allergies: patient recorded as having no known allergies to drugs attending: chief complaint: dyspnea major surgical or invasive procedure: endotracheal intubation flexible bronchoscopy history of present illness: ms. is a year-old female with a history of htn, dm, ?chronic aspiration, and alzheimer's dementia who was transferred from the ed intubated after presenting with hypoxia and tachypnea. she was in her usual state of health until two days ago when she began experiencing a nonproductive cough and dyspnea. her symptoms worsened and her and son-in-law, whom she lives with, brought her to the ed. on presentation, her vs were 98.1 74 154/82 18 79%ra. she appeared to be in acute respiratory distress, with increased work of breathing. she was placed on a nrb and was satting in the 80-85% range, and a cxr demonstrated left sided consolidation. she was started on levofloxacin and ceftriaxone and intubated because of worsening tachypnea and hypoxia and then transferred to the . . per discussion with her , the patient has not received a flu shot this year but did receive the pneumovax about five years ago. she has no sick contacts and has no recent hospital or nursing home exposure. she last had pneumonia one year ago and was treated as an outpatient. review of systems is otherwise negative for fevers, chills, arthralgias, nausea, vomiting, diarrhea, and chest pain. ms. has chronic constipation at baseline. past medical history: htn dm2 (diet controlled) ?chronic aspiration alzheimer's dementia breast cancer (diagnosed seven years ago) lower back pressure ulcer social history: ms. is russian speaking and wheelchair bound at baseline. she lives with her and son-in-law in and moved to the united states from five years ago. she does not smoke or drink alcohol. she has vna services for dressing changes for her lower back pressure ulcer. she has only seen her pcp once and most of her medical history is part of the system. family history: no heart disease or diabetes. otherwise non-contributory. physical exam: on discharge satting 100% on 4l nc, hr 59, bp 161/58. physical exam general: nad, opens eyes to voice, but does not interact heent: normocephalic, atraumatic. no conjunctival pallor. no scleral icterus. perrla/eomi. mmm. op clear. neck supple, no lad, no thyromegaly. cardiac: regular rhythm, normal rate. normal s1, s2. no murmurs, rubs or . lungs: decreased lung sounds on right, crackles on left abdomen: nabs. soft, nt, nd. no hsm extremities: muscle wasting, no edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. skin: no rashes/lesions, ecchymoses. neuro: moves all extremities, downgoing toes, responds to noxious stimuli. pertinent results: 04:13am blood wbc-10.9 rbc-4.05* hgb-12.3 hct-37.3 mcv-92 mch-30.4 mchc-33.0 rdw-14.5 plt ct-384 04:15pm blood wbc-15.7*# rbc-4.37 hgb-13.5 hct-40.0 mcv-92 mch-30.9 mchc-33.8 rdw-15.1 plt ct-351 03:38am blood neuts-72.0* lymphs-21.0 monos-4.8 eos-1.9 baso-0.3 03:39am blood pt-13.5* ptt-25.8 inr(pt)-1.2* 04:13am blood glucose-123* urean-25* creat-1.1 na-141 k-4.2 cl-97 hco3-36* angap-12 04:44am blood alt-38 ast-30 ld(ldh)-159 alkphos-134* totbili-0.3 04:15pm blood ctropnt-<0.01 04:15pm blood ck-mb-notdone probnp-5423* 04:48am blood calcium-8.6 phos-2.6* mg-2.2 03:12pm urine color-yellow appear-clear sp -1.010 03:12pm urine blood-mod nitrite-neg protein-30 glucose-neg ketone-10 bilirub-neg urobiln-neg ph-5.0 leuks-sm 03:12pm urine rbc-92* wbc-14* bacteri-few yeast-none epi-0 urine, blood and sputum cultures negative studies: echo: ef 70-75%, preserved regional and global biventricular systolic function. severe pulmonary hypertension. moderate mitral regurgitation. mild to moderate functional mitral stenosis from mitral annular calcification. mild to moderate tricuspid regurgitation. ruq us: 1. limited evaluation of gallbladder without evidence of cholelithiasis. 2. very limited evaluation of the liver. mass and hepatic calcifications are better evaluated on concurrent ct abdomen. 3. splenic calcifications suggest prior granulomatous disease. cta chest: 1. negative examination for pulmonary embolism. 2. large to moderate amount of bilateral pleural effusion associated with adjacent atelectasis. 3. multifocal areas of consolidation of right upper lobe, right middle lobe, and both lower lobes are probably related to pneumonia. 4. known mass in left axilla that seems to be invading the left breast. 5. multiple calcified nodules in the liver and spleen suggest prior granulomatous exposure. 6. hypodense mass in right hepatic lobe. dedicated abdominal evaluation is suggested. cxr : there is interval development of new whiteout of right hemithorax with right mediastinal shift, finding consistent with a complete atelectasis of the right lung. given the rapid development it is consistent with a mucus plug aspiration. the left lung aeration is preserved and demonstrates the presence of a mild to moderate pulmonary edema. a left pleural effusion is present. the ng tube tip is in the stomach. brief hospital course: ms. is a year-old female with a history of htn, dm, ?chronic aspiration, and alzheimer's dementia who was transferred from the ed intubated after presenting with hypoxia and tachypnea. #. respiratory failure/pneumonia: patient presented with hypoxia and tachypnea and chest radiograph c/w a lul consolidation pneumonia. she was started on ceftriazone/azithromycin for community acquired pneumonia on presentation. on her second hospital day her chest radiograph changed significantly with the consolidation in her left upper