CHIEF COMPLAINT: unresponsive, s/p 3 minutes chest compressions

PRESENT ILLNESS: Pt is a 69y/o male with history of MS, bedbound from nursing
home, chronic suprapubic foley, found to be unresponsive and
given 3 cycles of CPR with ROSC. According to past medical
documentation pt is alert and [**First Name3 (LF) 11087**] at baseline. Reported to
normally follow commands, but cannot grip with either hand, and
has dysphagia with h/o PNA. Of note, pt was last admitted at
[**Hospital1 18**] [**5-23**] for sepsis secondary to pyelonephritis and
bacteremia.
.
Pt was by report found unresponsive by aide on day of admission
(pulse not checked. CPR initiated and recieved 2-3 minutes of
chest compressions, AED advised no shock. On EMS arrival pulse
was found to be present (ROSC - although not definitively
established that pt lost pulse at any time)
.
On arrival to ED, vital signs were HR 52, BP 120/54, sat 100%
NRB, T 97.8.
Labs showed:
-CBC: 7.8>43.4<180 (PMN 68%)
-chemistries: 131/5.0; 94/31; 13/0.4; 177
-INR 1.0. trop 0.02. lactate 2.6 -->2.3.
urine studies showed  100 protein 2urobili pH8.5 Lg leuks, 4WBC
few bact 0 epis.
Pt was unresponsive and not reacting to sternal rub, was
intubated for c/f inability to protect airway. ABG showed
7.46/31/292/23 on vent settings of RR16,TV500,peep5,Fio2-100.
Head CT negative for acute process. Stool was guiaic negative.
CXR showed no significant changes from prior CXR [**9-/2167**],
bilateral pleural effusions persisting.
EKG showed SR@45, normal axis, ?prolonged QT ?Qwaves V1/2/3
TWI II, aVR, aVL
.
In [**Name (NI) **], pt was given vanc/levoflox for concern for aspiration
pneumonia. Received approximately 3L IVF in ED. Pt remained
comatose off sedation, and plan was to initiate therapeutic
hypothermia with Arctic Sun for 24 hours. EEG was considered in
ED but was deferred to inpatient team for 48hr EEG per protocol.
However, prior to transfer pt began opening eyes spontaneously
and it was felt that cooling protocol was no longer necessary.
On admission vitals were: HR 47 RR 16 sat 100% vent BP 94/56
.
In the MICU, pt arrived on propofol for sedation. Propofol was
stopped temporarily and pt was opening eyes and nodding no but
not clearly responsive to commands.

MEDICAL HISTORY: 1. MS, endstage secondary progressive type.
1. Decubitus ulcer (healing).
2. History of lung aspiration and lung abscess.
3. Hypertension.
4. Gastroesophageal reflux.
5. Status post gastrostomy tube.
6. Status post suprapubic catheter.
7. H/o Afib
8. H/o olgilvie's syndrome

MEDICATION ON ADMISSION: per [**Hospital3 **] records:
NPO
proteinpowder one scoop mix with H20 via gtube [**Hospital1 **]
mag citrate give [**12-14**] bottle via gtube on m/w/f
generlac 10G/15mL solution (lactulose) give 15mls via gtube 4
times weekly on tues/thurs/sat/sun
omeprazole 2mg/ml give 10mLs (20mg) via gtube daily
levothyroxine 50mcg daily via gtube
provigil 200mg tab via gtube daily
simvastatin 40mg tab
cp-baclofen 5mg/ml oral susp give 3ml (15mg) via gtube [**Hospital1 **]
6am/6pm
metoclopramide 5mg/5ml solution give 5mls daily via gtube TID
natural balance tears drops instill 2 drops in both eyes every 8
hours
guiatuss 100mg/5ml syrup (robitussin give 10mLs via gtube q6hrs
prn for cough)
mild of mag 400mg/5ml oral susp give 30mls via gtube daily prn
constipation
acetaminophen 325mg tab give 2tabs via gtube q4hrs prn temp>101
acetaminophen 325 tab give 2 tabs via gtube q4hrs as needed for
pain
fleet enema insert 1 suppository rectally QD PRN for
constipation
ipratropium-albuterol 0.5-3mg/3ampule neb - inhale 3mls via neb
q6hrs as needed for cough/wheezing

