history of present illness: mr. is a 28-year-old gentlemen with a history of type 1 diabetes and hypertension who presented on to the emergency department with a three day history of total body myalgias, a one day history of fever to 102 associated with rigors, and a productive cough without hemoptysis times three days alongside worsening dyspnea at rest and exertional dyspnea. the patient denied chest pain or pleurisy at the time of admission. he had had no recent nasal congestion, headache, swollen glands, but he did report a sick contact seen over the weekend one week prior to admission. there was no recent travel. no pets at home. no chronic steroid use or history of opportunistic infections or insect bites. when the patient presented to the emergency department, he was diagnosed with a right lower lobe pneumonia and started on levofloxacin and volume resuscitated with two liters of normal saline. his initial oxygen saturation was 95% on room air at the time of arrival to the emergency department. by the time of arrival to the floor, 18 hours later, his oxygen saturation was 94% on four liters nasal cannula with a normal respiratory rate. upon arrival to the floor, he had the acute onset of hypoxia with tachypnea with an oxygen saturation of 91% on 100% nonrebreather and respiratory rate into the 40s. an arterial blood gas at the time was 742, 33 and 62. a chest x-ray showed blossomed left upper lobe infiltrated in addition to the right lower lobe and the patient's clinical status resolved quickly with chest physical therapy. it was felt that he had developed a mucus plus. the patient was clinically stable until when he developed a similar episode of acute onset hypoxemic respiratory distress which was nonresponsive to chest physical therapy. he was intubated semiurgently and brought to the intensive care unit for further evaluation and management. past medical history: 1. insulin dependent diabetes times 25 years followed at the . 2. diabetic retinopathy status post laser photocoagulation. 3. hypertension. medications on admission: 1. insulin humalog 12 units q.a.m., 12 units q.p.m. and nph 32 units q.a.m. and 24 units q.p.m. 2. zestril, dose unknown. allergies: no known drug allergies. social history: no tobacco, no intravenous drug use, mild alcohol consumption. patient is sexually active with a longtime female partner at times unprotected. he lives with multiple roommates. he is physically very active. family history: father with diabetes otherwise unremarkable. admission physical examination: physical examination at time of admission to intensive care unit: temperature 100.2. heart rate 129. blood pressure 128/72. respiratory rate 43. oxygen saturation 94% on six liters nasal cannula. general: a young white male in moderate respiratory distress. head, eyes, ears, nose and throat: pupils equal, round and reactive to light. extraocular movements intact. sclerae are anicteric. oropharynx clear. no nystagmus. mucous membranes were dry. neck: jugular veins were flat. no thyromegaly, no thyroid tenderness to palpation. chest: inspiratory crackles halfway up on the right. patient talking in full sentences, using expiratory muscles, no wheezes were auscultated. cardiac: tachycardic, no murmurs, rubs or gallops. abdomen: soft, nontender, no hepatosplenomegaly, normal active bowel sounds. extremities: trace bilateral lower extremity edema. no clubbing, no cyanosis, no intertriginal rash. neurological: alert and oriented times two. cranial nerves ii through xii are intact. strength 5/5 in all four extremities. laboratories: white blood cell count 9.9, hematocrit 40.6, platelets 216,000. sma-7: sodium 134, potassium 3.8, chloride 98, bicarbonate 23, bun 15, creatinine 1.0, glucose 246. arterial blood gas 742, 30, 80 on six liters nasal cannula oxygen. chest x-ray: bilateral diffuse infiltrates with sparing of the apices and bases. no effusions. normal cardiac silhouette. urinalysis: 1.07 large blood, 8 red blood cells, 2 white blood cells, greater than 1000 glucose, trace ketones. electrocardiogram: sinus tachycardia at 130, axis is 100 degrees, normal intervals, t wave inversions in ii, iii and avf. q waves in ii, iii and avf. hospital course: the patient was admitted to the medical intensive care unit for management of hypoxic respiratory distress. the following will outline his medical intensive care unit course from to by systems: 1. neurological: the patient had no acute neurological issues. he had an escalating sedation requirement additionally managed on ativan and fentanyl drips. ativan was switched over to midazolam on for prophylaxis against crystal induced acute renal failure. 2. respiratory: the patient was originally admitted to the service with atypical community acquired pneumonia. he was initially started on levofloxacin after being admitted to the unit and intubated ceftriaxone was added on . bronchoscopy was done which was unremarkable except for friable mucosa. bal studies were negative for pcp. caused her acid fast bacilli smear viral and >.....