history of present illness: mr. is a 54-year-old male with a history of bipolar disorder, alcohol abuse, hypertension, and hypothyroidism who was admitted to the for manic symptoms, disorganized behavior, and aggressiveness. the patient was transferred to for further evaluation of mental status changes, delirium, chest pain/shortness of breath on , two days after presentation to . the patient was admitted to the medical floor. he had received ceftriaxone/acyclovir for concern for meningitis/encephalitis. the patient had ruled out for myocardial infarction on admission and had been initiated on ciwa scale. the patient was determined to be in active delirium tremens while on the medical floor and was transferred to the for frequent sedation requirements and a level of nursing care that could not be provided on the medical floor. the patient had received ativan at 2 mg q. one hour plus additional 6 mg of ativan and valium 10 mg pushes x 3 with persistent agitation, tachycardia, and hypertension. he was initiated on an ativan drip, was titrated up to 10 mg per hour for persistent agitation which led to respiratory depression and ativan was subsequently discontinued. the patient was started on bipap and this was quickly titrated off as the benzodiazepines had worn off. he continued to be agitated with increased blood pressures and tachycardia and the ativan was changed to valium per ciwa scale. of note, the patient had spiked a temperature to 101.8 degrees on and he was pancultured and a chest x-ray was performed. the patient's sputum had gram-positive cocci in pairs and clusters and he was initiated on levaquin therapy for a tracheobronchitis. on the patient had persistent thick secretions requiring frequent suction, and he had a large liquid stool which was tested for c. difficile as a cause for his fevers. this culture returned negative for c. difficile. the patient was also noted to have decreasing urine output requiring several fluid boluses. the psychiatrist who had been following this patient since admission recommended a quick taper with valium secondary to his increased sedation at that time. haldol was given for agitation and the patient's qtc was followed closely. on the patient's ciwa scale was discontinued and haldol was used preferentially for agitation. the sputum returned with speciation of staphylococcus aureus and his levofloxacin was changed to vancomycin on this date until the sensitivities returned. he had been transiently started on tube feeds which were subsequently held secondary to agitation. as the sensitivities from his sputum culture returned on as oxacillin sensitive, his antibiotics were change to oxacillin at that time. the patient also had received approximately 30 mg of haldol for agitation and his o2 requirement subsequently increased over this day which led to his intubation on for respiratory distress and airway protection. he remained on a propofol drip for sedation while he was intubated. repeat head ct and eeg were performed for his persistent mental status changes. the ct scan of his head was negative and his eeg ultimately returned with results consistent with encephalopathy. the patient was successfully extubated on without difficulty. his mental status continued to improve and his oxacillin was subsequently changed to levofloxacin on . the patient completed a 10-day course of antibiotics on prior to transfer to the medical floor. of note, the patient was found to have significant liver function test abnormalities on admission with an alt of 383, ast 615, alkaline phosphatase of 206, total bilirubin of 0.7 with normal pancreatic enzymes. this was felt to be consistent with alcoholic hepatitis, with the transaminases significantly decreased to within normal limits prior to his transfer. hepatitis serologies were checked and were determined to be negative. mr. had received a total of 275 mg of valium while admitted and has not required any haldol since . currently the patient is not agitated and he denies any current complaints. past medical history: 1. alcohol abuse. 2. hypertension. 3. hypothyroidism. 4. bipolar disorder. 5. peripheral vascular disease. allergies: the patient has no known drug allergies. medications at home: 1. lithium 300 mg p.o. q.a.m./600 mg p.o. q.p.m. 2. seroquel 300 mg p.o. q.h.s. 3. levoxyl 0.1 mg p.o. q.d. 4. ziac 10 mg p.o. b.i.d. medications on transfer: 1. tylenol p.r.n. 2. guaifenesin 10 mg p.o. q. 4 hours. 3. albuterol 2 puffs q. 4 hours. 4. atrovent 2 puffs q. 4 hours. 5. levoxyl 100 mcg p.o. q.d. 6. famotidine 20 mg p.o. b.i.d. 7. thiamine 100 mg p.o. q.d. 8. folic acid 1 mg p.o. q.d. 9. lopressor 12.5 mg p.o. q.d. 10. albuterol/atrovent nebulizers p.r.n. 11. levofloxacin 500 mg p.o. q.d. - last dose to be administered on . social history: the patient presented from , had lived alone and has a significant alcohol history as noted in the history of present illness. physical examination: vital signs - temperature 97.1, blood pressure 134/80, oxygen saturation 96%, heart rate 88. general: chronically ill appearing, no acute distress, older than stated age, calm, confident and alert. heent: mucous membranes moist, oropharynx clear, extraocular movements intact. neck: no jugular venous distension, supple, full range of motion. chest: clear to auscultation bilaterally, no dullness to percussion, symmetric excursion, expiratory