CHIEF COMPLAINT: Acute respiratory Distress

PRESENT ILLNESS: 47M with history of OSA/COPD, bipolar, schizophrenia presenting
with increased somnolence and respiratory distress. At
approximately 940 this morning, patient was found by staff at
nursing home to be acute SOB with altered MS. [**Name14 (STitle) 103309**] to 53% on
RA. Was placed on 15L O2 non-rebreather, and O2 sat came up to
88%.  [**Name6 (MD) **] by NP, who called EMS.  On EMS arrival, GCS
reportedly 8. Given nebs, BiPAP, manually bagging, then with
improvement to GCS of 11. But even after nebs, poor breath
sounds bilaterally.

MEDICAL HISTORY: 1. Complex sleep disorder on bipap at night with severe
nocturnal and daytime hypoxia related to hypoventiliation
2. Schizophrenia
3. Bipolar disorder
4. CHF with diastolic dysfxn
5. Asthma
6. HTN
7. DM type 2, diet controlled
8. Erythrocythosis, thought secondary to hypoxia

MEDICATION ON ADMISSION: Medications:  This is old list -- check against nursing home
records
albuterol nebs prn
combinebs prn
asa 325
carbamazepine 200 qid
doxepin 10 qhs
furosemide 100mg [**Hospital1 **]
lisinopril 2.5 daily
metolazone 2.5 daily
metoprolol 12..5 [**Hospital1 **]
omeprazole 20 daily
kcl 60meq daily
risperidone 4mg [**Hospital1 **]
acetaminophen 650 q4 prn
benztropine 0.5mg daily prn dystonia
atrovent nebs q 6 hours prn

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission exam:
Admit Vitals:
General Appearance: Overweight / Obese / Intubated / Not
responsive to voice
Cardiovascular: (S1: Normal), (S2: Normal)
Respiratory / Chest: (Expansion: Symmetric)
Abdominal: Soft, Non-tender, Distended, Obese
Extremities: No(t) Cyanosis, No(t) Clubbing
Skin: Warm
Neurologic: Not following commands

FAMILY HISTORY: Mother with asthma, Several sibling all in good health. No
family history of cardiac dz or DM.

SOCIAL HISTORY: Has been living at [**Location 1268**] [**Hospital1 1501**] (RossCommons) since [**Month (only) 958**]
[**2134**] for his sleep apnea and BIPAP use. Sister is HCP
- [**Name (NI) 1139**]: none
- Alcohol: none
- Illicits: none
Acute and chronic respiratory failure,Cardiogenic shock,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Atrioventricular block, complete,Body Mass Index 40.0-44.9, adult,Bacteremia,Obesity hypoventilation syndrome,Chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Obstructive sleep apnea (adult)(pediatric),Schizoaffective disorder, unspecified,Redundant prepuce and phimosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Bipolar disorder, unspecified,Polycythemia vera,Other specified cardiac dysrhythmias,Chronic obstructive asthma, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Constipation, unspecified
Acute & chronc resp fail,Cardiogenic shock,Food/vomit pneumonitis,Acute kidney failure NOS,Atriovent block complete,BMI 40.0-44.9, adult,Bacteremia,Obesity hypovent synd,Chr diastolic hrt fail,Hyperosmolality,Obstructive sleep apnea,Schizoaffective dis NOS,Redun prepuce & phimosis,DMII wo cmp nt st uncntr,Hypertension NOS,Bipolar disorder NOS,Polycythemia vera,Cardiac dysrhythmias NEC,Chronic obst asthma NOS,Mth sus Stph aur els/NOS,Constipation NOS
Admission Date:  [**2135-8-13**]              [**Month/Day/Year **] Date:   [**2135-8-27**]

Date of Birth:  [**2087-8-23**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Acute respiratory Distress

Major Surgical or Invasive Procedure:
Tracheostomy Tube Placement
Central Venous Acces through Right Internal Jugular Vein
Phimosis retraction


History of Present Illness:
47M with history of OSA/COPD, bipolar, schizophrenia presenting
with increased somnolence and respiratory distress. At
approximately 940 this morning, patient was found by staff at
nursing home to be acute SOB with altered MS. [**Name14 (STitle) 103309**] to 53% on
RA. Was placed on 15L O2 non-rebreather, and O2 sat came up to
88%.  [**Name6 (MD) **] by NP, who called EMS.  On EMS arrival, GCS
reportedly 8. Given nebs, BiPAP, manually bagging, then with
improvement to GCS of 11. But even after nebs, poor breath
sounds bilaterally.

