CHIEF COMPLAINT: Dyspnea

PRESENT ILLNESS: 66F with morbid obesity, COPD on 2-3L at baseline, OSA, obesity
hypoventialtion, recurrent aspiration PNA initially presented to
[**Hospital1 **] with SOB and s/p fall and now transferred here in shock,
intubated for hypoxic respiratory failure, with A flutter with
RVR.
.
Pt intubated prior to admission so history obtained mostly from
medical records and confirmation with sister. She had been
having SOB x2-3 days. Unclear if she had also been having cough
or fevers. [**3-26**] she had an unwitnessed fall with associated
dizziness and then called out to her [**Age over 90 **] y.o. mother whom she
lives with for help. She appeared to have hit her head though it
was unclear if she had LOC. She was brought to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] by
EMS. Prior to arrival she was noted to be tachycardic to 150s
which was felt to be SVT. She received adenosine 6 mg then 12 mg
with little effect. In [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] she was started on dilt drip
and digoxin 0.5mg without effect. She was also quite dyspneic
and she was started on BiPAP. She clinically worsened and was
noted to be altered so she was intubated. Pt was a difficult
intubation d/t size, anatomy, was successfully tubed w/ 2nd
attempt. She also uncerwent head CT and C-spine CT for her fall
which were negative except for old C2 fracture and cervical
stenosis/DJD. Her pupils unequal in size, both reactive, R->3 to
2, L->5-3/4. Because of the unequal pupils her head CT was
repeated which again did not show ICH or mass effect. There was
also concern for PE so she received one dose of lovenox and then
transferred to [**Hospital1 18**].
.
In the ED, initial VS were: Pulse: 150, RR: 24, BP: 142/75,
Rhythm: Atrial Fibrillation, O2Sat: 89, O2Flow: 100 fio2. Her
initial ABG was 7.32/51/72/27. Her lactate was normal and her
first set of troponins was normal. Cardiology performed a
limited bedside echo which showed small RV with good
contractility, no suggestion of PE per report from ED. She was
given Vanc/zosyn and admitted to the MICU.
.
On arrival to the MICU, patient's VS. HR150 BP 120/102. Shortly
after admission her BP dropped to systolic in 60s with HR
persistently 150s. EKG showed ventricular rate of 150, rhythm
appeared either sinus tach or flutter with 2:1 conduction. She
was given 6mg IV adenosine which slowed the vent rate and
demonstrated flutter waves.
She received 1L NS bolus and digoxin 0.25. Her blood pressure
repsoned well and slowly her HR decreased to 90-100s.
.
Of note she has been hospitalized twice ([**Month (only) 404**] then [**Month (only) 958**])
this year for falls complicated by hypoxia. The most recent time
she was treated with levo/flagyl for presumed aspiration PNA.
.

MEDICAL HISTORY: hemorrhoids - since age 20
COPD - on 2.5 L oxygen during exertion
osteoarthritis
obstructive sleep apnea on CPAP
?CHF - EF unknown
h/o colon polyps - [**11-13**] polypectomy
s/p tonsilectomy
s/p appendectomy

MEDICATION ON ADMISSION: venlafaxine 75 Daily
tramadol 50 mg QID
Oxycodone-acetaminophen 5 mg-325 mg [**12-10**] Tablet(s) Every 4-6 hrs,
PRN
Ambien 10 mg QHS
cholecalciferol (vitamin D3) 1,000 unit Tab Oral
omeprazole 20 mg daily
fluticasone-salmeterol 500 mcg-50 [**Hospital1 **]
tiotropium bromide 18 mcg
mupirocin 2 % Ointment Topical
gabapentin 800 mg Tab Oral QHS
gabapentin 400 mg Tab Oral daily
duloxetine 30 mg Cap, delayed release Oral 2 daily
fluticasone 0.05 % Topical Cream Topical PRN
Celebrex 200 mg Cap Oral daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
General: Morbidly obese woman, intubated and sedated,
withdrawing to pain and flashlight
HEENT: Small abrasion over forehead, dried blood in nostril,
Sclera anicteric, dMM, L pupil 5->4, R 3->2
Neck: Unable to appreciate JVD because of body habitus.
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Intubated with transmitted vent sounds throughout, no
wheezes or crackles heard on anterior exam.
Abdomen: Obese, soft, non-distended, bowel sounds present, not
withdrawing to palpation
GU: foley in place
Ext: somewhat cool but appearing well perfused, b/l LE edema.

FAMILY HISTORY: h/o colon CA

SOCIAL HISTORY: h/o tobacco use, occasional EtOH. Divorced. Lives with [**Age over 90 **] year
old mother.
Other staphylococcal septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute and chronic respiratory failure,Hemoptysis, unspecified,Atrial flutter,Obesity hypoventilation syndrome,Body Mass Index 50.0-59.9, adult,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Delirium due to conditions classified elsewhere,Urinary tract infection, site not specified,Severe sepsis,Obstructive sleep apnea (adult)(pediatric),Chronic airway obstruction, not elsewhere classified,Depressive disorder, not elsewhere classified,Constipation, unspecified,Fever, unspecified,Other extrapyramidal diseases and abnormal movement disorders,Other chronic pain,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Anemia, unspecified,Other dependence on machines, supplemental oxygen,History of fall,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use
Staphylcocc septicem NEC,Septic shock,Food/vomit pneumonitis,Acute & chronc resp fail,Hemoptysis NOS,Atrial flutter,Obesity hypovent synd,BMI 50.0-59.9, adult,Acute kidney failure NOS,Hyperosmolality,Delirium d/t other cond,Urin tract infection NOS,Severe sepsis,Obstructive sleep apnea,Chr airway obstruct NEC,Depressive disorder NEC,Constipation NOS,Fever NOS,Extrapyramidal dis NEC,Chronic pain NEC,Osteoarthros NOS-unspec,Anemia NOS,Depend-supplement oxygen,Personal history of fall,Adv eff antipsychotc NEC
Admission Date:  [**2193-3-26**]              Discharge Date:   [**2193-4-29**]

Date of Birth:  [**2126-4-22**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Dyspnea

Major Surgical or Invasive Procedure:
Intubation and Mechanical Ventilation
Bronchoscopy x2
Internal jugular central line placement
Swan Ganz catheter placement
PICC line placement, removal and replacement

History of Present Illness:
66F with morbid obesity, COPD on 2-3L at baseline, OSA, obesity
hypoventialtion, recurrent aspiration PNA initially presented to
[**Hospital1 **] with SOB and s/p fall and now transferred here in shock,
intubated for hypoxic respiratory failure, with A flutter with
RVR.
.
Pt intubated prior to admission so history obtained mostly from
medical records and confirmation with sister. She had been
having SOB x2-3 days. Unclear if she had also been having cough
or fevers. [**3-26**] she had an unwitnessed fall with associated
dizziness and then called out to her [**Age over 90 **] y.o. mother whom she
lives with for help. She appeared to have hit her head though it
was unclear if she had LOC. She was brought to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] by
EMS. Prior to arrival she was noted to be tachycardic to 150s
which was felt to be SVT. She received adenosine 6 mg then 12 mg
with little effect. In [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] she was started on dilt drip
and digoxin 0.5mg without effect. She was also quite dyspneic
and she was started on BiPAP. She clinically worsened and was
noted to be altered so she was intubated. Pt was a difficult
intubation d/t size, anatomy, was successfully tubed w/ 2nd
attempt. She also uncerwent head CT and C-spine CT for her fall
which were negative except for old C2 fracture and cervical
stenosis/DJD. Her pupils unequal in size, both reactive, R->3 to
2, L->5-3/4. Because of the unequal pupils her head CT was
repeated which again did not show ICH or mass effect. There was
also concern for PE so she received one dose of lovenox and then
transferred to [**Hospital1 18**].
.
In the ED, initial VS were: Pulse: 150, RR: 24, BP: 142/75,
Rhythm: Atrial Fibrillation, O2Sat: 89, O2Flow: 100 fio2. Her
initial ABG was 7.32/51/72/27. Her lactate was normal and her
first set of troponins was normal. Cardiology performed a
limited bedside echo which showed small RV with good
contractility, no suggestion of PE per report from ED. She was
given Vanc/zosyn and admitted to the MICU.
.
On arrival to the MICU, patient's VS. HR150 BP 120/102. Shortly
after admission her BP dropped to systolic in 60s with HR
persistently 150s. EKG showed ventricular rate of 150, rhythm
appeared either sinus tach or flutter with 2:1 conduction. She
was given 6mg IV adenosine which slowed the vent rate and
demonstrated flutter waves.
She received 1L NS bolus and digoxin 0.25. Her blood pressure
repsoned well and slowly her HR decreased to 90-100s.
.
Of note she has been hospitalized twice ([**Month (only) 404**] then [**Month (only) 958**])
this year for falls complicated by hypoxia. The most recent time
she was treated with levo/flagyl for presumed aspiration PNA.
.


Past Medical History:
hemorrhoids - since age 20
COPD - on 2.5 L oxygen during exertion
osteoarthritis
obstructive sleep apnea on CPAP
?CHF - EF unknown
h/o colon polyps - [**11-13**] polypectomy
s/p tonsilectomy
s/p appendectomy


Social History:
h/o tobacco use, occasional EtOH. Divorced. Lives with [**Age over 90 **] year
old mother.


Family History:
h/o colon CA

Physical Exam:
ADMISSION EXAM:
General: Morbidly obese woman, intubated and sedated,
withdrawing to pain and flashlight
HEENT: Small abrasion over forehead, dried blood in nostril,
Sclera anicteric, dMM, L pupil 5->4, R 3->2
Neck: Unable to appreciate JVD because of body habitus.
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Intubated with transmitted vent sounds throughout, no
wheezes or crackles heard on anterior exam.
Abdomen: Obese, soft, non-distended, bowel sounds present, not
withdrawing to palpation
GU: foley in place
Ext: somewhat cool but appearing well perfused, b/l LE edema.

DISCHARGE EXAM:
Tmax: 37.3 ??????C (99.1 ??????F)
Tcurrent: 37.1 ??????C (98.7 ??????F)
HR: 90 (77 - 97) bpm
BP: 103/39(43) {90/39(43) - 141/107(112)} mmHg
RR: 15 (14 - 28) insp/min
SpO2: 96%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 126.5 kg (admission): 147.7 kg
Height: 65 Inch
General: Morbidly obese woman in NAD, mildly agitated at times
but readily reirectable with encouragment and prn seroquel,
able to mouth words ??????I feel cold?????? when not using pass?????? muir
valve, and fully able to express needs with valve in place
NEURO: opens eye to voice. Moves all 4 extremities to command,
tracks, mouths words
HEENT: Sclera anicteric, PERRL, conjugate gaze
Neck: trach in place. Obese neck.
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Anterior/lateral exam only.  Less coarse breath sounds,
no wheezes, no crackles, Posterior: scattered rhonchi, improved
with deep breathing
Abdomen: Obese, soft, nondistended, mild TTP in the LLQ, bowel
sounds present
GU: foley in place  draining yellow urine
Ext: well perfused w/palpable DP/PT pulses, positive LE edema

