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the patient is a 76-year-old male who had been hospitalized at the from through of after undergoing a left femoral-at bypass graft and was subsequently discharged to a rehabilitation facility. on , he presented again to the after being found to have a systolic blood pressure in the 70s and no urine output for 17 hours. a foley catheter placed at the rehabilitation facility yielded 100 cc of murky/brown urine. there may also have been purulent discharge at the penile meatus at this time. on presentation to the emergency department, the patient was without subjective complaints. in the emergency department, he was found to have systolic blood pressure of 85. he was given 6 liters of intravenous fluids and transiently started on dopamine for a systolic blood pressure in the 80.s past medical history: 1. coronary artery disease with diffuse 3-vessel disease; right-dominant, status post proximal left circumflex stent in with occlusion of the distal left circumflex; status post right coronary artery stent on (no percutaneous coronary intervention to 99% diagonal left circumflex, 80% small proximal left anterior descending artery, or 80% small distal left anterior descending artery). 2. congestive heart failure (with an ejection fraction of 15% to 20%). 3. type 2 diabetes with neuropathy. 4. hypertension. 5. diverticulosis (found on colonoscopy in ). 6. alzheimer's dementia. 7. history of gastrointestinal bleed (while the patient was taking eptifibatide). 8. cardiac risk factors (with a baseline creatinine of 1.4 to 1.6). 9. hypercholesterolemia. 10. history of methicillin-resistant staphylococcus aureus and pseudomonas growth in wound cultures. 11. severe peripheral vascular disease; status post left femoral-at bypass graft on . 12. chronic nonhealing foot ulcers. 13. recent right pedal cellulitis. allergies: the patient has no known drug allergies. medications on admission: 1. vancomycin 1 g intravenously q.24h. for a level of less than 15 (started on ). 2. levofloxacin 250 mg p.o. q.d. (started on ). 3. metronidazole 500 mg p.o. q.8h. (started on ). 4. heparin 5000 units subcutaneous b.i.d. 5. simvastatin 40 mg p.o. q.d. 6. lisinopril 5 mg p.o. q.d. 7. furosemide 40 mg p.o. q.d. 8. vitamin e 400 iu p.o. q.d. 9. atenolol 25 mg p.o. q.d. 10. pantoprazole 40 mg p.o. q.d. 11. ascorbic acid 500 mg p.o. b.i.d. 12. nph 17 units b.i.d. 13. regular insulin sliding-scale. 14. bisacodyl 10 mg p.o./p.r. as needed. 15. docusate 100 mg p.o. b.i.d. 16. percocet 5/325 mg one tablet p.o. q.4-6h. as needed for pain. 17. aspirin 81 mg p.o. q.d. 18. metoprolol 75 mg p.o. b.i.d. social history: the patient is retired and had been living at home with his wife prior to his admission to the hospital on ; he had been living at for the day prior to admission. he is a social drinker and has a 40-pack-year smoking history; although, he quit smoking 20 years ago. physical examination on presentation: initial physical examination revealed temperature was 96.1 degrees fahrenheit, heart rate was 83, blood pressure was 124/42 (following administration of 3 liters of normal saline), respiratory was 24, and his oxygen saturation was 100% on 2 liters nasal cannula. his heart had a regular rate and rhythm. there were normal first and second heart sounds. there was a 2/6 systolic ejection murmur, and there were no rubs or gallops. his lungs were clear to auscultation bilaterally. his abdomen was soft, nontender, and nondistended, and there were hypoactive bowel sounds. he had a palpable bypass graft pulse, dorsalis pedis and posterior tibialis pulses bilaterally; and his surgical incision was clean, dry, and intact. please note that the above examination was done by the vascular surgery team, which was the team that was initially planning to admit the patient to the hospital. pertinent laboratory data on presentation: on initial laboratory evaluation the patient had a white blood cell count of 12.7, hematocrit was 30.2, and platelets were 282,000. his pt was 13.5, ptt was 30.7, and inr was 1.3. his serum chemistries revealed sodium was 136, potassium was 5.4, chloride was 99, bicarbonate was 25, blood urea nitrogen was 53, creatinine was 3.2, and blood glucose was 91. his calcium was 8.2, magnesium was 2.4, and phosphate was 4.8. blood cultures drawn on admission were pending, but ultimately negative. a urine culture taken on admission was initially pending, but ultimately grew out yeast. a sputum culture taken on admission was also initially pending, but ultimately also grew out yeast. radiology/imaging: his admission chest x-ray demonstrated stable prominence of the right main pulmonary artery; no focal areas of consolidation; overall stable appearance of the chest compared with a study. no radiographic evidence of congestive heart failure or pneumonia. his admission electrocardiogram demonstrated a sinus rhythm, nonspecific inferior/lateral t wave changes, low qrs voltages in the limb leads, and t wave changes in v5 and v6 when compared with an electrocardiogram dated . an initial abdominal ct was a limited noncontrast examination that demonstrated diffuse vascular calcifications. no evidence of an abdominal aortic aneurysm or free fluid, incompletely imaged coronary artery calcification, a simple left renal cyst, sigmoid diverticulosis, and an enlarged and partially calcified prostate gland. hospital course by system: 1. cardiovascular: the patient was initially admitted to the vascular intensive care unit with hypotension, decreased urine output, and acute renal failure; most likely secondary to a presumed gram-negative urosepsis (although there were never any positive culture data to confirm this diagnosis). while boarding in the medical intensive care unit on the night of admission, the patient had a sudden cardiorespiratory arrest. he was resuscitated with epinephrine, lidocaine, and direct current cardioversion times four. he was also intubate for airway protection. following these measures, the patient returned to a sinus rhythm with a systolic blood pressure of approximately 100; the total time elapsed from the beginning of the arrest to the return of a pulse was approximately 16 minutes. he subsequently required double pressors to maintain his blood pressure. an echocardiogram performed at the bedside demonstrated a trivial pericardial effusion and a left ventricular ejection fraction of 20% to 25% in the setting of tachycardia and a hyperdynamic right ventricle; suggesting elevated right-sided filling pressures. although the definitive etiology of this arrest remained unknown, the most likely trigger was a non-q-wave myocardial infarction, as his troponin values were elevated to greater than 50 following his arrest. a repeat echocardiogram done on demonstrated mild left atrial dilation, an ejection fraction of 15% to 20%, resting regional wall motion abnormalities including inferior, mid, and apical left ventricular akinesis, depressed right ventricular systolic function, and moderate mitral regurgitation. compared with the prior study of ; the left ventricular function was unchanged. there was moderate mitral regurgitation, and the right ventricular function appeared worse. on , the patient was loaded with amiodarone and was subsequently started on oral amiodarone. the following day, he was started on heparin intravenously given his elevated serum troponin to greater than 50; this medication was continued for 72 hours. given his elevated troponins and non-q-wave myocardial infarction, the patient was a candidate for cardiac catheterization. after discussions between the medical intensive care unit team and the patient's family, however, the decision was made to not pursue further invasive procedures given that the patient had been made do not resuscitate/do not intubate following the resuscitation mentioned above, and his family no longer wished for aggressive resuscitating measures. by , he was off pressors and he was restarted on a beta blocker and ace inhibitor at low doses. on the evening of , the patient complained of substernal chest pain that was relieved by npg sl and morphine. he also had st segment depressions in v2 and v3 that reverted to baseline after the resolution of his pain. therefore, the patient was again started on heparin; although, this was discontinued on when the patient ruled out for a myocardial infarction by cardiac enzymes. he again had substernal chest pain on ; although, he had no electrocardiogram changes, and he again ruled out for a myocardial infarction by cardiac enzymes. by hospital day four, the patient began to develop evidence of congestive heart failure given his aggressive fluid resuscitation, and gentle diuresis with furosemide was begun. by the time of his transfer to the general medicine service on , the patient was still significantly volume overloaded following his aggressive fluid resuscitation in the medical intensive care unit. therefore, he was continued on the program of gentle diuresis given that he was having signs and symptoms of right-sided congestive heart failure. he achieved adequate diuresis by the time of his discharge to rehabilitation, as his oxygen saturation was greater than 95% on 2 liters nasal cannula. 2. infectious disease/sepsis: the patient was started on gentamicin and piperacillin/tazobactam in addition to the levofloxacin, metronidazole, and vancomycin he was already taking for right lower extremity cellulitis prior to admission for empiric coverage of a presumed gram-negative urosepsis, and he was aggressively hydrated with intravenous fluids. on , his levofloxacin and metronidazole was discontinued, and he was started on fluconazole given the growth of yeast on urine culture. he was taken off of gentamicin on hospital day three, and his fluconazole was discontinued on hospital day five (as per the infectious disease service). he was taken off of vancomycin on , and his piperacillin/tazobactam was discontinued on . despite the presumption of a gram-negative urosepsis precipitating this admission, the patient did not have any positive blood or urine cultures aside from the growth of yeast in two urine cultures noted above. he remained afebrile both before and after discontinuation of his antibiotics, and he was found to be clostridium difficile negative on . 3. pulmonary: as noted above, the patient was intubated and he was extubated on . he subsequently developed wheezing and mild hypoxia; most likely secondary to cardiac asthma and fluid overload in the setting of his aggressive fluid resuscitation. he was gently diuresed toward the end of his hospitalization, and by the time of his he was maintaining an oxygen saturation of greater than 95% on 2 liters nasal cannula, intermittent ipratropium nebulizers, and chest physical therapy for clearance of his respiratory secretions. 4. renal: the patient presented with acute renal failure and prerenal azotemia that rapidly resolved following fluid resuscitation. by the time of discharge, his serum creatinine was stable and at his preadmission baseline. 5. nutrition: the patient was found to be profoundly malnourished with a serum albumin of 1.8 on admission. once he was extubated and taking orals, he performed poorly on a modified barium swallowing study and was started on a thin liquid, ground-solid diet with whole medication tablets, small bites and sips, upright posture with meals, and aspiration precautions. he was also given promod shakes with and between meals for nutritional supplementation of his heart-healthy/diabetic diet. 6. vascular: the patient's operative incisions and foot ulcers continued to heal throughout this admission. he was started on an multivitamin, vitamin c, and zinc for improved wound healing. 7. hematology: the patient was transfused one unit of packed red blood cells on to maintain a hematocrit of greater than 30 given his history of severe coronary artery disease. his hematocrit subsequently remained stable. condition at discharge: condition on discharge was stable. discharge status: rehabilitation facility. discharge diagnoses: 1. cardiorespiratory arrest. 2. non-q-wave myocardial infarction. 3. acute renal failure. 4. coronary artery disease with diffuse 3-vessel disease; right-dominant, status post proximal left circumflex stent in with occlusion of distal left circumflex; status post right coronary artery stent on (no percutaneous coronary intervention to 99%, distal left circumflex, 80% small proximal left anterior descending artery, 80% small distal left anterior descending artery). 5. congestive heart failure (with an ejection fraction of 15% to 20%). 6. type 2 diabetes with neuropathy. 7. hypertension. 8. diverticulosis (found on colonoscopy in ). 9. alzheimer's dementia. 10. history of gastrointestinal bleed (while the patient was taking eptifibatide). 11. cardiac risk factors (with a baseline creatinine of 1.4 to 1.6). 12. history of methicillin-resistant staphylococcus aureus and pseudomonas growth in wound cultures. 13. severe peripheral vascular disease; status post left femoral-at bypass graft on . 14. chronic nonhealing foot ulcers. medications on discharge: 1. amiodarone 400 mg p.o. b.i.d. (through ), then 400 mg p.o. q.d. (times one week), then 200 mg p.o. q.d. 2. metoprolol 50 mg p.o. b.i.d. 3. captopril 6.25 mg p.o. t.i.d. 4. aspirin 325 mg p.o. q.d. 5. pantoprazole 40 mg p.o. q.d. 6. heparin 5000 units subcutaneously b.i.d. 7. multivitamin one tablet p.o. q.d. 8. zinc sulfate 220 mg p.o. q.d. 9. vitamin c 500 mg p.o. q.d. 10. ipratropium nebulizers q.4-6h. as needed (for wheezing). 11. acetaminophen 325 mg to 650 mg p.o. q.4-6h. as needed (for pain). 12. miconazole 2% powder to groin b.i.d. 13. santyl lotion to heels b.i.d. 14. regular insulin sliding-scale. code status: do not resuscitate/do not intubate. note: if applicable, an addendum to this discharge summary will be dictated to include follow-up appointments as well as any changes to the medication list noted above. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other electric countershock of heart Pulmonary artery wedge monitoring Diagnoses: Other primary cardiomyopathies Subendocardial infarction, initial episode of care Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Unspecified protein-calorie malnutrition Cardiac arrest Other shock without mention of trauma Cellulitis and abscess of leg, except foot

the patient is a 47-year-old female with a history of human immunodeficiency virus (last cd4 count 42 and a viral load of 65,000), cirrhosis, diabetes, and hypothyroidism presented with eight days of fevers to 104, chills, shortness of breath, cough, dyspnea on exertion, and fatigue. the patient states she has become progressively dyspneic to the point where she is short of breath with speaking. she has also had night sweats for the past two days and whitish sputum. she complains of myalgias. no recent ill contacts. known tuberculosis exposure. in the emergency department, the patient was initially 96% on room air, with a respiratory rate of 20, and a heart rate of 117. a chest x-ray showed diffuse interstitial opacities. she received 3 liters of normal saline, clindamycin, and primaquine for likely pneumocystis carinii pneumonia. she spiked a temperature to 102.1 and became progressively dyspneic with her respiratory rate increasing to 40, and her oxygen saturations dropping to 89% on room air. she was placed on 6 liters by nasal cannula, and an arterial blood gas showed 7.47/28/74. the patient was given prednisone and aztreonam for possible cholangitis. past medical history: 1. human immunodeficiency virus diagnosed in ; acquired from her ex-husband (in , cd4 count was 42 and viral load was 65,000). 2. cirrhosis; status post liver biopsy in consistent with cytosis and sinusoidal fibrosis consistent with toxic metabolic disease possibly from highly active antiretroviral therapy. 3. insulin-dependent diabetes mellitus since . 4. hypothyroidism. 5. esophagogastroduodenoscopy in was normal with no varices. medications on admission: 1. viread 300 mg once per day. 2. epivir 150 mg twice per day. 3. acyclovir 400 mg twice per day. 4. diflucan 200 mg twice per day. 5. videx 400 mg once per day. 6. zantac 150 mg once per day. 7. klonopin as needed. 8. lantus 6 units subcutaneously in the morning; no sliding-scale. allergies: penicillin and sulfa drugs (cause a rash). dapsone (causes nausea). family history: family history was noncontributory. social history: the patient lives at home with her son. she quit tobacco five years ago. no alcohol. no illicit drugs. no intravenous drug use. no transfusions. physical examination on presentation: on admission, the patient had a temperature of 102.1, her heart rate was 118, her respiratory rate was 40, her blood pressure was 117/57, and her oxygen saturation was 89% on room air and 94% on 6 liters. in general, she was ill and toxic appearing. she was unable to speak in complete sentences. she was cachectic. head, eyes, ears, nose, and throat examination revealed anicteric. the mucous membranes were dry. the extraocular movements were intact. no thrush. the neck was supple. there was no jugular venous distention. thorax revealed bilateral basilar rales. no wheezes. cardiovascular examination revealed tachycardia. there were no murmurs. the abdomen revealed mild diffuse tenderness to percussion, hepatomegaly 6 cm below the costal margin, no spleen palpated, positive bowel sounds. there was no rebound or guarding. extremities revealed no lower extremity edema. pulses were 2+. neurologic examination revealed cranial nerves ii through xii were intact. strength was in all extremities. pertinent laboratory values on presentation: the patient had a white blood cell count of 9.7 (with 89% neutrophils and 7% lymphocytes), and her hematocrit was 34.2. chemistries were within normal limits with a blood urea nitrogen of 9 and a creatinine of 0.5. her aspartate aminotransferase was 69, her alanine-aminotransferase was 28, her alkaline phosphatase was 994, and her total bilirubin was 2.2, and her direct bilirubin was 1.5. her lactate was 2.1. urinalysis was negative for leukocyte esterase or nitrites. it was positive for 30 protein. pertinent radiology/imaging: an electrocardiogram revealed sinus tachycardia; unchanged from . a chest x-ray revealed bilateral interstitial opacities in the left mid lung; consistent with pneumocystis carinii pneumonia or viral pneumonia. a right upper quadrant ultrasound revealed no cholelithiasis. no gallbladder wall edema. common bile duct was 4 mm. brief summary of hospital course by issue/system: 1. pulmonary issues: from the emergency room, the patient was transferred to the intensive care unit secondary to respiratory distress. symptoms consistent with a respectively alkalosis. a chest x-ray was consistent with possible pneumocystis pneumonia versus a viral pneumonia. given her allergies to both sulfa and dapsone, she was started on empiric pneumocystis carinii pneumonia coverage with primaquine and clindamycin. she was also started on prednisone given her low oxygen saturations, and given her low pao2. in the intensive care unit, she requested noninvasive positive pressure ventilation. a bronchoscopy was performed with 1+ gram-positive cocci in pairs and positive pneumocystis carinii pneumonia. acid-fast bacillus smears were negative. the patient's respiratory status continued to improve on her medication regimen. she was weaned off of the noninvasive positive pressure ventilation and eventually was able to saturate 98% on room air. she was to be continued on primaquine and clindamycin for a total of a 21-day course of antibiotics as well as a 21-day steroid taper. 2. bacteremia issues: the patient's blood cultures from admission from and grew out methicillin-sensitive staphylococcus aureus ( blood cultures). at that time, the patient was started on vancomycin therapy with quick clearance of her blood cultures. a transthoracic echocardiogram was performed to rule out endocarditis, and it did not show any valvular abnormalities; although, the tricuspid valve was obscured by her peripherally inserted central catheter line. the subsequent surveillance blood cultures from on were negative, and the patient was to be continued on vancomycin intravenously for a 3-week course. after that time, blood cultures should be repeated for surveillance. the patient remained afebrile during the remainder of her hospital stay. 3. cirrhosis issues: the patient has child a class cirrhosis from a liver biopsy done in . her cirrhosis was thought to be secondary to her highly active antiretroviral therapy. she was to follow up with dr. in for a visit. a right upper quadrant ultrasound was performed as the patient's alanine-aminotransferase was slightly elevated and was within normal limits. 4. human immunodeficiency virus issues: the patient was restarted on her highly active antiretroviral therapy regimen on hospital day four. the patient tolerated these medications without any problems. she was also continued on acyclovir and fluconazole for prophylaxis. the patient was to follow up with dr. in clinic over the next two weeks. 5. diabetes mellitus issues: the patient was placed on original regimen of lantus without a sliding-scale secondary to her steroid taper. her blood sugars remained elevated while in house; ranging from the 200s to the 400s. her lantus was increased to 12 units subcutaneously in the morning, and her sliding-scale was increased as well with improved blood sugars. she was to be discharged on 12 units of lantus in the morning with a strict sliding-scale for the next three days until her prednisone is tapered; at which time her lantus will be decreased to 7 units in the morning, and her sliding-scale will be decreased as well. 6. hypothyroidism issues: the patient was continued on her levoxyl. 7. access issues: a peripherally inserted central catheter line was placed on for intravenous antibiotics. it was found to be in the right atrium on chest x-ray and was pulled back 6 cm with a repeat chest x-ray location in the superior vena cava. she will need the peripherally inserted central catheter line for 14 more days as she finishes her course of intravenous vancomycin. condition at discharge: condition on discharge was good. discharge status: the patient was discharged to home. discharge instructions/followup: the patient was instructed to follow up with dr. for cirrhosis and with dr. for her human immunodeficiency virus. she was to follow up with dr. and dr. next friday for primary care. medications on discharge: 1. prednisone 40 mg once per day times three days; then 20 mg once per day times 11 days. 2. acyclovir 200 mg by mouth twice per day. 3. fluconazole 200 mg by mouth twice per day. 4. primaquine 26.3 two tablets by mouth every day (times 14 days). 5. levoxyl 25 mcg by mouth once per day. 6. tenofovir disoproxil fumarate 300 mg by mouth once per day. 7. lamivudine 300 mg twice per day. 8. didanosine 400 mg by mouth once per day. 9. lantus 12 units subcutaneously in the morning times three days; and then 7 units subcutaneously in the morning. 10. regular insulin sliding-scale as directed (per sliding-scale). 11. clindamycin 300 mg by mouth four times per day (times 14 days). 12. vancomycin 750 mg intravenously twice per day (times 14 days). 13. codeine/guaifenesin syrup 5 cc to 10 cc by mouth q.6h. as needed. 14. klonopin 0.75 mg by mouth in the morning and 0.5 mg by mouth at hour of sleep. 15. multivitamin one tablet by mouth once per day. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Diagnostic ultrasound of heart Other bronchoscopy Diagnoses: Cirrhosis of liver without mention of alcohol Infection with microorganisms resistant to penicillins Human immunodeficiency virus [HIV] disease Pneumocystosis Cachexia Alkalosis Bacteremia Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Antiviral drugs causing adverse effects in therapeutic use

