tokens: Admission Date : 2012-05-21 Discharge Date : 2012-05-25 Date of Birth : 1957-01-05 Sex : F Service : CMED CCU HISTORY OF PRESENT ILLNESS : This is a 55-year-old female with multiple prior admissions for pneumonia , COPD , asthma exacerbation , over 3 weeks of upper respiratory like infection unremitting with increased nebulizer treatments at home . The patient saw her PCP and was known to have an oxygen saturation of 82 to 85 percent on room air . She was referred to the Emergency Department . In the Emergency Department , the patient received Zithromax , ceftriaxone , and Flagyl . Chest x-ray was remarkable for a questionable left lower lobe infiltrate . The patient received nebulizer treatment with oxygen saturations increasing up to 98 percent on room air . PAST MEDICAL HISTORY : Asthma / COPD on BiPAP , history of intubation . Restrictive lung disease . Chronic inflammatory demyelinating polyradiculopathy . Gastritis and duodenitis . Question of Tyrone esophagus . Chronic abdominal pain . Neurogenic bladder . Chronic muscle spasms . Coronary artery disease status post negative stress echo on 10-12 . History of syncope . Adrenal insufficiency . Hypercholesterolemia . Depression and anxiety . Hyperthyroidism . IgG deficiency . Status post cholecystectomy and appendectomy . Anemia of chronic disease . ALLERGIES : AZMACORT , CLINDAMYCIN , VERSED , FENTANYL , and MORPHINE . SOCIAL HISTORY : History of 20-to-30-pack-year smoking , quit approximately 15 years ago . She denies any alcohol or drug use . Married with children , wheelchair bound mostly . PHYSICAL EXAMINATION : From admission , vital signs 98.3 , blood pressure 128/74 , 68 to 112 is her heart rate , respiratory rate 24 , 100 percent on room air . General : She is a chronically ill-appearing female , in no acute distress . HEENT : Benign . Cardiac exam : Normal . Pulmonary exam : Diffuse bronchial breath sounds , no wheezes . Abdominal exam : Benign . Extremity exam : No edema . Left lower extremity and left upper extremity weaker at 3/5 compared to right upper extremity and right lower extremity , chronic according to the patient . MEDICATIONS : On admission 1. Vitamin D 400 mg q.d. 2. Levoxyl 50 mcg q.d. 3. Baclofen 20 mg p.o. t.i.d. 4. Florinef 0.1 mg p.o. q.a.m. 5. Klonopin 2 mg t.i.d. 6. BuSpar 10 mg t.i.d. 7. Zanaflex 8 mg q.4 h. 8. Oxazepam 30 mg p.r.n. 9. Singulair 10 mg q.p.m. 10. Lipitor 10 mg q.p.m. 11. Ativan 2 mg p.r.n. 12. Protonix 20 mg p.o. b.i.d. 13. Sucralfate 2 mg b.i.d. 14. Albuterol nebulizer q.03-14 h. p.r.n. 15. Pamidronate 30 mg IV every month . HOSPITAL COURSE : Shortness of breath . The patient was maintained on albuterol nebulizer treatments and Ipratropium nebulizer treatments , as this was apparently thought to be related to her chronic obstructive pulmonary disease . Given the presence of consolidation on chest x-ray , however , and previous history of pneumonia , the patient was maintained on antibiotics of Zithromax 500 mg daily and ceftriaxone . The patient was also started on Solu-Medrol IV for active airway disease component of her shortness of breath . The patient was maintained on supplemental oxygen and sputum production was maximized with the help of an Acapella device and respiratory therapy . Mucomyst was also considered as a mucolytic component towards secretions . Adrenal insufficiency . The patient was maintained on IV Solu - Medrol 60 mg q. 8 h. Chest soreness . The patient describes chest discomfort without any significant EKG changes . The patient was maintained on Percocet p.r.n. for pain relief . This was thought to be related to musculoskeletal . There was no evidence of acute rib factors on her chest x-ray . GI . The patient was maintained on PPI for reflux disease and known gastritis . CMED . The patient has a history of neurogenic bladder and , therefore , she required a Foley catheterization . Endocrine . The patient was on Levoxyl at home as her home dose for hyperthyroidism . CMED CSRU transfer . The patient was transferred on the evening of 2012-05-22 to the ICU given persistent carbon dioxide retention and respiratory acidosis and the intermittent mental status changes . The patient had had ABG on the floor , which prompted her to transfer to the ICU . Her pH was 7.23 , PCO2 73 , PO2 146 on a nonrebreather . The patient had BiPAP initiated once she reached the unit , but did not tolerate it , becoming apneic and obstructing . The patient was switched to 2 liters nasal cannula and oxygen saturating at 98 to 100 percent . After BiPAP was initiated , the patient became hypotensive down to 75/28 and bradycardiac , responding to 3 fluid boluses over the course of the night . The patient was started on Florinef for concern of adrenal insufficiency ; however , she was hemodynamically stable that morning and was transferred back out to the floor . It was thought that the patient may have been mucous plugging during her stay in the ICU . Hematologic . The patient has a history of high MCV and megaloblastic cells on smear in the setting of anemia ; question B12 deficiency , the patient also has a history of borderline low B12 levels . The patient was diagnosed for B12 deficiency due to her long history of poor p.o. intake . Methylmalonic acid levels were sent , the results are pending at the time of discharge . DISCHARGE DIAGNOSES : Asthma flare and bronchitis . Chronic obstructive pulmonary disease . Demyelinating polyradiculopathy . Anxiety disorder . Chronic abdominal pain . DISCHARGE STATUS : The patient will be discharged to home . DISCHARGE CONDITION : The patient is stable without an oxygen requirement . DISCHARGE FOLLOWUP : The patient is instructed to followup with her doctor in 1 to 2 weeks of discharge . DISCHARGE MEDICATIONS : 1. Cholecalciferol . 2. Vitamin D . 3. Levothyroxine 50 mcg p.o. q.d. 4. Baclofen 10 mg p.o. t.i.d. 5. Clonazepam 1 mg p.o. t.i.d. 6. Buspirone 10 mg p.o. t.i.d. 7. Montelukast sodium 10 mg p.o. q.h.s. 8. Atorvastatin 10 mg p.o. q.h.s. 9. Protonix 40 mg p.o. q.d. 10. Albuterol sulfate solution q.05-15 h. p.r.n. for shortness of breath . 11. Tizanidine 8 mg p.o. q.6 h. 12. Acetaminophen p.r.n. 13. Prednisone taper for 3 days . 14. Levofloxacin 500 mg p.o. q.d. for 10 more days . 15. Florinef Acetate 0.1 mg p.o. q.d. James Grunow , M.D. 53-506 Dictated By : Elizabeth A Eaton , M.D. MEDQUIST36 D : 2012-08-01 12:27:33 T : 2012-08-01 20:27:59 Job #: 33698 Signed electronically by : DR. Kenneth Wilford on : Maxine 2012-08-16 12:22 PM ( End of Report )