Consider the following medical report that includes the patient's historical health records. Use it to predict the disease that the patient is high likely exposed to. 

 Medical Report: allergies: no known allergies / adverse drug reactions attending: chief complaint: nausea major surgical or invasive procedure: video swallow study egd insertion of pigtail catheter in r pleural space history of present illness: 74 year-old man with glottic squamous cell carcinomal s/p chemo and xrt as well as t3n0mx poorly differentiated carcinoma of the lung in remission presenting after a recent hospitalization for dysphagia with continued dysphagia and poor po intake leading to weakness. he was discharged approximately a week before this presentation and at that time was admitted for dysphagia. he had dilation of a relativley quite minor esophageal stricture during that hospitalization and afterwards improved and was discharged. he reports that his swallowing is slightly better but he is not able to take much food at all. he reports his appetite is very poor. in the context of this poor intake he reports he has gotten very week and though he reports a month or so ago he could walk several blocks over the last weeks he does not think he could do this. aside from his weakness and poor intake he reports chronic back pain on his left side, where he had a previous surgery. he has subjective fevers and chills and reports chronic cough but this is nonproductive. he does have chronic production of sputum in his mouth that he does not feel he can handle and swallow and spits in a basin throughout our interview. he denies odynophagia. he also endorses chronic anorexia and more recently having had some subjective fevers or chills though he reports dysuria or localizing singns except for his chronic, nonproductive cough and approximately two episodes of loose stool a day, which he reports are immediately after he eats. he has mild headache. he denies abdominal pain, dysuria, or flank pain. he very rarely has nausea and will vomit with dyspnea after vomiting. he denies dyspnea at any other time. because of inability to manage these symptoms at home he presented to the ed. in the ed all vital signs were stable. t 98, p 108, bp 92/65, rr 18, o2 sat 100% ra. he had labs and cultures, which revealed a leukocytosis but ua and chest radiograph were both without signs of acute infection and he was afebrile. he was admitted for further management. currently, he discusses his litany of complaints and is very irritated by how poorly he is feeling. he is particularly concerned about how little he is eating and mentioned to a nurse he would die without ivf. he does ask for supplements, however, and is very concerned with his po intake. review of systems: positive per hpi. notably negative for abdominal pain, shortness of breath (except immediately following emesis), and vomiting with liquids. otherwise review of systems performed and unremarkable. past medical history: - diabetes mellitus, type ii - hypertension - t3 n0 m0 glottic squamous cell carcinoma s/p chemoradiation therapy - tracheostomy on - peg tube placed on . - poorly differentiated large cell carcinoma t3n0mx in the left upper lobe s/p left thoracotomy, partial decortication of lung, left upper lobectomy, mediastinal lymphadenectomy, en bloc resection of pericardium on . - hospitalization for dysphagia a week previous with very minor stricture that was dilated social history: he quit smoking three years ago after 150-pack-year history. previously a teacher in . history of heavy alcohol use but quit in his 50s. he used to be a teacher in . former etoh use, quit 20 years ago. lives with his wife and son. family history: his mother died at age 85 of unclear causes. father died in siberia after being taken from family, unclear medical history. sisters and sons without notable problems at this time. physical exam: admission exam: vs: t 99.1, p 94, bp 116/60, rr 18, o2 99% on ra appearance: thin elderly man appearing uncomfortable and frequently spitting in a basin but non-toxic eyes: eomi, conjunctiva clear ent: dry appearing, edentulous,no ulcers or erythema, no jvd, chronic fibrotic changes of anterior throat (presumably from radiation) cv: regular, normal s1 and s2, no systolic or diastolic murmurs, no lower