SUBJECT_ID,INDEX_HADM_ID,INDEX_ROW_ID,INDEX_CHARTDATE,ROW_ID,HADM_ID,CHARTDATE,CATEGORY,TEXT,days_from_index,ADMITTIME,DISCHTIME,ADMISSION_TYPE,ADMISSION_LOCATION,DISCHARGE_LOCATION,DIAGNOSIS,hospital_course_processed,Diagnosis_Description,BertSummarizer,t5seq2eq 109,140167.0,14802,2141-12-23,14796,139061.0,2141-09-14,Discharge summary,"Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Right leg pain. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 24 y.o. F with lupus, Chronic Kidney Disease V (not currently on HD or PD), and multiple admissions for hypertensive urgency/emergency, who presented to the ED for continued R leg pain that starts in her R buttocks and refers down her R leg. She describes it as feeling like the pain is deep within her bone. The pain was [**10-20**] in the AM, and she felt like she couldn't get out of bed. Denies any swelling of her RLE. When getting VS in [**Name (NI) **], pt noted to be very hypertensive at 263/176. The patient reportedly has baseline SBPs in 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM on day of admission. She denies any recent recrational drug use including cocaine and amphetamines. She denies headache, vision changes, double vision, chest pain, shortness of breath, abdominal pain, BRBPR, dysuria. During MD interview, the patient was nauseous and had small amount of emesis of a recent Coolata. Pt states that flushing her PD cath causes a large amount of stomach pain. . Of note, the patient was recently admitted from 08.26-29.08. The patient initially presented to the ED after referral from her nephrologist's office where she had complaints of right leg pain and was found to be hypertensive to 250/145. She was admitted after initiation of a labetalol drip and nitropaste with improvement in sbp to 180. The patient did receive 2 U of PRBC's during this hospitalization for baseline anemia. The patient did have a work-up for her right leg pain complaints with plain films of the right hip and MRI of the L-spine which did not reveal an explanation for her symptoms and did rule out avascular necrosis. The patient received dilaudid for pain control and was ambulating without pain prior to discharge. In addition, the patient completed a course of ciprofloxacin for a positive UA with negative cultures. The patient was unable to tolerate peritoneal dialysis for unclear reasons. Peritoneal dialysate culture was negative for infection. . In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in ED ranged from [**Telephone/Fax (3) 43494**]-175 with HR in 96-108. Initially given labetalol 10 mg IV x 1 and then started on labetalol gtt for her elevated blood pressures and titrated to 3 mg/min. LENI of R leg was negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per ED, cannot do V/Q scan due to volume overload after talking with radiology. Renal c/s initiated. A-line placed. Past Medical History: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] . PAST SURGICAL HISTORY: - Placement of multiple catheters including dialysis. - Tonsillectomy. - Left eye enucleation in [**2140-4-10**]. - PD catheter placement in [**2141-5-11**]. Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 98.9 [**Telephone/Fax (2) 43495**] 99$% RA GEN: NAD, pleasant female sitting in bed with moon facies HEENT: EOMI of R eye, L eye prosthesis, no exudate, no erythema, MMM, no LAD CHEST: CTAB except at R base with decreased breath sounds; no w/r/r CV: tachy, normal S1S2, II/VI systolic murmur accentuated with Valsalva ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i EXT: no c/c/e, strength of LEs [**5-15**] and symmetric bilaterally. Negative straight leg test, no pain with internal rotation, external rotation, extension, adduction or abduction. Some pain on flexion at the hip. NEURO: II - XII intact to direct testing. No deficit in light tough sensation. Gait normal. DERM: no rashes noted Pertinent Results: LABS AT ADMISSION: [**2141-9-11**] 11:43AM GLUCOSE-86 UREA N-49* CREAT-8.1* SODIUM-139 POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-16* ANION GAP-18 [**2141-9-11**] 11:43AM CALCIUM-6.2* PHOSPHATE-5.8* MAGNESIUM-1.6 [**2141-9-11**] 11:43AM PT-18.4* PTT-42.8* INR(PT)-1.7* [**2141-9-11**] 07:00AM WBC-5.5 RBC-2.88* HGB-8.1* HCT-24.7* MCV-86 MCH-28.1 MCHC-32.8 RDW-18.0* [**2141-9-11**] 07:00AM NEUTS-74.7* LYMPHS-17.5* MONOS-4.2 EOS-3.3 BASOS-0.2 [**2141-9-11**] 07:00AM PLT COUNT-101* UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50 WBC . MICROBIOLOGY: Urine culture ([**2141-9-11**]): Mixed flora . STUDIES: Cardiology Report ECG Study Date of [**2141-9-11**] 6:55:16 AM Sinus tachycardia. The tracing is marred by baseline artifact. There is left atrial enlargement. Compared to the previous tracing of [**2141-9-5**] the rate has increased. The axis is more rightward. Otherwise, no diagnostic interim change. . UNILAT LOWER EXT VEINS RIGHT Study Date of [**2141-9-11**] 8:54 AM [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and popliteal veins demonstrate normal flow, compressibility, augmentation, waveforms. Appropriate color flow and compression is noted within the calf veins. No intraluminal thrombus is present. IMPRESSION: No evidence of right lower extremity DVT. . TTE ([**2140-8-26**]): The left atrium is normal in size. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . R HIP XR [**2141-9-6**]: No acute fracture or dislocation. . MRI L-SPINE [**2141-9-6**]: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. LAB RESULTS AT DISCHARGE: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-9-14**] 06:15AM 4.0 2.63* 7.6* 23.1* 88 29.1 33.0 18.0* 100* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-9-14**] 06:15AM 100 44* 8.1* 137 4.8 109* 17* 16 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2141-9-14**] 06:15AM 6.8* 5.4* 1.6 CALCIUM freeCa [**2141-9-14**] 11:30AM 0.94* Brief Hospital Course: ICU course: EKG showed no change from prior, and CXR showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home medication regimen. The patient was found to by hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. . [**Hospital1 **] history: . 1. Hypertensive urgency: During the patient's [**Hospital1 **] stay, her SBPs ranged from 140s-160s during the day, which is her baseline systolic blood pressure. She was maintained on her home oral medication regimen. At night, she became more hypertensive, with SBP to the 170s-180s, which was controlled with both IV hydralazine and PO nifedipine. PO nifedipine was most successful at bringing her SBP back to her baseline. SBP at discharge was 140. Throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. The renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. Right leg pain: Upon arrival on the floor, the patient complained of [**2143-4-15**] pain in R buttock and posterior thigh, much exacerbated with standing. Of note, lumbar spine MRI and R hip XR on most recent admission were both negative. Her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. Her pain when she was symptomatic was controlled well with PO dilaudid. If the pain recurs, an MRI of the right hip can be considered to evaluate for osteonecrosis. . 3. UTI: The patient had a urinalysis suggestive of UTI, though she remained asymptomatic throughout. She was treated with a three day course of ciprofloxacin. Her urine culture showed mixed flora consistent with skin contamination. . 4. ESRD: The patient has end-stage renal disease due to her lupus. The patient's creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. She was followed by the renal consult service. Her potassium remained stable. Her calcium was low during admission, and supplemental calcium was given in addition to starting Calcitriol. She was not dialyzed through her PD catheter secondary to discomfort, but may reinitiate PD as an outpatient. Her laboratories will be checked as an outpatient in renal clinic. . 5. Anemia: The patient's hematocrit remained near her baseline low 20s throughout her stay. She has anemia from chronic kidney disease and chronic disease. The patient is not on Epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. Prior SVC thrombus: The patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with INR goal 2.5 to 3.0. . 7. Systemic lupus erythematosus: No active issues. The patient's home prednisone regimen was continued. Medications on Admission: - Prednisone 5 mg Daily - Coumadin 2 mg at bedtime - Nifedipine 60 mg Sustained Release Daily - Hydralazine 50 mg every 8 hours - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY - Aliskiren 150 mg Twice daily - Docusate Sodium 100 mg 2 times a day - Labetalol 900 mg three times a day - Lactulose 15-30 ml once a day: goal is [**1-11**] soft bowel movements per day Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 7. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: - Hypertensive urgency - Right lower extremity pain - Urinary tract infection Secondary diagnosis: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) - HOCM: Last noted on echo [**8-17**] - Anemia - History of left eye enucleation [**2139-4-20**] for fungal infection - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Discharge Condition: Stable systolic blood pressure over past 24 hours. Discharge Instructions: You were admitted to the hospital for uncontrolled high blood pressure. You spent one day in the intensive care unit, where you were treated with intravenous medication to lower your blood pressure. You were then transferred to a regular hospital floor, where your blood pressure was managed with your home oral medications. You were also treated for urinary tract infection with antibiotics. Your right leg pain improved during admission, and we are unsure of the cause of this pain. You should discuss the need for an MRI of the hip if the pain returns when you meet with your primary care doctor. Please call your physician or return to the emergency room if you experience fever, chills, chest pain, difficulty breathing, abdominal pain, headache, changes in your vision, or any other symptoms that are concerning. Please take your medications as prescribed. - Calcitriol was added to your medications. - You should hold Coumadin for two days and restart Saturday, [**2141-9-16**]. You should have your INR checked at your visit in kidney clinic [**2141-9-18**]. - You can take Dilaudid 2-4 mg every eight hours as needed for pain. You should be vigilant about taking lactulose if you need to take Dilaudid. - You should continue Lactulose as per Dr.[**Name (NI) 12913**] instructions. - No other changes were made. Please keep follow up appointments as described below. Followup Instructions: Please call the office of your kidney doctor, Dr. [**Last Name (STitle) 4883**], at ([**Telephone/Fax (1) 773**] to schedule an appointment for [**Last Name (LF) 766**], [**9-19**] as discussed. Follow up with your lung doctor: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-9-21**] 1:00 Follow up with your new primary care doctor: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 ",100,2141-09-11 10:12:00,2141-09-14 20:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home medication regimen. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. . [**hospital1 **] history: . 1. hypertensive urgency: during the patients [**hospital1 **] stay, her sbps ranged from 140s-160s during the day, which is her baseline systolic blood pressure. she was maintained on her home oral medication regimen. at night, she became more hypertensive, with sbp to the 170s-180s, which was controlled with both iv hydralazine and po nifedipine. po nifedipine was most successful at bringing her sbp back to her baseline. sbp at discharge was 140. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. the renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. her pain when she was symptomatic was controlled well with po dilaudid. if the pain recurs, an mri of the right hip can be considered to evaluate for osteonecrosis. . 3. uti: the patient had a urinalysis suggestive of uti, though she remained asymptomatic throughout. she was treated with a three day course of ciprofloxacin. her urine culture showed mixed flora consistent with skin contamination. . 4. esrd: the patient has end-stage renal disease due to her lupus. the patients creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. she was followed by the renal consult service. her potassium remained stable. her calcium was low during admission, and supplemental calcium was given in addition to starting calcitriol. she was not dialyzed through her pd catheter secondary to discomfort, but may reinitiate pd as an outpatient. her laboratories will be checked as an outpatient in renal clinic. . 5. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay. she has anemia from chronic kidney disease and chronic disease. the patient is not on epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. prior svc thrombus: the patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with inr goal 2.5 to 3.0. . 7. systemic lupus erythematosus: no active issues. the patients home prednisone regimen was continued. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Urinary tract infection, site not specified; Other primary cardiomyopathies; Systemic lupus erythematosus; Sciatica; Hyperpotassemia; Thrombocytopenia, unspecified; Abnormal coagulation profile; Hyperparathyroidism, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism]","icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the renal team was consulted, and recommended no change to home medication regimen. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. she was treated with a three day course of ciprofloxacin. esrd: the patient has end-stage renal disease due to her lupus. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay.","ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. she became more hypertensive, with sbps to the 170s-180s during the day. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency." 109,140167.0,14802,2141-12-23,14797,172335.0,2141-09-24,Discharge summary,"Admission Date: [**2141-9-18**] Discharge Date: [**2141-9-24**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1936**] Chief Complaint: hip pain Major Surgical or Invasive Procedure: None History of Present Illness: 24yo woman with hx SLE, CKD(not currently on HD or PD), labile HTN here with right leg pain and HTN urgency. Patient was recently d/ced on [**9-14**] following admission for the same complaints. . Patient took her hydralazine dose on am of admission. BP at presentation to the ER was 250/140 (The patient reportedly has baseline SBPs in 130-170s) She was given 900 labetolol and 50 hydralazine in the ED. BP following this was 175/124. Her EKG was unchanged. K was 5.7. . Patient also complaining of [**10-20**] right hip pain. Patient was d/ced on [**9-14**] with oral dilaudid for hip/leg pain. She took this only for one day due to severe itching. Denies any parasthesias/weakness. Her RLE/hip pain has been extensively worked up with negative LENIs, Lumbar spine MRI and hip plain films in the past. She was given 4mg IV morphine in the ER. . On admission to the floor, leg/hip pain somwhat improved with morphine.She denies any headache, vision changes, double vision, chest pain or SOB. Feels warm but no chills. Past Medical History: Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 97.3 HR 81 BP 135/91 RR 16 100%RA Gen:NAD, happy, pleasant female HEENT:NC/AT, L eye prosthesis, R PERRL, EOMI, MMM, facial swelling, L side>R, scerla anicteric Neck: supple, no JVD, no LAD, scars from prior CVL and HD lines CV:S1S2+, 2/6 SEM LUSB, loud P2, RRR, no ectopy Pulm: CTA B/L, good inspiratory effort Abd: +BS, soft, nontender, slightly distended and resonant to percussion, PD catheter in place in left abdomen ext: no c/c/e, 2+DP b/L, L foream swollen>R, R hip is mobile without pain elicited on passive or active movement neuro: AAOx3, nonfocal exam, CN 2-12 intact, moves all 4 extremities psych: mood/affect appropriate Pertinent Results: MRI Right Hip ([**9-18**]): There is no signal abnormality on the fluid-sensitive sequences in the proximal femur, acetabulum, or other osseous structure. On T1- weighted images, there is a focal rounded region within the right femoral head measuring approximately 9 mm in a subchondral location, which is nonspecific but may represent an unusual focus of red marrow. No sclerosis is seen on the corresponding plain films. There is a small right hip joint effusion and a small amount of fluid in the left hip joint as well, at the upper limits of normal. There is no soft tissue abnormality, no muscular edema, and no fluid collections. IMPRESSION: 1. Small right hip joint effusion. 2. No bone marrow edema in the proximal femurs or the pelvis. 3. Nonspecific small focus of low signal on T1-weighted images in the right femoral head is nonspecific but may represent an unusual focus of red marrow. TTE ([**9-21**]): The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF 80%). A mild (18 mmHg) mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. There is no systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Severe symmetric left ventricular hypertrophy with hyperdynamic systolic function and mild mid-cavitary gradient. Mild aortic regurgitation. Moderate pulmonary hypertension. Findings consistent with hyperrtophic cardiomyopathy. Compared with the prior study (images reviewed) of [**2140-8-26**], pulmonary hypertension has developed (also present on the study from [**2140-5-20**]). Pericardial effusion is also new. V/Q scan ([**9-21**]): Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate no focal defects with improved ventilation to the posterior right basal segment. Perfusion images in the same 8 views show improved perfusion to the posterior right basal segement with a persistent small defect but no new findings. Chest x-ray shows cardiomgealy and left basilar atelectasis. IMPRESSION: Improved V/Q scan from [**9-/2139**] with no findings to suggest acute pulmonary embolism. B/L upper ext U/S ([**9-21**]): Grayscale and Doppler son[**Name (NI) 867**] of the right and left internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. There is nonocclusive focal thrombus seen in the left subclavian vein, where the vein is not fully compressible. Flow is seen in the region, indicating that the thrombus is nonocclusive. Elsewhere, normal flow, augmentation, compressibility were appropriate and waveforms are demonstrated. IMPRESSION: 1. Focal nonocclusive thrombus in the left subclavian vein. 2. Otherwise, patent upper extremity veins as described. [**2141-9-18**] 02:15PM POTASSIUM-5.1 [**2141-9-18**] 02:15PM HCT-21.2* [**2141-9-18**] 08:45AM POTASSIUM-5.7* [**2141-9-18**] 07:30AM GLUCOSE-88 UREA N-54* CREAT-8.6* SODIUM-136 POTASSIUM-5.8* CHLORIDE-108 TOTAL CO2-15* ANION GAP-19 [**2141-9-18**] 07:30AM estGFR-Using this [**2141-9-18**] 07:30AM CALCIUM-7.3* PHOSPHATE-5.3* MAGNESIUM-1.6 [**2141-9-18**] 07:30AM WBC-5.2 RBC-2.32* HGB-6.5* HCT-20.1* MCV-87 MCH-28.1 MCHC-32.4 RDW-18.4* [**2141-9-18**] 07:30AM NEUTS-78.0* LYMPHS-14.7* MONOS-3.9 EOS-3.2 BASOS-0.3 [**2141-9-18**] 07:30AM PLT COUNT-107* [**2141-9-18**] 07:30AM PT-20.8* PTT-43.3* INR(PT)-2.0* . [**2141-9-21**] CXR: There is no significant change when compared to the recent previous examination. The previously described left retrocardiac opacity is unchanged in appearance. Cardiomegaly is also unchanged. The mediastinal contour, bony thorax and pulmonary vasculature are normal. IMPRESSION: No significant change compared to study done roughly 7 hours prior. Brief Hospital Course: 24 yo with h/o of Lupus, HTN, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for R hip pain. Patient was on the floor on [**9-20**], given morphine for the hip pain. She then had an episode of hypotension and unresponsiveness and transferred to the MICU for closer monitoring. The patient got 2L IVFs and narcan and improved, in fact, found to be hypertensive upon arrival to MICU. . MICU Course: On [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. Concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. Mental status cleared somewhat with narcan. Renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. V/Q scan demonstrated improvement since prior study. Patient's home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. She was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. PD fluid was not c/w SBP. CXR was clear. Urine culture and blood cultures are pending. Patient's BP was in the 110s so hydralazine was stopped. Her other BP meds were otherwise continued. Plan was/is to follow renal recs for PD. If, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. Would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. If patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. Would add neurontin 100mg TID with room to titrate up to 300mg TID. Neuro also recommended PT with TENS unit and referral to pain clinic although patient's pain is currently absent. . FYI **** per Dr. [**Last Name (STitle) **] --- Because of ? increase in cardiomegaly on CXR, she got an echo yesterday. In addition to her known HOCM, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm Hg. They probably need to be followed up over time (particularly the pulmonary hypertension). We did evaluated the PHTN with a VQ scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. It would be good if we could arrange a PULMONARY CLINIC FOLLOW UP for Ms. [**Known lastname **] after discharge with either [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].**** . She underwent CT head, and V/Q scan which were unremarkable. Her steroid dose was increased to 15mg given concern for need for stress dose steroids. After transfer from the MICU, her steroids were dropped back to 5mg, her home dose with the approval of [**Last Name (un) **]. . Her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. Her hydralazine was discontinued. On day 2 of her MICU stay, she developed a fever to 102. She was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. Broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. There was question of retrocardiac opacity on CXR, though not clear. Rheum consult obtained given hip discomfort, who felt septic joint unlikely. Neurology consult obtained who felt autonomic seizure unlikely. . Pt initiated peritoneal dialysis. In this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising BPs. She is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. Her hip pain has resolved completely without further intervention. . Floor course: Fever: Spike fever in MICU to 102. Started on Levoquin, Aztreonam, and Vanc. Source unclear at this point, but CXR with question of retrocardiac opacity. There is a possibility of aspiration pneumonitis. Other etiologies include peritoneal fluid (PD cath), urine, and blood (though patient does not have any indwelling lines). Hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. Peritoneal dialysis cultures negative so far. Continued levo/vanco/aztreonam for 2 days empirically. Then d/ced the Abx as no infectious etiologies were found. Steroids back to home dosage. BCx, UCx (final neg), Peritoneal cultures negative at discharge. . # Labile blood pressure: h/o of difficult to control BP with episodes of hypertensive emergency in the past. Normal SBP runs in 170s. Having nausea in setting of new PD, no evidence of intracranial bleeding on clinical exam, though INR had been supratherapeutic so remains in differential, though not bradycardic. Continue home BP meds :Labetalol 900 mg PO TID but difficult for patient to tolerate due to nausea, Aliskiren *NF* 150 mg Oral [**Hospital1 **], NIFEdipine CR 60 mg PO DAILY, clonidine patch, hydralazine given hypertensive in setting of nausa. . # Right leg/hip pain: no evidence of avascular necrosis or fracture on MRI though there is a small effusion. Pain resolved without intervention. Continued to monitor and would avoid narcotics, restart slowly if pain resumes. Physical therapy to follow as an outpatient. [**Last Name (un) 18183**] followed. Please see consult note. . # Hyperkalemia: Chronic issue. Patient takes kayexalate intermittently per her report (last dose [**Last Name (un) 766**]). Monitored K but patient did not need it on floor. # CKD V: Renal following. Did well with PD on [**9-22**] but did report some nause and cramping. She was not tolerating all 1.5L in exchanges on discharge. # Anemia: Hct stable around 20. S/p 1 U PRBCs in MICU with Hct 20.1 to 21.9. Likely due to chronic hemolysis consistent with SLE> #. Prior SVC thrombus: Physical exam with L arm swelling consistent with this. No flow limitations. INR 3.5 on ICU admission. Held warfarin but restarted home 2mg daily the day before discharge. # Systemic lupus erythematosus: Home prednisone dose 5mg. Currently on 15mg in setting of acute illness (day 2). # General care: FEN: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, PD initiated, Proph: INR therapeutic, no indication for PPI, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. Code: Full code, confirmed with patient Communication: with the patient and her mother [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (2) 43497**]contact. Access: 2 PIVs Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly dilaudid PO prn benadryl prn lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily coumadin 2mg PO qday calcitriol 1 mcg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Hypertensive urgency Transient Hypotension due to Narcotics Sciatica . Secondary: End stage renal disease Systemic Lupus Erythematosus Anemia Discharge Condition: Stable. Blood pressures at baseline. Hip/leg pain resolved. Ambulating without assistance. Discharge Instructions: You were admitted to the hospital with high blood pressure and right leg/hip pain. We gave you pain medications and blood pressure lowering medications. Your blood pressure then dropped which was caused by the pain medication, and you were transferred to the Intensive Care Unit(ICU) where you recovered quickly. During your stay in the ICU, you developed a fever and were started on antibiotics. However, the cultures that were obtained were negative, and we discontinued the Antibiotics. During your hospitalization, your blood pressure normalized on your home regimen, and your right leg/hip pain resolved. You had an MRI of your hip done, which did not show an acute infection. You were seen by the kidney doctors and they recommended starting peritoneal dialysis. You were also given some blood for your anemia. Please follow up with the Peritoneal Dialysis nurse at the scheduled day/time. Please make an appointment to meet with your PCP in the next couple of weeks. Your Hip pain may benefit from physical therapy or outpatient anesthetic joint injection. Please discuss these options with your rheumatologist. . Please call the number given below to schedule outpatient physical therapy. . Please restart your home medications. You were also started on Sodium Bicarb 650mg by mouth three times a day. . If you develop fevers, chills, trouble breathing, chest pain, worsening of hip pain, headaches, changes in your vision or any other symptoms that concern you please return to the emergency room or call your doctor. Followup Instructions: Please follow up with your Peritoneal Dialysis nurse ([**Doctor First Name 3040**]) on [**Doctor First Name 766**] [**2141-9-25**] . Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 . Please call to schedule Outpatient Physical Therapy:[**Telephone/Fax (1) 2484**] Completed by:[**2141-9-25**]",90,2141-09-18 10:32:00,2141-09-24 13:53:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,LEG PAIN," 24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. patient was on the floor on [**9-20**], given morphine for the hip pain. she then had an episode of hypotension and unresponsiveness and transferred to the micu for closer monitoring. the patient got 2l ivfs and narcan and improved, in fact, found to be hypertensive upon arrival to micu. . micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. mental status cleared somewhat with narcan. renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. v/q scan demonstrated improvement since prior study. patients home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. she was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. pd fluid was not c/w sbp. cxr was clear. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. plan was/is to follow renal recs for pd. if, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. would add neurontin 100mg tid with room to titrate up to 300mg tid. neuro also recommended pt with tens unit and referral to pain clinic although patients pain is currently absent. . fyi **** per dr. [**last name (stitle) **] --- because of ? increase in cardiomegaly on cxr, she got an echo yesterday. in addition to her known hocm, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm hg. they probably need to be followed up over time (particularly the pulmonary hypertension). we did evaluated the phtn with a vq scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. it would be good if we could arrange a pulmonary clinic follow up for ms. [**known lastname **] after discharge with either [**first name4 (namepattern1) **] [**last name (namepattern1) **] or [**first name4 (namepattern1) **] [**last name (namepattern1) **].**** . she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. after transfer from the micu, her steroids were dropped back to 5mg, her home dose with the approval of [**last name (un) **]. . her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. her hydralazine was discontinued. on day 2 of her micu stay, she developed a fever to 102. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. there was question of retrocardiac opacity on cxr, though not clear. rheum consult obtained given hip discomfort, who felt septic joint unlikely. neurology consult obtained who felt autonomic seizure unlikely. . pt initiated peritoneal dialysis. in this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising bps. she is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. her hip pain has resolved completely without further intervention. . fever: spike fever in micu to 102. started on levoquin, aztreonam, and vanc. source unclear at this point, but cxr with question of retrocardiac opacity. there is a possibility of aspiration pneumonitis. other etiologies include peritoneal fluid (pd cath), urine, and blood (though patient does not have any indwelling lines). hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. peritoneal dialysis cultures negative so far. continued levo/vanco/aztreonam for 2 days empirically. then d/ced the abx as no infectious etiologies were found. steroids back to home dosage. bcx, ucx (final neg), peritoneal cultures negative at discharge. . # labile blood pressure: h/o of difficult to control bp with episodes of hypertensive emergency in the past. normal sbp runs in 170s. having nausea in setting of new pd, no evidence of intracranial bleeding on clinical exam, though inr had been supratherapeutic so remains in differential, though not bradycardic. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. . # right leg/hip pain: no evidence of avascular necrosis or fracture on mri though there is a small effusion. pain resolved without intervention. continued to monitor and would avoid narcotics, restart slowly if pain resumes. physical therapy to follow as an outpatient. [**last name (un) 18183**] followed. please see consult note. . # hyperkalemia: chronic issue. patient takes kayexalate intermittently per her report (last dose [**last name (un) 766**]). monitored k but patient did not need it on floor. # ckd v: renal following. did well with pd on [**9-22**] but did report some nause and cramping. she was not tolerating all 1.5l in exchanges on discharge. # anemia: hct stable around 20. s/p 1 u prbcs in micu with hct 20.1 to 21.9. likely due to chronic hemolysis consistent with sle> #. prior svc thrombus: physical exam with l arm swelling consistent with this. no flow limitations. inr 3.5 on icu admission. held warfarin but restarted home 2mg daily the day before discharge. # systemic lupus erythematosus: home prednisone dose 5mg. currently on 15mg in setting of acute illness (day 2). # general care: fen: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, pd initiated, proph: inr therapeutic, no indication for ppi, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. code: full code, confirmed with patient communication: with the patient and her mother [**name (ni) **] [**name (ni) **], [**telephone/fax (2) 43497**]contact. access: 2 pivs ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Pneumonia, organism unspecified; Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Hyperpotassemia; Sciatica; Other iatrogenic hypotension; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Anemia of other chronic disease; Hypocalcemia]","24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. it would be good if we could arrange a pulmonary clinic follow up for ms. [** she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. source unclear at this point, but cxr with question of retrocardiac opacity. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. did well with pd on [**9-22**] but did report some nause and cramping. # systemic lupus erythematosus: home prednisone dose 5mg.","lupus nephropathy patient on peitoneal dialysis with htn and lupus nephropathy. triggered for hypotension (82/45), hypothermia (92.9), altered mental status. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis." 109,140167.0,14802,2141-12-23,14798,126055.0,2141-11-03,Discharge summary,"Admission Date: [**2141-10-13**] Discharge Date: [**2141-11-3**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 6734**] Chief Complaint: Nausea, Vomitting, Abdominal Pain, HTN Urgenc Major Surgical or Invasive Procedure: Upper GI endoscopy Exploratory laparotomy Tunneled hemodialysis catheter in R femoral vein Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 24 y/o F with h/o ESRD, HTN who started peritoneal dialysis during the week of [**2141-10-8**] and presented with a 1 day history of acute onset N/V, sharp abdominal pain on [**2141-10-13**]. (Of note, the patient had presented to the ED on [**10-11**] with hypotension, SBPs in the 80s off after approximately 1.5L was taken off during dialysis in the setting of taking her PO Anti-HTNs. On [**2141-10-11**] she received 0.5L IVF, labs WNL, and was d/c'd home). On the day of admission on [**2141-10-13**], the patient reported that the previous night, she was awoken from sleep with severe, sharp abdominal pain, 6 episodes of frothy emesis, 10+ yellowish BMs without melena or BRBRP.She was admitted for further work- up of this abdminal pain. . In the ED here vitals were as follows: T: 97.0 HR: 101 BP: 240/180 RR: 17 O2sat: 100%RA. She received Labetolol 20mg IV and was subsequently placed on a labetolol drip. She also received ceftriaxone 1gm IV, Flagyl 500mg IV, Dilaudid 0.5-1mg IV q1hr and Zofran. Her abdominal CT showed multifocal areas of small bowel wall thickening. Her peritoneal Cell count was negtaive for SBP. She had some signs of peritonitis and thus surgery was consulted. Her lactate was normal. . Upon arrival to the MICU the patient was mentating well with complaints of diffuse sharp abdominal pain that radiated to the back and diarrhea. She had no headache or visual changes. Past Medical History: - SLE DX ([**2134**] - 16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter Placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). - Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS: 98.4 HR 98 192/131 21 100%RA GEN: Mild Distress, AOx3 HEENT: PEERLA, EOMI NECK: Supple, No LAD, No bruit RESP: CTAB CARD: 2/6 systolic ejection murmur ABD: soft, moderately tender with +/- guarding, BS+ EXTR: Warm well perfused NEURO: Motor Grossly Intact RECTAL: Yellow Stool BACK: B CVAT Pertinent Results: [**2141-11-3**] 08:50AM BLOOD WBC-3.5* RBC-2.55* Hgb-7.8* Hct-23.6* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.8* Plt Ct-176 [**2141-11-3**] 03:55PM BLOOD PT-15.5* PTT-50.8* INR(PT)-1.4* [**2141-11-3**] 08:50AM BLOOD Glucose-121* UreaN-33* Creat-5.2*# Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [**2141-10-26**] 06:15AM BLOOD ALT-11 AST-49* AlkPhos-122* Amylase-186* TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2141-10-26**] 06:15AM BLOOD Lipase-30 [**2141-11-3**] 08:50AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.9 [**2141-10-30**] 06:55AM BLOOD HBsAg-NEGATIVE [**2141-10-17**] 10:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2141-10-25**] 11:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2141-10-25**] 11:56AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2141-10-25**] 11:56AM URINE RBC-0-2 WBC-[**3-15**] Bacteri-FEW Yeast-NONE Epi-21-50 Blood cultures: all negative EKG ([**2141-10-13**]): Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of [**2141-10-2**] there is no significant diagnostic change. CXR ([**2141-10-13**]): No acute cardiopulmonary abnormality. No free air under the diaphragms. CT chest/abdomen/pelvis ([**2141-10-13**]): There is a moderate-sized pericardial effusion, similar in appearance from [**2141-10-13**]. The great vessels are normal in caliber, without aneurysmal dilatation. Evaluation of the great vessels is limited without IV contrast. Interstitial thickening, particularly within the perihilar regions, is suggestive of fluid overload. There is bibasilar atelectasis with a small focus of consolidation in the right lower lobe (2:35) unchanged from [**2141-10-13**], and may reflect aspiration or pneumonia. Scattered bilateral nodules are largely stable from as far back as [**2139-10-9**]. Specifically, there is a 5 mm nodule in the right middle lobe (2:25), two adjacent nodules in the right lower lobe measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule within the left lower lobe. A nodular density seen adjacent and anterior to the right main pulmonary artery (2:23) may reflect a vessel. There is a small right pleural effusion. Axillary lymphadenopathy, with axillary nodes measuring up to approximately 10 mm in short axis, is seen. Ill- defined soft tissue thickening within the hilus bilaterally may reflect hilar lymphadenopathy, but assessment is limited without IV contrast. A catheter is visualized within the visualized right upper extremity, which may reflect a PICC line that terminates within the right subclavian vein. The esophagus is distended and filled with contrast, with marked wall thickening and edema throughout its entire length, a new finding. There is a moderate- sized hiatal hernia. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval development of a moderate amount of free intraperitoneal air, that layers anteriorly and along the anterior abdominal wall. Additional small clustered foci of extraluminal air is seen adjacent to the proximal stomach and the gastroesophageal junction, with a focus of air tracking into the fissure of ligamentum venosum. Additionally, there appears to be air tracking into the anterior subcutaneous tissues in the region of the umbilicus. These findings are all new from the prior CT on [**2141-10-13**], but free air was present on chest radiograph performed [**2141-10-25**]. There is no obvious evidence of extravasation of oral contrast into the peritoneum. Of note, a peritoneal dialysis catheter is in place that could represent a route of entry of intraperitoneal air. The stomach, small bowel, and colon are filled with contrast, without evidence of obstruction. Evaluation for wall thickening is limited without IV contrast. Limited non-contrast views of the liver demonstrates a rounded 1.6 cm x 1.2 cm hypodensity in the right lobe of the liver, previously characterized as a hemangioma. The liver is otherwise unremarkable. The gallbladder, spleen, pancreas, and adrenal glands demonstrate no gross abnormality. Both kidneys are atrophic. Evaluation of solid organs is limited by lack of IV contrast. There is a peritoneal dialysis catheter, coiled within the pelvis, unchanged. There is a large amount of free fluid throughout the abdomen, similar in appearance to the prior study. CT OF THE PELVIS WITHOUT IV CONTRAST: Uterus and rectum are grossly unremarkable. However, assessment of the rectal wall is limited without IV contrast. OSSEOUS STRUCTURES: Bones are diffusely sclerotic, which may be related to renal osteodystrophy. There is bilateral sacroiliitis. IMPRESSION: 1. Interval development of a moderate amount of free intraperitoneal air, new from [**2141-10-13**]. A peritoneal dialysis catheter is in place and could represent the route of entry of free intraperitoneal air. However, as foci of air is seen in the region of the proximal stomach and GE junction in the setting of a recent endoscopy, perforation cannot be excluded, though no frank extravasation of contrast is identified. 2. New dilation and wall thickening of the entire esophagus, a nonspecific finding that could relate to infectious or inflammatory esophagitis; clinical correlation is recommended. Esophagus is contrast-filled possibly representing reflux. Hiatal hernia. 3. Anasarca, with moderate-sized pericardial effusion, pulmonary edema, and small right pleural effusion. 4. Large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. Imaging cannot exclude SBP, which should be evaluated for clinically. 5. Focus of consolidation within the right lower lobe, could represent aspiration or pneumonia, but unchanged from the prior study. Gastric Biopsies ([**2141-10-18**]): Antrum: Corpus-type mucosa, no diagnostic abnormalities recognized. Jejunum: Small intestinal mucosa, no diagnostic abnormalities recognized. UE Venous U/S: No evidence of DVT of the left upper extremity, without thrombus identified within the left subclavian vein. Brief Hospital Course: This is a 24 year old woman with ESRD secondary to SLE (started peritoneal dialysis approximately one week prior to admission), malignant HTN, h/o SVC syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. Her hospital course was complicated by multiple transfers between the MICU and the floor secondary to hypertensive urgency. # Abdominal Pain/Diarrhea: During the patient's admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. Infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. However, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. The patient was empirically placed on IV flagyl, but this was discontinued when stool samples were negative for C.difficile. Serial abdominal exams showed no peritoneal signs. Peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. CT of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. Other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to SLE vasculitis, malignant HTN, or microthrombosis and SLE enteritis. Surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. A heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible GI bleed. With regards to SLE vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to SLE. On [**10-18**], GI performed an EGD which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. Approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. Both cardiac, GI, and pulmonary etiologies were considered for the origin of her epigastric pain. Pericarditis was considered, but her EKG was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. Her lungs were also essentially unchanged from [**2141-10-13**]. However, her abdominal CT on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. As a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. There were no major findings: no evidence of perforation, obstruction, or infection. The patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. At discharge, the patient only complained of some mild incisional pain. # Hypertensive urgency: The patient was initially admitted to the MICU with a blood pressure of 240/180. Her hospital course was complicated by extremely labile HTN and was transferred back and forth between the MICU and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of SBPs > 260. Throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. Her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. Multiple medication regimens were attempted and changed throughout her hospital course. However, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for SBPs > 180. At discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg PO. Her regimen as per Dr. [**Last Name (STitle) 4883**]: Nifedipine SR 90 mg daily Aliskiren 150 mg [**Hospital1 **] Labetalol 300 mg TID Hydralazine 75 mg TID Clonidine patch 0.3 mg/24 hr patch qWed When SBP>180, she then uses a hydralazine sliding scale. When SBP>180, give 25 mg PO hydral every 30 min until SBP<150. You can use this for up to 2-3 hours. In between PO hydral doses, can then also use 10 IV hydralazine. # ESRD: The etiology of the patient's ESRD is secondary to SLE. Her Creatinine on admission was 7.9, which was near her baseline of 8 - 9. During her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. Prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2L per PD. After her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. Initially, the patient adamantly refused hemodialysis. However, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. As a result, after a long coversation with her primary renal physician, [**Name10 (NameIs) **] agreed to restart hemodialysis. A tunneled catheter was placed in her R femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. She underwent hemodialysis two more times prior to discharge. Upon discharge, her electrolytes were back to her baseline. She is expected to undergo hemodialysis (Tues/[**Last Name (un) **]/SAT) as an outpatient. # Anemia: During her admission, the patient's HCT was monitored daily with HCT to low-mid 20's. On [**2141-10-17**], she was found to have guaiac positive stools and her HCT was found to have dropped to a low of 18.6. The patient was transfused a total of 2 units of [**Date Range **] between [**2141-10-17**] and [**2141-10-18**]. Epo Alfa SC was also given on [**2141-10-17**]. She remained hemodynamically stable. GI consulted and EGD results were as stated above. The patient's HCT remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. Between [**2141-10-23**] - [**2141-10-24**], the patient had a HCT drop from 26 to 20 in the setting of occult positive emesis. She received two units of [**Month/Day/Year **] and her HCT returned to 28. GI was aware and planned to perform a non-urgent EGD on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her HCT returned to baseline. However, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her HCt remained stable and near baseline for the remiainder of her hospital course. # H/O Thrombosis: The patient was initially placed on her home dose of warfarin 2mg qd. Her INR on admission was 1.2. She was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. However, this was stopped for her EGD and after she had evidence of a GI bleed. The heparin drip was discontinued on [**10-22**]. The patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in HCT and in preparation for a possible GI intervention. After her surgery, her coumadin was held and she was off the heparin drip, but her INR continued to drift up, getting as high as 2.6 on [**2141-10-30**]. This was mostly attributed to nutritional deficiency [**2-11**] poor PO intake, but there was concern for possible synthetic dysfunction as well. As a result, she was given a test dose of vitamin K, which she responded to well (Her INR came back down to 1.4). As a result, her home dose of coumadin at 2 mg qday was restarted. At discharge, her INR was still sub- therapeutic at 1.4. Of note, the patient has a history of SVC syndrome and had a L subclavian venous thrombosis. During the last few days of her hospital stay, the patient complained of increased tongue swelling and her L face was noted to be slightly more swollen than previously noted. As a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a DVT within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # SLE: Rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. Her outside rheumatologist was also consulted. Both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # Obstructive sleep apnea: The patient was noted to have OSA based on clinical nocturnal exam during admission. Patient attempted 1 trial of CPAP at 2L/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. The paitent stated that she would pursue further work-up and treatment for OSA as an outpatient. While the mask and CPAP machine were at her bedside throughout her hospital course, the patient rarely used it. # Metabolic Acidosis: The patient's bicarbonate on admission was 13. Her baseline is normally between 16-20. She received 150mEq NaHCO3 over 24hrs from [**Date range (1) 43500**]. During her brief returns to the MICU, her HC03 was 18-19, which was presumed to be her baseline at home secondary to her CRF. At discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. Medications on Admission: Nifedipine 60 mg PO daily Labetalol 900 mg PO TID Hydralazine 50 mg PO TID Clonidine 0.3 mg/24hr patch qWED Lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 4 mg daily Warfarin 2mg PO daily Calcitriol 1 mcg daily Calcium carbonate 500mg QID Dilaudid 2mg PO Q4-6hr prn pain Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*30 Patch Weekly(s)* Refills:*2* 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. [**Hospital1 **]:*1500 ML(s)* Refills:*0* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Twice daily (). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): In addition to 75 mg TID, if SBP>180, take 1 tab every 30 min until BP decreases to 150. If no improvement after 2 hours, call your doctor. [**Last Name (Titles) **]:*300 Tablet(s)* Refills:*6* 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). [**Last Name (Titles) **]:*1500 ML(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet Sustained Release(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 5 days. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. [**Last Name (Titles) **]:*30 Capsule(s)* Refills:*2* 13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO once a day. [**Last Name (Titles) **]:*30 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: end stage renal disease malignant hypertension abdominal free air subclavian deep vein thrombosis initiation of hemodialysis Secondary: SLE Anemia Discharge Condition: stable, pain well controlled, blood pressure at baseline Discharge Instructions: You were admitted for abdominal pain and then subsequently had a very long hospital course with high blood pressures, severe abdominal pain, some free air in your abdomen resulting in an exploratory laparotomy. You have also been initiated on hemodialysis on Tuesday/Thursday/Saturday schedule. Please take all medications as prescribed in the list that you will be given at discharge. There have been some changes to your medications. Please call your doctor if you have any worsening abdominal pain, fevers, chills, nausea, vomiting, headache, palpitations, diarrhea or any other concerning symptoms. Followup Instructions: You will see Dr. [**Last Name (STitle) 4883**] at hemodialysis on Tuesday, [**11-7**], [**2141**]. You should have your coumadin level checked at this appointment. Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] to schedule an appointment in [**1-11**] weeks to have your staples removed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**] ",50,2141-10-13 23:10:00,2141-11-03 18:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. her hospital course was complicated by multiple transfers between the micu and the floor secondary to hypertensive urgency. # abdominal pain/diarrhea: during the patients admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. the patient was empirically placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. serial abdominal exams showed no peritoneal signs. peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. ct of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to sle vasculitis, malignant htn, or microthrombosis and sle enteritis. surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible gi bleed. with regards to sle vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to sle. on [**10-18**], gi performed an egd which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. both cardiac, gi, and pulmonary etiologies were considered for the origin of her epigastric pain. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. her lungs were also essentially unchanged from [**2141-10-13**]. however, her abdominal ct on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. as a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. there were no major findings: no evidence of perforation, obstruction, or infection. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. at discharge, the patient only complained of some mild incisional pain. # hypertensive urgency: the patient was initially admitted to the micu with a blood pressure of 240/180. her hospital course was complicated by extremely labile htn and was transferred back and forth between the micu and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of sbps > 260. throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. multiple medication regimens were attempted and changed throughout her hospital course. however, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for sbps > 180. at discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg po. her regimen as per dr. [**last name (stitle) 4883**]: nifedipine sr 90 mg daily aliskiren 150 mg [**hospital1 **] labetalol 300 mg tid hydralazine 75 mg tid clonidine patch 0.3 mg/24 hr patch qwed when sbp>180, she then uses a hydralazine sliding scale. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. you can use this for up to 2-3 hours. in between po hydral doses, can then also use 10 iv hydralazine. # esrd: the etiology of the patients esrd is secondary to sle. her creatinine on admission was 7.9, which was near her baseline of 8 - 9. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2l per pd. after her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. initially, the patient adamantly refused hemodialysis. however, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. as a result, after a long coversation with her primary renal physician, [**name10 (nameis) **] agreed to restart hemodialysis. a tunneled catheter was placed in her r femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. she underwent hemodialysis two more times prior to discharge. upon discharge, her electrolytes were back to her baseline. she is expected to undergo hemodialysis (tues/[**last name (un) **]/sat) as an outpatient. # anemia: during her admission, the patients hct was monitored daily with hct to low-mid 20s. on [**2141-10-17**], she was found to have guaiac positive stools and her hct was found to have dropped to a low of 18.6. the patient was transfused a total of 2 units of [**date range **] between [**2141-10-17**] and [**2141-10-18**]. epo alfa sc was also given on [**2141-10-17**]. she remained hemodynamically stable. gi consulted and egd results were as stated above. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. she received two units of [**month/day/year **] and her hct returned to 28. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. however, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her hct remained stable and near baseline for the remiainder of her hospital course. # h/o thrombosis: the patient was initially placed on her home dose of warfarin 2mg qd. her inr on admission was 1.2. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. however, this was stopped for her egd and after she had evidence of a gi bleed. the heparin drip was discontinued on [**10-22**]. the patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in hct and in preparation for a possible gi intervention. after her surgery, her coumadin was held and she was off the heparin drip, but her inr continued to drift up, getting as high as 2.6 on [**2141-10-30**]. this was mostly attributed to nutritional deficiency [**2-11**] poor po intake, but there was concern for possible synthetic dysfunction as well. as a result, she was given a test dose of vitamin k, which she responded to well (her inr came back down to 1.4). as a result, her home dose of coumadin at 2 mg qday was restarted. at discharge, her inr was still sub- therapeutic at 1.4. of note, the patient has a history of svc syndrome and had a l subclavian venous thrombosis. during the last few days of her hospital stay, the patient complained of increased tongue swelling and her l face was noted to be slightly more swollen than previously noted. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. her outside rheumatologist was also consulted. both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission. patient attempted 1 trial of cpap at 2l/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. the paitent stated that she would pursue further work-up and treatment for osa as an outpatient. while the mask and cpap machine were at her bedside throughout her hospital course, the patient rarely used it. # metabolic acidosis: the patients bicarbonate on admission was 13. her baseline is normally between 16-20. she received 150meq nahco3 over 24hrs from [**date range (1) 43500**]. during her brief returns to the micu, her hc03 was 18-19, which was presumed to be her baseline at home secondary to her crf. at discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. ","PRIMARY: [Malignant essential hypertension] SECONDARY: [Renal dialysis status; Epilepsy, unspecified, without mention of intractable epilepsy; Constipation, unspecified; Anemia in chronic kidney disease; Abnormal coagulation profile; Obstructive sleep apnea (adult)(pediatric); Other diseases of lung, not elsewhere classified; Other chest pain; Fever, unspecified; Rash and other nonspecific skin eruption; Other chronic pulmonary heart diseases; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified disease of pericardium; Other ascites; Acidosis; Hyposmolality and/or hyponatremia; Abdominal pain, other specified site; Abdominal pain, epigastric; Nausea with vomiting; Diarrhea; Systemic lupus erythematosus; Hyperparathyroidism, unspecified; Anemia, unspecified; Thrombocytopenia, unspecified; Esophageal reflux]","this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. multiple medication regimens were attempted and changed throughout her hospital course. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. upon discharge, her electrolytes were back to her baseline. epo alfa sc was also given on [**2141-10-17**]. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission.","esrd secondary to sle, malignant htn, h/o svc syndrome, and multiple thrombotic events were considered. the patient was placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia." 109,140167.0,14802,2141-12-23,14799,125288.0,2141-11-23,Discharge summary,"Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypertensive Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: (from MICU admit note) 24yoF ESRD-HD, SLE, HTN presents with 1 month abdominal pain and hypertension. Pt has had work-up over recent months for abd pain, including exploratory laparotomy, all of which essentially (-). Was admitted [**Date range (1) 34629**], for abdominal pain, then returned [**11-16**] for sob with (-)CTA, dc'ed [**11-17**]. In [**Hospital1 18**] ED, T98.5 hr95 BP 220/110 then 183/133 RR13 O2 100% on RA, rectal exam negative, guaiac(-), pelvic exam unremarkable with no cervical motion tenderness. Renal was consulted, taken for hemodialysis. CT abd showed large ascites, no other pathology; CT head improved from prior with no acute ICH; cxr(-). Given iv dilaudid for abdominal pain. BP treated with 10mg iv labetalol. Blood and urine cultures drawn, peritoneal fluid cx sent from catheter. Admitted to MICU for hypertension management. Access: R-HD catheter, 1 pIV in hand, 1 non-functioning peritoneal dialysis catheter. Past Medical History: PMH: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSH: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: PE: T:99.4 BP:158/108 HR:95 RR:12 O2 100% RA GEN: NAD/ pt eyes closed due to pain/ pleasant despite pain HEENT: AT, NC, PERRLA, EOMI on R eye, L eye prosthesis, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD CV: S1 & S2, RRR II/VI HSM at R/L USB, no rubs/gallops PULM: CTAB, no w/r/r ABD: soft, mildly tender at PD catheter, ND, + BS, midline incision with steri-stripes, PD catheter dressing C/I/D EXT: warm, dry, +2 distal pulses BL, no edema NEURO: alert & oriented, CN II-XII grossly intact (except L eye), 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: Admission Labs: [**2141-11-18**] 07:00AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.7* Hct-30.7* MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* Plt Ct-142* [**2141-11-18**] 07:00AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.3* [**2141-11-18**] 07:00AM BLOOD Glucose-86 UreaN-22* Creat-5.0* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2141-11-18**] 07:00AM BLOOD ALT-8 AST-39 AlkPhos-92 TotBili-0.3 [**2141-11-18**] 07:00AM BLOOD Lipase-76* [**2141-11-18**] 07:00AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.9 [**2141-11-18**] 11:00PM ASCITES WBC-1265* RBC-1680* Polys-43* Lymphs-1* Monos-2* Mesothe-11* Macroph-43* [**2141-11-18**] 10:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2141-11-18**] 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2141-11-18**] 10:05AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-[**3-15**] Discharge Labs: [**2141-11-23**] 04:40AM BLOOD WBC-2.9* RBC-3.08* Hgb-9.0* Hct-28.3* MCV-92 MCH-29.2 MCHC-31.8 RDW-17.5* Plt Ct-182 [**2141-11-23**] 04:40AM BLOOD PT-20.8* PTT-76.1* INR(PT)-2.0* [**2141-11-23**] 04:40AM BLOOD Glucose-80 UreaN-21* Creat-4.7* Na-139 K-4.8 Cl-106 HCO3-24 AnGap-14 [**2141-11-23**] 04:40AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8 [**2141-11-22**] 04:55AM BLOOD TSH-6.1* [**2141-11-23**] 04:40AM BLOOD Free T4-1.2 Blood cx ([**11-18**], [**11-19**]): 1/4 bottles with coag neg Staph, [**3-14**] NGTD Urine cx ([**11-18**]): mixed flora c/w contamination Peritoneal fluid ([**11-18**]): Gram stain 2+ polys. Culture no growth. Imaging: CXR Portable ([**11-18**]): Since [**2141-11-16**], heart size enlargement is unchanged due to known pericardial effusion. Lungs are otherwise clear. Hilar contours are normal. Incidentally, widening of both acromioclavicular joints is unchanged. CT A/P ([**11-18**]): 1. No evidence of bowel obstruction or rim-enhancing fluid collection. 2. Large ascites, slightly increased from [**2141-11-13**], with peritoneal dialysis catheter in place. Interval removal of surgical skin staples along the abdomen. 3. Moderate pericardial effusion as before. 4. Symmetric heterogeneous attenuation of the kidneys could be related to renal failure; however, pyelonephritis could also give this appearance. Appearance of the kidneys is unchanged from [**2141-11-13**]. CT Head w/o contrast ([**11-18**]): 1. No evidence of acute intracranial hemorrhage. 2. Regions of hypoattenuation in the bifrontal white matter and left posterior temporal lobe have resolved since [**2141-6-11**]. No new regions of hypoattenuation seen. Brief Hospital Course: 1) Hypertension: Patient has history of extremely labile hypertension on an aggressive outpatient regimen. Overnight in the MICU, patient required IV and PO labetalol for SBP > 200. Her hydralazine was increased from 75mg to 100mg TID with mild improvement. Her labetalol was also increased from 300mg to 400mg TID. Her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. TSH was sent and elevated, although free T4 was normal. Plasma metanephrines were sent and pending at discharge. 2) Abdominal pain: CT scan showed increasing ascites, but no acute pathology. Peritoneal fluid was obtained and contained 544 polys. Treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing GPC pairs/clusters. Blood cultures ended up growing 1 out of 4 bottles coag-neg Staph, likely contaminant, so vancomycin was stopped. Since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. The peritoneal cultures remained negative. Her PD catheter was left in place as the patient refuses HD any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) SVC/brachiocephalic thrombosis: Patient's INR was subtherapeutic on admission at 1.3. Due to the proximal location of her old venous thrombi, she was started on a heparin gtt. This was continued during her admission and her warfarin was increased to 5mg daily. Her INR reached 2.0 at discharge (therapeutic range 2-3). The dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) Anxiety: Patient noted feeling short of breath and anxious around the time of her recent admissions. Her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. They felt her symptoms were suggestive of anxiety and panic attacks, recommended checking TSH and metanephrines as above, and starting citalopram 20mg, which was done. She was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h PRN. Patient is agreeable to outpatient follow up with [**Company 191**] social work, and potential CBT. These can be arranged by her PCP. Medications on Admission: 1. Aliskiren 150 mg [**Hospital1 **] 2. Clonidine 0.3 mg/24 qwk 3. Prochlorperazine Maleate 10 mg prn 4. Hydromorphone 2 mg Tablet Sig: [**1-11**] q6 prn 5. Bisacodyl 10mg [**Hospital1 **] 6. Ergocalciferol (Vitamin D2) 50,000 qmonth 7. Hydralazine 75mg tid 8. Hydralazine scale prn 9. Labetalol 300 mg tid 10. Nifedipine 90 mg qd 11. Prednisone 4mg qd 12. Warfarin 2 mg qd at 4pm Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Hospital1 766**]). 5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day. [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 7 days. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO q30 min prn as needed for hypertension: for SBP > 180. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive urgency Headache Abdominal pain Anxiety Secondary Diagnosis: HTN SLE ESRD on HD SVC and IJ thrombosis, chronic Anemia Discharge Condition: Stable, BPs improved. Discharge Instructions: You were admitted with elevated blood pressures, headache, and abdominal pain. You were found to have increased amounts of white blood cells in your abdominal cavity, but this was not infected. Your abdominal pain resolved and you continued to have intermittent headaches. Your blood pressure medications were adjusted as below. You were also seen by psychiatry who recommended starting new medications for your anxiety. The following changes were made to your medication regimen: - We increased your hydralazine to 100 mg three times a day. - We also increased your labetalol to 400 mg three times a day. - We have started a medication called celexa 20 mg daily as well as ativan 1 mg three times a day as needed for anxiety. - We have increased your coumadin to 4 mg daily. - Please continue taking all other medications as previously prescribed. Call your doctor or return to the emergency room if you experience any of the following: worsening abdominal pain, nausea, vomiting, blurry vision, worsening headache, fever > 101. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. Please continue to follow with your nephrologist and go to outpatient dialysis as previously arranged. Please discuss with your PCP the possibility of talking to a social worker at [**Name (NI) 191**]. You will need to continue to have your INR monitored at [**Hospital 191**] [**Hospital 2786**] clinic. Please have this level checked on [**Hospital 766**], [**11-27**]. Completed by:[**2141-11-23**]",30,2141-11-18 14:00:00,2141-11-23 16:42:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. her hydralazine was increased from 75mg to 100mg tid with mild improvement. her labetalol was also increased from 300mg to 400mg tid. her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. tsh was sent and elevated, although free t4 was normal. plasma metanephrines were sent and pending at discharge. 2) abdominal pain: ct scan showed increasing ascites, but no acute pathology. peritoneal fluid was obtained and contained 544 polys. treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing gpc pairs/clusters. blood cultures ended up growing 1 out of 4 bottles coag-neg staph, likely contaminant, so vancomycin was stopped. since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. the peritoneal cultures remained negative. her pd catheter was left in place as the patient refuses hd any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) svc/brachiocephalic thrombosis: patients inr was subtherapeutic on admission at 1.3. due to the proximal location of her old venous thrombi, she was started on a heparin gtt. this was continued during her admission and her warfarin was increased to 5mg daily. her inr reached 2.0 at discharge (therapeutic range 2-3). the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) anxiety: patient noted feeling short of breath and anxious around the time of her recent admissions. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. they felt her symptoms were suggestive of anxiety and panic attacks, recommended checking tsh and metanephrines as above, and starting citalopram 20mg, which was done. she was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h prn. patient is agreeable to outpatient follow up with [**company 191**] social work, and potential cbt. these can be arranged by her pcp. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Abdominal pain, unspecified site; Anemia, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. her hydralazine was increased from 75mg to 100mg tid with mild improvement. peritoneal fluid was obtained and contained 544 polys. the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted.","patient has history of extremely labile hypertension on aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. ct scan showed increasing ascites, but no acute pathology." 109,140167.0,14802,2141-12-23,14800,161950.0,2141-12-01,Discharge summary,"Admission Date: [**2141-11-24**] Discharge Date: [**2141-12-1**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Headache, abdominal pain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24yo F w/PMHx of ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning, awakening her from sleep. Had been previously discharged from [**Hospital1 **] yesterday after being admitted for hypertension and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Upon discharge yesterday she states her abdominal pain had subsided. She had HD yesterday without complications. She awoke at 6am with a headache and crampy, stabbing abdominal pain. Took 2mg PO Dilaudid without relief and came to ED. No nausea/vomiting, no changes in vision, no fevers, chills, night sweats. No chest pain, SOB, diarrhea. In the ED, initial vitals were T98.7, BP260/130, HR70, RR16. Was initially given 10mg IV Labetalol X 2, 4mg Zofran for nausea. No improvement in BP and started on Labetolol gtt. Got 1mg IV Dilaudid for pain. Currently, patient continues to complain of headache and abdominal pain, both [**7-17**]. No vision changes, chest pain or shortness of breath. Has been feeling increased anxiety recently and saw psychiatrist, was put on Celexa. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T98.2, BP176/135, HR94, RR 22, 100% RA Gen: well-appearing african-american woman, lying comfortably HEENT: anicteric, L eye prosthetic non-reactive, R pupil reactive, MMM, neck supple with submanibular LAD CV: RRR, II/VI SEM best heard at apex Pulm: CTA b/l Abd: hyperactive bowel sounds, midline scar well-healed, soft, diffusely tender to palpation, +rebound, no guarding. PD catheter in LLQ without erythema or purulent material draining. +dullness on percusion with evidence of clinical ascites. Ext: no edema, no clubbing, 2+ peripheral pulses DP and radial. R femoral HD [**Last Name (un) **] in place without erythema, purulance Neuro: A&O X 3, CN intact II-XII, [**5-15**] motor strength in upper and lower extremities Pertinent Results: Admission labs: CBC: [**2141-11-26**] 05:21AM BLOOD WBC-3.5* RBC-3.07* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-17.6* Plt Ct-180 CHEM 10: [**2141-11-26**] 01:16PM BLOOD Glucose-87 UreaN-17 Creat-4.0* Na-136 K-5.2* Cl-106 HCO3-23 AnGap-12 [**2141-11-26**] 09:20PM BLOOD Calcium-7.6* Phos-3.8 Mg-1.8 COAGS: [**2141-11-26**] 01:16PM BLOOD PT-23.9* PTT-40.2* INR(PT)-2.3* STUDIES: 1)Peritoneal fluid ([**11-26**]): negative for malignant cells. Reactive mesothelial cells, macrophages, eosinophils and lymphocytes. 2)BILAT UP EXT VEINS US ([**11-26**]): No evidence of deep vein thrombosis of the right or left upper extremity. 3) MRI/MRA ([**11-30**]): FINDINGS: Examination is somewhat limited by patient motion. T2/FLAIR sequences are unremarkable with interval resolve of previously noted posterior abnormalities. The major vessels appear patent proximally. There are stable areas of low signal in the left frontal and right occipetal/temporal lobes. IMPRESSION: 1. Interval resolution of previously noted posterior white matter abnormalities. 2. Stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions. 3. Very limited MRA as above. Brief Hospital Course: 24yo F with SLE, ESRD on HD and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**Hospital Unit Name 153**] course: The patient was admitted for blood pressure management and evaluation of abd pain. An A-line was placed. EKG showed no change from prior, and Abd x-ray showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home med regimen. The patient was found to be hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. Upon transfer to the floor, the following was her course: 1. Hypertensive Urgency: Pt had had hemodialysis one day prior to admission, so unlikely that she was volume overloaded. Unclear what precipitated this episode of hypertensive urgency, although suspect secondary to abdominal pain leading to an anxiety which then precipitates hypertension. She may not have been taking her medications secondary to pain. Negative serum tox. On the floor, we continued hemodialysis Tu, Th, Sat. She was initially continued on PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine 90mg PO qday and clonidine; she received hydralazine 10mg IV for goal BP < 180/100. Renal team followed patient during this hospitalization. Per renal team recs, labetalol was increased to 800mg TID due to poor blood pressure control. Pt discharged on clonidine 0.3mg patch, Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, Nifedipine 90mg daily and lobatalol 800mg TID. This regimen worked well. 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT scan during prior admission which did not show source of abdominal pain. On admission, LFTs were normal except for slightly low albumin, lipase was slightly elevated and KUB was negative for free air or evidence of SBO. Peritoneal fluid was negative for malignant cells but showed reactive mesothelial cells, macrophages, eosinophils and lymphocytes. Negative gram stain or peritoneal fluid cultures, excluding SBP as a cause of the abdominal pain. PD catheter was not removed. Pt was continued on PO dilaudid 1-2mg Q6h and pain resolved. She denied N/V/diarrhea or constipation. 3. ESRD: Pt on hemodialysis, on T/Th/Sat schedule. Renal following patient closely throughout this hospitalization. Lytes were checked frequently and kayexalate given prn. 4. Hx of SVC/brachiocephalic DVT: Pt was initially subtherapeutic on coumadin. Unclear if she had not been taking Coumadin although patient reported that she has been taking all home meds. We started heparin gtt to bridge to Coumadin. Once therapeutic, continued Coumadin 5mg PO qday. 5. Anxiety: Likely contributing to medical problems and could have very well been the etiology of this admission. Although pt stated she was taking her current medications, she did report increased anxiety which can lead to medication non-compliance and hypertension. Pt recently saw psychiatrist who started her on Celexa. She was continued on celexa 20mg PO qday, ativan 1mg PO q8hours PRN and psychiatry was re-consulted. Per psych recs, started standing clonazepam. Pt refused psych VNA. Outpatient PCP followup recommended. 6. Headache NOS: Pt complained of R-sided HA for several weeks, radiating to R jaw where patient had previous tooth extraction. Right upper extremity ultrasound was negative for DVT. She did not have any focal neuro findings, no visual deficits. She was initially treated with tylenol PRN Q6h; pt requested IV dilaudid for HA, but use of this medication by IV route was limited by team. It was felt by the pain service that her HA did not fit migraine, tension type HA or rebound HA. They recommended increasing dilaudid to 4-6mg Q6h PRN, continuing tylenol and starting neurontin 300mg Qhs which was slowly titrated to 300mg [**Hospital1 **] for better control. Per pain recs, a neurology consult was also obtained during this admission. MRI/MRA showed interval resolution of previously noted posterior white matter abnormalities and stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions, but very limited MRA as above. Per pain recs, dilaudid was further increased to 4mg q4h for better control of her HA. Neurology recommended outpt f/u and Pt scheduled with [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**]. 7. Anemia: Likely related to ESRD. No evidence of acute bleeding. Hct remained stable during this hospitalization. 8. SLE: no acute issues. continued Prednisone 4mg PO qday 9. FEN: tolerated regular diet, repleted lytes PRN 9. Prophylaxis: Heparin gtt, then coumadin, bowel regigmen Medications on Admission: (from prior discharge summary) Bisacodyl 10mg PO qday PRN Prednisone 4mg PO qday Aliskiren 150mg PO BID Clonidine 0.3mg / 24 hr patch weekly qmonday Labetalol 400mg PO TID Warfarin 4mg PO qday Nifedipine 90mg PO qday Hydralazine 100mg PO q8H Hydromorphone 2-4mg PO q4H PRN Lorazepam 1mg PO q8H Celexa 20mg PO qday Prochlorperazine 10mg PO q6H Colace 100mg PO BID Hydralazine 25mg PO q30min PRN for HTN Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Year (4 digits) 766**]). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). [**Year (4 digits) **]:*100 Tablet(s)* Refills:*2* 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*90 Capsule(s)* Refills:*2* 9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for headache. [**Year (4 digits) **]:*84 Tablet(s)* Refills:*0* 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*60 Capsule(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours. [**Year (4 digits) **]:*360 Tablet(s)* Refills:*2* 16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. [**Year (4 digits) **]:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive Emergency 2. SLE 3. Headache, NOS 4. Abdominal pain Discharge Condition: BP better controlled. Headache managed on oral meds Discharge Instructions: You were admitted with abdominal pain, high blood pressure, and headache. Your abdominal pain resolved - no serious cause of this pain was found. Your blood pressure medications were continued, and with an increased in one medication, the labetalol. Your blood pressure improved. You should continue the clonidine 0.3mg patch changed on [**Year (4 digits) 766**], Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, and Nifedipine 90mg daily. The dose of Labetalol was increased to 800 mg three times daily by you kidney doctor and you are given a new prescription. Please take all medications as listed below. For your headache, you had an MRI and MRA of the head, which did not show a new or serious abnormality. You were seen by the neurology and pain services. You should follow up at [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**] at 6:30 PM (in the evening). Your pain was managed by oral dilaudid, 4mg. You should take this medication every 4 hours as needed. You were also started on Gabapentin (also called Neurontin) for the headache. The dose was slowly increased to twice a day. You may not need as much dilaudid for your headache and should wean this medication as tolerated, given it's potential for side effects (constipation, lethargy, dependence). Finally, you will likely need medications for constipation while you take dilaudid. Take colace (a stool softener), senna (a laxative), and bisacodyl (another laxative), as needed. It is really important that you have a primary care doctor. You are scheduled with Dr. [**Last Name (STitle) **] (see below) next Tuesday. You will need your INR checked since you are on coumadin. Call your doctor if you have worsened headache, chest pain, confusion, or any other concerning symptom. Followup Instructions: Please make sure you attend the following doctor appointments: 1) Dr. [**Last Name (STitle) 4883**] (nephrologist) on Tuesday, [**2141-12-5**] at 10AM. Phone number [**Telephone/Fax (1) 60**]. 2) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Location (un) **], [**Hospital Ward Name 23**] center, [**Location (un) **]. Phone:[**Telephone/Fax (1) 250**]. Date/Time:[**2141-12-5**] 3:20 3) Neurology: Dr. [**Last Name (STitle) 43502**] [**Name (STitle) **]. He is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-12-12**] 6:30 PM [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2141-12-2**]",22,2141-11-24 16:11:00,2141-12-01 19:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**hospital unit name 153**] the patient was admitted for blood pressure management and evaluation of abd pain. an a-line was placed. ekg showed no change from prior, and abd x-ray showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home med regimen. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. upon transfer to the floor, the following was her ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other ascites; ; Systemic lupus erythematosus; Headache; Anemia in chronic kidney disease; Anxiety state, unspecified; Other chest pain; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Renal dialysis status; Acquired absence of organ, eye]","24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. the renal team was consulted, and recommended no change to home med regimen.","a 24yo f with sle, esrd on hd and malignant hypertension presented with abdominal pain and headache. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. she successfully switched to po meds and was transferred to the floor." 109,140167.0,14802,2141-12-23,14801,173633.0,2141-12-14,Discharge summary,"Admission Date: [**2141-12-8**] Discharge Date: [**2141-12-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 8104**] Chief Complaint: abdominal pain & hypertension Major Surgical or Invasive Procedure: Hemodialysis PICC Line [**12-11**] History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with a history of CKD V (on HD) from lupus nephritis, chronic intermittent abdominal pain, and multiple prior ICU admissions for hypertensive urgency who presented to the ED complaining of two days' of abdominal pain, nausea, and loose stools. She was feeling well until after her hemodialysis session on Wednesday. Thereafter, she complained of nausea with occasional vomitting and has been unable to keep down any of her oral medications. She also has had diffuse abdominal pain consistent with her prior flares of pain as well as her typical diffuse headache. The headache in particular was worsening and, for her, this is a sign of poorly-controlled hypertension so she came to the [**Hospital1 18**] ED. Upon arrival to the ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room air. She was given 4 mg of IV ondansetron, [**1-11**] inch intropaste, 1 mg of IV hydromorphone x3, 1000cc of NS, and was put on a labetalol drip which had to be increased up to 2 mg/min. A head CT showed no acute abnormality (including hemorrhage) and an abdominal CT showed some possible mild colitis, though it is unclear if this is due to her recent peritoneal dialysis. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 97.9 BP 165/120 HR 93 RR 12 Sat 100% ra Gen: mildly fatigued, but no distress HEENT: oropharynx clear Neck: no JVP, no LAD Chest: clear to auscultation throughout, no w/r/r CV: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard Abdomen: soft, tender diffusely to moderate palpation without rebound or guarding; hyperactive bowel sounds; no masses or HSM, PD catheter in palce Extr: no edema, 2+ PT pulses Neuro: alert, appropriate, strength grossly intact in all four limbs Skin: no rashes Pertinent Results: [**2141-12-14**] 05:53AM BLOOD WBC-4.3 RBC-2.81* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.7 MCHC-33.8 RDW-19.3* Plt Ct-148* [**2141-12-14**] 05:53AM BLOOD PT-42.6* PTT-51.0* INR(PT)-4.7* [**2141-12-10**] 05:10AM BLOOD Ret Aut-2.5 [**2141-12-14**] 05:53AM BLOOD Glucose-83 UreaN-21* Creat-5.1*# Na-138 K-5.3* Cl-105 HCO3-24 AnGap-14 [**2141-12-10**] 05:10AM BLOOD LD(LDH)-234 Amylase-347* TotBili-0.1 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-10**] 05:10AM BLOOD Lipase-72* [**2141-12-14**] 05:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 [**2141-12-10**] 05:10AM BLOOD Hapto-142 [**2141-12-8**] 04:02AM BLOOD calTIBC-138* VitB12-445 Folate-18.5 Ferritn-220* TRF-106* ON ADMISSION: [**2141-12-7**] 09:50PM BLOOD WBC-4.5 RBC-2.78* Hgb-8.4* Hct-25.2* MCV-91 MCH-30.2 MCHC-33.3 RDW-19.2* Plt Ct-158 [**2141-12-7**] 09:50PM BLOOD Neuts-65.2 Lymphs-23.4 Monos-8.0 Eos-2.9 Baso-0.4 [**2141-12-7**] 09:50PM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3* [**2141-12-8**] 04:02AM BLOOD Ret Aut-2.5 [**2141-12-7**] 09:50PM BLOOD Glucose-89 UreaN-25* Creat-5.1*# Na-139 K-4.8 Cl-104 HCO3-26 AnGap-14 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-7**] 09:50PM BLOOD Lipase-89* [**2141-12-7**] 09:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9* Mg-1.9 [**2141-12-7**] 09:54PM BLOOD Glucose-75 Lactate-1.3 Na-139 K-4.8 Cl-101 calHCO3-23 Micro: Blood Cx: [**12-7**], [**12-7**], [**12-11**], [**12-11**] No growth FECAL CULTURE (Final [**2141-12-10**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2141-12-10**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2141-12-8**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-12-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CT HEAD [**2141-12-8**]: IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. The hypodensities noted in the parietal white matter are stable. However in the setting of the hypertension, PRES cannot be excluded. If further evaluation is required MR can be obtained. CT Abdomin/Pelvis [**2141-12-8**] IMPRESSION: 1. Moderate amount of free fluid in the pelvis is compatible with the patient's known peritoneal dialysis. Unchanged peritoneal enhancement. 2. Stable liver hemangioma. CXR [**12-11**] IMPRESSION: Small left pleural effusion. Left lower lobe opacity which is either atelectasis versus pneumonia. Brief Hospital Course: 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. MICU course: Current plan on transfer 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. 1. Hypertensive urgency: The patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. Initially her blood pressure over-corrected to SBPs in the 80s (patient was asymptomatic). Her clonidine patch and hydralazine was held and she again became hypertensive with SBPs 190s. The patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. The following dialysis the patient asymptomatic with SBPs in 80s, MAPs 60s asymptomatic again. Her hydralazine was stopped and continued on all her other home medications at the advice of renal. The patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. On [**12-11**] the patient's SBP dropped to the 80's and due to her pain medications she was extremely lethargic, but arousable. A PICC line was placed because lack of access and she was bolused 250cc NS. The patient's pressures responded and additional narcotics were held due to her mental status. The patient's blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. The patient did require IV hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. A possible component to the patient's malignant hypertension is likely due to OSA. An inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on BiPAP for OSA. The patient was continuned on her admission hypertensive regimen. . 2. Abdominal pain: The etiology of her abdominal pain is unclear, but has been a chronic issue for her. A CT scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. The patient also had diarrhea, but stool studies were negative. The patient's pain was initially treated with hydromorphone, but because of the patient's lethargy on [**12-11**] they were initially held. She continued to complain of severe abdominal pain. She was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. Surgery was consulted in regards to removal of her PD catheter, but given that she may return to PD it was deferred to the outpatient setting. 3. CKD V from lupus nephritis: The patient was continued on HD during her admission. She was also continued on her home prednisone dose. She was closely followed by the renal team. . 4. History of SVC/subclavian vein thrombus: The patient was found to have a subtherapeutic INR on admission 1.3. She was started on a heparin gtt and continued on coumadin. The patient's heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her PICC line was placed. She was therapetuic the same day and her heparin gtt was stopped. On discharge her coumadin was supratherapeutic (4.7) and was held. She will have her INR checked at HD. . 5. Anemia: The patient's Hct slowly trended down. She was guaiac negative and hemolysis labs were negative. She was transfused 1U pRBC at HD on [**12-12**]. She was also given epo at HD. Medications on Admission: prednisone 4 mg daily clonidine 0.3 mg/day patch qWeek ergocalciferol 50,000 units qMonth nifedipine SR 90 mg daily hydralazine 100 mg q8h citalopram 20 mg daily warfarin 2 mg qhs gabapentin 300 mg [**Hospital1 **] hydromorphone 4 mg q4h prn clonazepam 0.5 mg [**Hospital1 **] alikiren 150 mg [**Hospital1 **] docusate 100 mg [**Hospital1 **] senna 8.6 mg [**Hospital1 **] prn acetaminophen prn labetalol 800 mg q8h bisacodyl 5 mg daily prn Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. [**Hospital1 **]:*84 Tablet(s)* Refills:*0* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed: please take as needed for anxiety prior to CPAP at bedtime. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 14. CPAP Home CPAP Dx: OSA Prefer: AutoCPAP/ Pressure setting [**5-20**] Alt: Straight CPAP/ Pressure setting 7 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency Abdominal Pain ESRD on HD SVC Thrombus Secondary: Systemic lupus erythematosus Malignant hypertension Thrombocytopenia HOCM Anemia History of left eye enucleation History of vaginal bleeding Thrombotic microangiopathy Discharge Condition: Stable Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because of elevated blood pressure and abdominal pain. You were initially admitted to the ICU and your blood pressure was controlled. You were stabilized and transferred back to th floor. Your pressures remained stable throughout the rest of your stay. Additionally, you had abdominal pain and diarrhea. Your stool was tested for infections and was negative. Your diarrhea resolved without intervention. Your abdominal pain was controlled with pain medications. You had a sleep study in the hospital which showed that you had sleep apnea. Please continue to take your medications as prescribed. 1. Please do not take your coumadin until your doctor tells you to. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: You will have dialysis at [**Location (un) **] Dialysis on your normal schedule. You need to go to dialysis on Saturday. Please follow-up with the Sleep Clinic in [**12-19**] @ 11:45 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Completed by:[**2141-12-16**]",9,2141-12-08 01:40:00,2141-12-14 17:16:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. micu course: current plan on transfer 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. 1. hypertensive urgency: the patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). her clonidine patch and hydralazine was held and she again became hypertensive with sbps 190s. the patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. the following dialysis the patient asymptomatic with sbps in 80s, maps 60s asymptomatic again. her hydralazine was stopped and continued on all her other home medications at the advice of renal. the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. on [**12-11**] the patients sbp dropped to the 80s and due to her pain medications she was extremely lethargic, but arousable. a picc line was placed because lack of access and she was bolused 250cc ns. the patients pressures responded and additional narcotics were held due to her mental status. the patients blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. the patient did require iv hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. a possible component to the patients malignant hypertension is likely due to osa. an inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on bipap for osa. the patient was continuned on her admission hypertensive regimen. . 2. abdominal pain: the etiology of her abdominal pain is unclear, but has been a chronic issue for her. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. the patient also had diarrhea, but stool studies were negative. the patients pain was initially treated with hydromorphone, but because of the patients lethargy on [**12-11**] they were initially held. she continued to complain of severe abdominal pain. she was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. surgery was consulted in regards to removal of her pd catheter, but given that she may return to pd it was deferred to the outpatient setting. 3. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was also continued on her home prednisone dose. she was closely followed by the renal team. . 4. history of svc/subclavian vein thrombus: the patient was found to have a subtherapeutic inr on admission 1.3. she was started on a heparin gtt and continued on coumadin. the patients heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her picc line was placed. she was therapetuic the same day and her heparin gtt was stopped. on discharge her coumadin was supratherapeutic (4.7) and was held. she will have her inr checked at hd. . 5. anemia: the patients hct slowly trended down. she was guaiac negative and hemolysis labs were negative. she was transfused 1u prbc at hd on [**12-12**]. she was also given epo at hd. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Systemic lupus erythematosus; Other and unspecified noninfectious gastroenteritis and colitis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other iatrogenic hypotension; Obstructive sleep apnea (adult)(pediatric); Hemangioma of intra-abdominal structures; Other chronic pain; Abdominal pain, unspecified site; Abnormal coagulation profile; Renal dialysis status; Personal history of venous thrombosis and embolism]","24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. the patient was continuned on her admission hypertensive regimen. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was therapetuic the same day and her heparin gtt was stopped.",24 year old woman with ckd v and severe hypertension due to sle admitted. patient was initially maintained on a labetalol drip and hydralazine iv prn. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic) 109,173633.0,14801,2141-12-14,14796,139061.0,2141-09-14,Discharge summary,"Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Right leg pain. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 24 y.o. F with lupus, Chronic Kidney Disease V (not currently on HD or PD), and multiple admissions for hypertensive urgency/emergency, who presented to the ED for continued R leg pain that starts in her R buttocks and refers down her R leg. She describes it as feeling like the pain is deep within her bone. The pain was [**10-20**] in the AM, and she felt like she couldn't get out of bed. Denies any swelling of her RLE. When getting VS in [**Name (NI) **], pt noted to be very hypertensive at 263/176. The patient reportedly has baseline SBPs in 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM on day of admission. She denies any recent recrational drug use including cocaine and amphetamines. She denies headache, vision changes, double vision, chest pain, shortness of breath, abdominal pain, BRBPR, dysuria. During MD interview, the patient was nauseous and had small amount of emesis of a recent Coolata. Pt states that flushing her PD cath causes a large amount of stomach pain. . Of note, the patient was recently admitted from 08.26-29.08. The patient initially presented to the ED after referral from her nephrologist's office where she had complaints of right leg pain and was found to be hypertensive to 250/145. She was admitted after initiation of a labetalol drip and nitropaste with improvement in sbp to 180. The patient did receive 2 U of PRBC's during this hospitalization for baseline anemia. The patient did have a work-up for her right leg pain complaints with plain films of the right hip and MRI of the L-spine which did not reveal an explanation for her symptoms and did rule out avascular necrosis. The patient received dilaudid for pain control and was ambulating without pain prior to discharge. In addition, the patient completed a course of ciprofloxacin for a positive UA with negative cultures. The patient was unable to tolerate peritoneal dialysis for unclear reasons. Peritoneal dialysate culture was negative for infection. . In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in ED ranged from [**Telephone/Fax (3) 43494**]-175 with HR in 96-108. Initially given labetalol 10 mg IV x 1 and then started on labetalol gtt for her elevated blood pressures and titrated to 3 mg/min. LENI of R leg was negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per ED, cannot do V/Q scan due to volume overload after talking with radiology. Renal c/s initiated. A-line placed. Past Medical History: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] . PAST SURGICAL HISTORY: - Placement of multiple catheters including dialysis. - Tonsillectomy. - Left eye enucleation in [**2140-4-10**]. - PD catheter placement in [**2141-5-11**]. Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 98.9 [**Telephone/Fax (2) 43495**] 99$% RA GEN: NAD, pleasant female sitting in bed with moon facies HEENT: EOMI of R eye, L eye prosthesis, no exudate, no erythema, MMM, no LAD CHEST: CTAB except at R base with decreased breath sounds; no w/r/r CV: tachy, normal S1S2, II/VI systolic murmur accentuated with Valsalva ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i EXT: no c/c/e, strength of LEs [**5-15**] and symmetric bilaterally. Negative straight leg test, no pain with internal rotation, external rotation, extension, adduction or abduction. Some pain on flexion at the hip. NEURO: II - XII intact to direct testing. No deficit in light tough sensation. Gait normal. DERM: no rashes noted Pertinent Results: LABS AT ADMISSION: [**2141-9-11**] 11:43AM GLUCOSE-86 UREA N-49* CREAT-8.1* SODIUM-139 POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-16* ANION GAP-18 [**2141-9-11**] 11:43AM CALCIUM-6.2* PHOSPHATE-5.8* MAGNESIUM-1.6 [**2141-9-11**] 11:43AM PT-18.4* PTT-42.8* INR(PT)-1.7* [**2141-9-11**] 07:00AM WBC-5.5 RBC-2.88* HGB-8.1* HCT-24.7* MCV-86 MCH-28.1 MCHC-32.8 RDW-18.0* [**2141-9-11**] 07:00AM NEUTS-74.7* LYMPHS-17.5* MONOS-4.2 EOS-3.3 BASOS-0.2 [**2141-9-11**] 07:00AM PLT COUNT-101* UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50 WBC . MICROBIOLOGY: Urine culture ([**2141-9-11**]): Mixed flora . STUDIES: Cardiology Report ECG Study Date of [**2141-9-11**] 6:55:16 AM Sinus tachycardia. The tracing is marred by baseline artifact. There is left atrial enlargement. Compared to the previous tracing of [**2141-9-5**] the rate has increased. The axis is more rightward. Otherwise, no diagnostic interim change. . UNILAT LOWER EXT VEINS RIGHT Study Date of [**2141-9-11**] 8:54 AM [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and popliteal veins demonstrate normal flow, compressibility, augmentation, waveforms. Appropriate color flow and compression is noted within the calf veins. No intraluminal thrombus is present. IMPRESSION: No evidence of right lower extremity DVT. . TTE ([**2140-8-26**]): The left atrium is normal in size. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . R HIP XR [**2141-9-6**]: No acute fracture or dislocation. . MRI L-SPINE [**2141-9-6**]: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. LAB RESULTS AT DISCHARGE: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-9-14**] 06:15AM 4.0 2.63* 7.6* 23.1* 88 29.1 33.0 18.0* 100* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-9-14**] 06:15AM 100 44* 8.1* 137 4.8 109* 17* 16 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2141-9-14**] 06:15AM 6.8* 5.4* 1.6 CALCIUM freeCa [**2141-9-14**] 11:30AM 0.94* Brief Hospital Course: ICU course: EKG showed no change from prior, and CXR showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home medication regimen. The patient was found to by hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. . [**Hospital1 **] history: . 1. Hypertensive urgency: During the patient's [**Hospital1 **] stay, her SBPs ranged from 140s-160s during the day, which is her baseline systolic blood pressure. She was maintained on her home oral medication regimen. At night, she became more hypertensive, with SBP to the 170s-180s, which was controlled with both IV hydralazine and PO nifedipine. PO nifedipine was most successful at bringing her SBP back to her baseline. SBP at discharge was 140. Throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. The renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. Right leg pain: Upon arrival on the floor, the patient complained of [**2143-4-15**] pain in R buttock and posterior thigh, much exacerbated with standing. Of note, lumbar spine MRI and R hip XR on most recent admission were both negative. Her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. Her pain when she was symptomatic was controlled well with PO dilaudid. If the pain recurs, an MRI of the right hip can be considered to evaluate for osteonecrosis. . 3. UTI: The patient had a urinalysis suggestive of UTI, though she remained asymptomatic throughout. She was treated with a three day course of ciprofloxacin. Her urine culture showed mixed flora consistent with skin contamination. . 4. ESRD: The patient has end-stage renal disease due to her lupus. The patient's creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. She was followed by the renal consult service. Her potassium remained stable. Her calcium was low during admission, and supplemental calcium was given in addition to starting Calcitriol. She was not dialyzed through her PD catheter secondary to discomfort, but may reinitiate PD as an outpatient. Her laboratories will be checked as an outpatient in renal clinic. . 5. Anemia: The patient's hematocrit remained near her baseline low 20s throughout her stay. She has anemia from chronic kidney disease and chronic disease. The patient is not on Epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. Prior SVC thrombus: The patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with INR goal 2.5 to 3.0. . 7. Systemic lupus erythematosus: No active issues. The patient's home prednisone regimen was continued. Medications on Admission: - Prednisone 5 mg Daily - Coumadin 2 mg at bedtime - Nifedipine 60 mg Sustained Release Daily - Hydralazine 50 mg every 8 hours - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY - Aliskiren 150 mg Twice daily - Docusate Sodium 100 mg 2 times a day - Labetalol 900 mg three times a day - Lactulose 15-30 ml once a day: goal is [**1-11**] soft bowel movements per day Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 7. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: - Hypertensive urgency - Right lower extremity pain - Urinary tract infection Secondary diagnosis: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) - HOCM: Last noted on echo [**8-17**] - Anemia - History of left eye enucleation [**2139-4-20**] for fungal infection - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Discharge Condition: Stable systolic blood pressure over past 24 hours. Discharge Instructions: You were admitted to the hospital for uncontrolled high blood pressure. You spent one day in the intensive care unit, where you were treated with intravenous medication to lower your blood pressure. You were then transferred to a regular hospital floor, where your blood pressure was managed with your home oral medications. You were also treated for urinary tract infection with antibiotics. Your right leg pain improved during admission, and we are unsure of the cause of this pain. You should discuss the need for an MRI of the hip if the pain returns when you meet with your primary care doctor. Please call your physician or return to the emergency room if you experience fever, chills, chest pain, difficulty breathing, abdominal pain, headache, changes in your vision, or any other symptoms that are concerning. Please take your medications as prescribed. - Calcitriol was added to your medications. - You should hold Coumadin for two days and restart Saturday, [**2141-9-16**]. You should have your INR checked at your visit in kidney clinic [**2141-9-18**]. - You can take Dilaudid 2-4 mg every eight hours as needed for pain. You should be vigilant about taking lactulose if you need to take Dilaudid. - You should continue Lactulose as per Dr.[**Name (NI) 12913**] instructions. - No other changes were made. Please keep follow up appointments as described below. Followup Instructions: Please call the office of your kidney doctor, Dr. [**Last Name (STitle) 4883**], at ([**Telephone/Fax (1) 773**] to schedule an appointment for [**Last Name (LF) 766**], [**9-19**] as discussed. Follow up with your lung doctor: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-9-21**] 1:00 Follow up with your new primary care doctor: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 ",91,2141-09-11 10:12:00,2141-09-14 20:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home medication regimen. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. . [**hospital1 **] history: . 1. hypertensive urgency: during the patients [**hospital1 **] stay, her sbps ranged from 140s-160s during the day, which is her baseline systolic blood pressure. she was maintained on her home oral medication regimen. at night, she became more hypertensive, with sbp to the 170s-180s, which was controlled with both iv hydralazine and po nifedipine. po nifedipine was most successful at bringing her sbp back to her baseline. sbp at discharge was 140. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. the renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. her pain when she was symptomatic was controlled well with po dilaudid. if the pain recurs, an mri of the right hip can be considered to evaluate for osteonecrosis. . 3. uti: the patient had a urinalysis suggestive of uti, though she remained asymptomatic throughout. she was treated with a three day course of ciprofloxacin. her urine culture showed mixed flora consistent with skin contamination. . 4. esrd: the patient has end-stage renal disease due to her lupus. the patients creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. she was followed by the renal consult service. her potassium remained stable. her calcium was low during admission, and supplemental calcium was given in addition to starting calcitriol. she was not dialyzed through her pd catheter secondary to discomfort, but may reinitiate pd as an outpatient. her laboratories will be checked as an outpatient in renal clinic. . 5. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay. she has anemia from chronic kidney disease and chronic disease. the patient is not on epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. prior svc thrombus: the patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with inr goal 2.5 to 3.0. . 7. systemic lupus erythematosus: no active issues. the patients home prednisone regimen was continued. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Urinary tract infection, site not specified; Other primary cardiomyopathies; Systemic lupus erythematosus; Sciatica; Hyperpotassemia; Thrombocytopenia, unspecified; Abnormal coagulation profile; Hyperparathyroidism, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism]","icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the renal team was consulted, and recommended no change to home medication regimen. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. she was treated with a three day course of ciprofloxacin. esrd: the patient has end-stage renal disease due to her lupus. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay.","ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. she became more hypertensive, with sbps to the 170s-180s during the day. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency." 109,173633.0,14801,2141-12-14,14797,172335.0,2141-09-24,Discharge summary,"Admission Date: [**2141-9-18**] Discharge Date: [**2141-9-24**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1936**] Chief Complaint: hip pain Major Surgical or Invasive Procedure: None History of Present Illness: 24yo woman with hx SLE, CKD(not currently on HD or PD), labile HTN here with right leg pain and HTN urgency. Patient was recently d/ced on [**9-14**] following admission for the same complaints. . Patient took her hydralazine dose on am of admission. BP at presentation to the ER was 250/140 (The patient reportedly has baseline SBPs in 130-170s) She was given 900 labetolol and 50 hydralazine in the ED. BP following this was 175/124. Her EKG was unchanged. K was 5.7. . Patient also complaining of [**10-20**] right hip pain. Patient was d/ced on [**9-14**] with oral dilaudid for hip/leg pain. She took this only for one day due to severe itching. Denies any parasthesias/weakness. Her RLE/hip pain has been extensively worked up with negative LENIs, Lumbar spine MRI and hip plain films in the past. She was given 4mg IV morphine in the ER. . On admission to the floor, leg/hip pain somwhat improved with morphine.She denies any headache, vision changes, double vision, chest pain or SOB. Feels warm but no chills. Past Medical History: Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 97.3 HR 81 BP 135/91 RR 16 100%RA Gen:NAD, happy, pleasant female HEENT:NC/AT, L eye prosthesis, R PERRL, EOMI, MMM, facial swelling, L side>R, scerla anicteric Neck: supple, no JVD, no LAD, scars from prior CVL and HD lines CV:S1S2+, 2/6 SEM LUSB, loud P2, RRR, no ectopy Pulm: CTA B/L, good inspiratory effort Abd: +BS, soft, nontender, slightly distended and resonant to percussion, PD catheter in place in left abdomen ext: no c/c/e, 2+DP b/L, L foream swollen>R, R hip is mobile without pain elicited on passive or active movement neuro: AAOx3, nonfocal exam, CN 2-12 intact, moves all 4 extremities psych: mood/affect appropriate Pertinent Results: MRI Right Hip ([**9-18**]): There is no signal abnormality on the fluid-sensitive sequences in the proximal femur, acetabulum, or other osseous structure. On T1- weighted images, there is a focal rounded region within the right femoral head measuring approximately 9 mm in a subchondral location, which is nonspecific but may represent an unusual focus of red marrow. No sclerosis is seen on the corresponding plain films. There is a small right hip joint effusion and a small amount of fluid in the left hip joint as well, at the upper limits of normal. There is no soft tissue abnormality, no muscular edema, and no fluid collections. IMPRESSION: 1. Small right hip joint effusion. 2. No bone marrow edema in the proximal femurs or the pelvis. 3. Nonspecific small focus of low signal on T1-weighted images in the right femoral head is nonspecific but may represent an unusual focus of red marrow. TTE ([**9-21**]): The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF 80%). A mild (18 mmHg) mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. There is no systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Severe symmetric left ventricular hypertrophy with hyperdynamic systolic function and mild mid-cavitary gradient. Mild aortic regurgitation. Moderate pulmonary hypertension. Findings consistent with hyperrtophic cardiomyopathy. Compared with the prior study (images reviewed) of [**2140-8-26**], pulmonary hypertension has developed (also present on the study from [**2140-5-20**]). Pericardial effusion is also new. V/Q scan ([**9-21**]): Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate no focal defects with improved ventilation to the posterior right basal segment. Perfusion images in the same 8 views show improved perfusion to the posterior right basal segement with a persistent small defect but no new findings. Chest x-ray shows cardiomgealy and left basilar atelectasis. IMPRESSION: Improved V/Q scan from [**9-/2139**] with no findings to suggest acute pulmonary embolism. B/L upper ext U/S ([**9-21**]): Grayscale and Doppler son[**Name (NI) 867**] of the right and left internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. There is nonocclusive focal thrombus seen in the left subclavian vein, where the vein is not fully compressible. Flow is seen in the region, indicating that the thrombus is nonocclusive. Elsewhere, normal flow, augmentation, compressibility were appropriate and waveforms are demonstrated. IMPRESSION: 1. Focal nonocclusive thrombus in the left subclavian vein. 2. Otherwise, patent upper extremity veins as described. [**2141-9-18**] 02:15PM POTASSIUM-5.1 [**2141-9-18**] 02:15PM HCT-21.2* [**2141-9-18**] 08:45AM POTASSIUM-5.7* [**2141-9-18**] 07:30AM GLUCOSE-88 UREA N-54* CREAT-8.6* SODIUM-136 POTASSIUM-5.8* CHLORIDE-108 TOTAL CO2-15* ANION GAP-19 [**2141-9-18**] 07:30AM estGFR-Using this [**2141-9-18**] 07:30AM CALCIUM-7.3* PHOSPHATE-5.3* MAGNESIUM-1.6 [**2141-9-18**] 07:30AM WBC-5.2 RBC-2.32* HGB-6.5* HCT-20.1* MCV-87 MCH-28.1 MCHC-32.4 RDW-18.4* [**2141-9-18**] 07:30AM NEUTS-78.0* LYMPHS-14.7* MONOS-3.9 EOS-3.2 BASOS-0.3 [**2141-9-18**] 07:30AM PLT COUNT-107* [**2141-9-18**] 07:30AM PT-20.8* PTT-43.3* INR(PT)-2.0* . [**2141-9-21**] CXR: There is no significant change when compared to the recent previous examination. The previously described left retrocardiac opacity is unchanged in appearance. Cardiomegaly is also unchanged. The mediastinal contour, bony thorax and pulmonary vasculature are normal. IMPRESSION: No significant change compared to study done roughly 7 hours prior. Brief Hospital Course: 24 yo with h/o of Lupus, HTN, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for R hip pain. Patient was on the floor on [**9-20**], given morphine for the hip pain. She then had an episode of hypotension and unresponsiveness and transferred to the MICU for closer monitoring. The patient got 2L IVFs and narcan and improved, in fact, found to be hypertensive upon arrival to MICU. . MICU Course: On [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. Concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. Mental status cleared somewhat with narcan. Renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. V/Q scan demonstrated improvement since prior study. Patient's home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. She was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. PD fluid was not c/w SBP. CXR was clear. Urine culture and blood cultures are pending. Patient's BP was in the 110s so hydralazine was stopped. Her other BP meds were otherwise continued. Plan was/is to follow renal recs for PD. If, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. Would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. If patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. Would add neurontin 100mg TID with room to titrate up to 300mg TID. Neuro also recommended PT with TENS unit and referral to pain clinic although patient's pain is currently absent. . FYI **** per Dr. [**Last Name (STitle) **] --- Because of ? increase in cardiomegaly on CXR, she got an echo yesterday. In addition to her known HOCM, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm Hg. They probably need to be followed up over time (particularly the pulmonary hypertension). We did evaluated the PHTN with a VQ scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. It would be good if we could arrange a PULMONARY CLINIC FOLLOW UP for Ms. [**Known lastname **] after discharge with either [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].**** . She underwent CT head, and V/Q scan which were unremarkable. Her steroid dose was increased to 15mg given concern for need for stress dose steroids. After transfer from the MICU, her steroids were dropped back to 5mg, her home dose with the approval of [**Last Name (un) **]. . Her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. Her hydralazine was discontinued. On day 2 of her MICU stay, she developed a fever to 102. She was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. Broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. There was question of retrocardiac opacity on CXR, though not clear. Rheum consult obtained given hip discomfort, who felt septic joint unlikely. Neurology consult obtained who felt autonomic seizure unlikely. . Pt initiated peritoneal dialysis. In this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising BPs. She is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. Her hip pain has resolved completely without further intervention. . Floor course: Fever: Spike fever in MICU to 102. Started on Levoquin, Aztreonam, and Vanc. Source unclear at this point, but CXR with question of retrocardiac opacity. There is a possibility of aspiration pneumonitis. Other etiologies include peritoneal fluid (PD cath), urine, and blood (though patient does not have any indwelling lines). Hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. Peritoneal dialysis cultures negative so far. Continued levo/vanco/aztreonam for 2 days empirically. Then d/ced the Abx as no infectious etiologies were found. Steroids back to home dosage. BCx, UCx (final neg), Peritoneal cultures negative at discharge. . # Labile blood pressure: h/o of difficult to control BP with episodes of hypertensive emergency in the past. Normal SBP runs in 170s. Having nausea in setting of new PD, no evidence of intracranial bleeding on clinical exam, though INR had been supratherapeutic so remains in differential, though not bradycardic. Continue home BP meds :Labetalol 900 mg PO TID but difficult for patient to tolerate due to nausea, Aliskiren *NF* 150 mg Oral [**Hospital1 **], NIFEdipine CR 60 mg PO DAILY, clonidine patch, hydralazine given hypertensive in setting of nausa. . # Right leg/hip pain: no evidence of avascular necrosis or fracture on MRI though there is a small effusion. Pain resolved without intervention. Continued to monitor and would avoid narcotics, restart slowly if pain resumes. Physical therapy to follow as an outpatient. [**Last Name (un) 18183**] followed. Please see consult note. . # Hyperkalemia: Chronic issue. Patient takes kayexalate intermittently per her report (last dose [**Last Name (un) 766**]). Monitored K but patient did not need it on floor. # CKD V: Renal following. Did well with PD on [**9-22**] but did report some nause and cramping. She was not tolerating all 1.5L in exchanges on discharge. # Anemia: Hct stable around 20. S/p 1 U PRBCs in MICU with Hct 20.1 to 21.9. Likely due to chronic hemolysis consistent with SLE> #. Prior SVC thrombus: Physical exam with L arm swelling consistent with this. No flow limitations. INR 3.5 on ICU admission. Held warfarin but restarted home 2mg daily the day before discharge. # Systemic lupus erythematosus: Home prednisone dose 5mg. Currently on 15mg in setting of acute illness (day 2). # General care: FEN: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, PD initiated, Proph: INR therapeutic, no indication for PPI, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. Code: Full code, confirmed with patient Communication: with the patient and her mother [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (2) 43497**]contact. Access: 2 PIVs Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly dilaudid PO prn benadryl prn lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily coumadin 2mg PO qday calcitriol 1 mcg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Hypertensive urgency Transient Hypotension due to Narcotics Sciatica . Secondary: End stage renal disease Systemic Lupus Erythematosus Anemia Discharge Condition: Stable. Blood pressures at baseline. Hip/leg pain resolved. Ambulating without assistance. Discharge Instructions: You were admitted to the hospital with high blood pressure and right leg/hip pain. We gave you pain medications and blood pressure lowering medications. Your blood pressure then dropped which was caused by the pain medication, and you were transferred to the Intensive Care Unit(ICU) where you recovered quickly. During your stay in the ICU, you developed a fever and were started on antibiotics. However, the cultures that were obtained were negative, and we discontinued the Antibiotics. During your hospitalization, your blood pressure normalized on your home regimen, and your right leg/hip pain resolved. You had an MRI of your hip done, which did not show an acute infection. You were seen by the kidney doctors and they recommended starting peritoneal dialysis. You were also given some blood for your anemia. Please follow up with the Peritoneal Dialysis nurse at the scheduled day/time. Please make an appointment to meet with your PCP in the next couple of weeks. Your Hip pain may benefit from physical therapy or outpatient anesthetic joint injection. Please discuss these options with your rheumatologist. . Please call the number given below to schedule outpatient physical therapy. . Please restart your home medications. You were also started on Sodium Bicarb 650mg by mouth three times a day. . If you develop fevers, chills, trouble breathing, chest pain, worsening of hip pain, headaches, changes in your vision or any other symptoms that concern you please return to the emergency room or call your doctor. Followup Instructions: Please follow up with your Peritoneal Dialysis nurse ([**Doctor First Name 3040**]) on [**Doctor First Name 766**] [**2141-9-25**] . Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 . Please call to schedule Outpatient Physical Therapy:[**Telephone/Fax (1) 2484**] Completed by:[**2141-9-25**]",81,2141-09-18 10:32:00,2141-09-24 13:53:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,LEG PAIN," 24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. patient was on the floor on [**9-20**], given morphine for the hip pain. she then had an episode of hypotension and unresponsiveness and transferred to the micu for closer monitoring. the patient got 2l ivfs and narcan and improved, in fact, found to be hypertensive upon arrival to micu. . micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. mental status cleared somewhat with narcan. renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. v/q scan demonstrated improvement since prior study. patients home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. she was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. pd fluid was not c/w sbp. cxr was clear. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. plan was/is to follow renal recs for pd. if, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. would add neurontin 100mg tid with room to titrate up to 300mg tid. neuro also recommended pt with tens unit and referral to pain clinic although patients pain is currently absent. . fyi **** per dr. [**last name (stitle) **] --- because of ? increase in cardiomegaly on cxr, she got an echo yesterday. in addition to her known hocm, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm hg. they probably need to be followed up over time (particularly the pulmonary hypertension). we did evaluated the phtn with a vq scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. it would be good if we could arrange a pulmonary clinic follow up for ms. [**known lastname **] after discharge with either [**first name4 (namepattern1) **] [**last name (namepattern1) **] or [**first name4 (namepattern1) **] [**last name (namepattern1) **].**** . she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. after transfer from the micu, her steroids were dropped back to 5mg, her home dose with the approval of [**last name (un) **]. . her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. her hydralazine was discontinued. on day 2 of her micu stay, she developed a fever to 102. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. there was question of retrocardiac opacity on cxr, though not clear. rheum consult obtained given hip discomfort, who felt septic joint unlikely. neurology consult obtained who felt autonomic seizure unlikely. . pt initiated peritoneal dialysis. in this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising bps. she is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. her hip pain has resolved completely without further intervention. . fever: spike fever in micu to 102. started on levoquin, aztreonam, and vanc. source unclear at this point, but cxr with question of retrocardiac opacity. there is a possibility of aspiration pneumonitis. other etiologies include peritoneal fluid (pd cath), urine, and blood (though patient does not have any indwelling lines). hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. peritoneal dialysis cultures negative so far. continued levo/vanco/aztreonam for 2 days empirically. then d/ced the abx as no infectious etiologies were found. steroids back to home dosage. bcx, ucx (final neg), peritoneal cultures negative at discharge. . # labile blood pressure: h/o of difficult to control bp with episodes of hypertensive emergency in the past. normal sbp runs in 170s. having nausea in setting of new pd, no evidence of intracranial bleeding on clinical exam, though inr had been supratherapeutic so remains in differential, though not bradycardic. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. . # right leg/hip pain: no evidence of avascular necrosis or fracture on mri though there is a small effusion. pain resolved without intervention. continued to monitor and would avoid narcotics, restart slowly if pain resumes. physical therapy to follow as an outpatient. [**last name (un) 18183**] followed. please see consult note. . # hyperkalemia: chronic issue. patient takes kayexalate intermittently per her report (last dose [**last name (un) 766**]). monitored k but patient did not need it on floor. # ckd v: renal following. did well with pd on [**9-22**] but did report some nause and cramping. she was not tolerating all 1.5l in exchanges on discharge. # anemia: hct stable around 20. s/p 1 u prbcs in micu with hct 20.1 to 21.9. likely due to chronic hemolysis consistent with sle> #. prior svc thrombus: physical exam with l arm swelling consistent with this. no flow limitations. inr 3.5 on icu admission. held warfarin but restarted home 2mg daily the day before discharge. # systemic lupus erythematosus: home prednisone dose 5mg. currently on 15mg in setting of acute illness (day 2). # general care: fen: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, pd initiated, proph: inr therapeutic, no indication for ppi, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. code: full code, confirmed with patient communication: with the patient and her mother [**name (ni) **] [**name (ni) **], [**telephone/fax (2) 43497**]contact. access: 2 pivs ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Pneumonia, organism unspecified; Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Hyperpotassemia; Sciatica; Other iatrogenic hypotension; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Anemia of other chronic disease; Hypocalcemia]","24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. it would be good if we could arrange a pulmonary clinic follow up for ms. [** she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. source unclear at this point, but cxr with question of retrocardiac opacity. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. did well with pd on [**9-22**] but did report some nause and cramping. # systemic lupus erythematosus: home prednisone dose 5mg.","lupus nephropathy patient on peitoneal dialysis with htn and lupus nephropathy. triggered for hypotension (82/45), hypothermia (92.9), altered mental status. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis." 109,173633.0,14801,2141-12-14,14798,126055.0,2141-11-03,Discharge summary,"Admission Date: [**2141-10-13**] Discharge Date: [**2141-11-3**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 6734**] Chief Complaint: Nausea, Vomitting, Abdominal Pain, HTN Urgenc Major Surgical or Invasive Procedure: Upper GI endoscopy Exploratory laparotomy Tunneled hemodialysis catheter in R femoral vein Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 24 y/o F with h/o ESRD, HTN who started peritoneal dialysis during the week of [**2141-10-8**] and presented with a 1 day history of acute onset N/V, sharp abdominal pain on [**2141-10-13**]. (Of note, the patient had presented to the ED on [**10-11**] with hypotension, SBPs in the 80s off after approximately 1.5L was taken off during dialysis in the setting of taking her PO Anti-HTNs. On [**2141-10-11**] she received 0.5L IVF, labs WNL, and was d/c'd home). On the day of admission on [**2141-10-13**], the patient reported that the previous night, she was awoken from sleep with severe, sharp abdominal pain, 6 episodes of frothy emesis, 10+ yellowish BMs without melena or BRBRP.She was admitted for further work- up of this abdminal pain. . In the ED here vitals were as follows: T: 97.0 HR: 101 BP: 240/180 RR: 17 O2sat: 100%RA. She received Labetolol 20mg IV and was subsequently placed on a labetolol drip. She also received ceftriaxone 1gm IV, Flagyl 500mg IV, Dilaudid 0.5-1mg IV q1hr and Zofran. Her abdominal CT showed multifocal areas of small bowel wall thickening. Her peritoneal Cell count was negtaive for SBP. She had some signs of peritonitis and thus surgery was consulted. Her lactate was normal. . Upon arrival to the MICU the patient was mentating well with complaints of diffuse sharp abdominal pain that radiated to the back and diarrhea. She had no headache or visual changes. Past Medical History: - SLE DX ([**2134**] - 16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter Placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). - Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS: 98.4 HR 98 192/131 21 100%RA GEN: Mild Distress, AOx3 HEENT: PEERLA, EOMI NECK: Supple, No LAD, No bruit RESP: CTAB CARD: 2/6 systolic ejection murmur ABD: soft, moderately tender with +/- guarding, BS+ EXTR: Warm well perfused NEURO: Motor Grossly Intact RECTAL: Yellow Stool BACK: B CVAT Pertinent Results: [**2141-11-3**] 08:50AM BLOOD WBC-3.5* RBC-2.55* Hgb-7.8* Hct-23.6* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.8* Plt Ct-176 [**2141-11-3**] 03:55PM BLOOD PT-15.5* PTT-50.8* INR(PT)-1.4* [**2141-11-3**] 08:50AM BLOOD Glucose-121* UreaN-33* Creat-5.2*# Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [**2141-10-26**] 06:15AM BLOOD ALT-11 AST-49* AlkPhos-122* Amylase-186* TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2141-10-26**] 06:15AM BLOOD Lipase-30 [**2141-11-3**] 08:50AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.9 [**2141-10-30**] 06:55AM BLOOD HBsAg-NEGATIVE [**2141-10-17**] 10:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2141-10-25**] 11:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2141-10-25**] 11:56AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2141-10-25**] 11:56AM URINE RBC-0-2 WBC-[**3-15**] Bacteri-FEW Yeast-NONE Epi-21-50 Blood cultures: all negative EKG ([**2141-10-13**]): Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of [**2141-10-2**] there is no significant diagnostic change. CXR ([**2141-10-13**]): No acute cardiopulmonary abnormality. No free air under the diaphragms. CT chest/abdomen/pelvis ([**2141-10-13**]): There is a moderate-sized pericardial effusion, similar in appearance from [**2141-10-13**]. The great vessels are normal in caliber, without aneurysmal dilatation. Evaluation of the great vessels is limited without IV contrast. Interstitial thickening, particularly within the perihilar regions, is suggestive of fluid overload. There is bibasilar atelectasis with a small focus of consolidation in the right lower lobe (2:35) unchanged from [**2141-10-13**], and may reflect aspiration or pneumonia. Scattered bilateral nodules are largely stable from as far back as [**2139-10-9**]. Specifically, there is a 5 mm nodule in the right middle lobe (2:25), two adjacent nodules in the right lower lobe measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule within the left lower lobe. A nodular density seen adjacent and anterior to the right main pulmonary artery (2:23) may reflect a vessel. There is a small right pleural effusion. Axillary lymphadenopathy, with axillary nodes measuring up to approximately 10 mm in short axis, is seen. Ill- defined soft tissue thickening within the hilus bilaterally may reflect hilar lymphadenopathy, but assessment is limited without IV contrast. A catheter is visualized within the visualized right upper extremity, which may reflect a PICC line that terminates within the right subclavian vein. The esophagus is distended and filled with contrast, with marked wall thickening and edema throughout its entire length, a new finding. There is a moderate- sized hiatal hernia. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval development of a moderate amount of free intraperitoneal air, that layers anteriorly and along the anterior abdominal wall. Additional small clustered foci of extraluminal air is seen adjacent to the proximal stomach and the gastroesophageal junction, with a focus of air tracking into the fissure of ligamentum venosum. Additionally, there appears to be air tracking into the anterior subcutaneous tissues in the region of the umbilicus. These findings are all new from the prior CT on [**2141-10-13**], but free air was present on chest radiograph performed [**2141-10-25**]. There is no obvious evidence of extravasation of oral contrast into the peritoneum. Of note, a peritoneal dialysis catheter is in place that could represent a route of entry of intraperitoneal air. The stomach, small bowel, and colon are filled with contrast, without evidence of obstruction. Evaluation for wall thickening is limited without IV contrast. Limited non-contrast views of the liver demonstrates a rounded 1.6 cm x 1.2 cm hypodensity in the right lobe of the liver, previously characterized as a hemangioma. The liver is otherwise unremarkable. The gallbladder, spleen, pancreas, and adrenal glands demonstrate no gross abnormality. Both kidneys are atrophic. Evaluation of solid organs is limited by lack of IV contrast. There is a peritoneal dialysis catheter, coiled within the pelvis, unchanged. There is a large amount of free fluid throughout the abdomen, similar in appearance to the prior study. CT OF THE PELVIS WITHOUT IV CONTRAST: Uterus and rectum are grossly unremarkable. However, assessment of the rectal wall is limited without IV contrast. OSSEOUS STRUCTURES: Bones are diffusely sclerotic, which may be related to renal osteodystrophy. There is bilateral sacroiliitis. IMPRESSION: 1. Interval development of a moderate amount of free intraperitoneal air, new from [**2141-10-13**]. A peritoneal dialysis catheter is in place and could represent the route of entry of free intraperitoneal air. However, as foci of air is seen in the region of the proximal stomach and GE junction in the setting of a recent endoscopy, perforation cannot be excluded, though no frank extravasation of contrast is identified. 2. New dilation and wall thickening of the entire esophagus, a nonspecific finding that could relate to infectious or inflammatory esophagitis; clinical correlation is recommended. Esophagus is contrast-filled possibly representing reflux. Hiatal hernia. 3. Anasarca, with moderate-sized pericardial effusion, pulmonary edema, and small right pleural effusion. 4. Large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. Imaging cannot exclude SBP, which should be evaluated for clinically. 5. Focus of consolidation within the right lower lobe, could represent aspiration or pneumonia, but unchanged from the prior study. Gastric Biopsies ([**2141-10-18**]): Antrum: Corpus-type mucosa, no diagnostic abnormalities recognized. Jejunum: Small intestinal mucosa, no diagnostic abnormalities recognized. UE Venous U/S: No evidence of DVT of the left upper extremity, without thrombus identified within the left subclavian vein. Brief Hospital Course: This is a 24 year old woman with ESRD secondary to SLE (started peritoneal dialysis approximately one week prior to admission), malignant HTN, h/o SVC syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. Her hospital course was complicated by multiple transfers between the MICU and the floor secondary to hypertensive urgency. # Abdominal Pain/Diarrhea: During the patient's admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. Infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. However, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. The patient was empirically placed on IV flagyl, but this was discontinued when stool samples were negative for C.difficile. Serial abdominal exams showed no peritoneal signs. Peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. CT of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. Other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to SLE vasculitis, malignant HTN, or microthrombosis and SLE enteritis. Surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. A heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible GI bleed. With regards to SLE vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to SLE. On [**10-18**], GI performed an EGD which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. Approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. Both cardiac, GI, and pulmonary etiologies were considered for the origin of her epigastric pain. Pericarditis was considered, but her EKG was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. Her lungs were also essentially unchanged from [**2141-10-13**]. However, her abdominal CT on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. As a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. There were no major findings: no evidence of perforation, obstruction, or infection. The patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. At discharge, the patient only complained of some mild incisional pain. # Hypertensive urgency: The patient was initially admitted to the MICU with a blood pressure of 240/180. Her hospital course was complicated by extremely labile HTN and was transferred back and forth between the MICU and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of SBPs > 260. Throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. Her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. Multiple medication regimens were attempted and changed throughout her hospital course. However, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for SBPs > 180. At discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg PO. Her regimen as per Dr. [**Last Name (STitle) 4883**]: Nifedipine SR 90 mg daily Aliskiren 150 mg [**Hospital1 **] Labetalol 300 mg TID Hydralazine 75 mg TID Clonidine patch 0.3 mg/24 hr patch qWed When SBP>180, she then uses a hydralazine sliding scale. When SBP>180, give 25 mg PO hydral every 30 min until SBP<150. You can use this for up to 2-3 hours. In between PO hydral doses, can then also use 10 IV hydralazine. # ESRD: The etiology of the patient's ESRD is secondary to SLE. Her Creatinine on admission was 7.9, which was near her baseline of 8 - 9. During her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. Prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2L per PD. After her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. Initially, the patient adamantly refused hemodialysis. However, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. As a result, after a long coversation with her primary renal physician, [**Name10 (NameIs) **] agreed to restart hemodialysis. A tunneled catheter was placed in her R femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. She underwent hemodialysis two more times prior to discharge. Upon discharge, her electrolytes were back to her baseline. She is expected to undergo hemodialysis (Tues/[**Last Name (un) **]/SAT) as an outpatient. # Anemia: During her admission, the patient's HCT was monitored daily with HCT to low-mid 20's. On [**2141-10-17**], she was found to have guaiac positive stools and her HCT was found to have dropped to a low of 18.6. The patient was transfused a total of 2 units of [**Date Range **] between [**2141-10-17**] and [**2141-10-18**]. Epo Alfa SC was also given on [**2141-10-17**]. She remained hemodynamically stable. GI consulted and EGD results were as stated above. The patient's HCT remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. Between [**2141-10-23**] - [**2141-10-24**], the patient had a HCT drop from 26 to 20 in the setting of occult positive emesis. She received two units of [**Month/Day/Year **] and her HCT returned to 28. GI was aware and planned to perform a non-urgent EGD on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her HCT returned to baseline. However, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her HCt remained stable and near baseline for the remiainder of her hospital course. # H/O Thrombosis: The patient was initially placed on her home dose of warfarin 2mg qd. Her INR on admission was 1.2. She was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. However, this was stopped for her EGD and after she had evidence of a GI bleed. The heparin drip was discontinued on [**10-22**]. The patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in HCT and in preparation for a possible GI intervention. After her surgery, her coumadin was held and she was off the heparin drip, but her INR continued to drift up, getting as high as 2.6 on [**2141-10-30**]. This was mostly attributed to nutritional deficiency [**2-11**] poor PO intake, but there was concern for possible synthetic dysfunction as well. As a result, she was given a test dose of vitamin K, which she responded to well (Her INR came back down to 1.4). As a result, her home dose of coumadin at 2 mg qday was restarted. At discharge, her INR was still sub- therapeutic at 1.4. Of note, the patient has a history of SVC syndrome and had a L subclavian venous thrombosis. During the last few days of her hospital stay, the patient complained of increased tongue swelling and her L face was noted to be slightly more swollen than previously noted. As a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a DVT within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # SLE: Rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. Her outside rheumatologist was also consulted. Both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # Obstructive sleep apnea: The patient was noted to have OSA based on clinical nocturnal exam during admission. Patient attempted 1 trial of CPAP at 2L/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. The paitent stated that she would pursue further work-up and treatment for OSA as an outpatient. While the mask and CPAP machine were at her bedside throughout her hospital course, the patient rarely used it. # Metabolic Acidosis: The patient's bicarbonate on admission was 13. Her baseline is normally between 16-20. She received 150mEq NaHCO3 over 24hrs from [**Date range (1) 43500**]. During her brief returns to the MICU, her HC03 was 18-19, which was presumed to be her baseline at home secondary to her CRF. At discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. Medications on Admission: Nifedipine 60 mg PO daily Labetalol 900 mg PO TID Hydralazine 50 mg PO TID Clonidine 0.3 mg/24hr patch qWED Lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 4 mg daily Warfarin 2mg PO daily Calcitriol 1 mcg daily Calcium carbonate 500mg QID Dilaudid 2mg PO Q4-6hr prn pain Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*30 Patch Weekly(s)* Refills:*2* 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. [**Hospital1 **]:*1500 ML(s)* Refills:*0* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Twice daily (). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): In addition to 75 mg TID, if SBP>180, take 1 tab every 30 min until BP decreases to 150. If no improvement after 2 hours, call your doctor. [**Last Name (Titles) **]:*300 Tablet(s)* Refills:*6* 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). [**Last Name (Titles) **]:*1500 ML(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet Sustained Release(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 5 days. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. [**Last Name (Titles) **]:*30 Capsule(s)* Refills:*2* 13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO once a day. [**Last Name (Titles) **]:*30 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: end stage renal disease malignant hypertension abdominal free air subclavian deep vein thrombosis initiation of hemodialysis Secondary: SLE Anemia Discharge Condition: stable, pain well controlled, blood pressure at baseline Discharge Instructions: You were admitted for abdominal pain and then subsequently had a very long hospital course with high blood pressures, severe abdominal pain, some free air in your abdomen resulting in an exploratory laparotomy. You have also been initiated on hemodialysis on Tuesday/Thursday/Saturday schedule. Please take all medications as prescribed in the list that you will be given at discharge. There have been some changes to your medications. Please call your doctor if you have any worsening abdominal pain, fevers, chills, nausea, vomiting, headache, palpitations, diarrhea or any other concerning symptoms. Followup Instructions: You will see Dr. [**Last Name (STitle) 4883**] at hemodialysis on Tuesday, [**11-7**], [**2141**]. You should have your coumadin level checked at this appointment. Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] to schedule an appointment in [**1-11**] weeks to have your staples removed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**] ",41,2141-10-13 23:10:00,2141-11-03 18:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. her hospital course was complicated by multiple transfers between the micu and the floor secondary to hypertensive urgency. # abdominal pain/diarrhea: during the patients admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. the patient was empirically placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. serial abdominal exams showed no peritoneal signs. peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. ct of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to sle vasculitis, malignant htn, or microthrombosis and sle enteritis. surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible gi bleed. with regards to sle vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to sle. on [**10-18**], gi performed an egd which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. both cardiac, gi, and pulmonary etiologies were considered for the origin of her epigastric pain. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. her lungs were also essentially unchanged from [**2141-10-13**]. however, her abdominal ct on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. as a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. there were no major findings: no evidence of perforation, obstruction, or infection. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. at discharge, the patient only complained of some mild incisional pain. # hypertensive urgency: the patient was initially admitted to the micu with a blood pressure of 240/180. her hospital course was complicated by extremely labile htn and was transferred back and forth between the micu and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of sbps > 260. throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. multiple medication regimens were attempted and changed throughout her hospital course. however, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for sbps > 180. at discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg po. her regimen as per dr. [**last name (stitle) 4883**]: nifedipine sr 90 mg daily aliskiren 150 mg [**hospital1 **] labetalol 300 mg tid hydralazine 75 mg tid clonidine patch 0.3 mg/24 hr patch qwed when sbp>180, she then uses a hydralazine sliding scale. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. you can use this for up to 2-3 hours. in between po hydral doses, can then also use 10 iv hydralazine. # esrd: the etiology of the patients esrd is secondary to sle. her creatinine on admission was 7.9, which was near her baseline of 8 - 9. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2l per pd. after her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. initially, the patient adamantly refused hemodialysis. however, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. as a result, after a long coversation with her primary renal physician, [**name10 (nameis) **] agreed to restart hemodialysis. a tunneled catheter was placed in her r femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. she underwent hemodialysis two more times prior to discharge. upon discharge, her electrolytes were back to her baseline. she is expected to undergo hemodialysis (tues/[**last name (un) **]/sat) as an outpatient. # anemia: during her admission, the patients hct was monitored daily with hct to low-mid 20s. on [**2141-10-17**], she was found to have guaiac positive stools and her hct was found to have dropped to a low of 18.6. the patient was transfused a total of 2 units of [**date range **] between [**2141-10-17**] and [**2141-10-18**]. epo alfa sc was also given on [**2141-10-17**]. she remained hemodynamically stable. gi consulted and egd results were as stated above. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. she received two units of [**month/day/year **] and her hct returned to 28. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. however, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her hct remained stable and near baseline for the remiainder of her hospital course. # h/o thrombosis: the patient was initially placed on her home dose of warfarin 2mg qd. her inr on admission was 1.2. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. however, this was stopped for her egd and after she had evidence of a gi bleed. the heparin drip was discontinued on [**10-22**]. the patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in hct and in preparation for a possible gi intervention. after her surgery, her coumadin was held and she was off the heparin drip, but her inr continued to drift up, getting as high as 2.6 on [**2141-10-30**]. this was mostly attributed to nutritional deficiency [**2-11**] poor po intake, but there was concern for possible synthetic dysfunction as well. as a result, she was given a test dose of vitamin k, which she responded to well (her inr came back down to 1.4). as a result, her home dose of coumadin at 2 mg qday was restarted. at discharge, her inr was still sub- therapeutic at 1.4. of note, the patient has a history of svc syndrome and had a l subclavian venous thrombosis. during the last few days of her hospital stay, the patient complained of increased tongue swelling and her l face was noted to be slightly more swollen than previously noted. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. her outside rheumatologist was also consulted. both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission. patient attempted 1 trial of cpap at 2l/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. the paitent stated that she would pursue further work-up and treatment for osa as an outpatient. while the mask and cpap machine were at her bedside throughout her hospital course, the patient rarely used it. # metabolic acidosis: the patients bicarbonate on admission was 13. her baseline is normally between 16-20. she received 150meq nahco3 over 24hrs from [**date range (1) 43500**]. during her brief returns to the micu, her hc03 was 18-19, which was presumed to be her baseline at home secondary to her crf. at discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. ","PRIMARY: [Malignant essential hypertension] SECONDARY: [Renal dialysis status; Epilepsy, unspecified, without mention of intractable epilepsy; Constipation, unspecified; Anemia in chronic kidney disease; Abnormal coagulation profile; Obstructive sleep apnea (adult)(pediatric); Other diseases of lung, not elsewhere classified; Other chest pain; Fever, unspecified; Rash and other nonspecific skin eruption; Other chronic pulmonary heart diseases; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified disease of pericardium; Other ascites; Acidosis; Hyposmolality and/or hyponatremia; Abdominal pain, other specified site; Abdominal pain, epigastric; Nausea with vomiting; Diarrhea; Systemic lupus erythematosus; Hyperparathyroidism, unspecified; Anemia, unspecified; Thrombocytopenia, unspecified; Esophageal reflux]","this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. multiple medication regimens were attempted and changed throughout her hospital course. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. upon discharge, her electrolytes were back to her baseline. epo alfa sc was also given on [**2141-10-17**]. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission.","esrd secondary to sle, malignant htn, h/o svc syndrome, and multiple thrombotic events were considered. the patient was placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia." 109,173633.0,14801,2141-12-14,14799,125288.0,2141-11-23,Discharge summary,"Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypertensive Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: (from MICU admit note) 24yoF ESRD-HD, SLE, HTN presents with 1 month abdominal pain and hypertension. Pt has had work-up over recent months for abd pain, including exploratory laparotomy, all of which essentially (-). Was admitted [**Date range (1) 34629**], for abdominal pain, then returned [**11-16**] for sob with (-)CTA, dc'ed [**11-17**]. In [**Hospital1 18**] ED, T98.5 hr95 BP 220/110 then 183/133 RR13 O2 100% on RA, rectal exam negative, guaiac(-), pelvic exam unremarkable with no cervical motion tenderness. Renal was consulted, taken for hemodialysis. CT abd showed large ascites, no other pathology; CT head improved from prior with no acute ICH; cxr(-). Given iv dilaudid for abdominal pain. BP treated with 10mg iv labetalol. Blood and urine cultures drawn, peritoneal fluid cx sent from catheter. Admitted to MICU for hypertension management. Access: R-HD catheter, 1 pIV in hand, 1 non-functioning peritoneal dialysis catheter. Past Medical History: PMH: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSH: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: PE: T:99.4 BP:158/108 HR:95 RR:12 O2 100% RA GEN: NAD/ pt eyes closed due to pain/ pleasant despite pain HEENT: AT, NC, PERRLA, EOMI on R eye, L eye prosthesis, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD CV: S1 & S2, RRR II/VI HSM at R/L USB, no rubs/gallops PULM: CTAB, no w/r/r ABD: soft, mildly tender at PD catheter, ND, + BS, midline incision with steri-stripes, PD catheter dressing C/I/D EXT: warm, dry, +2 distal pulses BL, no edema NEURO: alert & oriented, CN II-XII grossly intact (except L eye), 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: Admission Labs: [**2141-11-18**] 07:00AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.7* Hct-30.7* MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* Plt Ct-142* [**2141-11-18**] 07:00AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.3* [**2141-11-18**] 07:00AM BLOOD Glucose-86 UreaN-22* Creat-5.0* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2141-11-18**] 07:00AM BLOOD ALT-8 AST-39 AlkPhos-92 TotBili-0.3 [**2141-11-18**] 07:00AM BLOOD Lipase-76* [**2141-11-18**] 07:00AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.9 [**2141-11-18**] 11:00PM ASCITES WBC-1265* RBC-1680* Polys-43* Lymphs-1* Monos-2* Mesothe-11* Macroph-43* [**2141-11-18**] 10:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2141-11-18**] 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2141-11-18**] 10:05AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-[**3-15**] Discharge Labs: [**2141-11-23**] 04:40AM BLOOD WBC-2.9* RBC-3.08* Hgb-9.0* Hct-28.3* MCV-92 MCH-29.2 MCHC-31.8 RDW-17.5* Plt Ct-182 [**2141-11-23**] 04:40AM BLOOD PT-20.8* PTT-76.1* INR(PT)-2.0* [**2141-11-23**] 04:40AM BLOOD Glucose-80 UreaN-21* Creat-4.7* Na-139 K-4.8 Cl-106 HCO3-24 AnGap-14 [**2141-11-23**] 04:40AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8 [**2141-11-22**] 04:55AM BLOOD TSH-6.1* [**2141-11-23**] 04:40AM BLOOD Free T4-1.2 Blood cx ([**11-18**], [**11-19**]): 1/4 bottles with coag neg Staph, [**3-14**] NGTD Urine cx ([**11-18**]): mixed flora c/w contamination Peritoneal fluid ([**11-18**]): Gram stain 2+ polys. Culture no growth. Imaging: CXR Portable ([**11-18**]): Since [**2141-11-16**], heart size enlargement is unchanged due to known pericardial effusion. Lungs are otherwise clear. Hilar contours are normal. Incidentally, widening of both acromioclavicular joints is unchanged. CT A/P ([**11-18**]): 1. No evidence of bowel obstruction or rim-enhancing fluid collection. 2. Large ascites, slightly increased from [**2141-11-13**], with peritoneal dialysis catheter in place. Interval removal of surgical skin staples along the abdomen. 3. Moderate pericardial effusion as before. 4. Symmetric heterogeneous attenuation of the kidneys could be related to renal failure; however, pyelonephritis could also give this appearance. Appearance of the kidneys is unchanged from [**2141-11-13**]. CT Head w/o contrast ([**11-18**]): 1. No evidence of acute intracranial hemorrhage. 2. Regions of hypoattenuation in the bifrontal white matter and left posterior temporal lobe have resolved since [**2141-6-11**]. No new regions of hypoattenuation seen. Brief Hospital Course: 1) Hypertension: Patient has history of extremely labile hypertension on an aggressive outpatient regimen. Overnight in the MICU, patient required IV and PO labetalol for SBP > 200. Her hydralazine was increased from 75mg to 100mg TID with mild improvement. Her labetalol was also increased from 300mg to 400mg TID. Her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. TSH was sent and elevated, although free T4 was normal. Plasma metanephrines were sent and pending at discharge. 2) Abdominal pain: CT scan showed increasing ascites, but no acute pathology. Peritoneal fluid was obtained and contained 544 polys. Treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing GPC pairs/clusters. Blood cultures ended up growing 1 out of 4 bottles coag-neg Staph, likely contaminant, so vancomycin was stopped. Since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. The peritoneal cultures remained negative. Her PD catheter was left in place as the patient refuses HD any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) SVC/brachiocephalic thrombosis: Patient's INR was subtherapeutic on admission at 1.3. Due to the proximal location of her old venous thrombi, she was started on a heparin gtt. This was continued during her admission and her warfarin was increased to 5mg daily. Her INR reached 2.0 at discharge (therapeutic range 2-3). The dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) Anxiety: Patient noted feeling short of breath and anxious around the time of her recent admissions. Her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. They felt her symptoms were suggestive of anxiety and panic attacks, recommended checking TSH and metanephrines as above, and starting citalopram 20mg, which was done. She was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h PRN. Patient is agreeable to outpatient follow up with [**Company 191**] social work, and potential CBT. These can be arranged by her PCP. Medications on Admission: 1. Aliskiren 150 mg [**Hospital1 **] 2. Clonidine 0.3 mg/24 qwk 3. Prochlorperazine Maleate 10 mg prn 4. Hydromorphone 2 mg Tablet Sig: [**1-11**] q6 prn 5. Bisacodyl 10mg [**Hospital1 **] 6. Ergocalciferol (Vitamin D2) 50,000 qmonth 7. Hydralazine 75mg tid 8. Hydralazine scale prn 9. Labetalol 300 mg tid 10. Nifedipine 90 mg qd 11. Prednisone 4mg qd 12. Warfarin 2 mg qd at 4pm Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Hospital1 766**]). 5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day. [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 7 days. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO q30 min prn as needed for hypertension: for SBP > 180. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive urgency Headache Abdominal pain Anxiety Secondary Diagnosis: HTN SLE ESRD on HD SVC and IJ thrombosis, chronic Anemia Discharge Condition: Stable, BPs improved. Discharge Instructions: You were admitted with elevated blood pressures, headache, and abdominal pain. You were found to have increased amounts of white blood cells in your abdominal cavity, but this was not infected. Your abdominal pain resolved and you continued to have intermittent headaches. Your blood pressure medications were adjusted as below. You were also seen by psychiatry who recommended starting new medications for your anxiety. The following changes were made to your medication regimen: - We increased your hydralazine to 100 mg three times a day. - We also increased your labetalol to 400 mg three times a day. - We have started a medication called celexa 20 mg daily as well as ativan 1 mg three times a day as needed for anxiety. - We have increased your coumadin to 4 mg daily. - Please continue taking all other medications as previously prescribed. Call your doctor or return to the emergency room if you experience any of the following: worsening abdominal pain, nausea, vomiting, blurry vision, worsening headache, fever > 101. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. Please continue to follow with your nephrologist and go to outpatient dialysis as previously arranged. Please discuss with your PCP the possibility of talking to a social worker at [**Name (NI) 191**]. You will need to continue to have your INR monitored at [**Hospital 191**] [**Hospital 2786**] clinic. Please have this level checked on [**Hospital 766**], [**11-27**]. Completed by:[**2141-11-23**]",21,2141-11-18 14:00:00,2141-11-23 16:42:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. her hydralazine was increased from 75mg to 100mg tid with mild improvement. her labetalol was also increased from 300mg to 400mg tid. her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. tsh was sent and elevated, although free t4 was normal. plasma metanephrines were sent and pending at discharge. 2) abdominal pain: ct scan showed increasing ascites, but no acute pathology. peritoneal fluid was obtained and contained 544 polys. treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing gpc pairs/clusters. blood cultures ended up growing 1 out of 4 bottles coag-neg staph, likely contaminant, so vancomycin was stopped. since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. the peritoneal cultures remained negative. her pd catheter was left in place as the patient refuses hd any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) svc/brachiocephalic thrombosis: patients inr was subtherapeutic on admission at 1.3. due to the proximal location of her old venous thrombi, she was started on a heparin gtt. this was continued during her admission and her warfarin was increased to 5mg daily. her inr reached 2.0 at discharge (therapeutic range 2-3). the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) anxiety: patient noted feeling short of breath and anxious around the time of her recent admissions. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. they felt her symptoms were suggestive of anxiety and panic attacks, recommended checking tsh and metanephrines as above, and starting citalopram 20mg, which was done. she was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h prn. patient is agreeable to outpatient follow up with [**company 191**] social work, and potential cbt. these can be arranged by her pcp. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Abdominal pain, unspecified site; Anemia, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. her hydralazine was increased from 75mg to 100mg tid with mild improvement. peritoneal fluid was obtained and contained 544 polys. the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted.","patient has history of extremely labile hypertension on aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. ct scan showed increasing ascites, but no acute pathology." 109,173633.0,14801,2141-12-14,14800,161950.0,2141-12-01,Discharge summary,"Admission Date: [**2141-11-24**] Discharge Date: [**2141-12-1**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Headache, abdominal pain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24yo F w/PMHx of ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning, awakening her from sleep. Had been previously discharged from [**Hospital1 **] yesterday after being admitted for hypertension and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Upon discharge yesterday she states her abdominal pain had subsided. She had HD yesterday without complications. She awoke at 6am with a headache and crampy, stabbing abdominal pain. Took 2mg PO Dilaudid without relief and came to ED. No nausea/vomiting, no changes in vision, no fevers, chills, night sweats. No chest pain, SOB, diarrhea. In the ED, initial vitals were T98.7, BP260/130, HR70, RR16. Was initially given 10mg IV Labetalol X 2, 4mg Zofran for nausea. No improvement in BP and started on Labetolol gtt. Got 1mg IV Dilaudid for pain. Currently, patient continues to complain of headache and abdominal pain, both [**7-17**]. No vision changes, chest pain or shortness of breath. Has been feeling increased anxiety recently and saw psychiatrist, was put on Celexa. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T98.2, BP176/135, HR94, RR 22, 100% RA Gen: well-appearing african-american woman, lying comfortably HEENT: anicteric, L eye prosthetic non-reactive, R pupil reactive, MMM, neck supple with submanibular LAD CV: RRR, II/VI SEM best heard at apex Pulm: CTA b/l Abd: hyperactive bowel sounds, midline scar well-healed, soft, diffusely tender to palpation, +rebound, no guarding. PD catheter in LLQ without erythema or purulent material draining. +dullness on percusion with evidence of clinical ascites. Ext: no edema, no clubbing, 2+ peripheral pulses DP and radial. R femoral HD [**Last Name (un) **] in place without erythema, purulance Neuro: A&O X 3, CN intact II-XII, [**5-15**] motor strength in upper and lower extremities Pertinent Results: Admission labs: CBC: [**2141-11-26**] 05:21AM BLOOD WBC-3.5* RBC-3.07* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-17.6* Plt Ct-180 CHEM 10: [**2141-11-26**] 01:16PM BLOOD Glucose-87 UreaN-17 Creat-4.0* Na-136 K-5.2* Cl-106 HCO3-23 AnGap-12 [**2141-11-26**] 09:20PM BLOOD Calcium-7.6* Phos-3.8 Mg-1.8 COAGS: [**2141-11-26**] 01:16PM BLOOD PT-23.9* PTT-40.2* INR(PT)-2.3* STUDIES: 1)Peritoneal fluid ([**11-26**]): negative for malignant cells. Reactive mesothelial cells, macrophages, eosinophils and lymphocytes. 2)BILAT UP EXT VEINS US ([**11-26**]): No evidence of deep vein thrombosis of the right or left upper extremity. 3) MRI/MRA ([**11-30**]): FINDINGS: Examination is somewhat limited by patient motion. T2/FLAIR sequences are unremarkable with interval resolve of previously noted posterior abnormalities. The major vessels appear patent proximally. There are stable areas of low signal in the left frontal and right occipetal/temporal lobes. IMPRESSION: 1. Interval resolution of previously noted posterior white matter abnormalities. 2. Stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions. 3. Very limited MRA as above. Brief Hospital Course: 24yo F with SLE, ESRD on HD and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**Hospital Unit Name 153**] course: The patient was admitted for blood pressure management and evaluation of abd pain. An A-line was placed. EKG showed no change from prior, and Abd x-ray showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home med regimen. The patient was found to be hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. Upon transfer to the floor, the following was her course: 1. Hypertensive Urgency: Pt had had hemodialysis one day prior to admission, so unlikely that she was volume overloaded. Unclear what precipitated this episode of hypertensive urgency, although suspect secondary to abdominal pain leading to an anxiety which then precipitates hypertension. She may not have been taking her medications secondary to pain. Negative serum tox. On the floor, we continued hemodialysis Tu, Th, Sat. She was initially continued on PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine 90mg PO qday and clonidine; she received hydralazine 10mg IV for goal BP < 180/100. Renal team followed patient during this hospitalization. Per renal team recs, labetalol was increased to 800mg TID due to poor blood pressure control. Pt discharged on clonidine 0.3mg patch, Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, Nifedipine 90mg daily and lobatalol 800mg TID. This regimen worked well. 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT scan during prior admission which did not show source of abdominal pain. On admission, LFTs were normal except for slightly low albumin, lipase was slightly elevated and KUB was negative for free air or evidence of SBO. Peritoneal fluid was negative for malignant cells but showed reactive mesothelial cells, macrophages, eosinophils and lymphocytes. Negative gram stain or peritoneal fluid cultures, excluding SBP as a cause of the abdominal pain. PD catheter was not removed. Pt was continued on PO dilaudid 1-2mg Q6h and pain resolved. She denied N/V/diarrhea or constipation. 3. ESRD: Pt on hemodialysis, on T/Th/Sat schedule. Renal following patient closely throughout this hospitalization. Lytes were checked frequently and kayexalate given prn. 4. Hx of SVC/brachiocephalic DVT: Pt was initially subtherapeutic on coumadin. Unclear if she had not been taking Coumadin although patient reported that she has been taking all home meds. We started heparin gtt to bridge to Coumadin. Once therapeutic, continued Coumadin 5mg PO qday. 5. Anxiety: Likely contributing to medical problems and could have very well been the etiology of this admission. Although pt stated she was taking her current medications, she did report increased anxiety which can lead to medication non-compliance and hypertension. Pt recently saw psychiatrist who started her on Celexa. She was continued on celexa 20mg PO qday, ativan 1mg PO q8hours PRN and psychiatry was re-consulted. Per psych recs, started standing clonazepam. Pt refused psych VNA. Outpatient PCP followup recommended. 6. Headache NOS: Pt complained of R-sided HA for several weeks, radiating to R jaw where patient had previous tooth extraction. Right upper extremity ultrasound was negative for DVT. She did not have any focal neuro findings, no visual deficits. She was initially treated with tylenol PRN Q6h; pt requested IV dilaudid for HA, but use of this medication by IV route was limited by team. It was felt by the pain service that her HA did not fit migraine, tension type HA or rebound HA. They recommended increasing dilaudid to 4-6mg Q6h PRN, continuing tylenol and starting neurontin 300mg Qhs which was slowly titrated to 300mg [**Hospital1 **] for better control. Per pain recs, a neurology consult was also obtained during this admission. MRI/MRA showed interval resolution of previously noted posterior white matter abnormalities and stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions, but very limited MRA as above. Per pain recs, dilaudid was further increased to 4mg q4h for better control of her HA. Neurology recommended outpt f/u and Pt scheduled with [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**]. 7. Anemia: Likely related to ESRD. No evidence of acute bleeding. Hct remained stable during this hospitalization. 8. SLE: no acute issues. continued Prednisone 4mg PO qday 9. FEN: tolerated regular diet, repleted lytes PRN 9. Prophylaxis: Heparin gtt, then coumadin, bowel regigmen Medications on Admission: (from prior discharge summary) Bisacodyl 10mg PO qday PRN Prednisone 4mg PO qday Aliskiren 150mg PO BID Clonidine 0.3mg / 24 hr patch weekly qmonday Labetalol 400mg PO TID Warfarin 4mg PO qday Nifedipine 90mg PO qday Hydralazine 100mg PO q8H Hydromorphone 2-4mg PO q4H PRN Lorazepam 1mg PO q8H Celexa 20mg PO qday Prochlorperazine 10mg PO q6H Colace 100mg PO BID Hydralazine 25mg PO q30min PRN for HTN Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Year (4 digits) 766**]). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). [**Year (4 digits) **]:*100 Tablet(s)* Refills:*2* 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*90 Capsule(s)* Refills:*2* 9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for headache. [**Year (4 digits) **]:*84 Tablet(s)* Refills:*0* 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*60 Capsule(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours. [**Year (4 digits) **]:*360 Tablet(s)* Refills:*2* 16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. [**Year (4 digits) **]:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive Emergency 2. SLE 3. Headache, NOS 4. Abdominal pain Discharge Condition: BP better controlled. Headache managed on oral meds Discharge Instructions: You were admitted with abdominal pain, high blood pressure, and headache. Your abdominal pain resolved - no serious cause of this pain was found. Your blood pressure medications were continued, and with an increased in one medication, the labetalol. Your blood pressure improved. You should continue the clonidine 0.3mg patch changed on [**Year (4 digits) 766**], Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, and Nifedipine 90mg daily. The dose of Labetalol was increased to 800 mg three times daily by you kidney doctor and you are given a new prescription. Please take all medications as listed below. For your headache, you had an MRI and MRA of the head, which did not show a new or serious abnormality. You were seen by the neurology and pain services. You should follow up at [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**] at 6:30 PM (in the evening). Your pain was managed by oral dilaudid, 4mg. You should take this medication every 4 hours as needed. You were also started on Gabapentin (also called Neurontin) for the headache. The dose was slowly increased to twice a day. You may not need as much dilaudid for your headache and should wean this medication as tolerated, given it's potential for side effects (constipation, lethargy, dependence). Finally, you will likely need medications for constipation while you take dilaudid. Take colace (a stool softener), senna (a laxative), and bisacodyl (another laxative), as needed. It is really important that you have a primary care doctor. You are scheduled with Dr. [**Last Name (STitle) **] (see below) next Tuesday. You will need your INR checked since you are on coumadin. Call your doctor if you have worsened headache, chest pain, confusion, or any other concerning symptom. Followup Instructions: Please make sure you attend the following doctor appointments: 1) Dr. [**Last Name (STitle) 4883**] (nephrologist) on Tuesday, [**2141-12-5**] at 10AM. Phone number [**Telephone/Fax (1) 60**]. 2) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Location (un) **], [**Hospital Ward Name 23**] center, [**Location (un) **]. Phone:[**Telephone/Fax (1) 250**]. Date/Time:[**2141-12-5**] 3:20 3) Neurology: Dr. [**Last Name (STitle) 43502**] [**Name (STitle) **]. He is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-12-12**] 6:30 PM [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2141-12-2**]",13,2141-11-24 16:11:00,2141-12-01 19:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**hospital unit name 153**] the patient was admitted for blood pressure management and evaluation of abd pain. an a-line was placed. ekg showed no change from prior, and abd x-ray showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home med regimen. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. upon transfer to the floor, the following was her ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other ascites; ; Systemic lupus erythematosus; Headache; Anemia in chronic kidney disease; Anxiety state, unspecified; Other chest pain; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Renal dialysis status; Acquired absence of organ, eye]","24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. the renal team was consulted, and recommended no change to home med regimen.","a 24yo f with sle, esrd on hd and malignant hypertension presented with abdominal pain and headache. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. she successfully switched to po meds and was transferred to the floor." 109,173633.0,14801,2141-12-14,15330,131345.0,2141-09-08,Discharge summary,"Admission Date: [**2141-9-5**] Discharge Date: [**2141-9-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 348**] Chief Complaint: right leg pain, hypertension Major Surgical or Invasive Procedure: blood transfusion x2 History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. The pain is worst when she tried to bear weight on the leg, or when she uses it to roll over or adjust her position in bed. The pain begins in her buttock and travels down the posterior thigh and calf but stops before reaching the ankle. It occasionally feels like it is coming from her low back. She denies any parasthesias or weakness in the leg, and she denies any numbness in her foot or groin. She denies any fevers or incontinence. The pain was unrelieved by Vicodin that she had at home, so she scheduled an urgent visit with her nephrologist yesterday [**2141-9-4**]. At her nephrologist??????s office, she was hypertensive to 250/145 and so she was referred to the ED. She ended up leaving the ED against medical advice yesterday, but returned today because of persistent leg pain. She reports that she took all of her morning and noon BP meds. She denies any fevers, headaches, visual changes, nausea (prior to coming to the ED), or leg weakness. Upon arrival to the ED today, she was afebrile, BP 237/146, HR 97, RR 16, Sat 100% on room air. She received a total of 90 mg of IV labetalol and nitropaste, and was eventually put on a labetalol drip for her hypertension. With these interventions, her SBP dropped to the 180s, but she reported feeling nauseous and so the drip was discontinued. She was also given 4 mg of IV morphine and 1 mg of IV hydromorphone for her leg pain with decent relief. Due to a urinalysis suggestive of infection, she was given one tablet of DS TMP/SMX. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: MICU physical: Tmax: 36.3 ??????C (97.4 ??????F) Tcurrent: 36.3 ??????C (97.4 ??????F) HR: 92 (92 - 94) bpm BP: 209/138(152) {201/134(151) - 209/138(152)} mmHg RR: 19 (19 - 30) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Height: 59 Inch General: well-appearing young woman in no acute distress HEENT: no scleral icterus; prosthetic right eye Neck: supple Chest: clear to auscultation throughout, no wheezes/rales/ronchi CV: regular rate/rhythm, normal s1s2, no murmurs Abdomen: soft, nontender, nondistended, PD catheter in place in left abdomen Back: very mild spinal tenderness over approx L3 level of spine Extremities: no edema, 1+ PT pulses, warm Skin: no rashes or jaundice Neuro: alert, oriented x3, 5/5 strength in bilateral deltoids, biceps, triceps, hip flexors/extensors, ankle flexors/extensors; unable to elicit patellar reflexes bilaterally; negative straight leg raise bilaterally Pertinent Results: 138 111 54 -----------------< 83 5.4 14 8.2 . WBC: 3.7 HCT: 19 PLT: 101 N:69.3 L:23.4 M:5.5 E:1.7 Bas:0.1 PT: 21.9 PTT: 48.2 INR: 2.1 . Trends: HCT: 19 -> 22 w 1u then received another unit. INR 3.4 on discharge Discharge chem: Glucose-104 UreaN-51* Creat-8.4* Na-136 K-5.3* Cl-106 HCO3-18* AnGap-17 . [**2141-9-8**] 07:30AM BLOOD CK(CPK)-126 [**2141-9-5**] 02:50PM BLOOD HCG-<5 . [**2141-9-8**] 1:37 pm PERITONEAL FLUID GRAM STAIN (Final [**2141-9-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count . MRI L-spine: IMPRESSION: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. . CXR admit: IMPRESSION: Moderate cardiomegaly, bilateral pleural effusions, and pulmonary vascular prominence consistent with pulmonary edema. . Hip film: FINDINGS: No comparisons. No acute fracture or dislocation is seen. No lucent or sclerotic lesion is noted. There is a distal aspect of a catheter or shunt seen in the pelvis. Soft tissues are otherwise unremarkable. There is minimal degenerative change of the pubic symphysis. IMPRESSION: No acute fracture or dislocation. . Abdominal film: FINDINGS: A PD catheter is seen with its tip coiled in the pelvis. There is normal bowel gas. The underlying osseous structures are unremarkable. IMPRESSION: PD catheter with tip coiled in the pelvis . CXR [**9-8**]: IMPRESSION: Marked cardiomegaly, unchanged. Interval resolution of pulmonary edema. Brief Hospital Course: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. She was initially admitted to the MICU for hypertensive urgency and then transfered to the floor after a day. # Hypertensive urgency: had been on labetalol drip in the ED, but this was stopped due to nausea (presumed that her BP was coming down too fast). She was started on her home meds and tolerated these fairly well. Transferred to the floor and noted to have SPBs in the 90s. She required 1L IVF bolus since her baseline SBP is thought to run in the 130-170 range. She also had transient dizziness during this episode. BP meds were held and later that night her SBP was in the 220s. BP meds restarted. She remained stable thereafter with SBPs in the 130-170s. We opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # Right leg pain: no evidence of avascular necrosis or fracture on plain film. MRI and plain films were ordered and showed no acute pathology. The pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. CK was normal. Pain was treated with dilaudid initially. On day of discharge, she was able to ambulate without gait abnormality or pain. PT saw her and rec outpt PT followup. . # CKD V: PD catheter placement in place. Pt was tried on PD on a number of occasions but did not tolerate it [**2-11**] pain. KUB confirmed tip in place. Cx of peritoneal fluid not suggestive of peritonitis. K remained mildly elevated. Hyperpara treated with sevelamer (although patient refused) then tums. Pt will reconsider PD as outpatient. . # Anemia: chronic. Received 2u pRBC while inhouse for Hct in the 18-19 range. Had appropriate response. Not on Epo given hypertension . # ID: Rx with cipro for ? UTI although urine cx neg. Also had temp to 101 on evening prior to discharge. No clear source. PD fluid cultured and NGTD. Pt remainded HD stable on day of discharge. . # Prior SVC thrombus. Continued warfarin with appropriate INR checks. INR elevated on day of discharge. Rec holding coumadin for 2d . # Systemic lupus erythematosus: cont home prednisone dose . # Dispo status: ambulating, pain free, BP in the 150/90 range Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly Vicodin prn Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO WEEKLY (). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*20 Capsule(s)* Refills:*0* 9. Outpatient Physical Therapy Please provide PT for right hamstring injury 10. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*0* 11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold dose until [**9-10**]. Disp:*30 Tablet(s)* Refills:*0* 12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO once a day: goal is [**1-11**] soft bowel movements per day. Disp:*500 ml* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - HTN urgency - right leg pain - thought [**2-11**] hamstring injury - chronic kidney disease - not currently on dialysis - SLE - anemia [**2-11**] CKD and SLE - hx of SVC thrombosis on coumadin now Secondary: - hx hypertrophic obstructive cardiomyopathy - chronic thrombocytopenia Discharge Condition: ambulating without difficulty. tolerating oral diet. afebrile and SBP in the 130-150 range. Discharge Instructions: You came in with right leg pain and poorly controlled hypertension. Your blood pressure was controlled initially with IV medications then your home medications. Since your blood pressure was occasionally low, we recommend that you hold your labetalol if you are feeling lightheaded or have dizziness or have blood pressure less than 110/60. In terms of your leg pain, we performed xrays, ultrasound, and MRI without finding a cause. We suspect a hamstring injury given its location. Please take pain medications if needed. We recommend followup with physical therapy. You also had a fever which is suggestive of infection. We treated you with cipro in case you had a UTI. Otherwise, your cultures were unrevealing. We attempted peritoneal dialysis but this was unsuccessful. Please followup with your nephrologist. Please return to the ED if you experience headache, chest pain, shortness of breath, high fevers, or worsening leg pain. Please hold your coumadin for two days then restart as per previously written. Please take lactulose for constipation. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-9-12**] 5:00 Provider: [**Name10 (NameIs) 706**] NURSE Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 2:00 Provider: [**Name10 (NameIs) 7548**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 3:00 Please followup with your nephrologist and PCP. [**Name10 (NameIs) **] would like you to see your nephrologist within the next 1-2 weeks. ",97,2141-09-05 20:04:00,2141-09-08 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transfered to the floor after a day. # hypertensive urgency: had been on labetalol drip in the ed, but this was stopped due to nausea (presumed that her bp was coming down too fast). she was started on her home meds and tolerated these fairly well. transferred to the floor and noted to have spbs in the 90s. she required 1l ivf bolus since her baseline sbp is thought to run in the 130-170 range. she also had transient dizziness during this episode. bp meds were held and later that night her sbp was in the 220s. bp meds restarted. she remained stable thereafter with sbps in the 130-170s. we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # right leg pain: no evidence of avascular necrosis or fracture on plain film. mri and plain films were ordered and showed no acute pathology. the pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. ck was normal. pain was treated with dilaudid initially. on day of discharge, she was able to ambulate without gait abnormality or pain. pt saw her and rec outpt pt followup. . # ckd v: pd catheter placement in place. pt was tried on pd on a number of occasions but did not tolerate it [**2-11**] pain. kub confirmed tip in place. cx of peritoneal fluid not suggestive of peritonitis. k remained mildly elevated. hyperpara treated with sevelamer (although patient refused) then tums. pt will reconsider pd as outpatient. . # anemia: chronic. received 2u prbc while inhouse for hct in the 18-19 range. had appropriate response. not on epo given hypertension . # id: rx with cipro for ? uti although urine cx neg. also had temp to 101 on evening prior to discharge. no clear source. pd fluid cultured and ngtd. pt remainded hd stable on day of discharge. . # prior svc thrombus. continued warfarin with appropriate inr checks. inr elevated on day of discharge. rec holding coumadin for 2d . # systemic lupus erythematosus: cont home prednisone dose . # dispo status: ambulating, pain free, bp in the 150/90 range ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Nausea alone; Other antihypertensive agents causing adverse effects in therapeutic use; Hip and thigh injury; Unspecified accident; Hypotension, unspecified; Anemia, unspecified; Personal history of venous thrombosis and embolism; End stage renal disease; ; Urinary tract infection, site not specified; Hyperpotassemia; Acidosis; Disorders of phosphorus metabolism; Hypocalcemia; Secondary hyperparathyroidism (of renal origin)]","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. # right leg pain: no evidence of avascular necrosis or fracture on plain film. also had temp to 101 on evening prior to discharge. # systemic lupus erythematosus: cont home prednisone dose .","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension. she presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transferred to the floor after a day. she was started on her home meds and tolerated them fairly well." 109,140167.0,14802,2141-12-23,15330,131345.0,2141-09-08,Discharge summary,"Admission Date: [**2141-9-5**] Discharge Date: [**2141-9-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 348**] Chief Complaint: right leg pain, hypertension Major Surgical or Invasive Procedure: blood transfusion x2 History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. The pain is worst when she tried to bear weight on the leg, or when she uses it to roll over or adjust her position in bed. The pain begins in her buttock and travels down the posterior thigh and calf but stops before reaching the ankle. It occasionally feels like it is coming from her low back. She denies any parasthesias or weakness in the leg, and she denies any numbness in her foot or groin. She denies any fevers or incontinence. The pain was unrelieved by Vicodin that she had at home, so she scheduled an urgent visit with her nephrologist yesterday [**2141-9-4**]. At her nephrologist??????s office, she was hypertensive to 250/145 and so she was referred to the ED. She ended up leaving the ED against medical advice yesterday, but returned today because of persistent leg pain. She reports that she took all of her morning and noon BP meds. She denies any fevers, headaches, visual changes, nausea (prior to coming to the ED), or leg weakness. Upon arrival to the ED today, she was afebrile, BP 237/146, HR 97, RR 16, Sat 100% on room air. She received a total of 90 mg of IV labetalol and nitropaste, and was eventually put on a labetalol drip for her hypertension. With these interventions, her SBP dropped to the 180s, but she reported feeling nauseous and so the drip was discontinued. She was also given 4 mg of IV morphine and 1 mg of IV hydromorphone for her leg pain with decent relief. Due to a urinalysis suggestive of infection, she was given one tablet of DS TMP/SMX. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: MICU physical: Tmax: 36.3 ??????C (97.4 ??????F) Tcurrent: 36.3 ??????C (97.4 ??????F) HR: 92 (92 - 94) bpm BP: 209/138(152) {201/134(151) - 209/138(152)} mmHg RR: 19 (19 - 30) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Height: 59 Inch General: well-appearing young woman in no acute distress HEENT: no scleral icterus; prosthetic right eye Neck: supple Chest: clear to auscultation throughout, no wheezes/rales/ronchi CV: regular rate/rhythm, normal s1s2, no murmurs Abdomen: soft, nontender, nondistended, PD catheter in place in left abdomen Back: very mild spinal tenderness over approx L3 level of spine Extremities: no edema, 1+ PT pulses, warm Skin: no rashes or jaundice Neuro: alert, oriented x3, 5/5 strength in bilateral deltoids, biceps, triceps, hip flexors/extensors, ankle flexors/extensors; unable to elicit patellar reflexes bilaterally; negative straight leg raise bilaterally Pertinent Results: 138 111 54 -----------------< 83 5.4 14 8.2 . WBC: 3.7 HCT: 19 PLT: 101 N:69.3 L:23.4 M:5.5 E:1.7 Bas:0.1 PT: 21.9 PTT: 48.2 INR: 2.1 . Trends: HCT: 19 -> 22 w 1u then received another unit. INR 3.4 on discharge Discharge chem: Glucose-104 UreaN-51* Creat-8.4* Na-136 K-5.3* Cl-106 HCO3-18* AnGap-17 . [**2141-9-8**] 07:30AM BLOOD CK(CPK)-126 [**2141-9-5**] 02:50PM BLOOD HCG-<5 . [**2141-9-8**] 1:37 pm PERITONEAL FLUID GRAM STAIN (Final [**2141-9-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count . MRI L-spine: IMPRESSION: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. . CXR admit: IMPRESSION: Moderate cardiomegaly, bilateral pleural effusions, and pulmonary vascular prominence consistent with pulmonary edema. . Hip film: FINDINGS: No comparisons. No acute fracture or dislocation is seen. No lucent or sclerotic lesion is noted. There is a distal aspect of a catheter or shunt seen in the pelvis. Soft tissues are otherwise unremarkable. There is minimal degenerative change of the pubic symphysis. IMPRESSION: No acute fracture or dislocation. . Abdominal film: FINDINGS: A PD catheter is seen with its tip coiled in the pelvis. There is normal bowel gas. The underlying osseous structures are unremarkable. IMPRESSION: PD catheter with tip coiled in the pelvis . CXR [**9-8**]: IMPRESSION: Marked cardiomegaly, unchanged. Interval resolution of pulmonary edema. Brief Hospital Course: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. She was initially admitted to the MICU for hypertensive urgency and then transfered to the floor after a day. # Hypertensive urgency: had been on labetalol drip in the ED, but this was stopped due to nausea (presumed that her BP was coming down too fast). She was started on her home meds and tolerated these fairly well. Transferred to the floor and noted to have SPBs in the 90s. She required 1L IVF bolus since her baseline SBP is thought to run in the 130-170 range. She also had transient dizziness during this episode. BP meds were held and later that night her SBP was in the 220s. BP meds restarted. She remained stable thereafter with SBPs in the 130-170s. We opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # Right leg pain: no evidence of avascular necrosis or fracture on plain film. MRI and plain films were ordered and showed no acute pathology. The pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. CK was normal. Pain was treated with dilaudid initially. On day of discharge, she was able to ambulate without gait abnormality or pain. PT saw her and rec outpt PT followup. . # CKD V: PD catheter placement in place. Pt was tried on PD on a number of occasions but did not tolerate it [**2-11**] pain. KUB confirmed tip in place. Cx of peritoneal fluid not suggestive of peritonitis. K remained mildly elevated. Hyperpara treated with sevelamer (although patient refused) then tums. Pt will reconsider PD as outpatient. . # Anemia: chronic. Received 2u pRBC while inhouse for Hct in the 18-19 range. Had appropriate response. Not on Epo given hypertension . # ID: Rx with cipro for ? UTI although urine cx neg. Also had temp to 101 on evening prior to discharge. No clear source. PD fluid cultured and NGTD. Pt remainded HD stable on day of discharge. . # Prior SVC thrombus. Continued warfarin with appropriate INR checks. INR elevated on day of discharge. Rec holding coumadin for 2d . # Systemic lupus erythematosus: cont home prednisone dose . # Dispo status: ambulating, pain free, BP in the 150/90 range Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly Vicodin prn Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO WEEKLY (). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*20 Capsule(s)* Refills:*0* 9. Outpatient Physical Therapy Please provide PT for right hamstring injury 10. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*0* 11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold dose until [**9-10**]. Disp:*30 Tablet(s)* Refills:*0* 12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO once a day: goal is [**1-11**] soft bowel movements per day. Disp:*500 ml* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - HTN urgency - right leg pain - thought [**2-11**] hamstring injury - chronic kidney disease - not currently on dialysis - SLE - anemia [**2-11**] CKD and SLE - hx of SVC thrombosis on coumadin now Secondary: - hx hypertrophic obstructive cardiomyopathy - chronic thrombocytopenia Discharge Condition: ambulating without difficulty. tolerating oral diet. afebrile and SBP in the 130-150 range. Discharge Instructions: You came in with right leg pain and poorly controlled hypertension. Your blood pressure was controlled initially with IV medications then your home medications. Since your blood pressure was occasionally low, we recommend that you hold your labetalol if you are feeling lightheaded or have dizziness or have blood pressure less than 110/60. In terms of your leg pain, we performed xrays, ultrasound, and MRI without finding a cause. We suspect a hamstring injury given its location. Please take pain medications if needed. We recommend followup with physical therapy. You also had a fever which is suggestive of infection. We treated you with cipro in case you had a UTI. Otherwise, your cultures were unrevealing. We attempted peritoneal dialysis but this was unsuccessful. Please followup with your nephrologist. Please return to the ED if you experience headache, chest pain, shortness of breath, high fevers, or worsening leg pain. Please hold your coumadin for two days then restart as per previously written. Please take lactulose for constipation. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-9-12**] 5:00 Provider: [**Name10 (NameIs) 706**] NURSE Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 2:00 Provider: [**Name10 (NameIs) 7548**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 3:00 Please followup with your nephrologist and PCP. [**Name10 (NameIs) **] would like you to see your nephrologist within the next 1-2 weeks. ",106,2141-09-05 20:04:00,2141-09-08 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transfered to the floor after a day. # hypertensive urgency: had been on labetalol drip in the ed, but this was stopped due to nausea (presumed that her bp was coming down too fast). she was started on her home meds and tolerated these fairly well. transferred to the floor and noted to have spbs in the 90s. she required 1l ivf bolus since her baseline sbp is thought to run in the 130-170 range. she also had transient dizziness during this episode. bp meds were held and later that night her sbp was in the 220s. bp meds restarted. she remained stable thereafter with sbps in the 130-170s. we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # right leg pain: no evidence of avascular necrosis or fracture on plain film. mri and plain films were ordered and showed no acute pathology. the pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. ck was normal. pain was treated with dilaudid initially. on day of discharge, she was able to ambulate without gait abnormality or pain. pt saw her and rec outpt pt followup. . # ckd v: pd catheter placement in place. pt was tried on pd on a number of occasions but did not tolerate it [**2-11**] pain. kub confirmed tip in place. cx of peritoneal fluid not suggestive of peritonitis. k remained mildly elevated. hyperpara treated with sevelamer (although patient refused) then tums. pt will reconsider pd as outpatient. . # anemia: chronic. received 2u prbc while inhouse for hct in the 18-19 range. had appropriate response. not on epo given hypertension . # id: rx with cipro for ? uti although urine cx neg. also had temp to 101 on evening prior to discharge. no clear source. pd fluid cultured and ngtd. pt remainded hd stable on day of discharge. . # prior svc thrombus. continued warfarin with appropriate inr checks. inr elevated on day of discharge. rec holding coumadin for 2d . # systemic lupus erythematosus: cont home prednisone dose . # dispo status: ambulating, pain free, bp in the 150/90 range ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Nausea alone; Other antihypertensive agents causing adverse effects in therapeutic use; Hip and thigh injury; Unspecified accident; Hypotension, unspecified; Anemia, unspecified; Personal history of venous thrombosis and embolism; End stage renal disease; ; Urinary tract infection, site not specified; Hyperpotassemia; Acidosis; Disorders of phosphorus metabolism; Hypocalcemia; Secondary hyperparathyroidism (of renal origin)]","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. # right leg pain: no evidence of avascular necrosis or fracture on plain film. also had temp to 101 on evening prior to discharge. # systemic lupus erythematosus: cont home prednisone dose .","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension. she presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transferred to the floor after a day. she was started on her home meds and tolerated them fairly well." 109,124657.0,14804,2142-01-20,14797,172335.0,2141-09-24,Discharge summary,"Admission Date: [**2141-9-18**] Discharge Date: [**2141-9-24**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1936**] Chief Complaint: hip pain Major Surgical or Invasive Procedure: None History of Present Illness: 24yo woman with hx SLE, CKD(not currently on HD or PD), labile HTN here with right leg pain and HTN urgency. Patient was recently d/ced on [**9-14**] following admission for the same complaints. . Patient took her hydralazine dose on am of admission. BP at presentation to the ER was 250/140 (The patient reportedly has baseline SBPs in 130-170s) She was given 900 labetolol and 50 hydralazine in the ED. BP following this was 175/124. Her EKG was unchanged. K was 5.7. . Patient also complaining of [**10-20**] right hip pain. Patient was d/ced on [**9-14**] with oral dilaudid for hip/leg pain. She took this only for one day due to severe itching. Denies any parasthesias/weakness. Her RLE/hip pain has been extensively worked up with negative LENIs, Lumbar spine MRI and hip plain films in the past. She was given 4mg IV morphine in the ER. . On admission to the floor, leg/hip pain somwhat improved with morphine.She denies any headache, vision changes, double vision, chest pain or SOB. Feels warm but no chills. Past Medical History: Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 97.3 HR 81 BP 135/91 RR 16 100%RA Gen:NAD, happy, pleasant female HEENT:NC/AT, L eye prosthesis, R PERRL, EOMI, MMM, facial swelling, L side>R, scerla anicteric Neck: supple, no JVD, no LAD, scars from prior CVL and HD lines CV:S1S2+, 2/6 SEM LUSB, loud P2, RRR, no ectopy Pulm: CTA B/L, good inspiratory effort Abd: +BS, soft, nontender, slightly distended and resonant to percussion, PD catheter in place in left abdomen ext: no c/c/e, 2+DP b/L, L foream swollen>R, R hip is mobile without pain elicited on passive or active movement neuro: AAOx3, nonfocal exam, CN 2-12 intact, moves all 4 extremities psych: mood/affect appropriate Pertinent Results: MRI Right Hip ([**9-18**]): There is no signal abnormality on the fluid-sensitive sequences in the proximal femur, acetabulum, or other osseous structure. On T1- weighted images, there is a focal rounded region within the right femoral head measuring approximately 9 mm in a subchondral location, which is nonspecific but may represent an unusual focus of red marrow. No sclerosis is seen on the corresponding plain films. There is a small right hip joint effusion and a small amount of fluid in the left hip joint as well, at the upper limits of normal. There is no soft tissue abnormality, no muscular edema, and no fluid collections. IMPRESSION: 1. Small right hip joint effusion. 2. No bone marrow edema in the proximal femurs or the pelvis. 3. Nonspecific small focus of low signal on T1-weighted images in the right femoral head is nonspecific but may represent an unusual focus of red marrow. TTE ([**9-21**]): The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF 80%). A mild (18 mmHg) mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. There is no systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Severe symmetric left ventricular hypertrophy with hyperdynamic systolic function and mild mid-cavitary gradient. Mild aortic regurgitation. Moderate pulmonary hypertension. Findings consistent with hyperrtophic cardiomyopathy. Compared with the prior study (images reviewed) of [**2140-8-26**], pulmonary hypertension has developed (also present on the study from [**2140-5-20**]). Pericardial effusion is also new. V/Q scan ([**9-21**]): Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate no focal defects with improved ventilation to the posterior right basal segment. Perfusion images in the same 8 views show improved perfusion to the posterior right basal segement with a persistent small defect but no new findings. Chest x-ray shows cardiomgealy and left basilar atelectasis. IMPRESSION: Improved V/Q scan from [**9-/2139**] with no findings to suggest acute pulmonary embolism. B/L upper ext U/S ([**9-21**]): Grayscale and Doppler son[**Name (NI) 867**] of the right and left internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. There is nonocclusive focal thrombus seen in the left subclavian vein, where the vein is not fully compressible. Flow is seen in the region, indicating that the thrombus is nonocclusive. Elsewhere, normal flow, augmentation, compressibility were appropriate and waveforms are demonstrated. IMPRESSION: 1. Focal nonocclusive thrombus in the left subclavian vein. 2. Otherwise, patent upper extremity veins as described. [**2141-9-18**] 02:15PM POTASSIUM-5.1 [**2141-9-18**] 02:15PM HCT-21.2* [**2141-9-18**] 08:45AM POTASSIUM-5.7* [**2141-9-18**] 07:30AM GLUCOSE-88 UREA N-54* CREAT-8.6* SODIUM-136 POTASSIUM-5.8* CHLORIDE-108 TOTAL CO2-15* ANION GAP-19 [**2141-9-18**] 07:30AM estGFR-Using this [**2141-9-18**] 07:30AM CALCIUM-7.3* PHOSPHATE-5.3* MAGNESIUM-1.6 [**2141-9-18**] 07:30AM WBC-5.2 RBC-2.32* HGB-6.5* HCT-20.1* MCV-87 MCH-28.1 MCHC-32.4 RDW-18.4* [**2141-9-18**] 07:30AM NEUTS-78.0* LYMPHS-14.7* MONOS-3.9 EOS-3.2 BASOS-0.3 [**2141-9-18**] 07:30AM PLT COUNT-107* [**2141-9-18**] 07:30AM PT-20.8* PTT-43.3* INR(PT)-2.0* . [**2141-9-21**] CXR: There is no significant change when compared to the recent previous examination. The previously described left retrocardiac opacity is unchanged in appearance. Cardiomegaly is also unchanged. The mediastinal contour, bony thorax and pulmonary vasculature are normal. IMPRESSION: No significant change compared to study done roughly 7 hours prior. Brief Hospital Course: 24 yo with h/o of Lupus, HTN, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for R hip pain. Patient was on the floor on [**9-20**], given morphine for the hip pain. She then had an episode of hypotension and unresponsiveness and transferred to the MICU for closer monitoring. The patient got 2L IVFs and narcan and improved, in fact, found to be hypertensive upon arrival to MICU. . MICU Course: On [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. Concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. Mental status cleared somewhat with narcan. Renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. V/Q scan demonstrated improvement since prior study. Patient's home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. She was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. PD fluid was not c/w SBP. CXR was clear. Urine culture and blood cultures are pending. Patient's BP was in the 110s so hydralazine was stopped. Her other BP meds were otherwise continued. Plan was/is to follow renal recs for PD. If, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. Would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. If patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. Would add neurontin 100mg TID with room to titrate up to 300mg TID. Neuro also recommended PT with TENS unit and referral to pain clinic although patient's pain is currently absent. . FYI **** per Dr. [**Last Name (STitle) **] --- Because of ? increase in cardiomegaly on CXR, she got an echo yesterday. In addition to her known HOCM, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm Hg. They probably need to be followed up over time (particularly the pulmonary hypertension). We did evaluated the PHTN with a VQ scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. It would be good if we could arrange a PULMONARY CLINIC FOLLOW UP for Ms. [**Known lastname **] after discharge with either [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].**** . She underwent CT head, and V/Q scan which were unremarkable. Her steroid dose was increased to 15mg given concern for need for stress dose steroids. After transfer from the MICU, her steroids were dropped back to 5mg, her home dose with the approval of [**Last Name (un) **]. . Her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. Her hydralazine was discontinued. On day 2 of her MICU stay, she developed a fever to 102. She was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. Broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. There was question of retrocardiac opacity on CXR, though not clear. Rheum consult obtained given hip discomfort, who felt septic joint unlikely. Neurology consult obtained who felt autonomic seizure unlikely. . Pt initiated peritoneal dialysis. In this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising BPs. She is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. Her hip pain has resolved completely without further intervention. . Floor course: Fever: Spike fever in MICU to 102. Started on Levoquin, Aztreonam, and Vanc. Source unclear at this point, but CXR with question of retrocardiac opacity. There is a possibility of aspiration pneumonitis. Other etiologies include peritoneal fluid (PD cath), urine, and blood (though patient does not have any indwelling lines). Hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. Peritoneal dialysis cultures negative so far. Continued levo/vanco/aztreonam for 2 days empirically. Then d/ced the Abx as no infectious etiologies were found. Steroids back to home dosage. BCx, UCx (final neg), Peritoneal cultures negative at discharge. . # Labile blood pressure: h/o of difficult to control BP with episodes of hypertensive emergency in the past. Normal SBP runs in 170s. Having nausea in setting of new PD, no evidence of intracranial bleeding on clinical exam, though INR had been supratherapeutic so remains in differential, though not bradycardic. Continue home BP meds :Labetalol 900 mg PO TID but difficult for patient to tolerate due to nausea, Aliskiren *NF* 150 mg Oral [**Hospital1 **], NIFEdipine CR 60 mg PO DAILY, clonidine patch, hydralazine given hypertensive in setting of nausa. . # Right leg/hip pain: no evidence of avascular necrosis or fracture on MRI though there is a small effusion. Pain resolved without intervention. Continued to monitor and would avoid narcotics, restart slowly if pain resumes. Physical therapy to follow as an outpatient. [**Last Name (un) 18183**] followed. Please see consult note. . # Hyperkalemia: Chronic issue. Patient takes kayexalate intermittently per her report (last dose [**Last Name (un) 766**]). Monitored K but patient did not need it on floor. # CKD V: Renal following. Did well with PD on [**9-22**] but did report some nause and cramping. She was not tolerating all 1.5L in exchanges on discharge. # Anemia: Hct stable around 20. S/p 1 U PRBCs in MICU with Hct 20.1 to 21.9. Likely due to chronic hemolysis consistent with SLE> #. Prior SVC thrombus: Physical exam with L arm swelling consistent with this. No flow limitations. INR 3.5 on ICU admission. Held warfarin but restarted home 2mg daily the day before discharge. # Systemic lupus erythematosus: Home prednisone dose 5mg. Currently on 15mg in setting of acute illness (day 2). # General care: FEN: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, PD initiated, Proph: INR therapeutic, no indication for PPI, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. Code: Full code, confirmed with patient Communication: with the patient and her mother [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (2) 43497**]contact. Access: 2 PIVs Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly dilaudid PO prn benadryl prn lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily coumadin 2mg PO qday calcitriol 1 mcg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Hypertensive urgency Transient Hypotension due to Narcotics Sciatica . Secondary: End stage renal disease Systemic Lupus Erythematosus Anemia Discharge Condition: Stable. Blood pressures at baseline. Hip/leg pain resolved. Ambulating without assistance. Discharge Instructions: You were admitted to the hospital with high blood pressure and right leg/hip pain. We gave you pain medications and blood pressure lowering medications. Your blood pressure then dropped which was caused by the pain medication, and you were transferred to the Intensive Care Unit(ICU) where you recovered quickly. During your stay in the ICU, you developed a fever and were started on antibiotics. However, the cultures that were obtained were negative, and we discontinued the Antibiotics. During your hospitalization, your blood pressure normalized on your home regimen, and your right leg/hip pain resolved. You had an MRI of your hip done, which did not show an acute infection. You were seen by the kidney doctors and they recommended starting peritoneal dialysis. You were also given some blood for your anemia. Please follow up with the Peritoneal Dialysis nurse at the scheduled day/time. Please make an appointment to meet with your PCP in the next couple of weeks. Your Hip pain may benefit from physical therapy or outpatient anesthetic joint injection. Please discuss these options with your rheumatologist. . Please call the number given below to schedule outpatient physical therapy. . Please restart your home medications. You were also started on Sodium Bicarb 650mg by mouth three times a day. . If you develop fevers, chills, trouble breathing, chest pain, worsening of hip pain, headaches, changes in your vision or any other symptoms that concern you please return to the emergency room or call your doctor. Followup Instructions: Please follow up with your Peritoneal Dialysis nurse ([**Doctor First Name 3040**]) on [**Doctor First Name 766**] [**2141-9-25**] . Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 . Please call to schedule Outpatient Physical Therapy:[**Telephone/Fax (1) 2484**] Completed by:[**2141-9-25**]",118,2141-09-18 10:32:00,2141-09-24 13:53:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,LEG PAIN," 24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. patient was on the floor on [**9-20**], given morphine for the hip pain. she then had an episode of hypotension and unresponsiveness and transferred to the micu for closer monitoring. the patient got 2l ivfs and narcan and improved, in fact, found to be hypertensive upon arrival to micu. . micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. mental status cleared somewhat with narcan. renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. v/q scan demonstrated improvement since prior study. patients home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. she was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. pd fluid was not c/w sbp. cxr was clear. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. plan was/is to follow renal recs for pd. if, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. would add neurontin 100mg tid with room to titrate up to 300mg tid. neuro also recommended pt with tens unit and referral to pain clinic although patients pain is currently absent. . fyi **** per dr. [**last name (stitle) **] --- because of ? increase in cardiomegaly on cxr, she got an echo yesterday. in addition to her known hocm, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm hg. they probably need to be followed up over time (particularly the pulmonary hypertension). we did evaluated the phtn with a vq scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. it would be good if we could arrange a pulmonary clinic follow up for ms. [**known lastname **] after discharge with either [**first name4 (namepattern1) **] [**last name (namepattern1) **] or [**first name4 (namepattern1) **] [**last name (namepattern1) **].**** . she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. after transfer from the micu, her steroids were dropped back to 5mg, her home dose with the approval of [**last name (un) **]. . her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. her hydralazine was discontinued. on day 2 of her micu stay, she developed a fever to 102. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. there was question of retrocardiac opacity on cxr, though not clear. rheum consult obtained given hip discomfort, who felt septic joint unlikely. neurology consult obtained who felt autonomic seizure unlikely. . pt initiated peritoneal dialysis. in this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising bps. she is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. her hip pain has resolved completely without further intervention. . fever: spike fever in micu to 102. started on levoquin, aztreonam, and vanc. source unclear at this point, but cxr with question of retrocardiac opacity. there is a possibility of aspiration pneumonitis. other etiologies include peritoneal fluid (pd cath), urine, and blood (though patient does not have any indwelling lines). hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. peritoneal dialysis cultures negative so far. continued levo/vanco/aztreonam for 2 days empirically. then d/ced the abx as no infectious etiologies were found. steroids back to home dosage. bcx, ucx (final neg), peritoneal cultures negative at discharge. . # labile blood pressure: h/o of difficult to control bp with episodes of hypertensive emergency in the past. normal sbp runs in 170s. having nausea in setting of new pd, no evidence of intracranial bleeding on clinical exam, though inr had been supratherapeutic so remains in differential, though not bradycardic. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. . # right leg/hip pain: no evidence of avascular necrosis or fracture on mri though there is a small effusion. pain resolved without intervention. continued to monitor and would avoid narcotics, restart slowly if pain resumes. physical therapy to follow as an outpatient. [**last name (un) 18183**] followed. please see consult note. . # hyperkalemia: chronic issue. patient takes kayexalate intermittently per her report (last dose [**last name (un) 766**]). monitored k but patient did not need it on floor. # ckd v: renal following. did well with pd on [**9-22**] but did report some nause and cramping. she was not tolerating all 1.5l in exchanges on discharge. # anemia: hct stable around 20. s/p 1 u prbcs in micu with hct 20.1 to 21.9. likely due to chronic hemolysis consistent with sle> #. prior svc thrombus: physical exam with l arm swelling consistent with this. no flow limitations. inr 3.5 on icu admission. held warfarin but restarted home 2mg daily the day before discharge. # systemic lupus erythematosus: home prednisone dose 5mg. currently on 15mg in setting of acute illness (day 2). # general care: fen: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, pd initiated, proph: inr therapeutic, no indication for ppi, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. code: full code, confirmed with patient communication: with the patient and her mother [**name (ni) **] [**name (ni) **], [**telephone/fax (2) 43497**]contact. access: 2 pivs ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Pneumonia, organism unspecified; Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Hyperpotassemia; Sciatica; Other iatrogenic hypotension; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Anemia of other chronic disease; Hypocalcemia]","24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. it would be good if we could arrange a pulmonary clinic follow up for ms. [** she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. source unclear at this point, but cxr with question of retrocardiac opacity. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. did well with pd on [**9-22**] but did report some nause and cramping. # systemic lupus erythematosus: home prednisone dose 5mg.","lupus nephropathy patient on peitoneal dialysis with htn and lupus nephropathy. triggered for hypotension (82/45), hypothermia (92.9), altered mental status. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis." 109,124657.0,14804,2142-01-20,14798,126055.0,2141-11-03,Discharge summary,"Admission Date: [**2141-10-13**] Discharge Date: [**2141-11-3**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 6734**] Chief Complaint: Nausea, Vomitting, Abdominal Pain, HTN Urgenc Major Surgical or Invasive Procedure: Upper GI endoscopy Exploratory laparotomy Tunneled hemodialysis catheter in R femoral vein Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 24 y/o F with h/o ESRD, HTN who started peritoneal dialysis during the week of [**2141-10-8**] and presented with a 1 day history of acute onset N/V, sharp abdominal pain on [**2141-10-13**]. (Of note, the patient had presented to the ED on [**10-11**] with hypotension, SBPs in the 80s off after approximately 1.5L was taken off during dialysis in the setting of taking her PO Anti-HTNs. On [**2141-10-11**] she received 0.5L IVF, labs WNL, and was d/c'd home). On the day of admission on [**2141-10-13**], the patient reported that the previous night, she was awoken from sleep with severe, sharp abdominal pain, 6 episodes of frothy emesis, 10+ yellowish BMs without melena or BRBRP.She was admitted for further work- up of this abdminal pain. . In the ED here vitals were as follows: T: 97.0 HR: 101 BP: 240/180 RR: 17 O2sat: 100%RA. She received Labetolol 20mg IV and was subsequently placed on a labetolol drip. She also received ceftriaxone 1gm IV, Flagyl 500mg IV, Dilaudid 0.5-1mg IV q1hr and Zofran. Her abdominal CT showed multifocal areas of small bowel wall thickening. Her peritoneal Cell count was negtaive for SBP. She had some signs of peritonitis and thus surgery was consulted. Her lactate was normal. . Upon arrival to the MICU the patient was mentating well with complaints of diffuse sharp abdominal pain that radiated to the back and diarrhea. She had no headache or visual changes. Past Medical History: - SLE DX ([**2134**] - 16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter Placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). - Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS: 98.4 HR 98 192/131 21 100%RA GEN: Mild Distress, AOx3 HEENT: PEERLA, EOMI NECK: Supple, No LAD, No bruit RESP: CTAB CARD: 2/6 systolic ejection murmur ABD: soft, moderately tender with +/- guarding, BS+ EXTR: Warm well perfused NEURO: Motor Grossly Intact RECTAL: Yellow Stool BACK: B CVAT Pertinent Results: [**2141-11-3**] 08:50AM BLOOD WBC-3.5* RBC-2.55* Hgb-7.8* Hct-23.6* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.8* Plt Ct-176 [**2141-11-3**] 03:55PM BLOOD PT-15.5* PTT-50.8* INR(PT)-1.4* [**2141-11-3**] 08:50AM BLOOD Glucose-121* UreaN-33* Creat-5.2*# Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [**2141-10-26**] 06:15AM BLOOD ALT-11 AST-49* AlkPhos-122* Amylase-186* TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2141-10-26**] 06:15AM BLOOD Lipase-30 [**2141-11-3**] 08:50AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.9 [**2141-10-30**] 06:55AM BLOOD HBsAg-NEGATIVE [**2141-10-17**] 10:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2141-10-25**] 11:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2141-10-25**] 11:56AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2141-10-25**] 11:56AM URINE RBC-0-2 WBC-[**3-15**] Bacteri-FEW Yeast-NONE Epi-21-50 Blood cultures: all negative EKG ([**2141-10-13**]): Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of [**2141-10-2**] there is no significant diagnostic change. CXR ([**2141-10-13**]): No acute cardiopulmonary abnormality. No free air under the diaphragms. CT chest/abdomen/pelvis ([**2141-10-13**]): There is a moderate-sized pericardial effusion, similar in appearance from [**2141-10-13**]. The great vessels are normal in caliber, without aneurysmal dilatation. Evaluation of the great vessels is limited without IV contrast. Interstitial thickening, particularly within the perihilar regions, is suggestive of fluid overload. There is bibasilar atelectasis with a small focus of consolidation in the right lower lobe (2:35) unchanged from [**2141-10-13**], and may reflect aspiration or pneumonia. Scattered bilateral nodules are largely stable from as far back as [**2139-10-9**]. Specifically, there is a 5 mm nodule in the right middle lobe (2:25), two adjacent nodules in the right lower lobe measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule within the left lower lobe. A nodular density seen adjacent and anterior to the right main pulmonary artery (2:23) may reflect a vessel. There is a small right pleural effusion. Axillary lymphadenopathy, with axillary nodes measuring up to approximately 10 mm in short axis, is seen. Ill- defined soft tissue thickening within the hilus bilaterally may reflect hilar lymphadenopathy, but assessment is limited without IV contrast. A catheter is visualized within the visualized right upper extremity, which may reflect a PICC line that terminates within the right subclavian vein. The esophagus is distended and filled with contrast, with marked wall thickening and edema throughout its entire length, a new finding. There is a moderate- sized hiatal hernia. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval development of a moderate amount of free intraperitoneal air, that layers anteriorly and along the anterior abdominal wall. Additional small clustered foci of extraluminal air is seen adjacent to the proximal stomach and the gastroesophageal junction, with a focus of air tracking into the fissure of ligamentum venosum. Additionally, there appears to be air tracking into the anterior subcutaneous tissues in the region of the umbilicus. These findings are all new from the prior CT on [**2141-10-13**], but free air was present on chest radiograph performed [**2141-10-25**]. There is no obvious evidence of extravasation of oral contrast into the peritoneum. Of note, a peritoneal dialysis catheter is in place that could represent a route of entry of intraperitoneal air. The stomach, small bowel, and colon are filled with contrast, without evidence of obstruction. Evaluation for wall thickening is limited without IV contrast. Limited non-contrast views of the liver demonstrates a rounded 1.6 cm x 1.2 cm hypodensity in the right lobe of the liver, previously characterized as a hemangioma. The liver is otherwise unremarkable. The gallbladder, spleen, pancreas, and adrenal glands demonstrate no gross abnormality. Both kidneys are atrophic. Evaluation of solid organs is limited by lack of IV contrast. There is a peritoneal dialysis catheter, coiled within the pelvis, unchanged. There is a large amount of free fluid throughout the abdomen, similar in appearance to the prior study. CT OF THE PELVIS WITHOUT IV CONTRAST: Uterus and rectum are grossly unremarkable. However, assessment of the rectal wall is limited without IV contrast. OSSEOUS STRUCTURES: Bones are diffusely sclerotic, which may be related to renal osteodystrophy. There is bilateral sacroiliitis. IMPRESSION: 1. Interval development of a moderate amount of free intraperitoneal air, new from [**2141-10-13**]. A peritoneal dialysis catheter is in place and could represent the route of entry of free intraperitoneal air. However, as foci of air is seen in the region of the proximal stomach and GE junction in the setting of a recent endoscopy, perforation cannot be excluded, though no frank extravasation of contrast is identified. 2. New dilation and wall thickening of the entire esophagus, a nonspecific finding that could relate to infectious or inflammatory esophagitis; clinical correlation is recommended. Esophagus is contrast-filled possibly representing reflux. Hiatal hernia. 3. Anasarca, with moderate-sized pericardial effusion, pulmonary edema, and small right pleural effusion. 4. Large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. Imaging cannot exclude SBP, which should be evaluated for clinically. 5. Focus of consolidation within the right lower lobe, could represent aspiration or pneumonia, but unchanged from the prior study. Gastric Biopsies ([**2141-10-18**]): Antrum: Corpus-type mucosa, no diagnostic abnormalities recognized. Jejunum: Small intestinal mucosa, no diagnostic abnormalities recognized. UE Venous U/S: No evidence of DVT of the left upper extremity, without thrombus identified within the left subclavian vein. Brief Hospital Course: This is a 24 year old woman with ESRD secondary to SLE (started peritoneal dialysis approximately one week prior to admission), malignant HTN, h/o SVC syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. Her hospital course was complicated by multiple transfers between the MICU and the floor secondary to hypertensive urgency. # Abdominal Pain/Diarrhea: During the patient's admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. Infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. However, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. The patient was empirically placed on IV flagyl, but this was discontinued when stool samples were negative for C.difficile. Serial abdominal exams showed no peritoneal signs. Peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. CT of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. Other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to SLE vasculitis, malignant HTN, or microthrombosis and SLE enteritis. Surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. A heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible GI bleed. With regards to SLE vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to SLE. On [**10-18**], GI performed an EGD which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. Approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. Both cardiac, GI, and pulmonary etiologies were considered for the origin of her epigastric pain. Pericarditis was considered, but her EKG was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. Her lungs were also essentially unchanged from [**2141-10-13**]. However, her abdominal CT on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. As a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. There were no major findings: no evidence of perforation, obstruction, or infection. The patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. At discharge, the patient only complained of some mild incisional pain. # Hypertensive urgency: The patient was initially admitted to the MICU with a blood pressure of 240/180. Her hospital course was complicated by extremely labile HTN and was transferred back and forth between the MICU and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of SBPs > 260. Throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. Her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. Multiple medication regimens were attempted and changed throughout her hospital course. However, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for SBPs > 180. At discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg PO. Her regimen as per Dr. [**Last Name (STitle) 4883**]: Nifedipine SR 90 mg daily Aliskiren 150 mg [**Hospital1 **] Labetalol 300 mg TID Hydralazine 75 mg TID Clonidine patch 0.3 mg/24 hr patch qWed When SBP>180, she then uses a hydralazine sliding scale. When SBP>180, give 25 mg PO hydral every 30 min until SBP<150. You can use this for up to 2-3 hours. In between PO hydral doses, can then also use 10 IV hydralazine. # ESRD: The etiology of the patient's ESRD is secondary to SLE. Her Creatinine on admission was 7.9, which was near her baseline of 8 - 9. During her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. Prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2L per PD. After her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. Initially, the patient adamantly refused hemodialysis. However, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. As a result, after a long coversation with her primary renal physician, [**Name10 (NameIs) **] agreed to restart hemodialysis. A tunneled catheter was placed in her R femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. She underwent hemodialysis two more times prior to discharge. Upon discharge, her electrolytes were back to her baseline. She is expected to undergo hemodialysis (Tues/[**Last Name (un) **]/SAT) as an outpatient. # Anemia: During her admission, the patient's HCT was monitored daily with HCT to low-mid 20's. On [**2141-10-17**], she was found to have guaiac positive stools and her HCT was found to have dropped to a low of 18.6. The patient was transfused a total of 2 units of [**Date Range **] between [**2141-10-17**] and [**2141-10-18**]. Epo Alfa SC was also given on [**2141-10-17**]. She remained hemodynamically stable. GI consulted and EGD results were as stated above. The patient's HCT remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. Between [**2141-10-23**] - [**2141-10-24**], the patient had a HCT drop from 26 to 20 in the setting of occult positive emesis. She received two units of [**Month/Day/Year **] and her HCT returned to 28. GI was aware and planned to perform a non-urgent EGD on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her HCT returned to baseline. However, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her HCt remained stable and near baseline for the remiainder of her hospital course. # H/O Thrombosis: The patient was initially placed on her home dose of warfarin 2mg qd. Her INR on admission was 1.2. She was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. However, this was stopped for her EGD and after she had evidence of a GI bleed. The heparin drip was discontinued on [**10-22**]. The patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in HCT and in preparation for a possible GI intervention. After her surgery, her coumadin was held and she was off the heparin drip, but her INR continued to drift up, getting as high as 2.6 on [**2141-10-30**]. This was mostly attributed to nutritional deficiency [**2-11**] poor PO intake, but there was concern for possible synthetic dysfunction as well. As a result, she was given a test dose of vitamin K, which she responded to well (Her INR came back down to 1.4). As a result, her home dose of coumadin at 2 mg qday was restarted. At discharge, her INR was still sub- therapeutic at 1.4. Of note, the patient has a history of SVC syndrome and had a L subclavian venous thrombosis. During the last few days of her hospital stay, the patient complained of increased tongue swelling and her L face was noted to be slightly more swollen than previously noted. As a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a DVT within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # SLE: Rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. Her outside rheumatologist was also consulted. Both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # Obstructive sleep apnea: The patient was noted to have OSA based on clinical nocturnal exam during admission. Patient attempted 1 trial of CPAP at 2L/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. The paitent stated that she would pursue further work-up and treatment for OSA as an outpatient. While the mask and CPAP machine were at her bedside throughout her hospital course, the patient rarely used it. # Metabolic Acidosis: The patient's bicarbonate on admission was 13. Her baseline is normally between 16-20. She received 150mEq NaHCO3 over 24hrs from [**Date range (1) 43500**]. During her brief returns to the MICU, her HC03 was 18-19, which was presumed to be her baseline at home secondary to her CRF. At discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. Medications on Admission: Nifedipine 60 mg PO daily Labetalol 900 mg PO TID Hydralazine 50 mg PO TID Clonidine 0.3 mg/24hr patch qWED Lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 4 mg daily Warfarin 2mg PO daily Calcitriol 1 mcg daily Calcium carbonate 500mg QID Dilaudid 2mg PO Q4-6hr prn pain Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*30 Patch Weekly(s)* Refills:*2* 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. [**Hospital1 **]:*1500 ML(s)* Refills:*0* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Twice daily (). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): In addition to 75 mg TID, if SBP>180, take 1 tab every 30 min until BP decreases to 150. If no improvement after 2 hours, call your doctor. [**Last Name (Titles) **]:*300 Tablet(s)* Refills:*6* 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). [**Last Name (Titles) **]:*1500 ML(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet Sustained Release(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 5 days. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. [**Last Name (Titles) **]:*30 Capsule(s)* Refills:*2* 13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO once a day. [**Last Name (Titles) **]:*30 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: end stage renal disease malignant hypertension abdominal free air subclavian deep vein thrombosis initiation of hemodialysis Secondary: SLE Anemia Discharge Condition: stable, pain well controlled, blood pressure at baseline Discharge Instructions: You were admitted for abdominal pain and then subsequently had a very long hospital course with high blood pressures, severe abdominal pain, some free air in your abdomen resulting in an exploratory laparotomy. You have also been initiated on hemodialysis on Tuesday/Thursday/Saturday schedule. Please take all medications as prescribed in the list that you will be given at discharge. There have been some changes to your medications. Please call your doctor if you have any worsening abdominal pain, fevers, chills, nausea, vomiting, headache, palpitations, diarrhea or any other concerning symptoms. Followup Instructions: You will see Dr. [**Last Name (STitle) 4883**] at hemodialysis on Tuesday, [**11-7**], [**2141**]. You should have your coumadin level checked at this appointment. Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] to schedule an appointment in [**1-11**] weeks to have your staples removed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**] ",78,2141-10-13 23:10:00,2141-11-03 18:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. her hospital course was complicated by multiple transfers between the micu and the floor secondary to hypertensive urgency. # abdominal pain/diarrhea: during the patients admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. the patient was empirically placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. serial abdominal exams showed no peritoneal signs. peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. ct of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to sle vasculitis, malignant htn, or microthrombosis and sle enteritis. surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible gi bleed. with regards to sle vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to sle. on [**10-18**], gi performed an egd which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. both cardiac, gi, and pulmonary etiologies were considered for the origin of her epigastric pain. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. her lungs were also essentially unchanged from [**2141-10-13**]. however, her abdominal ct on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. as a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. there were no major findings: no evidence of perforation, obstruction, or infection. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. at discharge, the patient only complained of some mild incisional pain. # hypertensive urgency: the patient was initially admitted to the micu with a blood pressure of 240/180. her hospital course was complicated by extremely labile htn and was transferred back and forth between the micu and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of sbps > 260. throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. multiple medication regimens were attempted and changed throughout her hospital course. however, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for sbps > 180. at discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg po. her regimen as per dr. [**last name (stitle) 4883**]: nifedipine sr 90 mg daily aliskiren 150 mg [**hospital1 **] labetalol 300 mg tid hydralazine 75 mg tid clonidine patch 0.3 mg/24 hr patch qwed when sbp>180, she then uses a hydralazine sliding scale. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. you can use this for up to 2-3 hours. in between po hydral doses, can then also use 10 iv hydralazine. # esrd: the etiology of the patients esrd is secondary to sle. her creatinine on admission was 7.9, which was near her baseline of 8 - 9. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2l per pd. after her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. initially, the patient adamantly refused hemodialysis. however, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. as a result, after a long coversation with her primary renal physician, [**name10 (nameis) **] agreed to restart hemodialysis. a tunneled catheter was placed in her r femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. she underwent hemodialysis two more times prior to discharge. upon discharge, her electrolytes were back to her baseline. she is expected to undergo hemodialysis (tues/[**last name (un) **]/sat) as an outpatient. # anemia: during her admission, the patients hct was monitored daily with hct to low-mid 20s. on [**2141-10-17**], she was found to have guaiac positive stools and her hct was found to have dropped to a low of 18.6. the patient was transfused a total of 2 units of [**date range **] between [**2141-10-17**] and [**2141-10-18**]. epo alfa sc was also given on [**2141-10-17**]. she remained hemodynamically stable. gi consulted and egd results were as stated above. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. she received two units of [**month/day/year **] and her hct returned to 28. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. however, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her hct remained stable and near baseline for the remiainder of her hospital course. # h/o thrombosis: the patient was initially placed on her home dose of warfarin 2mg qd. her inr on admission was 1.2. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. however, this was stopped for her egd and after she had evidence of a gi bleed. the heparin drip was discontinued on [**10-22**]. the patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in hct and in preparation for a possible gi intervention. after her surgery, her coumadin was held and she was off the heparin drip, but her inr continued to drift up, getting as high as 2.6 on [**2141-10-30**]. this was mostly attributed to nutritional deficiency [**2-11**] poor po intake, but there was concern for possible synthetic dysfunction as well. as a result, she was given a test dose of vitamin k, which she responded to well (her inr came back down to 1.4). as a result, her home dose of coumadin at 2 mg qday was restarted. at discharge, her inr was still sub- therapeutic at 1.4. of note, the patient has a history of svc syndrome and had a l subclavian venous thrombosis. during the last few days of her hospital stay, the patient complained of increased tongue swelling and her l face was noted to be slightly more swollen than previously noted. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. her outside rheumatologist was also consulted. both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission. patient attempted 1 trial of cpap at 2l/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. the paitent stated that she would pursue further work-up and treatment for osa as an outpatient. while the mask and cpap machine were at her bedside throughout her hospital course, the patient rarely used it. # metabolic acidosis: the patients bicarbonate on admission was 13. her baseline is normally between 16-20. she received 150meq nahco3 over 24hrs from [**date range (1) 43500**]. during her brief returns to the micu, her hc03 was 18-19, which was presumed to be her baseline at home secondary to her crf. at discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. ","PRIMARY: [Malignant essential hypertension] SECONDARY: [Renal dialysis status; Epilepsy, unspecified, without mention of intractable epilepsy; Constipation, unspecified; Anemia in chronic kidney disease; Abnormal coagulation profile; Obstructive sleep apnea (adult)(pediatric); Other diseases of lung, not elsewhere classified; Other chest pain; Fever, unspecified; Rash and other nonspecific skin eruption; Other chronic pulmonary heart diseases; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified disease of pericardium; Other ascites; Acidosis; Hyposmolality and/or hyponatremia; Abdominal pain, other specified site; Abdominal pain, epigastric; Nausea with vomiting; Diarrhea; Systemic lupus erythematosus; Hyperparathyroidism, unspecified; Anemia, unspecified; Thrombocytopenia, unspecified; Esophageal reflux]","this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. multiple medication regimens were attempted and changed throughout her hospital course. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. upon discharge, her electrolytes were back to her baseline. epo alfa sc was also given on [**2141-10-17**]. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission.","esrd secondary to sle, malignant htn, h/o svc syndrome, and multiple thrombotic events were considered. the patient was placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia." 109,124657.0,14804,2142-01-20,14799,125288.0,2141-11-23,Discharge summary,"Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypertensive Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: (from MICU admit note) 24yoF ESRD-HD, SLE, HTN presents with 1 month abdominal pain and hypertension. Pt has had work-up over recent months for abd pain, including exploratory laparotomy, all of which essentially (-). Was admitted [**Date range (1) 34629**], for abdominal pain, then returned [**11-16**] for sob with (-)CTA, dc'ed [**11-17**]. In [**Hospital1 18**] ED, T98.5 hr95 BP 220/110 then 183/133 RR13 O2 100% on RA, rectal exam negative, guaiac(-), pelvic exam unremarkable with no cervical motion tenderness. Renal was consulted, taken for hemodialysis. CT abd showed large ascites, no other pathology; CT head improved from prior with no acute ICH; cxr(-). Given iv dilaudid for abdominal pain. BP treated with 10mg iv labetalol. Blood and urine cultures drawn, peritoneal fluid cx sent from catheter. Admitted to MICU for hypertension management. Access: R-HD catheter, 1 pIV in hand, 1 non-functioning peritoneal dialysis catheter. Past Medical History: PMH: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSH: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: PE: T:99.4 BP:158/108 HR:95 RR:12 O2 100% RA GEN: NAD/ pt eyes closed due to pain/ pleasant despite pain HEENT: AT, NC, PERRLA, EOMI on R eye, L eye prosthesis, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD CV: S1 & S2, RRR II/VI HSM at R/L USB, no rubs/gallops PULM: CTAB, no w/r/r ABD: soft, mildly tender at PD catheter, ND, + BS, midline incision with steri-stripes, PD catheter dressing C/I/D EXT: warm, dry, +2 distal pulses BL, no edema NEURO: alert & oriented, CN II-XII grossly intact (except L eye), 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: Admission Labs: [**2141-11-18**] 07:00AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.7* Hct-30.7* MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* Plt Ct-142* [**2141-11-18**] 07:00AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.3* [**2141-11-18**] 07:00AM BLOOD Glucose-86 UreaN-22* Creat-5.0* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2141-11-18**] 07:00AM BLOOD ALT-8 AST-39 AlkPhos-92 TotBili-0.3 [**2141-11-18**] 07:00AM BLOOD Lipase-76* [**2141-11-18**] 07:00AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.9 [**2141-11-18**] 11:00PM ASCITES WBC-1265* RBC-1680* Polys-43* Lymphs-1* Monos-2* Mesothe-11* Macroph-43* [**2141-11-18**] 10:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2141-11-18**] 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2141-11-18**] 10:05AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-[**3-15**] Discharge Labs: [**2141-11-23**] 04:40AM BLOOD WBC-2.9* RBC-3.08* Hgb-9.0* Hct-28.3* MCV-92 MCH-29.2 MCHC-31.8 RDW-17.5* Plt Ct-182 [**2141-11-23**] 04:40AM BLOOD PT-20.8* PTT-76.1* INR(PT)-2.0* [**2141-11-23**] 04:40AM BLOOD Glucose-80 UreaN-21* Creat-4.7* Na-139 K-4.8 Cl-106 HCO3-24 AnGap-14 [**2141-11-23**] 04:40AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8 [**2141-11-22**] 04:55AM BLOOD TSH-6.1* [**2141-11-23**] 04:40AM BLOOD Free T4-1.2 Blood cx ([**11-18**], [**11-19**]): 1/4 bottles with coag neg Staph, [**3-14**] NGTD Urine cx ([**11-18**]): mixed flora c/w contamination Peritoneal fluid ([**11-18**]): Gram stain 2+ polys. Culture no growth. Imaging: CXR Portable ([**11-18**]): Since [**2141-11-16**], heart size enlargement is unchanged due to known pericardial effusion. Lungs are otherwise clear. Hilar contours are normal. Incidentally, widening of both acromioclavicular joints is unchanged. CT A/P ([**11-18**]): 1. No evidence of bowel obstruction or rim-enhancing fluid collection. 2. Large ascites, slightly increased from [**2141-11-13**], with peritoneal dialysis catheter in place. Interval removal of surgical skin staples along the abdomen. 3. Moderate pericardial effusion as before. 4. Symmetric heterogeneous attenuation of the kidneys could be related to renal failure; however, pyelonephritis could also give this appearance. Appearance of the kidneys is unchanged from [**2141-11-13**]. CT Head w/o contrast ([**11-18**]): 1. No evidence of acute intracranial hemorrhage. 2. Regions of hypoattenuation in the bifrontal white matter and left posterior temporal lobe have resolved since [**2141-6-11**]. No new regions of hypoattenuation seen. Brief Hospital Course: 1) Hypertension: Patient has history of extremely labile hypertension on an aggressive outpatient regimen. Overnight in the MICU, patient required IV and PO labetalol for SBP > 200. Her hydralazine was increased from 75mg to 100mg TID with mild improvement. Her labetalol was also increased from 300mg to 400mg TID. Her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. TSH was sent and elevated, although free T4 was normal. Plasma metanephrines were sent and pending at discharge. 2) Abdominal pain: CT scan showed increasing ascites, but no acute pathology. Peritoneal fluid was obtained and contained 544 polys. Treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing GPC pairs/clusters. Blood cultures ended up growing 1 out of 4 bottles coag-neg Staph, likely contaminant, so vancomycin was stopped. Since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. The peritoneal cultures remained negative. Her PD catheter was left in place as the patient refuses HD any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) SVC/brachiocephalic thrombosis: Patient's INR was subtherapeutic on admission at 1.3. Due to the proximal location of her old venous thrombi, she was started on a heparin gtt. This was continued during her admission and her warfarin was increased to 5mg daily. Her INR reached 2.0 at discharge (therapeutic range 2-3). The dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) Anxiety: Patient noted feeling short of breath and anxious around the time of her recent admissions. Her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. They felt her symptoms were suggestive of anxiety and panic attacks, recommended checking TSH and metanephrines as above, and starting citalopram 20mg, which was done. She was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h PRN. Patient is agreeable to outpatient follow up with [**Company 191**] social work, and potential CBT. These can be arranged by her PCP. Medications on Admission: 1. Aliskiren 150 mg [**Hospital1 **] 2. Clonidine 0.3 mg/24 qwk 3. Prochlorperazine Maleate 10 mg prn 4. Hydromorphone 2 mg Tablet Sig: [**1-11**] q6 prn 5. Bisacodyl 10mg [**Hospital1 **] 6. Ergocalciferol (Vitamin D2) 50,000 qmonth 7. Hydralazine 75mg tid 8. Hydralazine scale prn 9. Labetalol 300 mg tid 10. Nifedipine 90 mg qd 11. Prednisone 4mg qd 12. Warfarin 2 mg qd at 4pm Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Hospital1 766**]). 5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day. [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 7 days. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO q30 min prn as needed for hypertension: for SBP > 180. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive urgency Headache Abdominal pain Anxiety Secondary Diagnosis: HTN SLE ESRD on HD SVC and IJ thrombosis, chronic Anemia Discharge Condition: Stable, BPs improved. Discharge Instructions: You were admitted with elevated blood pressures, headache, and abdominal pain. You were found to have increased amounts of white blood cells in your abdominal cavity, but this was not infected. Your abdominal pain resolved and you continued to have intermittent headaches. Your blood pressure medications were adjusted as below. You were also seen by psychiatry who recommended starting new medications for your anxiety. The following changes were made to your medication regimen: - We increased your hydralazine to 100 mg three times a day. - We also increased your labetalol to 400 mg three times a day. - We have started a medication called celexa 20 mg daily as well as ativan 1 mg three times a day as needed for anxiety. - We have increased your coumadin to 4 mg daily. - Please continue taking all other medications as previously prescribed. Call your doctor or return to the emergency room if you experience any of the following: worsening abdominal pain, nausea, vomiting, blurry vision, worsening headache, fever > 101. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. Please continue to follow with your nephrologist and go to outpatient dialysis as previously arranged. Please discuss with your PCP the possibility of talking to a social worker at [**Name (NI) 191**]. You will need to continue to have your INR monitored at [**Hospital 191**] [**Hospital 2786**] clinic. Please have this level checked on [**Hospital 766**], [**11-27**]. Completed by:[**2141-11-23**]",58,2141-11-18 14:00:00,2141-11-23 16:42:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. her hydralazine was increased from 75mg to 100mg tid with mild improvement. her labetalol was also increased from 300mg to 400mg tid. her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. tsh was sent and elevated, although free t4 was normal. plasma metanephrines were sent and pending at discharge. 2) abdominal pain: ct scan showed increasing ascites, but no acute pathology. peritoneal fluid was obtained and contained 544 polys. treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing gpc pairs/clusters. blood cultures ended up growing 1 out of 4 bottles coag-neg staph, likely contaminant, so vancomycin was stopped. since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. the peritoneal cultures remained negative. her pd catheter was left in place as the patient refuses hd any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) svc/brachiocephalic thrombosis: patients inr was subtherapeutic on admission at 1.3. due to the proximal location of her old venous thrombi, she was started on a heparin gtt. this was continued during her admission and her warfarin was increased to 5mg daily. her inr reached 2.0 at discharge (therapeutic range 2-3). the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) anxiety: patient noted feeling short of breath and anxious around the time of her recent admissions. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. they felt her symptoms were suggestive of anxiety and panic attacks, recommended checking tsh and metanephrines as above, and starting citalopram 20mg, which was done. she was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h prn. patient is agreeable to outpatient follow up with [**company 191**] social work, and potential cbt. these can be arranged by her pcp. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Abdominal pain, unspecified site; Anemia, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. her hydralazine was increased from 75mg to 100mg tid with mild improvement. peritoneal fluid was obtained and contained 544 polys. the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted.","patient has history of extremely labile hypertension on aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. ct scan showed increasing ascites, but no acute pathology." 109,124657.0,14804,2142-01-20,14800,161950.0,2141-12-01,Discharge summary,"Admission Date: [**2141-11-24**] Discharge Date: [**2141-12-1**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Headache, abdominal pain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24yo F w/PMHx of ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning, awakening her from sleep. Had been previously discharged from [**Hospital1 **] yesterday after being admitted for hypertension and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Upon discharge yesterday she states her abdominal pain had subsided. She had HD yesterday without complications. She awoke at 6am with a headache and crampy, stabbing abdominal pain. Took 2mg PO Dilaudid without relief and came to ED. No nausea/vomiting, no changes in vision, no fevers, chills, night sweats. No chest pain, SOB, diarrhea. In the ED, initial vitals were T98.7, BP260/130, HR70, RR16. Was initially given 10mg IV Labetalol X 2, 4mg Zofran for nausea. No improvement in BP and started on Labetolol gtt. Got 1mg IV Dilaudid for pain. Currently, patient continues to complain of headache and abdominal pain, both [**7-17**]. No vision changes, chest pain or shortness of breath. Has been feeling increased anxiety recently and saw psychiatrist, was put on Celexa. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T98.2, BP176/135, HR94, RR 22, 100% RA Gen: well-appearing african-american woman, lying comfortably HEENT: anicteric, L eye prosthetic non-reactive, R pupil reactive, MMM, neck supple with submanibular LAD CV: RRR, II/VI SEM best heard at apex Pulm: CTA b/l Abd: hyperactive bowel sounds, midline scar well-healed, soft, diffusely tender to palpation, +rebound, no guarding. PD catheter in LLQ without erythema or purulent material draining. +dullness on percusion with evidence of clinical ascites. Ext: no edema, no clubbing, 2+ peripheral pulses DP and radial. R femoral HD [**Last Name (un) **] in place without erythema, purulance Neuro: A&O X 3, CN intact II-XII, [**5-15**] motor strength in upper and lower extremities Pertinent Results: Admission labs: CBC: [**2141-11-26**] 05:21AM BLOOD WBC-3.5* RBC-3.07* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-17.6* Plt Ct-180 CHEM 10: [**2141-11-26**] 01:16PM BLOOD Glucose-87 UreaN-17 Creat-4.0* Na-136 K-5.2* Cl-106 HCO3-23 AnGap-12 [**2141-11-26**] 09:20PM BLOOD Calcium-7.6* Phos-3.8 Mg-1.8 COAGS: [**2141-11-26**] 01:16PM BLOOD PT-23.9* PTT-40.2* INR(PT)-2.3* STUDIES: 1)Peritoneal fluid ([**11-26**]): negative for malignant cells. Reactive mesothelial cells, macrophages, eosinophils and lymphocytes. 2)BILAT UP EXT VEINS US ([**11-26**]): No evidence of deep vein thrombosis of the right or left upper extremity. 3) MRI/MRA ([**11-30**]): FINDINGS: Examination is somewhat limited by patient motion. T2/FLAIR sequences are unremarkable with interval resolve of previously noted posterior abnormalities. The major vessels appear patent proximally. There are stable areas of low signal in the left frontal and right occipetal/temporal lobes. IMPRESSION: 1. Interval resolution of previously noted posterior white matter abnormalities. 2. Stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions. 3. Very limited MRA as above. Brief Hospital Course: 24yo F with SLE, ESRD on HD and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**Hospital Unit Name 153**] course: The patient was admitted for blood pressure management and evaluation of abd pain. An A-line was placed. EKG showed no change from prior, and Abd x-ray showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home med regimen. The patient was found to be hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. Upon transfer to the floor, the following was her course: 1. Hypertensive Urgency: Pt had had hemodialysis one day prior to admission, so unlikely that she was volume overloaded. Unclear what precipitated this episode of hypertensive urgency, although suspect secondary to abdominal pain leading to an anxiety which then precipitates hypertension. She may not have been taking her medications secondary to pain. Negative serum tox. On the floor, we continued hemodialysis Tu, Th, Sat. She was initially continued on PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine 90mg PO qday and clonidine; she received hydralazine 10mg IV for goal BP < 180/100. Renal team followed patient during this hospitalization. Per renal team recs, labetalol was increased to 800mg TID due to poor blood pressure control. Pt discharged on clonidine 0.3mg patch, Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, Nifedipine 90mg daily and lobatalol 800mg TID. This regimen worked well. 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT scan during prior admission which did not show source of abdominal pain. On admission, LFTs were normal except for slightly low albumin, lipase was slightly elevated and KUB was negative for free air or evidence of SBO. Peritoneal fluid was negative for malignant cells but showed reactive mesothelial cells, macrophages, eosinophils and lymphocytes. Negative gram stain or peritoneal fluid cultures, excluding SBP as a cause of the abdominal pain. PD catheter was not removed. Pt was continued on PO dilaudid 1-2mg Q6h and pain resolved. She denied N/V/diarrhea or constipation. 3. ESRD: Pt on hemodialysis, on T/Th/Sat schedule. Renal following patient closely throughout this hospitalization. Lytes were checked frequently and kayexalate given prn. 4. Hx of SVC/brachiocephalic DVT: Pt was initially subtherapeutic on coumadin. Unclear if she had not been taking Coumadin although patient reported that she has been taking all home meds. We started heparin gtt to bridge to Coumadin. Once therapeutic, continued Coumadin 5mg PO qday. 5. Anxiety: Likely contributing to medical problems and could have very well been the etiology of this admission. Although pt stated she was taking her current medications, she did report increased anxiety which can lead to medication non-compliance and hypertension. Pt recently saw psychiatrist who started her on Celexa. She was continued on celexa 20mg PO qday, ativan 1mg PO q8hours PRN and psychiatry was re-consulted. Per psych recs, started standing clonazepam. Pt refused psych VNA. Outpatient PCP followup recommended. 6. Headache NOS: Pt complained of R-sided HA for several weeks, radiating to R jaw where patient had previous tooth extraction. Right upper extremity ultrasound was negative for DVT. She did not have any focal neuro findings, no visual deficits. She was initially treated with tylenol PRN Q6h; pt requested IV dilaudid for HA, but use of this medication by IV route was limited by team. It was felt by the pain service that her HA did not fit migraine, tension type HA or rebound HA. They recommended increasing dilaudid to 4-6mg Q6h PRN, continuing tylenol and starting neurontin 300mg Qhs which was slowly titrated to 300mg [**Hospital1 **] for better control. Per pain recs, a neurology consult was also obtained during this admission. MRI/MRA showed interval resolution of previously noted posterior white matter abnormalities and stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions, but very limited MRA as above. Per pain recs, dilaudid was further increased to 4mg q4h for better control of her HA. Neurology recommended outpt f/u and Pt scheduled with [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**]. 7. Anemia: Likely related to ESRD. No evidence of acute bleeding. Hct remained stable during this hospitalization. 8. SLE: no acute issues. continued Prednisone 4mg PO qday 9. FEN: tolerated regular diet, repleted lytes PRN 9. Prophylaxis: Heparin gtt, then coumadin, bowel regigmen Medications on Admission: (from prior discharge summary) Bisacodyl 10mg PO qday PRN Prednisone 4mg PO qday Aliskiren 150mg PO BID Clonidine 0.3mg / 24 hr patch weekly qmonday Labetalol 400mg PO TID Warfarin 4mg PO qday Nifedipine 90mg PO qday Hydralazine 100mg PO q8H Hydromorphone 2-4mg PO q4H PRN Lorazepam 1mg PO q8H Celexa 20mg PO qday Prochlorperazine 10mg PO q6H Colace 100mg PO BID Hydralazine 25mg PO q30min PRN for HTN Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Year (4 digits) 766**]). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). [**Year (4 digits) **]:*100 Tablet(s)* Refills:*2* 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*90 Capsule(s)* Refills:*2* 9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for headache. [**Year (4 digits) **]:*84 Tablet(s)* Refills:*0* 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*60 Capsule(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours. [**Year (4 digits) **]:*360 Tablet(s)* Refills:*2* 16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. [**Year (4 digits) **]:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive Emergency 2. SLE 3. Headache, NOS 4. Abdominal pain Discharge Condition: BP better controlled. Headache managed on oral meds Discharge Instructions: You were admitted with abdominal pain, high blood pressure, and headache. Your abdominal pain resolved - no serious cause of this pain was found. Your blood pressure medications were continued, and with an increased in one medication, the labetalol. Your blood pressure improved. You should continue the clonidine 0.3mg patch changed on [**Year (4 digits) 766**], Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, and Nifedipine 90mg daily. The dose of Labetalol was increased to 800 mg three times daily by you kidney doctor and you are given a new prescription. Please take all medications as listed below. For your headache, you had an MRI and MRA of the head, which did not show a new or serious abnormality. You were seen by the neurology and pain services. You should follow up at [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**] at 6:30 PM (in the evening). Your pain was managed by oral dilaudid, 4mg. You should take this medication every 4 hours as needed. You were also started on Gabapentin (also called Neurontin) for the headache. The dose was slowly increased to twice a day. You may not need as much dilaudid for your headache and should wean this medication as tolerated, given it's potential for side effects (constipation, lethargy, dependence). Finally, you will likely need medications for constipation while you take dilaudid. Take colace (a stool softener), senna (a laxative), and bisacodyl (another laxative), as needed. It is really important that you have a primary care doctor. You are scheduled with Dr. [**Last Name (STitle) **] (see below) next Tuesday. You will need your INR checked since you are on coumadin. Call your doctor if you have worsened headache, chest pain, confusion, or any other concerning symptom. Followup Instructions: Please make sure you attend the following doctor appointments: 1) Dr. [**Last Name (STitle) 4883**] (nephrologist) on Tuesday, [**2141-12-5**] at 10AM. Phone number [**Telephone/Fax (1) 60**]. 2) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Location (un) **], [**Hospital Ward Name 23**] center, [**Location (un) **]. Phone:[**Telephone/Fax (1) 250**]. Date/Time:[**2141-12-5**] 3:20 3) Neurology: Dr. [**Last Name (STitle) 43502**] [**Name (STitle) **]. He is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-12-12**] 6:30 PM [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2141-12-2**]",50,2141-11-24 16:11:00,2141-12-01 19:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**hospital unit name 153**] the patient was admitted for blood pressure management and evaluation of abd pain. an a-line was placed. ekg showed no change from prior, and abd x-ray showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home med regimen. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. upon transfer to the floor, the following was her ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other ascites; ; Systemic lupus erythematosus; Headache; Anemia in chronic kidney disease; Anxiety state, unspecified; Other chest pain; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Renal dialysis status; Acquired absence of organ, eye]","24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. the renal team was consulted, and recommended no change to home med regimen.","a 24yo f with sle, esrd on hd and malignant hypertension presented with abdominal pain and headache. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. she successfully switched to po meds and was transferred to the floor." 109,124657.0,14804,2142-01-20,14801,173633.0,2141-12-14,Discharge summary,"Admission Date: [**2141-12-8**] Discharge Date: [**2141-12-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 8104**] Chief Complaint: abdominal pain & hypertension Major Surgical or Invasive Procedure: Hemodialysis PICC Line [**12-11**] History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with a history of CKD V (on HD) from lupus nephritis, chronic intermittent abdominal pain, and multiple prior ICU admissions for hypertensive urgency who presented to the ED complaining of two days' of abdominal pain, nausea, and loose stools. She was feeling well until after her hemodialysis session on Wednesday. Thereafter, she complained of nausea with occasional vomitting and has been unable to keep down any of her oral medications. She also has had diffuse abdominal pain consistent with her prior flares of pain as well as her typical diffuse headache. The headache in particular was worsening and, for her, this is a sign of poorly-controlled hypertension so she came to the [**Hospital1 18**] ED. Upon arrival to the ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room air. She was given 4 mg of IV ondansetron, [**1-11**] inch intropaste, 1 mg of IV hydromorphone x3, 1000cc of NS, and was put on a labetalol drip which had to be increased up to 2 mg/min. A head CT showed no acute abnormality (including hemorrhage) and an abdominal CT showed some possible mild colitis, though it is unclear if this is due to her recent peritoneal dialysis. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 97.9 BP 165/120 HR 93 RR 12 Sat 100% ra Gen: mildly fatigued, but no distress HEENT: oropharynx clear Neck: no JVP, no LAD Chest: clear to auscultation throughout, no w/r/r CV: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard Abdomen: soft, tender diffusely to moderate palpation without rebound or guarding; hyperactive bowel sounds; no masses or HSM, PD catheter in palce Extr: no edema, 2+ PT pulses Neuro: alert, appropriate, strength grossly intact in all four limbs Skin: no rashes Pertinent Results: [**2141-12-14**] 05:53AM BLOOD WBC-4.3 RBC-2.81* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.7 MCHC-33.8 RDW-19.3* Plt Ct-148* [**2141-12-14**] 05:53AM BLOOD PT-42.6* PTT-51.0* INR(PT)-4.7* [**2141-12-10**] 05:10AM BLOOD Ret Aut-2.5 [**2141-12-14**] 05:53AM BLOOD Glucose-83 UreaN-21* Creat-5.1*# Na-138 K-5.3* Cl-105 HCO3-24 AnGap-14 [**2141-12-10**] 05:10AM BLOOD LD(LDH)-234 Amylase-347* TotBili-0.1 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-10**] 05:10AM BLOOD Lipase-72* [**2141-12-14**] 05:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 [**2141-12-10**] 05:10AM BLOOD Hapto-142 [**2141-12-8**] 04:02AM BLOOD calTIBC-138* VitB12-445 Folate-18.5 Ferritn-220* TRF-106* ON ADMISSION: [**2141-12-7**] 09:50PM BLOOD WBC-4.5 RBC-2.78* Hgb-8.4* Hct-25.2* MCV-91 MCH-30.2 MCHC-33.3 RDW-19.2* Plt Ct-158 [**2141-12-7**] 09:50PM BLOOD Neuts-65.2 Lymphs-23.4 Monos-8.0 Eos-2.9 Baso-0.4 [**2141-12-7**] 09:50PM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3* [**2141-12-8**] 04:02AM BLOOD Ret Aut-2.5 [**2141-12-7**] 09:50PM BLOOD Glucose-89 UreaN-25* Creat-5.1*# Na-139 K-4.8 Cl-104 HCO3-26 AnGap-14 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-7**] 09:50PM BLOOD Lipase-89* [**2141-12-7**] 09:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9* Mg-1.9 [**2141-12-7**] 09:54PM BLOOD Glucose-75 Lactate-1.3 Na-139 K-4.8 Cl-101 calHCO3-23 Micro: Blood Cx: [**12-7**], [**12-7**], [**12-11**], [**12-11**] No growth FECAL CULTURE (Final [**2141-12-10**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2141-12-10**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2141-12-8**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-12-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CT HEAD [**2141-12-8**]: IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. The hypodensities noted in the parietal white matter are stable. However in the setting of the hypertension, PRES cannot be excluded. If further evaluation is required MR can be obtained. CT Abdomin/Pelvis [**2141-12-8**] IMPRESSION: 1. Moderate amount of free fluid in the pelvis is compatible with the patient's known peritoneal dialysis. Unchanged peritoneal enhancement. 2. Stable liver hemangioma. CXR [**12-11**] IMPRESSION: Small left pleural effusion. Left lower lobe opacity which is either atelectasis versus pneumonia. Brief Hospital Course: 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. MICU course: Current plan on transfer 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. 1. Hypertensive urgency: The patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. Initially her blood pressure over-corrected to SBPs in the 80s (patient was asymptomatic). Her clonidine patch and hydralazine was held and she again became hypertensive with SBPs 190s. The patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. The following dialysis the patient asymptomatic with SBPs in 80s, MAPs 60s asymptomatic again. Her hydralazine was stopped and continued on all her other home medications at the advice of renal. The patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. On [**12-11**] the patient's SBP dropped to the 80's and due to her pain medications she was extremely lethargic, but arousable. A PICC line was placed because lack of access and she was bolused 250cc NS. The patient's pressures responded and additional narcotics were held due to her mental status. The patient's blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. The patient did require IV hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. A possible component to the patient's malignant hypertension is likely due to OSA. An inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on BiPAP for OSA. The patient was continuned on her admission hypertensive regimen. . 2. Abdominal pain: The etiology of her abdominal pain is unclear, but has been a chronic issue for her. A CT scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. The patient also had diarrhea, but stool studies were negative. The patient's pain was initially treated with hydromorphone, but because of the patient's lethargy on [**12-11**] they were initially held. She continued to complain of severe abdominal pain. She was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. Surgery was consulted in regards to removal of her PD catheter, but given that she may return to PD it was deferred to the outpatient setting. 3. CKD V from lupus nephritis: The patient was continued on HD during her admission. She was also continued on her home prednisone dose. She was closely followed by the renal team. . 4. History of SVC/subclavian vein thrombus: The patient was found to have a subtherapeutic INR on admission 1.3. She was started on a heparin gtt and continued on coumadin. The patient's heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her PICC line was placed. She was therapetuic the same day and her heparin gtt was stopped. On discharge her coumadin was supratherapeutic (4.7) and was held. She will have her INR checked at HD. . 5. Anemia: The patient's Hct slowly trended down. She was guaiac negative and hemolysis labs were negative. She was transfused 1U pRBC at HD on [**12-12**]. She was also given epo at HD. Medications on Admission: prednisone 4 mg daily clonidine 0.3 mg/day patch qWeek ergocalciferol 50,000 units qMonth nifedipine SR 90 mg daily hydralazine 100 mg q8h citalopram 20 mg daily warfarin 2 mg qhs gabapentin 300 mg [**Hospital1 **] hydromorphone 4 mg q4h prn clonazepam 0.5 mg [**Hospital1 **] alikiren 150 mg [**Hospital1 **] docusate 100 mg [**Hospital1 **] senna 8.6 mg [**Hospital1 **] prn acetaminophen prn labetalol 800 mg q8h bisacodyl 5 mg daily prn Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. [**Hospital1 **]:*84 Tablet(s)* Refills:*0* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed: please take as needed for anxiety prior to CPAP at bedtime. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 14. CPAP Home CPAP Dx: OSA Prefer: AutoCPAP/ Pressure setting [**5-20**] Alt: Straight CPAP/ Pressure setting 7 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency Abdominal Pain ESRD on HD SVC Thrombus Secondary: Systemic lupus erythematosus Malignant hypertension Thrombocytopenia HOCM Anemia History of left eye enucleation History of vaginal bleeding Thrombotic microangiopathy Discharge Condition: Stable Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because of elevated blood pressure and abdominal pain. You were initially admitted to the ICU and your blood pressure was controlled. You were stabilized and transferred back to th floor. Your pressures remained stable throughout the rest of your stay. Additionally, you had abdominal pain and diarrhea. Your stool was tested for infections and was negative. Your diarrhea resolved without intervention. Your abdominal pain was controlled with pain medications. You had a sleep study in the hospital which showed that you had sleep apnea. Please continue to take your medications as prescribed. 1. Please do not take your coumadin until your doctor tells you to. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: You will have dialysis at [**Location (un) **] Dialysis on your normal schedule. You need to go to dialysis on Saturday. Please follow-up with the Sleep Clinic in [**12-19**] @ 11:45 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Completed by:[**2141-12-16**]",37,2141-12-08 01:40:00,2141-12-14 17:16:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. micu course: current plan on transfer 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. 1. hypertensive urgency: the patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). her clonidine patch and hydralazine was held and she again became hypertensive with sbps 190s. the patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. the following dialysis the patient asymptomatic with sbps in 80s, maps 60s asymptomatic again. her hydralazine was stopped and continued on all her other home medications at the advice of renal. the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. on [**12-11**] the patients sbp dropped to the 80s and due to her pain medications she was extremely lethargic, but arousable. a picc line was placed because lack of access and she was bolused 250cc ns. the patients pressures responded and additional narcotics were held due to her mental status. the patients blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. the patient did require iv hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. a possible component to the patients malignant hypertension is likely due to osa. an inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on bipap for osa. the patient was continuned on her admission hypertensive regimen. . 2. abdominal pain: the etiology of her abdominal pain is unclear, but has been a chronic issue for her. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. the patient also had diarrhea, but stool studies were negative. the patients pain was initially treated with hydromorphone, but because of the patients lethargy on [**12-11**] they were initially held. she continued to complain of severe abdominal pain. she was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. surgery was consulted in regards to removal of her pd catheter, but given that she may return to pd it was deferred to the outpatient setting. 3. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was also continued on her home prednisone dose. she was closely followed by the renal team. . 4. history of svc/subclavian vein thrombus: the patient was found to have a subtherapeutic inr on admission 1.3. she was started on a heparin gtt and continued on coumadin. the patients heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her picc line was placed. she was therapetuic the same day and her heparin gtt was stopped. on discharge her coumadin was supratherapeutic (4.7) and was held. she will have her inr checked at hd. . 5. anemia: the patients hct slowly trended down. she was guaiac negative and hemolysis labs were negative. she was transfused 1u prbc at hd on [**12-12**]. she was also given epo at hd. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Systemic lupus erythematosus; Other and unspecified noninfectious gastroenteritis and colitis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other iatrogenic hypotension; Obstructive sleep apnea (adult)(pediatric); Hemangioma of intra-abdominal structures; Other chronic pain; Abdominal pain, unspecified site; Abnormal coagulation profile; Renal dialysis status; Personal history of venous thrombosis and embolism]","24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. the patient was continuned on her admission hypertensive regimen. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was therapetuic the same day and her heparin gtt was stopped.",24 year old woman with ckd v and severe hypertension due to sle admitted. patient was initially maintained on a labetalol drip and hydralazine iv prn. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic) 109,124657.0,14804,2142-01-20,14802,140167.0,2141-12-23,Discharge summary,"Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1973**] Chief Complaint: Malignant hypertension Major Surgical or Invasive Procedure: None History of Present Illness: 24 year old female with ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning. Patient had her hemodialysis day before yesterday. She has had multiple admissions to [**Hospital1 18**] with hypertensive urgency with symptoms of headache and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Patient states that her headache and abdominal pain are similar in characteristics to her previous admission. Patient denies any fever, chills, nightsweats, chest pain, shortness of breath, abdominal pain, nausea, vomitting, diarrhea, constipation, blood in stool, dysuria, hematuria, change in vision, hearing, weakness or numbness. In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was initially given 10mg IV Labetalol once and then started on drip at 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea. Her BP elevated as high as 270/174 and his labetolol was switched to nicardipine 1mg/kg/min. On arrival to the MICU her vitals were T 96.4 HR 99 BP 175/120 RR 15 100%RA. Patient was comfortable. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Vitals: 97.5 122/80 88 18 100%RA. Gen: sleeping, easily arousable, appears comfortable. HEENT: AT/NC, L eye prosthetic non-reactive, R pupil reactive, MMM. Heart: S1S2 RRR, III/VI SEM heard best at apex, + S3 Pulm: CTA b/l, no w/r/r. Abd: normal bowel sounds, midline scar well-healed, soft, nontender, prior PD site with dry dressing, patient with tenderness to palpation over prior PD cath site, no guarding/rebound Ext: no edema, no clubbing, WWP. R femoral HD catheter in place. Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: Admission: [**2141-12-18**] 02:00AM BLOOD WBC-5.8 RBC-3.30* Hgb-10.1* Hct-30.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-20.7* Plt Ct-199 [**2141-12-18**] 02:00AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.2* [**2141-12-18**] 02:00AM BLOOD UreaN-35* Creat-5.0* Na-138 K-5.5* Cl-103 HCO3-21* AnGap-20 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-18**] 02:00AM BLOOD Lipase-73* [**2141-12-18**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2141-12-19**] 06:45AM BLOOD Calcium-8.1* Phos-5.1* Mg-1.8 [**2141-12-18**] 03:52PM BLOOD dsDNA-NEGATIVE [**2141-12-18**] 03:52PM BLOOD CRP-11.5* [**2141-12-18**] 03:52PM BLOOD C3-68* C4-19 [**2141-12-20**] 12:09PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 [**2141-12-18**] 02:08AM BLOOD pO2-52* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 Comment-GREEN TOP [**2141-12-20**] 12:09PM BLOOD Lactate-0.9 [**2141-12-18**] 02:08AM BLOOD Glucose-68* Lactate-1.3 Na-140 K-4.8 Cl-103 [**2141-12-23**] 03:00PM BLOOD WBC-4.7 RBC-2.35* Hgb-7.1* Hct-22.3* MCV-95 MCH-30.3 MCHC-31.9 RDW-20.6* Plt Ct-131* [**2141-12-23**] 12:55AM BLOOD PT-14.7* PTT-66.2* INR(PT)-1.3* [**2141-12-18**] 03:52PM BLOOD ESR-21* [**2141-12-23**] 03:00PM BLOOD Glucose-97 UreaN-42* Creat-6.6* Na-138 K-4.3 Cl-106 HCO3-23 AnGap-13 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-23**] 03:00PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8 [**2141-12-18**] 04:23PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2141-12-18**] 04:23PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2141-12-18**] 04:23PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-12 TransE-<1 Micro: Blood Cx- [**12-18**]: No growth Urine Cx- [**12-18**]: No growth [**12-18**] TTE The left atrium and right atrium are normal in cavity size. A possible secundum type atrial septal defect is seen by color Doppler (clip [**Clip Number (Radiology) **]) There is severe symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. There is no significant resting LVOT gradient, but a mild gradient (30mmHg peak) is seen with Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Marked symmetric left ventricular hypertrophy with normal regional/global systolic function and mild inducible LVOT gradient. Mild aortic regurgitation. Mild pulmonary artery systolic hypertension. Possible secundum type atrial septal defect. Compared with the prior study (images reviewed) of [**2141-10-19**], a possible secundum type atrial septal defect is now suggested. If clinically indicated, a follow-up study with saline contrast and/or a TEE would be better able to characterize the possible atrial septal defect. CLINICAL IMPLICATIONS: Based on [**2140**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**12-18**] CXR IMPRESSION: 1. Cardiomegaly with findings suggestive of mild pulmonary edema. 2. Bibasilar linear opacities suggesting atelectasis, although developing pneumonia cannot be excluded. 3. No evidence of free intraperitoneal air. [**12-20**] MRV IMPRESSION: No appreciable change since the MRV chest exam dated [**2141-5-30**]. SVC is patent. Again seen is occlusion of the right internal jugular and left brachiocephalic veins. Right external jugular vein is provides the major venous drainage from the neck. Brief Hospital Course: 24 year old Female with SLE, ESRD on HD and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ED. 1. Malignant Hypertension: The patient had her hemodialysis two days prior to admission. Initially in the ED her BP was 253/170. She was given 10mg IV Labetalol and started on a labatelol drip. She also received hydralazine IV 10 mg once and 2 inches of nitropaste. She had morphine 4mg and 4mg Zofran for nausea. Her BP remained elevated so she was switched to nicardipine 1mg/kg/min. The patient was transferred to the MICU. In the ICU she was continued on the Nicardapine drip and her pressures decreased to 175/120. Nephrology was consulted and dialysis initiated in the AM. The Nicardapine drip dc'd on [**12-19**] and pt transferred to floor. While on the floor the patient had question of angioedema and markedly elevated BP. She was readmitted to the MICU on [**2141-12-20**]. Patient's Aliskerin was also held for conern for angioedema. The renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. The patient's PD catheter was removed. The patient was briefly on a nitro drip for hypertension. The patient's nifedepine was increased to 120mg. The patient was transferred to the floor with stable blood pressures, BP 124/72 on [**12-21**]. The morning of [**12-22**], the patient was noted to have a BP up to 247/120 at 0800. Hypertension persisted throughout the morning with BPs 210s-240s systolic. HR during this time was in the 90s. She received a total of 60 mg IV hydralazine over the course of the morning as well as 0.1 mg PO clonidine. She was also given her normal AM BP meds and restarted on aliskarin. Due to persistent hypertension, she was transferred to the ICU for further care. On arrival to the ICU, the patient reported severe abdominal pain over the site of recently removed PD catheter. She denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. She reports bilateral calf cramping but no leg swelling. She denies any difficulty breathing or chest pain. She took her AM BP meds without difficulty. Her blood pressure decreased to 130s-140s/60s without further intervention. She was transferred back to the floor on [**12-23**] and signed out AMA. 2. Angioedema: On [**12-20**] the patietn developed facial swelling and evidence of angioedema by ENT. The patient reported that her face is more swollen which was confirmed by her mother on the floor. The patient was give lasix IV as she has been unable to have any negative filtration with HD. The patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. Her tekturna was discontinued for concern that it might be causing angioedema. She denied difficulty with her breathing at that time, but was very somnulent. On arrival to the MICU her vitals were stable and oxygenating well at 100% on face mask. The patient's airway was supported with a nasal trumpet. The patient underwent MRV that showed no progression of her clot. Patient was diuresed with lasix and dialysis with significant improvement in her symptoms. She was treated with prednisone and decadron, famotidine and benadryl for angioedema. The patient was maintained on her heparin drip for her SVC syndrome. 3. Abdominal Pain: The patient has had extensive prior workup that has been unrevealing. The Transplant surgery team removed the PD cath on [**12-21**]. She continued to have abdominal pain post-op. She was continued on PO dilaudid 2mg po prn. She continuned to complain of abdominal pain throughout her admission and continued to requested IV dilaudid. 4. ESRD: The patient is on a T/Th/Sat schedule. She was closely followed by the renal team. She had dialysis on [**12-19**]. The patient's tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. The patient also had her PD catheter removed on [**12-21**] secondary to chronic abdominal pain. The patient was scheduled to have dialysis on [**12-23**]. 5. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last admission for supratherapeutic INR. She was admitted with a subtherpeutic INR of 1.2 She was started on a heparin drip. She was also started on Coumadin 2mg PO qday, but was held on [**12-19**] in prep her PD catheter removal. She was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by IR. However, the patient signed out AMA and thus it was not placed. 6. Anxiety: Pt recently saw psychiatrist who started her on Celexa. She was continued on Celexa 20mg PO daily. 7. Anemi of CKDa: The patient's Hct was 30.3 on admission. It trended down to 22.3 on discharge when she left AMA. There was no evidence of active, acute bleeding. THis is likely seoncdary to her ESRD. The patient was closely monitored. 8. Systemic Lupus Erythematosis: Rheumatology was consulted and does not suspect acute flare and dsDNA, C3, C4 nl, ESR and CRP slightly elevated. Her Echo did not suggest worsening pericarditis. She was continued on her home prednisone dose of 4mg daily. 9. Obstructive Sleep Apnea: CPAP for sleep with 7 pressure. Medications on Admission: Aliskiren 150 mg [**Hospital1 **] Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Warfarin held on discharge [**2141-12-14**] due to supratherap INR Discharge Medications: As patient signed out AMA, no medications were issued. She was told to resume her admission medications, however no instructions were taken by the patient. Discharge Disposition: Home Discharge Diagnosis: 1) Hypertensive urgency 2) Abdominal pain 3) End stage renal disease on hemodialysis 4) Venous thromboembolism Discharge Condition: Signed out AMA Discharge Instructions: Pt signed out AMA Return to the hospital with any concerning symptoms. Be sure to call your doctor's office on [**Month/Day/Year 766**] to arrange hemodialysis and review your medications and discuss follow-up plan. Followup Instructions: Follow-up with your Dr. [**Last Name (STitle) **] next week, and call [**Last Name (STitle) 766**] to arrange your hemodialysis. Completed by:[**2141-12-26**]",28,2141-12-18 03:50:00,2141-12-23 19:51:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. 1. malignant hypertension: the patient had her hemodialysis two days prior to admission. initially in the ed her bp was 253/170. she was given 10mg iv labetalol and started on a labatelol drip. she also received hydralazine iv 10 mg once and 2 inches of nitropaste. she had morphine 4mg and 4mg zofran for nausea. her bp remained elevated so she was switched to nicardipine 1mg/kg/min. the patient was transferred to the micu. in the icu she was continued on the nicardapine drip and her pressures decreased to 175/120. nephrology was consulted and dialysis initiated in the am. the nicardapine drip dcd on [**12-19**] and pt transferred to floor. while on the floor the patient had question of angioedema and markedly elevated bp. she was readmitted to the micu on [**2141-12-20**]. patients aliskerin was also held for conern for angioedema. the renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. the patients pd catheter was removed. the patient was briefly on a nitro drip for hypertension. the patients nifedepine was increased to 120mg. the patient was transferred to the floor with stable blood pressures, bp 124/72 on [**12-21**]. the morning of [**12-22**], the patient was noted to have a bp up to 247/120 at 0800. hypertension persisted throughout the morning with bps 210s-240s systolic. hr during this time was in the 90s. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she was also given her normal am bp meds and restarted on aliskarin. due to persistent hypertension, she was transferred to the icu for further care. on arrival to the icu, the patient reported severe abdominal pain over the site of recently removed pd catheter. she denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. she reports bilateral calf cramping but no leg swelling. she denies any difficulty breathing or chest pain. she took her am bp meds without difficulty. her blood pressure decreased to 130s-140s/60s without further intervention. she was transferred back to the floor on [**12-23**] and signed out ama. 2. angioedema: on [**12-20**] the patietn developed facial swelling and evidence of angioedema by ent. the patient reported that her face is more swollen which was confirmed by her mother on the floor. the patient was give lasix iv as she has been unable to have any negative filtration with hd. the patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. her tekturna was discontinued for concern that it might be causing angioedema. she denied difficulty with her breathing at that time, but was very somnulent. on arrival to the micu her vitals were stable and oxygenating well at 100% on face mask. the patients airway was supported with a nasal trumpet. the patient underwent mrv that showed no progression of her clot. patient was diuresed with lasix and dialysis with significant improvement in her symptoms. she was treated with prednisone and decadron, famotidine and benadryl for angioedema. the patient was maintained on her heparin drip for her svc syndrome. 3. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the transplant surgery team removed the pd cath on [**12-21**]. she continued to have abdominal pain post-op. she was continued on po dilaudid 2mg po prn. she continuned to complain of abdominal pain throughout her admission and continued to requested iv dilaudid. 4. esrd: the patient is on a t/th/sat schedule. she was closely followed by the renal team. she had dialysis on [**12-19**]. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient also had her pd catheter removed on [**12-21**] secondary to chronic abdominal pain. the patient was scheduled to have dialysis on [**12-23**]. 5. hx of svc/brachiocephalic dvt: her coumadin was held during last admission for supratherapeutic inr. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. she was also started on coumadin 2mg po qday, but was held on [**12-19**] in prep her pd catheter removal. she was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by ir. however, the patient signed out ama and thus it was not placed. 6. anxiety: pt recently saw psychiatrist who started her on celexa. she was continued on celexa 20mg po daily. 7. anemi of ckda: the patients hct was 30.3 on admission. it trended down to 22.3 on discharge when she left ama. there was no evidence of active, acute bleeding. this is likely seoncdary to her esrd. the patient was closely monitored. 8. systemic lupus erythematosis: rheumatology was consulted and does not suspect acute flare and dsdna, c3, c4 nl, esr and crp slightly elevated. her echo did not suggest worsening pericarditis. she was continued on her home prednisone dose of 4mg daily. 9. obstructive sleep apnea: cpap for sleep with 7 pressure. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Mechanical complication due to peritoneal dialysis catheter; ; Unspecified disease of pericardium; Angioneurotic edema, not elsewhere classified; Abdominal pain, other specified site; Systemic lupus erythematosus; ; Anemia in chronic kidney disease; Dysthymic disorder; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of steroids; Long-term (current) use of anticoagulants; Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation; Other antihypertensive agents causing adverse effects in therapeutic use]","24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. she was given 10mg iv labetalol and started on a labatelol drip. nephrology was consulted and dialysis initiated in the am. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she reports bilateral calf cramping but no leg swelling. she took her am bp meds without difficulty. her tekturna was discontinued for concern that it might be causing angioedema. the patient was maintained on her heparin drip for her svc syndrome. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient was scheduled to have dialysis on [**12-23**]. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. there was no evidence of active, acute bleeding.","24 year old female with sle, esrd on hd presents with abdominal pain and headache consistent with her usual hypertensive urgency. she was found to be in hypertensive urgency in ed. she received hydralazine iv 10 mg once and 2 inches of nitropaste." 109,124657.0,14804,2142-01-20,14803,135923.0,2142-01-12,Discharge summary,"Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-13**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypertensive Urgency and HA Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with HA in the setting of hypertension. Upon arrival to the ED, her vitals were 284/140, HR 67, RR 28, 100% on 4LNC. She was started on a nicardipine drip. She denied shortness of breath or chest pain. She is due for HD today. She has a left groin catheter which was recently placed [**2141-12-21**] and is causing her pain. She was also given dilaudid IV 1 mg x 2 with some relief. CXR was performed and showed no pulmonary edema. . Upon arrival to the MICU, patient denies HA, CP, SOB, fevers, chills. Patient reports mild abdominal pain at sight of left anterior abdominal wall hematoma and left groin pain at site of femoral HD line. She reports that she was taking her medications as directed, including coumadin for SVC thrombus. Briefly, 24 yo F with ESRD on HD, SLE, malignant HTN admitted for HA in the setting of HTN to 284/140 in ED. Initially, she was treated with a nicardipine gtt to control her BP. Her cardiac enzymes were flat, no new ECG changes. She was started on a heparin gtt with transition to coumadin for a SVC thrombosis. HTN secondary to med noncompliance. She was restarted on her oral BP. She missed her PM meds yesterday, so nicardipine was restarted, and then turned off this AM. She received all her AM BP meds. Her BPs have been in the 160s/90s. She had no neurological deficits. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 176/105, 87, 18, 100% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: 2/6 systolic murmur LUSB Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: left ant wall abd hematoma, TTP Extremities: Right: Trace, Left: Trace, left fem HD line without oozing or drainage Skin: Warm Neurologic: AAO x 3 Pertinent Results: [**2142-1-8**] 05:15AM PT-13.7* PTT-33.6 INR(PT)-1.2* [**2142-1-8**] 05:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-1+ STIPPLED-OCCASIONAL TEARDROP-1+ BITE-NORMAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2142-1-8**] 05:15AM cTropnT-0.08* [**2142-1-8**] 05:15AM CK(CPK)-119 [**2142-1-8**] 04:12PM PTT-120.8* [**2142-1-8**] 10:41PM PTT-144.8* [**2142-1-8**] 02:55PM CK-MB-NotDone cTropnT-0.06* Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. Patient was initially observed in the MICU and placed on a nicardipine drip. Patient was stablized on home medicaitons, suggesting medication non-compliance. Additionally, patient presented subtheraputic on coumadin for SVC thrombosis. Patient was started on heparin ggt. After the nicardipine drip was turned off, patient was called out to the floor. Heparin drip was continued until INR [**2-13**]. Pressures were managed to her baseline. Pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with Narcan. Patient received dialysis 3x/wk as per outpatient schedule. # Hypertension: Pt with extensive history of repeated admissions for hypertension. Patient's BP improved with nicardipine drip and after HD off drip on home PO medication regimen. Resumed oral antihypertensives with improved BP control. HTn likely from renal disease, possible medication noncompliance, lupus. No evidence of MI. Continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. Renal increased clonidine patch, and added Nicardipine with improvement of BP control. Pt is to follow up with an appointment in the next week to establish care at [**Company 191**], and to re-check her BP and adjust medications further. # SLE: Stable, continued prednisone at 4 mg PO daily. # Left groin pain. Permanent HD line was placed on [**12-25**]. Line and hematoma from prior peritoneal line on abdomen okay. No leukocytosis or fevers to suggest infection. Patient was oversedated on Dilaudid and had episode of oxygen desaturation which was reversed with Narcan. Patient was solmolent with morphine SR so that was d/c'ed as well, patient was given standing tylenlol and Morphine IR PRN. Transplant surgery removed remaining sutures today from L groin. Pt has a follow-up appointment in the next week with Dr. [**First Name (STitle) **] (Transplant Surgery). She will be sent home with low-dose Morphine IR and Tylenol PRN pain. If L groin pain should become uncontrollable on current meds, pt should return to the ED for re-evaluation. It is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #ESRD: Renal following, continuing HD Th/Th/Sat. CaCO3 was started for elevated calcium-phosphate product. Pt will follow-up with Dr. [**Last Name (STitle) 7473**] in the next 1-2 weeks. # Anemia: Pt's baseline is 26. This is likely secondary to AOCD and renal failure. Hct was stable on day of discharge at 25.9. # SVC thrombus: Pt has a history of an SVC thrombus, and is on coumadin. She is supposed to be on lifelong anticoagulation due to recurrent thrombosis but INR subtherapeutic on arrival. Heparin drip was stopped on the floor once the INR was theraputic. INR was therapeutic on day of discharge. Pt will need an INR check in the next week at her follow-up with her PCP. # HOCM: Pt has evidence of myocardial hypertrophy on Echo. She is currently not symptomatic. Echo did not show evidence of worsening pericardial effusion. She was continued on her beta-blocker and other BP medications. # Depression/anxiety: Stable. She was continued on Celexa and Clonazepam. # OSA: Pt as continued on CPAP for sleep with 7 pressure. # FEN: regular diet # PPX: heparin drip --> coumadin, bowel regimen # ACCESS: PIV x2 / permanent dialysis cath L fem # CODE: FULL # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] # DISPO: home with PCP and Renal [**Name9 (PRE) 702**] to re-check BP, INR level. Follow-up with Transplant Surgery. Medications on Admission: Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Aliskiren 150 [**Hospital1 **] Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Nicardipine 30 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain for 2 weeks. [**Hospital1 **]:*20 Tablet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Urgency End Stage Renal Disease Discharge Condition: stable, blood pressure moderately controlled, afebrile, tolerating POs Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. Some of medications were increased as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to take the coumadin as prescribed by your doctor, and have your INR checked frequently per your PCP's recommendations. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Renal) Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-1-15**] 3:00 - Will follow-up Vitamin D [**2-4**] level Provider: [**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD ([**Company 191**]) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-1-16**] 3:30 - Will re-check your INR level Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Transplant Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-1-19**] 2:50p [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-1-12**]",8,2142-01-08 06:36:00,2142-01-13 21:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE URGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was initially observed in the micu and placed on a nicardipine drip. patient was stablized on home medicaitons, suggesting medication non-compliance. additionally, patient presented subtheraputic on coumadin for svc thrombosis. patient was started on heparin ggt. after the nicardipine drip was turned off, patient was called out to the floor. heparin drip was continued until inr [**2-13**]. pressures were managed to her baseline. pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with narcan. patient received dialysis 3x/wk as per outpatient schedule. # hypertension: pt with extensive history of repeated admissions for hypertension. patients bp improved with nicardipine drip and after hd off drip on home po medication regimen. resumed oral antihypertensives with improved bp control. htn likely from renal disease, possible medication noncompliance, lupus. no evidence of mi. continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. renal increased clonidine patch, and added nicardipine with improvement of bp control. pt is to follow up with an appointment in the next week to establish care at [**company 191**], and to re-check her bp and adjust medications further. # sle: stable, continued prednisone at 4 mg po daily. # left groin pain. permanent hd line was placed on [**12-25**]. line and hematoma from prior peritoneal line on abdomen okay. no leukocytosis or fevers to suggest infection. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. patient was solmolent with morphine sr so that was d/ced as well, patient was given standing tylenlol and morphine ir prn. transplant surgery removed remaining sutures today from l groin. pt has a follow-up appointment in the next week with dr. [**first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. it is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #esrd: renal following, continuing hd th/th/sat. caco3 was started for elevated calcium-phosphate product. pt will follow-up with dr. [**last name (stitle) 7473**] in the next 1-2 weeks. # anemia: pts baseline is 26. this is likely secondary to aocd and renal failure. hct was stable on day of discharge at 25.9. # svc thrombus: pt has a history of an svc thrombus, and is on coumadin. she is supposed to be on lifelong anticoagulation due to recurrent thrombosis but inr subtherapeutic on arrival. heparin drip was stopped on the floor once the inr was theraputic. inr was therapeutic on day of discharge. pt will need an inr check in the next week at her follow-up with her pcp. # hocm: pt has evidence of myocardial hypertrophy on echo. she is currently not symptomatic. echo did not show evidence of worsening pericardial effusion. she was continued on her beta-blocker and other bp medications. # depression/anxiety: stable. she was continued on celexa and clonazepam. # osa: pt as continued on cpap for sleep with 7 pressure. # fen: regular diet # ppx: heparin drip --> coumadin, bowel regimen # access: piv x2 / permanent dialysis cath l fem # code: full # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] # dispo: home with pcp and renal [**name9 (pre) 702**] to re-check bp, inr level. follow-up with transplant surgery. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Hypoxemia; Other opiates and related narcotics causing adverse effects in therapeutic use; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Abdominal pain, other specified site; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Renal dialysis status; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Other postprocedural status]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. # hypertension: pt with extensive history of repeated admissions for hypertension. # sle: stable, continued prednisone at 4 mg po daily. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. this is likely secondary to aocd and renal failure. pt will need an inr check in the next week at her follow-up with her pcp.","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was stablized on home medicaitons, suggesting medication non-compliance. patient was oversedated on dilaudid and had episode of oxygen desaturation." 109,135923.0,14803,2142-01-12,14796,139061.0,2141-09-14,Discharge summary,"Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Right leg pain. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 24 y.o. F with lupus, Chronic Kidney Disease V (not currently on HD or PD), and multiple admissions for hypertensive urgency/emergency, who presented to the ED for continued R leg pain that starts in her R buttocks and refers down her R leg. She describes it as feeling like the pain is deep within her bone. The pain was [**10-20**] in the AM, and she felt like she couldn't get out of bed. Denies any swelling of her RLE. When getting VS in [**Name (NI) **], pt noted to be very hypertensive at 263/176. The patient reportedly has baseline SBPs in 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM on day of admission. She denies any recent recrational drug use including cocaine and amphetamines. She denies headache, vision changes, double vision, chest pain, shortness of breath, abdominal pain, BRBPR, dysuria. During MD interview, the patient was nauseous and had small amount of emesis of a recent Coolata. Pt states that flushing her PD cath causes a large amount of stomach pain. . Of note, the patient was recently admitted from 08.26-29.08. The patient initially presented to the ED after referral from her nephrologist's office where she had complaints of right leg pain and was found to be hypertensive to 250/145. She was admitted after initiation of a labetalol drip and nitropaste with improvement in sbp to 180. The patient did receive 2 U of PRBC's during this hospitalization for baseline anemia. The patient did have a work-up for her right leg pain complaints with plain films of the right hip and MRI of the L-spine which did not reveal an explanation for her symptoms and did rule out avascular necrosis. The patient received dilaudid for pain control and was ambulating without pain prior to discharge. In addition, the patient completed a course of ciprofloxacin for a positive UA with negative cultures. The patient was unable to tolerate peritoneal dialysis for unclear reasons. Peritoneal dialysate culture was negative for infection. . In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in ED ranged from [**Telephone/Fax (3) 43494**]-175 with HR in 96-108. Initially given labetalol 10 mg IV x 1 and then started on labetalol gtt for her elevated blood pressures and titrated to 3 mg/min. LENI of R leg was negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per ED, cannot do V/Q scan due to volume overload after talking with radiology. Renal c/s initiated. A-line placed. Past Medical History: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] . PAST SURGICAL HISTORY: - Placement of multiple catheters including dialysis. - Tonsillectomy. - Left eye enucleation in [**2140-4-10**]. - PD catheter placement in [**2141-5-11**]. Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 98.9 [**Telephone/Fax (2) 43495**] 99$% RA GEN: NAD, pleasant female sitting in bed with moon facies HEENT: EOMI of R eye, L eye prosthesis, no exudate, no erythema, MMM, no LAD CHEST: CTAB except at R base with decreased breath sounds; no w/r/r CV: tachy, normal S1S2, II/VI systolic murmur accentuated with Valsalva ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i EXT: no c/c/e, strength of LEs [**5-15**] and symmetric bilaterally. Negative straight leg test, no pain with internal rotation, external rotation, extension, adduction or abduction. Some pain on flexion at the hip. NEURO: II - XII intact to direct testing. No deficit in light tough sensation. Gait normal. DERM: no rashes noted Pertinent Results: LABS AT ADMISSION: [**2141-9-11**] 11:43AM GLUCOSE-86 UREA N-49* CREAT-8.1* SODIUM-139 POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-16* ANION GAP-18 [**2141-9-11**] 11:43AM CALCIUM-6.2* PHOSPHATE-5.8* MAGNESIUM-1.6 [**2141-9-11**] 11:43AM PT-18.4* PTT-42.8* INR(PT)-1.7* [**2141-9-11**] 07:00AM WBC-5.5 RBC-2.88* HGB-8.1* HCT-24.7* MCV-86 MCH-28.1 MCHC-32.8 RDW-18.0* [**2141-9-11**] 07:00AM NEUTS-74.7* LYMPHS-17.5* MONOS-4.2 EOS-3.3 BASOS-0.2 [**2141-9-11**] 07:00AM PLT COUNT-101* UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50 WBC . MICROBIOLOGY: Urine culture ([**2141-9-11**]): Mixed flora . STUDIES: Cardiology Report ECG Study Date of [**2141-9-11**] 6:55:16 AM Sinus tachycardia. The tracing is marred by baseline artifact. There is left atrial enlargement. Compared to the previous tracing of [**2141-9-5**] the rate has increased. The axis is more rightward. Otherwise, no diagnostic interim change. . UNILAT LOWER EXT VEINS RIGHT Study Date of [**2141-9-11**] 8:54 AM [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and popliteal veins demonstrate normal flow, compressibility, augmentation, waveforms. Appropriate color flow and compression is noted within the calf veins. No intraluminal thrombus is present. IMPRESSION: No evidence of right lower extremity DVT. . TTE ([**2140-8-26**]): The left atrium is normal in size. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . R HIP XR [**2141-9-6**]: No acute fracture or dislocation. . MRI L-SPINE [**2141-9-6**]: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. LAB RESULTS AT DISCHARGE: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-9-14**] 06:15AM 4.0 2.63* 7.6* 23.1* 88 29.1 33.0 18.0* 100* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-9-14**] 06:15AM 100 44* 8.1* 137 4.8 109* 17* 16 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2141-9-14**] 06:15AM 6.8* 5.4* 1.6 CALCIUM freeCa [**2141-9-14**] 11:30AM 0.94* Brief Hospital Course: ICU course: EKG showed no change from prior, and CXR showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home medication regimen. The patient was found to by hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. . [**Hospital1 **] history: . 1. Hypertensive urgency: During the patient's [**Hospital1 **] stay, her SBPs ranged from 140s-160s during the day, which is her baseline systolic blood pressure. She was maintained on her home oral medication regimen. At night, she became more hypertensive, with SBP to the 170s-180s, which was controlled with both IV hydralazine and PO nifedipine. PO nifedipine was most successful at bringing her SBP back to her baseline. SBP at discharge was 140. Throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. The renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. Right leg pain: Upon arrival on the floor, the patient complained of [**2143-4-15**] pain in R buttock and posterior thigh, much exacerbated with standing. Of note, lumbar spine MRI and R hip XR on most recent admission were both negative. Her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. Her pain when she was symptomatic was controlled well with PO dilaudid. If the pain recurs, an MRI of the right hip can be considered to evaluate for osteonecrosis. . 3. UTI: The patient had a urinalysis suggestive of UTI, though she remained asymptomatic throughout. She was treated with a three day course of ciprofloxacin. Her urine culture showed mixed flora consistent with skin contamination. . 4. ESRD: The patient has end-stage renal disease due to her lupus. The patient's creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. She was followed by the renal consult service. Her potassium remained stable. Her calcium was low during admission, and supplemental calcium was given in addition to starting Calcitriol. She was not dialyzed through her PD catheter secondary to discomfort, but may reinitiate PD as an outpatient. Her laboratories will be checked as an outpatient in renal clinic. . 5. Anemia: The patient's hematocrit remained near her baseline low 20s throughout her stay. She has anemia from chronic kidney disease and chronic disease. The patient is not on Epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. Prior SVC thrombus: The patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with INR goal 2.5 to 3.0. . 7. Systemic lupus erythematosus: No active issues. The patient's home prednisone regimen was continued. Medications on Admission: - Prednisone 5 mg Daily - Coumadin 2 mg at bedtime - Nifedipine 60 mg Sustained Release Daily - Hydralazine 50 mg every 8 hours - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY - Aliskiren 150 mg Twice daily - Docusate Sodium 100 mg 2 times a day - Labetalol 900 mg three times a day - Lactulose 15-30 ml once a day: goal is [**1-11**] soft bowel movements per day Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 7. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: - Hypertensive urgency - Right lower extremity pain - Urinary tract infection Secondary diagnosis: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) - HOCM: Last noted on echo [**8-17**] - Anemia - History of left eye enucleation [**2139-4-20**] for fungal infection - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Discharge Condition: Stable systolic blood pressure over past 24 hours. Discharge Instructions: You were admitted to the hospital for uncontrolled high blood pressure. You spent one day in the intensive care unit, where you were treated with intravenous medication to lower your blood pressure. You were then transferred to a regular hospital floor, where your blood pressure was managed with your home oral medications. You were also treated for urinary tract infection with antibiotics. Your right leg pain improved during admission, and we are unsure of the cause of this pain. You should discuss the need for an MRI of the hip if the pain returns when you meet with your primary care doctor. Please call your physician or return to the emergency room if you experience fever, chills, chest pain, difficulty breathing, abdominal pain, headache, changes in your vision, or any other symptoms that are concerning. Please take your medications as prescribed. - Calcitriol was added to your medications. - You should hold Coumadin for two days and restart Saturday, [**2141-9-16**]. You should have your INR checked at your visit in kidney clinic [**2141-9-18**]. - You can take Dilaudid 2-4 mg every eight hours as needed for pain. You should be vigilant about taking lactulose if you need to take Dilaudid. - You should continue Lactulose as per Dr.[**Name (NI) 12913**] instructions. - No other changes were made. Please keep follow up appointments as described below. Followup Instructions: Please call the office of your kidney doctor, Dr. [**Last Name (STitle) 4883**], at ([**Telephone/Fax (1) 773**] to schedule an appointment for [**Last Name (LF) 766**], [**9-19**] as discussed. Follow up with your lung doctor: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-9-21**] 1:00 Follow up with your new primary care doctor: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 ",120,2141-09-11 10:12:00,2141-09-14 20:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home medication regimen. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. . [**hospital1 **] history: . 1. hypertensive urgency: during the patients [**hospital1 **] stay, her sbps ranged from 140s-160s during the day, which is her baseline systolic blood pressure. she was maintained on her home oral medication regimen. at night, she became more hypertensive, with sbp to the 170s-180s, which was controlled with both iv hydralazine and po nifedipine. po nifedipine was most successful at bringing her sbp back to her baseline. sbp at discharge was 140. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. the renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. her pain when she was symptomatic was controlled well with po dilaudid. if the pain recurs, an mri of the right hip can be considered to evaluate for osteonecrosis. . 3. uti: the patient had a urinalysis suggestive of uti, though she remained asymptomatic throughout. she was treated with a three day course of ciprofloxacin. her urine culture showed mixed flora consistent with skin contamination. . 4. esrd: the patient has end-stage renal disease due to her lupus. the patients creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. she was followed by the renal consult service. her potassium remained stable. her calcium was low during admission, and supplemental calcium was given in addition to starting calcitriol. she was not dialyzed through her pd catheter secondary to discomfort, but may reinitiate pd as an outpatient. her laboratories will be checked as an outpatient in renal clinic. . 5. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay. she has anemia from chronic kidney disease and chronic disease. the patient is not on epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. prior svc thrombus: the patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with inr goal 2.5 to 3.0. . 7. systemic lupus erythematosus: no active issues. the patients home prednisone regimen was continued. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Urinary tract infection, site not specified; Other primary cardiomyopathies; Systemic lupus erythematosus; Sciatica; Hyperpotassemia; Thrombocytopenia, unspecified; Abnormal coagulation profile; Hyperparathyroidism, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism]","icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the renal team was consulted, and recommended no change to home medication regimen. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. she was treated with a three day course of ciprofloxacin. esrd: the patient has end-stage renal disease due to her lupus. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay.","ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. she became more hypertensive, with sbps to the 170s-180s during the day. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency." 109,135923.0,14803,2142-01-12,14797,172335.0,2141-09-24,Discharge summary,"Admission Date: [**2141-9-18**] Discharge Date: [**2141-9-24**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1936**] Chief Complaint: hip pain Major Surgical or Invasive Procedure: None History of Present Illness: 24yo woman with hx SLE, CKD(not currently on HD or PD), labile HTN here with right leg pain and HTN urgency. Patient was recently d/ced on [**9-14**] following admission for the same complaints. . Patient took her hydralazine dose on am of admission. BP at presentation to the ER was 250/140 (The patient reportedly has baseline SBPs in 130-170s) She was given 900 labetolol and 50 hydralazine in the ED. BP following this was 175/124. Her EKG was unchanged. K was 5.7. . Patient also complaining of [**10-20**] right hip pain. Patient was d/ced on [**9-14**] with oral dilaudid for hip/leg pain. She took this only for one day due to severe itching. Denies any parasthesias/weakness. Her RLE/hip pain has been extensively worked up with negative LENIs, Lumbar spine MRI and hip plain films in the past. She was given 4mg IV morphine in the ER. . On admission to the floor, leg/hip pain somwhat improved with morphine.She denies any headache, vision changes, double vision, chest pain or SOB. Feels warm but no chills. Past Medical History: Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 97.3 HR 81 BP 135/91 RR 16 100%RA Gen:NAD, happy, pleasant female HEENT:NC/AT, L eye prosthesis, R PERRL, EOMI, MMM, facial swelling, L side>R, scerla anicteric Neck: supple, no JVD, no LAD, scars from prior CVL and HD lines CV:S1S2+, 2/6 SEM LUSB, loud P2, RRR, no ectopy Pulm: CTA B/L, good inspiratory effort Abd: +BS, soft, nontender, slightly distended and resonant to percussion, PD catheter in place in left abdomen ext: no c/c/e, 2+DP b/L, L foream swollen>R, R hip is mobile without pain elicited on passive or active movement neuro: AAOx3, nonfocal exam, CN 2-12 intact, moves all 4 extremities psych: mood/affect appropriate Pertinent Results: MRI Right Hip ([**9-18**]): There is no signal abnormality on the fluid-sensitive sequences in the proximal femur, acetabulum, or other osseous structure. On T1- weighted images, there is a focal rounded region within the right femoral head measuring approximately 9 mm in a subchondral location, which is nonspecific but may represent an unusual focus of red marrow. No sclerosis is seen on the corresponding plain films. There is a small right hip joint effusion and a small amount of fluid in the left hip joint as well, at the upper limits of normal. There is no soft tissue abnormality, no muscular edema, and no fluid collections. IMPRESSION: 1. Small right hip joint effusion. 2. No bone marrow edema in the proximal femurs or the pelvis. 3. Nonspecific small focus of low signal on T1-weighted images in the right femoral head is nonspecific but may represent an unusual focus of red marrow. TTE ([**9-21**]): The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF 80%). A mild (18 mmHg) mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. There is no systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Severe symmetric left ventricular hypertrophy with hyperdynamic systolic function and mild mid-cavitary gradient. Mild aortic regurgitation. Moderate pulmonary hypertension. Findings consistent with hyperrtophic cardiomyopathy. Compared with the prior study (images reviewed) of [**2140-8-26**], pulmonary hypertension has developed (also present on the study from [**2140-5-20**]). Pericardial effusion is also new. V/Q scan ([**9-21**]): Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate no focal defects with improved ventilation to the posterior right basal segment. Perfusion images in the same 8 views show improved perfusion to the posterior right basal segement with a persistent small defect but no new findings. Chest x-ray shows cardiomgealy and left basilar atelectasis. IMPRESSION: Improved V/Q scan from [**9-/2139**] with no findings to suggest acute pulmonary embolism. B/L upper ext U/S ([**9-21**]): Grayscale and Doppler son[**Name (NI) 867**] of the right and left internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. There is nonocclusive focal thrombus seen in the left subclavian vein, where the vein is not fully compressible. Flow is seen in the region, indicating that the thrombus is nonocclusive. Elsewhere, normal flow, augmentation, compressibility were appropriate and waveforms are demonstrated. IMPRESSION: 1. Focal nonocclusive thrombus in the left subclavian vein. 2. Otherwise, patent upper extremity veins as described. [**2141-9-18**] 02:15PM POTASSIUM-5.1 [**2141-9-18**] 02:15PM HCT-21.2* [**2141-9-18**] 08:45AM POTASSIUM-5.7* [**2141-9-18**] 07:30AM GLUCOSE-88 UREA N-54* CREAT-8.6* SODIUM-136 POTASSIUM-5.8* CHLORIDE-108 TOTAL CO2-15* ANION GAP-19 [**2141-9-18**] 07:30AM estGFR-Using this [**2141-9-18**] 07:30AM CALCIUM-7.3* PHOSPHATE-5.3* MAGNESIUM-1.6 [**2141-9-18**] 07:30AM WBC-5.2 RBC-2.32* HGB-6.5* HCT-20.1* MCV-87 MCH-28.1 MCHC-32.4 RDW-18.4* [**2141-9-18**] 07:30AM NEUTS-78.0* LYMPHS-14.7* MONOS-3.9 EOS-3.2 BASOS-0.3 [**2141-9-18**] 07:30AM PLT COUNT-107* [**2141-9-18**] 07:30AM PT-20.8* PTT-43.3* INR(PT)-2.0* . [**2141-9-21**] CXR: There is no significant change when compared to the recent previous examination. The previously described left retrocardiac opacity is unchanged in appearance. Cardiomegaly is also unchanged. The mediastinal contour, bony thorax and pulmonary vasculature are normal. IMPRESSION: No significant change compared to study done roughly 7 hours prior. Brief Hospital Course: 24 yo with h/o of Lupus, HTN, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for R hip pain. Patient was on the floor on [**9-20**], given morphine for the hip pain. She then had an episode of hypotension and unresponsiveness and transferred to the MICU for closer monitoring. The patient got 2L IVFs and narcan and improved, in fact, found to be hypertensive upon arrival to MICU. . MICU Course: On [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. Concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. Mental status cleared somewhat with narcan. Renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. V/Q scan demonstrated improvement since prior study. Patient's home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. She was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. PD fluid was not c/w SBP. CXR was clear. Urine culture and blood cultures are pending. Patient's BP was in the 110s so hydralazine was stopped. Her other BP meds were otherwise continued. Plan was/is to follow renal recs for PD. If, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. Would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. If patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. Would add neurontin 100mg TID with room to titrate up to 300mg TID. Neuro also recommended PT with TENS unit and referral to pain clinic although patient's pain is currently absent. . FYI **** per Dr. [**Last Name (STitle) **] --- Because of ? increase in cardiomegaly on CXR, she got an echo yesterday. In addition to her known HOCM, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm Hg. They probably need to be followed up over time (particularly the pulmonary hypertension). We did evaluated the PHTN with a VQ scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. It would be good if we could arrange a PULMONARY CLINIC FOLLOW UP for Ms. [**Known lastname **] after discharge with either [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].**** . She underwent CT head, and V/Q scan which were unremarkable. Her steroid dose was increased to 15mg given concern for need for stress dose steroids. After transfer from the MICU, her steroids were dropped back to 5mg, her home dose with the approval of [**Last Name (un) **]. . Her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. Her hydralazine was discontinued. On day 2 of her MICU stay, she developed a fever to 102. She was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. Broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. There was question of retrocardiac opacity on CXR, though not clear. Rheum consult obtained given hip discomfort, who felt septic joint unlikely. Neurology consult obtained who felt autonomic seizure unlikely. . Pt initiated peritoneal dialysis. In this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising BPs. She is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. Her hip pain has resolved completely without further intervention. . Floor course: Fever: Spike fever in MICU to 102. Started on Levoquin, Aztreonam, and Vanc. Source unclear at this point, but CXR with question of retrocardiac opacity. There is a possibility of aspiration pneumonitis. Other etiologies include peritoneal fluid (PD cath), urine, and blood (though patient does not have any indwelling lines). Hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. Peritoneal dialysis cultures negative so far. Continued levo/vanco/aztreonam for 2 days empirically. Then d/ced the Abx as no infectious etiologies were found. Steroids back to home dosage. BCx, UCx (final neg), Peritoneal cultures negative at discharge. . # Labile blood pressure: h/o of difficult to control BP with episodes of hypertensive emergency in the past. Normal SBP runs in 170s. Having nausea in setting of new PD, no evidence of intracranial bleeding on clinical exam, though INR had been supratherapeutic so remains in differential, though not bradycardic. Continue home BP meds :Labetalol 900 mg PO TID but difficult for patient to tolerate due to nausea, Aliskiren *NF* 150 mg Oral [**Hospital1 **], NIFEdipine CR 60 mg PO DAILY, clonidine patch, hydralazine given hypertensive in setting of nausa. . # Right leg/hip pain: no evidence of avascular necrosis or fracture on MRI though there is a small effusion. Pain resolved without intervention. Continued to monitor and would avoid narcotics, restart slowly if pain resumes. Physical therapy to follow as an outpatient. [**Last Name (un) 18183**] followed. Please see consult note. . # Hyperkalemia: Chronic issue. Patient takes kayexalate intermittently per her report (last dose [**Last Name (un) 766**]). Monitored K but patient did not need it on floor. # CKD V: Renal following. Did well with PD on [**9-22**] but did report some nause and cramping. She was not tolerating all 1.5L in exchanges on discharge. # Anemia: Hct stable around 20. S/p 1 U PRBCs in MICU with Hct 20.1 to 21.9. Likely due to chronic hemolysis consistent with SLE> #. Prior SVC thrombus: Physical exam with L arm swelling consistent with this. No flow limitations. INR 3.5 on ICU admission. Held warfarin but restarted home 2mg daily the day before discharge. # Systemic lupus erythematosus: Home prednisone dose 5mg. Currently on 15mg in setting of acute illness (day 2). # General care: FEN: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, PD initiated, Proph: INR therapeutic, no indication for PPI, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. Code: Full code, confirmed with patient Communication: with the patient and her mother [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (2) 43497**]contact. Access: 2 PIVs Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly dilaudid PO prn benadryl prn lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily coumadin 2mg PO qday calcitriol 1 mcg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Hypertensive urgency Transient Hypotension due to Narcotics Sciatica . Secondary: End stage renal disease Systemic Lupus Erythematosus Anemia Discharge Condition: Stable. Blood pressures at baseline. Hip/leg pain resolved. Ambulating without assistance. Discharge Instructions: You were admitted to the hospital with high blood pressure and right leg/hip pain. We gave you pain medications and blood pressure lowering medications. Your blood pressure then dropped which was caused by the pain medication, and you were transferred to the Intensive Care Unit(ICU) where you recovered quickly. During your stay in the ICU, you developed a fever and were started on antibiotics. However, the cultures that were obtained were negative, and we discontinued the Antibiotics. During your hospitalization, your blood pressure normalized on your home regimen, and your right leg/hip pain resolved. You had an MRI of your hip done, which did not show an acute infection. You were seen by the kidney doctors and they recommended starting peritoneal dialysis. You were also given some blood for your anemia. Please follow up with the Peritoneal Dialysis nurse at the scheduled day/time. Please make an appointment to meet with your PCP in the next couple of weeks. Your Hip pain may benefit from physical therapy or outpatient anesthetic joint injection. Please discuss these options with your rheumatologist. . Please call the number given below to schedule outpatient physical therapy. . Please restart your home medications. You were also started on Sodium Bicarb 650mg by mouth three times a day. . If you develop fevers, chills, trouble breathing, chest pain, worsening of hip pain, headaches, changes in your vision or any other symptoms that concern you please return to the emergency room or call your doctor. Followup Instructions: Please follow up with your Peritoneal Dialysis nurse ([**Doctor First Name 3040**]) on [**Doctor First Name 766**] [**2141-9-25**] . Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 . Please call to schedule Outpatient Physical Therapy:[**Telephone/Fax (1) 2484**] Completed by:[**2141-9-25**]",110,2141-09-18 10:32:00,2141-09-24 13:53:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,LEG PAIN," 24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. patient was on the floor on [**9-20**], given morphine for the hip pain. she then had an episode of hypotension and unresponsiveness and transferred to the micu for closer monitoring. the patient got 2l ivfs and narcan and improved, in fact, found to be hypertensive upon arrival to micu. . micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. mental status cleared somewhat with narcan. renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. v/q scan demonstrated improvement since prior study. patients home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. she was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. pd fluid was not c/w sbp. cxr was clear. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. plan was/is to follow renal recs for pd. if, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. would add neurontin 100mg tid with room to titrate up to 300mg tid. neuro also recommended pt with tens unit and referral to pain clinic although patients pain is currently absent. . fyi **** per dr. [**last name (stitle) **] --- because of ? increase in cardiomegaly on cxr, she got an echo yesterday. in addition to her known hocm, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm hg. they probably need to be followed up over time (particularly the pulmonary hypertension). we did evaluated the phtn with a vq scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. it would be good if we could arrange a pulmonary clinic follow up for ms. [**known lastname **] after discharge with either [**first name4 (namepattern1) **] [**last name (namepattern1) **] or [**first name4 (namepattern1) **] [**last name (namepattern1) **].**** . she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. after transfer from the micu, her steroids were dropped back to 5mg, her home dose with the approval of [**last name (un) **]. . her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. her hydralazine was discontinued. on day 2 of her micu stay, she developed a fever to 102. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. there was question of retrocardiac opacity on cxr, though not clear. rheum consult obtained given hip discomfort, who felt septic joint unlikely. neurology consult obtained who felt autonomic seizure unlikely. . pt initiated peritoneal dialysis. in this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising bps. she is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. her hip pain has resolved completely without further intervention. . fever: spike fever in micu to 102. started on levoquin, aztreonam, and vanc. source unclear at this point, but cxr with question of retrocardiac opacity. there is a possibility of aspiration pneumonitis. other etiologies include peritoneal fluid (pd cath), urine, and blood (though patient does not have any indwelling lines). hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. peritoneal dialysis cultures negative so far. continued levo/vanco/aztreonam for 2 days empirically. then d/ced the abx as no infectious etiologies were found. steroids back to home dosage. bcx, ucx (final neg), peritoneal cultures negative at discharge. . # labile blood pressure: h/o of difficult to control bp with episodes of hypertensive emergency in the past. normal sbp runs in 170s. having nausea in setting of new pd, no evidence of intracranial bleeding on clinical exam, though inr had been supratherapeutic so remains in differential, though not bradycardic. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. . # right leg/hip pain: no evidence of avascular necrosis or fracture on mri though there is a small effusion. pain resolved without intervention. continued to monitor and would avoid narcotics, restart slowly if pain resumes. physical therapy to follow as an outpatient. [**last name (un) 18183**] followed. please see consult note. . # hyperkalemia: chronic issue. patient takes kayexalate intermittently per her report (last dose [**last name (un) 766**]). monitored k but patient did not need it on floor. # ckd v: renal following. did well with pd on [**9-22**] but did report some nause and cramping. she was not tolerating all 1.5l in exchanges on discharge. # anemia: hct stable around 20. s/p 1 u prbcs in micu with hct 20.1 to 21.9. likely due to chronic hemolysis consistent with sle> #. prior svc thrombus: physical exam with l arm swelling consistent with this. no flow limitations. inr 3.5 on icu admission. held warfarin but restarted home 2mg daily the day before discharge. # systemic lupus erythematosus: home prednisone dose 5mg. currently on 15mg in setting of acute illness (day 2). # general care: fen: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, pd initiated, proph: inr therapeutic, no indication for ppi, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. code: full code, confirmed with patient communication: with the patient and her mother [**name (ni) **] [**name (ni) **], [**telephone/fax (2) 43497**]contact. access: 2 pivs ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Pneumonia, organism unspecified; Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Hyperpotassemia; Sciatica; Other iatrogenic hypotension; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Anemia of other chronic disease; Hypocalcemia]","24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. it would be good if we could arrange a pulmonary clinic follow up for ms. [** she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. source unclear at this point, but cxr with question of retrocardiac opacity. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. did well with pd on [**9-22**] but did report some nause and cramping. # systemic lupus erythematosus: home prednisone dose 5mg.","lupus nephropathy patient on peitoneal dialysis with htn and lupus nephropathy. triggered for hypotension (82/45), hypothermia (92.9), altered mental status. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis." 109,135923.0,14803,2142-01-12,14798,126055.0,2141-11-03,Discharge summary,"Admission Date: [**2141-10-13**] Discharge Date: [**2141-11-3**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 6734**] Chief Complaint: Nausea, Vomitting, Abdominal Pain, HTN Urgenc Major Surgical or Invasive Procedure: Upper GI endoscopy Exploratory laparotomy Tunneled hemodialysis catheter in R femoral vein Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 24 y/o F with h/o ESRD, HTN who started peritoneal dialysis during the week of [**2141-10-8**] and presented with a 1 day history of acute onset N/V, sharp abdominal pain on [**2141-10-13**]. (Of note, the patient had presented to the ED on [**10-11**] with hypotension, SBPs in the 80s off after approximately 1.5L was taken off during dialysis in the setting of taking her PO Anti-HTNs. On [**2141-10-11**] she received 0.5L IVF, labs WNL, and was d/c'd home). On the day of admission on [**2141-10-13**], the patient reported that the previous night, she was awoken from sleep with severe, sharp abdominal pain, 6 episodes of frothy emesis, 10+ yellowish BMs without melena or BRBRP.She was admitted for further work- up of this abdminal pain. . In the ED here vitals were as follows: T: 97.0 HR: 101 BP: 240/180 RR: 17 O2sat: 100%RA. She received Labetolol 20mg IV and was subsequently placed on a labetolol drip. She also received ceftriaxone 1gm IV, Flagyl 500mg IV, Dilaudid 0.5-1mg IV q1hr and Zofran. Her abdominal CT showed multifocal areas of small bowel wall thickening. Her peritoneal Cell count was negtaive for SBP. She had some signs of peritonitis and thus surgery was consulted. Her lactate was normal. . Upon arrival to the MICU the patient was mentating well with complaints of diffuse sharp abdominal pain that radiated to the back and diarrhea. She had no headache or visual changes. Past Medical History: - SLE DX ([**2134**] - 16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter Placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). - Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS: 98.4 HR 98 192/131 21 100%RA GEN: Mild Distress, AOx3 HEENT: PEERLA, EOMI NECK: Supple, No LAD, No bruit RESP: CTAB CARD: 2/6 systolic ejection murmur ABD: soft, moderately tender with +/- guarding, BS+ EXTR: Warm well perfused NEURO: Motor Grossly Intact RECTAL: Yellow Stool BACK: B CVAT Pertinent Results: [**2141-11-3**] 08:50AM BLOOD WBC-3.5* RBC-2.55* Hgb-7.8* Hct-23.6* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.8* Plt Ct-176 [**2141-11-3**] 03:55PM BLOOD PT-15.5* PTT-50.8* INR(PT)-1.4* [**2141-11-3**] 08:50AM BLOOD Glucose-121* UreaN-33* Creat-5.2*# Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [**2141-10-26**] 06:15AM BLOOD ALT-11 AST-49* AlkPhos-122* Amylase-186* TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2141-10-26**] 06:15AM BLOOD Lipase-30 [**2141-11-3**] 08:50AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.9 [**2141-10-30**] 06:55AM BLOOD HBsAg-NEGATIVE [**2141-10-17**] 10:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2141-10-25**] 11:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2141-10-25**] 11:56AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2141-10-25**] 11:56AM URINE RBC-0-2 WBC-[**3-15**] Bacteri-FEW Yeast-NONE Epi-21-50 Blood cultures: all negative EKG ([**2141-10-13**]): Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of [**2141-10-2**] there is no significant diagnostic change. CXR ([**2141-10-13**]): No acute cardiopulmonary abnormality. No free air under the diaphragms. CT chest/abdomen/pelvis ([**2141-10-13**]): There is a moderate-sized pericardial effusion, similar in appearance from [**2141-10-13**]. The great vessels are normal in caliber, without aneurysmal dilatation. Evaluation of the great vessels is limited without IV contrast. Interstitial thickening, particularly within the perihilar regions, is suggestive of fluid overload. There is bibasilar atelectasis with a small focus of consolidation in the right lower lobe (2:35) unchanged from [**2141-10-13**], and may reflect aspiration or pneumonia. Scattered bilateral nodules are largely stable from as far back as [**2139-10-9**]. Specifically, there is a 5 mm nodule in the right middle lobe (2:25), two adjacent nodules in the right lower lobe measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule within the left lower lobe. A nodular density seen adjacent and anterior to the right main pulmonary artery (2:23) may reflect a vessel. There is a small right pleural effusion. Axillary lymphadenopathy, with axillary nodes measuring up to approximately 10 mm in short axis, is seen. Ill- defined soft tissue thickening within the hilus bilaterally may reflect hilar lymphadenopathy, but assessment is limited without IV contrast. A catheter is visualized within the visualized right upper extremity, which may reflect a PICC line that terminates within the right subclavian vein. The esophagus is distended and filled with contrast, with marked wall thickening and edema throughout its entire length, a new finding. There is a moderate- sized hiatal hernia. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval development of a moderate amount of free intraperitoneal air, that layers anteriorly and along the anterior abdominal wall. Additional small clustered foci of extraluminal air is seen adjacent to the proximal stomach and the gastroesophageal junction, with a focus of air tracking into the fissure of ligamentum venosum. Additionally, there appears to be air tracking into the anterior subcutaneous tissues in the region of the umbilicus. These findings are all new from the prior CT on [**2141-10-13**], but free air was present on chest radiograph performed [**2141-10-25**]. There is no obvious evidence of extravasation of oral contrast into the peritoneum. Of note, a peritoneal dialysis catheter is in place that could represent a route of entry of intraperitoneal air. The stomach, small bowel, and colon are filled with contrast, without evidence of obstruction. Evaluation for wall thickening is limited without IV contrast. Limited non-contrast views of the liver demonstrates a rounded 1.6 cm x 1.2 cm hypodensity in the right lobe of the liver, previously characterized as a hemangioma. The liver is otherwise unremarkable. The gallbladder, spleen, pancreas, and adrenal glands demonstrate no gross abnormality. Both kidneys are atrophic. Evaluation of solid organs is limited by lack of IV contrast. There is a peritoneal dialysis catheter, coiled within the pelvis, unchanged. There is a large amount of free fluid throughout the abdomen, similar in appearance to the prior study. CT OF THE PELVIS WITHOUT IV CONTRAST: Uterus and rectum are grossly unremarkable. However, assessment of the rectal wall is limited without IV contrast. OSSEOUS STRUCTURES: Bones are diffusely sclerotic, which may be related to renal osteodystrophy. There is bilateral sacroiliitis. IMPRESSION: 1. Interval development of a moderate amount of free intraperitoneal air, new from [**2141-10-13**]. A peritoneal dialysis catheter is in place and could represent the route of entry of free intraperitoneal air. However, as foci of air is seen in the region of the proximal stomach and GE junction in the setting of a recent endoscopy, perforation cannot be excluded, though no frank extravasation of contrast is identified. 2. New dilation and wall thickening of the entire esophagus, a nonspecific finding that could relate to infectious or inflammatory esophagitis; clinical correlation is recommended. Esophagus is contrast-filled possibly representing reflux. Hiatal hernia. 3. Anasarca, with moderate-sized pericardial effusion, pulmonary edema, and small right pleural effusion. 4. Large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. Imaging cannot exclude SBP, which should be evaluated for clinically. 5. Focus of consolidation within the right lower lobe, could represent aspiration or pneumonia, but unchanged from the prior study. Gastric Biopsies ([**2141-10-18**]): Antrum: Corpus-type mucosa, no diagnostic abnormalities recognized. Jejunum: Small intestinal mucosa, no diagnostic abnormalities recognized. UE Venous U/S: No evidence of DVT of the left upper extremity, without thrombus identified within the left subclavian vein. Brief Hospital Course: This is a 24 year old woman with ESRD secondary to SLE (started peritoneal dialysis approximately one week prior to admission), malignant HTN, h/o SVC syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. Her hospital course was complicated by multiple transfers between the MICU and the floor secondary to hypertensive urgency. # Abdominal Pain/Diarrhea: During the patient's admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. Infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. However, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. The patient was empirically placed on IV flagyl, but this was discontinued when stool samples were negative for C.difficile. Serial abdominal exams showed no peritoneal signs. Peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. CT of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. Other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to SLE vasculitis, malignant HTN, or microthrombosis and SLE enteritis. Surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. A heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible GI bleed. With regards to SLE vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to SLE. On [**10-18**], GI performed an EGD which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. Approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. Both cardiac, GI, and pulmonary etiologies were considered for the origin of her epigastric pain. Pericarditis was considered, but her EKG was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. Her lungs were also essentially unchanged from [**2141-10-13**]. However, her abdominal CT on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. As a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. There were no major findings: no evidence of perforation, obstruction, or infection. The patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. At discharge, the patient only complained of some mild incisional pain. # Hypertensive urgency: The patient was initially admitted to the MICU with a blood pressure of 240/180. Her hospital course was complicated by extremely labile HTN and was transferred back and forth between the MICU and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of SBPs > 260. Throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. Her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. Multiple medication regimens were attempted and changed throughout her hospital course. However, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for SBPs > 180. At discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg PO. Her regimen as per Dr. [**Last Name (STitle) 4883**]: Nifedipine SR 90 mg daily Aliskiren 150 mg [**Hospital1 **] Labetalol 300 mg TID Hydralazine 75 mg TID Clonidine patch 0.3 mg/24 hr patch qWed When SBP>180, she then uses a hydralazine sliding scale. When SBP>180, give 25 mg PO hydral every 30 min until SBP<150. You can use this for up to 2-3 hours. In between PO hydral doses, can then also use 10 IV hydralazine. # ESRD: The etiology of the patient's ESRD is secondary to SLE. Her Creatinine on admission was 7.9, which was near her baseline of 8 - 9. During her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. Prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2L per PD. After her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. Initially, the patient adamantly refused hemodialysis. However, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. As a result, after a long coversation with her primary renal physician, [**Name10 (NameIs) **] agreed to restart hemodialysis. A tunneled catheter was placed in her R femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. She underwent hemodialysis two more times prior to discharge. Upon discharge, her electrolytes were back to her baseline. She is expected to undergo hemodialysis (Tues/[**Last Name (un) **]/SAT) as an outpatient. # Anemia: During her admission, the patient's HCT was monitored daily with HCT to low-mid 20's. On [**2141-10-17**], she was found to have guaiac positive stools and her HCT was found to have dropped to a low of 18.6. The patient was transfused a total of 2 units of [**Date Range **] between [**2141-10-17**] and [**2141-10-18**]. Epo Alfa SC was also given on [**2141-10-17**]. She remained hemodynamically stable. GI consulted and EGD results were as stated above. The patient's HCT remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. Between [**2141-10-23**] - [**2141-10-24**], the patient had a HCT drop from 26 to 20 in the setting of occult positive emesis. She received two units of [**Month/Day/Year **] and her HCT returned to 28. GI was aware and planned to perform a non-urgent EGD on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her HCT returned to baseline. However, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her HCt remained stable and near baseline for the remiainder of her hospital course. # H/O Thrombosis: The patient was initially placed on her home dose of warfarin 2mg qd. Her INR on admission was 1.2. She was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. However, this was stopped for her EGD and after she had evidence of a GI bleed. The heparin drip was discontinued on [**10-22**]. The patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in HCT and in preparation for a possible GI intervention. After her surgery, her coumadin was held and she was off the heparin drip, but her INR continued to drift up, getting as high as 2.6 on [**2141-10-30**]. This was mostly attributed to nutritional deficiency [**2-11**] poor PO intake, but there was concern for possible synthetic dysfunction as well. As a result, she was given a test dose of vitamin K, which she responded to well (Her INR came back down to 1.4). As a result, her home dose of coumadin at 2 mg qday was restarted. At discharge, her INR was still sub- therapeutic at 1.4. Of note, the patient has a history of SVC syndrome and had a L subclavian venous thrombosis. During the last few days of her hospital stay, the patient complained of increased tongue swelling and her L face was noted to be slightly more swollen than previously noted. As a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a DVT within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # SLE: Rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. Her outside rheumatologist was also consulted. Both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # Obstructive sleep apnea: The patient was noted to have OSA based on clinical nocturnal exam during admission. Patient attempted 1 trial of CPAP at 2L/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. The paitent stated that she would pursue further work-up and treatment for OSA as an outpatient. While the mask and CPAP machine were at her bedside throughout her hospital course, the patient rarely used it. # Metabolic Acidosis: The patient's bicarbonate on admission was 13. Her baseline is normally between 16-20. She received 150mEq NaHCO3 over 24hrs from [**Date range (1) 43500**]. During her brief returns to the MICU, her HC03 was 18-19, which was presumed to be her baseline at home secondary to her CRF. At discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. Medications on Admission: Nifedipine 60 mg PO daily Labetalol 900 mg PO TID Hydralazine 50 mg PO TID Clonidine 0.3 mg/24hr patch qWED Lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 4 mg daily Warfarin 2mg PO daily Calcitriol 1 mcg daily Calcium carbonate 500mg QID Dilaudid 2mg PO Q4-6hr prn pain Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*30 Patch Weekly(s)* Refills:*2* 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. [**Hospital1 **]:*1500 ML(s)* Refills:*0* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Twice daily (). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): In addition to 75 mg TID, if SBP>180, take 1 tab every 30 min until BP decreases to 150. If no improvement after 2 hours, call your doctor. [**Last Name (Titles) **]:*300 Tablet(s)* Refills:*6* 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). [**Last Name (Titles) **]:*1500 ML(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet Sustained Release(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 5 days. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. [**Last Name (Titles) **]:*30 Capsule(s)* Refills:*2* 13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO once a day. [**Last Name (Titles) **]:*30 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: end stage renal disease malignant hypertension abdominal free air subclavian deep vein thrombosis initiation of hemodialysis Secondary: SLE Anemia Discharge Condition: stable, pain well controlled, blood pressure at baseline Discharge Instructions: You were admitted for abdominal pain and then subsequently had a very long hospital course with high blood pressures, severe abdominal pain, some free air in your abdomen resulting in an exploratory laparotomy. You have also been initiated on hemodialysis on Tuesday/Thursday/Saturday schedule. Please take all medications as prescribed in the list that you will be given at discharge. There have been some changes to your medications. Please call your doctor if you have any worsening abdominal pain, fevers, chills, nausea, vomiting, headache, palpitations, diarrhea or any other concerning symptoms. Followup Instructions: You will see Dr. [**Last Name (STitle) 4883**] at hemodialysis on Tuesday, [**11-7**], [**2141**]. You should have your coumadin level checked at this appointment. Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] to schedule an appointment in [**1-11**] weeks to have your staples removed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**] ",70,2141-10-13 23:10:00,2141-11-03 18:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. her hospital course was complicated by multiple transfers between the micu and the floor secondary to hypertensive urgency. # abdominal pain/diarrhea: during the patients admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. the patient was empirically placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. serial abdominal exams showed no peritoneal signs. peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. ct of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to sle vasculitis, malignant htn, or microthrombosis and sle enteritis. surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible gi bleed. with regards to sle vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to sle. on [**10-18**], gi performed an egd which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. both cardiac, gi, and pulmonary etiologies were considered for the origin of her epigastric pain. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. her lungs were also essentially unchanged from [**2141-10-13**]. however, her abdominal ct on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. as a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. there were no major findings: no evidence of perforation, obstruction, or infection. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. at discharge, the patient only complained of some mild incisional pain. # hypertensive urgency: the patient was initially admitted to the micu with a blood pressure of 240/180. her hospital course was complicated by extremely labile htn and was transferred back and forth between the micu and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of sbps > 260. throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. multiple medication regimens were attempted and changed throughout her hospital course. however, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for sbps > 180. at discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg po. her regimen as per dr. [**last name (stitle) 4883**]: nifedipine sr 90 mg daily aliskiren 150 mg [**hospital1 **] labetalol 300 mg tid hydralazine 75 mg tid clonidine patch 0.3 mg/24 hr patch qwed when sbp>180, she then uses a hydralazine sliding scale. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. you can use this for up to 2-3 hours. in between po hydral doses, can then also use 10 iv hydralazine. # esrd: the etiology of the patients esrd is secondary to sle. her creatinine on admission was 7.9, which was near her baseline of 8 - 9. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2l per pd. after her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. initially, the patient adamantly refused hemodialysis. however, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. as a result, after a long coversation with her primary renal physician, [**name10 (nameis) **] agreed to restart hemodialysis. a tunneled catheter was placed in her r femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. she underwent hemodialysis two more times prior to discharge. upon discharge, her electrolytes were back to her baseline. she is expected to undergo hemodialysis (tues/[**last name (un) **]/sat) as an outpatient. # anemia: during her admission, the patients hct was monitored daily with hct to low-mid 20s. on [**2141-10-17**], she was found to have guaiac positive stools and her hct was found to have dropped to a low of 18.6. the patient was transfused a total of 2 units of [**date range **] between [**2141-10-17**] and [**2141-10-18**]. epo alfa sc was also given on [**2141-10-17**]. she remained hemodynamically stable. gi consulted and egd results were as stated above. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. she received two units of [**month/day/year **] and her hct returned to 28. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. however, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her hct remained stable and near baseline for the remiainder of her hospital course. # h/o thrombosis: the patient was initially placed on her home dose of warfarin 2mg qd. her inr on admission was 1.2. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. however, this was stopped for her egd and after she had evidence of a gi bleed. the heparin drip was discontinued on [**10-22**]. the patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in hct and in preparation for a possible gi intervention. after her surgery, her coumadin was held and she was off the heparin drip, but her inr continued to drift up, getting as high as 2.6 on [**2141-10-30**]. this was mostly attributed to nutritional deficiency [**2-11**] poor po intake, but there was concern for possible synthetic dysfunction as well. as a result, she was given a test dose of vitamin k, which she responded to well (her inr came back down to 1.4). as a result, her home dose of coumadin at 2 mg qday was restarted. at discharge, her inr was still sub- therapeutic at 1.4. of note, the patient has a history of svc syndrome and had a l subclavian venous thrombosis. during the last few days of her hospital stay, the patient complained of increased tongue swelling and her l face was noted to be slightly more swollen than previously noted. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. her outside rheumatologist was also consulted. both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission. patient attempted 1 trial of cpap at 2l/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. the paitent stated that she would pursue further work-up and treatment for osa as an outpatient. while the mask and cpap machine were at her bedside throughout her hospital course, the patient rarely used it. # metabolic acidosis: the patients bicarbonate on admission was 13. her baseline is normally between 16-20. she received 150meq nahco3 over 24hrs from [**date range (1) 43500**]. during her brief returns to the micu, her hc03 was 18-19, which was presumed to be her baseline at home secondary to her crf. at discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. ","PRIMARY: [Malignant essential hypertension] SECONDARY: [Renal dialysis status; Epilepsy, unspecified, without mention of intractable epilepsy; Constipation, unspecified; Anemia in chronic kidney disease; Abnormal coagulation profile; Obstructive sleep apnea (adult)(pediatric); Other diseases of lung, not elsewhere classified; Other chest pain; Fever, unspecified; Rash and other nonspecific skin eruption; Other chronic pulmonary heart diseases; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified disease of pericardium; Other ascites; Acidosis; Hyposmolality and/or hyponatremia; Abdominal pain, other specified site; Abdominal pain, epigastric; Nausea with vomiting; Diarrhea; Systemic lupus erythematosus; Hyperparathyroidism, unspecified; Anemia, unspecified; Thrombocytopenia, unspecified; Esophageal reflux]","this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. multiple medication regimens were attempted and changed throughout her hospital course. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. upon discharge, her electrolytes were back to her baseline. epo alfa sc was also given on [**2141-10-17**]. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission.","esrd secondary to sle, malignant htn, h/o svc syndrome, and multiple thrombotic events were considered. the patient was placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia." 109,135923.0,14803,2142-01-12,14799,125288.0,2141-11-23,Discharge summary,"Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypertensive Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: (from MICU admit note) 24yoF ESRD-HD, SLE, HTN presents with 1 month abdominal pain and hypertension. Pt has had work-up over recent months for abd pain, including exploratory laparotomy, all of which essentially (-). Was admitted [**Date range (1) 34629**], for abdominal pain, then returned [**11-16**] for sob with (-)CTA, dc'ed [**11-17**]. In [**Hospital1 18**] ED, T98.5 hr95 BP 220/110 then 183/133 RR13 O2 100% on RA, rectal exam negative, guaiac(-), pelvic exam unremarkable with no cervical motion tenderness. Renal was consulted, taken for hemodialysis. CT abd showed large ascites, no other pathology; CT head improved from prior with no acute ICH; cxr(-). Given iv dilaudid for abdominal pain. BP treated with 10mg iv labetalol. Blood and urine cultures drawn, peritoneal fluid cx sent from catheter. Admitted to MICU for hypertension management. Access: R-HD catheter, 1 pIV in hand, 1 non-functioning peritoneal dialysis catheter. Past Medical History: PMH: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSH: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: PE: T:99.4 BP:158/108 HR:95 RR:12 O2 100% RA GEN: NAD/ pt eyes closed due to pain/ pleasant despite pain HEENT: AT, NC, PERRLA, EOMI on R eye, L eye prosthesis, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD CV: S1 & S2, RRR II/VI HSM at R/L USB, no rubs/gallops PULM: CTAB, no w/r/r ABD: soft, mildly tender at PD catheter, ND, + BS, midline incision with steri-stripes, PD catheter dressing C/I/D EXT: warm, dry, +2 distal pulses BL, no edema NEURO: alert & oriented, CN II-XII grossly intact (except L eye), 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: Admission Labs: [**2141-11-18**] 07:00AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.7* Hct-30.7* MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* Plt Ct-142* [**2141-11-18**] 07:00AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.3* [**2141-11-18**] 07:00AM BLOOD Glucose-86 UreaN-22* Creat-5.0* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2141-11-18**] 07:00AM BLOOD ALT-8 AST-39 AlkPhos-92 TotBili-0.3 [**2141-11-18**] 07:00AM BLOOD Lipase-76* [**2141-11-18**] 07:00AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.9 [**2141-11-18**] 11:00PM ASCITES WBC-1265* RBC-1680* Polys-43* Lymphs-1* Monos-2* Mesothe-11* Macroph-43* [**2141-11-18**] 10:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2141-11-18**] 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2141-11-18**] 10:05AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-[**3-15**] Discharge Labs: [**2141-11-23**] 04:40AM BLOOD WBC-2.9* RBC-3.08* Hgb-9.0* Hct-28.3* MCV-92 MCH-29.2 MCHC-31.8 RDW-17.5* Plt Ct-182 [**2141-11-23**] 04:40AM BLOOD PT-20.8* PTT-76.1* INR(PT)-2.0* [**2141-11-23**] 04:40AM BLOOD Glucose-80 UreaN-21* Creat-4.7* Na-139 K-4.8 Cl-106 HCO3-24 AnGap-14 [**2141-11-23**] 04:40AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8 [**2141-11-22**] 04:55AM BLOOD TSH-6.1* [**2141-11-23**] 04:40AM BLOOD Free T4-1.2 Blood cx ([**11-18**], [**11-19**]): 1/4 bottles with coag neg Staph, [**3-14**] NGTD Urine cx ([**11-18**]): mixed flora c/w contamination Peritoneal fluid ([**11-18**]): Gram stain 2+ polys. Culture no growth. Imaging: CXR Portable ([**11-18**]): Since [**2141-11-16**], heart size enlargement is unchanged due to known pericardial effusion. Lungs are otherwise clear. Hilar contours are normal. Incidentally, widening of both acromioclavicular joints is unchanged. CT A/P ([**11-18**]): 1. No evidence of bowel obstruction or rim-enhancing fluid collection. 2. Large ascites, slightly increased from [**2141-11-13**], with peritoneal dialysis catheter in place. Interval removal of surgical skin staples along the abdomen. 3. Moderate pericardial effusion as before. 4. Symmetric heterogeneous attenuation of the kidneys could be related to renal failure; however, pyelonephritis could also give this appearance. Appearance of the kidneys is unchanged from [**2141-11-13**]. CT Head w/o contrast ([**11-18**]): 1. No evidence of acute intracranial hemorrhage. 2. Regions of hypoattenuation in the bifrontal white matter and left posterior temporal lobe have resolved since [**2141-6-11**]. No new regions of hypoattenuation seen. Brief Hospital Course: 1) Hypertension: Patient has history of extremely labile hypertension on an aggressive outpatient regimen. Overnight in the MICU, patient required IV and PO labetalol for SBP > 200. Her hydralazine was increased from 75mg to 100mg TID with mild improvement. Her labetalol was also increased from 300mg to 400mg TID. Her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. TSH was sent and elevated, although free T4 was normal. Plasma metanephrines were sent and pending at discharge. 2) Abdominal pain: CT scan showed increasing ascites, but no acute pathology. Peritoneal fluid was obtained and contained 544 polys. Treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing GPC pairs/clusters. Blood cultures ended up growing 1 out of 4 bottles coag-neg Staph, likely contaminant, so vancomycin was stopped. Since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. The peritoneal cultures remained negative. Her PD catheter was left in place as the patient refuses HD any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) SVC/brachiocephalic thrombosis: Patient's INR was subtherapeutic on admission at 1.3. Due to the proximal location of her old venous thrombi, she was started on a heparin gtt. This was continued during her admission and her warfarin was increased to 5mg daily. Her INR reached 2.0 at discharge (therapeutic range 2-3). The dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) Anxiety: Patient noted feeling short of breath and anxious around the time of her recent admissions. Her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. They felt her symptoms were suggestive of anxiety and panic attacks, recommended checking TSH and metanephrines as above, and starting citalopram 20mg, which was done. She was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h PRN. Patient is agreeable to outpatient follow up with [**Company 191**] social work, and potential CBT. These can be arranged by her PCP. Medications on Admission: 1. Aliskiren 150 mg [**Hospital1 **] 2. Clonidine 0.3 mg/24 qwk 3. Prochlorperazine Maleate 10 mg prn 4. Hydromorphone 2 mg Tablet Sig: [**1-11**] q6 prn 5. Bisacodyl 10mg [**Hospital1 **] 6. Ergocalciferol (Vitamin D2) 50,000 qmonth 7. Hydralazine 75mg tid 8. Hydralazine scale prn 9. Labetalol 300 mg tid 10. Nifedipine 90 mg qd 11. Prednisone 4mg qd 12. Warfarin 2 mg qd at 4pm Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Hospital1 766**]). 5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day. [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 7 days. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO q30 min prn as needed for hypertension: for SBP > 180. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive urgency Headache Abdominal pain Anxiety Secondary Diagnosis: HTN SLE ESRD on HD SVC and IJ thrombosis, chronic Anemia Discharge Condition: Stable, BPs improved. Discharge Instructions: You were admitted with elevated blood pressures, headache, and abdominal pain. You were found to have increased amounts of white blood cells in your abdominal cavity, but this was not infected. Your abdominal pain resolved and you continued to have intermittent headaches. Your blood pressure medications were adjusted as below. You were also seen by psychiatry who recommended starting new medications for your anxiety. The following changes were made to your medication regimen: - We increased your hydralazine to 100 mg three times a day. - We also increased your labetalol to 400 mg three times a day. - We have started a medication called celexa 20 mg daily as well as ativan 1 mg three times a day as needed for anxiety. - We have increased your coumadin to 4 mg daily. - Please continue taking all other medications as previously prescribed. Call your doctor or return to the emergency room if you experience any of the following: worsening abdominal pain, nausea, vomiting, blurry vision, worsening headache, fever > 101. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. Please continue to follow with your nephrologist and go to outpatient dialysis as previously arranged. Please discuss with your PCP the possibility of talking to a social worker at [**Name (NI) 191**]. You will need to continue to have your INR monitored at [**Hospital 191**] [**Hospital 2786**] clinic. Please have this level checked on [**Hospital 766**], [**11-27**]. Completed by:[**2141-11-23**]",50,2141-11-18 14:00:00,2141-11-23 16:42:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. her hydralazine was increased from 75mg to 100mg tid with mild improvement. her labetalol was also increased from 300mg to 400mg tid. her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. tsh was sent and elevated, although free t4 was normal. plasma metanephrines were sent and pending at discharge. 2) abdominal pain: ct scan showed increasing ascites, but no acute pathology. peritoneal fluid was obtained and contained 544 polys. treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing gpc pairs/clusters. blood cultures ended up growing 1 out of 4 bottles coag-neg staph, likely contaminant, so vancomycin was stopped. since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. the peritoneal cultures remained negative. her pd catheter was left in place as the patient refuses hd any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) svc/brachiocephalic thrombosis: patients inr was subtherapeutic on admission at 1.3. due to the proximal location of her old venous thrombi, she was started on a heparin gtt. this was continued during her admission and her warfarin was increased to 5mg daily. her inr reached 2.0 at discharge (therapeutic range 2-3). the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) anxiety: patient noted feeling short of breath and anxious around the time of her recent admissions. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. they felt her symptoms were suggestive of anxiety and panic attacks, recommended checking tsh and metanephrines as above, and starting citalopram 20mg, which was done. she was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h prn. patient is agreeable to outpatient follow up with [**company 191**] social work, and potential cbt. these can be arranged by her pcp. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Abdominal pain, unspecified site; Anemia, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. her hydralazine was increased from 75mg to 100mg tid with mild improvement. peritoneal fluid was obtained and contained 544 polys. the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted.","patient has history of extremely labile hypertension on aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. ct scan showed increasing ascites, but no acute pathology." 109,135923.0,14803,2142-01-12,14800,161950.0,2141-12-01,Discharge summary,"Admission Date: [**2141-11-24**] Discharge Date: [**2141-12-1**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Headache, abdominal pain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24yo F w/PMHx of ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning, awakening her from sleep. Had been previously discharged from [**Hospital1 **] yesterday after being admitted for hypertension and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Upon discharge yesterday she states her abdominal pain had subsided. She had HD yesterday without complications. She awoke at 6am with a headache and crampy, stabbing abdominal pain. Took 2mg PO Dilaudid without relief and came to ED. No nausea/vomiting, no changes in vision, no fevers, chills, night sweats. No chest pain, SOB, diarrhea. In the ED, initial vitals were T98.7, BP260/130, HR70, RR16. Was initially given 10mg IV Labetalol X 2, 4mg Zofran for nausea. No improvement in BP and started on Labetolol gtt. Got 1mg IV Dilaudid for pain. Currently, patient continues to complain of headache and abdominal pain, both [**7-17**]. No vision changes, chest pain or shortness of breath. Has been feeling increased anxiety recently and saw psychiatrist, was put on Celexa. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T98.2, BP176/135, HR94, RR 22, 100% RA Gen: well-appearing african-american woman, lying comfortably HEENT: anicteric, L eye prosthetic non-reactive, R pupil reactive, MMM, neck supple with submanibular LAD CV: RRR, II/VI SEM best heard at apex Pulm: CTA b/l Abd: hyperactive bowel sounds, midline scar well-healed, soft, diffusely tender to palpation, +rebound, no guarding. PD catheter in LLQ without erythema or purulent material draining. +dullness on percusion with evidence of clinical ascites. Ext: no edema, no clubbing, 2+ peripheral pulses DP and radial. R femoral HD [**Last Name (un) **] in place without erythema, purulance Neuro: A&O X 3, CN intact II-XII, [**5-15**] motor strength in upper and lower extremities Pertinent Results: Admission labs: CBC: [**2141-11-26**] 05:21AM BLOOD WBC-3.5* RBC-3.07* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-17.6* Plt Ct-180 CHEM 10: [**2141-11-26**] 01:16PM BLOOD Glucose-87 UreaN-17 Creat-4.0* Na-136 K-5.2* Cl-106 HCO3-23 AnGap-12 [**2141-11-26**] 09:20PM BLOOD Calcium-7.6* Phos-3.8 Mg-1.8 COAGS: [**2141-11-26**] 01:16PM BLOOD PT-23.9* PTT-40.2* INR(PT)-2.3* STUDIES: 1)Peritoneal fluid ([**11-26**]): negative for malignant cells. Reactive mesothelial cells, macrophages, eosinophils and lymphocytes. 2)BILAT UP EXT VEINS US ([**11-26**]): No evidence of deep vein thrombosis of the right or left upper extremity. 3) MRI/MRA ([**11-30**]): FINDINGS: Examination is somewhat limited by patient motion. T2/FLAIR sequences are unremarkable with interval resolve of previously noted posterior abnormalities. The major vessels appear patent proximally. There are stable areas of low signal in the left frontal and right occipetal/temporal lobes. IMPRESSION: 1. Interval resolution of previously noted posterior white matter abnormalities. 2. Stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions. 3. Very limited MRA as above. Brief Hospital Course: 24yo F with SLE, ESRD on HD and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**Hospital Unit Name 153**] course: The patient was admitted for blood pressure management and evaluation of abd pain. An A-line was placed. EKG showed no change from prior, and Abd x-ray showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home med regimen. The patient was found to be hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. Upon transfer to the floor, the following was her course: 1. Hypertensive Urgency: Pt had had hemodialysis one day prior to admission, so unlikely that she was volume overloaded. Unclear what precipitated this episode of hypertensive urgency, although suspect secondary to abdominal pain leading to an anxiety which then precipitates hypertension. She may not have been taking her medications secondary to pain. Negative serum tox. On the floor, we continued hemodialysis Tu, Th, Sat. She was initially continued on PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine 90mg PO qday and clonidine; she received hydralazine 10mg IV for goal BP < 180/100. Renal team followed patient during this hospitalization. Per renal team recs, labetalol was increased to 800mg TID due to poor blood pressure control. Pt discharged on clonidine 0.3mg patch, Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, Nifedipine 90mg daily and lobatalol 800mg TID. This regimen worked well. 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT scan during prior admission which did not show source of abdominal pain. On admission, LFTs were normal except for slightly low albumin, lipase was slightly elevated and KUB was negative for free air or evidence of SBO. Peritoneal fluid was negative for malignant cells but showed reactive mesothelial cells, macrophages, eosinophils and lymphocytes. Negative gram stain or peritoneal fluid cultures, excluding SBP as a cause of the abdominal pain. PD catheter was not removed. Pt was continued on PO dilaudid 1-2mg Q6h and pain resolved. She denied N/V/diarrhea or constipation. 3. ESRD: Pt on hemodialysis, on T/Th/Sat schedule. Renal following patient closely throughout this hospitalization. Lytes were checked frequently and kayexalate given prn. 4. Hx of SVC/brachiocephalic DVT: Pt was initially subtherapeutic on coumadin. Unclear if she had not been taking Coumadin although patient reported that she has been taking all home meds. We started heparin gtt to bridge to Coumadin. Once therapeutic, continued Coumadin 5mg PO qday. 5. Anxiety: Likely contributing to medical problems and could have very well been the etiology of this admission. Although pt stated she was taking her current medications, she did report increased anxiety which can lead to medication non-compliance and hypertension. Pt recently saw psychiatrist who started her on Celexa. She was continued on celexa 20mg PO qday, ativan 1mg PO q8hours PRN and psychiatry was re-consulted. Per psych recs, started standing clonazepam. Pt refused psych VNA. Outpatient PCP followup recommended. 6. Headache NOS: Pt complained of R-sided HA for several weeks, radiating to R jaw where patient had previous tooth extraction. Right upper extremity ultrasound was negative for DVT. She did not have any focal neuro findings, no visual deficits. She was initially treated with tylenol PRN Q6h; pt requested IV dilaudid for HA, but use of this medication by IV route was limited by team. It was felt by the pain service that her HA did not fit migraine, tension type HA or rebound HA. They recommended increasing dilaudid to 4-6mg Q6h PRN, continuing tylenol and starting neurontin 300mg Qhs which was slowly titrated to 300mg [**Hospital1 **] for better control. Per pain recs, a neurology consult was also obtained during this admission. MRI/MRA showed interval resolution of previously noted posterior white matter abnormalities and stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions, but very limited MRA as above. Per pain recs, dilaudid was further increased to 4mg q4h for better control of her HA. Neurology recommended outpt f/u and Pt scheduled with [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**]. 7. Anemia: Likely related to ESRD. No evidence of acute bleeding. Hct remained stable during this hospitalization. 8. SLE: no acute issues. continued Prednisone 4mg PO qday 9. FEN: tolerated regular diet, repleted lytes PRN 9. Prophylaxis: Heparin gtt, then coumadin, bowel regigmen Medications on Admission: (from prior discharge summary) Bisacodyl 10mg PO qday PRN Prednisone 4mg PO qday Aliskiren 150mg PO BID Clonidine 0.3mg / 24 hr patch weekly qmonday Labetalol 400mg PO TID Warfarin 4mg PO qday Nifedipine 90mg PO qday Hydralazine 100mg PO q8H Hydromorphone 2-4mg PO q4H PRN Lorazepam 1mg PO q8H Celexa 20mg PO qday Prochlorperazine 10mg PO q6H Colace 100mg PO BID Hydralazine 25mg PO q30min PRN for HTN Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Year (4 digits) 766**]). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). [**Year (4 digits) **]:*100 Tablet(s)* Refills:*2* 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*90 Capsule(s)* Refills:*2* 9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for headache. [**Year (4 digits) **]:*84 Tablet(s)* Refills:*0* 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*60 Capsule(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours. [**Year (4 digits) **]:*360 Tablet(s)* Refills:*2* 16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. [**Year (4 digits) **]:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive Emergency 2. SLE 3. Headache, NOS 4. Abdominal pain Discharge Condition: BP better controlled. Headache managed on oral meds Discharge Instructions: You were admitted with abdominal pain, high blood pressure, and headache. Your abdominal pain resolved - no serious cause of this pain was found. Your blood pressure medications were continued, and with an increased in one medication, the labetalol. Your blood pressure improved. You should continue the clonidine 0.3mg patch changed on [**Year (4 digits) 766**], Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, and Nifedipine 90mg daily. The dose of Labetalol was increased to 800 mg three times daily by you kidney doctor and you are given a new prescription. Please take all medications as listed below. For your headache, you had an MRI and MRA of the head, which did not show a new or serious abnormality. You were seen by the neurology and pain services. You should follow up at [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**] at 6:30 PM (in the evening). Your pain was managed by oral dilaudid, 4mg. You should take this medication every 4 hours as needed. You were also started on Gabapentin (also called Neurontin) for the headache. The dose was slowly increased to twice a day. You may not need as much dilaudid for your headache and should wean this medication as tolerated, given it's potential for side effects (constipation, lethargy, dependence). Finally, you will likely need medications for constipation while you take dilaudid. Take colace (a stool softener), senna (a laxative), and bisacodyl (another laxative), as needed. It is really important that you have a primary care doctor. You are scheduled with Dr. [**Last Name (STitle) **] (see below) next Tuesday. You will need your INR checked since you are on coumadin. Call your doctor if you have worsened headache, chest pain, confusion, or any other concerning symptom. Followup Instructions: Please make sure you attend the following doctor appointments: 1) Dr. [**Last Name (STitle) 4883**] (nephrologist) on Tuesday, [**2141-12-5**] at 10AM. Phone number [**Telephone/Fax (1) 60**]. 2) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Location (un) **], [**Hospital Ward Name 23**] center, [**Location (un) **]. Phone:[**Telephone/Fax (1) 250**]. Date/Time:[**2141-12-5**] 3:20 3) Neurology: Dr. [**Last Name (STitle) 43502**] [**Name (STitle) **]. He is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-12-12**] 6:30 PM [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2141-12-2**]",42,2141-11-24 16:11:00,2141-12-01 19:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**hospital unit name 153**] the patient was admitted for blood pressure management and evaluation of abd pain. an a-line was placed. ekg showed no change from prior, and abd x-ray showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home med regimen. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. upon transfer to the floor, the following was her ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other ascites; ; Systemic lupus erythematosus; Headache; Anemia in chronic kidney disease; Anxiety state, unspecified; Other chest pain; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Renal dialysis status; Acquired absence of organ, eye]","24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. the renal team was consulted, and recommended no change to home med regimen.","a 24yo f with sle, esrd on hd and malignant hypertension presented with abdominal pain and headache. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. she successfully switched to po meds and was transferred to the floor." 109,135923.0,14803,2142-01-12,14801,173633.0,2141-12-14,Discharge summary,"Admission Date: [**2141-12-8**] Discharge Date: [**2141-12-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 8104**] Chief Complaint: abdominal pain & hypertension Major Surgical or Invasive Procedure: Hemodialysis PICC Line [**12-11**] History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with a history of CKD V (on HD) from lupus nephritis, chronic intermittent abdominal pain, and multiple prior ICU admissions for hypertensive urgency who presented to the ED complaining of two days' of abdominal pain, nausea, and loose stools. She was feeling well until after her hemodialysis session on Wednesday. Thereafter, she complained of nausea with occasional vomitting and has been unable to keep down any of her oral medications. She also has had diffuse abdominal pain consistent with her prior flares of pain as well as her typical diffuse headache. The headache in particular was worsening and, for her, this is a sign of poorly-controlled hypertension so she came to the [**Hospital1 18**] ED. Upon arrival to the ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room air. She was given 4 mg of IV ondansetron, [**1-11**] inch intropaste, 1 mg of IV hydromorphone x3, 1000cc of NS, and was put on a labetalol drip which had to be increased up to 2 mg/min. A head CT showed no acute abnormality (including hemorrhage) and an abdominal CT showed some possible mild colitis, though it is unclear if this is due to her recent peritoneal dialysis. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 97.9 BP 165/120 HR 93 RR 12 Sat 100% ra Gen: mildly fatigued, but no distress HEENT: oropharynx clear Neck: no JVP, no LAD Chest: clear to auscultation throughout, no w/r/r CV: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard Abdomen: soft, tender diffusely to moderate palpation without rebound or guarding; hyperactive bowel sounds; no masses or HSM, PD catheter in palce Extr: no edema, 2+ PT pulses Neuro: alert, appropriate, strength grossly intact in all four limbs Skin: no rashes Pertinent Results: [**2141-12-14**] 05:53AM BLOOD WBC-4.3 RBC-2.81* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.7 MCHC-33.8 RDW-19.3* Plt Ct-148* [**2141-12-14**] 05:53AM BLOOD PT-42.6* PTT-51.0* INR(PT)-4.7* [**2141-12-10**] 05:10AM BLOOD Ret Aut-2.5 [**2141-12-14**] 05:53AM BLOOD Glucose-83 UreaN-21* Creat-5.1*# Na-138 K-5.3* Cl-105 HCO3-24 AnGap-14 [**2141-12-10**] 05:10AM BLOOD LD(LDH)-234 Amylase-347* TotBili-0.1 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-10**] 05:10AM BLOOD Lipase-72* [**2141-12-14**] 05:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 [**2141-12-10**] 05:10AM BLOOD Hapto-142 [**2141-12-8**] 04:02AM BLOOD calTIBC-138* VitB12-445 Folate-18.5 Ferritn-220* TRF-106* ON ADMISSION: [**2141-12-7**] 09:50PM BLOOD WBC-4.5 RBC-2.78* Hgb-8.4* Hct-25.2* MCV-91 MCH-30.2 MCHC-33.3 RDW-19.2* Plt Ct-158 [**2141-12-7**] 09:50PM BLOOD Neuts-65.2 Lymphs-23.4 Monos-8.0 Eos-2.9 Baso-0.4 [**2141-12-7**] 09:50PM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3* [**2141-12-8**] 04:02AM BLOOD Ret Aut-2.5 [**2141-12-7**] 09:50PM BLOOD Glucose-89 UreaN-25* Creat-5.1*# Na-139 K-4.8 Cl-104 HCO3-26 AnGap-14 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-7**] 09:50PM BLOOD Lipase-89* [**2141-12-7**] 09:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9* Mg-1.9 [**2141-12-7**] 09:54PM BLOOD Glucose-75 Lactate-1.3 Na-139 K-4.8 Cl-101 calHCO3-23 Micro: Blood Cx: [**12-7**], [**12-7**], [**12-11**], [**12-11**] No growth FECAL CULTURE (Final [**2141-12-10**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2141-12-10**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2141-12-8**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-12-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CT HEAD [**2141-12-8**]: IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. The hypodensities noted in the parietal white matter are stable. However in the setting of the hypertension, PRES cannot be excluded. If further evaluation is required MR can be obtained. CT Abdomin/Pelvis [**2141-12-8**] IMPRESSION: 1. Moderate amount of free fluid in the pelvis is compatible with the patient's known peritoneal dialysis. Unchanged peritoneal enhancement. 2. Stable liver hemangioma. CXR [**12-11**] IMPRESSION: Small left pleural effusion. Left lower lobe opacity which is either atelectasis versus pneumonia. Brief Hospital Course: 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. MICU course: Current plan on transfer 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. 1. Hypertensive urgency: The patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. Initially her blood pressure over-corrected to SBPs in the 80s (patient was asymptomatic). Her clonidine patch and hydralazine was held and she again became hypertensive with SBPs 190s. The patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. The following dialysis the patient asymptomatic with SBPs in 80s, MAPs 60s asymptomatic again. Her hydralazine was stopped and continued on all her other home medications at the advice of renal. The patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. On [**12-11**] the patient's SBP dropped to the 80's and due to her pain medications she was extremely lethargic, but arousable. A PICC line was placed because lack of access and she was bolused 250cc NS. The patient's pressures responded and additional narcotics were held due to her mental status. The patient's blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. The patient did require IV hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. A possible component to the patient's malignant hypertension is likely due to OSA. An inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on BiPAP for OSA. The patient was continuned on her admission hypertensive regimen. . 2. Abdominal pain: The etiology of her abdominal pain is unclear, but has been a chronic issue for her. A CT scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. The patient also had diarrhea, but stool studies were negative. The patient's pain was initially treated with hydromorphone, but because of the patient's lethargy on [**12-11**] they were initially held. She continued to complain of severe abdominal pain. She was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. Surgery was consulted in regards to removal of her PD catheter, but given that she may return to PD it was deferred to the outpatient setting. 3. CKD V from lupus nephritis: The patient was continued on HD during her admission. She was also continued on her home prednisone dose. She was closely followed by the renal team. . 4. History of SVC/subclavian vein thrombus: The patient was found to have a subtherapeutic INR on admission 1.3. She was started on a heparin gtt and continued on coumadin. The patient's heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her PICC line was placed. She was therapetuic the same day and her heparin gtt was stopped. On discharge her coumadin was supratherapeutic (4.7) and was held. She will have her INR checked at HD. . 5. Anemia: The patient's Hct slowly trended down. She was guaiac negative and hemolysis labs were negative. She was transfused 1U pRBC at HD on [**12-12**]. She was also given epo at HD. Medications on Admission: prednisone 4 mg daily clonidine 0.3 mg/day patch qWeek ergocalciferol 50,000 units qMonth nifedipine SR 90 mg daily hydralazine 100 mg q8h citalopram 20 mg daily warfarin 2 mg qhs gabapentin 300 mg [**Hospital1 **] hydromorphone 4 mg q4h prn clonazepam 0.5 mg [**Hospital1 **] alikiren 150 mg [**Hospital1 **] docusate 100 mg [**Hospital1 **] senna 8.6 mg [**Hospital1 **] prn acetaminophen prn labetalol 800 mg q8h bisacodyl 5 mg daily prn Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. [**Hospital1 **]:*84 Tablet(s)* Refills:*0* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed: please take as needed for anxiety prior to CPAP at bedtime. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 14. CPAP Home CPAP Dx: OSA Prefer: AutoCPAP/ Pressure setting [**5-20**] Alt: Straight CPAP/ Pressure setting 7 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency Abdominal Pain ESRD on HD SVC Thrombus Secondary: Systemic lupus erythematosus Malignant hypertension Thrombocytopenia HOCM Anemia History of left eye enucleation History of vaginal bleeding Thrombotic microangiopathy Discharge Condition: Stable Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because of elevated blood pressure and abdominal pain. You were initially admitted to the ICU and your blood pressure was controlled. You were stabilized and transferred back to th floor. Your pressures remained stable throughout the rest of your stay. Additionally, you had abdominal pain and diarrhea. Your stool was tested for infections and was negative. Your diarrhea resolved without intervention. Your abdominal pain was controlled with pain medications. You had a sleep study in the hospital which showed that you had sleep apnea. Please continue to take your medications as prescribed. 1. Please do not take your coumadin until your doctor tells you to. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: You will have dialysis at [**Location (un) **] Dialysis on your normal schedule. You need to go to dialysis on Saturday. Please follow-up with the Sleep Clinic in [**12-19**] @ 11:45 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Completed by:[**2141-12-16**]",29,2141-12-08 01:40:00,2141-12-14 17:16:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. micu course: current plan on transfer 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. 1. hypertensive urgency: the patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). her clonidine patch and hydralazine was held and she again became hypertensive with sbps 190s. the patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. the following dialysis the patient asymptomatic with sbps in 80s, maps 60s asymptomatic again. her hydralazine was stopped and continued on all her other home medications at the advice of renal. the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. on [**12-11**] the patients sbp dropped to the 80s and due to her pain medications she was extremely lethargic, but arousable. a picc line was placed because lack of access and she was bolused 250cc ns. the patients pressures responded and additional narcotics were held due to her mental status. the patients blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. the patient did require iv hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. a possible component to the patients malignant hypertension is likely due to osa. an inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on bipap for osa. the patient was continuned on her admission hypertensive regimen. . 2. abdominal pain: the etiology of her abdominal pain is unclear, but has been a chronic issue for her. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. the patient also had diarrhea, but stool studies were negative. the patients pain was initially treated with hydromorphone, but because of the patients lethargy on [**12-11**] they were initially held. she continued to complain of severe abdominal pain. she was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. surgery was consulted in regards to removal of her pd catheter, but given that she may return to pd it was deferred to the outpatient setting. 3. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was also continued on her home prednisone dose. she was closely followed by the renal team. . 4. history of svc/subclavian vein thrombus: the patient was found to have a subtherapeutic inr on admission 1.3. she was started on a heparin gtt and continued on coumadin. the patients heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her picc line was placed. she was therapetuic the same day and her heparin gtt was stopped. on discharge her coumadin was supratherapeutic (4.7) and was held. she will have her inr checked at hd. . 5. anemia: the patients hct slowly trended down. she was guaiac negative and hemolysis labs were negative. she was transfused 1u prbc at hd on [**12-12**]. she was also given epo at hd. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Systemic lupus erythematosus; Other and unspecified noninfectious gastroenteritis and colitis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other iatrogenic hypotension; Obstructive sleep apnea (adult)(pediatric); Hemangioma of intra-abdominal structures; Other chronic pain; Abdominal pain, unspecified site; Abnormal coagulation profile; Renal dialysis status; Personal history of venous thrombosis and embolism]","24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. the patient was continuned on her admission hypertensive regimen. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was therapetuic the same day and her heparin gtt was stopped.",24 year old woman with ckd v and severe hypertension due to sle admitted. patient was initially maintained on a labetalol drip and hydralazine iv prn. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic) 109,135923.0,14803,2142-01-12,14802,140167.0,2141-12-23,Discharge summary,"Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1973**] Chief Complaint: Malignant hypertension Major Surgical or Invasive Procedure: None History of Present Illness: 24 year old female with ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning. Patient had her hemodialysis day before yesterday. She has had multiple admissions to [**Hospital1 18**] with hypertensive urgency with symptoms of headache and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Patient states that her headache and abdominal pain are similar in characteristics to her previous admission. Patient denies any fever, chills, nightsweats, chest pain, shortness of breath, abdominal pain, nausea, vomitting, diarrhea, constipation, blood in stool, dysuria, hematuria, change in vision, hearing, weakness or numbness. In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was initially given 10mg IV Labetalol once and then started on drip at 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea. Her BP elevated as high as 270/174 and his labetolol was switched to nicardipine 1mg/kg/min. On arrival to the MICU her vitals were T 96.4 HR 99 BP 175/120 RR 15 100%RA. Patient was comfortable. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Vitals: 97.5 122/80 88 18 100%RA. Gen: sleeping, easily arousable, appears comfortable. HEENT: AT/NC, L eye prosthetic non-reactive, R pupil reactive, MMM. Heart: S1S2 RRR, III/VI SEM heard best at apex, + S3 Pulm: CTA b/l, no w/r/r. Abd: normal bowel sounds, midline scar well-healed, soft, nontender, prior PD site with dry dressing, patient with tenderness to palpation over prior PD cath site, no guarding/rebound Ext: no edema, no clubbing, WWP. R femoral HD catheter in place. Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: Admission: [**2141-12-18**] 02:00AM BLOOD WBC-5.8 RBC-3.30* Hgb-10.1* Hct-30.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-20.7* Plt Ct-199 [**2141-12-18**] 02:00AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.2* [**2141-12-18**] 02:00AM BLOOD UreaN-35* Creat-5.0* Na-138 K-5.5* Cl-103 HCO3-21* AnGap-20 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-18**] 02:00AM BLOOD Lipase-73* [**2141-12-18**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2141-12-19**] 06:45AM BLOOD Calcium-8.1* Phos-5.1* Mg-1.8 [**2141-12-18**] 03:52PM BLOOD dsDNA-NEGATIVE [**2141-12-18**] 03:52PM BLOOD CRP-11.5* [**2141-12-18**] 03:52PM BLOOD C3-68* C4-19 [**2141-12-20**] 12:09PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 [**2141-12-18**] 02:08AM BLOOD pO2-52* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 Comment-GREEN TOP [**2141-12-20**] 12:09PM BLOOD Lactate-0.9 [**2141-12-18**] 02:08AM BLOOD Glucose-68* Lactate-1.3 Na-140 K-4.8 Cl-103 [**2141-12-23**] 03:00PM BLOOD WBC-4.7 RBC-2.35* Hgb-7.1* Hct-22.3* MCV-95 MCH-30.3 MCHC-31.9 RDW-20.6* Plt Ct-131* [**2141-12-23**] 12:55AM BLOOD PT-14.7* PTT-66.2* INR(PT)-1.3* [**2141-12-18**] 03:52PM BLOOD ESR-21* [**2141-12-23**] 03:00PM BLOOD Glucose-97 UreaN-42* Creat-6.6* Na-138 K-4.3 Cl-106 HCO3-23 AnGap-13 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-23**] 03:00PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8 [**2141-12-18**] 04:23PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2141-12-18**] 04:23PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2141-12-18**] 04:23PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-12 TransE-<1 Micro: Blood Cx- [**12-18**]: No growth Urine Cx- [**12-18**]: No growth [**12-18**] TTE The left atrium and right atrium are normal in cavity size. A possible secundum type atrial septal defect is seen by color Doppler (clip [**Clip Number (Radiology) **]) There is severe symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. There is no significant resting LVOT gradient, but a mild gradient (30mmHg peak) is seen with Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Marked symmetric left ventricular hypertrophy with normal regional/global systolic function and mild inducible LVOT gradient. Mild aortic regurgitation. Mild pulmonary artery systolic hypertension. Possible secundum type atrial septal defect. Compared with the prior study (images reviewed) of [**2141-10-19**], a possible secundum type atrial septal defect is now suggested. If clinically indicated, a follow-up study with saline contrast and/or a TEE would be better able to characterize the possible atrial septal defect. CLINICAL IMPLICATIONS: Based on [**2140**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**12-18**] CXR IMPRESSION: 1. Cardiomegaly with findings suggestive of mild pulmonary edema. 2. Bibasilar linear opacities suggesting atelectasis, although developing pneumonia cannot be excluded. 3. No evidence of free intraperitoneal air. [**12-20**] MRV IMPRESSION: No appreciable change since the MRV chest exam dated [**2141-5-30**]. SVC is patent. Again seen is occlusion of the right internal jugular and left brachiocephalic veins. Right external jugular vein is provides the major venous drainage from the neck. Brief Hospital Course: 24 year old Female with SLE, ESRD on HD and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ED. 1. Malignant Hypertension: The patient had her hemodialysis two days prior to admission. Initially in the ED her BP was 253/170. She was given 10mg IV Labetalol and started on a labatelol drip. She also received hydralazine IV 10 mg once and 2 inches of nitropaste. She had morphine 4mg and 4mg Zofran for nausea. Her BP remained elevated so she was switched to nicardipine 1mg/kg/min. The patient was transferred to the MICU. In the ICU she was continued on the Nicardapine drip and her pressures decreased to 175/120. Nephrology was consulted and dialysis initiated in the AM. The Nicardapine drip dc'd on [**12-19**] and pt transferred to floor. While on the floor the patient had question of angioedema and markedly elevated BP. She was readmitted to the MICU on [**2141-12-20**]. Patient's Aliskerin was also held for conern for angioedema. The renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. The patient's PD catheter was removed. The patient was briefly on a nitro drip for hypertension. The patient's nifedepine was increased to 120mg. The patient was transferred to the floor with stable blood pressures, BP 124/72 on [**12-21**]. The morning of [**12-22**], the patient was noted to have a BP up to 247/120 at 0800. Hypertension persisted throughout the morning with BPs 210s-240s systolic. HR during this time was in the 90s. She received a total of 60 mg IV hydralazine over the course of the morning as well as 0.1 mg PO clonidine. She was also given her normal AM BP meds and restarted on aliskarin. Due to persistent hypertension, she was transferred to the ICU for further care. On arrival to the ICU, the patient reported severe abdominal pain over the site of recently removed PD catheter. She denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. She reports bilateral calf cramping but no leg swelling. She denies any difficulty breathing or chest pain. She took her AM BP meds without difficulty. Her blood pressure decreased to 130s-140s/60s without further intervention. She was transferred back to the floor on [**12-23**] and signed out AMA. 2. Angioedema: On [**12-20**] the patietn developed facial swelling and evidence of angioedema by ENT. The patient reported that her face is more swollen which was confirmed by her mother on the floor. The patient was give lasix IV as she has been unable to have any negative filtration with HD. The patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. Her tekturna was discontinued for concern that it might be causing angioedema. She denied difficulty with her breathing at that time, but was very somnulent. On arrival to the MICU her vitals were stable and oxygenating well at 100% on face mask. The patient's airway was supported with a nasal trumpet. The patient underwent MRV that showed no progression of her clot. Patient was diuresed with lasix and dialysis with significant improvement in her symptoms. She was treated with prednisone and decadron, famotidine and benadryl for angioedema. The patient was maintained on her heparin drip for her SVC syndrome. 3. Abdominal Pain: The patient has had extensive prior workup that has been unrevealing. The Transplant surgery team removed the PD cath on [**12-21**]. She continued to have abdominal pain post-op. She was continued on PO dilaudid 2mg po prn. She continuned to complain of abdominal pain throughout her admission and continued to requested IV dilaudid. 4. ESRD: The patient is on a T/Th/Sat schedule. She was closely followed by the renal team. She had dialysis on [**12-19**]. The patient's tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. The patient also had her PD catheter removed on [**12-21**] secondary to chronic abdominal pain. The patient was scheduled to have dialysis on [**12-23**]. 5. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last admission for supratherapeutic INR. She was admitted with a subtherpeutic INR of 1.2 She was started on a heparin drip. She was also started on Coumadin 2mg PO qday, but was held on [**12-19**] in prep her PD catheter removal. She was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by IR. However, the patient signed out AMA and thus it was not placed. 6. Anxiety: Pt recently saw psychiatrist who started her on Celexa. She was continued on Celexa 20mg PO daily. 7. Anemi of CKDa: The patient's Hct was 30.3 on admission. It trended down to 22.3 on discharge when she left AMA. There was no evidence of active, acute bleeding. THis is likely seoncdary to her ESRD. The patient was closely monitored. 8. Systemic Lupus Erythematosis: Rheumatology was consulted and does not suspect acute flare and dsDNA, C3, C4 nl, ESR and CRP slightly elevated. Her Echo did not suggest worsening pericarditis. She was continued on her home prednisone dose of 4mg daily. 9. Obstructive Sleep Apnea: CPAP for sleep with 7 pressure. Medications on Admission: Aliskiren 150 mg [**Hospital1 **] Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Warfarin held on discharge [**2141-12-14**] due to supratherap INR Discharge Medications: As patient signed out AMA, no medications were issued. She was told to resume her admission medications, however no instructions were taken by the patient. Discharge Disposition: Home Discharge Diagnosis: 1) Hypertensive urgency 2) Abdominal pain 3) End stage renal disease on hemodialysis 4) Venous thromboembolism Discharge Condition: Signed out AMA Discharge Instructions: Pt signed out AMA Return to the hospital with any concerning symptoms. Be sure to call your doctor's office on [**Month/Day/Year 766**] to arrange hemodialysis and review your medications and discuss follow-up plan. Followup Instructions: Follow-up with your Dr. [**Last Name (STitle) **] next week, and call [**Last Name (STitle) 766**] to arrange your hemodialysis. Completed by:[**2141-12-26**]",20,2141-12-18 03:50:00,2141-12-23 19:51:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. 1. malignant hypertension: the patient had her hemodialysis two days prior to admission. initially in the ed her bp was 253/170. she was given 10mg iv labetalol and started on a labatelol drip. she also received hydralazine iv 10 mg once and 2 inches of nitropaste. she had morphine 4mg and 4mg zofran for nausea. her bp remained elevated so she was switched to nicardipine 1mg/kg/min. the patient was transferred to the micu. in the icu she was continued on the nicardapine drip and her pressures decreased to 175/120. nephrology was consulted and dialysis initiated in the am. the nicardapine drip dcd on [**12-19**] and pt transferred to floor. while on the floor the patient had question of angioedema and markedly elevated bp. she was readmitted to the micu on [**2141-12-20**]. patients aliskerin was also held for conern for angioedema. the renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. the patients pd catheter was removed. the patient was briefly on a nitro drip for hypertension. the patients nifedepine was increased to 120mg. the patient was transferred to the floor with stable blood pressures, bp 124/72 on [**12-21**]. the morning of [**12-22**], the patient was noted to have a bp up to 247/120 at 0800. hypertension persisted throughout the morning with bps 210s-240s systolic. hr during this time was in the 90s. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she was also given her normal am bp meds and restarted on aliskarin. due to persistent hypertension, she was transferred to the icu for further care. on arrival to the icu, the patient reported severe abdominal pain over the site of recently removed pd catheter. she denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. she reports bilateral calf cramping but no leg swelling. she denies any difficulty breathing or chest pain. she took her am bp meds without difficulty. her blood pressure decreased to 130s-140s/60s without further intervention. she was transferred back to the floor on [**12-23**] and signed out ama. 2. angioedema: on [**12-20**] the patietn developed facial swelling and evidence of angioedema by ent. the patient reported that her face is more swollen which was confirmed by her mother on the floor. the patient was give lasix iv as she has been unable to have any negative filtration with hd. the patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. her tekturna was discontinued for concern that it might be causing angioedema. she denied difficulty with her breathing at that time, but was very somnulent. on arrival to the micu her vitals were stable and oxygenating well at 100% on face mask. the patients airway was supported with a nasal trumpet. the patient underwent mrv that showed no progression of her clot. patient was diuresed with lasix and dialysis with significant improvement in her symptoms. she was treated with prednisone and decadron, famotidine and benadryl for angioedema. the patient was maintained on her heparin drip for her svc syndrome. 3. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the transplant surgery team removed the pd cath on [**12-21**]. she continued to have abdominal pain post-op. she was continued on po dilaudid 2mg po prn. she continuned to complain of abdominal pain throughout her admission and continued to requested iv dilaudid. 4. esrd: the patient is on a t/th/sat schedule. she was closely followed by the renal team. she had dialysis on [**12-19**]. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient also had her pd catheter removed on [**12-21**] secondary to chronic abdominal pain. the patient was scheduled to have dialysis on [**12-23**]. 5. hx of svc/brachiocephalic dvt: her coumadin was held during last admission for supratherapeutic inr. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. she was also started on coumadin 2mg po qday, but was held on [**12-19**] in prep her pd catheter removal. she was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by ir. however, the patient signed out ama and thus it was not placed. 6. anxiety: pt recently saw psychiatrist who started her on celexa. she was continued on celexa 20mg po daily. 7. anemi of ckda: the patients hct was 30.3 on admission. it trended down to 22.3 on discharge when she left ama. there was no evidence of active, acute bleeding. this is likely seoncdary to her esrd. the patient was closely monitored. 8. systemic lupus erythematosis: rheumatology was consulted and does not suspect acute flare and dsdna, c3, c4 nl, esr and crp slightly elevated. her echo did not suggest worsening pericarditis. she was continued on her home prednisone dose of 4mg daily. 9. obstructive sleep apnea: cpap for sleep with 7 pressure. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Mechanical complication due to peritoneal dialysis catheter; ; Unspecified disease of pericardium; Angioneurotic edema, not elsewhere classified; Abdominal pain, other specified site; Systemic lupus erythematosus; ; Anemia in chronic kidney disease; Dysthymic disorder; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of steroids; Long-term (current) use of anticoagulants; Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation; Other antihypertensive agents causing adverse effects in therapeutic use]","24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. she was given 10mg iv labetalol and started on a labatelol drip. nephrology was consulted and dialysis initiated in the am. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she reports bilateral calf cramping but no leg swelling. she took her am bp meds without difficulty. her tekturna was discontinued for concern that it might be causing angioedema. the patient was maintained on her heparin drip for her svc syndrome. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient was scheduled to have dialysis on [**12-23**]. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. there was no evidence of active, acute bleeding.","24 year old female with sle, esrd on hd presents with abdominal pain and headache consistent with her usual hypertensive urgency. she was found to be in hypertensive urgency in ed. she received hydralazine iv 10 mg once and 2 inches of nitropaste." 109,135923.0,14803,2142-01-12,15330,131345.0,2141-09-08,Discharge summary,"Admission Date: [**2141-9-5**] Discharge Date: [**2141-9-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 348**] Chief Complaint: right leg pain, hypertension Major Surgical or Invasive Procedure: blood transfusion x2 History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. The pain is worst when she tried to bear weight on the leg, or when she uses it to roll over or adjust her position in bed. The pain begins in her buttock and travels down the posterior thigh and calf but stops before reaching the ankle. It occasionally feels like it is coming from her low back. She denies any parasthesias or weakness in the leg, and she denies any numbness in her foot or groin. She denies any fevers or incontinence. The pain was unrelieved by Vicodin that she had at home, so she scheduled an urgent visit with her nephrologist yesterday [**2141-9-4**]. At her nephrologist??????s office, she was hypertensive to 250/145 and so she was referred to the ED. She ended up leaving the ED against medical advice yesterday, but returned today because of persistent leg pain. She reports that she took all of her morning and noon BP meds. She denies any fevers, headaches, visual changes, nausea (prior to coming to the ED), or leg weakness. Upon arrival to the ED today, she was afebrile, BP 237/146, HR 97, RR 16, Sat 100% on room air. She received a total of 90 mg of IV labetalol and nitropaste, and was eventually put on a labetalol drip for her hypertension. With these interventions, her SBP dropped to the 180s, but she reported feeling nauseous and so the drip was discontinued. She was also given 4 mg of IV morphine and 1 mg of IV hydromorphone for her leg pain with decent relief. Due to a urinalysis suggestive of infection, she was given one tablet of DS TMP/SMX. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: MICU physical: Tmax: 36.3 ??????C (97.4 ??????F) Tcurrent: 36.3 ??????C (97.4 ??????F) HR: 92 (92 - 94) bpm BP: 209/138(152) {201/134(151) - 209/138(152)} mmHg RR: 19 (19 - 30) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Height: 59 Inch General: well-appearing young woman in no acute distress HEENT: no scleral icterus; prosthetic right eye Neck: supple Chest: clear to auscultation throughout, no wheezes/rales/ronchi CV: regular rate/rhythm, normal s1s2, no murmurs Abdomen: soft, nontender, nondistended, PD catheter in place in left abdomen Back: very mild spinal tenderness over approx L3 level of spine Extremities: no edema, 1+ PT pulses, warm Skin: no rashes or jaundice Neuro: alert, oriented x3, 5/5 strength in bilateral deltoids, biceps, triceps, hip flexors/extensors, ankle flexors/extensors; unable to elicit patellar reflexes bilaterally; negative straight leg raise bilaterally Pertinent Results: 138 111 54 -----------------< 83 5.4 14 8.2 . WBC: 3.7 HCT: 19 PLT: 101 N:69.3 L:23.4 M:5.5 E:1.7 Bas:0.1 PT: 21.9 PTT: 48.2 INR: 2.1 . Trends: HCT: 19 -> 22 w 1u then received another unit. INR 3.4 on discharge Discharge chem: Glucose-104 UreaN-51* Creat-8.4* Na-136 K-5.3* Cl-106 HCO3-18* AnGap-17 . [**2141-9-8**] 07:30AM BLOOD CK(CPK)-126 [**2141-9-5**] 02:50PM BLOOD HCG-<5 . [**2141-9-8**] 1:37 pm PERITONEAL FLUID GRAM STAIN (Final [**2141-9-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count . MRI L-spine: IMPRESSION: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. . CXR admit: IMPRESSION: Moderate cardiomegaly, bilateral pleural effusions, and pulmonary vascular prominence consistent with pulmonary edema. . Hip film: FINDINGS: No comparisons. No acute fracture or dislocation is seen. No lucent or sclerotic lesion is noted. There is a distal aspect of a catheter or shunt seen in the pelvis. Soft tissues are otherwise unremarkable. There is minimal degenerative change of the pubic symphysis. IMPRESSION: No acute fracture or dislocation. . Abdominal film: FINDINGS: A PD catheter is seen with its tip coiled in the pelvis. There is normal bowel gas. The underlying osseous structures are unremarkable. IMPRESSION: PD catheter with tip coiled in the pelvis . CXR [**9-8**]: IMPRESSION: Marked cardiomegaly, unchanged. Interval resolution of pulmonary edema. Brief Hospital Course: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. She was initially admitted to the MICU for hypertensive urgency and then transfered to the floor after a day. # Hypertensive urgency: had been on labetalol drip in the ED, but this was stopped due to nausea (presumed that her BP was coming down too fast). She was started on her home meds and tolerated these fairly well. Transferred to the floor and noted to have SPBs in the 90s. She required 1L IVF bolus since her baseline SBP is thought to run in the 130-170 range. She also had transient dizziness during this episode. BP meds were held and later that night her SBP was in the 220s. BP meds restarted. She remained stable thereafter with SBPs in the 130-170s. We opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # Right leg pain: no evidence of avascular necrosis or fracture on plain film. MRI and plain films were ordered and showed no acute pathology. The pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. CK was normal. Pain was treated with dilaudid initially. On day of discharge, she was able to ambulate without gait abnormality or pain. PT saw her and rec outpt PT followup. . # CKD V: PD catheter placement in place. Pt was tried on PD on a number of occasions but did not tolerate it [**2-11**] pain. KUB confirmed tip in place. Cx of peritoneal fluid not suggestive of peritonitis. K remained mildly elevated. Hyperpara treated with sevelamer (although patient refused) then tums. Pt will reconsider PD as outpatient. . # Anemia: chronic. Received 2u pRBC while inhouse for Hct in the 18-19 range. Had appropriate response. Not on Epo given hypertension . # ID: Rx with cipro for ? UTI although urine cx neg. Also had temp to 101 on evening prior to discharge. No clear source. PD fluid cultured and NGTD. Pt remainded HD stable on day of discharge. . # Prior SVC thrombus. Continued warfarin with appropriate INR checks. INR elevated on day of discharge. Rec holding coumadin for 2d . # Systemic lupus erythematosus: cont home prednisone dose . # Dispo status: ambulating, pain free, BP in the 150/90 range Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly Vicodin prn Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO WEEKLY (). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*20 Capsule(s)* Refills:*0* 9. Outpatient Physical Therapy Please provide PT for right hamstring injury 10. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*0* 11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold dose until [**9-10**]. Disp:*30 Tablet(s)* Refills:*0* 12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO once a day: goal is [**1-11**] soft bowel movements per day. Disp:*500 ml* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - HTN urgency - right leg pain - thought [**2-11**] hamstring injury - chronic kidney disease - not currently on dialysis - SLE - anemia [**2-11**] CKD and SLE - hx of SVC thrombosis on coumadin now Secondary: - hx hypertrophic obstructive cardiomyopathy - chronic thrombocytopenia Discharge Condition: ambulating without difficulty. tolerating oral diet. afebrile and SBP in the 130-150 range. Discharge Instructions: You came in with right leg pain and poorly controlled hypertension. Your blood pressure was controlled initially with IV medications then your home medications. Since your blood pressure was occasionally low, we recommend that you hold your labetalol if you are feeling lightheaded or have dizziness or have blood pressure less than 110/60. In terms of your leg pain, we performed xrays, ultrasound, and MRI without finding a cause. We suspect a hamstring injury given its location. Please take pain medications if needed. We recommend followup with physical therapy. You also had a fever which is suggestive of infection. We treated you with cipro in case you had a UTI. Otherwise, your cultures were unrevealing. We attempted peritoneal dialysis but this was unsuccessful. Please followup with your nephrologist. Please return to the ED if you experience headache, chest pain, shortness of breath, high fevers, or worsening leg pain. Please hold your coumadin for two days then restart as per previously written. Please take lactulose for constipation. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-9-12**] 5:00 Provider: [**Name10 (NameIs) 706**] NURSE Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 2:00 Provider: [**Name10 (NameIs) 7548**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 3:00 Please followup with your nephrologist and PCP. [**Name10 (NameIs) **] would like you to see your nephrologist within the next 1-2 weeks. ",126,2141-09-05 20:04:00,2141-09-08 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transfered to the floor after a day. # hypertensive urgency: had been on labetalol drip in the ed, but this was stopped due to nausea (presumed that her bp was coming down too fast). she was started on her home meds and tolerated these fairly well. transferred to the floor and noted to have spbs in the 90s. she required 1l ivf bolus since her baseline sbp is thought to run in the 130-170 range. she also had transient dizziness during this episode. bp meds were held and later that night her sbp was in the 220s. bp meds restarted. she remained stable thereafter with sbps in the 130-170s. we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # right leg pain: no evidence of avascular necrosis or fracture on plain film. mri and plain films were ordered and showed no acute pathology. the pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. ck was normal. pain was treated with dilaudid initially. on day of discharge, she was able to ambulate without gait abnormality or pain. pt saw her and rec outpt pt followup. . # ckd v: pd catheter placement in place. pt was tried on pd on a number of occasions but did not tolerate it [**2-11**] pain. kub confirmed tip in place. cx of peritoneal fluid not suggestive of peritonitis. k remained mildly elevated. hyperpara treated with sevelamer (although patient refused) then tums. pt will reconsider pd as outpatient. . # anemia: chronic. received 2u prbc while inhouse for hct in the 18-19 range. had appropriate response. not on epo given hypertension . # id: rx with cipro for ? uti although urine cx neg. also had temp to 101 on evening prior to discharge. no clear source. pd fluid cultured and ngtd. pt remainded hd stable on day of discharge. . # prior svc thrombus. continued warfarin with appropriate inr checks. inr elevated on day of discharge. rec holding coumadin for 2d . # systemic lupus erythematosus: cont home prednisone dose . # dispo status: ambulating, pain free, bp in the 150/90 range ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Nausea alone; Other antihypertensive agents causing adverse effects in therapeutic use; Hip and thigh injury; Unspecified accident; Hypotension, unspecified; Anemia, unspecified; Personal history of venous thrombosis and embolism; End stage renal disease; ; Urinary tract infection, site not specified; Hyperpotassemia; Acidosis; Disorders of phosphorus metabolism; Hypocalcemia; Secondary hyperparathyroidism (of renal origin)]","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. # right leg pain: no evidence of avascular necrosis or fracture on plain film. also had temp to 101 on evening prior to discharge. # systemic lupus erythematosus: cont home prednisone dose .","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension. she presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transferred to the floor after a day. she was started on her home meds and tolerated them fairly well." 109,124657.0,14804,2142-01-20,15330,131345.0,2141-09-08,Discharge summary,"Admission Date: [**2141-9-5**] Discharge Date: [**2141-9-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 348**] Chief Complaint: right leg pain, hypertension Major Surgical or Invasive Procedure: blood transfusion x2 History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. The pain is worst when she tried to bear weight on the leg, or when she uses it to roll over or adjust her position in bed. The pain begins in her buttock and travels down the posterior thigh and calf but stops before reaching the ankle. It occasionally feels like it is coming from her low back. She denies any parasthesias or weakness in the leg, and she denies any numbness in her foot or groin. She denies any fevers or incontinence. The pain was unrelieved by Vicodin that she had at home, so she scheduled an urgent visit with her nephrologist yesterday [**2141-9-4**]. At her nephrologist??????s office, she was hypertensive to 250/145 and so she was referred to the ED. She ended up leaving the ED against medical advice yesterday, but returned today because of persistent leg pain. She reports that she took all of her morning and noon BP meds. She denies any fevers, headaches, visual changes, nausea (prior to coming to the ED), or leg weakness. Upon arrival to the ED today, she was afebrile, BP 237/146, HR 97, RR 16, Sat 100% on room air. She received a total of 90 mg of IV labetalol and nitropaste, and was eventually put on a labetalol drip for her hypertension. With these interventions, her SBP dropped to the 180s, but she reported feeling nauseous and so the drip was discontinued. She was also given 4 mg of IV morphine and 1 mg of IV hydromorphone for her leg pain with decent relief. Due to a urinalysis suggestive of infection, she was given one tablet of DS TMP/SMX. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: MICU physical: Tmax: 36.3 ??????C (97.4 ??????F) Tcurrent: 36.3 ??????C (97.4 ??????F) HR: 92 (92 - 94) bpm BP: 209/138(152) {201/134(151) - 209/138(152)} mmHg RR: 19 (19 - 30) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Height: 59 Inch General: well-appearing young woman in no acute distress HEENT: no scleral icterus; prosthetic right eye Neck: supple Chest: clear to auscultation throughout, no wheezes/rales/ronchi CV: regular rate/rhythm, normal s1s2, no murmurs Abdomen: soft, nontender, nondistended, PD catheter in place in left abdomen Back: very mild spinal tenderness over approx L3 level of spine Extremities: no edema, 1+ PT pulses, warm Skin: no rashes or jaundice Neuro: alert, oriented x3, 5/5 strength in bilateral deltoids, biceps, triceps, hip flexors/extensors, ankle flexors/extensors; unable to elicit patellar reflexes bilaterally; negative straight leg raise bilaterally Pertinent Results: 138 111 54 -----------------< 83 5.4 14 8.2 . WBC: 3.7 HCT: 19 PLT: 101 N:69.3 L:23.4 M:5.5 E:1.7 Bas:0.1 PT: 21.9 PTT: 48.2 INR: 2.1 . Trends: HCT: 19 -> 22 w 1u then received another unit. INR 3.4 on discharge Discharge chem: Glucose-104 UreaN-51* Creat-8.4* Na-136 K-5.3* Cl-106 HCO3-18* AnGap-17 . [**2141-9-8**] 07:30AM BLOOD CK(CPK)-126 [**2141-9-5**] 02:50PM BLOOD HCG-<5 . [**2141-9-8**] 1:37 pm PERITONEAL FLUID GRAM STAIN (Final [**2141-9-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count . MRI L-spine: IMPRESSION: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. . CXR admit: IMPRESSION: Moderate cardiomegaly, bilateral pleural effusions, and pulmonary vascular prominence consistent with pulmonary edema. . Hip film: FINDINGS: No comparisons. No acute fracture or dislocation is seen. No lucent or sclerotic lesion is noted. There is a distal aspect of a catheter or shunt seen in the pelvis. Soft tissues are otherwise unremarkable. There is minimal degenerative change of the pubic symphysis. IMPRESSION: No acute fracture or dislocation. . Abdominal film: FINDINGS: A PD catheter is seen with its tip coiled in the pelvis. There is normal bowel gas. The underlying osseous structures are unremarkable. IMPRESSION: PD catheter with tip coiled in the pelvis . CXR [**9-8**]: IMPRESSION: Marked cardiomegaly, unchanged. Interval resolution of pulmonary edema. Brief Hospital Course: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. She was initially admitted to the MICU for hypertensive urgency and then transfered to the floor after a day. # Hypertensive urgency: had been on labetalol drip in the ED, but this was stopped due to nausea (presumed that her BP was coming down too fast). She was started on her home meds and tolerated these fairly well. Transferred to the floor and noted to have SPBs in the 90s. She required 1L IVF bolus since her baseline SBP is thought to run in the 130-170 range. She also had transient dizziness during this episode. BP meds were held and later that night her SBP was in the 220s. BP meds restarted. She remained stable thereafter with SBPs in the 130-170s. We opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # Right leg pain: no evidence of avascular necrosis or fracture on plain film. MRI and plain films were ordered and showed no acute pathology. The pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. CK was normal. Pain was treated with dilaudid initially. On day of discharge, she was able to ambulate without gait abnormality or pain. PT saw her and rec outpt PT followup. . # CKD V: PD catheter placement in place. Pt was tried on PD on a number of occasions but did not tolerate it [**2-11**] pain. KUB confirmed tip in place. Cx of peritoneal fluid not suggestive of peritonitis. K remained mildly elevated. Hyperpara treated with sevelamer (although patient refused) then tums. Pt will reconsider PD as outpatient. . # Anemia: chronic. Received 2u pRBC while inhouse for Hct in the 18-19 range. Had appropriate response. Not on Epo given hypertension . # ID: Rx with cipro for ? UTI although urine cx neg. Also had temp to 101 on evening prior to discharge. No clear source. PD fluid cultured and NGTD. Pt remainded HD stable on day of discharge. . # Prior SVC thrombus. Continued warfarin with appropriate INR checks. INR elevated on day of discharge. Rec holding coumadin for 2d . # Systemic lupus erythematosus: cont home prednisone dose . # Dispo status: ambulating, pain free, BP in the 150/90 range Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly Vicodin prn Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO WEEKLY (). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*20 Capsule(s)* Refills:*0* 9. Outpatient Physical Therapy Please provide PT for right hamstring injury 10. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*0* 11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold dose until [**9-10**]. Disp:*30 Tablet(s)* Refills:*0* 12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO once a day: goal is [**1-11**] soft bowel movements per day. Disp:*500 ml* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - HTN urgency - right leg pain - thought [**2-11**] hamstring injury - chronic kidney disease - not currently on dialysis - SLE - anemia [**2-11**] CKD and SLE - hx of SVC thrombosis on coumadin now Secondary: - hx hypertrophic obstructive cardiomyopathy - chronic thrombocytopenia Discharge Condition: ambulating without difficulty. tolerating oral diet. afebrile and SBP in the 130-150 range. Discharge Instructions: You came in with right leg pain and poorly controlled hypertension. Your blood pressure was controlled initially with IV medications then your home medications. Since your blood pressure was occasionally low, we recommend that you hold your labetalol if you are feeling lightheaded or have dizziness or have blood pressure less than 110/60. In terms of your leg pain, we performed xrays, ultrasound, and MRI without finding a cause. We suspect a hamstring injury given its location. Please take pain medications if needed. We recommend followup with physical therapy. You also had a fever which is suggestive of infection. We treated you with cipro in case you had a UTI. Otherwise, your cultures were unrevealing. We attempted peritoneal dialysis but this was unsuccessful. Please followup with your nephrologist. Please return to the ED if you experience headache, chest pain, shortness of breath, high fevers, or worsening leg pain. Please hold your coumadin for two days then restart as per previously written. Please take lactulose for constipation. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-9-12**] 5:00 Provider: [**Name10 (NameIs) 706**] NURSE Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 2:00 Provider: [**Name10 (NameIs) 7548**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 3:00 Please followup with your nephrologist and PCP. [**Name10 (NameIs) **] would like you to see your nephrologist within the next 1-2 weeks. ",134,2141-09-05 20:04:00,2141-09-08 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transfered to the floor after a day. # hypertensive urgency: had been on labetalol drip in the ed, but this was stopped due to nausea (presumed that her bp was coming down too fast). she was started on her home meds and tolerated these fairly well. transferred to the floor and noted to have spbs in the 90s. she required 1l ivf bolus since her baseline sbp is thought to run in the 130-170 range. she also had transient dizziness during this episode. bp meds were held and later that night her sbp was in the 220s. bp meds restarted. she remained stable thereafter with sbps in the 130-170s. we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # right leg pain: no evidence of avascular necrosis or fracture on plain film. mri and plain films were ordered and showed no acute pathology. the pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. ck was normal. pain was treated with dilaudid initially. on day of discharge, she was able to ambulate without gait abnormality or pain. pt saw her and rec outpt pt followup. . # ckd v: pd catheter placement in place. pt was tried on pd on a number of occasions but did not tolerate it [**2-11**] pain. kub confirmed tip in place. cx of peritoneal fluid not suggestive of peritonitis. k remained mildly elevated. hyperpara treated with sevelamer (although patient refused) then tums. pt will reconsider pd as outpatient. . # anemia: chronic. received 2u prbc while inhouse for hct in the 18-19 range. had appropriate response. not on epo given hypertension . # id: rx with cipro for ? uti although urine cx neg. also had temp to 101 on evening prior to discharge. no clear source. pd fluid cultured and ngtd. pt remainded hd stable on day of discharge. . # prior svc thrombus. continued warfarin with appropriate inr checks. inr elevated on day of discharge. rec holding coumadin for 2d . # systemic lupus erythematosus: cont home prednisone dose . # dispo status: ambulating, pain free, bp in the 150/90 range ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Nausea alone; Other antihypertensive agents causing adverse effects in therapeutic use; Hip and thigh injury; Unspecified accident; Hypotension, unspecified; Anemia, unspecified; Personal history of venous thrombosis and embolism; End stage renal disease; ; Urinary tract infection, site not specified; Hyperpotassemia; Acidosis; Disorders of phosphorus metabolism; Hypocalcemia; Secondary hyperparathyroidism (of renal origin)]","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. # right leg pain: no evidence of avascular necrosis or fracture on plain film. also had temp to 101 on evening prior to discharge. # systemic lupus erythematosus: cont home prednisone dose .","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension. she presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transferred to the floor after a day. she was started on her home meds and tolerated them fairly well." 109,161950.0,14800,2141-12-01,15329,147469.0,2141-06-17,Discharge summary,"Admission Date: [**2141-6-11**] Discharge Date: [**2141-6-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: hypertensive urgency Major Surgical or Invasive Procedure: arterial line History of Present Illness: HPI: 23 F with h/o Lupus, ESRD not on HD (planned PD), labile hypertension, RUE VTE on anticoagulation, recent facial swelling who presents with hypertensive emergency. Patient developed severe frontal HA last evenening, a/w nausea. BP was not [**Location (un) 1131**] on home BP cuff. In the AM her HA was severe [**10-20**] a/w nausea and vomiting yellow/green liquid and BP cuff again not able to obtain BP. Patient was last seen by VNA this past Friday with BP 130/70. Patient denies any CP, shortness of breath, abd pain. Her facial swelling is slightly worse today. She denies any weakness, dizziness, difficulty with speach, no numbness or tingling. She says that she is compliant with all of her medications. She denies any GU/GI complaints despite +UA in ED. . In the ED, VS: 98.2 92 SBP >300/P [**Telephone/Fax (3) 44541**]-131) 16 98 % RA. Patient received zofran IV, Hydral IV, Labetalol 20 mg IV x 1, Nipride gtt started. Kayexalate 30 mg x 1. Other po meds written but patient did not take due to nausea. CT head showing no hemorrhage but hypoattenuation in frontal area, which is change from prior MRI in [**Month (only) **]. She is on coumadin for RUE VTE with INR 2.1. Also with UTI in ED, started Cirpo x 1. Labs showing K 5.6 ECG with ?hyperacute T waves, otherwise no changes, given kayexalate only. . Interval Hx: Patient was admitted [**2141-5-24**] to [**6-6**] with facial swelling and hypertensive emergency requiring ICU care. She was also admitted [**Date range (1) 43498**] with similar complaints. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 98.8 84 [**Telephone/Fax (2) 44542**]% RA Gen: swollen face L>R, alert and cooperative, NAD, snoring when asleep but easily arousable Heent: OP clear, swollen eye lids L>R, Left eye retracted with prosthesis, anicteric, OP moist Neck: supple, no JVD elevation, no meningismus CV: nl S1 S2, RRR, [**1-15**] SM Lungs: CTAB Abd: obese, soft, NT, ND, BS+ Ext: dry, no c/c/e, diminished, Neuro: Alert and oriented x 3, gets drowsy intermittently but arousable, CN II-XII intact, strength 5/5 throughout, sensations intact Pertinent Results: [**6-14**]: AXR:IMPRESSION: PD catheter with tip coiled in the pelvis. [**6-11**]: IMPRESSION: 1. Areas of hypoattenuation in the high bifrontal white matter, and subcortical hypoattenuation in the left posterior temporal lobe with loss of [**Doctor Last Name 352**]-white differentiation. These findings are new from MRI brain [**12-29**], [**2140**], and could represent areas of new edema with underlying focal lesion or possibly areas of new infarcts. An MRI head without and with Iv conrast is recommended for further characterization. 2. No evidence of intracranial hemorrhage. [**6-11**]: PA AND LATERAL VIEWS OF THE CHEST: There has been an interval increase in retrocardiac opacity obscuring the left hemidiaphragm. The right lung and the left upper lung zone are clear. The right costophrenic angle is slightly blunted, suggesting a very small right pleural effusion. The heart is slightly enlarged, but the cardiomediastinal silhouette is unchanged. There is no hilar enlargement. Soft tissue and bony structures are unremarkable. IMPRESSION: Interval increase in left basilar atelectasis with pleural effusion. Superimposed pneumonia cannot be excluded. Possible small right pleural effusion. [**6-11**]: MR [**Name13 (STitle) 430**]: INDINGS: In comparison with a prior CT of the head, the previously described low attenuation areas in the parietal regions appear with hyperintensity signal on the FLAIR sequence, mildly hyperintense on the diffusion-weighted sequence, and also slightly hyperintense on the corresponding ADC maps, these findings are nonspecific and may represent posterior reversible encephalopathic changes, please correlate clinically. There is no evidence of acute hemorrhage, hydrocephalus, or midline shift. A low-attenuation area is identified on the right occipital region, likely consistent with chronic deposits of hemosiderin, please correlate with the prior MRI dated [**2140-12-28**]. IMPRESSION: Limited examination secondary to motion artifacts. On the FLAIR sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. The prior low-attenuation area of the right occipital lobe is unchanged and may represent chronic deposits of hemosiderin. There is no evidence of hydrocephalus or midline shifting. Followup with MRI of the head with and without contrast under conscious sedation is recommended if clinically warranted. Brief Hospital Course: A/P: 23 F with SLE, ESRD not on HD, chronic VTE with RUE and facial swelling p/w hypertensive emergency and delta MS initially admitted to the [**Hospital Unit Name 153**]. In the [**Hospital Unit Name 153**] she was on a labetalol gtt as well as home medications. She had head imaging (MRI) with following results; On the FLAIR sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. She was evaluated by neurology who considered PRES, though she did not seize. She was started on keppra as she has had seizures before, and will follow up with them. . # HTN Emergency. She has had multiple admissions in the past with neurological involvement, hemolysis in the past. SBP >300 in ED. Her BP was lowered slowly with a labetolol gtt in the ICU. When it was stably below 180 she was transferred to the medical floor on the [**Hospital Ward Name 517**]. She was continued on clonidine TP, po labetalol, aliskiren. I/O goal was even. Her BP remained between 120-170 before discharge, she no longer had any headaches, or nausea. She was oriented times three. Aliskiren was not covered by masshealth, and a prior auth was faxed over. A supply from the pharmacy was sought but unavailable. She was given a prescription for 5 pills to bridge her to the time when the prior auth would have been approved in order to facilitate her paying for the prescription. She was also given hydralazine and instructed on how to take extra doses when her blood pressure increased. . # Delta MS. [**2-11**] to hypertension likely ischemic/hypertensive changes on CT. AAO times three, no focal neurological signs currently. Also likely component of OSA although this seems chronic. No seizures although has had them in the past. Neuro was consulted, and she was started on Keppra for question of PRES, keppra for 6 weeks until f/u with neuro, has outpatient MRI appointment as well. They will likely keep her on keppra until the changes in her parietal regions have resolved. . #UTI-found on admission, was on Cipro-will complete course of 5 days . # VTE. L Brachiocephalic VTE chronic with collaterals. Also h/o other VTE [**2-11**] to lines in the past. Currently on coumadin. INR 2.1 coumadin was held in [**Hospital Unit Name 153**] for anticipation of procedures. Her coumadin was restarted, has VNA set up and will be followed by [**Hospital3 **]. . # Facial Swelling. Unclear etiology likely [**2-11**] to VTE in RUE (brachiocephalic) vs. angioedema-pt now without swelling . # ESRD. Currently no on HD due to patient preference, awaiting to start PD next week. Since patient has refused HD there was an attempt to correct lytes and acid base with medications. Avoided fluid overload with lasix, patient currently making urine. Lytes - see below. She will commence PD as an outpatient (had issues yesterday with catheter flushing)-still not working-will try laxatives to relieve loops of bowel possibly wrapped around catheter and she will follow up with renal on Monday. Her ACE/[**Last Name (un) **] were held, renally dosed her meds, and phos binder was administered. . # Metabolic Acidosis/Electrolytes abnormalities. AG 15 likely [**2-11**] to uremia. K elevated to 5.6-6.0 however has been elevated in the past, likely some chronic hyerkalemia. She received kayexalate 30 mg tid until K <5 Her electrolytes stabilized and she was continued on her home regimen of sodium bicarb (650mg two tabs daily). . # SLE. On prednisone chronically, likely needs PCP [**Name9 (PRE) **] at some point --Atovaquone to prevent hyperkalemia Continued on prednisone 10mg (dropped from 15mg 2 weeks ago) . # Anemia-Hct and plts dropped on this admission but now stable . # HOCM. Avoid dehydration. Currently on Labetalol. . # PPX: systemically anticoagulated, getting kayexalate, PPI # FEN: Electrolytes as above, no standing fluids I/Os goal even. # Access: 2x PIV currently # Code: Full # Dispo: home Medications on Admission: Pantoprazole 40 mg daily - Clonidine TP 0.3/24 hrs q wednesday - Prednisone 10 mg daily (just decreased from 15 mg) - Calcitriol 0.25 mcg daily - Sodium bicarbonate 650 mg 2 tabs daily - Vit D3 400 mg daily - Vit D2 50,000 q wed, x 10 weeks - Labetalol 300 mg po 3 tabs TID - Nifedipine SR 90 mg [**Hospital1 **] - Warfarin 2 mg daily - Hydral 25 mg TID - Lasix 40 mg [**Hospital1 **] (started friday) - Benadryl 25 mg po prn - Ativan 1 mg [**Hospital1 **] prn - Colace 100 mg [**Hospital1 **] prn - Morphine 15 mg po q 6 hrs x 14 days - Diovan 320 mg daily - Dilaudid prn Discharge Medications: 1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): on alternating days with 15mg. 