Nursing home reports patient has been well and at baseline
(independent except in bathing and dressing) until yesterday,
when we felt fatigued.  This morning he did not come to
breakfast, so staff went to see him in his room, where he was
found to be SOB, as above.  Was oriented and asked to see
doctor, but fatigued and with occassional jerking motions of
hand.  Last med change was increase in metformin on [**7-19**].  No
other recent med changes.  Nurse gives him meds.  No vomiting,
diarrhea, or decreased PO intake.  Has been using BiPAP
consistently for OSA/COPD at night.

In the [**Name (NI) **], pt continued to have poor breath sounds B/L.  He
responded to voice and sternal rubs, not responding to commands.
 No wheezing or crackles, just poor air movement.  He was on
BiPAP in ED, then woke up and complained of back pain, and he
was given 30mg IV Toradol.  First ABG showed PO2 140, PCO2 93,
pH 7.21, bicarb 39.  He then desatted again, and became more
somnolent.  At that point, he was intubated (1 attempt, not
difficult airway).  He does have trach scar (hx of difficulty
weaning from vent).  He had fluffy infiltrates on CXR and very
dry, tea-colored urine.  He got fluid, but was hypotensive.  He
got RIJ line and was started on levophed once placement was
confirmed.  Potassium was 7.7 on arrival, so he was given 10U of
insulin, 1 amp of calcium gluc, 1 amp D50, repeat 7.3.  In ED
was satting 88% on 100% FiO2 on vent with good air movement.
Azithromycin and solumedrol 125 for presumed copd.  In terms of
hi BP, he 75/50 before pressor.  He came up to 101/64 now after
levophed.  His HR was 64, rr18, sat 87%.  Before pt came up to
MICU, he bradyed to 35, then came back up to 70.  ED talked to
cardiology, may have had mobitz 2 or complete heart block when
bradyed, then 1st degree avblock after.  Renal fellow will see
in micu.

On arrival patient is responsive to voice and sternal rub. Does
not follow commands.

Review of systems:
(+) Per HPI


Past Medical History:
1. Complex sleep disorder on bipap at night with severe
nocturnal and daytime hypoxia related to hypoventiliation
2. Schizophrenia
3. Bipolar disorder
4. CHF with diastolic dysfxn
5. Asthma
6. HTN
7. DM type 2, diet controlled
8. Erythrocythosis, thought secondary to hypoxia


Social History:
Has been living at [**Location 1268**] [**Hospital1 1501**] (RossCommons) since [**Month (only) 958**]
[**2134**] for his sleep apnea and BIPAP use. Sister is HCP
- [**Name (NI) 1139**]: none
- Alcohol: none
- Illicits: none


Family History:
Mother with asthma, Several sibling all in good health. No
family history of cardiac dz or DM.


Physical Exam:
Admission exam:
Admit Vitals:
General Appearance: Overweight / Obese / Intubated / Not
responsive to voice
Cardiovascular: (S1: Normal), (S2: Normal)
Respiratory / Chest: (Expansion: Symmetric)
Abdominal: Soft, Non-tender, Distended, Obese
Extremities: No(t) Cyanosis, No(t) Clubbing
Skin: Warm
Neurologic: Not following commands

[**Name (NI) **] Exam:
Vitals Tmax: 37.7 ??????C (99.9 ??????F)
Tcurrent: 37.4 ??????C (99.4 ??????F)
HR: 83 (69 - 104) bpm
BP: 140/69(83) {119/40(63) - 150/129(134)} mmHg
RR: 20 (16 - 38) insp/min
SpO2: 93%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 134.8 kg (admission): 132.9 kg
O2 Delivery Device: Tracheostomy tube
Ventilator mode: CPAP/PSV
Vt (Set): 450 (450 - 450) mL
Vt (Spontaneous): 417 (271 - 470) mL
PS : 12 cmH2O
RR (Set): 16
RR (Spontaneous): 31
PEEP: 16 cmH2O
FiO2: 50%
PIP: 29 cmH2O
Plateau: 28 cmH2O
Compliance: 25 cmH2O/mL
SpO2: 93%
ABG: 7.36/50/64/35/1
Ve: 12.5 L/min
PaO2 / FiO2: 128

General Appearance: Overweight / Obese / trached / awakes
follows commands
Cardiovascular: distal heart sounds no MRG.
Respiratory / Chest: Distant breath sounds
Abdominal: Soft, Non-tender, Obese, +hypoactive BS
Skin: Warm
Neurologic: trached, interactive, follows commands, MAE.  writes
on paper coherently to communicate.