extremity edema appreciated respiratory: breathing appears comfortable, diminished breath sounds over the left upper chest, , diminished breath sounds at the bases bilaterally with a few crackles at the left base on auscultation, lidocaine patches on left back gi: soft, nontender, nondistended, bowel sounds positive, no hepatomegaly or splenomegaly msk: tone wnl, bulk wnl, upper extremity strength 5/5 and symmetrical, lower extremity strength 4+/5 and symmetrical, no cyanosis, no clubbing, no joint swelling neuro: cnii-xii intact, normal attention, fluent heavily accented speech integument: warm, dry, no rash psychiatric: appears anxious but generally pleasant hematologic / lymphatic: no cervical , thyroid wnl discharge exam (prior to death) vs: 98.1 90s/40s 90s af 98% on fio2 35% trach collar general: non-alert, cachectic man sitting in bed, in distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad, trach site without oozing lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi. transmitted upper airway sounds from trach. cv: irreg irreg. rate approx 80s. normal s1 + s2, no murmurs, rubs, gallops abdomen: peg dressing and wound c/d/i. abdomen soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: foley drainaing dark yellow urine ext: diffuse anasarca with 2-3+ pitting edema. warm, well perfused, 2+ pulses, no clubbing, cyanosis. rue picc without erythema or purulence pertinent results: =================== laboratory results =================== wbc-14.1* rbc-3.50* hgb-9.8* hct-29.2* mcv-84 rdw-13.7 plt ct-514* ---neuts-88* lymphs-4* monos-8 hypochr-normal anisocy-normal poiklo-normal macrocy-normal microcy-normal polychr-occasional glucose-196* urean-23* creat-0.8 na-134 k-4.1 cl-96 hco3-25 ============== other studies ============== chest radiograph pa and lateral (my read): general greater density over the left lung field, likely due to volume loss (chronic). no infiltrate or pulmonary edema appreciated. no effusions. there is a circular lucency of the left clavicle that appears new from previous chest radiographs though radiograph from shows a circular lucency likely linked to the lung. no acute intrapulmonary process, ? lytic lesion in left clavicle. bed side swallow study summary / impression: mr. is well known to me from previous swallowing evaluations. he had been tolerating thin liquids and ground solids before his recent left thoracotomy, left upper lobectomy and pericardial resection for biopsy proven non-small cell lung cancer. we repeated his video swallow after that procedure before d/c but swallow function was c/w previous exams and he remained safe for thin liquids and soft foods with extra sauce and gravy. he was given a 10 days course of antibiotics for h pylori but was only able to take 3 1/2 days of the medication and did not finish the prescription. it is unlikely his oral and pharyngeal have changed since when we did his last video swallow and he has been recently dilated which rules out the possibility he restrictured. my guess is that the biggest change is likely continued h pylori, as he vomited up most of the medication and stoped taking it after 3 days. suggest considering restarting meds for h pylori (not sure if it needs to be rediagnosed before starting meds) to try to improve comfort. he remains safe to drink his liquid supplements, and takes 5 cans of nutren 2.0, 500 calories each which he should be ordered for here. he can also take water safely, which can keep him hydrated. we will plan to f/u with him after treatment for h pylori to see if he feels his oral and pharyngeal swallow has improved further. this swallowing pattern correlates to a functional oral intake scale (fois) rating of 5. . tte (): the left atrium is elongated. no atrial septal defect is seen by 2d or color doppler. left ventricular wall thickness, cavity size and regional/global systolic function are normal (lvef >55%). there is no ventricular septal defect. right ventricular chamber size and free wall motion are normal. the diameters of aorta at the sinus, ascending and arch levels are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. no aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild (1+) mitral regurgitation is seen. the tricuspid valve leaflets are mildly thickened. there is borderline pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , no change. . gastric biopsy (): gastric antrum and body, mucosal biopsies: antral and corpus mucosa with focal intestinal metaplasia, focal regeneration of gastric pits and minimal inflammation; see note. note: the findings are non-specific, but are most suggestive of a chemical-type gastropathy. at the request of the clinician, a helicobacter immunostain is performed and is negative for h. pylori, with satisfactory controls. . egd () procedure: the procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. a physical exam was performed. the patient was administered mac anesthesia. supplemental oxygen was used. the patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the third part of the duodenum was reached. careful visualization of the upper gi tract was performed. the procedure was not difficult. the patient tolerated the procedure well. there were no complications. findings: esophagus: mucosa: stricture seen near upper esophogeal sphincter as previously described. the scope was able to traverse the lesion. stomach: lumen: a medium size hiatal hernia was seen. mucosa: erythema of the mucosa was noted in the stomach. this was worse in the antrum. consistent with pan gastritis. duodenum: normal duodenum. impression: abnormal mucosa in the esophagus erythema in the stomach medium hiatal hernia otherwise normal egd to third part of the duodenum . gastric emptying study (): impression: normal gastric emptying study. . radiology chest (portable ap) 1. moderate bilateral pleural effusions, likely stable. 2. bibasilar opacities, probable compressive atelectasis. pneumonia and aspiration are within the differential, though less likely. 4. widened mediastinum corresponding with fluid and adenopathy seen on recent chest ct. 5. known pulmonary nodules not well characterized. radiology mr /t-spine w & w/o cont 1. severe compression deformity of t6 vertebral body with mild retropulsion, but no cord compression. this finding is compatible with either a pathologic fracture secondary to a metastasis, or an osteoporotic fracture. no additional metastases are seen in the thoracic or lumbar spine. 2. chronic moderate compression deformity of the l2 vertebral body with mild retropulsion, but no nerve root compression radiology n-g tube placement/perc g/g-j tube plmt prelim report not available radiology -intestinal tube pl unsuccessful attempted passage of a nasogastric tube despite fluoroscopy. findings discussed with dr. by dr. at 1510 hours on . please note this precludes gastrostomy by the ir team. surgical consult suggested. radiology ct neck w/contrast 1. status post tracheostomy. no evidence of recurrent laryngeal tumor. 2. 2. upper mediastinal lymphadenopathy and right pleural effusion, better evaluated on the dedicated chest ct examination performed on the same day. 3. persistent left hydrothorax. attending note: 1. a right sided level 2 lymphnode (2:19) has increased in size since and measures 13-mm and has hetrogenous density suggestive of metastasis. 2. right pleural effusion is new since , correlate with chest ct. 3. there is increased glottic and supra-glottic edema likely related to treatment changes radiology ct chest w/contrast 1. incompletely-imaged multiple liver masses, new since the ct examination, compatible with malignancy. further evaluation with abdominal and pelvic ct is recommended. 2. see neck ct report assessment for any recurrent right laryngeal tumor. 3. interval complete collapse of the t6 vertebral body since the examination may be pathologic given the findings of new hepatic malignancy. 4. enlarging right upper lobe pulmonary nodule, new left lower lobe nodule, and equivocal left pleural-based nodule. 5. status post tracheostomy, with patent airways to the subsegmental levels. 6. moderate-sized bilateral pleural effusions, greater on the right, with adjacent compressive atelectasis. 7. persistent left hydrothorax, with resolution of a previously seen small loculated pneumothorax. 8. new small amount of intra-abdominal ascites. 9. new prominent upper mediastinal lymph nodes, suspicious for malignancy. radiology chest (portable ap) 1. developing retrocardiac opacity compatible with aspiration, pneumonia, or atelectasis. 2. small left pleural effusion radiology video oropharyngeal swa aspiration of thin liquids and nectar-thick liquids. pharyngeal residue with pudding. please refer to note from speech and swallow division in the omr for further details. radiology chest (portable ap) , approved 1. diffuse increase in left lung opacity, compatible with worsening pleural effusion. 2. right lower lung atelectasis. radiology rib unilat, w/ ap chest , approved no definite rib fx or rib lesion. gallstones noted. changes in left lung, as described microbiology blood culture blood culture, routine-pending inpatient sputum gram stain-final; respiratory culture-preliminary {pseudomonas aeruginosa, staph aureus coag +} inpatient blood culture blood culture, routine-pending inpatient urine urine culture-final inpatient urine urine culture-final inpatient blood culture blood culture, routine-final inpatient mrsa screen mrsa screen-final inpatient stool clostridium difficile toxin a & b test-final {clostridium difficile} inpatient sputum gram stain-final; respiratory culture-final inpatient blood culture blood culture, routine-final inpatient urine urine culture-final inpatient blood culture blood culture, routine-final inpatient mrsa screen mrsa screen-final inpatient blood culture blood culture, routine-final inpatient urine urine culture-final inpatient blood culture blood culture, routine-final inpatient blood culture blood culture, routine-final inpatient urine urine culture-final inpatient blood culture blood culture, routine-final inpatient urine urine culture-final inpatient sputum gram stain-final; respiratory culture-final inpatient blood culture blood culture, routine-final inpatient urine urine culture-final inpatient blood culture blood culture, routine-final emergency = ================================================================ 10:20 am sputum site: endotracheal source: endotracheal. gram stain (final ): >25 pmns and <10 epithelial cells/100x field. 3+ (5-10 per 1000x field): gram negative rod(s). respiratory culture (final ): commensal respiratory flora absent. due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. pseudomonas aeruginosa. moderate growth of two colonial morphologies. stenotrophomonas (xanthomonas) maltophilia. sparse growth. gram negative rod #3. sparse growth. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | stenotrophomonas (xanthomonas) maltoph | | cefepime-------------- 16 i ceftazidime----------- 16 i ciprofloxacin--------- 1 s gentamicin------------ 4 s levofloxacin---------- 2 s meropenem------------- 2 s piperacillin/tazo----- s tobramycin------------ <=1 s trimethoprim/sulfa---- 2 s legionella culture (final ): no legionella isolated. fungal culture (preliminary): no fungus isolated. acid fast smear (final ): no acid fast bacilli seen on concentrated smear. acid fast culture (preliminary): no mycobacteria isolated. =========================================================== 11:00am blood wbc-14.1* rbc-3.50* hgb-9.8* hct-29.2* mcv-84 mch-28.1 mchc-33.7 rdw-13.7 plt ct-514* 06:55am blood wbc-13.1* rbc-2.94* hgb-8.1* hct-24.6* mcv-84 mch-27.6 mchc-33.0 rdw-14.3 plt ct-452* 07:20am blood wbc-15.0* rbc-2.97* hgb-8.0* hct-24.7* mcv-83 mch-26.9* mchc-32.2 rdw-14.0 plt ct-481* 01:59pm blood wbc-15.1* rbc-2.75* hgb-7.5* hct-23.0* mcv-84 mch-27.4 mchc-32.8 rdw-14.1 plt ct-452* 03:23am blood wbc-18.5* rbc-2.57* hgb-6.8* hct-22.5* mcv-87 mch-26.3* mchc-30.1* rdw-15.2 plt ct-565* 04:33am blood wbc-22.4* rbc-2.75* hgb-7.2* hct-23.8* mcv-87 mch-26.1* mchc-30.1* rdw-15.4 plt ct-230 03:32am blood wbc-22.5* rbc-2.77* hgb-7.3* hct-24.0* mcv-87 mch-26.2* mchc-30.3* rdw-16.6* plt ct-144* 03:53am blood wbc-12.3* rbc-2.33* hgb-6.4* hct-20.1* mcv-86 mch-27.4 mchc-31.8 rdw-16.5* plt ct-106* 06:00am blood wbc-11.9* rbc-2.70* hgb-7.1* hct-23.2* mcv-86 mch-26.4* mchc-30.7* rdw-17.1* plt ct-107* 05:23am blood wbc-10.8 rbc-2.69* hgb-7.5* hct-23.6* mcv-88 mch-27.8 mchc-31.7 rdw-16.9* plt ct-49* 06:00am blood glucose-135* urean-21* creat-0.6 na-139 k-3.5 cl-100 hco3-33* angap-10 06:00am blood glucose-125* urean-21* creat-0.6 na-141 k-3.6 cl-101 hco3-31 angap-13 02:35pm blood glucose-112* urean-21* creat-0.6 na-141 k-4.3 cl-103 hco3-32 angap-10 05:50am blood glucose-139* urean-27* creat-0.9 na-141 k-4.0 cl-102 hco3-30 angap-13 05:28am blood glucose-154* urean-39* creat-1.1 na-143 k-3.4 cl-104 