had episodes of nausea that
were well controlled with medications.  The nausea and vomiting
also coincided with episodes of constipation.  Your bowel
regiment was maximized and your symptoms always resolved with
movement of stool.  You will be sent to Rehab on a bowel
regiment that will help to keep you regular.  It is important
that you learn to care for your colostomy bag as you will need
to do a lot of self-care after discharge from Rehab.  The Rehab
facility will be given instructions on how to care for the
colostomy bag as well as the debrided gangrene site.
.
The Following medications were STARTED during this admission:
Bisacodyl 10 mg by mouth DAILY
Milk of Magnesia 30 mL by mouth every 6 hours
Polyethylene Glycol 17 g by mouth DAILY
Senna 2 TAB by mouth at bedtime
Zinc Sulfate 220 mg by mouth DAILY
Ondansetron 8 mg by mouth every 8 hours as needed for nausea
Famotidine 20 mg by mouth daily

Please take your medications as prescribed.

Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 32949**] when you are out of rehab
for an appt for follow up.

Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2178-2-17**] at 10:30 AM
With: [**Name6 (MD) 1532**] [**Last Name (NamePattern4) 8786**], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: EAST     Best Parking: [**Street Address(1) 592**] Garage
{'Acute and chronic respiratory failure,Methicillin resistant pneumonia due to Staphylococcus aureus,Acute on chronic systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Urinary tract infection, site not specified,Mechanical complication of tracheostomy,Ventilator associated pneumonia,Other primary cardiomyopathies,Acute bronchitis,Gastroparesis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Pressure ulcer, buttock,Dysthymic disorder,Chronic kidney disease, unspecified,Vascular disorders of male genital organs,Anemia of other chronic disease,Pure hypercholesterolemia,Other constipation,Hyperpotassemia,Obstructive sleep apnea (adult)(pediatric),Long-term (current) use of insulin,Personal history of Methicillin resistant Staphylococcus aureus,Colostomy status'}


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: Hypoxia

PRESENT ILLNESS: 56M with T2DM, HTN, DL, previously admitted for Fournier's
gangrene c/b need for diverting colostomy and failure to wean
from vent, s/p tracheostomy now p/w respiratory distress from
[**Hospital3 **] hospital.
.
At rehab, in the PM of [**1-5**], began c/o of SOB/left chest pain.
On assessment, was AAOx3, 80% sat on 12 L O2 tracheostomy. His
BP ranged from 133/73-151/81, HR 100. Enroute 02 sat decreasd to
70s. Tracheostomy suctioned x4 enroute with improvement in
oxygenationation to 70's to 80s.
.
In the ED initial vitals, 97.8, 85, 160/75, 18, 86% on NRB.
Patient was uncomfortable in obvious distress. Unable to
ventilate through trach. ED team bronched patient and found an
obstructing 'mass'- fibrinous. Was given toradol when feeling
feverish and ativan for anxiety. Surgery was consulted and
replaced trach - patient desatted. ABG at this time 7.40/51/69.
Anesthesia was contact[**Name (NI) **] and patient was intubated (difficult
intubation). CXR with ET tube at 6.8 cm, bilateral patchy
infiltrates stable from prior, cardiomegaly with left lower lobe
opacity conerning for effusion vs infiltrate. Labs with white
count of 16.4 with left shift. Creatinine of 1.4. BNP of [**Numeric Identifier 87941**]
and Troponin T of 0.18. EKG with sinus tachycardia no evidence
of ischemia. Patient started on nitro drip and lasix 40mg IV x
one given concern for CHF. Also given Vanc/Zosyn for HAP.
Dysynchronous on vent so given propofol and patient became
hypotension. Vitals prior to transfer: HR 82, CMV 15/500/Fi02
100%, 136/75.
.
In the ICU, patient intubated and sedated, hemodynamically
stable.

MEDICAL HISTORY: -DM type 2
-gastroparesis
-MRSA infections
-kidney stones
-hypertension
-hypercholesterolemia
-Fournier's gangrene

MEDICATION ON ADMISSION: Norvasc 10 mg daily
Lasix 40 mg daily
Neurontin 300 mg [**Hospital1 **]
Amaryl 4 mg daily
lisinopril 5 mg daily
Reglan 10 mg QID
Lopressor 50 mg [**Hospital1 **]
Zocor 40 mg daily
DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Neb Solution INH Q6H PRN
Clonidine 0.3 mg/24 hr Transdermal Patch QSunday
Heparin (porcine) 5,000 unit SC TID
Aspirin 325 mg Tab daily
Hydromorphone 2-4 mg Tab Q4H PRN
Novolin N 12 units QAM at 0730 and 16 units QPM at 1700 SC
Hyoscyamine 0.25 mg Q6H PRN
Hexavitamin daily
Milk of Magnesia 30 mL QHS

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: VS: Temp: Afebrile BP:133/72 HR:80 RR:14 O2sat 100
GEN: intubated, sedated
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: Diminished left base, good airmovement no
wheezing/rales/rhonchi
CV: RR, S1 and S2 wnl, no m/r/g
ABD: obese, nd, +b/s, soft, nt
EXT: 3+ lower extremity
SKIN: no rashes/no jaundice/no splinters - deep decubitus
ulceration perineum and left gluteus which appears stable.
NEURO: Sedated.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Former policeman. Was at rehab recovering from recent
hospitalization ([**Hospital3 7665**] in [**Hospital1 3597**], NH). HCP is brother
[**Name (NI) **] [**Name (NI) **]. 

### Response:
{'Acute and chronic respiratory failure,Methicillin resistant pneumonia due to Staphylococcus aureus,Acute on chronic systolic heart failure,Acute kidney failure with lesion of tubular necrosis,Urinary tract infection, site not specified,Mechanical complication of tracheostomy,Ventilator associated pneumonia,Other primary cardiomyopathies,Acute bronchitis,Gastroparesis,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Pressure ulcer, buttock,Dysthymic disorder,Chronic kidney disease, unspecified,Vascular disorders of male genital organs,Anemia of other chronic disease,Pure hypercholesterolemia,Other constipation,Hyperpotassemia,Obstructive sleep apnea (adult)(pediatric),Long-term (current) use of insulin,Personal history of Methicillin resistant Staphylococcus aureus,Colostomy status'}
