allergies: no known allergies / adverse drug reactions attending: chief complaint: respiratory failure major surgical or invasive procedure: intubation history of present illness: 71 yo m w/ pmh dm, osa, and copd initially presented to st. hospital with sob requiring transfer to micu for higher level of care. pt with chronic copd at baseline reliant on 4.5l o2 by nc at home and spiriva, advair and albuterol nebs. he had increasing dyspnea over past few months, most notably in the past few days. sob is present at rest and worsened with exertion, however he denies chest pain. cough productive of small amounts of white sputum. no hemoptysis. no fever, night sweats or notable change in weight. no dysphagia. yesterday he found himself gasping for air, for which he called his pcp who suggested ambulance transfer to . in pt's vitals: t:98.7, bp 160/66, hr 77, r 16, sao2 96% on 6l nc. pt thought to have stridor on exam in addition to rhonchi and wheezes bilaterally. cxr showed right suprahilar mass with left tracheal deviation. ct chest with contrast showed large paratracheal mediastinal 7cm necrotic mass with airway and svc effacement. basic lab work: chemistry: sodium 136, k 4.7, cl 97, bicarbonate 30, bun 19, creatinine 1.0, glucose 193, calcium 8.8. hematology: hemoglobin 12.6, hematocrit 39.3, wbc 10.7, platelets 201. ck 188, troponins negative, bnp 312. urinalysis, glucosuria. pt given iv azithromycin, iv methylprednisolone 125mg and nebulization treatment. foley placed. on arrival to the micu, vitals t:98.2 bp:154/73 p:87 r:20 o2: 97% on 6l nc. pt alert and oriented x3 with labored breathing and frequent coughing. past medical history: -diabetic mellitus -diabetic neuropathy and retinopathy -htn -hyperlipidemia -copd, requiring 4.5l continuous oxygen at home -obesity -osa -osteoporosis -berrylium exposure (tested positive on multiple blood tests) social history: social history: he is a retired metal worker in a factory with significant berrylium exposure. he lives at home with wife. former alcoholic, has not drank in 29 years. former smoker 1.5 ppd for over 50 yrs, quit 4 years ago. denies illicits family history: significant for diabetes, htn, and cad. physical exam: admission exam: vitals: t:98.2 bp:154/73 p:87 r:20 o2: 97% on 6l nc general: obese man wearing glasses. alert, oriented, in mild distress frequent coughing. nc in place. heent: sclera anicteric, mmm, oropharynx clear, eomi, perrl neck: supple, jvp not elevated, no lad cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops lungs: rhonchi throughout with inspiratory and expiratory wheezes heard bilaterally. no rales. abdomen: obese, soft, non-tender, non-distended, bowel sounds present gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing, +1 edema to mid calf. right lower leg with wound at lateral aspect. neuro: cnii-xii intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred, finger-to-nose intact discharge exam: pt expired. pertinent results: admission labs: 11:17pm blood wbc-14.8* rbc-4.49* hgb-13.8* hct-42.4 mcv-94 mch-30.7 mchc-32.5 rdw-12.6 plt ct-242 11:17pm blood pt-13.0* ptt-29.9 inr(pt)-1.2* 11:17pm blood fibrino-757* 11:17pm blood glucose-224* urean-20 creat-1.0 na-139 k-4.9 cl-98 hco3-28 angap-18 11:17pm blood calcium-9.1 phos-3.3 mg-2.1 micro data: bronchial washings: no organisms blood cultures and urine cultures were all no growth diagnosis: ebus-tbna, paratracheal mass: positive for malignant cells, consistent with poorly differentiated non-small cell carcinoma; see note. 11:17pm glucose-224* urea n-20 creat-1.0 sodium-139 potassium-4.9 chloride-98 total co2-28 anion gap-18 11:17pm wbc-14.8* rbc-4.49* hgb-13.8* hct-42.4 mcv-94 mch-30.7 mchc-32.5 rdw-12.6 11:17pm fibrinoge-757* mrsa screen (final ): positive for methicillin resistant staph aureus. the lung volumes are normal. the lung bases on the left and right show linear opacities with air bronchograms, most likely consistent with atelectasis. however, a presence of pneumonia cannot be excluded. no other lung parenchymal abnormalities. in the mediastinum however, there is increased density, notably in the right paratracheal compartment, associated with substantial narrowing of the lower third of the trachea and distortion of both the right and left main bronchus. right and left main bronchus are also narrowed. to clarify the morphologic situation, notably for exclusion of a central malignancy, ct should be performed. no pulmonary edema. normal size of the cardiac silhouette. no pleural effusions. sinus rhythm. left atrial abnormality. early r wave progression. single wide complex beat, probable ventricular premature beat but consider atrial premature beat with aberration. no previous tracing available for comparison. intervals axes rate pr qrs qt/qtc p qrs t 76 152 86 388/416 21 36 50 brief hospital course: 71 yo m with oxygen dependent copd, obstructive sleep apnea, diabetes mellitus presenting with shortness of breath found to have large central mediastinal mass with airway effacement as per outside hospital radiology report. active issues: # squamous cell lung carcinoma: patient initially presented to outside hospital with hypoxia secondary to paratracheal mediastinal mass, which on pathology was poorly differentiated squamous cell carcinoma. radiation oncology and oncology were consulted for further management. patient received xrt while admitted but due to continued hypoxia and respiratory failure, poor progress and overall poor prognosis (see below) the family decision was to focus on comfort, and patient extubated and expired quietly and peacefully in the presence of family members. # hypoxia: patient with progressive increase in dyspnea at rest over past few days increasing his baseline home 02 requirement. most likely secondary to necrotic paratracheal mediastinal mass with airway effacement that was seen on ct from outside hospital. interventional pulmonary team consulted and rigid bronchoscopy done on , along with biopsy of lung mass. after procedure he returned to the icu with diffculty managing secretions and was intubated. patient was extubated the following morning, however was intubated again due to difficulty in managing secretions resulting in hypercarbia. pathology returned as poorly differentiated squamous cell lung carcinoma and patient was transferred to for radiation of lung mass. patient remained intubated for his entire course without ability to safely extubate. after multiple discussions with patient's family, family clearly endorsed patient's clearly expressed wishes to avoid long-term life support, including mechanical ventilation, and tracheostomy was not acceptable to patient. focus of care was shifted to comfort. the patient was extubated, and quietly and peacefully expired in the presence of family members. # cellulitis: patient with traumatic skin tear on r lower extremity on admission, which appeared to be erythematous and indurated on hospital day 2, a change from admission exam. he was started on vancomycin for coverage of cellultis which continued until patient death. # atn: patient developed increased creatine with muddy brown casts in urine consistent with atn. medications were renal dosed and nephrotoxic medications were held. chronic diagnoses #diabetes mellitus: held home meds and placed on sliding scale insulin. #htn: initially held home meds and blood pressure was managed with iv and po meds. #hyperlipidemia: continued home simvastatin 40mg daily transitional issues pt expired. medications on admission: preadmission medications listed are correct and complete. information was obtained from patient . 1. metoprolol tartrate 25 mg po bid 2. simvastatin 20 mg po daily 3. furosemide 40 mg po daily hold for sbp <100 4. lisinopril 20 mg po daily 5. aspirin 81 mg po daily 6. 70/30 74 units breakfast 70/30 56 units dinner 7. spiriva handihaler 1 cap ih daily 8. advair diskus (250/50) 1 inh ih 9. albuterol 0.083% neb soln 1 neb ih q6h:prn sob discharge medications: none. pt expired. discharge disposition: expired discharge diagnosis: expired discharge condition: expired discharge instructions: expired followup instructions: expired md Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Insertion of endotracheal tube Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other intubation of respiratory tract Other intubation of respiratory tract Other intubation of respiratory tract Other intubation of respiratory tract Other intubation of respiratory tract Closed endoscopic biopsy of lung Endoscopic excision or destruction of lesion or tissue of lung Endoscopic excision or destruction of lesion or tissue of lung Other radiotherapeutic procedure Central venous catheter placement with guidance Diagnoses: Obstructive sleep apnea (adult)(pediatric) Acute kidney failure with lesion of tubular necrosis Unspecified essential hypertension Chronic airway obstruction, not elsewhere classified Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled Polyneuropathy in diabetes Personal history of tobacco use Pulmonary collapse Other and unspecified hyperlipidemia Acute respiratory failure Malignant neoplasm of upper lobe, bronchus or lung Cellulitis and abscess of leg, except foot Osteoporosis, unspecified Rash and other nonspecific skin eruption Obesity, unspecified Do not resuscitate status Fall from other slipping, tripping, or stumbling Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy Nonspecific low blood pressure reading Other dependence on machines, supplemental oxygen Open wound of knee, leg [except thigh], and ankle, complicated Contact with and (suspected) exposure to other hazardous metals