hco3-30 angap-12 05:23am blood glucose-220* urean-52* creat-1.6* na-141 k-4.7 cl-104 hco3-28 angap-14 05:23am blood albumin-1.5* calcium-7.0* phos-4.8* mg-2.6 05:50am blood calcium-7.7* phos-3.8 mg-2.3 02:35pm blood totprot-3.5* albumin-1.5* globuln-2.0 calcium-7.1* phos-2.6* mg-2.1 06:00am blood calcium-7.5* phos-2.7 mg-2.2 06:00am blood albumin-1.6* calcium-7.2* phos-3.1 mg-2.1 03:08pm blood calcium-7.6* phos-3.4 mg-2.1 ====================================== , m 74 radiology report cta chest w&w/o c&recons, non-coronary study date of 6:22 pm , omed 11r 6:22 pm cta chest w&w/o c&recons, non- clip # reason: ?r/o pe contrast: medical condition: 74 year old man with metastatic lung cancer, glottic cancer, presumed aspiration pneumonia, and acutely worsening sob. reason for this examination: ?r/o pe contraindications for iv contrast: none. wet read: ygd mon 10:31 pm subtle filling defect involving rml subsegmental branch (4:158-161, 402b:25, and 3:4) could represent trace pulmonary embolism. small right ptx and right posterior pleurx catheter in place. fluid distends esophagus and aerosolized material in lower lobe airways and extensive aspiration pneumonitis. bilateral pulmonary nodules some pleural based. right apical paraseptal emphysema. trace pleural effusions. left 7th rib sclerosis, probably post traumatic. stable severe t6 wedge compression. d/w dr. at 7:30 pm and 10:00 pm on via phone by x final report cta chest with and without contrast date: . comparison: ct chest; mr thoracic spine , ; ct abdomen and pelvis . clinical indication: 74 year old man with metastatic lung cancer, glottic cancer, presumed aspiration pneumonia, and acutely worsening sob. rule out pe. technique: axial images of the chest were obtained without the use of intravenous contrast. subsequently, axial images were obtained after the uneventful administration of 100 ml optiray intravenous contrast. coronal and sagittal reformatted images were constructed. chest findings: there is no central or segmental pulmonary embolus. evaluation of distal subsegmental branches is slightly limited secondary to incomplete opacification with contrast. the previously described subtle filling defect involving the right middle lobe subsegmental branch is favored to be artifactual. no additional filling defects are identified. the heart is normal in size. there is a small pericardial effusion. loculated fluid in the left anterior hemithorax with peripheral enhancement is unchanged. there are small, left greater than right, bilateral pleural effusions with adjacent compressive atelectasis at the bases. there is no axillary lymphadenopathy. mediastinal lymphadenopathy, predominantly involving the prevascular space/anterior mediastinum, is unchanged in size. a small right pneumothorax is new from the prior examination. a right posteriorly placed chest tube is in place. there is underlying centrilobular and periseptal emphysema. there are new and worsening areas of scattered ground-glass opacities with septal thickening, predominantly involving the right lung. on the left, there is bronchial wall thickening involving the lower lobe bronchi, minimally progressed from the prior examination. patchy parenchymal opacity in the medial base is noted. there is a new subpleural nodular opacity measuring 6 mm in the left upper lobe (3:12). a pleural-based nodule at the left base measuring 10 x 12 mm is essentially unchanged. also stable is the right upper lobe pulmonary nodule (9mm, 2:10). the esophagus is newly distended and fluid filled. atherosclerotic changes are present within the normal caliber aorta. there is focal narrowing of mild degree in the left main pulmonary artery, unchanged from prior examinations (3:16). the patient has a tracheostomy tube which is unchanged in appearance. an enlarging liver lesion in the left hepatic lobe measures 6.1 x 8.2 cm. this is incompletely imaged. there is abdominal ascites. musculoskeletal findings: there is asymmetric left greater than right subcutaneous fat stranding in the chest wall. compression deformity of t6 vertebral body is redemonstrated and stable. post-surgical changes are present in the left posterior ribs. incompletely healed fracture with callus formation is present in the left fifth lateral rib. impression: 1. new small right pneumothorax. right chest tube is posteriorly positioned. please ensure chest tube is to suction. 