Pertinent Results:
ADMISSION LABS:
[**2193-3-26**] 07:23PM   WBC-10.2 RBC-4.29 HGB-11.9* HCT-40.1 MCV-94
MCH-27.8 MCHC-29.7* RDW-16.3*
[**2193-3-26**] 07:23PM   NEUTS-91.4* LYMPHS-6.9* MONOS-1.0* EOS-0.4
BASOS-0.3
[**2193-3-26**] 07:23PM   PT-12.5 PTT-34.8 INR(PT)-1.2*
[**2193-3-26**] 07:23PM   PLT COUNT-289
[**2193-3-26**] 07:22PM   GLUCOSE-167* LACTATE-1.1 NA+-141 K+-4.5
CL--105 TCO2-25
[**2193-3-26**] 07:23PM   GLUCOSE-174* UREA N-8 CREAT-0.5 SODIUM-144
POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-25 ANION GAP-15
[**2193-3-26**] 07:23PM   cTropnT-0.01
[**2193-3-26**] 10:22PM   LACTATE-1.5
[**2193-3-26**] 08:30PM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM

[**2193-3-26**] 08:30PM URINE  RBC-15* WBC-11* BACTERIA-FEW YEAST-NONE
EPI-1
[**2193-3-26**] 07:37PM  TYPE-ART PO2-72* PCO2-51* PH-7.32* TOTAL
CO2-27 BASE XS-0
.
OTHER PERTINENT LABS
[**2193-4-13**] 03:11PM BLOOD ESR-124*
[**2193-4-13**] 02:31AM BLOOD CRP-78.3*
[**2193-3-27**] 02:14AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2193-3-29**] 02:52AM BLOOD RheuFac-9
[**2193-4-12**] 03:02PM BLOOD C3-162 C4-36
[**2193-3-27**] 02:14AM BLOOD ANCA-NEGATIVE B
[**2193-4-9**] 02:44AM BLOOD TSH-5.5*
[**2193-4-10**] 02:39AM BLOOD Free T4-1.1
[**2193-4-9**] 02:44AM BLOOD Cortsol-22.0*
[**2193-4-13**] 02:31AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND
[**2193-4-8**] 02:16AM BLOOD B-GLUCAN-146 pg/mL (positive = > 80
pg/mL)
[**2193-4-8**] 02:16am BLOOD ASPERGILLUS ANTIGEN 0.1 (NEGATIVE)
[**2193-3-27**] 02:14AM BLOOD ANTI-GBM IgG <1.0 (negative)
.
DISCHARGE LABS
.
MICRO
[**2193-4-13**] IMMUNOLOGY CMV Viral Load-PENDING
[**2193-4-13**] Rapid Respiratory Viral Screen & Culture-PENDING;
Respiratory Viral Antigen Screen-PENDING
[**2193-4-13**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY; LEGIONELLA CULTURE-PRELIMINARY INPATIENT
[**2193-4-11**] STOOL C. difficile DNA amplification assay-FINAL;
FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL
[**2193-4-10**] CATHETER TIP-IV WOUND CULTURE-FINAL
[**2193-4-10**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2193-4-9**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST}
[**2193-4-9**] URINE URINE CULTURE-FINAL
[**2193-4-9**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2193-4-7**] URINE URINE CULTURE-FINAL
[**2193-4-7**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2193-4-7**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST}
[**2193-4-7**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2193-4-5**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2193-4-5**] URINE URINE CULTURE-FINAL
[**2193-4-5**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2193-4-4**] CATHETER TIP-IV WOUND CULTURE-FINAL
[**2193-4-4**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2193-4-3**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2193-4-3**] CATHETER TIP-IV WOUND CULTURE-FINAL
[**2193-4-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2193-3-31**] CATHETER TIP-IV WOUND CULTURE-FINAL
[**2193-3-30**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2193-3-30**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2193-3-30**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL
CULTURE-PRELIMINARY; BLOOD/AFB CULTURE-PRELIMINARY
[**2193-3-29**] BLOOD CULTURE NOT PROCESSED
[**2193-3-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2193-3-29**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2193-3-28**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2193-3-27**] Rapid Respiratory Viral Screen & Culture Respiratory
Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL
INPATIENT
[**2193-3-27**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL; LEGIONELLA CULTURE-FINAL; POTASSIUM HYDROXIDE
PREPARATION-FINAL; Immunoflourescent test for Pneumocystis
jirovecii (carinii)-FINAL; FUNGAL CULTURE-FINAL; VIRAL CULTURE:
R/O CYTOMEGALOVIRUS-PRELIMINARY; CYTOMEGALOVIRUS EARLY ANTIGEN
TEST (SHELL VIAL METHOD)-FINAL
[**2193-3-27**] MRSA SCREEN MRSA SCREEN-FINAL
[**2193-3-27**] Rapid Respiratory Viral Screen & Culture Respiratory
Viral Culture-FINAL; Respiratory Viral Antigen Screen-FINAL
[**2193-3-27**] URINE Legionella Urinary Antigen -FINAL
[**2193-3-27**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL;
LEGIONELLA CULTURE-FINAL; FUNGAL CULTURE-FINAL {YEAST}
[**2193-3-26**] MRSA SCREEN MRSA SCREEN-FINAL
[**2193-3-26**] BLOOD CULTURE Blood Culture, Routine-FINAL {ANAEROBIC
GRAM POSITIVE COCCUS(I)}; Anaerobic Bottle Gram Stain-FINAL
[**2193-3-26**] URINE URINE CULTURE-FINAL
[**2193-3-26**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPHYLOCOCCUS, COAGULASE NEGATIVE, CORYNEBACTERIUM SPECIES
(DIPHTHEROIDS), STAPHYLOCOCCUS EPIDERMIDIS, ANAEROBIC GRAM
POSITIVE COCCUS(I)}; Aerobic Bottle Gram Stain-FINAL; Anaerobic
Bottle Gram Stain-FINAL
.
STUDIES
.
EKG [**3-26**]
Probable atrial flutter with 2:1 block. Low voltage throughout.
Since the
previous tracing of [**2187-5-11**] atrial flutter is new. Low voltage is
new.
The axis is now more leftward. Clinical correlation is
suggested.
.
[**2193-3-27**] TTE ECHO
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with severe
hypokinesis of the apex (clip [**Clip Number (Radiology) **]) and possibly the basal
inferior wall (clip [**Clip Number (Radiology) **]). The remaining segments contract
normally (LVEF = 55-60 %). Right ventricular chamber size and
free wall motion are normal. The aortic valve leaflets (?#)
appear structurally normal with good leaflet excursion. There is
no aortic valve stenosis. There is no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a small posterior pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal cavity size and regional
systolic dysfunction suggestive of CAD, but preserved global
systolic function. No definite valvular pathology or pathologic
flow identified. Small posterior pericardial effusion.
.
[**2193-3-29**] TEE ECHO
Findings
Patient was intubated in the ICU and sedated with a versed and
fentanyl drip. The GE junction was not crossed.
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Good RAA ejection velocity
(>20cm/s). Normal interatrial septum. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Complex (>4mm) atheroma in the descending thoracic aorta.