50 yo m w/ type 2 dm, depression who was admitted to deaconness 4 for major depressive episode and possible . while on 4, the patient was given ativan 1 mg x 1. his klonopin was held. he was given normal dose of nph as npo for . the following am, the paitent was found to be shaking. he was given 2 mg ativan and became nonresponsive over the next 20 minutes and a code was called. the patient's fingerstick was 30 so he was given 1 amp of d50. he was also given 4 mg iv ativan. he stopped shaking and mental status cleared in 30 minutes. he was started on a dilantin load. he was seen by neuro who felt that in the setting of hypoglycemia (severe)and withdrawal of his klonopin, he was at risk to have a seizure. past medical history: - iddm, type ii - osa - borderline htn - hypercholestremia - h/o rbbb past psychiatric history: panic d/o x 20yrs on klonopin x 12 yrs, occassional xanax outpt psychiatry intermittently, until 4 weeks ago when he began to see dr. with significant depression since . of this year pt and wife sought counseling for sleep issue with children x 2 sessions. no assaultive or suicidal behavior social history: substance abuse history: denies alcohol, tobacco or other street drugs. one episode of mj use in . social history: attorney for , division. married to for 11 yrs this children 4yo and 2 yo . denies physical or sexual abuse in past or currently. denies military or legal hx. family history: denies physical exam: vs: tm 99.8 hr 87-133 (98) bp 117-166/75-97 rr 17-27 o2 sat - 95-100% ra 2740/2455 gen: nad, sitting in bed heent: perrl, eomi, sclera anicteric, mmm, no op lesions cv: normal s1/s2, rrr, no m/g/r. pul: cta b/l. abd: soft, nt, nd +bs. ext: no edema. neuro: a and ox3, cn 2-12 intact, m ue/le b/l, sensation grossly intact pertinent results: 07:30pm blood wbc-12.8* rbc-4.69 hgb-13.8* hct-39.7* mcv-85 mch-29.5 mchc-34.9 rdw-13.9 plt ct-217 07:30pm blood plt ct-217 07:45am blood glucose-186* urean-12 creat-1.0 na-139 k-3.9 cl-101 hco3-25 angap-17 07:30pm blood ck-mb-1 ctropnt-<0.01 06:14am blood ck-mb-1 ctropnt-<0.01 03:38pm blood phenyto-15.5 11:36am blood asa-neg ethanol-neg acetmnp-neg bnzodzp-neg barbitr-neg tricycl-neg 11:44am blood type-art po2-198* pco2-29* ph-7.54* calhco3-26 base xs-3 . eeg this is a normal eeg in the awake and drowsy states. note is incidentally made of a resting tachycardia. brief hospital course: a/p: 50m with history of hypertension, type ii diabetes, originally admitted to psychiatry for , made npo p mn for in am with 1/2 dose of insulin, who was found unresponsive and in apparent seizure state, who was found to have a blood glucose of 30. . 1)convulsions: a code was called and the patient was given ativan 2mg po x1, as well as an amp of d50, loaded with dilantin and transferred to the micu. the seizure was attributed to his hypoglycemic state, although psych thought there was an element of klonopin withdrawal and thus continued to give ativan 0.5mg po q4. pt had frequent bs checks in the micu and patient recovered from his initial event without any post-seizure sequelae. pt continued to be monitored and had no further events. neurology was consulted for his ? seizure event and after a negative exam and negative eeg, concluded that it was all due to hypoglycemia, and that further dilantin would not be necessary. dilantin was d/ced and patient continued to do well. he was eventually transferred to the floor. all home medications were continued and patient continued to express interest in his treatment on monday, although refused to be transferred back to 4. all home medications although his insulin dose (nph 20 qpm) was halved (--> nph 10 qpm) on the floor, and his sugars were running in the 150s-250s range. pt was sent home to return for on monday as an outpatient. explicit instructions were given to take all medications as normal the night before, including his klonopin, and only take dose of nph insulin the night before, npo p mn, no morning nph dose, and to cover his elevated morning sugars with humalog at a conservative sliding scale. goal sugars 150s-250s. 2) type 2 dm - follow sugars closely - continue normal dose insulin while taking pos, and when npo p mn for in am, pt was instructed to take nph dose the evening before, no nph in the am, and to cover with humalog prn according to conservative insulin ss to prevent hypoglycemic episodes. . 3) depression: pt with a h/o refractory depression that was originally admitted to the psych service for . psych consult remained aware as pt was admitted to the micu and then called out to the floors. recommended continuing his klonopin 3mg po bid for his anxiety, and added ativan 0.5mg po q4 for coverage of his anxiety and alleviation of ? withdrawal during periods when he is off the klonopin. continued his home doses of celexa, nortriptyline, seroquel and trazodone for sleep. pt was to be discharged to return on monday for treatments as an outpatient. . 4) f/e/n: -diabetic diet, replete lytes prn . 5) code: full . 6) dispo: medically cleared per micu team as well as pcp. to be discharged to follow up with outpatient on monday. medications on admission: nortriptylline 50mg qd (started a week pta) seroquel 50mg tid klonopin 3mg lexapro 20mg po qd trazadone 200mg qhs crestor 10mg po qd insulin ss + nph 20 qhs lisinopril 10mg po qd discharge medications: 1. nortriptyline 50 mg capsule sig: one (1) capsule po daily (daily). disp:*30 capsule(s)* refills:*2* 2. quetiapine 25 mg tablet sig: two (2) tablet po tid (3 times a day). disp:*180 tablet(s)* refills:*2* 3. trazodone 100 mg tablet sig: two (2) tablet po qhs (once a day (at bedtime)). disp:*60 tablet(s)* refills:*2* 4. escitalopram 10 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 5. rosuvastatin 5 mg tablet sig: two (2) tablet po daily (daily). disp:*60 tablet(s)* refills:*2* 6. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 7. lisinopril 10 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*2* 8. insulin nph human recomb 100 unit/ml suspension sig: twenty (20) units subcutaneous qam (in the morning) . disp:*qs units* refills:*2* 9. insulin nph human recomb 100 unit/ml suspension sig: five (5) units subcutaneous qhs (at bedtime) for 1 doses. disp:*qs units* refills:*0* 10. insulin nph human recomb 100 unit/ml suspension sig: twenty (20) units subcutaneous at bedtime: please start after treatments tomorrow night . do not use this dose when not eating. disp:*qs units* refills:*2* 11. klonopin 1 mg tablet sig: three (3) tablet po twice a day. disp:*180 tablet(s)* refills:*2* 12. ativan 0.5 mg tablet sig: one (1) tablet po every four (4) hours as needed for anxiety. disp:*60 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: major depression hypoglycemic seizure . dmii htn discharge condition: afebrile, fs running in high normal range, stable to be discharged home. discharge instructions: 1. please return monday morning to receive your treatment with psychiatry as below. please call for your scheduled time. . 2. for preparations for tomorrow morning: (a) please take nph 5 units tonight, no regular insulin (b) do not take nph morning dose tomorrow. (c) nothing to eat past midnight. (d) take your klonopin 3mg dose tonight. (e) no morning medications prior to including klonopin. (f) have fingersticks checked in morning, and prior to , and give regular insulin based on sliding scale. . 3. please take your other medications as below. . 4. if develop lightheadedness, dizziness, sweating, chest pain, shortness of breath, confusion, or other symptoms, please call dr. (or dr. or report to the nearest er. followup instructions: provider: , clinic where: clinic date/time: 8:00 . provider: , md where: ra (/ complex) hmfp phone: date/time: 9:50 . provider: , md where: ra (/ complex) hmfp phone: date/time: 1:30 md Procedure: Non-invasive mechanical ventilation Electroencephalogram Other psychiatric drug therapy Diagnoses: Pure hypercholesterolemia Unspecified essential hypertension Other convulsions Loss of weight Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Major depressive affective disorder, recurrent episode, severe, without mention of psychotic behavior Long-term (current) use of insulin Insulins and antidiabetic agents causing adverse effects in therapeutic use Long-term (current) use of other medications Other diseases of pharynx, not elsewhere classified Unspecified sleep apnea Right bundle branch block Family history of psychiatric condition

the pt is a 24 y.o. f with esrd on hd, sle, malignant htn, history of svc syndrome, pres, recently discharged on after admission for abdominal pain, mssa bacteremia, paroxysmal hypertension and esrd line, presents with central crampy abdominal pain, chest discomfort, sob, htn to 230s. pt states that at around 11pm last night developed shortness of breath that felt as though someone was sitting on her chest. she states that she feels as though she cannot catch her breath. pt also describes chest discomfort which she states that she has not had before. she also has her chronic abdominal pain. she states that it comes and goes and is unchanged from her baseline. . in the ed, initial vitals: 98.9 4 100%ra. sbp as high as 241 recorded. she received labetalol 20 iv x 2 without improvement. she was given hydral 20 iv without improvement, so she was placed on a labetalol gtt @ 4 mg/min with improvement of sbp 220. she was given iv zofran, iv dilaudid, hydralazine 50mg po, labetolol 200mg po, labetolol 100mg iv x 3, levofloxacin 750mg iv, ceftriaxone 1g iv, vancomycin 1g iv, weregiven for question of infiltrate on cxr prior to ct. nitroprusside gtt added and .5 mg/kg, pressure initially improved to 180s. tried to wean off the nitroprusside and pressure went back up to 208. chest pain has resolved, still sob with abdominal pain. pan-scan w/o contrast showed interval worsening of chronic pulmonary edema. pleural and pericardial effusions stable. ativan seemed to help symptoms. one blood culture was sent in the ed. per report, ekg showed lvh, st depression in v6. trop a little more elevated than normal but cks flat. was discussed with renal and it was not felt that htn is a volume issue so no need for emergent . . upon arrival to the floor, her sbp was 203. she continued to complain of abdominal pain and shortness of breath though her chest discomfort was improved. respiratory rate up to 30. past medical history: 1. systemic lupus erythematosus: - diagnosed (16 years old) when she had swollen fingers, arm rash and arthralgias - previous treatment with cytoxan, cellcept; currently on prednisone - complicated by uveitis () and esrd () 2. ckd/esrd: - diagosed - initiated but refused it as of , has survived despite this - pd catheter placement 3. malignant hypertension - baseline bps 180's - 120's - history of hypertensive crisis with seizures - history of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with le paresis in that resolved 4. thrombocytopenia: - ttp (got plasmapheresisis) versus malignant htn 5. thrombotic events: - svc thrombosis (); related to a catheter - negative lupus anticoagulant (, , ) - negative anticardiolipin antibodies igg and igm x4 (-) - negative beta-2 glycoprotein antibody (, ) 6. hocm: last noted on echo 7. anemia 8. history of left eye enucleation for fungal infection 9. history of vaginal bleeding lasting 2 months s/p depoprovera injection requiring transfusion 10. history of coag negative staph bacteremia and hd line infection - and 11. thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. obstructive sleep apnea, autocpap/ pressure setting , straight cpap/ pressure setting 7 13. left abdominal wall hematoma 14. mssa bacteremia associated with hd line -, , getting vanc with hd. . pshx: 1. placement of multiple catheters including . 2. tonsillectomy. 3. left eye enucleation in . 4. pd catheter placement in . 5. s/p ex-lap for free air in abdomen, ex-lap normal social history: denies any substance abuse (etoh, tobacco, illicits). she lives with her mother. on disability for multiple medical problems. family history: no known autoimmune disease but there is a history of cardiovascular disease and cerebrovascular accident in her grandfather. physical exam: pe: 98.6 128/98 82 20 100% on 2l nc vitals gen- nad heent- mmm cv- regular, nl s1, s2, + s3. lungs- cta bilat abd- + bs, soft, nd. tender only to deep palpation ext- 2+ dp bilat. trace pedal edema neuro- aa+ox3. pertinent results: admission labs: 02:20am wbc-5.0 rbc-2.61* hgb-7.7* hct-23.5* mcv-90 mch-29.4 mchc-32.6 rdw-19.3* 02:20am neuts-76.1* bands-0 lymphs-17.9* monos-4.5 eos-1.1 basos-0.5 02:20am plt smr-normal plt count-168 02:20am pt-21.8* ptt-34.7 inr(pt)-2.1* 02:20am ctropnt-0.12* 02:20am alt(sgpt)-46* ast(sgot)-94* ck(cpk)-76 alk phos-173* tot bili-0.4 02:20am glucose-74 urea n-47* creat-7.3* sodium-140 potassium-5.8* chloride-109* total co2-19* anion gap-18 04:00am urine blood-tr nitrite-neg protein-100 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-8.0 leuk-neg 08:00am urine blood-sm nitrite-neg protein-500 glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-7.0 leuk-neg 12:58pm ck-mb-notdone ctropnt-0.12* . ct c/a/p - - 1. interval worsening of pulmonary edema, now moderate to severe. unchanged moderate pericardial effusion. periportal edema persists. 2. small right pleural effusion, unchanged. 3. small amount of ascites. 4. no evidence of bowel obstruction. contrast material reaches the rectum. 5. redemonstration of extensive mediastinal and hilar lymphadenopathy. the study and the report were reviewed by the staff radiologist. discharge labs: 12:00pm blood wbc-3.7* rbc-2.87* hgb-8.7* hct-26.1* mcv-91 mch-30.3 mchc-33.3 rdw-19.4* plt ct-130* 12:00pm blood plt ct-130* 12:00pm blood pt-28.8* ptt-58.6* inr(pt)-2.9* 12:00pm blood glucose-77 urean-31* creat-6.0*# na-137 k-4.8 cl-104 hco3-24 angap-14 12:00pm blood calcium-8.4 phos-5.7* mg-1.9 brief hospital course: this is a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. . # hypertension: the patient had very high blood pressures on presentation (200's/100's) that nevertheless are within levels she's certainly reached during previous admissions. initial attempts were made to control her bp with hydralazine and labetalol iv but after these failed to control her blood pressure, she was started on a labetalol and nitroprusside drip and admitted to the icu. this was then changed to a nicardipine drip. she was successfully transitioned to home medications of clonidine, labetalol, aliskiren, nifedipine and hydralazine on and transferred to the medicine floor. the next day, her bp remained within goal of 120's/80's. she was dialyzed and sent home. . tachypnea/shortness of breath - on admission, likely due to pulmonary edema, however, cannot rule out cardiac etiology in setting of small enzyme leak. has osa. ce's were cycled and were negative. cpap was continued as tolerated at home settings. sob resolved after hd on . # abdominal pain: consistent with patient's baseline chronic abdominal pain. medication effect also possible. ct prelim neg for small bowel obstruction. lfts doubled from . on arrival to the floor, abd pain was back to baseline and well controlled on dilaudid 2mg po q 4hrs . # esrd: renal followed. hd given and . # coagulopathy: patient on lifetime anticoagulation for hx of multiple thrombotic events. continued coumadin . # hocm: evidence of myocardial hypertrophy on echo. currently not symptomatic. continued labetalol. medications on admission: 1. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 2. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 4. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4pm. 5. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 6. hydralazine 50 mg tablet sig: two (2) tablet po tid (3 times a day). 7. labetalol 200 mg tablet sig: 4.5 tablets po tid (3 times a day). 8. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 9. aliskiren 150 mg tablet sig: one (1) tablet po bid 10. hydromorphone 2 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for abdominal pain. 11. acetaminophen 325 mg tablet sig: 1-2 tablets po q6h (every 6 hours) as needed. 12. citalopram 20 mg tablet sig: one (1) tablet po daily 13. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po three times a day as needed for nausea for 4 days. 14. vancomycin at hd discharge medications: 1. clonidine 0.1 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 2. clonidine 0.3 mg/24 hr patch weekly sig: one (1) patch weekly transdermal qwed (every wednesday). 3. prednisone 1 mg tablet sig: four (4) tablet po daily (daily). 4. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 5. warfarin 1 mg tablet sig: three (3) tablet po once daily at 4 pm. 6. aliskiren 150 mg tablet sig: one (1) tablet po bid () as needed for severe htn. 7. citalopram 20 mg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*2* 8. nifedipine 90 mg tablet sustained release sig: one (1) tablet sustained release po daily (daily). 9. ondansetron 4 mg tablet, rapid dissolve sig: one (1) tablet, rapid dissolve po q8h (every 8 hours) as needed. 10. labetalol 200 mg tablet sig: 4.5 tablets po tid (3 times a day). 11. hydralazine 50 mg tablet sig: two (2) tablet po tid (3 times a day). discharge disposition: home discharge diagnosis: sle esrd on hd malignant hypertension chronic abdominal pain discharge condition: good. tolerating pos. bp 110's/80's discharge instructions: you were admitted with hypertension and abdominal pain. while you were here, we treated your hypertension with medications and dialyzed you. your hypertension is resolved at the time of discharge. your belly pain partially resolved and at time of discharge is comparable to your chronic belly pain. . please follow up as below. . please continue your medications as prescribed. . please call your doctor or return to the ed if you have any headaches, lightheadedness, changes in vision, vomitting, blood in your stool, loss of consciousness or any other concerning symptoms. followup instructions: please follow up with your primary care doctor within 1 week. you need to schedule an appointment with either your pcp or ob/gyn for a pap smear as soon as possible. you should also get a repeat urinalysis and urine culture if you have any uti symptoms. . please continue sessions as directed by the nephrology team- your next session should be on tuesday. Procedure: Hemodialysis Non-invasive mechanical ventilation Transfusion of packed cells Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Chronic glomerulonephritis in diseases classified elsewhere Other primary cardiomyopathies Acidosis Systemic lupus erythematosus Hyperpotassemia Thrombocytopenia, unspecified Anemia in chronic kidney disease End stage renal disease Obstructive sleep apnea (adult)(pediatric) Other chronic pain Abdominal pain, unspecified site Urinary tract infection, site not specified Unspecified disease of pericardium Bacteremia Compression of vein Long-term (current) use of anticoagulants Other chest pain Personal history of venous thrombosis and embolism Noncompliance with renal dialysis Infection and inflammatory reaction due to other vascular device, implant, and graft Primary hypercoagulable state Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus] Kidney dialysis as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site

allergies: penicillins / percocet / morphine attending: chief complaint: altered mental status, solmolence, and relative hypotension major surgical or invasive procedure: none, hd per schedule on the day of discharge, transfused 1u prbc

the patient is a 69 year old female with no significant past medical history who presented to hospital with acute onset of respiratory distress. the patient had been noticing an enlarging neck mass for the past three to four years. as hospital notes, the patient noticed increasing phlegm production two days prior to admission and increasing shortness of breath. she was being evaluated by otorhinolaryngology as an outpatient and sent to hospital for head/neck/chest computerized tomography scan. while in the waiting room the patient had an acute onset of respiratory distress requiring intubation and was admitted to the hospital intensive care unit. because the outside hospital was unable to provide radiation, the patient was transferred to the . 100 cc of necrotic material was aspirated from the left neck mass which by report is consistent with squamous cell carcinoma. computerized tomography scan of the neck/chest revealed a 7 by 7 cm left-sided neck mass with deviation of the trachea to the right and compression of the trachea around the endotracheal tube. no obvious tumor was seen in the chest computerized tomography scan. past medical history: none. allergies: no known drug allergies. medications: medications as an outpatient, none. medications on transfer were heparin subcutaneously, morphine and ativan prn. family history: non-contributory social history: the patient lives with one son and her grandson. she quit tobacco 30 years ago and smoked less than half a pack per day for a few years. she denies alcohol use. she works at and was working prior to her otorhinolaryngology visit. before that she worked for 14 years at a stride-rite factory gluing soles to bottom of shoes. laboratory data: laboratory studies at an outside hospital revealed sodium 138, potassium 3.9, chloride 101, bicarbonate 31, bun 7, creatinine .8, glucose 128, white blood cell count 8.2, hematocrit 32.9, platelets 300, ldh 228. arterial blood gases, pressor support ventilation of 10 and 5 is 7.54, 27, and greater than 250. physical examination: on physical examination vital signs were 100.2, heartrate 98, blood pressure 141/93, respiratory rate 14 and oxygen saturations 100%. in general the patient is an elderly female in no apparent distress, awake, and answering questions. head, eyes, ears, nose and throat, extraocular muscles intact. pupils, equal and reactive to light and accommodation. large left-sided neck mass, nontender, approximately 8 by 8 cm. small 1 cm area of ecchymosis around the biopsy site. heart, normal s1 and s2, no murmurs, rubs or gallops. lungs clear to auscultation bilaterally. abdomen obese, soft, nontender, positive bowel sounds. extremities, no cyanosis, clubbing or edema. radiographs: chest x-ray from outside hospital, large left neck mass with questionable mediastinal lymphadenopathy, endotracheal tube at carina. chest computerized tomography scan without contrast, large neck mass, 7 by 7 in diameter, left trachea shifted to right, trachea compressed around endotracheal tube. computerized tomography scan of chest revealed multiple anterior mediastinal lymph nodes and para-aortic tracheal compression with deviation to the right, no parenchymal lung lesions are seen, small left pleural effusion. hospital course: this is a 69 year old female with left-sided neck mass consistent with squamous cell carcinoma, most likely of esophageal origin, causing airway compromise, intubated for airway protection. 1. left-sided neck mass - on arrival to , the patient was evaluated by radiation medical oncology and otorhinolaryngology. it was felt given the size of the mass that extubation could not be done safely without further securing the airway. the patient had a computerized tomography scan of the neck and chest with contrast and an magnetic resonance imaging scan of the chest which revealed the following. computerized tomography scan of the head revealed no evidence of intracranial metastatic disease. computerized tomography scan of the chest showed a large neck mass which tracks along the posterior wall of the trachea into the thoracic inlet, measuring 7 by 11 cm, multiple enlarged mediastinal lymph nodes and a small lower thoracic vertebral body hemangioma. the magnetic resonance imaging scan of the neck with gadolinium showed redemonstration of an enormous neck mass with probable infiltration in the region of the left carotid sheath and other signs of spread. in light of these findings, the patient was scheduled for operating room placement of a tracheostomy. the patient was sent to the operating room on , hospital day #9. in the operating room the procedure was noted to be very difficult and a tracheoesophageal fistula was found. the patient's trachea was dissected to the fifth tracheal ring and an endotracheal tube was placed instead of a stable tracheostomy tube, given the difficulty of the procedure. on hospital day #10, the patient had an open gastrostomy tube placed and a port-a-cath placed by general surgery. a panendoscopy was done at the time of her tracheostomy placement on hospital day #10 which showed diffuse tumor in both the trachea and the esophagus. multiple biopsies were done of the esophagus and it was felt at this time that the tumor was originating from the cervical esophagus, although this could not be definitely confirmed. on the day after gastrostomy tube and port-a-cath placement, extensive discussions were taken with the family. interventional pulmonology was consulted for possible stenting of the esophageal tracheal fistula, however, given the location it was felt that no stent could be placed in either the esophagus or the trachea at this time. given the poor prognosis with the extent of disease, complicated by the tracheoesophageal fistula, the decision on whether to pursue radiation and chemotherapy was in question. the patient met with both radiation oncology and medical oncology and was told about the risks and benefits of treatment. given the fistula, it was thought that radiation and chemotherapy, while possibly able to provide some local control of tumor extension, would only worsen the fistula and cause neutropenia increasing infection risk. the patient decided that she wanted to not pursue chemotherapy and radiation therapy and would want to go home with home hospice care. the patient was also made do-not-resuscitate at this time. given the unusual nature of the patient's tracheostomy tube, a customized tracheostomy was ordered and is currently enroute to the hospital. the patient is to have a more permanent airway placed on wednesday, . if the patient is able to tolerate the patient and her airway remains stable, she should be able to be discharged home with maximal home services. during this hospitalization palliative care was consulted to aid in placement and home services. they are currently following the patient and have already provided some possible resources for the patient. 2. tracheobronchitis - on hospital day #2 the patient had a bronchoscopy to evaluate for any intrinsic compression of airways by the neck mass. airways appeared patent below the endotracheal tube, however, numerous secretions were seen. bal later grew out staphylococcus aureus which was pansensitive. the patient completed a ten-day course of levaquin and clindamycin which was later added after the tracheal esophageal fistula was found. currently, the patient has occasional secretions and lowgrade temperatures, however, secretions overall have decreased this admission and the patient's cough has not increased. we will try to observe the patient off of antibiotics but anticipate that she may continue to have lowgrade fevers due to her tracheoesophageal fistula and extent of tumor burden. 3. urinary tract infection - the patient had an urinary tract infection during this admission which was escherichia coli pansensitive. the patient was treated with levaquin, and subsequent cultures have remained negative. the foley catheter was discontinued on hospital day #19. 4. thrush - it was noted that the patient has several plaques on her tongue and was started on nystatin swish and swallow which will have to continue while at home. 5. constipation - it was noted that the patient had multiple episodes of constipation in the setting of roxicet narcotic use for incisional pain. this has resolved with an adequate bowel regimen. 6. physical therapy - the patient was evaluated by physical therapy who felt that the patient may be able to be discharged home with maximal services. the patient has been ambulating without complications. 7. respiratory status - the patient was initially on vent support, however, this was slowly weaned during her hospital course and she is currently on a t-piece 24 hours a day without any necessary vent support. she should be able to go home with a similar apparatus. she no longer needs any vent support. 8. tubes, lines and drains - the patient has had her foley catheter discontinued. she has a port-a-cath which has been deaccessed and has a percutaneous endoscopic gastrostomy tube. she is currently receiving tube feeds 24 hours a day at 60 cc/hr. 9. code status - the patient is currently do-not-resuscitate. discharge diagnosis: 1. stage 4 cervical esophageal cancer 2. airway compromise, status post tracheostomy 3. tracheobronchitis 4. urinary tract infection 5. thrush 6. constipation an addendum will be added to this dictation summary with the rest of the hospital course. this dictation cover the timeframe from to . disposition will be determined at a later date. the patient will follow up with her primary care physician, . who is . dr., 12-981 dictated by: medquist36 Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Enteral infusion of concentrated nutritional substances Other permanent tracheostomy Temporary tracheostomy Closed [endoscopic] biopsy of bronchus Bronchoscopy through artificial stoma Insertion of totally implantable vascular access device [VAD] Other gastrostomy Aspiration of other soft tissue Aspiration of other soft tissue Diagnoses: Urinary tract infection, site not specified Other pulmonary insufficiency, not elsewhere classified Candidiasis of mouth Other constipation Acute bronchitis Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes Malignant neoplasm of other specified part of esophagus Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck Tracheoesophageal fistula

past medical history: 1. coronary artery disease, status post catheterization in with diffuse lad disease. the patient had a normal p mibi in . 2. history of left bundle branch block. 3. history of noninsulin-dependent diabetes mellitus. 4. hypertension. 5. anemia secondary to mgus. 6. status post left carotid endarterectomy. 7. history of zoster. allergies: the patient has no known drug allergies. medications on admission: 1. aspirin 325 mg p.o. q.d. 2. atenolol 50 mg p.o. q.d. 3. lasix 80 mg p.o. q.d. 4. mavik 16 mg p.o. q.d. 5. metformin 500 mg p.o. b.i.d. 6. norvasc 10 mg p.o. q.d. 7. iron 325 mg p.o. q.d. social history: the patient quit smoking approximately 25 years ago. she denied alcohol use. she lives alone. she served as a waitress for 52 years. physical examination on admission: in general, the patient was comfortable in no acute distress. heent examination revealed that the oropharynx was clear with moist mucous membranes. neck: jvp went to the level of approximately 10 cm. the neck was supple. chest: rales at both bases were noted. heart: regular rate and rhythm with normal s1, s2 with no appreciable murmurs. abdomen: soft, nontender, nondistended, guaiac negative in the emergency department. extremities: trace pedal edema with 1+ dp pulses. laboratories on admission: white count 6.5, hematocrit 28.8, platelets 253,000. chem-7 on admission revealed a sodium of 135, potassium 5.0, bun 37, creatinine 1.4, glucose 145, magnesium 2.2. pt 12.5, inr 1.1, ptt 30.2. the ekg was normal sinus rhythm with left bundle branch block. chest x-ray was notable for mild chf. hospital course: the patient is a 73-year-old with known coronary artery disease, left bundle branch block, presenting with chest pain. the patient's presentation was concerning for acute coronary syndrome and her admission ekg had an old left bundle branch block with no significant change from a prior ekg. the patient was treated for acute coronary syndrome with aspirin, nitro drip, heparin drip, as well as aggrastat. she had cardiac enzymes cycled which had negative ck and troponin. the patient was ruled out for myocardial infarction with enzymes. she went to cardiac cath where right heart catheterization revealed hemodynamics with a right atrium pressure of 15, pulmonary artery pressure of 62/28 with a mean of 43, and pulmonary capillary wedge pressure of 19. a wave 29 with v of 22. the patient's cardiac output by fick was 5.09 liters per minute. given the patient's renal labs at that point revealing a creatinine of approximately 1.6 and the patient's hematocrit was 28.7, it was decided to admit the patient to the ccu briefly for blood transfusion, hydration, and acetylcysteine treatment. the patient received a total of 2 units of packed red blood cells during this admission. her hematocrit on admission was 28.8 and had increased to 32.2 after 2 units of the packed red blood cells. after the patient's prehydration and blood transfusion, she underwent cardiac catheterization. the cardiac catheterization showed three vessel coronary artery disease. the lmca had a distal 40% stenosis which involved the origins of the lad and lcx, lad had moderate disease throughout which was more severe in the middle with a maximal stenosis of 50-60%. the circumflex had a 50% stenosis. the catheterization was also notable for moderate diastolic biventricular dysfunction as well as severe pulmonary hypertension. after the catheterization, the patient was transferred back to the cardiac medicine floor where she had an echocardiogram which showed the left atrium to be mildly dilated with mild metric lv hypertrophy. there was mild lv systolic dysfunction with mild hypokinesis of the anterior septum. the rv was normal size with normal free wall motion. regarding the patient's catheterization, it was felt that the patient should continue her current medical management and in addition imdur 30 mg p.o. q.d. was added to her regimen. discharge condition: good. discharge status: the patient is to be discharged to home. discharge diagnosis: 1. status post cardiac catheterization and history of coronary artery disease. 2. history of noninsulin-dependent diabetes mellitus. 3. history of anemia. discharge medications: 1. mavik 16 mg p.o. q.d. 2. imdur 30 mg p.o. q.d. 3. lasix 80 mg p.o. q.d. 4. protonix 40 mg p.o. q.d. 5. iron 325 mg p.o. t.i.d. 6. metoprolol 50 mg p.o. q.d. 7. aspirin 325 mg p.o. q.d. 8. sublingual nitroglycerin p.r.n. 9. norvasc 10 mg p.o. q.d. 10. metformin 500 mg p.o. b.i.d. follow-up: the patient is to follow-up with her cardiologist, dr. , in two weeks. , m.d. dictated by: medquist36 Procedure: Combined right and left heart cardiac catheterization Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Diagnoses: Anemia, unspecified Coronary atherosclerosis of native coronary artery Intermediate coronary syndrome Unspecified essential hypertension Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Other chronic pulmonary heart diseases Unspecified disorder of kidney and ureter Heart disease, unspecified

discharge status: the patient was to be discharged to the tippete house. medications on discharge: 1. morphine 5 ml t0 10 ml of a 10-mg/5 ml solution by mouth q.4h. as needed (for discomfort). 2. ativan 0.5 mg by mouth q.4-6h. as needed (for anxiety). discharge instructions/followup: none. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Diagnoses: Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Acute respiratory failure Septic shock Malignant neoplasm of other parts of bronchus or lung Encounter for palliative care Pneumococcal septicemia [Streptococcus pneumoniae septicemia] Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]

mrs. is a 62-year-old female with a complicated medical history including sarcoidosis, hepatic cirrhosis, grade ii esophageal varices, hypertension, multiple orthopaedic procedures to her left hip, right hip and right knee, who presented with left thigh recently admitted to surgery for ventral hernia repair, which had caused an ileus and ascites, which required two - drains. these drains were recently removed. the patient developed abdominal pain and diarrhea soon after. the patient also developed left thigh pain. the patient reported that the pain worsened to the point where she was unable to weight bear. she denied any nausea, vomiting, chills, feeling cold, and lightheadedness. this prompted her to present to the emergency department. in the emergency department, the patient was found to be hypotensive, with blood pressure 80/palpation, the heart rate in the 160s. her white blood cell count was noted to be 30, with 26% bandemia, and the patient was found to also be in acute renal failure with a creatinine up to 3.0. she was also hyperkalemic, acidotic, with an anion gap of 14. per the emergency department record, the patient appeared to have received 1 gram of vancomycin, 100 mg of hydrocortisone, 10 units of regular insulin, 1 amp of dextrose, and 2 mg of intravenous dilaudid. she was transferred to the medical intensive care unit on the . on arrival to the medical intensive care unit, the patient was found to be lethargic, with pinpoint pupils secondary to dilaudid. an amp of narcan was given, with improvement of mental status. on review of systems, the patient complains of exquisite pain in her left thigh, with decreased range of motion of her knee. past medical history: 1. sarcoidosis diagnosed in , with pulmonary and hepatic involvement, on chronic steroids 2. status post ventral hernia repair on 3. history of cirrhosis diagnosed by ct in with grade ii varices 4. status post right total hip replacement and right total knee replacement 5. status post open reduction and internal fixation of her left hip 6. osteoporosis 7. hypertension 8. choledocholithiasis 9. hypercholesterolemia 10. aortic stenosis with ejection fraction of 55% 11. status post total abdominal hysterectomy and bilateral salpingo-oophorectomy medications on admission: lasix 20 mg by mouth once daily, aldactone 15 mg twice a day, actigall 300 mg three times a day, protonix 40 mg by mouth once daily, prednisone 10 mg by mouth twice a day, aleve 220 mg by mouth twice a day. social history: the patient is divorced. she lives with her daughter. physical examination: on arrival to the medical intensive care unit, the patient's temperature was 99.2, blood pressure 120/84, heart rate 117, respiratory rate 12, oxygen saturation 96% on room air, and her weight was 70 kg. general examination revealed a lethargic patient, who became alert and oriented x 3 after narcan administration. she was not in any acute distress. head, eyes, ears, nose and throat examination revealed cataracts, normal mucous membranes. pupils went from 1 mm to 3 mm after narcan administration. neck examination revealed no jugular venous distention. cardiovascular examination revealed that the patient was tachycardic, with normal s1 and s2, and iii/vi systolic ejection murmur at right upper sternal border. this murmur radiates to the carotids and apex. she had no s3 and no s4. lung examination revealed lungs clear to auscultation bilaterally, with no wheezes or crackles. abdominal examination revealed a soft abdomen with decreased bowel sounds. the patient had a well-healed surgical scar with a scab in the subumbilical abdominal area. the patient was mildly tender on palpation of the middle of her abdomen. extremity examination revealed trace bilateral lower extremity edema, tenderness and warmth along her left lateral thigh. there was no induration or erythema. neurologic examination: the patient was able to move all of her toes and her ankles. she was unable to bend her left knee to full flexion secondary to pain. she was otherwise alert and oriented x 3. laboratory data: on admission, hematocrit 41.2, white count 29, and platelet count of 367. her serum chemistry revealed a sodium of 137, potassium 4.9, chloride 107, bicarbonate 16, bun 83, creatinine 2.9, glucose 78. anion gap was 14. on her initial blood work, her white count differential revealed 69% neutrophils and 26% bands. coagulation studies revealed an inr of 1.4. her esr was 87. liver studies revealed an alt of 9, ast of 30, total bilirubin of 2.9, ck of 20, calcium of 8.2, magnesium of 2.1, and phosphate of 5.6. her electrocardiogram revealed sinus tachycardia. her chest x-ray revealed no effusion, no pneumonia, and no pneumothorax. there was minimal increased interstitial opacity, questionable atelectasis, in the lower lung bases. her ultrasound of her left thigh revealed a small fluid collection in the left lateral thigh. hospital course: after being found hypotensive with hyperkalemia, the patient was treated with intravenous fluids and insulin and d-50, as well as hydrocortisone for stress dose steroids. the patient's left thigh was evaluated by ultrasound, which showed a fluid collection suspicious for an abscess. this fluid collection was aspirated by orthopaedic consultation team. the patient received a total of 12 liters of normal saline within 24 hours' time prior to producing any urine output. the patient was also started empirically on clindamycin for antibiotic coverage. surgery was consulted to evaluate the possibility of fasciitis in her left thigh. they recommended ultrasound-guided tap aspirate of the left thigh fluid collection, which on gram stain showed 4+ polymorhoneucleocytes. the patient's hypotension resolved with aggressive intravenous fluid hydration and a brief course of pressors. her acute renal failure also appeared to improve after she was aggressively hydrated. the nephrolog was consulted. her hyperkalemia began to resolved after insulin and d-50 treatments. the patient's initial tachycardia on admission resolved after intravenous fluid hydration. in terms of the patient's leukocytosis, the suspicion was that this is a reaction to the abscess in her left thigh. an mri of her left thigh was obtained on . on this mri, the patient was found to have a discrete fluid collection in the subcutaneous tissue of the anterior abdominal wall measuring 16 x 20 x 3 cm. it extends from above the umbilicus to the pubic symphysis, and is predominantly on the left side of the abdomen. the source of this fluid was not entirely clear on this mri. orthopedics thought this unlikely to involve her hip prosthesis. the patient was also found to have extensive subcutaneous edema and small fluid collections in her left thigh. she was found to not have any significant fluid within her left hip joint. at this time, the patient was on clindamycin and vancomycin as her antibiotic coverage. the patient also received a right internal jugular centrally-placed catheter on , for access. on this date, the patient had continual hypotension requiring aggressive fluid hydration, and also low-dose dopamine to be added via her central catheter. her blood culture on this date was found to have staphylococcus bacteremia. she underwent a transthoracic echocardiogram, which did not show any vegetations. on this date, the initial fluid aspirate from her left thigh also grew out coagulase positive staphylococcus aureus. the patient's hypotension was improved and was able to be weaned off dopamine on . on this date, she was also started on fluconazole for yeast in her urine. infectious diseases was consulted on . they recommended tapping of the patient's abdominal fluid collection, which was found on the mri study of her left thigh and abdomen. however, at the same time, the surgical consultants felt strongly that this fluid should not be tapped due to potential for infecting it, and a potential connection with the patient's abdominal cavity, especially in the setting of known ascites. this fluid collection therefore was not tapped on this date. the patient continued to improve. on , the patient was no longer requiring pressor support, and her creatinine had decreased to 2.0. she was no longer febrile. the patient's final cultures came back as methicillin-sensitive staphylococcus aureus in her blood obtained on . she also grew methicillin-sensitive staphylococcus aureus at the aspirate of one fluid collection in her left thigh. in the same culture, she also grew some bacillus species. on , the patient was found to have a positive urine culture growing klebsiella pneumoniae. she was started on levofloxacin by mouth for this infection. her foley catheter was removed on this date. she was also started on prednisone for her sarcoidosis. by this time, the patient's white blood cell count had decreased to 19.4. her serum creatinine had decreased to 1.9. as the patient has had stable blood pressure up until now, and has had peripheral edema due to saline resuscitation, the patient received a low-dose diuretic, and her urine output increased. on the early morning of , the patient was called out of the intensive care unit and transferred to the floor. by this time, her serum creatinine was down at 1.4. her blood pressure has been stable. she is no longer tachycardic. her methicillin-sensitive staphylococcus aureus bacteremia and left thigh abscess have been treated by continuing dosages of vancomycin, and the left thigh aspiration. her left thigh pain was much improved at this time, with no requirement of narcotics for pain control. after arrival to the floor, the patient received a picc line placement in the morning of . her right internal jugular vein central catheter was therefore removed. the patient was continued on her levofloxacin and vancomycin. the plan at this time was to further treat the patient's infections, stabilize her, diurese her, and have physiotherapist screen her, with eventual plans to discharge her to a rehabilitation center. with regards to the patient's methicillin-sensitive staphylococcus aureus bacteremia, the patient was determined to be too high risk to receive a transesophageal echocardiogram for further evaluation of her valves. this is because she has known grade ii varices in her esophagus. after much discussion with the infectious disease team and the patient's primary doctor, dr. , it was determined that the patient should be treated for a total course of eight weeks with vancomycin. this is because she is thought to be high risk for seeding her known stenosed aortic valve. the patient did very well on the floor between and 29. she was diuresed with initially 20 mg of lasix by mouth, with minimal effects. she received intravenous lasix after that, with better responses. the patient was still generally edematous, especially in her legs. she had not been able to ambulate because of her gross lower extremity edema. her renal failure was completely resolved by this time. her baseline creatinine of 0.7 was reached on . her white blood cell count was also noted to be decreasing. into the morning of , the patient was noted to be tachycardic up to 118 to 120s. this was thought to be from intravascular volume depletion due to aggressive diuresis. the patient received a trial of 250 cc of saline bolus, and her heart rate decreased from 120 to 108. this was thought to be a positive test result for her intravascular volume status. her lasix was therefore discontinued. by the next morning, the patient's tachycardia had resolved, and her heart rate ranged between 80s to 100s. however, on the same day, the patient noted new onset left thigh tenderness. this was concerning for reaccumulation of fluids or reappearance of her left thigh abscess. the patient was afebrile on this date. given the concerning symptoms, another ultrasound of her left lower extremity was obtained. on this ultrasound, the patient was again found to have hypoechoic fluid collection tracking along her left lateral thigh. this collection measures 3.2 cm in the largest ap diameter, and was thought to be more than 10 cm in length. after discussion with surgery and orthopaedics, it was determined that this fluid collection needed to be drained, with the placement of a pigtail catheter. this was done on the morning of , without complications. the patient had purulent fluids drained from her left thigh fluid collection. this fluid was sent for cell count and culture. the patient also received a chest x-ray on this date for crackles noted on physical examination. on the chest x-ray, the patient had no evidence of pneumonia. the patient was thought to have low-grade atelectasis, and was encouraged to take deeper breaths in. the patient has been using an incentive spirometer ever since admission to the intensive care unit. on the morning of , the patient experienced an episode of spontaneous drainage of most likely the subcutaneous fluid collection seen on mri in her abdomen. per patient's report, she stood up to go to the commode, and all of a sudden she felt gushing fluid coming from her abdomen. the scab in her subumbilical region apparently lifted and clear fluid drained out in copious amounts. the scab was later on covered with dry dressing. the patient did require frequent dressing change, and had persistent leakage of clear-looking fluid from this site. the surgery service was notified of this event. they recommended dry dressings frequently. they were not concerned that this fluid could be infected fluid. due to the physical characteristics of the fluid drained from the patient's left thigh fluid collection, she was started on levofloxacin by mouth for broadening antibiotic coverage until this fluid culture returns. the concern here is multiorganism infection which was not covered by vancomycin. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Incision of abdominal wall Excisional debridement of wound, infection, or burn Other incision with drainage of skin and subcutaneous tissue Diagnoses: Acidosis Other postoperative infection Urinary tract infection, site not specified Acute kidney failure, unspecified Mitral valve insufficiency and aortic valve insufficiency Methicillin susceptible Staphylococcus aureus septicemia Pulmonary collapse Cellulitis and abscess of leg, except foot Seroma complicating a procedure

this is a 63 year-old female with a history of prednisone dependent sarcoid, cirrhosis, ascites with sbp who presented with one day of nausea, vomiting, diarrhea and change in mental status. she was discharged to nursing home on after admission for back pain. she has had multiple admissions including three day admissions for compression fracture of the spine, which was complicated by pneumonia and ascites with a 7 liter tap. she also had azotemia and hypophosphatemia as well as urinary tract infection, right tibia fibula fracture and that admission date was from until . the patient was doing well at nursing home, eating well and comfortable one night prior to admission when this morning had nausea, vomiting and diarrhea, initially presented to and was transferred to . she received enema twice yesterday and had diarrhea since then. in the emergency department her vital status was heart rate 120, blood pressure 100/68, respirations 18, and then she became hypotensive. her blood pressure dropped down to the 80s. her regular blood pressure ranging between 90s to 110. she was given phenergan and her abdominal x-ray was concerning for obstruction. we recommended to have an abdominal ct, but the patient did not tolerate ng tube placement. her blood culture was sent and we also gave her 1 liter of normal saline. she was seen by surgery who recommended broad spectrum antibiotics. ct scan was later done without any contrast. past medical history: cirrhosis, sarcoid, osteoporosis, hyperlipidemia, hypertension, portal hypertension, thrombocytopenia, esophageal varices and aortic stenosis. past surgical history: total abdominal hysterectomy, total right hip placement. allergies: she has multiple allergies including penicillin, oxacillin, percocet, keflex, intravenous iodine, oxycontin, flagyl, and codeine. social history: the patient is divorced with many children. she currently lives with children prior to being at rehabilitation. she denies tobacco and alcohol. laboratory: ascites fluid white blood cell is , red blood cell equal to 7700, poly 95%, band 1%. urinalysis large amount of blood, positive nitrites, moderate leukocytes, few bacteria. ct of the abdomen with intravenous contrast, there is extensive ascites with severely shrunken nodular cirrhotic liver. the pancrease is atrophic. there is a diffused wall thickening of the colon as well as several loops of small bowel. this is not evident on the previous examination. extensive vascular calcifications are again noted, however, in the interval there has been development of extensive clot within the smv. no free air or pneumoptosis is identified. hospital course: 1. smv/thrombosis: ct of the abdomen on the 4th, showed diffuse thickening of loops of large and small bowel in the setting of extensive clots within smv. these findings are concerning for venous ischemia. also showing clots within the protal venous confluents as previous ct scan . heparin was started. repeated abdominal ct on shows no growth change in the clots within the smv and portal venous confluence. heparin therapy continues. 2. respiratory: the patient's respiratory deteriorated since admission, became progressively labored and tachypneic. chest x-ray shows lung volumes are extremely low due to massive ascites pushing up on diaphragm. ct showed atelectasis at the lung bases. on the patient's respiratory status worsened with mental status change. arterial blood gas showed 7.09/68/78. the patient's proxy did not wish to intubate the patient. therapeutic paracentesis was done to remove 6 liters of fluid. the patient received three bags of albumin, however, still developed hypotensive episodes and became unresponsive afterwards. 3. cirrhosis: the patient had end stage renal disease with cirrhosis and massive ascites. the patient received albumin 75 grams on and another 50 grams on . (per liver consult suggestion to decrease motility in people with ascites). 4. infectious disease: paracentesis on showed white blood cell of more then 5000 and gram negative rods, which was later identified to be pseudomonal and urinalysis was consistent with urinary tract infection. the patient was initially put on vancomycin and cipro, but later changed to flagyl and aztreonam per id consult suggestion. 5. code: the patient was initially on full code, however, on after taping the patient had a discussion with the patient's proxy and family members and decision was made to keep the patient on comfort measures only. o line was discontinued and medications stopped except for morphine drips to keep the patient pain free. the patient expired on the evening of at 7:30 p.m. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Percutaneous abdominal drainage Diagnoses: Urinary tract infection, site not specified Cirrhosis of liver without mention of alcohol Aortic valve disorders Sarcoidosis Other shock without mention of trauma Acute vascular insufficiency of intestine Infection and inflammatory reaction due to indwelling urinary catheter

allergies: penicillins / codeine attending: chief complaint: hematemesis major surgical or invasive procedure: - egd - tips angioplasty and embolization of varices

46 yo f w/ etoh/hcv cirrhosis, grade 1 varices and portal gastropathy who presented to the ed yesterday with 1 episode of hematemesis on , which the patient describes as "dark clots...just old blood". she subsequently left ama and returned the next day with melena x 1. of note, pt was recently admitted in with hematemesis and melena and admitted to the micu due to hypotension to sbp 70s. at that time she was treated with ng lavage, ffp, vitamin k, levofloxacin 500, octreotide, ppi and fluid resucitation along large volume blood transfusions (9 units). her course was complicated by hypoxia and fluid overload. she is s/p tips in and since that time has been doing relatively well. the patient denies the use of nsaids, anti-coagulants, iron supplementation or pepto bismol. past medical history: cirrhosis -heavy etoh abuse, +hcv (viral load undetectable), c/b coagulopathy/thrombocytopenia, elevated portal pressures with varices and portal gastropathy s/p tips -celiac sprue dx on bx egd however not on diet since has no symptoms according to patient -chronic le neuropathy -diastolic chf a. last echo in , pasp 28, ef >55% b. ett/mibi: , no ischemic regions -anemia: baseline hct ~30, chronic blood loss, ?sprue -asthma -depression -osteopenia -hypothyroidism -s/p ccy -tah for endometrial hyperplasia social history: lives with husband and 29 y.o son. heavy etoh abuse in the past, last drink long time ago according to patient. hx of +screens here in the past, tobacco 1 ppd x 30 years. no ivdu. family history: father died of mi in 80's. many alcoholics in family. one cousin with celiac sprue. physical exam: vs: 98.4 102/53 92 20 99% ra gen: looks older than stated age, very aggressive personality but answers questions appropriately, nad heent: perrla, eomi, no icterus, dry mm, telangiectasias on face, poor dentition, neck supple cv: rrr no m/r/g lungs: ctab on anterior exam abd: soft, nt, nd, +bs, trace of liver edge beneath costal margin, no rebound or guarding ext: no edema, warm, dry skin, tender to touch skin: + spider angiomata neuro: no gross deficits pertinent results: serum tox negative hct 31 inr 1.9 plts 83 recent imaging: ekg : sr at 93 bpm, nl axis, qtc slightly prolonged at 450 ms, twi v1-3 u/s: patent tips stent with no significant change in velocities of flow compared to . egd : varices at the lower third of the esophagus erythema and congestion in the stomach body and fundus compatible with moderate portal gastropathy varices at the second part of the duodenum no gastric varices tips 1. successful placement of a transjugular intrahepatic portosystemic shunt using three 10-mm bare metallic wallstents extending from a right portal vein to the right hepatic vein. 2. slightly unusual hepatic venous anatomy identified with two separate right hepatic veins which were small in caliber. 3. gradient between the portal vein and ivc pre-tips placement was 13 mmhg. post- tips placement the gradient was 9 mmhg. egd: grade i varices at the lower third of the esophagus grade 1 esophagitis in the gastroesophageal junction portal gastropathy duodenitis in the proximal bulb large duodenal varix brief hospital course: blood loss anemia/gi bleeding: pt was transferred from floor to micu after an episode of hematemesis and melena. after transfer to micu, patient was followed closely by transplant hepatology. pt was s/p tips placement by ir on - pt now returns with duodenal bleeding and had an egd with cauterization. hepatic venogram performed on revealed a probable umbilical varix, which was embolized with multiple coils. pressure gradients across the tips were about 10 mmhg before and after angioplasty of proximal portion. pt's blood count remained stable and patient was discharged to home from the micu. medications on admission: - gabapentin 900 mg po q8h - levothyroxine 50 mcg po daily - albuterol 1-2 puffs inhalation q6h as needed. - levofloxacin 500 mg tablet po daily for sbp ppx - not taking x 1 month - lactulose prn for constipation >3 days - pantoprazole 40 mg tablet daily discharge medications: 1. gabapentin 300 mg capsule sig: three (3) capsule po tid (3 times a day). 2. levothyroxine 25 mcg tablet sig: two (2) tablet po daily (daily). 3. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime). 4. nadolol 20 mg tablet sig: one (1) tablet po daily (daily). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 6. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours). discharge disposition: home discharge diagnosis: primary: upper gi bleed secondary: etoh cirrhosis discharge condition: good - patient is ambulating, taking oral intake, and back to baseline condition. discharge instructions: please take all medications as prescribed. if you have any symptoms of bleeding, change in the color or consistency of your stool, vomiting, or vomiting any blood, please seek immediate medical attention. followup instructions: .provider: , md phone: date/time: 5:20 provider: , rd phone: date/time: 2:00 Procedure: Venous catheterization, not elsewhere classified Other endoscopy of small intestine Angioplasty of other non-coronary vessel(s) Transcatheter embolization for gastric or duodenal bleeding Transfusion of packed cells Transfusion of other serum Phlebography of the portal venous system using contrast material Procedure on single vessel Diagnoses: Thrombocytopenia, unspecified Congestive heart failure, unspecified Chronic hepatitis C without mention of hepatic coma Alcoholic cirrhosis of liver Iron deficiency anemia secondary to blood loss (chronic) Unspecified acquired hypothyroidism Asthma, unspecified type, unspecified Depressive disorder, not elsewhere classified Mononeuritis of lower limb, unspecified Blood in stool Esophageal varices in diseases classified elsewhere, with bleeding Hematemesis Hypovolemia Varices of other sites Diastolic heart failure, unspecified Other and unspecified alcohol dependence, unspecified Mechanical complication of other vascular device, implant, and graft Disorder of bone and cartilage, unspecified

allergies: penicillins / codeine attending: chief complaint: cc: coffee ground emesis, black diarrhea major surgical or invasive procedure: upper endoscopy

the patient is a 46 year old woman with etoh/hcv cirrhosis, grade 1 varices and portal gastropathy who presents with n/v/d, abdominal pain and coffee ground emesis since this am. in the ed, she was initially hemodynamically stable with maintained hct. ng lavage revealed red blood that cleared after 750 cc. she also passed large amounts of melena. in the ed she was given 2 units of ffp, vitamin k, levofloxacin 500 mg x 1, octreotide gtt, and 1 liter of ns. upon stabilization she said that her only complaint was rlq abd pain which was somewhat worse with movement, it was non-radiating and intermittent. she has chronic diarrhea for the past several years, but had not experienced any in the few days prior to admission. on review of systems she denied headache, dizziness, chest pain, sob or cough. she did feel weak and described having a sore throat. she has no history of easy bruising or bleeding problems. she denied having any gu symptoms including hematuria prior to admission. past medical history: -heavy etoh abuse -hcv -elevated portal pressures with varices and portal gastropathy -chronic le neuropathy -diastolic chf -asthma -depression -osteopenia . psh: -ccy -tah for endometrial hyperplasia social history: lives with husband and 29 y.o son from a previous marriage. heavy etoh abuse in the past, last drink 3 months ago. had "dts" in during years of etoh abuse never admitted for withdrawal symptoms. tobacco 1 ppd x 30 years. no ivdu. family history: father died of mi in 80's. many alcoholics in family. one cousin with celiac sprue. physical exam: on arrival to medical floor: vitals: 98.3 92/55 79 20 97%ra gen: alert, mildly uncomfortable with movement. heent: l pupil 5->3, r pupil 3->2 (patient reports this is normal for her). mmm, remnants of blood on teeth, erythematous oropharynx, no discrete lesions. chest: soften breath sounds bilat. good air entry no wheeze or crackles cv: rrr no murmur/rub/gallop abd: soft, non-distended, mild tenderness to rlq but diffusely as well. indirect tenderness across abdomen extr: tender on lower extremities neuropathy neuro: a&ox3, pupils as described above. pertinent results: 02:25pm wbc-8.9 rbc-3.82* hgb-11.8* hct-33.3* mcv-87# mch-30.8 mchc-35.4* rdw-14.5 02:25pm pt-19.9* ptt-40.1* inr(pt)-1.9* 08:55pm wbc-4.9 rbc-3.19* hgb-9.8* hct-27.9* mcv-87 mch-30.8 mchc-35.3* rdw-14.7 08:55pm glucose-70 urea n-19 creat-0.6 sodium-135 potassium-4.0 chloride-98 total co2-23 anion gap-18 08:55pm ck(cpk)-25* . : egd: grade i varices at the lower third of the esophagus grade 1 esophagitis in the gastroesophageal junction portal gastropathy duodenitis in the proximal bulb large duodenal varix. brief hospital course: the patient is a 46 year old woman with history of alcohol/hep c cirrhosis, portal hypertension and recent episode of colitis who presented with an upper gi bleed. . 1.) upper gi bleed: the patient presented with a ugib. she was volume expanded with normal saline and a total of 9 prbc units. she underwent egd to evaluate the source of her bleeding. there were no active bleeding vessels visible during the procedure and none of the lesions detected required intervention. the leading culprit was thought to be the large duodenal varix. she continued on the iv ppi twice daily while in the micu, but this was decreased upon discharge to once daily oral dosing. her hematocrit stablized in the mid 30s but time of discharge and she exhibited no evidence of re-bleeding. she was discharged in stable condition, tolerating oral food and medication. she was referred to follow-up with dr. in the liver center with the consideration that a tips procedure might be therapeutic to treat her duodenal varix that was the presumptive cause of the bleeding. . 2.) hypotension: in the ed the patient became hypotensive to sbp ~80s. she was relatively asymptomatic at the time and was able to mentate well. she was vigorously volume expanded with saline and blood products and transfered to the micu for close observation. following stabilization and transfer to the medical floor, she stated that her blood pressure has always run low and 80s and 90s systolic are not uncommon for her. her home diuretics were held during the hospitalization, and only the furosemide at a low dose was to be re-started at discharge. her blood pressure increased by time of discharge and was stable with systolic in the 110s. . 3.) hypoxia: with the history of diastolic chf the patient developed mild hypoxia following the vigorous volume expansion with saline and blood. this was corrected with natural diuresis and supplemental oxygen. upon transfer to the medical floor her oxygen saturation was 97% on room air alone. . 4.) thrombocytopenia: the patient has a baseline platelet count range 110s over the past 4 months. this could be secondary to hypersplenism. however the level dropped on admission with a nadir of 48,000. this was thought secondary to octreotide (which was later stopped) on top of chronic hypersplenism, however, other possiblities were entertained included secondary to the ppi, itp or dic, and hit. the smear did not reveal appreciable shistocytes and the dic panel including trend did not support dic. heparin was held. there were no thombotic events to support an immune hit picture. the platelet level should be followed as outpatient for return with consideration for discontinuing the ppi if the platelet count does not recover. . 5.) liver disease: the patient has a history of alcohol and hep c cirrhosis. the last viral load was measured in with 600-700,000 copies/ml detected. her inr has slowly increased over the past year now stabilizing at 1.7 prior to discharge. the total bilirubin has fluctuated highly over the past year but during this hospitalization was toward the low of the the range at 3.4. ct scan demonstrated a increase in her splenic diameter compared to . at discharge she was re-started on low dose nadolol and furosemide and scheduled for liver center follow-up. . 6.) hematuria: the patient reported no history of hematuria prior to admission. however, a large rbc count was measured in a sample from a foley catheter. this was thought to be secondary to a traumatic foley placement. a follow-up ua after the foley was removed showed a decrease in the rbc by more than half the prior level. routine ua follow-up is recommended to confirm the clearance of the urine. . 7.) abd pain: the patient described a pain in her rlq. upon examination she was more tender in a diffuse location instead of a more focal area. potential diagnoses included a re-lapse of her pancoltis from , appendicitis, mesenteric adenitis, constipation, or less likely ovarian cyst. a abdominal ct was obtained that revealed portal gastropathy and mesenteric collaterals, resolved colitis, but no obvious source for abd. pain. her bowel regimen was changed and she was tolerating food upon discharge. . 8.) chronic diarrhea/bloating: this was thought likely secondary to celiac sprue (+fh, duodenal biopsy + for early disease, ttg reported as + although no result in omr). she was prescribed a gluten free diet and asked to make an appointment with the dietician whom she had already contact. a nutrition consult was made for some inpatient teaching. . 9.) fen: tolerating full regular diet. . 10.) prophy: on ppi, had pneumoboots while on bedrest but later was ambulating well. . 11.) code status: the patient remained full code througout her hospitalization. . 12.) dispo: home with liver center follow-up. medications on admission: pantoprazole 40 mg po daily gabapentin 400 mg po 3x/day nadolol 20 mg po daily spironolactone 25 mg po daily furosemide 80 mg po daily levothyroxine 50 mcg po daily discharge medications: 1. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*2* 2. gabapentin 300 mg capsule sig: three (3) capsule po tid (3 times a day). 3. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 4. nadolol 20 mg tablet sig: one (1) tablet po once a day. :*30 tablet(s)* refills:*2* 5. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*2* discharge disposition: home discharge diagnosis: primary: upper gastro-intestinal bleed secondary: cirrhosis alcoholic hepatitis chronic hepatitis c esophageal varices peripheral neuropathy celiac sprue discharge condition: good: hct stable, bp stable at her baseline, no evidence of re-bleeding. discharge instructions: please call your doctor if you begin to vomit blood, she will likely tell you to call 911 and come to the hospital. please attend your follow-up appointments. followup instructions: please call your dietician to arrange for an appointment. please call dr. office to schedule an appoinment in the next 1-2 weeks. () please see dr. in the liver center on at 3:30pm () md Procedure: Other endoscopy of small intestine Transfusion of packed cells Transfusion of other serum Diagnoses: Thrombocytopenia, unspecified Congestive heart failure, unspecified Acute posthemorrhagic anemia Alcoholic cirrhosis of liver Portal hypertension Unspecified acquired hypothyroidism Unspecified viral hepatitis C without hepatic coma Asthma, unspecified type, unspecified Depressive disorder, not elsewhere classified Mononeuritis of lower limb, unspecified Hemorrhage complicating a procedure Hypotension, unspecified Celiac disease Hypoxemia Hematemesis Urinary catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure Varices of other sites Diastolic heart failure, unspecified Other and unspecified alcohol dependence, unspecified Disorder of bone and cartilage, unspecified Acute alcoholic hepatitis Esophageal varices without mention of bleeding Unspecified disorder of stomach and duodenum

allergies: penicillins / codeine / optiray 350 attending: chief complaint: hcv/hcc here for liver transplant major surgical or invasive procedure: : orthotopic liver transplant

ms. is a 50 yo f with h/o etoh/hcv cirrhosis, focal liver lesion likely hcc by imaging (path : small cell dysplasia),and tips x2 with h/o encephalopathy, meld 29, listed for a liver transplant on , now presents for liver transplant. pt is morbidly obese, and her most recent bmi was calculated at 41.6. she is 5 feet 3 inches and weighs 106.8 kilos. pt feels well. no recent illness except for possible r leg cellulitis treated with clinamycin in mid , which has since resolved. denies fever, cp, sob, nausea, vomiting. denies dysuria. past medical history: - copd - cirrhosis c/b variceal bleed, hepatic encephalopathy, and ascites s/p tips procedure and embolization of duodenal varix - history of heavy etoh abuse - hcv (antibody postive, rna negative) - celiac: diagnosed with bx, noncompliant to gluten free diet - chronic le neuropathy - ?diastolic chf - depression - osteopenia - hypothyroidism - s/p ccy - s/p tah for endometrial hyperplasia social history: lives with husband. 1 son. previously worked as an accountant but is not currently working. former smoker, quit in , has 30 pack year smoking history. was drinking alcohol gallon of vodka until when she quit. denies ivdu. family history: father died of mi in 80s. many alcoholics in family. one cousin with celiac sprue. physical exam: nad heent nc, at, trachea midline, jvd can't be appreciated, cn ii-xii intact no murmurs appreciated, but distant breath sounds ctab abd soft, nt, nd but protuberant, no rebound or guarding 1+ le edema. no erythema of rle. pertinent results: on admission: wbc-5.1 rbc-4.91 hgb-15.4 hct-44.2 mcv-90 mch-31.3 mchc-34.8 rdw-14.2 plt ct-159 pt-15.4* ptt-26.1 inr(pt)-1.3* glucose-108* urean-19 creat-1.0 na-140 k-4.0 cl-102 hco3-27 angap-15 alt-63* ast-75* alkphos-67 totbili-1.2 albumin-4.2 calcium-9.4 phos-3.2 mg-1.8 at discharge: wbc-11.8* rbc-3.36* hgb-10.1* hct-29.7* mcv-88 mch-30.0 mchc-34.0 rdw-15.0 plt ct-121* glucose-107* urean-66* creat-1.9* na-130* k-4.8 cl-93* hco3-25 angap-17 alt-100* ast-45* alkphos-123* totbili-0.6 calcium-8.2* phos-3.0 mg-3.0* fk: brief hospital course: 51 y/o female with history of hcv and possible hcc and etoh abuse in the past who now presents for orthotopic liver transplant. she was taken to the or with dr and underwent orthotopic deceased donor liver transplant (piggyback) portal vein to portal vein anastomosis, common bile duct to common bile duct without a t tube, splenic artery of the recipient to the common hepatic artery of the donor. the patient received 4 units ffp and 4 units rbcs in the or. she had persistent air in the right chest. despite earlier aspiration, the air persisted so a drain was placed as a chest tube into the right chest and placed to pleur-evac suction. she had two jp drains placed. she tolerated the surgery and was transferred to the sicu intubated, in stable condition. she received routine induction immunsuppression, to include solumedrol 500 mg (with subsequent protocol taper) mmf and prograf was started on the evening of pod 0. routine ultrasound on pod 1 showed patent hepatic arteries and veins and portal veins post-transplant. the chest tube was removed on pod 1, the patient extubated and she was able to transfer to the regular surgical floor on pod 2. she continued the solumedrol to prednisone taper, tolerated the mycophenylate and had daily trough prograf levels drawn with adjustments. it was held a few days due to levels as high as 17. the patient received several days of iv lasix to help with volume management. lower extremity edema was greatly improved. creatinine peaked at 2.8 and was trending back to normal by day of discharge. urine output was adequate, and responded well to the lasix. home venlaxafine and pregabalin were restarted. the patient was evaluated by physical and occupational therapy and they recommended rehab medications on admission: albuterol sulfate - 2.5 mg/3 ml (0.083 %) q6 prn fluticasone-salmeterol - 250 mcg-50 mcg furosemide 80qam, 40 qpm ibandronate - 3 mg/3 ml syringe - 1 injection q3mo lactulose - 10 gram/15 ml solution - 30cc solution 3-4x/day prn levothyroxine - 50 mcg tablet qday omeprazole ec 20 mg qdaily pregabalin - 50 mg rifaximin - 550 mg tablet spironolactone - 100 mg tablet tiotropium bromide - 18 mcg capsule qdaily venlafaxine - 75 mg tablet qdaily zolpidem - 10 mg tablet qhs discharge medications: 1. fluconazole 200 mg tablet sig: two (2) tablet po q24h (every 24 hours). 2. prednisone 5 mg tablet sig: four (4) tablet po daily (daily): follow transplant clinic taper. 3. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 4. mycophenolate mofetil 500 mg tablet sig: two (2) tablet po bid (2 times a day). 5. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 6. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). 7. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 8. albuterol sulfate 90 mcg/actuation hfa aerosol inhaler sig: four (4) puff inhalation q4h (every 4 hours) as needed for wheezing. 9. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) neb inhalation q4h (every 4 hours) as needed for wheezing. 10. valganciclovir 450 mg tablet sig: one (1) tablet po once a day. 11. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical prn (as needed) as needed for dry skin. 12. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). 13. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). 14. venlafaxine 75 mg tablet sig: one (1) tablet po daily (daily). 15. pregabalin 50 mg capsule sig: one (1) capsule po twice a day. 16. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. 17. nph insulin human recomb 100 unit/ml suspension sig: fourteen (14) units subcutaneous once a day: breakfast. 18. insulin lispro 100 unit/ml solution sig: per sliding scale subcutaneous four times a day. 19. tacrolimus 1 mg capsule sig: one (1) capsule po q12h (every 12 hours). discharge disposition: extended care facility: - discharge diagnosis: hcv/hcc cirrhosis now s/p liver transplant discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). please see pt/ot evaluation discharge instructions: please call the transplant clinic at for fever > 101, chills, nausea, vomiting, diarrhea, constipation, increased abdominal pain, redness, drainage or bleeding from the incision or old drain sites, increased edema, weight gain of greater than 3 pounds in a day or 5 pounds in a week, worsening respiratory status, inability to tolerate food, fluids or medications, yellowing of skin or eyes or any other concerning symptoms. please obtain labwork on mondays and thursday and fax labs to the transplant clinic at . cbc, chem 10, ast, alt, alk phos, t bili, trough prograf level. please do not change medications without consultation with the transplant clinic. no heavy lifting. patient may shower, no tub baths or swimming followup instructions: provider: , md, phd: date/time: 9:00, medical building, , , , ma provider: , md, phd: date/time: 10:00 provider: , phone: date/time: 11:00 md, Procedure: Insertion of intercostal catheter for drainage Other transplant of liver Other operations on lacrimal gland Transplant from cadaver Diagnoses: Acute kidney failure with lesion of tubular necrosis Cirrhosis of liver without mention of alcohol Chronic hepatitis C without mention of hepatic coma Alcoholic cirrhosis of liver Portal hypertension Unspecified acquired hypothyroidism Morbid obesity Celiac disease Malignant neoplasm of liver, primary Chronic obstructive asthma, unspecified Emphysema (subcutaneous) (surgical) resulting from procedure Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Unspecified hereditary and idiopathic peripheral neuropathy Disorder of bone and cartilage, unspecified Esophageal varices without mention of bleeding Alcohol abuse, in remission Body Mass Index 40.0-44.9, adult

allergies: penicillins / codeine / optiray 350 attending: chief complaint: reason for admission/cc: major surgical or invasive procedure: none

51f pmhx hcv/hcc cirrhosis now pod10 s/p olt discharged to rehab 5 days prior to readmission with post-operative course remarkable for acute renal insufficiency and hyponatremia which were resolving at time of discharge. per report, pt with acute change in mental status this morning at rehab facility described as confusion without agitation. pt reportedly had adequate pain control, tolerating po without nausea/vomiting, voiding without difficulty, and ambulating with assistance. direct admission given temporal association with olt and acute altered mental status. no reported ingestion, abdominal trauma or head trauma. at time of admission, pt coherent, nad, a/ox3, but some word-finding difficulty and distractability without focal neurologic deficits. afvss without abdominal pain or signs of wound infection. past medical history: - copd - cirrhosis c/b variceal bleed, hepatic encephalopathy, and ascites s/p tips procedure and embolization of duodenal varix - history of heavy etoh abuse - hcv (antibody postive, rna negative) - celiac: diagnosed with bx, noncompliant to gluten free diet - chronic le neuropathy - ?diastolic chf - depression - osteopenia - hypothyroidism - s/p ccy - s/p tah for endometrial hyperplasia social history: lives with husband. 1 son. previously worked as an accountant but is not currently working. former smoker, quit in , has 30 pack year smoking history. was drinking alcohol gallon of vodka until when she quit. denies ivdu. family history: father died of mi in 80s. many alcoholics in family. one cousin with celiac sprue. physical exam: vs: t 97.6, hr 87, bp 138/73, rr 26, sao2 100%3lnc gen: nad, a/ox3, confused, stuttering words but easily directable neuro: cn2-12 intact, no facial droop, tongue midline, no obvious asymmetry on exam. extremity strength/sensation intact without focal deficits. heent: perrl, no scleral icterus cv: rrr, no m/r/g, nl s1s2 pulm: ctab, no w/r/r back: no cvat abd: soft, nontender, nondistended. extended subcostal staple line intact without fluctuance/drainage/erythema. punctate ecchymoses at staple line and former drain insertion sites, no underlying fluctuance/tenderness. pelvis: deferred ext: wwp, 1+ pedal edema, 2+ distal pulses labs: 7.7 19.4 >------< 243 &#8710; 23.3 121 / 86 / 67 ---------------<183 agap=19 5.0 / 21 / 2.1 estgfr: 25/30 ca: 8.0 mg: 2.5 p: 5.3 &#8710; alt: 60 ast: 42 ap: 104 tbili: 0.7 alb: 3.0 pt: 11.6 ptt: 20.8 inr: 1.0 imaging: liver duplex hepatic artery: portal system: peak ri main - 50 0.69 main - ?turbulent flow v artifact left - 29.6 0.63 left - patent right - 27.8 0.57 r ant - patent r post - patent hepatic veins: patent fluid collections: none pertinent results: 07:25pm blood wbc-19.4*# rbc-2.61* hgb-7.7* hct-23.3* mcv-89 mch-29.6 mchc-33.1 rdw-15.7* plt ct-243# 05:06am blood wbc-16.2* rbc-2.35* hgb-7.0* hct-21.6* mcv-92 mch-29.9 mchc-32.4 rdw-16.0* plt ct-240 02:16am blood wbc-15.6* rbc-2.98*# hgb-8.8*# hct-26.3* mcv-88 mch-29.6 mchc-33.6 rdw-15.9* plt ct-208 05:14am blood wbc-11.2* rbc-3.35* hgb-10.2* hct-30.4* mcv-91 mch-30.6 mchc-33.8 rdw-15.7* plt ct-240 02:20am blood pt-12.4 ptt-21.3* inr(pt)-1.0 05:14am blood glucose-112* urean-21* creat-0.8 na-136 k-3.8 cl-104 hco3-21* angap-15 07:25pm blood alt-60* ast-42* alkphos-104 totbili-0.7 05:06am blood alt-50* ast-37 alkphos-84 totbili-0.7 05:14am blood alt-64* ast-46* alkphos-207* totbili-0.7 05:50am blood albumin-3.1* calcium-8.3* phos-4.3 mg-1.5* 05:30am blood tacrofk-7.7 brief hospital course: 51f with h/o hcv/hcv cirrhosis pod10 from liver transplant admitted with ams, no clinical or radiographic evidence of graft rejection / portal vein compromise in setting of leukocytosis, renal insufficiency,and anemia. she was admitted to transplant surgery (dr. and pan cultured. ivf resuscitation for hyponatremia was administered. broad spectrum antibiotics were given. ct abd/pel was done to assess for intraabdominal pathology. this demonstrated a lesser sac fluid collection adjacent to the pancreas. a smaller fluid collection was seen anterior to the stomach deep to the left anterior abdominal wall, which did not communicate with the lesser sac collection. dilated loops of small bowel with no focal transition point were noted. fluid collection was unable to be drained by radiology. post-transplantation immunosuppressive regimen continued. hct was 21. she was transfused with hct increase to 27. this remained stable. sodium was 125. iv ns at 75 was continued with improvement of serum sodium to 130. an ng was placed for emesis and kub demonstrated dilated small bowel. tpn in addition to ns was started. feeding tube was placed. neuro was consulted for confusion, insomnia, hallucinations and twitching. head ct was done and was negative for acute intracranial abnormality. neuro status was most likely a metabolic/toxic encephalopathy with features of an agitated delirium. steroid psychosis was suspected that may have been exacerbated by ssri. effexor was stopped and zyprexa given. the twitching/myoclonus could not be explained by steroid side effects. tacrolimus was a potential culpert and dose was lowered. mental status improved. nausea/vomiting resolved. diet was advanced and tolerated. appetite and po intake were excellent. tpn was stopped and feeding tube feeds was removed. was consulted and recommended continuing nph 10 units qam with humalog sliding scale. vanco & zosyn were given thru . cultures (blood/urine and stool)remained negative. pt declared her safe for home with rolling walker. she was discharged to home. care group vna 1- for nsg, pt, ot, hha was arranged. medications on admission: albuterol 2.5 mg/3 ml (0.083 %)prn, fluticasone-salmeterol 250/50'', ibandronate 3mg/3ml 1inj q3mo, levothyroxine 50, omeprazole ec 20, pregabalin 50'', tiotropium 18, venlafaxine 75, zolpidem 10qhs, nph14u qam/lisproriss, valcyte 450, fluconazole 400, bss, prednisone 20, mmf 1000'', tacrolimus 1'', oxycodone 5prn discharge medications: 1. docusate sodium 100 mg capsule sig: one (1) capsule po bid (2 times a day). 2. fluconazole 200 mg tablet sig: one (1) tablet po q24h (every 24 hours). 3. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*2* 4. prednisone 20 mg tablet sig: one (1) tablet po daily (daily): follow taper. decrease dose to 17.5mg on . 5. pregabalin 25 mg capsule sig: two (2) capsule po bid (2 times a day). :*60 capsule(s)* refills:*2* 6. sulfamethoxazole-trimethoprim 400-80 mg tablet sig: one (1) tablet po daily (daily). 7. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily). :*30 * refills:*2* 8. omeprazole 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po daily (daily). 9. mycophenolate mofetil 500 mg tablet sig: one (1) tablet po qid (4 times a day). 10. fluticasone-salmeterol 250-50 mcg/dose disk with device sig: one (1) disk with device inhalation (2 times a day). :*1 disk with device(s)* refills:*2* 11. valganciclovir 450 mg tablet sig: two (2) tablet po daily (daily). 12. oxycodone 5 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed for pain. :*30 tablet(s)* refills:*0* 13. furosemide 20 mg tablet sig: one (1) tablet po daily (daily). :*8 tablet(s)* refills:*0* 14. insulin lispro 100 unit/ml solution sig: one (1) subcutaneous four times a day. :*1 bottle* refills:*2* 15. nph insulin human recomb 100 unit/ml suspension sig: ten (10) units subcutaneous once a day. :*1 bottle* refills:*2* 16. syringes low dose insulin syringes for daily nph and sliding scale humalog qid 25-26 gauge needles supply: 1 box refill: 2 17. tacrolimus 1 mg capsule sig: one (1) capsule po q12h (every 12 hours). 18. tacrolimus 0.5 mg capsule sig: one (1) capsule po twice a day. 19. prilosec 20 mg capsule, delayed release(e.c.) sig: one (1) capsule, delayed release(e.c.) po once a day for 1 months. :*30 capsule, delayed release(e.c.)(s)* refills:*1* 20. freestyle lite strips strip sig: one (1) miscellaneous four times a day. :*1 bottle* refills:*2* 21. freestyle lite meter kit sig: one (1) kit miscellaneous once a day. :*1 meter* refills:*0* 22. freestyle lancets misc sig: one (1) miscellaneous four times a day. :*1 box* refills:*2* discharge disposition: home with service facility: homecare discharge diagnosis: acute mental status changes likely r/t steroid psychosis, resolved h/o liver transplant abdominal collection dm discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - requires assistance or aid (walker or cane). discharge instructions: -care group vna 1- has been arranged to see you at home -please call the transplant office if you have any of the warning signs -you will need to have blood drawn for labs every monday and thursday for lab monitoring at lab on of medical office building -you may shower -check your weight daily and call if you have a 3 pound/day weight gain or you feel dizzy/thirsty or legs look less swollen -you may shower -no heavy lifting/straining followup instructions: provider: , md, phd: date/time: 9:40 provider: , md, phd: date/time: 9:40 Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Arterial catheterization Diagnoses: Toxic encephalopathy Adrenal cortical steroids causing adverse effects in therapeutic use Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Chronic airway obstruction, not elsewhere classified Depressive disorder, not elsewhere classified Celiac disease Liver replaced by transplant Peritoneal abscess Delirium due to conditions classified elsewhere Disorder of bone and cartilage, unspecified Insomnia, unspecified Hallucinations Abnormal involuntary movements

*allergies: pcn, codeine neuro: pt a&o x3, follows commands, moves in bed by self, perrl 3mm/brisk. complaints of discomfort, worrying about the alarms, lines, iv's and not able to get comfortable. also complaints of pain in feet, neuropathy, on neurontin @ home, started here as well. given 2.5mg ambien @ 0430 to help get some rest before am. cardiac: nsr w/o ectopy, 62-84, sbp 84-100, stated always on the lower side. plt 76, md's aware. hct 34.4, 30.3, 0600 hct pending, will transfuse @ 28 md, cont serial hct labs q4h, next @ 1000. type and cross already sent last night. resp: rr 13-18, o2sat 91-96 on ra. was requiring 2l nc early in shift, but was not tolerating and sat's were improved, has been on ra since w/o issue. ls clear throughout. cxr this am, results pending. gi/gu: npo for endoscopy this am. attempted last evening, but pt gagged and vomited food eaten in ed around 1530. unable to cont, md's stated will retry this am. +bs, no stool this shift. voids urine yellow/clear 610cc total this shift. 40meq k given po, 4grams mgsulf iv given. id: temp 96.6-97.7, wbc 4.1. no signs of infection. levofloxacin iv given prophylactically. psychosocial: husband was in when she came to icu. she has been here before and is in and out of the hospital, so familiar w/ "the routine". Procedure: Other endoscopy of small intestine Injection of anesthetic into spinal canal for analgesia Intra-abdominal venous shunt Diagnoses: Thrombocytopenia, unspecified Congestive heart failure, unspecified Cirrhosis of liver without mention of alcohol Alcoholic cirrhosis of liver Portal hypertension Unspecified acquired hypothyroidism Unspecified viral hepatitis C without hepatic coma Asthma, unspecified type, unspecified Depressive disorder, not elsewhere classified Pulmonary collapse Mononeuritis of lower limb, unspecified Blood in stool Celiac disease Varices of other sites Other specified disorders of stomach and duodenum Surgical or other procedure not carried out because of contraindication Diastolic heart failure, unspecified Other and unspecified alcohol dependence, unspecified Disorder of bone and cartilage, unspecified Esophageal varices without mention of bleeding

*allergies: pcn, codeine *access: r ant 16g, r ant 20g, rij trauma line neuro: pt lethargic/sleeping most of shift following tips procedure in ir w/ fentanyl used throughout procedure, also did not sleep last night here in icu. easily arousable, a&ox3, perrl 3mm/brisk, moves self in bed, no complaints of pain this shift, typically neuropathy in feet, but no complaints. cardiac: nsr/st w/o ectopy, hr 88-108, sbp 89-107, pt stated yesterday she normally has low bp's. hct being followed after admit for tarry stools, scoped yesterday, noted grade 1 non-bleeding varices which can not be banded md, and a grade 1 duodenal ulcer. hct's have been stable @ 32.9 and 30.2, will transfuse @ 28, not blood products required as of yet. resp: was intubated during procedure, extubated in ir immediately following, returned to micu on 6l nc, eventually required additional face tent @ 50%. she does not like having either on but gives in understanding it is required. asked to take deep breaths and doesn't appear to try, doesn't appear to try and cough hard enough as well, seems content to sleep. rr 14-19, o2sat 86-100, mainly in low 90's even w/ face tent and nc. ls clear throughout, productive cough, can swallow liquids and pills. gi/gu: remains npo for am us @ 0845. +bs, no stool this shift. urine out foley that was inserted in ir yellow/clear, 60-450cc/hr w/ larger volumes following return to micu, did receive 1500cc crystaloid in ir. cont d5 1/2ns @ 150cc/hr for 2000cc, first 1000 still running. hepatic: tips procudure done yesterday in ir, reporting nurse stated that gradient decrease goal < 12 and is now 9 so procedure was successful and unremarkable for any events. f/u us sheduled for this am @ 0845. id: temp 98.1-101.0, wbc 7.3, temp 101 following additional heavy blankets as pt complained of being cold. removed extra blankets and retook temp and decreased to 99.7 and again decreased later. cont on levofloxacin prophylactically following gi bleed. psychosocial: husband was by to visit yesterday afternoon but left before she returned from the procedure. called again later, but she was still quite groggy from the procedure, i updated him on the procedure and her condition. Procedure: Other endoscopy of small intestine Injection of anesthetic into spinal canal for analgesia Intra-abdominal venous shunt Diagnoses: Thrombocytopenia, unspecified Congestive heart failure, unspecified Cirrhosis of liver without mention of alcohol Alcoholic cirrhosis of liver Portal hypertension Unspecified acquired hypothyroidism Unspecified viral hepatitis C without hepatic coma Asthma, unspecified type, unspecified Depressive disorder, not elsewhere classified Pulmonary collapse Mononeuritis of lower limb, unspecified Blood in stool Celiac disease Varices of other sites Other specified disorders of stomach and duodenum Surgical or other procedure not carried out because of contraindication Diastolic heart failure, unspecified Other and unspecified alcohol dependence, unspecified Disorder of bone and cartilage, unspecified Esophageal varices without mention of bleeding

allergies: penicillins / codeine attending: chief complaint: tarry black stools major surgical or invasive procedure: egd tips