2. no definite evidence of pulmonary embolus. 3. stable pleural/parenchymal nodules, left hydrothorax and small left pleural effusion. 4. new areas of scattered ground-glass opacities with septal thickening, predominantly on the right, related to inflammatory or infectious etiology. 5. bronchial wall thickening at the left base with patchy consolidation, minimally progressed, possibly secondary to aspiration. 6. fluid-filled and dilated esophagus, new from the prior examination which may relate to esophagitis or possibly early stricture formation. please correlate for symptoms of esophagitis. 7. enlarging incompletely imaged liver metastasis. 8. stable t6 wedge compression deformity. the study and the report were reviewed by the staff radiologist. dr. dr. approved: tue 5:09 pm imaging lab brief hospital course: 74 year-old man with laryngeal cancer and nsclc s/p chemo and xrt, history of chronic dysphagia (to solids), and h.pylori infection presents with progressive nausea and resulting decreased po intake. . #icu course #1: he was first admitted to the icu shortly after admission when he looked very sleepy, with tachypnia and labored breathing. in the icu, he was started on heliox, racemic epinephrine and iv dedacrdone. he was kept strict npo and some of his meds were switched to iv form. he was evaluated by ent who placed tracheostomy on the day of the admission with no complications. cxr post trach showed no complications with larger lung volumes. . # icu course #2: patient was readmitted to the icu on for afib with rvr. he was initially placed on a diltiazem drip and amiodarone infusion was also started to obtain rhythm control. heart rate was better controlled with amiodarone, but attempts to transition to po amiadorone were hindered by persistent dysphagia. patient failed video swallow study and patient had g tube placed by ir on . he was then transitioned to po dilt. during this stay, he complained of persistent dyspnea and cxr showed a new worsening pleural effusion on the right. ct of the chest on showed multiple liver mets, t6 collapse, enlarging rt upper pulm nodule, new lll nodule, equivocal lft pleural based nodule, prominent mediastinal nodes, and moderate sized bilateral pleural effusions, greater on the right. heme/onc was consulted who did not feel chemotherapy or further imaging was indicated. diagnostic thoracentesis of rt pleural effusion was considered, but patient could not be properly positioned. additionally, radiation oncology was consulted for palliative xrt, but again, patient positioning limited treatment options. mri of the spine was ordered, and spine consult planned at this time. he was called out to the floor . . # metastatic disease: patient with glottic scc (t3n0)s/p chemoradiation in and stage iib nsclc s/p left upper lobectomy in . following surgery in , patient was told he was 'cancer free'. patient developed persistent dyspnea during hospital stay, and cxr noted bilateral pleural effusions. ct of the chest on showed multiple liver mets, t6 collapse, enlarging rt upper pulm nodule, new lll nodule, equivocal lft pleural based nodule, prominent mediastinal nodes, and moderate sized bilateral pleural effusions, greater on the right. heme/onc was consulted who did not feel chemotherapy or further imaging was indicated. diagnostic thoracentesis of rt pleural effusion was considered, but patient could not be properly positioned. additionally, radiation oncology was consulted for palliative xrt, but again, patient positioning limited treatment options. mri of the spine was ordered, and spine consult planned at this time. # nausea, heartburn: initially an attempt at h.pylori eradication was done to eliminate that as a potential cause of his nausea. however, he was unable to tolerate sequential therapy and was taken off of it. he was therefore started on ppi and given antiemetics, particularly zofran. he then had an egd and gastric emptying study. his gastric emptying study was normal. egd showed stricture in his upper esophageal sphincter, abnormal mucosa in the esophagus, erythema in the stomach, medium hiatal hernia. his ues was dilated. he also had heartburn, which was treated as above and with zofran, which