Unspecified septicemia Pneumonia organism unspecified Acute respiratory failure Blood in stool Acidosis Urinary tract infection site not specified Severe sepsis Coronary atherosclerosis of native coronary artery Percutaneous transluminal coronary angioplasty status Chronic airway obstruction not elsewhere classified Diabetes mellitus without mention of complication type II or unspecified type not stated as uncontrolled Unspecified essential hypertension Other and unspecified hyperlipidemia Other persistent mental disorders due to conditions classified elsewhere Encounter for palliative care Hypoxemia
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Sulfa (Sulfonamides)
 
Attending: ___.
 
Chief Complaint:
Hypoxia & GI bleed
 
Major Surgical or Invasive Procedure:
none
 
History of Present Illness:
___ y/o M with PMHx of Dementia, CAD s/p PCI, COPD and recent 
ARDS s/p appendectomy who was at ___ prior to recent 
admission for GI bleed. Pt was discharged on ___ and was found 
this morning to have black guaic positive stools and increased 
work of breathing.  
.  
In the ED, initial vs were: T 100.3 P ___ BP 102/48 R 30 O2 sat 
of 100% on NRB. Pt triggered on arrival with diaphoresis and 
tachypnea. He was noted to black guaic + stool and concentrated 
urine. He was weaned from NRB and had a Tmax of 102 in the ED. 
CXR showed worsening in bilateral infiltrates and he was given 
Zosyn, Levofloxacin, Protonix and 1L IVF for possible PNA. PIV 
was placed and blood was typed/crossed for GI bleed.  
.  
On arrival to the ICU, pt was oriented to person only and c/o 
feeling tired and thirsty. Pt has mild shortness of breath but 
denies cough, congestion or significant increased work of 
breathing. He denies abd pain, nausea, vomiting, diarrhea, 
bloody stools, changes in vision or sore throat but does report 
decreased appetite.  

 
Past Medical History:
Severe Dementia  
Depression  
CAD s/p MI in ___ c/b VF with stenting of the L circ, PCI to R 
PDA with DES in ___  
COPD  
Recent ARDS s/p appendectomy  
Type II DM  
Hypertension  
Spinal Stenosis  
Hyperlipidemia  
CDiff  
Zoster on rectal area  
.  
Surgical History  
s/p CCY  
s/p hernia repair  
s/p appendectomy 

 
Social History:
___
Family History:
His father died of a myocardial infarction at ___. His mother 
died of a myocardial infarction at 74. His three brothers, who 
died one of a motor vehicle accident and one of leukemia. 
 
Physical Exam:
T 97 HR 95 BP 98/41 RR 29 Sats 95% on 6LNC
General: NAD, comfortable, breathing comfortably with NC O2  
HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear  
Neck: no pre-cervical lymphadenopathy  
Lungs: Bilateral inspiratory rales, no rhonchi, no congestive 
cough  
CV: Irreg, mildly tachy, intermittent S4. PMI non-displaced  
Abdomen: soft, NT/ND, NABS, no rebound or guarding  
Ext: cool hands, warm feet, good distal pulses 

 
Pertinent Results:
___ 01:55AM BLOOD WBC-11.2* RBC-3.29* Hgb-10.4* Hct-31.2* 
MCV-95 MCH-31.8 MCHC-33.4 RDW-17.2* Plt ___
___ 07:15PM BLOOD WBC-11.4* RBC-3.49* Hgb-10.8* Hct-33.0* 
MCV-95 MCH-30.9 MCHC-32.7 RDW-17.5* Plt ___
___ 01:55AM BLOOD ___ PTT-28.8 ___
___ 07:15PM BLOOD ___ PTT-28.8 ___
___ 07:15PM BLOOD Glucose-166* UreaN-6 Creat-0.6 Na-133 
K-3.7 Cl-93* HCO3-31 AnGap-13
___ 01:55AM BLOOD Glucose-168* UreaN-6 Creat-0.6 Na-135 
K-3.3 Cl-97 HCO3-32 AnGap-9
___ 01:55AM BLOOD CK(CPK)-31*
___ 01:55AM BLOOD CK-MB-NotDone cTropnT-<0.01
___ 07:15PM BLOOD Albumin-2.6___ 01:55AM BLOOD Calcium-7.5* Phos-1.3* Mg-1.7
___ 10:50PM BLOOD Type-ART Temp-37.2 pO2-66* pCO2-45 
pH-7.48* calTCO2-34* Base XS-8
___ 07:16PM BLOOD Lactate-2.4*
.
CXR ___: FINDINGS: AP upright portable chest radiograph is 
obtained. As compared with the prior radiograph, there has been 
no significant change. Motion artifact somewhat limits 
evaluation. Bilateral extensive parenchymal opacities are again 
noted, consistent with the provided history of ARDS. There has 
been no significant interval change. Small bilateral pleural 
effusions cannot be excluded. Heart size is difficult to assess. 
No large pneumothorax is present. Bony structures appear intact. 


 
Brief Hospital Course:
# Hypoxic Resp Distress: Pt with poor substrate given recent 
ARDS who p/w fever, increased O2 requirement and worsening in 
bilateral infiltrates concerning for PNA. Appeared clinically 
euvolemic to dry and large A-a gradient on ABG.  There was no 
evidence of COPD exacerbation or acute CO2 retention.  
Oxygenation remained poor despite broad spectrum antibiotics, 
patient was unable to be weaned off O2, he remained on 6 L plus 
facemask.  After discussion with HCP and patient on ___, 
decision was made to transition patient to CMO.  IV antibiotics 
were continued at the family's request because they wanted to 
have some more time to spend with him.  Patient passed away on 
___.
.
# GI bleed: Pt presented with guaiac positive black stools, but 
had stable hematocrit at his baseline.  He likely has a slow 
upper GI bleed.  After patient was made CMO, morphine was used 
to treat abdominal pain.  
 
Medications on Admission:
Sitagliptin 50mg daily  
Vancomycin 250mg po BID  
Ipratropium neb q6hrs  
Senna prn  
Clotrimazole TP  
Lasix 20mg IV  
Insulin SS  
Lactobacillus BID  
Levalbuterol neb q6hrs  
Omeprazole 40mg BID  
Sertraline 50mg daily  
Simvastatin 40mg daily  

 
Discharge Medications:
Expired
 
Discharge Disposition:
Expired
 
Discharge Diagnosis:
expired
 
Discharge Condition:
expired
 
Discharge Instructions:
expired
 
Followup Instructions:
___

{'Hypoxia': ['Pneumonia', 'Acute respiratory failure', 'Hypoxemia'], 'GI bleed': ['Blood in stool'], 'feeling tired': [], 'thirsty': [], 'mild shortness of breath': ['Pneumonia', 'Acute respiratory failure'], 'decreased appetite': []}