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 4. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): please take as directed when blood pressure is above 180. Disp:*90 Tablet(s)* Refills:*2* 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). Disp:*405 Tablet(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for hold for sbp < 130. Disp:*10 Tablet(s)* Refills:*0* 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Outpatient Lab Work for [**Known firstname **] [**Known lastname **] DOB [**2117-8-7**] please check INR once a week and have results faxed to [**Hospital3 **] at [**Hospital1 18**] phone-[**Telephone/Fax (1) 14650**], fax-[**Telephone/Fax (1) 44543**] 16. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO once a day: hold for sbp<130. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: -hypertensive emergency -Lupus - [**2134**]. Diagnosed after she began to have swolen fingers, a rash and painful joints. -ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose every 3 months for 2 years until began dialysis 3 times a week in [**2137**] (T, Th, Sat). Now no longer on Hemodialysis, with hyperkalemia/Hypocalcemia/Hyperphosphatemia/Elevated PTH/Metabolic Acidosis; PD Catheter placed [**5-18**] -h/o seizures, ICU admissions; h/o two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] that resolved -Uveitis secondary to SLE - [**4-16**]; s/p surgery [**2-16**]; she had blood cleared and cataract removed as well as glaucoma. -HOCM - per Echo in [**2137**] -Mulitple episodes of dialysis reactions -Anemia -H/O SVC thrombus [**10-16**] [**2-11**] catheter placement, was on coumadin then stopped; Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]); Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]); Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) -Facial and left breast swelling - attributed to angioedema vs chronic L Brachiocephalic vein occlusion -Thrombophilia ?????? likely related to SLE, h/o recurrent VTE -Thrombocytopenia NOS -TTP (got plasmapheresisis) versus malignant HTN -History of left eye enucleation [**2139-4-20**] for fungal infection Discharge Condition: stable, afebrile, SBP 120's-170's Discharge Instructions: You were admitted with hypertensive emergency, your blood pressure was extremely high. You had a head CT and MRI that showed some changes concerning for PRES (posterior reversible leukoencephalopathy syndrome), and neurology recommended initiating Keppra. Your blood pressure was brought under control in the intensive care unit and now you have a new regimen of medications. In addition peritoneal dialysis was attempted but there were difficulties with your catheter. This will be further addressed by your outpatient nephrologist. You will continue to have your INR drawn and sent to coumadin clinic. You should take all your medications as prescribed, you will be taking the keppra until you follow up with a neurologist in approximately 6 weeks. You will also be taking the Aliskiren following discharge. You will be discharged on hydralazine (which you will take three times daily EVERY DAY), as well as when your blood pressure gets too high as follows; if you blood pressure is above 180 please take an extra dose of hydralazine, check your blood pressure in 10 minutes, if it is still not take another dose and recheck your blood pressure in another 10 minutes-if it is still elevated take another 25mg hydralazine and recheck in 10 minutes-if it is still elevated please call your doctor or go to the ER. Continue taking your coumadin and having your INR sent to coumadin clinic. Please seek medication attention if you have any headaches, chest pain, shortness of breath, dizzyness, nausea or any other concerning symptoms. Please follow up as outlined below. Followup Instructions: -Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00 -Your renal team will contact you regarding follow up-you should call CB for home teaching. -Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2141-7-12**] 10:30 -MRI Tuesday [**7-25**]-9:30am, [**Location (un) **] [**Hospital Ward Name 23**] Building -[**Company 191**] [**Telephone/Fax (1) 250**] N.P-[**7-25**] 1:40pm -Stroke center Dr. [**Last Name (STitle) **] at the [**Hospital Ward Name 23**] center, [**Location (un) **]-Tuesday [**8-1**], 5:00pm-you will need to call your PCP for [**Name Initial (PRE) **] referral -Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Company 191**] ([**Hospital Ward Name 23**] Building) Tuesday [**8-15**] 2:00pm [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2141-6-19**]",167,2141-06-11 10:17:00,2141-06-17 16:29:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSIVE EMERGENCY," a/p: 23 f with sle, esrd not on hd, chronic vte with rue and facial swelling p/w hypertensive emergency and delta ms initially admitted to the [**hospital unit name 153**]. in the [**hospital unit name 153**] she was on a labetalol gtt as well as home medications. she had head imaging (mri) with following results; on the flair sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. she was evaluated by neurology who considered pres, though she did not seize. she was started on keppra as she has had seizures before, and will follow up with them. . # htn emergency. she has had multiple admissions in the past with neurological involvement, hemolysis in the past. sbp >300 in ed. her bp was lowered slowly with a labetolol gtt in the icu. when it was stably below 180 she was transferred to the medical floor on the [**hospital ward name 517**]. she was continued on clonidine tp, po labetalol, aliskiren. i/o goal was even. her bp remained between 120-170 before discharge, she no longer had any headaches, or nausea. she was oriented times three. aliskiren was not covered by masshealth, and a prior auth was faxed over. a supply from the pharmacy was sought but unavailable. she was given a prescription for 5 pills to bridge her to the time when the prior auth would have been approved in order to facilitate her paying for the prescription. she was also given hydralazine and instructed on how to take extra doses when her blood pressure increased. . # delta ms. [**2-11**] to hypertension likely ischemic/hypertensive changes on ct. aao times three, no focal neurological signs currently. also likely component of osa although this seems chronic. no seizures although has had them in the past. neuro was consulted, and she was started on keppra for question of pres, keppra for 6 weeks until f/u with neuro, has outpatient mri appointment as well. they will likely keep her on keppra until the changes in her parietal regions have resolved. . #uti-found on admission, was on cipro-will complete course of 5 days . # vte. l brachiocephalic vte chronic with collaterals. also h/o other vte [**2-11**] to lines in the past. currently on coumadin. inr 2.1 coumadin was held in [**hospital unit name 153**] for anticipation of procedures. her coumadin was restarted, has vna set up and will be followed by [**hospital3 **]. . # facial swelling. unclear etiology likely [**2-11**] to vte in rue (brachiocephalic) vs. angioedema-pt now without swelling . # esrd. currently no on hd due to patient preference, awaiting to start pd next week. since patient has refused hd there was an attempt to correct lytes and acid base with medications. avoided fluid overload with lasix, patient currently making urine. lytes - see below. she will commence pd as an outpatient (had issues yesterday with catheter flushing)-still not working-will try laxatives to relieve loops of bowel possibly wrapped around catheter and she will follow up with renal on monday. her ace/[**last name (un) **] were held, renally dosed her meds, and phos binder was administered. . # metabolic acidosis/electrolytes abnormalities. ag 15 likely [**2-11**] to uremia. k elevated to 5.6-6.0 however has been elevated in the past, likely some chronic hyerkalemia. she received kayexalate 30 mg tid until k <5 her electrolytes stabilized and she was continued on her home regimen of sodium bicarb (650mg two tabs daily). . # sle. on prednisone chronically, likely needs pcp [**name9 (pre) **] at some point --atovaquone to prevent hyperkalemia continued on prednisone 10mg (dropped from 15mg 2 weeks ago) . # anemia-hct and plts dropped on this admission but now stable . # hocm. avoid dehydration. currently on labetalol. . # ppx: systemically anticoagulated, getting kayexalate, ppi # fen: electrolytes as above, no standing fluids i/os goal even. # access: 2x piv currently # code: full # dispo: home ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other encephalopathy; Chronic glomerulonephritis in diseases classified elsewhere; Urinary tract infection, site not specified; Acidosis; Unspecified iridocyclitis; Acquired hemolytic anemia, unspecified; Systemic lupus erythematosus; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Swelling, mass, or lump in head and neck; Hyperpotassemia; Lump or mass in breast; Thrombocytopenia, unspecified; Hypocalcemia; Disorders of phosphorus metabolism]","a/p: 23 f with sle, esrd not on hd, chronic vte with rue and facial swelling p/w hypertensive emergency and delta ms initially admitted to the [**hospital unit name 153**]. she was evaluated by neurology who considered pres, though she did not seize. aliskiren was not covered by masshealth, and a prior auth was faxed over. also likely component of osa although this seems chronic. inr 2.1 coumadin was held in [**hospital unit name 153**] for anticipation of procedures. avoided fluid overload with lasix, patient currently making urine. # metabolic acidosis/electrolytes abnormalities. # ppx: systemically anticoagulated, getting kayexalate, ppi # fen: electrolytes as above, no standing fluids i/os goal even.","delta ms was evaluated by neurology who considered pres, though she did not seize. she was started on keppra as she has had seizures before, and will follow up with them. her bp remained between 120-170 before discharge, she no longer had headaches, or nausea." 109,126055.0,14798,2141-11-03,14796,139061.0,2141-09-14,Discharge summary,"Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Right leg pain. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 24 y.o. F with lupus, Chronic Kidney Disease V (not currently on HD or PD), and multiple admissions for hypertensive urgency/emergency, who presented to the ED for continued R leg pain that starts in her R buttocks and refers down her R leg. She describes it as feeling like the pain is deep within her bone. The pain was [**10-20**] in the AM, and she felt like she couldn't get out of bed. Denies any swelling of her RLE. When getting VS in [**Name (NI) **], pt noted to be very hypertensive at 263/176. The patient reportedly has baseline SBPs in 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM on day of admission. She denies any recent recrational drug use including cocaine and amphetamines. She denies headache, vision changes, double vision, chest pain, shortness of breath, abdominal pain, BRBPR, dysuria. During MD interview, the patient was nauseous and had small amount of emesis of a recent Coolata. Pt states that flushing her PD cath causes a large amount of stomach pain. . Of note, the patient was recently admitted from 08.26-29.08. The patient initially presented to the ED after referral from her nephrologist's office where she had complaints of right leg pain and was found to be hypertensive to 250/145. She was admitted after initiation of a labetalol drip and nitropaste with improvement in sbp to 180. The patient did receive 2 U of PRBC's during this hospitalization for baseline anemia. The patient did have a work-up for her right leg pain complaints with plain films of the right hip and MRI of the L-spine which did not reveal an explanation for her symptoms and did rule out avascular necrosis. The patient received dilaudid for pain control and was ambulating without pain prior to discharge. In addition, the patient completed a course of ciprofloxacin for a positive UA with negative cultures. The patient was unable to tolerate peritoneal dialysis for unclear reasons. Peritoneal dialysate culture was negative for infection. . In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in ED ranged from [**Telephone/Fax (3) 43494**]-175 with HR in 96-108. Initially given labetalol 10 mg IV x 1 and then started on labetalol gtt for her elevated blood pressures and titrated to 3 mg/min. LENI of R leg was negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per ED, cannot do V/Q scan due to volume overload after talking with radiology. Renal c/s initiated. A-line placed. Past Medical History: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] . PAST SURGICAL HISTORY: - Placement of multiple catheters including dialysis. - Tonsillectomy. - Left eye enucleation in [**2140-4-10**]. - PD catheter placement in [**2141-5-11**]. Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 98.9 [**Telephone/Fax (2) 43495**] 99$% RA GEN: NAD, pleasant female sitting in bed with moon facies HEENT: EOMI of R eye, L eye prosthesis, no exudate, no erythema, MMM, no LAD CHEST: CTAB except at R base with decreased breath sounds; no w/r/r CV: tachy, normal S1S2, II/VI systolic murmur accentuated with Valsalva ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i EXT: no c/c/e, strength of LEs [**5-15**] and symmetric bilaterally. Negative straight leg test, no pain with internal rotation, external rotation, extension, adduction or abduction. Some pain on flexion at the hip. NEURO: II - XII intact to direct testing. No deficit in light tough sensation. Gait normal. DERM: no rashes noted Pertinent Results: LABS AT ADMISSION: [**2141-9-11**] 11:43AM GLUCOSE-86 UREA N-49* CREAT-8.1* SODIUM-139 POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-16* ANION GAP-18 [**2141-9-11**] 11:43AM CALCIUM-6.2* PHOSPHATE-5.8* MAGNESIUM-1.6 [**2141-9-11**] 11:43AM PT-18.4* PTT-42.8* INR(PT)-1.7* [**2141-9-11**] 07:00AM WBC-5.5 RBC-2.88* HGB-8.1* HCT-24.7* MCV-86 MCH-28.1 MCHC-32.8 RDW-18.0* [**2141-9-11**] 07:00AM NEUTS-74.7* LYMPHS-17.5* MONOS-4.2 EOS-3.3 BASOS-0.2 [**2141-9-11**] 07:00AM PLT COUNT-101* UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50 WBC . MICROBIOLOGY: Urine culture ([**2141-9-11**]): Mixed flora . STUDIES: Cardiology Report ECG Study Date of [**2141-9-11**] 6:55:16 AM Sinus tachycardia. The tracing is marred by baseline artifact. There is left atrial enlargement. Compared to the previous tracing of [**2141-9-5**] the rate has increased. The axis is more rightward. Otherwise, no diagnostic interim change. . UNILAT LOWER EXT VEINS RIGHT Study Date of [**2141-9-11**] 8:54 AM [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and popliteal veins demonstrate normal flow, compressibility, augmentation, waveforms. Appropriate color flow and compression is noted within the calf veins. No intraluminal thrombus is present. IMPRESSION: No evidence of right lower extremity DVT. . TTE ([**2140-8-26**]): The left atrium is normal in size. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . R HIP XR [**2141-9-6**]: No acute fracture or dislocation. . MRI L-SPINE [**2141-9-6**]: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. LAB RESULTS AT DISCHARGE: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-9-14**] 06:15AM 4.0 2.63* 7.6* 23.1* 88 29.1 33.0 18.0* 100* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-9-14**] 06:15AM 100 44* 8.1* 137 4.8 109* 17* 16 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2141-9-14**] 06:15AM 6.8* 5.4* 1.6 CALCIUM freeCa [**2141-9-14**] 11:30AM 0.94* Brief Hospital Course: ICU course: EKG showed no change from prior, and CXR showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home medication regimen. The patient was found to by hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. . [**Hospital1 **] history: . 1. Hypertensive urgency: During the patient's [**Hospital1 **] stay, her SBPs ranged from 140s-160s during the day, which is her baseline systolic blood pressure. She was maintained on her home oral medication regimen. At night, she became more hypertensive, with SBP to the 170s-180s, which was controlled with both IV hydralazine and PO nifedipine. PO nifedipine was most successful at bringing her SBP back to her baseline. SBP at discharge was 140. Throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. The renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. Right leg pain: Upon arrival on the floor, the patient complained of [**2143-4-15**] pain in R buttock and posterior thigh, much exacerbated with standing. Of note, lumbar spine MRI and R hip XR on most recent admission were both negative. Her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. Her pain when she was symptomatic was controlled well with PO dilaudid. If the pain recurs, an MRI of the right hip can be considered to evaluate for osteonecrosis. . 3. UTI: The patient had a urinalysis suggestive of UTI, though she remained asymptomatic throughout. She was treated with a three day course of ciprofloxacin. Her urine culture showed mixed flora consistent with skin contamination. . 4. ESRD: The patient has end-stage renal disease due to her lupus. The patient's creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. She was followed by the renal consult service. Her potassium remained stable. Her calcium was low during admission, and supplemental calcium was given in addition to starting Calcitriol. She was not dialyzed through her PD catheter secondary to discomfort, but may reinitiate PD as an outpatient. Her laboratories will be checked as an outpatient in renal clinic. . 5. Anemia: The patient's hematocrit remained near her baseline low 20s throughout her stay. She has anemia from chronic kidney disease and chronic disease. The patient is not on Epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. Prior SVC thrombus: The patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with INR goal 2.5 to 3.0. . 7. Systemic lupus erythematosus: No active issues. The patient's home prednisone regimen was continued. Medications on Admission: - Prednisone 5 mg Daily - Coumadin 2 mg at bedtime - Nifedipine 60 mg Sustained Release Daily - Hydralazine 50 mg every 8 hours - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY - Aliskiren 150 mg Twice daily - Docusate Sodium 100 mg 2 times a day - Labetalol 900 mg three times a day - Lactulose 15-30 ml once a day: goal is [**1-11**] soft bowel movements per day Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 7. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: - Hypertensive urgency - Right lower extremity pain - Urinary tract infection Secondary diagnosis: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) - HOCM: Last noted on echo [**8-17**] - Anemia - History of left eye enucleation [**2139-4-20**] for fungal infection - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Discharge Condition: Stable systolic blood pressure over past 24 hours. Discharge Instructions: You were admitted to the hospital for uncontrolled high blood pressure. You spent one day in the intensive care unit, where you were treated with intravenous medication to lower your blood pressure. You were then transferred to a regular hospital floor, where your blood pressure was managed with your home oral medications. You were also treated for urinary tract infection with antibiotics. Your right leg pain improved during admission, and we are unsure of the cause of this pain. You should discuss the need for an MRI of the hip if the pain returns when you meet with your primary care doctor. Please call your physician or return to the emergency room if you experience fever, chills, chest pain, difficulty breathing, abdominal pain, headache, changes in your vision, or any other symptoms that are concerning. Please take your medications as prescribed. - Calcitriol was added to your medications. - You should hold Coumadin for two days and restart Saturday, [**2141-9-16**]. You should have your INR checked at your visit in kidney clinic [**2141-9-18**]. - You can take Dilaudid 2-4 mg every eight hours as needed for pain. You should be vigilant about taking lactulose if you need to take Dilaudid. - You should continue Lactulose as per Dr.[**Name (NI) 12913**] instructions. - No other changes were made. Please keep follow up appointments as described below. Followup Instructions: Please call the office of your kidney doctor, Dr. [**Last Name (STitle) 4883**], at ([**Telephone/Fax (1) 773**] to schedule an appointment for [**Last Name (LF) 766**], [**9-19**] as discussed. Follow up with your lung doctor: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-9-21**] 1:00 Follow up with your new primary care doctor: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 ",50,2141-09-11 10:12:00,2141-09-14 20:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home medication regimen. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. . [**hospital1 **] history: . 1. hypertensive urgency: during the patients [**hospital1 **] stay, her sbps ranged from 140s-160s during the day, which is her baseline systolic blood pressure. she was maintained on her home oral medication regimen. at night, she became more hypertensive, with sbp to the 170s-180s, which was controlled with both iv hydralazine and po nifedipine. po nifedipine was most successful at bringing her sbp back to her baseline. sbp at discharge was 140. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. the renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. her pain when she was symptomatic was controlled well with po dilaudid. if the pain recurs, an mri of the right hip can be considered to evaluate for osteonecrosis. . 3. uti: the patient had a urinalysis suggestive of uti, though she remained asymptomatic throughout. she was treated with a three day course of ciprofloxacin. her urine culture showed mixed flora consistent with skin contamination. . 4. esrd: the patient has end-stage renal disease due to her lupus. the patients creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. she was followed by the renal consult service. her potassium remained stable. her calcium was low during admission, and supplemental calcium was given in addition to starting calcitriol. she was not dialyzed through her pd catheter secondary to discomfort, but may reinitiate pd as an outpatient. her laboratories will be checked as an outpatient in renal clinic. . 5. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay. she has anemia from chronic kidney disease and chronic disease. the patient is not on epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. prior svc thrombus: the patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with inr goal 2.5 to 3.0. . 7. systemic lupus erythematosus: no active issues. the patients home prednisone regimen was continued. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Urinary tract infection, site not specified; Other primary cardiomyopathies; Systemic lupus erythematosus; Sciatica; Hyperpotassemia; Thrombocytopenia, unspecified; Abnormal coagulation profile; Hyperparathyroidism, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism]","icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the renal team was consulted, and recommended no change to home medication regimen. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. she was treated with a three day course of ciprofloxacin. esrd: the patient has end-stage renal disease due to her lupus. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay.","ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. she became more hypertensive, with sbps to the 170s-180s during the day. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency." 109,126055.0,14798,2141-11-03,14797,172335.0,2141-09-24,Discharge summary,"Admission Date: [**2141-9-18**] Discharge Date: [**2141-9-24**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1936**] Chief Complaint: hip pain Major Surgical or Invasive Procedure: None History of Present Illness: 24yo woman with hx SLE, CKD(not currently on HD or PD), labile HTN here with right leg pain and HTN urgency. Patient was recently d/ced on [**9-14**] following admission for the same complaints. . Patient took her hydralazine dose on am of admission. BP at presentation to the ER was 250/140 (The patient reportedly has baseline SBPs in 130-170s) She was given 900 labetolol and 50 hydralazine in the ED. BP following this was 175/124. Her EKG was unchanged. K was 5.7. . Patient also complaining of [**10-20**] right hip pain. Patient was d/ced on [**9-14**] with oral dilaudid for hip/leg pain. She took this only for one day due to severe itching. Denies any parasthesias/weakness. Her RLE/hip pain has been extensively worked up with negative LENIs, Lumbar spine MRI and hip plain films in the past. She was given 4mg IV morphine in the ER. . On admission to the floor, leg/hip pain somwhat improved with morphine.She denies any headache, vision changes, double vision, chest pain or SOB. Feels warm but no chills. Past Medical History: Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 97.3 HR 81 BP 135/91 RR 16 100%RA Gen:NAD, happy, pleasant female HEENT:NC/AT, L eye prosthesis, R PERRL, EOMI, MMM, facial swelling, L side>R, scerla anicteric Neck: supple, no JVD, no LAD, scars from prior CVL and HD lines CV:S1S2+, 2/6 SEM LUSB, loud P2, RRR, no ectopy Pulm: CTA B/L, good inspiratory effort Abd: +BS, soft, nontender, slightly distended and resonant to percussion, PD catheter in place in left abdomen ext: no c/c/e, 2+DP b/L, L foream swollen>R, R hip is mobile without pain elicited on passive or active movement neuro: AAOx3, nonfocal exam, CN 2-12 intact, moves all 4 extremities psych: mood/affect appropriate Pertinent Results: MRI Right Hip ([**9-18**]): There is no signal abnormality on the fluid-sensitive sequences in the proximal femur, acetabulum, or other osseous structure. On T1- weighted images, there is a focal rounded region within the right femoral head measuring approximately 9 mm in a subchondral location, which is nonspecific but may represent an unusual focus of red marrow. No sclerosis is seen on the corresponding plain films. There is a small right hip joint effusion and a small amount of fluid in the left hip joint as well, at the upper limits of normal. There is no soft tissue abnormality, no muscular edema, and no fluid collections. IMPRESSION: 1. Small right hip joint effusion. 2. No bone marrow edema in the proximal femurs or the pelvis. 3. Nonspecific small focus of low signal on T1-weighted images in the right femoral head is nonspecific but may represent an unusual focus of red marrow. TTE ([**9-21**]): The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF 80%). A mild (18 mmHg) mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. There is no systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Severe symmetric left ventricular hypertrophy with hyperdynamic systolic function and mild mid-cavitary gradient. Mild aortic regurgitation. Moderate pulmonary hypertension. Findings consistent with hyperrtophic cardiomyopathy. Compared with the prior study (images reviewed) of [**2140-8-26**], pulmonary hypertension has developed (also present on the study from [**2140-5-20**]). Pericardial effusion is also new. V/Q scan ([**9-21**]): Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate no focal defects with improved ventilation to the posterior right basal segment. Perfusion images in the same 8 views show improved perfusion to the posterior right basal segement with a persistent small defect but no new findings. Chest x-ray shows cardiomgealy and left basilar atelectasis. IMPRESSION: Improved V/Q scan from [**9-/2139**] with no findings to suggest acute pulmonary embolism. B/L upper ext U/S ([**9-21**]): Grayscale and Doppler son[**Name (NI) 867**] of the right and left internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. There is nonocclusive focal thrombus seen in the left subclavian vein, where the vein is not fully compressible. Flow is seen in the region, indicating that the thrombus is nonocclusive. Elsewhere, normal flow, augmentation, compressibility were appropriate and waveforms are demonstrated. IMPRESSION: 1. Focal nonocclusive thrombus in the left subclavian vein. 2. Otherwise, patent upper extremity veins as described. [**2141-9-18**] 02:15PM POTASSIUM-5.1 [**2141-9-18**] 02:15PM HCT-21.2* [**2141-9-18**] 08:45AM POTASSIUM-5.7* [**2141-9-18**] 07:30AM GLUCOSE-88 UREA N-54* CREAT-8.6* SODIUM-136 POTASSIUM-5.8* CHLORIDE-108 TOTAL CO2-15* ANION GAP-19 [**2141-9-18**] 07:30AM estGFR-Using this [**2141-9-18**] 07:30AM CALCIUM-7.3* PHOSPHATE-5.3* MAGNESIUM-1.6 [**2141-9-18**] 07:30AM WBC-5.2 RBC-2.32* HGB-6.5* HCT-20.1* MCV-87 MCH-28.1 MCHC-32.4 RDW-18.4* [**2141-9-18**] 07:30AM NEUTS-78.0* LYMPHS-14.7* MONOS-3.9 EOS-3.2 BASOS-0.3 [**2141-9-18**] 07:30AM PLT COUNT-107* [**2141-9-18**] 07:30AM PT-20.8* PTT-43.3* INR(PT)-2.0* . [**2141-9-21**] CXR: There is no significant change when compared to the recent previous examination. The previously described left retrocardiac opacity is unchanged in appearance. Cardiomegaly is also unchanged. The mediastinal contour, bony thorax and pulmonary vasculature are normal. IMPRESSION: No significant change compared to study done roughly 7 hours prior. Brief Hospital Course: 24 yo with h/o of Lupus, HTN, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for R hip pain. Patient was on the floor on [**9-20**], given morphine for the hip pain. She then had an episode of hypotension and unresponsiveness and transferred to the MICU for closer monitoring. The patient got 2L IVFs and narcan and improved, in fact, found to be hypertensive upon arrival to MICU. . MICU Course: On [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. Concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. Mental status cleared somewhat with narcan. Renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. V/Q scan demonstrated improvement since prior study. Patient's home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. She was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. PD fluid was not c/w SBP. CXR was clear. Urine culture and blood cultures are pending. Patient's BP was in the 110s so hydralazine was stopped. Her other BP meds were otherwise continued. Plan was/is to follow renal recs for PD. If, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. Would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. If patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. Would add neurontin 100mg TID with room to titrate up to 300mg TID. Neuro also recommended PT with TENS unit and referral to pain clinic although patient's pain is currently absent. . FYI **** per Dr. [**Last Name (STitle) **] --- Because of ? increase in cardiomegaly on CXR, she got an echo yesterday. In addition to her known HOCM, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm Hg. They probably need to be followed up over time (particularly the pulmonary hypertension). We did evaluated the PHTN with a VQ scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. It would be good if we could arrange a PULMONARY CLINIC FOLLOW UP for Ms. [**Known lastname **] after discharge with either [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].**** . She underwent CT head, and V/Q scan which were unremarkable. Her steroid dose was increased to 15mg given concern for need for stress dose steroids. After transfer from the MICU, her steroids were dropped back to 5mg, her home dose with the approval of [**Last Name (un) **]. . Her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. Her hydralazine was discontinued. On day 2 of her MICU stay, she developed a fever to 102. She was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. Broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. There was question of retrocardiac opacity on CXR, though not clear. Rheum consult obtained given hip discomfort, who felt septic joint unlikely. Neurology consult obtained who felt autonomic seizure unlikely. . Pt initiated peritoneal dialysis. In this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising BPs. She is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. Her hip pain has resolved completely without further intervention. . Floor course: Fever: Spike fever in MICU to 102. Started on Levoquin, Aztreonam, and Vanc. Source unclear at this point, but CXR with question of retrocardiac opacity. There is a possibility of aspiration pneumonitis. Other etiologies include peritoneal fluid (PD cath), urine, and blood (though patient does not have any indwelling lines). Hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. Peritoneal dialysis cultures negative so far. Continued levo/vanco/aztreonam for 2 days empirically. Then d/ced the Abx as no infectious etiologies were found. Steroids back to home dosage. BCx, UCx (final neg), Peritoneal cultures negative at discharge. . # Labile blood pressure: h/o of difficult to control BP with episodes of hypertensive emergency in the past. Normal SBP runs in 170s. Having nausea in setting of new PD, no evidence of intracranial bleeding on clinical exam, though INR had been supratherapeutic so remains in differential, though not bradycardic. Continue home BP meds :Labetalol 900 mg PO TID but difficult for patient to tolerate due to nausea, Aliskiren *NF* 150 mg Oral [**Hospital1 **], NIFEdipine CR 60 mg PO DAILY, clonidine patch, hydralazine given hypertensive in setting of nausa. . # Right leg/hip pain: no evidence of avascular necrosis or fracture on MRI though there is a small effusion. Pain resolved without intervention. Continued to monitor and would avoid narcotics, restart slowly if pain resumes. Physical therapy to follow as an outpatient. [**Last Name (un) 18183**] followed. Please see consult note. . # Hyperkalemia: Chronic issue. Patient takes kayexalate intermittently per her report (last dose [**Last Name (un) 766**]). Monitored K but patient did not need it on floor. # CKD V: Renal following. Did well with PD on [**9-22**] but did report some nause and cramping. She was not tolerating all 1.5L in exchanges on discharge. # Anemia: Hct stable around 20. S/p 1 U PRBCs in MICU with Hct 20.1 to 21.9. Likely due to chronic hemolysis consistent with SLE> #. Prior SVC thrombus: Physical exam with L arm swelling consistent with this. No flow limitations. INR 3.5 on ICU admission. Held warfarin but restarted home 2mg daily the day before discharge. # Systemic lupus erythematosus: Home prednisone dose 5mg. Currently on 15mg in setting of acute illness (day 2). # General care: FEN: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, PD initiated, Proph: INR therapeutic, no indication for PPI, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. Code: Full code, confirmed with patient Communication: with the patient and her mother [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (2) 43497**]contact. Access: 2 PIVs Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly dilaudid PO prn benadryl prn lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily coumadin 2mg PO qday calcitriol 1 mcg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Hypertensive urgency Transient Hypotension due to Narcotics Sciatica . Secondary: End stage renal disease Systemic Lupus Erythematosus Anemia Discharge Condition: Stable. Blood pressures at baseline. Hip/leg pain resolved. Ambulating without assistance. Discharge Instructions: You were admitted to the hospital with high blood pressure and right leg/hip pain. We gave you pain medications and blood pressure lowering medications. Your blood pressure then dropped which was caused by the pain medication, and you were transferred to the Intensive Care Unit(ICU) where you recovered quickly. During your stay in the ICU, you developed a fever and were started on antibiotics. However, the cultures that were obtained were negative, and we discontinued the Antibiotics. During your hospitalization, your blood pressure normalized on your home regimen, and your right leg/hip pain resolved. You had an MRI of your hip done, which did not show an acute infection. You were seen by the kidney doctors and they recommended starting peritoneal dialysis. You were also given some blood for your anemia. Please follow up with the Peritoneal Dialysis nurse at the scheduled day/time. Please make an appointment to meet with your PCP in the next couple of weeks. Your Hip pain may benefit from physical therapy or outpatient anesthetic joint injection. Please discuss these options with your rheumatologist. . Please call the number given below to schedule outpatient physical therapy. . Please restart your home medications. You were also started on Sodium Bicarb 650mg by mouth three times a day. . If you develop fevers, chills, trouble breathing, chest pain, worsening of hip pain, headaches, changes in your vision or any other symptoms that concern you please return to the emergency room or call your doctor. Followup Instructions: Please follow up with your Peritoneal Dialysis nurse ([**Doctor First Name 3040**]) on [**Doctor First Name 766**] [**2141-9-25**] . Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 . Please call to schedule Outpatient Physical Therapy:[**Telephone/Fax (1) 2484**] Completed by:[**2141-9-25**]",40,2141-09-18 10:32:00,2141-09-24 13:53:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,LEG PAIN," 24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. patient was on the floor on [**9-20**], given morphine for the hip pain. she then had an episode of hypotension and unresponsiveness and transferred to the micu for closer monitoring. the patient got 2l ivfs and narcan and improved, in fact, found to be hypertensive upon arrival to micu. . micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. mental status cleared somewhat with narcan. renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. v/q scan demonstrated improvement since prior study. patients home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. she was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. pd fluid was not c/w sbp. cxr was clear. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. plan was/is to follow renal recs for pd. if, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. would add neurontin 100mg tid with room to titrate up to 300mg tid. neuro also recommended pt with tens unit and referral to pain clinic although patients pain is currently absent. . fyi **** per dr. [**last name (stitle) **] --- because of ? increase in cardiomegaly on cxr, she got an echo yesterday. in addition to her known hocm, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm hg. they probably need to be followed up over time (particularly the pulmonary hypertension). we did evaluated the phtn with a vq scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. it would be good if we could arrange a pulmonary clinic follow up for ms. [**known lastname **] after discharge with either [**first name4 (namepattern1) **] [**last name (namepattern1) **] or [**first name4 (namepattern1) **] [**last name (namepattern1) **].**** . she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. after transfer from the micu, her steroids were dropped back to 5mg, her home dose with the approval of [**last name (un) **]. . her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. her hydralazine was discontinued. on day 2 of her micu stay, she developed a fever to 102. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. there was question of retrocardiac opacity on cxr, though not clear. rheum consult obtained given hip discomfort, who felt septic joint unlikely. neurology consult obtained who felt autonomic seizure unlikely. . pt initiated peritoneal dialysis. in this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising bps. she is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. her hip pain has resolved completely without further intervention. . fever: spike fever in micu to 102. started on levoquin, aztreonam, and vanc. source unclear at this point, but cxr with question of retrocardiac opacity. there is a possibility of aspiration pneumonitis. other etiologies include peritoneal fluid (pd cath), urine, and blood (though patient does not have any indwelling lines). hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. peritoneal dialysis cultures negative so far. continued levo/vanco/aztreonam for 2 days empirically. then d/ced the abx as no infectious etiologies were found. steroids back to home dosage. bcx, ucx (final neg), peritoneal cultures negative at discharge. . # labile blood pressure: h/o of difficult to control bp with episodes of hypertensive emergency in the past. normal sbp runs in 170s. having nausea in setting of new pd, no evidence of intracranial bleeding on clinical exam, though inr had been supratherapeutic so remains in differential, though not bradycardic. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. . # right leg/hip pain: no evidence of avascular necrosis or fracture on mri though there is a small effusion. pain resolved without intervention. continued to monitor and would avoid narcotics, restart slowly if pain resumes. physical therapy to follow as an outpatient. [**last name (un) 18183**] followed. please see consult note. . # hyperkalemia: chronic issue. patient takes kayexalate intermittently per her report (last dose [**last name (un) 766**]). monitored k but patient did not need it on floor. # ckd v: renal following. did well with pd on [**9-22**] but did report some nause and cramping. she was not tolerating all 1.5l in exchanges on discharge. # anemia: hct stable around 20. s/p 1 u prbcs in micu with hct 20.1 to 21.9. likely due to chronic hemolysis consistent with sle> #. prior svc thrombus: physical exam with l arm swelling consistent with this. no flow limitations. inr 3.5 on icu admission. held warfarin but restarted home 2mg daily the day before discharge. # systemic lupus erythematosus: home prednisone dose 5mg. currently on 15mg in setting of acute illness (day 2). # general care: fen: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, pd initiated, proph: inr therapeutic, no indication for ppi, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. code: full code, confirmed with patient communication: with the patient and her mother [**name (ni) **] [**name (ni) **], [**telephone/fax (2) 43497**]contact. access: 2 pivs ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Pneumonia, organism unspecified; Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Hyperpotassemia; Sciatica; Other iatrogenic hypotension; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Anemia of other chronic disease; Hypocalcemia]","24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. it would be good if we could arrange a pulmonary clinic follow up for ms. [** she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. source unclear at this point, but cxr with question of retrocardiac opacity. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. did well with pd on [**9-22**] but did report some nause and cramping. # systemic lupus erythematosus: home prednisone dose 5mg.","lupus nephropathy patient on peitoneal dialysis with htn and lupus nephropathy. triggered for hypotension (82/45), hypothermia (92.9), altered mental status. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis." 109,126055.0,14798,2141-11-03,15328,170149.0,2141-06-06,Discharge summary,"Admission Date: [**2141-5-24**] Discharge Date: [**2141-6-6**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 759**] Chief Complaint: Face, Left arm and breast swelling Major Surgical or Invasive Procedure: Intravenous Catheterization of SVC/IVC. History of Present Illness: 23 year old woman with ESRD, SLE, recently placed PD catheter who presents with periorbital swelling and Hypertensive urgency. Of note she was recently admitted for tongue swelling on [**4-7**]. At that time she was treated with Solu-Medrol, famotidine and Benadryl in the emergency room, which was continued for a total of three doses on the floor. The swelling improved throughout her stay. She had been on both an ACE, [**Last Name (un) **] and DRI at home, which she has been taking for many years. Patient states that the tongue swelling is most likely due to a sardine allergy. However, she had recently added Dilaudid to her medications following PD catheter placement, so allergy to Dilaudid was also considered. The ACE, [**Last Name (un) **] and DRI were held on the day of admission for ?angioedema but restarted on day of discharge without incident so she was discharged on them. She returned to the ED [**5-24**] with acute onset bilateral eye swelling since night of [**5-23**]. VS T 97.9 HR 78 BP 231/120 RR 20 Sat 100% RA. She was given IV solumedrol 125iv, benadryl IV, and pepcid. Her BP was noted to be 240's despite labetolol 900mg po, then labetolol 20mg iv x2 so was started on labetolol gtt: highest dose 2mg/min. This was stopped after 35 minutes, in favor of nitro gtt. States compliant with meds at home. Patient was comfortable on admission to the MICU. Notes pain in abdomen 7.5/10 related to PD catheter placement (has had since then), improves with morphine. Also notes swelling in eyes/face since last night (has had in the past but never this severe, always goes away on its own). She feels whole body is swollen slightly but no more upper extremities than lower. She denies visual changes, HA, change in hearing/tinitus, congestion, sore throat, cough, SOB, chest pain, palpitations, nausea, vomitting, diarrhea. Has baseline constipation (takes stool softener), last BM 2 days ago (normal), no melena, brbpr, diarrhea. No dysuria, hematuria, change in uop, increase weight or size (clothes fit the same), tingling, numbness, weakness, discoordination, rash, joint pain, recent travel, ill contacts, exotic foods. She notes episode of throat swelling over weekend resolved, seemed to be related to sardine eating (not new for her). Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient denies past or current alcohol, tobacco, or illicit drug use. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: ON ADMISSION: VS: T 98.0 BP 187/120 HR 77 RR 17 Sat 100% on RA GEN: NAD HEENT: + periorbital edema, AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD, no carotid bruits CV: RRR, nl s1, s2, II/VI HSM at R/L USB, S4, no rub PULM: CTAB, no w/r/r with good air movement throughout ABD: soft, mildly tender at PD catheter, ND, + BS, no HSM EXT: warm, dry, +2 distal pulses BL, no femoral bruits, trace non-pitting edema NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect ON [**6-6**]: -General: AAOx3, in NAD. -VS: Tc: 95.2, Tmax (24hrs): 97.8 BP: 172/98 (80/43, 240/110 on [**5-30**]; 120/70, 218/120 over last 24 hrs), P: 80 (80, 98), RR: 16, O2: 98% RA. -HEENT: Head NC, AT. MMM. Face, Neck swollen: equal bilaterally. -Neck: Supple, No JVD, No tracheal deviation. -CV: RRR, S1,S2. Grade II/XII holosystolic murmur radiating to R carotid. JVP not elevated. No S4. -Lungs: CTAB, no w/r. -Abdomen: +BS, soft, nontender. -Extremities: Warm, no lower extremity edema. L arm appears slightly less swollen than yesterday. Dorsalis pedis and radial pulses strong bilaterally. No evidence of rashes, ulcers or varicose veins. -Breast: L breast still swollen relative to R, but diminished from initial presentation of swelling. Skin no longer tense. Pertinent Results: WBC-3.9* RBC-2.19* Hgb-6.6* Hct-20.4* MCV-93 MCH-30.3 MCHC-32.4 RDW-19.7* Plt Ct-114* - Neuts-52.8 Lymphs-39.9 Monos-5.0 Eos-2.0 Baso-0.2 PT-20.5* PTT-89.9* INR(PT)-1.9* Fibrino-268 Thrombn-37.4*# AT III-92 ProtCFn-65* ProtCAg-PND ProtSFn-68 Glucose-105 UreaN-62* Creat-8.1* Na-139 K-4.5 Cl-109* HCO3-17* ALT-14 AST-35 LD(LDH)-254* CK(CPK)-176* AlkPhos-137* Amylase-277* TotBili-0.4 Calcium-6.8* Phos-5.9* Mg-1.5* Hapto-90 Homocys-37.8* PTH-1603* UA: Color Straw Appear Clear SpecGr 1.009 pH 6.0 Urobil Neg Bili Neg Leuk Sm Bld Neg Nitr Neg Prot 30 Glu Neg Ket Neg RBC 0-2 WBC [**11-30**] Bact Few Yeast None Epi 0-2 U Tox: Urine Opiates Pos;Urine Benzos, Barbs, Cocaine, Amphet, Mthdne Negative; UCG: Negative STUDIES: Portable CXR [**5-24**]: Small left pleural effusion with associated atelectasis, although early pneumonia cannot be excluded. No CHF. ECG [**5-24**]: NSR (87), nl axis and intervals, TWI V5-V6, no change from [**5-20**]. MRA [**5-24**]: 1. Occlusion of the right internal jugular vein below the mandible which communicates with external jugular and subclavian vein. Appearance suggest chronic disease. 2. Patent SVC. 3. Patent but narrowed left internal jugular vein but left brachiocephalic vein not visualized (possibly from technique). 4. Bibasilar atelectasis US upper extremity [**5-26**]: [**Doctor Last Name **]-scale, color and Doppler son[**Name (NI) 1417**] of the left IJ, subclavian, axillary, brachial, basilic, and cephalic veins were performed. There is normal flow, compression, and augmentation seen in all of the vessels. IMPRESSION: No evidence of deep vein thrombosis in the left arm. MRV Chest [**5-30**]: 1. Limited study which demonstrates a chronically occluded and completely atrophic left brachiocephalic vein. 2. Right internal jugular vein not identified, likely chronically occluded. Left internal jugular vein is very diminuitive as before. 3. Large right external jugular vein emptying into the subclavian vein. Venogram [**5-31**]: 1. Occlusion of the left brachiocephalic vein at the junction of the subclavian and internal jugular with extensive collateral formation consistent with chronic obstruction. 2. Patent left brachial, axillary, subclavian, and distal internal jugular vein. 3. Unsuccessful attempt to recanalize the left brachiocephalic vein using a catheter and guidewire technique. Brief Hospital Course: Ms. [**Known lastname **] is a 23yo woman with a history of SLE, ESRD and HTN who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into L sided facial, L arm and L breast swelling throughout her stay. # L facial/arm and breast swelling: Initially this presented only as facial swellingand ACE and [**Last Name (un) **] were held for possible angioedema, however holding medications nad giving benadryl failed to relieve symptoms. We then suspected possible venous thrombus with occlusion leading to edema. US of upper left extremity failed to show evidence of acute occlusion, but showed R IJ occlusion consistent with prior studies. MRA could not visualize the L brachiocephalic vein. Repeat MRV suggested chronic occlusion of the L brachiocephalic vein. Venogram performed on [**5-31**] showed extensive collateralization of the L brachiocephalic vein with patent flow through these collaterals. Intervention on the L brachiocephalic vein was attempted by IR, but was unsuccessful. The primary team, renal team, [**Month/Year (2) **] team and hematology team suspect that the most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of the L brachiocephalic vein. For this reason, the patient was placed on Heparin IV as a bridge to coumadin anticoagulation with goal INR [**2-12**]. Per consult with hematology the patient is to remain on this regimen for at least 6 months, and will then revisit as an outpatient the question of possible lifelong anticoagulation. The patient has had extensive negative testing for hypercoagulable states, including during this work-up with negative anticardiolipin, antiphospholipid, Beta-2 glycoprotein and AT3 antibodies. Protein C and S levels were unremarkable. Although her clots seem to have all occured in the setting of lines, her continued thrombosis is likey due to hypercoagulability from her lupus (in absence of lupus anticoagulant). Her INR will be followed first by Dr. [**Last Name (STitle) 4883**], her nephrologist, and then by the coumadin clinic of [**Company 191**]. It will be especially important that her coumadin be well titrated given her risk of intracranial bleed with hypertension. This was communicated tothe patient and she understands and plans to be compliant with frequent blood draws for INR testing and varying her coumadin dose as directed. . # Hypertension: The patient has chronically labile hypertension, with frequent episodes of hypertensive urgency over systolic 200, as well as lows as far as the 80s during this admission. It remains unclear why her blood pressure is so chronically labile. The hope is that once she starts dialysis this will help to stabilize her blood pressure, however in the interim various adjustments were made to her regimen. The patient received frequent extra doses during her stay (especially of hydralazine), however, this occasionally causes her blood pressure to swing too low to tolerate her subsequent standing dose of medication. We stopped her Ace and [**Last Name (un) **] as above. We discharged her to home on a regimen that was reviewed with her nephrologist, Dr. [**Last Name (STitle) 4883**]. She is discharged on clonidine patch 0.3mg qweek, labetalol 900mg po tid, nifedipine CR 90mg po bid, hydralazine 35mg po tid. These medications were reviewed extensively with the patient and she was given prescriptions for all meds. She is discharged with home VNA for blood pressure checks and assistance with meds. She has purchased a portable BP cuff and will keep a BP diary to bring to subsequent appointments as well. The importance of BP control, especially in the setting of new anticoagulation, was discussed extensively with the patient. Her goal SBP is 140-160 at this time. . # ESRD: The patient has ESRD due to lupus nephritis. PD catheter was placed before admission and the patient received morphine prn pain at her catheter site. The renal team followed her closely throughout her stay. She was treated for hypocalcemia as well as hyperkalemia. Her regimen was changed to calcitriol 0.25mcg po qday, sodium bicarb 1300mg po qday, cholecalciferol 400units po qday, ergocalciferol 50,000 units po qweek for ten weeks. She plans to start HD within 1-2 weeks of discharge. She will call [**Doctor First Name 3040**] the PD nurse tomorrow to set up an appointment to have her catheter flushed and to start PD. She will be closely followed by Dr. [**Last Name (STitle) 4883**] at PD. # SLE: The patient was maintained on her home dose of prednisone 15mg po qday throughout her stay. She has no symptoms of acute SLE flare, so her nephrologist and outpatient physicians may attempt to wean this down as an outpatient. . # abnormal pap smear: The pt is noted to have an abnormal pap and colpo two years ago with CIN 2 and high risk HPV. This has never been repeated, as the patient failed to schedule appointments and DNK others. We discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. The patient was discharged to home with a clear plan to call [**Doctor First Name 3040**], the PD nurse on the day after discharge to set up an appointment to have her PD catheter flushed later this week, as well as to set a date to start her PD. She will see Dr. [**Last Name (STitle) 44539**] in [**Hospital **] clinic within the next 1-2 weeks. She will have her blood drawn for INR in two days and faxed to Dr. [**Last Name (STitle) 4883**], subsequently this will be faxed to the [**Company 191**] coumadin clinic and her dose will be adjusted for INR [**2-12**]. We have also given her the phone number to call [**Company 191**] and establish care with a new PCP, [**Name10 (NameIs) 3**] her old PCP has now graduated and her complex management makes a PCP [**Name Initial (PRE) 44540**]. (Her PCP must be at [**Company 191**] for the [**Company 191**] coumadin clinic to follow her as well.) Finally, the patient was given an appointment with ob/gyn to have a follow up pap smear, as her last pap and colpo two years ago showed CIN 2 with high risk HPV and this has not been followed. The above plan and appoitnments were reviewed with the pt and her mother extensively. [**Name2 (NI) **] medication hcanges were also extensively reviewed. Medications on Admission: Hydralazine 50 mg PO TID Labetalol 900 mg PO TID Nicardipine 60 mg Sustained Release PO once a day Cinacalcet 30 mg PO DAILY: she is not sure if taking Calcium Acetate 667 mg PO TID W/MEALS Sodium Bicarbonate 1300 mg PO TID Aliskiren 150 mg PO once a day (was never taking) Pantoprazole 40 mg PO once a day Valsartan 320mg PO DAILY Lisinopril 40 mg PO bid Clonidine 0.3 mg/24 hr Patch Weekly QSUN: not sure when last placed Prednisone 15 mg PO DAILY Morphine 15 mg Tablet PO Q6H as needed Ergocalciferol (Vitamin D2) 50,000 unit Capsule daily: states not taking Epo 4,000 units M/W/F: states not taking colace Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Disp:*4 Patch Weekly(s)* Refills:*2* 3. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 5. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO qwednesday (): for 10 weeks. Disp:*10 Capsule(s)* Refills:*0* 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*2* 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 10. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: dose to be adjusted by coumadin clinic. Disp:*120 Tablet(s)* Refills:*2* 11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 12. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for itching. Disp:*50 Capsule(s)* Refills:*0* 13. Ativan 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. Disp:*60 Tablet(s)* Refills:*0* 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 15. Morphine 15 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 14 days. Disp:*56 Tablet(s)* Refills:*0* 16. Outpatient Lab Work Please have blood drawn on Friday, [**6-9**] for PT/INR. Please have result faxed to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you to adjust your coumadin (also called warfarin) dose as needed. 17. Outpatient Lab Work Please have blood drawn on Monday [**2141-6-12**] for PT/INR and twice per week thereafter until told by coumadin clinic that you can decrease lab draws. Please have result faxed to the [**Hospital1 18**] coumadin clinic at [**Telephone/Fax (1) 3534**]. They will call you to adjust your coumadin (also called warfarin) dose as needed. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnoses: Malignant Hypertension (Hypertensive Urgency) Acute Exacerbation of Chronic Left Brachiocephalic vein occlusion Anemia Secondary Diagnoses: SLE ESRD Hypertrophic Cardiomyopathy Thrombocytopenia Discharge Condition: Stable Discharge Instructions: You were admitted and treated for an acute exacerbation of a chronic left brachiocephalic vein occlusion (a chronically obstructed large vein closed off entirely) and hypertensive urgency (very high blood pressure). We attempted to remove the clot in your left brachiocephalic vein, but were unable to do so. You have been started on long-term Coumadin (also called warfarin) therapy to prevent future blood clots and to allow natural dissolution of your current blood clot. Please change your medicines to only those you are given here! There were many changes and it is very important that you stick to the medication list as you have large, life-threatening swings in the blood pressure when not taking consistently. We also treated you for high potassium levels and anemia, and low vitamin D and calcium levels, which are related to your kidney failure. Please follow up with Dr. [**Last Name (STitle) 4883**] for long term treatment. Please check your blood pressure three times per day and keep a blood pressure diary to bring with you to all medical appointments. Please have your blood drawn on Friday [**6-9**] for PT/INR and faxed to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you if needed to adjust your coumadin (warfarin) dose. After that, please have your blood drawn on Monday [**6-12**] for PT/INR and faxed to the [**Hospital1 18**] coumadin clinic at [**Telephone/Fax (1) 434**]. They will follow you in a regular way to adjust your coumadin dose as needed. MEDICINES FOR BLOOD PRESSURE: LABETALOL 900mg three times per day (same as before) HYDRALAZINE 25mg three times per day (lower dose than before) CLONIDINE PATCH 0.3mg qWednesday (same as before) NIFEDIPINE SR 90mg twice per day (new medicine!) **stop taking your lisinopril, nicardipine, Diovan and Aliskerin!** MEDICINES FOR RENAL FAILURE: ERGOCALCIFEROL [**Numeric Identifier 1871**] units pill every Wednesday (same as before) CHOLECALCIFEROL 400 units every day (new) CALCITRIOL 0.25 mg every day (new) SODIUM BICARBONATE 1300mg once per day (less often then before) ** stop taking your calcium acetate (phoslo), cinecalcet, and epo injection (you'll get it at peritoneal dialysis only)** OTHER MEDICINES: PANTOPRAZOLE 40mg every day (same as before) PREDNISONE 15mg every day (same as before) MORPHINE 15mg every 6 hrs if needed for pain (same as before) ATIVAN 1mg as needed for anxiety (same as before) BENADRYL 25mg every 6 hrs if needed for itch (new) COLACE 100mg twice per day if needed for constipation(same as before) APPOINTMENTS: **1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on Friday to flush your dialysis catheter and start dialysis next week! 2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00AM 3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**] Date/Time: [**2141-6-13**] 9:30AM **4. Please call [**Hospital3 **] next week to make an appointment with a new primary doctor. I recommend Dr. [**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE FOLLOWED IN [**Hospital **] CLINIC. **5. Please have your blood drawn as above. Your coumadin level will be followed by the [**Hospital 197**] clinic. Their phone # is [**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**]. If you have increased swelling, fever greater than 101, shortness of breath, chest pain, or if you at any time become concerned about your health please contact Dr. [**Last Name (STitle) 4883**] or go to the nearest ER. Followup Instructions: APPOINTMENTS: **1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on Friday to flush your dialysis catheter and start dialysis next week! 2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00AM 3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**] Date/Time: [**2141-6-13**] 9:30AM **4. Please call [**Hospital3 **] next week to make an appointment with a new primary doctor. I recommend Dr. [**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE FOLLOWED IN [**Hospital **] CLINIC. **5. Please have your blood drawn as above. Your coumadin level will be followed by the [**Hospital 197**] clinic. Their phone # is [**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**]. Completed by:[**2141-6-17**]",150,2141-05-24 14:47:00,2141-06-06 19:55:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ACUTE RENAL FAILURE," ms. [**known lastname **] is a 23yo woman with a history of sle, esrd and htn who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into l sided facial, l arm and l breast swelling throughout her stay. # l facial/arm and breast swelling: initially this presented only as facial swellingand ace and [**last name (un) **] were held for possible angioedema, however holding medications nad giving benadryl failed to relieve symptoms. we then suspected possible venous thrombus with occlusion leading to edema. us of upper left extremity failed to show evidence of acute occlusion, but showed r ij occlusion consistent with prior studies. mra could not visualize the l brachiocephalic vein. repeat mrv suggested chronic occlusion of the l brachiocephalic vein. venogram performed on [**5-31**] showed extensive collateralization of the l brachiocephalic vein with patent flow through these collaterals. intervention on the l brachiocephalic vein was attempted by ir, but was unsuccessful. the primary team, renal team, [**month/year (2) **] team and hematology team suspect that the most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of the l brachiocephalic vein. for this reason, the patient was placed on heparin iv as a bridge to coumadin anticoagulation with goal inr [**2-12**]. per consult with hematology the patient is to remain on this regimen for at least 6 months, and will then revisit as an outpatient the question of possible lifelong anticoagulation. the patient has had extensive negative testing for hypercoagulable states, including during this work-up with negative anticardiolipin, antiphospholipid, beta-2 glycoprotein and at3 antibodies. protein c and s levels were unremarkable. although her clots seem to have all occured in the setting of lines, her continued thrombosis is likey due to hypercoagulability from her lupus (in absence of lupus anticoagulant). her inr will be followed first by dr. [**last name (stitle) 4883**], her nephrologist, and then by the coumadin clinic of [**company 191**]. it will be especially important that her coumadin be well titrated given her risk of intracranial bleed with hypertension. this was communicated tothe patient and she understands and plans to be compliant with frequent blood draws for inr testing and varying her coumadin dose as directed. . # hypertension: the patient has chronically labile hypertension, with frequent episodes of hypertensive urgency over systolic 200, as well as lows as far as the 80s during this admission. it remains unclear why her blood pressure is so chronically labile. the hope is that once she starts dialysis this will help to stabilize her blood pressure, however in the interim various adjustments were made to her regimen. the patient received frequent extra doses during her stay (especially of hydralazine), however, this occasionally causes her blood pressure to swing too low to tolerate her subsequent standing dose of medication. we stopped her ace and [**last name (un) **] as above. we discharged her to home on a regimen that was reviewed with her nephrologist, dr. [**last name (stitle) 4883**]. she is discharged on clonidine patch 0.3mg qweek, labetalol 900mg po tid, nifedipine cr 90mg po bid, hydralazine 35mg po tid. these medications were reviewed extensively with the patient and she was given prescriptions for all meds. she is discharged with home vna for blood pressure checks and assistance with meds. she has purchased a portable bp cuff and will keep a bp diary to bring to subsequent appointments as well. the importance of bp control, especially in the setting of new anticoagulation, was discussed extensively with the patient. her goal sbp is 140-160 at this time. . # esrd: the patient has esrd due to lupus nephritis. pd catheter was placed before admission and the patient received morphine prn pain at her catheter site. the renal team followed her closely throughout her stay. she was treated for hypocalcemia as well as hyperkalemia. her regimen was changed to calcitriol 0.25mcg po qday, sodium bicarb 1300mg po qday, cholecalciferol 400units po qday, ergocalciferol 50,000 units po qweek for ten weeks. she plans to start hd within 1-2 weeks of discharge. she will call [**doctor first name 3040**] the pd nurse tomorrow to set up an appointment to have her catheter flushed and to start pd. she will be closely followed by dr. [**last name (stitle) 4883**] at pd. # sle: the patient was maintained on her home dose of prednisone 15mg po qday throughout her stay. she has no symptoms of acute sle flare, so her nephrologist and outpatient physicians may attempt to wean this down as an outpatient. . # abnormal pap smear: the pt is noted to have an abnormal pap and colpo two years ago with cin 2 and high risk hpv. this has never been repeated, as the patient failed to schedule appointments and dnk others. we discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. the patient was discharged to home with a clear plan to call [**doctor first name 3040**], the pd nurse on the day after discharge to set up an appointment to have her pd catheter flushed later this week, as well as to set a date to start her pd. she will see dr. [**last name (stitle) 44539**] in [**hospital **] clinic within the next 1-2 weeks. she will have her blood drawn for inr in two days and faxed to dr. [**last name (stitle) 4883**], subsequently this will be faxed to the [**company 191**] coumadin clinic and her dose will be adjusted for inr [**2-12**]. we have also given her the phone number to call [**company 191**] and establish care with a new pcp, [**name10 (nameis) 3**] her old pcp has now graduated and her complex management makes a pcp [**name initial (pre) 44540**]. (her pcp must be at [**company 191**] for the [**company 191**] coumadin clinic to follow her as well.) finally, the patient was given an appointment with ob/gyn to have a follow up pap smear, as her last pap and colpo two years ago showed cin 2 with high risk hpv and this has not been followed. the above plan and appoitnments were reviewed with the pt and her mother extensively. [**name2 (ni) **] medication hcanges were also extensively reviewed. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Compression of vein; Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Hyperpotassemia; Hyperparathyroidism, unspecified; Other iatrogenic hypotension; Nausea with vomiting; ; Abnormal glandular Papanicolaou smear of cervix; Abdominal pain, other specified site; Other specified disorders of pancreatic internal secretion; Adrenal cortical steroids causing adverse effects in therapeutic use]","known lastname **] is a 23yo woman with a history of sle, esrd and htn who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into l sided facial, l arm and l breast swelling throughout her stay. mra could not visualize the l brachiocephalic vein. it remains unclear why her blood pressure is so chronically labile. we stopped her ace and [**last name (un) **] as above. the importance of bp control, especially in the setting of new anticoagulation, was discussed extensively with the patient. # esrd: the patient has esrd due to lupus nephritis. the renal team followed her closely throughout her stay. she will call [**doctor first name 3040**] the pd nurse tomorrow to set up an appointment to have her catheter flushed and to start pd. we discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. the above plan and appoitnments were reviewed with the pt and her mother extensively. [**","a 23yo woman with a history of sle, esrd and htn presented with bilateral facial swelling. she developed l sided facial, l arm and l breast swelling throughout her stay. most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of l brachiocephalic vein." 109,126055.0,14798,2141-11-03,15329,147469.0,2141-06-17,Discharge summary,"Admission Date: [**2141-6-11**] Discharge Date: [**2141-6-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: hypertensive urgency Major Surgical or Invasive Procedure: arterial line History of Present Illness: HPI: 23 F with h/o Lupus, ESRD not on HD (planned PD), labile hypertension, RUE VTE on anticoagulation, recent facial swelling who presents with hypertensive emergency. Patient developed severe frontal HA last evenening, a/w nausea. BP was not [**Location (un) 1131**] on home BP cuff. In the AM her HA was severe [**10-20**] a/w nausea and vomiting yellow/green liquid and BP cuff again not able to obtain BP. Patient was last seen by VNA this past Friday with BP 130/70. Patient denies any CP, shortness of breath, abd pain. Her facial swelling is slightly worse today. She denies any weakness, dizziness, difficulty with speach, no numbness or tingling. She says that she is compliant with all of her medications. She denies any GU/GI complaints despite +UA in ED. . In the ED, VS: 98.2 92 SBP >300/P [**Telephone/Fax (3) 44541**]-131) 16 98 % RA. Patient received zofran IV, Hydral IV, Labetalol 20 mg IV x 1, Nipride gtt started. Kayexalate 30 mg x 1. Other po meds written but patient did not take due to nausea. CT head showing no hemorrhage but hypoattenuation in frontal area, which is change from prior MRI in [**Month (only) **]. She is on coumadin for RUE VTE with INR 2.1. Also with UTI in ED, started Cirpo x 1. Labs showing K 5.6 ECG with ?hyperacute T waves, otherwise no changes, given kayexalate only. . Interval Hx: Patient was admitted [**2141-5-24**] to [**6-6**] with facial swelling and hypertensive emergency requiring ICU care. She was also admitted [**Date range (1) 43498**] with similar complaints. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 98.8 84 [**Telephone/Fax (2) 44542**]% RA Gen: swollen face L>R, alert and cooperative, NAD, snoring when asleep but easily arousable Heent: OP clear, swollen eye lids L>R, Left eye retracted with prosthesis, anicteric, OP moist Neck: supple, no JVD elevation, no meningismus CV: nl S1 S2, RRR, [**1-15**] SM Lungs: CTAB Abd: obese, soft, NT, ND, BS+ Ext: dry, no c/c/e, diminished, Neuro: Alert and oriented x 3, gets drowsy intermittently but arousable, CN II-XII intact, strength 5/5 throughout, sensations intact Pertinent Results: [**6-14**]: AXR:IMPRESSION: PD catheter with tip coiled in the pelvis. [**6-11**]: IMPRESSION: 1. Areas of hypoattenuation in the high bifrontal white matter, and subcortical hypoattenuation in the left posterior temporal lobe with loss of [**Doctor Last Name 352**]-white differentiation. These findings are new from MRI brain [**12-29**], [**2140**], and could represent areas of new edema with underlying focal lesion or possibly areas of new infarcts. An MRI head without and with Iv conrast is recommended for further characterization. 2. No evidence of intracranial hemorrhage. [**6-11**]: PA AND LATERAL VIEWS OF THE CHEST: There has been an interval increase in retrocardiac opacity obscuring the left hemidiaphragm. The right lung and the left upper lung zone are clear. The right costophrenic angle is slightly blunted, suggesting a very small right pleural effusion. The heart is slightly enlarged, but the cardiomediastinal silhouette is unchanged. There is no hilar enlargement. Soft tissue and bony structures are unremarkable. IMPRESSION: Interval increase in left basilar atelectasis with pleural effusion. Superimposed pneumonia cannot be excluded. Possible small right pleural effusion. [**6-11**]: MR [**Name13 (STitle) 430**]: INDINGS: In comparison with a prior CT of the head, the previously described low attenuation areas in the parietal regions appear with hyperintensity signal on the FLAIR sequence, mildly hyperintense on the diffusion-weighted sequence, and also slightly hyperintense on the corresponding ADC maps, these findings are nonspecific and may represent posterior reversible encephalopathic changes, please correlate clinically. There is no evidence of acute hemorrhage, hydrocephalus, or midline shift. A low-attenuation area is identified on the right occipital region, likely consistent with chronic deposits of hemosiderin, please correlate with the prior MRI dated [**2140-12-28**]. IMPRESSION: Limited examination secondary to motion artifacts. On the FLAIR sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. The prior low-attenuation area of the right occipital lobe is unchanged and may represent chronic deposits of hemosiderin. There is no evidence of hydrocephalus or midline shifting. Followup with MRI of the head with and without contrast under conscious sedation is recommended if clinically warranted. Brief Hospital Course: A/P: 23 F with SLE, ESRD not on HD, chronic VTE with RUE and facial swelling p/w hypertensive emergency and delta MS initially admitted to the [**Hospital Unit Name 153**]. In the [**Hospital Unit Name 153**] she was on a labetalol gtt as well as home medications. She had head imaging (MRI) with following results; On the FLAIR sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. She was evaluated by neurology who considered PRES, though she did not seize. She was started on keppra as she has had seizures before, and will follow up with them. . # HTN Emergency. She has had multiple admissions in the past with neurological involvement, hemolysis in the past. SBP >300 in ED. Her BP was lowered slowly with a labetolol gtt in the ICU. When it was stably below 180 she was transferred to the medical floor on the [**Hospital Ward Name 517**]. She was continued on clonidine TP, po labetalol, aliskiren. I/O goal was even. Her BP remained between 120-170 before discharge, she no longer had any headaches, or nausea. She was oriented times three. Aliskiren was not covered by masshealth, and a prior auth was faxed over. A supply from the pharmacy was sought but unavailable. She was given a prescription for 5 pills to bridge her to the time when the prior auth would have been approved in order to facilitate her paying for the prescription. She was also given hydralazine and instructed on how to take extra doses when her blood pressure increased. . # Delta MS. [**2-11**] to hypertension likely ischemic/hypertensive changes on CT. AAO times three, no focal neurological signs currently. Also likely component of OSA although this seems chronic. No seizures although has had them in the past. Neuro was consulted, and she was started on Keppra for question of PRES, keppra for 6 weeks until f/u with neuro, has outpatient MRI appointment as well. They will likely keep her on keppra until the changes in her parietal regions have resolved. . #UTI-found on admission, was on Cipro-will complete course of 5 days . # VTE. L Brachiocephalic VTE chronic with collaterals. Also h/o other VTE [**2-11**] to lines in the past. Currently on coumadin. INR 2.1 coumadin was held in [**Hospital Unit Name 153**] for anticipation of procedures. Her coumadin was restarted, has VNA set up and will be followed by [**Hospital3 **]. . # Facial Swelling. Unclear etiology likely [**2-11**] to VTE in RUE (brachiocephalic) vs. angioedema-pt now without swelling . # ESRD. Currently no on HD due to patient preference, awaiting to start PD next week. Since patient has refused HD there was an attempt to correct lytes and acid base with medications. Avoided fluid overload with lasix, patient currently making urine. Lytes - see below. She will commence PD as an outpatient (had issues yesterday with catheter flushing)-still not working-will try laxatives to relieve loops of bowel possibly wrapped around catheter and she will follow up with renal on Monday. Her ACE/[**Last Name (un) **] were held, renally dosed her meds, and phos binder was administered. . # Metabolic Acidosis/Electrolytes abnormalities. AG 15 likely [**2-11**] to uremia. K elevated to 5.6-6.0 however has been elevated in the past, likely some chronic hyerkalemia. She received kayexalate 30 mg tid until K <5 Her electrolytes stabilized and she was continued on her home regimen of sodium bicarb (650mg two tabs daily). . # SLE. On prednisone chronically, likely needs PCP [**Name9 (PRE) **] at some point --Atovaquone to prevent hyperkalemia Continued on prednisone 10mg (dropped from 15mg 2 weeks ago) . # Anemia-Hct and plts dropped on this admission but now stable . # HOCM. Avoid dehydration. Currently on Labetalol. . # PPX: systemically anticoagulated, getting kayexalate, PPI # FEN: Electrolytes as above, no standing fluids I/Os goal even. # Access: 2x PIV currently # Code: Full # Dispo: home Medications on Admission: Pantoprazole 40 mg daily - Clonidine TP 0.3/24 hrs q wednesday - Prednisone 10 mg daily (just decreased from 15 mg) - Calcitriol 0.25 mcg daily - Sodium bicarbonate 650 mg 2 tabs daily - Vit D3 400 mg daily - Vit D2 50,000 q wed, x 10 weeks - Labetalol 300 mg po 3 tabs TID - Nifedipine SR 90 mg [**Hospital1 **] - Warfarin 2 mg daily - Hydral 25 mg TID - Lasix 40 mg [**Hospital1 **] (started friday) - Benadryl 25 mg po prn - Ativan 1 mg [**Hospital1 **] prn - Colace 100 mg [**Hospital1 **] prn - Morphine 15 mg po q 6 hrs x 14 days - Diovan 320 mg daily - Dilaudid prn Discharge Medications: 1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): on alternating days with 15mg. 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 4. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): please take as directed when blood pressure is above 180. Disp:*90 Tablet(s)* Refills:*2* 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). Disp:*405 Tablet(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for hold for sbp < 130. Disp:*10 Tablet(s)* Refills:*0* 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Outpatient Lab Work for [**Known firstname **] [**Known lastname **] DOB [**2117-8-7**] please check INR once a week and have results faxed to [**Hospital3 **] at [**Hospital1 18**] phone-[**Telephone/Fax (1) 14650**], fax-[**Telephone/Fax (1) 44543**] 16. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO once a day: hold for sbp<130. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: -hypertensive emergency -Lupus - [**2134**]. Diagnosed after she began to have swolen fingers, a rash and painful joints. -ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose every 3 months for 2 years until began dialysis 3 times a week in [**2137**] (T, Th, Sat). Now no longer on Hemodialysis, with hyperkalemia/Hypocalcemia/Hyperphosphatemia/Elevated PTH/Metabolic Acidosis; PD Catheter placed [**5-18**] -h/o seizures, ICU admissions; h/o two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] that resolved -Uveitis secondary to SLE - [**4-16**]; s/p surgery [**2-16**]; she had blood cleared and cataract removed as well as glaucoma. -HOCM - per Echo in [**2137**] -Mulitple episodes of dialysis reactions -Anemia -H/O SVC thrombus [**10-16**] [**2-11**] catheter placement, was on coumadin then stopped; Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]); Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]); Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) -Facial and left breast swelling - attributed to angioedema vs chronic L Brachiocephalic vein occlusion -Thrombophilia ?????? likely related to SLE, h/o recurrent VTE -Thrombocytopenia NOS -TTP (got plasmapheresisis) versus malignant HTN -History of left eye enucleation [**2139-4-20**] for fungal infection Discharge Condition: stable, afebrile, SBP 120's-170's Discharge Instructions: You were admitted with hypertensive emergency, your blood pressure was extremely high. You had a head CT and MRI that showed some changes concerning for PRES (posterior reversible leukoencephalopathy syndrome), and neurology recommended initiating Keppra. Your blood pressure was brought under control in the intensive care unit and now you have a new regimen of medications. In addition peritoneal dialysis was attempted but there were difficulties with your catheter. This will be further addressed by your outpatient nephrologist. You will continue to have your INR drawn and sent to coumadin clinic. You should take all your medications as prescribed, you will be taking the keppra until you follow up with a neurologist in approximately 6 weeks. You will also be taking the Aliskiren following discharge. You will be discharged on hydralazine (which you will take three times daily EVERY DAY), as well as when your blood pressure gets too high as follows; if you blood pressure is above 180 please take an extra dose of hydralazine, check your blood pressure in 10 minutes, if it is still not take another dose and recheck your blood pressure in another 10 minutes-if it is still elevated take another 25mg hydralazine and recheck in 10 minutes-if it is still elevated please call your doctor or go to the ER. Continue taking your coumadin and having your INR sent to coumadin clinic. Please seek medication attention if you have any headaches, chest pain, shortness of breath, dizzyness, nausea or any other concerning symptoms. Please follow up as outlined below. Followup Instructions: -Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00 -Your renal team will contact you regarding follow up-you should call CB for home teaching. -Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2141-7-12**] 10:30 -MRI Tuesday [**7-25**]-9:30am, [**Location (un) **] [**Hospital Ward Name 23**] Building -[**Company 191**] [**Telephone/Fax (1) 250**] N.P-[**7-25**] 1:40pm -Stroke center Dr. [**Last Name (STitle) **] at the [**Hospital Ward Name 23**] center, [**Location (un) **]-Tuesday [**8-1**], 5:00pm-you will need to call your PCP for [**Name Initial (PRE) **] referral -Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Company 191**] ([**Hospital Ward Name 23**] Building) Tuesday [**8-15**] 2:00pm [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2141-6-19**]",139,2141-06-11 10:17:00,2141-06-17 16:29:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSIVE EMERGENCY," a/p: 23 f with sle, esrd not on hd, chronic vte with rue and facial swelling p/w hypertensive emergency and delta ms initially admitted to the [**hospital unit name 153**]. in the [**hospital unit name 153**] she was on a labetalol gtt as well as home medications. she had head imaging (mri) with following results; on the flair sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. she was evaluated by neurology who considered pres, though she did not seize. she was started on keppra as she has had seizures before, and will follow up with them. . # htn emergency. she has had multiple admissions in the past with neurological involvement, hemolysis in the past. sbp >300 in ed. her bp was lowered slowly with a labetolol gtt in the icu. when it was stably below 180 she was transferred to the medical floor on the [**hospital ward name 517**]. she was continued on clonidine tp, po labetalol, aliskiren. i/o goal was even. her bp remained between 120-170 before discharge, she no longer had any headaches, or nausea. she was oriented times three. aliskiren was not covered by masshealth, and a prior auth was faxed over. a supply from the pharmacy was sought but unavailable. she was given a prescription for 5 pills to bridge her to the time when the prior auth would have been approved in order to facilitate her paying for the prescription. she was also given hydralazine and instructed on how to take extra doses when her blood pressure increased. . # delta ms. [**2-11**] to hypertension likely ischemic/hypertensive changes on ct. aao times three, no focal neurological signs currently. also likely component of osa although this seems chronic. no seizures although has had them in the past. neuro was consulted, and she was started on keppra for question of pres, keppra for 6 weeks until f/u with neuro, has outpatient mri appointment as well. they will likely keep her on keppra until the changes in her parietal regions have resolved. . #uti-found on admission, was on cipro-will complete course of 5 days . # vte. l brachiocephalic vte chronic with collaterals. also h/o other vte [**2-11**] to lines in the past. currently on coumadin. inr 2.1 coumadin was held in [**hospital unit name 153**] for anticipation of procedures. her coumadin was restarted, has vna set up and will be followed by [**hospital3 **]. . # facial swelling. unclear etiology likely [**2-11**] to vte in rue (brachiocephalic) vs. angioedema-pt now without swelling . # esrd. currently no on hd due to patient preference, awaiting to start pd next week. since patient has refused hd there was an attempt to correct lytes and acid base with medications. avoided fluid overload with lasix, patient currently making urine. lytes - see below. she will commence pd as an outpatient (had issues yesterday with catheter flushing)-still not working-will try laxatives to relieve loops of bowel possibly wrapped around catheter and she will follow up with renal on monday. her ace/[**last name (un) **] were held, renally dosed her meds, and phos binder was administered. . # metabolic acidosis/electrolytes abnormalities. ag 15 likely [**2-11**] to uremia. k elevated to 5.6-6.0 however has been elevated in the past, likely some chronic hyerkalemia. she received kayexalate 30 mg tid until k <5 her electrolytes stabilized and she was continued on her home regimen of sodium bicarb (650mg two tabs daily). . # sle. on prednisone chronically, likely needs pcp [**name9 (pre) **] at some point --atovaquone to prevent hyperkalemia continued on prednisone 10mg (dropped from 15mg 2 weeks ago) . # anemia-hct and plts dropped on this admission but now stable . # hocm. avoid dehydration. currently on labetalol. . # ppx: systemically anticoagulated, getting kayexalate, ppi # fen: electrolytes as above, no standing fluids i/os goal even. # access: 2x piv currently # code: full # dispo: home ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other encephalopathy; Chronic glomerulonephritis in diseases classified elsewhere; Urinary tract infection, site not specified; Acidosis; Unspecified iridocyclitis; Acquired hemolytic anemia, unspecified; Systemic lupus erythematosus; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Swelling, mass, or lump in head and neck; Hyperpotassemia; Lump or mass in breast; Thrombocytopenia, unspecified; Hypocalcemia; Disorders of phosphorus metabolism]","a/p: 23 f with sle, esrd not on hd, chronic vte with rue and facial swelling p/w hypertensive emergency and delta ms initially admitted to the [**hospital unit name 153**]. she was evaluated by neurology who considered pres, though she did not seize. aliskiren was not covered by masshealth, and a prior auth was faxed over. also likely component of osa although this seems chronic. inr 2.1 coumadin was held in [**hospital unit name 153**] for anticipation of procedures. avoided fluid overload with lasix, patient currently making urine. # metabolic acidosis/electrolytes abnormalities. # ppx: systemically anticoagulated, getting kayexalate, ppi # fen: electrolytes as above, no standing fluids i/os goal even.","delta ms was evaluated by neurology who considered pres, though she did not seize. she was started on keppra as she has had seizures before, and will follow up with them. her bp remained between 120-170 before discharge, she no longer had headaches, or nausea." 109,172335.0,14797,2141-09-24,15329,147469.0,2141-06-17,Discharge summary,"Admission Date: [**2141-6-11**] Discharge Date: [**2141-6-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: hypertensive urgency Major Surgical or Invasive Procedure: arterial line History of Present Illness: HPI: 23 F with h/o Lupus, ESRD not on HD (planned PD), labile hypertension, RUE VTE on anticoagulation, recent facial swelling who presents with hypertensive emergency. Patient developed severe frontal HA last evenening, a/w nausea. BP was not [**Location (un) 1131**] on home BP cuff. In the AM her HA was severe [**10-20**] a/w nausea and vomiting yellow/green liquid and BP cuff again not able to obtain BP. Patient was last seen by VNA this past Friday with BP 130/70. Patient denies any CP, shortness of breath, abd pain. Her facial swelling is slightly worse today. She denies any weakness, dizziness, difficulty with speach, no numbness or tingling. She says that she is compliant with all of her medications. She denies any GU/GI complaints despite +UA in ED. . In the ED, VS: 98.2 92 SBP >300/P [**Telephone/Fax (3) 44541**]-131) 16 98 % RA. Patient received zofran IV, Hydral IV, Labetalol 20 mg IV x 1, Nipride gtt started. Kayexalate 30 mg x 1. Other po meds written but patient did not take due to nausea. CT head showing no hemorrhage but hypoattenuation in frontal area, which is change from prior MRI in [**Month (only) **]. She is on coumadin for RUE VTE with INR 2.1. Also with UTI in ED, started Cirpo x 1. Labs showing K 5.6 ECG with ?hyperacute T waves, otherwise no changes, given kayexalate only. . Interval Hx: Patient was admitted [**2141-5-24**] to [**6-6**] with facial swelling and hypertensive emergency requiring ICU care. She was also admitted [**Date range (1) 43498**] with similar complaints. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 98.8 84 [**Telephone/Fax (2) 44542**]% RA Gen: swollen face L>R, alert and cooperative, NAD, snoring when asleep but easily arousable Heent: OP clear, swollen eye lids L>R, Left eye retracted with prosthesis, anicteric, OP moist Neck: supple, no JVD elevation, no meningismus CV: nl S1 S2, RRR, [**1-15**] SM Lungs: CTAB Abd: obese, soft, NT, ND, BS+ Ext: dry, no c/c/e, diminished, Neuro: Alert and oriented x 3, gets drowsy intermittently but arousable, CN II-XII intact, strength 5/5 throughout, sensations intact Pertinent Results: [**6-14**]: AXR:IMPRESSION: PD catheter with tip coiled in the pelvis. [**6-11**]: IMPRESSION: 1. Areas of hypoattenuation in the high bifrontal white matter, and subcortical hypoattenuation in the left posterior temporal lobe with loss of [**Doctor Last Name 352**]-white differentiation. These findings are new from MRI brain [**12-29**], [**2140**], and could represent areas of new edema with underlying focal lesion or possibly areas of new infarcts. An MRI head without and with Iv conrast is recommended for further characterization. 2. No evidence of intracranial hemorrhage. [**6-11**]: PA AND LATERAL VIEWS OF THE CHEST: There has been an interval increase in retrocardiac opacity obscuring the left hemidiaphragm. The right lung and the left upper lung zone are clear. The right costophrenic angle is slightly blunted, suggesting a very small right pleural effusion. The heart is slightly enlarged, but the cardiomediastinal silhouette is unchanged. There is no hilar enlargement. Soft tissue and bony structures are unremarkable. IMPRESSION: Interval increase in left basilar atelectasis with pleural effusion. Superimposed pneumonia cannot be excluded. Possible small right pleural effusion. [**6-11**]: MR [**Name13 (STitle) 430**]: INDINGS: In comparison with a prior CT of the head, the previously described low attenuation areas in the parietal regions appear with hyperintensity signal on the FLAIR sequence, mildly hyperintense on the diffusion-weighted sequence, and also slightly hyperintense on the corresponding ADC maps, these findings are nonspecific and may represent posterior reversible encephalopathic changes, please correlate clinically. There is no evidence of acute hemorrhage, hydrocephalus, or midline shift. A low-attenuation area is identified on the right occipital region, likely consistent with chronic deposits of hemosiderin, please correlate with the prior MRI dated [**2140-12-28**]. IMPRESSION: Limited examination secondary to motion artifacts. On the FLAIR sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. The prior low-attenuation area of the right occipital lobe is unchanged and may represent chronic deposits of hemosiderin. There is no evidence of hydrocephalus or midline shifting. Followup with MRI of the head with and without contrast under conscious sedation is recommended if clinically warranted. Brief Hospital Course: A/P: 23 F with SLE, ESRD not on HD, chronic VTE with RUE and facial swelling p/w hypertensive emergency and delta MS initially admitted to the [**Hospital Unit Name 153**]. In the [**Hospital Unit Name 153**] she was on a labetalol gtt as well as home medications. She had head imaging (MRI) with following results; On the FLAIR sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. She was evaluated by neurology who considered PRES, though she did not seize. She was started on keppra as she has had seizures before, and will follow up with them. . # HTN Emergency. She has had multiple admissions in the past with neurological involvement, hemolysis in the past. SBP >300 in ED. Her BP was lowered slowly with a labetolol gtt in the ICU. When it was stably below 180 she was transferred to the medical floor on the [**Hospital Ward Name 517**]. She was continued on clonidine TP, po labetalol, aliskiren. I/O goal was even. Her BP remained between 120-170 before discharge, she no longer had any headaches, or nausea. She was oriented times three. Aliskiren was not covered by masshealth, and a prior auth was faxed over. A supply from the pharmacy was sought but unavailable. She was given a prescription for 5 pills to bridge her to the time when the prior auth would have been approved in order to facilitate her paying for the prescription. She was also given hydralazine and instructed on how to take extra doses when her blood pressure increased. . # Delta MS. [**2-11**] to hypertension likely ischemic/hypertensive changes on CT. AAO times three, no focal neurological signs currently. Also likely component of OSA although this seems chronic. No seizures although has had them in the past. Neuro was consulted, and she was started on Keppra for question of PRES, keppra for 6 weeks until f/u with neuro, has outpatient MRI appointment as well. They will likely keep her on keppra until the changes in her parietal regions have resolved. . #UTI-found on admission, was on Cipro-will complete course of 5 days . # VTE. L Brachiocephalic VTE chronic with collaterals. Also h/o other VTE [**2-11**] to lines in the past. Currently on coumadin. INR 2.1 coumadin was held in [**Hospital Unit Name 153**] for anticipation of procedures. Her coumadin was restarted, has VNA set up and will be followed by [**Hospital3 **]. . # Facial Swelling. Unclear etiology likely [**2-11**] to VTE in RUE (brachiocephalic) vs. angioedema-pt now without swelling . # ESRD. Currently no on HD due to patient preference, awaiting to start PD next week. Since patient has refused HD there was an attempt to correct lytes and acid base with medications. Avoided fluid overload with lasix, patient currently making urine. Lytes - see below. She will commence PD as an outpatient (had issues yesterday with catheter flushing)-still not working-will try laxatives to relieve loops of bowel possibly wrapped around catheter and she will follow up with renal on Monday. Her ACE/[**Last Name (un) **] were held, renally dosed her meds, and phos binder was administered. . # Metabolic Acidosis/Electrolytes abnormalities. AG 15 likely [**2-11**] to uremia. K elevated to 5.6-6.0 however has been elevated in the past, likely some chronic hyerkalemia. She received kayexalate 30 mg tid until K <5 Her electrolytes stabilized and she was continued on her home regimen of sodium bicarb (650mg two tabs daily). . # SLE. On prednisone chronically, likely needs PCP [**Name9 (PRE) **] at some point --Atovaquone to prevent hyperkalemia Continued on prednisone 10mg (dropped from 15mg 2 weeks ago) . # Anemia-Hct and plts dropped on this admission but now stable . # HOCM. Avoid dehydration. Currently on Labetalol. . # PPX: systemically anticoagulated, getting kayexalate, PPI # FEN: Electrolytes as above, no standing fluids I/Os goal even. # Access: 2x PIV currently # Code: Full # Dispo: home Medications on Admission: Pantoprazole 40 mg daily - Clonidine TP 0.3/24 hrs q wednesday - Prednisone 10 mg daily (just decreased from 15 mg) - Calcitriol 0.25 mcg daily - Sodium bicarbonate 650 mg 2 tabs daily - Vit D3 400 mg daily - Vit D2 50,000 q wed, x 10 weeks - Labetalol 300 mg po 3 tabs TID - Nifedipine SR 90 mg [**Hospital1 **] - Warfarin 2 mg daily - Hydral 25 mg TID - Lasix 40 mg [**Hospital1 **] (started friday) - Benadryl 25 mg po prn - Ativan 1 mg [**Hospital1 **] prn - Colace 100 mg [**Hospital1 **] prn - Morphine 15 mg po q 6 hrs x 14 days - Diovan 320 mg daily - Dilaudid prn Discharge Medications: 1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): on alternating days with 15mg. 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 4. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): please take as directed when blood pressure is above 180. Disp:*90 Tablet(s)* Refills:*2* 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). Disp:*405 Tablet(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for hold for sbp < 130. Disp:*10 Tablet(s)* Refills:*0* 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Outpatient Lab Work for [**Known firstname **] [**Known lastname **] DOB [**2117-8-7**] please check INR once a week and have results faxed to [**Hospital3 **] at [**Hospital1 18**] phone-[**Telephone/Fax (1) 14650**], fax-[**Telephone/Fax (1) 44543**] 16. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO once a day: hold for sbp<130. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: -hypertensive emergency -Lupus - [**2134**]. Diagnosed after she began to have swolen fingers, a rash and painful joints. -ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose every 3 months for 2 years until began dialysis 3 times a week in [**2137**] (T, Th, Sat). Now no longer on Hemodialysis, with hyperkalemia/Hypocalcemia/Hyperphosphatemia/Elevated PTH/Metabolic Acidosis; PD Catheter placed [**5-18**] -h/o seizures, ICU admissions; h/o two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] that resolved -Uveitis secondary to SLE - [**4-16**]; s/p surgery [**2-16**]; she had blood cleared and cataract removed as well as glaucoma. -HOCM - per Echo in [**2137**] -Mulitple episodes of dialysis reactions -Anemia -H/O SVC thrombus [**10-16**] [**2-11**] catheter placement, was on coumadin then stopped; Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]); Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]); Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) -Facial and left breast swelling - attributed to angioedema vs chronic L Brachiocephalic vein occlusion -Thrombophilia ?????? likely related to SLE, h/o recurrent VTE -Thrombocytopenia NOS -TTP (got plasmapheresisis) versus malignant HTN -History of left eye enucleation [**2139-4-20**] for fungal infection Discharge Condition: stable, afebrile, SBP 120's-170's Discharge Instructions: You were admitted with hypertensive emergency, your blood pressure was extremely high. You had a head CT and MRI that showed some changes concerning for PRES (posterior reversible leukoencephalopathy syndrome), and neurology recommended initiating Keppra. Your blood pressure was brought under control in the intensive care unit and now you have a new regimen of medications. In addition peritoneal dialysis was attempted but there were difficulties with your catheter. This will be further addressed by your outpatient nephrologist. You will continue to have your INR drawn and sent to coumadin clinic. You should take all your medications as prescribed, you will be taking the keppra until you follow up with a neurologist in approximately 6 weeks. You will also be taking the Aliskiren following discharge. You will be discharged on hydralazine (which you will take three times daily EVERY DAY), as well as when your blood pressure gets too high as follows; if you blood pressure is above 180 please take an extra dose of hydralazine, check your blood pressure in 10 minutes, if it is still not take another dose and recheck your blood pressure in another 10 minutes-if it is still elevated take another 25mg hydralazine and recheck in 10 minutes-if it is still elevated please call your doctor or go to the ER. Continue taking your coumadin and having your INR sent to coumadin clinic. Please seek medication attention if you have any headaches, chest pain, shortness of breath, dizzyness, nausea or any other concerning symptoms. Please follow up as outlined below. Followup Instructions: -Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00 -Your renal team will contact you regarding follow up-you should call CB for home teaching. -Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2141-7-12**] 10:30 -MRI Tuesday [**7-25**]-9:30am, [**Location (un) **] [**Hospital Ward Name 23**] Building -[**Company 191**] [**Telephone/Fax (1) 250**] N.P-[**7-25**] 1:40pm -Stroke center Dr. [**Last Name (STitle) **] at the [**Hospital Ward Name 23**] center, [**Location (un) **]-Tuesday [**8-1**], 5:00pm-you will need to call your PCP for [**Name Initial (PRE) **] referral -Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Company 191**] ([**Hospital Ward Name 23**] Building) Tuesday [**8-15**] 2:00pm [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2141-6-19**]",99,2141-06-11 10:17:00,2141-06-17 16:29:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSIVE EMERGENCY," a/p: 23 f with sle, esrd not on hd, chronic vte with rue and facial swelling p/w hypertensive emergency and delta ms initially admitted to the [**hospital unit name 153**]. in the [**hospital unit name 153**] she was on a labetalol gtt as well as home medications. she had head imaging (mri) with following results; on the flair sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. she was evaluated by neurology who considered pres, though she did not seize. she was started on keppra as she has had seizures before, and will follow up with them. . # htn emergency. she has had multiple admissions in the past with neurological involvement, hemolysis in the past. sbp >300 in ed. her bp was lowered slowly with a labetolol gtt in the icu. when it was stably below 180 she was transferred to the medical floor on the [**hospital ward name 517**]. she was continued on clonidine tp, po labetalol, aliskiren. i/o goal was even. her bp remained between 120-170 before discharge, she no longer had any headaches, or nausea. she was oriented times three. aliskiren was not covered by masshealth, and a prior auth was faxed over. a supply from the pharmacy was sought but unavailable. she was given a prescription for 5 pills to bridge her to the time when the prior auth would have been approved in order to facilitate her paying for the prescription. she was also given hydralazine and instructed on how to take extra doses when her blood pressure increased. . # delta ms. [**2-11**] to hypertension likely ischemic/hypertensive changes on ct. aao times three, no focal neurological signs currently. also likely component of osa although this seems chronic. no seizures although has had them in the past. neuro was consulted, and she was started on keppra for question of pres, keppra for 6 weeks until f/u with neuro, has outpatient mri appointment as well. they will likely keep her on keppra until the changes in her parietal regions have resolved. . #uti-found on admission, was on cipro-will complete course of 5 days . # vte. l brachiocephalic vte chronic with collaterals. also h/o other vte [**2-11**] to lines in the past. currently on coumadin. inr 2.1 coumadin was held in [**hospital unit name 153**] for anticipation of procedures. her coumadin was restarted, has vna set up and will be followed by [**hospital3 **]. . # facial swelling. unclear etiology likely [**2-11**] to vte in rue (brachiocephalic) vs. angioedema-pt now without swelling . # esrd. currently no on hd due to patient preference, awaiting to start pd next week. since patient has refused hd there was an attempt to correct lytes and acid base with medications. avoided fluid overload with lasix, patient currently making urine. lytes - see below. she will commence pd as an outpatient (had issues yesterday with catheter flushing)-still not working-will try laxatives to relieve loops of bowel possibly wrapped around catheter and she will follow up with renal on monday. her ace/[**last name (un) **] were held, renally dosed her meds, and phos binder was administered. . # metabolic acidosis/electrolytes abnormalities. ag 15 likely [**2-11**] to uremia. k elevated to 5.6-6.0 however has been elevated in the past, likely some chronic hyerkalemia. she received kayexalate 30 mg tid until k <5 her electrolytes stabilized and she was continued on her home regimen of sodium bicarb (650mg two tabs daily). . # sle. on prednisone chronically, likely needs pcp [**name9 (pre) **] at some point --atovaquone to prevent hyperkalemia continued on prednisone 10mg (dropped from 15mg 2 weeks ago) . # anemia-hct and plts dropped on this admission but now stable . # hocm. avoid dehydration. currently on labetalol. . # ppx: systemically anticoagulated, getting kayexalate, ppi # fen: electrolytes as above, no standing fluids i/os goal even. # access: 2x piv currently # code: full # dispo: home ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other encephalopathy; Chronic glomerulonephritis in diseases classified elsewhere; Urinary tract infection, site not specified; Acidosis; Unspecified iridocyclitis; Acquired hemolytic anemia, unspecified; Systemic lupus erythematosus; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Swelling, mass, or lump in head and neck; Hyperpotassemia; Lump or mass in breast; Thrombocytopenia, unspecified; Hypocalcemia; Disorders of phosphorus metabolism]","a/p: 23 f with sle, esrd not on hd, chronic vte with rue and facial swelling p/w hypertensive emergency and delta ms initially admitted to the [**hospital unit name 153**]. she was evaluated by neurology who considered pres, though she did not seize. aliskiren was not covered by masshealth, and a prior auth was faxed over. also likely component of osa although this seems chronic. inr 2.1 coumadin was held in [**hospital unit name 153**] for anticipation of procedures. avoided fluid overload with lasix, patient currently making urine. # metabolic acidosis/electrolytes abnormalities. # ppx: systemically anticoagulated, getting kayexalate, ppi # fen: electrolytes as above, no standing fluids i/os goal even.","delta ms was evaluated by neurology who considered pres, though she did not seize. she was started on keppra as she has had seizures before, and will follow up with them. her bp remained between 120-170 before discharge, she no longer had headaches, or nausea." 109,172335.0,14797,2141-09-24,14796,139061.0,2141-09-14,Discharge summary,"Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Right leg pain. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 24 y.o. F with lupus, Chronic Kidney Disease V (not currently on HD or PD), and multiple admissions for hypertensive urgency/emergency, who presented to the ED for continued R leg pain that starts in her R buttocks and refers down her R leg. She describes it as feeling like the pain is deep within her bone. The pain was [**10-20**] in the AM, and she felt like she couldn't get out of bed. Denies any swelling of her RLE. When getting VS in [**Name (NI) **], pt noted to be very hypertensive at 263/176. The patient reportedly has baseline SBPs in 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM on day of admission. She denies any recent recrational drug use including cocaine and amphetamines. She denies headache, vision changes, double vision, chest pain, shortness of breath, abdominal pain, BRBPR, dysuria. During MD interview, the patient was nauseous and had small amount of emesis of a recent Coolata. Pt states that flushing her PD cath causes a large amount of stomach pain. . Of note, the patient was recently admitted from 08.26-29.08. The patient initially presented to the ED after referral from her nephrologist's office where she had complaints of right leg pain and was found to be hypertensive to 250/145. She was admitted after initiation of a labetalol drip and nitropaste with improvement in sbp to 180. The patient did receive 2 U of PRBC's during this hospitalization for baseline anemia. The patient did have a work-up for her right leg pain complaints with plain films of the right hip and MRI of the L-spine which did not reveal an explanation for her symptoms and did rule out avascular necrosis. The patient received dilaudid for pain control and was ambulating without pain prior to discharge. In addition, the patient completed a course of ciprofloxacin for a positive UA with negative cultures. The patient was unable to tolerate peritoneal dialysis for unclear reasons. Peritoneal dialysate culture was negative for infection. . In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in ED ranged from [**Telephone/Fax (3) 43494**]-175 with HR in 96-108. Initially given labetalol 10 mg IV x 1 and then started on labetalol gtt for her elevated blood pressures and titrated to 3 mg/min. LENI of R leg was negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per ED, cannot do V/Q scan due to volume overload after talking with radiology. Renal c/s initiated. A-line placed. Past Medical History: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] . PAST SURGICAL HISTORY: - Placement of multiple catheters including dialysis. - Tonsillectomy. - Left eye enucleation in [**2140-4-10**]. - PD catheter placement in [**2141-5-11**]. Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 98.9 [**Telephone/Fax (2) 43495**] 99$% RA GEN: NAD, pleasant female sitting in bed with moon facies HEENT: EOMI of R eye, L eye prosthesis, no exudate, no erythema, MMM, no LAD CHEST: CTAB except at R base with decreased breath sounds; no w/r/r CV: tachy, normal S1S2, II/VI systolic murmur accentuated with Valsalva ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i EXT: no c/c/e, strength of LEs [**5-15**] and symmetric bilaterally. Negative straight leg test, no pain with internal rotation, external rotation, extension, adduction or abduction. Some pain on flexion at the hip. NEURO: II - XII intact to direct testing. No deficit in light tough sensation. Gait normal. DERM: no rashes noted Pertinent Results: LABS AT ADMISSION: [**2141-9-11**] 11:43AM GLUCOSE-86 UREA N-49* CREAT-8.1* SODIUM-139 POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-16* ANION GAP-18 [**2141-9-11**] 11:43AM CALCIUM-6.2* PHOSPHATE-5.8* MAGNESIUM-1.6 [**2141-9-11**] 11:43AM PT-18.4* PTT-42.8* INR(PT)-1.7* [**2141-9-11**] 07:00AM WBC-5.5 RBC-2.88* HGB-8.1* HCT-24.7* MCV-86 MCH-28.1 MCHC-32.8 RDW-18.0* [**2141-9-11**] 07:00AM NEUTS-74.7* LYMPHS-17.5* MONOS-4.2 EOS-3.3 BASOS-0.2 [**2141-9-11**] 07:00AM PLT COUNT-101* UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50 WBC . MICROBIOLOGY: Urine culture ([**2141-9-11**]): Mixed flora . STUDIES: Cardiology Report ECG Study Date of [**2141-9-11**] 6:55:16 AM Sinus tachycardia. The tracing is marred by baseline artifact. There is left atrial enlargement. Compared to the previous tracing of [**2141-9-5**] the rate has increased. The axis is more rightward. Otherwise, no diagnostic interim change. . UNILAT LOWER EXT VEINS RIGHT Study Date of [**2141-9-11**] 8:54 AM [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and popliteal veins demonstrate normal flow, compressibility, augmentation, waveforms. Appropriate color flow and compression is noted within the calf veins. No intraluminal thrombus is present. IMPRESSION: No evidence of right lower extremity DVT. . TTE ([**2140-8-26**]): The left atrium is normal in size. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . R HIP XR [**2141-9-6**]: No acute fracture or dislocation. . MRI L-SPINE [**2141-9-6**]: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. LAB RESULTS AT DISCHARGE: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-9-14**] 06:15AM 4.0 2.63* 7.6* 23.1* 88 29.1 33.0 18.0* 100* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-9-14**] 06:15AM 100 44* 8.1* 137 4.8 109* 17* 16 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2141-9-14**] 06:15AM 6.8* 5.4* 1.6 CALCIUM freeCa [**2141-9-14**] 11:30AM 0.94* Brief Hospital Course: ICU course: EKG showed no change from prior, and CXR showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home medication regimen. The patient was found to by hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. . [**Hospital1 **] history: . 1. Hypertensive urgency: During the patient's [**Hospital1 **] stay, her SBPs ranged from 140s-160s during the day, which is her baseline systolic blood pressure. She was maintained on her home oral medication regimen. At night, she became more hypertensive, with SBP to the 170s-180s, which was controlled with both IV hydralazine and PO nifedipine. PO nifedipine was most successful at bringing her SBP back to her baseline. SBP at discharge was 140. Throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. The renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. Right leg pain: Upon arrival on the floor, the patient complained of [**2143-4-15**] pain in R buttock and posterior thigh, much exacerbated with standing. Of note, lumbar spine MRI and R hip XR on most recent admission were both negative. Her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. Her pain when she was symptomatic was controlled well with PO dilaudid. If the pain recurs, an MRI of the right hip can be considered to evaluate for osteonecrosis. . 3. UTI: The patient had a urinalysis suggestive of UTI, though she remained asymptomatic throughout. She was treated with a three day course of ciprofloxacin. Her urine culture showed mixed flora consistent with skin contamination. . 4. ESRD: The patient has end-stage renal disease due to her lupus. The patient's creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. She was followed by the renal consult service. Her potassium remained stable. Her calcium was low during admission, and supplemental calcium was given in addition to starting Calcitriol. She was not dialyzed through her PD catheter secondary to discomfort, but may reinitiate PD as an outpatient. Her laboratories will be checked as an outpatient in renal clinic. . 5. Anemia: The patient's hematocrit remained near her baseline low 20s throughout her stay. She has anemia from chronic kidney disease and chronic disease. The patient is not on Epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. Prior SVC thrombus: The patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with INR goal 2.5 to 3.0. . 7. Systemic lupus erythematosus: No active issues. The patient's home prednisone regimen was continued. Medications on Admission: - Prednisone 5 mg Daily - Coumadin 2 mg at bedtime - Nifedipine 60 mg Sustained Release Daily - Hydralazine 50 mg every 8 hours - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY - Aliskiren 150 mg Twice daily - Docusate Sodium 100 mg 2 times a day - Labetalol 900 mg three times a day - Lactulose 15-30 ml once a day: goal is [**1-11**] soft bowel movements per day Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 7. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: - Hypertensive urgency - Right lower extremity pain - Urinary tract infection Secondary diagnosis: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) - HOCM: Last noted on echo [**8-17**] - Anemia - History of left eye enucleation [**2139-4-20**] for fungal infection - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Discharge Condition: Stable systolic blood pressure over past 24 hours. Discharge Instructions: You were admitted to the hospital for uncontrolled high blood pressure. You spent one day in the intensive care unit, where you were treated with intravenous medication to lower your blood pressure. You were then transferred to a regular hospital floor, where your blood pressure was managed with your home oral medications. You were also treated for urinary tract infection with antibiotics. Your right leg pain improved during admission, and we are unsure of the cause of this pain. You should discuss the need for an MRI of the hip if the pain returns when you meet with your primary care doctor. Please call your physician or return to the emergency room if you experience fever, chills, chest pain, difficulty breathing, abdominal pain, headache, changes in your vision, or any other symptoms that are concerning. Please take your medications as prescribed. - Calcitriol was added to your medications. - You should hold Coumadin for two days and restart Saturday, [**2141-9-16**]. You should have your INR checked at your visit in kidney clinic [**2141-9-18**]. - You can take Dilaudid 2-4 mg every eight hours as needed for pain. You should be vigilant about taking lactulose if you need to take Dilaudid. - You should continue Lactulose as per Dr.[**Name (NI) 12913**] instructions. - No other changes were made. Please keep follow up appointments as described below. Followup Instructions: Please call the office of your kidney doctor, Dr. [**Last Name (STitle) 4883**], at ([**Telephone/Fax (1) 773**] to schedule an appointment for [**Last Name (LF) 766**], [**9-19**] as discussed. Follow up with your lung doctor: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-9-21**] 1:00 Follow up with your new primary care doctor: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 ",10,2141-09-11 10:12:00,2141-09-14 20:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home medication regimen. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. . [**hospital1 **] history: . 1. hypertensive urgency: during the patients [**hospital1 **] stay, her sbps ranged from 140s-160s during the day, which is her baseline systolic blood pressure. she was maintained on her home oral medication regimen. at night, she became more hypertensive, with sbp to the 170s-180s, which was controlled with both iv hydralazine and po nifedipine. po nifedipine was most successful at bringing her sbp back to her baseline. sbp at discharge was 140. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. the renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. her pain when she was symptomatic was controlled well with po dilaudid. if the pain recurs, an mri of the right hip can be considered to evaluate for osteonecrosis. . 3. uti: the patient had a urinalysis suggestive of uti, though she remained asymptomatic throughout. she was treated with a three day course of ciprofloxacin. her urine culture showed mixed flora consistent with skin contamination. . 4. esrd: the patient has end-stage renal disease due to her lupus. the patients creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. she was followed by the renal consult service. her potassium remained stable. her calcium was low during admission, and supplemental calcium was given in addition to starting calcitriol. she was not dialyzed through her pd catheter secondary to discomfort, but may reinitiate pd as an outpatient. her laboratories will be checked as an outpatient in renal clinic. . 5. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay. she has anemia from chronic kidney disease and chronic disease. the patient is not on epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. prior svc thrombus: the patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with inr goal 2.5 to 3.0. . 7. systemic lupus erythematosus: no active issues. the patients home prednisone regimen was continued. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Urinary tract infection, site not specified; Other primary cardiomyopathies; Systemic lupus erythematosus; Sciatica; Hyperpotassemia; Thrombocytopenia, unspecified; Abnormal coagulation profile; Hyperparathyroidism, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism]","icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the renal team was consulted, and recommended no change to home medication regimen. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. she was treated with a three day course of ciprofloxacin. esrd: the patient has end-stage renal disease due to her lupus. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay.","ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. she became more hypertensive, with sbps to the 170s-180s during the day. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency." 109,172335.0,14797,2141-09-24,15330,131345.0,2141-09-08,Discharge summary,"Admission Date: [**2141-9-5**] Discharge Date: [**2141-9-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 348**] Chief Complaint: right leg pain, hypertension Major Surgical or Invasive Procedure: blood transfusion x2 History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. The pain is worst when she tried to bear weight on the leg, or when she uses it to roll over or adjust her position in bed. The pain begins in her buttock and travels down the posterior thigh and calf but stops before reaching the ankle. It occasionally feels like it is coming from her low back. She denies any parasthesias or weakness in the leg, and she denies any numbness in her foot or groin. She denies any fevers or incontinence. The pain was unrelieved by Vicodin that she had at home, so she scheduled an urgent visit with her nephrologist yesterday [**2141-9-4**]. At her nephrologist??????s office, she was hypertensive to 250/145 and so she was referred to the ED. She ended up leaving the ED against medical advice yesterday, but returned today because of persistent leg pain. She reports that she took all of her morning and noon BP meds. She denies any fevers, headaches, visual changes, nausea (prior to coming to the ED), or leg weakness. Upon arrival to the ED today, she was afebrile, BP 237/146, HR 97, RR 16, Sat 100% on room air. She received a total of 90 mg of IV labetalol and nitropaste, and was eventually put on a labetalol drip for her hypertension. With these interventions, her SBP dropped to the 180s, but she reported feeling nauseous and so the drip was discontinued. She was also given 4 mg of IV morphine and 1 mg of IV hydromorphone for her leg pain with decent relief. Due to a urinalysis suggestive of infection, she was given one tablet of DS TMP/SMX. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: MICU physical: Tmax: 36.3 ??????C (97.4 ??????F) Tcurrent: 36.3 ??????C (97.4 ??????F) HR: 92 (92 - 94) bpm BP: 209/138(152) {201/134(151) - 209/138(152)} mmHg RR: 19 (19 - 30) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Height: 59 Inch General: well-appearing young woman in no acute distress HEENT: no scleral icterus; prosthetic right eye Neck: supple Chest: clear to auscultation throughout, no wheezes/rales/ronchi CV: regular rate/rhythm, normal s1s2, no murmurs Abdomen: soft, nontender, nondistended, PD catheter in place in left abdomen Back: very mild spinal tenderness over approx L3 level of spine Extremities: no edema, 1+ PT pulses, warm Skin: no rashes or jaundice Neuro: alert, oriented x3, 5/5 strength in bilateral deltoids, biceps, triceps, hip flexors/extensors, ankle flexors/extensors; unable to elicit patellar reflexes bilaterally; negative straight leg raise bilaterally Pertinent Results: 138 111 54 -----------------< 83 5.4 14 8.2 . WBC: 3.7 HCT: 19 PLT: 101 N:69.3 L:23.4 M:5.5 E:1.7 Bas:0.1 PT: 21.9 PTT: 48.2 INR: 2.1 . Trends: HCT: 19 -> 22 w 1u then received another unit. INR 3.4 on discharge Discharge chem: Glucose-104 UreaN-51* Creat-8.4* Na-136 K-5.3* Cl-106 HCO3-18* AnGap-17 . [**2141-9-8**] 07:30AM BLOOD CK(CPK)-126 [**2141-9-5**] 02:50PM BLOOD HCG-<5 . [**2141-9-8**] 1:37 pm PERITONEAL FLUID GRAM STAIN (Final [**2141-9-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count . MRI L-spine: IMPRESSION: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. . CXR admit: IMPRESSION: Moderate cardiomegaly, bilateral pleural effusions, and pulmonary vascular prominence consistent with pulmonary edema. . Hip film: FINDINGS: No comparisons. No acute fracture or dislocation is seen. No lucent or sclerotic lesion is noted. There is a distal aspect of a catheter or shunt seen in the pelvis. Soft tissues are otherwise unremarkable. There is minimal degenerative change of the pubic symphysis. IMPRESSION: No acute fracture or dislocation. . Abdominal film: FINDINGS: A PD catheter is seen with its tip coiled in the pelvis. There is normal bowel gas. The underlying osseous structures are unremarkable. IMPRESSION: PD catheter with tip coiled in the pelvis . CXR [**9-8**]: IMPRESSION: Marked cardiomegaly, unchanged. Interval resolution of pulmonary edema. Brief Hospital Course: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. She was initially admitted to the MICU for hypertensive urgency and then transfered to the floor after a day. # Hypertensive urgency: had been on labetalol drip in the ED, but this was stopped due to nausea (presumed that her BP was coming down too fast). She was started on her home meds and tolerated these fairly well. Transferred to the floor and noted to have SPBs in the 90s. She required 1L IVF bolus since her baseline SBP is thought to run in the 130-170 range. She also had transient dizziness during this episode. BP meds were held and later that night her SBP was in the 220s. BP meds restarted. She remained stable thereafter with SBPs in the 130-170s. We opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # Right leg pain: no evidence of avascular necrosis or fracture on plain film. MRI and plain films were ordered and showed no acute pathology. The pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. CK was normal. Pain was treated with dilaudid initially. On day of discharge, she was able to ambulate without gait abnormality or pain. PT saw her and rec outpt PT followup. . # CKD V: PD catheter placement in place. Pt was tried on PD on a number of occasions but did not tolerate it [**2-11**] pain. KUB confirmed tip in place. Cx of peritoneal fluid not suggestive of peritonitis. K remained mildly elevated. Hyperpara treated with sevelamer (although patient refused) then tums. Pt will reconsider PD as outpatient. . # Anemia: chronic. Received 2u pRBC while inhouse for Hct in the 18-19 range. Had appropriate response. Not on Epo given hypertension . # ID: Rx with cipro for ? UTI although urine cx neg. Also had temp to 101 on evening prior to discharge. No clear source. PD fluid cultured and NGTD. Pt remainded HD stable on day of discharge. . # Prior SVC thrombus. Continued warfarin with appropriate INR checks. INR elevated on day of discharge. Rec holding coumadin for 2d . # Systemic lupus erythematosus: cont home prednisone dose . # Dispo status: ambulating, pain free, BP in the 150/90 range Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly Vicodin prn Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO WEEKLY (). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*20 Capsule(s)* Refills:*0* 9. Outpatient Physical Therapy Please provide PT for right hamstring injury 10. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*0* 11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold dose until [**9-10**]. Disp:*30 Tablet(s)* Refills:*0* 12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO once a day: goal is [**1-11**] soft bowel movements per day. Disp:*500 ml* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - HTN urgency - right leg pain - thought [**2-11**] hamstring injury - chronic kidney disease - not currently on dialysis - SLE - anemia [**2-11**] CKD and SLE - hx of SVC thrombosis on coumadin now Secondary: - hx hypertrophic obstructive cardiomyopathy - chronic thrombocytopenia Discharge Condition: ambulating without difficulty. tolerating oral diet. afebrile and SBP in the 130-150 range. Discharge Instructions: You came in with right leg pain and poorly controlled hypertension. Your blood pressure was controlled initially with IV medications then your home medications. Since your blood pressure was occasionally low, we recommend that you hold your labetalol if you are feeling lightheaded or have dizziness or have blood pressure less than 110/60. In terms of your leg pain, we performed xrays, ultrasound, and MRI without finding a cause. We suspect a hamstring injury given its location. Please take pain medications if needed. We recommend followup with physical therapy. You also had a fever which is suggestive of infection. We treated you with cipro in case you had a UTI. Otherwise, your cultures were unrevealing. We attempted peritoneal dialysis but this was unsuccessful. Please followup with your nephrologist. Please return to the ED if you experience headache, chest pain, shortness of breath, high fevers, or worsening leg pain. Please hold your coumadin for two days then restart as per previously written. Please take lactulose for constipation. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-9-12**] 5:00 Provider: [**Name10 (NameIs) 706**] NURSE Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 2:00 Provider: [**Name10 (NameIs) 7548**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 3:00 Please followup with your nephrologist and PCP. [**Name10 (NameIs) **] would like you to see your nephrologist within the next 1-2 weeks. ",16,2141-09-05 20:04:00,2141-09-08 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transfered to the floor after a day. # hypertensive urgency: had been on labetalol drip in the ed, but this was stopped due to nausea (presumed that her bp was coming down too fast). she was started on her home meds and tolerated these fairly well. transferred to the floor and noted to have spbs in the 90s. she required 1l ivf bolus since her baseline sbp is thought to run in the 130-170 range. she also had transient dizziness during this episode. bp meds were held and later that night her sbp was in the 220s. bp meds restarted. she remained stable thereafter with sbps in the 130-170s. we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # right leg pain: no evidence of avascular necrosis or fracture on plain film. mri and plain films were ordered and showed no acute pathology. the pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. ck was normal. pain was treated with dilaudid initially. on day of discharge, she was able to ambulate without gait abnormality or pain. pt saw her and rec outpt pt followup. . # ckd v: pd catheter placement in place. pt was tried on pd on a number of occasions but did not tolerate it [**2-11**] pain. kub confirmed tip in place. cx of peritoneal fluid not suggestive of peritonitis. k remained mildly elevated. hyperpara treated with sevelamer (although patient refused) then tums. pt will reconsider pd as outpatient. . # anemia: chronic. received 2u prbc while inhouse for hct in the 18-19 range. had appropriate response. not on epo given hypertension . # id: rx with cipro for ? uti although urine cx neg. also had temp to 101 on evening prior to discharge. no clear source. pd fluid cultured and ngtd. pt remainded hd stable on day of discharge. . # prior svc thrombus. continued warfarin with appropriate inr checks. inr elevated on day of discharge. rec holding coumadin for 2d . # systemic lupus erythematosus: cont home prednisone dose . # dispo status: ambulating, pain free, bp in the 150/90 range ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Nausea alone; Other antihypertensive agents causing adverse effects in therapeutic use; Hip and thigh injury; Unspecified accident; Hypotension, unspecified; Anemia, unspecified; Personal history of venous thrombosis and embolism; End stage renal disease; ; Urinary tract infection, site not specified; Hyperpotassemia; Acidosis; Disorders of phosphorus metabolism; Hypocalcemia; Secondary hyperparathyroidism (of renal origin)]","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. # right leg pain: no evidence of avascular necrosis or fracture on plain film. also had temp to 101 on evening prior to discharge. # systemic lupus erythematosus: cont home prednisone dose .","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension. she presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transferred to the floor after a day. she was started on her home meds and tolerated them fairly well." 109,172335.0,14797,2141-09-24,15328,170149.0,2141-06-06,Discharge summary,"Admission Date: [**2141-5-24**] Discharge Date: [**2141-6-6**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 759**] Chief Complaint: Face, Left arm and breast swelling Major Surgical or Invasive Procedure: Intravenous Catheterization of SVC/IVC. History of Present Illness: 23 year old woman with ESRD, SLE, recently placed PD catheter who presents with periorbital swelling and Hypertensive urgency. Of note she was recently admitted for tongue swelling on [**4-7**]. At that time she was treated with Solu-Medrol, famotidine and Benadryl in the emergency room, which was continued for a total of three doses on the floor. The swelling improved throughout her stay. She had been on both an ACE, [**Last Name (un) **] and DRI at home, which she has been taking for many years. Patient states that the tongue swelling is most likely due to a sardine allergy. However, she had recently added Dilaudid to her medications following PD catheter placement, so allergy to Dilaudid was also considered. The ACE, [**Last Name (un) **] and DRI were held on the day of admission for ?angioedema but restarted on day of discharge without incident so she was discharged on them. She returned to the ED [**5-24**] with acute onset bilateral eye swelling since night of [**5-23**]. VS T 97.9 HR 78 BP 231/120 RR 20 Sat 100% RA. She was given IV solumedrol 125iv, benadryl IV, and pepcid. Her BP was noted to be 240's despite labetolol 900mg po, then labetolol 20mg iv x2 so was started on labetolol gtt: highest dose 2mg/min. This was stopped after 35 minutes, in favor of nitro gtt. States compliant with meds at home. Patient was comfortable on admission to the MICU. Notes pain in abdomen 7.5/10 related to PD catheter placement (has had since then), improves with morphine. Also notes swelling in eyes/face since last night (has had in the past but never this severe, always goes away on its own). She feels whole body is swollen slightly but no more upper extremities than lower. She denies visual changes, HA, change in hearing/tinitus, congestion, sore throat, cough, SOB, chest pain, palpitations, nausea, vomitting, diarrhea. Has baseline constipation (takes stool softener), last BM 2 days ago (normal), no melena, brbpr, diarrhea. No dysuria, hematuria, change in uop, increase weight or size (clothes fit the same), tingling, numbness, weakness, discoordination, rash, joint pain, recent travel, ill contacts, exotic foods. She notes episode of throat swelling over weekend resolved, seemed to be related to sardine eating (not new for her). Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient denies past or current alcohol, tobacco, or illicit drug use. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: ON ADMISSION: VS: T 98.0 BP 187/120 HR 77 RR 17 Sat 100% on RA GEN: NAD HEENT: + periorbital edema, AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD, no carotid bruits CV: RRR, nl s1, s2, II/VI HSM at R/L USB, S4, no rub PULM: CTAB, no w/r/r with good air movement throughout ABD: soft, mildly tender at PD catheter, ND, + BS, no HSM EXT: warm, dry, +2 distal pulses BL, no femoral bruits, trace non-pitting edema NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect ON [**6-6**]: -General: AAOx3, in NAD. -VS: Tc: 95.2, Tmax (24hrs): 97.8 BP: 172/98 (80/43, 240/110 on [**5-30**]; 120/70, 218/120 over last 24 hrs), P: 80 (80, 98), RR: 16, O2: 98% RA. -HEENT: Head NC, AT. MMM. Face, Neck swollen: equal bilaterally. -Neck: Supple, No JVD, No tracheal deviation. -CV: RRR, S1,S2. Grade II/XII holosystolic murmur radiating to R carotid. JVP not elevated. No S4. -Lungs: CTAB, no w/r. -Abdomen: +BS, soft, nontender. -Extremities: Warm, no lower extremity edema. L arm appears slightly less swollen than yesterday. Dorsalis pedis and radial pulses strong bilaterally. No evidence of rashes, ulcers or varicose veins. -Breast: L breast still swollen relative to R, but diminished from initial presentation of swelling. Skin no longer tense. Pertinent Results: WBC-3.9* RBC-2.19* Hgb-6.6* Hct-20.4* MCV-93 MCH-30.3 MCHC-32.4 RDW-19.7* Plt Ct-114* - Neuts-52.8 Lymphs-39.9 Monos-5.0 Eos-2.0 Baso-0.2 PT-20.5* PTT-89.9* INR(PT)-1.9* Fibrino-268 Thrombn-37.4*# AT III-92 ProtCFn-65* ProtCAg-PND ProtSFn-68 Glucose-105 UreaN-62* Creat-8.1* Na-139 K-4.5 Cl-109* HCO3-17* ALT-14 AST-35 LD(LDH)-254* CK(CPK)-176* AlkPhos-137* Amylase-277* TotBili-0.4 Calcium-6.8* Phos-5.9* Mg-1.5* Hapto-90 Homocys-37.8* PTH-1603* UA: Color Straw Appear Clear SpecGr 1.009 pH 6.0 Urobil Neg Bili Neg Leuk Sm Bld Neg Nitr Neg Prot 30 Glu Neg Ket Neg RBC 0-2 WBC [**11-30**] Bact Few Yeast None Epi 0-2 U Tox: Urine Opiates Pos;Urine Benzos, Barbs, Cocaine, Amphet, Mthdne Negative; UCG: Negative STUDIES: Portable CXR [**5-24**]: Small left pleural effusion with associated atelectasis, although early pneumonia cannot be excluded. No CHF. ECG [**5-24**]: NSR (87), nl axis and intervals, TWI V5-V6, no change from [**5-20**]. MRA [**5-24**]: 1. Occlusion of the right internal jugular vein below the mandible which communicates with external jugular and subclavian vein. Appearance suggest chronic disease. 2. Patent SVC. 3. Patent but narrowed left internal jugular vein but left brachiocephalic vein not visualized (possibly from technique). 4. Bibasilar atelectasis US upper extremity [**5-26**]: [**Doctor Last Name **]-scale, color and Doppler son[**Name (NI) 1417**] of the left IJ, subclavian, axillary, brachial, basilic, and cephalic veins were performed. There is normal flow, compression, and augmentation seen in all of the vessels. IMPRESSION: No evidence of deep vein thrombosis in the left arm. MRV Chest [**5-30**]: 1. Limited study which demonstrates a chronically occluded and completely atrophic left brachiocephalic vein. 2. Right internal jugular vein not identified, likely chronically occluded. Left internal jugular vein is very diminuitive as before. 3. Large right external jugular vein emptying into the subclavian vein. Venogram [**5-31**]: 1. Occlusion of the left brachiocephalic vein at the junction of the subclavian and internal jugular with extensive collateral formation consistent with chronic obstruction. 2. Patent left brachial, axillary, subclavian, and distal internal jugular vein. 3. Unsuccessful attempt to recanalize the left brachiocephalic vein using a catheter and guidewire technique. Brief Hospital Course: Ms. [**Known lastname **] is a 23yo woman with a history of SLE, ESRD and HTN who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into L sided facial, L arm and L breast swelling throughout her stay. # L facial/arm and breast swelling: Initially this presented only as facial swellingand ACE and [**Last Name (un) **] were held for possible angioedema, however holding medications nad giving benadryl failed to relieve symptoms. We then suspected possible venous thrombus with occlusion leading to edema. US of upper left extremity failed to show evidence of acute occlusion, but showed R IJ occlusion consistent with prior studies. MRA could not visualize the L brachiocephalic vein. Repeat MRV suggested chronic occlusion of the L brachiocephalic vein. Venogram performed on [**5-31**] showed extensive collateralization of the L brachiocephalic vein with patent flow through these collaterals. Intervention on the L brachiocephalic vein was attempted by IR, but was unsuccessful. The primary team, renal team, [**Month/Year (2) **] team and hematology team suspect that the most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of the L brachiocephalic vein. For this reason, the patient was placed on Heparin IV as a bridge to coumadin anticoagulation with goal INR [**2-12**]. Per consult with hematology the patient is to remain on this regimen for at least 6 months, and will then revisit as an outpatient the question of possible lifelong anticoagulation. The patient has had extensive negative testing for hypercoagulable states, including during this work-up with negative anticardiolipin, antiphospholipid, Beta-2 glycoprotein and AT3 antibodies. Protein C and S levels were unremarkable. Although her clots seem to have all occured in the setting of lines, her continued thrombosis is likey due to hypercoagulability from her lupus (in absence of lupus anticoagulant). Her INR will be followed first by Dr. [**Last Name (STitle) 4883**], her nephrologist, and then by the coumadin clinic of [**Company 191**]. It will be especially important that her coumadin be well titrated given her risk of intracranial bleed with hypertension. This was communicated tothe patient and she understands and plans to be compliant with frequent blood draws for INR testing and varying her coumadin dose as directed. . # Hypertension: The patient has chronically labile hypertension, with frequent episodes of hypertensive urgency over systolic 200, as well as lows as far as the 80s during this admission. It remains unclear why her blood pressure is so chronically labile. The hope is that once she starts dialysis this will help to stabilize her blood pressure, however in the interim various adjustments were made to her regimen. The patient received frequent extra doses during her stay (especially of hydralazine), however, this occasionally causes her blood pressure to swing too low to tolerate her subsequent standing dose of medication. We stopped her Ace and [**Last Name (un) **] as above. We discharged her to home on a regimen that was reviewed with her nephrologist, Dr. [**Last Name (STitle) 4883**]. She is discharged on clonidine patch 0.3mg qweek, labetalol 900mg po tid, nifedipine CR 90mg po bid, hydralazine 35mg po tid. These medications were reviewed extensively with the patient and she was given prescriptions for all meds. She is discharged with home VNA for blood pressure checks and assistance with meds. She has purchased a portable BP cuff and will keep a BP diary to bring to subsequent appointments as well. The importance of BP control, especially in the setting of new anticoagulation, was discussed extensively with the patient. Her goal SBP is 140-160 at this time. . # ESRD: The patient has ESRD due to lupus nephritis. PD catheter was placed before admission and the patient received morphine prn pain at her catheter site. The renal team followed her closely throughout her stay. She was treated for hypocalcemia as well as hyperkalemia. Her regimen was changed to calcitriol 0.25mcg po qday, sodium bicarb 1300mg po qday, cholecalciferol 400units po qday, ergocalciferol 50,000 units po qweek for ten weeks. She plans to start HD within 1-2 weeks of discharge. She will call [**Doctor First Name 3040**] the PD nurse tomorrow to set up an appointment to have her catheter flushed and to start PD. She will be closely followed by Dr. [**Last Name (STitle) 4883**] at PD. # SLE: The patient was maintained on her home dose of prednisone 15mg po qday throughout her stay. She has no symptoms of acute SLE flare, so her nephrologist and outpatient physicians may attempt to wean this down as an outpatient. . # abnormal pap smear: The pt is noted to have an abnormal pap and colpo two years ago with CIN 2 and high risk HPV. This has never been repeated, as the patient failed to schedule appointments and DNK others. We discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. The patient was discharged to home with a clear plan to call [**Doctor First Name 3040**], the PD nurse on the day after discharge to set up an appointment to have her PD catheter flushed later this week, as well as to set a date to start her PD. She will see Dr. [**Last Name (STitle) 44539**] in [**Hospital **] clinic within the next 1-2 weeks. She will have her blood drawn for INR in two days and faxed to Dr. [**Last Name (STitle) 4883**], subsequently this will be faxed to the [**Company 191**] coumadin clinic and her dose will be adjusted for INR [**2-12**]. We have also given her the phone number to call [**Company 191**] and establish care with a new PCP, [**Name10 (NameIs) 3**] her old PCP has now graduated and her complex management makes a PCP [**Name Initial (PRE) 44540**]. (Her PCP must be at [**Company 191**] for the [**Company 191**] coumadin clinic to follow her as well.) Finally, the patient was given an appointment with ob/gyn to have a follow up pap smear, as her last pap and colpo two years ago showed CIN 2 with high risk HPV and this has not been followed. The above plan and appoitnments were reviewed with the pt and her mother extensively. [**Name2 (NI) **] medication hcanges were also extensively reviewed. Medications on Admission: Hydralazine 50 mg PO TID Labetalol 900 mg PO TID Nicardipine 60 mg Sustained Release PO once a day Cinacalcet 30 mg PO DAILY: she is not sure if taking Calcium Acetate 667 mg PO TID W/MEALS Sodium Bicarbonate 1300 mg PO TID Aliskiren 150 mg PO once a day (was never taking) Pantoprazole 40 mg PO once a day Valsartan 320mg PO DAILY Lisinopril 40 mg PO bid Clonidine 0.3 mg/24 hr Patch Weekly QSUN: not sure when last placed Prednisone 15 mg PO DAILY Morphine 15 mg Tablet PO Q6H as needed Ergocalciferol (Vitamin D2) 50,000 unit Capsule daily: states not taking Epo 4,000 units M/W/F: states not taking colace Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Disp:*4 Patch Weekly(s)* Refills:*2* 3. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 5. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO qwednesday (): for 10 weeks. Disp:*10 Capsule(s)* Refills:*0* 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*2* 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 10. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: dose to be adjusted by coumadin clinic. Disp:*120 Tablet(s)* Refills:*2* 11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 12. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for itching. Disp:*50 Capsule(s)* Refills:*0* 13. Ativan 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. Disp:*60 Tablet(s)* Refills:*0* 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 15. Morphine 15 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 14 days. Disp:*56 Tablet(s)* Refills:*0* 16. Outpatient Lab Work Please have blood drawn on Friday, [**6-9**] for PT/INR. Please have result faxed to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you to adjust your coumadin (also called warfarin) dose as needed. 17. Outpatient Lab Work Please have blood drawn on Monday [**2141-6-12**] for PT/INR and twice per week thereafter until told by coumadin clinic that you can decrease lab draws. Please have result faxed to the [**Hospital1 18**] coumadin clinic at [**Telephone/Fax (1) 3534**]. They will call you to adjust your coumadin (also called warfarin) dose as needed. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnoses: Malignant Hypertension (Hypertensive Urgency) Acute Exacerbation of Chronic Left Brachiocephalic vein occlusion Anemia Secondary Diagnoses: SLE ESRD Hypertrophic Cardiomyopathy Thrombocytopenia Discharge Condition: Stable Discharge Instructions: You were admitted and treated for an acute exacerbation of a chronic left brachiocephalic vein occlusion (a chronically obstructed large vein closed off entirely) and hypertensive urgency (very high blood pressure). We attempted to remove the clot in your left brachiocephalic vein, but were unable to do so. You have been started on long-term Coumadin (also called warfarin) therapy to prevent future blood clots and to allow natural dissolution of your current blood clot. Please change your medicines to only those you are given here! There were many changes and it is very important that you stick to the medication list as you have large, life-threatening swings in the blood pressure when not taking consistently. We also treated you for high potassium levels and anemia, and low vitamin D and calcium levels, which are related to your kidney failure. Please follow up with Dr. [**Last Name (STitle) 4883**] for long term treatment. Please check your blood pressure three times per day and keep a blood pressure diary to bring with you to all medical appointments. Please have your blood drawn on Friday [**6-9**] for PT/INR and faxed to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you if needed to adjust your coumadin (warfarin) dose. After that, please have your blood drawn on Monday [**6-12**] for PT/INR and faxed to the [**Hospital1 18**] coumadin clinic at [**Telephone/Fax (1) 434**]. They will follow you in a regular way to adjust your coumadin dose as needed. MEDICINES FOR BLOOD PRESSURE: LABETALOL 900mg three times per day (same as before) HYDRALAZINE 25mg three times per day (lower dose than before) CLONIDINE PATCH 0.3mg qWednesday (same as before) NIFEDIPINE SR 90mg twice per day (new medicine!) **stop taking your lisinopril, nicardipine, Diovan and Aliskerin!