<virilized and culture. the patient appeared to have developed adult respiratory distress syndrome and was management with a long protective strategy. he was aggressively volume resusitated to a wedge of 29 which corrected to 24 with discounting of a peep of 20. he was ruled out for pe by ct angio and a normal echocardiogram on . in addition to atypical community acquired pneumonia, adult respiratory distress syndrome and volume overload, it appeared that the patient had developed a vent associated pneumonia as evidenced by a new retrocardiac opacity and increased purulence secretions; vancomycin was added on . ceftazidime was subsequently added on for persistent fevers to cover gram negative pathogens. at the time of this dictation, the patient is on assist controlled ventilation with peep of 14 and fio2 of 50%. 3. cardiac: in pursuit of the patient's concerning electrocardiogram, there were no prior electrocardiograms for comparison and the clinical suspicion was high for rv strain in the setting of multiple pes. however, an echocardiogram showed a normal ejection fraction, normal rv size and function and a normal left ventricular ejection fraction and normal left ventricular size. there were no significant valvular abnormalities and no vegetations on transfer >.....<ultrasound. for the first five days of the hospital course, he was noted to be on a high cardiac output low svr state. during that, he never developed hypotension or oliguria. he was eventually volume resusitated to a wedge pressure of 29. 4. renal: the patient came to the unit originally in renal failure with a creatinine of 2 over a baseline of 1.0. after aggressive volume recessitation, his creatinine returned to . fena obtained was consistent with previous azotemia. since , the patient has been on a lasix drip to achieve diuresis to help resolve respiratory failure, which he has tolerated well from a renal and hemodynamic standpoint. 5. gastrointestinal: the patient has had stabilely elevated liver biochemistries including an alkaline phosphatase of roughly 400 and t bilirubin that had risen from .2 to 1.1. a gallbladder ultrasound obtained on showed mild gallbladder distention with a normal gallbladder wall thickness and question of pericholecystic fluid. subsequent hida scan to evaluate for a calculus cholecystitis showed equivocal results. the results of a repeat ultrasound of the gallbladder on are pending. the patient is currently being ruled out for c. difficile and is negative times one. 6. infectious disease: the patient was initially managed on levofloxacin for community acquired pneumonia started on . ceftriaxone was added to that on . levofloxacin was added to that on for suspicion of vent associated pneumonia. ceftriaxone was replaced by ceftazidime on to cover for possible gram negative pulmonary pathogens. the patient has had persistent fevers since . , anca and hiv antibody were all negative obtained during this hospitalization. urine legionella antigen is negative. pcp immunofluorescent on bal is negative. his right internal jugular and right arterial line were both changed to a left subclavian and a left-sided radial arterial line on with tip sent. gallbladder evaluation for a calculus cholecystitis was underway. the patient was being ruled out for c. difficile. drug fever may be the culprit here with likely pathogens including ceftazidime and lasix. the patient does have eosinophilia with an absolute eosinophils count of 800 on and a truncal rash has developed from to . at the current time, ceftazidime is on, but may be discontinued with patient observation should the rest of his infectious disease work-up be negative. the patient has had no positive culture date including multiple blood cultures, sputum cultures and bal cultures. 7. endocrine: the patient had a high dose acth stimulation test which was normal. the patient's diabetes has been managed with an insulin drip. 8. nutrition: the patient is currently on hyperalimentation with tube feds being titrated up as tolerated. 9. prophylaxis: patient on subcutaneous heparin and proton pump inhibitor along with tube feds. 10. access: left subclavian placed on . left radial arterial line placed on . diagnoses at the time of this discharge summary: 1. atypical community acquired pneumonia. 2. adult respiratory distress syndrome. 3. vent associated pneumonia. 4. volume overload. 5. persistent fevers. 6. right axis deviation of unclear etiology and duration. 7. status post peripheral compartment syndrome from tense peripheral edema. 8. diabetes mellitus. 9. possible drug fever. 10. possible a calculus cholecystitis. medications at time of discharge: 1. vancomycin 1 gram q. 12 hours. 2. levofloxacin 500 mg q. 24 hours. 3. ceftazidime 2 grams q. 8 hours. 4. insulin drip. 5. midazolam drip. 6. fentanyl drip. 7. lasix drip. 8. insulin drip. 9. protonix. 10. subcutaneous heparin. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Parenteral infusion of concentrated nutritional substances Other endoscopy of small intestine Insertion of endotracheal tube Fiber-optic bronchoscopy Enteral infusion of concentrated nutritional substances Thoracentesis Other bronchoscopy Percutaneous [endoscopic] gastrostomy [PEG] Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Percutaneous [endoscopic] gastrojejunostomy Injection or infusion of oxazolidinone class of antibiotics Diagnoses: Unspecified pleural effusion Urinary tract infection, site not specified Acute kidney failure, unspecified Other pulmonary insufficiency, not elsewhere classified Candidiasis of mouth Methicillin susceptible pneumonia due to Staphylococcus aureus Infection and inflammatory reaction due to other vascular device, implant, and graft Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled