allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bleeding at trach site major surgical or invasive procedure: flexible bronchoscopy and exploration of tracheostomy site with revision of tracheostomy. history of present illness: mr. is a 69 year-old male who s/p trach on who presented to the emeragency department with bleeding from his trach site. past medical history: 1. osa s/p trach 2. asthma 3. htn 4. dm 5. hyperlipidemia 6. pud 7. chf - diastolic heart failure (documented on echo in ) 8. pulmonary hypertension social history: social history: lives with his wife, used to work in demolition, never smoked, no etoh, no ivdu family history: family history: father had an mi at 49, mother with mi at 44, brother with mi at 75 physical exam: general: 69 year-old male in nad heent: normocephalic, mucus membranes moist, ppor dental hygiene neck; supple no lymphadenopathy card: regular, rate & rhythm, normal s1s2 no murmur/gallop/rub lungs: decreased breath sounds, occasional experitory wheeze gi: obese, bowel sounds positive, soft non-tender/non-distended extr: warm no edema skin: trach site clean no heme or edema neuro: non-focal pertinent results: wbc-12.0* rbc-4.41* hgb-13.8* hct-40.7 plt ct-223 glucose-193* urean-20 creat-1.0 na-137 k-5.2 cl-99 hco3-32 cxr: tracheostomy tube is in adequate position. there are low lung volumes. bibasilar atelectases are persistent. right pleural effusion is small. mild enlarged cardiomediastinal silhouette is unchanged. brief hospital course: mr. was taken directly to the operating room and underwent successful flexible bronchoscopy and exploration of tracheostomy site with revision of tracheostomy. he was transfered to the pacu in stable condition. his oxygenation requirements improved over the day. his blood gas on 50% face mask was 7.37/46/87. he was transferred to the floor on postoperative day 1 with oxygen saturation 85-87% with activity. on postoperative day 2 he continued to improve with room air saturation of 94% and was discharged to home. medications on admission: 1. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 2. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours). 3. glyburide 5 mg tablet sig: one (1) tablet po bid (2 times a day). 4. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 5. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po daily (daily). 6. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 7. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 8. lovastatin 20 mg tablet sig: one (1) tablet po once a day. 9. nexium 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 2. ipratropium bromide 17 mcg/actuation aerosol sig: two (2) puff inhalation q6h (every 6 hours). 3. glyburide 5 mg tablet sig: one (1) tablet po bid (2 times a day). 4. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 5. hydrochlorothiazide 25 mg tablet sig: one (1) tablet po daily (daily). 6. lisinopril 20 mg tablet sig: two (2) tablet po daily (daily). 7. metoprolol succinate 100 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 8. lovastatin 20 mg tablet sig: one (1) tablet po once a day. 9. nexium 40 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day. discharge disposition: home discharge diagnosis: trach stomal revision 6.5 cuffed fenestrated f. aline asthma osa s/p trach pulmonary hypertension diabetes mellitus congestive heart failure pvd discharge condition: stable discharge instructions: call dr. office if experience: -fever > 101 or chills. -bleeding at trach site or discharge -difficulty breathing or increased secretions -trach care as previous: 6.5 cuffed fenestrated followup instructions: follow-up with dr. on at 10:00 am on the clinical center . suture removal. Procedure: Bronchoscopy through artificial stoma Revision of tracheostomy Diagnoses: Obstructive sleep apnea (adult)(pediatric) Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Asthma, unspecified type, unspecified Other chronic pulmonary heart diseases Other and unspecified hyperlipidemia Chronic diastolic heart failure Other tracheostomy complications