Pertinent Results:
ADMISSION LABS
[**2135-8-13**] 11:00PM URINE  HOURS-RANDOM
[**2135-8-13**] 11:00PM URINE  UHOLD-HOLD
[**2135-8-13**] 10:36PM   CARBAMZPN-3.2*
[**2135-8-13**] 09:29PM   TYPE-ART TEMP-37.7 PO2-79* PCO2-54* PH-7.39
TOTAL CO2-34* BASE XS-5 INTUBATED-INTUBATED
[**2135-8-13**] 09:29PM   LACTATE-1.7 K+-5.8*
[**2135-8-13**] 09:29PM   freeCa-1.28
[**2135-8-13**] 08:13PM   TYPE-ART TEMP-37.1 PO2-60* PCO2-44 PH-7.43
TOTAL CO2-30 BASE XS-3 INTUBATED-INTUBATED
[**2135-8-13**] 08:13PM   LACTATE-2.8*
[**2135-8-13**] 08:13PM   O2 SAT-91
[**2135-8-13**] 08:13PM   freeCa-1.14
[**2135-8-13**] 08:00PM   GLUCOSE-126* UREA N-50* CREAT-2.2* SODIUM-136
POTASSIUM-7.5* CHLORIDE-100 TOTAL CO2-27 ANION GAP-17
[**2135-8-13**] 08:00PM   CK(CPK)-63
[**2135-8-13**] 08:00PM   CK-MB-2 cTropnT-0.09* proBNP-2275*
[**2135-8-13**] 08:00PM   CALCIUM-9.0 PHOSPHATE-2.5* MAGNESIUM-1.8
[**2135-8-13**] 08:00PM URINE  HOURS-RANDOM UREA N-391 CREAT-97
SODIUM-49 POTASSIUM-68 CHLORIDE-85
[**2135-8-13**] 08:00PM URINE  OSMOLAL-391
[**2135-8-13**] 08:00PM   WBC-12.4* RBC-6.05 HGB-17.2 HCT-55.9* MCV-92
MCH-28.3 MCHC-30.7* RDW-15.7*
[**2135-8-13**] 08:00PM   PLT COUNT-235
[**2135-8-13**] 07:57PM   TYPE-ART TEMP-37.7 PH-7.42 COMMENTS-GREEN TOP
[**2135-8-13**] 07:57PM   freeCa-1.09*
[**2135-8-13**] 05:25PM   GLUCOSE-152* UREA N-51* CREAT-2.3* SODIUM-138
POTASSIUM-7.9* CHLORIDE-103 TOTAL CO2-26 ANION GAP-17
[**2135-8-13**] 05:25PM   ALT(SGPT)-18 AST(SGOT)-16 LD(LDH)-245 ALK
PHOS-65 AMYLASE-333* TOT BILI-0.4
[**2135-8-13**] 05:25PM   ALBUMIN-3.8 PHOSPHATE-3.4 MAGNESIUM-1.8
[**2135-8-13**] 05:25PM   TYPE-ART TEMP-37 PO2-57* PCO2-47* PH-7.38
TOTAL CO2-29 BASE XS-1 INTUBATED-INTUBATED
[**2135-8-13**] 05:25PM   GLUCOSE-143* LACTATE-2.1* K+-7.3*
[**2135-8-13**] 05:25PM   freeCa-1.14
[**2135-8-13**] 05:25PM   WBC-12.7* RBC-6.20 HGB-17.3 HCT-57.6*
MCV-92.9 MCH-27.6 MCHC-30.0* RDW-15.9*
[**2135-8-13**] 05:25PM   PT-13.0* PTT-29.6 INR(PT)-1.2*
[**2135-8-13**] 05:25PM   PLT COUNT-228
[**2135-8-13**] 03:31PM   K+-7.7*
[**2135-8-13**] 02:57PM   COMMENTS-QNS TO [**Last Name (un) **]
[**2135-8-13**] 02:57PM   GLUCOSE-125* K+-GREATER TH
[**2135-8-13**] 02:40PM   VoidSpec-GROSSLY HE
[**2135-8-13**] 02:38PM   TYPE-ART TEMP-37.8 RATES-18/0 TIDAL VOL-1000
O2-100 PO2-56* PCO2-62* PH-7.29* TOTAL CO2-31* BASE XS-1
AADO2-601 REQ O2-97 -ASSIST/CON INTUBATED-INTUBATED
[**2135-8-13**] 12:19PM   PO2-161* PCO2-80* PH-7.25* TOTAL CO2-37* BASE
XS-5 COMMENTS-SPECIMEN A
[**2135-8-13**] 11:38AM   TYPE-ART PO2-140* PCO2-93* PH-7.21* TOTAL
CO2-39* BASE XS-5
[**2135-8-13**] 11:25AM   PH-7.25* COMMENTS-GREEN TOP
[**2135-8-13**] 11:25AM   GLUCOSE-111* LACTATE-2.0 NA+-140 K+-7.7*
CL--93* TCO2-33*
[**2135-8-13**] 11:25AM   freeCa-0.99*
[**2135-8-13**] 11:05AM   UREA N-54* CREAT-2.6*
[**2135-8-13**] 11:05AM   estGFR-Using this
[**2135-8-13**] 11:05AM   LIPASE-19
[**2135-8-13**] 11:05AM   WBC-11.9* RBC-6.25* HGB-17.7 HCT-59.4* MCV-95
MCH-28.3 MCHC-29.8* RDW-15.6*
[**2135-8-13**] 11:05AM   PT-12.7* PTT-27.8 INR(PT)-1.2*
[**2135-8-13**] 11:05AM   PLT COUNT-263
[**2135-8-13**] 11:05AM   FIBRINOGE-363