46 year old woman with etoh/hcv cirrhosis who was recently admitted on with coffee ground emesis and black colored stools. . today the patient called her pcp and reported 3 episodes of jet black diarrhea, which was similar to her prior episode of ugib. she denied hematemesis, but reported diffuse abdominal pain and poor po intake all weekend. the patient denies the use of nsaids, anti-coagulants, iron supplementation or pepto bismol. she has no known history of bleeding disorders. of note since her last discharge she was having loose, brown watery stools. due to her chronic diarrhea, she is always orthostatic. . in the ed the patient's vitals were as follows t 98.3 hr 86, bp 92/66 (bp tends to run chronically low) rr 20 o2sat 96% ra. her stool was grossly guaiac positive. she received 4l of ivf. her hct was 41 (thought to be hemoconcentrated as her entire cell line was up from baseline). she was seen by gi and transferred to the unit for an egd and overnight monitoring. . during her last admission, she required 9u prbcs and aggressive ivf resuscitation. an egd was performed on which showed grade i varices at the lower third of the esophagus, grade 1 esophagitis in the gastroesophageal junction, portal gastropathy, duodenitis in the proximal bulb and large duodenal varix. past medical history: -heavy etoh abuse -hcv -elevated portal pressures with varices and portal gastropathy -chronic le neuropathy -diastolic chf -asthma -depression -osteopenia . psh: -ccy -tah for endometrial hyperplasia social history: lives with husband and 29 y.o son from a previous marriage. heavy etoh abuse in the past, last drink 3 months ago. had "dts" in during years of etoh abuse never admitted for withdrawal symptoms. tobacco 1 ppd x 30 years. no ivdu. family history: father died of mi in 80's. many alcoholics in family. one cousin with celiac sprue. physical exam: vitals: t97.7 hr 77 bp 100/36 r16 o2 99ra gen: caucasian female in nad lying on stretcher heent: mmm dry, poor dentition, oropharynx chest: cta b/l, no gmr cv: nl rate, s1s2, no gmr abd: soft, round, slightly protuberant, +bs, liver 2 finger breadth below costal margin extr: warm, no cce neuro: a & o x 3, strength 5/5 in upper and lower extremity skin: spider angiomata on upper torso pertinent results: labs on admission 11:30am blood wbc-8.3# rbc-4.69 hgb-14.0 hct-41.3 mcv-88 mch-29.7 mchc-33.8 rdw-15.6* plt ct-119*# 11:30am blood neuts-72.5* lymphs-19.9 monos-4.5 eos-2.3 baso-0.9 11:30am blood plt ct-119*# 11:30am blood pt-19.1* ptt-39.6* inr(pt)-1.8* 11:30am blood glucose-113* urean-13 creat-0.7 na-132* k-4.6 cl-96 hco3-24 angap-17 11:30am blood alt-19 ast-48* alkphos-93 amylase-23 totbili-4.1* 11:30am blood ctropnt-<0.01 04:18pm blood hgb-12.8 calchct-38 . tips impression: 1. successful placement of a transjugular intrahepatic portosystemic shunt using three 10-mm bare metallic wallstents extending from a right portal vein to the right hepatic vein. 2. slightly unusual hepatic venous anatomy identified with two separate right hepatic veins which were small in caliber. 3. gradient between the portal vein and ivc pre-tips placement was 13 mmhg. post- tips placement the gradient was 9 mmhg. . . . 05:30am blood wbc-4.6 rbc-3.24* hgb-10.2* hct-28.7* mcv-89 mch-31.5 mchc-35.6* rdw-15.7* plt ct-59* 12:01am blood hct-27.6* 06:22pm blood hct-29.6* 03:03am blood wbc-7.3 rbc-3.37* hgb-10.2* hct-30.2* mcv-90 mch-30.3 mchc-33.9 rdw-15.6* plt ct-77* 11:39pm blood hct-31.5* brief hospital course: 46 f with history of alcohol/hep c cirrhosis, portal hypertension who was recently admitted with an ugib found to have a grade i varices, represents today with black tarry stools similar to her prior presentation. . ddx includes from most likely to least likely bleeding varices (given prior egd), pud, avms, dieulafoy lesion, m-w tears (unlikely given no hx of retching) . 1) upper gi bleed: an egd was performed on hd#1 but was aborted due to the fact that the patient had consumed a while in the ed and was vomiting during the procedure. the patient was aggressively suctioned, but there is a possibility that she may have aspirated. serial hcts were done and remained >30. the patient remained hd stable. she was kept on levo, octreotide and iv ppi. she had a 16 and 18 gauge iv. . an egd was performed the following day with showed a duodenal varix. due to the patient's hx of ugib and the nature of the varix, tips was performed on the same day. there were no complications. doppler u/s was performed the following day which showed the following: . patent tips with flow rates ranging from 84 to 151 cm/sec. patent and appropriate directional flow in the portal vein, hepatic vein, hepatic artery. . she was transferred to the general medical wards following her procedure on , with hct (31->29-27->28). on the morning of discharge, pt was frustrated, and stated that she wanted to leave ama. she was ultimately seen by interventional radiology, who inspected the site of her tips procedure, and by the gi service. she was discharged home with instructions to check her hct and follow-up with her pcp and the gi service within weeks. . . 2) transient episode of hypoxia - during the egd, she vomited up gastric contents and had a transient episode of hypoxia. her o2sats fell to the high 80s. she was placed temporarily on 2l nc and her sats improved to the high 90s. throughout her course the patient had transient desats to high 80s. she reported being asymptomatic. repeat cxr showed moderate right pleural effusion and a small left pleural effusion. consolidation was also present at the bases c/w atelectasis or aspiration. repeat cxr on showed "moderate bilateral pleural effusions and pulmonary vascular congestion, which developed between and have decreased substantially, there is no interstitial edema, and consolidation in the left lower lobe, probably atelectasis has improved." she was discharged home without further treatment, as she declined to go home with oxygen. . . 3) thrombocytopenia: on admission patient's plts were 119. this is around baseline. of note on last admission plts fell to 48k. this was attributed to octreotide and chronic hypersplenism. low platelets may also be a reflection of liver disease and low thrombopoietin. . 4) cirrhotic liver disease patient reports that she drank for over 30 years. she also has a history of hep c (vl 600-700,000 copies/ml detected.) her coagulopathy (inr 1.8) liver disease. . she is on nadolol, furosemide and spironolactone at home but this has been held in the setting of her gib. elevated lfts to chronic liver disease. will monitor. she has no localizing abd pain on exam. . 6) neuropathy continue neurontin. . 7) hypothyroidism continue levoxyl. . 9.) fen: npo for egd, following procedure gluten free diet given celiac disease. hyponatremia prob to poor po intake. . 10.) prophy: on ppi, pneumoboots, no sc heparin given gib and inr>1.8 . 11.) code status: full code . pt was discharged home on , with stable hct (28's). she continued to require o2 to maintain o2 sats in the 90s, however she refused to take home o2, and denied any symptoms of sob with o2 sats in the 80s on ra. she was instructed to follow-up with the gi service and her primary care physician 2-4 weeks, and specifically to have her hematocrit checked before following up with her pcp. medications on admission: levothyroxine 50 mcg neurontin 900 protonix 40 nadolol 20 lasix 40 albuterol atrovent niacin 250 trental 400 tid kcl 80 meq pyridoxine spirinolactone 25 thiamine discharge medications: 1. gabapentin 400 mg capsule sig: two (2) capsule po q8h (every 8 hours). 2. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). 3. albuterol 90 mcg/actuation aerosol sig: 1-2 puffs inhalation q6h (every 6 hours) as needed. 4. phytonadione 5 mg tablet sig: two (2) tablet po once (once) for 1 doses. 5. thiamine hcl 100 mg tablet sig: one (1) tablet po daily (daily). 6. niacin 250 mg capsule, sustained release sig: one (1) capsule, sustained release po bid (2 times a day). 7. levofloxacin 500 mg tablet sig: one (1) tablet po once a day: for sbp prophylaxis. . :*30 tablet(s)* refills:*2* 8. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. :*30 tablet, delayed release (e.c.)(s)* refills:*2* 9. trental 400 mg tablet sustained release sig: one (1) tablet sustained release po three times a day. 10. pyridoxine 25 mg tablet sig: one (1) tablet po qd prn: take as needed for nausea. . discharge disposition: home discharge diagnosis: gi bleeding from duodenal varices secondary to portal hypertension. discharge condition: stable. discharge instructions: please continue to take all of your medications as prescribed. if you experience any worsening symptoms such as vomitting blood, dark tarry stools, light-headedness, chest pain, shortness of breath, abdominal pain or distension, please contact your primary care provider or the emergency department. followup instructions: please follow-up with your primary care provider weeks. please also follow-up with your dr. , please have your cbc drawn prior to seeing dr. . Procedure: Other endoscopy of small intestine Injection of anesthetic into spinal canal for analgesia Intra-abdominal venous shunt Diagnoses: Thrombocytopenia, unspecified Congestive heart failure, unspecified Cirrhosis of liver without mention of alcohol Alcoholic cirrhosis of liver Portal hypertension Unspecified acquired hypothyroidism Unspecified viral hepatitis C without hepatic coma Asthma, unspecified type, unspecified Depressive disorder, not elsewhere classified Pulmonary collapse Mononeuritis of lower limb, unspecified Blood in stool Celiac disease Varices of other sites Other specified disorders of stomach and duodenum Surgical or other procedure not carried out because of contraindication Diastolic heart failure, unspecified Other and unspecified alcohol dependence, unspecified Disorder of bone and cartilage, unspecified Esophageal varices without mention of bleeding

allergies: penicillins / codeine / rifaximin attending: chief complaint: melena and coffee ground emesis. major surgical or invasive procedure: revision of tips embolization of duodenal varix egd intubated bronchoscopy

46 year old female with a history of alcohol and hcv cirrhosis, esophageal and duodenal varices, multiple gi bleeds, status post tips. recently admitted on with hematemesis and melena. per report, on day of admission , the patient had originally experienced episodes of vomiting "coffee ground" material, which was preceded by abdominal pain. when found by ems, she was in bed dry heaving, having dark color diarrhea, and only oriented to name. in ed, she was intubated for airway protection and transferred to the icu. she underwent egd, which revealed a large duodenal varix as culprit, that was unable to be banded or injected. she then underwent embolization, followed by tips revision. her hct was stable afterwards. she was also noted to be difficult to wean off the ventilator, and was noted on bronchoscopy to have a pneumonia that was likely secondary to aspiration. she was treated for 7 days with vancomycin and aztreonam. when she was transfered to cc-7 from the micu on she was being actively diuresed. past medical history: *cirrhosis -heavy etoh abuse, +hcv (viral load undetectable), c/b coagulopathy/thrombocytopenia, elevated portal pressures with varices and portal gastropathy s/p tips * early celiac sprue dx on bx egd however not on diet since has no symptoms according to patient *chronic le neuropathy *diastolic chf a. last echo in , pasp 28, ef >55% b. ett/mibi: , no ischemic regions *anemia: baseline hct ~30, chronic blood loss, ?sprue *asthma *depression *osteopenia *hypothyroidism *s/p ccy for cholelithiasis *tah for endometrial hyperplasia *mild copd *gerd social history: lives with husband and 29 year old son. heavy etoh abuse in the past, but last drink occurred on , per patient. history of positive screens in past. stopped tobacco on "day of admission ()", per patient. 1 ppd x 30 years. no ivdu. family history: father died of mi in 80's. many alcoholics in family. one cousin with celiac sprue. physical exam: physical exam (on admission to medical floor ). . vitals: t:98.6, bp:102/60, hr:73, rr:20, rr:93% room air general: no acute distress. patient examined and laying comfortably in bed. denies fever, chest pain, abdominal pain, nausea, and vomiting. heent: mild scleral icterus. no phrenular icterus. poor dentition. moist mucous membranes. neck: supple. no cervical adenopathy. lungs: clear to auscultation, bilaterally. slightly decreased breath sounds in lower lung fields. cardiac: regular rate and rhythm. normal s1 and s2. no murmurs, rubs, or gallops. abd: surgical scar. soft. active bowel sounds throughout. nontender and nondistended. ext: minimal dorsal feet edema. nonpitting. 2+ bilateral dp and radial pulses, bilaterally. skin: multiple telangiectasias on chest. no palmar erythema. ecchymosis on left wrist. neuro: alert and oriented to person, place, and date. mildly confused during questioning, but could relate current president. asterixis. pertinent results: 04:48pm blood wbc-7.6 rbc-2.89* hgb-9.2* hct-26.6* mcv-92 mch-31.9 mchc-34.7 rdw-17.7* plt ct-95* 03:52am blood wbc-4.7 rbc-3.10* hgb-9.8* hct-28.7* mcv-93 mch-31.7 mchc-34.2 rdw-17.3* plt ct-54* 04:27am blood wbc-8.7 rbc-3.29* hgb-10.3* hct-29.2* mcv-89 mch-31.2 mchc-35.2* rdw-16.2* plt ct-56* 02:54am blood wbc-10.5 rbc-2.72* hgb-8.7* hct-24.5* mcv-90 mch-32.1* mchc-35.6* rdw-15.7* plt ct-89*# 09:22pm blood wbc-17.5*# rbc-2.70* hgb-8.5* hct-24.1* mcv-89 mch-31.3 mchc-35.1* rdw-16.5* plt ct-216# 09:00pm blood wbc-15.8*# rbc-2.45*# hgb-7.7* hct-21.8*# mcv-89 mch-31.2 mchc-35.1* rdw-16.4* plt ct-196# 04:48pm blood plt ct-95* 04:48pm blood pt-17.6* ptt-32.9 inr(pt)-1.6* 09:00pm blood pt-22.9* ptt-44.5* inr(pt)-2.3* 11:48am blood fibrino-277 02:54am blood fibrino-188 04:48pm blood glucose-88 urean-11 creat-0.7 na-142 k-4.2 cl-109* hco3-24 angap-13 09:00pm blood glucose-261* urean-77* creat-1.2* na-138 k-4.1 cl-92* hco3-24 angap-26* 04:52am blood alt-23 ast-37 ld(ldh)-179 alkphos-56 amylase-9 totbili-3.4* 09:00pm blood alt-24 ast-69* ck(cpk)-52 alkphos-78 amylase-20 totbili-3.9* 04:52am blood lipase-15 04:48pm blood calcium-8.4 phos-2.2* mg-1.9 09:00pm blood albumin-3.6 calcium-8.9 phos-5.5*# mg-1.5* 05:49am blood cortsol-5.3 11:39am blood cortsol-0.9* 01:09pm blood type-art po2-93 pco2-40 ph-7.50* caltco2-32* base xs-6 09:43am blood type-art temp-37.3 rates-/16 tidal v-890 fio2-50 po2-81* pco2-45 ph-7.43 caltco2-31* base xs-4 intubat-intubated vent-spontaneou 09:44pm blood glucose-267* lactate-8.3* 03:18am blood lactate-2.5* . urine culture: no growth. negative for legionella. blood cultures: no growth. sputum: pending. . 08:40pm urine color-yellow appear-clear sp -1.022 08:40pm urine blood-neg nitrite-neg protein-neg glucose-neg ketone-neg bilirub-neg urobiln-neg ph-6.0 leuks-tr . studies: endoscopy : varices at the lower third of the esophagus. congestion and erythema in the antrum; stomach body and fundus compatible with gastroapathy. erythema and friability in the first part of the duodenum compatible with duodenitis. varices at the second part of the duodenum. . head ct : no evidence of acute intracranial process. widespread sinus opacification. however, this could be seen in intubation. subcutaneous left parietal nodule, unchanged. it measures 13 mm in diameter and may represent a sebaceous cyst. . bronchoscopy : indication: respiratory failure with left-sided atelectasis,hypoxemia, lack of chest rise on the left. noted: the airways were examined to the subsegmental level bilaterally and there were no endobronchial lesions seen. the right side was within normal limits, however, the left side was completely obstructed by tenacious and copious thick secretions which were therapeutically aspirated. subsequent to the bronchoscopy, the airways on the left side were patent and the patient had good chest rise on the left. brief hospital course: a/p: 46 year old female with alcohol and questionable hcv cirrhosis and portal hypertension, admitted for variceal bleed and status post tips revision and varix embolization. stable hematocrit over the past several days. . 1) gi bleed: -emergent egd on revealed grade 1 varices in distal of esophagus that were not bleeding; portal gastropathy was noted. the protruding second part of the duodenum showed stigmata of recent bleed. the varix was smaller than on prior egd, consistent with recent embolization. no bleeding was visualized so no intervention was performed. despite no evidence of bleed, hematocrit fell from 31 on to 21 on . patient was continued on octreotide gtt and protonix gtt; she also received 6 units packed rbcs and 6 units ffp. - on the patient's pre-tips gradient was 13mmhg and post-tips gradient was 9mmhg. on patient underwent tips revision and repeat embolization. if patient rebleeds, then injection of glue (experimental) will be considered. once transferred from the micu, she continued proton pump inhibitor, . her hematocrit stayed stable in high 20's (nadir was 20-21 during acute gi bleed). . 2) end stage liver disease: -etiology likely from alcoholic or hcv cirrhosis. patient was followed by gi and liver teams throughout her hospital stay. she received lactulose, rifamixin and spironolactone during hospital stay; she was discharged on these medications. the patient has no history of sbp, so prophylaxis was not restarted. she was maintained on low dose nadolol 10mg. she will follow up with dr. on . . 3) hypokalemia: transferred from icu and noted to have hypokalemia, probably secondary to diuresis. lasix and sliding scale insulin were discontinued, but she remained on spironolactone. by the time of discharge, her potassium was in the range of 3.5-4.0. she was not discharged with any potassium supplementation due to concern for hyperkalemia on spironolactone. patient was instructed to return to for follow up electrolyte blood work on at dr. office. . 4) hypoxemia: -bronchoscopy revealed and therapeutically aspirated left mainstem mucous plugs, presumed to be the result of pneumonia secondary to aspiration. patient was treated with 7 day course of vancomycin and aztreonam. patient was slowly weaned off the ventilator on . a series of cxrs showed mild interstitial edema, moderate right and small left pleural effusion which worsened minimally and a left lower lobe atelectasis that improved. patient had persistent pleural effusions but was aggressively diuresed. on discharge, she did not require supplemental oxygenation to maintain an oxygen saturation in the mid 90's. . 5) hypotension: -while in the icu the patient's sbp fell to 80-90's on , so she received 3l ivf. there was initial concern for sepsis, so patient was started on a seven day-course vancomycin, aztreonam and flagyl for presumed aspiration pneumonia (stopped on ). there was also concern about adrenal insufficiency (see below). patient initially required levophed for pressure support, but was weaned off pressors, as she was stable following blood product and ivf bolus infusions. on she was started on nadolol 10mg for her portal hypertension, had some spb's in high 80's/low 90's. orthostatics were normal. was discharged with week's worth of nadolol with instructions to follow up with dr. on . . 6) adrenal insufficiency: -patient had a cortisol 0.9 on admission to the icu, but increased to 6 with acth. this prompted a questioned underlying adrenal insufficiency given her low level on admission and patient received a week's course of hydrocortisone 50mg (finished ). repeat cortisol level on was 10.3. patient should have a repeat cortisol stimulation test at pcp visit on to assess adrenal function in non-stress situation and after a period since finishing steroid course. . 7) neuropathy: -gabapentin was initially held due to concern for renal clearance but was restarted once the patient left the icu. . 8) hypothyroidism: -patient continued with her levothyroxine treatment throughout her hospital course. . 9) fen: -due to concern for her volume overload and early celiac disease, patient was discharged with instructions to follow low-salt and gluten free diet. medications on admission: medications at last discharge (): 1. gabapentin 300 mg capsule sig: three (3) capsule po tid (3 times a day). 2. levothyroxine 25 mcg tablet sig: two (2) tablet po daily (daily). 3. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime). 4. nadolol 20 mg tablet sig: one (1) tablet po daily (daily). 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 6. levofloxacin 500 mg tablet sig: one (1) tablet po q24h (every 24 hours). discharge medications: 1. albuterol 90 mcg/actuation aerosol sig: six (6) puff inhalation q4h (every 4 hours) as needed. 2. spironolactone 100 mg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*2* 3. rifaximin 200 mg tablet sig: two (2) tablet po tid (3 times a day). :*180 tablet(s)* refills:*2* 4. levothyroxine 50 mcg tablet sig: one (1) tablet po daily (daily). :*30 tablet(s)* refills:*2* 5. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). :*60 tablet, delayed release (e.c.)(s)* refills:*2* 6. zolpidem 5 mg tablet sig: one (1) tablet po hs (at bedtime) as needed. :*30 tablet(s)* refills:*0* 7. nicotine 21 mg/24 hr patch 24hr sig: one (1) patch 24hr transdermal daily (daily). :*30 patch 24hr(s)* refills:*2* 8. gabapentin 300 mg tablet sig: three (3) capsule po tid (3 times a day). :*270 capsule(s)* refills:*2* 9. lactulose 10 g/15 ml syrup sig: thirty (30) ml po tid (3 times a day): hold if having three regular bowel movements each day. :*2700 ml(s)* refills:*2* 10. nadolol 20 mg tablet sig: 0.5 tablet po daily (daily). :*14 tablet(s)* refills:*0* 11. outpatient lab work please have blood work drawn on monday, . have basic metabolic panel drawn. please fax results to dr. office. thank you. discharge disposition: home discharge diagnosis: primary: duodenal varix bleed alcohol induced cirrhosis delirium aspiration pneumonia . secondary: adrenal insufficiency? hypothyroidism neuropathy diastolic chf asthma depression osteopenia early celiac disease discharge condition: stable discharge instructions: **you have been admitted for a gi bleed. you were treated and the bleed was stabilized. while in the icu, you developed an aspiration pneumonia, so you received antibiotics. your cirrhosis also was treated. **when you go home, you need to take all medications that are prescribed. you should remain on a gluten-free and sodium free diet, as recommended by gi. **you have an outpatient appointment with dr. and dr. resident, , on friday, at 1pm and 2:30pm. **if you develop any light headedness, dizziness, difficulty concentrating, vomiting, bleeding from your rectum, or any other concerning symptoms, please call your doctor immediately or go to the nearest ed. ** you have been provided a "prescription" to have your blood drawn on monday at the building. the results will be sent to dr. office. ** in addition, you will need to contact the patient assistance program () in the next to weeks to try and have the rifaximin prescription subsidized. followup instructions: you are scheduled for an appointment with dr. at 1:00 pm on friday, . , . you have an appointment with dr. office at 2:30pm on friday . ** you will have blood work drawn on monday, . Procedure: Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Other endoscopy of small intestine Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Angioplasty of other non-coronary vessel(s) Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Closed [endoscopic] biopsy of bronchus Insertion of non-drug-eluting peripheral (non-coronary) vessel stent(s) Transcatheter embolization for gastric or duodenal bleeding Transfusion of packed cells Other irrigation of (naso-)gastric tube Transfusion of other serum Phlebography of the portal venous system using contrast material Infusion of vasopressor agent Cranial or peripheral nerve graft Insertion of one vascular stent Procedure on single vessel Diagnoses: Acute posthemorrhagic anemia Acute and subacute necrosis of liver Alcoholic cirrhosis of liver Acquired coagulation factor deficiency Unspecified septicemia Severe sepsis Other and unspecified alcohol dependence, in remission Portal hypertension Unspecified acquired hypothyroidism Chronic airway obstruction, not elsewhere classified Hypopotassemia Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Other shock without mention of trauma Blood in stool Celiac disease Hematemesis Varices of other sites Unspecified hereditary and idiopathic peripheral neuropathy Diastolic heart failure, unspecified Foreign body in main bronchus Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation Unspecified viral hepatitis C with hepatic coma

allergies: nafcillin / aminoglycosides / bactrim / ceftriaxone / penicillins attending: chief complaint: respiratory distress, change in mental status major surgical or invasive procedure: 1. intubation