lobe generally resolving suggesting this was more consistent with mucous plugging and volume loss. she went on to have a ct scan that showed multifocal pneumonia as well as probable pulmonary edema with large bilateral pleural effusions. she was transiently intubated with reexpansion of a previously collapsed upper lobe. given that her pulmonary edema and large pleural effusions were likely contributing to her volume loss and respiratory compromise an attempt was made to diurese with furosemide boluses, to which she responded well with decreasing oxygen requirements, down to 4l nc at dischage. pt also had intermittent lobar collapse, thought to be due to mucous plugging and aspirating of secretions. she generally responded to deep suctioning but was unable to effectively cough to clear her own secretions. #. hypertension: the patient has severe and labile hypertension and was continued on an aggressive anti-hypertensive regimen at home including beta , -1 , ccb, and ace inhibitor. in the setting of diuresis, pt was intermittently hypotensive requiring fluid boluses. she also at times was hypertensive, requiring prn doses of hydralazine. #. alzheimer's dementia: the patient has severe dementia at baseline, but is on no treatment for this at home. as of extubation her mental status was at baseline (opens eyes to voice but does not interact or follow commands). #. breast cancer: the patient has a necrotic mass in her left axilla of locally advanced breast cancer. no aggressive therapies are being pursued. # lower back pressure ulcer: care per wound nurse recommendaitons #. dm2: finger sticks were monitored qid and treated with iss. #. nutrition: given pt's repeated aspiration, pt was fed via ngt. contacts: makes health decisions, (c). granddaughter, , was pharmacist in and can be reached at (c). code: cpr not indicated but intubation allowed - confirmed with daughter and granddaughter. . medications on admission: diltiazem 180 doxazosin 2 qd enalapril 20 furosemide 20 qd toprol 100 potassium 8 meq qd arimidex simvastatin 20 qd catapres 2( clonidine patch 0.2 mg/24 hours) clonidine 0.2 po tid discharge medications: 1. famotidine 20 mg tablet sig: one (1) tablet po q24h (every 24 hours): per ngt. 2. simvastatin 10 mg tablet sig: two (2) tablet po daily (daily): per ngt. 3. metoprolol tartrate 50 mg tablet sig: two (2) tablet po bid (2 times a day): per ngt. 4. docusate sodium 50 mg/5 ml liquid sig: po bid (2 times a day) as needed for constipation: per ngt. 5. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed: per ngt. 6. captopril 25 mg tablet sig: three (3) tablet po tid (3 times a day): per ngt. 7. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q6h (every 6 hours) as needed for sob. 8. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours). 9. clonidine 0.1 mg tablet sig: one (1) tablet po tid (3 times a day): per ngt. 10. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day). 11. digoxin 0.125 mg iv every other day 12. arimidex 1 mg tablet sig: one (1) tablet po once a day. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: pneumonia secondary: hypertension discharge condition: stable, breathing comfortably on 4l nc. discharge instructions: ms : you were admitted with shortness of breath and low blood oxygen levels and you were intubated (a breathing tube was placed) in the emergency room because of your shortness of breath. you were found to have a pneumonia and you were treated with antibiotics. your pneumonia improved, but you continued to be short of breath due to aspiration of your saliva and heart failure. for your heart failure your medications were changed to control your blood pressure and remove fluid as it was collecting in your lung. because your cough is very weak you continued to have difficulties during this admission with secretions, and several times your secretions would fill your airway and cause collapse of the lung which we would then see on xray. sometimes it would help to do deep suction to remove the secretions, but sometimes this did not help. . . the following medication changes were made during this admission: . diltiazem was stopped. doxazosin was stopped. enalapril was changed to captopril. furosemide was increased. toprol was changed to metoprolol. potassium was stopped. catapres was changed to oral clonidine pill. clonidine 0.2mg was changed to a different dose of clonidine. . the following medications were started: digoxin, famotidine, senna, colace, albuterol, ipratropium. . all of your other home medications remain the same. . weigh yourself every morning, md if weight > 3 lbs. adhere to 2 gm sodium diet fluid restriction: 1.5 l. if you develop shortness of breath, chest pain, or any other concerning symptom please call your primary care doctor or return to the hospital. followup instructions: rehab: please make an appointment for the pt to see the primary care doctor (dr. ) when she leaves rehab. md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Arterial catheterization Insertion of other (naso-)gastric tube Closed [endoscopic] biopsy of bronchus Diagnoses: Pneumonia, organism unspecified Mitral valve disorders Unspecified pleural effusion Congestive heart failure, unspecified Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Atrial fibrillation Personal history of malignant neoplasm of breast Pulmonary collapse Acute respiratory failure Pressure ulcer, lower back Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Pressure ulcer, unspecified stage Malignant neoplasm of breast (female), unspecified