[**Month/Day/Year 894**] LABORATORY DATA
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2135-8-27**] 04:03    8.3 4.04* 11.0* 36.3* 90 27.2 30.2* 16.7*
419
Source: Line-central
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2135-8-14**] 04:02    72* 2 18 5 0 0 3* 0 0
Source: Line-aline
  BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2135-8-27**] 04:03        419
Source: Line-central
[**2135-8-27**] 04:03    13.1* 27.5   1.2*
Source: Line-central
  BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) Fibrino
[**2135-8-25**] 08:00    570*
  LAB USE ONLY
[**2135-8-27**] 04:03
Source: Line-central

Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2135-8-27**] 04:03    114*1 13 0.5 147* 3.4 104 35* 11

  ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2135-8-20**] 20:49    Using this1

  ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2135-8-23**] 04:17    9 14 192   43   0.2
Source: Line-a-line
OTHER ENZYMES & BILIRUBINS Lipase
[**2135-8-13**] 11:05    19
TRAUMA; MODERATELY HEMOLYZED SPECIMEN
  CPK ISOENZYMES CK-MB cTropnT proBNP
[**2135-8-14**] 04:02    2 0.07*1

  CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron

[**2135-8-27**] 04:03          8.4 3.3 2.0
LIPID/CHOLESTEROL Cholest Triglyc
[**2135-8-20**] 02:14      1461

  ANTIBIOTICS Vanco
[**2135-8-18**] 06:18    21.0*
Source: Line-[**Female First Name (un) 71368**]#1; Vancomycin @ Trough
  TOXICOLOGY, SERUM AND OTHER DRUGS Carbamz
[**2135-8-22**] 02:15    6.6


Blood Gas
  BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2
pH calTCO2 Base XS AADO2 REQ O2   Intubat Vent Comment
[**2135-8-26**] 12:01    ART 37.5 /19     50   64* 50* 7.36 29 1
 INTUBATED SPONTANEOU1
[**2135-8-26**] 04:17    ART 37.6     20     80* 55* 7.46* 40* 12
  INTUBATED
  WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Lactate Na K Cl
calHCO3
[**2135-8-26**] 12:01          3.3
[**2135-8-26**] 04:17      0.8
  HEMOGLOBLIN FRACTIONS ( COOXIMETRY) Hgb calcHCT O2 Sat
[**2135-8-25**] 11:51    12.5* 38
[**2135-8-25**] 11:03    12.6* 38
[**2135-8-25**] 08:08    13.9* 42
  CALCIUM freeCa
[**2135-8-26**] 12:01    1.14
[**2135-8-26**] 04:17    1.11*



CXR [**8-13**] AP
Semi-upright portable radiograph of the chest was obtained.
Left lower lung opacification likely reflects a combination of
atelectasis, possible
aspiration or pneumonia, and external soft tissues.  No
pneumothorax is seen. Small left greater than right pleural
effusions are likely also present. Moderate cardiomegaly is
presumed. Low lung volumes results in crowding of the
bronchovascular markings, though there is likely a degree of
pulmonary vascular congestion.
IMPRESSION:  Left basal opacification, which may reflect,
atelectasis,
aspiration and/or infection. Small bilateral pleural effusions
and pulmonary vascular congestion.

CXR [**8-13**] AP-ETT placement
FINDINGS:  Endotracheal tube terminates 1.5 cm above the carina.
 However,
given kyphotic positioning and neck flexion it is likely at the
lower limits of acceptable positioning it should not be advanced
any further, but does not need to be withdrawn.  Asymmetric
pulmonary opacities, left greater than right, likely reflect a
combination of edema and atelectasis.  The costophrenic angles
are not well assessed, though small right effusion is likely
present.  The heart size is moderately enlarged. Previously
noted left basilar opacities persists.

CXR- [**8-13**] central line
FINDINGS:  As compared to the previous radiograph, the patient
has received a nasogastric tube.  The course of the tube is
unremarkable, the tip of the tube is not included in the image.
The patient has also received a new right internal jugular vein
catheter.  The course of the catheter is unremarkable, the tip
of the catheter projects over the lower SVC.  No evidence of
complications, notably no pneumothorax.
Better seen than on the previous image are areas of bilateral
atelectasis as well as small bilateral pleural effusions.
Borderline size of the cardiac silhouette.  No pneumothorax.