** MEDICINES FOR RENAL FAILURE: ERGOCALCIFEROL [**Numeric Identifier 1871**] units pill every Wednesday (same as before) CHOLECALCIFEROL 400 units every day (new) CALCITRIOL 0.25 mg every day (new) SODIUM BICARBONATE 1300mg once per day (less often then before) ** stop taking your calcium acetate (phoslo), cinecalcet, and epo injection (you'll get it at peritoneal dialysis only)** OTHER MEDICINES: PANTOPRAZOLE 40mg every day (same as before) PREDNISONE 15mg every day (same as before) MORPHINE 15mg every 6 hrs if needed for pain (same as before) ATIVAN 1mg as needed for anxiety (same as before) BENADRYL 25mg every 6 hrs if needed for itch (new) COLACE 100mg twice per day if needed for constipation(same as before) APPOINTMENTS: **1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on Friday to flush your dialysis catheter and start dialysis next week! 2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00AM 3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**] Date/Time: [**2141-6-13**] 9:30AM **4. Please call [**Hospital3 **] next week to make an appointment with a new primary doctor. I recommend Dr. [**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE FOLLOWED IN [**Hospital **] CLINIC. **5. Please have your blood drawn as above. Your coumadin level will be followed by the [**Hospital 197**] clinic. Their phone # is [**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**]. If you have increased swelling, fever greater than 101, shortness of breath, chest pain, or if you at any time become concerned about your health please contact Dr. [**Last Name (STitle) 4883**] or go to the nearest ER. Followup Instructions: APPOINTMENTS: **1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on Friday to flush your dialysis catheter and start dialysis next week! 2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00AM 3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**] Date/Time: [**2141-6-13**] 9:30AM **4. Please call [**Hospital3 **] next week to make an appointment with a new primary doctor. I recommend Dr. [**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE FOLLOWED IN [**Hospital **] CLINIC. **5. Please have your blood drawn as above. Your coumadin level will be followed by the [**Hospital 197**] clinic. Their phone # is [**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**]. Completed by:[**2141-6-17**]",110,2141-05-24 14:47:00,2141-06-06 19:55:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ACUTE RENAL FAILURE," ms. [**known lastname **] is a 23yo woman with a history of sle, esrd and htn who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into l sided facial, l arm and l breast swelling throughout her stay. # l facial/arm and breast swelling: initially this presented only as facial swellingand ace and [**last name (un) **] were held for possible angioedema, however holding medications nad giving benadryl failed to relieve symptoms. we then suspected possible venous thrombus with occlusion leading to edema. us of upper left extremity failed to show evidence of acute occlusion, but showed r ij occlusion consistent with prior studies. mra could not visualize the l brachiocephalic vein. repeat mrv suggested chronic occlusion of the l brachiocephalic vein. venogram performed on [**5-31**] showed extensive collateralization of the l brachiocephalic vein with patent flow through these collaterals. intervention on the l brachiocephalic vein was attempted by ir, but was unsuccessful. the primary team, renal team, [**month/year (2) **] team and hematology team suspect that the most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of the l brachiocephalic vein. for this reason, the patient was placed on heparin iv as a bridge to coumadin anticoagulation with goal inr [**2-12**]. per consult with hematology the patient is to remain on this regimen for at least 6 months, and will then revisit as an outpatient the question of possible lifelong anticoagulation. the patient has had extensive negative testing for hypercoagulable states, including during this work-up with negative anticardiolipin, antiphospholipid, beta-2 glycoprotein and at3 antibodies. protein c and s levels were unremarkable. although her clots seem to have all occured in the setting of lines, her continued thrombosis is likey due to hypercoagulability from her lupus (in absence of lupus anticoagulant). her inr will be followed first by dr. [**last name (stitle) 4883**], her nephrologist, and then by the coumadin clinic of [**company 191**]. it will be especially important that her coumadin be well titrated given her risk of intracranial bleed with hypertension. this was communicated tothe patient and she understands and plans to be compliant with frequent blood draws for inr testing and varying her coumadin dose as directed. . # hypertension: the patient has chronically labile hypertension, with frequent episodes of hypertensive urgency over systolic 200, as well as lows as far as the 80s during this admission. it remains unclear why her blood pressure is so chronically labile. the hope is that once she starts dialysis this will help to stabilize her blood pressure, however in the interim various adjustments were made to her regimen. the patient received frequent extra doses during her stay (especially of hydralazine), however, this occasionally causes her blood pressure to swing too low to tolerate her subsequent standing dose of medication. we stopped her ace and [**last name (un) **] as above. we discharged her to home on a regimen that was reviewed with her nephrologist, dr. [**last name (stitle) 4883**]. she is discharged on clonidine patch 0.3mg qweek, labetalol 900mg po tid, nifedipine cr 90mg po bid, hydralazine 35mg po tid. these medications were reviewed extensively with the patient and she was given prescriptions for all meds. she is discharged with home vna for blood pressure checks and assistance with meds. she has purchased a portable bp cuff and will keep a bp diary to bring to subsequent appointments as well. the importance of bp control, especially in the setting of new anticoagulation, was discussed extensively with the patient. her goal sbp is 140-160 at this time. . # esrd: the patient has esrd due to lupus nephritis. pd catheter was placed before admission and the patient received morphine prn pain at her catheter site. the renal team followed her closely throughout her stay. she was treated for hypocalcemia as well as hyperkalemia. her regimen was changed to calcitriol 0.25mcg po qday, sodium bicarb 1300mg po qday, cholecalciferol 400units po qday, ergocalciferol 50,000 units po qweek for ten weeks. she plans to start hd within 1-2 weeks of discharge. she will call [**doctor first name 3040**] the pd nurse tomorrow to set up an appointment to have her catheter flushed and to start pd. she will be closely followed by dr. [**last name (stitle) 4883**] at pd. # sle: the patient was maintained on her home dose of prednisone 15mg po qday throughout her stay. she has no symptoms of acute sle flare, so her nephrologist and outpatient physicians may attempt to wean this down as an outpatient. . # abnormal pap smear: the pt is noted to have an abnormal pap and colpo two years ago with cin 2 and high risk hpv. this has never been repeated, as the patient failed to schedule appointments and dnk others. we discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. the patient was discharged to home with a clear plan to call [**doctor first name 3040**], the pd nurse on the day after discharge to set up an appointment to have her pd catheter flushed later this week, as well as to set a date to start her pd. she will see dr. [**last name (stitle) 44539**] in [**hospital **] clinic within the next 1-2 weeks. she will have her blood drawn for inr in two days and faxed to dr. [**last name (stitle) 4883**], subsequently this will be faxed to the [**company 191**] coumadin clinic and her dose will be adjusted for inr [**2-12**]. we have also given her the phone number to call [**company 191**] and establish care with a new pcp, [**name10 (nameis) 3**] her old pcp has now graduated and her complex management makes a pcp [**name initial (pre) 44540**]. (her pcp must be at [**company 191**] for the [**company 191**] coumadin clinic to follow her as well.) finally, the patient was given an appointment with ob/gyn to have a follow up pap smear, as her last pap and colpo two years ago showed cin 2 with high risk hpv and this has not been followed. the above plan and appoitnments were reviewed with the pt and her mother extensively. [**name2 (ni) **] medication hcanges were also extensively reviewed. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Compression of vein; Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Hyperpotassemia; Hyperparathyroidism, unspecified; Other iatrogenic hypotension; Nausea with vomiting; ; Abnormal glandular Papanicolaou smear of cervix; Abdominal pain, other specified site; Other specified disorders of pancreatic internal secretion; Adrenal cortical steroids causing adverse effects in therapeutic use]","known lastname **] is a 23yo woman with a history of sle, esrd and htn who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into l sided facial, l arm and l breast swelling throughout her stay. mra could not visualize the l brachiocephalic vein. it remains unclear why her blood pressure is so chronically labile. we stopped her ace and [**last name (un) **] as above. the importance of bp control, especially in the setting of new anticoagulation, was discussed extensively with the patient. # esrd: the patient has esrd due to lupus nephritis. the renal team followed her closely throughout her stay. she will call [**doctor first name 3040**] the pd nurse tomorrow to set up an appointment to have her catheter flushed and to start pd. we discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. the above plan and appoitnments were reviewed with the pt and her mother extensively. [**","a 23yo woman with a history of sle, esrd and htn presented with bilateral facial swelling. she developed l sided facial, l arm and l breast swelling throughout her stay. most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of l brachiocephalic vein." 109,161950.0,14800,2141-12-01,15330,131345.0,2141-09-08,Discharge summary,"Admission Date: [**2141-9-5**] Discharge Date: [**2141-9-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 348**] Chief Complaint: right leg pain, hypertension Major Surgical or Invasive Procedure: blood transfusion x2 History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. The pain is worst when she tried to bear weight on the leg, or when she uses it to roll over or adjust her position in bed. The pain begins in her buttock and travels down the posterior thigh and calf but stops before reaching the ankle. It occasionally feels like it is coming from her low back. She denies any parasthesias or weakness in the leg, and she denies any numbness in her foot or groin. She denies any fevers or incontinence. The pain was unrelieved by Vicodin that she had at home, so she scheduled an urgent visit with her nephrologist yesterday [**2141-9-4**]. At her nephrologist??????s office, she was hypertensive to 250/145 and so she was referred to the ED. She ended up leaving the ED against medical advice yesterday, but returned today because of persistent leg pain. She reports that she took all of her morning and noon BP meds. She denies any fevers, headaches, visual changes, nausea (prior to coming to the ED), or leg weakness. Upon arrival to the ED today, she was afebrile, BP 237/146, HR 97, RR 16, Sat 100% on room air. She received a total of 90 mg of IV labetalol and nitropaste, and was eventually put on a labetalol drip for her hypertension. With these interventions, her SBP dropped to the 180s, but she reported feeling nauseous and so the drip was discontinued. She was also given 4 mg of IV morphine and 1 mg of IV hydromorphone for her leg pain with decent relief. Due to a urinalysis suggestive of infection, she was given one tablet of DS TMP/SMX. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: MICU physical: Tmax: 36.3 ??????C (97.4 ??????F) Tcurrent: 36.3 ??????C (97.4 ??????F) HR: 92 (92 - 94) bpm BP: 209/138(152) {201/134(151) - 209/138(152)} mmHg RR: 19 (19 - 30) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Height: 59 Inch General: well-appearing young woman in no acute distress HEENT: no scleral icterus; prosthetic right eye Neck: supple Chest: clear to auscultation throughout, no wheezes/rales/ronchi CV: regular rate/rhythm, normal s1s2, no murmurs Abdomen: soft, nontender, nondistended, PD catheter in place in left abdomen Back: very mild spinal tenderness over approx L3 level of spine Extremities: no edema, 1+ PT pulses, warm Skin: no rashes or jaundice Neuro: alert, oriented x3, 5/5 strength in bilateral deltoids, biceps, triceps, hip flexors/extensors, ankle flexors/extensors; unable to elicit patellar reflexes bilaterally; negative straight leg raise bilaterally Pertinent Results: 138 111 54 -----------------< 83 5.4 14 8.2 . WBC: 3.7 HCT: 19 PLT: 101 N:69.3 L:23.4 M:5.5 E:1.7 Bas:0.1 PT: 21.9 PTT: 48.2 INR: 2.1 . Trends: HCT: 19 -> 22 w 1u then received another unit. INR 3.4 on discharge Discharge chem: Glucose-104 UreaN-51* Creat-8.4* Na-136 K-5.3* Cl-106 HCO3-18* AnGap-17 . [**2141-9-8**] 07:30AM BLOOD CK(CPK)-126 [**2141-9-5**] 02:50PM BLOOD HCG-<5 . [**2141-9-8**] 1:37 pm PERITONEAL FLUID GRAM STAIN (Final [**2141-9-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count . MRI L-spine: IMPRESSION: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. . CXR admit: IMPRESSION: Moderate cardiomegaly, bilateral pleural effusions, and pulmonary vascular prominence consistent with pulmonary edema. . Hip film: FINDINGS: No comparisons. No acute fracture or dislocation is seen. No lucent or sclerotic lesion is noted. There is a distal aspect of a catheter or shunt seen in the pelvis. Soft tissues are otherwise unremarkable. There is minimal degenerative change of the pubic symphysis. IMPRESSION: No acute fracture or dislocation. . Abdominal film: FINDINGS: A PD catheter is seen with its tip coiled in the pelvis. There is normal bowel gas. The underlying osseous structures are unremarkable. IMPRESSION: PD catheter with tip coiled in the pelvis . CXR [**9-8**]: IMPRESSION: Marked cardiomegaly, unchanged. Interval resolution of pulmonary edema. Brief Hospital Course: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. She was initially admitted to the MICU for hypertensive urgency and then transfered to the floor after a day. # Hypertensive urgency: had been on labetalol drip in the ED, but this was stopped due to nausea (presumed that her BP was coming down too fast). She was started on her home meds and tolerated these fairly well. Transferred to the floor and noted to have SPBs in the 90s. She required 1L IVF bolus since her baseline SBP is thought to run in the 130-170 range. She also had transient dizziness during this episode. BP meds were held and later that night her SBP was in the 220s. BP meds restarted. She remained stable thereafter with SBPs in the 130-170s. We opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # Right leg pain: no evidence of avascular necrosis or fracture on plain film. MRI and plain films were ordered and showed no acute pathology. The pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. CK was normal. Pain was treated with dilaudid initially. On day of discharge, she was able to ambulate without gait abnormality or pain. PT saw her and rec outpt PT followup. . # CKD V: PD catheter placement in place. Pt was tried on PD on a number of occasions but did not tolerate it [**2-11**] pain. KUB confirmed tip in place. Cx of peritoneal fluid not suggestive of peritonitis. K remained mildly elevated. Hyperpara treated with sevelamer (although patient refused) then tums. Pt will reconsider PD as outpatient. . # Anemia: chronic. Received 2u pRBC while inhouse for Hct in the 18-19 range. Had appropriate response. Not on Epo given hypertension . # ID: Rx with cipro for ? UTI although urine cx neg. Also had temp to 101 on evening prior to discharge. No clear source. PD fluid cultured and NGTD. Pt remainded HD stable on day of discharge. . # Prior SVC thrombus. Continued warfarin with appropriate INR checks. INR elevated on day of discharge. Rec holding coumadin for 2d . # Systemic lupus erythematosus: cont home prednisone dose . # Dispo status: ambulating, pain free, BP in the 150/90 range Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly Vicodin prn Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO WEEKLY (). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*20 Capsule(s)* Refills:*0* 9. Outpatient Physical Therapy Please provide PT for right hamstring injury 10. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*0* 11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold dose until [**9-10**]. Disp:*30 Tablet(s)* Refills:*0* 12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO once a day: goal is [**1-11**] soft bowel movements per day. Disp:*500 ml* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - HTN urgency - right leg pain - thought [**2-11**] hamstring injury - chronic kidney disease - not currently on dialysis - SLE - anemia [**2-11**] CKD and SLE - hx of SVC thrombosis on coumadin now Secondary: - hx hypertrophic obstructive cardiomyopathy - chronic thrombocytopenia Discharge Condition: ambulating without difficulty. tolerating oral diet. afebrile and SBP in the 130-150 range. Discharge Instructions: You came in with right leg pain and poorly controlled hypertension. Your blood pressure was controlled initially with IV medications then your home medications. Since your blood pressure was occasionally low, we recommend that you hold your labetalol if you are feeling lightheaded or have dizziness or have blood pressure less than 110/60. In terms of your leg pain, we performed xrays, ultrasound, and MRI without finding a cause. We suspect a hamstring injury given its location. Please take pain medications if needed. We recommend followup with physical therapy. You also had a fever which is suggestive of infection. We treated you with cipro in case you had a UTI. Otherwise, your cultures were unrevealing. We attempted peritoneal dialysis but this was unsuccessful. Please followup with your nephrologist. Please return to the ED if you experience headache, chest pain, shortness of breath, high fevers, or worsening leg pain. Please hold your coumadin for two days then restart as per previously written. Please take lactulose for constipation. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-9-12**] 5:00 Provider: [**Name10 (NameIs) 706**] NURSE Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 2:00 Provider: [**Name10 (NameIs) 7548**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 3:00 Please followup with your nephrologist and PCP. [**Name10 (NameIs) **] would like you to see your nephrologist within the next 1-2 weeks. ",84,2141-09-05 20:04:00,2141-09-08 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transfered to the floor after a day. # hypertensive urgency: had been on labetalol drip in the ed, but this was stopped due to nausea (presumed that her bp was coming down too fast). she was started on her home meds and tolerated these fairly well. transferred to the floor and noted to have spbs in the 90s. she required 1l ivf bolus since her baseline sbp is thought to run in the 130-170 range. she also had transient dizziness during this episode. bp meds were held and later that night her sbp was in the 220s. bp meds restarted. she remained stable thereafter with sbps in the 130-170s. we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # right leg pain: no evidence of avascular necrosis or fracture on plain film. mri and plain films were ordered and showed no acute pathology. the pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. ck was normal. pain was treated with dilaudid initially. on day of discharge, she was able to ambulate without gait abnormality or pain. pt saw her and rec outpt pt followup. . # ckd v: pd catheter placement in place. pt was tried on pd on a number of occasions but did not tolerate it [**2-11**] pain. kub confirmed tip in place. cx of peritoneal fluid not suggestive of peritonitis. k remained mildly elevated. hyperpara treated with sevelamer (although patient refused) then tums. pt will reconsider pd as outpatient. . # anemia: chronic. received 2u prbc while inhouse for hct in the 18-19 range. had appropriate response. not on epo given hypertension . # id: rx with cipro for ? uti although urine cx neg. also had temp to 101 on evening prior to discharge. no clear source. pd fluid cultured and ngtd. pt remainded hd stable on day of discharge. . # prior svc thrombus. continued warfarin with appropriate inr checks. inr elevated on day of discharge. rec holding coumadin for 2d . # systemic lupus erythematosus: cont home prednisone dose . # dispo status: ambulating, pain free, bp in the 150/90 range ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Nausea alone; Other antihypertensive agents causing adverse effects in therapeutic use; Hip and thigh injury; Unspecified accident; Hypotension, unspecified; Anemia, unspecified; Personal history of venous thrombosis and embolism; End stage renal disease; ; Urinary tract infection, site not specified; Hyperpotassemia; Acidosis; Disorders of phosphorus metabolism; Hypocalcemia; Secondary hyperparathyroidism (of renal origin)]","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. # right leg pain: no evidence of avascular necrosis or fracture on plain film. also had temp to 101 on evening prior to discharge. # systemic lupus erythematosus: cont home prednisone dose .","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension. she presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transferred to the floor after a day. she was started on her home meds and tolerated them fairly well." 109,126055.0,14798,2141-11-03,15330,131345.0,2141-09-08,Discharge summary,"Admission Date: [**2141-9-5**] Discharge Date: [**2141-9-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 348**] Chief Complaint: right leg pain, hypertension Major Surgical or Invasive Procedure: blood transfusion x2 History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. The pain is worst when she tried to bear weight on the leg, or when she uses it to roll over or adjust her position in bed. The pain begins in her buttock and travels down the posterior thigh and calf but stops before reaching the ankle. It occasionally feels like it is coming from her low back. She denies any parasthesias or weakness in the leg, and she denies any numbness in her foot or groin. She denies any fevers or incontinence. The pain was unrelieved by Vicodin that she had at home, so she scheduled an urgent visit with her nephrologist yesterday [**2141-9-4**]. At her nephrologist??????s office, she was hypertensive to 250/145 and so she was referred to the ED. She ended up leaving the ED against medical advice yesterday, but returned today because of persistent leg pain. She reports that she took all of her morning and noon BP meds. She denies any fevers, headaches, visual changes, nausea (prior to coming to the ED), or leg weakness. Upon arrival to the ED today, she was afebrile, BP 237/146, HR 97, RR 16, Sat 100% on room air. She received a total of 90 mg of IV labetalol and nitropaste, and was eventually put on a labetalol drip for her hypertension. With these interventions, her SBP dropped to the 180s, but she reported feeling nauseous and so the drip was discontinued. She was also given 4 mg of IV morphine and 1 mg of IV hydromorphone for her leg pain with decent relief. Due to a urinalysis suggestive of infection, she was given one tablet of DS TMP/SMX. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: MICU physical: Tmax: 36.3 ??????C (97.4 ??????F) Tcurrent: 36.3 ??????C (97.4 ??????F) HR: 92 (92 - 94) bpm BP: 209/138(152) {201/134(151) - 209/138(152)} mmHg RR: 19 (19 - 30) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Height: 59 Inch General: well-appearing young woman in no acute distress HEENT: no scleral icterus; prosthetic right eye Neck: supple Chest: clear to auscultation throughout, no wheezes/rales/ronchi CV: regular rate/rhythm, normal s1s2, no murmurs Abdomen: soft, nontender, nondistended, PD catheter in place in left abdomen Back: very mild spinal tenderness over approx L3 level of spine Extremities: no edema, 1+ PT pulses, warm Skin: no rashes or jaundice Neuro: alert, oriented x3, 5/5 strength in bilateral deltoids, biceps, triceps, hip flexors/extensors, ankle flexors/extensors; unable to elicit patellar reflexes bilaterally; negative straight leg raise bilaterally Pertinent Results: 138 111 54 -----------------< 83 5.4 14 8.2 . WBC: 3.7 HCT: 19 PLT: 101 N:69.3 L:23.4 M:5.5 E:1.7 Bas:0.1 PT: 21.9 PTT: 48.2 INR: 2.1 . Trends: HCT: 19 -> 22 w 1u then received another unit. INR 3.4 on discharge Discharge chem: Glucose-104 UreaN-51* Creat-8.4* Na-136 K-5.3* Cl-106 HCO3-18* AnGap-17 . [**2141-9-8**] 07:30AM BLOOD CK(CPK)-126 [**2141-9-5**] 02:50PM BLOOD HCG-<5 . [**2141-9-8**] 1:37 pm PERITONEAL FLUID GRAM STAIN (Final [**2141-9-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count . MRI L-spine: IMPRESSION: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. . CXR admit: IMPRESSION: Moderate cardiomegaly, bilateral pleural effusions, and pulmonary vascular prominence consistent with pulmonary edema. . Hip film: FINDINGS: No comparisons. No acute fracture or dislocation is seen. No lucent or sclerotic lesion is noted. There is a distal aspect of a catheter or shunt seen in the pelvis. Soft tissues are otherwise unremarkable. There is minimal degenerative change of the pubic symphysis. IMPRESSION: No acute fracture or dislocation. . Abdominal film: FINDINGS: A PD catheter is seen with its tip coiled in the pelvis. There is normal bowel gas. The underlying osseous structures are unremarkable. IMPRESSION: PD catheter with tip coiled in the pelvis . CXR [**9-8**]: IMPRESSION: Marked cardiomegaly, unchanged. Interval resolution of pulmonary edema. Brief Hospital Course: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. She was initially admitted to the MICU for hypertensive urgency and then transfered to the floor after a day. # Hypertensive urgency: had been on labetalol drip in the ED, but this was stopped due to nausea (presumed that her BP was coming down too fast). She was started on her home meds and tolerated these fairly well. Transferred to the floor and noted to have SPBs in the 90s. She required 1L IVF bolus since her baseline SBP is thought to run in the 130-170 range. She also had transient dizziness during this episode. BP meds were held and later that night her SBP was in the 220s. BP meds restarted. She remained stable thereafter with SBPs in the 130-170s. We opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # Right leg pain: no evidence of avascular necrosis or fracture on plain film. MRI and plain films were ordered and showed no acute pathology. The pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. CK was normal. Pain was treated with dilaudid initially. On day of discharge, she was able to ambulate without gait abnormality or pain. PT saw her and rec outpt PT followup. . # CKD V: PD catheter placement in place. Pt was tried on PD on a number of occasions but did not tolerate it [**2-11**] pain. KUB confirmed tip in place. Cx of peritoneal fluid not suggestive of peritonitis. K remained mildly elevated. Hyperpara treated with sevelamer (although patient refused) then tums. Pt will reconsider PD as outpatient. . # Anemia: chronic. Received 2u pRBC while inhouse for Hct in the 18-19 range. Had appropriate response. Not on Epo given hypertension . # ID: Rx with cipro for ? UTI although urine cx neg. Also had temp to 101 on evening prior to discharge. No clear source. PD fluid cultured and NGTD. Pt remainded HD stable on day of discharge. . # Prior SVC thrombus. Continued warfarin with appropriate INR checks. INR elevated on day of discharge. Rec holding coumadin for 2d . # Systemic lupus erythematosus: cont home prednisone dose . # Dispo status: ambulating, pain free, BP in the 150/90 range Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly Vicodin prn Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO WEEKLY (). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*20 Capsule(s)* Refills:*0* 9. Outpatient Physical Therapy Please provide PT for right hamstring injury 10. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*0* 11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold dose until [**9-10**]. Disp:*30 Tablet(s)* Refills:*0* 12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO once a day: goal is [**1-11**] soft bowel movements per day. Disp:*500 ml* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - HTN urgency - right leg pain - thought [**2-11**] hamstring injury - chronic kidney disease - not currently on dialysis - SLE - anemia [**2-11**] CKD and SLE - hx of SVC thrombosis on coumadin now Secondary: - hx hypertrophic obstructive cardiomyopathy - chronic thrombocytopenia Discharge Condition: ambulating without difficulty. tolerating oral diet. afebrile and SBP in the 130-150 range. Discharge Instructions: You came in with right leg pain and poorly controlled hypertension. Your blood pressure was controlled initially with IV medications then your home medications. Since your blood pressure was occasionally low, we recommend that you hold your labetalol if you are feeling lightheaded or have dizziness or have blood pressure less than 110/60. In terms of your leg pain, we performed xrays, ultrasound, and MRI without finding a cause. We suspect a hamstring injury given its location. Please take pain medications if needed. We recommend followup with physical therapy. You also had a fever which is suggestive of infection. We treated you with cipro in case you had a UTI. Otherwise, your cultures were unrevealing. We attempted peritoneal dialysis but this was unsuccessful. Please followup with your nephrologist. Please return to the ED if you experience headache, chest pain, shortness of breath, high fevers, or worsening leg pain. Please hold your coumadin for two days then restart as per previously written. Please take lactulose for constipation. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-9-12**] 5:00 Provider: [**Name10 (NameIs) 706**] NURSE Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 2:00 Provider: [**Name10 (NameIs) 7548**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 3:00 Please followup with your nephrologist and PCP. [**Name10 (NameIs) **] would like you to see your nephrologist within the next 1-2 weeks. ",56,2141-09-05 20:04:00,2141-09-08 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transfered to the floor after a day. # hypertensive urgency: had been on labetalol drip in the ed, but this was stopped due to nausea (presumed that her bp was coming down too fast). she was started on her home meds and tolerated these fairly well. transferred to the floor and noted to have spbs in the 90s. she required 1l ivf bolus since her baseline sbp is thought to run in the 130-170 range. she also had transient dizziness during this episode. bp meds were held and later that night her sbp was in the 220s. bp meds restarted. she remained stable thereafter with sbps in the 130-170s. we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # right leg pain: no evidence of avascular necrosis or fracture on plain film. mri and plain films were ordered and showed no acute pathology. the pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. ck was normal. pain was treated with dilaudid initially. on day of discharge, she was able to ambulate without gait abnormality or pain. pt saw her and rec outpt pt followup. . # ckd v: pd catheter placement in place. pt was tried on pd on a number of occasions but did not tolerate it [**2-11**] pain. kub confirmed tip in place. cx of peritoneal fluid not suggestive of peritonitis. k remained mildly elevated. hyperpara treated with sevelamer (although patient refused) then tums. pt will reconsider pd as outpatient. . # anemia: chronic. received 2u prbc while inhouse for hct in the 18-19 range. had appropriate response. not on epo given hypertension . # id: rx with cipro for ? uti although urine cx neg. also had temp to 101 on evening prior to discharge. no clear source. pd fluid cultured and ngtd. pt remainded hd stable on day of discharge. . # prior svc thrombus. continued warfarin with appropriate inr checks. inr elevated on day of discharge. rec holding coumadin for 2d . # systemic lupus erythematosus: cont home prednisone dose . # dispo status: ambulating, pain free, bp in the 150/90 range ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Nausea alone; Other antihypertensive agents causing adverse effects in therapeutic use; Hip and thigh injury; Unspecified accident; Hypotension, unspecified; Anemia, unspecified; Personal history of venous thrombosis and embolism; End stage renal disease; ; Urinary tract infection, site not specified; Hyperpotassemia; Acidosis; Disorders of phosphorus metabolism; Hypocalcemia; Secondary hyperparathyroidism (of renal origin)]","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. # right leg pain: no evidence of avascular necrosis or fracture on plain film. also had temp to 101 on evening prior to discharge. # systemic lupus erythematosus: cont home prednisone dose .","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension. she presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transferred to the floor after a day. she was started on her home meds and tolerated them fairly well." 109,161950.0,14800,2141-12-01,14796,139061.0,2141-09-14,Discharge summary,"Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Right leg pain. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 24 y.o. F with lupus, Chronic Kidney Disease V (not currently on HD or PD), and multiple admissions for hypertensive urgency/emergency, who presented to the ED for continued R leg pain that starts in her R buttocks and refers down her R leg. She describes it as feeling like the pain is deep within her bone. The pain was [**10-20**] in the AM, and she felt like she couldn't get out of bed. Denies any swelling of her RLE. When getting VS in [**Name (NI) **], pt noted to be very hypertensive at 263/176. The patient reportedly has baseline SBPs in 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM on day of admission. She denies any recent recrational drug use including cocaine and amphetamines. She denies headache, vision changes, double vision, chest pain, shortness of breath, abdominal pain, BRBPR, dysuria. During MD interview, the patient was nauseous and had small amount of emesis of a recent Coolata. Pt states that flushing her PD cath causes a large amount of stomach pain. . Of note, the patient was recently admitted from 08.26-29.08. The patient initially presented to the ED after referral from her nephrologist's office where she had complaints of right leg pain and was found to be hypertensive to 250/145. She was admitted after initiation of a labetalol drip and nitropaste with improvement in sbp to 180. The patient did receive 2 U of PRBC's during this hospitalization for baseline anemia. The patient did have a work-up for her right leg pain complaints with plain films of the right hip and MRI of the L-spine which did not reveal an explanation for her symptoms and did rule out avascular necrosis. The patient received dilaudid for pain control and was ambulating without pain prior to discharge. In addition, the patient completed a course of ciprofloxacin for a positive UA with negative cultures. The patient was unable to tolerate peritoneal dialysis for unclear reasons. Peritoneal dialysate culture was negative for infection. . In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in ED ranged from [**Telephone/Fax (3) 43494**]-175 with HR in 96-108. Initially given labetalol 10 mg IV x 1 and then started on labetalol gtt for her elevated blood pressures and titrated to 3 mg/min. LENI of R leg was negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per ED, cannot do V/Q scan due to volume overload after talking with radiology. Renal c/s initiated. A-line placed. Past Medical History: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] . PAST SURGICAL HISTORY: - Placement of multiple catheters including dialysis. - Tonsillectomy. - Left eye enucleation in [**2140-4-10**]. - PD catheter placement in [**2141-5-11**]. Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 98.9 [**Telephone/Fax (2) 43495**] 99$% RA GEN: NAD, pleasant female sitting in bed with moon facies HEENT: EOMI of R eye, L eye prosthesis, no exudate, no erythema, MMM, no LAD CHEST: CTAB except at R base with decreased breath sounds; no w/r/r CV: tachy, normal S1S2, II/VI systolic murmur accentuated with Valsalva ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i EXT: no c/c/e, strength of LEs [**5-15**] and symmetric bilaterally. Negative straight leg test, no pain with internal rotation, external rotation, extension, adduction or abduction. Some pain on flexion at the hip. NEURO: II - XII intact to direct testing. No deficit in light tough sensation. Gait normal. DERM: no rashes noted Pertinent Results: LABS AT ADMISSION: [**2141-9-11**] 11:43AM GLUCOSE-86 UREA N-49* CREAT-8.1* SODIUM-139 POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-16* ANION GAP-18 [**2141-9-11**] 11:43AM CALCIUM-6.2* PHOSPHATE-5.8* MAGNESIUM-1.6 [**2141-9-11**] 11:43AM PT-18.4* PTT-42.8* INR(PT)-1.7* [**2141-9-11**] 07:00AM WBC-5.5 RBC-2.88* HGB-8.1* HCT-24.7* MCV-86 MCH-28.1 MCHC-32.8 RDW-18.0* [**2141-9-11**] 07:00AM NEUTS-74.7* LYMPHS-17.5* MONOS-4.2 EOS-3.3 BASOS-0.2 [**2141-9-11**] 07:00AM PLT COUNT-101* UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50 WBC . MICROBIOLOGY: Urine culture ([**2141-9-11**]): Mixed flora . STUDIES: Cardiology Report ECG Study Date of [**2141-9-11**] 6:55:16 AM Sinus tachycardia. The tracing is marred by baseline artifact. There is left atrial enlargement. Compared to the previous tracing of [**2141-9-5**] the rate has increased. The axis is more rightward. Otherwise, no diagnostic interim change. . UNILAT LOWER EXT VEINS RIGHT Study Date of [**2141-9-11**] 8:54 AM [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and popliteal veins demonstrate normal flow, compressibility, augmentation, waveforms. Appropriate color flow and compression is noted within the calf veins. No intraluminal thrombus is present. IMPRESSION: No evidence of right lower extremity DVT. . TTE ([**2140-8-26**]): The left atrium is normal in size. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . R HIP XR [**2141-9-6**]: No acute fracture or dislocation. . MRI L-SPINE [**2141-9-6**]: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. LAB RESULTS AT DISCHARGE: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-9-14**] 06:15AM 4.0 2.63* 7.6* 23.1* 88 29.1 33.0 18.0* 100* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-9-14**] 06:15AM 100 44* 8.1* 137 4.8 109* 17* 16 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2141-9-14**] 06:15AM 6.8* 5.4* 1.6 CALCIUM freeCa [**2141-9-14**] 11:30AM 0.94* Brief Hospital Course: ICU course: EKG showed no change from prior, and CXR showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home medication regimen. The patient was found to by hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. . [**Hospital1 **] history: . 1. Hypertensive urgency: During the patient's [**Hospital1 **] stay, her SBPs ranged from 140s-160s during the day, which is her baseline systolic blood pressure. She was maintained on her home oral medication regimen. At night, she became more hypertensive, with SBP to the 170s-180s, which was controlled with both IV hydralazine and PO nifedipine. PO nifedipine was most successful at bringing her SBP back to her baseline. SBP at discharge was 140. Throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. The renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. Right leg pain: Upon arrival on the floor, the patient complained of [**2143-4-15**] pain in R buttock and posterior thigh, much exacerbated with standing. Of note, lumbar spine MRI and R hip XR on most recent admission were both negative. Her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. Her pain when she was symptomatic was controlled well with PO dilaudid. If the pain recurs, an MRI of the right hip can be considered to evaluate for osteonecrosis. . 3. UTI: The patient had a urinalysis suggestive of UTI, though she remained asymptomatic throughout. She was treated with a three day course of ciprofloxacin. Her urine culture showed mixed flora consistent with skin contamination. . 4. ESRD: The patient has end-stage renal disease due to her lupus. The patient's creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. She was followed by the renal consult service. Her potassium remained stable. Her calcium was low during admission, and supplemental calcium was given in addition to starting Calcitriol. She was not dialyzed through her PD catheter secondary to discomfort, but may reinitiate PD as an outpatient. Her laboratories will be checked as an outpatient in renal clinic. . 5. Anemia: The patient's hematocrit remained near her baseline low 20s throughout her stay. She has anemia from chronic kidney disease and chronic disease. The patient is not on Epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. Prior SVC thrombus: The patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with INR goal 2.5 to 3.0. . 7. Systemic lupus erythematosus: No active issues. The patient's home prednisone regimen was continued. Medications on Admission: - Prednisone 5 mg Daily - Coumadin 2 mg at bedtime - Nifedipine 60 mg Sustained Release Daily - Hydralazine 50 mg every 8 hours - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY - Aliskiren 150 mg Twice daily - Docusate Sodium 100 mg 2 times a day - Labetalol 900 mg three times a day - Lactulose 15-30 ml once a day: goal is [**1-11**] soft bowel movements per day Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 7. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: - Hypertensive urgency - Right lower extremity pain - Urinary tract infection Secondary diagnosis: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) - HOCM: Last noted on echo [**8-17**] - Anemia - History of left eye enucleation [**2139-4-20**] for fungal infection - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Discharge Condition: Stable systolic blood pressure over past 24 hours. Discharge Instructions: You were admitted to the hospital for uncontrolled high blood pressure. You spent one day in the intensive care unit, where you were treated with intravenous medication to lower your blood pressure. You were then transferred to a regular hospital floor, where your blood pressure was managed with your home oral medications. You were also treated for urinary tract infection with antibiotics. Your right leg pain improved during admission, and we are unsure of the cause of this pain. You should discuss the need for an MRI of the hip if the pain returns when you meet with your primary care doctor. Please call your physician or return to the emergency room if you experience fever, chills, chest pain, difficulty breathing, abdominal pain, headache, changes in your vision, or any other symptoms that are concerning. Please take your medications as prescribed. - Calcitriol was added to your medications. - You should hold Coumadin for two days and restart Saturday, [**2141-9-16**]. You should have your INR checked at your visit in kidney clinic [**2141-9-18**]. - You can take Dilaudid 2-4 mg every eight hours as needed for pain. You should be vigilant about taking lactulose if you need to take Dilaudid. - You should continue Lactulose as per Dr.[**Name (NI) 12913**] instructions. - No other changes were made. Please keep follow up appointments as described below. Followup Instructions: Please call the office of your kidney doctor, Dr. [**Last Name (STitle) 4883**], at ([**Telephone/Fax (1) 773**] to schedule an appointment for [**Last Name (LF) 766**], [**9-19**] as discussed. Follow up with your lung doctor: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-9-21**] 1:00 Follow up with your new primary care doctor: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 ",78,2141-09-11 10:12:00,2141-09-14 20:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home medication regimen. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. . [**hospital1 **] history: . 1. hypertensive urgency: during the patients [**hospital1 **] stay, her sbps ranged from 140s-160s during the day, which is her baseline systolic blood pressure. she was maintained on her home oral medication regimen. at night, she became more hypertensive, with sbp to the 170s-180s, which was controlled with both iv hydralazine and po nifedipine. po nifedipine was most successful at bringing her sbp back to her baseline. sbp at discharge was 140. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. the renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. her pain when she was symptomatic was controlled well with po dilaudid. if the pain recurs, an mri of the right hip can be considered to evaluate for osteonecrosis. . 3. uti: the patient had a urinalysis suggestive of uti, though she remained asymptomatic throughout. she was treated with a three day course of ciprofloxacin. her urine culture showed mixed flora consistent with skin contamination. . 4. esrd: the patient has end-stage renal disease due to her lupus. the patients creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. she was followed by the renal consult service. her potassium remained stable. her calcium was low during admission, and supplemental calcium was given in addition to starting calcitriol. she was not dialyzed through her pd catheter secondary to discomfort, but may reinitiate pd as an outpatient. her laboratories will be checked as an outpatient in renal clinic. . 5. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay. she has anemia from chronic kidney disease and chronic disease. the patient is not on epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. prior svc thrombus: the patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with inr goal 2.5 to 3.0. . 7. systemic lupus erythematosus: no active issues. the patients home prednisone regimen was continued. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Urinary tract infection, site not specified; Other primary cardiomyopathies; Systemic lupus erythematosus; Sciatica; Hyperpotassemia; Thrombocytopenia, unspecified; Abnormal coagulation profile; Hyperparathyroidism, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism]","icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the renal team was consulted, and recommended no change to home medication regimen. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. she was treated with a three day course of ciprofloxacin. esrd: the patient has end-stage renal disease due to her lupus. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay.","ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. she became more hypertensive, with sbps to the 170s-180s during the day. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency." 109,161950.0,14800,2141-12-01,14797,172335.0,2141-09-24,Discharge summary,"Admission Date: [**2141-9-18**] Discharge Date: [**2141-9-24**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1936**] Chief Complaint: hip pain Major Surgical or Invasive Procedure: None History of Present Illness: 24yo woman with hx SLE, CKD(not currently on HD or PD), labile HTN here with right leg pain and HTN urgency. Patient was recently d/ced on [**9-14**] following admission for the same complaints. . Patient took her hydralazine dose on am of admission. BP at presentation to the ER was 250/140 (The patient reportedly has baseline SBPs in 130-170s) She was given 900 labetolol and 50 hydralazine in the ED. BP following this was 175/124. Her EKG was unchanged. K was 5.7. . Patient also complaining of [**10-20**] right hip pain. Patient was d/ced on [**9-14**] with oral dilaudid for hip/leg pain. She took this only for one day due to severe itching. Denies any parasthesias/weakness. Her RLE/hip pain has been extensively worked up with negative LENIs, Lumbar spine MRI and hip plain films in the past. She was given 4mg IV morphine in the ER. . On admission to the floor, leg/hip pain somwhat improved with morphine.She denies any headache, vision changes, double vision, chest pain or SOB. Feels warm but no chills. Past Medical History: Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 97.3 HR 81 BP 135/91 RR 16 100%RA Gen:NAD, happy, pleasant female HEENT:NC/AT, L eye prosthesis, R PERRL, EOMI, MMM, facial swelling, L side>R, scerla anicteric Neck: supple, no JVD, no LAD, scars from prior CVL and HD lines CV:S1S2+, 2/6 SEM LUSB, loud P2, RRR, no ectopy Pulm: CTA B/L, good inspiratory effort Abd: +BS, soft, nontender, slightly distended and resonant to percussion, PD catheter in place in left abdomen ext: no c/c/e, 2+DP b/L, L foream swollen>R, R hip is mobile without pain elicited on passive or active movement neuro: AAOx3, nonfocal exam, CN 2-12 intact, moves all 4 extremities psych: mood/affect appropriate Pertinent Results: MRI Right Hip ([**9-18**]): There is no signal abnormality on the fluid-sensitive sequences in the proximal femur, acetabulum, or other osseous structure. On T1- weighted images, there is a focal rounded region within the right femoral head measuring approximately 9 mm in a subchondral location, which is nonspecific but may represent an unusual focus of red marrow. No sclerosis is seen on the corresponding plain films. There is a small right hip joint effusion and a small amount of fluid in the left hip joint as well, at the upper limits of normal. There is no soft tissue abnormality, no muscular edema, and no fluid collections. IMPRESSION: 1. Small right hip joint effusion. 2. No bone marrow edema in the proximal femurs or the pelvis. 3. Nonspecific small focus of low signal on T1-weighted images in the right femoral head is nonspecific but may represent an unusual focus of red marrow. TTE ([**9-21**]): The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF 80%). A mild (18 mmHg) mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. There is no systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Severe symmetric left ventricular hypertrophy with hyperdynamic systolic function and mild mid-cavitary gradient. Mild aortic regurgitation. Moderate pulmonary hypertension. Findings consistent with hyperrtophic cardiomyopathy. Compared with the prior study (images reviewed) of [**2140-8-26**], pulmonary hypertension has developed (also present on the study from [**2140-5-20**]). Pericardial effusion is also new. V/Q scan ([**9-21**]): Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate no focal defects with improved ventilation to the posterior right basal segment. Perfusion images in the same 8 views show improved perfusion to the posterior right basal segement with a persistent small defect but no new findings. Chest x-ray shows cardiomgealy and left basilar atelectasis. IMPRESSION: Improved V/Q scan from [**9-/2139**] with no findings to suggest acute pulmonary embolism. B/L upper ext U/S ([**9-21**]): Grayscale and Doppler son[**Name (NI) 867**] of the right and left internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. There is nonocclusive focal thrombus seen in the left subclavian vein, where the vein is not fully compressible. Flow is seen in the region, indicating that the thrombus is nonocclusive. Elsewhere, normal flow, augmentation, compressibility were appropriate and waveforms are demonstrated. IMPRESSION: 1. Focal nonocclusive thrombus in the left subclavian vein. 2. Otherwise, patent upper extremity veins as described. [**2141-9-18**] 02:15PM POTASSIUM-5.1 [**2141-9-18**] 02:15PM HCT-21.2* [**2141-9-18**] 08:45AM POTASSIUM-5.7* [**2141-9-18**] 07:30AM GLUCOSE-88 UREA N-54* CREAT-8.6* SODIUM-136 POTASSIUM-5.8* CHLORIDE-108 TOTAL CO2-15* ANION GAP-19 [**2141-9-18**] 07:30AM estGFR-Using this [**2141-9-18**] 07:30AM CALCIUM-7.3* PHOSPHATE-5.3* MAGNESIUM-1.6 [**2141-9-18**] 07:30AM WBC-5.2 RBC-2.32* HGB-6.5* HCT-20.1* MCV-87 MCH-28.1 MCHC-32.4 RDW-18.4* [**2141-9-18**] 07:30AM NEUTS-78.0* LYMPHS-14.7* MONOS-3.9 EOS-3.2 BASOS-0.3 [**2141-9-18**] 07:30AM PLT COUNT-107* [**2141-9-18**] 07:30AM PT-20.8* PTT-43.3* INR(PT)-2.0* . [**2141-9-21**] CXR: There is no significant change when compared to the recent previous examination. The previously described left retrocardiac opacity is unchanged in appearance. Cardiomegaly is also unchanged. The mediastinal contour, bony thorax and pulmonary vasculature are normal. IMPRESSION: No significant change compared to study done roughly 7 hours prior. Brief Hospital Course: 24 yo with h/o of Lupus, HTN, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for R hip pain. Patient was on the floor on [**9-20**], given morphine for the hip pain. She then had an episode of hypotension and unresponsiveness and transferred to the MICU for closer monitoring. The patient got 2L IVFs and narcan and improved, in fact, found to be hypertensive upon arrival to MICU. . MICU Course: On [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. Concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. Mental status cleared somewhat with narcan. Renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. V/Q scan demonstrated improvement since prior study. Patient's home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. She was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. PD fluid was not c/w SBP. CXR was clear. Urine culture and blood cultures are pending. Patient's BP was in the 110s so hydralazine was stopped. Her other BP meds were otherwise continued. Plan was/is to follow renal recs for PD. If, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. Would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. If patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. Would add neurontin 100mg TID with room to titrate up to 300mg TID. Neuro also recommended PT with TENS unit and referral to pain clinic although patient's pain is currently absent. . FYI **** per Dr. [**Last Name (STitle) **] --- Because of ? increase in cardiomegaly on CXR, she got an echo yesterday. In addition to her known HOCM, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm Hg. They probably need to be followed up over time (particularly the pulmonary hypertension). We did evaluated the PHTN with a VQ scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. It would be good if we could arrange a PULMONARY CLINIC FOLLOW UP for Ms. [**Known lastname **] after discharge with either [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].**** . She underwent CT head, and V/Q scan which were unremarkable. Her steroid dose was increased to 15mg given concern for need for stress dose steroids. After transfer from the MICU, her steroids were dropped back to 5mg, her home dose with the approval of [**Last Name (un) **]. . Her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. Her hydralazine was discontinued. On day 2 of her MICU stay, she developed a fever to 102. She was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. Broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. There was question of retrocardiac opacity on CXR, though not clear. Rheum consult obtained given hip discomfort, who felt septic joint unlikely. Neurology consult obtained who felt autonomic seizure unlikely. . Pt initiated peritoneal dialysis. In this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising BPs. She is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. Her hip pain has resolved completely without further intervention. . Floor course: Fever: Spike fever in MICU to 102. Started on Levoquin, Aztreonam, and Vanc. Source unclear at this point, but CXR with question of retrocardiac opacity. There is a possibility of aspiration pneumonitis. Other etiologies include peritoneal fluid (PD cath), urine, and blood (though patient does not have any indwelling lines). Hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. Peritoneal dialysis cultures negative so far. Continued levo/vanco/aztreonam for 2 days empirically. Then d/ced the Abx as no infectious etiologies were found. Steroids back to home dosage. BCx, UCx (final neg), Peritoneal cultures negative at discharge. . # Labile blood pressure: h/o of difficult to control BP with episodes of hypertensive emergency in the past. Normal SBP runs in 170s. Having nausea in setting of new PD, no evidence of intracranial bleeding on clinical exam, though INR had been supratherapeutic so remains in differential, though not bradycardic. Continue home BP meds :Labetalol 900 mg PO TID but difficult for patient to tolerate due to nausea, Aliskiren *NF* 150 mg Oral [**Hospital1 **], NIFEdipine CR 60 mg PO DAILY, clonidine patch, hydralazine given hypertensive in setting of nausa. . # Right leg/hip pain: no evidence of avascular necrosis or fracture on MRI though there is a small effusion. Pain resolved without intervention. Continued to monitor and would avoid narcotics, restart slowly if pain resumes. Physical therapy to follow as an outpatient. [**Last Name (un) 18183**] followed. Please see consult note. . # Hyperkalemia: Chronic issue. Patient takes kayexalate intermittently per her report (last dose [**Last Name (un) 766**]). Monitored K but patient did not need it on floor. # CKD V: Renal following. Did well with PD on [**9-22**] but did report some nause and cramping. She was not tolerating all 1.5L in exchanges on discharge. # Anemia: Hct stable around 20. S/p 1 U PRBCs in MICU with Hct 20.1 to 21.9. Likely due to chronic hemolysis consistent with SLE> #. Prior SVC thrombus: Physical exam with L arm swelling consistent with this. No flow limitations. INR 3.5 on ICU admission. Held warfarin but restarted home 2mg daily the day before discharge. # Systemic lupus erythematosus: Home prednisone dose 5mg. Currently on 15mg in setting of acute illness (day 2). # General care: FEN: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, PD initiated, Proph: INR therapeutic, no indication for PPI, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. Code: Full code, confirmed with patient Communication: with the patient and her mother [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (2) 43497**]contact. Access: 2 PIVs Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly dilaudid PO prn benadryl prn lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily coumadin 2mg PO qday calcitriol 1 mcg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Hypertensive urgency Transient Hypotension due to Narcotics Sciatica . Secondary: End stage renal disease Systemic Lupus Erythematosus Anemia Discharge Condition: Stable. Blood pressures at baseline. Hip/leg pain resolved. Ambulating without assistance. Discharge Instructions: You were admitted to the hospital with high blood pressure and right leg/hip pain. We gave you pain medications and blood pressure lowering medications. Your blood pressure then dropped which was caused by the pain medication, and you were transferred to the Intensive Care Unit(ICU) where you recovered quickly. During your stay in the ICU, you developed a fever and were started on antibiotics. However, the cultures that were obtained were negative, and we discontinued the Antibiotics. During your hospitalization, your blood pressure normalized on your home regimen, and your right leg/hip pain resolved. You had an MRI of your hip done, which did not show an acute infection. You were seen by the kidney doctors and they recommended starting peritoneal dialysis. You were also given some blood for your anemia. Please follow up with the Peritoneal Dialysis nurse at the scheduled day/time. Please make an appointment to meet with your PCP in the next couple of weeks. Your Hip pain may benefit from physical therapy or outpatient anesthetic joint injection. Please discuss these options with your rheumatologist. . Please call the number given below to schedule outpatient physical therapy. . Please restart your home medications. You were also started on Sodium Bicarb 650mg by mouth three times a day. . If you develop fevers, chills, trouble breathing, chest pain, worsening of hip pain, headaches, changes in your vision or any other symptoms that concern you please return to the emergency room or call your doctor. Followup Instructions: Please follow up with your Peritoneal Dialysis nurse ([**Doctor First Name 3040**]) on [**Doctor First Name 766**] [**2141-9-25**] . Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 . Please call to schedule Outpatient Physical Therapy:[**Telephone/Fax (1) 2484**] Completed by:[**2141-9-25**]",68,2141-09-18 10:32:00,2141-09-24 13:53:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,LEG PAIN," 24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. patient was on the floor on [**9-20**], given morphine for the hip pain. she then had an episode of hypotension and unresponsiveness and transferred to the micu for closer monitoring. the patient got 2l ivfs and narcan and improved, in fact, found to be hypertensive upon arrival to micu. . micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. mental status cleared somewhat with narcan. renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. v/q scan demonstrated improvement since prior study. patients home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. she was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. pd fluid was not c/w sbp. cxr was clear. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. plan was/is to follow renal recs for pd. if, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. would add neurontin 100mg tid with room to titrate up to 300mg tid. neuro also recommended pt with tens unit and referral to pain clinic although patients pain is currently absent. . fyi **** per dr. [**last name (stitle) **] --- because of ? increase in cardiomegaly on cxr, she got an echo yesterday. in addition to her known hocm, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm hg. they probably need to be followed up over time (particularly the pulmonary hypertension). we did evaluated the phtn with a vq scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. it would be good if we could arrange a pulmonary clinic follow up for ms. [**known lastname **] after discharge with either [**first name4 (namepattern1) **] [**last name (namepattern1) **] or [**first name4 (namepattern1) **] [**last name (namepattern1) **].**** . she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. after transfer from the micu, her steroids were dropped back to 5mg, her home dose with the approval of [**last name (un) **]. . her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. her hydralazine was discontinued. on day 2 of her micu stay, she developed a fever to 102. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. there was question of retrocardiac opacity on cxr, though not clear. rheum consult obtained given hip discomfort, who felt septic joint unlikely. neurology consult obtained who felt autonomic seizure unlikely. . pt initiated peritoneal dialysis. in this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising bps. she is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. her hip pain has resolved completely without further intervention. . fever: spike fever in micu to 102. started on levoquin, aztreonam, and vanc. source unclear at this point, but cxr with question of retrocardiac opacity. there is a possibility of aspiration pneumonitis. other etiologies include peritoneal fluid (pd cath), urine, and blood (though patient does not have any indwelling lines). hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. peritoneal dialysis cultures negative so far. continued levo/vanco/aztreonam for 2 days empirically. then d/ced the abx as no infectious etiologies were found. steroids back to home dosage. bcx, ucx (final neg), peritoneal cultures negative at discharge. . # labile blood pressure: h/o of difficult to control bp with episodes of hypertensive emergency in the past. normal sbp runs in 170s. having nausea in setting of new pd, no evidence of intracranial bleeding on clinical exam, though inr had been supratherapeutic so remains in differential, though not bradycardic. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. . # right leg/hip pain: no evidence of avascular necrosis or fracture on mri though there is a small effusion. pain resolved without intervention. continued to monitor and would avoid narcotics, restart slowly if pain resumes. physical therapy to follow as an outpatient. [**last name (un) 18183**] followed. please see consult note. . # hyperkalemia: chronic issue. patient takes kayexalate intermittently per her report (last dose [**last name (un) 766**]). monitored k but patient did not need it on floor. # ckd v: renal following. did well with pd on [**9-22**] but did report some nause and cramping. she was not tolerating all 1.5l in exchanges on discharge. # anemia: hct stable around 20. s/p 1 u prbcs in micu with hct 20.1 to 21.9. likely due to chronic hemolysis consistent with sle> #. prior svc thrombus: physical exam with l arm swelling consistent with this. no flow limitations. inr 3.5 on icu admission. held warfarin but restarted home 2mg daily the day before discharge. # systemic lupus erythematosus: home prednisone dose 5mg. currently on 15mg in setting of acute illness (day 2). # general care: fen: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, pd initiated, proph: inr therapeutic, no indication for ppi, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. code: full code, confirmed with patient communication: with the patient and her mother [**name (ni) **] [**name (ni) **], [**telephone/fax (2) 43497**]contact. access: 2 pivs ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Pneumonia, organism unspecified; Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Hyperpotassemia; Sciatica; Other iatrogenic hypotension; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Anemia of other chronic disease; Hypocalcemia]","24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. it would be good if we could arrange a pulmonary clinic follow up for ms. [** she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. source unclear at this point, but cxr with question of retrocardiac opacity. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. did well with pd on [**9-22**] but did report some nause and cramping. # systemic lupus erythematosus: home prednisone dose 5mg.","lupus nephropathy patient on peitoneal dialysis with htn and lupus nephropathy. triggered for hypotension (82/45), hypothermia (92.9), altered mental status. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis." 109,161950.0,14800,2141-12-01,14798,126055.0,2141-11-03,Discharge summary,"Admission Date: [**2141-10-13**] Discharge Date: [**2141-11-3**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 6734**] Chief Complaint: Nausea, Vomitting, Abdominal Pain, HTN Urgenc Major Surgical or Invasive Procedure: Upper GI endoscopy Exploratory laparotomy Tunneled hemodialysis catheter in R femoral vein Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 24 y/o F with h/o ESRD, HTN who started peritoneal dialysis during the week of [**2141-10-8**] and presented with a 1 day history of acute onset N/V, sharp abdominal pain on [**2141-10-13**]. (Of note, the patient had presented to the ED on [**10-11**] with hypotension, SBPs in the 80s off after approximately 1.5L was taken off during dialysis in the setting of taking her PO Anti-HTNs. On [**2141-10-11**] she received 0.5L IVF, labs WNL, and was d/c'd home). On the day of admission on [**2141-10-13**], the patient reported that the previous night, she was awoken from sleep with severe, sharp abdominal pain, 6 episodes of frothy emesis, 10+ yellowish BMs without melena or BRBRP.She was admitted for further work- up of this abdminal pain. . In the ED here vitals were as follows: T: 97.0 HR: 101 BP: 240/180 RR: 17 O2sat: 100%RA. She received Labetolol 20mg IV and was subsequently placed on a labetolol drip. She also received ceftriaxone 1gm IV, Flagyl 500mg IV, Dilaudid 0.5-1mg IV q1hr and Zofran. Her abdominal CT showed multifocal areas of small bowel wall thickening. Her peritoneal Cell count was negtaive for SBP. She had some signs of peritonitis and thus surgery was consulted. Her lactate was normal. . Upon arrival to the MICU the patient was mentating well with complaints of diffuse sharp abdominal pain that radiated to the back and diarrhea. She had no headache or visual changes. Past Medical History: - SLE DX ([**2134**] - 16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter Placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). - Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS: 98.4 HR 98 192/131 21 100%RA GEN: Mild Distress, AOx3 HEENT: PEERLA, EOMI NECK: Supple, No LAD, No bruit RESP: CTAB CARD: 2/6 systolic ejection murmur ABD: soft, moderately tender with +/- guarding, BS+ EXTR: Warm well perfused NEURO: Motor Grossly Intact RECTAL: Yellow Stool BACK: B CVAT Pertinent Results: [**2141-11-3**] 08:50AM BLOOD WBC-3.5* RBC-2.55* Hgb-7.8* Hct-23.6* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.8* Plt Ct-176 [**2141-11-3**] 03:55PM BLOOD PT-15.5* PTT-50.8* INR(PT)-1.4* [**2141-11-3**] 08:50AM BLOOD Glucose-121* UreaN-33* Creat-5.2*# Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [**2141-10-26**] 06:15AM BLOOD ALT-11 AST-49* AlkPhos-122* Amylase-186* TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2141-10-26**] 06:15AM BLOOD Lipase-30 [**2141-11-3**] 08:50AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.9 [**2141-10-30**] 06:55AM BLOOD HBsAg-NEGATIVE [**2141-10-17**] 10:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2141-10-25**] 11:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2141-10-25**] 11:56AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2141-10-25**] 11:56AM URINE RBC-0-2 WBC-[**3-15**] Bacteri-FEW Yeast-NONE Epi-21-50 Blood cultures: all negative EKG ([**2141-10-13**]): Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of [**2141-10-2**] there is no significant diagnostic change. CXR ([**2141-10-13**]): No acute cardiopulmonary abnormality. No free air under the diaphragms. CT chest/abdomen/pelvis ([**2141-10-13**]): There is a moderate-sized pericardial effusion, similar in appearance from [**2141-10-13**]. The great vessels are normal in caliber, without aneurysmal dilatation. Evaluation of the great vessels is limited without IV contrast. Interstitial thickening, particularly within the perihilar regions, is suggestive of fluid overload. There is bibasilar atelectasis with a small focus of consolidation in the right lower lobe (2:35) unchanged from [**2141-10-13**], and may reflect aspiration or pneumonia. Scattered bilateral nodules are largely stable from as far back as [**2139-10-9**]. Specifically, there is a 5 mm nodule in the right middle lobe (2:25), two adjacent nodules in the right lower lobe measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule within the left lower lobe. A nodular density seen adjacent and anterior to the right main pulmonary artery (2:23) may reflect a vessel. There is a small right pleural effusion. Axillary lymphadenopathy, with axillary nodes measuring up to approximately 10 mm in short axis, is seen. Ill- defined soft tissue thickening within the hilus bilaterally may reflect hilar lymphadenopathy, but assessment is limited without IV contrast. A catheter is visualized within the visualized right upper extremity, which may reflect a PICC line that terminates within the right subclavian vein. The esophagus is distended and filled with contrast, with marked wall thickening and edema throughout its entire length, a new finding. There is a moderate- sized hiatal hernia. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval development of a moderate amount of free intraperitoneal air, that layers anteriorly and along the anterior abdominal wall. Additional small clustered foci of extraluminal air is seen adjacent to the proximal stomach and the gastroesophageal junction, with a focus of air tracking into the fissure of ligamentum venosum. Additionally, there appears to be air tracking into the anterior subcutaneous tissues in the region of the umbilicus. These findings are all new from the prior CT on [**2141-10-13**], but free air was present on chest radiograph performed [**2141-10-25**]. There is no obvious evidence of extravasation of oral contrast into the peritoneum. Of note, a peritoneal dialysis catheter is in place that could represent a route of entry of intraperitoneal air. The stomach, small bowel, and colon are filled with contrast, without evidence of obstruction. Evaluation for wall thickening is limited without IV contrast. Limited non-contrast views of the liver demonstrates a rounded 1.6 cm x 1.2 cm hypodensity in the right lobe of the liver, previously characterized as a hemangioma. The liver is otherwise unremarkable. The gallbladder, spleen, pancreas, and adrenal glands demonstrate no gross abnormality. Both kidneys are atrophic. Evaluation of solid organs is limited by lack of IV contrast. There is a peritoneal dialysis catheter, coiled within the pelvis, unchanged. There is a large amount of free fluid throughout the abdomen, similar in appearance to the prior study. CT OF THE PELVIS WITHOUT IV CONTRAST: Uterus and rectum are grossly unremarkable. However, assessment of the rectal wall is limited without IV contrast. OSSEOUS STRUCTURES: Bones are diffusely sclerotic, which may be related to renal osteodystrophy. There is bilateral sacroiliitis. IMPRESSION: 1. Interval development of a moderate amount of free intraperitoneal air, new from [**2141-10-13**]. A peritoneal dialysis catheter is in place and could represent the route of entry of free intraperitoneal air. However, as foci of air is seen in the region of the proximal stomach and GE junction in the setting of a recent endoscopy, perforation cannot be excluded, though no frank extravasation of contrast is identified. 2. New dilation and wall thickening of the entire esophagus, a nonspecific finding that could relate to infectious or inflammatory esophagitis; clinical correlation is recommended. Esophagus is contrast-filled possibly representing reflux. Hiatal hernia. 3. Anasarca, with moderate-sized pericardial effusion, pulmonary edema, and small right pleural effusion. 4. Large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. Imaging cannot exclude SBP, which should be evaluated for clinically. 5. Focus of consolidation within the right lower lobe, could represent aspiration or pneumonia, but unchanged from the prior study. Gastric Biopsies ([**2141-10-18**]): Antrum: Corpus-type mucosa, no diagnostic abnormalities recognized. Jejunum: Small intestinal mucosa, no diagnostic abnormalities recognized. UE Venous U/S: No evidence of DVT of the left upper extremity, without thrombus identified within the left subclavian vein. Brief Hospital Course: This is a 24 year old woman with ESRD secondary to SLE (started peritoneal dialysis approximately one week prior to admission), malignant HTN, h/o SVC syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. Her hospital course was complicated by multiple transfers between the MICU and the floor secondary to hypertensive urgency. # Abdominal Pain/Diarrhea: During the patient's admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. Infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. However, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. The patient was empirically placed on IV flagyl, but this was discontinued when stool samples were negative for C.difficile. Serial abdominal exams showed no peritoneal signs. Peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. CT of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. Other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to SLE vasculitis, malignant HTN, or microthrombosis and SLE enteritis. Surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. A heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible GI bleed. With regards to SLE vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to SLE. On [**10-18**], GI performed an EGD which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. Approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. Both cardiac, GI, and pulmonary etiologies were considered for the origin of her epigastric pain. Pericarditis was considered, but her EKG was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. Her lungs were also essentially unchanged from [**2141-10-13**]. However, her abdominal CT on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. As a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. There were no major findings: no evidence of perforation, obstruction, or infection. The patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. At discharge, the patient only complained of some mild incisional pain. # Hypertensive urgency: The patient was initially admitted to the MICU with a blood pressure of 240/180. Her hospital course was complicated by extremely labile HTN and was transferred back and forth between the MICU and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of SBPs > 260. Throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. Her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. Multiple medication regimens were attempted and changed throughout her hospital course. However, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for SBPs > 180. At discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg PO. Her regimen as per Dr. [**Last Name (STitle) 4883**]: Nifedipine SR 90 mg daily Aliskiren 150 mg [**Hospital1 **] Labetalol 300 mg TID Hydralazine 75 mg TID Clonidine patch 0.3 mg/24 hr patch qWed When SBP>180, she then uses a hydralazine sliding scale. When SBP>180, give 25 mg PO hydral every 30 min until SBP<150. You can use this for up to 2-3 hours. In between PO hydral doses, can then also use 10 IV hydralazine. # ESRD: The etiology of the patient's ESRD is secondary to SLE. Her Creatinine on admission was 7.9, which was near her baseline of 8 - 9. During her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. Prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2L per PD. After her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. Initially, the patient adamantly refused hemodialysis. However, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. As a result, after a long coversation with her primary renal physician, [**Name10 (NameIs) **] agreed to restart hemodialysis. A tunneled catheter was placed in her R femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. She underwent hemodialysis two more times prior to discharge. Upon discharge, her electrolytes were back to her baseline. She is expected to undergo hemodialysis (Tues/[**Last Name (un) **]/SAT) as an outpatient. # Anemia: During her admission, the patient's HCT was monitored daily with HCT to low-mid 20's. On [**2141-10-17**], she was found to have guaiac positive stools and her HCT was found to have dropped to a low of 18.6. The patient was transfused a total of 2 units of [**Date Range **] between [**2141-10-17**] and [**2141-10-18**]. Epo Alfa SC was also given on [**2141-10-17**]. She remained hemodynamically stable. GI consulted and EGD results were as stated above. The patient's HCT remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. Between [**2141-10-23**] - [**2141-10-24**], the patient had a HCT drop from 26 to 20 in the setting of occult positive emesis. She received two units of [**Month/Day/Year **] and her HCT returned to 28. GI was aware and planned to perform a non-urgent EGD on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her HCT returned to baseline. However, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her HCt remained stable and near baseline for the remiainder of her hospital course. # H/O Thrombosis: The patient was initially placed on her home dose of warfarin 2mg qd. Her INR on admission was 1.2. She was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. However, this was stopped for her EGD and after she had evidence of a GI bleed. The heparin drip was discontinued on [**10-22**]. The patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in HCT and in preparation for a possible GI intervention. After her surgery, her coumadin was held and she was off the heparin drip, but her INR continued to drift up, getting as high as 2.6 on [**2141-10-30**]. This was mostly attributed to nutritional deficiency [**2-11**] poor PO intake, but there was concern for possible synthetic dysfunction as well. As a result, she was given a test dose of vitamin K, which she responded to well (Her INR came back down to 1.4). As a result, her home dose of coumadin at 2 mg qday was restarted. At discharge, her INR was still sub- therapeutic at 1.4. Of note, the patient has a history of SVC syndrome and had a L subclavian venous thrombosis. During the last few days of her hospital stay, the patient complained of increased tongue swelling and her L face was noted to be slightly more swollen than previously noted. As a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a DVT within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # SLE: Rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. Her outside rheumatologist was also consulted. Both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # Obstructive sleep apnea: The patient was noted to have OSA based on clinical nocturnal exam during admission. Patient attempted 1 trial of CPAP at 2L/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. The paitent stated that she would pursue further work-up and treatment for OSA as an outpatient. While the mask and CPAP machine were at her bedside throughout her hospital course, the patient rarely used it. # Metabolic Acidosis: The patient's bicarbonate on admission was 13. Her baseline is normally between 16-20. She received 150mEq NaHCO3 over 24hrs from [**Date range (1) 43500**]. During her brief returns to the MICU, her HC03 was 18-19, which was presumed to be her baseline at home secondary to her CRF. At discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. Medications on Admission: Nifedipine 60 mg PO daily Labetalol 900 mg PO TID Hydralazine 50 mg PO TID Clonidine 0.3 mg/24hr patch qWED Lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 4 mg daily Warfarin 2mg PO daily Calcitriol 1 mcg daily Calcium carbonate 500mg QID Dilaudid 2mg PO Q4-6hr prn pain Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*30 Patch Weekly(s)* Refills:*2* 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. [**Hospital1 **]:*1500 ML(s)* Refills:*0* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Twice daily (). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): In addition to 75 mg TID, if SBP>180, take 1 tab every 30 min until BP decreases to 150. If no improvement after 2 hours, call your doctor. [**Last Name (Titles) **]:*300 Tablet(s)* Refills:*6* 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). [**Last Name (Titles) **]:*1500 ML(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet Sustained Release(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 5 days. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. [**Last Name (Titles) **]:*30 Capsule(s)* Refills:*2* 13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO once a day. [**Last Name (Titles) **]:*30 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: end stage renal disease malignant hypertension abdominal free air subclavian deep vein thrombosis initiation of hemodialysis Secondary: SLE Anemia Discharge Condition: stable, pain well controlled, blood pressure at baseline Discharge Instructions: You were admitted for abdominal pain and then subsequently had a very long hospital course with high blood pressures, severe abdominal pain, some free air in your abdomen resulting in an exploratory laparotomy. You have also been initiated on hemodialysis on Tuesday/Thursday/Saturday schedule. Please take all medications as prescribed in the list that you will be given at discharge. There have been some changes to your medications. Please call your doctor if you have any worsening abdominal pain, fevers, chills, nausea, vomiting, headache, palpitations, diarrhea or any other concerning symptoms. Followup Instructions: You will see Dr. [**Last Name (STitle) 4883**] at hemodialysis on Tuesday, [**11-7**], [**2141**]. You should have your coumadin level checked at this appointment. Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] to schedule an appointment in [**1-11**] weeks to have your staples removed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**] ",28,2141-10-13 23:10:00,2141-11-03 18:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. her hospital course was complicated by multiple transfers between the micu and the floor secondary to hypertensive urgency. # abdominal pain/diarrhea: during the patients admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. the patient was empirically placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. serial abdominal exams showed no peritoneal signs. peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. ct of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to sle vasculitis, malignant htn, or microthrombosis and sle enteritis. surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible gi bleed. with regards to sle vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to sle. on [**10-18**], gi performed an egd which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. both cardiac, gi, and pulmonary etiologies were considered for the origin of her epigastric pain. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. her lungs were also essentially unchanged from [**2141-10-13**]. however, her abdominal ct on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. as a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. there were no major findings: no evidence of perforation, obstruction, or infection. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. at discharge, the patient only complained of some mild incisional pain. # hypertensive urgency: the patient was initially admitted to the micu with a blood pressure of 240/180. her hospital course was complicated by extremely labile htn and was transferred back and forth between the micu and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of sbps > 260. throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. multiple medication regimens were attempted and changed throughout her hospital course. however, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for sbps > 180. at discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg po. her regimen as per dr. [**last name (stitle) 4883**]: nifedipine sr 90 mg daily aliskiren 150 mg [**hospital1 **] labetalol 300 mg tid hydralazine 75 mg tid clonidine patch 0.3 mg/24 hr patch qwed when sbp>180, she then uses a hydralazine sliding scale. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. you can use this for up to 2-3 hours. in between po hydral doses, can then also use 10 iv hydralazine. # esrd: the etiology of the patients esrd is secondary to sle. her creatinine on admission was 7.9, which was near her baseline of 8 - 9. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2l per pd. after her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. initially, the patient adamantly refused hemodialysis. however, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. as a result, after a long coversation with her primary renal physician, [**name10 (nameis) **] agreed to restart hemodialysis. a tunneled catheter was placed in her r femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. she underwent hemodialysis two more times prior to discharge. upon discharge, her electrolytes were back to her baseline. she is expected to undergo hemodialysis (tues/[**last name (un) **]/sat) as an outpatient. # anemia: during her admission, the patients hct was monitored daily with hct to low-mid 20s. on [**2141-10-17**], she was found to have guaiac positive stools and her hct was found to have dropped to a low of 18.6. the patient was transfused a total of 2 units of [**date range **] between [**2141-10-17**] and [**2141-10-18**]. epo alfa sc was also given on [**2141-10-17**]. she remained hemodynamically stable. gi consulted and egd results were as stated above. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. she received two units of [**month/day/year **] and her hct returned to 28. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. however, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her hct remained stable and near baseline for the remiainder of her hospital course. # h/o thrombosis: the patient was initially placed on her home dose of warfarin 2mg qd. her inr on admission was 1.2. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. however, this was stopped for her egd and after she had evidence of a gi bleed. the heparin drip was discontinued on [**10-22**]. the patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in hct and in preparation for a possible gi intervention. after her surgery, her coumadin was held and she was off the heparin drip, but her inr continued to drift up, getting as high as 2.6 on [**2141-10-30**]. this was mostly attributed to nutritional deficiency [**2-11**] poor po intake, but there was concern for possible synthetic dysfunction as well. as a result, she was given a test dose of vitamin k, which she responded to well (her inr came back down to 1.4). as a result, her home dose of coumadin at 2 mg qday was restarted. at discharge, her inr was still sub- therapeutic at 1.4. of note, the patient has a history of svc syndrome and had a l subclavian venous thrombosis. during the last few days of her hospital stay, the patient complained of increased tongue swelling and her l face was noted to be slightly more swollen than previously noted. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. her outside rheumatologist was also consulted. both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission. patient attempted 1 trial of cpap at 2l/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. the paitent stated that she would pursue further work-up and treatment for osa as an outpatient. while the mask and cpap machine were at her bedside throughout her hospital course, the patient rarely used it. # metabolic acidosis: the patients bicarbonate on admission was 13. her baseline is normally between 16-20. she received 150meq nahco3 over 24hrs from [**date range (1) 43500**]. during her brief returns to the micu, her hc03 was 18-19, which was presumed to be her baseline at home secondary to her crf. at discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. ","PRIMARY: [Malignant essential hypertension] SECONDARY: [Renal dialysis status; Epilepsy, unspecified, without mention of intractable epilepsy; Constipation, unspecified; Anemia in chronic kidney disease; Abnormal coagulation profile; Obstructive sleep apnea (adult)(pediatric); Other diseases of lung, not elsewhere classified; Other chest pain; Fever, unspecified; Rash and other nonspecific skin eruption; Other chronic pulmonary heart diseases; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified disease of pericardium; Other ascites; Acidosis; Hyposmolality and/or hyponatremia; Abdominal pain, other specified site; Abdominal pain, epigastric; Nausea with vomiting; Diarrhea; Systemic lupus erythematosus; Hyperparathyroidism, unspecified; Anemia, unspecified; Thrombocytopenia, unspecified; Esophageal reflux]","this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. multiple medication regimens were attempted and changed throughout her hospital course. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. upon discharge, her electrolytes were back to her baseline. epo alfa sc was also given on [**2141-10-17**]. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission.","esrd secondary to sle, malignant htn, h/o svc syndrome, and multiple thrombotic events were considered. the patient was placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia." 109,161950.0,14800,2141-12-01,14799,125288.0,2141-11-23,Discharge summary,"Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypertensive Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: (from MICU admit note) 24yoF ESRD-HD, SLE, HTN presents with 1 month abdominal pain and hypertension. Pt has had work-up over recent months for abd pain, including exploratory laparotomy, all of which essentially (-). Was admitted [**Date range (1) 34629**], for abdominal pain, then returned [**11-16**] for sob with (-)CTA, dc'ed [**11-17**]. In [**Hospital1 18**] ED, T98.5 hr95 BP 220/110 then 183/133 RR13 O2 100% on RA, rectal exam negative, guaiac(-), pelvic exam unremarkable with no cervical motion tenderness. Renal was consulted, taken for hemodialysis. CT abd showed large ascites, no other pathology; CT head improved from prior with no acute ICH; cxr(-). Given iv dilaudid for abdominal pain. BP treated with 10mg iv labetalol. Blood and urine cultures drawn, peritoneal fluid cx sent from catheter. Admitted to MICU for hypertension management. Access: R-HD catheter, 1 pIV in hand, 1 non-functioning peritoneal dialysis catheter. Past Medical History: PMH: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSH: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: PE: T:99.4 BP:158/108 HR:95 RR:12 O2 100% RA GEN: NAD/ pt eyes closed due to pain/ pleasant despite pain HEENT: AT, NC, PERRLA, EOMI on R eye, L eye prosthesis, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD CV: S1 & S2, RRR II/VI HSM at R/L USB, no rubs/gallops PULM: CTAB, no w/r/r ABD: soft, mildly tender at PD catheter, ND, + BS, midline incision with steri-stripes, PD catheter dressing C/I/D EXT: warm, dry, +2 distal pulses BL, no edema NEURO: alert & oriented, CN II-XII grossly intact (except L eye), 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: Admission Labs: [**2141-11-18**] 07:00AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.7* Hct-30.7* MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* Plt Ct-142* [**2141-11-18**] 07:00AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.3* [**2141-11-18**] 07:00AM BLOOD Glucose-86 UreaN-22* Creat-5.0* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2141-11-18**] 07:00AM BLOOD ALT-8 AST-39 AlkPhos-92 TotBili-0.3 [**2141-11-18**] 07:00AM BLOOD Lipase-76* [**2141-11-18**] 07:00AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.9 [**2141-11-18**] 11:00PM ASCITES WBC-1265* RBC-1680* Polys-43* Lymphs-1* Monos-2* Mesothe-11* Macroph-43* [**2141-11-18**] 10:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2141-11-18**] 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2141-11-18**] 10:05AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-[**3-15**] Discharge Labs: [**2141-11-23**] 04:40AM BLOOD WBC-2.9* RBC-3.08* Hgb-9.0* Hct-28.3* MCV-92 MCH-29.2 MCHC-31.8 RDW-17.5* Plt Ct-182 [**2141-11-23**] 04:40AM BLOOD PT-20.8* PTT-76.1* INR(PT)-2.0* [**2141-11-23**] 04:40AM BLOOD Glucose-80 UreaN-21* Creat-4.7* Na-139 K-4.8 Cl-106 HCO3-24 AnGap-14 [**2141-11-23**] 04:40AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8 [**2141-11-22**] 04:55AM BLOOD TSH-6.1* [**2141-11-23**] 04:40AM BLOOD Free T4-1.2 Blood cx ([**11-18**], [**11-19**]): 1/4 bottles with coag neg Staph, [**3-14**] NGTD Urine cx ([**11-18**]): mixed flora c/w contamination Peritoneal fluid ([**11-18**]): Gram stain 2+ polys. Culture no growth. Imaging: CXR Portable ([**11-18**]): Since [**2141-11-16**], heart size enlargement is unchanged due to known pericardial effusion. Lungs are otherwise clear. Hilar contours are normal. Incidentally, widening of both acromioclavicular joints is unchanged. CT A/P ([**11-18**]): 1. No evidence of bowel obstruction or rim-enhancing fluid collection. 2. Large ascites, slightly increased from [**2141-11-13**], with peritoneal dialysis catheter in place. Interval removal of surgical skin staples along the abdomen. 3. Moderate pericardial effusion as before. 4. Symmetric heterogeneous attenuation of the kidneys could be related to renal failure; however, pyelonephritis could also give this appearance. Appearance of the kidneys is unchanged from [**2141-11-13**]. CT Head w/o contrast ([**11-18**]): 1. No evidence of acute intracranial hemorrhage. 2. Regions of hypoattenuation in the bifrontal white matter and left posterior temporal lobe have resolved since [**2141-6-11**]. No new regions of hypoattenuation seen. Brief Hospital Course: 1) Hypertension: Patient has history of extremely labile hypertension on an aggressive outpatient regimen. Overnight in the MICU, patient required IV and PO labetalol for SBP > 200. Her hydralazine was increased from 75mg to 100mg TID with mild improvement. Her labetalol was also increased from 300mg to 400mg TID. Her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. TSH was sent and elevated, although free T4 was normal. Plasma metanephrines were sent and pending at discharge. 2) Abdominal pain: CT scan showed increasing ascites, but no acute pathology. Peritoneal fluid was obtained and contained 544 polys. Treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing GPC pairs/clusters. Blood cultures ended up growing 1 out of 4 bottles coag-neg Staph, likely contaminant, so vancomycin was stopped. Since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. The peritoneal cultures remained negative. Her PD catheter was left in place as the patient refuses HD any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) SVC/brachiocephalic thrombosis: Patient's INR was subtherapeutic on admission at 1.3. Due to the proximal location of her old venous thrombi, she was started on a heparin gtt. This was continued during her admission and her warfarin was increased to 5mg daily. Her INR reached 2.0 at discharge (therapeutic range 2-3). The dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) Anxiety: Patient noted feeling short of breath and anxious around the time of her recent admissions. Her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. They felt her symptoms were suggestive of anxiety and panic attacks, recommended checking TSH and metanephrines as above, and starting citalopram 20mg, which was done. She was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h PRN. Patient is agreeable to outpatient follow up with [**Company 191**] social work, and potential CBT. These can be arranged by her PCP. Medications on Admission: 1. Aliskiren 150 mg [**Hospital1 **] 2. Clonidine 0.3 mg/24 qwk 3. Prochlorperazine Maleate 10 mg prn 4. Hydromorphone 2 mg Tablet Sig: [**1-11**] q6 prn 5. Bisacodyl 10mg [**Hospital1 **] 6. Ergocalciferol (Vitamin D2) 50,000 qmonth 7. Hydralazine 75mg tid 8. Hydralazine scale prn 9. Labetalol 300 mg tid 10. Nifedipine 90 mg qd 11. Prednisone 4mg qd 12. Warfarin 2 mg qd at 4pm Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Hospital1 766**]). 5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day. [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 7 days. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO q30 min prn as needed for hypertension: for SBP > 180. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive urgency Headache Abdominal pain Anxiety Secondary Diagnosis: HTN SLE ESRD on HD SVC and IJ thrombosis, chronic Anemia Discharge Condition: Stable, BPs improved. Discharge Instructions: You were admitted with elevated blood pressures, headache, and abdominal pain. You were found to have increased amounts of white blood cells in your abdominal cavity, but this was not infected. Your abdominal pain resolved and you continued to have intermittent headaches. Your blood pressure medications were adjusted as below. You were also seen by psychiatry who recommended starting new medications for your anxiety. The following changes were made to your medication regimen: - We increased your hydralazine to 100 mg three times a day. - We also increased your labetalol to 400 mg three times a day. - We have started a medication called celexa 20 mg daily as well as ativan 1 mg three times a day as needed for anxiety. - We have increased your coumadin to 4 mg daily. - Please continue taking all other medications as previously prescribed. Call your doctor or return to the emergency room if you experience any of the following: worsening abdominal pain, nausea, vomiting, blurry vision, worsening headache, fever > 101. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. Please continue to follow with your nephrologist and go to outpatient dialysis as previously arranged. Please discuss with your PCP the possibility of talking to a social worker at [**Name (NI) 191**]. You will need to continue to have your INR monitored at [**Hospital 191**] [**Hospital 2786**] clinic. Please have this level checked on [**Hospital 766**], [**11-27**]. Completed by:[**2141-11-23**]",8,2141-11-18 14:00:00,2141-11-23 16:42:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. her hydralazine was increased from 75mg to 100mg tid with mild improvement. her labetalol was also increased from 300mg to 400mg tid. her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. tsh was sent and elevated, although free t4 was normal. plasma metanephrines were sent and pending at discharge. 2) abdominal pain: ct scan showed increasing ascites, but no acute pathology. peritoneal fluid was obtained and contained 544 polys. treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing gpc pairs/clusters. blood cultures ended up growing 1 out of 4 bottles coag-neg staph, likely contaminant, so vancomycin was stopped. since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. the peritoneal cultures remained negative. her pd catheter was left in place as the patient refuses hd any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) svc/brachiocephalic thrombosis: patients inr was subtherapeutic on admission at 1.3. due to the proximal location of her old venous thrombi, she was started on a heparin gtt. this was continued during her admission and her warfarin was increased to 5mg daily. her inr reached 2.0 at discharge (therapeutic range 2-3). the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) anxiety: patient noted feeling short of breath and anxious around the time of her recent admissions. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. they felt her symptoms were suggestive of anxiety and panic attacks, recommended checking tsh and metanephrines as above, and starting citalopram 20mg, which was done. she was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h prn. patient is agreeable to outpatient follow up with [**company 191**] social work, and potential cbt. these can be arranged by her pcp. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Abdominal pain, unspecified site; Anemia, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. her hydralazine was increased from 75mg to 100mg tid with mild improvement. peritoneal fluid was obtained and contained 544 polys. the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted.","patient has history of extremely labile hypertension on aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. ct scan showed increasing ascites, but no acute pathology." 109,161950.0,14800,2141-12-01,15328,170149.0,2141-06-06,Discharge summary,"Admission Date: [**2141-5-24**] Discharge Date: [**2141-6-6**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 759**] Chief Complaint: Face, Left arm and breast swelling Major Surgical or Invasive Procedure: Intravenous Catheterization of SVC/IVC. History of Present Illness: 23 year old woman with ESRD, SLE, recently placed PD catheter who presents with periorbital swelling and Hypertensive urgency. Of note she was recently admitted for tongue swelling on [**4-7**]. At that time she was treated with Solu-Medrol, famotidine and Benadryl in the emergency room, which was continued for a total of three doses on the floor. The swelling improved throughout her stay. She had been on both an ACE, [**Last Name (un) **] and DRI at home, which she has been taking for many years. Patient states that the tongue swelling is most likely due to a sardine allergy. However, she had recently added Dilaudid to her medications following PD catheter placement, so allergy to Dilaudid was also considered. The ACE, [**Last Name (un) **] and DRI were held on the day of admission for ?angioedema but restarted on day of discharge without incident so she was discharged on them. She returned to the ED [**5-24**] with acute onset bilateral eye swelling since night of [**5-23**]. VS T 97.9 HR 78 BP 231/120 RR 20 Sat 100% RA. She was given IV solumedrol 125iv, benadryl IV, and pepcid. Her BP was noted to be 240's despite labetolol 900mg po, then labetolol 20mg iv x2 so was started on labetolol gtt: highest dose 2mg/min. This was stopped after 35 minutes, in favor of nitro gtt. States compliant with meds at home. Patient was comfortable on admission to the MICU. Notes pain in abdomen 7.5/10 related to PD catheter placement (has had since then), improves with morphine. Also notes swelling in eyes/face since last night (has had in the past but never this severe, always goes away on its own). She feels whole body is swollen slightly but no more upper extremities than lower. She denies visual changes, HA, change in hearing/tinitus, congestion, sore throat, cough, SOB, chest pain, palpitations, nausea, vomitting, diarrhea. Has baseline constipation (takes stool softener), last BM 2 days ago (normal), no melena, brbpr, diarrhea. No dysuria, hematuria, change in uop, increase weight or size (clothes fit the same), tingling, numbness, weakness, discoordination, rash, joint pain, recent travel, ill contacts, exotic foods. She notes episode of throat swelling over weekend resolved, seemed to be related to sardine eating (not new for her). Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient denies past or current alcohol, tobacco, or illicit drug use. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: ON ADMISSION: VS: T 98.0 BP 187/120 HR 77 RR 17 Sat 100% on RA GEN: NAD HEENT: + periorbital edema, AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD, no carotid bruits CV: RRR, nl s1, s2, II/VI HSM at R/L USB, S4, no rub PULM: CTAB, no w/r/r with good air movement throughout ABD: soft, mildly tender at PD catheter, ND, + BS, no HSM EXT: warm, dry, +2 distal pulses BL, no femoral bruits, trace non-pitting edema NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect ON [**6-6**]: -General: AAOx3, in NAD. -VS: Tc: 95.2, Tmax (24hrs): 97.8 BP: 172/98 (80/43, 240/110 on [**5-30**]; 120/70, 218/120 over last 24 hrs), P: 80 (80, 98), RR: 16, O2: 98% RA. -HEENT: Head NC, AT. MMM. Face, Neck swollen: equal bilaterally. -Neck: Supple, No JVD, No tracheal deviation. -CV: RRR, S1,S2. Grade II/XII holosystolic murmur radiating to R carotid. JVP not elevated. No S4. -Lungs: CTAB, no w/r. -Abdomen: +BS, soft, nontender. -Extremities: Warm, no lower extremity edema. L arm appears slightly less swollen than yesterday. Dorsalis pedis and radial pulses strong bilaterally. No evidence of rashes, ulcers or varicose veins. -Breast: L breast still swollen relative to R, but diminished from initial presentation of swelling. Skin no longer tense. Pertinent Results: WBC-3.9* RBC-2.19* Hgb-6.6* Hct-20.4* MCV-93 MCH-30.3 MCHC-32.4 RDW-19.7* Plt Ct-114* - Neuts-52.8 Lymphs-39.9 Monos-5.0 Eos-2.0 Baso-0.2 PT-20.5* PTT-89.9* INR(PT)-1.9* Fibrino-268 Thrombn-37.4*# AT III-92 ProtCFn-65* ProtCAg-PND ProtSFn-68 Glucose-105 UreaN-62* Creat-8.1* Na-139 K-4.5 Cl-109* HCO3-17* ALT-14 AST-35 LD(LDH)-254* CK(CPK)-176* AlkPhos-137* Amylase-277* TotBili-0.4 Calcium-6.8* Phos-5.9* Mg-1.5* Hapto-90 Homocys-37.8* PTH-1603* UA: Color Straw Appear Clear SpecGr 1.009 pH 6.0 Urobil Neg Bili Neg Leuk Sm Bld Neg Nitr Neg Prot 30 Glu Neg Ket Neg RBC 0-2 WBC [**11-30**] Bact Few Yeast None Epi 0-2 U Tox: Urine Opiates Pos;Urine Benzos, Barbs, Cocaine, Amphet, Mthdne Negative; UCG: Negative STUDIES: Portable CXR [**5-24**]: Small left pleural effusion with associated atelectasis, although early pneumonia cannot be excluded. No CHF. ECG [**5-24**]: NSR (87), nl axis and intervals, TWI V5-V6, no change from [**5-20**]. MRA [**5-24**]: 1. Occlusion of the right internal jugular vein below the mandible which communicates with external jugular and subclavian vein. Appearance suggest chronic disease. 2. Patent SVC. 3. Patent but narrowed left internal jugular vein but left brachiocephalic vein not visualized (possibly from technique). 4. Bibasilar atelectasis US upper extremity [**5-26**]: [**Doctor Last Name **]-scale, color and Doppler son[**Name (NI) 1417**] of the left IJ, subclavian, axillary, brachial, basilic, and cephalic veins were performed. There is normal flow, compression, and augmentation seen in all of the vessels. IMPRESSION: No evidence of deep vein thrombosis in the left arm. MRV Chest [**5-30**]: 1. Limited study which demonstrates a chronically occluded and completely atrophic left brachiocephalic vein. 2. Right internal jugular vein not identified, likely chronically occluded. Left internal jugular vein is very diminuitive as before. 3. Large right external jugular vein emptying into the subclavian vein. Venogram [**5-31**]: 1. Occlusion of the left brachiocephalic vein at the junction of the subclavian and internal jugular with extensive collateral formation consistent with chronic obstruction. 2. Patent left brachial, axillary, subclavian, and distal internal jugular vein. 3. Unsuccessful attempt to recanalize the left brachiocephalic vein using a catheter and guidewire technique. Brief Hospital Course: Ms. [**Known lastname **] is a 23yo woman with a history of SLE, ESRD and HTN who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into L sided facial, L arm and L breast swelling throughout her stay. # L facial/arm and breast swelling: Initially this presented only as facial swellingand ACE and [**Last Name (un) **] were held for possible angioedema, however holding medications nad giving benadryl failed to relieve symptoms. We then suspected possible venous thrombus with occlusion leading to edema. US of upper left extremity failed to show evidence of acute occlusion, but showed R IJ occlusion consistent with prior studies. MRA could not visualize the L brachiocephalic vein. Repeat MRV suggested chronic occlusion of the L brachiocephalic vein. Venogram performed on [**5-31**] showed extensive collateralization of the L brachiocephalic vein with patent flow through these collaterals. Intervention on the L brachiocephalic vein was attempted by IR, but was unsuccessful. The primary team, renal team, [**Month/Year (2) **] team and hematology team suspect that the most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of the L brachiocephalic vein. For this reason, the patient was placed on Heparin IV as a bridge to coumadin anticoagulation with goal INR [**2-12**]. Per consult with hematology the patient is to remain on this regimen for at least 6 months, and will then revisit as an outpatient the question of possible lifelong anticoagulation. The patient has had extensive negative testing for hypercoagulable states, including during this work-up with negative anticardiolipin, antiphospholipid, Beta-2 glycoprotein and AT3 antibodies. Protein C and S levels were unremarkable. Although her clots seem to have all occured in the setting of lines, her continued thrombosis is likey due to hypercoagulability from her lupus (in absence of lupus anticoagulant). Her INR will be followed first by Dr. [**Last Name (STitle) 4883**], her nephrologist, and then by the coumadin clinic of [**Company 191**]. It will be especially important that her coumadin be well titrated given her risk of intracranial bleed with hypertension. This was communicated tothe patient and she understands and plans to be compliant with frequent blood draws for INR testing and varying her coumadin dose as directed. . # Hypertension: The patient has chronically labile hypertension, with frequent episodes of hypertensive urgency over systolic 200, as well as lows as far as the 80s during this admission. It remains unclear why her blood pressure is so chronically labile. The hope is that once she starts dialysis this will help to stabilize her blood pressure, however in the interim various adjustments were made to her regimen. The patient received frequent extra doses during her stay (especially of hydralazine), however, this occasionally causes her blood pressure to swing too low to tolerate her subsequent standing dose of medication. We stopped her Ace and [**Last Name (un) **] as above. We discharged her to home on a regimen that was reviewed with her nephrologist, Dr. [**Last Name (STitle) 4883**]. She is discharged on clonidine patch 0.3mg qweek, labetalol 900mg po tid, nifedipine CR 90mg po bid, hydralazine 35mg po tid. These medications were reviewed extensively with the patient and she was given prescriptions for all meds. She is discharged with home VNA for blood pressure checks and assistance with meds. She has purchased a portable BP cuff and will keep a BP diary to bring to subsequent appointments as well. The importance of BP control, especially in the setting of new anticoagulation, was discussed extensively with the patient. Her goal SBP is 140-160 at this time. . # ESRD: The patient has ESRD due to lupus nephritis. PD catheter was placed before admission and the patient received morphine prn pain at her catheter site. The renal team followed her closely throughout her stay. She was treated for hypocalcemia as well as hyperkalemia. Her regimen was changed to calcitriol 0.25mcg po qday, sodium bicarb 1300mg po qday, cholecalciferol 400units po qday, ergocalciferol 50,000 units po qweek for ten weeks. She plans to start HD within 1-2 weeks of discharge. She will call [**Doctor First Name 3040**] the PD nurse tomorrow to set up an appointment to have her catheter flushed and to start PD. She will be closely followed by Dr. [**Last Name (STitle) 4883**] at PD. # SLE: The patient was maintained on her home dose of prednisone 15mg po qday throughout her stay. She has no symptoms of acute SLE flare, so her nephrologist and outpatient physicians may attempt to wean this down as an outpatient. . # abnormal pap smear: The pt is noted to have an abnormal pap and colpo two years ago with CIN 2 and high risk HPV. This has never been repeated, as the patient failed to schedule appointments and DNK others. We discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. The patient was discharged to home with a clear plan to call [**Doctor First Name 3040**], the PD nurse on the day after discharge to set up an appointment to have her PD catheter flushed later this week, as well as to set a date to start her PD. She will see Dr. [**Last Name (STitle) 44539**] in [**Hospital **] clinic within the next 1-2 weeks. She will have her blood drawn for INR in two days and faxed to Dr. [**Last Name (STitle) 4883**], subsequently this will be faxed to the [**Company 191**] coumadin clinic and her dose will be adjusted for INR [**2-12**]. We have also given her the phone number to call [**Company 191**] and establish care with a new PCP, [**Name10 (NameIs) 3**] her old PCP has now graduated and her complex management makes a PCP [**Name Initial (PRE) 44540**]. (Her PCP must be at [**Company 191**] for the [**Company 191**] coumadin clinic to follow her as well.) Finally, the patient was given an appointment with ob/gyn to have a follow up pap smear, as her last pap and colpo two years ago showed CIN 2 with high risk HPV and this has not been followed. The above plan and appoitnments were reviewed with the pt and her mother extensively. [**Name2 (NI) **] medication hcanges were also extensively reviewed. Medications on Admission: Hydralazine 50 mg PO TID Labetalol 900 mg PO TID Nicardipine 60 mg Sustained Release PO once a day Cinacalcet 30 mg PO DAILY: she is not sure if taking Calcium Acetate 667 mg PO TID W/MEALS Sodium Bicarbonate 1300 mg PO TID Aliskiren 150 mg PO once a day (was never taking) Pantoprazole 40 mg PO once a day Valsartan 320mg PO DAILY Lisinopril 40 mg PO bid Clonidine 0.3 mg/24 hr Patch Weekly QSUN: not sure when last placed Prednisone 15 mg PO DAILY Morphine 15 mg Tablet PO Q6H as needed Ergocalciferol (Vitamin D2) 50,000 unit Capsule daily: states not taking Epo 4,000 units M/W/F: states not taking colace Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Disp:*4 Patch Weekly(s)* Refills:*2* 3. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 5. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO qwednesday (): for 10 weeks. Disp:*10 Capsule(s)* Refills:*0* 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*2* 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 10. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: dose to be adjusted by coumadin clinic. Disp:*120 Tablet(s)* Refills:*2* 11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 12. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for itching. Disp:*50 Capsule(s)* Refills:*0* 13. Ativan 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. Disp:*60 Tablet(s)* Refills:*0* 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 15. Morphine 15 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 14 days. Disp:*56 Tablet(s)* Refills:*0* 16. Outpatient Lab Work Please have blood drawn on Friday, [**6-9**] for PT/INR. Please have result faxed to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you to adjust your coumadin (also called warfarin) dose as needed. 17. Outpatient Lab Work Please have blood drawn on Monday [**2141-6-12**] for PT/INR and twice per week thereafter until told by coumadin clinic that you can decrease lab draws. Please have result faxed to the [**Hospital1 18**] coumadin clinic at [**Telephone/Fax (1) 3534**]. They will call you to adjust your coumadin (also called warfarin) dose as needed. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnoses: Malignant Hypertension (Hypertensive Urgency) Acute Exacerbation of Chronic Left Brachiocephalic vein occlusion Anemia Secondary Diagnoses: SLE ESRD Hypertrophic Cardiomyopathy Thrombocytopenia Discharge Condition: Stable Discharge Instructions: You were admitted and treated for an acute exacerbation of a chronic left brachiocephalic vein occlusion (a chronically obstructed large vein closed off entirely) and hypertensive urgency (very high blood pressure). We attempted to remove the clot in your left brachiocephalic vein, but were unable to do so. You have been started on long-term Coumadin (also called warfarin) therapy to prevent future blood clots and to allow natural dissolution of your current blood clot. Please change your medicines to only those you are given here! There were many changes and it is very important that you stick to the medication list as you have large, life-threatening swings in the blood pressure when not taking consistently. We also treated you for high potassium levels and anemia, and low vitamin D and calcium levels, which are related to your kidney failure. Please follow up with Dr. [**Last Name (STitle) 4883**] for long term treatment. Please check your blood pressure three times per day and keep a blood pressure diary to bring with you to all medical appointments. Please have your blood drawn on Friday [**6-9**] for PT/INR and faxed to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you if needed to adjust your coumadin (warfarin) dose. After that, please have your blood drawn on Monday [**6-12**] for PT/INR and faxed to the [**Hospital1 18**] coumadin clinic at [**Telephone/Fax (1) 434**]. They will follow you in a regular way to adjust your coumadin dose as needed. MEDICINES FOR BLOOD PRESSURE: LABETALOL 900mg three times per day (same as before) HYDRALAZINE 25mg three times per day (lower dose than before) CLONIDINE PATCH 0.3mg qWednesday (same as before) NIFEDIPINE SR 90mg twice per day (new medicine!) **stop taking your lisinopril, nicardipine, Diovan and Aliskerin!** MEDICINES FOR RENAL FAILURE: ERGOCALCIFEROL [**Numeric Identifier 1871**] units pill every Wednesday (same as before) CHOLECALCIFEROL 400 units every day (new) CALCITRIOL 0.25 mg every day (new) SODIUM BICARBONATE 1300mg once per day (less often then before) ** stop taking your calcium acetate (phoslo), cinecalcet, and epo injection (you'll get it at peritoneal dialysis only)** OTHER MEDICINES: PANTOPRAZOLE 40mg every day (same as before) PREDNISONE 15mg every day (same as before) MORPHINE 15mg every 6 hrs if needed for pain (same as before) ATIVAN 1mg as needed for anxiety (same as before) BENADRYL 25mg every 6 hrs if needed for itch (new) COLACE 100mg twice per day if needed for constipation(same as before) APPOINTMENTS: **1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on Friday to flush your dialysis catheter and start dialysis next week! 2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00AM 3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**] Date/Time: [**2141-6-13**] 9:30AM **4. Please call [**Hospital3 **] next week to make an appointment with a new primary doctor. I recommend Dr. [**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE FOLLOWED IN [**Hospital **] CLINIC. **5. Please have your blood drawn as above. Your coumadin level will be followed by the [**Hospital 197**] clinic. Their phone # is [**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**]. If you have increased swelling, fever greater than 101, shortness of breath, chest pain, or if you at any time become concerned about your health please contact Dr. [**Last Name (STitle) 4883**] or go to the nearest ER. Followup Instructions: APPOINTMENTS: **1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on Friday to flush your dialysis catheter and start dialysis next week! 2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00AM 3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**] Date/Time: [**2141-6-13**] 9:30AM **4. Please call [**Hospital3 **] next week to make an appointment with a new primary doctor. I recommend Dr. [**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE FOLLOWED IN [**Hospital **] CLINIC. **5. Please have your blood drawn as above. Your coumadin level will be followed by the [**Hospital 197**] clinic. Their phone # is [**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**]. Completed by:[**2141-6-17**]",178,2141-05-24 14:47:00,2141-06-06 19:55:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ACUTE RENAL FAILURE," ms. [**known lastname **] is a 23yo woman with a history of sle, esrd and htn who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into l sided facial, l arm and l breast swelling throughout her stay. # l facial/arm and breast swelling: initially this presented only as facial swellingand ace and [**last name (un) **] were held for possible angioedema, however holding medications nad giving benadryl failed to relieve symptoms. we then suspected possible venous thrombus with occlusion leading to edema. us of upper left extremity failed to show evidence of acute occlusion, but showed r ij occlusion consistent with prior studies. mra could not visualize the l brachiocephalic vein. repeat mrv suggested chronic occlusion of the l brachiocephalic vein. venogram performed on [**5-31**] showed extensive collateralization of the l brachiocephalic vein with patent flow through these collaterals. intervention on the l brachiocephalic vein was attempted by ir, but was unsuccessful. the primary team, renal team, [**month/year (2) **] team and hematology team suspect that the most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of the l brachiocephalic vein. for this reason, the patient was placed on heparin iv as a bridge to coumadin anticoagulation with goal inr [**2-12**]. per consult with hematology the patient is to remain on this regimen for at least 6 months, and will then revisit as an outpatient the question of possible lifelong anticoagulation. the patient has had extensive negative testing for hypercoagulable states, including during this work-up with negative anticardiolipin, antiphospholipid, beta-2 glycoprotein and at3 antibodies. protein c and s levels were unremarkable. although her clots seem to have all occured in the setting of lines, her continued thrombosis is likey due to hypercoagulability from her lupus (in absence of lupus anticoagulant). her inr will be followed first by dr. [**last name (stitle) 4883**], her nephrologist, and then by the coumadin clinic of [**company 191**]. it will be especially important that her coumadin be well titrated given her risk of intracranial bleed with hypertension. this was communicated tothe patient and she understands and plans to be compliant with frequent blood draws for inr testing and varying her coumadin dose as directed. . # hypertension: the patient has chronically labile hypertension, with frequent episodes of hypertensive urgency over systolic 200, as well as lows as far as the 80s during this admission. it remains unclear why her blood pressure is so chronically labile. the hope is that once she starts dialysis this will help to stabilize her blood pressure, however in the interim various adjustments were made to her regimen. the patient received frequent extra doses during her stay (especially of hydralazine), however, this occasionally causes her blood pressure to swing too low to tolerate her subsequent standing dose of medication. we stopped her ace and [**last name (un) **] as above. we discharged her to home on a regimen that was reviewed with her nephrologist, dr. [**last name (stitle) 4883**]. she is discharged on clonidine patch 0.3mg qweek, labetalol 900mg po tid, nifedipine cr 90mg po bid, hydralazine 35mg po tid. these medications were reviewed extensively with the patient and she was given prescriptions for all meds. she is discharged with home vna for blood pressure checks and assistance with meds. she has purchased a portable bp cuff and will keep a bp diary to bring to subsequent appointments as well. the importance of bp control, especially in the setting of new anticoagulation, was discussed extensively with the patient. her goal sbp is 140-160 at this time. . # esrd: the patient has esrd due to lupus nephritis. pd catheter was placed before admission and the patient received morphine prn pain at her catheter site. the renal team followed her closely throughout her stay. she was treated for hypocalcemia as well as hyperkalemia. her regimen was changed to calcitriol 0.25mcg po qday, sodium bicarb 1300mg po qday, cholecalciferol 400units po qday, ergocalciferol 50,000 units po qweek for ten weeks. she plans to start hd within 1-2 weeks of discharge. she will call [**doctor first name 3040**] the pd nurse tomorrow to set up an appointment to have her catheter flushed and to start pd. she will be closely followed by dr. [**last name (stitle) 4883**] at pd. # sle: the patient was maintained on her home dose of prednisone 15mg po qday throughout her stay. she has no symptoms of acute sle flare, so her nephrologist and outpatient physicians may attempt to wean this down as an outpatient. . # abnormal pap smear: the pt is noted to have an abnormal pap and colpo two years ago with cin 2 and high risk hpv. this has never been repeated, as the patient failed to schedule appointments and dnk others. we discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. the patient was discharged to home with a clear plan to call [**doctor first name 3040**], the pd nurse on the day after discharge to set up an appointment to have her pd catheter flushed later this week, as well as to set a date to start her pd. she will see dr. [**last name (stitle) 44539**] in [**hospital **] clinic within the next 1-2 weeks. she will have her blood drawn for inr in two days and faxed to dr. [**last name (stitle) 4883**], subsequently this will be faxed to the [**company 191**] coumadin clinic and her dose will be adjusted for inr [**2-12**]. we have also given her the phone number to call [**company 191**] and establish care with a new pcp, [**name10 (nameis) 3**] her old pcp has now graduated and her complex management makes a pcp [**name initial (pre) 44540**]. (her pcp must be at [**company 191**] for the [**company 191**] coumadin clinic to follow her as well.) finally, the patient was given an appointment with ob/gyn to have a follow up pap smear, as her last pap and colpo two years ago showed cin 2 with high risk hpv and this has not been followed. the above plan and appoitnments were reviewed with the pt and her mother extensively. [**name2 (ni) **] medication hcanges were also extensively reviewed. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Compression of vein; Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Hyperpotassemia; Hyperparathyroidism, unspecified; Other iatrogenic hypotension; Nausea with vomiting; ; Abnormal glandular Papanicolaou smear of cervix; Abdominal pain, other specified site; Other specified disorders of pancreatic internal secretion; Adrenal cortical steroids causing adverse effects in therapeutic use]","known lastname **] is a 23yo woman with a history of sle, esrd and htn who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into l sided facial, l arm and l breast swelling throughout her stay. mra could not visualize the l brachiocephalic vein. it remains unclear why her blood pressure is so chronically labile. we stopped her ace and [**last name (un) **] as above. the importance of bp control, especially in the setting of new anticoagulation, was discussed extensively with the patient. # esrd: the patient has esrd due to lupus nephritis. the renal team followed her closely throughout her stay. she will call [**doctor first name 3040**] the pd nurse tomorrow to set up an appointment to have her catheter flushed and to start pd. we discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. the above plan and appoitnments were reviewed with the pt and her mother extensively. [**","a 23yo woman with a history of sle, esrd and htn presented with bilateral facial swelling. she developed l sided facial, l arm and l breast swelling throughout her stay. most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of l brachiocephalic vein." 109,125288.0,14799,2141-11-23,15329,147469.0,2141-06-17,Discharge summary,"Admission Date: [**2141-6-11**] Discharge Date: [**2141-6-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: hypertensive urgency Major Surgical or Invasive Procedure: arterial line History of Present Illness: HPI: 23 F with h/o Lupus, ESRD not on HD (planned PD), labile hypertension, RUE VTE on anticoagulation, recent facial swelling who presents with hypertensive emergency. Patient developed severe frontal HA last evenening, a/w nausea. BP was not [**Location (un) 1131**] on home BP cuff. In the AM her HA was severe [**10-20**] a/w nausea and vomiting yellow/green liquid and BP cuff again not able to obtain BP. Patient was last seen by VNA this past Friday with BP 130/70. Patient denies any CP, shortness of breath, abd pain. Her facial swelling is slightly worse today. She denies any weakness, dizziness, difficulty with speach, no numbness or tingling. She says that she is compliant with all of her medications. She denies any GU/GI complaints despite +UA in ED. . In the ED, VS: 98.2 92 SBP >300/P [**Telephone/Fax (3) 44541**]-131) 16 98 % RA. Patient received zofran IV, Hydral IV, Labetalol 20 mg IV x 1, Nipride gtt started. Kayexalate 30 mg x 1. Other po meds written but patient did not take due to nausea. CT head showing no hemorrhage but hypoattenuation in frontal area, which is change from prior MRI in [**Month (only) **]. She is on coumadin for RUE VTE with INR 2.1. Also with UTI in ED, started Cirpo x 1. Labs showing K 5.6 ECG with ?hyperacute T waves, otherwise no changes, given kayexalate only. . Interval Hx: Patient was admitted [**2141-5-24**] to [**6-6**] with facial swelling and hypertensive emergency requiring ICU care. She was also admitted [**Date range (1) 43498**] with similar complaints. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 98.8 84 [**Telephone/Fax (2) 44542**]% RA Gen: swollen face L>R, alert and cooperative, NAD, snoring when asleep but easily arousable Heent: OP clear, swollen eye lids L>R, Left eye retracted with prosthesis, anicteric, OP moist Neck: supple, no JVD elevation, no meningismus CV: nl S1 S2, RRR, [**1-15**] SM Lungs: CTAB Abd: obese, soft, NT, ND, BS+ Ext: dry, no c/c/e, diminished, Neuro: Alert and oriented x 3, gets drowsy intermittently but arousable, CN II-XII intact, strength 5/5 throughout, sensations intact Pertinent Results: [**6-14**]: AXR:IMPRESSION: PD catheter with tip coiled in the pelvis. [**6-11**]: IMPRESSION: 1. Areas of hypoattenuation in the high bifrontal white matter, and subcortical hypoattenuation in the left posterior temporal lobe with loss of [**Doctor Last Name 352**]-white differentiation. These findings are new from MRI brain [**12-29**], [**2140**], and could represent areas of new edema with underlying focal lesion or possibly areas of new infarcts. An MRI head without and with Iv conrast is recommended for further characterization. 2. No evidence of intracranial hemorrhage. [**6-11**]: PA AND LATERAL VIEWS OF THE CHEST: There has been an interval increase in retrocardiac opacity obscuring the left hemidiaphragm. The right lung and the left upper lung zone are clear. The right costophrenic angle is slightly blunted, suggesting a very small right pleural effusion. The heart is slightly enlarged, but the cardiomediastinal silhouette is unchanged. There is no hilar enlargement. Soft tissue and bony structures are unremarkable. IMPRESSION: Interval increase in left basilar atelectasis with pleural effusion. Superimposed pneumonia cannot be excluded. Possible small right pleural effusion. [**6-11**]: MR [**Name13 (STitle) 430**]: INDINGS: In comparison with a prior CT of the head, the previously described low attenuation areas in the parietal regions appear with hyperintensity signal on the FLAIR sequence, mildly hyperintense on the diffusion-weighted sequence, and also slightly hyperintense on the corresponding ADC maps, these findings are nonspecific and may represent posterior reversible encephalopathic changes, please correlate clinically. There is no evidence of acute hemorrhage, hydrocephalus, or midline shift. A low-attenuation area is identified on the right occipital region, likely consistent with chronic deposits of hemosiderin, please correlate with the prior MRI dated [**2140-12-28**]. IMPRESSION: Limited examination secondary to motion artifacts. On the FLAIR sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. The prior low-attenuation area of the right occipital lobe is unchanged and may represent chronic deposits of hemosiderin. There is no evidence of hydrocephalus or midline shifting. Followup with MRI of the head with and without contrast under conscious sedation is recommended if clinically warranted. Brief Hospital Course: A/P: 23 F with SLE, ESRD not on HD, chronic VTE with RUE and facial swelling p/w hypertensive emergency and delta MS initially admitted to the [**Hospital Unit Name 153**]. In the [**Hospital Unit Name 153**] she was on a labetalol gtt as well as home medications. She had head imaging (MRI) with following results; On the FLAIR sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. She was evaluated by neurology who considered PRES, though she did not seize. She was started on keppra as she has had seizures before, and will follow up with them. . # HTN Emergency. She has had multiple admissions in the past with neurological involvement, hemolysis in the past. SBP >300 in ED. Her BP was lowered slowly with a labetolol gtt in the ICU. When it was stably below 180 she was transferred to the medical floor on the [**Hospital Ward Name 517**]. She was continued on clonidine TP, po labetalol, aliskiren. I/O goal was even. Her BP remained between 120-170 before discharge, she no longer had any headaches, or nausea. She was oriented times three. Aliskiren was not covered by masshealth, and a prior auth was faxed over. A supply from the pharmacy was sought but unavailable. She was given a prescription for 5 pills to bridge her to the time when the prior auth would have been approved in order to facilitate her paying for the prescription. She was also given hydralazine and instructed on how to take extra doses when her blood pressure increased. . # Delta MS. [**2-11**] to hypertension likely ischemic/hypertensive changes on CT. AAO times three, no focal neurological signs currently. Also likely component of OSA although this seems chronic. No seizures although has had them in the past. Neuro was consulted, and she was started on Keppra for question of PRES, keppra for 6 weeks until f/u with neuro, has outpatient MRI appointment as well. They will likely keep her on keppra until the changes in her parietal regions have resolved. . #UTI-found on admission, was on Cipro-will complete course of 5 days . # VTE. L Brachiocephalic VTE chronic with collaterals. Also h/o other VTE [**2-11**] to lines in the past. Currently on coumadin. INR 2.1 coumadin was held in [**Hospital Unit Name 153**] for anticipation of procedures. Her coumadin was restarted, has VNA set up and will be followed by [**Hospital3 **]. . # Facial Swelling. Unclear etiology likely [**2-11**] to VTE in RUE (brachiocephalic) vs. angioedema-pt now without swelling . # ESRD. Currently no on HD due to patient preference, awaiting to start PD next week. Since patient has refused HD there was an attempt to correct lytes and acid base with medications. Avoided fluid overload with lasix, patient currently making urine. Lytes - see below. She will commence PD as an outpatient (had issues yesterday with catheter flushing)-still not working-will try laxatives to relieve loops of bowel possibly wrapped around catheter and she will follow up with renal on Monday. Her ACE/[**Last Name (un) **] were held, renally dosed her meds, and phos binder was administered. . # Metabolic Acidosis/Electrolytes abnormalities. AG 15 likely [**2-11**] to uremia. K elevated to 5.6-6.0 however has been elevated in the past, likely some chronic hyerkalemia. She received kayexalate 30 mg tid until K <5 Her electrolytes stabilized and she was continued on her home regimen of sodium bicarb (650mg two tabs daily). . # SLE. On prednisone chronically, likely needs PCP [**Name9 (PRE) **] at some point --Atovaquone to prevent hyperkalemia Continued on prednisone 10mg (dropped from 15mg 2 weeks ago) . # Anemia-Hct and plts dropped on this admission but now stable . # HOCM. Avoid dehydration. Currently on Labetalol. . # PPX: systemically anticoagulated, getting kayexalate, PPI # FEN: Electrolytes as above, no standing fluids I/Os goal even. # Access: 2x PIV currently # Code: Full # Dispo: home Medications on Admission: Pantoprazole 40 mg daily - Clonidine TP 0.3/24 hrs q wednesday - Prednisone 10 mg daily (just decreased from 15 mg) - Calcitriol 0.25 mcg daily - Sodium bicarbonate 650 mg 2 tabs daily - Vit D3 400 mg daily - Vit D2 50,000 q wed, x 10 weeks - Labetalol 300 mg po 3 tabs TID - Nifedipine SR 90 mg [**Hospital1 **] - Warfarin 2 mg daily - Hydral 25 mg TID - Lasix 40 mg [**Hospital1 **] (started friday) - Benadryl 25 mg po prn - Ativan 1 mg [**Hospital1 **] prn - Colace 100 mg [**Hospital1 **] prn - Morphine 15 mg po q 6 hrs x 14 days - Diovan 320 mg daily - Dilaudid prn Discharge Medications: 1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): on alternating days with 15mg. 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 4. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): please take as directed when blood pressure is above 180. Disp:*90 Tablet(s)* Refills:*2* 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). Disp:*405 Tablet(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for hold for sbp < 130. Disp:*10 Tablet(s)* Refills:*0* 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Outpatient Lab Work for [**Known firstname **] [**Known lastname **] DOB [**2117-8-7**] please check INR once a week and have results faxed to [**Hospital3 **] at [**Hospital1 18**] phone-[**Telephone/Fax (1) 14650**], fax-[**Telephone/Fax (1) 44543**] 16. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO once a day: hold for sbp<130. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: -hypertensive emergency -Lupus - [**2134**]. Diagnosed after she began to have swolen fingers, a rash and painful joints. -ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose every 3 months for 2 years until began dialysis 3 times a week in [**2137**] (T, Th, Sat). Now no longer on Hemodialysis, with hyperkalemia/Hypocalcemia/Hyperphosphatemia/Elevated PTH/Metabolic Acidosis; PD Catheter placed [**5-18**] -h/o seizures, ICU admissions; h/o two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] that resolved -Uveitis secondary to SLE - [**4-16**]; s/p surgery [**2-16**]; she had blood cleared and cataract removed as well as glaucoma. -HOCM - per Echo in [**2137**] -Mulitple episodes of dialysis reactions -Anemia -H/O SVC thrombus [**10-16**] [**2-11**] catheter placement, was on coumadin then stopped; Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]); Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]); Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) -Facial and left breast swelling - attributed to angioedema vs chronic L Brachiocephalic vein occlusion -Thrombophilia ?????? likely related to SLE, h/o recurrent VTE -Thrombocytopenia NOS -TTP (got plasmapheresisis) versus malignant HTN -History of left eye enucleation [**2139-4-20**] for fungal infection Discharge Condition: stable, afebrile, SBP 120's-170's Discharge Instructions: You were admitted with hypertensive emergency, your blood pressure was extremely high. You had a head CT and MRI that showed some changes concerning for PRES (posterior reversible leukoencephalopathy syndrome), and neurology recommended initiating Keppra. Your blood pressure was brought under control in the intensive care unit and now you have a new regimen of medications. In addition peritoneal dialysis was attempted but there were difficulties with your catheter. This will be further addressed by your outpatient nephrologist. You will continue to have your INR drawn and sent to coumadin clinic. You should take all your medications as prescribed, you will be taking the keppra until you follow up with a neurologist in approximately 6 weeks. You will also be taking the Aliskiren following discharge. You will be discharged on hydralazine (which you will take three times daily EVERY DAY), as well as when your blood pressure gets too high as follows; if you blood pressure is above 180 please take an extra dose of hydralazine, check your blood pressure in 10 minutes, if it is still not take another dose and recheck your blood pressure in another 10 minutes-if it is still elevated take another 25mg hydralazine and recheck in 10 minutes-if it is still elevated please call your doctor or go to the ER. Continue taking your coumadin and having your INR sent to coumadin clinic. Please seek medication attention if you have any headaches, chest pain, shortness of breath, dizzyness, nausea or any other concerning symptoms. Please follow up as outlined below. Followup Instructions: -Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00 -Your renal team will contact you regarding follow up-you should call CB for home teaching. -Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2141-7-12**] 10:30 -MRI Tuesday [**7-25**]-9:30am, [**Location (un) **] [**Hospital Ward Name 23**] Building -[**Company 191**] [**Telephone/Fax (1) 250**] N.P-[**7-25**] 1:40pm -Stroke center Dr. [**Last Name (STitle) **] at the [**Hospital Ward Name 23**] center, [**Location (un) **]-Tuesday [**8-1**], 5:00pm-you will need to call your PCP for [**Name Initial (PRE) **] referral -Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Company 191**] ([**Hospital Ward Name 23**] Building) Tuesday [**8-15**] 2:00pm [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2141-6-19**]",159,2141-06-11 10:17:00,2141-06-17 16:29:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSIVE EMERGENCY," a/p: 23 f with sle, esrd not on hd, chronic vte with rue and facial swelling p/w hypertensive emergency and delta ms initially admitted to the [**hospital unit name 153**]. in the [**hospital unit name 153**] she was on a labetalol gtt as well as home medications. she had head imaging (mri) with following results; on the flair sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. she was evaluated by neurology who considered pres, though she did not seize. she was started on keppra as she has had seizures before, and will follow up with them. . # htn emergency. she has had multiple admissions in the past with neurological involvement, hemolysis in the past. sbp >300 in ed. her bp was lowered slowly with a labetolol gtt in the icu. when it was stably below 180 she was transferred to the medical floor on the [**hospital ward name 517**]. she was continued on clonidine tp, po labetalol, aliskiren. i/o goal was even. her bp remained between 120-170 before discharge, she no longer had any headaches, or nausea. she was oriented times three. aliskiren was not covered by masshealth, and a prior auth was faxed over. a supply from the pharmacy was sought but unavailable. she was given a prescription for 5 pills to bridge her to the time when the prior auth would have been approved in order to facilitate her paying for the prescription. she was also given hydralazine and instructed on how to take extra doses when her blood pressure increased. . # delta ms. [**2-11**] to hypertension likely ischemic/hypertensive changes on ct. aao times three, no focal neurological signs currently. also likely component of osa although this seems chronic. no seizures although has had them in the past. neuro was consulted, and she was started on keppra for question of pres, keppra for 6 weeks until f/u with neuro, has outpatient mri appointment as well. they will likely keep her on keppra until the changes in her parietal regions have resolved. . #uti-found on admission, was on cipro-will complete course of 5 days . # vte. l brachiocephalic vte chronic with collaterals. also h/o other vte [**2-11**] to lines in the past. currently on coumadin. inr 2.1 coumadin was held in [**hospital unit name 153**] for anticipation of procedures. her coumadin was restarted, has vna set up and will be followed by [**hospital3 **]. . # facial swelling. unclear etiology likely [**2-11**] to vte in rue (brachiocephalic) vs. angioedema-pt now without swelling . # esrd. currently no on hd due to patient preference, awaiting to start pd next week. since patient has refused hd there was an attempt to correct lytes and acid base with medications. avoided fluid overload with lasix, patient currently making urine. lytes - see below. she will commence pd as an outpatient (had issues yesterday with catheter flushing)-still not working-will try laxatives to relieve loops of bowel possibly wrapped around catheter and she will follow up with renal on monday. her ace/[**last name (un) **] were held, renally dosed her meds, and phos binder was administered. . # metabolic acidosis/electrolytes abnormalities. ag 15 likely [**2-11**] to uremia. k elevated to 5.6-6.0 however has been elevated in the past, likely some chronic hyerkalemia. she received kayexalate 30 mg tid until k <5 her electrolytes stabilized and she was continued on her home regimen of sodium bicarb (650mg two tabs daily). . # sle. on prednisone chronically, likely needs pcp [**name9 (pre) **] at some point --atovaquone to prevent hyperkalemia continued on prednisone 10mg (dropped from 15mg 2 weeks ago) . # anemia-hct and plts dropped on this admission but now stable . # hocm. avoid dehydration. currently on labetalol. . # ppx: systemically anticoagulated, getting kayexalate, ppi # fen: electrolytes as above, no standing fluids i/os goal even. # access: 2x piv currently # code: full # dispo: home ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other encephalopathy; Chronic glomerulonephritis in diseases classified elsewhere; Urinary tract infection, site not specified; Acidosis; Unspecified iridocyclitis; Acquired hemolytic anemia, unspecified; Systemic lupus erythematosus; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Swelling, mass, or lump in head and neck; Hyperpotassemia; Lump or mass in breast; Thrombocytopenia, unspecified; Hypocalcemia; Disorders of phosphorus metabolism]","a/p: 23 f with sle, esrd not on hd, chronic vte with rue and facial swelling p/w hypertensive emergency and delta ms initially admitted to the [**hospital unit name 153**]. she was evaluated by neurology who considered pres, though she did not seize. aliskiren was not covered by masshealth, and a prior auth was faxed over. also likely component of osa although this seems chronic. inr 2.1 coumadin was held in [**hospital unit name 153**] for anticipation of procedures. avoided fluid overload with lasix, patient currently making urine. # metabolic acidosis/electrolytes abnormalities. # ppx: systemically anticoagulated, getting kayexalate, ppi # fen: electrolytes as above, no standing fluids i/os goal even.","delta ms was evaluated by neurology who considered pres, though she did not seize. she was started on keppra as she has had seizures before, and will follow up with them. her bp remained between 120-170 before discharge, she no longer had headaches, or nausea." 109,125288.0,14799,2141-11-23,14796,139061.0,2141-09-14,Discharge summary,"Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Right leg pain. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 24 y.o. F with lupus, Chronic Kidney Disease V (not currently on HD or PD), and multiple admissions for hypertensive urgency/emergency, who presented to the ED for continued R leg pain that starts in her R buttocks and refers down her R leg. She describes it as feeling like the pain is deep within her bone. The pain was [**10-20**] in the AM, and she felt like she couldn't get out of bed. Denies any swelling of her RLE. When getting VS in [**Name (NI) **], pt noted to be very hypertensive at 263/176. The patient reportedly has baseline SBPs in 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM on day of admission. She denies any recent recrational drug use including cocaine and amphetamines. She denies headache, vision changes, double vision, chest pain, shortness of breath, abdominal pain, BRBPR, dysuria. During MD interview, the patient was nauseous and had small amount of emesis of a recent Coolata. Pt states that flushing her PD cath causes a large amount of stomach pain. . Of note, the patient was recently admitted from 08.26-29.08. The patient initially presented to the ED after referral from her nephrologist's office where she had complaints of right leg pain and was found to be hypertensive to 250/145. She was admitted after initiation of a labetalol drip and nitropaste with improvement in sbp to 180. The patient did receive 2 U of PRBC's during this hospitalization for baseline anemia. The patient did have a work-up for her right leg pain complaints with plain films of the right hip and MRI of the L-spine which did not reveal an explanation for her symptoms and did rule out avascular necrosis. The patient received dilaudid for pain control and was ambulating without pain prior to discharge. In addition, the patient completed a course of ciprofloxacin for a positive UA with negative cultures. The patient was unable to tolerate peritoneal dialysis for unclear reasons. Peritoneal dialysate culture was negative for infection. . In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in ED ranged from [**Telephone/Fax (3) 43494**]-175 with HR in 96-108. Initially given labetalol 10 mg IV x 1 and then started on labetalol gtt for her elevated blood pressures and titrated to 3 mg/min. LENI of R leg was negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per ED, cannot do V/Q scan due to volume overload after talking with radiology. Renal c/s initiated. A-line placed. Past Medical History: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] . PAST SURGICAL HISTORY: - Placement of multiple catheters including dialysis. - Tonsillectomy. - Left eye enucleation in [**2140-4-10**]. - PD catheter placement in [**2141-5-11**]. Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 98.9 [**Telephone/Fax (2) 43495**] 99$% RA GEN: NAD, pleasant female sitting in bed with moon facies HEENT: EOMI of R eye, L eye prosthesis, no exudate, no erythema, MMM, no LAD CHEST: CTAB except at R base with decreased breath sounds; no w/r/r CV: tachy, normal S1S2, II/VI systolic murmur accentuated with Valsalva ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i EXT: no c/c/e, strength of LEs [**5-15**] and symmetric bilaterally. Negative straight leg test, no pain with internal rotation, external rotation, extension, adduction or abduction. Some pain on flexion at the hip. NEURO: II - XII intact to direct testing. No deficit in light tough sensation. Gait normal. DERM: no rashes noted Pertinent Results: LABS AT ADMISSION: [**2141-9-11**] 11:43AM GLUCOSE-86 UREA N-49* CREAT-8.1* SODIUM-139 POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-16* ANION GAP-18 [**2141-9-11**] 11:43AM CALCIUM-6.2* PHOSPHATE-5.8* MAGNESIUM-1.6 [**2141-9-11**] 11:43AM PT-18.4* PTT-42.8* INR(PT)-1.7* [**2141-9-11**] 07:00AM WBC-5.5 RBC-2.88* HGB-8.1* HCT-24.7* MCV-86 MCH-28.1 MCHC-32.8 RDW-18.0* [**2141-9-11**] 07:00AM NEUTS-74.7* LYMPHS-17.5* MONOS-4.2 EOS-3.3 BASOS-0.2 [**2141-9-11**] 07:00AM PLT COUNT-101* UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50 WBC . MICROBIOLOGY: Urine culture ([**2141-9-11**]): Mixed flora . STUDIES: Cardiology Report ECG Study Date of [**2141-9-11**] 6:55:16 AM Sinus tachycardia. The tracing is marred by baseline artifact. There is left atrial enlargement. Compared to the previous tracing of [**2141-9-5**] the rate has increased. The axis is more rightward. Otherwise, no diagnostic interim change. . UNILAT LOWER EXT VEINS RIGHT Study Date of [**2141-9-11**] 8:54 AM [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and popliteal veins demonstrate normal flow, compressibility, augmentation, waveforms. Appropriate color flow and compression is noted within the calf veins. No intraluminal thrombus is present. IMPRESSION: No evidence of right lower extremity DVT. . TTE ([**2140-8-26**]): The left atrium is normal in size. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . R HIP XR [**2141-9-6**]: No acute fracture or dislocation. . MRI L-SPINE [**2141-9-6**]: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. LAB RESULTS AT DISCHARGE: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-9-14**] 06:15AM 4.0 2.63* 7.6* 23.1* 88 29.1 33.0 18.0* 100* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-9-14**] 06:15AM 100 44* 8.1* 137 4.8 109* 17* 16 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2141-9-14**] 06:15AM 6.8* 5.4* 1.6 CALCIUM freeCa [**2141-9-14**] 11:30AM 0.94* Brief Hospital Course: ICU course: EKG showed no change from prior, and CXR showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home medication regimen. The patient was found to by hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. . [**Hospital1 **] history: . 1. Hypertensive urgency: During the patient's [**Hospital1 **] stay, her SBPs ranged from 140s-160s during the day, which is her baseline systolic blood pressure. She was maintained on her home oral medication regimen. At night, she became more hypertensive, with SBP to the 170s-180s, which was controlled with both IV hydralazine and PO nifedipine. PO nifedipine was most successful at bringing her SBP back to her baseline. SBP at discharge was 140. Throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. The renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. Right leg pain: Upon arrival on the floor, the patient complained of [**2143-4-15**] pain in R buttock and posterior thigh, much exacerbated with standing. Of note, lumbar spine MRI and R hip XR on most recent admission were both negative. Her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. Her pain when she was symptomatic was controlled well with PO dilaudid. If the pain recurs, an MRI of the right hip can be considered to evaluate for osteonecrosis. . 3. UTI: The patient had a urinalysis suggestive of UTI, though she remained asymptomatic throughout. She was treated with a three day course of ciprofloxacin. Her urine culture showed mixed flora consistent with skin contamination. . 4. ESRD: The patient has end-stage renal disease due to her lupus. The patient's creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. She was followed by the renal consult service. Her potassium remained stable. Her calcium was low during admission, and supplemental calcium was given in addition to starting Calcitriol. She was not dialyzed through her PD catheter secondary to discomfort, but may reinitiate PD as an outpatient. Her laboratories will be checked as an outpatient in renal clinic. . 5. Anemia: The patient's hematocrit remained near her baseline low 20s throughout her stay. She has anemia from chronic kidney disease and chronic disease. The patient is not on Epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. Prior SVC thrombus: The patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with INR goal 2.5 to 3.0. . 7. Systemic lupus erythematosus: No active issues. The patient's home prednisone regimen was continued. Medications on Admission: - Prednisone 5 mg Daily - Coumadin 2 mg at bedtime - Nifedipine 60 mg Sustained Release Daily - Hydralazine 50 mg every 8 hours - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY - Aliskiren 150 mg Twice daily - Docusate Sodium 100 mg 2 times a day - Labetalol 900 mg three times a day - Lactulose 15-30 ml once a day: goal is [**1-11**] soft bowel movements per day Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 7. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: - Hypertensive urgency - Right lower extremity pain - Urinary tract infection Secondary diagnosis: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) - HOCM: Last noted on echo [**8-17**] - Anemia - History of left eye enucleation [**2139-4-20**] for fungal infection - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Discharge Condition: Stable systolic blood pressure over past 24 hours. Discharge Instructions: You were admitted to the hospital for uncontrolled high blood pressure. You spent one day in the intensive care unit, where you were treated with intravenous medication to lower your blood pressure. You were then transferred to a regular hospital floor, where your blood pressure was managed with your home oral medications. You were also treated for urinary tract infection with antibiotics. Your right leg pain improved during admission, and we are unsure of the cause of this pain. You should discuss the need for an MRI of the hip if the pain returns when you meet with your primary care doctor. Please call your physician or return to the emergency room if you experience fever, chills, chest pain, difficulty breathing, abdominal pain, headache, changes in your vision, or any other symptoms that are concerning. Please take your medications as prescribed. - Calcitriol was added to your medications. - You should hold Coumadin for two days and restart Saturday, [**2141-9-16**]. You should have your INR checked at your visit in kidney clinic [**2141-9-18**]. - You can take Dilaudid 2-4 mg every eight hours as needed for pain. You should be vigilant about taking lactulose if you need to take Dilaudid. - You should continue Lactulose as per Dr.[**Name (NI) 12913**] instructions. - No other changes were made. Please keep follow up appointments as described below. Followup Instructions: Please call the office of your kidney doctor, Dr. [**Last Name (STitle) 4883**], at ([**Telephone/Fax (1) 773**] to schedule an appointment for [**Last Name (LF) 766**], [**9-19**] as discussed. Follow up with your lung doctor: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-9-21**] 1:00 Follow up with your new primary care doctor: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 ",70,2141-09-11 10:12:00,2141-09-14 20:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home medication regimen. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. . [**hospital1 **] history: . 1. hypertensive urgency: during the patients [**hospital1 **] stay, her sbps ranged from 140s-160s during the day, which is her baseline systolic blood pressure. she was maintained on her home oral medication regimen. at night, she became more hypertensive, with sbp to the 170s-180s, which was controlled with both iv hydralazine and po nifedipine. po nifedipine was most successful at bringing her sbp back to her baseline. sbp at discharge was 140. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. the renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. her pain when she was symptomatic was controlled well with po dilaudid. if the pain recurs, an mri of the right hip can be considered to evaluate for osteonecrosis. . 3. uti: the patient had a urinalysis suggestive of uti, though she remained asymptomatic throughout. she was treated with a three day course of ciprofloxacin. her urine culture showed mixed flora consistent with skin contamination. . 4. esrd: the patient has end-stage renal disease due to her lupus. the patients creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. she was followed by the renal consult service. her potassium remained stable. her calcium was low during admission, and supplemental calcium was given in addition to starting calcitriol. she was not dialyzed through her pd catheter secondary to discomfort, but may reinitiate pd as an outpatient. her laboratories will be checked as an outpatient in renal clinic. . 5. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay. she has anemia from chronic kidney disease and chronic disease. the patient is not on epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. prior svc thrombus: the patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with inr goal 2.5 to 3.0. . 7. systemic lupus erythematosus: no active issues. the patients home prednisone regimen was continued. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Urinary tract infection, site not specified; Other primary cardiomyopathies; Systemic lupus erythematosus; Sciatica; Hyperpotassemia; Thrombocytopenia, unspecified; Abnormal coagulation profile; Hyperparathyroidism, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism]","icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the renal team was consulted, and recommended no change to home medication regimen. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. she was treated with a three day course of ciprofloxacin. esrd: the patient has end-stage renal disease due to her lupus. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay.","ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. she became more hypertensive, with sbps to the 170s-180s during the day. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency." 109,125288.0,14799,2141-11-23,14797,172335.0,2141-09-24,Discharge summary,"Admission Date: [**2141-9-18**] Discharge Date: [**2141-9-24**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1936**] Chief Complaint: hip pain Major Surgical or Invasive Procedure: None History of Present Illness: 24yo woman with hx SLE, CKD(not currently on HD or PD), labile HTN here with right leg pain and HTN urgency. Patient was recently d/ced on [**9-14**] following admission for the same complaints. . Patient took her hydralazine dose on am of admission. BP at presentation to the ER was 250/140 (The patient reportedly has baseline SBPs in 130-170s) She was given 900 labetolol and 50 hydralazine in the ED. BP following this was 175/124. Her EKG was unchanged. K was 5.7. . Patient also complaining of [**10-20**] right hip pain. Patient was d/ced on [**9-14**] with oral dilaudid for hip/leg pain. She took this only for one day due to severe itching. Denies any parasthesias/weakness. Her RLE/hip pain has been extensively worked up with negative LENIs, Lumbar spine MRI and hip plain films in the past. She was given 4mg IV morphine in the ER. . On admission to the floor, leg/hip pain somwhat improved with morphine.She denies any headache, vision changes, double vision, chest pain or SOB. Feels warm but no chills. Past Medical History: Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 97.3 HR 81 BP 135/91 RR 16 100%RA Gen:NAD, happy, pleasant female HEENT:NC/AT, L eye prosthesis, R PERRL, EOMI, MMM, facial swelling, L side>R, scerla anicteric Neck: supple, no JVD, no LAD, scars from prior CVL and HD lines CV:S1S2+, 2/6 SEM LUSB, loud P2, RRR, no ectopy Pulm: CTA B/L, good inspiratory effort Abd: +BS, soft, nontender, slightly distended and resonant to percussion, PD catheter in place in left abdomen ext: no c/c/e, 2+DP b/L, L foream swollen>R, R hip is mobile without pain elicited on passive or active movement neuro: AAOx3, nonfocal exam, CN 2-12 intact, moves all 4 extremities psych: mood/affect appropriate Pertinent Results: MRI Right Hip ([**9-18**]): There is no signal abnormality on the fluid-sensitive sequences in the proximal femur, acetabulum, or other osseous structure. On T1- weighted images, there is a focal rounded region within the right femoral head measuring approximately 9 mm in a subchondral location, which is nonspecific but may represent an unusual focus of red marrow. No sclerosis is seen on the corresponding plain films. There is a small right hip joint effusion and a small amount of fluid in the left hip joint as well, at the upper limits of normal. There is no soft tissue abnormality, no muscular edema, and no fluid collections. IMPRESSION: 1. Small right hip joint effusion. 2. No bone marrow edema in the proximal femurs or the pelvis. 3. Nonspecific small focus of low signal on T1-weighted images in the right femoral head is nonspecific but may represent an unusual focus of red marrow. TTE ([**9-21**]): The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF 80%). A mild (18 mmHg) mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. There is no systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Severe symmetric left ventricular hypertrophy with hyperdynamic systolic function and mild mid-cavitary gradient. Mild aortic regurgitation. Moderate pulmonary hypertension. Findings consistent with hyperrtophic cardiomyopathy. Compared with the prior study (images reviewed) of [**2140-8-26**], pulmonary hypertension has developed (also present on the study from [**2140-5-20**]). Pericardial effusion is also new. V/Q scan ([**9-21**]): Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate no focal defects with improved ventilation to the posterior right basal segment. Perfusion images in the same 8 views show improved perfusion to the posterior right basal segement with a persistent small defect but no new findings. Chest x-ray shows cardiomgealy and left basilar atelectasis. IMPRESSION: Improved V/Q scan from [**9-/2139**] with no findings to suggest acute pulmonary embolism. B/L upper ext U/S ([**9-21**]): Grayscale and Doppler son[**Name (NI) 867**] of the right and left internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. There is nonocclusive focal thrombus seen in the left subclavian vein, where the vein is not fully compressible. Flow is seen in the region, indicating that the thrombus is nonocclusive. Elsewhere, normal flow, augmentation, compressibility were appropriate and waveforms are demonstrated. IMPRESSION: 1. Focal nonocclusive thrombus in the left subclavian vein. 2. Otherwise, patent upper extremity veins as described. [**2141-9-18**] 02:15PM POTASSIUM-5.1 [**2141-9-18**] 02:15PM HCT-21.2* [**2141-9-18**] 08:45AM POTASSIUM-5.7* [**2141-9-18**] 07:30AM GLUCOSE-88 UREA N-54* CREAT-8.6* SODIUM-136 POTASSIUM-5.8* CHLORIDE-108 TOTAL CO2-15* ANION GAP-19 [**2141-9-18**] 07:30AM estGFR-Using this [**2141-9-18**] 07:30AM CALCIUM-7.3* PHOSPHATE-5.3* MAGNESIUM-1.6 [**2141-9-18**] 07:30AM WBC-5.2 RBC-2.32* HGB-6.5* HCT-20.1* MCV-87 MCH-28.1 MCHC-32.4 RDW-18.4* [**2141-9-18**] 07:30AM NEUTS-78.0* LYMPHS-14.7* MONOS-3.9 EOS-3.2 BASOS-0.3 [**2141-9-18**] 07:30AM PLT COUNT-107* [**2141-9-18**] 07:30AM PT-20.8* PTT-43.3* INR(PT)-2.0* . [**2141-9-21**] CXR: There is no significant change when compared to the recent previous examination. The previously described left retrocardiac opacity is unchanged in appearance. Cardiomegaly is also unchanged. The mediastinal contour, bony thorax and pulmonary vasculature are normal. IMPRESSION: No significant change compared to study done roughly 7 hours prior. Brief Hospital Course: 24 yo with h/o of Lupus, HTN, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for R hip pain. Patient was on the floor on [**9-20**], given morphine for the hip pain. She then had an episode of hypotension and unresponsiveness and transferred to the MICU for closer monitoring. The patient got 2L IVFs and narcan and improved, in fact, found to be hypertensive upon arrival to MICU. . MICU Course: On [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. Concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. Mental status cleared somewhat with narcan. Renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. V/Q scan demonstrated improvement since prior study. Patient's home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. She was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. PD fluid was not c/w SBP. CXR was clear. Urine culture and blood cultures are pending. Patient's BP was in the 110s so hydralazine was stopped. Her other BP meds were otherwise continued. Plan was/is to follow renal recs for PD. If, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. Would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. If patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. Would add neurontin 100mg TID with room to titrate up to 300mg TID. Neuro also recommended PT with TENS unit and referral to pain clinic although patient's pain is currently absent. . FYI **** per Dr. [**Last Name (STitle) **] --- Because of ? increase in cardiomegaly on CXR, she got an echo yesterday. In addition to her known HOCM, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm Hg. They probably need to be followed up over time (particularly the pulmonary hypertension). We did evaluated the PHTN with a VQ scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. It would be good if we could arrange a PULMONARY CLINIC FOLLOW UP for Ms. [**Known lastname **] after discharge with either [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].**** . She underwent CT head, and V/Q scan which were unremarkable. Her steroid dose was increased to 15mg given concern for need for stress dose steroids. After transfer from the MICU, her steroids were dropped back to 5mg, her home dose with the approval of [**Last Name (un) **]. . Her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. Her hydralazine was discontinued. On day 2 of her MICU stay, she developed a fever to 102. She was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. Broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. There was question of retrocardiac opacity on CXR, though not clear. Rheum consult obtained given hip discomfort, who felt septic joint unlikely. Neurology consult obtained who felt autonomic seizure unlikely. . Pt initiated peritoneal dialysis. In this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising BPs. She is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. Her hip pain has resolved completely without further intervention. . Floor course: Fever: Spike fever in MICU to 102. Started on Levoquin, Aztreonam, and Vanc. Source unclear at this point, but CXR with question of retrocardiac opacity. There is a possibility of aspiration pneumonitis. Other etiologies include peritoneal fluid (PD cath), urine, and blood (though patient does not have any indwelling lines). Hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. Peritoneal dialysis cultures negative so far. Continued levo/vanco/aztreonam for 2 days empirically. Then d/ced the Abx as no infectious etiologies were found. Steroids back to home dosage. BCx, UCx (final neg), Peritoneal cultures negative at discharge. . # Labile blood pressure: h/o of difficult to control BP with episodes of hypertensive emergency in the past. Normal SBP runs in 170s. Having nausea in setting of new PD, no evidence of intracranial bleeding on clinical exam, though INR had been supratherapeutic so remains in differential, though not bradycardic. Continue home BP meds :Labetalol 900 mg PO TID but difficult for patient to tolerate due to nausea, Aliskiren *NF* 150 mg Oral [**Hospital1 **], NIFEdipine CR 60 mg PO DAILY, clonidine patch, hydralazine given hypertensive in setting of nausa. . # Right leg/hip pain: no evidence of avascular necrosis or fracture on MRI though there is a small effusion. Pain resolved without intervention. Continued to monitor and would avoid narcotics, restart slowly if pain resumes. Physical therapy to follow as an outpatient. [**Last Name (un) 18183**] followed. Please see consult note. . # Hyperkalemia: Chronic issue. Patient takes kayexalate intermittently per her report (last dose [**Last Name (un) 766**]). Monitored K but patient did not need it on floor. # CKD V: Renal following. Did well with PD on [**9-22**] but did report some nause and cramping. She was not tolerating all 1.5L in exchanges on discharge. # Anemia: Hct stable around 20. S/p 1 U PRBCs in MICU with Hct 20.1 to 21.9. Likely due to chronic hemolysis consistent with SLE> #. Prior SVC thrombus: Physical exam with L arm swelling consistent with this. No flow limitations. INR 3.5 on ICU admission. Held warfarin but restarted home 2mg daily the day before discharge. # Systemic lupus erythematosus: Home prednisone dose 5mg. Currently on 15mg in setting of acute illness (day 2). # General care: FEN: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, PD initiated, Proph: INR therapeutic, no indication for PPI, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. Code: Full code, confirmed with patient Communication: with the patient and her mother [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (2) 43497**]contact. Access: 2 PIVs Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly dilaudid PO prn benadryl prn lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily coumadin 2mg PO qday calcitriol 1 mcg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Hypertensive urgency Transient Hypotension due to Narcotics Sciatica . Secondary: End stage renal disease Systemic Lupus Erythematosus Anemia Discharge Condition: Stable. Blood pressures at baseline. Hip/leg pain resolved. Ambulating without assistance. Discharge Instructions: You were admitted to the hospital with high blood pressure and right leg/hip pain. We gave you pain medications and blood pressure lowering medications. Your blood pressure then dropped which was caused by the pain medication, and you were transferred to the Intensive Care Unit(ICU) where you recovered quickly. During your stay in the ICU, you developed a fever and were started on antibiotics. However, the cultures that were obtained were negative, and we discontinued the Antibiotics. During your hospitalization, your blood pressure normalized on your home regimen, and your right leg/hip pain resolved. You had an MRI of your hip done, which did not show an acute infection. You were seen by the kidney doctors and they recommended starting peritoneal dialysis. You were also given some blood for your anemia. Please follow up with the Peritoneal Dialysis nurse at the scheduled day/time. Please make an appointment to meet with your PCP in the next couple of weeks. Your Hip pain may benefit from physical therapy or outpatient anesthetic joint injection. Please discuss these options with your rheumatologist. . Please call the number given below to schedule outpatient physical therapy. . Please restart your home medications. You were also started on Sodium Bicarb 650mg by mouth three times a day. . If you develop fevers, chills, trouble breathing, chest pain, worsening of hip pain, headaches, changes in your vision or any other symptoms that concern you please return to the emergency room or call your doctor. Followup Instructions: Please follow up with your Peritoneal Dialysis nurse ([**Doctor First Name 3040**]) on [**Doctor First Name 766**] [**2141-9-25**] . Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 . Please call to schedule Outpatient Physical Therapy:[**Telephone/Fax (1) 2484**] Completed by:[**2141-9-25**]",60,2141-09-18 10:32:00,2141-09-24 13:53:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,LEG PAIN," 24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. patient was on the floor on [**9-20**], given morphine for the hip pain. she then had an episode of hypotension and unresponsiveness and transferred to the micu for closer monitoring. the patient got 2l ivfs and narcan and improved, in fact, found to be hypertensive upon arrival to micu. . micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. mental status cleared somewhat with narcan. renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. v/q scan demonstrated improvement since prior study. patients home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. she was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. pd fluid was not c/w sbp. cxr was clear. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. plan was/is to follow renal recs for pd. if, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. would add neurontin 100mg tid with room to titrate up to 300mg tid. neuro also recommended pt with tens unit and referral to pain clinic although patients pain is currently absent. . fyi **** per dr. [**last name (stitle) **] --- because of ? increase in cardiomegaly on cxr, she got an echo yesterday. in addition to her known hocm, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm hg. they probably need to be followed up over time (particularly the pulmonary hypertension). we did evaluated the phtn with a vq scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. it would be good if we could arrange a pulmonary clinic follow up for ms. [**known lastname **] after discharge with either [**first name4 (namepattern1) **] [**last name (namepattern1) **] or [**first name4 (namepattern1) **] [**last name (namepattern1) **].**** . she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. after transfer from the micu, her steroids were dropped back to 5mg, her home dose with the approval of [**last name (un) **]. . her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. her hydralazine was discontinued. on day 2 of her micu stay, she developed a fever to 102. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. there was question of retrocardiac opacity on cxr, though not clear. rheum consult obtained given hip discomfort, who felt septic joint unlikely. neurology consult obtained who felt autonomic seizure unlikely. . pt initiated peritoneal dialysis. in this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising bps. she is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. her hip pain has resolved completely without further intervention. . fever: spike fever in micu to 102. started on levoquin, aztreonam, and vanc. source unclear at this point, but cxr with question of retrocardiac opacity. there is a possibility of aspiration pneumonitis. other etiologies include peritoneal fluid (pd cath), urine, and blood (though patient does not have any indwelling lines). hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. peritoneal dialysis cultures negative so far. continued levo/vanco/aztreonam for 2 days empirically. then d/ced the abx as no infectious etiologies were found. steroids back to home dosage. bcx, ucx (final neg), peritoneal cultures negative at discharge. . # labile blood pressure: h/o of difficult to control bp with episodes of hypertensive emergency in the past. normal sbp runs in 170s. having nausea in setting of new pd, no evidence of intracranial bleeding on clinical exam, though inr had been supratherapeutic so remains in differential, though not bradycardic. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. . # right leg/hip pain: no evidence of avascular necrosis or fracture on mri though there is a small effusion. pain resolved without intervention. continued to monitor and would avoid narcotics, restart slowly if pain resumes. physical therapy to follow as an outpatient. [**last name (un) 18183**] followed. please see consult note. . # hyperkalemia: chronic issue. patient takes kayexalate intermittently per her report (last dose [**last name (un) 766**]). monitored k but patient did not need it on floor. # ckd v: renal following. did well with pd on [**9-22**] but did report some nause and cramping. she was not tolerating all 1.5l in exchanges on discharge. # anemia: hct stable around 20. s/p 1 u prbcs in micu with hct 20.1 to 21.9. likely due to chronic hemolysis consistent with sle> #. prior svc thrombus: physical exam with l arm swelling consistent with this. no flow limitations. inr 3.5 on icu admission. held warfarin but restarted home 2mg daily the day before discharge. # systemic lupus erythematosus: home prednisone dose 5mg. currently on 15mg in setting of acute illness (day 2). # general care: fen: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, pd initiated, proph: inr therapeutic, no indication for ppi, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. code: full code, confirmed with patient communication: with the patient and her mother [**name (ni) **] [**name (ni) **], [**telephone/fax (2) 43497**]contact. access: 2 pivs ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Pneumonia, organism unspecified; Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Hyperpotassemia; Sciatica; Other iatrogenic hypotension; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Anemia of other chronic disease; Hypocalcemia]","24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. it would be good if we could arrange a pulmonary clinic follow up for ms. [** she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. source unclear at this point, but cxr with question of retrocardiac opacity. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. did well with pd on [**9-22**] but did report some nause and cramping. # systemic lupus erythematosus: home prednisone dose 5mg.","lupus nephropathy patient on peitoneal dialysis with htn and lupus nephropathy. triggered for hypotension (82/45), hypothermia (92.9), altered mental status. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis." 109,125288.0,14799,2141-11-23,14798,126055.0,2141-11-03,Discharge summary,"Admission Date: [**2141-10-13**] Discharge Date: [**2141-11-3**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 6734**] Chief Complaint: Nausea, Vomitting, Abdominal Pain, HTN Urgenc Major Surgical or Invasive Procedure: Upper GI endoscopy Exploratory laparotomy Tunneled hemodialysis catheter in R femoral vein Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 24 y/o F with h/o ESRD, HTN who started peritoneal dialysis during the week of [**2141-10-8**] and presented with a 1 day history of acute onset N/V, sharp abdominal pain on [**2141-10-13**]. (Of note, the patient had presented to the ED on [**10-11**] with hypotension, SBPs in the 80s off after approximately 1.5L was taken off during dialysis in the setting of taking her PO Anti-HTNs. On [**2141-10-11**] she received 0.5L IVF, labs WNL, and was d/c'd home). On the day of admission on [**2141-10-13**], the patient reported that the previous night, she was awoken from sleep with severe, sharp abdominal pain, 6 episodes of frothy emesis, 10+ yellowish BMs without melena or BRBRP.She was admitted for further work- up of this abdminal pain. . In the ED here vitals were as follows: T: 97.0 HR: 101 BP: 240/180 RR: 17 O2sat: 100%RA. She received Labetolol 20mg IV and was subsequently placed on a labetolol drip. She also received ceftriaxone 1gm IV, Flagyl 500mg IV, Dilaudid 0.5-1mg IV q1hr and Zofran. Her abdominal CT showed multifocal areas of small bowel wall thickening. Her peritoneal Cell count was negtaive for SBP. She had some signs of peritonitis and thus surgery was consulted. Her lactate was normal. . Upon arrival to the MICU the patient was mentating well with complaints of diffuse sharp abdominal pain that radiated to the back and diarrhea. She had no headache or visual changes. Past Medical History: - SLE DX ([**2134**] - 16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter Placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). - Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS: 98.4 HR 98 192/131 21 100%RA GEN: Mild Distress, AOx3 HEENT: PEERLA, EOMI NECK: Supple, No LAD, No bruit RESP: CTAB CARD: 2/6 systolic ejection murmur ABD: soft, moderately tender with +/- guarding, BS+ EXTR: Warm well perfused NEURO: Motor Grossly Intact RECTAL: Yellow Stool BACK: B CVAT Pertinent Results: [**2141-11-3**] 08:50AM BLOOD WBC-3.5* RBC-2.55* Hgb-7.8* Hct-23.6* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.8* Plt Ct-176 [**2141-11-3**] 03:55PM BLOOD PT-15.5* PTT-50.8* INR(PT)-1.4* [**2141-11-3**] 08:50AM BLOOD Glucose-121* UreaN-33* Creat-5.2*# Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [**2141-10-26**] 06:15AM BLOOD ALT-11 AST-49* AlkPhos-122* Amylase-186* TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2141-10-26**] 06:15AM BLOOD Lipase-30 [**2141-11-3**] 08:50AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.9 [**2141-10-30**] 06:55AM BLOOD HBsAg-NEGATIVE [**2141-10-17**] 10:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2141-10-25**] 11:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2141-10-25**] 11:56AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2141-10-25**] 11:56AM URINE RBC-0-2 WBC-[**3-15**] Bacteri-FEW Yeast-NONE Epi-21-50 Blood cultures: all negative EKG ([**2141-10-13**]): Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of [**2141-10-2**] there is no significant diagnostic change. CXR ([**2141-10-13**]): No acute cardiopulmonary abnormality. No free air under the diaphragms. CT chest/abdomen/pelvis ([**2141-10-13**]): There is a moderate-sized pericardial effusion, similar in appearance from [**2141-10-13**]. The great vessels are normal in caliber, without aneurysmal dilatation. Evaluation of the great vessels is limited without IV contrast. Interstitial thickening, particularly within the perihilar regions, is suggestive of fluid overload. There is bibasilar atelectasis with a small focus of consolidation in the right lower lobe (2:35) unchanged from [**2141-10-13**], and may reflect aspiration or pneumonia. Scattered bilateral nodules are largely stable from as far back as [**2139-10-9**]. Specifically, there is a 5 mm nodule in the right middle lobe (2:25), two adjacent nodules in the right lower lobe measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule within the left lower lobe. A nodular density seen adjacent and anterior to the right main pulmonary artery (2:23) may reflect a vessel. There is a small right pleural effusion. Axillary lymphadenopathy, with axillary nodes measuring up to approximately 10 mm in short axis, is seen. Ill- defined soft tissue thickening within the hilus bilaterally may reflect hilar lymphadenopathy, but assessment is limited without IV contrast. A catheter is visualized within the visualized right upper extremity, which may reflect a PICC line that terminates within the right subclavian vein. The esophagus is distended and filled with contrast, with marked wall thickening and edema throughout its entire length, a new finding. There is a moderate- sized hiatal hernia. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval development of a moderate amount of free intraperitoneal air, that layers anteriorly and along the anterior abdominal wall. Additional small clustered foci of extraluminal air is seen adjacent to the proximal stomach and the gastroesophageal junction, with a focus of air tracking into the fissure of ligamentum venosum. Additionally, there appears to be air tracking into the anterior subcutaneous tissues in the region of the umbilicus. These findings are all new from the prior CT on [**2141-10-13**], but free air was present on chest radiograph performed [**2141-10-25**]. There is no obvious evidence of extravasation of oral contrast into the peritoneum. Of note, a peritoneal dialysis catheter is in place that could represent a route of entry of intraperitoneal air. The stomach, small bowel, and colon are filled with contrast, without evidence of obstruction. Evaluation for wall thickening is limited without IV contrast. Limited non-contrast views of the liver demonstrates a rounded 1.6 cm x 1.2 cm hypodensity in the right lobe of the liver, previously characterized as a hemangioma. The liver is otherwise unremarkable. The gallbladder, spleen, pancreas, and adrenal glands demonstrate no gross abnormality. Both kidneys are atrophic. Evaluation of solid organs is limited by lack of IV contrast. There is a peritoneal dialysis catheter, coiled within the pelvis, unchanged. There is a large amount of free fluid throughout the abdomen, similar in appearance to the prior study. CT OF THE PELVIS WITHOUT IV CONTRAST: Uterus and rectum are grossly unremarkable. However, assessment of the rectal wall is limited without IV contrast. OSSEOUS STRUCTURES: Bones are diffusely sclerotic, which may be related to renal osteodystrophy. There is bilateral sacroiliitis. IMPRESSION: 1. Interval development of a moderate amount of free intraperitoneal air, new from [**2141-10-13**]. A peritoneal dialysis catheter is in place and could represent the route of entry of free intraperitoneal air. However, as foci of air is seen in the region of the proximal stomach and GE junction in the setting of a recent endoscopy, perforation cannot be excluded, though no frank extravasation of contrast is identified. 2. New dilation and wall thickening of the entire esophagus, a nonspecific finding that could relate to infectious or inflammatory esophagitis; clinical correlation is recommended. Esophagus is contrast-filled possibly representing reflux. Hiatal hernia. 3. Anasarca, with moderate-sized pericardial effusion, pulmonary edema, and small right pleural effusion. 4. Large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. Imaging cannot exclude SBP, which should be evaluated for clinically. 5. Focus of consolidation within the right lower lobe, could represent aspiration or pneumonia, but unchanged from the prior study. Gastric Biopsies ([**2141-10-18**]): Antrum: Corpus-type mucosa, no diagnostic abnormalities recognized. Jejunum: Small intestinal mucosa, no diagnostic abnormalities recognized. UE Venous U/S: No evidence of DVT of the left upper extremity, without thrombus identified within the left subclavian vein. Brief Hospital Course: This is a 24 year old woman with ESRD secondary to SLE (started peritoneal dialysis approximately one week prior to admission), malignant HTN, h/o SVC syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. Her hospital course was complicated by multiple transfers between the MICU and the floor secondary to hypertensive urgency. # Abdominal Pain/Diarrhea: During the patient's admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. Infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. However, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. The patient was empirically placed on IV flagyl, but this was discontinued when stool samples were negative for C.difficile. Serial abdominal exams showed no peritoneal signs. Peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. CT of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. Other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to SLE vasculitis, malignant HTN, or microthrombosis and SLE enteritis. Surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. A heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible GI bleed. With regards to SLE vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to SLE. On [**10-18**], GI performed an EGD which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. Approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. Both cardiac, GI, and pulmonary etiologies were considered for the origin of her epigastric pain. Pericarditis was considered, but her EKG was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. Her lungs were also essentially unchanged from [**2141-10-13**]. However, her abdominal CT on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. As a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. There were no major findings: no evidence of perforation, obstruction, or infection. The patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. At discharge, the patient only complained of some mild incisional pain. # Hypertensive urgency: The patient was initially admitted to the MICU with a blood pressure of 240/180. Her hospital course was complicated by extremely labile HTN and was transferred back and forth between the MICU and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of SBPs > 260. Throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. Her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. Multiple medication regimens were attempted and changed throughout her hospital course. However, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for SBPs > 180. At discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg PO. Her regimen as per Dr. [**Last Name (STitle) 4883**]: Nifedipine SR 90 mg daily Aliskiren 150 mg [**Hospital1 **] Labetalol 300 mg TID Hydralazine 75 mg TID Clonidine patch 0.3 mg/24 hr patch qWed When SBP>180, she then uses a hydralazine sliding scale. When SBP>180, give 25 mg PO hydral every 30 min until SBP<150. You can use this for up to 2-3 hours. In between PO hydral doses, can then also use 10 IV hydralazine. # ESRD: The etiology of the patient's ESRD is secondary to SLE. Her Creatinine on admission was 7.9, which was near her baseline of 8 - 9. During her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. Prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2L per PD. After her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. Initially, the patient adamantly refused hemodialysis. However, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. As a result, after a long coversation with her primary renal physician, [**Name10 (NameIs) **] agreed to restart hemodialysis. A tunneled catheter was placed in her R femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. She underwent hemodialysis two more times prior to discharge. Upon discharge, her electrolytes were back to her baseline. She is expected to undergo hemodialysis (Tues/[**Last Name (un) **]/SAT) as an outpatient. # Anemia: During her admission, the patient's HCT was monitored daily with HCT to low-mid 20's. On [**2141-10-17**], she was found to have guaiac positive stools and her HCT was found to have dropped to a low of 18.6. The patient was transfused a total of 2 units of [**Date Range **] between [**2141-10-17**] and [**2141-10-18**]. Epo Alfa SC was also given on [**2141-10-17**]. She remained hemodynamically stable. GI consulted and EGD results were as stated above. The patient's HCT remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. Between [**2141-10-23**] - [**2141-10-24**], the patient had a HCT drop from 26 to 20 in the setting of occult positive emesis. She received two units of [**Month/Day/Year **] and her HCT returned to 28. GI was aware and planned to perform a non-urgent EGD on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her HCT returned to baseline. However, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her HCt remained stable and near baseline for the remiainder of her hospital course. # H/O Thrombosis: The patient was initially placed on her home dose of warfarin 2mg qd. Her INR on admission was 1.2. She was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. However, this was stopped for her EGD and after she had evidence of a GI bleed. The heparin drip was discontinued on [**10-22**]. The patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in HCT and in preparation for a possible GI intervention. After her surgery, her coumadin was held and she was off the heparin drip, but her INR continued to drift up, getting as high as 2.6 on [**2141-10-30**]. This was mostly attributed to nutritional deficiency [**2-11**] poor PO intake, but there was concern for possible synthetic dysfunction as well. As a result, she was given a test dose of vitamin K, which she responded to well (Her INR came back down to 1.4). As a result, her home dose of coumadin at 2 mg qday was restarted. At discharge, her INR was still sub- therapeutic at 1.4. Of note, the patient has a history of SVC syndrome and had a L subclavian venous thrombosis. During the last few days of her hospital stay, the patient complained of increased tongue swelling and her L face was noted to be slightly more swollen than previously noted. As a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a DVT within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # SLE: Rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. Her outside rheumatologist was also consulted. Both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # Obstructive sleep apnea: The patient was noted to have OSA based on clinical nocturnal exam during admission. Patient attempted 1 trial of CPAP at 2L/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. The paitent stated that she would pursue further work-up and treatment for OSA as an outpatient. While the mask and CPAP machine were at her bedside throughout her hospital course, the patient rarely used it. # Metabolic Acidosis: The patient's bicarbonate on admission was 13. Her baseline is normally between 16-20. She received 150mEq NaHCO3 over 24hrs from [**Date range (1) 43500**]. During her brief returns to the MICU, her HC03 was 18-19, which was presumed to be her baseline at home secondary to her CRF. At discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. Medications on Admission: Nifedipine 60 mg PO daily Labetalol 900 mg PO TID Hydralazine 50 mg PO TID Clonidine 0.3 mg/24hr patch qWED Lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 4 mg daily Warfarin 2mg PO daily Calcitriol 1 mcg daily Calcium carbonate 500mg QID Dilaudid 2mg PO Q4-6hr prn pain Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*30 Patch Weekly(s)* Refills:*2* 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. [**Hospital1 **]:*1500 ML(s)* Refills:*0* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Twice daily (). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): In addition to 75 mg TID, if SBP>180, take 1 tab every 30 min until BP decreases to 150. If no improvement after 2 hours, call your doctor. [**Last Name (Titles) **]:*300 Tablet(s)* Refills:*6* 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). [**Last Name (Titles) **]:*1500 ML(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet Sustained Release(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 5 days. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. [**Last Name (Titles) **]:*30 Capsule(s)* Refills:*2* 13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO once a day. [**Last Name (Titles) **]:*30 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: end stage renal disease malignant hypertension abdominal free air subclavian deep vein thrombosis initiation of hemodialysis Secondary: SLE Anemia Discharge Condition: stable, pain well controlled, blood pressure at baseline Discharge Instructions: You were admitted for abdominal pain and then subsequently had a very long hospital course with high blood pressures, severe abdominal pain, some free air in your abdomen resulting in an exploratory laparotomy. You have also been initiated on hemodialysis on Tuesday/Thursday/Saturday schedule. Please take all medications as prescribed in the list that you will be given at discharge. There have been some changes to your medications. Please call your doctor if you have any worsening abdominal pain, fevers, chills, nausea, vomiting, headache, palpitations, diarrhea or any other concerning symptoms. Followup Instructions: You will see Dr. [**Last Name (STitle) 4883**] at hemodialysis on Tuesday, [**11-7**], [**2141**]. You should have your coumadin level checked at this appointment. Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] to schedule an appointment in [**1-11**] weeks to have your staples removed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**] ",20,2141-10-13 23:10:00,2141-11-03 18:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. her hospital course was complicated by multiple transfers between the micu and the floor secondary to hypertensive urgency. # abdominal pain/diarrhea: during the patients admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. the patient was empirically placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. serial abdominal exams showed no peritoneal signs. peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. ct of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to sle vasculitis, malignant htn, or microthrombosis and sle enteritis. surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible gi bleed. with regards to sle vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to sle. on [**10-18**], gi performed an egd which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. both cardiac, gi, and pulmonary etiologies were considered for the origin of her epigastric pain. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. her lungs were also essentially unchanged from [**2141-10-13**]. however, her abdominal ct on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. as a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. there were no major findings: no evidence of perforation, obstruction, or infection. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. at discharge, the patient only complained of some mild incisional pain. # hypertensive urgency: the patient was initially admitted to the micu with a blood pressure of 240/180. her hospital course was complicated by extremely labile htn and was transferred back and forth between the micu and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of sbps > 260. throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. multiple medication regimens were attempted and changed throughout her hospital course. however, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for sbps > 180. at discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg po. her regimen as per dr. [**last name (stitle) 4883**]: nifedipine sr 90 mg daily aliskiren 150 mg [**hospital1 **] labetalol 300 mg tid hydralazine 75 mg tid clonidine patch 0.3 mg/24 hr patch qwed when sbp>180, she then uses a hydralazine sliding scale. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. you can use this for up to 2-3 hours. in between po hydral doses, can then also use 10 iv hydralazine. # esrd: the etiology of the patients esrd is secondary to sle. her creatinine on admission was 7.9, which was near her baseline of 8 - 9. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2l per pd. after her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. initially, the patient adamantly refused hemodialysis. however, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. as a result, after a long coversation with her primary renal physician, [**name10 (nameis) **] agreed to restart hemodialysis. a tunneled catheter was placed in her r femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. she underwent hemodialysis two more times prior to discharge. upon discharge, her electrolytes were back to her baseline. she is expected to undergo hemodialysis (tues/[**last name (un) **]/sat) as an outpatient. # anemia: during her admission, the patients hct was monitored daily with hct to low-mid 20s. on [**2141-10-17**], she was found to have guaiac positive stools and her hct was found to have dropped to a low of 18.6. the patient was transfused a total of 2 units of [**date range **] between [**2141-10-17**] and [**2141-10-18**]. epo alfa sc was also given on [**2141-10-17**]. she remained hemodynamically stable. gi consulted and egd results were as stated above. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. she received two units of [**month/day/year **] and her hct returned to 28. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. however, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her hct remained stable and near baseline for the remiainder of her hospital course. # h/o thrombosis: the patient was initially placed on her home dose of warfarin 2mg qd. her inr on admission was 1.2. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. however, this was stopped for her egd and after she had evidence of a gi bleed. the heparin drip was discontinued on [**10-22**]. the patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in hct and in preparation for a possible gi intervention. after her surgery, her coumadin was held and she was off the heparin drip, but her inr continued to drift up, getting as high as 2.6 on [**2141-10-30**]. this was mostly attributed to nutritional deficiency [**2-11**] poor po intake, but there was concern for possible synthetic dysfunction as well. as a result, she was given a test dose of vitamin k, which she responded to well (her inr came back down to 1.4). as a result, her home dose of coumadin at 2 mg qday was restarted. at discharge, her inr was still sub- therapeutic at 1.4. of note, the patient has a history of svc syndrome and had a l subclavian venous thrombosis. during the last few days of her hospital stay, the patient complained of increased tongue swelling and her l face was noted to be slightly more swollen than previously noted. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. her outside rheumatologist was also consulted. both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission. patient attempted 1 trial of cpap at 2l/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. the paitent stated that she would pursue further work-up and treatment for osa as an outpatient. while the mask and cpap machine were at her bedside throughout her hospital course, the patient rarely used it. # metabolic acidosis: the patients bicarbonate on admission was 13. her baseline is normally between 16-20. she received 150meq nahco3 over 24hrs from [**date range (1) 43500**]. during her brief returns to the micu, her hc03 was 18-19, which was presumed to be her baseline at home secondary to her crf. at discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. ","PRIMARY: [Malignant essential hypertension] SECONDARY: [Renal dialysis status; Epilepsy, unspecified, without mention of intractable epilepsy; Constipation, unspecified; Anemia in chronic kidney disease; Abnormal coagulation profile; Obstructive sleep apnea (adult)(pediatric); Other diseases of lung, not elsewhere classified; Other chest pain; Fever, unspecified; Rash and other nonspecific skin eruption; Other chronic pulmonary heart diseases; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified disease of pericardium; Other ascites; Acidosis; Hyposmolality and/or hyponatremia; Abdominal pain, other specified site; Abdominal pain, epigastric; Nausea with vomiting; Diarrhea; Systemic lupus erythematosus; Hyperparathyroidism, unspecified; Anemia, unspecified; Thrombocytopenia, unspecified; Esophageal reflux]","this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. multiple medication regimens were attempted and changed throughout her hospital course. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. upon discharge, her electrolytes were back to her baseline. epo alfa sc was also given on [**2141-10-17**]. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission.","esrd secondary to sle, malignant htn, h/o svc syndrome, and multiple thrombotic events were considered. the patient was placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia." 109,125288.0,14799,2141-11-23,15330,131345.0,2141-09-08,Discharge summary,"Admission Date: [**2141-9-5**] Discharge Date: [**2141-9-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 348**] Chief Complaint: right leg pain, hypertension Major Surgical or Invasive Procedure: blood transfusion x2 History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. The pain is worst when she tried to bear weight on the leg, or when she uses it to roll over or adjust her position in bed. The pain begins in her buttock and travels down the posterior thigh and calf but stops before reaching the ankle. It occasionally feels like it is coming from her low back. She denies any parasthesias or weakness in the leg, and she denies any numbness in her foot or groin. She denies any fevers or incontinence. The pain was unrelieved by Vicodin that she had at home, so she scheduled an urgent visit with her nephrologist yesterday [**2141-9-4**]. At her nephrologist??????s office, she was hypertensive to 250/145 and so she was referred to the ED. She ended up leaving the ED against medical advice yesterday, but returned today because of persistent leg pain. She reports that she took all of her morning and noon BP meds. She denies any fevers, headaches, visual changes, nausea (prior to coming to the ED), or leg weakness. Upon arrival to the ED today, she was afebrile, BP 237/146, HR 97, RR 16, Sat 100% on room air. She received a total of 90 mg of IV labetalol and nitropaste, and was eventually put on a labetalol drip for her hypertension. With these interventions, her SBP dropped to the 180s, but she reported feeling nauseous and so the drip was discontinued. She was also given 4 mg of IV morphine and 1 mg of IV hydromorphone for her leg pain with decent relief. Due to a urinalysis suggestive of infection, she was given one tablet of DS TMP/SMX. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: MICU physical: Tmax: 36.3 ??????C (97.4 ??????F) Tcurrent: 36.3 ??????C (97.4 ??????F) HR: 92 (92 - 94) bpm BP: 209/138(152) {201/134(151) - 209/138(152)} mmHg RR: 19 (19 - 30) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Height: 59 Inch General: well-appearing young woman in no acute distress HEENT: no scleral icterus; prosthetic right eye Neck: supple Chest: clear to auscultation throughout, no wheezes/rales/ronchi CV: regular rate/rhythm, normal s1s2, no murmurs Abdomen: soft, nontender, nondistended, PD catheter in place in left abdomen Back: very mild spinal tenderness over approx L3 level of spine Extremities: no edema, 1+ PT pulses, warm Skin: no rashes or jaundice Neuro: alert, oriented x3, 5/5 strength in bilateral deltoids, biceps, triceps, hip flexors/extensors, ankle flexors/extensors; unable to elicit patellar reflexes bilaterally; negative straight leg raise bilaterally Pertinent Results: 138 111 54 -----------------< 83 5.4 14 8.2 . WBC: 3.7 HCT: 19 PLT: 101 N:69.3 L:23.4 M:5.5 E:1.7 Bas:0.1 PT: 21.9 PTT: 48.2 INR: 2.1 . Trends: HCT: 19 -> 22 w 1u then received another unit. INR 3.4 on discharge Discharge chem: Glucose-104 UreaN-51* Creat-8.4* Na-136 K-5.3* Cl-106 HCO3-18* AnGap-17 . [**2141-9-8**] 07:30AM BLOOD CK(CPK)-126 [**2141-9-5**] 02:50PM BLOOD HCG-<5 . [**2141-9-8**] 1:37 pm PERITONEAL FLUID GRAM STAIN (Final [**2141-9-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count . MRI L-spine: IMPRESSION: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. . CXR admit: IMPRESSION: Moderate cardiomegaly, bilateral pleural effusions, and pulmonary vascular prominence consistent with pulmonary edema. . Hip film: FINDINGS: No comparisons. No acute fracture or dislocation is seen. No lucent or sclerotic lesion is noted. There is a distal aspect of a catheter or shunt seen in the pelvis. Soft tissues are otherwise unremarkable. There is minimal degenerative change of the pubic symphysis. IMPRESSION: No acute fracture or dislocation. . Abdominal film: FINDINGS: A PD catheter is seen with its tip coiled in the pelvis. There is normal bowel gas. The underlying osseous structures are unremarkable. IMPRESSION: PD catheter with tip coiled in the pelvis . CXR [**9-8**]: IMPRESSION: Marked cardiomegaly, unchanged. Interval resolution of pulmonary edema. Brief Hospital Course: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. She was initially admitted to the MICU for hypertensive urgency and then transfered to the floor after a day. # Hypertensive urgency: had been on labetalol drip in the ED, but this was stopped due to nausea (presumed that her BP was coming down too fast). She was started on her home meds and tolerated these fairly well. Transferred to the floor and noted to have SPBs in the 90s. She required 1L IVF bolus since her baseline SBP is thought to run in the 130-170 range. She also had transient dizziness during this episode. BP meds were held and later that night her SBP was in the 220s. BP meds restarted. She remained stable thereafter with SBPs in the 130-170s. We opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # Right leg pain: no evidence of avascular necrosis or fracture on plain film. MRI and plain films were ordered and showed no acute pathology. The pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. CK was normal. Pain was treated with dilaudid initially. On day of discharge, she was able to ambulate without gait abnormality or pain. PT saw her and rec outpt PT followup. . # CKD V: PD catheter placement in place. Pt was tried on PD on a number of occasions but did not tolerate it [**2-11**] pain. KUB confirmed tip in place. Cx of peritoneal fluid not suggestive of peritonitis. K remained mildly elevated. Hyperpara treated with sevelamer (although patient refused) then tums. Pt will reconsider PD as outpatient. . # Anemia: chronic. Received 2u pRBC while inhouse for Hct in the 18-19 range. Had appropriate response. Not on Epo given hypertension . # ID: Rx with cipro for ? UTI although urine cx neg. Also had temp to 101 on evening prior to discharge. No clear source. PD fluid cultured and NGTD. Pt remainded HD stable on day of discharge. . # Prior SVC thrombus. Continued warfarin with appropriate INR checks. INR elevated on day of discharge. Rec holding coumadin for 2d . # Systemic lupus erythematosus: cont home prednisone dose . # Dispo status: ambulating, pain free, BP in the 150/90 range Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly Vicodin prn Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO WEEKLY (). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*20 Capsule(s)* Refills:*0* 9. Outpatient Physical Therapy Please provide PT for right hamstring injury 10. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*0* 11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold dose until [**9-10**]. Disp:*30 Tablet(s)* Refills:*0* 12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO once a day: goal is [**1-11**] soft bowel movements per day. Disp:*500 ml* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - HTN urgency - right leg pain - thought [**2-11**] hamstring injury - chronic kidney disease - not currently on dialysis - SLE - anemia [**2-11**] CKD and SLE - hx of SVC thrombosis on coumadin now Secondary: - hx hypertrophic obstructive cardiomyopathy - chronic thrombocytopenia Discharge Condition: ambulating without difficulty. tolerating oral diet. afebrile and SBP in the 130-150 range. Discharge Instructions: You came in with right leg pain and poorly controlled hypertension. Your blood pressure was controlled initially with IV medications then your home medications. Since your blood pressure was occasionally low, we recommend that you hold your labetalol if you are feeling lightheaded or have dizziness or have blood pressure less than 110/60. In terms of your leg pain, we performed xrays, ultrasound, and MRI without finding a cause. We suspect a hamstring injury given its location. Please take pain medications if needed. We recommend followup with physical therapy. You also had a fever which is suggestive of infection. We treated you with cipro in case you had a UTI. Otherwise, your cultures were unrevealing. We attempted peritoneal dialysis but this was unsuccessful. Please followup with your nephrologist. Please return to the ED if you experience headache, chest pain, shortness of breath, high fevers, or worsening leg pain. Please hold your coumadin for two days then restart as per previously written. Please take lactulose for constipation. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-9-12**] 5:00 Provider: [**Name10 (NameIs) 706**] NURSE Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 2:00 Provider: [**Name10 (NameIs) 7548**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 3:00 Please followup with your nephrologist and PCP. [**Name10 (NameIs) **] would like you to see your nephrologist within the next 1-2 weeks. ",76,2141-09-05 20:04:00,2141-09-08 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transfered to the floor after a day. # hypertensive urgency: had been on labetalol drip in the ed, but this was stopped due to nausea (presumed that her bp was coming down too fast). she was started on her home meds and tolerated these fairly well. transferred to the floor and noted to have spbs in the 90s. she required 1l ivf bolus since her baseline sbp is thought to run in the 130-170 range. she also had transient dizziness during this episode. bp meds were held and later that night her sbp was in the 220s. bp meds restarted. she remained stable thereafter with sbps in the 130-170s. we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # right leg pain: no evidence of avascular necrosis or fracture on plain film. mri and plain films were ordered and showed no acute pathology. the pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. ck was normal. pain was treated with dilaudid initially. on day of discharge, she was able to ambulate without gait abnormality or pain. pt saw her and rec outpt pt followup. . # ckd v: pd catheter placement in place. pt was tried on pd on a number of occasions but did not tolerate it [**2-11**] pain. kub confirmed tip in place. cx of peritoneal fluid not suggestive of peritonitis. k remained mildly elevated. hyperpara treated with sevelamer (although patient refused) then tums. pt will reconsider pd as outpatient. . # anemia: chronic. received 2u prbc while inhouse for hct in the 18-19 range. had appropriate response. not on epo given hypertension . # id: rx with cipro for ? uti although urine cx neg. also had temp to 101 on evening prior to discharge. no clear source. pd fluid cultured and ngtd. pt remainded hd stable on day of discharge. . # prior svc thrombus. continued warfarin with appropriate inr checks. inr elevated on day of discharge. rec holding coumadin for 2d . # systemic lupus erythematosus: cont home prednisone dose . # dispo status: ambulating, pain free, bp in the 150/90 range ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Nausea alone; Other antihypertensive agents causing adverse effects in therapeutic use; Hip and thigh injury; Unspecified accident; Hypotension, unspecified; Anemia, unspecified; Personal history of venous thrombosis and embolism; End stage renal disease; ; Urinary tract infection, site not specified; Hyperpotassemia; Acidosis; Disorders of phosphorus metabolism; Hypocalcemia; Secondary hyperparathyroidism (of renal origin)]","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. # right leg pain: no evidence of avascular necrosis or fracture on plain film. also had temp to 101 on evening prior to discharge. # systemic lupus erythematosus: cont home prednisone dose .","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension. she presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transferred to the floor after a day. she was started on her home meds and tolerated them fairly well." 109,125288.0,14799,2141-11-23,15328,170149.0,2141-06-06,Discharge summary,"Admission Date: [**2141-5-24**] Discharge Date: [**2141-6-6**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 759**] Chief Complaint: Face, Left arm and breast swelling Major Surgical or Invasive Procedure: Intravenous Catheterization of SVC/IVC. History of Present Illness: 23 year old woman with ESRD, SLE, recently placed PD catheter who presents with periorbital swelling and Hypertensive urgency. Of note she was recently admitted for tongue swelling on [**4-7**]. At that time she was treated with Solu-Medrol, famotidine and Benadryl in the emergency room, which was continued for a total of three doses on the floor. The swelling improved throughout her stay. She had been on both an ACE, [**Last Name (un) **] and DRI at home, which she has been taking for many years. Patient states that the tongue swelling is most likely due to a sardine allergy. However, she had recently added Dilaudid to her medications following PD catheter placement, so allergy to Dilaudid was also considered. The ACE, [**Last Name (un) **] and DRI were held on the day of admission for ?angioedema but restarted on day of discharge without incident so she was discharged on them. She returned to the ED [**5-24**] with acute onset bilateral eye swelling since night of [**5-23**]. VS T 97.9 HR 78 BP 231/120 RR 20 Sat 100% RA. She was given IV solumedrol 125iv, benadryl IV, and pepcid. Her BP was noted to be 240's despite labetolol 900mg po, then labetolol 20mg iv x2 so was started on labetolol gtt: highest dose 2mg/min. This was stopped after 35 minutes, in favor of nitro gtt. States compliant with meds at home. Patient was comfortable on admission to the MICU. Notes pain in abdomen 7.5/10 related to PD catheter placement (has had since then), improves with morphine. Also notes swelling in eyes/face since last night (has had in the past but never this severe, always goes away on its own). She feels whole body is swollen slightly but no more upper extremities than lower. She denies visual changes, HA, change in hearing/tinitus, congestion, sore throat, cough, SOB, chest pain, palpitations, nausea, vomitting, diarrhea. Has baseline constipation (takes stool softener), last BM 2 days ago (normal), no melena, brbpr, diarrhea. No dysuria, hematuria, change in uop, increase weight or size (clothes fit the same), tingling, numbness, weakness, discoordination, rash, joint pain, recent travel, ill contacts, exotic foods. She notes episode of throat swelling over weekend resolved, seemed to be related to sardine eating (not new for her). Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient denies past or current alcohol, tobacco, or illicit drug use. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: ON ADMISSION: VS: T 98.0 BP 187/120 HR 77 RR 17 Sat 100% on RA GEN: NAD HEENT: + periorbital edema, AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD, no carotid bruits CV: RRR, nl s1, s2, II/VI HSM at R/L USB, S4, no rub PULM: CTAB, no w/r/r with good air movement throughout ABD: soft, mildly tender at PD catheter, ND, + BS, no HSM EXT: warm, dry, +2 distal pulses BL, no femoral bruits, trace non-pitting edema NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect ON [**6-6**]: -General: AAOx3, in NAD. -VS: Tc: 95.2, Tmax (24hrs): 97.8 BP: 172/98 (80/43, 240/110 on [**5-30**]; 120/70, 218/120 over last 24 hrs), P: 80 (80, 98), RR: 16, O2: 98% RA. -HEENT: Head NC, AT. MMM. Face, Neck swollen: equal bilaterally. -Neck: Supple, No JVD, No tracheal deviation. -CV: RRR, S1,S2. Grade II/XII holosystolic murmur radiating to R carotid. JVP not elevated. No S4. -Lungs: CTAB, no w/r. -Abdomen: +BS, soft, nontender. -Extremities: Warm, no lower extremity edema. L arm appears slightly less swollen than yesterday. Dorsalis pedis and radial pulses strong bilaterally. No evidence of rashes, ulcers or varicose veins. -Breast: L breast still swollen relative to R, but diminished from initial presentation of swelling. Skin no longer tense. Pertinent Results: WBC-3.9* RBC-2.19* Hgb-6.6* Hct-20.4* MCV-93 MCH-30.3 MCHC-32.4 RDW-19.7* Plt Ct-114* - Neuts-52.8 Lymphs-39.9 Monos-5.0 Eos-2.0 Baso-0.2 PT-20.5* PTT-89.9* INR(PT)-1.9* Fibrino-268 Thrombn-37.4*# AT III-92 ProtCFn-65* ProtCAg-PND ProtSFn-68 Glucose-105 UreaN-62* Creat-8.1* Na-139 K-4.5 Cl-109* HCO3-17* ALT-14 AST-35 LD(LDH)-254* CK(CPK)-176* AlkPhos-137* Amylase-277* TotBili-0.4 Calcium-6.8* Phos-5.9* Mg-1.5* Hapto-90 Homocys-37.8* PTH-1603* UA: Color Straw Appear Clear SpecGr 1.009 pH 6.0 Urobil Neg Bili Neg Leuk Sm Bld Neg Nitr Neg Prot 30 Glu Neg Ket Neg RBC 0-2 WBC [**11-30**] Bact Few Yeast None Epi 0-2 U Tox: Urine Opiates Pos;Urine Benzos, Barbs, Cocaine, Amphet, Mthdne Negative; UCG: Negative STUDIES: Portable CXR [**5-24**]: Small left pleural effusion with associated atelectasis, although early pneumonia cannot be excluded. No CHF. ECG [**5-24**]: NSR (87), nl axis and intervals, TWI V5-V6, no change from [**5-20**]. MRA [**5-24**]: 1. Occlusion of the right internal jugular vein below the mandible which communicates with external jugular and subclavian vein. Appearance suggest chronic disease. 2. Patent SVC. 3. Patent but narrowed left internal jugular vein but left brachiocephalic vein not visualized (possibly from technique). 4. Bibasilar atelectasis US upper extremity [**5-26**]: [**Doctor Last Name **]-scale, color and Doppler son[**Name (NI) 1417**] of the left IJ, subclavian, axillary, brachial, basilic, and cephalic veins were performed. There is normal flow, compression, and augmentation seen in all of the vessels. IMPRESSION: No evidence of deep vein thrombosis in the left arm. MRV Chest [**5-30**]: 1. Limited study which demonstrates a chronically occluded and completely atrophic left brachiocephalic vein. 2. Right internal jugular vein not identified, likely chronically occluded. Left internal jugular vein is very diminuitive as before. 3. Large right external jugular vein emptying into the subclavian vein. Venogram [**5-31**]: 1. Occlusion of the left brachiocephalic vein at the junction of the subclavian and internal jugular with extensive collateral formation consistent with chronic obstruction. 2. Patent left brachial, axillary, subclavian, and distal internal jugular vein. 3. Unsuccessful attempt to recanalize the left brachiocephalic vein using a catheter and guidewire technique. Brief Hospital Course: Ms. [**Known lastname **] is a 23yo woman with a history of SLE, ESRD and HTN who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into L sided facial, L arm and L breast swelling throughout her stay. # L facial/arm and breast swelling: Initially this presented only as facial swellingand ACE and [**Last Name (un) **] were held for possible angioedema, however holding medications nad giving benadryl failed to relieve symptoms. We then suspected possible venous thrombus with occlusion leading to edema. US of upper left extremity failed to show evidence of acute occlusion, but showed R IJ occlusion consistent with prior studies. MRA could not visualize the L brachiocephalic vein. Repeat MRV suggested chronic occlusion of the L brachiocephalic vein. Venogram performed on [**5-31**] showed extensive collateralization of the L brachiocephalic vein with patent flow through these collaterals. Intervention on the L brachiocephalic vein was attempted by IR, but was unsuccessful. The primary team, renal team, [**Month/Year (2) **] team and hematology team suspect that the most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of the L brachiocephalic vein. For this reason, the patient was placed on Heparin IV as a bridge to coumadin anticoagulation with goal INR [**2-12**]. Per consult with hematology the patient is to remain on this regimen for at least 6 months, and will then revisit as an outpatient the question of possible lifelong anticoagulation. The patient has had extensive negative testing for hypercoagulable states, including during this work-up with negative anticardiolipin, antiphospholipid, Beta-2 glycoprotein and AT3 antibodies. Protein C and S levels were unremarkable. Although her clots seem to have all occured in the setting of lines, her continued thrombosis is likey due to hypercoagulability from her lupus (in absence of lupus anticoagulant). Her INR will be followed first by Dr. [**Last Name (STitle) 4883**], her nephrologist, and then by the coumadin clinic of [**Company 191**]. It will be especially important that her coumadin be well titrated given her risk of intracranial bleed with hypertension. This was communicated tothe patient and she understands and plans to be compliant with frequent blood draws for INR testing and varying her coumadin dose as directed. . # Hypertension: The patient has chronically labile hypertension, with frequent episodes of hypertensive urgency over systolic 200, as well as lows as far as the 80s during this admission. It remains unclear why her blood pressure is so chronically labile. The hope is that once she starts dialysis this will help to stabilize her blood pressure, however in the interim various adjustments were made to her regimen. The patient received frequent extra doses during her stay (especially of hydralazine), however, this occasionally causes her blood pressure to swing too low to tolerate her subsequent standing dose of medication. We stopped her Ace and [**Last Name (un) **] as above. We discharged her to home on a regimen that was reviewed with her nephrologist, Dr. [**Last Name (STitle) 4883**]. She is discharged on clonidine patch 0.3mg qweek, labetalol 900mg po tid, nifedipine CR 90mg po bid, hydralazine 35mg po tid. These medications were reviewed extensively with the patient and she was given prescriptions for all meds. She is discharged with home VNA for blood pressure checks and assistance with meds. She has purchased a portable BP cuff and will keep a BP diary to bring to subsequent appointments as well. The importance of BP control, especially in the setting of new anticoagulation, was discussed extensively with the patient. Her goal SBP is 140-160 at this time. . # ESRD: The patient has ESRD due to lupus nephritis. PD catheter was placed before admission and the patient received morphine prn pain at her catheter site. The renal team followed her closely throughout her stay. She was treated for hypocalcemia as well as hyperkalemia. Her regimen was changed to calcitriol 0.25mcg po qday, sodium bicarb 1300mg po qday, cholecalciferol 400units po qday, ergocalciferol 50,000 units po qweek for ten weeks. She plans to start HD within 1-2 weeks of discharge. She will call [**Doctor First Name 3040**] the PD nurse tomorrow to set up an appointment to have her catheter flushed and to start PD. She will be closely followed by Dr. [**Last Name (STitle) 4883**] at PD. # SLE: The patient was maintained on her home dose of prednisone 15mg po qday throughout her stay. She has no symptoms of acute SLE flare, so her nephrologist and outpatient physicians may attempt to wean this down as an outpatient. . # abnormal pap smear: The pt is noted to have an abnormal pap and colpo two years ago with CIN 2 and high risk HPV. This has never been repeated, as the patient failed to schedule appointments and DNK others. We discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. The patient was discharged to home with a clear plan to call [**Doctor First Name 3040**], the PD nurse on the day after discharge to set up an appointment to have her PD catheter flushed later this week, as well as to set a date to start her PD. She will see Dr. [**Last Name (STitle) 44539**] in [**Hospital **] clinic within the next 1-2 weeks. She will have her blood drawn for INR in two days and faxed to Dr. [**Last Name (STitle) 4883**], subsequently this will be faxed to the [**Company 191**] coumadin clinic and her dose will be adjusted for INR [**2-12**]. We have also given her the phone number to call [**Company 191**] and establish care with a new PCP, [**Name10 (NameIs) 3**] her old PCP has now graduated and her complex management makes a PCP [**Name Initial (PRE) 44540**]. (Her PCP must be at [**Company 191**] for the [**Company 191**] coumadin clinic to follow her as well.) Finally, the patient was given an appointment with ob/gyn to have a follow up pap smear, as her last pap and colpo two years ago showed CIN 2 with high risk HPV and this has not been followed. The above plan and appoitnments were reviewed with the pt and her mother extensively. [**Name2 (NI) **] medication hcanges were also extensively reviewed. Medications on Admission: Hydralazine 50 mg PO TID Labetalol 900 mg PO TID Nicardipine 60 mg Sustained Release PO once a day Cinacalcet 30 mg PO DAILY: she is not sure if taking Calcium Acetate 667 mg PO TID W/MEALS Sodium Bicarbonate 1300 mg PO TID Aliskiren 150 mg PO once a day (was never taking) Pantoprazole 40 mg PO once a day Valsartan 320mg PO DAILY Lisinopril 40 mg PO bid Clonidine 0.3 mg/24 hr Patch Weekly QSUN: not sure when last placed Prednisone 15 mg PO DAILY Morphine 15 mg Tablet PO Q6H as needed Ergocalciferol (Vitamin D2) 50,000 unit Capsule daily: states not taking Epo 4,000 units M/W/F: states not taking colace Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Disp:*4 Patch Weekly(s)* Refills:*2* 3. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 5. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO qwednesday (): for 10 weeks. Disp:*10 Capsule(s)* Refills:*0* 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*2* 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 10. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: dose to be adjusted by coumadin clinic. Disp:*120 Tablet(s)* Refills:*2* 11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 12. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for itching. Disp:*50 Capsule(s)* Refills:*0* 13. Ativan 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. Disp:*60 Tablet(s)* Refills:*0* 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 15. Morphine 15 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 14 days. Disp:*56 Tablet(s)* Refills:*0* 16. Outpatient Lab Work Please have blood drawn on Friday, [**6-9**] for PT/INR. Please have result faxed to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you to adjust your coumadin (also called warfarin) dose as needed. 17. Outpatient Lab Work Please have blood drawn on Monday [**2141-6-12**] for PT/INR and twice per week thereafter until told by coumadin clinic that you can decrease lab draws. Please have result faxed to the [**Hospital1 18**] coumadin clinic at [**Telephone/Fax (1) 3534**]. They will call you to adjust your coumadin (also called warfarin) dose as needed. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnoses: Malignant Hypertension (Hypertensive Urgency) Acute Exacerbation of Chronic Left Brachiocephalic vein occlusion Anemia Secondary Diagnoses: SLE ESRD Hypertrophic Cardiomyopathy Thrombocytopenia Discharge Condition: Stable Discharge Instructions: You were admitted and treated for an acute exacerbation of a chronic left brachiocephalic vein occlusion (a chronically obstructed large vein closed off entirely) and hypertensive urgency (very high blood pressure). We attempted to remove the clot in your left brachiocephalic vein, but were unable to do so. You have been started on long-term Coumadin (also called warfarin) therapy to prevent future blood clots and to allow natural dissolution of your current blood clot. Please change your medicines to only those you are given here! There were many changes and it is very important that you stick to the medication list as you have large, life-threatening swings in the blood pressure when not taking consistently. We also treated you for high potassium levels and anemia, and low vitamin D and calcium levels, which are related to your kidney failure. Please follow up with Dr. [**Last Name (STitle) 4883**] for long term treatment. Please check your blood pressure three times per day and keep a blood pressure diary to bring with you to all medical appointments. Please have your blood drawn on Friday [**6-9**] for PT/INR and faxed to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you if needed to adjust your coumadin (warfarin) dose. After that, please have your blood drawn on Monday [**6-12**] for PT/INR and faxed to the [**Hospital1 18**] coumadin clinic at [**Telephone/Fax (1) 434**]. They will follow you in a regular way to adjust your coumadin dose as needed. MEDICINES FOR BLOOD PRESSURE: LABETALOL 900mg three times per day (same as before) HYDRALAZINE 25mg three times per day (lower dose than before) CLONIDINE PATCH 0.3mg qWednesday (same as before) NIFEDIPINE SR 90mg twice per day (new medicine!) **stop taking your lisinopril, nicardipine, Diovan and Aliskerin!** MEDICINES FOR RENAL FAILURE: ERGOCALCIFEROL [**Numeric Identifier 1871**] units pill every Wednesday (same as before) CHOLECALCIFEROL 400 units every day (new) CALCITRIOL 0.25 mg every day (new) SODIUM BICARBONATE 1300mg once per day (less often then before) ** stop taking your calcium acetate (phoslo), cinecalcet, and epo injection (you'll get it at peritoneal dialysis only)** OTHER MEDICINES: PANTOPRAZOLE 40mg every day (same as before) PREDNISONE 15mg every day (same as before) MORPHINE 15mg every 6 hrs if needed for pain (same as before) ATIVAN 1mg as needed for anxiety (same as before) BENADRYL 25mg every 6 hrs if needed for itch (new) COLACE 100mg twice per day if needed for constipation(same as before) APPOINTMENTS: **1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on Friday to flush your dialysis catheter and start dialysis next week! 2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00AM 3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**] Date/Time: [**2141-6-13**] 9:30AM **4. Please call [**Hospital3 **] next week to make an appointment with a new primary doctor. I recommend Dr. [**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE FOLLOWED IN [**Hospital **] CLINIC. **5. Please have your blood drawn as above. Your coumadin level will be followed by the [**Hospital 197**] clinic. Their phone # is [**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**]. If you have increased swelling, fever greater than 101, shortness of breath, chest pain, or if you at any time become concerned about your health please contact Dr. [**Last Name (STitle) 4883**] or go to the nearest ER. Followup Instructions: APPOINTMENTS: **1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on Friday to flush your dialysis catheter and start dialysis next week! 2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00AM 3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**] Date/Time: [**2141-6-13**] 9:30AM **4. Please call [**Hospital3 **] next week to make an appointment with a new primary doctor. I recommend Dr. [**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE FOLLOWED IN [**Hospital **] CLINIC. **5. Please have your blood drawn as above. Your coumadin level will be followed by the [**Hospital 197**] clinic. Their phone # is [**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**]. Completed by:[**2141-6-17**]",170,2141-05-24 14:47:00,2141-06-06 19:55:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ACUTE RENAL FAILURE," ms. [**known lastname **] is a 23yo woman with a history of sle, esrd and htn who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into l sided facial, l arm and l breast swelling throughout her stay. # l facial/arm and breast swelling: initially this presented only as facial swellingand ace and [**last name (un) **] were held for possible angioedema, however holding medications nad giving benadryl failed to relieve symptoms. we then suspected possible venous thrombus with occlusion leading to edema. us of upper left extremity failed to show evidence of acute occlusion, but showed r ij occlusion consistent with prior studies. mra could not visualize the l brachiocephalic vein. repeat mrv suggested chronic occlusion of the l brachiocephalic vein. venogram performed on [**5-31**] showed extensive collateralization of the l brachiocephalic vein with patent flow through these collaterals. intervention on the l brachiocephalic vein was attempted by ir, but was unsuccessful. the primary team, renal team, [**month/year (2) **] team and hematology team suspect that the most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of the l brachiocephalic vein. for this reason, the patient was placed on heparin iv as a bridge to coumadin anticoagulation with goal inr [**2-12**]. per consult with hematology the patient is to remain on this regimen for at least 6 months, and will then revisit as an outpatient the question of possible lifelong anticoagulation. the patient has had extensive negative testing for hypercoagulable states, including during this work-up with negative anticardiolipin, antiphospholipid, beta-2 glycoprotein and at3 antibodies. protein c and s levels were unremarkable. although her clots seem to have all occured in the setting of lines, her continued thrombosis is likey due to hypercoagulability from her lupus (in absence of lupus anticoagulant). her inr will be followed first by dr. [**last name (stitle) 4883**], her nephrologist, and then by the coumadin clinic of [**company 191**]. it will be especially important that her coumadin be well titrated given her risk of intracranial bleed with hypertension. this was communicated tothe patient and she understands and plans to be compliant with frequent blood draws for inr testing and varying her coumadin dose as directed. . # hypertension: the patient has chronically labile hypertension, with frequent episodes of hypertensive urgency over systolic 200, as well as lows as far as the 80s during this admission. it remains unclear why her blood pressure is so chronically labile. the hope is that once she starts dialysis this will help to stabilize her blood pressure, however in the interim various adjustments were made to her regimen. the patient received frequent extra doses during her stay (especially of hydralazine), however, this occasionally causes her blood pressure to swing too low to tolerate her subsequent standing dose of medication. we stopped her ace and [**last name (un) **] as above. we discharged her to home on a regimen that was reviewed with her nephrologist, dr. [**last name (stitle) 4883**]. she is discharged on clonidine patch 0.3mg qweek, labetalol 900mg po tid, nifedipine cr 90mg po bid, hydralazine 35mg po tid. these medications were reviewed extensively with the patient and she was given prescriptions for all meds. she is discharged with home vna for blood pressure checks and assistance with meds. she has purchased a portable bp cuff and will keep a bp diary to bring to subsequent appointments as well. the importance of bp control, especially in the setting of new anticoagulation, was discussed extensively with the patient. her goal sbp is 140-160 at this time. . # esrd: the patient has esrd due to lupus nephritis. pd catheter was placed before admission and the patient received morphine prn pain at her catheter site. the renal team followed her closely throughout her stay. she was treated for hypocalcemia as well as hyperkalemia. her regimen was changed to calcitriol 0.25mcg po qday, sodium bicarb 1300mg po qday, cholecalciferol 400units po qday, ergocalciferol 50,000 units po qweek for ten weeks. she plans to start hd within 1-2 weeks of discharge. she will call [**doctor first name 3040**] the pd nurse tomorrow to set up an appointment to have her catheter flushed and to start pd. she will be closely followed by dr. [**last name (stitle) 4883**] at pd. # sle: the patient was maintained on her home dose of prednisone 15mg po qday throughout her stay. she has no symptoms of acute sle flare, so her nephrologist and outpatient physicians may attempt to wean this down as an outpatient. . # abnormal pap smear: the pt is noted to have an abnormal pap and colpo two years ago with cin 2 and high risk hpv. this has never been repeated, as the patient failed to schedule appointments and dnk others. we discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. the patient was discharged to home with a clear plan to call [**doctor first name 3040**], the pd nurse on the day after discharge to set up an appointment to have her pd catheter flushed later this week, as well as to set a date to start her pd. she will see dr. [**last name (stitle) 44539**] in [**hospital **] clinic within the next 1-2 weeks. she will have her blood drawn for inr in two days and faxed to dr. [**last name (stitle) 4883**], subsequently this will be faxed to the [**company 191**] coumadin clinic and her dose will be adjusted for inr [**2-12**]. we have also given her the phone number to call [**company 191**] and establish care with a new pcp, [**name10 (nameis) 3**] her old pcp has now graduated and her complex management makes a pcp [**name initial (pre) 44540**]. (her pcp must be at [**company 191**] for the [**company 191**] coumadin clinic to follow her as well.) finally, the patient was given an appointment with ob/gyn to have a follow up pap smear, as her last pap and colpo two years ago showed cin 2 with high risk hpv and this has not been followed. the above plan and appoitnments were reviewed with the pt and her mother extensively. [**name2 (ni) **] medication hcanges were also extensively reviewed. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Compression of vein; Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Hyperpotassemia; Hyperparathyroidism, unspecified; Other iatrogenic hypotension; Nausea with vomiting; ; Abnormal glandular Papanicolaou smear of cervix; Abdominal pain, other specified site; Other specified disorders of pancreatic internal secretion; Adrenal cortical steroids causing adverse effects in therapeutic use]","known lastname **] is a 23yo woman with a history of sle, esrd and htn who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into l sided facial, l arm and l breast swelling throughout her stay. mra could not visualize the l brachiocephalic vein. it remains unclear why her blood pressure is so chronically labile. we stopped her ace and [**last name (un) **] as above. the importance of bp control, especially in the setting of new anticoagulation, was discussed extensively with the patient. # esrd: the patient has esrd due to lupus nephritis. the renal team followed her closely throughout her stay. she will call [**doctor first name 3040**] the pd nurse tomorrow to set up an appointment to have her catheter flushed and to start pd. we discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. the above plan and appoitnments were reviewed with the pt and her mother extensively. [**","a 23yo woman with a history of sle, esrd and htn presented with bilateral facial swelling. she developed l sided facial, l arm and l breast swelling throughout her stay. most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of l brachiocephalic vein." 109,137510.0,14810,2142-04-22,14798,126055.0,2141-11-03,Discharge summary,"Admission Date: [**2141-10-13**] Discharge Date: [**2141-11-3**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 6734**] Chief Complaint: Nausea, Vomitting, Abdominal Pain, HTN Urgenc Major Surgical or Invasive Procedure: Upper GI endoscopy Exploratory laparotomy Tunneled hemodialysis catheter in R femoral vein Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 24 y/o F with h/o ESRD, HTN who started peritoneal dialysis during the week of [**2141-10-8**] and presented with a 1 day history of acute onset N/V, sharp abdominal pain on [**2141-10-13**]. (Of note, the patient had presented to the ED on [**10-11**] with hypotension, SBPs in the 80s off after approximately 1.5L was taken off during dialysis in the setting of taking her PO Anti-HTNs. On [**2141-10-11**] she received 0.5L IVF, labs WNL, and was d/c'd home). On the day of admission on [**2141-10-13**], the patient reported that the previous night, she was awoken from sleep with severe, sharp abdominal pain, 6 episodes of frothy emesis, 10+ yellowish BMs without melena or BRBRP.She was admitted for further work- up of this abdminal pain. . In the ED here vitals were as follows: T: 97.0 HR: 101 BP: 240/180 RR: 17 O2sat: 100%RA. She received Labetolol 20mg IV and was subsequently placed on a labetolol drip. She also received ceftriaxone 1gm IV, Flagyl 500mg IV, Dilaudid 0.5-1mg IV q1hr and Zofran. Her abdominal CT showed multifocal areas of small bowel wall thickening. Her peritoneal Cell count was negtaive for SBP. She had some signs of peritonitis and thus surgery was consulted. Her lactate was normal. . Upon arrival to the MICU the patient was mentating well with complaints of diffuse sharp abdominal pain that radiated to the back and diarrhea. She had no headache or visual changes. Past Medical History: - SLE DX ([**2134**] - 16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter Placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). - Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS: 98.4 HR 98 192/131 21 100%RA GEN: Mild Distress, AOx3 HEENT: PEERLA, EOMI NECK: Supple, No LAD, No bruit RESP: CTAB CARD: 2/6 systolic ejection murmur ABD: soft, moderately tender with +/- guarding, BS+ EXTR: Warm well perfused NEURO: Motor Grossly Intact RECTAL: Yellow Stool BACK: B CVAT Pertinent Results: [**2141-11-3**] 08:50AM BLOOD WBC-3.5* RBC-2.55* Hgb-7.8* Hct-23.6* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.8* Plt Ct-176 [**2141-11-3**] 03:55PM BLOOD PT-15.5* PTT-50.8* INR(PT)-1.4* [**2141-11-3**] 08:50AM BLOOD Glucose-121* UreaN-33* Creat-5.2*# Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [**2141-10-26**] 06:15AM BLOOD ALT-11 AST-49* AlkPhos-122* Amylase-186* TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2141-10-26**] 06:15AM BLOOD Lipase-30 [**2141-11-3**] 08:50AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.9 [**2141-10-30**] 06:55AM BLOOD HBsAg-NEGATIVE [**2141-10-17**] 10:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2141-10-25**] 11:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2141-10-25**] 11:56AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2141-10-25**] 11:56AM URINE RBC-0-2 WBC-[**3-15**] Bacteri-FEW Yeast-NONE Epi-21-50 Blood cultures: all negative EKG ([**2141-10-13**]): Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of [**2141-10-2**] there is no significant diagnostic change. CXR ([**2141-10-13**]): No acute cardiopulmonary abnormality. No free air under the diaphragms. CT chest/abdomen/pelvis ([**2141-10-13**]): There is a moderate-sized pericardial effusion, similar in appearance from [**2141-10-13**]. The great vessels are normal in caliber, without aneurysmal dilatation. Evaluation of the great vessels is limited without IV contrast. Interstitial thickening, particularly within the perihilar regions, is suggestive of fluid overload. There is bibasilar atelectasis with a small focus of consolidation in the right lower lobe (2:35) unchanged from [**2141-10-13**], and may reflect aspiration or pneumonia. Scattered bilateral nodules are largely stable from as far back as [**2139-10-9**]. Specifically, there is a 5 mm nodule in the right middle lobe (2:25), two adjacent nodules in the right lower lobe measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule within the left lower lobe. A nodular density seen adjacent and anterior to the right main pulmonary artery (2:23) may reflect a vessel. There is a small right pleural effusion. Axillary lymphadenopathy, with axillary nodes measuring up to approximately 10 mm in short axis, is seen. Ill- defined soft tissue thickening within the hilus bilaterally may reflect hilar lymphadenopathy, but assessment is limited without IV contrast. A catheter is visualized within the visualized right upper extremity, which may reflect a PICC line that terminates within the right subclavian vein. The esophagus is distended and filled with contrast, with marked wall thickening and edema throughout its entire length, a new finding. There is a moderate- sized hiatal hernia. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval development of a moderate amount of free intraperitoneal air, that layers anteriorly and along the anterior abdominal wall. Additional small clustered foci of extraluminal air is seen adjacent to the proximal stomach and the gastroesophageal junction, with a focus of air tracking into the fissure of ligamentum venosum. Additionally, there appears to be air tracking into the anterior subcutaneous tissues in the region of the umbilicus. These findings are all new from the prior CT on [**2141-10-13**], but free air was present on chest radiograph performed [**2141-10-25**]. There is no obvious evidence of extravasation of oral contrast into the peritoneum. Of note, a peritoneal dialysis catheter is in place that could represent a route of entry of intraperitoneal air. The stomach, small bowel, and colon are filled with contrast, without evidence of obstruction. Evaluation for wall thickening is limited without IV contrast. Limited non-contrast views of the liver demonstrates a rounded 1.6 cm x 1.2 cm hypodensity in the right lobe of the liver, previously characterized as a hemangioma. The liver is otherwise unremarkable. The gallbladder, spleen, pancreas, and adrenal glands demonstrate no gross abnormality. Both kidneys are atrophic. Evaluation of solid organs is limited by lack of IV contrast. There is a peritoneal dialysis catheter, coiled within the pelvis, unchanged. There is a large amount of free fluid throughout the abdomen, similar in appearance to the prior study. CT OF THE PELVIS WITHOUT IV CONTRAST: Uterus and rectum are grossly unremarkable. However, assessment of the rectal wall is limited without IV contrast. OSSEOUS STRUCTURES: Bones are diffusely sclerotic, which may be related to renal osteodystrophy. There is bilateral sacroiliitis. IMPRESSION: 1. Interval development of a moderate amount of free intraperitoneal air, new from [**2141-10-13**]. A peritoneal dialysis catheter is in place and could represent the route of entry of free intraperitoneal air. However, as foci of air is seen in the region of the proximal stomach and GE junction in the setting of a recent endoscopy, perforation cannot be excluded, though no frank extravasation of contrast is identified. 2. New dilation and wall thickening of the entire esophagus, a nonspecific finding that could relate to infectious or inflammatory esophagitis; clinical correlation is recommended. Esophagus is contrast-filled possibly representing reflux. Hiatal hernia. 3. Anasarca, with moderate-sized pericardial effusion, pulmonary edema, and small right pleural effusion. 4. Large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. Imaging cannot exclude SBP, which should be evaluated for clinically. 5. Focus of consolidation within the right lower lobe, could represent aspiration or pneumonia, but unchanged from the prior study. Gastric Biopsies ([**2141-10-18**]): Antrum: Corpus-type mucosa, no diagnostic abnormalities recognized. Jejunum: Small intestinal mucosa, no diagnostic abnormalities recognized. UE Venous U/S: No evidence of DVT of the left upper extremity, without thrombus identified within the left subclavian vein. Brief Hospital Course: This is a 24 year old woman with ESRD secondary to SLE (started peritoneal dialysis approximately one week prior to admission), malignant HTN, h/o SVC syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. Her hospital course was complicated by multiple transfers between the MICU and the floor secondary to hypertensive urgency. # Abdominal Pain/Diarrhea: During the patient's admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. Infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. However, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. The patient was empirically placed on IV flagyl, but this was discontinued when stool samples were negative for C.difficile. Serial abdominal exams showed no peritoneal signs. Peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. CT of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. Other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to SLE vasculitis, malignant HTN, or microthrombosis and SLE enteritis. Surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. A heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible GI bleed. With regards to SLE vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to SLE. On [**10-18**], GI performed an EGD which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. Approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. Both cardiac, GI, and pulmonary etiologies were considered for the origin of her epigastric pain. Pericarditis was considered, but her EKG was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. Her lungs were also essentially unchanged from [**2141-10-13**]. However, her abdominal CT on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. As a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. There were no major findings: no evidence of perforation, obstruction, or infection. The patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. At discharge, the patient only complained of some mild incisional pain. # Hypertensive urgency: The patient was initially admitted to the MICU with a blood pressure of 240/180. Her hospital course was complicated by extremely labile HTN and was transferred back and forth between the MICU and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of SBPs > 260. Throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. Her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. Multiple medication regimens were attempted and changed throughout her hospital course. However, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for SBPs > 180. At discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg PO. Her regimen as per Dr. [**Last Name (STitle) 4883**]: Nifedipine SR 90 mg daily Aliskiren 150 mg [**Hospital1 **] Labetalol 300 mg TID Hydralazine 75 mg TID Clonidine patch 0.3 mg/24 hr patch qWed When SBP>180, she then uses a hydralazine sliding scale. When SBP>180, give 25 mg PO hydral every 30 min until SBP<150. You can use this for up to 2-3 hours. In between PO hydral doses, can then also use 10 IV hydralazine. # ESRD: The etiology of the patient's ESRD is secondary to SLE. Her Creatinine on admission was 7.9, which was near her baseline of 8 - 9. During her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. Prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2L per PD. After her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. Initially, the patient adamantly refused hemodialysis. However, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. As a result, after a long coversation with her primary renal physician, [**Name10 (NameIs) **] agreed to restart hemodialysis. A tunneled catheter was placed in her R femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. She underwent hemodialysis two more times prior to discharge. Upon discharge, her electrolytes were back to her baseline. She is expected to undergo hemodialysis (Tues/[**Last Name (un) **]/SAT) as an outpatient. # Anemia: During her admission, the patient's HCT was monitored daily with HCT to low-mid 20's. On [**2141-10-17**], she was found to have guaiac positive stools and her HCT was found to have dropped to a low of 18.6. The patient was transfused a total of 2 units of [**Date Range **] between [**2141-10-17**] and [**2141-10-18**]. Epo Alfa SC was also given on [**2141-10-17**]. She remained hemodynamically stable. GI consulted and EGD results were as stated above. The patient's HCT remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. Between [**2141-10-23**] - [**2141-10-24**], the patient had a HCT drop from 26 to 20 in the setting of occult positive emesis. She received two units of [**Month/Day/Year **] and her HCT returned to 28. GI was aware and planned to perform a non-urgent EGD on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her HCT returned to baseline. However, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her HCt remained stable and near baseline for the remiainder of her hospital course. # H/O Thrombosis: The patient was initially placed on her home dose of warfarin 2mg qd. Her INR on admission was 1.2. She was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. However, this was stopped for her EGD and after she had evidence of a GI bleed. The heparin drip was discontinued on [**10-22**]. The patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in HCT and in preparation for a possible GI intervention. After her surgery, her coumadin was held and she was off the heparin drip, but her INR continued to drift up, getting as high as 2.6 on [**2141-10-30**]. This was mostly attributed to nutritional deficiency [**2-11**] poor PO intake, but there was concern for possible synthetic dysfunction as well. As a result, she was given a test dose of vitamin K, which she responded to well (Her INR came back down to 1.4). As a result, her home dose of coumadin at 2 mg qday was restarted. At discharge, her INR was still sub- therapeutic at 1.4. Of note, the patient has a history of SVC syndrome and had a L subclavian venous thrombosis. During the last few days of her hospital stay, the patient complained of increased tongue swelling and her L face was noted to be slightly more swollen than previously noted. As a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a DVT within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # SLE: Rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. Her outside rheumatologist was also consulted. Both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # Obstructive sleep apnea: The patient was noted to have OSA based on clinical nocturnal exam during admission. Patient attempted 1 trial of CPAP at 2L/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. The paitent stated that she would pursue further work-up and treatment for OSA as an outpatient. While the mask and CPAP machine were at her bedside throughout her hospital course, the patient rarely used it. # Metabolic Acidosis: The patient's bicarbonate on admission was 13. Her baseline is normally between 16-20. She received 150mEq NaHCO3 over 24hrs from [**Date range (1) 43500**]. During her brief returns to the MICU, her HC03 was 18-19, which was presumed to be her baseline at home secondary to her CRF. At discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. Medications on Admission: Nifedipine 60 mg PO daily Labetalol 900 mg PO TID Hydralazine 50 mg PO TID Clonidine 0.3 mg/24hr patch qWED Lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 4 mg daily Warfarin 2mg PO daily Calcitriol 1 mcg daily Calcium carbonate 500mg QID Dilaudid 2mg PO Q4-6hr prn pain Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*30 Patch Weekly(s)* Refills:*2* 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. [**Hospital1 **]:*1500 ML(s)* Refills:*0* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Twice daily (). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): In addition to 75 mg TID, if SBP>180, take 1 tab every 30 min until BP decreases to 150. If no improvement after 2 hours, call your doctor. [**Last Name (Titles) **]:*300 Tablet(s)* Refills:*6* 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). [**Last Name (Titles) **]:*1500 ML(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet Sustained Release(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 5 days. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. [**Last Name (Titles) **]:*30 Capsule(s)* Refills:*2* 13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO once a day. [**Last Name (Titles) **]:*30 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: end stage renal disease malignant hypertension abdominal free air subclavian deep vein thrombosis initiation of hemodialysis Secondary: SLE Anemia Discharge Condition: stable, pain well controlled, blood pressure at baseline Discharge Instructions: You were admitted for abdominal pain and then subsequently had a very long hospital course with high blood pressures, severe abdominal pain, some free air in your abdomen resulting in an exploratory laparotomy. You have also been initiated on hemodialysis on Tuesday/Thursday/Saturday schedule. Please take all medications as prescribed in the list that you will be given at discharge. There have been some changes to your medications. Please call your doctor if you have any worsening abdominal pain, fevers, chills, nausea, vomiting, headache, palpitations, diarrhea or any other concerning symptoms. Followup Instructions: You will see Dr. [**Last Name (STitle) 4883**] at hemodialysis on Tuesday, [**11-7**], [**2141**]. You should have your coumadin level checked at this appointment. Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] to schedule an appointment in [**1-11**] weeks to have your staples removed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**] ",170,2141-10-13 23:10:00,2141-11-03 18:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. her hospital course was complicated by multiple transfers between the micu and the floor secondary to hypertensive urgency. # abdominal pain/diarrhea: during the patients admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. the patient was empirically placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. serial abdominal exams showed no peritoneal signs. peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. ct of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to sle vasculitis, malignant htn, or microthrombosis and sle enteritis. surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible gi bleed. with regards to sle vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to sle. on [**10-18**], gi performed an egd which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. both cardiac, gi, and pulmonary etiologies were considered for the origin of her epigastric pain. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. her lungs were also essentially unchanged from [**2141-10-13**]. however, her abdominal ct on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. as a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. there were no major findings: no evidence of perforation, obstruction, or infection. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. at discharge, the patient only complained of some mild incisional pain. # hypertensive urgency: the patient was initially admitted to the micu with a blood pressure of 240/180. her hospital course was complicated by extremely labile htn and was transferred back and forth between the micu and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of sbps > 260. throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. multiple medication regimens were attempted and changed throughout her hospital course. however, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for sbps > 180. at discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg po. her regimen as per dr. [**last name (stitle) 4883**]: nifedipine sr 90 mg daily aliskiren 150 mg [**hospital1 **] labetalol 300 mg tid hydralazine 75 mg tid clonidine patch 0.3 mg/24 hr patch qwed when sbp>180, she then uses a hydralazine sliding scale. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. you can use this for up to 2-3 hours. in between po hydral doses, can then also use 10 iv hydralazine. # esrd: the etiology of the patients esrd is secondary to sle. her creatinine on admission was 7.9, which was near her baseline of 8 - 9. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2l per pd. after her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. initially, the patient adamantly refused hemodialysis. however, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. as a result, after a long coversation with her primary renal physician, [**name10 (nameis) **] agreed to restart hemodialysis. a tunneled catheter was placed in her r femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. she underwent hemodialysis two more times prior to discharge. upon discharge, her electrolytes were back to her baseline. she is expected to undergo hemodialysis (tues/[**last name (un) **]/sat) as an outpatient. # anemia: during her admission, the patients hct was monitored daily with hct to low-mid 20s. on [**2141-10-17**], she was found to have guaiac positive stools and her hct was found to have dropped to a low of 18.6. the patient was transfused a total of 2 units of [**date range **] between [**2141-10-17**] and [**2141-10-18**]. epo alfa sc was also given on [**2141-10-17**]. she remained hemodynamically stable. gi consulted and egd results were as stated above. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. she received two units of [**month/day/year **] and her hct returned to 28. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. however, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her hct remained stable and near baseline for the remiainder of her hospital course. # h/o thrombosis: the patient was initially placed on her home dose of warfarin 2mg qd. her inr on admission was 1.2. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. however, this was stopped for her egd and after she had evidence of a gi bleed. the heparin drip was discontinued on [**10-22**]. the patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in hct and in preparation for a possible gi intervention. after her surgery, her coumadin was held and she was off the heparin drip, but her inr continued to drift up, getting as high as 2.6 on [**2141-10-30**]. this was mostly attributed to nutritional deficiency [**2-11**] poor po intake, but there was concern for possible synthetic dysfunction as well. as a result, she was given a test dose of vitamin k, which she responded to well (her inr came back down to 1.4). as a result, her home dose of coumadin at 2 mg qday was restarted. at discharge, her inr was still sub- therapeutic at 1.4. of note, the patient has a history of svc syndrome and had a l subclavian venous thrombosis. during the last few days of her hospital stay, the patient complained of increased tongue swelling and her l face was noted to be slightly more swollen than previously noted. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. her outside rheumatologist was also consulted. both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission. patient attempted 1 trial of cpap at 2l/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. the paitent stated that she would pursue further work-up and treatment for osa as an outpatient. while the mask and cpap machine were at her bedside throughout her hospital course, the patient rarely used it. # metabolic acidosis: the patients bicarbonate on admission was 13. her baseline is normally between 16-20. she received 150meq nahco3 over 24hrs from [**date range (1) 43500**]. during her brief returns to the micu, her hc03 was 18-19, which was presumed to be her baseline at home secondary to her crf. at discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. ","PRIMARY: [Malignant essential hypertension] SECONDARY: [Renal dialysis status; Epilepsy, unspecified, without mention of intractable epilepsy; Constipation, unspecified; Anemia in chronic kidney disease; Abnormal coagulation profile; Obstructive sleep apnea (adult)(pediatric); Other diseases of lung, not elsewhere classified; Other chest pain; Fever, unspecified; Rash and other nonspecific skin eruption; Other chronic pulmonary heart diseases; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified disease of pericardium; Other ascites; Acidosis; Hyposmolality and/or hyponatremia; Abdominal pain, other specified site; Abdominal pain, epigastric; Nausea with vomiting; Diarrhea; Systemic lupus erythematosus; Hyperparathyroidism, unspecified; Anemia, unspecified; Thrombocytopenia, unspecified; Esophageal reflux]","this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. multiple medication regimens were attempted and changed throughout her hospital course. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. upon discharge, her electrolytes were back to her baseline. epo alfa sc was also given on [**2141-10-17**]. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission.","esrd secondary to sle, malignant htn, h/o svc syndrome, and multiple thrombotic events were considered. the patient was placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia." 109,137510.0,14810,2142-04-22,14799,125288.0,2141-11-23,Discharge summary,"Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypertensive Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: (from MICU admit note) 24yoF ESRD-HD, SLE, HTN presents with 1 month abdominal pain and hypertension. Pt has had work-up over recent months for abd pain, including exploratory laparotomy, all of which essentially (-). Was admitted [**Date range (1) 34629**], for abdominal pain, then returned [**11-16**] for sob with (-)CTA, dc'ed [**11-17**]. In [**Hospital1 18**] ED, T98.5 hr95 BP 220/110 then 183/133 RR13 O2 100% on RA, rectal exam negative, guaiac(-), pelvic exam unremarkable with no cervical motion tenderness. Renal was consulted, taken for hemodialysis. CT abd showed large ascites, no other pathology; CT head improved from prior with no acute ICH; cxr(-). Given iv dilaudid for abdominal pain. BP treated with 10mg iv labetalol. Blood and urine cultures drawn, peritoneal fluid cx sent from catheter. Admitted to MICU for hypertension management. Access: R-HD catheter, 1 pIV in hand, 1 non-functioning peritoneal dialysis catheter. Past Medical History: PMH: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSH: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: PE: T:99.4 BP:158/108 HR:95 RR:12 O2 100% RA GEN: NAD/ pt eyes closed due to pain/ pleasant despite pain HEENT: AT, NC, PERRLA, EOMI on R eye, L eye prosthesis, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD CV: S1 & S2, RRR II/VI HSM at R/L USB, no rubs/gallops PULM: CTAB, no w/r/r ABD: soft, mildly tender at PD catheter, ND, + BS, midline incision with steri-stripes, PD catheter dressing C/I/D EXT: warm, dry, +2 distal pulses BL, no edema NEURO: alert & oriented, CN II-XII grossly intact (except L eye), 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: Admission Labs: [**2141-11-18**] 07:00AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.7* Hct-30.7* MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* Plt Ct-142* [**2141-11-18**] 07:00AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.3* [**2141-11-18**] 07:00AM BLOOD Glucose-86 UreaN-22* Creat-5.0* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2141-11-18**] 07:00AM BLOOD ALT-8 AST-39 AlkPhos-92 TotBili-0.3 [**2141-11-18**] 07:00AM BLOOD Lipase-76* [**2141-11-18**] 07:00AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.9 [**2141-11-18**] 11:00PM ASCITES WBC-1265* RBC-1680* Polys-43* Lymphs-1* Monos-2* Mesothe-11* Macroph-43* [**2141-11-18**] 10:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2141-11-18**] 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2141-11-18**] 10:05AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-[**3-15**] Discharge Labs: [**2141-11-23**] 04:40AM BLOOD WBC-2.9* RBC-3.08* Hgb-9.0* Hct-28.3* MCV-92 MCH-29.2 MCHC-31.8 RDW-17.5* Plt Ct-182 [**2141-11-23**] 04:40AM BLOOD PT-20.8* PTT-76.1* INR(PT)-2.0* [**2141-11-23**] 04:40AM BLOOD Glucose-80 UreaN-21* Creat-4.7* Na-139 K-4.8 Cl-106 HCO3-24 AnGap-14 [**2141-11-23**] 04:40AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8 [**2141-11-22**] 04:55AM BLOOD TSH-6.1* [**2141-11-23**] 04:40AM BLOOD Free T4-1.2 Blood cx ([**11-18**], [**11-19**]): 1/4 bottles with coag neg Staph, [**3-14**] NGTD Urine cx ([**11-18**]): mixed flora c/w contamination Peritoneal fluid ([**11-18**]): Gram stain 2+ polys. Culture no growth. Imaging: CXR Portable ([**11-18**]): Since [**2141-11-16**], heart size enlargement is unchanged due to known pericardial effusion. Lungs are otherwise clear. Hilar contours are normal. Incidentally, widening of both acromioclavicular joints is unchanged. CT A/P ([**11-18**]): 1. No evidence of bowel obstruction or rim-enhancing fluid collection. 2. Large ascites, slightly increased from [**2141-11-13**], with peritoneal dialysis catheter in place. Interval removal of surgical skin staples along the abdomen. 3. Moderate pericardial effusion as before. 4. Symmetric heterogeneous attenuation of the kidneys could be related to renal failure; however, pyelonephritis could also give this appearance. Appearance of the kidneys is unchanged from [**2141-11-13**]. CT Head w/o contrast ([**11-18**]): 1. No evidence of acute intracranial hemorrhage. 2. Regions of hypoattenuation in the bifrontal white matter and left posterior temporal lobe have resolved since [**2141-6-11**]. No new regions of hypoattenuation seen. Brief Hospital Course: 1) Hypertension: Patient has history of extremely labile hypertension on an aggressive outpatient regimen. Overnight in the MICU, patient required IV and PO labetalol for SBP > 200. Her hydralazine was increased from 75mg to 100mg TID with mild improvement. Her labetalol was also increased from 300mg to 400mg TID. Her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. TSH was sent and elevated, although free T4 was normal. Plasma metanephrines were sent and pending at discharge. 2) Abdominal pain: CT scan showed increasing ascites, but no acute pathology. Peritoneal fluid was obtained and contained 544 polys. Treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing GPC pairs/clusters. Blood cultures ended up growing 1 out of 4 bottles coag-neg Staph, likely contaminant, so vancomycin was stopped. Since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. The peritoneal cultures remained negative. Her PD catheter was left in place as the patient refuses HD any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) SVC/brachiocephalic thrombosis: Patient's INR was subtherapeutic on admission at 1.3. Due to the proximal location of her old venous thrombi, she was started on a heparin gtt. This was continued during her admission and her warfarin was increased to 5mg daily. Her INR reached 2.0 at discharge (therapeutic range 2-3). The dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) Anxiety: Patient noted feeling short of breath and anxious around the time of her recent admissions. Her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. They felt her symptoms were suggestive of anxiety and panic attacks, recommended checking TSH and metanephrines as above, and starting citalopram 20mg, which was done. She was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h PRN. Patient is agreeable to outpatient follow up with [**Company 191**] social work, and potential CBT. These can be arranged by her PCP. Medications on Admission: 1. Aliskiren 150 mg [**Hospital1 **] 2. Clonidine 0.3 mg/24 qwk 3. Prochlorperazine Maleate 10 mg prn 4. Hydromorphone 2 mg Tablet Sig: [**1-11**] q6 prn 5. Bisacodyl 10mg [**Hospital1 **] 6. Ergocalciferol (Vitamin D2) 50,000 qmonth 7. Hydralazine 75mg tid 8. Hydralazine scale prn 9. Labetalol 300 mg tid 10. Nifedipine 90 mg qd 11. Prednisone 4mg qd 12. Warfarin 2 mg qd at 4pm Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Hospital1 766**]). 5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day. [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 7 days. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO q30 min prn as needed for hypertension: for SBP > 180. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive urgency Headache Abdominal pain Anxiety Secondary Diagnosis: HTN SLE ESRD on HD SVC and IJ thrombosis, chronic Anemia Discharge Condition: Stable, BPs improved. Discharge Instructions: You were admitted with elevated blood pressures, headache, and abdominal pain. You were found to have increased amounts of white blood cells in your abdominal cavity, but this was not infected. Your abdominal pain resolved and you continued to have intermittent headaches. Your blood pressure medications were adjusted as below. You were also seen by psychiatry who recommended starting new medications for your anxiety. The following changes were made to your medication regimen: - We increased your hydralazine to 100 mg three times a day. - We also increased your labetalol to 400 mg three times a day. - We have started a medication called celexa 20 mg daily as well as ativan 1 mg three times a day as needed for anxiety. - We have increased your coumadin to 4 mg daily. - Please continue taking all other medications as previously prescribed. Call your doctor or return to the emergency room if you experience any of the following: worsening abdominal pain, nausea, vomiting, blurry vision, worsening headache, fever > 101. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. Please continue to follow with your nephrologist and go to outpatient dialysis as previously arranged. Please discuss with your PCP the possibility of talking to a social worker at [**Name (NI) 191**]. You will need to continue to have your INR monitored at [**Hospital 191**] [**Hospital 2786**] clinic. Please have this level checked on [**Hospital 766**], [**11-27**]. Completed by:[**2141-11-23**]",150,2141-11-18 14:00:00,2141-11-23 16:42:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. her hydralazine was increased from 75mg to 100mg tid with mild improvement. her labetalol was also increased from 300mg to 400mg tid. her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. tsh was sent and elevated, although free t4 was normal. plasma metanephrines were sent and pending at discharge. 2) abdominal pain: ct scan showed increasing ascites, but no acute pathology. peritoneal fluid was obtained and contained 544 polys. treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing gpc pairs/clusters. blood cultures ended up growing 1 out of 4 bottles coag-neg staph, likely contaminant, so vancomycin was stopped. since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. the peritoneal cultures remained negative. her pd catheter was left in place as the patient refuses hd any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) svc/brachiocephalic thrombosis: patients inr was subtherapeutic on admission at 1.3. due to the proximal location of her old venous thrombi, she was started on a heparin gtt. this was continued during her admission and her warfarin was increased to 5mg daily. her inr reached 2.0 at discharge (therapeutic range 2-3). the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) anxiety: patient noted feeling short of breath and anxious around the time of her recent admissions. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. they felt her symptoms were suggestive of anxiety and panic attacks, recommended checking tsh and metanephrines as above, and starting citalopram 20mg, which was done. she was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h prn. patient is agreeable to outpatient follow up with [**company 191**] social work, and potential cbt. these can be arranged by her pcp. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Abdominal pain, unspecified site; Anemia, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. her hydralazine was increased from 75mg to 100mg tid with mild improvement. peritoneal fluid was obtained and contained 544 polys. the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted.","patient has history of extremely labile hypertension on aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. ct scan showed increasing ascites, but no acute pathology." 109,137510.0,14810,2142-04-22,14800,161950.0,2141-12-01,Discharge summary,"Admission Date: [**2141-11-24**] Discharge Date: [**2141-12-1**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Headache, abdominal pain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24yo F w/PMHx of ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning, awakening her from sleep. Had been previously discharged from [**Hospital1 **] yesterday after being admitted for hypertension and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Upon discharge yesterday she states her abdominal pain had subsided. She had HD yesterday without complications. She awoke at 6am with a headache and crampy, stabbing abdominal pain. Took 2mg PO Dilaudid without relief and came to ED. No nausea/vomiting, no changes in vision, no fevers, chills, night sweats. No chest pain, SOB, diarrhea. In the ED, initial vitals were T98.7, BP260/130, HR70, RR16. Was initially given 10mg IV Labetalol X 2, 4mg Zofran for nausea. No improvement in BP and started on Labetolol gtt. Got 1mg IV Dilaudid for pain. Currently, patient continues to complain of headache and abdominal pain, both [**7-17**]. No vision changes, chest pain or shortness of breath. Has been feeling increased anxiety recently and saw psychiatrist, was put on Celexa. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T98.2, BP176/135, HR94, RR 22, 100% RA Gen: well-appearing african-american woman, lying comfortably HEENT: anicteric, L eye prosthetic non-reactive, R pupil reactive, MMM, neck supple with submanibular LAD CV: RRR, II/VI SEM best heard at apex Pulm: CTA b/l Abd: hyperactive bowel sounds, midline scar well-healed, soft, diffusely tender to palpation, +rebound, no guarding. PD catheter in LLQ without erythema or purulent material draining. +dullness on percusion with evidence of clinical ascites. Ext: no edema, no clubbing, 2+ peripheral pulses DP and radial. R femoral HD [**Last Name (un) **] in place without erythema, purulance Neuro: A&O X 3, CN intact II-XII, [**5-15**] motor strength in upper and lower extremities Pertinent Results: Admission labs: CBC: [**2141-11-26**] 05:21AM BLOOD WBC-3.5* RBC-3.07* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-17.6* Plt Ct-180 CHEM 10: [**2141-11-26**] 01:16PM BLOOD Glucose-87 UreaN-17 Creat-4.0* Na-136 K-5.2* Cl-106 HCO3-23 AnGap-12 [**2141-11-26**] 09:20PM BLOOD Calcium-7.6* Phos-3.8 Mg-1.8 COAGS: [**2141-11-26**] 01:16PM BLOOD PT-23.9* PTT-40.2* INR(PT)-2.3* STUDIES: 1)Peritoneal fluid ([**11-26**]): negative for malignant cells. Reactive mesothelial cells, macrophages, eosinophils and lymphocytes. 2)BILAT UP EXT VEINS US ([**11-26**]): No evidence of deep vein thrombosis of the right or left upper extremity. 3) MRI/MRA ([**11-30**]): FINDINGS: Examination is somewhat limited by patient motion. T2/FLAIR sequences are unremarkable with interval resolve of previously noted posterior abnormalities. The major vessels appear patent proximally. There are stable areas of low signal in the left frontal and right occipetal/temporal lobes. IMPRESSION: 1. Interval resolution of previously noted posterior white matter abnormalities. 2. Stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions. 3. Very limited MRA as above. Brief Hospital Course: 24yo F with SLE, ESRD on HD and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**Hospital Unit Name 153**] course: The patient was admitted for blood pressure management and evaluation of abd pain. An A-line was placed. EKG showed no change from prior, and Abd x-ray showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home med regimen. The patient was found to be hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. Upon transfer to the floor, the following was her course: 1. Hypertensive Urgency: Pt had had hemodialysis one day prior to admission, so unlikely that she was volume overloaded. Unclear what precipitated this episode of hypertensive urgency, although suspect secondary to abdominal pain leading to an anxiety which then precipitates hypertension. She may not have been taking her medications secondary to pain. Negative serum tox. On the floor, we continued hemodialysis Tu, Th, Sat. She was initially continued on PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine 90mg PO qday and clonidine; she received hydralazine 10mg IV for goal BP < 180/100. Renal team followed patient during this hospitalization. Per renal team recs, labetalol was increased to 800mg TID due to poor blood pressure control. Pt discharged on clonidine 0.3mg patch, Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, Nifedipine 90mg daily and lobatalol 800mg TID. This regimen worked well. 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT scan during prior admission which did not show source of abdominal pain. On admission, LFTs were normal except for slightly low albumin, lipase was slightly elevated and KUB was negative for free air or evidence of SBO. Peritoneal fluid was negative for malignant cells but showed reactive mesothelial cells, macrophages, eosinophils and lymphocytes. Negative gram stain or peritoneal fluid cultures, excluding SBP as a cause of the abdominal pain. PD catheter was not removed. Pt was continued on PO dilaudid 1-2mg Q6h and pain resolved. She denied N/V/diarrhea or constipation. 3. ESRD: Pt on hemodialysis, on T/Th/Sat schedule. Renal following patient closely throughout this hospitalization. Lytes were checked frequently and kayexalate given prn. 4. Hx of SVC/brachiocephalic DVT: Pt was initially subtherapeutic on coumadin. Unclear if she had not been taking Coumadin although patient reported that she has been taking all home meds. We started heparin gtt to bridge to Coumadin. Once therapeutic, continued Coumadin 5mg PO qday. 5. Anxiety: Likely contributing to medical problems and could have very well been the etiology of this admission. Although pt stated she was taking her current medications, she did report increased anxiety which can lead to medication non-compliance and hypertension. Pt recently saw psychiatrist who started her on Celexa. She was continued on celexa 20mg PO qday, ativan 1mg PO q8hours PRN and psychiatry was re-consulted. Per psych recs, started standing clonazepam. Pt refused psych VNA. Outpatient PCP followup recommended. 6. Headache NOS: Pt complained of R-sided HA for several weeks, radiating to R jaw where patient had previous tooth extraction. Right upper extremity ultrasound was negative for DVT. She did not have any focal neuro findings, no visual deficits. She was initially treated with tylenol PRN Q6h; pt requested IV dilaudid for HA, but use of this medication by IV route was limited by team. It was felt by the pain service that her HA did not fit migraine, tension type HA or rebound HA. They recommended increasing dilaudid to 4-6mg Q6h PRN, continuing tylenol and starting neurontin 300mg Qhs which was slowly titrated to 300mg [**Hospital1 **] for better control. Per pain recs, a neurology consult was also obtained during this admission. MRI/MRA showed interval resolution of previously noted posterior white matter abnormalities and stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions, but very limited MRA as above. Per pain recs, dilaudid was further increased to 4mg q4h for better control of her HA. Neurology recommended outpt f/u and Pt scheduled with [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**]. 7. Anemia: Likely related to ESRD. No evidence of acute bleeding. Hct remained stable during this hospitalization. 8. SLE: no acute issues. continued Prednisone 4mg PO qday 9. FEN: tolerated regular diet, repleted lytes PRN 9. Prophylaxis: Heparin gtt, then coumadin, bowel regigmen Medications on Admission: (from prior discharge summary) Bisacodyl 10mg PO qday PRN Prednisone 4mg PO qday Aliskiren 150mg PO BID Clonidine 0.3mg / 24 hr patch weekly qmonday Labetalol 400mg PO TID Warfarin 4mg PO qday Nifedipine 90mg PO qday Hydralazine 100mg PO q8H Hydromorphone 2-4mg PO q4H PRN Lorazepam 1mg PO q8H Celexa 20mg PO qday Prochlorperazine 10mg PO q6H Colace 100mg PO BID Hydralazine 25mg PO q30min PRN for HTN Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Year (4 digits) 766**]). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). [**Year (4 digits) **]:*100 Tablet(s)* Refills:*2* 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*90 Capsule(s)* Refills:*2* 9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for headache. [**Year (4 digits) **]:*84 Tablet(s)* Refills:*0* 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*60 Capsule(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours. [**Year (4 digits) **]:*360 Tablet(s)* Refills:*2* 16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. [**Year (4 digits) **]:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive Emergency 2. SLE 3. Headache, NOS 4. Abdominal pain Discharge Condition: BP better controlled. Headache managed on oral meds Discharge Instructions: You were admitted with abdominal pain, high blood pressure, and headache. Your abdominal pain resolved - no serious cause of this pain was found. Your blood pressure medications were continued, and with an increased in one medication, the labetalol. Your blood pressure improved. You should continue the clonidine 0.3mg patch changed on [**Year (4 digits) 766**], Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, and Nifedipine 90mg daily. The dose of Labetalol was increased to 800 mg three times daily by you kidney doctor and you are given a new prescription. Please take all medications as listed below. For your headache, you had an MRI and MRA of the head, which did not show a new or serious abnormality. You were seen by the neurology and pain services. You should follow up at [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**] at 6:30 PM (in the evening). Your pain was managed by oral dilaudid, 4mg. You should take this medication every 4 hours as needed. You were also started on Gabapentin (also called Neurontin) for the headache. The dose was slowly increased to twice a day. You may not need as much dilaudid for your headache and should wean this medication as tolerated, given it's potential for side effects (constipation, lethargy, dependence). Finally, you will likely need medications for constipation while you take dilaudid. Take colace (a stool softener), senna (a laxative), and bisacodyl (another laxative), as needed. It is really important that you have a primary care doctor. You are scheduled with Dr. [**Last Name (STitle) **] (see below) next Tuesday. You will need your INR checked since you are on coumadin. Call your doctor if you have worsened headache, chest pain, confusion, or any other concerning symptom. Followup Instructions: Please make sure you attend the following doctor appointments: 1) Dr. [**Last Name (STitle) 4883**] (nephrologist) on Tuesday, [**2141-12-5**] at 10AM. Phone number [**Telephone/Fax (1) 60**]. 2) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Location (un) **], [**Hospital Ward Name 23**] center, [**Location (un) **]. Phone:[**Telephone/Fax (1) 250**]. Date/Time:[**2141-12-5**] 3:20 3) Neurology: Dr. [**Last Name (STitle) 43502**] [**Name (STitle) **]. He is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-12-12**] 6:30 PM [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2141-12-2**]",142,2141-11-24 16:11:00,2141-12-01 19:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**hospital unit name 153**] the patient was admitted for blood pressure management and evaluation of abd pain. an a-line was placed. ekg showed no change from prior, and abd x-ray showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home med regimen. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. upon transfer to the floor, the following was her ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other ascites; ; Systemic lupus erythematosus; Headache; Anemia in chronic kidney disease; Anxiety state, unspecified; Other chest pain; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Renal dialysis status; Acquired absence of organ, eye]","24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. the renal team was consulted, and recommended no change to home med regimen.","a 24yo f with sle, esrd on hd and malignant hypertension presented with abdominal pain and headache. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. she successfully switched to po meds and was transferred to the floor." 109,137510.0,14810,2142-04-22,14801,173633.0,2141-12-14,Discharge summary,"Admission Date: [**2141-12-8**] Discharge Date: [**2141-12-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 8104**] Chief Complaint: abdominal pain & hypertension Major Surgical or Invasive Procedure: Hemodialysis PICC Line [**12-11**] History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with a history of CKD V (on HD) from lupus nephritis, chronic intermittent abdominal pain, and multiple prior ICU admissions for hypertensive urgency who presented to the ED complaining of two days' of abdominal pain, nausea, and loose stools. She was feeling well until after her hemodialysis session on Wednesday. Thereafter, she complained of nausea with occasional vomitting and has been unable to keep down any of her oral medications. She also has had diffuse abdominal pain consistent with her prior flares of pain as well as her typical diffuse headache. The headache in particular was worsening and, for her, this is a sign of poorly-controlled hypertension so she came to the [**Hospital1 18**] ED. Upon arrival to the ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room air. She was given 4 mg of IV ondansetron, [**1-11**] inch intropaste, 1 mg of IV hydromorphone x3, 1000cc of NS, and was put on a labetalol drip which had to be increased up to 2 mg/min. A head CT showed no acute abnormality (including hemorrhage) and an abdominal CT showed some possible mild colitis, though it is unclear if this is due to her recent peritoneal dialysis. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 97.9 BP 165/120 HR 93 RR 12 Sat 100% ra Gen: mildly fatigued, but no distress HEENT: oropharynx clear Neck: no JVP, no LAD Chest: clear to auscultation throughout, no w/r/r CV: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard Abdomen: soft, tender diffusely to moderate palpation without rebound or guarding; hyperactive bowel sounds; no masses or HSM, PD catheter in palce Extr: no edema, 2+ PT pulses Neuro: alert, appropriate, strength grossly intact in all four limbs Skin: no rashes Pertinent Results: [**2141-12-14**] 05:53AM BLOOD WBC-4.3 RBC-2.81* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.7 MCHC-33.8 RDW-19.3* Plt Ct-148* [**2141-12-14**] 05:53AM BLOOD PT-42.6* PTT-51.0* INR(PT)-4.7* [**2141-12-10**] 05:10AM BLOOD Ret Aut-2.5 [**2141-12-14**] 05:53AM BLOOD Glucose-83 UreaN-21* Creat-5.1*# Na-138 K-5.3* Cl-105 HCO3-24 AnGap-14 [**2141-12-10**] 05:10AM BLOOD LD(LDH)-234 Amylase-347* TotBili-0.1 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-10**] 05:10AM BLOOD Lipase-72* [**2141-12-14**] 05:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 [**2141-12-10**] 05:10AM BLOOD Hapto-142 [**2141-12-8**] 04:02AM BLOOD calTIBC-138* VitB12-445 Folate-18.5 Ferritn-220* TRF-106* ON ADMISSION: [**2141-12-7**] 09:50PM BLOOD WBC-4.5 RBC-2.78* Hgb-8.4* Hct-25.2* MCV-91 MCH-30.2 MCHC-33.3 RDW-19.2* Plt Ct-158 [**2141-12-7**] 09:50PM BLOOD Neuts-65.2 Lymphs-23.4 Monos-8.0 Eos-2.9 Baso-0.4 [**2141-12-7**] 09:50PM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3* [**2141-12-8**] 04:02AM BLOOD Ret Aut-2.5 [**2141-12-7**] 09:50PM BLOOD Glucose-89 UreaN-25* Creat-5.1*# Na-139 K-4.8 Cl-104 HCO3-26 AnGap-14 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-7**] 09:50PM BLOOD Lipase-89* [**2141-12-7**] 09:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9* Mg-1.9 [**2141-12-7**] 09:54PM BLOOD Glucose-75 Lactate-1.3 Na-139 K-4.8 Cl-101 calHCO3-23 Micro: Blood Cx: [**12-7**], [**12-7**], [**12-11**], [**12-11**] No growth FECAL CULTURE (Final [**2141-12-10**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2141-12-10**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2141-12-8**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-12-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CT HEAD [**2141-12-8**]: IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. The hypodensities noted in the parietal white matter are stable. However in the setting of the hypertension, PRES cannot be excluded. If further evaluation is required MR can be obtained. CT Abdomin/Pelvis [**2141-12-8**] IMPRESSION: 1. Moderate amount of free fluid in the pelvis is compatible with the patient's known peritoneal dialysis. Unchanged peritoneal enhancement. 2. Stable liver hemangioma. CXR [**12-11**] IMPRESSION: Small left pleural effusion. Left lower lobe opacity which is either atelectasis versus pneumonia. Brief Hospital Course: 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. MICU course: Current plan on transfer 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. 1. Hypertensive urgency: The patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. Initially her blood pressure over-corrected to SBPs in the 80s (patient was asymptomatic). Her clonidine patch and hydralazine was held and she again became hypertensive with SBPs 190s. The patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. The following dialysis the patient asymptomatic with SBPs in 80s, MAPs 60s asymptomatic again. Her hydralazine was stopped and continued on all her other home medications at the advice of renal. The patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. On [**12-11**] the patient's SBP dropped to the 80's and due to her pain medications she was extremely lethargic, but arousable. A PICC line was placed because lack of access and she was bolused 250cc NS. The patient's pressures responded and additional narcotics were held due to her mental status. The patient's blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. The patient did require IV hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. A possible component to the patient's malignant hypertension is likely due to OSA. An inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on BiPAP for OSA. The patient was continuned on her admission hypertensive regimen. . 2. Abdominal pain: The etiology of her abdominal pain is unclear, but has been a chronic issue for her. A CT scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. The patient also had diarrhea, but stool studies were negative. The patient's pain was initially treated with hydromorphone, but because of the patient's lethargy on [**12-11**] they were initially held. She continued to complain of severe abdominal pain. She was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. Surgery was consulted in regards to removal of her PD catheter, but given that she may return to PD it was deferred to the outpatient setting. 3. CKD V from lupus nephritis: The patient was continued on HD during her admission. She was also continued on her home prednisone dose. She was closely followed by the renal team. . 4. History of SVC/subclavian vein thrombus: The patient was found to have a subtherapeutic INR on admission 1.3. She was started on a heparin gtt and continued on coumadin. The patient's heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her PICC line was placed. She was therapetuic the same day and her heparin gtt was stopped. On discharge her coumadin was supratherapeutic (4.7) and was held. She will have her INR checked at HD. . 5. Anemia: The patient's Hct slowly trended down. She was guaiac negative and hemolysis labs were negative. She was transfused 1U pRBC at HD on [**12-12**]. She was also given epo at HD. Medications on Admission: prednisone 4 mg daily clonidine 0.3 mg/day patch qWeek ergocalciferol 50,000 units qMonth nifedipine SR 90 mg daily hydralazine 100 mg q8h citalopram 20 mg daily warfarin 2 mg qhs gabapentin 300 mg [**Hospital1 **] hydromorphone 4 mg q4h prn clonazepam 0.5 mg [**Hospital1 **] alikiren 150 mg [**Hospital1 **] docusate 100 mg [**Hospital1 **] senna 8.6 mg [**Hospital1 **] prn acetaminophen prn labetalol 800 mg q8h bisacodyl 5 mg daily prn Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. [**Hospital1 **]:*84 Tablet(s)* Refills:*0* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed: please take as needed for anxiety prior to CPAP at bedtime. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 14. CPAP Home CPAP Dx: OSA Prefer: AutoCPAP/ Pressure setting [**5-20**] Alt: Straight CPAP/ Pressure setting 7 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency Abdominal Pain ESRD on HD SVC Thrombus Secondary: Systemic lupus erythematosus Malignant hypertension Thrombocytopenia HOCM Anemia History of left eye enucleation History of vaginal bleeding Thrombotic microangiopathy Discharge Condition: Stable Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because of elevated blood pressure and abdominal pain. You were initially admitted to the ICU and your blood pressure was controlled. You were stabilized and transferred back to th floor. Your pressures remained stable throughout the rest of your stay. Additionally, you had abdominal pain and diarrhea. Your stool was tested for infections and was negative. Your diarrhea resolved without intervention. Your abdominal pain was controlled with pain medications. You had a sleep study in the hospital which showed that you had sleep apnea. Please continue to take your medications as prescribed. 1. Please do not take your coumadin until your doctor tells you to. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: You will have dialysis at [**Location (un) **] Dialysis on your normal schedule. You need to go to dialysis on Saturday. Please follow-up with the Sleep Clinic in [**12-19**] @ 11:45 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Completed by:[**2141-12-16**]",129,2141-12-08 01:40:00,2141-12-14 17:16:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. micu course: current plan on transfer 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. 1. hypertensive urgency: the patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). her clonidine patch and hydralazine was held and she again became hypertensive with sbps 190s. the patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. the following dialysis the patient asymptomatic with sbps in 80s, maps 60s asymptomatic again. her hydralazine was stopped and continued on all her other home medications at the advice of renal. the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. on [**12-11**] the patients sbp dropped to the 80s and due to her pain medications she was extremely lethargic, but arousable. a picc line was placed because lack of access and she was bolused 250cc ns. the patients pressures responded and additional narcotics were held due to her mental status. the patients blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. the patient did require iv hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. a possible component to the patients malignant hypertension is likely due to osa. an inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on bipap for osa. the patient was continuned on her admission hypertensive regimen. . 2. abdominal pain: the etiology of her abdominal pain is unclear, but has been a chronic issue for her. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. the patient also had diarrhea, but stool studies were negative. the patients pain was initially treated with hydromorphone, but because of the patients lethargy on [**12-11**] they were initially held. she continued to complain of severe abdominal pain. she was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. surgery was consulted in regards to removal of her pd catheter, but given that she may return to pd it was deferred to the outpatient setting. 3. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was also continued on her home prednisone dose. she was closely followed by the renal team. . 4. history of svc/subclavian vein thrombus: the patient was found to have a subtherapeutic inr on admission 1.3. she was started on a heparin gtt and continued on coumadin. the patients heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her picc line was placed. she was therapetuic the same day and her heparin gtt was stopped. on discharge her coumadin was supratherapeutic (4.7) and was held. she will have her inr checked at hd. . 5. anemia: the patients hct slowly trended down. she was guaiac negative and hemolysis labs were negative. she was transfused 1u prbc at hd on [**12-12**]. she was also given epo at hd. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Systemic lupus erythematosus; Other and unspecified noninfectious gastroenteritis and colitis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other iatrogenic hypotension; Obstructive sleep apnea (adult)(pediatric); Hemangioma of intra-abdominal structures; Other chronic pain; Abdominal pain, unspecified site; Abnormal coagulation profile; Renal dialysis status; Personal history of venous thrombosis and embolism]","24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. the patient was continuned on her admission hypertensive regimen. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was therapetuic the same day and her heparin gtt was stopped.",24 year old woman with ckd v and severe hypertension due to sle admitted. patient was initially maintained on a labetalol drip and hydralazine iv prn. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic) 109,137510.0,14810,2142-04-22,14802,140167.0,2141-12-23,Discharge summary,"Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1973**] Chief Complaint: Malignant hypertension Major Surgical or Invasive Procedure: None History of Present Illness: 24 year old female with ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning. Patient had her hemodialysis day before yesterday. She has had multiple admissions to [**Hospital1 18**] with hypertensive urgency with symptoms of headache and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Patient states that her headache and abdominal pain are similar in characteristics to her previous admission. Patient denies any fever, chills, nightsweats, chest pain, shortness of breath, abdominal pain, nausea, vomitting, diarrhea, constipation, blood in stool, dysuria, hematuria, change in vision, hearing, weakness or numbness. In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was initially given 10mg IV Labetalol once and then started on drip at 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea. Her BP elevated as high as 270/174 and his labetolol was switched to nicardipine 1mg/kg/min. On arrival to the MICU her vitals were T 96.4 HR 99 BP 175/120 RR 15 100%RA. Patient was comfortable. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Vitals: 97.5 122/80 88 18 100%RA. Gen: sleeping, easily arousable, appears comfortable. HEENT: AT/NC, L eye prosthetic non-reactive, R pupil reactive, MMM. Heart: S1S2 RRR, III/VI SEM heard best at apex, + S3 Pulm: CTA b/l, no w/r/r. Abd: normal bowel sounds, midline scar well-healed, soft, nontender, prior PD site with dry dressing, patient with tenderness to palpation over prior PD cath site, no guarding/rebound Ext: no edema, no clubbing, WWP. R femoral HD catheter in place. Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: Admission: [**2141-12-18**] 02:00AM BLOOD WBC-5.8 RBC-3.30* Hgb-10.1* Hct-30.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-20.7* Plt Ct-199 [**2141-12-18**] 02:00AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.2* [**2141-12-18**] 02:00AM BLOOD UreaN-35* Creat-5.0* Na-138 K-5.5* Cl-103 HCO3-21* AnGap-20 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-18**] 02:00AM BLOOD Lipase-73* [**2141-12-18**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2141-12-19**] 06:45AM BLOOD Calcium-8.1* Phos-5.1* Mg-1.8 [**2141-12-18**] 03:52PM BLOOD dsDNA-NEGATIVE [**2141-12-18**] 03:52PM BLOOD CRP-11.5* [**2141-12-18**] 03:52PM BLOOD C3-68* C4-19 [**2141-12-20**] 12:09PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 [**2141-12-18**] 02:08AM BLOOD pO2-52* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 Comment-GREEN TOP [**2141-12-20**] 12:09PM BLOOD Lactate-0.9 [**2141-12-18**] 02:08AM BLOOD Glucose-68* Lactate-1.3 Na-140 K-4.8 Cl-103 [**2141-12-23**] 03:00PM BLOOD WBC-4.7 RBC-2.35* Hgb-7.1* Hct-22.3* MCV-95 MCH-30.3 MCHC-31.9 RDW-20.6* Plt Ct-131* [**2141-12-23**] 12:55AM BLOOD PT-14.7* PTT-66.2* INR(PT)-1.3* [**2141-12-18**] 03:52PM BLOOD ESR-21* [**2141-12-23**] 03:00PM BLOOD Glucose-97 UreaN-42* Creat-6.6* Na-138 K-4.3 Cl-106 HCO3-23 AnGap-13 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-23**] 03:00PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8 [**2141-12-18**] 04:23PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2141-12-18**] 04:23PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2141-12-18**] 04:23PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-12 TransE-<1 Micro: Blood Cx- [**12-18**]: No growth Urine Cx- [**12-18**]: No growth [**12-18**] TTE The left atrium and right atrium are normal in cavity size. A possible secundum type atrial septal defect is seen by color Doppler (clip [**Clip Number (Radiology) **]) There is severe symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. There is no significant resting LVOT gradient, but a mild gradient (30mmHg peak) is seen with Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Marked symmetric left ventricular hypertrophy with normal regional/global systolic function and mild inducible LVOT gradient. Mild aortic regurgitation. Mild pulmonary artery systolic hypertension. Possible secundum type atrial septal defect. Compared with the prior study (images reviewed) of [**2141-10-19**], a possible secundum type atrial septal defect is now suggested. If clinically indicated, a follow-up study with saline contrast and/or a TEE would be better able to characterize the possible atrial septal defect. CLINICAL IMPLICATIONS: Based on [**2140**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**12-18**] CXR IMPRESSION: 1. Cardiomegaly with findings suggestive of mild pulmonary edema. 2. Bibasilar linear opacities suggesting atelectasis, although developing pneumonia cannot be excluded. 3. No evidence of free intraperitoneal air. [**12-20**] MRV IMPRESSION: No appreciable change since the MRV chest exam dated [**2141-5-30**]. SVC is patent. Again seen is occlusion of the right internal jugular and left brachiocephalic veins. Right external jugular vein is provides the major venous drainage from the neck. Brief Hospital Course: 24 year old Female with SLE, ESRD on HD and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ED. 1. Malignant Hypertension: The patient had her hemodialysis two days prior to admission. Initially in the ED her BP was 253/170. She was given 10mg IV Labetalol and started on a labatelol drip. She also received hydralazine IV 10 mg once and 2 inches of nitropaste. She had morphine 4mg and 4mg Zofran for nausea. Her BP remained elevated so she was switched to nicardipine 1mg/kg/min. The patient was transferred to the MICU. In the ICU she was continued on the Nicardapine drip and her pressures decreased to 175/120. Nephrology was consulted and dialysis initiated in the AM. The Nicardapine drip dc'd on [**12-19**] and pt transferred to floor. While on the floor the patient had question of angioedema and markedly elevated BP. She was readmitted to the MICU on [**2141-12-20**]. Patient's Aliskerin was also held for conern for angioedema. The renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. The patient's PD catheter was removed. The patient was briefly on a nitro drip for hypertension. The patient's nifedepine was increased to 120mg. The patient was transferred to the floor with stable blood pressures, BP 124/72 on [**12-21**]. The morning of [**12-22**], the patient was noted to have a BP up to 247/120 at 0800. Hypertension persisted throughout the morning with BPs 210s-240s systolic. HR during this time was in the 90s. She received a total of 60 mg IV hydralazine over the course of the morning as well as 0.1 mg PO clonidine. She was also given her normal AM BP meds and restarted on aliskarin. Due to persistent hypertension, she was transferred to the ICU for further care. On arrival to the ICU, the patient reported severe abdominal pain over the site of recently removed PD catheter. She denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. She reports bilateral calf cramping but no leg swelling. She denies any difficulty breathing or chest pain. She took her AM BP meds without difficulty. Her blood pressure decreased to 130s-140s/60s without further intervention. She was transferred back to the floor on [**12-23**] and signed out AMA. 2. Angioedema: On [**12-20**] the patietn developed facial swelling and evidence of angioedema by ENT. The patient reported that her face is more swollen which was confirmed by her mother on the floor. The patient was give lasix IV as she has been unable to have any negative filtration with HD. The patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. Her tekturna was discontinued for concern that it might be causing angioedema. She denied difficulty with her breathing at that time, but was very somnulent. On arrival to the MICU her vitals were stable and oxygenating well at 100% on face mask. The patient's airway was supported with a nasal trumpet. The patient underwent MRV that showed no progression of her clot. Patient was diuresed with lasix and dialysis with significant improvement in her symptoms. She was treated with prednisone and decadron, famotidine and benadryl for angioedema. The patient was maintained on her heparin drip for her SVC syndrome. 3. Abdominal Pain: The patient has had extensive prior workup that has been unrevealing. The Transplant surgery team removed the PD cath on [**12-21**]. She continued to have abdominal pain post-op. She was continued on PO dilaudid 2mg po prn. She continuned to complain of abdominal pain throughout her admission and continued to requested IV dilaudid. 4. ESRD: The patient is on a T/Th/Sat schedule. She was closely followed by the renal team. She had dialysis on [**12-19**]. The patient's tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. The patient also had her PD catheter removed on [**12-21**] secondary to chronic abdominal pain. The patient was scheduled to have dialysis on [**12-23**]. 5. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last admission for supratherapeutic INR. She was admitted with a subtherpeutic INR of 1.2 She was started on a heparin drip. She was also started on Coumadin 2mg PO qday, but was held on [**12-19**] in prep her PD catheter removal. She was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by IR. However, the patient signed out AMA and thus it was not placed. 6. Anxiety: Pt recently saw psychiatrist who started her on Celexa. She was continued on Celexa 20mg PO daily. 7. Anemi of CKDa: The patient's Hct was 30.3 on admission. It trended down to 22.3 on discharge when she left AMA. There was no evidence of active, acute bleeding. THis is likely seoncdary to her ESRD. The patient was closely monitored. 8. Systemic Lupus Erythematosis: Rheumatology was consulted and does not suspect acute flare and dsDNA, C3, C4 nl, ESR and CRP slightly elevated. Her Echo did not suggest worsening pericarditis. She was continued on her home prednisone dose of 4mg daily. 9. Obstructive Sleep Apnea: CPAP for sleep with 7 pressure. Medications on Admission: Aliskiren 150 mg [**Hospital1 **] Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Warfarin held on discharge [**2141-12-14**] due to supratherap INR Discharge Medications: As patient signed out AMA, no medications were issued. She was told to resume her admission medications, however no instructions were taken by the patient. Discharge Disposition: Home Discharge Diagnosis: 1) Hypertensive urgency 2) Abdominal pain 3) End stage renal disease on hemodialysis 4) Venous thromboembolism Discharge Condition: Signed out AMA Discharge Instructions: Pt signed out AMA Return to the hospital with any concerning symptoms. Be sure to call your doctor's office on [**Month/Day/Year 766**] to arrange hemodialysis and review your medications and discuss follow-up plan. Followup Instructions: Follow-up with your Dr. [**Last Name (STitle) **] next week, and call [**Last Name (STitle) 766**] to arrange your hemodialysis. Completed by:[**2141-12-26**]",120,2141-12-18 03:50:00,2141-12-23 19:51:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. 1. malignant hypertension: the patient had her hemodialysis two days prior to admission. initially in the ed her bp was 253/170. she was given 10mg iv labetalol and started on a labatelol drip. she also received hydralazine iv 10 mg once and 2 inches of nitropaste. she had morphine 4mg and 4mg zofran for nausea. her bp remained elevated so she was switched to nicardipine 1mg/kg/min. the patient was transferred to the micu. in the icu she was continued on the nicardapine drip and her pressures decreased to 175/120. nephrology was consulted and dialysis initiated in the am. the nicardapine drip dcd on [**12-19**] and pt transferred to floor. while on the floor the patient had question of angioedema and markedly elevated bp. she was readmitted to the micu on [**2141-12-20**]. patients aliskerin was also held for conern for angioedema. the renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. the patients pd catheter was removed. the patient was briefly on a nitro drip for hypertension. the patients nifedepine was increased to 120mg. the patient was transferred to the floor with stable blood pressures, bp 124/72 on [**12-21**]. the morning of [**12-22**], the patient was noted to have a bp up to 247/120 at 0800. hypertension persisted throughout the morning with bps 210s-240s systolic. hr during this time was in the 90s. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she was also given her normal am bp meds and restarted on aliskarin. due to persistent hypertension, she was transferred to the icu for further care. on arrival to the icu, the patient reported severe abdominal pain over the site of recently removed pd catheter. she denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. she reports bilateral calf cramping but no leg swelling. she denies any difficulty breathing or chest pain. she took her am bp meds without difficulty. her blood pressure decreased to 130s-140s/60s without further intervention. she was transferred back to the floor on [**12-23**] and signed out ama. 2. angioedema: on [**12-20**] the patietn developed facial swelling and evidence of angioedema by ent. the patient reported that her face is more swollen which was confirmed by her mother on the floor. the patient was give lasix iv as she has been unable to have any negative filtration with hd. the patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. her tekturna was discontinued for concern that it might be causing angioedema. she denied difficulty with her breathing at that time, but was very somnulent. on arrival to the micu her vitals were stable and oxygenating well at 100% on face mask. the patients airway was supported with a nasal trumpet. the patient underwent mrv that showed no progression of her clot. patient was diuresed with lasix and dialysis with significant improvement in her symptoms. she was treated with prednisone and decadron, famotidine and benadryl for angioedema. the patient was maintained on her heparin drip for her svc syndrome. 3. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the transplant surgery team removed the pd cath on [**12-21**]. she continued to have abdominal pain post-op. she was continued on po dilaudid 2mg po prn. she continuned to complain of abdominal pain throughout her admission and continued to requested iv dilaudid. 4. esrd: the patient is on a t/th/sat schedule. she was closely followed by the renal team. she had dialysis on [**12-19**]. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient also had her pd catheter removed on [**12-21**] secondary to chronic abdominal pain. the patient was scheduled to have dialysis on [**12-23**]. 5. hx of svc/brachiocephalic dvt: her coumadin was held during last admission for supratherapeutic inr. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. she was also started on coumadin 2mg po qday, but was held on [**12-19**] in prep her pd catheter removal. she was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by ir. however, the patient signed out ama and thus it was not placed. 6. anxiety: pt recently saw psychiatrist who started her on celexa. she was continued on celexa 20mg po daily. 7. anemi of ckda: the patients hct was 30.3 on admission. it trended down to 22.3 on discharge when she left ama. there was no evidence of active, acute bleeding. this is likely seoncdary to her esrd. the patient was closely monitored. 8. systemic lupus erythematosis: rheumatology was consulted and does not suspect acute flare and dsdna, c3, c4 nl, esr and crp slightly elevated. her echo did not suggest worsening pericarditis. she was continued on her home prednisone dose of 4mg daily. 9. obstructive sleep apnea: cpap for sleep with 7 pressure. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Mechanical complication due to peritoneal dialysis catheter; ; Unspecified disease of pericardium; Angioneurotic edema, not elsewhere classified; Abdominal pain, other specified site; Systemic lupus erythematosus; ; Anemia in chronic kidney disease; Dysthymic disorder; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of steroids; Long-term (current) use of anticoagulants; Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation; Other antihypertensive agents causing adverse effects in therapeutic use]","24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. she was given 10mg iv labetalol and started on a labatelol drip. nephrology was consulted and dialysis initiated in the am. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she reports bilateral calf cramping but no leg swelling. she took her am bp meds without difficulty. her tekturna was discontinued for concern that it might be causing angioedema. the patient was maintained on her heparin drip for her svc syndrome. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient was scheduled to have dialysis on [**12-23**]. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. there was no evidence of active, acute bleeding.","24 year old female with sle, esrd on hd presents with abdominal pain and headache consistent with her usual hypertensive urgency. she was found to be in hypertensive urgency in ed. she received hydralazine iv 10 mg once and 2 inches of nitropaste." 109,137510.0,14810,2142-04-22,14803,135923.0,2142-01-12,Discharge summary,"Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-13**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypertensive Urgency and HA Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with HA in the setting of hypertension. Upon arrival to the ED, her vitals were 284/140, HR 67, RR 28, 100% on 4LNC. She was started on a nicardipine drip. She denied shortness of breath or chest pain. She is due for HD today. She has a left groin catheter which was recently placed [**2141-12-21**] and is causing her pain. She was also given dilaudid IV 1 mg x 2 with some relief. CXR was performed and showed no pulmonary edema. . Upon arrival to the MICU, patient denies HA, CP, SOB, fevers, chills. Patient reports mild abdominal pain at sight of left anterior abdominal wall hematoma and left groin pain at site of femoral HD line. She reports that she was taking her medications as directed, including coumadin for SVC thrombus. Briefly, 24 yo F with ESRD on HD, SLE, malignant HTN admitted for HA in the setting of HTN to 284/140 in ED. Initially, she was treated with a nicardipine gtt to control her BP. Her cardiac enzymes were flat, no new ECG changes. She was started on a heparin gtt with transition to coumadin for a SVC thrombosis. HTN secondary to med noncompliance. She was restarted on her oral BP. She missed her PM meds yesterday, so nicardipine was restarted, and then turned off this AM. She received all her AM BP meds. Her BPs have been in the 160s/90s. She had no neurological deficits. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 176/105, 87, 18, 100% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: 2/6 systolic murmur LUSB Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: left ant wall abd hematoma, TTP Extremities: Right: Trace, Left: Trace, left fem HD line without oozing or drainage Skin: Warm Neurologic: AAO x 3 Pertinent Results: [**2142-1-8**] 05:15AM PT-13.7* PTT-33.6 INR(PT)-1.2* [**2142-1-8**] 05:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-1+ STIPPLED-OCCASIONAL TEARDROP-1+ BITE-NORMAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2142-1-8**] 05:15AM cTropnT-0.08* [**2142-1-8**] 05:15AM CK(CPK)-119 [**2142-1-8**] 04:12PM PTT-120.8* [**2142-1-8**] 10:41PM PTT-144.8* [**2142-1-8**] 02:55PM CK-MB-NotDone cTropnT-0.06* Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. Patient was initially observed in the MICU and placed on a nicardipine drip. Patient was stablized on home medicaitons, suggesting medication non-compliance. Additionally, patient presented subtheraputic on coumadin for SVC thrombosis. Patient was started on heparin ggt. After the nicardipine drip was turned off, patient was called out to the floor. Heparin drip was continued until INR [**2-13**]. Pressures were managed to her baseline. Pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with Narcan. Patient received dialysis 3x/wk as per outpatient schedule. # Hypertension: Pt with extensive history of repeated admissions for hypertension. Patient's BP improved with nicardipine drip and after HD off drip on home PO medication regimen. Resumed oral antihypertensives with improved BP control. HTn likely from renal disease, possible medication noncompliance, lupus. No evidence of MI. Continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. Renal increased clonidine patch, and added Nicardipine with improvement of BP control. Pt is to follow up with an appointment in the next week to establish care at [**Company 191**], and to re-check her BP and adjust medications further. # SLE: Stable, continued prednisone at 4 mg PO daily. # Left groin pain. Permanent HD line was placed on [**12-25**]. Line and hematoma from prior peritoneal line on abdomen okay. No leukocytosis or fevers to suggest infection. Patient was oversedated on Dilaudid and had episode of oxygen desaturation which was reversed with Narcan. Patient was solmolent with morphine SR so that was d/c'ed as well, patient was given standing tylenlol and Morphine IR PRN. Transplant surgery removed remaining sutures today from L groin. Pt has a follow-up appointment in the next week with Dr. [**First Name (STitle) **] (Transplant Surgery). She will be sent home with low-dose Morphine IR and Tylenol PRN pain. If L groin pain should become uncontrollable on current meds, pt should return to the ED for re-evaluation. It is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #ESRD: Renal following, continuing HD Th/Th/Sat. CaCO3 was started for elevated calcium-phosphate product. Pt will follow-up with Dr. [**Last Name (STitle) 7473**] in the next 1-2 weeks. # Anemia: Pt's baseline is 26. This is likely secondary to AOCD and renal failure. Hct was stable on day of discharge at 25.9. # SVC thrombus: Pt has a history of an SVC thrombus, and is on coumadin. She is supposed to be on lifelong anticoagulation due to recurrent thrombosis but INR subtherapeutic on arrival. Heparin drip was stopped on the floor once the INR was theraputic. INR was therapeutic on day of discharge. Pt will need an INR check in the next week at her follow-up with her PCP. # HOCM: Pt has evidence of myocardial hypertrophy on Echo. She is currently not symptomatic. Echo did not show evidence of worsening pericardial effusion. She was continued on her beta-blocker and other BP medications. # Depression/anxiety: Stable. She was continued on Celexa and Clonazepam. # OSA: Pt as continued on CPAP for sleep with 7 pressure. # FEN: regular diet # PPX: heparin drip --> coumadin, bowel regimen # ACCESS: PIV x2 / permanent dialysis cath L fem # CODE: FULL # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] # DISPO: home with PCP and Renal [**Name9 (PRE) 702**] to re-check BP, INR level. Follow-up with Transplant Surgery. Medications on Admission: Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Aliskiren 150 [**Hospital1 **] Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Nicardipine 30 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain for 2 weeks. [**Hospital1 **]:*20 Tablet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Urgency End Stage Renal Disease Discharge Condition: stable, blood pressure moderately controlled, afebrile, tolerating POs Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. Some of medications were increased as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to take the coumadin as prescribed by your doctor, and have your INR checked frequently per your PCP's recommendations. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Renal) Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-1-15**] 3:00 - Will follow-up Vitamin D [**2-4**] level Provider: [**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD ([**Company 191**]) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-1-16**] 3:30 - Will re-check your INR level Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Transplant Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-1-19**] 2:50p [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-1-12**]",100,2142-01-08 06:36:00,2142-01-13 21:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE URGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was initially observed in the micu and placed on a nicardipine drip. patient was stablized on home medicaitons, suggesting medication non-compliance. additionally, patient presented subtheraputic on coumadin for svc thrombosis. patient was started on heparin ggt. after the nicardipine drip was turned off, patient was called out to the floor. heparin drip was continued until inr [**2-13**]. pressures were managed to her baseline. pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with narcan. patient received dialysis 3x/wk as per outpatient schedule. # hypertension: pt with extensive history of repeated admissions for hypertension. patients bp improved with nicardipine drip and after hd off drip on home po medication regimen. resumed oral antihypertensives with improved bp control. htn likely from renal disease, possible medication noncompliance, lupus. no evidence of mi. continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. renal increased clonidine patch, and added nicardipine with improvement of bp control. pt is to follow up with an appointment in the next week to establish care at [**company 191**], and to re-check her bp and adjust medications further. # sle: stable, continued prednisone at 4 mg po daily. # left groin pain. permanent hd line was placed on [**12-25**]. line and hematoma from prior peritoneal line on abdomen okay. no leukocytosis or fevers to suggest infection. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. patient was solmolent with morphine sr so that was d/ced as well, patient was given standing tylenlol and morphine ir prn. transplant surgery removed remaining sutures today from l groin. pt has a follow-up appointment in the next week with dr. [**first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. it is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #esrd: renal following, continuing hd th/th/sat. caco3 was started for elevated calcium-phosphate product. pt will follow-up with dr. [**last name (stitle) 7473**] in the next 1-2 weeks. # anemia: pts baseline is 26. this is likely secondary to aocd and renal failure. hct was stable on day of discharge at 25.9. # svc thrombus: pt has a history of an svc thrombus, and is on coumadin. she is supposed to be on lifelong anticoagulation due to recurrent thrombosis but inr subtherapeutic on arrival. heparin drip was stopped on the floor once the inr was theraputic. inr was therapeutic on day of discharge. pt will need an inr check in the next week at her follow-up with her pcp. # hocm: pt has evidence of myocardial hypertrophy on echo. she is currently not symptomatic. echo did not show evidence of worsening pericardial effusion. she was continued on her beta-blocker and other bp medications. # depression/anxiety: stable. she was continued on celexa and clonazepam. # osa: pt as continued on cpap for sleep with 7 pressure. # fen: regular diet # ppx: heparin drip --> coumadin, bowel regimen # access: piv x2 / permanent dialysis cath l fem # code: full # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] # dispo: home with pcp and renal [**name9 (pre) 702**] to re-check bp, inr level. follow-up with transplant surgery. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Hypoxemia; Other opiates and related narcotics causing adverse effects in therapeutic use; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Abdominal pain, other specified site; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Renal dialysis status; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Other postprocedural status]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. # hypertension: pt with extensive history of repeated admissions for hypertension. # sle: stable, continued prednisone at 4 mg po daily. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. this is likely secondary to aocd and renal failure. pt will need an inr check in the next week at her follow-up with her pcp.","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was stablized on home medicaitons, suggesting medication non-compliance. patient was oversedated on dilaudid and had episode of oxygen desaturation." 109,137510.0,14810,2142-04-22,14804,124657.0,2142-01-20,Discharge summary,"Admission Date: [**2142-1-14**] Discharge Date: [**2142-1-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 4028**] Chief Complaint: headache Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with mild headache, mild shortness of breath and consistent abdominal pain at the site of her known left abdominal wall hematoma in the setting of hypertension. Her last HD was yesterday. . Upon arrival to the ED, her vitals were BP 240's systolic, HR 90's, 93% on RA. A head CT scan was done which showed no acute process. An abdominal CT was done given her femoral line pain, which also was normal. She was given nitropaste X2 initially, then switched to labetalol 100mg x2, then 200mg x2, then finally started on nicardipine drip when she showed benefit with a decrease in her BP to 170/123 and improvement in her headache. . Upon arrival to the MICU, patient denies any current symptoms. She reports that her headache, shortness of breath and abdominal pain all resolved with blood pressure management and pain medications. . Pt was transferred to the floor when blood pressure was controlled. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: HR 96 BP 171/111 RR 12 O2 98% on RA Physical Exam: General in NAD HEENT NC, AT, EOMI, PERRLA, MMM CVS RRR, 3/6 systolic murmur in all heart fields RESP CTA BL, no crackles or wheezes ABD soft, hematoma raised on left anterior abdominal wall, +BS, mildly tender over hematoma EXT left sided femoral HD line in place, no erythema, no edema NEURO A+Ox3, CN2-12 intact, pt has left sided artificial eye, motor and sensory intact Pertinent Results: ***LABS ON ADMISSION*** [**2142-1-13**] 07:03AM WBC-5.2 RBC-2.79* HGB-8.5* HCT-26.3* MCV-94 MCH-30.3 MCHC-32.2 RDW-19.2* [**2142-1-13**] 07:03AM PLT COUNT-154 [**2142-1-13**] 07:03AM PT-29.5* PTT-49.2* INR(PT)-3.0* [**2142-1-13**] 07:03AM GLUCOSE-94 UREA N-53* CREAT-7.0* SODIUM-136 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [**2142-1-13**] 07:03AM CALCIUM-8.8 PHOSPHATE-5.0* MAGNESIUM-1.9 [**2142-1-14**] 12:00PM PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-14**] 12:00PM LIPASE-42 [**2142-1-14**] 12:00PM ALT(SGPT)-12 AST(SGOT)-43* ALK PHOS-96 TOT BILI-0.4 [**2142-1-14**] 03:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-1-14**] 03:25PM URINE RBC-[**3-15**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-[**3-15**] [**2142-1-14**] 12:00PM BLOOD PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-19**] 06:40AM BLOOD PT-18.6* PTT-38.7* INR(PT)-1.7* . ***LABS ON DAY OF DISCHARGE*** [**2142-1-20**] 06:35AM BLOOD WBC-5.7 RBC-2.39* Hgb-7.1* Hct-22.1* MCV-93 MCH-29.8 MCHC-32.2 RDW-18.6* Plt Ct-136* [**2142-1-20**] 06:35AM BLOOD Glucose-107* UreaN-34* Creat-4.8* Na-137 K-5.2* Cl-101 HCO3-27 AnGap-14 [**2142-1-20**] 06:35AM BLOOD PT-22.8* PTT-42.3* INR(PT)-2.2* . IMAGING [**2142-1-14**] EKG Sinus rhythm. Possible left atrial abnormality. Borderline voltage criteria for left ventricular hypertrophy. Inferolateral ST-T wave changes may be related to left ventricular hypertrophy. Compared to the previous tracing of [**2142-1-8**] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 99 190 86 368/436 13 100 24 [**2142-1-14**] CT ABD/PELV IMPRESSION: 1. Interval decrease in size to subcutaneous anterior abdominal wall hematoma. 2. Infectious versus inflammatory process within the right lower lobe of the lung. Small right simple pleural effusion. 3. Cardiomegaly with slight decrease in size of moderate pericardial effusion. 4. Right lobe liver hemangioma, unchanged. [**2142-1-14**] CT HEAD IMPRESSION: 1. Mildly limited study given administration of small amount of IV contrast material. However, no evidence of hemorrhage or mass effect. NOTE ADDED AT ATTENDING REVIEW: This patient was administered contrast for the abdominal CT, and the head CT was performed after part of this dose. Therefore, this is neither a noncontrast examination, nor a proper contrast CT. [**2142-1-14**] CXR CONCLUSION: Persistent cardiomegaly and mild pulmonary edema. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. . # Hypertensive Urgency: Pt with extensive history of hypertension. Patient's BP improved with nicardipine drip. Became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. Restarted all home oral antihypertensives including nicardipine 30 Q8H, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Blood pressure remains labile and renal continues to follow patient. Pt was transferred to the floor as blood pressure stabilized. BP has remained stable with systolics 140s-170s. In the MICU, Nifedipine extended release was added in place of Nicardipine as pt's blood pressures seemed to rise prior to Nicardipine doses. . # Hyperkalemia: Ocurred on the day after admission. Resolved with administration of kayexalate. Pt continued hemodialysis on TuThSat. . # Left abdominal wall hematoma: Abd CT showed a mild decrease in the size. Pt reported that morphine did not help pain, and was switched to dilaudid PO in the MICU. However, given pt's recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/c'ed on the floor. Pt was continued on gabapentin, tylenol around the clock, and low-dose Morphine as needed for pain. Narcotics should be avoided in the future. Pain should also resolve in the next few weeks as hematoma resolves. . # SLE: Pt was continued on prednisone at 4 mg PO daily. . #ESRD: Renal was following during her stay. She continued HD on her T, Th, Sat schedule. # Anemia: Hct was mildly decreased from baseline during admission. This is likely secondary to AOCD and in the setting of renal failure. . # SVC thrombus: Patient is on anticoagulation, likely lifelong. Patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. Then INR became subtherapeutic, so heparin gtt was used to bridge. On day of discharge, INR became therapeutic, and pt was discharged home on Coumadin 4mg PO daily, with INR to be checked next at hemodialysis . # HOCM: Pt has evidence of myocardial hypertrophy on recent Echo. She was not symptomatic during her stay. She was continued on her beta blocker. . # Depression/anxiety. She was continued on celexa and clonazepam PRN. . # OSA: CPAP for sleep with 7 pressure. . # FEN: repleted lytes prn / regular diet . # PPX: coumadin, bowel regimen . # ACCESS: PIV/ permanent dialysis cath L fem . # CODE: FULL . # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nicardipine 30mg PO TID Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for breakthrough pain for 2 weeks. 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*1* 13. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*260 Tablet(s)* Refills:*1* 14. Respiratory Therapy Please adjust settings of CPAP machine to a lower volume as it is uncomfortable for the patient. Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Discharge Condition: Good, hemodynamically stable, afebrile, pain controlled Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. One new medication was added as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to continue your Coumadin at 4mg daily and have your INR checked AT DIALYSIS next week. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep ALL scheduled appointments. Medications changes include: 1. STOP NICARDIPINE 2. Start Nifedipine CR 90mg by mouth daily 3. INCREASE Labetalol to 900mg by mouth 3 times daily 4. Continue at Warfarin 4mg by mouth daily If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to set up a follow-up appointment in 1-2weeks. Please continue your HD TuThSat. Completed by:[**2142-1-20**]",92,2142-01-14 17:34:00,2142-01-20 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. . # hypertensive urgency: pt with extensive history of hypertension. patients bp improved with nicardipine drip. became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. restarted all home oral antihypertensives including nicardipine 30 q8h, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. blood pressure remains labile and renal continues to follow patient. pt was transferred to the floor as blood pressure stabilized. bp has remained stable with systolics 140s-170s. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. . # hyperkalemia: ocurred on the day after admission. resolved with administration of kayexalate. pt continued hemodialysis on tuthsat. . # left abdominal wall hematoma: abd ct showed a mild decrease in the size. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu. however, given pts recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/ced on the floor. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. narcotics should be avoided in the future. pain should also resolve in the next few weeks as hematoma resolves. . # sle: pt was continued on prednisone at 4 mg po daily. . #esrd: renal was following during her stay. she continued hd on her t, th, sat schedule. # anemia: hct was mildly decreased from baseline during admission. this is likely secondary to aocd and in the setting of renal failure. . # svc thrombus: patient is on anticoagulation, likely lifelong. patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. then inr became subtherapeutic, so heparin gtt was used to bridge. on day of discharge, inr became therapeutic, and pt was discharged home on coumadin 4mg po daily, with inr to be checked next at hemodialysis . # hocm: pt has evidence of myocardial hypertrophy on recent echo. she was not symptomatic during her stay. she was continued on her beta blocker. . # depression/anxiety. she was continued on celexa and clonazepam prn. . # osa: cpap for sleep with 7 pressure. . # fen: repleted lytes prn / regular diet . # ppx: coumadin, bowel regimen . # access: piv/ permanent dialysis cath l fem . # code: full . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Other vascular complications of medical care, not elsewhere classified; Systemic lupus erythematosus; Hyperpotassemia; Phlebitis and thrombophlebitis of upper extremities, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. # anemia: hct was mildly decreased from baseline during admission. # hocm: pt has evidence of myocardial hypertrophy on recent echo. # fen: repleted lytes prn / regular diet . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. pt was transferred to the floor as blood pressure stabilized. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu." 109,137510.0,14810,2142-04-22,14805,176760.0,2142-01-23,Discharge summary,"Admission Date: [**2142-1-21**] Discharge Date: [**2142-1-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Hypertensive Urgency and fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with hypertensive urgency, subjective fevers, and pain. . Of note, she had been hospitalized [**Date range (1) 43505**] with hypertensive urgency. Her nicardipine was changed to nifedipine in hospital and her labetalol was increased to 900mg TID from 800mg TID.BPs were reportedly stable in the 140's-170's on the medical floor on nifedipine, aliskerin, labetalol, clonidine, and hydralazine prior to discharge. Last HD was [**1-20**]. . She reports feeling well at time of discharge [**1-20**], however woke this evening feeling sweaty, hot, and mildly SOB. She did not check her temperature and denies any rigors. She had total body aching (worst in her left wrist at site of recent IV and abdomen at site of known hematoma). +Palpitations overnight now resolved. No CP, SOB, cough, diarrhea, dysuria, erythema/tenderness/drainage from HD catheter. Denies recent joint symptoms with her lupus. No sick contacts. Says she took her BP meds. . Upon arrival to the ED, her vitals were 99.9 104 254/145 16 96% on RA. She was started on a nicardipine drip, given 1"" nitropaste with improvement in her BP. Did spike a fever while in the ED, currently 101F 101 173/106 Given vancomycin and zoysn for ?pna as CXR with right sided haziness. Also received 3mg IV dilaudid for body pains. LUE ultrasound without evidence of DVT. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 98.5 P 92 Bp 173/116 RR 16 O2 100% on RA General Pleasant young woman appearing comfortable HEENT Cushingoid faces, L eye prosthesis, MMM Pulm Lungs clear bilaterally, no rales or wheezing CV Regular S1 S2 ?soft systolic murmur Abd Soft +hematoma left abdomen unchanged from prior exam Extrem Warm full distal pulses. Left hand with slight edema ++ tender to palpation of wrist patient unable to make fist secondary to pain, no erythema +warmth ?purulence at site of old PIV Skin No peripehral stigmata of endocarditis Lines Left groin HD catheter site without erythema, purulence, or tenderness Neuro Alert and awake, moving all extremities Pertinent Results: CXR [**1-21**]: In comparison with the earlier study of this date, the diffuse pulmonary edema has substantially decreased, possibly following hemodialysis. Enlargement of the cardiac silhouette persists and there is no definite pleural effusion. Suggestion of an area of increased opacification at the right base. This could merely represent asymmetric edema, though the possibility of a developing consolidation cannot be unequivocally excluded. . LUE US [**1-21**]: IMPRESSION: No DVT in the left upper extremity. . L wrist xray [**1-21**]: There is prominent soft tissue swelling about the wrist, relatively diffuse, but quite prominent along the dorsum of the wrist. No fracture, dislocation, degenerative change, focal lytic or sclerotic lesion, or erosion is identified. No soft tissue calcification or radiopaque foreign body is identified. A tiny (1.7 mm) linear density is seen along the dorsum of the wrist on the oblique view is seen only on that view and is consistent with a small film artifact. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency and left wrist pain. . 1. Hypertensive urgency: Patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. Patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. She was started on nicardipine drip and 1"" nitropaste and admitted to the ICU for further treatment. There was no evidence of end-organ ischemia. Upon arrival to the ICU she was given her usual home antihypertensives and the nicardipine was quickly weaned off. It was felt that pain and anxiety were both contributing to her elevated BPs. Her BP quickly stabilized and she was called out to the medical floor where her SBP ranged 110-150. She was continued on nifepidine 90mg daily, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Given her repeated admissions with hypertensive urgency a meeting was held between the patient's nephrologist Dr. [**Last Name (STitle) 4883**], her ICU physician and her [**Name9 (PRE) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the ICU where she quickly improves with simply continuing her home medications. The following plan was drafted and placed in a note in OMR titled "" Care Protocol"". . CARE PROTOCOL: . BLOOD PRESSURE MANAGEMENT: . For BP > 230/140 1. Hydralazine: 100 mg PO OR 10 mg IV q 20 minutes until blood pressure back to baseline*. . 2. Give daily blood pressure medications, if she has not already taken them before arrival. . 3. If after one hour of therapy AND/OR evidence of end organ damage, transfer to the ICU. . * Note: Her usual blood pressure is ~ 160/100. Efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. In the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . PAIN MANAGEMENT: . As an outpatient, Ms. [**Name13 (STitle) **] takes dilaudid 2-4 mg PO q 4 PRN.This is being slowly tapered, she should not be administered IV pain medications. . ANTICOAGULATION: . In the absence of bleeding, warfarin does not need to be stopped on admission. Similarly, in the absence of new thrombosis, subtherapeutic INR's do not require bridging with IV UFH. . 2. Fever: Possible sources included line infection, thombophlebitis, septic arthritis, PNA. Received vanc/zosyn in ED for possible PNA. UA without pyuria and urine culture negative. CXR also without convinving infiltrate on repeat PA/Lat so zosyn was discontinued. Patient was complaining of severe pain at her IV site and was noted to have a small abscess there which was felt to be the cause of her fever. She was continued on IV vanco with HD for 10day course. She remained afebrile and did not have a leukocytosis. . 3. Left wrist pain: Began following IV placement during recent hospitalization. Likely due to septic thrombophlebitis. Small abscess was too small to drain. This was treated with warm soaks and prn PO dilaudid. Vanco was continued for 10 day course. L wrist films were enremarkable. . 4. Left abdominal wall hematoma: Stable on exam from recent admission. She was continued on pain management with morphine 7.5mg TID, gabapentin and tylenol as needed for pain. . 5. SLE: Continued prednisone at 4 mg PO daily . 6. ESRD: Continued on regularly scheduled dialysis. . 7. Anemia: Baseline Hct 26. Her Hct was mildly decreased from baseline. Secondary to AOCD and renal failure. There was no evidence of bleeding. . 8. SVC thrombus: Known SVC thrombus, therapeutic on coumadin. Continued warfarin. . 9. HOCM: evidence of myocardial hypertrophy on recent Echo. Currently not symptomatic. Echo without evidence of worsening pericardial effusion. Continued beta blocker . 10. Depression/anxiety. Continued Celexa, clonazepam 0.5mg [**Hospital1 **] . 11. OSA: Continued CPAP Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nifedipine 90mg PO daily Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325-650 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*270 Tablet(s)* Refills:*2* 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 7 days. [**Hospital1 **]:*4 dose* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Septic thrombophlebitis Discharge Condition: Stable, afebrile, BP improved. Discharge Instructions: You were admitted to the hospital with hypertensive urgency. You required IV medications and were observed overnight in the ICU. Your usual oral blood pressure medications were continued and your blood pressure remained well-controlled. You were found to have an infection at your prior IV site on your left hand. For this you were given IV vancomycin. You will need 7 days more of antibiotics which will be given with dialysis. Please resume your usual dialysis schedule. Your last dialysis was [**1-23**]. Please continue to take your medications as prescribed. You should hold your coumadin today. You can resume this on wednesday at your normal dose. You should have your INR checked at dialyis as usual on thursday. . If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-12**] weeks. ",89,2142-01-21 11:23:00,2142-01-23 16:40:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE EMERGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. . 1. hypertensive urgency: patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. there was no evidence of end-organ ischemia. upon arrival to the icu she was given her usual home antihypertensives and the nicardipine was quickly weaned off. it was felt that pain and anxiety were both contributing to her elevated bps. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150. she was continued on nifepidine 90mg daily, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. given her repeated admissions with hypertensive urgency a meeting was held between the patients nephrologist dr. [**last name (stitle) 4883**], her icu physician and her [**name9 (pre) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the icu where she quickly improves with simply continuing her home medications. the following plan was drafted and placed in a note in omr titled "" care protocol"". . care protocol: . blood pressure management: . for bp > 230/140 1. hydralazine: 100 mg po or 10 mg iv q 20 minutes until blood pressure back to baseline*. . 2. give daily blood pressure medications, if she has not already taken them before arrival. . 3. if after one hour of therapy and/or evidence of end organ damage, transfer to the icu. . * note: her usual blood pressure is ~ 160/100. efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. in the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . pain management: . as an outpatient, ms. [**name13 (stitle) **] takes dilaudid 2-4 mg po q 4 prn.this is being slowly tapered, she should not be administered iv pain medications. . anticoagulation: . in the absence of bleeding, warfarin does not need to be stopped on admission. similarly, in the absence of new thrombosis, subtherapeutic inrs do not require bridging with iv ufh. . 2. fever: possible sources included line infection, thombophlebitis, septic arthritis, pna. received vanc/zosyn in ed for possible pna. ua without pyuria and urine culture negative. cxr also without convinving infiltrate on repeat pa/lat so zosyn was discontinued. patient was complaining of severe pain at her iv site and was noted to have a small abscess there which was felt to be the cause of her fever. she was continued on iv vanco with hd for 10day course. she remained afebrile and did not have a leukocytosis. . 3. left wrist pain: began following iv placement during recent hospitalization. likely due to septic thrombophlebitis. small abscess was too small to drain. this was treated with warm soaks and prn po dilaudid. vanco was continued for 10 day course. l wrist films were enremarkable. . 4. left abdominal wall hematoma: stable on exam from recent admission. she was continued on pain management with morphine 7.5mg tid, gabapentin and tylenol as needed for pain. . 5. sle: continued prednisone at 4 mg po daily . 6. esrd: continued on regularly scheduled dialysis. . 7. anemia: baseline hct 26. her hct was mildly decreased from baseline. secondary to aocd and renal failure. there was no evidence of bleeding. . 8. svc thrombus: known svc thrombus, therapeutic on coumadin. continued warfarin. . 9. hocm: evidence of myocardial hypertrophy on recent echo. currently not symptomatic. echo without evidence of worsening pericardial effusion. continued beta blocker . 10. depression/anxiety. continued celexa, clonazepam 0.5mg [**hospital1 **] . 11. osa: continued cpap ","PRIMARY: [Other vascular complications of medical care, not elsewhere classified] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; ; Systemic lupus erythematosus; Phlebitis and thrombophlebitis of upper extremities, unspecified]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. she was continued on iv vanco with hd for 10day course. esrd: continued on regularly scheduled dialysis. her hct was mildly decreased from baseline. hocm: evidence of myocardial hypertrophy on recent echo. echo without evidence of worsening pericardial effusion. continued celexa, clonazepam 0.5mg [**hospital1 **] .","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150." 109,137510.0,14810,2142-04-22,14806,113189.0,2142-02-17,Discharge summary,"Admission Date: [**2142-2-14**] Discharge Date: [**2142-2-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: From admission note: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome admitted with HTN and SOB in the setting of missed HD. The patient reported missing HD yesterday because she thinks she is being overdiuresed. She reports persistent pain at site of rectus sheath hematoma. Denies N/V/D. Pt recently admitted from [**Date range (1) 13924**] with consistent abdominal pain at the site of her known left abdominal wall hematoma, hypertensive to 230's and hyperkalemic to 6.2 after missing her last two dialysis sessions. At this time the pt. was dialyzed, received a blood transfusion, and was administered her daily antihypertensive medications. Pt. left AMA after her transfusion despite the primary team's concerns to look for an active area of bleeding. In the ED, patient complain of mild dyspnea, sating well on RA. CXR mild volume overload. KUB with no evidence of obstruction. She was started on a labetalol gtt. ECG - RAD, LVH no change from prior. HCT stable at 21. The renal team evaluated pt and recommended HD, however the patient refused. She was transferred to ICU for BP control. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: [**2142-2-14**] 07:40AM WBC-3.9* RBC-2.38* HGB-7.0* HCT-21.3* MCV-90 MCH-29.5 MCHC-33.0 RDW-18.9* [**2142-2-14**] 07:40AM NEUTS-74.9* LYMPHS-18.7 MONOS-3.1 EOS-3.0 BASOS-0.2 [**2142-2-14**] 07:40AM PLT COUNT-101* [**2142-2-14**] 07:40AM PT-16.3* PTT-36.6* INR(PT)-1.5* [**2142-2-14**] 07:40AM CK-MB-6 [**2142-2-14**] 07:40AM cTropnT-0.09* [**2142-2-14**] 07:40AM LIPASE-80* [**2142-2-14**] 07:40AM ALT(SGPT)-34 AST(SGOT)-72* CK(CPK)-120 ALK PHOS-124* TOT BILI-0.4 [**2142-2-14**] 07:40AM GLUCOSE-85 UREA N-32* CREAT-7.0* SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-19* ANION GAP-17 [**2142-2-14**] 07:44AM LACTATE-1.3 [**2142-2-14**] CXR: Stable cardiomegaly with mild CHF and a small left pleural effusion. Left basilar air space disease which may represent pneumonia. Clinical correlation and a follow up chest x-ray to clearance is recommended. [**2142-2-14**] KUB: 1. Nonspecific bowel gas pattern with no evidence of obstruction. 2. Left basilar airspace disease which may represent pneumonia and a small left pleural effusion. Please ensure follow-up to clearance. Brief Hospital Course: 24 y.o female with SLE, ESRD on HD and malignant hypertension who presents with HTN and SOB aftering missing HD. . # Malignant hypertension/hypertensive urgency: The patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and HD compliance. Has previously presented with BP up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. Pt was treated per OMR hypertensive protocol created by the patient's primary providers, with a goal SBP of 160-180. With short course of IV antihypertensives and hemodialysis, pt's BP fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # ESRD: Pt was followed by the renal service and underwent HD without any complications. Pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting HD. She will discuss this further with the Renal team as an outpatient. . # SLE: Pt was continued on her home dose of prednisone with no sign of SLE flair. . # Coagulopathy/history of DVT: Patient on lifetime anticoagulation for hx of multiple thrombotic events. Pt was continued on coumadin. . # Pain management: Pt was treated with PO dilaudid for her abdominal pain, as recommended per her OMR protocol. She asked for IV dilaudid multiple times but there was no clinical indication. She was also continued on gabapentin. . # Anemia: Secondary to AOCD and renal failure. The patietns Hct remained stable in the low 20s during admission. No PRBC infusions were needed. . # Depression/anxiety: Continued Celexa, clonazepam 0.5mg [**Hospital1 **] Medications on Admission: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain. 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Disposition: Home Discharge Diagnosis: Primary: Malignant Hypertension Secondary: SLE, End stage renal disease on hemodialysis, SVC syndrome Discharge Condition: Stable. SBP in 160s. Discharge Instructions: You were admitted with dangerously high hypertension and some shortness of breath in the setting of missing several dialysis sessions. You were admitted and treated with your usual regimen of blood pressure meds and a short course of IV meds. With dialysis, your symptoms improved. You also had some abdominal pain, which was well controlled on your usual pain medications. We made no changes to your medications. Please take everything as prescribed. Please call your PCP or return to the hospital if you develop any headaches, visual changes, confusion or chest pain, or any other concerning symptoms. Followup Instructions: Please schedule a follow up with Dr [**Last Name (STitle) **] in [**Month (only) 958**] as scheduled. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2142-2-21**]",64,2142-02-14 10:42:00,2142-02-17 18:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. . # malignant hypertension/hypertensive urgency: the patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and hd compliance. has previously presented with bp up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. with short course of iv antihypertensives and hemodialysis, pts bp fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # esrd: pt was followed by the renal service and underwent hd without any complications. pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting hd. she will discuss this further with the renal team as an outpatient. . # sle: pt was continued on her home dose of prednisone with no sign of sle flair. . # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events. pt was continued on coumadin. . # pain management: pt was treated with po dilaudid for her abdominal pain, as recommended per her omr protocol. she asked for iv dilaudid multiple times but there was no clinical indication. she was also continued on gabapentin. . # anemia: secondary to aocd and renal failure. the patietns hct remained stable in the low 20s during admission. no prbc infusions were needed. . # depression/anxiety: continued celexa, clonazepam 0.5mg [**hospital1 **] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Thrombotic microangiopathy; Systemic lupus erythematosus; Anemia in chronic kidney disease; Thrombocytopenia, unspecified; Obstructive sleep apnea (adult)(pediatric); Nontraumatic hematoma of soft tissue; Dysthymic disorder; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events.","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob after missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. she was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine." 109,137510.0,14810,2142-04-22,14808,158943.0,2142-03-23,Discharge summary,"Admission Date: [**2142-3-21**] Discharge Date: [**2142-3-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: Abdominal Pain, Shortness of breath, Chest discomfort Major Surgical or Invasive Procedure: HD [**2142-3-21**] and [**2142-3-23**] History of Present Illness: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] 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 [**Telephone/Fax (3) 43508**]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. [**Telephone/Fax (3) **] was discussed with renal and it was not felt that HTN is a volume issue so no need for emergent [**Telephone/Fax (3) 2286**]. . 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 [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**], getting Vanc with HD. . PSHx: 1. Placement of multiple catheters including [**Year (4 digits) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] 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: [**2142-3-21**] 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* [**2142-3-21**] 02:20AM NEUTS-76.1* BANDS-0 LYMPHS-17.9* MONOS-4.5 EOS-1.1 BASOS-0.5 [**2142-3-21**] 02:20AM PLT SMR-NORMAL PLT COUNT-168 [**2142-3-21**] 02:20AM PT-21.8* PTT-34.7 INR(PT)-2.1* [**2142-3-21**] 02:20AM cTropnT-0.12* [**2142-3-21**] 02:20AM ALT(SGPT)-46* AST(SGOT)-94* CK(CPK)-76 ALK PHOS-173* TOT BILI-0.4 [**2142-3-21**] 02:20AM GLUCOSE-74 UREA N-47* CREAT-7.3* SODIUM-140 POTASSIUM-5.8* CHLORIDE-109* TOTAL CO2-19* ANION GAP-18 [**2142-3-21**] 04:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-21**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2142-3-21**] 12:58PM CK-MB-NotDone cTropnT-0.12* . CT C/A/P - [**2142-3-20**] - 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: [**2142-3-23**] 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* [**2142-3-23**] 12:00PM BLOOD Plt Ct-130* [**2142-3-23**] 12:00PM BLOOD PT-28.8* PTT-58.6* INR(PT)-2.9* [**2142-3-23**] 12:00PM BLOOD Glucose-77 UreaN-31* Creat-6.0*# Na-137 K-4.8 Cl-104 HCO3-24 AnGap-14 [**2142-3-23**] 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 [**3-22**] 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 [**2142-3-21**] . # abdominal pain: Consistent with patient's baseline chronic abdominal pain. Medication effect also possible. CT prelim neg for small bowel obstruction. LFTs doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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). [**Month/Year (2) **]:*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 [**Month/Year (2) 2286**] sessions as directed by the nephrology team- your next session should be on Tuesday. Completed by:[**2142-3-26**]",30,2142-03-21 09:25:00,2142-03-23 18:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,CHEST PAIN;TELEMETRY," 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 (200s/100s) that nevertheless are within levels shes 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 [**3-22**] and transferred to the medicine floor. the next day, her bp remained within goal of 120s/80s. 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. ces were cycled and were negative. cpap was continued as tolerated at home settings. sob resolved after hd on [**2142-3-21**] . # abdominal pain: consistent with patients baseline chronic abdominal pain. medication effect also possible. ct prelim neg for small bowel obstruction. lfts doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Compression of vein; Unspecified disease of pericardium; Infection and inflammatory reaction due to other vascular device, implant, and graft; Bacteremia; Primary hypercoagulable state; Other primary cardiomyopathies; ; Abdominal pain, unspecified site; Urinary tract infection, site not specified; Acidosis; Other chest pain; Other chronic pain; Systemic lupus erythematosus; Noncompliance with renal dialysis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Hyperpotassemia; 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; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","this is a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. ct prelim neg for small bowel obstruction. on arrival to the floor, abd pain was back to baseline and well controlled on dilaudid 2mg po q 4hrs .","a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. initial attempts were made to control her bp with hydralazine and labetalol iv but after these failed to control her blood pressure. she was successfully transitioned to home medications of clonidine, labetalol, aliskiren, nifedipine" 109,137510.0,14810,2142-04-22,14809,124398.0,2142-03-31,Discharge summary,"Admission Date: [**2142-3-24**] Discharge Date: [**2142-3-31**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: HTN, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 24F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] after admission for abdominal pain, MSSA bacteremia, paroxysmal hypertension and ESRD line, followed by readmission [**3-22**], now presents with usual central crampy abdominal pain, 3 loose nonbloody stools this AM, SOB, and HTN to 270s. Pt was d/c'd from [**Hospital1 18**] yesterday after HD session, went home, states she took her PM meds, took her 8 AM medds (hydral, labetalol), then developed these symptoms which precluded her from taking her usual home meds (no afternoon meds - nifedipine, labetalol, hydral). The abd pain comes and goes and is unchanged from her baseline. While she has nausea, she is asking for dinner. . In the ED, initial BP 272/148. CXR w/o evidence of volume overload. No CT scan performed. Started on NTG gtt, given Hydralazine 10 x 1, Dilaudid 2 mg, labetaolo 20mg IV x 1. . Upon arrival to the floor, her BP was 240/135. She continued to complain of abdominal pain but was eating crackers, breathing felt better. RR 17. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: 98.2 97 [**Telephone/Fax (2) 43509**]0% on 2 L nC Gen: pleasant, comfortable HEENT: L eye enucleated. moon facies. Right pupil reactive Heart: hrrr, no m/r/g Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, diffuse TTP, no rebound/guarding Ext: no c/c/e Neuro: aox4, cn 2-12 intact grossly. Pertinent Results: [**2142-3-24**] 07:17PM PT-22.4* PTT-43.64* INR(PT)-2.1* [**2142-3-24**] 04:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2142-3-24**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-24**] 04:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**11-30**] [**2142-3-24**] 02:05PM GLUCOSE-76 UREA N-21* CREAT-4.8*# SODIUM-139 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2142-3-24**] 02:05PM ALT(SGPT)-78* AST(SGOT)-181* CK(CPK)-55 ALK PHOS-192* TOT BILI-0.5 [**2142-3-24**] 02:05PM cTropnT-0.12* [**2142-3-24**] 02:05PM CK-MB-5 [**2142-3-24**] 02:05PM WBC-3.6* RBC-2.90* HGB-8.9* HCT-26.6* MCV-92 MCH-30.7 MCHC-33.4 RDW-19.8* [**2142-3-24**] 02:05PM NEUTS-73.9* BANDS-0 LYMPHS-18.5 MONOS-3.8 EOS-3.0 BASOS-0.8 [**2142-3-24**] 02:05PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-1+ TARGET-1+ SCHISTOCY-OCCASIONAL TEARDROP-1+ ELLIPTOCY-OCCASIONAL [**2142-3-24**] 02:05PM PLT SMR-LOW PLT COUNT-129* [**2142-3-23**] 12:00PM GLUCOSE-77 UREA N-31* CREAT-6.0*# SODIUM-137 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14 [**2142-3-23**] 12:00PM estGFR-Using this [**2142-3-23**] 12:00PM CALCIUM-8.4 PHOSPHATE-5.7* MAGNESIUM-1.9 [**2142-3-23**] 12:00PM WBC-3.7* RBC-2.87* HGB-8.7* HCT-26.1* MCV-91 MCH-30.3 MCHC-33.3 RDW-19.4* [**2142-3-23**] 12:00PM PLT COUNT-130* [**2142-3-23**] 12:00PM PT-28.8* PTT-58.6* INR(PT)-2.9* Brief Hospital Course: The patient was admitted to the MICU on a NTG gtt from the ED. Her abdominal pain had imporved and she was eating crackers and peanut butter. She was given her usual afternoon home medications, and transitioned to a Nicardipine gtt, which has worked well for her in the past. Her BP goal was for a systolic of 180-200. The Nicardipine gtt was titrated off quickly and she was transfered to the floor. . On arrival to the floor, she in fact missed her morning medications on [**Month/Day/Year 766**]. This resulted in elevate blood pressures requiring IV hydralazing for control. She went to dialyisis Tuesday [**3-27**] and again had markedly elevated blood pressures while at [**Month/Year (2) 2286**] from missing her AM doses. Instructions were written for explicit AM administration and Nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. She was continued on labetalol 900mg TID, Aliskerin, Hydralazine 100mg po TID, and clonidine patch 0.4mg/24 weekly patch. . HEr BP remained relativly stable. She established a three three times weekly Dialysus regemin. A PAP smear was attempted due to her history of CIN I and no PCP follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . Her abdominal pain was also a chronic issue, which appeared stable. She was not administered IV narcotics, only PO. It was wihtout clear percipitating events or etiology. She will need GI follow up. She was contact[**Name (NI) **] by phone several times to arrange a GI follow up appointment but did not return messages. She has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . She was discharged to followup with her nephrologist, Dr. [**Last Name (STitle) 4883**]. . 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. Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Last Name (STitle) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2* 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). [**Last Name (STitle) **]:*405 Tablet(s)* Refills:*2* 5. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*2* 6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). [**Last Name (STitle) **]:*60 Tablet(s)* Refills:*2* 9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patches Transdermal once a week: Place two patches every week on Fridays. [**Last Name (STitle) **]:*8 Patches* Refills:*2* 10. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*0* 11. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO twice a day as needed for prn SBP>200: if nauseated and cannot keep down meds, may use 1 sublingual clonidine if sbp>200. . [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0* 12. Kayexalate Powder Sig: Thirty (30) grams PO once a day for 2 days: please take [**2142-4-1**] and [**2142-4-2**] for elevated potassium. [**Month/Day/Year **]:*240 grams* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Systemic Lupus Erythematosus End Stage Renal Disease Hypertension Abdominal Pain Discharge Condition: Blood pressure stable and abdominal pain at baseline Discharge Instructions: You were admitted with high blood pressure. You were in the ICU overnight for treatment. Some of your medications were changed and you were increased to three times weekly [**Location (un) 2286**]. Your abdominal pain is a difficult problem, as the reason for the pain is unclear. [**Name2 (NI) **] were continued on oral dilaudid. IV dilaudid is strongly discouraged and will continue to be in the future. You are now taking Nifedipine SR 30mg at night in addition to 90mg in the morning. Your other medications were the same. At home, if your blood pressure is above 200, then take 100mg hydralazine. If after 1 hour, your blood pressure does not decrease to below 200 with this, then take another 100mg hydralazine. If you are nauseated and cannot take in oral meds, then take sublingual clonidine, then wait 1 hour and repeat if BP still > 200. Finally, your potassium has been high. Please take kayexalate 30gm tomorrow and the next day. Followup Instructions: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-3-31**] 7:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule appointment We will attempt to contact you on [**Name (NI) 766**] with appointment times for you. ",22,2142-03-24 16:34:00,2142-03-31 15:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," the patient was admitted to the micu on a ntg gtt from the ed. her abdominal pain had imporved and she was eating crackers and peanut butter. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. her bp goal was for a systolic of 180-200. the nicardipine gtt was titrated off quickly and she was transfered to the floor. . on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**]. this resulted in elevate blood pressures requiring iv hydralazing for control. she went to dialyisis tuesday [**3-27**] and again had markedly elevated blood pressures while at [**month/year (2) 2286**] from missing her am doses. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she was continued on labetalol 900mg tid, aliskerin, hydralazine 100mg po tid, and clonidine patch 0.4mg/24 weekly patch. . her bp remained relativly stable. she established a three three times weekly dialysus regemin. a pap smear was attempted due to her history of cin i and no pcp follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . her abdominal pain was also a chronic issue, which appeared stable. she was not administered iv narcotics, only po. it was wihtout clear percipitating events or etiology. she will need gi follow up. she was contact[**name (ni) **] by phone several times to arrange a gi follow up appointment but did not return messages. she has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . she was discharged to followup with her nephrologist, dr. [**last name (stitle) 4883**]. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Long-term (current) use of steroids; Other chronic pain; Obstructive sleep apnea (adult)(pediatric); Abdominal pain, generalized; Hyperpotassemia]","the patient was admitted to the micu on a ntg gtt from the ed. her bp goal was for a systolic of 180-200. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she established a three three times weekly dialysus regemin.","the patient was admitted to the micu on a nicardipine gtt from the ed. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**] this resulted in elevate blood pressures requiring iv hydralazing for control " 109,137510.0,14810,2142-04-22,14807,158995.0,2142-02-26,Discharge summary,"Admission Date: [**2142-2-25**] Discharge Date: [**2142-2-26**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 338**] 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 History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, hx of malignant HTN admitted with change in mental status. Patient missed HD on [**2142-2-24**] and was found unresponsive and diaphoretic by mother this morning after she took some dilaudid. EMS was called, 1 mg of narcan was administered with slight improvement in mental status. On arrival to the ED her vitals were 112/64 62 16 99RA she was noted to be hyperkalemic in the absence of EKG changes and was given calcium, D5, 10U regular insulin, 30 mg po kayxalate and repeat K was 5.4. ABG: 7.29/38/199. Repeat glucose was 41 and 1amp D50 was given. She was sent to the ICU for monitoring. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including [**Month/Year (2) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: HR: 80 (79 - 80) bpm BP: 127/59(76) {127/59(76) - 139/64(82)} mmHg RR: 34 (21 - 34) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Physical Examination Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact Pertinent Results: [**2142-2-25**] 01:50PM PT-14.9* PTT-36.8* INR(PT)-1.3* [**2142-2-25**] 01:50PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2142-2-25**] 01:50PM WBC-5.0 RBC-2.21* HGB-6.4* HCT-20.7* MCV-94 MCH-29.1 MCHC-31.1 RDW-19.6* [**2142-2-25**] 10:30PM GLUCOSE-87 UREA N-66* CREAT-8.4* SODIUM-142 POTASSIUM-5.9* CHLORIDE-110* TOTAL CO2-16* ANION GAP-22* HISTORY: Altered mental status. Evaluate underlying for pneumonia. UPRIGHT PORTABLE CHEST: Comparison is made to [**2-14**] and [**2142-2-19**], exams. Study is slightly limited by patient motion. In the interval, the degree of pulmonary edema appears improved with slightly decreased prominence of the pulmonary vascularity. There is unchanged extensive retrocardiac consolidation obscuring the majority of the left hemidiaphragm with persistent blunting of the left CP angle, likely related to small effusion. Exam is otherwise unchanged from prior with persistent cardiomegaly. A catheter is seen projecting over the abdomen, partially imaged. IMPRESSION: Slight improvement in pulmonary edema with persistent retrocardiac opacity, which again may represent atelectasis versus underlying pneumonia. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted hypotension and decreased mental status. Hypotension and altered mental status were in the setting of excessive narcotic use. Patient's narcotics were held, pressors returned to [**Location 213**] and patient was mentating fine. Hct was below baseline and patient was transfused 1u PRBC and was given HD before discharge. Patient is to continue anti-hypertensive medications as previously scheduled. Patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # Change in mental status: Resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. Patient received 1 dose of narcan with slight improvement in BP and mental status. patient without fevers or leuckocytosis which argue against infection. # Hypertension ?????? resumed outpatient regimen. Patient did not have any hypertensive episodes requiring hydralizine 10mg IV. # Hypotension: resolved, Patient normotensive on arrival to ICU. Relative hypotension likely due to dilaudid. Other considerations include sepsis, although patient without objective signs of infection. Held pain medications and hypotension resolved. Resumed hypertensive medications. # Abdominal pain ?????? from previous peritoneal [**Location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # Hyperkalemia: Likely due to missed HD session. She received calcium, D5, insulin and kayexalate in ED. HD in am ESRD: Renal following, had HD the day of discharge, transfused while there. Will continue normal schedule as an outpatient with HD T/Th/F this week. # Metabolic Acidosis: likely due to renal failure and missed HD. # SLE: continued prednisone at 4 mg PO daily. # OSA: CPAP for sleep with 7 pressure, however patient refuses. Continued to offer as inpatient. Should try to follow up with sleep medicine. Medications on Admission: Prednisone 4mg qd Citalopram 20 mg daily Gabapentin 300 mg [**Hospital1 **] Warfarin 4mg daily Pantoprazole 40 mg qd Clonidine 0.1 mg/24 QWED Clonidine 0.3 mg/24 hr QWED Labetalol 900 mg tid Nifedipine 90 mg qd Aliskiren 150 mg [**Hospital1 **] Hydralazine 100 mg q8h Morphine 7.5 mg q8h prn pain Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Home Discharge Diagnosis: Primary: narcotic overdose relative hypotension anemia Secondary: ESRD on HD [**2-12**] SLE malignant hypertension Discharge Condition: stable - received HD prior to discharge Discharge Instructions: You were admitted for altered mental status after missing hemodialysis. It was likely from the dilaudid you took as well as missing your scheduled [**Month/Day (2) 2286**]. You were also relatively hypotensive in the setting of excessive narcotic medicaiton usage. Narcotic medications were held and hypotension and altered mental status resolved. Please use narcotic medications with caution. You are recommended to use morphine for pain control rather than dilaudid. No medication changes were made. Please return to the ED if you have any altered mental status or miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] or have symptoms such as vision changes or headache from your history of malignant hypertension. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-3-20**] 3:00 HD as previously scheduled Completed by:[**2142-2-26**]",55,2142-02-25 15:49:00,2142-02-26 16:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ALTERED MENTAL STATUS," 24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. patients narcotics were held, pressors returned to [**location 213**] and patient was mentating fine. hct was below baseline and patient was transfused 1u prbc and was given hd before discharge. patient is to continue anti-hypertensive medications as previously scheduled. patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # change in mental status: resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. patient received 1 dose of narcan with slight improvement in bp and mental status. patient without fevers or leuckocytosis which argue against infection. # hypertension ?????? resumed outpatient regimen. patient did not have any hypertensive episodes requiring hydralizine 10mg iv. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. other considerations include sepsis, although patient without objective signs of infection. held pain medications and hypotension resolved. resumed hypertensive medications. # abdominal pain ?????? from previous peritoneal [**location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # hyperkalemia: likely due to missed hd session. she received calcium, d5, insulin and kayexalate in ed. hd in am esrd: renal following, had hd the day of discharge, transfused while there. will continue normal schedule as an outpatient with hd t/th/f this week. # metabolic acidosis: likely due to renal failure and missed hd. # sle: continued prednisone at 4 mg po daily. # osa: cpap for sleep with 7 pressure, however patient refuses. continued to offer as inpatient. should try to follow up with sleep medicine. ","PRIMARY: [Poisoning by other opiates and related narcotics] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Thrombotic microangiopathy; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Altered mental status; Other iatrogenic hypotension; Accidental poisoning by other opiates and related narcotics; Hyperpotassemia; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Nontraumatic hematoma of soft tissue; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. from previous peritoneal [**location 2286**] hematoma ??????","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. narcotics were held, pressors returned to and patient was mentating fine. patient was encouraged to take less pain medications and to use morphine." 109,124398.0,14809,2142-03-31,14798,126055.0,2141-11-03,Discharge summary,"Admission Date: [**2141-10-13**] Discharge Date: [**2141-11-3**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 6734**] Chief Complaint: Nausea, Vomitting, Abdominal Pain, HTN Urgenc Major Surgical or Invasive Procedure: Upper GI endoscopy Exploratory laparotomy Tunneled hemodialysis catheter in R femoral vein Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 24 y/o F with h/o ESRD, HTN who started peritoneal dialysis during the week of [**2141-10-8**] and presented with a 1 day history of acute onset N/V, sharp abdominal pain on [**2141-10-13**]. (Of note, the patient had presented to the ED on [**10-11**] with hypotension, SBPs in the 80s off after approximately 1.5L was taken off during dialysis in the setting of taking her PO Anti-HTNs. On [**2141-10-11**] she received 0.5L IVF, labs WNL, and was d/c'd home). On the day of admission on [**2141-10-13**], the patient reported that the previous night, she was awoken from sleep with severe, sharp abdominal pain, 6 episodes of frothy emesis, 10+ yellowish BMs without melena or BRBRP.She was admitted for further work- up of this abdminal pain. . In the ED here vitals were as follows: T: 97.0 HR: 101 BP: 240/180 RR: 17 O2sat: 100%RA. She received Labetolol 20mg IV and was subsequently placed on a labetolol drip. She also received ceftriaxone 1gm IV, Flagyl 500mg IV, Dilaudid 0.5-1mg IV q1hr and Zofran. Her abdominal CT showed multifocal areas of small bowel wall thickening. Her peritoneal Cell count was negtaive for SBP. She had some signs of peritonitis and thus surgery was consulted. Her lactate was normal. . Upon arrival to the MICU the patient was mentating well with complaints of diffuse sharp abdominal pain that radiated to the back and diarrhea. She had no headache or visual changes. Past Medical History: - SLE DX ([**2134**] - 16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter Placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). - Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS: 98.4 HR 98 192/131 21 100%RA GEN: Mild Distress, AOx3 HEENT: PEERLA, EOMI NECK: Supple, No LAD, No bruit RESP: CTAB CARD: 2/6 systolic ejection murmur ABD: soft, moderately tender with +/- guarding, BS+ EXTR: Warm well perfused NEURO: Motor Grossly Intact RECTAL: Yellow Stool BACK: B CVAT Pertinent Results: [**2141-11-3**] 08:50AM BLOOD WBC-3.5* RBC-2.55* Hgb-7.8* Hct-23.6* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.8* Plt Ct-176 [**2141-11-3**] 03:55PM BLOOD PT-15.5* PTT-50.8* INR(PT)-1.4* [**2141-11-3**] 08:50AM BLOOD Glucose-121* UreaN-33* Creat-5.2*# Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [**2141-10-26**] 06:15AM BLOOD ALT-11 AST-49* AlkPhos-122* Amylase-186* TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2141-10-26**] 06:15AM BLOOD Lipase-30 [**2141-11-3**] 08:50AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.9 [**2141-10-30**] 06:55AM BLOOD HBsAg-NEGATIVE [**2141-10-17**] 10:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2141-10-25**] 11:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2141-10-25**] 11:56AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2141-10-25**] 11:56AM URINE RBC-0-2 WBC-[**3-15**] Bacteri-FEW Yeast-NONE Epi-21-50 Blood cultures: all negative EKG ([**2141-10-13**]): Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of [**2141-10-2**] there is no significant diagnostic change. CXR ([**2141-10-13**]): No acute cardiopulmonary abnormality. No free air under the diaphragms. CT chest/abdomen/pelvis ([**2141-10-13**]): There is a moderate-sized pericardial effusion, similar in appearance from [**2141-10-13**]. The great vessels are normal in caliber, without aneurysmal dilatation. Evaluation of the great vessels is limited without IV contrast. Interstitial thickening, particularly within the perihilar regions, is suggestive of fluid overload. There is bibasilar atelectasis with a small focus of consolidation in the right lower lobe (2:35) unchanged from [**2141-10-13**], and may reflect aspiration or pneumonia. Scattered bilateral nodules are largely stable from as far back as [**2139-10-9**]. Specifically, there is a 5 mm nodule in the right middle lobe (2:25), two adjacent nodules in the right lower lobe measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule within the left lower lobe. A nodular density seen adjacent and anterior to the right main pulmonary artery (2:23) may reflect a vessel. There is a small right pleural effusion. Axillary lymphadenopathy, with axillary nodes measuring up to approximately 10 mm in short axis, is seen. Ill- defined soft tissue thickening within the hilus bilaterally may reflect hilar lymphadenopathy, but assessment is limited without IV contrast. A catheter is visualized within the visualized right upper extremity, which may reflect a PICC line that terminates within the right subclavian vein. The esophagus is distended and filled with contrast, with marked wall thickening and edema throughout its entire length, a new finding. There is a moderate- sized hiatal hernia. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval development of a moderate amount of free intraperitoneal air, that layers anteriorly and along the anterior abdominal wall. Additional small clustered foci of extraluminal air is seen adjacent to the proximal stomach and the gastroesophageal junction, with a focus of air tracking into the fissure of ligamentum venosum. Additionally, there appears to be air tracking into the anterior subcutaneous tissues in the region of the umbilicus. These findings are all new from the prior CT on [**2141-10-13**], but free air was present on chest radiograph performed [**2141-10-25**]. There is no obvious evidence of extravasation of oral contrast into the peritoneum. Of note, a peritoneal dialysis catheter is in place that could represent a route of entry of intraperitoneal air. The stomach, small bowel, and colon are filled with contrast, without evidence of obstruction. Evaluation for wall thickening is limited without IV contrast. Limited non-contrast views of the liver demonstrates a rounded 1.6 cm x 1.2 cm hypodensity in the right lobe of the liver, previously characterized as a hemangioma. The liver is otherwise unremarkable. The gallbladder, spleen, pancreas, and adrenal glands demonstrate no gross abnormality. Both kidneys are atrophic. Evaluation of solid organs is limited by lack of IV contrast. There is a peritoneal dialysis catheter, coiled within the pelvis, unchanged. There is a large amount of free fluid throughout the abdomen, similar in appearance to the prior study. CT OF THE PELVIS WITHOUT IV CONTRAST: Uterus and rectum are grossly unremarkable. However, assessment of the rectal wall is limited without IV contrast. OSSEOUS STRUCTURES: Bones are diffusely sclerotic, which may be related to renal osteodystrophy. There is bilateral sacroiliitis. IMPRESSION: 1. Interval development of a moderate amount of free intraperitoneal air, new from [**2141-10-13**]. A peritoneal dialysis catheter is in place and could represent the route of entry of free intraperitoneal air. However, as foci of air is seen in the region of the proximal stomach and GE junction in the setting of a recent endoscopy, perforation cannot be excluded, though no frank extravasation of contrast is identified. 2. New dilation and wall thickening of the entire esophagus, a nonspecific finding that could relate to infectious or inflammatory esophagitis; clinical correlation is recommended. Esophagus is contrast-filled possibly representing reflux. Hiatal hernia. 3. Anasarca, with moderate-sized pericardial effusion, pulmonary edema, and small right pleural effusion. 4. Large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. Imaging cannot exclude SBP, which should be evaluated for clinically. 5. Focus of consolidation within the right lower lobe, could represent aspiration or pneumonia, but unchanged from the prior study. Gastric Biopsies ([**2141-10-18**]): Antrum: Corpus-type mucosa, no diagnostic abnormalities recognized. Jejunum: Small intestinal mucosa, no diagnostic abnormalities recognized. UE Venous U/S: No evidence of DVT of the left upper extremity, without thrombus identified within the left subclavian vein. Brief Hospital Course: This is a 24 year old woman with ESRD secondary to SLE (started peritoneal dialysis approximately one week prior to admission), malignant HTN, h/o SVC syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. Her hospital course was complicated by multiple transfers between the MICU and the floor secondary to hypertensive urgency. # Abdominal Pain/Diarrhea: During the patient's admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. Infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. However, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. The patient was empirically placed on IV flagyl, but this was discontinued when stool samples were negative for C.difficile. Serial abdominal exams showed no peritoneal signs. Peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. CT of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. Other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to SLE vasculitis, malignant HTN, or microthrombosis and SLE enteritis. Surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. A heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible GI bleed. With regards to SLE vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to SLE. On [**10-18**], GI performed an EGD which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. Approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. Both cardiac, GI, and pulmonary etiologies were considered for the origin of her epigastric pain. Pericarditis was considered, but her EKG was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. Her lungs were also essentially unchanged from [**2141-10-13**]. However, her abdominal CT on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. As a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. There were no major findings: no evidence of perforation, obstruction, or infection. The patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. At discharge, the patient only complained of some mild incisional pain. # Hypertensive urgency: The patient was initially admitted to the MICU with a blood pressure of 240/180. Her hospital course was complicated by extremely labile HTN and was transferred back and forth between the MICU and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of SBPs > 260. Throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. Her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. Multiple medication regimens were attempted and changed throughout her hospital course. However, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for SBPs > 180. At discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg PO. Her regimen as per Dr. [**Last Name (STitle) 4883**]: Nifedipine SR 90 mg daily Aliskiren 150 mg [**Hospital1 **] Labetalol 300 mg TID Hydralazine 75 mg TID Clonidine patch 0.3 mg/24 hr patch qWed When SBP>180, she then uses a hydralazine sliding scale. When SBP>180, give 25 mg PO hydral every 30 min until SBP<150. You can use this for up to 2-3 hours. In between PO hydral doses, can then also use 10 IV hydralazine. # ESRD: The etiology of the patient's ESRD is secondary to SLE. Her Creatinine on admission was 7.9, which was near her baseline of 8 - 9. During her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. Prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2L per PD. After her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. Initially, the patient adamantly refused hemodialysis. However, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. As a result, after a long coversation with her primary renal physician, [**Name10 (NameIs) **] agreed to restart hemodialysis. A tunneled catheter was placed in her R femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. She underwent hemodialysis two more times prior to discharge. Upon discharge, her electrolytes were back to her baseline. She is expected to undergo hemodialysis (Tues/[**Last Name (un) **]/SAT) as an outpatient. # Anemia: During her admission, the patient's HCT was monitored daily with HCT to low-mid 20's. On [**2141-10-17**], she was found to have guaiac positive stools and her HCT was found to have dropped to a low of 18.6. The patient was transfused a total of 2 units of [**Date Range **] between [**2141-10-17**] and [**2141-10-18**]. Epo Alfa SC was also given on [**2141-10-17**]. She remained hemodynamically stable. GI consulted and EGD results were as stated above. The patient's HCT remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. Between [**2141-10-23**] - [**2141-10-24**], the patient had a HCT drop from 26 to 20 in the setting of occult positive emesis. She received two units of [**Month/Day/Year **] and her HCT returned to 28. GI was aware and planned to perform a non-urgent EGD on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her HCT returned to baseline. However, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her HCt remained stable and near baseline for the remiainder of her hospital course. # H/O Thrombosis: The patient was initially placed on her home dose of warfarin 2mg qd. Her INR on admission was 1.2. She was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. However, this was stopped for her EGD and after she had evidence of a GI bleed. The heparin drip was discontinued on [**10-22**]. The patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in HCT and in preparation for a possible GI intervention. After her surgery, her coumadin was held and she was off the heparin drip, but her INR continued to drift up, getting as high as 2.6 on [**2141-10-30**]. This was mostly attributed to nutritional deficiency [**2-11**] poor PO intake, but there was concern for possible synthetic dysfunction as well. As a result, she was given a test dose of vitamin K, which she responded to well (Her INR came back down to 1.4). As a result, her home dose of coumadin at 2 mg qday was restarted. At discharge, her INR was still sub- therapeutic at 1.4. Of note, the patient has a history of SVC syndrome and had a L subclavian venous thrombosis. During the last few days of her hospital stay, the patient complained of increased tongue swelling and her L face was noted to be slightly more swollen than previously noted. As a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a DVT within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # SLE: Rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. Her outside rheumatologist was also consulted. Both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # Obstructive sleep apnea: The patient was noted to have OSA based on clinical nocturnal exam during admission. Patient attempted 1 trial of CPAP at 2L/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. The paitent stated that she would pursue further work-up and treatment for OSA as an outpatient. While the mask and CPAP machine were at her bedside throughout her hospital course, the patient rarely used it. # Metabolic Acidosis: The patient's bicarbonate on admission was 13. Her baseline is normally between 16-20. She received 150mEq NaHCO3 over 24hrs from [**Date range (1) 43500**]. During her brief returns to the MICU, her HC03 was 18-19, which was presumed to be her baseline at home secondary to her CRF. At discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. Medications on Admission: Nifedipine 60 mg PO daily Labetalol 900 mg PO TID Hydralazine 50 mg PO TID Clonidine 0.3 mg/24hr patch qWED Lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 4 mg daily Warfarin 2mg PO daily Calcitriol 1 mcg daily Calcium carbonate 500mg QID Dilaudid 2mg PO Q4-6hr prn pain Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*30 Patch Weekly(s)* Refills:*2* 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. [**Hospital1 **]:*1500 ML(s)* Refills:*0* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Twice daily (). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): In addition to 75 mg TID, if SBP>180, take 1 tab every 30 min until BP decreases to 150. If no improvement after 2 hours, call your doctor. [**Last Name (Titles) **]:*300 Tablet(s)* Refills:*6* 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). [**Last Name (Titles) **]:*1500 ML(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet Sustained Release(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 5 days. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. [**Last Name (Titles) **]:*30 Capsule(s)* Refills:*2* 13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO once a day. [**Last Name (Titles) **]:*30 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: end stage renal disease malignant hypertension abdominal free air subclavian deep vein thrombosis initiation of hemodialysis Secondary: SLE Anemia Discharge Condition: stable, pain well controlled, blood pressure at baseline Discharge Instructions: You were admitted for abdominal pain and then subsequently had a very long hospital course with high blood pressures, severe abdominal pain, some free air in your abdomen resulting in an exploratory laparotomy. You have also been initiated on hemodialysis on Tuesday/Thursday/Saturday schedule. Please take all medications as prescribed in the list that you will be given at discharge. There have been some changes to your medications. Please call your doctor if you have any worsening abdominal pain, fevers, chills, nausea, vomiting, headache, palpitations, diarrhea or any other concerning symptoms. Followup Instructions: You will see Dr. [**Last Name (STitle) 4883**] at hemodialysis on Tuesday, [**11-7**], [**2141**]. You should have your coumadin level checked at this appointment. Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] to schedule an appointment in [**1-11**] weeks to have your staples removed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**] ",148,2141-10-13 23:10:00,2141-11-03 18:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. her hospital course was complicated by multiple transfers between the micu and the floor secondary to hypertensive urgency. # abdominal pain/diarrhea: during the patients admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. the patient was empirically placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. serial abdominal exams showed no peritoneal signs. peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. ct of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to sle vasculitis, malignant htn, or microthrombosis and sle enteritis. surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible gi bleed. with regards to sle vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to sle. on [**10-18**], gi performed an egd which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. both cardiac, gi, and pulmonary etiologies were considered for the origin of her epigastric pain. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. her lungs were also essentially unchanged from [**2141-10-13**]. however, her abdominal ct on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. as a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. there were no major findings: no evidence of perforation, obstruction, or infection. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. at discharge, the patient only complained of some mild incisional pain. # hypertensive urgency: the patient was initially admitted to the micu with a blood pressure of 240/180. her hospital course was complicated by extremely labile htn and was transferred back and forth between the micu and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of sbps > 260. throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. multiple medication regimens were attempted and changed throughout her hospital course. however, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for sbps > 180. at discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg po. her regimen as per dr. [**last name (stitle) 4883**]: nifedipine sr 90 mg daily aliskiren 150 mg [**hospital1 **] labetalol 300 mg tid hydralazine 75 mg tid clonidine patch 0.3 mg/24 hr patch qwed when sbp>180, she then uses a hydralazine sliding scale. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. you can use this for up to 2-3 hours. in between po hydral doses, can then also use 10 iv hydralazine. # esrd: the etiology of the patients esrd is secondary to sle. her creatinine on admission was 7.9, which was near her baseline of 8 - 9. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2l per pd. after her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. initially, the patient adamantly refused hemodialysis. however, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. as a result, after a long coversation with her primary renal physician, [**name10 (nameis) **] agreed to restart hemodialysis. a tunneled catheter was placed in her r femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. she underwent hemodialysis two more times prior to discharge. upon discharge, her electrolytes were back to her baseline. she is expected to undergo hemodialysis (tues/[**last name (un) **]/sat) as an outpatient. # anemia: during her admission, the patients hct was monitored daily with hct to low-mid 20s. on [**2141-10-17**], she was found to have guaiac positive stools and her hct was found to have dropped to a low of 18.6. the patient was transfused a total of 2 units of [**date range **] between [**2141-10-17**] and [**2141-10-18**]. epo alfa sc was also given on [**2141-10-17**]. she remained hemodynamically stable. gi consulted and egd results were as stated above. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. she received two units of [**month/day/year **] and her hct returned to 28. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. however, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her hct remained stable and near baseline for the remiainder of her hospital course. # h/o thrombosis: the patient was initially placed on her home dose of warfarin 2mg qd. her inr on admission was 1.2. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. however, this was stopped for her egd and after she had evidence of a gi bleed. the heparin drip was discontinued on [**10-22**]. the patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in hct and in preparation for a possible gi intervention. after her surgery, her coumadin was held and she was off the heparin drip, but her inr continued to drift up, getting as high as 2.6 on [**2141-10-30**]. this was mostly attributed to nutritional deficiency [**2-11**] poor po intake, but there was concern for possible synthetic dysfunction as well. as a result, she was given a test dose of vitamin k, which she responded to well (her inr came back down to 1.4). as a result, her home dose of coumadin at 2 mg qday was restarted. at discharge, her inr was still sub- therapeutic at 1.4. of note, the patient has a history of svc syndrome and had a l subclavian venous thrombosis. during the last few days of her hospital stay, the patient complained of increased tongue swelling and her l face was noted to be slightly more swollen than previously noted. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. her outside rheumatologist was also consulted. both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission. patient attempted 1 trial of cpap at 2l/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. the paitent stated that she would pursue further work-up and treatment for osa as an outpatient. while the mask and cpap machine were at her bedside throughout her hospital course, the patient rarely used it. # metabolic acidosis: the patients bicarbonate on admission was 13. her baseline is normally between 16-20. she received 150meq nahco3 over 24hrs from [**date range (1) 43500**]. during her brief returns to the micu, her hc03 was 18-19, which was presumed to be her baseline at home secondary to her crf. at discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. ","PRIMARY: [Malignant essential hypertension] SECONDARY: [Renal dialysis status; Epilepsy, unspecified, without mention of intractable epilepsy; Constipation, unspecified; Anemia in chronic kidney disease; Abnormal coagulation profile; Obstructive sleep apnea (adult)(pediatric); Other diseases of lung, not elsewhere classified; Other chest pain; Fever, unspecified; Rash and other nonspecific skin eruption; Other chronic pulmonary heart diseases; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified disease of pericardium; Other ascites; Acidosis; Hyposmolality and/or hyponatremia; Abdominal pain, other specified site; Abdominal pain, epigastric; Nausea with vomiting; Diarrhea; Systemic lupus erythematosus; Hyperparathyroidism, unspecified; Anemia, unspecified; Thrombocytopenia, unspecified; Esophageal reflux]","this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. multiple medication regimens were attempted and changed throughout her hospital course. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. upon discharge, her electrolytes were back to her baseline. epo alfa sc was also given on [**2141-10-17**]. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission.","esrd secondary to sle, malignant htn, h/o svc syndrome, and multiple thrombotic events were considered. the patient was placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia." 109,124398.0,14809,2142-03-31,14799,125288.0,2141-11-23,Discharge summary,"Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypertensive Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: (from MICU admit note) 24yoF ESRD-HD, SLE, HTN presents with 1 month abdominal pain and hypertension. Pt has had work-up over recent months for abd pain, including exploratory laparotomy, all of which essentially (-). Was admitted [**Date range (1) 34629**], for abdominal pain, then returned [**11-16**] for sob with (-)CTA, dc'ed [**11-17**]. In [**Hospital1 18**] ED, T98.5 hr95 BP 220/110 then 183/133 RR13 O2 100% on RA, rectal exam negative, guaiac(-), pelvic exam unremarkable with no cervical motion tenderness. Renal was consulted, taken for hemodialysis. CT abd showed large ascites, no other pathology; CT head improved from prior with no acute ICH; cxr(-). Given iv dilaudid for abdominal pain. BP treated with 10mg iv labetalol. Blood and urine cultures drawn, peritoneal fluid cx sent from catheter. Admitted to MICU for hypertension management. Access: R-HD catheter, 1 pIV in hand, 1 non-functioning peritoneal dialysis catheter. Past Medical History: PMH: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSH: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: PE: T:99.4 BP:158/108 HR:95 RR:12 O2 100% RA GEN: NAD/ pt eyes closed due to pain/ pleasant despite pain HEENT: AT, NC, PERRLA, EOMI on R eye, L eye prosthesis, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD CV: S1 & S2, RRR II/VI HSM at R/L USB, no rubs/gallops PULM: CTAB, no w/r/r ABD: soft, mildly tender at PD catheter, ND, + BS, midline incision with steri-stripes, PD catheter dressing C/I/D EXT: warm, dry, +2 distal pulses BL, no edema NEURO: alert & oriented, CN II-XII grossly intact (except L eye), 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: Admission Labs: [**2141-11-18**] 07:00AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.7* Hct-30.7* MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* Plt Ct-142* [**2141-11-18**] 07:00AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.3* [**2141-11-18**] 07:00AM BLOOD Glucose-86 UreaN-22* Creat-5.0* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2141-11-18**] 07:00AM BLOOD ALT-8 AST-39 AlkPhos-92 TotBili-0.3 [**2141-11-18**] 07:00AM BLOOD Lipase-76* [**2141-11-18**] 07:00AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.9 [**2141-11-18**] 11:00PM ASCITES WBC-1265* RBC-1680* Polys-43* Lymphs-1* Monos-2* Mesothe-11* Macroph-43* [**2141-11-18**] 10:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2141-11-18**] 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2141-11-18**] 10:05AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-[**3-15**] Discharge Labs: [**2141-11-23**] 04:40AM BLOOD WBC-2.9* RBC-3.08* Hgb-9.0* Hct-28.3* MCV-92 MCH-29.2 MCHC-31.8 RDW-17.5* Plt Ct-182 [**2141-11-23**] 04:40AM BLOOD PT-20.8* PTT-76.1* INR(PT)-2.0* [**2141-11-23**] 04:40AM BLOOD Glucose-80 UreaN-21* Creat-4.7* Na-139 K-4.8 Cl-106 HCO3-24 AnGap-14 [**2141-11-23**] 04:40AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8 [**2141-11-22**] 04:55AM BLOOD TSH-6.1* [**2141-11-23**] 04:40AM BLOOD Free T4-1.2 Blood cx ([**11-18**], [**11-19**]): 1/4 bottles with coag neg Staph, [**3-14**] NGTD Urine cx ([**11-18**]): mixed flora c/w contamination Peritoneal fluid ([**11-18**]): Gram stain 2+ polys. Culture no growth. Imaging: CXR Portable ([**11-18**]): Since [**2141-11-16**], heart size enlargement is unchanged due to known pericardial effusion. Lungs are otherwise clear. Hilar contours are normal. Incidentally, widening of both acromioclavicular joints is unchanged. CT A/P ([**11-18**]): 1. No evidence of bowel obstruction or rim-enhancing fluid collection. 2. Large ascites, slightly increased from [**2141-11-13**], with peritoneal dialysis catheter in place. Interval removal of surgical skin staples along the abdomen. 3. Moderate pericardial effusion as before. 4. Symmetric heterogeneous attenuation of the kidneys could be related to renal failure; however, pyelonephritis could also give this appearance. Appearance of the kidneys is unchanged from [**2141-11-13**]. CT Head w/o contrast ([**11-18**]): 1. No evidence of acute intracranial hemorrhage. 2. Regions of hypoattenuation in the bifrontal white matter and left posterior temporal lobe have resolved since [**2141-6-11**]. No new regions of hypoattenuation seen. Brief Hospital Course: 1) Hypertension: Patient has history of extremely labile hypertension on an aggressive outpatient regimen. Overnight in the MICU, patient required IV and PO labetalol for SBP > 200. Her hydralazine was increased from 75mg to 100mg TID with mild improvement. Her labetalol was also increased from 300mg to 400mg TID. Her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. TSH was sent and elevated, although free T4 was normal. Plasma metanephrines were sent and pending at discharge. 2) Abdominal pain: CT scan showed increasing ascites, but no acute pathology. Peritoneal fluid was obtained and contained 544 polys. Treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing GPC pairs/clusters. Blood cultures ended up growing 1 out of 4 bottles coag-neg Staph, likely contaminant, so vancomycin was stopped. Since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. The peritoneal cultures remained negative. Her PD catheter was left in place as the patient refuses HD any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) SVC/brachiocephalic thrombosis: Patient's INR was subtherapeutic on admission at 1.3. Due to the proximal location of her old venous thrombi, she was started on a heparin gtt. This was continued during her admission and her warfarin was increased to 5mg daily. Her INR reached 2.0 at discharge (therapeutic range 2-3). The dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) Anxiety: Patient noted feeling short of breath and anxious around the time of her recent admissions. Her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. They felt her symptoms were suggestive of anxiety and panic attacks, recommended checking TSH and metanephrines as above, and starting citalopram 20mg, which was done. She was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h PRN. Patient is agreeable to outpatient follow up with [**Company 191**] social work, and potential CBT. These can be arranged by her PCP. Medications on Admission: 1. Aliskiren 150 mg [**Hospital1 **] 2. Clonidine 0.3 mg/24 qwk 3. Prochlorperazine Maleate 10 mg prn 4. Hydromorphone 2 mg Tablet Sig: [**1-11**] q6 prn 5. Bisacodyl 10mg [**Hospital1 **] 6. Ergocalciferol (Vitamin D2) 50,000 qmonth 7. Hydralazine 75mg tid 8. Hydralazine scale prn 9. Labetalol 300 mg tid 10. Nifedipine 90 mg qd 11. Prednisone 4mg qd 12. Warfarin 2 mg qd at 4pm Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Hospital1 766**]). 5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day. [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 7 days. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO q30 min prn as needed for hypertension: for SBP > 180. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive urgency Headache Abdominal pain Anxiety Secondary Diagnosis: HTN SLE ESRD on HD SVC and IJ thrombosis, chronic Anemia Discharge Condition: Stable, BPs improved. Discharge Instructions: You were admitted with elevated blood pressures, headache, and abdominal pain. You were found to have increased amounts of white blood cells in your abdominal cavity, but this was not infected. Your abdominal pain resolved and you continued to have intermittent headaches. Your blood pressure medications were adjusted as below. You were also seen by psychiatry who recommended starting new medications for your anxiety. The following changes were made to your medication regimen: - We increased your hydralazine to 100 mg three times a day. - We also increased your labetalol to 400 mg three times a day. - We have started a medication called celexa 20 mg daily as well as ativan 1 mg three times a day as needed for anxiety. - We have increased your coumadin to 4 mg daily. - Please continue taking all other medications as previously prescribed. Call your doctor or return to the emergency room if you experience any of the following: worsening abdominal pain, nausea, vomiting, blurry vision, worsening headache, fever > 101. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. Please continue to follow with your nephrologist and go to outpatient dialysis as previously arranged. Please discuss with your PCP the possibility of talking to a social worker at [**Name (NI) 191**]. You will need to continue to have your INR monitored at [**Hospital 191**] [**Hospital 2786**] clinic. Please have this level checked on [**Hospital 766**], [**11-27**]. Completed by:[**2141-11-23**]",128,2141-11-18 14:00:00,2141-11-23 16:42:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. her hydralazine was increased from 75mg to 100mg tid with mild improvement. her labetalol was also increased from 300mg to 400mg tid. her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. tsh was sent and elevated, although free t4 was normal. plasma metanephrines were sent and pending at discharge. 2) abdominal pain: ct scan showed increasing ascites, but no acute pathology. peritoneal fluid was obtained and contained 544 polys. treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing gpc pairs/clusters. blood cultures ended up growing 1 out of 4 bottles coag-neg staph, likely contaminant, so vancomycin was stopped. since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. the peritoneal cultures remained negative. her pd catheter was left in place as the patient refuses hd any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) svc/brachiocephalic thrombosis: patients inr was subtherapeutic on admission at 1.3. due to the proximal location of her old venous thrombi, she was started on a heparin gtt. this was continued during her admission and her warfarin was increased to 5mg daily. her inr reached 2.0 at discharge (therapeutic range 2-3). the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) anxiety: patient noted feeling short of breath and anxious around the time of her recent admissions. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. they felt her symptoms were suggestive of anxiety and panic attacks, recommended checking tsh and metanephrines as above, and starting citalopram 20mg, which was done. she was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h prn. patient is agreeable to outpatient follow up with [**company 191**] social work, and potential cbt. these can be arranged by her pcp. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Abdominal pain, unspecified site; Anemia, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. her hydralazine was increased from 75mg to 100mg tid with mild improvement. peritoneal fluid was obtained and contained 544 polys. the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted.","patient has history of extremely labile hypertension on aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. ct scan showed increasing ascites, but no acute pathology." 109,124398.0,14809,2142-03-31,14800,161950.0,2141-12-01,Discharge summary,"Admission Date: [**2141-11-24**] Discharge Date: [**2141-12-1**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Headache, abdominal pain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24yo F w/PMHx of ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning, awakening her from sleep. Had been previously discharged from [**Hospital1 **] yesterday after being admitted for hypertension and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Upon discharge yesterday she states her abdominal pain had subsided. She had HD yesterday without complications. She awoke at 6am with a headache and crampy, stabbing abdominal pain. Took 2mg PO Dilaudid without relief and came to ED. No nausea/vomiting, no changes in vision, no fevers, chills, night sweats. No chest pain, SOB, diarrhea. In the ED, initial vitals were T98.7, BP260/130, HR70, RR16. Was initially given 10mg IV Labetalol X 2, 4mg Zofran for nausea. No improvement in BP and started on Labetolol gtt. Got 1mg IV Dilaudid for pain. Currently, patient continues to complain of headache and abdominal pain, both [**7-17**]. No vision changes, chest pain or shortness of breath. Has been feeling increased anxiety recently and saw psychiatrist, was put on Celexa. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T98.2, BP176/135, HR94, RR 22, 100% RA Gen: well-appearing african-american woman, lying comfortably HEENT: anicteric, L eye prosthetic non-reactive, R pupil reactive, MMM, neck supple with submanibular LAD CV: RRR, II/VI SEM best heard at apex Pulm: CTA b/l Abd: hyperactive bowel sounds, midline scar well-healed, soft, diffusely tender to palpation, +rebound, no guarding. PD catheter in LLQ without erythema or purulent material draining. +dullness on percusion with evidence of clinical ascites. Ext: no edema, no clubbing, 2+ peripheral pulses DP and radial. R femoral HD [**Last Name (un) **] in place without erythema, purulance Neuro: A&O X 3, CN intact II-XII, [**5-15**] motor strength in upper and lower extremities Pertinent Results: Admission labs: CBC: [**2141-11-26**] 05:21AM BLOOD WBC-3.5* RBC-3.07* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-17.6* Plt Ct-180 CHEM 10: [**2141-11-26**] 01:16PM BLOOD Glucose-87 UreaN-17 Creat-4.0* Na-136 K-5.2* Cl-106 HCO3-23 AnGap-12 [**2141-11-26**] 09:20PM BLOOD Calcium-7.6* Phos-3.8 Mg-1.8 COAGS: [**2141-11-26**] 01:16PM BLOOD PT-23.9* PTT-40.2* INR(PT)-2.3* STUDIES: 1)Peritoneal fluid ([**11-26**]): negative for malignant cells. Reactive mesothelial cells, macrophages, eosinophils and lymphocytes. 2)BILAT UP EXT VEINS US ([**11-26**]): No evidence of deep vein thrombosis of the right or left upper extremity. 3) MRI/MRA ([**11-30**]): FINDINGS: Examination is somewhat limited by patient motion. T2/FLAIR sequences are unremarkable with interval resolve of previously noted posterior abnormalities. The major vessels appear patent proximally. There are stable areas of low signal in the left frontal and right occipetal/temporal lobes. IMPRESSION: 1. Interval resolution of previously noted posterior white matter abnormalities. 2. Stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions. 3. Very limited MRA as above. Brief Hospital Course: 24yo F with SLE, ESRD on HD and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**Hospital Unit Name 153**] course: The patient was admitted for blood pressure management and evaluation of abd pain. An A-line was placed. EKG showed no change from prior, and Abd x-ray showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home med regimen. The patient was found to be hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. Upon transfer to the floor, the following was her course: 1. Hypertensive Urgency: Pt had had hemodialysis one day prior to admission, so unlikely that she was volume overloaded. Unclear what precipitated this episode of hypertensive urgency, although suspect secondary to abdominal pain leading to an anxiety which then precipitates hypertension. She may not have been taking her medications secondary to pain. Negative serum tox. On the floor, we continued hemodialysis Tu, Th, Sat. She was initially continued on PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine 90mg PO qday and clonidine; she received hydralazine 10mg IV for goal BP < 180/100. Renal team followed patient during this hospitalization. Per renal team recs, labetalol was increased to 800mg TID due to poor blood pressure control. Pt discharged on clonidine 0.3mg patch, Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, Nifedipine 90mg daily and lobatalol 800mg TID. This regimen worked well. 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT scan during prior admission which did not show source of abdominal pain. On admission, LFTs were normal except for slightly low albumin, lipase was slightly elevated and KUB was negative for free air or evidence of SBO. Peritoneal fluid was negative for malignant cells but showed reactive mesothelial cells, macrophages, eosinophils and lymphocytes. Negative gram stain or peritoneal fluid cultures, excluding SBP as a cause of the abdominal pain. PD catheter was not removed. Pt was continued on PO dilaudid 1-2mg Q6h and pain resolved. She denied N/V/diarrhea or constipation. 3. ESRD: Pt on hemodialysis, on T/Th/Sat schedule. Renal following patient closely throughout this hospitalization. Lytes were checked frequently and kayexalate given prn. 4. Hx of SVC/brachiocephalic DVT: Pt was initially subtherapeutic on coumadin. Unclear if she had not been taking Coumadin although patient reported that she has been taking all home meds. We started heparin gtt to bridge to Coumadin. Once therapeutic, continued Coumadin 5mg PO qday. 5. Anxiety: Likely contributing to medical problems and could have very well been the etiology of this admission. Although pt stated she was taking her current medications, she did report increased anxiety which can lead to medication non-compliance and hypertension. Pt recently saw psychiatrist who started her on Celexa. She was continued on celexa 20mg PO qday, ativan 1mg PO q8hours PRN and psychiatry was re-consulted. Per psych recs, started standing clonazepam. Pt refused psych VNA. Outpatient PCP followup recommended. 6. Headache NOS: Pt complained of R-sided HA for several weeks, radiating to R jaw where patient had previous tooth extraction. Right upper extremity ultrasound was negative for DVT. She did not have any focal neuro findings, no visual deficits. She was initially treated with tylenol PRN Q6h; pt requested IV dilaudid for HA, but use of this medication by IV route was limited by team. It was felt by the pain service that her HA did not fit migraine, tension type HA or rebound HA. They recommended increasing dilaudid to 4-6mg Q6h PRN, continuing tylenol and starting neurontin 300mg Qhs which was slowly titrated to 300mg [**Hospital1 **] for better control. Per pain recs, a neurology consult was also obtained during this admission. MRI/MRA showed interval resolution of previously noted posterior white matter abnormalities and stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions, but very limited MRA as above. Per pain recs, dilaudid was further increased to 4mg q4h for better control of her HA. Neurology recommended outpt f/u and Pt scheduled with [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**]. 7. Anemia: Likely related to ESRD. No evidence of acute bleeding. Hct remained stable during this hospitalization. 8. SLE: no acute issues. continued Prednisone 4mg PO qday 9. FEN: tolerated regular diet, repleted lytes PRN 9. Prophylaxis: Heparin gtt, then coumadin, bowel regigmen Medications on Admission: (from prior discharge summary) Bisacodyl 10mg PO qday PRN Prednisone 4mg PO qday Aliskiren 150mg PO BID Clonidine 0.3mg / 24 hr patch weekly qmonday Labetalol 400mg PO TID Warfarin 4mg PO qday Nifedipine 90mg PO qday Hydralazine 100mg PO q8H Hydromorphone 2-4mg PO q4H PRN Lorazepam 1mg PO q8H Celexa 20mg PO qday Prochlorperazine 10mg PO q6H Colace 100mg PO BID Hydralazine 25mg PO q30min PRN for HTN Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Year (4 digits) 766**]). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). [**Year (4 digits) **]:*100 Tablet(s)* Refills:*2* 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*90 Capsule(s)* Refills:*2* 9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for headache. [**Year (4 digits) **]:*84 Tablet(s)* Refills:*0* 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*60 Capsule(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours. [**Year (4 digits) **]:*360 Tablet(s)* Refills:*2* 16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. [**Year (4 digits) **]:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive Emergency 2. SLE 3. Headache, NOS 4. Abdominal pain Discharge Condition: BP better controlled. Headache managed on oral meds Discharge Instructions: You were admitted with abdominal pain, high blood pressure, and headache. Your abdominal pain resolved - no serious cause of this pain was found. Your blood pressure medications were continued, and with an increased in one medication, the labetalol. Your blood pressure improved. You should continue the clonidine 0.3mg patch changed on [**Year (4 digits) 766**], Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, and Nifedipine 90mg daily. The dose of Labetalol was increased to 800 mg three times daily by you kidney doctor and you are given a new prescription. Please take all medications as listed below. For your headache, you had an MRI and MRA of the head, which did not show a new or serious abnormality. You were seen by the neurology and pain services. You should follow up at [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**] at 6:30 PM (in the evening). Your pain was managed by oral dilaudid, 4mg. You should take this medication every 4 hours as needed. You were also started on Gabapentin (also called Neurontin) for the headache. The dose was slowly increased to twice a day. You may not need as much dilaudid for your headache and should wean this medication as tolerated, given it's potential for side effects (constipation, lethargy, dependence). Finally, you will likely need medications for constipation while you take dilaudid. Take colace (a stool softener), senna (a laxative), and bisacodyl (another laxative), as needed. It is really important that you have a primary care doctor. You are scheduled with Dr. [**Last Name (STitle) **] (see below) next Tuesday. You will need your INR checked since you are on coumadin. Call your doctor if you have worsened headache, chest pain, confusion, or any other concerning symptom. Followup Instructions: Please make sure you attend the following doctor appointments: 1) Dr. [**Last Name (STitle) 4883**] (nephrologist) on Tuesday, [**2141-12-5**] at 10AM. Phone number [**Telephone/Fax (1) 60**]. 2) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Location (un) **], [**Hospital Ward Name 23**] center, [**Location (un) **]. Phone:[**Telephone/Fax (1) 250**]. Date/Time:[**2141-12-5**] 3:20 3) Neurology: Dr. [**Last Name (STitle) 43502**] [**Name (STitle) **]. He is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-12-12**] 6:30 PM [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2141-12-2**]",120,2141-11-24 16:11:00,2141-12-01 19:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**hospital unit name 153**] the patient was admitted for blood pressure management and evaluation of abd pain. an a-line was placed. ekg showed no change from prior, and abd x-ray showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home med regimen. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. upon transfer to the floor, the following was her ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other ascites; ; Systemic lupus erythematosus; Headache; Anemia in chronic kidney disease; Anxiety state, unspecified; Other chest pain; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Renal dialysis status; Acquired absence of organ, eye]","24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. the renal team was consulted, and recommended no change to home med regimen.","a 24yo f with sle, esrd on hd and malignant hypertension presented with abdominal pain and headache. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. she successfully switched to po meds and was transferred to the floor." 109,124398.0,14809,2142-03-31,14801,173633.0,2141-12-14,Discharge summary,"Admission Date: [**2141-12-8**] Discharge Date: [**2141-12-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 8104**] Chief Complaint: abdominal pain & hypertension Major Surgical or Invasive Procedure: Hemodialysis PICC Line [**12-11**] History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with a history of CKD V (on HD) from lupus nephritis, chronic intermittent abdominal pain, and multiple prior ICU admissions for hypertensive urgency who presented to the ED complaining of two days' of abdominal pain, nausea, and loose stools. She was feeling well until after her hemodialysis session on Wednesday. Thereafter, she complained of nausea with occasional vomitting and has been unable to keep down any of her oral medications. She also has had diffuse abdominal pain consistent with her prior flares of pain as well as her typical diffuse headache. The headache in particular was worsening and, for her, this is a sign of poorly-controlled hypertension so she came to the [**Hospital1 18**] ED. Upon arrival to the ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room air. She was given 4 mg of IV ondansetron, [**1-11**] inch intropaste, 1 mg of IV hydromorphone x3, 1000cc of NS, and was put on a labetalol drip which had to be increased up to 2 mg/min. A head CT showed no acute abnormality (including hemorrhage) and an abdominal CT showed some possible mild colitis, though it is unclear if this is due to her recent peritoneal dialysis. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 97.9 BP 165/120 HR 93 RR 12 Sat 100% ra Gen: mildly fatigued, but no distress HEENT: oropharynx clear Neck: no JVP, no LAD Chest: clear to auscultation throughout, no w/r/r CV: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard Abdomen: soft, tender diffusely to moderate palpation without rebound or guarding; hyperactive bowel sounds; no masses or HSM, PD catheter in palce Extr: no edema, 2+ PT pulses Neuro: alert, appropriate, strength grossly intact in all four limbs Skin: no rashes Pertinent Results: [**2141-12-14**] 05:53AM BLOOD WBC-4.3 RBC-2.81* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.7 MCHC-33.8 RDW-19.3* Plt Ct-148* [**2141-12-14**] 05:53AM BLOOD PT-42.6* PTT-51.0* INR(PT)-4.7* [**2141-12-10**] 05:10AM BLOOD Ret Aut-2.5 [**2141-12-14**] 05:53AM BLOOD Glucose-83 UreaN-21* Creat-5.1*# Na-138 K-5.3* Cl-105 HCO3-24 AnGap-14 [**2141-12-10**] 05:10AM BLOOD LD(LDH)-234 Amylase-347* TotBili-0.1 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-10**] 05:10AM BLOOD Lipase-72* [**2141-12-14**] 05:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 [**2141-12-10**] 05:10AM BLOOD Hapto-142 [**2141-12-8**] 04:02AM BLOOD calTIBC-138* VitB12-445 Folate-18.5 Ferritn-220* TRF-106* ON ADMISSION: [**2141-12-7**] 09:50PM BLOOD WBC-4.5 RBC-2.78* Hgb-8.4* Hct-25.2* MCV-91 MCH-30.2 MCHC-33.3 RDW-19.2* Plt Ct-158 [**2141-12-7**] 09:50PM BLOOD Neuts-65.2 Lymphs-23.4 Monos-8.0 Eos-2.9 Baso-0.4 [**2141-12-7**] 09:50PM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3* [**2141-12-8**] 04:02AM BLOOD Ret Aut-2.5 [**2141-12-7**] 09:50PM BLOOD Glucose-89 UreaN-25* Creat-5.1*# Na-139 K-4.8 Cl-104 HCO3-26 AnGap-14 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-7**] 09:50PM BLOOD Lipase-89* [**2141-12-7**] 09:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9* Mg-1.9 [**2141-12-7**] 09:54PM BLOOD Glucose-75 Lactate-1.3 Na-139 K-4.8 Cl-101 calHCO3-23 Micro: Blood Cx: [**12-7**], [**12-7**], [**12-11**], [**12-11**] No growth FECAL CULTURE (Final [**2141-12-10**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2141-12-10**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2141-12-8**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-12-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CT HEAD [**2141-12-8**]: IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. The hypodensities noted in the parietal white matter are stable. However in the setting of the hypertension, PRES cannot be excluded. If further evaluation is required MR can be obtained. CT Abdomin/Pelvis [**2141-12-8**] IMPRESSION: 1. Moderate amount of free fluid in the pelvis is compatible with the patient's known peritoneal dialysis. Unchanged peritoneal enhancement. 2. Stable liver hemangioma. CXR [**12-11**] IMPRESSION: Small left pleural effusion. Left lower lobe opacity which is either atelectasis versus pneumonia. Brief Hospital Course: 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. MICU course: Current plan on transfer 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. 1. Hypertensive urgency: The patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. Initially her blood pressure over-corrected to SBPs in the 80s (patient was asymptomatic). Her clonidine patch and hydralazine was held and she again became hypertensive with SBPs 190s. The patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. The following dialysis the patient asymptomatic with SBPs in 80s, MAPs 60s asymptomatic again. Her hydralazine was stopped and continued on all her other home medications at the advice of renal. The patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. On [**12-11**] the patient's SBP dropped to the 80's and due to her pain medications she was extremely lethargic, but arousable. A PICC line was placed because lack of access and she was bolused 250cc NS. The patient's pressures responded and additional narcotics were held due to her mental status. The patient's blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. The patient did require IV hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. A possible component to the patient's malignant hypertension is likely due to OSA. An inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on BiPAP for OSA. The patient was continuned on her admission hypertensive regimen. . 2. Abdominal pain: The etiology of her abdominal pain is unclear, but has been a chronic issue for her. A CT scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. The patient also had diarrhea, but stool studies were negative. The patient's pain was initially treated with hydromorphone, but because of the patient's lethargy on [**12-11**] they were initially held. She continued to complain of severe abdominal pain. She was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. Surgery was consulted in regards to removal of her PD catheter, but given that she may return to PD it was deferred to the outpatient setting. 3. CKD V from lupus nephritis: The patient was continued on HD during her admission. She was also continued on her home prednisone dose. She was closely followed by the renal team. . 4. History of SVC/subclavian vein thrombus: The patient was found to have a subtherapeutic INR on admission 1.3. She was started on a heparin gtt and continued on coumadin. The patient's heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her PICC line was placed. She was therapetuic the same day and her heparin gtt was stopped. On discharge her coumadin was supratherapeutic (4.7) and was held. She will have her INR checked at HD. . 5. Anemia: The patient's Hct slowly trended down. She was guaiac negative and hemolysis labs were negative. She was transfused 1U pRBC at HD on [**12-12**]. She was also given epo at HD. Medications on Admission: prednisone 4 mg daily clonidine 0.3 mg/day patch qWeek ergocalciferol 50,000 units qMonth nifedipine SR 90 mg daily hydralazine 100 mg q8h citalopram 20 mg daily warfarin 2 mg qhs gabapentin 300 mg [**Hospital1 **] hydromorphone 4 mg q4h prn clonazepam 0.5 mg [**Hospital1 **] alikiren 150 mg [**Hospital1 **] docusate 100 mg [**Hospital1 **] senna 8.6 mg [**Hospital1 **] prn acetaminophen prn labetalol 800 mg q8h bisacodyl 5 mg daily prn Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. [**Hospital1 **]:*84 Tablet(s)* Refills:*0* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed: please take as needed for anxiety prior to CPAP at bedtime. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 14. CPAP Home CPAP Dx: OSA Prefer: AutoCPAP/ Pressure setting [**5-20**] Alt: Straight CPAP/ Pressure setting 7 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency Abdominal Pain ESRD on HD SVC Thrombus Secondary: Systemic lupus erythematosus Malignant hypertension Thrombocytopenia HOCM Anemia History of left eye enucleation History of vaginal bleeding Thrombotic microangiopathy Discharge Condition: Stable Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because of elevated blood pressure and abdominal pain. You were initially admitted to the ICU and your blood pressure was controlled. You were stabilized and transferred back to th floor. Your pressures remained stable throughout the rest of your stay. Additionally, you had abdominal pain and diarrhea. Your stool was tested for infections and was negative. Your diarrhea resolved without intervention. Your abdominal pain was controlled with pain medications. You had a sleep study in the hospital which showed that you had sleep apnea. Please continue to take your medications as prescribed. 1. Please do not take your coumadin until your doctor tells you to. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: You will have dialysis at [**Location (un) **] Dialysis on your normal schedule. You need to go to dialysis on Saturday. Please follow-up with the Sleep Clinic in [**12-19**] @ 11:45 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Completed by:[**2141-12-16**]",107,2141-12-08 01:40:00,2141-12-14 17:16:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. micu course: current plan on transfer 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. 1. hypertensive urgency: the patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). her clonidine patch and hydralazine was held and she again became hypertensive with sbps 190s. the patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. the following dialysis the patient asymptomatic with sbps in 80s, maps 60s asymptomatic again. her hydralazine was stopped and continued on all her other home medications at the advice of renal. the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. on [**12-11**] the patients sbp dropped to the 80s and due to her pain medications she was extremely lethargic, but arousable. a picc line was placed because lack of access and she was bolused 250cc ns. the patients pressures responded and additional narcotics were held due to her mental status. the patients blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. the patient did require iv hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. a possible component to the patients malignant hypertension is likely due to osa. an inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on bipap for osa. the patient was continuned on her admission hypertensive regimen. . 2. abdominal pain: the etiology of her abdominal pain is unclear, but has been a chronic issue for her. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. the patient also had diarrhea, but stool studies were negative. the patients pain was initially treated with hydromorphone, but because of the patients lethargy on [**12-11**] they were initially held. she continued to complain of severe abdominal pain. she was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. surgery was consulted in regards to removal of her pd catheter, but given that she may return to pd it was deferred to the outpatient setting. 3. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was also continued on her home prednisone dose. she was closely followed by the renal team. . 4. history of svc/subclavian vein thrombus: the patient was found to have a subtherapeutic inr on admission 1.3. she was started on a heparin gtt and continued on coumadin. the patients heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her picc line was placed. she was therapetuic the same day and her heparin gtt was stopped. on discharge her coumadin was supratherapeutic (4.7) and was held. she will have her inr checked at hd. . 5. anemia: the patients hct slowly trended down. she was guaiac negative and hemolysis labs were negative. she was transfused 1u prbc at hd on [**12-12**]. she was also given epo at hd. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Systemic lupus erythematosus; Other and unspecified noninfectious gastroenteritis and colitis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other iatrogenic hypotension; Obstructive sleep apnea (adult)(pediatric); Hemangioma of intra-abdominal structures; Other chronic pain; Abdominal pain, unspecified site; Abnormal coagulation profile; Renal dialysis status; Personal history of venous thrombosis and embolism]","24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. the patient was continuned on her admission hypertensive regimen. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was therapetuic the same day and her heparin gtt was stopped.",24 year old woman with ckd v and severe hypertension due to sle admitted. patient was initially maintained on a labetalol drip and hydralazine iv prn. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic) 109,124398.0,14809,2142-03-31,14802,140167.0,2141-12-23,Discharge summary,"Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1973**] Chief Complaint: Malignant hypertension Major Surgical or Invasive Procedure: None History of Present Illness: 24 year old female with ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning. Patient had her hemodialysis day before yesterday. She has had multiple admissions to [**Hospital1 18**] with hypertensive urgency with symptoms of headache and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Patient states that her headache and abdominal pain are similar in characteristics to her previous admission. Patient denies any fever, chills, nightsweats, chest pain, shortness of breath, abdominal pain, nausea, vomitting, diarrhea, constipation, blood in stool, dysuria, hematuria, change in vision, hearing, weakness or numbness. In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was initially given 10mg IV Labetalol once and then started on drip at 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea. Her BP elevated as high as 270/174 and his labetolol was switched to nicardipine 1mg/kg/min. On arrival to the MICU her vitals were T 96.4 HR 99 BP 175/120 RR 15 100%RA. Patient was comfortable. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Vitals: 97.5 122/80 88 18 100%RA. Gen: sleeping, easily arousable, appears comfortable. HEENT: AT/NC, L eye prosthetic non-reactive, R pupil reactive, MMM. Heart: S1S2 RRR, III/VI SEM heard best at apex, + S3 Pulm: CTA b/l, no w/r/r. Abd: normal bowel sounds, midline scar well-healed, soft, nontender, prior PD site with dry dressing, patient with tenderness to palpation over prior PD cath site, no guarding/rebound Ext: no edema, no clubbing, WWP. R femoral HD catheter in place. Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: Admission: [**2141-12-18**] 02:00AM BLOOD WBC-5.8 RBC-3.30* Hgb-10.1* Hct-30.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-20.7* Plt Ct-199 [**2141-12-18**] 02:00AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.2* [**2141-12-18**] 02:00AM BLOOD UreaN-35* Creat-5.0* Na-138 K-5.5* Cl-103 HCO3-21* AnGap-20 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-18**] 02:00AM BLOOD Lipase-73* [**2141-12-18**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2141-12-19**] 06:45AM BLOOD Calcium-8.1* Phos-5.1* Mg-1.8 [**2141-12-18**] 03:52PM BLOOD dsDNA-NEGATIVE [**2141-12-18**] 03:52PM BLOOD CRP-11.5* [**2141-12-18**] 03:52PM BLOOD C3-68* C4-19 [**2141-12-20**] 12:09PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 [**2141-12-18**] 02:08AM BLOOD pO2-52* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 Comment-GREEN TOP [**2141-12-20**] 12:09PM BLOOD Lactate-0.9 [**2141-12-18**] 02:08AM BLOOD Glucose-68* Lactate-1.3 Na-140 K-4.8 Cl-103 [**2141-12-23**] 03:00PM BLOOD WBC-4.7 RBC-2.35* Hgb-7.1* Hct-22.3* MCV-95 MCH-30.3 MCHC-31.9 RDW-20.6* Plt Ct-131* [**2141-12-23**] 12:55AM BLOOD PT-14.7* PTT-66.2* INR(PT)-1.3* [**2141-12-18**] 03:52PM BLOOD ESR-21* [**2141-12-23**] 03:00PM BLOOD Glucose-97 UreaN-42* Creat-6.6* Na-138 K-4.3 Cl-106 HCO3-23 AnGap-13 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-23**] 03:00PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8 [**2141-12-18**] 04:23PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2141-12-18**] 04:23PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2141-12-18**] 04:23PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-12 TransE-<1 Micro: Blood Cx- [**12-18**]: No growth Urine Cx- [**12-18**]: No growth [**12-18**] TTE The left atrium and right atrium are normal in cavity size. A possible secundum type atrial septal defect is seen by color Doppler (clip [**Clip Number (Radiology) **]) There is severe symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. There is no significant resting LVOT gradient, but a mild gradient (30mmHg peak) is seen with Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Marked symmetric left ventricular hypertrophy with normal regional/global systolic function and mild inducible LVOT gradient. Mild aortic regurgitation. Mild pulmonary artery systolic hypertension. Possible secundum type atrial septal defect. Compared with the prior study (images reviewed) of [**2141-10-19**], a possible secundum type atrial septal defect is now suggested. If clinically indicated, a follow-up study with saline contrast and/or a TEE would be better able to characterize the possible atrial septal defect. CLINICAL IMPLICATIONS: Based on [**2140**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**12-18**] CXR IMPRESSION: 1. Cardiomegaly with findings suggestive of mild pulmonary edema. 