past medical history: 1. asthma. 2. copd. medications on transfer: 1. pepcid. 2. reglan 10 mg p.o. q.i.d. 3. gatafloxacin 400 mg p.o. q.d. started on . 4. vancomycin 1 gram q. 12 hours. 5. nystatin swish and swallow. 6. monistat. 7. atrovent q. four hours. 8. mucomyst nebulizers. 9. albuterol nebulizers q. four hours. 10. solu-medrol 60 mg q.i.d. started on . 11. theophylline 100 mg p.o. b.i.d. allergies: the patient has no known drug allergies. family history: noncontributory. social history: positive for two pack per day smoking history. she lives with her husband who also smokes. positive alcohol consumption. no illicit drug use. physical examination on admission: vital signs: temperature maximum 99.4, blood pressure 132/77, 69 heart rate, 16 respirations, 93% on continuous mask ventilation, 600/14/60%/12.5. general: the patient was obese, intubated, sedated, in no acute distress. heent: perrla, o/p moist plus thrush, right ij line clear, dry, and intact. cardiac: regular rate and rhythm. no murmurs, rubs, or gallops. normal s1, s2. pulmonary: bilateral rhonchorous and bronchial breath sounds. abdomen: obese, soft, nontender, nondistended, decreased abdomen sounds. extremities: no clubbing, cyanosis or edema. peripheral pulses 2+. neurologic: alert. does not follow commands. positive gag reflex. laboratory/radiologic data: white blood cell count 26.2, hematocrit 46.5, platelets 227,000. sodium 138, k 3.4, chloride 98, bicarbonate 30, bun 22, creatinine 0.4, glucose 310. coagulations: pt13.2, ptt 24.2, inr 1.2, ast 25, alt 37, ldh 332, total bilirubin 0.5, albumin 2.7, alkaline phosphatase 116. chest x-ray showing obscure right heart border, right diaphragm, fluid in right fissure, patchy left lower lobe atelectasis with left upper lobe opacity, et tube, ng tube, and a right ij in good position. ekg revealed normal sinus rate at 67, axis normal, intervals normal, borderline lae, twi, abl, v1, unchanged, c/w prior ecgs. hospital course: 1. respiratory failure: due to mrsa pneumonia on top of copd flare, mrsa pneumonia diagnosed at an outside hospital on and left upper lobe treated with multiple antibiotics including zosyn started on , levaquin, vancomycin, steroids were given for copd flare. the patient was extubated on with multiple desaturations secondary to mucous plugs. the patient underwent bronchoscopy which again noticed mucous plugs. was treated with mucomyst. the patient was transferred to the floor from the icu on off all antibiotics and oral steroids. continued on nebulizers and inhalers (albuterol, atrovent, fluticasone). on the floor, the patient used incentive spirometry. the patient continued to improve from a respiratory standpoint and was discharged on 3 liters nasal cannula which she will continue to use at rehabilitation and will continue to be weaned from. 2. diabetes insipidus: the patient had been urinating a large amount of hyperosmolar urine and when in the icu the patient developed hypernatremia while intubated. renal was consulted and given laboratory data of a very dilute urine in the setting of high serum osms and the patient's history of greater than one gallon of water consumption a day. the team felt that the patient had an underlying diabetes insipidus. the plan was to continue to allow the patient to have free water access. this resulted in resolution of her hypernatremia. the patient will be followed by the renal service as an outpatient. 3. acute renal failure: the patient had a climbing creatinine while in-house with a peak of 2.2. this was thought to be due to atn secondary to high urinary output with little fluid intake while intubated in the icu. zosyn was discontinued in case of possible ain but no serum or urine eosinophils were noted to suggest this diagnosis. the renal team were following and will follow the patient as an outpatient. discharge creatinine was 1.9 and will be followed as an outpatient. 4. right hand cellulitis: developed following peripheral iv site infiltration. followed by plastic surgery in-house who recommended antibacterial ointment q.d. with sterile dry dressing changes q.d. the patient will follow plastics as an outpatient. 5. fen/gi: the patient cleared by speech and swallow for a regular diet. 6. disorientation/agitation: occurred while in the icu, treated with haldol, risperdal, and zyprexa p.r.n., self-resolving. currently not on any medications. currently oriented, likely icu psychosis. 7. disposition: the patient will he discharged to health sound hospital for further management of respiratory function. will follow-up at the clinics listed below. condition on discharge: stable. discharge diagnosis: 1. hypercapnic respiratory failure. 2. chronic obstructive pulmonary disease exacerbation. 3. pneumonia with methicillin-resistant staphylococcus aureus. 4. right hand cellulitis. 5. acute renal failure. 6. diabetes insipidus. discharge medications: 1. albuterol nebulizer treatment q. four hours p.r.n. 2. atrovent nebulizer q. six hours, q. 2-4 hours p.r.n. 3. fluticasone 110 micrograms inhaler two puffs b.i.d. 4. pantoprazole 40 mg p.o. q.d. 5. mvi p.o. q.d. follow-up plans: 1. the patient will follow-up in the primary care clinic with dr. at on , thursday, at 3:00 p.m. 2. plastic surgery clinic on tuesday, at 10:30 with dr. . 3. follow-up with dr. /dr. in clinic on tuesday, at 2:30 p.m. disposition: the patient was discharged to rehabilitation in stable condition. , m.d. dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Fiber-optic bronchoscopy Closed [endoscopic] biopsy of bronchus Diagnoses: Acute kidney failure with lesion of tubular necrosis Infection with microorganisms resistant to penicillins Obstructive chronic bronchitis with (acute) exacerbation Acute respiratory failure Methicillin susceptible pneumonia due to Staphylococcus aureus Hyperosmolality and/or hypernatremia Diabetes insipidus Cellulitis and abscess of hand, except fingers and thumb