Need final reads on other us

Echo [**8-15**]:
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.

IMPRESSION: Suboptimal image quality. Right ventricular cavity
enlargement with free wall hypokinesis. Normal left ventricular
cavity size with preserved global systolic function.
Compared with the prior study (images reviewed) of [**2135-2-11**], the
findings are similar. The RV appears mildly dilated and
hypokinetic on review of the prior study images.

CTA Chest:
IMPRESSION:  Study somewhat limited by poor contrast bolus
timing, with:
1.  No evidence of central pulmonary embolus to the level of the
segmental
pulmonary arteries.
2.  Dilatation of the main pulmonary artery, which appears to
have progressed
since [**12/2132**] and likely reflects pulmonary hypertension
secondary to the
patient's known obstructive sleep apnea.
3.  No evidence of thoracic aortic dissection.
4.  Left lower lobe, particularly posterior basal segmental,
consolidation and
collapse, with no definite evidence of airway obstruction; a
pneumonic process
is a consideration.
5.  Cardiomegaly with small bilateral pleural effusions but no
pulmonary
edema.

CXR [**2135-8-19**]
Note is made that the original dictation was lost and the study
was brought to our review today on [**2135-8-20**], approximately
around 4:00 p.m.
The ET tube tip is 7 cm above the carina.  The NG tube tip
passes below the diaphragm, most likely terminating in the
stomach.  Multiple parenchymal consolidations appear to be
progressed as compared to the prior study.  The findings are
worrisome for continuous progress of multifocal infection.  No
pneumothorax is seen.

ECHO [**2135-8-24**]:
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). with mild global free
wall hypokinesis. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. Mild (1+)
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
a trivial/physiologic pericardial effusion. Ecmo cannulas placed
with tee guidance. Aortic contours intact throughout. No changes
to cardiac structures throughout the exam.

CXR [**2135-8-25**]
Tracheostomy tube is in standard placement.  There is no
mediastinal air or widening.  Previous moderately severe
pulmonary edema has improved, with the most pronounced residual
around the left hilus and in the right infrahilar lung.
Substantial atelectasis persists at the left lung base.  There
is no pneumothorax or more than minimal pleural effusion.  Heart
size normal.  Right jugular line ends in the mid-to-low SVC and
a nasogastric tube passes below the diaphragm and out of view.


PRELIMINARY ECHO REPORT AT TIME OF [**Month/Day/Year 894**]
(ECHO FROM [**2135-8-25**])
Results  Measurements  Normal Range
Left Ventricle - Septal Wall Thickness:  0.8 cm  0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:  0.8 cm  0.6 - 1.1 cm

Left Ventricle - Ejection Fraction:  50% to 55%  >= 55%

Findings
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%).

RIGHT VENTRICLE: Mild global RV free wall hypokinesis.

AORTA: Normal aortic diameter at the sinus level. Normal aortic
arch diameter. Normal descending aorta diameter.

AORTIC VALVE: Normal aortic valve leaflets (3). Mild (1+) AR.

MITRAL VALVE: Normal mitral valve leaflets with trivial MR.

TRICUSPID VALVE: Normal tricuspid valve leaflets. Physiologic
TR.

PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.

PERICARDIUM: Trivial/physiologic pericardial effusion.

GENERAL COMMENTS: No TEE related complications.
Conclusions
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). with mild global free
wall hypokinesis. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. Mild (1+)
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
a trivial/physiologic pericardial effusion. Ecmo cannulas placed
with tee guidance. Aortic contours intact throughout. No changes
to cardiac structures throughout the exam.




Brief Hospital Course:
47 yo with obesity hypoventilation, severe obstructive sleep
apnea, and asthma presenting with somnolence, hypoxia,
hyperkalemia, and shock.  Etiology of acute decompensation was
not clear, but he has had other similar admissions for
respiratory failure.

Respiratory failure: Patient had been living in a skilled
nursing facility since [**2134-3-30**] for his sleep apnea and BIPAP
use.  He presented with hypoxemia in the setting of somnolence.
Has longstanding history of complex breathing disorder,
including components of OSA, with history of acute respiratory
failure.  Additionally, there was possiblity of a health care
associated pneumonia on imaging.  The patient was intubated on
presentation, requiring high levels of PEEP> 20 cmH20 to
maintain oxygenation.  He was empirically started on vancomycin,
aztreonam, and metronidazole for possible aspiration pneumonia.
Pulmonary emobolism was considered, and although the patient had
negative lower extremity ultrasounds, he was empirically started
on heparin for a possible pulmonary embolism (PE).  After his
renal failure improved (see below), he was CT scanned which was
negative for a PE, and his heparin drip was discontinued.  His
blood cultures came back positive for coagulase negative
Staphylococcus, and his antibiotics were weaned down to
cefazolin.  Several attempts were made at weaning from the
ventilator, however the patient would become hypoxic with PEEP
amounts below 17 cmH20.  Given multiple failed attempts at
extubation, an open surgical tracheostomy was placed.   During
the procedure extra-corporeal oxygenation was required.
Post-operatively he did well. His trach should NEVER be removed
as it is unlikely emergent replacement or intubation would be
successful. Patient continued to require PEEP amounts between 10
and 16 cm of H20 for oxygen saturations between 86 and 92
percent.
*Given mechincal ventilation, was started on mouth care with
chlorhexadine.
*Was started on oral lansoprazole disolving tablet for peptic
ulcer disease prophylaxis while on ventilator.
*Again - he can NEVER BE DECANNULATED given that another
tracheostomy tube placement, should he need it, would be
technically complicated if not impossible and highly morbid.

Hypotension: Initially presented with blood pressures with
systolics in the 90 mmHg range.  Felt to be consistent with
dehydration with possible component of heart failure.  Echo
performed showed normal systolic function, with mild dilation
and mild global free wall hypokenesis.  Given his associated
renal failure, IVF boluses were provided, which helped increase
his blood pressures.  The patient remained hemodynamically
stable after IVF hydration.

Acute Renal Injury ([**Doctor First Name 48**]): Unclear cause of [**Doctor First Name 48**].  No recent
changes in medications or fluid intake.  Likely prerenal
azotemia in setting of K+ supplementation, possible
decompensated diastolic CHF, and hypovolemia.  We treated
medically with insulin, D50, bicarb, and Ca gluconate, but the
K+ did not normalize.  A hemodialysis line could not be placed
in femoral by MICU/renal teams.  IR placed line, and patient
received dialysis, which corrected the creatinine and K+.  Both
have been normal since the 3rd day of hospital admission.

Schozaffective disorder: While in the MICU he was on his home
carbamazepine, doxepin, and risperidone.  For assitance with
agitation while intubated, he was additionally placed on
quetiapine for several days, which was discontinued prior to
[**Doctor First Name **] from the MICU as he appeared less agitated.

Phimosis: Patient found to have a phimosis due to foreskin
entrapping the glans of the penis.  Urology saw the patient and
reduced phimosis.  Has been receiving topical bacitracin
topically, and can continue for the next 2 weeks (can
discontinue around [**2135-9-9**]).  Should evaluate genitalia as
clinically indicated (and, at a minimum at least once per week)
to ensure no recurrence of phimosis.

Chronic Issues
Diabetes: on metformin at home.  Maintained on sliding scale
insulin at home.  Restarted metformin at [**Month/Day/Year **].  Was taking
aspirin 325 mg daily presumably for coronary artery disease
risk.  No history of stroke per notes or physical exam.  Changed
dosing from 325 mg qday to 81 mg qday to decrease risk of
gastrointestinal bleed.

Chronic diastolic congestive heart failure:  At nursing home,
patient was receiving 100 mg [**Hospital1 **] furosemide and metolazone 2.5
mg 1 tablet po daily.  Given issues with hypernatremia, his
diuresis was held and he was supplmented with free water flushes
via his tube feeds.  On [**Hospital1 **], his diuresis with furosemide
was resumed, but his metolazone was still held.  Should be kept
on low sodium diet with weights checked daily, with more acute
diuresis with a 3 lbs weight gain in 24 hours.  At time of
[**Hospital1 **] from the ICU the patient was approximately 15 Liters
positive.

Erythrocytosis: On admission had elevated hematocrit.  Given his
chronic respiratory issues, felt to be secondary to chronic
hypoxemia.

Hypertension:  His lisinopril and metoprolol were held during
his MICU admission.  Given the low dose medications (lisinopril
2.5 mg and metoprolol tartrate 12.5 mg [**Hospital1 **]), they were
discontinued in house while as his HR remained around 80 beats
per minute and his blood pressures were around 130mmHg systolic.
 At time of [**Hospital1 **], his metoprolol was resumed for management
of chronic heart failure, and his lisinopril was held given
complications with [**Last Name (un) **] at time of admission.


Code Status: Confirmed Full
Communication: Sister [**Name (NI) **] [**Name (NI) 103310**] (HCP) - [**Telephone/Fax (1) 103299**] cell:
[**Telephone/Fax (1) 103311**]

TRANSITIONAL ISSUES
*Chronic Diastolic Heart Failure:  Patient's diuresis was held
while hospitalized due to hypernatremia.  Furosemide was
restarted however metolazone was still held  upon [**Telephone/Fax (1) **] to
[**Hospital **] Rehab.  He will need clinical evaluation to determine
when to resume metolazone. (Please see chronic dCHF above
regarding dosing).  For hypernatremia he is receiving 200 cc
free water flushes through his dobhoff.

*Patient was on theophyline at nursing home prior to admission
to the hospital.  His theophyline was DISCONTINUED while at the
hospital and was continued to be held at time of dischare to
rehab.

*Regarding his hypertension, patient was normotensive and
nontachycardic while in the hospital.  His metoprolol was held
as well as his lisinopril given his inital hypotension.  Given
his complications of acute kidney injury on presentation, his
lisinopril was continued to be held at time of [**Hospital **], but
his metoprolol was resumed (more so for management of his
chronic diastolic heart failure).  Can reevaluate renal function
and whether to start lisinopril at rehab.

*Regarding feedings and ventilation, the patient had a
tracheostomy tube placed on [**2135-8-24**].  Speech and swallow was
consulted who said the patient will need further evaluation
first for a Passy-Muir valve, and then further speech and
swallow evaluation to deterimine if he can receive PO feedings.
Thus, a dobhoff tube was placed to provide the patient with tube
feedings and a route for oral medications while speech and
swallow evaluation should be on going at rehabilitation.  The
patient has been having sips of water for comfort, however he
should NOT be allowed to have PO feedings/fluids in general as
he is currently at risk of aspiration.

*Regarding his tracheostomy tube, the patient had an open
tracheostomy procedure.  If his tracheostomy tube should fall
out, it is a medical emergency and will need emergent transfer
to a facility for replacement of his tracheostomy tube.  As he
had an open procedure, if his tracheostomy tube falls out
attempts at reinserting his endotracheal tube SHOULD NOT BE
ATTEMPTED as there is a risk of cannulation of a false lumen and
intubation of a tissue plane rather than his trachea.
Additionally, as noted above - he CANNOT BE DECANNULATED without
clearly and unambiguously understanding that repeat tracheostomy
(should he need it) would be technically complicated if not
impossible, and decannulation would place him at great clinical
risk including death.

Medications on Admission:
Medications:  This is old list -- check against nursing home
records
albuterol nebs prn
combinebs prn
asa 325
carbamazepine 200 qid
doxepin 10 qhs
furosemide 100mg [**Hospital1 **]
lisinopril 2.5 daily
metolazone 2.5 daily
metoprolol 12..5 [**Hospital1 **]
omeprazole 20 daily
kcl 60meq daily
risperidone 4mg [**Hospital1 **]
acetaminophen 650 q4 prn
benztropine 0.5mg daily prn dystonia
atrovent nebs q 6 hours prn


[**Hospital1 **] Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. Albuterol Inhaler [**7-10**] PUFF IH Q4H:PRN shortness of breath,
wheeze
3. Albuterol-Ipratropium [**7-10**] PUFF IH Q6H
4. Bacitracin Ointment 1 Appl TP QID
Please apply to glans and under foreskin
5. Bisacodyl 10 mg PO/PR DAILY constipation
6. Carbamazepine 200 mg PO QID
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 ml ORAL [**Hospital1 **]
Use only if patient is on mechanical ventilation.
8. Docusate Sodium (Liquid) 100 mg PO BID
9. Doxepin HCl 10 mg PO HS
10. Heparin 5000 UNIT SC TID
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Risperidone 4 mg PO BID
13. Senna 1 TAB PO BID constipation
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Benztropine Mesylate 0.5 mg PO Q24 PRN dystonia
16. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
17. Metoprolol Tartrate 12.5 mg PO BID
Hold for HR<60/ SBP<100 mmHg
18. Aspirin 81 mg PO DAILY


[**Hospital1 **] Disposition:
Extended Care

Facility:
[**Hospital3 105**] - [**Location (un) 86**]

[**Location (un) **] Diagnosis:
Primary Diagnosis:
Acute respiratory failure secondary to pnemonia

Secondary Diagnosis:
OBSTRUCTIVE SLEEP APNEA
CHRONIC DIASTOLIC DYSFUNCTION
ACUTE KIDNEY FAILURE
OBSTRUCTIVE SLEEP APNEA
DIABETES-NON INSULIN DEPENDENT
OBESITY UNSPECIFIED
SECONDARY POLYCYTHEMIA
ASTHMA, UNSPECIFIED
MANIC-DEPRESSIVE DISORDER
SCHIZOAFFECTIVE DISORDER


[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


[**Location (un) **] Instructions:
Mr. [**Known lastname 732**]
[**Last Name (NamePattern1) **] were admitted to [**Hospital1 18**] in the intensive care unit because
of your difficulty breathing.  Your breathing became so
difficult that you were placed on a machine ("ventilator") to
assit your ventilation.  Unfortunately, you were not able to
adequately breath on your own without assistance from the
ventilator, and required the placement of a tracheostomy tube.
This allows you to receive assitance from the ventilator, while
attempting trials without assitance, through access from the
tracheostomy tube.