would aid in gastric motility given his lack of a les. his nausea and heartburn gradually improved. however, due to persistent dysphagia, he was made npo and g tube was placed on . . # cdiff: during his hospital course, he began having low grade fevers and diarrhea. cxr, blood cultures, urine culture were unrevealing. cdiff antigen was positive on and patient was started on iv flagyl. due to his high risk, vancomycin enemas were added on as he could not tolerate po vancomycin. po vancomycin was added to regimen following successful placement of g tube on . . # dysphagia: he has history of glottic cancer s/p chemo xrt, s/p trach with course complicated by chronic dysphagia with dilation esophageal stricture . pt had an egd approximately one week prior to admission that did not show a significant narrowing and patient had dilation with improvement and even acknowledges this improvement in the dysphagia component of his symptoms. to ensure that esophageal stricture was not still contributing to his symptoms, he had a video swallow study which was none revealing of contributory pathology. he was supplemented with nutren given his risk for malnutrition. however, as his hospital course prolonged, his dysphagia progressed and he failed a second video swallow study on . he was made npo with tpn until a g-tube was placed by ir on . . #chronic pain, like post-thoracotomy pain: he was seen by the chronic pain service as well as the pain and palliative care service. he was treated with a lidocaine patch, prn dilaudid, basal fentanyl patch, and gabapentin. plain films of right ribs were negative for fracture. ct scan of thorax to eval progression of pleural effusion noted compression fracture of t6. he was previously being considered by pain clinic for nerve block for post-thoracotomy pain; he may follow with them. he will also follow with palliative care upon outpt referral by oncology. given newly found metastatic disease, may also consider bone scan to r/o mets as outpt. # atrial fibrillation: he was noted to have asymptomatic atrial fibrillation with rvr on . tsh was checked and normal; tte showed elongated la but was unchanged from prior tte. on , he again developed rvr and attempts to control with iv nodal agents resulted in decreased blood pressure. he was transferred to the icu where diltiazem gtt was started to control rate. during this time, amiadarone infusion was started and rhythm control was adequately obtained. he was transitioned to po amiadarone following placement of g tube. #normocytic anemia: pt with poor po may also be component of iron deficiency although normocytic. he may also have some mild gastric blood loss due to his severe gastritis. studies included levated ferritin, esr, crp markedly elevated, pointing to anemia of chronic disease. his hct responded appropriately to 1 unit prbc . he again received 1 unit prbc on and . . # thrombocytopenia: plt count began trending down from 403 on to 120 on . etiology was thought to be due to platelet clumping seen on smear, although cdiff infection and amiadarone therapy could not be ruled out. . # cough, dry mouth, upper airway secretions: various other complaints were addressed, including cepacol prn cough; mouth swabs for dry mouth (may consider artificial saliva); albuterol nebulizers for thick secretions from upper airway chronic disease. he should follow up with ppc as an outpt (to be referred by outpt oncology). . status: full code omed course ( - ): # fevers/pna: pt febrile on with cxr concerning for pneumonia, witnessed aspiration of bilious content. iv vanc and zosyn restarted on . zosyn coverage obtained because of risk for aspiration pneumonia and better coverage of anaerobes. furthermore, prior pseudomonas cultures were intermediate to cefepime and sensitive to zosyn. sputum cx positive gram negative rods (pseudomonas- to zosyn and stenotrophomonas- to levo/bactrim). iv zosyn and bactrim discontinued on due to renal toxicity and worsening thrombocytopenia, levofloxacin started for pseudomonas/stenotrophomonas coverage. mr. was eventually made cmo by his family on and passed that evening. the family declined an autopsy. . # dyspnea: a pigtail pleural drain was placed by ir on for palliation of shortness of breath. 