83-year-old female with myasthenia, dementia, afib not on coumadin, chf, s/p mvr who has been having recurrent aspiration pna presented with cough, low-grade fever. patient unable to give any history. per family, the patient had been more somnolent and coughing for more than 1 week. the family also noted that she has slightly increased respiratory rate. she was bought to the ed where her vitals were stable but an xray showed increase in bilateral pleural effusions and perihilar opacities consistent with congestive heart failure. she got iv lasix, clindamycin, levofloxacin and transferred to the micu for possible intubation for increased work of breathing. the family was not infavour of an intubation unless it was unavoidable. past medical history: 1. myasthenia on chronic prednisone. 2. alzheimer's dementia such that she is noncommunitive at baseline. 3. atrial fibrillation that is rate controlled. she is not on anticoagulation. 4. congestive heart failure on chronic lasix. 5. status post mitral valve replacement from endocarditis. 6. status post splenectomy. 7. status post orif for hip fracture. 8. history of frequent urinary tract infections. social history: she lives with her daughter who is her primary caretaker. at baseline, she is noncommunitive and spends most of her day in bed or in a chair. she can ambulate with assistance and will walk about 3 times per day. she doesn't drink alcohol or smoke. family history: non-contributory. physical exam: gen: 98.3, 152/87, 90, 18, 98%/2l nc heent: perla, eomi, mmm neck: jvd flat heart: s1/s2, rrr, holosytolic murmur at the apex/lusb lungs: clear anteriorly, decreased bs in bases, ? crackles posteriorly abdomen: s/nt/nd ext: no edema pertinent results: 10:16pm pt-12.9 ptt-24.8 inr(pt)-1.1 10:16pm plt count-598*# 10:16pm neuts-76.9* bands-0 lymphs-18.6 monos-3.9 eos-0.5 basos-0.2 10:16pm wbc-20.0*# rbc-3.70* hgb-9.3* hct-28.2* mcv-76*# mch-25.1*# mchc-32.8 rdw-16.6* 10:16pm ctropnt-<0.01 10:16pm ck(cpk)-53 10:16pm glucose-176* urea n-39* creat-0.8 sodium-135 potassium-5.1 chloride-92* total co2-27 anion gap-21* 11:08pm lactate-3.0* 12:05am urine rbc-0-2 wbc->50 bacteria-many yeast-none epi-0-2 03:25am wbc-13.5* rbc-3.33* hgb-8.2* hct-25.1* mcv-75* mch-24.8* mchc-32.9 rdw-16.4* cardiology report echo study date of conclusions: the left atrium is mildly dilated. left ventricular wall thickness, cavity size, and systolic function are normal (lvef>55%). regional left ventricular wall motion is normal. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. mild (1+) aortic regurgitation is seen. a bioprosthetic mitral valve prosthesis is present. the prosthetic mitral valve leaflets are thickened. the gradients are higher than expected for this type of prosthesis (likely related to mitral regurgitation rather than prosthesis stenosis). an eccentric, anteriorly directed jet of at least moderate to severe (3+) mitral regurgitation is seen. there is moderate pulmonary artery systolic hypertension. there is no pericardial effusion. compared with the prior study (images reviewed) of , the severity of mitral regurgitation may be slightly higher (was at least moderate on review of the prior study). the estimated pulmonary artery systolic pressure is slightly increased. if clinically indicated, a tee is suggested to better evaluate the mitral prosthesis and to quantify the severity of mitral regurgitation. brief hospital course: this is an 83 year-old female myasthenia, dementia, afib not on coumadin, chf, s/p mvr now with recurrent aspirations, cough and respo distress. . # respiratory distress: patient was admitted with respiratory distress, likely multifactorial in etiology from aspiration pneumonia, myasthenia , pleural effusions, pulmonary edema, and 3+ moderate mitral regurgitation as confirmed by echo. patient's respiratory distress worsened, was initially ventilated unsuccessfully with bipap, and was then intubated on . while patient was intubated, attempts were made to further improve respiratory status with aggressive diuresis to treat pulmonary edema likely secondary to mitral regurgitation and also with antibiotic treatment of likely aspiration pneumonia. patient initially treated broadly with levofloxacin, vancomycin, and flagyl but were further tailored as sputum cultures returned. during her micu course, sputum cultures grew the following bacteria: 1) stenotrophomonas maltophila sensitive only to bactrim to which the patient has an allergy, 2) mssa for which she received vancomycin due to a nafcillin allergy. after one week of mildly improved pulmonary edema with diuresis, continued antibiotic treatment, and discussion with the family regarding the goals of hospitalization, the patient was extubated without any complications and has remained stable on nasal canula. after discussion with id, it was felt that the stenotrophomonas was possibly only a colonizer rather than a pathogen and did not need to be treated. the course of vancomycin was completed and patient remained afebrile with improved respiratory status. she was maintained on her daily furosemide regimen while on the floor to ensure that pulmonary edema was kept to a minimum. patient was on room air at discharge, not requiring any supplemental oxygen. . #. arf/hypernatremia: the patient's creatinine began rising due to diuresis for pulmonary edema. eventually a fluid balance was achieved such that the creatinine was able to stabilize and the patient's respiratory status was also able to stabilize. . #. atrial fibrillation: the patient also has a history of atrial fibrillation which has been controlled primarily with rate control not anticoagulation. the anticoagulation was not done due to history of gi bleed. while patient was hypotensive, her metoprolol was held and then restarted once her blood pressure became more stable. patient was without complications regarding her atrial fibrillation. upon return to the general medical floor she did have episodes of sinus tachycardia that responded to fluid repletion. her metoprolol was titrated back up to 25mg and she was discharged on this dose. . # valve: patient is s/p mitral valve replacement due to a past episode of endocarditis. subsequently, echo during this admission demonstrated 3+ mitral regurgitation. patient's mitral regurgitation was thought to be contributing to her respiratory distress and worsening pulmonary edema. . # myasthenia : patient also has a known history of myasthenia and was continued on her prednisone without complication. neurology was consulted during this admission and did not feel her myasthenia was contributing to her respiratory distress. . # alzheimer's dementia: patient with alzheimer's dementia and is noncommunicative and nonverbal at baseline, according to the family. medications on admission: lopressor 37.5 lasix 20 qd prednisone 10 mg qd ranitidine 300 mg colace ca carb triamcinolone acetate . discharge medications: 1. prednisone 5 mg tablet sig: two (2) tablet po daily (daily) for 1 months. disp:*30 tablet(s)* refills:*0* 2. docusate sodium 150 mg/15 ml liquid sig: one (1) po bid (2 times a day) for 1 months. disp:*60 tablets* refills:*0* 3. ferrous sulfate 325 (65) mg tablet sig: one (1) tablet po daily (daily) for 1 months: please take with meals. disp:*30 tablet(s)* refills:*2* 4. ascorbic acid 500 mg tablet sig: one (1) tablet po daily (daily) for 1 months: please give with iron. disp:*30 tablet(s)* refills:*2* 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po bid (2 times a day) for 1 months. disp:*60 tablet(s)* refills:*0* 6. miconazole nitrate 2 % powder sig: one (1) appl topical (2 times a day) for 2 days: please apply to groin area twice per day for 2 days. disp:*qs 1 bottle* refills:*0* 7. furosemide 20 mg tablet sig: one (1) tablet po daily (daily) for 1 months. disp:*30 tablet(s)* refills:*2* 8. glyburide 2.5 mg tablet sig: one (1) tablet po once a day for 1 months. disp:*30 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary diagnoses: respiratory failure aspiration pneumonia chf exacerbation acute renal failure dehydration/hypernatremia iron deficiency anemia secondary diagnoses: atrial fibrillation mitral valve regurgitation myasthenia alzheimer's dementia decubitus ulcer h/o cva osteoporosis discharge condition: afebrile, blood pressure and heart rate stable, kidney function and electrolytes improved, and respiratory status stable. discharge instructions: you were diagnosed with pneumonia, congestive heart failure and dehydration. your pneumonia was treated appropriately with antibiotics for 2 weeks. your heart failure was also treated with diuretics and iv fluids. please contact your physician if you develop worsening shortness of breath, fevers greater than 101.5 degrees, or any other concerning symptoms. also please check your weight daily and contact your physician if you have weight gain greater than 3 pounds. please continue with the prescribed medication regimen. followup instructions: please follow up with your primary care physician. appointment has been made with a resident in the clinic who will be precepted by your primary care physician. provider: , md phone: date/time: 1:30 please continue with this tube-feed regimen: bolus tubefeeding: novasource pulmonary full strength 240ml per feeding 3 feedings per day at 8am, noon, and 4pm. residual check: before each feeding hold feeding for residual greater than 100 ml flush with 160ml of water before & after each feeding. also flush with 325ml of water at 8pm. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Non-invasive mechanical ventilation Arterial catheterization Transfusion of packed cells Diagnoses: Mitral valve disorders Urinary tract infection, site not specified Long-term (current) use of steroids Acute kidney failure, unspecified Atrial fibrillation Acute respiratory failure Pneumonitis due to inhalation of food or vomitus Alkalosis Personal history of other diseases of circulatory system Pressure ulcer, lower back Iron deficiency anemia, unspecified Heart valve replaced by transplant Pressure ulcer, heel Hyperosmolality and/or hypernatremia Myasthenia gravis without (acute) exacerbation Pressure ulcer, hip

allergies: nafcillin / aminoglycosides / bactrim / ceftriaxone / penicillins attending: chief complaint: hypoxic respiratory failure major surgical or invasive procedure: s/p intubation and extubation x 2 peg tube placement

83yo f with baseline dementia, myasthenia on prednisone, asp pna, splenectomy, hx of mvr (porcine valve), cva, afib, hx endocarditis who presents with hypoxic respiratory failure. the pt's family states that one month ago, the pt saw her neurologist; at that time they requested that decreased the prednisone dose. pt's mg has been stable for ~ 10 years on 10mg. initially, prednisone decreased to alternating 10/5mg; then decreased to 5mg qd, which is the current dose. per dtr, she noted pt developed non-productive cough, increased dysphagia, and increased lethargy 2 weeks ago - the grandson disagrees with this history. one day pta, pt was noted to have increased lethargy and difficulty walking (is able to walk with assistance at baseline). temp was noted to be 100; brought pt to ed. family denies recent chills, pains (pt is non-communicative), cough, changes in urination (incontinent at baseline), diarrhea. . on presentation to the ed, the pt was found to have a fever to 101.4 and to be hypoxic to the 80s and rapidly deteriorated to the 70s at which point she was intubated. started on propofol drip. initial labs remarkable for lactate 3.5, wbc 25. cxr with rml infiltrate. in the ed was given ceftriaxone and clindamycin. started on propofol drip. given 3l ns, tylenol, decadron 10mg iv x1. past medical history: - endocarditis - s/p mvr - ivig therapy for above c/b septic thrombophlebitis and endocarditis. wound up with porcine mvr - h/o strokes - frequent utis - chronic abd pain - chronic back pain - depression - mg on prednisone - afib - h/o asp pna - h/o brbpr - asthma - s/p splenectomt - s/p orif hip social history: lives with family. no current etoh, tob and goes to day care family history: nc physical exam: vs: t98, p85 (65-85), 119/60, 100-120/50-60, p67, 60-80, rr20, 100% ac 400/28/8/0.6 gen: cachetic, intubated, sedated heent: bilateral surgical pupils cv: rrr, nl s1 s2, holosytolic murmur at apex chest: rhonchi/crackles at right base abd: soft, nt, nd, +bs ext: no edema skin: macularpapular erythematous rash on abdomen pertinent results: 08:50pm ck-mb-notdone ctropnt-0.01 08:50pm ck(cpk)-66 03:50pm lactate-3.1* 03:30pm wbc-25.0*# rbc-4.21 hgb-12.8 hct-36.5 mcv-87 mch-30.3 mchc-34.9 rdw-14.8 03:30pm neuts-58 bands-26* lymphs-4* monos-11 eos-0 basos-0 atyps-1* metas-0 myelos-0 03:30pm hypochrom-normal anisocyt-1+ poikilocy-normal macrocyt-normal microcyt-normal polychrom-normal 03:30pm plt count-267 03:19pm lactate-3.4* 03:00pm urine color-straw appear-hazy sp -1.012 03:00pm urine blood-neg nitrite-pos protein-neg glucose-neg ketone-neg bilirubin-neg urobilngn-neg ph-6.5 leuk-tr 03:00pm urine rbc-0-2 wbc-0-2 bacteria-many yeast-none epi-<1 02:56pm glucose-155* urea n-23* creat-0.9 sodium-146* potassium-3.8 chloride-103 total co2-28 anion gap-19 02:56pm alt(sgpt)-13 ast(sgot)-22 ld(ldh)-262* ck(cpk)-78 alk phos-104 tot bili-0.6 02:56pm ctropnt-0.02* 02:56pm ck-mb-notdone 02:56pm pt-13.7* ptt-25.6 inr(pt)-1.2* brief hospital course: a/p 83yo f with myasthenia , asthma, hx of splenectomy and aspiration pna, cva and mvr with afib who is admitted from the ed with hypoxic respiratory failure secondary to pneumonia and rsv. . #. respiratory failure (hypoxic at admission then later hypercarbic for reintubation): the patient empirically started on ceftriaxone, azithromycin and clindamycin to cover community acquired pna as well as aspiration pna given her previous hx of aspiration pneumonia and myasthenia . because of her level of hypoxia, she was intubated for oxygenation. given her chronic steroid use for mg and immunosuppression, bronchoscopy was done and was ruled out of pcp. cx eventually grew s. pneumo and viral cx came back positive for rsv. the patient was continued on ceftriaxone, azithro, and clinida until the patient developed rash likely from ceftriaxone as she has a known pcn allergy causing rash. the patient was switched to levofloxacin and finished a total of 7 day course of antibiotics. the patient was successfully weaned off the ventilator and extubated on . while waiting to be called out to the floor, the patient developed chf exacerbation poor bp and pulse control as the patient has mvr. after diuresis and better bp and pulse control, the patient was ready to be called out but then developed somnolence. abg was obtained and was 7.22/90/91 c/w hypercarbic respiratory failure. the patient was placed on bipap with improvement with hypercarbia but did not resolve, thus the patient was re-intubated after discussing with family. on the day after intubation, the patient spiked a temp and developed leukocytosis, so pt was started on vanco and levo empircally for nosocomial pna. after cultures returned negative 48 hours however, the abx were discontinued. the patient was aggressively diuresed and bp and pulse were strictly controlled. after adequate diuresis, the patient was extubated again and weaned o2 supplement as tolerated. she was transferred to the floor where she remained stable. her oxygen was gradually weaned until patient was maintaining oxygen saturation of 94-95% on room air. . #. streptococcal pna/rsv/ citrobacter uti: the patient was on ceftriaxone, azithro and clinda for 5 days and then switched to levo to complete a 7 day course of abx for pna until . citrobacter was pansensitive. #. myasthenia : the patient was transiently on iv solumedrol then swithed to home dose prednisone 10mg qday. initially, there was a question whether recent lowering of prednisone to 5 mg could be contributing to difficulty ventilation weaning and neurology and neuromuscular were consulted. it was concluded that the patient was less likely to having myasthenia flare, and was continued on the same prednisone dose. the patient was extubated successfully with diuresis, nebs and treatment of pna. when the patient was re-intubated for hypercarbic respiratory failure, prednisone was increased to 10mg qday. . cvs: #. ischemia: the patient was ruled out with negative 3 sets of negative cardiac biomarkers. . #. chf: the patient received a lot of fluids while in the micu and developed pulmonary edema. the patient was subsequently diuresed with iv lasix and later auto-diuresed herself as well. the patient was given iv lasix/prn for diuresis. the patient was also started on bb and acei. the patient will likely need a standing po lasix as outpatient. . #. a-fib: hx of afib. the patient was in and out of a-fib while in the micu. as the patient was on no anticoagulation as outpatient, so no anticoagulation was started. the patient was started on low dose bb and was titrated up for rate control. . # htn: the patient was noted to be hypertensive in the micu and was started on a bb and acei. her blood pressure remained well-controlled on the current regimin. . # ppx: tylenol, ppi, bowel regimen, sc heparin . # fen: the patient failed speech and swallow on and post-pyloric tube was placed and started tube feeding. speech and swallow evaluation was repeated on and patient failed again. peg tube was placed on . there were well as discussions about the peg tube and the fact that she will likley remain unable to tolerate po indefintely. although they say they understand that she cannot tolerate food or liquids, they are also quite frank in their intention to try feeding the patient again at home, even though it was explained to them that this would almost certainly lead to aspiration, penumonia, and then on to intubation. the patient's daughter and granddaughter were trained by the clinical specialist in peg tube care and tube feedings and demonstrated the understanding and ability to do both. . # access: piv . # full code: confirmed with grandson and daughter. there were multiple discussions with the patient's family about the patient's prognosis and high likelihood that she will require re-intbation in the future. family is adamant that the patient would want to be a full code. . #social issues: patient has some kind of difficulty with her immigration status. at this time, she has no evidence of legal entry into the united sates and is ineligible for many services. patient does not have insurance. medications on admission: 1. ranitidine 300mg qd 2. prednisone 5 mg once a day. 3. calcium discharge medications: 1. acetaminophen 650 mg suppository sig: one (1) suppository rectal q4-6h (every 4 to 6 hours) as needed. 2. prednisone 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 3. camphor-menthol 0.5-0.5 % lotion sig: one (1) appl topical qid (4 times a day) as needed. disp:*1 bottle* refills:*0* 4. docusate sodium 150 mg/15 ml liquid sig: ten (10) ml po bid (2 times a day). disp:*qs * refills:*2* 5. metoprolol tartrate 25 mg tablet sig: 1.5 tablets po twice a day. disp:*90 tablet(s)* refills:*1* 6. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*1* 7. probalance liquid sig: two y (240) ml po five times a day. disp:*24 can* refills:*6* 8. outpatient speech/swallowing therapy patient needs repeat speeach and swallow evaluation in weeks after discharge. 9. lisinopril 20 mg tablet sig: one (1) tablet po once a day. disp:*30 tablet(s)* refills:*1* discharge disposition: home with service facility: caregroup vna discharge diagnosis: aspiration pneumonia community-acquired pneumonia atrial fibrillation discharge condition: stable discharge instructions: take all medications as prescribed - do not stop or change your medications without first speaking to your doctor. follow-up as outlined below. please contact your doctor if you experience any chest pain, shortness of breath, abdominal pain, fever, chills, or if there is any redness, swelling, or pus around the peg tube. tube feedings: please give 240 ml probalance five times per day. you should also give 240 ml of water three times per day. followup instructions: 1. provider: , md phone: date/time: 3:00 2. provider: , m.d. phone: date/time: 11:30 3. call to schedule a repeat speech and swallow test in weeks. there is a referral attached to this form. 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 Enteral infusion of concentrated nutritional substances Thoracentesis Thoracentesis Percutaneous [endoscopic] gastrostomy [PEG] Arterial catheterization Closed [endoscopic] biopsy of bronchus Diagnoses: Anemia, unspecified Unspecified pleural effusion Congestive heart failure, unspecified Long-term (current) use of steroids Unspecified septicemia Severe sepsis Atrial fibrillation Other persistent mental disorders due to conditions classified elsewhere Acute respiratory failure Heart valve replaced by transplant Hyperosmolality and/or hypernatremia Diastolic heart failure, unspecified Adult failure to thrive Myasthenia gravis without (acute) exacerbation Pneumonia due to respiratory syncytial virus

allergies: iron dextran complex attending: chief complaint: fevers major surgical or invasive procedure: -l ij central line -av fistulagram with recannalization attempt by interventional radiology -ct with contrast -echocardiogram -pericardiocentesis -thrombectomy of av graft thrombus