ALLERGIES: Benzodiazepines / Augmentin / Clavulanic Acid

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: T: AF BP:113/59 P:72 R:16 18 O2:100%
GENERAL: Pt intubated, sedated. Vent settings FIo2 50%, TV 500
RR16  PEEP 5
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils dilated
but roudn and reactive to light
Neck: supple, JVP not elevated, no LAD  but difficult to assess
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi,difficult to assess posterior lung fields while on vent
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, distended but not tympanic, does not appear to be
tender by pt reactions although this is unclear. [**Name2 (NI) **] guarding, no
organomegaly, pt has Gtube in place, site without drainage.
GU: suprapubic catheter
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
ON DISCHARGE:
HR 66 BP 116/39 afebrile RR 20
pt fully alert and [**Name2 (NI) 11087**], conversational.
exam otherwise unchanged.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Lives in Nursing Home at [**Hospital3 2558**], divorced, two children.
Retired Biochemist.  Denies etoh/tobacco/drugs.
Altered mental status,Encephalopathy, unspecified,Urinary tract infection, site not specified,Acidosis,Obstructive sleep apnea (adult)(pediatric),Other specified cardiac dysrhythmias,Unspecified acquired hypothyroidism,Multiple sclerosis,Neurogenic bladder NOS,Unspecified essential hypertension,Esophageal reflux,Bed confinement status,Gastrostomy status
Altered mental status,Encephalopathy NOS,Urin tract infection NOS,Acidosis,Obstructive sleep apnea,Cardiac dysrhythmias NEC,Hypothyroidism NOS,Multiple sclerosis,Neurogenic bladder NOS,Hypertension NOS,Esophageal reflux,Bed confinement status,Gastrostomy status
Admission Date:  [**2168-3-21**]              Discharge Date:   [**2168-3-23**]

Date of Birth:  [**2098-8-18**]             Sex:   M

Service: MEDICINE

Allergies:
Benzodiazepines / Augmentin / Clavulanic Acid

Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
unresponsive, s/p 3 minutes chest compressions


Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation

History of Present Illness:
Pt is a 69y/o male with history of MS, bedbound from nursing
home, chronic suprapubic foley, found to be unresponsive and
given 3 cycles of CPR with ROSC. According to past medical
documentation pt is alert and [**First Name3 (LF) 11087**] at baseline. Reported to
normally follow commands, but cannot grip with either hand, and
has dysphagia with h/o PNA. Of note, pt was last admitted at
[**Hospital1 18**] [**5-23**] for sepsis secondary to pyelonephritis and
bacteremia.
.
Pt was by report found unresponsive by aide on day of admission
(pulse not checked. CPR initiated and recieved 2-3 minutes of
chest compressions, AED advised no shock. On EMS arrival pulse
was found to be present (ROSC - although not definitively
established that pt lost pulse at any time)
.
On arrival to ED, vital signs were HR 52, BP 120/54, sat 100%
NRB, T 97.8.
Labs showed:
-CBC: 7.8>43.4<180 (PMN 68%)
-chemistries: 131/5.0; 94/31; 13/0.4; 177
-INR 1.0. trop 0.02. lactate 2.6 -->2.3.
urine studies showed  100 protein 2urobili pH8.5 Lg leuks, 4WBC
few bact 0 epis.
Pt was unresponsive and not reacting to sternal rub, was
intubated for c/f inability to protect airway. ABG showed
7.46/31/292/23 on vent settings of RR16,TV500,peep5,Fio2-100.
Head CT negative for acute process. Stool was guiaic negative.
CXR showed no significant changes from prior CXR [**9-/2167**],
bilateral pleural effusions persisting.
EKG showed SR@45, normal axis, ?prolonged QT ?Qwaves V1/2/3
TWI II, aVR, aVL
.
In [**Name (NI) **], pt was given vanc/levoflox for concern for aspiration
pneumonia. Received approximately 3L IVF in ED. Pt remained
comatose off sedation, and plan was to initiate therapeutic
hypothermia with Arctic Sun for 24 hours. EEG was considered in
ED but was deferred to inpatient team for 48hr EEG per protocol.
However, prior to transfer pt began opening eyes spontaneously
and it was felt that cooling protocol was no longer necessary.
On admission vitals were: HR 47 RR 16 sat 100% vent BP 94/56
.
In the MICU, pt arrived on propofol for sedation. Propofol was
stopped temporarily and pt was opening eyes and nodding no but
not clearly responsive to commands.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.


Past Medical History:
1. MS, endstage secondary progressive type.
1. Decubitus ulcer (healing).
2. History of lung aspiration and lung abscess.
3. Hypertension.
4. Gastroesophageal reflux.
5. Status post gastrostomy tube.
6. Status post suprapubic catheter.
7. H/o Afib
8. H/o olgilvie's syndrome


Social History:
Lives in Nursing Home at [**Hospital3 2558**], divorced, two children.
Retired Biochemist.  Denies etoh/tobacco/drugs.


Family History:
Non-contributory.

Physical Exam:
ADMISSION EXAM:
Vitals: T: AF BP:113/59 P:72 R:16 18 O2:100%
GENERAL: Pt intubated, sedated. Vent settings FIo2 50%, TV 500
RR16  PEEP 5
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils dilated
but roudn and reactive to light
Neck: supple, JVP not elevated, no LAD  but difficult to assess
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi,difficult to assess posterior lung fields while on vent
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, distended but not tympanic, does not appear to be
tender by pt reactions although this is unclear. [**Name2 (NI) **] guarding, no
organomegaly, pt has Gtube in place, site without drainage.
GU: suprapubic catheter
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
ON DISCHARGE:
HR 66 BP 116/39 afebrile RR 20
pt fully alert and [**Name2 (NI) 11087**], conversational.
exam otherwise unchanged.

Pertinent Results:
ADMISSION LABS:
[**2168-3-21**] 02:45PM BLOOD WBC-7.8 RBC-4.98 Hgb-13.9* Hct-43.4
MCV-87 MCH-27.9 MCHC-32.0# RDW-17.2* Plt Ct-180
[**2168-3-21**] 02:45PM BLOOD Neuts-68.1 Lymphs-24.5 Monos-4.7 Eos-2.1
Baso-0.6
[**2168-3-21**] 02:45PM BLOOD PT-10.6 PTT-30.4 INR(PT)-1.0
[**2168-3-21**] 02:45PM BLOOD Glucose-177* UreaN-13 Creat-0.4* Na-131*
K-5.0 Cl-94* HCO3-31 AnGap-11
[**2168-3-21**] 02:45PM BLOOD CK(CPK)-48
[**2168-3-21**] 02:45PM BLOOD CK-MB-3
[**2168-3-21**] 02:45PM BLOOD cTropnT-0.02*
[**2168-3-21**] 02:56PM BLOOD Lactate-2.6*
.
LABS ON DISCHARGE:
[**2168-3-23**] 05:10AM BLOOD WBC-6.2 RBC-4.22* Hgb-11.7* Hct-36.8*
MCV-87 MCH-27.8 MCHC-31.8 RDW-17.2* Plt Ct-159
[**2168-3-23**] 05:10AM BLOOD Glucose-169* UreaN-9 Creat-0.3* Na-141
K-3.7 Cl-107 HCO3-29 AnGap-9
[**2168-3-23**] 05:10AM BLOOD Calcium-7.9* Phos-2.7 Mg-2.1
[**2168-3-22**] 04:04AM BLOOD TSH-2.3
.
URINE STUDIES
[**2168-3-21**] 02:47PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-8.5* Leuks-LG
[**2168-3-21**] 02:47PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2168-3-21**] 02:47PM URINE RBC-3* WBC-4 Bacteri-FEW Yeast-NONE Epi-0
[**2168-3-21**] 02:47PM URINE 3PhosX-MOD
[**2168-3-21**] 10:17PM URINE Hours-RANDOM UreaN-693 Creat-46 Na-60
K-82 Cl-61
[**2168-3-21**] 10:17PM URINE Osmolal-635
.
URINE CULTURE (Preliminary):
      PROTEUS MIRABILIS.    >100,000 ORGANISMS/ML..
         Piperacillin/tazobactam sensitivity testing available
on request.
      GRAM NEGATIVE ROD(S).    10,000-100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PROTEUS MIRABILIS
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--     4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------     2 I
GENTAMICIN------------     4 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------     8 I
TRIMETHOPRIM/SULFA----  =>16 R

.
IMAGING:
.
CXR [**3-21**]: No acute intrathoracic process. No change from
[**2167-9-16**].
.
CT Head w/o contrast [**3-21**]: No evidence of acute intracranial
process.


Brief Hospital Course:
REASON FOR ICU ADMISSION:
69 y/o M history of MS [**First Name (Titles) **] [**Last Name (Titles) 11087**] at baseline, h/o aspiration
pna found unresponsive in nursing home possibly pulseless, s/p
CPR, intubated for airway protection now with eye opening and
head nodding but not clearly responding to commands.
.
#altered mental status ?????? presented with AMS but by time of
discharge pt was fully [**Last Name (Titles) 11087**] and conversational. Most likely
theory for episode of unresponsive was that pt had an episode of
sleep apnea causing significant hypoxia, or toxic-metabolic
encephalopathy. On the differential is UTI, see below, however
pt improved rapidly and it was felt that antibiotics were not
necessary at this time. Cardiogenic sources considered, but no
evidence of ischemia on ECG and only mildly elevated trops which
remained flat, vs symptomatic bradycardia (pt with HR in the
40-50 range on admission see bradycardia below) vs stroke (but
head CT negative for acute process). Metabolic disturbances must
be considered but electrolytes wnl. DDx includes
seizure/postictal unresponsiveness however this was felt to be
less likely. In short, it was felt that his episode of
unresponsiveness was [**1-14**] sleep apnea. Pt with history of sleep
apnea but noncompliance with cpap recommended in the past. Was
noted to desat to 70% overnight in the ICU which immediately
resolved on waking him up. Pt was not requiring oxygen at time
of discharge although it would be suggested that he use oxygen
at night. He needs to have an outpatient sleep study and more
aggressive control of his sleep apnea.

#bacteruria - urine growing GNRs (proteus), large leuks however
only 4 WBC and no nitrites. Pt has a chronic indwelling
suprapubic catheter and noted to have frequent instances of
bacteruria - has grown proteus, enterococcus, morganella, and a
variety of other species in the past. Appears he is most
frequently growing proteus. Per previous infectious disease
note, plan has been not to treat unless pt had symptoms (often
develops urgency). Pt denied symptoms at this point and because
his mental status was rapidly improving we did not initiate
antibiotic therapy at this time. Still, pt did receive
vanc/levoquin in the ED (x1 dose) and improvement could have
been [**1-14**] antibiotic administration, although this is less
likely. Should follow up on speciation/sensitivities of urine
culture from this admission. He has a chronic
Would recommend treatment with antibiotics should pt
decompensate - strongly consider urinary source - please see
sensitivities under "results" section of DC paperwork.
.
#Hyponatremia - sodium of 131 on presentation. Pt was initially
resuscitated with 4L NS. Sodium immediately normalized and
remained wnl.
.
#elevated lactate - p/w lactate of 2.6 trended down to 1.1 day
of discharge. Pt did recieve >6L IVF which likely contributed to
improvement. Assuming pt was truly pulseless (not definitively
known) this lactate likely reflects hypoxia to tissues in the
setting of poor circulation. Pt was able to maintain normal
blood pressure and lactate elevation resolved.
.
#bradycardia - initially found with HR of 45-50. No evidence of
cardiac ischemia. This resolved once pt was off sedation. Pt was
monitored on telemetry without events.
.
#history of aspiration pneumonia - NPO, tube feeds and meds via
Gtube. Continued PPI.
.
#hypothyroidism ?????? tsh normal. continued levothyroxine
.
#nutrition ?????? continued home tube feeds with free water flushes
prn.
.
#MS - at baseline is fully [**Month/Day (2) 11087**] although cannot move any
part of the body except his face. Pt to follow up with neurology
as an outpatient.
.
# FEN: Continued on home tube feeds with free water flushes.
.
# Communication: ex-wife  [**First Name8 (NamePattern2) **] [**Known lastname **] phone [**Telephone/Fax (1) 7233**]
.
# Code: FULL discussed w/ ex-wife HCP


Medications on Admission:
per [**Hospital3 **] records:
NPO
proteinpowder one scoop mix with H20 via gtube [**Hospital1 **]
mag citrate give [**12-14**] bottle via gtube on m/w/f
generlac 10G/15mL solution (lactulose) give 15mls via gtube 4
times weekly on tues/thurs/sat/sun
omeprazole 2mg/ml give 10mLs (20mg) via gtube daily
levothyroxine 50mcg daily via gtube
provigil 200mg tab via gtube daily
simvastatin 40mg tab
cp-baclofen 5mg/ml oral susp give 3ml (15mg) via gtube [**Hospital1 **]
6am/6pm
metoclopramide 5mg/5ml solution give 5mls daily via gtube TID
natural balance tears drops instill 2 drops in both eyes every 8
hours
guiatuss 100mg/5ml syrup (robitussin give 10mLs via gtube q6hrs
prn for cough)
mild of mag 400mg/5ml oral susp give 30mls via gtube daily prn
constipation
acetaminophen 325mg tab give 2tabs via gtube q4hrs prn temp>101
acetaminophen 325 tab give 2 tabs via gtube q4hrs as needed for
pain
fleet enema insert 1 suppository rectally QD PRN for
constipation
ipratropium-albuterol 0.5-3mg/3ampule neb - inhale 3mls via neb
q6hrs as needed for cough/wheezing


Discharge Medications:
1. Protein powder
one scoop mix with H20 via gtube [**Hospital1 **]
2. magnesium citrate     Solution Sig: One [**Age over 90 1230**]y (150)
ML PO MWF (Monday-Wednesday-Friday).
3. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO Q
tues/thurs/sat/sun.
4. omeprazole 2 mg/mL Suspension for Reconstitution Sig: Ten
(10) mL PO once a day.
5. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Provigil 200 mg Tablet Sig: One (1) Tablet PO once a day.
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. baclofen
5mg/ml oral susp give 3ml (15mg) via gtube [**Hospital1 **] 6am/6pm

9. metoclopramide 5 mg/5 mL Solution Sig: Five (5) mL PO three
times a day.
10. Natural Balance 0.4 % Drops Sig: Two (2) drops Ophthalmic
every eight (8) hours.
11. Guiatuss 100 mg/5 mL Liquid Sig: Ten (10) mL PO every [**5-20**]
hours as needed for cough.
12. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL
PO once a day as needed for constipation.
13. Guiatuss 100 mg/5 mL Liquid Sig: Ten (10) mL PO every six
(6) hours as needed for cough.
14. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL
PO daily:prn as needed for constipation.
15. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
16. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
DAILY (Daily) as needed for constipation.
17. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: Three (3) mL Inhalation every six (6)
hours as needed for chest pain/cough.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
PRIMARY
altered mental status
obstructive sleep apnea

SECONDARY:
mulitple sclerosis


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.


Discharge Instructions:
It was a pleasure taking care of you during your recent
hospitalization. You presented after being found unresponsive,
and you were intubated because of inability to protect your
airway. You became more alert and we extubated you. You regained
orientation and were fully alert and conversational by the time
of discharge. We thought this unresponsive episode was from low
oxygen because of your obstructive sleep apnea at night. It is
very important that you schedule a sleep study and use CPAP or
whatever treatment is recommended.

Followup Instructions:
The following are appointments that you already have scheduled.
It is very important that you also schedule appointments with
ENT, neurology, and to have a sleep study. Please call
[**Telephone/Fax (1) 6856**] to set up a time for a sleep study. Please call
[**Telephone/Fax (1) 41**] to schedule an appointment with ENT - any doctor.
Please also call ([**Telephone/Fax (1) 11088**] to set up an appointment with
Dr. [**Last Name (STitle) 8760**] (neurologist)
.
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2168-8-25**] at 1 PM
With: PELVIC FLOOR UNIT [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: RADIOLOGY
When: WEDNESDAY [**2168-8-17**] at 10:45 AM [**Telephone/Fax (1) 590**]
Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST     Best Parking: Main Garage

Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2168-3-30**] at 9:00 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
{'Altered mental status,Encephalopathy, unspecified,Urinary tract infection, site not specified,Acidosis,Obstructive sleep apnea (adult)(pediatric),Other specified cardiac dysrhythmias,Unspecified acquired hypothyroidism,Multiple sclerosis,Neurogenic bladder NOS,Unspecified essential hypertension,Esophageal reflux,Bed confinement status,Gastrostomy 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: unresponsive, s/p 3 minutes chest compressions

PRESENT ILLNESS: Pt is a 69y/o male with history of MS, bedbound from nursing
home, chronic suprapubic foley, found to be unresponsive and
given 3 cycles of CPR with ROSC. According to past medical
documentation pt is alert and [**First Name3 (LF) 11087**] at baseline. Reported to
normally follow commands, but cannot grip with either hand, and
has dysphagia with h/o PNA. Of note, pt was last admitted at
[**Hospital1 18**] [**5-23**] for sepsis secondary to pyelonephritis and
bacteremia.
.
Pt was by report found unresponsive by aide on day of admission
(pulse not checked. CPR initiated and recieved 2-3 minutes of
chest compressions, AED advised no shock. On EMS arrival pulse
was found to be present (ROSC - although not definitively
established that pt lost pulse at any time)
.
On arrival to ED, vital signs were HR 52, BP 120/54, sat 100%
NRB, T 97.8.
Labs showed:
-CBC: 7.8>43.4<180 (PMN 68%)
-chemistries: 131/5.0; 94/31; 13/0.4; 177
-INR 1.0. trop 0.02. lactate 2.6 -->2.3.
urine studies showed  100 protein 2urobili pH8.5 Lg leuks, 4WBC
few bact 0 epis.
Pt was unresponsive and not reacting to sternal rub, was
intubated for c/f inability to protect airway. ABG showed
7.46/31/292/23 on vent settings of RR16,TV500,peep5,Fio2-100.
Head CT negative for acute process. Stool was guiaic negative.
CXR showed no significant changes from prior CXR [**9-/2167**],
bilateral pleural effusions persisting.
EKG showed SR@45, normal axis, ?prolonged QT ?Qwaves V1/2/3
TWI II, aVR, aVL
.
In [**Name (NI) **], pt was given vanc/levoflox for concern for aspiration
pneumonia. Received approximately 3L IVF in ED. Pt remained
comatose off sedation, and plan was to initiate therapeutic
hypothermia with Arctic Sun for 24 hours. EEG was considered in
ED but was deferred to inpatient team for 48hr EEG per protocol.
However, prior to transfer pt began opening eyes spontaneously
and it was felt that cooling protocol was no longer necessary.
On admission vitals were: HR 47 RR 16 sat 100% vent BP 94/56
.
In the MICU, pt arrived on propofol for sedation. Propofol was
stopped temporarily and pt was opening eyes and nodding no but
not clearly responsive to commands.

MEDICAL HISTORY: 1. MS, endstage secondary progressive type.
1. Decubitus ulcer (healing).
2. History of lung aspiration and lung abscess.
3. Hypertension.
4. Gastroesophageal reflux.
5. Status post gastrostomy tube.
6. Status post suprapubic catheter.
7. H/o Afib
8. H/o olgilvie's syndrome

MEDICATION ON ADMISSION: per [**Hospital3 **] records:
NPO
proteinpowder one scoop mix with H20 via gtube [**Hospital1 **]
mag citrate give [**12-14**] bottle via gtube on m/w/f
generlac 10G/15mL solution (lactulose) give 15mls via gtube 4
times weekly on tues/thurs/sat/sun
omeprazole 2mg/ml give 10mLs (20mg) via gtube daily
levothyroxine 50mcg daily via gtube
provigil 200mg tab via gtube daily
simvastatin 40mg tab
cp-baclofen 5mg/ml oral susp give 3ml (15mg) via gtube [**Hospital1 **]
6am/6pm
metoclopramide 5mg/5ml solution give 5mls daily via gtube TID
natural balance tears drops instill 2 drops in both eyes every 8
hours
guiatuss 100mg/5ml syrup (robitussin give 10mLs via gtube q6hrs
prn for cough)
mild of mag 400mg/5ml oral susp give 30mls via gtube daily prn
constipation
acetaminophen 325mg tab give 2tabs via gtube q4hrs prn temp>101
acetaminophen 325 tab give 2 tabs via gtube q4hrs as needed for
pain
fleet enema insert 1 suppository rectally QD PRN for
constipation
ipratropium-albuterol 0.5-3mg/3ampule neb - inhale 3mls via neb
q6hrs as needed for cough/wheezing

ALLERGIES: Benzodiazepines / Augmentin / Clavulanic Acid

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: T: AF BP:113/59 P:72 R:16 18 O2:100%
GENERAL: Pt intubated, sedated. Vent settings FIo2 50%, TV 500
RR16  PEEP 5
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils dilated
but roudn and reactive to light
Neck: supple, JVP not elevated, no LAD  but difficult to assess
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi,difficult to assess posterior lung fields while on vent
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, distended but not tympanic, does not appear to be
tender by pt reactions although this is unclear. [**Name2 (NI) **] guarding, no
organomegaly, pt has Gtube in place, site without drainage.
GU: suprapubic catheter
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
ON DISCHARGE:
HR 66 BP 116/39 afebrile RR 20
pt fully alert and [**Name2 (NI) 11087**], conversational.
exam otherwise unchanged.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Lives in Nursing Home at [**Hospital3 2558**], divorced, two children.
Retired Biochemist.  Denies etoh/tobacco/drugs. 

### Response:
{'Altered mental status,Encephalopathy, unspecified,Urinary tract infection, site not specified,Acidosis,Obstructive sleep apnea (adult)(pediatric),Other specified cardiac dysrhythmias,Unspecified acquired hypothyroidism,Multiple sclerosis,Neurogenic bladder NOS,Unspecified essential hypertension,Esophageal reflux,Bed confinement status,Gastrostomy status'}
