allergies: aldactone precautions: mrsa neuro: pt is and oriented x3. calm and cooperative with care. denies any discomfort. mae x4. temp 99. resp: pt has trach with deflated cuff and valve in, on 40% trach collar and 2l nc with sats 97-98%. denies sob, no increased wob noted. lung sounds are diminished throughout. rr in the 20's. pt has occasional cough productive for thick yellow secretions. cv: hr 80's afib with rare pvc's noted. sbp 90's. denies cp. palpable radial/dp pulses. pt 2nd of 2 units prbc's at 1630-hct to be checked at 1800. gi: abdomen soft, bowel sounds present. had lge black guiac + stool upon arrival to micu. pt has j tube in place. gu: pt voids clear yellow urine via urinal in adequate amts. integ: skin on back and buttocks intact. l arm has dsg over scab from possible old picc line site-pt unsure. activity: pt able to ambulate from bed to chair/commode with minimal assist. social: pt lives alone in his own apartment, however is presently living at rehab. per pt, his brother is his spokeperson who should make any medical decisions for him if he is unable. Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Other endoscopy of small intestine Enteral infusion of concentrated nutritional substances Transfusion of packed cells Diagnoses: Congestive heart failure, unspecified Acute kidney failure, unspecified Iron deficiency anemia secondary to blood loss (chronic) Atrial fibrillation Depressive disorder, not elsewhere classified Anxiety state, unspecified Acute respiratory failure Bacteremia Chronic systolic heart failure Calculus of gallbladder without mention of cholecystitis, without mention of obstruction Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled Heart valve replaced by transplant Hemorrhage of gastrointestinal tract, unspecified Hyperosmolality and/or hypernatremia Delirium due to conditions classified elsewhere Other specified bacterial infections in conditions classified elsewhere and of unspecified site, other specified bacteria Chronic respiratory failure Tracheostomy status Foreign body in larynx Pneumonia due to other specified organism