ms. is a pleasant 77-year-old female who was recently diagnosed with nonsmall cell lung cancer in , and is status post four treatments consisting of taxol, carboplatin and xrt to the right pretracheal mediastinal area, who presents to the emergency department with fever and decreased blood pressure along with some confusion. the patient was recently discharged on with the new diagnosis of her nonsmall cell lung cancer and was sent to for conditioning while receiving her chemotherapy. the patient had been tolerating the treatments well until the night before admission when she started complaining of fatigue, and her o2 sat dropped to 93% on room air. later on, the patient became very hypoxic with an oxygen saturation of 87% on room air, and started experiencing lethargy along with increased confusion. the patient received percocet for her pain, and her temperature spiked to 101.8, and o2 sats continued to drop to 86% on 4 liters of nasal cannula. the patient also had decreased urine output, and her blood pressure on arrival to the ed was 100/60, with a pulse of 110, and a respiratory rate of 30. the patient also started to experience some diaphoresis along with accessory muscle use, and was sent to the ed of . on admission, the patient denied any headache, neck stiffness, rash, cough, shortness of breath, chest pain, abdominal pain, dysuria, frequency, urgency of her urine. the patient was started on zosyn and transferred to the kenard-icu on the mus ....... protocol for a working diagnosis of septic shock secondary to pneumonia. past medical history: 1. nonsmall cell lung cancer. 2. copd. allergies: no known drug allergies. social history: she was a retired psychologist at . she lives alone in , . she used to smoke but quit 15 years ago, but occasionally has 1 or 2 cigarettes a week. denies any iv drug use, but is an occasional alcohol drinker. medications on admission: 1. colace 100 mg . 2. protonix 40 mg qd. 3. trazodone 25 mg q hs prn. 4. tylenol prn. 5. percocet prn. 6. calcitonin 200 u intranasal qd. 7. albuterol-atrovent inhalers. 8. lasix 20 mg . 9. lactulose. 10.fluoxetine 20 mg qd. 11.dexamethasone 4 mg po qid. physical exam on admission - vital signs: temperature 95, pulse 107, blood pressure 132/68, respiratory rate 20, o2 sat 95% on 4 liters. general: pleasant, elderly female who appeared to be in no acute distress on admission. heent: perrla. neck: supple, dry mucosal membranes. heart: s1, s2, tachycardic. lungs: diffuse expiratory wheezing with no accessory muscle use at the time of admission. no paradoxical breathing. abdomen: soft, nondistended, nontender, positive bowel sounds. extremities: warm, no edema, 2+ pulses. neuro: alert, awake, oriented x 3, motor strength in upper and lower extremities. labs at admission: white count 0.2, anc 170, crit 33.2, platelets 85, pt 12.4, ptt 29.1, inr 1.0, sodium 124, potassium 4.7, chloride 93, bicarb 23, bun 19, creatinine 0.2, glucose 84, mag 1.6, phosphorus 2.7, alt 30, ast 26, amylase 37, lipase 9, alk phos 109, total bili 0.8, albumin 2.8, lactate 1.8. urinalysis was negative with no signs of infection. abgs 7.43, pco2 35, po2 77 on 100% nonrebreather. radiographic images: chest x-ray showed a large spiculated density in the right hilum, 7.0 x 5.2 cm, along with adenopathy. pulmonary vasculature was slightly prominent with kerley b lines consistent with chf. improved bilateral pleural effusions as compared to prior x-rays. ekg: showed 100 beats per minute, rate sinus rhythm, normal axis, normal intervals, delayed r wave progression, and there was some t wave inversions in v2-v4. hospital course - 1) sepsis/id: the patient presented to the hospital with hypotension, fever, lethargy, and had a white count of 0.2 most likely secondary to her most recent chemotherapy. although initially there were no clear presenting symptoms, or signs of patient infection, the patient was started on broad coverage of zosyn, zithromax and vancomycin. blood cultures, urine cultures, sputum cultures were sent, and throughout the hospital course the patient's blood culture grew back positive for strep pneumoniae, and so the patient was tailored accordingly to the sensitivities, and was started on ceftriaxone 1 gm qd. in addition, the zithromax and the zosyn were stopped, since the urine legionella was negative. the patient was also started on stress dose steroids of hydrocortisone 100 mg iv tid which the patient continued for 7 days. throughout the hospital course, the patient's white blood count slowly began to rise without requiring any neupogen. a surveillance set of blood cultures was sent on , and another one on which showed no further growth in the blood. the patient completed a 7-day course of iv ceftriaxone. 2) respiratory: when the patient initially presented, the patient did not appear to be in respiratory distress. however, throughout the hospital course a cat scan was obtained that showed significant right middle lobe and right lower lobe pneumonia, although the patient not producing much sputum. the patient was continued on the ceftriaxone, and on the patient was intubated secondary to respiratory failure. the patient began to retain carbon dioxide and became confused and less responsive. the patient was extubated on in anticipation for comfort measures only since the patient's condition continued to deteriorate with a very poor prognosis. 3) cardiology: the patient has no known coronary artery disease, and throughout the hospital course the patient was in sinus rhythm with occasional pacs and ectopy. the patient was tachycardic which was thought to be a combination from her being in sepsis, volume overload due to resuscitation, respiratory distress. in addition, after intubating, the patient became very hypotensive and had decreased urine output, and so required a significant amount of fluid resuscitation along with levophed to help maintain her blood pressure. her levophed was slowly weaned off a day or two prior to her extubation, since she was able to maintain an adequate amount of blood pressure. 4) heme/onc: the patient completed chemotherapy consisting of taxol, carboplatin and xrt for nonsmall cell lung cancer. dr. who is her primary oncologist was involved during the care of this patient in the icu who recommended that there was no need for neupogen, as her white count would slowly increase. dr. also had an extensive discussion with the family that despite her aggressive treatment, her prognosis is very poor, and so at that time it was decided that she would be extubated for goals of comfort measures only. 5) lines/access: the patient will have a right subclavian line to help get her medications to make her comfortable consisting of morphine and ativan. 6) code: the patient is dnr/dni. 7) communication: the healthcare proxy is her brother, , and their family consisting of mr. , , and ms. were very involved in her care. discharge status: the patient is being discharged to either inpatient hospice versus home hospice with comfort measure goals. discharge condition: the patient is comfortable at this time. discharge medications: morphine prn. discharge diagnoses: 1. nonsmall cell lung cancer. 2. pneumococcal pneumonia. 3. chronic obstructive pulmonary disease. 4. depression. , m.d. dictated by: medquist36 Procedure: Venous catheterization, not elsewhere classified Continuous invasive mechanical ventilation for 96 consecutive hours or more Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Diagnoses: Congestive heart failure, unspecified Chronic airway obstruction, not elsewhere classified Acute respiratory failure Septic shock Malignant neoplasm of other parts of bronchus or lung Encounter for palliative care Pneumococcal septicemia [Streptococcus pneumoniae septicemia] Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]

allergies: patient recorded as having no known allergies to drugs attending: addendum: podiatry performed an osteotomy on left second toe. there were no complications. patient still ready for rehab. swab from still reporting: gram + cocci to id or sensitivities discharge disposition: extended care facility: health of - md Procedure: Venous catheterization, not elsewhere classified Arteriography of femoral and other lower extremity arteries Other (peripheral) vascular shunt or bypass Aortography Nonexcisional debridement of wound, infection or burn Transfusion of packed cells Other amputation below knee Endarterectomy, lower limb arteries Diagnoses: Coronary atherosclerosis of native coronary artery Unspecified essential hypertension Other convulsions Atrial flutter Ulcer of other part of foot Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled Chronic obstructive asthma, unspecified Arterial embolism and thrombosis of lower extremity Atherosclerosis of native arteries of the extremities with ulceration Other bone involvement in diseases classified elsewhere Personal history of peptic ulcer disease Atherosclerosis of autologous vein bypass graft of the extremities Chronic osteomyelitis, ankle and foot

allergies: patient recorded as having no known allergies to drugs attending: chief complaint: bilateral foot ulcers major surgical or invasive procedure: right below knee amputation left5 sfa to pt bypassgraft with issvg, left sfa endartectomy, angioscopy angio with bilateral lower extremity runoff picc line rt.

hpi: mr. is a 57 year-old man with hx of esrd on hemodialysis since who presented with 1 day history of fever to 101 at home and 1 week history of cough. the patient reports he developed a cough approximately one week ago that has been productive of copius white sputum. he describes daily episodes of coughing upon waking and "throwing up white stuff." there is no evidence of food or bile in the secretions and he believes they are coming from his lungs rather than his stomach. he also notes that these coughing fits make him feel nauseus. 2 days prior to admission he was given reglan for nausea and "throwing up." he subsequently developed diarrhea, and has had approximately 5 mushy brown, non-bloody stools daily. he has not experienced any sore throat, chills, abdominal pain, dysuria. he notes lightheadedness on changing positions but has been experiencing this since begininning dialysis in . he also experiences achiness following dialysis. he denies any fever prior to the day before admission. . ros: has doe at baseline, cannot walk up a flight of stairs. denies chest pain, abdominal pain, sweats. . in the ed, the patient's temperature was 100.6. he underwent cxr (clear) and ct with contrast. blood cultures were sent and he received levofloxacin 500mg, flagyl 1000mg, vancomycin 1g past medical history: 1. esrd on hemodialysis, awaiting placement on transplant list 2. renal cell carcinoma of left kidney (s/p partial nephrectomy ) t1, n0, m0. surveillance mr was negative for recurrence. 3. hypertension 4. diabetes type 2, recently diagnoses, hba1c 9 5. hepatitis c infection 6. bilateral hearing loss 7. gout 8. anemia 9. ??????s esophagus 10.prostate nodule, psa 2.8 fall social history: lives with sister, previously worked in a hotel, quit after admission to hospital. previous 80 pack year smoking history, quit in . previous etoh history of 1 pint per week, quit in previous crack cocaine use (1-2 times per month), quite in previous heroin use, quite 5-6 years ago family history: sister- dm reported cad. positive for alcoholism. mother died of "liver problems"; father died of stroke at 51. he is unsure of any other medical problems in his family. physical exam: physical exam: vs: t100.6 bp 107/76 hr 101 rr 22 o2sat 94%ra gen: subdued-appearing middle-aged man in nad heent: icteric sclera, op clear, mmm neck: supple, no lad, no jvd card: tachycardic, regular rhythm, normal s1, s2. 3/6 systolic murmur at l upper sternal border lung: crackles on r from base to middle lung field. crackle on l at base only. moving air well. abd: protuberant, soft, nd, slightly tender in site of recent bx in ruq, no ascites. liver edge nonpalpable. no splenomegaly ext: wwp, dry, scaly skin on lower legs and feet bilaterally. dp 2+ bilaterally pertinent results: cxr : the left-sided ij central venous line has migrated slightly more proximally and the distal tip is in the distal left brachiocephalic vein. the cardiac size is prominent but unchanged. there is some tortuosity to the thoracic aorta. some streaky density seen at the left base, best seen on the lateral radiograph. this is likely secondary to atelectasis, however, early infiltrate cannot be completely excluded. attention to this region is recommended on followup studies. . . ct abdomen/pelvis w/ contrast : ct abdomen: there is bilateral pleural thickening and bibasilar atelectasis, which is unchanged from prior exam. there has been interval development of a large pericardial effusion. the effusion measures higher than fluid density at 30 hounsfield units and was not present previously. the liver, gallbladder, pancreas, spleen, adrenal glands, and kidneys are stable in appearance. the patient is status post partial left nephrectomy. multiple low attenuation renal foci are noted and may represent cysts but are too small to be fully characterized. the stomach and bowel loops are within normal limits. there is no free air or free fluid. of note, are prominent left diaphragmatic, paraesophageal, and para vena caval lymph nodes. they are increased in size compared to prior examination. ct pelvis: the bladder, prostate, seminal vesicles, and rectum are unremarkable. there is focal segment of narrowing in the sigmoid colon, which may relate to transient peristalsis. contrast is seen passing beyond this point. there is no free fluid and no pelvic or inguinal lymphadenopathy. bone windows: there are no suspicious lytic or sclerotic osseous lesions. impression: 1. interval development of a large pericardial effusion with high attenuation fluid. 2. interval increase in size of left diaphragmatic, paraesophageal, and para vena caval lymph nodes. these could be inflammatory, however, given the patient's history of renal cell carcinoma, neoplastic involvement cannot be excluded. 3. low attenuation renal foci, which may represent cysts but are too small to be fully characterized. 4. pleural thickening and atelectasis at both lung bases. . . cxr pa & lateral : cardiomegaly is unchanged. a left internal jugular central venous catheter is in unchanged position, with the tip in the superior portion of the svc. no pneumothorax is identified. there is no consolidation or evidence of congestive failure. no pleural effusion. impression: cardiomegaly. no evidence of pneumonia. . . ekg : sinus tachycardia modest st-t wave changes with probable qt interval prolonged although is difficult to measure - are nonspecific but clinical correlation is suggested. since previous tracing of , probable no significant change . . echocardiogram : conclusions: 1.the left atrium is mildly dilated. the left atrium is elongated. the inferior vena cava is dilated (>2.5 cm). 2.left ventricular wall thicknesses are normal. the left ventricular cavity size is normal. regional left ventricular wall motion is normal. overall left ventricular systolic function is normal (lvef>55%). 3.right ventricular chamber size is normal. right ventricular systolic function is normal. 4.the aortic valve leaflets are mildly thickened. no aortic regurgitation is seen. 5.the mitral valve leaflets are structurally normal. no mitral regurgitation seen. 6.there is a moderate to large sized pericardial effusion. the effusion appears circumferential. there is very mild diastolic invagination of the right ventricular outflow tract and there is respiratory variation of mitral valve inflow consistent with early tamponade. . . cardiac cath/pericardiocentesis : 1. right heart catheterization revealed severe elevation of right and left sided filling pressures along with equalization of ra, rv end diastolic, pa diastolic and pcwp at about 20mmhg. the cardiac index was preserved at 3.7. there was marked respiratory variation (peak to peak of 30mmhg) in the femoral artery pressure tracing. 2. pericardiocentesis was uncomplicated and revealed an opening pressure of 20mmhg and was essentially identical to ra pressure. 600 cc of bloody fluid were drained with improvement in ra pressure to 10mmhg. the cardiac index remained unchanged at 3.6. 3. echo done post procedure revealed only minimal effusion posteriorly (pt had 2.5cm circumfrential effusion yesterday). final diagnosis: 1. pericardial effusion with tamponade physiology 2. successful pericardiocentesis. . . echo : conclusions: there is a trivial/small pericardial effusion. there are no echocardiographic signs of tamponade. . . labs: 01:50pm: wbc-15.1* rbc-3.41* hgb-9.6* hct-30.4* plt count-692 mcv-89 mch-28.1 mchc-31.5 rdw-16.0* neuts-69.3 lymphs-23.3 monos-5.7 eos-1.0 basos-0.8 pt-13.4* ptt-24.9 inr(pt)-1.2* glucose-79 urea n-29* creat-7.9*# sodium-138 potassium-3.7 chloride-93* total co2-27 anion gap-22* lactate-1.6 06:10pm: urine sp -1.022 blood-neg nitrite-neg protein-100 glucose-neg ketone-neg bilirubin-sm urobilngn-neg ph-5.0 leuk-neg rbc-0 wbc-0-2 bacteria-mod yeast-none epi-0-2 brief hospital course: #. issues to be followed-up as outpatient: 1) needs echo to assess for reaccumulation of pericardial effusion in 4 weeks followed by appointement with dr. . the patient has been instructed to call to schedule echo and appointment. 2) assymetric lad of the left paraesophageal, diaphragmatic and vena caval lymph nodes seen on ct chest . needs repeat ct in weeks. 3) had one dark, guaiac-positive stool on . should have outpatient colonoscopy. 4) rcc, psa . #.pericardial effusion: first noted on ct chest on . viral etiology was felt to be most likely. despite his esrd it was thought that this was unlikely to be a uremic effusion because he has been well-dialyzed. on , the patient's sbp was in the 90's. it was unclear if this drop in bp was secondary to the effusion or to intravascular depletion from dialysis the day before. he was given 3 boluses of ivf and bp improved. pulsus paradoxus was monitored and remained stable at 10-12mmhg. cardiology was consulted and the patient underwent tte on which showed 1.5-2cm pericardial effusion. on he underwent pericardiocentesis: 600cc of fluid was removed and a pericardial drain was placed which drained 80cc of serosanginous fluid over 24 hours. the patient tolerated the procedure well and went to the ccu for post-procedure monitoring. pericardial fluid was found to be an exudate. wbcs were seen. diff was: n 27%, l 41%, mono 4%, eos 4%, macros 24%. gram stain and acid fast smear were negative. fluid culture showed no growth, anaerobic culture preliminarily no growth. fungal cultures preliminarily negative, acid fast culture pending. cytology was negative for malignant cells. ppd was negative. he tolerated the procedure well and a pericardial drain was placed. on , drain output was minimal and removal of the drain was attempted. removal was not successful and the patient underwent angiography for removal of the drain, which was found to be incorporated into a loculated portion of the pericardial sac. given these findings, this is most likely viral etiology, however, malignancy must still be considered. on echocardiogram 24 hours post-procedure, no re-accumulation of fluid was seen. the patient remained hemodynamically stable until discharged. he is to schedule a follow-up echocardiogram with dr. () in about 4 weeks (). . #.fever: the patient presented with fever to 101 at home, in the setting of 1 week of productive cough. his wbc was also elevated to 15.1 on admission, and he received vancomycin, levo and flagyl in the ed. blood cultures, urine cultures and stool cultures were sent and found to be negative. there was no evidence of pneumonia on chest films. given that mr. is a hemodailysis patient, the team's greatest concern was for infected venous access causing bacteremia, and blood cultures were repeated x3. as there was no evident source of infection, no further antibiotics were given. tylenol was held so fever curve could be monitored, and he continued to have low grade fever until his effusion was drained on . following drainage of the effusion the patient continued to become febrile during/after hemodialysis treatments, but was otherwise afebrile. given his history of renal cell carcinoma, this was also considered as a possible source of fevers. rcc is being followed as an outpatient. by the day of discharge, mr. was afebrile and his wbc had decreased to 9.9. . #.esrd: the patient has received hemodialysis since , on tues, thurs, sat schedule. dialysis was continued on this schedule while the patient was hospitalized. on saturday , 2.2kg fluid was removed resulting in sbp in 90's. he also reported lightheadedness with changes in position. subsequently, he received iv fluid boluses and his blood pressure improved. on the patient underwent fistulagram that had been scheduled as an outpatient to work-up difficulty with fistula access. the graft was found to be stenosed, and revision by angiography was performed. on post-procedure imaging the graft was found to be thrombosed, and re-cannulation was again attempted that afternoon. ultrasound the following morning () revealed complete occlusion of the fistula throughout its graft portion from the arterial anastomosis to the venous anastomosis. transplant surgery performed thrombectomy on , and post-procedure exam revealed 2+ graft pulse and restoration of a graft thrill. the patient missed his tuesday hemodialysis secondary to graft thrombosis and was subsequently dialyzed wednesday-thursday-friday-saturday. he continued to have good pulse and graft thrill at discharge. in addition to continuing dialysis, the patient was continued on calcium carbonate 500mg tid. electolytes were monitored. the transplant service was aware of the patient, and the renal service followed him while inpatient. . #. hypoxia: on the patient became hypoxic to 88% on ra. he was placed on 2l nc with sats 94-97%. he denied sob or chest pain at the time. concern was for pneumonia of chf, given his reports of dyspnea on exertion at baseline. cxr was checked with no evidence of pneumonia, pulmonary edema, or pleural effusion. his oxygen sats were monitored and the patient was instructed to use an incentive spirometer. sats improved over the next two days and supplemental oxygen was discontinued. . #.anemia: the patient has had anemia requiring transfusions in the past, likely related to esrd. on admission hct was 30.4, then declined over several days to 25.3. he was transfused 1 unit prior to pericardiocentesis, and his hct increased appropriately with the transfusion. on he had one dark, soft formed stool that was guaiac positive. hct was monitored. it remained stable and was 30.4 on the day of discharge. given recent negative colonoscopy () patient will simply require regular follow-up in 5 years. . #.nausea and diarrhea: at baseline, the patient has frequent nausea associated with acid reflux, for which he takes prilosec 40mg . he also gives a history of food "getting stuck" and being regurgitated, suggesting gastroparesis. on admission, the patient reported post-tussive nausea for 1 week. he has also described daily episodes of "throwing up" upon waking up in the morning, but these episodes were always associated with coughing, and the description given of the secretions was suggestive of sputum rather than emesis. on the day following admission the patient had one episode of vomiting after eating breakfast. he noted that he had not been eating for the week prior to adimission. he continued to experience intermittent nausea until , when his appetite improved. the patient had been started on reglan 2 days prior to admission for presumed nausea and vomiting and subsequently developed soft stools, approximately 5 per day. stool cultures were sent, and c. difficile toxin was negative. he continued to have guaiac-negative soft stools while hospitalized. one guaiac-positive dark, soft formed stool was recorded on . hct remained stable and the patient had a normal brown colored bm prior to discharge. he was not orthostatic on discharge. . #.depression: patient has had ongoing discussion with his outpatient treaters about starting an antidepressant medication. during his hospitalization he informed the team that he now feels that he needs to start a medication to help with depression. he was started on zoloft 25mg daily and advised of possible side effects of nausea, vomiting and diarrhea. he was also advised that the medication would most likely not have any effect on his mood for several weeks. . #. hypertension: remained stable. home medications (valsartan 360mg, diltiazem 320mg, amlodipine 5mg) were continued until , when the patient found to have low bp. valsartan was then decreased to 80mg daily and amlodipine was held. all bp meds were held on due to concern for early tamponade. home regimen was resumed after drainage of pericardial effusion; the patient's bp remained stable. . #. diabetes: the patient was placed on qid finger sticks and insulin sliding scale while hospitalized. he was continued on glipizide 5mg daily and lantus 10 units daily except when npo for procedures. the majority of his finger sticks were at goal. . #.gout: remained stable, without symptoms. allopurinol 100mg qod was continued. . #.??????s esophagus: continued ppi 40mg . #.hepatitis c: viral load was sent (currently pending). . #.prophylaxis: while on bed rest, the patient was maintained on sc heparin. this was discontinued when he began to feel better and get out of bed frequently. . #.fluids, electrolytes, nutrition: the patient was maintained on a renal/cardiac diet. electrolytes were checked daily and the patient received hemodialysis on his outpatient schedule plus two additional sessions. medications on admission: aspirin 81 mg daily nephrocaps 1 cap daily allopurinol 100 mg qod valsartan 320mg daily amlodipine 5mg daily diltiazem sr 360mg daily glipizide 5mg daily lantus 10units qam prilosec 40mg discharge medications: 1. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). 2. allopurinol 100 mg tablet sig: one (1) tablet po every other day (every other day). 3. prilosec 40mg one tablet twice daily 4. calcium carbonate 500 mg tablet, chewable sig: one (1) tablet, chewable po tid (3 times a day). 5. diltiazem hcl 360 mg capsule, sustained release sig: one (1) capsule, sustained release po daily (daily). 6. valsartan 160 mg tablet sig: two (2) tablet po daily (daily). 7. amlodipine 5 mg tablet sig: one (1) tablet po daily (daily). 8. sertraline 50 mg tablet sig: half tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 9. glipizide 5 mg tablet sig: one (1) tablet po daily (daily). 10. insulin glargine 100 unit/ml solution sig: one (1) 10 units subcutaneous once a day. discharge disposition: home discharge diagnosis: fever new pericardial effusion end-stage renal disease on hemodialysis occlusion of hemodialysis fistula graft anemia diabetes discharge condition: good discharge instructions: 1. please call your doctor or return to the emergency department if you develop fever >101, chills, vomiting, abdominal pain, chest pain, fainting, shortness of breath at rest or lying down, lightheadedness, or for any other concerning symptoms. 2. please keep all of your appointments as scheduled (see below). 3. please keep your dialysis schedule of tues/thurs/sat. 4. restart all of your home medications, including your diabetes medicines. we have added an antidepressant to your medications (sertraline 25mg); take half a tablet once a day followup instructions: 1. dr. at 4pm phone: 2. dr. , md-- at 8:40am phone: 3. please call ( to schedule an appointment with dr. to have an echocardiogram in 4 weeks. Procedure: Venous catheterization, not elsewhere classified Other revision of vascular procedure Other revision of vascular procedure Coronary arteriography using a single catheter Hemodialysis Angioplasty of other non-coronary vessel(s) Pericardiocentesis Transfusion of packed cells Right heart cardiac catheterization Procedure on single vessel Diagnoses: Anemia in chronic kidney disease End stage renal disease Chronic hepatitis C without mention of hepatic coma Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled Gout, unspecified Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Personal history of malignant neoplasm of kidney Barrett's esophagus Other complications due to renal dialysis device, implant, and graft Acute idiopathic pericarditis

allergies: iron dextran complex attending: chief complaint: esrd major surgical or invasive procedure: attempted renal transplant/aborted