phase not prolonged. cardiovascular: regular rate and rhythm, normal s1 and s2, no s3 or s4, no murmurs or rubs, no rv heave, point of maximal impulse not appreciated. abdomen: soft, nontender, nondistended, normal active bowel sounds, no hepatosplenomegaly nor masses. extremities: 2+ pedal pulses, warm. neurological: cranial nerves ii-xii were intact, motor in the upper and lower extremities bilaterally, reflexes were 2+ for quadriceps, ankles, biceps. distal sensation was intact. the patient was alert and oriented x 3. laboratory data: laboratory studies on transfer showed a white blood count of 10.5, hematocrit 33.5, left circumflex coronary artery 261, sodium 138, potassium 3.9, chloride 103, bicarbonate 27, bun 10, creatinine of 0.7, glucose 97, calcium 8.4, magnesium 1.9, phosphorous 4.1. pt, ptt and inr were 13.5, 28.2 and 1.2 respectively. notable microbiology: sputum - samples from and were poor samples demonstrating oropharyngeal growth. sputum sample from demonstrated 3+ gram-positive cocci in pairs and clusters which speciates as staphylococcus aureus sensitive to oxacillin, resistant to penicillin. sputum sample from demonstrated no microorganisms on gram stain and no growth. blood - (two sets) and were negative for growth. urine - urine culture from was negative. stool - c. difficile negative on . notable studies during admission: 1. chest x-ray from demonstrated no infiltrates or effusions. 2. chest x-ray from demonstrated a left retrocardiac opacity and possible layering of left pleural effusion. 3. chest x-ray from demonstrated improvement of the left retrocardiac opacity. 4. ct scan of the head from and were significant for no intracranial or extracranial hemorrhage. there were no significant white/ matter abnormalities. 5. lower extremity doppler ultrasound of left lower extremity on were negative for dvt. assessment: mr. is a 54-year-old male with a past medical history significant for alcohol abuse, hypertension, hypothyroidism, bipolar disorder and a prolonged medical intensive care unit admission for delirium tremens, left lower lobe pneumonia, now stable with no evidence of delirium tremens - the patient has not required haldol since . mr. is completing a 10-day course of antibiotics for staphylococcus aureus pneumonia currently doing well clinically with a normal oxygen saturation on room air. clearly, mr. will require psychiatric placement at a dual-diagnosis unit upon discharge. hospital course: 1. left lower lobe pneumonia: mr. oxygen saturations were only 96% on room air. his chest x-ray demonstrated resolution of the left retrocardiac opacity. he is currently completing a 10-day course of antibiotics upon transfer to the medical floor. we will continue to follow his temperature curve, will titrate his supplemental oxygen as needed to keep his o2 saturations greater than 93%. will continue metered dose inhalers/nebulizer treatments as needed. 2. delirium tremens: the patient is post the time period for delirium tremens to be occurring. he had been treated with a substantial amount of benzodiazepines, including 275 mg of valium and was treated with p.r.n. haldol with his last dose required was on . the patient may have become oversedated on the haldol versus substantial worsening of his pneumonia which led to his intubation. currently, the patient is alert and oriented to person, time and place. if he has further episodes of agitation, will use low doses of haldol p.r.n. 3. psychiatric: as mr. psychiatric medications had been held since his admission, he has received only benzodiazepines and haldol for agitation. as his mental status has cleared, he will be restarted on standing zyprexa. he will clearly need placement in an inpatient dual-diagnosis unit upon discharge. further medication additions will be directed by his psychiatrist at the inpatient psychiatric facility. the patient had been treated with lithium for his bipolar disorder which has been held since admission. discharge diagnoses: 1. left lower lobe pneumonia. 2. delirium tremens. 3. alcoholic hepatitis. 4. hypertension. 5. hypothyroidism. 6. anemia. 7. bipolar disorder. 8. alcohol withdrawal. discharge medications: 1. tylenol 325-650 mg p.o./p.r. q. 4-6 hours p.r.n. 2. levothyroxine sodium 100 mcg p.o. q.d. 3. famotidine 20 mg p.o. b.i.d. 4. thiamine 100 mg p.o. q.d. 5. folic acid 1 mg p.o. q.d. 6. lopressor 25 mg p.o. b.i.d. discharge status: the patient is being discharged to an inpatient psychiatric facility. condition on discharge: medically stable. discharge instructions: the patient is to take his medications as prescribed. return for increased shortness of breath, chest pains, fevers to greater than 101 degrees fahrenheit. physician follow up: the patient should follow up with his primary care physician within one to two weeks. , m.d. dictated by: medquist36 d: 00:51 t: 06:24 job#: Procedure: Continuous invasive mechanical ventilation for less than 96 consecutive hours Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Alcohol detoxification Diagnoses: Anemia, unspecified Unspecified essential hypertension Unspecified acquired hypothyroidism Methicillin susceptible pneumonia due to Staphylococcus aureus Bipolar I disorder, most recent episode (or current) unspecified Other and unspecified alcohol dependence, continuous Acute alcoholic hepatitis Alcohol withdrawal delirium