AORTIC VALVE: Normal aortic valve leaflets (3). No masses or
vegetations on aortic valve. No AR.
MITRAL VALVE: Normal mitral valve leaflets. No mass or
vegetation on mitral valve. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or
vegetation on tricuspid valve. Mild [1+] TR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Informed consent was obtained. A TEE was
performed in the location listed above. I certify I was present
in compliance with HCFA regulations. The patient was monitored
by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient
was under general anesthesia throughout the procedure. Local
anesthesia was provided by benzocaine topical spray. Results
Left pleural effusion.
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Right atrial appendage ejection
velocity is good (>20 cm/s). No atrial septal defect is seen by
2D or color Doppler. Overall left ventricular systolic function
is normal (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. There are complex (>4mm, non-mobile)
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No masses or vegetations are seen on the aortic
valve. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. No mass or vegetation is seen
on the mitral valve. Mild (1+) mitral regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of intracardiac
thrombus or endocarditis seen. Mild mitral regurgitation.
Complex, non-mobile atheroma in the descending aorta.
.
IMAGING
.
CXR [**3-26**]
Single AP portable view of the chest was obtained. Endotracheal
tube is seen terminating approximately 4.6 cm above the level of
the carina. Nasogastric tube is seen, coursing below the level
of the diaphragm, distal tip not well seen. There are diffuse
bilateral airspace opacities worrisome for severe pulmonary
edema. Cardiac silhouette is mildly enlarged. No large pleural
effusion or pneumothorax is seen, although the right
costophrenic angle is not fully included on the image.
.
CXR [**3-28**]
New right transjugular Swan-Ganz catheter ends in the right
pulmonary artery (best seen on the digitally augmented view).
Mild-to-moderate interstitial pulmonary abnormality is already
cleared from the left lung, improving on the right. Heart size
normal. No pneumothorax or appreciable pleural effusion.
Nasogastric tube passes into the stomach and out of view. Right
PIC line ends in the mid-to-low SVC.
.
[**4-5**] CT TORSO
CT CHEST:
64-row MDCT was performed from the thoracic inlet to the base of
the lung
following administration of 150 mL of intravenous contrast.
The endotracheal tube is in good position above the carina. Tip
of the NG
tube is in the distal stomach.
There is adequate opacification of the thoracic aorta and
pulmonary arteries.
There is no evidence of aneurysm or dissection. No central
filling defects
are seen in the main pulmonary arteries.
There is a 19 x 15 mm right hilar node, series 2, image 25. A
second, smaller right hilar node is seen measuring 11.6 mm,
series 2, image 26. There are bilateral pleural effusions, right
greater than left. There is associated atelectasis at both lung
bases. The upper lobes are relatively clear. There is a small
pericardial effusion, series 2, image 37 measuring an average of
10 Hounsfield units consistent with simple fluid.
The visualization of the abdominal organs is somewhat limited by
streak
artifact secondary to the patient's body habitus. However,
within these
limitations, the liver, spleen, adrenal glands, pancreas, and
gallbladder are unremarkable. Both kidneys enhance in a normal
fashion. There are no renal masses.
Evaluation of the right lateral subcutaneous soft tissues is
precluded
secondary to streak artifact from the patient's side abutting
the CT gantry.  However, along the left lateral abdominal wall,
there is an area of subcutaneous edema measuring approximately 4
x 9 x 20 cm. The wall of this collection does not enhance, and
findings are more consistent with
subcutaneous edema rather than an abscess. However, attention to
this area on subsequent imaging studies is recommended to ensure
that an abscess is not forming.
CT PELVIS:
64-row MDCT was performed from the iliac crest to the symphysis
pubis
following administration of oral and intravenous contrast.
In the subcutaneous fat of the anterior abdominal wall, left
greater than
right, are several subcutaneous soft tissue densities. These all
measure less than 2 cm and most likely represent site of prior
injection.
The colon is visualized from the cecum to the rectum and is
moderately
distended and fluid filled. However, the small bowel is not
dilated. The
bladder is decompressed with a Foley catheter.
BONE WINDOWS: There is narrowing of the L2-3 disc space. There
is narrowing of several mid thoracic disc spaces as well.
However, there are no lytic or blastic lesions.
IMPRESSION:
1. Several nonspecific findings including bilateral pleural
effusions with
associated lower lobe atelectasis, small pericardial effusion,
and fairly
extensive inflammatory changes in the subcutaneous fat of the
left abdominal wall.
2. Distended completely fluid-filled colon without evidence of
small bowel
dilatation. Question if the patient has diarrhea to explain the
fluid-filled colon. However, the wall of the colon does not
appear to be thickened and does not demonstrate any abnormal
enhancement.
.
[**2193-4-13**] CXR POST-PICC PLACEMENT
FINDINGS: The PICC line has been re-positioned and the tip is
now in the mid SVC. Again seen is pulmonary vascular
re-distribution and alveolar
infiltrate, right greater than left. Compared to the films from
earlier the same day, the appearance of the right lung is
slightly worse.
.
[**2193-4-11**] EEG - IMPRESSION: Abnormal EEG due to a slow and
disorganized background
rhythm and due to bursts of bifrontal slowing. These findings
indicate
an encephalopathy involving both cortex and subcortical
structures. The
most common causes of encephalopathy are metabolic, infectious
or
medication-related. There were no prominent areas of focal
slowing
but encephalopathies can obscure focal findings. There were no
clear
epileptiform discharges
.
[**2193-4-14**] CT TORSO - IMPRESSION:
1.  Mild interseptal thickening, might represent pulmonary
congestion.
No pericardial or pleural effusion is seen on current
examination.

2.  Subsegmental atelectasis in the apical segment of the left
lower lobe and
in both lung bases, infection cannot be definitely ruled out.

3.  Small and large bowels are within normal limits.

4.  No intra-abdominal source for fevers is identified.
.
CXR [**2193-4-22**]:
FINDINGS:  As compared to the previous radiograph, there is no
relevant
change.  Unchanged evidence of minimal interstitial fluid
overload.  Minimal atelectasis at the right lung base.
Borderline size of the cardiac silhouette.  No overt pulmonary
edema.  No pleural effusions.  No pneumonia
.
CXR [**2193-4-23**]:
IMPRESSION; In order to differentiate recent widening of left
upper
mediastinum due to engorged mediastinal vessels which appears
reasonable as reflected by interval worsening mild pulmonary
edema vs acute aortic
pathology, erect view is recommended for further evaluation.
.
CXR [**2193-4-24**]: IMPRESSION:
Views of the torso centered at the diaphragm and in the left
upper abdominal quadrant show a nasogastric feeding tube,
absent.  The wire stylet, ending in the mid stomach.  Volumes
are still low and mediastinal widening is most likely due to
vascular engorgement.  Aside from right basal atelectasis there
is no focal pulmonary abnormality.  Pulmonary edema which was
present on [**4-17**], not recurred.  Tracheostomy tube in standard
placement.
.
ECG's:
Cardiovascular Report ECG Study Date of [**2193-4-24**]  12:07:58 PM
Sinus tachycardia. Poor R wave progression, likely a normal
variant.
Cannot exclude a prior anteroseptal myocardial infarction.
Compared to the
previous tracing of [**2193-4-22**] the rate has increased. Other
findings are
similar.
.
Cardiovascular Report ECG Study Date of [**2193-4-22**]  11:44:32 AM
Sinus rhythm at upper limits of normal rate. Borderline low limb
lead voltage. Considerable baseline artifact. Since the previous
tracing of [**2193-4-21**] no significant change.
.
Cardiovascular Report ECG Study Date of [**2193-4-21**]  6:22:26 PM
Sinus tachycardia. Compared to tracing #1 there is no
significant diagnostic change.
.
Lab Results on Discharge:

[**2193-4-25**] 03:21AM BLOOD WBC-10.0 RBC-3.54* Hgb-9.4* Hct-31.3*
MCV-88 MCH-26.5* MCHC-30.0* RDW-16.2* Plt Ct-428
[**2193-4-26**] 03:35AM BLOOD PT-23.8* PTT-38.7* INR(PT)-2.3*
[**2193-4-29**] 03:36AM BLOOD Na-140 K-3.0* Cl-94*
[**2193-4-15**] 02:24PM BLOOD ALT-14 AST-24 AlkPhos-59 TotBili-0.8
[**2193-4-28**] 05:18AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2
[**2193-4-15**] 02:24PM BLOOD Lipase-21
[**2193-4-4**] 03:14AM BLOOD Hapto-338*
[**2193-4-22**] 12:43PM BLOOD Type-[**Last Name (un) **] Temp-37.3 PEEP-10 pO2-41*
pCO2-53* pH-7.38 calTCO2-33* Base XS-4