Additionally, you developed a pneumonia and a blood stream
infection for which you were treated.

You will be going to [**Hospital **] Rehab for further physical
rehabilitation as well as assitance with your new tracheostomy,
including speech and swallow studies.

Take your medications as directed.  It has been a pleasure
taking care of you.

Followup Instructions:
Please follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] from
rehab.

The following specialty appointments have already been made.

Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2135-9-8**] at 3:30 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital Ward Name 1570**]
When: THURSDAY [**2135-9-8**] at 3:30 PM

Department: MEDICAL SPECIALTIES
When: THURSDAY [**2135-9-8**] at 4:00 PM
With: DR. [**Last Name (STitle) 11071**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2135-8-28**]
{'Acute and chronic respiratory failure,Cardiogenic shock,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Atrioventricular block, complete,Body Mass Index 40.0-44.9, adult,Bacteremia,Obesity hypoventilation syndrome,Chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Obstructive sleep apnea (adult)(pediatric),Schizoaffective disorder, unspecified,Redundant prepuce and phimosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Bipolar disorder, unspecified,Polycythemia vera,Other specified cardiac dysrhythmias,Chronic obstructive asthma, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Constipation, unspecified'}


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: Acute respiratory Distress

PRESENT ILLNESS: 47M with history of OSA/COPD, bipolar, schizophrenia presenting
with increased somnolence and respiratory distress. At
approximately 940 this morning, patient was found by staff at
nursing home to be acute SOB with altered MS. [**Name14 (STitle) 103309**] to 53% on
RA. Was placed on 15L O2 non-rebreather, and O2 sat came up to
88%.  [**Name6 (MD) **] by NP, who called EMS.  On EMS arrival, GCS
reportedly 8. Given nebs, BiPAP, manually bagging, then with
improvement to GCS of 11. But even after nebs, poor breath
sounds bilaterally.

MEDICAL HISTORY: 1. Complex sleep disorder on bipap at night with severe
nocturnal and daytime hypoxia related to hypoventiliation
2. Schizophrenia
3. Bipolar disorder
4. CHF with diastolic dysfxn
5. Asthma
6. HTN
7. DM type 2, diet controlled
8. Erythrocythosis, thought secondary to hypoxia

MEDICATION ON ADMISSION: Medications:  This is old list -- check against nursing home
records
albuterol nebs prn
combinebs prn
asa 325
carbamazepine 200 qid
doxepin 10 qhs
furosemide 100mg [**Hospital1 **]
lisinopril 2.5 daily
metolazone 2.5 daily
metoprolol 12..5 [**Hospital1 **]
omeprazole 20 daily
kcl 60meq daily
risperidone 4mg [**Hospital1 **]
acetaminophen 650 q4 prn
benztropine 0.5mg daily prn dystonia
atrovent nebs q 6 hours prn

ALLERGIES: Penicillins

PHYSICAL EXAM: Admission exam:
Admit Vitals:
General Appearance: Overweight / Obese / Intubated / Not
responsive to voice
Cardiovascular: (S1: Normal), (S2: Normal)
Respiratory / Chest: (Expansion: Symmetric)
Abdominal: Soft, Non-tender, Distended, Obese
Extremities: No(t) Cyanosis, No(t) Clubbing
Skin: Warm
Neurologic: Not following commands

FAMILY HISTORY: Mother with asthma, Several sibling all in good health. No
family history of cardiac dz or DM.

SOCIAL HISTORY: Has been living at [**Location 1268**] [**Hospital1 1501**] (RossCommons) since [**Month (only) 958**]
[**2134**] for his sleep apnea and BIPAP use. Sister is HCP
- [**Name (NI) 1139**]: none
- Alcohol: none
- Illicits: none 

### Response:
{'Acute and chronic respiratory failure,Cardiogenic shock,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Atrioventricular block, complete,Body Mass Index 40.0-44.9, adult,Bacteremia,Obesity hypoventilation syndrome,Chronic diastolic heart failure,Hyperosmolality and/or hypernatremia,Obstructive sleep apnea (adult)(pediatric),Schizoaffective disorder, unspecified,Redundant prepuce and phimosis,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Bipolar disorder, unspecified,Polycythemia vera,Other specified cardiac dysrhythmias,Chronic obstructive asthma, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Constipation, unspecified'}