1200 cc of pleural fluid was drained. the tube was capped from - 3 for hypotension. . # af with rvr: rate was well controlled eventually on amiodarone 200mg daily. . # anasarca: likely secondary to hypoalbuminuria. attempts were made to diurese daily ~500 cc. however hypotension from to made diuresis impossible during these dates. albumin administration from did little to improve anasarca and pulmonary edema. mr. was eventually made cmo by his family on and passed that evening. . # : mr. developed renal failure on with progressive worsening over the next 4 days. given his hypotension, he was not a candidate for hemodialysis. the family ultimately decided against initiating cvvh in the icu, he was made cmo on and passed that evening. . #. metastatic disease (glottic scc and nsclc; s/p trach): pt has two underlying malignancies and evidence of likely metastatic disease with liver lesions and spine lesions. ortho spine rec'd tlso brace when oob. no liver biopsy was obtained per family discussion. pain control with intermittent iv morphine was continued. mr. was eventually made cmo by his family on and passed that evening. . # c diff: mr. was maintained on po vanc/iv flagyl with persistent diarrhea. . # anemia: given guiac positive bilious secretions and stool, coupled with slow drop in hct, likely slow bleeding from glottic carcinoma. mr. was transfused intermittently for hct < 25. . # thrombocytopenia: drop to 90s by date of demise from 600 on admission. likely tumor invasion, but initially could not rule out hit given heparin use. 4t's score was 3 and workup with hit antibody was currently not indicated. on , mr. complained of acute worsening shortness of breath. a cta was obtained and a hit antibody was sent. the cta was negative for pulmonary embolism, and the hit antibody was negative. thrombocytopenia likely tumor invasion of marrow vs. drug effect. on date of demise, given thrombocytopenia, zosyn was discontinued. . # gastritis: continue ppi and sucrafate, triggered for emesis of bilious secretions with aspiration. guiac positivity is expected given gastritis/scc. standing antiemetics were started and tube feeds were slowed. . # penile lesion: on , a stage 3 penile ulcer was noted. urology and wound consults were obtained. likely secondary to anasarca and paraphimosis. wet-to-dry dressings were started. medications on admission: -metformin 1000 mg po twice a day. -omeprazole 20 mg po daily -dilaudid 2-4 mg po every four hours as needed for pain. -colace 100 mg po twice a day as needed for constipation. -senna 8.6 mg : 1-2 tablets po twice a day as needed for constipation. discharge medications: none, patient died discharge disposition: expired discharge diagnosis: metastatic non-small cell lung cancer glottic squamous cell carcinoma sepsis secondary to hcap c diff infection discharge condition: deceased discharge instructions: deceased followup instructions: deceased md, procedure: parenteral infusion of concentrated nutritional substances thoracentesis thoracentesis laryngoscopy and other tracheoscopy temporary tracheostomy esophagogastroduodenoscopy [egd] with closed biopsy percutaneous [endoscopic] gastrojejunostomy diagnoses: thrombocytopenia, unspecified malignant neoplasm of liver, secondary unspecified essential hypertension acute kidney failure, unspecified acquired coagulation factor deficiency unspecified septicemia iron deficiency anemia secondary to blood loss (chronic) severe sepsis atrial fibrillation intestinal infection due to clostridium difficile malignant neoplasm of other parts of bronchus or lung other ascites diabetes mellitus without mention of complication, type ii or unspecified type, uncontrolled secondary malignant neoplasm of bone and bone marrow pneumonia due to klebsiella pneumoniae helicobacter pylori [h. pylori] stricture and stenosis of esophagus late effect of radiation radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure unilateral paralysis of vocal cords or larynx, partial pathologic fracture of vertebrae redundant prepuce and phimosis other severe protein-calorie malnutrition other dysphagia acute gastritis, without mention of hemorrhage persistent vomiting malignant neoplasm of glottis other specified disorders of penis malignant pleural effusion chronic post-thoracotomy pain 

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