Brief Hospital Course:
PRIMARY REASON FOR HOSPITALIZATION: Patient is a 66yo female
with history of morbid obesity, COPD on 2-3L at baseline, OSA,
obesity hypoventialtion, recurrent aspiration PNA who initially
presented to [**Hospital1 **] with SOB and s/p fall and transferred to
[**Hospital1 18**] in shock, and intubated for hypoxic respiratory failure,
with A flutter with RVR. She was cardioverted and anticoagulated
following the procedure for the prescribed amount of time. BAL
revealed blood on aspiration x3 consistent with diffuse alveolar
hemmorhage. Patient had a prolonged ventilator course with dense
delirium. She received a trach and was weaned to trach collar.
She was taken off of sedation and had gradual but steady
improvement in delirium to the point of being cooperative in her
care and not agitated. She was discharged for continued recovery
at a rehab facility.
.
ACUTE CARE:
1. Shock: Patient presented in shock of unclear etiology but
most likely septic versus cardiogenic. She did have evidence of
diffuse alveolar hemorrhage and ARDS presumed to be from
pneumonia though this was not clear. She was started on pressors
and broad spectrum antibiotics (Vanc/Zosyn/Levofloxacin). Her
blood cultures grew two bottles of coagulase negative
staphylococcus though her sputum cultures did not grow any
pathogenic organisms. Her body habitus and high PEEP requirement
made hemodynamic monitoring difficult and she persistently
required pressors so a swan ganz catheter was placed for further
hemodynamic monitoring. Her atrial flutter was believed to be
decreasing her cardiac output so she was cardioverted after TEE
did not show and thrombus or vegetations. After cardioversion,
fluid resucitation, and antibiotics she was able to be weaned
off pressors. She completed a 10 day course of antibiotics on
[**4-4**].
.
2. Hypoxic Respiratory Failure/Pneumonia: She has limited
baseline pulmonary function becasue of her COPD on 2-3L, OSA,
and obesity hypoventilation. The etiology of her acute
decompensation is of unclear etiology. CXR showed diffuse
bilateral alveolar reticular opacities and had ARDS by large A-a
gradient and PaO2/Fio2  ~72. Her bronchoscopy showed DAH though
vasculitis labs were negative. The most likely etiology was
believed to be pneumonia leading to ARDS and DAH. Because of her
large body habitus she required significant amount of PEEP to
maintain adequate oxygenation. Multiple attempts were made over
2 weeks to wean her from the vent, which were unsuccesful. She
was treated with a course of vancomycin, levofloxacin and zosyn
for a total of 10 days. Repeat bronchoscopy was performed [**4-13**]
and demonstrated blood-tinged sputum, suggestive of recurrent or
ongoing DAH. Eventually her vent settings were weaned and she
successfully underwent a tracheostomy on [**2193-4-17**].  She was weaned
from the vent after tracheostomy and was tolerating trach collar
at time of discharge. She was discharged on fluticasone and
ipratropium and albuterol inhaled. Salmetrol was held for
potential QT-prolonging interaction with seroquel, which she is
on for delirium.
.
3. Fluid overload: Patient was about 7L positive for length of
stay fluid balance. She was being diuresed with good effect on
60mg PO BID with potassium repletion on discharge. More
agressive diuresis had resultes in creatinine bumps. She was
discharged on the above lasix dosing and potassium repletion to
be followed and titrated to effect on discharge.
.
4. Atrial Flutter: Patient presented in atrial flutter with 2:1
conduction. Her rhythm was more apparent after she was given
adenosisne which demonstrated clear flutter waves. She was
started on digoxin for rate control though her rate persisted in
the low 100s. Because it was believed that her rhythm was
contributing to her persisttent pressor requirement, cardiology
was consulted for cardioversion. A TEE was performed which did
not show any clot and she was started on heparin and succesfully
cardioverted. She was then started on warfarin and amiodarone.
Heparin was stopped when her INR was therapeutic. She was
planned to receive one month of anticoagulation after her
cardioversion. She failed digoxin and was continued on
amiodarone, however this was discontinued out of concern for
continued drug fever.  Patient remained rate controlled on low
dose metoprolol which was discontinued after patient remained in
sinus rhythm for greater than 2 weeks after cardioversion.
Warfarin was continued for anticoagulation and titrated for
therapeutic INR for the prescibed duration post-cardioversion.
.
5. GPC Bacteremia: [**1-12**] initial blood cultures grew coagulase
negative staph. She was already started on vancomycin for her
PNA as above. Her cultures were sensitive to vancomycin.
Surveillance cultures remained negative. She underwent a TTE and
a TEE which did not show any vegetations. She did not have any
indwelling vascular access on admission. The PICC line that was
placed on the day after admission was removed. Later her central
line and arterial line were removed and cultures of the catheter
tips were negative.  She completed a 10 day course of
antibiotics on [**4-4**] and did not have any subsequent positive
blood cultures.
.
6. UTI: Patient had a positive UA on [**4-15**] and was started on
ceftriaxone. She received 3 day course, but urine culture
returned negative
.
7. Fever - patient developed persistent low grade fever on the
night of [**5-9**].  Temperature mainly rose in the PM and
overnight.  Persistent fever, curve trending up for a few days.
Source unclear. Only positive micro dat  was initial blood
culture from [**2193-3-26**] showing coagulase negative staph. Prior to
arrival she did not have any central lines, unclear source of
bacteremia. PICC line was placed on day of admission and was
later removed and culture negative, RIJ (cordis) placed later
while on vanc and was susbequently pulled with negative culture
tip as well. Now has only PICC, placed here.  No evolution of
her CXR, no diarrhea, no nasal mucus, skin intact.  Vanco/Zosyn
course completed [**4-4**]; she did appear to improve on ABX but not
entirely afebrile, but fever curve worsening.  CT torso
performed on [**4-5**] was unrevealing of any infectious source.
Sputum gram stain was notable for yeast and GPCs. Fungal
cultures were unremarkable.  ID was consulted given persistent
fever without identifiable cause. Felt pt most likely suffering
from drug fever, with seroquel most likely culprit medication.
It was stopped, and pt again spiked a fever above 101, making
that hypothesis unlikely. UA then showed moderate leukocytes,
and patient was started on ceftriaxone.  Urine culture was
negative, but patient did complete a 3 day course of
ceftriaxone.  Fever curver continued to be monitored and patient
remained afebrile for several days prior to discharge.
.
8. S/P fall: Pt had hx multiple falls prior to admission. On
presentation to the OSH the nature of her fall was unclear so
she underwent CT head and c-spine. Her CT head did not show any
changes though her C-Spine film did show an old C2 fracture.
Spine surgery evaluated the film and did not recommend further
workup. After treatment with albuterol and ipratropium at the
OSH she was noted to have an enlarged L pupil so a repeat head
CT was performed which again did not show any acute changes. On
admission here she had persisitently enlarged L pupil though
this resolved by the following day. This was believed to be from
incidental exposure of the eye to albuterol/ipratropium at the
OSH.
.
9. Altered mental status - patient was intermittently agitated
throughout the course of her ICU stay. Psychiatry was consulted
in the setting of acute agitation and inability to wean from
vent and patient was trialed on seroquel and haldol alternating.
 Seroquel was eventually used primarily with haldol prn, but
patient continued to become delirious at night, requiring extra
sedation.  Antipsychotics were weaned as tolerated and
benzodiazepines were avoided. QTc was monitored daily while
patient was on antipsychotics. On day of discharge, she was
requiring seroquel QHS and with a prn daytime seroquel dose that
she was not requiring.
.
CHRONIC CARE:
.
1. COPD: Patient is on 2-3L of home O2 at baseline. In the
settin of her acute respiratory illness, her home medications
were held and she was switched to standing albuterol and
ipratropium nebs. She was discharged on fluticasone MDI (she had
been on salmeterol/fluticasone at home prior to admission, and
only the inhaled glucocorticoid was continued on discharge). She
was also discharged on standing ipratropium and albuterol nebs.
.
2. DEPRESSION: Patient's home venlaxine was held and she was
placed on duloxetine with increased dosing while in the
hospital.
.
3. CHRONIC PAIN: Given patient's AMS, sedating medications were
held and she was given tylenol for pain. She had only a
complaint of mild cramping abdominal pain associated with tube
feeds during her stay.
.
.
.
.
TRANSITIONS IN CARE:
.
1. FOLLOW-UP: patient requires follow-up with PCP and with
pulmonology following discharge
2. MEDICATION CHANGES:
STOP: celebrex, venlafaxine, tramadol, percocet, ambien,
tiotropium, gabapentin, vitamin D tablets, omeprazole, advair
START:
ipratropium 6 puffs inhaled 4 times daily
albuterol sulfate 6 puff inhaled every six hours as needed for
shortness of breath or wheezing
seroquel 100mg by mouth nightly
seroquel 25mg by mouth four times daily as needed for agitation
potassium chloride 40meq by mouth twice daily
lasix 60mg by mouth twice daily
fluticasone 110mcg, 2 puffs inhaled twice daily
CHANGE:
duloxetine to 60mg by mouth daily
3. CONTACTS:[**Name2 (NI) **], Sister [**Name (NI) **] [**Name (NI) 1637**] [**Telephone/Fax (1) 97016**] (home);
work [**Telephone/Fax (1) 97019**]
4. OUTSTANDING CLINICAL ISSUES:
-patient will require titration of psychiatric and pain
medications stopped on this admission for altered mental status
as mental status clears
-on discharge, patient was positive approximately 7 liters
estimated for fluid balance. She had bumps in creatinine with
more agressive diuresis, but was continued on lasix 60 PO BID
for moderate diuresis with good effect, but requirement for
potassium supplementation. She should be monitored for
creatinine, fluid status, and potassium at least daily on
discharge
-patient's chronic pulmonary medications may need adjustment as
she is transitioned to a home regimen, keeping in mind the
QT-prolongation associated with salmeterol and seroquel
-patient requires close follow-up with pulmonology

Medications on Admission:
venlafaxine 75 Daily
tramadol 50 mg QID
Oxycodone-acetaminophen 5 mg-325 mg [**12-10**] Tablet(s) Every 4-6 hrs,
PRN
Ambien 10 mg QHS
cholecalciferol (vitamin D3) 1,000 unit Tab Oral
omeprazole 20 mg daily
fluticasone-salmeterol 500 mcg-50 [**Hospital1 **]
tiotropium bromide 18 mcg
mupirocin 2 % Ointment Topical
gabapentin 800 mg Tab Oral QHS
gabapentin 400 mg Tab Oral daily
duloxetine 30 mg Cap, delayed release Oral 2 daily
fluticasone 0.05 % Topical Cream Topical PRN
Celebrex 200 mg Cap Oral daily


Discharge Medications:
1. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation QID (4 times a day).
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
3. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
4. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. sodium chloride 0.65 % Aerosol, Spray Sig: [**12-10**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed for congestion.
7. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
8. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
9. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: do not administer more than 4 gm of
acetaminophen daily.
11. docusate sodium 50 mg/5 mL Liquid Sig: One (1) dose PO BID
(2 times a day) as needed for constipation.
12. quetiapine 25 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
13. quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QID (4 times
a day) as needed for agitation.
14. furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
15. potassium chloride 20 mEq Packet Sig: Two (2) Packet PO BID
(2 times a day).
16. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
17. 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.
18. Outpatient Lab Work
Please monitor daily electrolytes, particularly monitoring
potassium and creatinine while having lasix diuresis and
potassium repletion
19. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] at [**Hospital 1263**] Hospital

Discharge Diagnosis:
PRIMARY: Hypoxic respiratory failure, diffuse alveolar
hemmorhage, Shock, Delirium

Secondary: Chronic Obstructive Pulmonary Disease, Obesity
Hypoventilation Syndrome, Depression, Chronic Pain

Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.

Discharge Instructions:
Dear Ms. [**Known lastname 1637**],

You were admitted to the hospital after having fallen at home.
You developed severe shock and repiratory distress and required
a prolonged recovery period in the intesive care unit which was
complicated by you developing delirium. You had a tracheostomy
tube placed to allow you to breath with the ventilator, and you
slowly recovered ability to breath, and your mental status
improved. In the course of your stay, your heart entered an
abnormal rhythm and had to be shocked back to a normal rhythm as
well.

Please make the following changes to your medications:

STOP: celebrex, venlafaxine, tramadol, percocet, ambien,
tiotropium, gabapentin, vitamin D tablets, omeprazole, advair

START:
ipratropium 6 puffs inhaled 4 times daily
albuterol sulfate 6 puff inhaled every six hours as needed for
shortness of breath or wheezing
seroquel 100mg by mouth nightly
seroquel 25mg by mouth four times daily as needed for agitation
potassium chloride 40meq by mouth twice daily
lasix 60mg by mouth twice daily
fluticasone 110mcg, 2 puffs inhaled twice daily

CHANGE:
duloxetine to 60mg by mouth daily

Followup Instructions:
Please have your rehab facility arrange an appointment for your
with your PCP on discharge.

Department: Pulmonary
You will need to be seen by Pulmonary in 16-30 days after your
hospital discharge. The Pulmonary Department will contact you
with your appointment date and time. If you do not hear from the
Pulmonary Department in 2 business days please call the office
number listed below.
Phone: ([**Telephone/Fax (1) 513**]
{'Other staphylococcal septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute and chronic respiratory failure,Hemoptysis, unspecified,Atrial flutter,Obesity hypoventilation syndrome,Body Mass Index 50.0-59.9, adult,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Delirium due to conditions classified elsewhere,Urinary tract infection, site not specified,Severe sepsis,Obstructive sleep apnea (adult)(pediatric),Chronic airway obstruction, not elsewhere classified,Depressive disorder, not elsewhere classified,Constipation, unspecified,Fever, unspecified,Other extrapyramidal diseases and abnormal movement disorders,Other chronic pain,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Anemia, unspecified,Other dependence on machines, supplemental oxygen,History of fall,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use'}


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: Dyspnea

PRESENT ILLNESS: 66F with morbid obesity, COPD on 2-3L at baseline, OSA, obesity
hypoventialtion, recurrent aspiration PNA initially presented to
[**Hospital1 **] with SOB and s/p fall and now transferred here in shock,
intubated for hypoxic respiratory failure, with A flutter with
RVR.
.
Pt intubated prior to admission so history obtained mostly from
medical records and confirmation with sister. She had been
having SOB x2-3 days. Unclear if she had also been having cough
or fevers. [**3-26**] she had an unwitnessed fall with associated
dizziness and then called out to her [**Age over 90 **] y.o. mother whom she
lives with for help. She appeared to have hit her head though it
was unclear if she had LOC. She was brought to the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] by
EMS. Prior to arrival she was noted to be tachycardic to 150s
which was felt to be SVT. She received adenosine 6 mg then 12 mg
with little effect. In [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] she was started on dilt drip
and digoxin 0.5mg without effect. She was also quite dyspneic
and she was started on BiPAP. She clinically worsened and was
noted to be altered so she was intubated. Pt was a difficult
intubation d/t size, anatomy, was successfully tubed w/ 2nd
attempt. She also uncerwent head CT and C-spine CT for her fall
which were negative except for old C2 fracture and cervical
stenosis/DJD. Her pupils unequal in size, both reactive, R->3 to
2, L->5-3/4. Because of the unequal pupils her head CT was
repeated which again did not show ICH or mass effect. There was
also concern for PE so she received one dose of lovenox and then
transferred to [**Hospital1 18**].
.
In the ED, initial VS were: Pulse: 150, RR: 24, BP: 142/75,
Rhythm: Atrial Fibrillation, O2Sat: 89, O2Flow: 100 fio2. Her
initial ABG was 7.32/51/72/27. Her lactate was normal and her
first set of troponins was normal. Cardiology performed a
limited bedside echo which showed small RV with good
contractility, no suggestion of PE per report from ED. She was
given Vanc/zosyn and admitted to the MICU.
.
On arrival to the MICU, patient's VS. HR150 BP 120/102. Shortly
after admission her BP dropped to systolic in 60s with HR
persistently 150s. EKG showed ventricular rate of 150, rhythm
appeared either sinus tach or flutter with 2:1 conduction. She
was given 6mg IV adenosine which slowed the vent rate and
demonstrated flutter waves.
She received 1L NS bolus and digoxin 0.25. Her blood pressure
repsoned well and slowly her HR decreased to 90-100s.
.
Of note she has been hospitalized twice ([**Month (only) 404**] then [**Month (only) 958**])
this year for falls complicated by hypoxia. The most recent time
she was treated with levo/flagyl for presumed aspiration PNA.
.

MEDICAL HISTORY: hemorrhoids - since age 20
COPD - on 2.5 L oxygen during exertion
osteoarthritis
obstructive sleep apnea on CPAP
?CHF - EF unknown
h/o colon polyps - [**11-13**] polypectomy
s/p tonsilectomy
s/p appendectomy

MEDICATION ON ADMISSION: venlafaxine 75 Daily
tramadol 50 mg QID
Oxycodone-acetaminophen 5 mg-325 mg [**12-10**] Tablet(s) Every 4-6 hrs,
PRN
Ambien 10 mg QHS
cholecalciferol (vitamin D3) 1,000 unit Tab Oral
omeprazole 20 mg daily
fluticasone-salmeterol 500 mcg-50 [**Hospital1 **]
tiotropium bromide 18 mcg
mupirocin 2 % Ointment Topical
gabapentin 800 mg Tab Oral QHS
gabapentin 400 mg Tab Oral daily
duloxetine 30 mg Cap, delayed release Oral 2 daily
fluticasone 0.05 % Topical Cream Topical PRN
Celebrex 200 mg Cap Oral daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
General: Morbidly obese woman, intubated and sedated,
withdrawing to pain and flashlight
HEENT: Small abrasion over forehead, dried blood in nostril,
Sclera anicteric, dMM, L pupil 5->4, R 3->2
Neck: Unable to appreciate JVD because of body habitus.
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Intubated with transmitted vent sounds throughout, no
wheezes or crackles heard on anterior exam.
Abdomen: Obese, soft, non-distended, bowel sounds present, not
withdrawing to palpation
GU: foley in place
Ext: somewhat cool but appearing well perfused, b/l LE edema.

FAMILY HISTORY: h/o colon CA

SOCIAL HISTORY: h/o tobacco use, occasional EtOH. Divorced. Lives with [**Age over 90 **] year
old mother. 

### Response:
{'Other staphylococcal septicemia,Septic shock,Pneumonitis due to inhalation of food or vomitus,Acute and chronic respiratory failure,Hemoptysis, unspecified,Atrial flutter,Obesity hypoventilation syndrome,Body Mass Index 50.0-59.9, adult,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Delirium due to conditions classified elsewhere,Urinary tract infection, site not specified,Severe sepsis,Obstructive sleep apnea (adult)(pediatric),Chronic airway obstruction, not elsewhere classified,Depressive disorder, not elsewhere classified,Constipation, unspecified,Fever, unspecified,Other extrapyramidal diseases and abnormal movement disorders,Other chronic pain,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Anemia, unspecified,Other dependence on machines, supplemental oxygen,History of fall,Other antipsychotics, neuroleptics, and major tranquilizers causing adverse effects in therapeutic use'}