2. Bibasilar linear opacities suggesting atelectasis, although developing pneumonia cannot be excluded. 3. No evidence of free intraperitoneal air. [**12-20**] MRV IMPRESSION: No appreciable change since the MRV chest exam dated [**2141-5-30**]. SVC is patent. Again seen is occlusion of the right internal jugular and left brachiocephalic veins. Right external jugular vein is provides the major venous drainage from the neck. Brief Hospital Course: 24 year old Female with SLE, ESRD on HD and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ED. 1. Malignant Hypertension: The patient had her hemodialysis two days prior to admission. Initially in the ED her BP was 253/170. She was given 10mg IV Labetalol and started on a labatelol drip. She also received hydralazine IV 10 mg once and 2 inches of nitropaste. She had morphine 4mg and 4mg Zofran for nausea. Her BP remained elevated so she was switched to nicardipine 1mg/kg/min. The patient was transferred to the MICU. In the ICU she was continued on the Nicardapine drip and her pressures decreased to 175/120. Nephrology was consulted and dialysis initiated in the AM. The Nicardapine drip dc'd on [**12-19**] and pt transferred to floor. While on the floor the patient had question of angioedema and markedly elevated BP. She was readmitted to the MICU on [**2141-12-20**]. Patient's Aliskerin was also held for conern for angioedema. The renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. The patient's PD catheter was removed. The patient was briefly on a nitro drip for hypertension. The patient's nifedepine was increased to 120mg. The patient was transferred to the floor with stable blood pressures, BP 124/72 on [**12-21**]. The morning of [**12-22**], the patient was noted to have a BP up to 247/120 at 0800. Hypertension persisted throughout the morning with BPs 210s-240s systolic. HR during this time was in the 90s. She received a total of 60 mg IV hydralazine over the course of the morning as well as 0.1 mg PO clonidine. She was also given her normal AM BP meds and restarted on aliskarin. Due to persistent hypertension, she was transferred to the ICU for further care. On arrival to the ICU, the patient reported severe abdominal pain over the site of recently removed PD catheter. She denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. She reports bilateral calf cramping but no leg swelling. She denies any difficulty breathing or chest pain. She took her AM BP meds without difficulty. Her blood pressure decreased to 130s-140s/60s without further intervention. She was transferred back to the floor on [**12-23**] and signed out AMA. 2. Angioedema: On [**12-20**] the patietn developed facial swelling and evidence of angioedema by ENT. The patient reported that her face is more swollen which was confirmed by her mother on the floor. The patient was give lasix IV as she has been unable to have any negative filtration with HD. The patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. Her tekturna was discontinued for concern that it might be causing angioedema. She denied difficulty with her breathing at that time, but was very somnulent. On arrival to the MICU her vitals were stable and oxygenating well at 100% on face mask. The patient's airway was supported with a nasal trumpet. The patient underwent MRV that showed no progression of her clot. Patient was diuresed with lasix and dialysis with significant improvement in her symptoms. She was treated with prednisone and decadron, famotidine and benadryl for angioedema. The patient was maintained on her heparin drip for her SVC syndrome. 3. Abdominal Pain: The patient has had extensive prior workup that has been unrevealing. The Transplant surgery team removed the PD cath on [**12-21**]. She continued to have abdominal pain post-op. She was continued on PO dilaudid 2mg po prn. She continuned to complain of abdominal pain throughout her admission and continued to requested IV dilaudid. 4. ESRD: The patient is on a T/Th/Sat schedule. She was closely followed by the renal team. She had dialysis on [**12-19**]. The patient's tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. The patient also had her PD catheter removed on [**12-21**] secondary to chronic abdominal pain. The patient was scheduled to have dialysis on [**12-23**]. 5. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last admission for supratherapeutic INR. She was admitted with a subtherpeutic INR of 1.2 She was started on a heparin drip. She was also started on Coumadin 2mg PO qday, but was held on [**12-19**] in prep her PD catheter removal. She was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by IR. However, the patient signed out AMA and thus it was not placed. 6. Anxiety: Pt recently saw psychiatrist who started her on Celexa. She was continued on Celexa 20mg PO daily. 7. Anemi of CKDa: The patient's Hct was 30.3 on admission. It trended down to 22.3 on discharge when she left AMA. There was no evidence of active, acute bleeding. THis is likely seoncdary to her ESRD. The patient was closely monitored. 8. Systemic Lupus Erythematosis: Rheumatology was consulted and does not suspect acute flare and dsDNA, C3, C4 nl, ESR and CRP slightly elevated. Her Echo did not suggest worsening pericarditis. She was continued on her home prednisone dose of 4mg daily. 9. Obstructive Sleep Apnea: CPAP for sleep with 7 pressure. Medications on Admission: Aliskiren 150 mg [**Hospital1 **] Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Warfarin held on discharge [**2141-12-14**] due to supratherap INR Discharge Medications: As patient signed out AMA, no medications were issued. She was told to resume her admission medications, however no instructions were taken by the patient. Discharge Disposition: Home Discharge Diagnosis: 1) Hypertensive urgency 2) Abdominal pain 3) End stage renal disease on hemodialysis 4) Venous thromboembolism Discharge Condition: Signed out AMA Discharge Instructions: Pt signed out AMA Return to the hospital with any concerning symptoms. Be sure to call your doctor's office on [**Month/Day/Year 766**] to arrange hemodialysis and review your medications and discuss follow-up plan. Followup Instructions: Follow-up with your Dr. [**Last Name (STitle) **] next week, and call [**Last Name (STitle) 766**] to arrange your hemodialysis. Completed by:[**2141-12-26**]",98,2141-12-18 03:50:00,2141-12-23 19:51:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. 1. malignant hypertension: the patient had her hemodialysis two days prior to admission. initially in the ed her bp was 253/170. she was given 10mg iv labetalol and started on a labatelol drip. she also received hydralazine iv 10 mg once and 2 inches of nitropaste. she had morphine 4mg and 4mg zofran for nausea. her bp remained elevated so she was switched to nicardipine 1mg/kg/min. the patient was transferred to the micu. in the icu she was continued on the nicardapine drip and her pressures decreased to 175/120. nephrology was consulted and dialysis initiated in the am. the nicardapine drip dcd on [**12-19**] and pt transferred to floor. while on the floor the patient had question of angioedema and markedly elevated bp. she was readmitted to the micu on [**2141-12-20**]. patients aliskerin was also held for conern for angioedema. the renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. the patients pd catheter was removed. the patient was briefly on a nitro drip for hypertension. the patients nifedepine was increased to 120mg. the patient was transferred to the floor with stable blood pressures, bp 124/72 on [**12-21**]. the morning of [**12-22**], the patient was noted to have a bp up to 247/120 at 0800. hypertension persisted throughout the morning with bps 210s-240s systolic. hr during this time was in the 90s. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she was also given her normal am bp meds and restarted on aliskarin. due to persistent hypertension, she was transferred to the icu for further care. on arrival to the icu, the patient reported severe abdominal pain over the site of recently removed pd catheter. she denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. she reports bilateral calf cramping but no leg swelling. she denies any difficulty breathing or chest pain. she took her am bp meds without difficulty. her blood pressure decreased to 130s-140s/60s without further intervention. she was transferred back to the floor on [**12-23**] and signed out ama. 2. angioedema: on [**12-20**] the patietn developed facial swelling and evidence of angioedema by ent. the patient reported that her face is more swollen which was confirmed by her mother on the floor. the patient was give lasix iv as she has been unable to have any negative filtration with hd. the patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. her tekturna was discontinued for concern that it might be causing angioedema. she denied difficulty with her breathing at that time, but was very somnulent. on arrival to the micu her vitals were stable and oxygenating well at 100% on face mask. the patients airway was supported with a nasal trumpet. the patient underwent mrv that showed no progression of her clot. patient was diuresed with lasix and dialysis with significant improvement in her symptoms. she was treated with prednisone and decadron, famotidine and benadryl for angioedema. the patient was maintained on her heparin drip for her svc syndrome. 3. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the transplant surgery team removed the pd cath on [**12-21**]. she continued to have abdominal pain post-op. she was continued on po dilaudid 2mg po prn. she continuned to complain of abdominal pain throughout her admission and continued to requested iv dilaudid. 4. esrd: the patient is on a t/th/sat schedule. she was closely followed by the renal team. she had dialysis on [**12-19**]. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient also had her pd catheter removed on [**12-21**] secondary to chronic abdominal pain. the patient was scheduled to have dialysis on [**12-23**]. 5. hx of svc/brachiocephalic dvt: her coumadin was held during last admission for supratherapeutic inr. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. she was also started on coumadin 2mg po qday, but was held on [**12-19**] in prep her pd catheter removal. she was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by ir. however, the patient signed out ama and thus it was not placed. 6. anxiety: pt recently saw psychiatrist who started her on celexa. she was continued on celexa 20mg po daily. 7. anemi of ckda: the patients hct was 30.3 on admission. it trended down to 22.3 on discharge when she left ama. there was no evidence of active, acute bleeding. this is likely seoncdary to her esrd. the patient was closely monitored. 8. systemic lupus erythematosis: rheumatology was consulted and does not suspect acute flare and dsdna, c3, c4 nl, esr and crp slightly elevated. her echo did not suggest worsening pericarditis. she was continued on her home prednisone dose of 4mg daily. 9. obstructive sleep apnea: cpap for sleep with 7 pressure. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Mechanical complication due to peritoneal dialysis catheter; ; Unspecified disease of pericardium; Angioneurotic edema, not elsewhere classified; Abdominal pain, other specified site; Systemic lupus erythematosus; ; Anemia in chronic kidney disease; Dysthymic disorder; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of steroids; Long-term (current) use of anticoagulants; Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation; Other antihypertensive agents causing adverse effects in therapeutic use]","24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. she was given 10mg iv labetalol and started on a labatelol drip. nephrology was consulted and dialysis initiated in the am. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she reports bilateral calf cramping but no leg swelling. she took her am bp meds without difficulty. her tekturna was discontinued for concern that it might be causing angioedema. the patient was maintained on her heparin drip for her svc syndrome. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient was scheduled to have dialysis on [**12-23**]. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. there was no evidence of active, acute bleeding.","24 year old female with sle, esrd on hd presents with abdominal pain and headache consistent with her usual hypertensive urgency. she was found to be in hypertensive urgency in ed. she received hydralazine iv 10 mg once and 2 inches of nitropaste." 109,124398.0,14809,2142-03-31,14803,135923.0,2142-01-12,Discharge summary,"Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-13**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypertensive Urgency and HA Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with HA in the setting of hypertension. Upon arrival to the ED, her vitals were 284/140, HR 67, RR 28, 100% on 4LNC. She was started on a nicardipine drip. She denied shortness of breath or chest pain. She is due for HD today. She has a left groin catheter which was recently placed [**2141-12-21**] and is causing her pain. She was also given dilaudid IV 1 mg x 2 with some relief. CXR was performed and showed no pulmonary edema. . Upon arrival to the MICU, patient denies HA, CP, SOB, fevers, chills. Patient reports mild abdominal pain at sight of left anterior abdominal wall hematoma and left groin pain at site of femoral HD line. She reports that she was taking her medications as directed, including coumadin for SVC thrombus. Briefly, 24 yo F with ESRD on HD, SLE, malignant HTN admitted for HA in the setting of HTN to 284/140 in ED. Initially, she was treated with a nicardipine gtt to control her BP. Her cardiac enzymes were flat, no new ECG changes. She was started on a heparin gtt with transition to coumadin for a SVC thrombosis. HTN secondary to med noncompliance. She was restarted on her oral BP. She missed her PM meds yesterday, so nicardipine was restarted, and then turned off this AM. She received all her AM BP meds. Her BPs have been in the 160s/90s. She had no neurological deficits. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 176/105, 87, 18, 100% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: 2/6 systolic murmur LUSB Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: left ant wall abd hematoma, TTP Extremities: Right: Trace, Left: Trace, left fem HD line without oozing or drainage Skin: Warm Neurologic: AAO x 3 Pertinent Results: [**2142-1-8**] 05:15AM PT-13.7* PTT-33.6 INR(PT)-1.2* [**2142-1-8**] 05:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-1+ STIPPLED-OCCASIONAL TEARDROP-1+ BITE-NORMAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2142-1-8**] 05:15AM cTropnT-0.08* [**2142-1-8**] 05:15AM CK(CPK)-119 [**2142-1-8**] 04:12PM PTT-120.8* [**2142-1-8**] 10:41PM PTT-144.8* [**2142-1-8**] 02:55PM CK-MB-NotDone cTropnT-0.06* Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. Patient was initially observed in the MICU and placed on a nicardipine drip. Patient was stablized on home medicaitons, suggesting medication non-compliance. Additionally, patient presented subtheraputic on coumadin for SVC thrombosis. Patient was started on heparin ggt. After the nicardipine drip was turned off, patient was called out to the floor. Heparin drip was continued until INR [**2-13**]. Pressures were managed to her baseline. Pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with Narcan. Patient received dialysis 3x/wk as per outpatient schedule. # Hypertension: Pt with extensive history of repeated admissions for hypertension. Patient's BP improved with nicardipine drip and after HD off drip on home PO medication regimen. Resumed oral antihypertensives with improved BP control. HTn likely from renal disease, possible medication noncompliance, lupus. No evidence of MI. Continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. Renal increased clonidine patch, and added Nicardipine with improvement of BP control. Pt is to follow up with an appointment in the next week to establish care at [**Company 191**], and to re-check her BP and adjust medications further. # SLE: Stable, continued prednisone at 4 mg PO daily. # Left groin pain. Permanent HD line was placed on [**12-25**]. Line and hematoma from prior peritoneal line on abdomen okay. No leukocytosis or fevers to suggest infection. Patient was oversedated on Dilaudid and had episode of oxygen desaturation which was reversed with Narcan. Patient was solmolent with morphine SR so that was d/c'ed as well, patient was given standing tylenlol and Morphine IR PRN. Transplant surgery removed remaining sutures today from L groin. Pt has a follow-up appointment in the next week with Dr. [**First Name (STitle) **] (Transplant Surgery). She will be sent home with low-dose Morphine IR and Tylenol PRN pain. If L groin pain should become uncontrollable on current meds, pt should return to the ED for re-evaluation. It is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #ESRD: Renal following, continuing HD Th/Th/Sat. CaCO3 was started for elevated calcium-phosphate product. Pt will follow-up with Dr. [**Last Name (STitle) 7473**] in the next 1-2 weeks. # Anemia: Pt's baseline is 26. This is likely secondary to AOCD and renal failure. Hct was stable on day of discharge at 25.9. # SVC thrombus: Pt has a history of an SVC thrombus, and is on coumadin. She is supposed to be on lifelong anticoagulation due to recurrent thrombosis but INR subtherapeutic on arrival. Heparin drip was stopped on the floor once the INR was theraputic. INR was therapeutic on day of discharge. Pt will need an INR check in the next week at her follow-up with her PCP. # HOCM: Pt has evidence of myocardial hypertrophy on Echo. She is currently not symptomatic. Echo did not show evidence of worsening pericardial effusion. She was continued on her beta-blocker and other BP medications. # Depression/anxiety: Stable. She was continued on Celexa and Clonazepam. # OSA: Pt as continued on CPAP for sleep with 7 pressure. # FEN: regular diet # PPX: heparin drip --> coumadin, bowel regimen # ACCESS: PIV x2 / permanent dialysis cath L fem # CODE: FULL # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] # DISPO: home with PCP and Renal [**Name9 (PRE) 702**] to re-check BP, INR level. Follow-up with Transplant Surgery. Medications on Admission: Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Aliskiren 150 [**Hospital1 **] Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Nicardipine 30 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain for 2 weeks. [**Hospital1 **]:*20 Tablet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Urgency End Stage Renal Disease Discharge Condition: stable, blood pressure moderately controlled, afebrile, tolerating POs Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. Some of medications were increased as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to take the coumadin as prescribed by your doctor, and have your INR checked frequently per your PCP's recommendations. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Renal) Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-1-15**] 3:00 - Will follow-up Vitamin D [**2-4**] level Provider: [**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD ([**Company 191**]) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-1-16**] 3:30 - Will re-check your INR level Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Transplant Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-1-19**] 2:50p [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-1-12**]",78,2142-01-08 06:36:00,2142-01-13 21:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE URGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was initially observed in the micu and placed on a nicardipine drip. patient was stablized on home medicaitons, suggesting medication non-compliance. additionally, patient presented subtheraputic on coumadin for svc thrombosis. patient was started on heparin ggt. after the nicardipine drip was turned off, patient was called out to the floor. heparin drip was continued until inr [**2-13**]. pressures were managed to her baseline. pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with narcan. patient received dialysis 3x/wk as per outpatient schedule. # hypertension: pt with extensive history of repeated admissions for hypertension. patients bp improved with nicardipine drip and after hd off drip on home po medication regimen. resumed oral antihypertensives with improved bp control. htn likely from renal disease, possible medication noncompliance, lupus. no evidence of mi. continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. renal increased clonidine patch, and added nicardipine with improvement of bp control. pt is to follow up with an appointment in the next week to establish care at [**company 191**], and to re-check her bp and adjust medications further. # sle: stable, continued prednisone at 4 mg po daily. # left groin pain. permanent hd line was placed on [**12-25**]. line and hematoma from prior peritoneal line on abdomen okay. no leukocytosis or fevers to suggest infection. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. patient was solmolent with morphine sr so that was d/ced as well, patient was given standing tylenlol and morphine ir prn. transplant surgery removed remaining sutures today from l groin. pt has a follow-up appointment in the next week with dr. [**first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. it is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #esrd: renal following, continuing hd th/th/sat. caco3 was started for elevated calcium-phosphate product. pt will follow-up with dr. [**last name (stitle) 7473**] in the next 1-2 weeks. # anemia: pts baseline is 26. this is likely secondary to aocd and renal failure. hct was stable on day of discharge at 25.9. # svc thrombus: pt has a history of an svc thrombus, and is on coumadin. she is supposed to be on lifelong anticoagulation due to recurrent thrombosis but inr subtherapeutic on arrival. heparin drip was stopped on the floor once the inr was theraputic. inr was therapeutic on day of discharge. pt will need an inr check in the next week at her follow-up with her pcp. # hocm: pt has evidence of myocardial hypertrophy on echo. she is currently not symptomatic. echo did not show evidence of worsening pericardial effusion. she was continued on her beta-blocker and other bp medications. # depression/anxiety: stable. she was continued on celexa and clonazepam. # osa: pt as continued on cpap for sleep with 7 pressure. # fen: regular diet # ppx: heparin drip --> coumadin, bowel regimen # access: piv x2 / permanent dialysis cath l fem # code: full # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] # dispo: home with pcp and renal [**name9 (pre) 702**] to re-check bp, inr level. follow-up with transplant surgery. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Hypoxemia; Other opiates and related narcotics causing adverse effects in therapeutic use; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Abdominal pain, other specified site; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Renal dialysis status; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Other postprocedural status]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. # hypertension: pt with extensive history of repeated admissions for hypertension. # sle: stable, continued prednisone at 4 mg po daily. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. this is likely secondary to aocd and renal failure. pt will need an inr check in the next week at her follow-up with her pcp.","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was stablized on home medicaitons, suggesting medication non-compliance. patient was oversedated on dilaudid and had episode of oxygen desaturation." 109,124398.0,14809,2142-03-31,14804,124657.0,2142-01-20,Discharge summary,"Admission Date: [**2142-1-14**] Discharge Date: [**2142-1-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 4028**] Chief Complaint: headache Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with mild headache, mild shortness of breath and consistent abdominal pain at the site of her known left abdominal wall hematoma in the setting of hypertension. Her last HD was yesterday. . Upon arrival to the ED, her vitals were BP 240's systolic, HR 90's, 93% on RA. A head CT scan was done which showed no acute process. An abdominal CT was done given her femoral line pain, which also was normal. She was given nitropaste X2 initially, then switched to labetalol 100mg x2, then 200mg x2, then finally started on nicardipine drip when she showed benefit with a decrease in her BP to 170/123 and improvement in her headache. . Upon arrival to the MICU, patient denies any current symptoms. She reports that her headache, shortness of breath and abdominal pain all resolved with blood pressure management and pain medications. . Pt was transferred to the floor when blood pressure was controlled. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: HR 96 BP 171/111 RR 12 O2 98% on RA Physical Exam: General in NAD HEENT NC, AT, EOMI, PERRLA, MMM CVS RRR, 3/6 systolic murmur in all heart fields RESP CTA BL, no crackles or wheezes ABD soft, hematoma raised on left anterior abdominal wall, +BS, mildly tender over hematoma EXT left sided femoral HD line in place, no erythema, no edema NEURO A+Ox3, CN2-12 intact, pt has left sided artificial eye, motor and sensory intact Pertinent Results: ***LABS ON ADMISSION*** [**2142-1-13**] 07:03AM WBC-5.2 RBC-2.79* HGB-8.5* HCT-26.3* MCV-94 MCH-30.3 MCHC-32.2 RDW-19.2* [**2142-1-13**] 07:03AM PLT COUNT-154 [**2142-1-13**] 07:03AM PT-29.5* PTT-49.2* INR(PT)-3.0* [**2142-1-13**] 07:03AM GLUCOSE-94 UREA N-53* CREAT-7.0* SODIUM-136 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [**2142-1-13**] 07:03AM CALCIUM-8.8 PHOSPHATE-5.0* MAGNESIUM-1.9 [**2142-1-14**] 12:00PM PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-14**] 12:00PM LIPASE-42 [**2142-1-14**] 12:00PM ALT(SGPT)-12 AST(SGOT)-43* ALK PHOS-96 TOT BILI-0.4 [**2142-1-14**] 03:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-1-14**] 03:25PM URINE RBC-[**3-15**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-[**3-15**] [**2142-1-14**] 12:00PM BLOOD PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-19**] 06:40AM BLOOD PT-18.6* PTT-38.7* INR(PT)-1.7* . ***LABS ON DAY OF DISCHARGE*** [**2142-1-20**] 06:35AM BLOOD WBC-5.7 RBC-2.39* Hgb-7.1* Hct-22.1* MCV-93 MCH-29.8 MCHC-32.2 RDW-18.6* Plt Ct-136* [**2142-1-20**] 06:35AM BLOOD Glucose-107* UreaN-34* Creat-4.8* Na-137 K-5.2* Cl-101 HCO3-27 AnGap-14 [**2142-1-20**] 06:35AM BLOOD PT-22.8* PTT-42.3* INR(PT)-2.2* . IMAGING [**2142-1-14**] EKG Sinus rhythm. Possible left atrial abnormality. Borderline voltage criteria for left ventricular hypertrophy. Inferolateral ST-T wave changes may be related to left ventricular hypertrophy. Compared to the previous tracing of [**2142-1-8**] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 99 190 86 368/436 13 100 24 [**2142-1-14**] CT ABD/PELV IMPRESSION: 1. Interval decrease in size to subcutaneous anterior abdominal wall hematoma. 2. Infectious versus inflammatory process within the right lower lobe of the lung. Small right simple pleural effusion. 3. Cardiomegaly with slight decrease in size of moderate pericardial effusion. 4. Right lobe liver hemangioma, unchanged. [**2142-1-14**] CT HEAD IMPRESSION: 1. Mildly limited study given administration of small amount of IV contrast material. However, no evidence of hemorrhage or mass effect. NOTE ADDED AT ATTENDING REVIEW: This patient was administered contrast for the abdominal CT, and the head CT was performed after part of this dose. Therefore, this is neither a noncontrast examination, nor a proper contrast CT. [**2142-1-14**] CXR CONCLUSION: Persistent cardiomegaly and mild pulmonary edema. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. . # Hypertensive Urgency: Pt with extensive history of hypertension. Patient's BP improved with nicardipine drip. Became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. Restarted all home oral antihypertensives including nicardipine 30 Q8H, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Blood pressure remains labile and renal continues to follow patient. Pt was transferred to the floor as blood pressure stabilized. BP has remained stable with systolics 140s-170s. In the MICU, Nifedipine extended release was added in place of Nicardipine as pt's blood pressures seemed to rise prior to Nicardipine doses. . # Hyperkalemia: Ocurred on the day after admission. Resolved with administration of kayexalate. Pt continued hemodialysis on TuThSat. . # Left abdominal wall hematoma: Abd CT showed a mild decrease in the size. Pt reported that morphine did not help pain, and was switched to dilaudid PO in the MICU. However, given pt's recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/c'ed on the floor. Pt was continued on gabapentin, tylenol around the clock, and low-dose Morphine as needed for pain. Narcotics should be avoided in the future. Pain should also resolve in the next few weeks as hematoma resolves. . # SLE: Pt was continued on prednisone at 4 mg PO daily. . #ESRD: Renal was following during her stay. She continued HD on her T, Th, Sat schedule. # Anemia: Hct was mildly decreased from baseline during admission. This is likely secondary to AOCD and in the setting of renal failure. . # SVC thrombus: Patient is on anticoagulation, likely lifelong. Patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. Then INR became subtherapeutic, so heparin gtt was used to bridge. On day of discharge, INR became therapeutic, and pt was discharged home on Coumadin 4mg PO daily, with INR to be checked next at hemodialysis . # HOCM: Pt has evidence of myocardial hypertrophy on recent Echo. She was not symptomatic during her stay. She was continued on her beta blocker. . # Depression/anxiety. She was continued on celexa and clonazepam PRN. . # OSA: CPAP for sleep with 7 pressure. . # FEN: repleted lytes prn / regular diet . # PPX: coumadin, bowel regimen . # ACCESS: PIV/ permanent dialysis cath L fem . # CODE: FULL . # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nicardipine 30mg PO TID Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for breakthrough pain for 2 weeks. 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*1* 13. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*260 Tablet(s)* Refills:*1* 14. Respiratory Therapy Please adjust settings of CPAP machine to a lower volume as it is uncomfortable for the patient. Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Discharge Condition: Good, hemodynamically stable, afebrile, pain controlled Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. One new medication was added as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to continue your Coumadin at 4mg daily and have your INR checked AT DIALYSIS next week. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep ALL scheduled appointments. Medications changes include: 1. STOP NICARDIPINE 2. Start Nifedipine CR 90mg by mouth daily 3. INCREASE Labetalol to 900mg by mouth 3 times daily 4. Continue at Warfarin 4mg by mouth daily If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to set up a follow-up appointment in 1-2weeks. Please continue your HD TuThSat. Completed by:[**2142-1-20**]",70,2142-01-14 17:34:00,2142-01-20 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. . # hypertensive urgency: pt with extensive history of hypertension. patients bp improved with nicardipine drip. became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. restarted all home oral antihypertensives including nicardipine 30 q8h, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. blood pressure remains labile and renal continues to follow patient. pt was transferred to the floor as blood pressure stabilized. bp has remained stable with systolics 140s-170s. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. . # hyperkalemia: ocurred on the day after admission. resolved with administration of kayexalate. pt continued hemodialysis on tuthsat. . # left abdominal wall hematoma: abd ct showed a mild decrease in the size. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu. however, given pts recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/ced on the floor. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. narcotics should be avoided in the future. pain should also resolve in the next few weeks as hematoma resolves. . # sle: pt was continued on prednisone at 4 mg po daily. . #esrd: renal was following during her stay. she continued hd on her t, th, sat schedule. # anemia: hct was mildly decreased from baseline during admission. this is likely secondary to aocd and in the setting of renal failure. . # svc thrombus: patient is on anticoagulation, likely lifelong. patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. then inr became subtherapeutic, so heparin gtt was used to bridge. on day of discharge, inr became therapeutic, and pt was discharged home on coumadin 4mg po daily, with inr to be checked next at hemodialysis . # hocm: pt has evidence of myocardial hypertrophy on recent echo. she was not symptomatic during her stay. she was continued on her beta blocker. . # depression/anxiety. she was continued on celexa and clonazepam prn. . # osa: cpap for sleep with 7 pressure. . # fen: repleted lytes prn / regular diet . # ppx: coumadin, bowel regimen . # access: piv/ permanent dialysis cath l fem . # code: full . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Other vascular complications of medical care, not elsewhere classified; Systemic lupus erythematosus; Hyperpotassemia; Phlebitis and thrombophlebitis of upper extremities, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. # anemia: hct was mildly decreased from baseline during admission. # hocm: pt has evidence of myocardial hypertrophy on recent echo. # fen: repleted lytes prn / regular diet . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. pt was transferred to the floor as blood pressure stabilized. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu." 109,124398.0,14809,2142-03-31,14805,176760.0,2142-01-23,Discharge summary,"Admission Date: [**2142-1-21**] Discharge Date: [**2142-1-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Hypertensive Urgency and fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with hypertensive urgency, subjective fevers, and pain. . Of note, she had been hospitalized [**Date range (1) 43505**] with hypertensive urgency. Her nicardipine was changed to nifedipine in hospital and her labetalol was increased to 900mg TID from 800mg TID.BPs were reportedly stable in the 140's-170's on the medical floor on nifedipine, aliskerin, labetalol, clonidine, and hydralazine prior to discharge. Last HD was [**1-20**]. . She reports feeling well at time of discharge [**1-20**], however woke this evening feeling sweaty, hot, and mildly SOB. She did not check her temperature and denies any rigors. She had total body aching (worst in her left wrist at site of recent IV and abdomen at site of known hematoma). +Palpitations overnight now resolved. No CP, SOB, cough, diarrhea, dysuria, erythema/tenderness/drainage from HD catheter. Denies recent joint symptoms with her lupus. No sick contacts. Says she took her BP meds. . Upon arrival to the ED, her vitals were 99.9 104 254/145 16 96% on RA. She was started on a nicardipine drip, given 1"" nitropaste with improvement in her BP. Did spike a fever while in the ED, currently 101F 101 173/106 Given vancomycin and zoysn for ?pna as CXR with right sided haziness. Also received 3mg IV dilaudid for body pains. LUE ultrasound without evidence of DVT. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 98.5 P 92 Bp 173/116 RR 16 O2 100% on RA General Pleasant young woman appearing comfortable HEENT Cushingoid faces, L eye prosthesis, MMM Pulm Lungs clear bilaterally, no rales or wheezing CV Regular S1 S2 ?soft systolic murmur Abd Soft +hematoma left abdomen unchanged from prior exam Extrem Warm full distal pulses. Left hand with slight edema ++ tender to palpation of wrist patient unable to make fist secondary to pain, no erythema +warmth ?purulence at site of old PIV Skin No peripehral stigmata of endocarditis Lines Left groin HD catheter site without erythema, purulence, or tenderness Neuro Alert and awake, moving all extremities Pertinent Results: CXR [**1-21**]: In comparison with the earlier study of this date, the diffuse pulmonary edema has substantially decreased, possibly following hemodialysis. Enlargement of the cardiac silhouette persists and there is no definite pleural effusion. Suggestion of an area of increased opacification at the right base. This could merely represent asymmetric edema, though the possibility of a developing consolidation cannot be unequivocally excluded. . LUE US [**1-21**]: IMPRESSION: No DVT in the left upper extremity. . L wrist xray [**1-21**]: There is prominent soft tissue swelling about the wrist, relatively diffuse, but quite prominent along the dorsum of the wrist. No fracture, dislocation, degenerative change, focal lytic or sclerotic lesion, or erosion is identified. No soft tissue calcification or radiopaque foreign body is identified. A tiny (1.7 mm) linear density is seen along the dorsum of the wrist on the oblique view is seen only on that view and is consistent with a small film artifact. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency and left wrist pain. . 1. Hypertensive urgency: Patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. Patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. She was started on nicardipine drip and 1"" nitropaste and admitted to the ICU for further treatment. There was no evidence of end-organ ischemia. Upon arrival to the ICU she was given her usual home antihypertensives and the nicardipine was quickly weaned off. It was felt that pain and anxiety were both contributing to her elevated BPs. Her BP quickly stabilized and she was called out to the medical floor where her SBP ranged 110-150. She was continued on nifepidine 90mg daily, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Given her repeated admissions with hypertensive urgency a meeting was held between the patient's nephrologist Dr. [**Last Name (STitle) 4883**], her ICU physician and her [**Name9 (PRE) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the ICU where she quickly improves with simply continuing her home medications. The following plan was drafted and placed in a note in OMR titled "" Care Protocol"". . CARE PROTOCOL: . BLOOD PRESSURE MANAGEMENT: . For BP > 230/140 1. Hydralazine: 100 mg PO OR 10 mg IV q 20 minutes until blood pressure back to baseline*. . 2. Give daily blood pressure medications, if she has not already taken them before arrival. . 3. If after one hour of therapy AND/OR evidence of end organ damage, transfer to the ICU. . * Note: Her usual blood pressure is ~ 160/100. Efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. In the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . PAIN MANAGEMENT: . As an outpatient, Ms. [**Name13 (STitle) **] takes dilaudid 2-4 mg PO q 4 PRN.This is being slowly tapered, she should not be administered IV pain medications. . ANTICOAGULATION: . In the absence of bleeding, warfarin does not need to be stopped on admission. Similarly, in the absence of new thrombosis, subtherapeutic INR's do not require bridging with IV UFH. . 2. Fever: Possible sources included line infection, thombophlebitis, septic arthritis, PNA. Received vanc/zosyn in ED for possible PNA. UA without pyuria and urine culture negative. CXR also without convinving infiltrate on repeat PA/Lat so zosyn was discontinued. Patient was complaining of severe pain at her IV site and was noted to have a small abscess there which was felt to be the cause of her fever. She was continued on IV vanco with HD for 10day course. She remained afebrile and did not have a leukocytosis. . 3. Left wrist pain: Began following IV placement during recent hospitalization. Likely due to septic thrombophlebitis. Small abscess was too small to drain. This was treated with warm soaks and prn PO dilaudid. Vanco was continued for 10 day course. L wrist films were enremarkable. . 4. Left abdominal wall hematoma: Stable on exam from recent admission. She was continued on pain management with morphine 7.5mg TID, gabapentin and tylenol as needed for pain. . 5. SLE: Continued prednisone at 4 mg PO daily . 6. ESRD: Continued on regularly scheduled dialysis. . 7. Anemia: Baseline Hct 26. Her Hct was mildly decreased from baseline. Secondary to AOCD and renal failure. There was no evidence of bleeding. . 8. SVC thrombus: Known SVC thrombus, therapeutic on coumadin. Continued warfarin. . 9. HOCM: evidence of myocardial hypertrophy on recent Echo. Currently not symptomatic. Echo without evidence of worsening pericardial effusion. Continued beta blocker . 10. Depression/anxiety. Continued Celexa, clonazepam 0.5mg [**Hospital1 **] . 11. OSA: Continued CPAP Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nifedipine 90mg PO daily Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325-650 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*270 Tablet(s)* Refills:*2* 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 7 days. [**Hospital1 **]:*4 dose* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Septic thrombophlebitis Discharge Condition: Stable, afebrile, BP improved. Discharge Instructions: You were admitted to the hospital with hypertensive urgency. You required IV medications and were observed overnight in the ICU. Your usual oral blood pressure medications were continued and your blood pressure remained well-controlled. You were found to have an infection at your prior IV site on your left hand. For this you were given IV vancomycin. You will need 7 days more of antibiotics which will be given with dialysis. Please resume your usual dialysis schedule. Your last dialysis was [**1-23**]. Please continue to take your medications as prescribed. You should hold your coumadin today. You can resume this on wednesday at your normal dose. You should have your INR checked at dialyis as usual on thursday. . If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-12**] weeks. ",67,2142-01-21 11:23:00,2142-01-23 16:40:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE EMERGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. . 1. hypertensive urgency: patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. there was no evidence of end-organ ischemia. upon arrival to the icu she was given her usual home antihypertensives and the nicardipine was quickly weaned off. it was felt that pain and anxiety were both contributing to her elevated bps. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150. she was continued on nifepidine 90mg daily, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. given her repeated admissions with hypertensive urgency a meeting was held between the patients nephrologist dr. [**last name (stitle) 4883**], her icu physician and her [**name9 (pre) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the icu where she quickly improves with simply continuing her home medications. the following plan was drafted and placed in a note in omr titled "" care protocol"". . care protocol: . blood pressure management: . for bp > 230/140 1. hydralazine: 100 mg po or 10 mg iv q 20 minutes until blood pressure back to baseline*. . 2. give daily blood pressure medications, if she has not already taken them before arrival. . 3. if after one hour of therapy and/or evidence of end organ damage, transfer to the icu. . * note: her usual blood pressure is ~ 160/100. efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. in the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . pain management: . as an outpatient, ms. [**name13 (stitle) **] takes dilaudid 2-4 mg po q 4 prn.this is being slowly tapered, she should not be administered iv pain medications. . anticoagulation: . in the absence of bleeding, warfarin does not need to be stopped on admission. similarly, in the absence of new thrombosis, subtherapeutic inrs do not require bridging with iv ufh. . 2. fever: possible sources included line infection, thombophlebitis, septic arthritis, pna. received vanc/zosyn in ed for possible pna. ua without pyuria and urine culture negative. cxr also without convinving infiltrate on repeat pa/lat so zosyn was discontinued. patient was complaining of severe pain at her iv site and was noted to have a small abscess there which was felt to be the cause of her fever. she was continued on iv vanco with hd for 10day course. she remained afebrile and did not have a leukocytosis. . 3. left wrist pain: began following iv placement during recent hospitalization. likely due to septic thrombophlebitis. small abscess was too small to drain. this was treated with warm soaks and prn po dilaudid. vanco was continued for 10 day course. l wrist films were enremarkable. . 4. left abdominal wall hematoma: stable on exam from recent admission. she was continued on pain management with morphine 7.5mg tid, gabapentin and tylenol as needed for pain. . 5. sle: continued prednisone at 4 mg po daily . 6. esrd: continued on regularly scheduled dialysis. . 7. anemia: baseline hct 26. her hct was mildly decreased from baseline. secondary to aocd and renal failure. there was no evidence of bleeding. . 8. svc thrombus: known svc thrombus, therapeutic on coumadin. continued warfarin. . 9. hocm: evidence of myocardial hypertrophy on recent echo. currently not symptomatic. echo without evidence of worsening pericardial effusion. continued beta blocker . 10. depression/anxiety. continued celexa, clonazepam 0.5mg [**hospital1 **] . 11. osa: continued cpap ","PRIMARY: [Other vascular complications of medical care, not elsewhere classified] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; ; Systemic lupus erythematosus; Phlebitis and thrombophlebitis of upper extremities, unspecified]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. she was continued on iv vanco with hd for 10day course. esrd: continued on regularly scheduled dialysis. her hct was mildly decreased from baseline. hocm: evidence of myocardial hypertrophy on recent echo. echo without evidence of worsening pericardial effusion. continued celexa, clonazepam 0.5mg [**hospital1 **] .","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150." 109,124398.0,14809,2142-03-31,14807,158995.0,2142-02-26,Discharge summary,"Admission Date: [**2142-2-25**] Discharge Date: [**2142-2-26**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 338**] 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 History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, hx of malignant HTN admitted with change in mental status. Patient missed HD on [**2142-2-24**] and was found unresponsive and diaphoretic by mother this morning after she took some dilaudid. EMS was called, 1 mg of narcan was administered with slight improvement in mental status. On arrival to the ED her vitals were 112/64 62 16 99RA she was noted to be hyperkalemic in the absence of EKG changes and was given calcium, D5, 10U regular insulin, 30 mg po kayxalate and repeat K was 5.4. ABG: 7.29/38/199. Repeat glucose was 41 and 1amp D50 was given. She was sent to the ICU for monitoring. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including [**Month/Year (2) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: HR: 80 (79 - 80) bpm BP: 127/59(76) {127/59(76) - 139/64(82)} mmHg RR: 34 (21 - 34) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Physical Examination Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact Pertinent Results: [**2142-2-25**] 01:50PM PT-14.9* PTT-36.8* INR(PT)-1.3* [**2142-2-25**] 01:50PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2142-2-25**] 01:50PM WBC-5.0 RBC-2.21* HGB-6.4* HCT-20.7* MCV-94 MCH-29.1 MCHC-31.1 RDW-19.6* [**2142-2-25**] 10:30PM GLUCOSE-87 UREA N-66* CREAT-8.4* SODIUM-142 POTASSIUM-5.9* CHLORIDE-110* TOTAL CO2-16* ANION GAP-22* HISTORY: Altered mental status. Evaluate underlying for pneumonia. UPRIGHT PORTABLE CHEST: Comparison is made to [**2-14**] and [**2142-2-19**], exams. Study is slightly limited by patient motion. In the interval, the degree of pulmonary edema appears improved with slightly decreased prominence of the pulmonary vascularity. There is unchanged extensive retrocardiac consolidation obscuring the majority of the left hemidiaphragm with persistent blunting of the left CP angle, likely related to small effusion. Exam is otherwise unchanged from prior with persistent cardiomegaly. A catheter is seen projecting over the abdomen, partially imaged. IMPRESSION: Slight improvement in pulmonary edema with persistent retrocardiac opacity, which again may represent atelectasis versus underlying pneumonia. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted hypotension and decreased mental status. Hypotension and altered mental status were in the setting of excessive narcotic use. Patient's narcotics were held, pressors returned to [**Location 213**] and patient was mentating fine. Hct was below baseline and patient was transfused 1u PRBC and was given HD before discharge. Patient is to continue anti-hypertensive medications as previously scheduled. Patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # Change in mental status: Resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. Patient received 1 dose of narcan with slight improvement in BP and mental status. patient without fevers or leuckocytosis which argue against infection. # Hypertension ?????? resumed outpatient regimen. Patient did not have any hypertensive episodes requiring hydralizine 10mg IV. # Hypotension: resolved, Patient normotensive on arrival to ICU. Relative hypotension likely due to dilaudid. Other considerations include sepsis, although patient without objective signs of infection. Held pain medications and hypotension resolved. Resumed hypertensive medications. # Abdominal pain ?????? from previous peritoneal [**Location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # Hyperkalemia: Likely due to missed HD session. She received calcium, D5, insulin and kayexalate in ED. HD in am ESRD: Renal following, had HD the day of discharge, transfused while there. Will continue normal schedule as an outpatient with HD T/Th/F this week. # Metabolic Acidosis: likely due to renal failure and missed HD. # SLE: continued prednisone at 4 mg PO daily. # OSA: CPAP for sleep with 7 pressure, however patient refuses. Continued to offer as inpatient. Should try to follow up with sleep medicine. Medications on Admission: Prednisone 4mg qd Citalopram 20 mg daily Gabapentin 300 mg [**Hospital1 **] Warfarin 4mg daily Pantoprazole 40 mg qd Clonidine 0.1 mg/24 QWED Clonidine 0.3 mg/24 hr QWED Labetalol 900 mg tid Nifedipine 90 mg qd Aliskiren 150 mg [**Hospital1 **] Hydralazine 100 mg q8h Morphine 7.5 mg q8h prn pain Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Home Discharge Diagnosis: Primary: narcotic overdose relative hypotension anemia Secondary: ESRD on HD [**2-12**] SLE malignant hypertension Discharge Condition: stable - received HD prior to discharge Discharge Instructions: You were admitted for altered mental status after missing hemodialysis. It was likely from the dilaudid you took as well as missing your scheduled [**Month/Day (2) 2286**]. You were also relatively hypotensive in the setting of excessive narcotic medicaiton usage. Narcotic medications were held and hypotension and altered mental status resolved. Please use narcotic medications with caution. You are recommended to use morphine for pain control rather than dilaudid. No medication changes were made. Please return to the ED if you have any altered mental status or miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] or have symptoms such as vision changes or headache from your history of malignant hypertension. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-3-20**] 3:00 HD as previously scheduled Completed by:[**2142-2-26**]",33,2142-02-25 15:49:00,2142-02-26 16:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ALTERED MENTAL STATUS," 24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. patients narcotics were held, pressors returned to [**location 213**] and patient was mentating fine. hct was below baseline and patient was transfused 1u prbc and was given hd before discharge. patient is to continue anti-hypertensive medications as previously scheduled. patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # change in mental status: resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. patient received 1 dose of narcan with slight improvement in bp and mental status. patient without fevers or leuckocytosis which argue against infection. # hypertension ?????? resumed outpatient regimen. patient did not have any hypertensive episodes requiring hydralizine 10mg iv. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. other considerations include sepsis, although patient without objective signs of infection. held pain medications and hypotension resolved. resumed hypertensive medications. # abdominal pain ?????? from previous peritoneal [**location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # hyperkalemia: likely due to missed hd session. she received calcium, d5, insulin and kayexalate in ed. hd in am esrd: renal following, had hd the day of discharge, transfused while there. will continue normal schedule as an outpatient with hd t/th/f this week. # metabolic acidosis: likely due to renal failure and missed hd. # sle: continued prednisone at 4 mg po daily. # osa: cpap for sleep with 7 pressure, however patient refuses. continued to offer as inpatient. should try to follow up with sleep medicine. ","PRIMARY: [Poisoning by other opiates and related narcotics] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Thrombotic microangiopathy; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Altered mental status; Other iatrogenic hypotension; Accidental poisoning by other opiates and related narcotics; Hyperpotassemia; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Nontraumatic hematoma of soft tissue; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. from previous peritoneal [**location 2286**] hematoma ??????","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. narcotics were held, pressors returned to and patient was mentating fine. patient was encouraged to take less pain medications and to use morphine." 109,124398.0,14809,2142-03-31,14808,158943.0,2142-03-23,Discharge summary,"Admission Date: [**2142-3-21**] Discharge Date: [**2142-3-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: Abdominal Pain, Shortness of breath, Chest discomfort Major Surgical or Invasive Procedure: HD [**2142-3-21**] and [**2142-3-23**] History of Present Illness: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] 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 [**Telephone/Fax (3) 43508**]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. [**Telephone/Fax (3) **] was discussed with renal and it was not felt that HTN is a volume issue so no need for emergent [**Telephone/Fax (3) 2286**]. . 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 [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**], getting Vanc with HD. . PSHx: 1. Placement of multiple catheters including [**Year (4 digits) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] 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: [**2142-3-21**] 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* [**2142-3-21**] 02:20AM NEUTS-76.1* BANDS-0 LYMPHS-17.9* MONOS-4.5 EOS-1.1 BASOS-0.5 [**2142-3-21**] 02:20AM PLT SMR-NORMAL PLT COUNT-168 [**2142-3-21**] 02:20AM PT-21.8* PTT-34.7 INR(PT)-2.1* [**2142-3-21**] 02:20AM cTropnT-0.12* [**2142-3-21**] 02:20AM ALT(SGPT)-46* AST(SGOT)-94* CK(CPK)-76 ALK PHOS-173* TOT BILI-0.4 [**2142-3-21**] 02:20AM GLUCOSE-74 UREA N-47* CREAT-7.3* SODIUM-140 POTASSIUM-5.8* CHLORIDE-109* TOTAL CO2-19* ANION GAP-18 [**2142-3-21**] 04:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-21**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2142-3-21**] 12:58PM CK-MB-NotDone cTropnT-0.12* . CT C/A/P - [**2142-3-20**] - 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: [**2142-3-23**] 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* [**2142-3-23**] 12:00PM BLOOD Plt Ct-130* [**2142-3-23**] 12:00PM BLOOD PT-28.8* PTT-58.6* INR(PT)-2.9* [**2142-3-23**] 12:00PM BLOOD Glucose-77 UreaN-31* Creat-6.0*# Na-137 K-4.8 Cl-104 HCO3-24 AnGap-14 [**2142-3-23**] 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 [**3-22**] 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 [**2142-3-21**] . # abdominal pain: Consistent with patient's baseline chronic abdominal pain. Medication effect also possible. CT prelim neg for small bowel obstruction. LFTs doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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). [**Month/Year (2) **]:*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 [**Month/Year (2) 2286**] sessions as directed by the nephrology team- your next session should be on Tuesday. Completed by:[**2142-3-26**]",8,2142-03-21 09:25:00,2142-03-23 18:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,CHEST PAIN;TELEMETRY," 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 (200s/100s) that nevertheless are within levels shes 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 [**3-22**] and transferred to the medicine floor. the next day, her bp remained within goal of 120s/80s. 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. ces were cycled and were negative. cpap was continued as tolerated at home settings. sob resolved after hd on [**2142-3-21**] . # abdominal pain: consistent with patients baseline chronic abdominal pain. medication effect also possible. ct prelim neg for small bowel obstruction. lfts doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Compression of vein; Unspecified disease of pericardium; Infection and inflammatory reaction due to other vascular device, implant, and graft; Bacteremia; Primary hypercoagulable state; Other primary cardiomyopathies; ; Abdominal pain, unspecified site; Urinary tract infection, site not specified; Acidosis; Other chest pain; Other chronic pain; Systemic lupus erythematosus; Noncompliance with renal dialysis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Hyperpotassemia; 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; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","this is a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. ct prelim neg for small bowel obstruction. on arrival to the floor, abd pain was back to baseline and well controlled on dilaudid 2mg po q 4hrs .","a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. initial attempts were made to control her bp with hydralazine and labetalol iv but after these failed to control her blood pressure. she was successfully transitioned to home medications of clonidine, labetalol, aliskiren, nifedipine" 109,124398.0,14809,2142-03-31,14806,113189.0,2142-02-17,Discharge summary,"Admission Date: [**2142-2-14**] Discharge Date: [**2142-2-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: From admission note: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome admitted with HTN and SOB in the setting of missed HD. The patient reported missing HD yesterday because she thinks she is being overdiuresed. She reports persistent pain at site of rectus sheath hematoma. Denies N/V/D. Pt recently admitted from [**Date range (1) 13924**] with consistent abdominal pain at the site of her known left abdominal wall hematoma, hypertensive to 230's and hyperkalemic to 6.2 after missing her last two dialysis sessions. At this time the pt. was dialyzed, received a blood transfusion, and was administered her daily antihypertensive medications. Pt. left AMA after her transfusion despite the primary team's concerns to look for an active area of bleeding. In the ED, patient complain of mild dyspnea, sating well on RA. CXR mild volume overload. KUB with no evidence of obstruction. She was started on a labetalol gtt. ECG - RAD, LVH no change from prior. HCT stable at 21. The renal team evaluated pt and recommended HD, however the patient refused. She was transferred to ICU for BP control. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: [**2142-2-14**] 07:40AM WBC-3.9* RBC-2.38* HGB-7.0* HCT-21.3* MCV-90 MCH-29.5 MCHC-33.0 RDW-18.9* [**2142-2-14**] 07:40AM NEUTS-74.9* LYMPHS-18.7 MONOS-3.1 EOS-3.0 BASOS-0.2 [**2142-2-14**] 07:40AM PLT COUNT-101* [**2142-2-14**] 07:40AM PT-16.3* PTT-36.6* INR(PT)-1.5* [**2142-2-14**] 07:40AM CK-MB-6 [**2142-2-14**] 07:40AM cTropnT-0.09* [**2142-2-14**] 07:40AM LIPASE-80* [**2142-2-14**] 07:40AM ALT(SGPT)-34 AST(SGOT)-72* CK(CPK)-120 ALK PHOS-124* TOT BILI-0.4 [**2142-2-14**] 07:40AM GLUCOSE-85 UREA N-32* CREAT-7.0* SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-19* ANION GAP-17 [**2142-2-14**] 07:44AM LACTATE-1.3 [**2142-2-14**] CXR: Stable cardiomegaly with mild CHF and a small left pleural effusion. Left basilar air space disease which may represent pneumonia. Clinical correlation and a follow up chest x-ray to clearance is recommended. [**2142-2-14**] KUB: 1. Nonspecific bowel gas pattern with no evidence of obstruction. 2. Left basilar airspace disease which may represent pneumonia and a small left pleural effusion. Please ensure follow-up to clearance. Brief Hospital Course: 24 y.o female with SLE, ESRD on HD and malignant hypertension who presents with HTN and SOB aftering missing HD. . # Malignant hypertension/hypertensive urgency: The patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and HD compliance. Has previously presented with BP up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. Pt was treated per OMR hypertensive protocol created by the patient's primary providers, with a goal SBP of 160-180. With short course of IV antihypertensives and hemodialysis, pt's BP fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # ESRD: Pt was followed by the renal service and underwent HD without any complications. Pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting HD. She will discuss this further with the Renal team as an outpatient. . # SLE: Pt was continued on her home dose of prednisone with no sign of SLE flair. . # Coagulopathy/history of DVT: Patient on lifetime anticoagulation for hx of multiple thrombotic events. Pt was continued on coumadin. . # Pain management: Pt was treated with PO dilaudid for her abdominal pain, as recommended per her OMR protocol. She asked for IV dilaudid multiple times but there was no clinical indication. She was also continued on gabapentin. . # Anemia: Secondary to AOCD and renal failure. The patietns Hct remained stable in the low 20s during admission. No PRBC infusions were needed. . # Depression/anxiety: Continued Celexa, clonazepam 0.5mg [**Hospital1 **] Medications on Admission: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain. 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Disposition: Home Discharge Diagnosis: Primary: Malignant Hypertension Secondary: SLE, End stage renal disease on hemodialysis, SVC syndrome Discharge Condition: Stable. SBP in 160s. Discharge Instructions: You were admitted with dangerously high hypertension and some shortness of breath in the setting of missing several dialysis sessions. You were admitted and treated with your usual regimen of blood pressure meds and a short course of IV meds. With dialysis, your symptoms improved. You also had some abdominal pain, which was well controlled on your usual pain medications. We made no changes to your medications. Please take everything as prescribed. Please call your PCP or return to the hospital if you develop any headaches, visual changes, confusion or chest pain, or any other concerning symptoms. Followup Instructions: Please schedule a follow up with Dr [**Last Name (STitle) **] in [**Month (only) 958**] as scheduled. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2142-2-21**]",42,2142-02-14 10:42:00,2142-02-17 18:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. . # malignant hypertension/hypertensive urgency: the patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and hd compliance. has previously presented with bp up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. with short course of iv antihypertensives and hemodialysis, pts bp fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # esrd: pt was followed by the renal service and underwent hd without any complications. pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting hd. she will discuss this further with the renal team as an outpatient. . # sle: pt was continued on her home dose of prednisone with no sign of sle flair. . # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events. pt was continued on coumadin. . # pain management: pt was treated with po dilaudid for her abdominal pain, as recommended per her omr protocol. she asked for iv dilaudid multiple times but there was no clinical indication. she was also continued on gabapentin. . # anemia: secondary to aocd and renal failure. the patietns hct remained stable in the low 20s during admission. no prbc infusions were needed. . # depression/anxiety: continued celexa, clonazepam 0.5mg [**hospital1 **] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Thrombotic microangiopathy; Systemic lupus erythematosus; Anemia in chronic kidney disease; Thrombocytopenia, unspecified; Obstructive sleep apnea (adult)(pediatric); Nontraumatic hematoma of soft tissue; Dysthymic disorder; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events.","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob after missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. she was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine." 109,131345.0,15330,2141-09-08,15327,166018.0,2141-03-28,Discharge summary,"Admission Date: [**2141-3-27**] Discharge Date: [**2141-3-28**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Oxycodone Hcl/Acetaminophen Attending:[**First Name3 (LF) 3984**] Chief Complaint: Hypertensive urgency. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 23 year-old woman with a history of SLE and renal failure secondary to lupus nephritis, off HD for one year, who presents with elevated blood pressures. Patient was in her usual state of health when she presented to her nephrologist today. At that time appoinment, her blood pressure was noted to be 240/130. Other than mild nausea, the patient did not have specific complaints. In particular, she denied any headache, chest pains, shortness of breath, palpatations, edema or decreased urine output. She reports taking her blood pressure medications, as prescribed. Given the severity of the hypertension, the patient was referred to the ED for further evaluation. In the ED, initial blood pressure was 221/134 with a heart rate of 84. With use of 600mg labetolol, 40mg lisinopril, one inch of nitropaste, 50mg PO hydralazine, then a labetolol drip, the blood pressures improved to 160-180 systolic and 90-110s diastolic. Currently, the patient feels well other than some mild nausea. She is somewhat lightheaded. Upon arrival, labetolol gtt and nitro paste were still on with a SBP in the 140s. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN - ADAMTS 13 negative 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. Social History: Single and lives with her mother and a brother. She graduated from high school and has not continued studies due to her systemic lupus erythematosus. The patient is on disability, and participates in focus groups. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS - T 97.4, BP 148/89, HR 90, RR 25, 100% on room air. GENERAL: Well appearing thin female, in good spirits. Sitting up in bed in no distress. HEENT: Prosthesis of left eye. No icteris or palor. No carotid bruits. CARDIAC: Regular rate/rhythm. Harsh systolic murmur. Possible decrease with clenched fists. LUNG: Clear bilaterally with no rales/wheeze. ABDOMEN: Soft. Non-tender. EXT: Warm. No edema. NEURO: Alert. Oriented x3. Cranial nerves intact (except left eye extraocular muscles). Sensation intact grossly. Finger-to-nose normal. Strength 5/5 in all extremities. SKIN: No rash noted. Nail bed changes with mild pitting noted. Pertinent Results: ADMISSION LABS: =============== C3: 61 C4: 16 137 108 32 AGap=13 ------------ 4.4 20 6.2 Ca: 8.2 P: 5.2 ALT: 15 AP: 216 Tbili: 0.3 Alb: 3.8 AST: 41 TProt: 6.5 WBC: 3.4 PLT: 93 HCT: 26.5 N:53.8 L:38.2 M:4.5 E:3.0 Bas:0.4 STUDIES: ======== ECG ([**2141-3-27**]): NSR at 85. Normal axis. Normal intervals. LAA. LVH. No new ST or T-wave changes. CHEST ([**2141-3-27**]): 1. Patchy retrocardiac opacity, new, which may simply represent atelectasis. Early pneumonic infiltrate cannot be excluded. 2. No CHF. Brief Hospital Course: 23 y.o. F with lupus and renal failure [**2-11**] SLE, not on HD x 1 year, HTN, and cardiomyopathy admitted with elevated BPs. # Hypertensive Urgency: This has been an ongoing issue for this patient with prior admissions with hypertensive emergency (seizures, intraparenchymal hemorrhages). In the ER, she was on a labetalol drip and given nitropaste. On presentation to the ICU, her blood pressure was below her baseline, and the labetalol drip was stopped, and the nitropaste was removed. She was transitioned to PO meds alone. Her labetalol was increased to 900 mg TID. Nicardipine was increased to 60 mg [**Hospital1 **]. IV hydralazine was used prn. Goal SBP 160-190 with DBP<110. Her pressures remained in range during her stay, and she was discharged on her home medications with instructions to increase her labetalol to 900 TID. # ESRD: Secondary to lupus nephritis. Has been off HD for almost one year. Currently, the plan is for living related donor (mother). The work-up for this is in progress. There are no plans for dialysis while awaiting transplant. Renal consult followed patient throughout hospitalization and assisted with BP control. She was continued on Vitamin D. # Thrombocytopenia: At baseline. # SLE: Continued prednisone. On discharge, she was instructed to decrease her prednisone to 10 mg daily per renal. PCP [**Name9 (PRE) **] should be addressed as an outpatient. # FEN: Repleted lytes prn, renal diet # PPX: Heparin SQ, bowel regimen, PPI # CODE: Full # DISPO: Home with close follow up with renal. Medications on Admission: 1. Clonidine 0.3 mg/24 hour patchy weekly 2. Hydralazine 50 mg TID 3. Labetalol 600 mg TID 4. Nicardipine SR 60 mg daily 5. Lisinopril 40 mg po BID 6. Valsartan 320 mg po daily 7. Prednisone 15 mg po daily 8. Aranesp 40 mcg/0.4 mL syringe as directed every 2 weeks 9. Vitamin D2 50,000 unit capsule by mouth, one tablet per week x 5 weeks, then one tablet per month x 5 months 10. Lorazepam po q4 - q6 hours prn (rarely uses) 11. Hydrocortisone 2.5% ointment to affected areas (not currently using) 12. Tacrolimus 0.1% ointment to affected areas (not currently using) Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWEEK (). 2. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Nicardipine 60 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day. 6. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO monthly (). 9. Aranesp (Polysorbate) 40 mcg/0.4 mL Syringe Sig: One (1) injection Injection every 2 weeks: as directed by your doctor. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Hypertensive urgency Secondary Diagnosis: 1. End Stage Renal Disease 2. Thrombocytopenia 3. Lupus Discharge Condition: Stable. Ambulating. Tolerating po's. Afebrile. Discharge Instructions: You were admitted for hypertension urgency. You were treated with IV medications and then transitioned to medications by mouth. You were seen by the kidney doctors who helped [**Name5 (PTitle) **] manage your hypertension. Your blood pressure is now under control. It is very important that you take your medications as prescribed. . The following changes have been made to your medications: 1. Please decrease your prednisone dose to 10 mg daily. 2. Please increase labetalol 900 mg three times a day. . Please keep all your medical appointments. . If you have any of the following symptoms, please contact your physician or go to the nearest ER: fever>101, chest pain, shortness of breath, acute change of vision, abdominal pain, persistent nausea and vomiting, or any other concerning symptoms. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2141-4-5**] 8:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2141-4-10**] 1:00 Provider: [**Name Initial (NameIs) 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2141-4-10**] 3:30 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2141-3-28**]",164,2141-03-27 21:08:00,2141-03-28 17:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSIVE CRISIS," 23 y.o. f with lupus and renal failure [**2-11**] sle, not on hd x 1 year, htn, and cardiomyopathy admitted with elevated bps. # hypertensive urgency: this has been an ongoing issue for this patient with prior admissions with hypertensive emergency (seizures, intraparenchymal hemorrhages). in the er, she was on a labetalol drip and given nitropaste. on presentation to the icu, her blood pressure was below her baseline, and the labetalol drip was stopped, and the nitropaste was removed. she was transitioned to po meds alone. her labetalol was increased to 900 mg tid. nicardipine was increased to 60 mg [**hospital1 **]. iv hydralazine was used prn. goal sbp 160-190 with dbp<110. her pressures remained in range during her stay, and she was discharged on her home medications with instructions to increase her labetalol to 900 tid. # esrd: secondary to lupus nephritis. has been off hd for almost one year. currently, the plan is for living related donor (mother). the work-up for this is in progress. there are no plans for dialysis while awaiting transplant. renal consult followed patient throughout hospitalization and assisted with bp control. she was continued on vitamin d. # thrombocytopenia: at baseline. # sle: continued prednisone. on discharge, she was instructed to decrease her prednisone to 10 mg daily per renal. pcp [**name9 (pre) **] should be addressed as an outpatient. # fen: repleted lytes prn, renal diet # ppx: heparin sq, bowel regimen, ppi # code: full # dispo: home with close follow up with renal. ","PRIMARY: [Malignant essential hypertension] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; ; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Anemia, unspecified; ; Other postprocedural status; Other states following surgery of eye and adnexa]","f with lupus and renal failure [**2-11**] sle, not on hd x 1 year, htn, and cardiomyopathy admitted with elevated bps. on discharge, she was instructed to decrease her prednisone to 10 mg daily per renal. pcp [**name9 (pre) **] should be addressed as an outpatient.","sle, not on hd x 1 year, htn, and cardiomyopathy admitted with elevated bps. sle, not on hd x 1 year, not on hd x 1 year, htn, and cardiomyopathy admitted. sle, not on hd x 1 year, not on hd x 1 year, not on hd x 1 year." 109,131345.0,15330,2141-09-08,15328,170149.0,2141-06-06,Discharge summary,"Admission Date: [**2141-5-24**] Discharge Date: [**2141-6-6**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 759**] Chief Complaint: Face, Left arm and breast swelling Major Surgical or Invasive Procedure: Intravenous Catheterization of SVC/IVC. History of Present Illness: 23 year old woman with ESRD, SLE, recently placed PD catheter who presents with periorbital swelling and Hypertensive urgency. Of note she was recently admitted for tongue swelling on [**4-7**]. At that time she was treated with Solu-Medrol, famotidine and Benadryl in the emergency room, which was continued for a total of three doses on the floor. The swelling improved throughout her stay. She had been on both an ACE, [**Last Name (un) **] and DRI at home, which she has been taking for many years. Patient states that the tongue swelling is most likely due to a sardine allergy. However, she had recently added Dilaudid to her medications following PD catheter placement, so allergy to Dilaudid was also considered. The ACE, [**Last Name (un) **] and DRI were held on the day of admission for ?angioedema but restarted on day of discharge without incident so she was discharged on them. She returned to the ED [**5-24**] with acute onset bilateral eye swelling since night of [**5-23**]. VS T 97.9 HR 78 BP 231/120 RR 20 Sat 100% RA. She was given IV solumedrol 125iv, benadryl IV, and pepcid. Her BP was noted to be 240's despite labetolol 900mg po, then labetolol 20mg iv x2 so was started on labetolol gtt: highest dose 2mg/min. This was stopped after 35 minutes, in favor of nitro gtt. States compliant with meds at home. Patient was comfortable on admission to the MICU. Notes pain in abdomen 7.5/10 related to PD catheter placement (has had since then), improves with morphine. Also notes swelling in eyes/face since last night (has had in the past but never this severe, always goes away on its own). She feels whole body is swollen slightly but no more upper extremities than lower. She denies visual changes, HA, change in hearing/tinitus, congestion, sore throat, cough, SOB, chest pain, palpitations, nausea, vomitting, diarrhea. Has baseline constipation (takes stool softener), last BM 2 days ago (normal), no melena, brbpr, diarrhea. No dysuria, hematuria, change in uop, increase weight or size (clothes fit the same), tingling, numbness, weakness, discoordination, rash, joint pain, recent travel, ill contacts, exotic foods. She notes episode of throat swelling over weekend resolved, seemed to be related to sardine eating (not new for her). Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient denies past or current alcohol, tobacco, or illicit drug use. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: ON ADMISSION: VS: T 98.0 BP 187/120 HR 77 RR 17 Sat 100% on RA GEN: NAD HEENT: + periorbital edema, AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD, no carotid bruits CV: RRR, nl s1, s2, II/VI HSM at R/L USB, S4, no rub PULM: CTAB, no w/r/r with good air movement throughout ABD: soft, mildly tender at PD catheter, ND, + BS, no HSM EXT: warm, dry, +2 distal pulses BL, no femoral bruits, trace non-pitting edema NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect ON [**6-6**]: -General: AAOx3, in NAD. -VS: Tc: 95.2, Tmax (24hrs): 97.8 BP: 172/98 (80/43, 240/110 on [**5-30**]; 120/70, 218/120 over last 24 hrs), P: 80 (80, 98), RR: 16, O2: 98% RA. -HEENT: Head NC, AT. MMM. Face, Neck swollen: equal bilaterally. -Neck: Supple, No JVD, No tracheal deviation. -CV: RRR, S1,S2. Grade II/XII holosystolic murmur radiating to R carotid. JVP not elevated. No S4. -Lungs: CTAB, no w/r. -Abdomen: +BS, soft, nontender. -Extremities: Warm, no lower extremity edema. L arm appears slightly less swollen than yesterday. Dorsalis pedis and radial pulses strong bilaterally. No evidence of rashes, ulcers or varicose veins. -Breast: L breast still swollen relative to R, but diminished from initial presentation of swelling. Skin no longer tense. Pertinent Results: WBC-3.9* RBC-2.19* Hgb-6.6* Hct-20.4* MCV-93 MCH-30.3 MCHC-32.4 RDW-19.7* Plt Ct-114* - Neuts-52.8 Lymphs-39.9 Monos-5.0 Eos-2.0 Baso-0.2 PT-20.5* PTT-89.9* INR(PT)-1.9* Fibrino-268 Thrombn-37.4*# AT III-92 ProtCFn-65* ProtCAg-PND ProtSFn-68 Glucose-105 UreaN-62* Creat-8.1* Na-139 K-4.5 Cl-109* HCO3-17* ALT-14 AST-35 LD(LDH)-254* CK(CPK)-176* AlkPhos-137* Amylase-277* TotBili-0.4 Calcium-6.8* Phos-5.9* Mg-1.5* Hapto-90 Homocys-37.8* PTH-1603* UA: Color Straw Appear Clear SpecGr 1.009 pH 6.0 Urobil Neg Bili Neg Leuk Sm Bld Neg Nitr Neg Prot 30 Glu Neg Ket Neg RBC 0-2 WBC [**11-30**] Bact Few Yeast None Epi 0-2 U Tox: Urine Opiates Pos;Urine Benzos, Barbs, Cocaine, Amphet, Mthdne Negative; UCG: Negative STUDIES: Portable CXR [**5-24**]: Small left pleural effusion with associated atelectasis, although early pneumonia cannot be excluded. No CHF. ECG [**5-24**]: NSR (87), nl axis and intervals, TWI V5-V6, no change from [**5-20**]. MRA [**5-24**]: 1. Occlusion of the right internal jugular vein below the mandible which communicates with external jugular and subclavian vein. Appearance suggest chronic disease. 2. Patent SVC. 3. Patent but narrowed left internal jugular vein but left brachiocephalic vein not visualized (possibly from technique). 4. Bibasilar atelectasis US upper extremity [**5-26**]: [**Doctor Last Name **]-scale, color and Doppler son[**Name (NI) 1417**] of the left IJ, subclavian, axillary, brachial, basilic, and cephalic veins were performed. There is normal flow, compression, and augmentation seen in all of the vessels. IMPRESSION: No evidence of deep vein thrombosis in the left arm. MRV Chest [**5-30**]: 1. Limited study which demonstrates a chronically occluded and completely atrophic left brachiocephalic vein. 2. Right internal jugular vein not identified, likely chronically occluded. Left internal jugular vein is very diminuitive as before. 3. Large right external jugular vein emptying into the subclavian vein. Venogram [**5-31**]: 1. Occlusion of the left brachiocephalic vein at the junction of the subclavian and internal jugular with extensive collateral formation consistent with chronic obstruction. 2. Patent left brachial, axillary, subclavian, and distal internal jugular vein. 3. Unsuccessful attempt to recanalize the left brachiocephalic vein using a catheter and guidewire technique. Brief Hospital Course: Ms. [**Known lastname **] is a 23yo woman with a history of SLE, ESRD and HTN who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into L sided facial, L arm and L breast swelling throughout her stay. # L facial/arm and breast swelling: Initially this presented only as facial swellingand ACE and [**Last Name (un) **] were held for possible angioedema, however holding medications nad giving benadryl failed to relieve symptoms. We then suspected possible venous thrombus with occlusion leading to edema. US of upper left extremity failed to show evidence of acute occlusion, but showed R IJ occlusion consistent with prior studies. MRA could not visualize the L brachiocephalic vein. Repeat MRV suggested chronic occlusion of the L brachiocephalic vein. Venogram performed on [**5-31**] showed extensive collateralization of the L brachiocephalic vein with patent flow through these collaterals. Intervention on the L brachiocephalic vein was attempted by IR, but was unsuccessful. The primary team, renal team, [**Month/Year (2) **] team and hematology team suspect that the most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of the L brachiocephalic vein. For this reason, the patient was placed on Heparin IV as a bridge to coumadin anticoagulation with goal INR [**2-12**]. Per consult with hematology the patient is to remain on this regimen for at least 6 months, and will then revisit as an outpatient the question of possible lifelong anticoagulation. The patient has had extensive negative testing for hypercoagulable states, including during this work-up with negative anticardiolipin, antiphospholipid, Beta-2 glycoprotein and AT3 antibodies. Protein C and S levels were unremarkable. Although her clots seem to have all occured in the setting of lines, her continued thrombosis is likey due to hypercoagulability from her lupus (in absence of lupus anticoagulant). Her INR will be followed first by Dr. [**Last Name (STitle) 4883**], her nephrologist, and then by the coumadin clinic of [**Company 191**]. It will be especially important that her coumadin be well titrated given her risk of intracranial bleed with hypertension. This was communicated tothe patient and she understands and plans to be compliant with frequent blood draws for INR testing and varying her coumadin dose as directed. . # Hypertension: The patient has chronically labile hypertension, with frequent episodes of hypertensive urgency over systolic 200, as well as lows as far as the 80s during this admission. It remains unclear why her blood pressure is so chronically labile. The hope is that once she starts dialysis this will help to stabilize her blood pressure, however in the interim various adjustments were made to her regimen. The patient received frequent extra doses during her stay (especially of hydralazine), however, this occasionally causes her blood pressure to swing too low to tolerate her subsequent standing dose of medication. We stopped her Ace and [**Last Name (un) **] as above. We discharged her to home on a regimen that was reviewed with her nephrologist, Dr. [**Last Name (STitle) 4883**]. She is discharged on clonidine patch 0.3mg qweek, labetalol 900mg po tid, nifedipine CR 90mg po bid, hydralazine 35mg po tid. These medications were reviewed extensively with the patient and she was given prescriptions for all meds. She is discharged with home VNA for blood pressure checks and assistance with meds. She has purchased a portable BP cuff and will keep a BP diary to bring to subsequent appointments as well. The importance of BP control, especially in the setting of new anticoagulation, was discussed extensively with the patient. Her goal SBP is 140-160 at this time. . # ESRD: The patient has ESRD due to lupus nephritis. PD catheter was placed before admission and the patient received morphine prn pain at her catheter site. The renal team followed her closely throughout her stay. She was treated for hypocalcemia as well as hyperkalemia. Her regimen was changed to calcitriol 0.25mcg po qday, sodium bicarb 1300mg po qday, cholecalciferol 400units po qday, ergocalciferol 50,000 units po qweek for ten weeks. She plans to start HD within 1-2 weeks of discharge. She will call [**Doctor First Name 3040**] the PD nurse tomorrow to set up an appointment to have her catheter flushed and to start PD. She will be closely followed by Dr. [**Last Name (STitle) 4883**] at PD. # SLE: The patient was maintained on her home dose of prednisone 15mg po qday throughout her stay. She has no symptoms of acute SLE flare, so her nephrologist and outpatient physicians may attempt to wean this down as an outpatient. . # abnormal pap smear: The pt is noted to have an abnormal pap and colpo two years ago with CIN 2 and high risk HPV. This has never been repeated, as the patient failed to schedule appointments and DNK others. We discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. The patient was discharged to home with a clear plan to call [**Doctor First Name 3040**], the PD nurse on the day after discharge to set up an appointment to have her PD catheter flushed later this week, as well as to set a date to start her PD. She will see Dr. [**Last Name (STitle) 44539**] in [**Hospital **] clinic within the next 1-2 weeks. She will have her blood drawn for INR in two days and faxed to Dr. [**Last Name (STitle) 4883**], subsequently this will be faxed to the [**Company 191**] coumadin clinic and her dose will be adjusted for INR [**2-12**]. We have also given her the phone number to call [**Company 191**] and establish care with a new PCP, [**Name10 (NameIs) 3**] her old PCP has now graduated and her complex management makes a PCP [**Name Initial (PRE) 44540**]. (Her PCP must be at [**Company 191**] for the [**Company 191**] coumadin clinic to follow her as well.) Finally, the patient was given an appointment with ob/gyn to have a follow up pap smear, as her last pap and colpo two years ago showed CIN 2 with high risk HPV and this has not been followed. The above plan and appoitnments were reviewed with the pt and her mother extensively. [**Name2 (NI) **] medication hcanges were also extensively reviewed. Medications on Admission: Hydralazine 50 mg PO TID Labetalol 900 mg PO TID Nicardipine 60 mg Sustained Release PO once a day Cinacalcet 30 mg PO DAILY: she is not sure if taking Calcium Acetate 667 mg PO TID W/MEALS Sodium Bicarbonate 1300 mg PO TID Aliskiren 150 mg PO once a day (was never taking) Pantoprazole 40 mg PO once a day Valsartan 320mg PO DAILY Lisinopril 40 mg PO bid Clonidine 0.3 mg/24 hr Patch Weekly QSUN: not sure when last placed Prednisone 15 mg PO DAILY Morphine 15 mg Tablet PO Q6H as needed Ergocalciferol (Vitamin D2) 50,000 unit Capsule daily: states not taking Epo 4,000 units M/W/F: states not taking colace Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Disp:*4 Patch Weekly(s)* Refills:*2* 3. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 5. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO qwednesday (): for 10 weeks. Disp:*10 Capsule(s)* Refills:*0* 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*2* 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 10. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: dose to be adjusted by coumadin clinic. Disp:*120 Tablet(s)* Refills:*2* 11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 12. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for itching. Disp:*50 Capsule(s)* Refills:*0* 13. Ativan 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. Disp:*60 Tablet(s)* Refills:*0* 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 15. Morphine 15 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 14 days. Disp:*56 Tablet(s)* Refills:*0* 16. Outpatient Lab Work Please have blood drawn on Friday, [**6-9**] for PT/INR. Please have result faxed to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you to adjust your coumadin (also called warfarin) dose as needed. 17. Outpatient Lab Work Please have blood drawn on Monday [**2141-6-12**] for PT/INR and twice per week thereafter until told by coumadin clinic that you can decrease lab draws. Please have result faxed to the [**Hospital1 18**] coumadin clinic at [**Telephone/Fax (1) 3534**]. They will call you to adjust your coumadin (also called warfarin) dose as needed. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnoses: Malignant Hypertension (Hypertensive Urgency) Acute Exacerbation of Chronic Left Brachiocephalic vein occlusion Anemia Secondary Diagnoses: SLE ESRD Hypertrophic Cardiomyopathy Thrombocytopenia Discharge Condition: Stable Discharge Instructions: You were admitted and treated for an acute exacerbation of a chronic left brachiocephalic vein occlusion (a chronically obstructed large vein closed off entirely) and hypertensive urgency (very high blood pressure). We attempted to remove the clot in your left brachiocephalic vein, but were unable to do so. You have been started on long-term Coumadin (also called warfarin) therapy to prevent future blood clots and to allow natural dissolution of your current blood clot. Please change your medicines to only those you are given here! There were many changes and it is very important that you stick to the medication list as you have large, life-threatening swings in the blood pressure when not taking consistently. We also treated you for high potassium levels and anemia, and low vitamin D and calcium levels, which are related to your kidney failure. Please follow up with Dr. [**Last Name (STitle) 4883**] for long term treatment. Please check your blood pressure three times per day and keep a blood pressure diary to bring with you to all medical appointments. Please have your blood drawn on Friday [**6-9**] for PT/INR and faxed to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you if needed to adjust your coumadin (warfarin) dose. After that, please have your blood drawn on Monday [**6-12**] for PT/INR and faxed to the [**Hospital1 18**] coumadin clinic at [**Telephone/Fax (1) 434**]. They will follow you in a regular way to adjust your coumadin dose as needed. MEDICINES FOR BLOOD PRESSURE: LABETALOL 900mg three times per day (same as before) HYDRALAZINE 25mg three times per day (lower dose than before) CLONIDINE PATCH 0.3mg qWednesday (same as before) NIFEDIPINE SR 90mg twice per day (new medicine!) **stop taking your lisinopril, nicardipine, Diovan and Aliskerin!** MEDICINES FOR RENAL FAILURE: ERGOCALCIFEROL [**Numeric Identifier 1871**] units pill every Wednesday (same as before) CHOLECALCIFEROL 400 units every day (new) CALCITRIOL 0.25 mg every day (new) SODIUM BICARBONATE 1300mg once per day (less often then before) ** stop taking your calcium acetate (phoslo), cinecalcet, and epo injection (you'll get it at peritoneal dialysis only)** OTHER MEDICINES: PANTOPRAZOLE 40mg every day (same as before) PREDNISONE 15mg every day (same as before) MORPHINE 15mg every 6 hrs if needed for pain (same as before) ATIVAN 1mg as needed for anxiety (same as before) BENADRYL 25mg every 6 hrs if needed for itch (new) COLACE 100mg twice per day if needed for constipation(same as before) APPOINTMENTS: **1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on Friday to flush your dialysis catheter and start dialysis next week! 2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00AM 3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**] Date/Time: [**2141-6-13**] 9:30AM **4. Please call [**Hospital3 **] next week to make an appointment with a new primary doctor. I recommend Dr. [**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE FOLLOWED IN [**Hospital **] CLINIC. **5. Please have your blood drawn as above. Your coumadin level will be followed by the [**Hospital 197**] clinic. Their phone # is [**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**]. If you have increased swelling, fever greater than 101, shortness of breath, chest pain, or if you at any time become concerned about your health please contact Dr. [**Last Name (STitle) 4883**] or go to the nearest ER. Followup Instructions: APPOINTMENTS: **1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on Friday to flush your dialysis catheter and start dialysis next week! 2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00AM 3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**] Date/Time: [**2141-6-13**] 9:30AM **4. Please call [**Hospital3 **] next week to make an appointment with a new primary doctor. I recommend Dr. [**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE FOLLOWED IN [**Hospital **] CLINIC. **5. Please have your blood drawn as above. Your coumadin level will be followed by the [**Hospital 197**] clinic. Their phone # is [**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**]. Completed by:[**2141-6-17**]",94,2141-05-24 14:47:00,2141-06-06 19:55:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ACUTE RENAL FAILURE," ms. [**known lastname **] is a 23yo woman with a history of sle, esrd and htn who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into l sided facial, l arm and l breast swelling throughout her stay. # l facial/arm and breast swelling: initially this presented only as facial swellingand ace and [**last name (un) **] were held for possible angioedema, however holding medications nad giving benadryl failed to relieve symptoms. we then suspected possible venous thrombus with occlusion leading to edema. us of upper left extremity failed to show evidence of acute occlusion, but showed r ij occlusion consistent with prior studies. mra could not visualize the l brachiocephalic vein. repeat mrv suggested chronic occlusion of the l brachiocephalic vein. venogram performed on [**5-31**] showed extensive collateralization of the l brachiocephalic vein with patent flow through these collaterals. intervention on the l brachiocephalic vein was attempted by ir, but was unsuccessful. the primary team, renal team, [**month/year (2) **] team and hematology team suspect that the most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of the l brachiocephalic vein. for this reason, the patient was placed on heparin iv as a bridge to coumadin anticoagulation with goal inr [**2-12**]. per consult with hematology the patient is to remain on this regimen for at least 6 months, and will then revisit as an outpatient the question of possible lifelong anticoagulation. the patient has had extensive negative testing for hypercoagulable states, including during this work-up with negative anticardiolipin, antiphospholipid, beta-2 glycoprotein and at3 antibodies. protein c and s levels were unremarkable. although her clots seem to have all occured in the setting of lines, her continued thrombosis is likey due to hypercoagulability from her lupus (in absence of lupus anticoagulant). her inr will be followed first by dr. [**last name (stitle) 4883**], her nephrologist, and then by the coumadin clinic of [**company 191**]. it will be especially important that her coumadin be well titrated given her risk of intracranial bleed with hypertension. this was communicated tothe patient and she understands and plans to be compliant with frequent blood draws for inr testing and varying her coumadin dose as directed. . # hypertension: the patient has chronically labile hypertension, with frequent episodes of hypertensive urgency over systolic 200, as well as lows as far as the 80s during this admission. it remains unclear why her blood pressure is so chronically labile. the hope is that once she starts dialysis this will help to stabilize her blood pressure, however in the interim various adjustments were made to her regimen. the patient received frequent extra doses during her stay (especially of hydralazine), however, this occasionally causes her blood pressure to swing too low to tolerate her subsequent standing dose of medication. we stopped her ace and [**last name (un) **] as above. we discharged her to home on a regimen that was reviewed with her nephrologist, dr. [**last name (stitle) 4883**]. she is discharged on clonidine patch 0.3mg qweek, labetalol 900mg po tid, nifedipine cr 90mg po bid, hydralazine 35mg po tid. these medications were reviewed extensively with the patient and she was given prescriptions for all meds. she is discharged with home vna for blood pressure checks and assistance with meds. she has purchased a portable bp cuff and will keep a bp diary to bring to subsequent appointments as well. the importance of bp control, especially in the setting of new anticoagulation, was discussed extensively with the patient. her goal sbp is 140-160 at this time. . # esrd: the patient has esrd due to lupus nephritis. pd catheter was placed before admission and the patient received morphine prn pain at her catheter site. the renal team followed her closely throughout her stay. she was treated for hypocalcemia as well as hyperkalemia. her regimen was changed to calcitriol 0.25mcg po qday, sodium bicarb 1300mg po qday, cholecalciferol 400units po qday, ergocalciferol 50,000 units po qweek for ten weeks. she plans to start hd within 1-2 weeks of discharge. she will call [**doctor first name 3040**] the pd nurse tomorrow to set up an appointment to have her catheter flushed and to start pd. she will be closely followed by dr. [**last name (stitle) 4883**] at pd. # sle: the patient was maintained on her home dose of prednisone 15mg po qday throughout her stay. she has no symptoms of acute sle flare, so her nephrologist and outpatient physicians may attempt to wean this down as an outpatient. . # abnormal pap smear: the pt is noted to have an abnormal pap and colpo two years ago with cin 2 and high risk hpv. this has never been repeated, as the patient failed to schedule appointments and dnk others. we discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. the patient was discharged to home with a clear plan to call [**doctor first name 3040**], the pd nurse on the day after discharge to set up an appointment to have her pd catheter flushed later this week, as well as to set a date to start her pd. she will see dr. [**last name (stitle) 44539**] in [**hospital **] clinic within the next 1-2 weeks. she will have her blood drawn for inr in two days and faxed to dr. [**last name (stitle) 4883**], subsequently this will be faxed to the [**company 191**] coumadin clinic and her dose will be adjusted for inr [**2-12**]. we have also given her the phone number to call [**company 191**] and establish care with a new pcp, [**name10 (nameis) 3**] her old pcp has now graduated and her complex management makes a pcp [**name initial (pre) 44540**]. (her pcp must be at [**company 191**] for the [**company 191**] coumadin clinic to follow her as well.) finally, the patient was given an appointment with ob/gyn to have a follow up pap smear, as her last pap and colpo two years ago showed cin 2 with high risk hpv and this has not been followed. the above plan and appoitnments were reviewed with the pt and her mother extensively. [**name2 (ni) **] medication hcanges were also extensively reviewed. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Compression of vein; Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Hyperpotassemia; Hyperparathyroidism, unspecified; Other iatrogenic hypotension; Nausea with vomiting; ; Abnormal glandular Papanicolaou smear of cervix; Abdominal pain, other specified site; Other specified disorders of pancreatic internal secretion; Adrenal cortical steroids causing adverse effects in therapeutic use]","known lastname **] is a 23yo woman with a history of sle, esrd and htn who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into l sided facial, l arm and l breast swelling throughout her stay. mra could not visualize the l brachiocephalic vein. it remains unclear why her blood pressure is so chronically labile. we stopped her ace and [**last name (un) **] as above. the importance of bp control, especially in the setting of new anticoagulation, was discussed extensively with the patient. # esrd: the patient has esrd due to lupus nephritis. the renal team followed her closely throughout her stay. she will call [**doctor first name 3040**] the pd nurse tomorrow to set up an appointment to have her catheter flushed and to start pd. we discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. the above plan and appoitnments were reviewed with the pt and her mother extensively. [**","a 23yo woman with a history of sle, esrd and htn presented with bilateral facial swelling. she developed l sided facial, l arm and l breast swelling throughout her stay. most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of l brachiocephalic vein." 109,131345.0,15330,2141-09-08,15329,147469.0,2141-06-17,Discharge summary,"Admission Date: [**2141-6-11**] Discharge Date: [**2141-6-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: hypertensive urgency Major Surgical or Invasive Procedure: arterial line History of Present Illness: HPI: 23 F with h/o Lupus, ESRD not on HD (planned PD), labile hypertension, RUE VTE on anticoagulation, recent facial swelling who presents with hypertensive emergency. Patient developed severe frontal HA last evenening, a/w nausea. BP was not [**Location (un) 1131**] on home BP cuff. In the AM her HA was severe [**10-20**] a/w nausea and vomiting yellow/green liquid and BP cuff again not able to obtain BP. Patient was last seen by VNA this past Friday with BP 130/70. Patient denies any CP, shortness of breath, abd pain. Her facial swelling is slightly worse today. She denies any weakness, dizziness, difficulty with speach, no numbness or tingling. She says that she is compliant with all of her medications. She denies any GU/GI complaints despite +UA in ED. . In the ED, VS: 98.2 92 SBP >300/P [**Telephone/Fax (3) 44541**]-131) 16 98 % RA. Patient received zofran IV, Hydral IV, Labetalol 20 mg IV x 1, Nipride gtt started. Kayexalate 30 mg x 1. Other po meds written but patient did not take due to nausea. CT head showing no hemorrhage but hypoattenuation in frontal area, which is change from prior MRI in [**Month (only) **]. She is on coumadin for RUE VTE with INR 2.1. Also with UTI in ED, started Cirpo x 1. Labs showing K 5.6 ECG with ?hyperacute T waves, otherwise no changes, given kayexalate only. . Interval Hx: Patient was admitted [**2141-5-24**] to [**6-6**] with facial swelling and hypertensive emergency requiring ICU care. She was also admitted [**Date range (1) 43498**] with similar complaints. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 98.8 84 [**Telephone/Fax (2) 44542**]% RA Gen: swollen face L>R, alert and cooperative, NAD, snoring when asleep but easily arousable Heent: OP clear, swollen eye lids L>R, Left eye retracted with prosthesis, anicteric, OP moist Neck: supple, no JVD elevation, no meningismus CV: nl S1 S2, RRR, [**1-15**] SM Lungs: CTAB Abd: obese, soft, NT, ND, BS+ Ext: dry, no c/c/e, diminished, Neuro: Alert and oriented x 3, gets drowsy intermittently but arousable, CN II-XII intact, strength 5/5 throughout, sensations intact Pertinent Results: [**6-14**]: AXR:IMPRESSION: PD catheter with tip coiled in the pelvis. [**6-11**]: IMPRESSION: 1. Areas of hypoattenuation in the high bifrontal white matter, and subcortical hypoattenuation in the left posterior temporal lobe with loss of [**Doctor Last Name 352**]-white differentiation. These findings are new from MRI brain [**12-29**], [**2140**], and could represent areas of new edema with underlying focal lesion or possibly areas of new infarcts. An MRI head without and with Iv conrast is recommended for further characterization. 2. No evidence of intracranial hemorrhage. [**6-11**]: PA AND LATERAL VIEWS OF THE CHEST: There has been an interval increase in retrocardiac opacity obscuring the left hemidiaphragm. The right lung and the left upper lung zone are clear. The right costophrenic angle is slightly blunted, suggesting a very small right pleural effusion. The heart is slightly enlarged, but the cardiomediastinal silhouette is unchanged. There is no hilar enlargement. Soft tissue and bony structures are unremarkable. IMPRESSION: Interval increase in left basilar atelectasis with pleural effusion. Superimposed pneumonia cannot be excluded. Possible small right pleural effusion. [**6-11**]: MR [**Name13 (STitle) 430**]: INDINGS: In comparison with a prior CT of the head, the previously described low attenuation areas in the parietal regions appear with hyperintensity signal on the FLAIR sequence, mildly hyperintense on the diffusion-weighted sequence, and also slightly hyperintense on the corresponding ADC maps, these findings are nonspecific and may represent posterior reversible encephalopathic changes, please correlate clinically. There is no evidence of acute hemorrhage, hydrocephalus, or midline shift. A low-attenuation area is identified on the right occipital region, likely consistent with chronic deposits of hemosiderin, please correlate with the prior MRI dated [**2140-12-28**]. IMPRESSION: Limited examination secondary to motion artifacts. On the FLAIR sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. The prior low-attenuation area of the right occipital lobe is unchanged and may represent chronic deposits of hemosiderin. There is no evidence of hydrocephalus or midline shifting. Followup with MRI of the head with and without contrast under conscious sedation is recommended if clinically warranted. Brief Hospital Course: A/P: 23 F with SLE, ESRD not on HD, chronic VTE with RUE and facial swelling p/w hypertensive emergency and delta MS initially admitted to the [**Hospital Unit Name 153**]. In the [**Hospital Unit Name 153**] she was on a labetalol gtt as well as home medications. She had head imaging (MRI) with following results; On the FLAIR sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. She was evaluated by neurology who considered PRES, though she did not seize. She was started on keppra as she has had seizures before, and will follow up with them. . # HTN Emergency. She has had multiple admissions in the past with neurological involvement, hemolysis in the past. SBP >300 in ED. Her BP was lowered slowly with a labetolol gtt in the ICU. When it was stably below 180 she was transferred to the medical floor on the [**Hospital Ward Name 517**]. She was continued on clonidine TP, po labetalol, aliskiren. I/O goal was even. Her BP remained between 120-170 before discharge, she no longer had any headaches, or nausea. She was oriented times three. Aliskiren was not covered by masshealth, and a prior auth was faxed over. A supply from the pharmacy was sought but unavailable. She was given a prescription for 5 pills to bridge her to the time when the prior auth would have been approved in order to facilitate her paying for the prescription. She was also given hydralazine and instructed on how to take extra doses when her blood pressure increased. . # Delta MS. [**2-11**] to hypertension likely ischemic/hypertensive changes on CT. AAO times three, no focal neurological signs currently. Also likely component of OSA although this seems chronic. No seizures although has had them in the past. Neuro was consulted, and she was started on Keppra for question of PRES, keppra for 6 weeks until f/u with neuro, has outpatient MRI appointment as well. They will likely keep her on keppra until the changes in her parietal regions have resolved. . #UTI-found on admission, was on Cipro-will complete course of 5 days . # VTE. L Brachiocephalic VTE chronic with collaterals. Also h/o other VTE [**2-11**] to lines in the past. Currently on coumadin. INR 2.1 coumadin was held in [**Hospital Unit Name 153**] for anticipation of procedures. Her coumadin was restarted, has VNA set up and will be followed by [**Hospital3 **]. . # Facial Swelling. Unclear etiology likely [**2-11**] to VTE in RUE (brachiocephalic) vs. angioedema-pt now without swelling . # ESRD. Currently no on HD due to patient preference, awaiting to start PD next week. Since patient has refused HD there was an attempt to correct lytes and acid base with medications. Avoided fluid overload with lasix, patient currently making urine. Lytes - see below. She will commence PD as an outpatient (had issues yesterday with catheter flushing)-still not working-will try laxatives to relieve loops of bowel possibly wrapped around catheter and she will follow up with renal on Monday. Her ACE/[**Last Name (un) **] were held, renally dosed her meds, and phos binder was administered. . # Metabolic Acidosis/Electrolytes abnormalities. AG 15 likely [**2-11**] to uremia. K elevated to 5.6-6.0 however has been elevated in the past, likely some chronic hyerkalemia. She received kayexalate 30 mg tid until K <5 Her electrolytes stabilized and she was continued on her home regimen of sodium bicarb (650mg two tabs daily). . # SLE. On prednisone chronically, likely needs PCP [**Name9 (PRE) **] at some point --Atovaquone to prevent hyperkalemia Continued on prednisone 10mg (dropped from 15mg 2 weeks ago) . # Anemia-Hct and plts dropped on this admission but now stable . # HOCM. Avoid dehydration. Currently on Labetalol. . # PPX: systemically anticoagulated, getting kayexalate, PPI # FEN: Electrolytes as above, no standing fluids I/Os goal even. # Access: 2x PIV currently # Code: Full # Dispo: home Medications on Admission: Pantoprazole 40 mg daily - Clonidine TP 0.3/24 hrs q wednesday - Prednisone 10 mg daily (just decreased from 15 mg) - Calcitriol 0.25 mcg daily - Sodium bicarbonate 650 mg 2 tabs daily - Vit D3 400 mg daily - Vit D2 50,000 q wed, x 10 weeks - Labetalol 300 mg po 3 tabs TID - Nifedipine SR 90 mg [**Hospital1 **] - Warfarin 2 mg daily - Hydral 25 mg TID - Lasix 40 mg [**Hospital1 **] (started friday) - Benadryl 25 mg po prn - Ativan 1 mg [**Hospital1 **] prn - Colace 100 mg [**Hospital1 **] prn - Morphine 15 mg po q 6 hrs x 14 days - Diovan 320 mg daily - Dilaudid prn Discharge Medications: 1. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): on alternating days with 15mg. 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 4. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): please take as directed when blood pressure is above 180. Disp:*90 Tablet(s)* Refills:*2* 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). Disp:*405 Tablet(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for hold for sbp < 130. Disp:*10 Tablet(s)* Refills:*0* 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Outpatient Lab Work for [**Known firstname **] [**Known lastname **] DOB [**2117-8-7**] please check INR once a week and have results faxed to [**Hospital3 **] at [**Hospital1 18**] phone-[**Telephone/Fax (1) 14650**], fax-[**Telephone/Fax (1) 44543**] 16. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO once a day: hold for sbp<130. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: -hypertensive emergency -Lupus - [**2134**]. Diagnosed after she began to have swolen fingers, a rash and painful joints. -ESRD secodary to SLE - [**2135**]. Was initially on cytoxan, 1 dose every 3 months for 2 years until began dialysis 3 times a week in [**2137**] (T, Th, Sat). Now no longer on Hemodialysis, with hyperkalemia/Hypocalcemia/Hyperphosphatemia/Elevated PTH/Metabolic Acidosis; PD Catheter placed [**5-18**] -h/o seizures, ICU admissions; h/o two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] that resolved -Uveitis secondary to SLE - [**4-16**]; s/p surgery [**2-16**]; she had blood cleared and cataract removed as well as glaucoma. -HOCM - per Echo in [**2137**] -Mulitple episodes of dialysis reactions -Anemia -H/O SVC thrombus [**10-16**] [**2-11**] catheter placement, was on coumadin then stopped; Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]); Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]); Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) -Facial and left breast swelling - attributed to angioedema vs chronic L Brachiocephalic vein occlusion -Thrombophilia ?????? likely related to SLE, h/o recurrent VTE -Thrombocytopenia NOS -TTP (got plasmapheresisis) versus malignant HTN -History of left eye enucleation [**2139-4-20**] for fungal infection Discharge Condition: stable, afebrile, SBP 120's-170's Discharge Instructions: You were admitted with hypertensive emergency, your blood pressure was extremely high. You had a head CT and MRI that showed some changes concerning for PRES (posterior reversible leukoencephalopathy syndrome), and neurology recommended initiating Keppra. Your blood pressure was brought under control in the intensive care unit and now you have a new regimen of medications. In addition peritoneal dialysis was attempted but there were difficulties with your catheter. This will be further addressed by your outpatient nephrologist. You will continue to have your INR drawn and sent to coumadin clinic. You should take all your medications as prescribed, you will be taking the keppra until you follow up with a neurologist in approximately 6 weeks. You will also be taking the Aliskiren following discharge. You will be discharged on hydralazine (which you will take three times daily EVERY DAY), as well as when your blood pressure gets too high as follows; if you blood pressure is above 180 please take an extra dose of hydralazine, check your blood pressure in 10 minutes, if it is still not take another dose and recheck your blood pressure in another 10 minutes-if it is still elevated take another 25mg hydralazine and recheck in 10 minutes-if it is still elevated please call your doctor or go to the ER. Continue taking your coumadin and having your INR sent to coumadin clinic. Please seek medication attention if you have any headaches, chest pain, shortness of breath, dizzyness, nausea or any other concerning symptoms. Please follow up as outlined below. Followup Instructions: -Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00 -Your renal team will contact you regarding follow up-you should call CB for home teaching. -Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2141-7-12**] 10:30 -MRI Tuesday [**7-25**]-9:30am, [**Location (un) **] [**Hospital Ward Name 23**] Building -[**Company 191**] [**Telephone/Fax (1) 250**] N.P-[**7-25**] 1:40pm -Stroke center Dr. [**Last Name (STitle) **] at the [**Hospital Ward Name 23**] center, [**Location (un) **]-Tuesday [**8-1**], 5:00pm-you will need to call your PCP for [**Name Initial (PRE) **] referral -Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Company 191**] ([**Hospital Ward Name 23**] Building) Tuesday [**8-15**] 2:00pm [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2141-6-19**]",83,2141-06-11 10:17:00,2141-06-17 16:29:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSIVE EMERGENCY," a/p: 23 f with sle, esrd not on hd, chronic vte with rue and facial swelling p/w hypertensive emergency and delta ms initially admitted to the [**hospital unit name 153**]. in the [**hospital unit name 153**] she was on a labetalol gtt as well as home medications. she had head imaging (mri) with following results; on the flair sequence, there is evidence of hyperintensity areas in the parietal regions, left occipital lobe, which are nonspecific and may represent possible posterior reversible encephalopathic changes. she was evaluated by neurology who considered pres, though she did not seize. she was started on keppra as she has had seizures before, and will follow up with them. . # htn emergency. she has had multiple admissions in the past with neurological involvement, hemolysis in the past. sbp >300 in ed. her bp was lowered slowly with a labetolol gtt in the icu. when it was stably below 180 she was transferred to the medical floor on the [**hospital ward name 517**]. she was continued on clonidine tp, po labetalol, aliskiren. i/o goal was even. her bp remained between 120-170 before discharge, she no longer had any headaches, or nausea. she was oriented times three. aliskiren was not covered by masshealth, and a prior auth was faxed over. a supply from the pharmacy was sought but unavailable. she was given a prescription for 5 pills to bridge her to the time when the prior auth would have been approved in order to facilitate her paying for the prescription. she was also given hydralazine and instructed on how to take extra doses when her blood pressure increased. . # delta ms. [**2-11**] to hypertension likely ischemic/hypertensive changes on ct. aao times three, no focal neurological signs currently. also likely component of osa although this seems chronic. no seizures although has had them in the past. neuro was consulted, and she was started on keppra for question of pres, keppra for 6 weeks until f/u with neuro, has outpatient mri appointment as well. they will likely keep her on keppra until the changes in her parietal regions have resolved. . #uti-found on admission, was on cipro-will complete course of 5 days . # vte. l brachiocephalic vte chronic with collaterals. also h/o other vte [**2-11**] to lines in the past. currently on coumadin. inr 2.1 coumadin was held in [**hospital unit name 153**] for anticipation of procedures. her coumadin was restarted, has vna set up and will be followed by [**hospital3 **]. . # facial swelling. unclear etiology likely [**2-11**] to vte in rue (brachiocephalic) vs. angioedema-pt now without swelling . # esrd. currently no on hd due to patient preference, awaiting to start pd next week. since patient has refused hd there was an attempt to correct lytes and acid base with medications. avoided fluid overload with lasix, patient currently making urine. lytes - see below. she will commence pd as an outpatient (had issues yesterday with catheter flushing)-still not working-will try laxatives to relieve loops of bowel possibly wrapped around catheter and she will follow up with renal on monday. her ace/[**last name (un) **] were held, renally dosed her meds, and phos binder was administered. . # metabolic acidosis/electrolytes abnormalities. ag 15 likely [**2-11**] to uremia. k elevated to 5.6-6.0 however has been elevated in the past, likely some chronic hyerkalemia. she received kayexalate 30 mg tid until k <5 her electrolytes stabilized and she was continued on her home regimen of sodium bicarb (650mg two tabs daily). . # sle. on prednisone chronically, likely needs pcp [**name9 (pre) **] at some point --atovaquone to prevent hyperkalemia continued on prednisone 10mg (dropped from 15mg 2 weeks ago) . # anemia-hct and plts dropped on this admission but now stable . # hocm. avoid dehydration. currently on labetalol. . # ppx: systemically anticoagulated, getting kayexalate, ppi # fen: electrolytes as above, no standing fluids i/os goal even. # access: 2x piv currently # code: full # dispo: home ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other encephalopathy; Chronic glomerulonephritis in diseases classified elsewhere; Urinary tract infection, site not specified; Acidosis; Unspecified iridocyclitis; Acquired hemolytic anemia, unspecified; Systemic lupus erythematosus; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Swelling, mass, or lump in head and neck; Hyperpotassemia; Lump or mass in breast; Thrombocytopenia, unspecified; Hypocalcemia; Disorders of phosphorus metabolism]","a/p: 23 f with sle, esrd not on hd, chronic vte with rue and facial swelling p/w hypertensive emergency and delta ms initially admitted to the [**hospital unit name 153**]. she was evaluated by neurology who considered pres, though she did not seize. aliskiren was not covered by masshealth, and a prior auth was faxed over. also likely component of osa although this seems chronic. inr 2.1 coumadin was held in [**hospital unit name 153**] for anticipation of procedures. avoided fluid overload with lasix, patient currently making urine. # metabolic acidosis/electrolytes abnormalities. # ppx: systemically anticoagulated, getting kayexalate, ppi # fen: electrolytes as above, no standing fluids i/os goal even.","delta ms was evaluated by neurology who considered pres, though she did not seize. she was started on keppra as she has had seizures before, and will follow up with them. her bp remained between 120-170 before discharge, she no longer had headaches, or nausea." 109,147469.0,15329,2141-06-17,15327,166018.0,2141-03-28,Discharge summary,"Admission Date: [**2141-3-27**] Discharge Date: [**2141-3-28**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Oxycodone Hcl/Acetaminophen Attending:[**First Name3 (LF) 3984**] Chief Complaint: Hypertensive urgency. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 23 year-old woman with a history of SLE and renal failure secondary to lupus nephritis, off HD for one year, who presents with elevated blood pressures. Patient was in her usual state of health when she presented to her nephrologist today. At that time appoinment, her blood pressure was noted to be 240/130. Other than mild nausea, the patient did not have specific complaints. In particular, she denied any headache, chest pains, shortness of breath, palpatations, edema or decreased urine output. She reports taking her blood pressure medications, as prescribed. Given the severity of the hypertension, the patient was referred to the ED for further evaluation. In the ED, initial blood pressure was 221/134 with a heart rate of 84. With use of 600mg labetolol, 40mg lisinopril, one inch of nitropaste, 50mg PO hydralazine, then a labetolol drip, the blood pressures improved to 160-180 systolic and 90-110s diastolic. Currently, the patient feels well other than some mild nausea. She is somewhat lightheaded. Upon arrival, labetolol gtt and nitro paste were still on with a SBP in the 140s. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN - ADAMTS 13 negative 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. Social History: Single and lives with her mother and a brother. She graduated from high school and has not continued studies due to her systemic lupus erythematosus. The patient is on disability, and participates in focus groups. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS - T 97.4, BP 148/89, HR 90, RR 25, 100% on room air. GENERAL: Well appearing thin female, in good spirits. Sitting up in bed in no distress. HEENT: Prosthesis of left eye. No icteris or palor. No carotid bruits. CARDIAC: Regular rate/rhythm. Harsh systolic murmur. Possible decrease with clenched fists. LUNG: Clear bilaterally with no rales/wheeze. ABDOMEN: Soft. Non-tender. EXT: Warm. No edema. NEURO: Alert. Oriented x3. Cranial nerves intact (except left eye extraocular muscles). Sensation intact grossly. Finger-to-nose normal. Strength 5/5 in all extremities. SKIN: No rash noted. Nail bed changes with mild pitting noted. Pertinent Results: ADMISSION LABS: =============== C3: 61 C4: 16 137 108 32 AGap=13 ------------ 4.4 20 6.2 Ca: 8.2 P: 5.2 ALT: 15 AP: 216 Tbili: 0.3 Alb: 3.8 AST: 41 TProt: 6.5 WBC: 3.4 PLT: 93 HCT: 26.5 N:53.8 L:38.2 M:4.5 E:3.0 Bas:0.4 STUDIES: ======== ECG ([**2141-3-27**]): NSR at 85. Normal axis. Normal intervals. LAA. LVH. No new ST or T-wave changes. CHEST ([**2141-3-27**]): 1. Patchy retrocardiac opacity, new, which may simply represent atelectasis. Early pneumonic infiltrate cannot be excluded. 2. No CHF. Brief Hospital Course: 23 y.o. F with lupus and renal failure [**2-11**] SLE, not on HD x 1 year, HTN, and cardiomyopathy admitted with elevated BPs. # Hypertensive Urgency: This has been an ongoing issue for this patient with prior admissions with hypertensive emergency (seizures, intraparenchymal hemorrhages). In the ER, she was on a labetalol drip and given nitropaste. On presentation to the ICU, her blood pressure was below her baseline, and the labetalol drip was stopped, and the nitropaste was removed. She was transitioned to PO meds alone. Her labetalol was increased to 900 mg TID. Nicardipine was increased to 60 mg [**Hospital1 **]. IV hydralazine was used prn. Goal SBP 160-190 with DBP<110. Her pressures remained in range during her stay, and she was discharged on her home medications with instructions to increase her labetalol to 900 TID. # ESRD: Secondary to lupus nephritis. Has been off HD for almost one year. Currently, the plan is for living related donor (mother). The work-up for this is in progress. There are no plans for dialysis while awaiting transplant. Renal consult followed patient throughout hospitalization and assisted with BP control. She was continued on Vitamin D. # Thrombocytopenia: At baseline. # SLE: Continued prednisone. On discharge, she was instructed to decrease her prednisone to 10 mg daily per renal. PCP [**Name9 (PRE) **] should be addressed as an outpatient. # FEN: Repleted lytes prn, renal diet # PPX: Heparin SQ, bowel regimen, PPI # CODE: Full # DISPO: Home with close follow up with renal. Medications on Admission: 1. Clonidine 0.3 mg/24 hour patchy weekly 2. Hydralazine 50 mg TID 3. Labetalol 600 mg TID 4. Nicardipine SR 60 mg daily 5. Lisinopril 40 mg po BID 6. Valsartan 320 mg po daily 7. Prednisone 15 mg po daily 8. Aranesp 40 mcg/0.4 mL syringe as directed every 2 weeks 9. Vitamin D2 50,000 unit capsule by mouth, one tablet per week x 5 weeks, then one tablet per month x 5 months 10. Lorazepam po q4 - q6 hours prn (rarely uses) 11. Hydrocortisone 2.5% ointment to affected areas (not currently using) 12. Tacrolimus 0.1% ointment to affected areas (not currently using) Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWEEK (). 2. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Nicardipine 60 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day. 4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day. 6. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*2* 7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO monthly (). 9. Aranesp (Polysorbate) 40 mcg/0.4 mL Syringe Sig: One (1) injection Injection every 2 weeks: as directed by your doctor. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Hypertensive urgency Secondary Diagnosis: 1. End Stage Renal Disease 2. Thrombocytopenia 3. Lupus Discharge Condition: Stable. Ambulating. Tolerating po's. Afebrile. Discharge Instructions: You were admitted for hypertension urgency. You were treated with IV medications and then transitioned to medications by mouth. You were seen by the kidney doctors who helped [**Name5 (PTitle) **] manage your hypertension. Your blood pressure is now under control. It is very important that you take your medications as prescribed. . The following changes have been made to your medications: 1. Please decrease your prednisone dose to 10 mg daily. 2. Please increase labetalol 900 mg three times a day. . Please keep all your medical appointments. . If you have any of the following symptoms, please contact your physician or go to the nearest ER: fever>101, chest pain, shortness of breath, acute change of vision, abdominal pain, persistent nausea and vomiting, or any other concerning symptoms. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2141-4-5**] 8:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2141-4-10**] 1:00 Provider: [**Name Initial (NameIs) 11595**] (RHEUM LMOB) [**Doctor Last Name 11596**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2141-4-10**] 3:30 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Completed by:[**2141-3-28**]",81,2141-03-27 21:08:00,2141-03-28 17:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSIVE CRISIS," 23 y.o. f with lupus and renal failure [**2-11**] sle, not on hd x 1 year, htn, and cardiomyopathy admitted with elevated bps. # hypertensive urgency: this has been an ongoing issue for this patient with prior admissions with hypertensive emergency (seizures, intraparenchymal hemorrhages). in the er, she was on a labetalol drip and given nitropaste. on presentation to the icu, her blood pressure was below her baseline, and the labetalol drip was stopped, and the nitropaste was removed. she was transitioned to po meds alone. her labetalol was increased to 900 mg tid. nicardipine was increased to 60 mg [**hospital1 **]. iv hydralazine was used prn. goal sbp 160-190 with dbp<110. her pressures remained in range during her stay, and she was discharged on her home medications with instructions to increase her labetalol to 900 tid. # esrd: secondary to lupus nephritis. has been off hd for almost one year. currently, the plan is for living related donor (mother). the work-up for this is in progress. there are no plans for dialysis while awaiting transplant. renal consult followed patient throughout hospitalization and assisted with bp control. she was continued on vitamin d. # thrombocytopenia: at baseline. # sle: continued prednisone. on discharge, she was instructed to decrease her prednisone to 10 mg daily per renal. pcp [**name9 (pre) **] should be addressed as an outpatient. # fen: repleted lytes prn, renal diet # ppx: heparin sq, bowel regimen, ppi # code: full # dispo: home with close follow up with renal. ","PRIMARY: [Malignant essential hypertension] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; ; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Anemia, unspecified; ; Other postprocedural status; Other states following surgery of eye and adnexa]","f with lupus and renal failure [**2-11**] sle, not on hd x 1 year, htn, and cardiomyopathy admitted with elevated bps. on discharge, she was instructed to decrease her prednisone to 10 mg daily per renal. pcp [**name9 (pre) **] should be addressed as an outpatient.","sle, not on hd x 1 year, htn, and cardiomyopathy admitted with elevated bps. sle, not on hd x 1 year, not on hd x 1 year, htn, and cardiomyopathy admitted. sle, not on hd x 1 year, not on hd x 1 year, not on hd x 1 year." 109,147469.0,15329,2141-06-17,15328,170149.0,2141-06-06,Discharge summary,"Admission Date: [**2141-5-24**] Discharge Date: [**2141-6-6**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 759**] Chief Complaint: Face, Left arm and breast swelling Major Surgical or Invasive Procedure: Intravenous Catheterization of SVC/IVC. History of Present Illness: 23 year old woman with ESRD, SLE, recently placed PD catheter who presents with periorbital swelling and Hypertensive urgency. Of note she was recently admitted for tongue swelling on [**4-7**]. At that time she was treated with Solu-Medrol, famotidine and Benadryl in the emergency room, which was continued for a total of three doses on the floor. The swelling improved throughout her stay. She had been on both an ACE, [**Last Name (un) **] and DRI at home, which she has been taking for many years. Patient states that the tongue swelling is most likely due to a sardine allergy. However, she had recently added Dilaudid to her medications following PD catheter placement, so allergy to Dilaudid was also considered. The ACE, [**Last Name (un) **] and DRI were held on the day of admission for ?angioedema but restarted on day of discharge without incident so she was discharged on them. She returned to the ED [**5-24**] with acute onset bilateral eye swelling since night of [**5-23**]. VS T 97.9 HR 78 BP 231/120 RR 20 Sat 100% RA. She was given IV solumedrol 125iv, benadryl IV, and pepcid. Her BP was noted to be 240's despite labetolol 900mg po, then labetolol 20mg iv x2 so was started on labetolol gtt: highest dose 2mg/min. This was stopped after 35 minutes, in favor of nitro gtt. States compliant with meds at home. Patient was comfortable on admission to the MICU. Notes pain in abdomen 7.5/10 related to PD catheter placement (has had since then), improves with morphine. Also notes swelling in eyes/face since last night (has had in the past but never this severe, always goes away on its own). She feels whole body is swollen slightly but no more upper extremities than lower. She denies visual changes, HA, change in hearing/tinitus, congestion, sore throat, cough, SOB, chest pain, palpitations, nausea, vomitting, diarrhea. Has baseline constipation (takes stool softener), last BM 2 days ago (normal), no melena, brbpr, diarrhea. No dysuria, hematuria, change in uop, increase weight or size (clothes fit the same), tingling, numbness, weakness, discoordination, rash, joint pain, recent travel, ill contacts, exotic foods. She notes episode of throat swelling over weekend resolved, seemed to be related to sardine eating (not new for her). Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient denies past or current alcohol, tobacco, or illicit drug use. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: ON ADMISSION: VS: T 98.0 BP 187/120 HR 77 RR 17 Sat 100% on RA GEN: NAD HEENT: + periorbital edema, AT, NC, PERRLA, EOMI, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD, no carotid bruits CV: RRR, nl s1, s2, II/VI HSM at R/L USB, S4, no rub PULM: CTAB, no w/r/r with good air movement throughout ABD: soft, mildly tender at PD catheter, ND, + BS, no HSM EXT: warm, dry, +2 distal pulses BL, no femoral bruits, trace non-pitting edema NEURO: alert & oriented, CN II-XII grossly intact, 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect ON [**6-6**]: -General: AAOx3, in NAD. -VS: Tc: 95.2, Tmax (24hrs): 97.8 BP: 172/98 (80/43, 240/110 on [**5-30**]; 120/70, 218/120 over last 24 hrs), P: 80 (80, 98), RR: 16, O2: 98% RA. -HEENT: Head NC, AT. MMM. Face, Neck swollen: equal bilaterally. -Neck: Supple, No JVD, No tracheal deviation. -CV: RRR, S1,S2. Grade II/XII holosystolic murmur radiating to R carotid. JVP not elevated. No S4. -Lungs: CTAB, no w/r. -Abdomen: +BS, soft, nontender. -Extremities: Warm, no lower extremity edema. L arm appears slightly less swollen than yesterday. Dorsalis pedis and radial pulses strong bilaterally. No evidence of rashes, ulcers or varicose veins. -Breast: L breast still swollen relative to R, but diminished from initial presentation of swelling. Skin no longer tense. Pertinent Results: WBC-3.9* RBC-2.19* Hgb-6.6* Hct-20.4* MCV-93 MCH-30.3 MCHC-32.4 RDW-19.7* Plt Ct-114* - Neuts-52.8 Lymphs-39.9 Monos-5.0 Eos-2.0 Baso-0.2 PT-20.5* PTT-89.9* INR(PT)-1.9* Fibrino-268 Thrombn-37.4*# AT III-92 ProtCFn-65* ProtCAg-PND ProtSFn-68 Glucose-105 UreaN-62* Creat-8.1* Na-139 K-4.5 Cl-109* HCO3-17* ALT-14 AST-35 LD(LDH)-254* CK(CPK)-176* AlkPhos-137* Amylase-277* TotBili-0.4 Calcium-6.8* Phos-5.9* Mg-1.5* Hapto-90 Homocys-37.8* PTH-1603* UA: Color Straw Appear Clear SpecGr 1.009 pH 6.0 Urobil Neg Bili Neg Leuk Sm Bld Neg Nitr Neg Prot 30 Glu Neg Ket Neg RBC 0-2 WBC [**11-30**] Bact Few Yeast None Epi 0-2 U Tox: Urine Opiates Pos;Urine Benzos, Barbs, Cocaine, Amphet, Mthdne Negative; UCG: Negative STUDIES: Portable CXR [**5-24**]: Small left pleural effusion with associated atelectasis, although early pneumonia cannot be excluded. No CHF. ECG [**5-24**]: NSR (87), nl axis and intervals, TWI V5-V6, no change from [**5-20**]. MRA [**5-24**]: 1. Occlusion of the right internal jugular vein below the mandible which communicates with external jugular and subclavian vein. Appearance suggest chronic disease. 2. Patent SVC. 3. Patent but narrowed left internal jugular vein but left brachiocephalic vein not visualized (possibly from technique). 4. Bibasilar atelectasis US upper extremity [**5-26**]: [**Doctor Last Name **]-scale, color and Doppler son[**Name (NI) 1417**] of the left IJ, subclavian, axillary, brachial, basilic, and cephalic veins were performed. There is normal flow, compression, and augmentation seen in all of the vessels. IMPRESSION: No evidence of deep vein thrombosis in the left arm. MRV Chest [**5-30**]: 1. Limited study which demonstrates a chronically occluded and completely atrophic left brachiocephalic vein. 2. Right internal jugular vein not identified, likely chronically occluded. Left internal jugular vein is very diminuitive as before. 3. Large right external jugular vein emptying into the subclavian vein. Venogram [**5-31**]: 1. Occlusion of the left brachiocephalic vein at the junction of the subclavian and internal jugular with extensive collateral formation consistent with chronic obstruction. 2. Patent left brachial, axillary, subclavian, and distal internal jugular vein. 3. Unsuccessful attempt to recanalize the left brachiocephalic vein using a catheter and guidewire technique. Brief Hospital Course: Ms. [**Known lastname **] is a 23yo woman with a history of SLE, ESRD and HTN who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into L sided facial, L arm and L breast swelling throughout her stay. # L facial/arm and breast swelling: Initially this presented only as facial swellingand ACE and [**Last Name (un) **] were held for possible angioedema, however holding medications nad giving benadryl failed to relieve symptoms. We then suspected possible venous thrombus with occlusion leading to edema. US of upper left extremity failed to show evidence of acute occlusion, but showed R IJ occlusion consistent with prior studies. MRA could not visualize the L brachiocephalic vein. Repeat MRV suggested chronic occlusion of the L brachiocephalic vein. Venogram performed on [**5-31**] showed extensive collateralization of the L brachiocephalic vein with patent flow through these collaterals. Intervention on the L brachiocephalic vein was attempted by IR, but was unsuccessful. The primary team, renal team, [**Month/Year (2) **] team and hematology team suspect that the most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of the L brachiocephalic vein. For this reason, the patient was placed on Heparin IV as a bridge to coumadin anticoagulation with goal INR [**2-12**]. Per consult with hematology the patient is to remain on this regimen for at least 6 months, and will then revisit as an outpatient the question of possible lifelong anticoagulation. The patient has had extensive negative testing for hypercoagulable states, including during this work-up with negative anticardiolipin, antiphospholipid, Beta-2 glycoprotein and AT3 antibodies. Protein C and S levels were unremarkable. Although her clots seem to have all occured in the setting of lines, her continued thrombosis is likey due to hypercoagulability from her lupus (in absence of lupus anticoagulant). Her INR will be followed first by Dr. [**Last Name (STitle) 4883**], her nephrologist, and then by the coumadin clinic of [**Company 191**]. It will be especially important that her coumadin be well titrated given her risk of intracranial bleed with hypertension. This was communicated tothe patient and she understands and plans to be compliant with frequent blood draws for INR testing and varying her coumadin dose as directed. . # Hypertension: The patient has chronically labile hypertension, with frequent episodes of hypertensive urgency over systolic 200, as well as lows as far as the 80s during this admission. It remains unclear why her blood pressure is so chronically labile. The hope is that once she starts dialysis this will help to stabilize her blood pressure, however in the interim various adjustments were made to her regimen. The patient received frequent extra doses during her stay (especially of hydralazine), however, this occasionally causes her blood pressure to swing too low to tolerate her subsequent standing dose of medication. We stopped her Ace and [**Last Name (un) **] as above. We discharged her to home on a regimen that was reviewed with her nephrologist, Dr. [**Last Name (STitle) 4883**]. She is discharged on clonidine patch 0.3mg qweek, labetalol 900mg po tid, nifedipine CR 90mg po bid, hydralazine 35mg po tid. These medications were reviewed extensively with the patient and she was given prescriptions for all meds. She is discharged with home VNA for blood pressure checks and assistance with meds. She has purchased a portable BP cuff and will keep a BP diary to bring to subsequent appointments as well. The importance of BP control, especially in the setting of new anticoagulation, was discussed extensively with the patient. Her goal SBP is 140-160 at this time. . # ESRD: The patient has ESRD due to lupus nephritis. PD catheter was placed before admission and the patient received morphine prn pain at her catheter site. The renal team followed her closely throughout her stay. She was treated for hypocalcemia as well as hyperkalemia. Her regimen was changed to calcitriol 0.25mcg po qday, sodium bicarb 1300mg po qday, cholecalciferol 400units po qday, ergocalciferol 50,000 units po qweek for ten weeks. She plans to start HD within 1-2 weeks of discharge. She will call [**Doctor First Name 3040**] the PD nurse tomorrow to set up an appointment to have her catheter flushed and to start PD. She will be closely followed by Dr. [**Last Name (STitle) 4883**] at PD. # SLE: The patient was maintained on her home dose of prednisone 15mg po qday throughout her stay. She has no symptoms of acute SLE flare, so her nephrologist and outpatient physicians may attempt to wean this down as an outpatient. . # abnormal pap smear: The pt is noted to have an abnormal pap and colpo two years ago with CIN 2 and high risk HPV. This has never been repeated, as the patient failed to schedule appointments and DNK others. We discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. The patient was discharged to home with a clear plan to call [**Doctor First Name 3040**], the PD nurse on the day after discharge to set up an appointment to have her PD catheter flushed later this week, as well as to set a date to start her PD. She will see Dr. [**Last Name (STitle) 44539**] in [**Hospital **] clinic within the next 1-2 weeks. She will have her blood drawn for INR in two days and faxed to Dr. [**Last Name (STitle) 4883**], subsequently this will be faxed to the [**Company 191**] coumadin clinic and her dose will be adjusted for INR [**2-12**]. We have also given her the phone number to call [**Company 191**] and establish care with a new PCP, [**Name10 (NameIs) 3**] her old PCP has now graduated and her complex management makes a PCP [**Name Initial (PRE) 44540**]. (Her PCP must be at [**Company 191**] for the [**Company 191**] coumadin clinic to follow her as well.) Finally, the patient was given an appointment with ob/gyn to have a follow up pap smear, as her last pap and colpo two years ago showed CIN 2 with high risk HPV and this has not been followed. The above plan and appoitnments were reviewed with the pt and her mother extensively. [**Name2 (NI) **] medication hcanges were also extensively reviewed. Medications on Admission: Hydralazine 50 mg PO TID Labetalol 900 mg PO TID Nicardipine 60 mg Sustained Release PO once a day Cinacalcet 30 mg PO DAILY: she is not sure if taking Calcium Acetate 667 mg PO TID W/MEALS Sodium Bicarbonate 1300 mg PO TID Aliskiren 150 mg PO once a day (was never taking) Pantoprazole 40 mg PO once a day Valsartan 320mg PO DAILY Lisinopril 40 mg PO bid Clonidine 0.3 mg/24 hr Patch Weekly QSUN: not sure when last placed Prednisone 15 mg PO DAILY Morphine 15 mg Tablet PO Q6H as needed Ergocalciferol (Vitamin D2) 50,000 unit Capsule daily: states not taking Epo 4,000 units M/W/F: states not taking colace Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Disp:*4 Patch Weekly(s)* Refills:*2* 3. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 5. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO qwednesday (): for 10 weeks. Disp:*10 Capsule(s)* Refills:*0* 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*2* 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 10. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: dose to be adjusted by coumadin clinic. Disp:*120 Tablet(s)* Refills:*2* 11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 12. Benadryl 25 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for itching. Disp:*50 Capsule(s)* Refills:*0* 13. Ativan 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. Disp:*60 Tablet(s)* Refills:*0* 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* 15. Morphine 15 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 14 days. Disp:*56 Tablet(s)* Refills:*0* 16. Outpatient Lab Work Please have blood drawn on Friday, [**6-9**] for PT/INR. Please have result faxed to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you to adjust your coumadin (also called warfarin) dose as needed. 17. Outpatient Lab Work Please have blood drawn on Monday [**2141-6-12**] for PT/INR and twice per week thereafter until told by coumadin clinic that you can decrease lab draws. Please have result faxed to the [**Hospital1 18**] coumadin clinic at [**Telephone/Fax (1) 3534**]. They will call you to adjust your coumadin (also called warfarin) dose as needed. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnoses: Malignant Hypertension (Hypertensive Urgency) Acute Exacerbation of Chronic Left Brachiocephalic vein occlusion Anemia Secondary Diagnoses: SLE ESRD Hypertrophic Cardiomyopathy Thrombocytopenia Discharge Condition: Stable Discharge Instructions: You were admitted and treated for an acute exacerbation of a chronic left brachiocephalic vein occlusion (a chronically obstructed large vein closed off entirely) and hypertensive urgency (very high blood pressure). We attempted to remove the clot in your left brachiocephalic vein, but were unable to do so. You have been started on long-term Coumadin (also called warfarin) therapy to prevent future blood clots and to allow natural dissolution of your current blood clot. Please change your medicines to only those you are given here! There were many changes and it is very important that you stick to the medication list as you have large, life-threatening swings in the blood pressure when not taking consistently. We also treated you for high potassium levels and anemia, and low vitamin D and calcium levels, which are related to your kidney failure. Please follow up with Dr. [**Last Name (STitle) 4883**] for long term treatment. Please check your blood pressure three times per day and keep a blood pressure diary to bring with you to all medical appointments. Please have your blood drawn on Friday [**6-9**] for PT/INR and faxed to Dr. [**Last Name (STitle) 4883**] at [**Telephone/Fax (1) 434**]. He will call you if needed to adjust your coumadin (warfarin) dose. After that, please have your blood drawn on Monday [**6-12**] for PT/INR and faxed to the [**Hospital1 18**] coumadin clinic at [**Telephone/Fax (1) 434**]. They will follow you in a regular way to adjust your coumadin dose as needed. MEDICINES FOR BLOOD PRESSURE: LABETALOL 900mg three times per day (same as before) HYDRALAZINE 25mg three times per day (lower dose than before) CLONIDINE PATCH 0.3mg qWednesday (same as before) NIFEDIPINE SR 90mg twice per day (new medicine!) **stop taking your lisinopril, nicardipine, Diovan and Aliskerin!** MEDICINES FOR RENAL FAILURE: ERGOCALCIFEROL [**Numeric Identifier 1871**] units pill every Wednesday (same as before) CHOLECALCIFEROL 400 units every day (new) CALCITRIOL 0.25 mg every day (new) SODIUM BICARBONATE 1300mg once per day (less often then before) ** stop taking your calcium acetate (phoslo), cinecalcet, and epo injection (you'll get it at peritoneal dialysis only)** OTHER MEDICINES: PANTOPRAZOLE 40mg every day (same as before) PREDNISONE 15mg every day (same as before) MORPHINE 15mg every 6 hrs if needed for pain (same as before) ATIVAN 1mg as needed for anxiety (same as before) BENADRYL 25mg every 6 hrs if needed for itch (new) COLACE 100mg twice per day if needed for constipation(same as before) APPOINTMENTS: **1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on Friday to flush your dialysis catheter and start dialysis next week! 2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00AM 3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**] Date/Time: [**2141-6-13**] 9:30AM **4. Please call [**Hospital3 **] next week to make an appointment with a new primary doctor. I recommend Dr. [**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE FOLLOWED IN [**Hospital **] CLINIC. **5. Please have your blood drawn as above. Your coumadin level will be followed by the [**Hospital 197**] clinic. Their phone # is [**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**]. If you have increased swelling, fever greater than 101, shortness of breath, chest pain, or if you at any time become concerned about your health please contact Dr. [**Last Name (STitle) 4883**] or go to the nearest ER. Followup Instructions: APPOINTMENTS: **1. Be sure to call [**Doctor First Name 3040**] tomorrow for an appointment on Friday to flush your dialysis catheter and start dialysis next week! 2. gynecology appointment: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **], Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2141-6-30**] 10:00AM 3. nephrology appointment: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Phone:[**Telephone/Fax (1) 435**] Date/Time: [**2141-6-13**] 9:30AM **4. Please call [**Hospital3 **] next week to make an appointment with a new primary doctor. I recommend Dr. [**Last Name (STitle) 11009**], who is a resident who works with [**First Name8 (NamePattern2) 2426**] [**Last Name (NamePattern1) 2427**]. IT IS VERY IMPORTANT THAT YOU KEEP THIS APPOINTMENT SO YOU CAN BE FOLLOWED IN [**Hospital **] CLINIC. **5. Please have your blood drawn as above. Your coumadin level will be followed by the [**Hospital 197**] clinic. Their phone # is [**Telephone/Fax (1) 2173**]. Their fax # is [**Telephone/Fax (1) 3534**]. Completed by:[**2141-6-17**]",11,2141-05-24 14:47:00,2141-06-06 19:55:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ACUTE RENAL FAILURE," ms. [**known lastname **] is a 23yo woman with a history of sle, esrd and htn who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into l sided facial, l arm and l breast swelling throughout her stay. # l facial/arm and breast swelling: initially this presented only as facial swellingand ace and [**last name (un) **] were held for possible angioedema, however holding medications nad giving benadryl failed to relieve symptoms. we then suspected possible venous thrombus with occlusion leading to edema. us of upper left extremity failed to show evidence of acute occlusion, but showed r ij occlusion consistent with prior studies. mra could not visualize the l brachiocephalic vein. repeat mrv suggested chronic occlusion of the l brachiocephalic vein. venogram performed on [**5-31**] showed extensive collateralization of the l brachiocephalic vein with patent flow through these collaterals. intervention on the l brachiocephalic vein was attempted by ir, but was unsuccessful. the primary team, renal team, [**month/year (2) **] team and hematology team suspect that the most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of the l brachiocephalic vein. for this reason, the patient was placed on heparin iv as a bridge to coumadin anticoagulation with goal inr [**2-12**]. per consult with hematology the patient is to remain on this regimen for at least 6 months, and will then revisit as an outpatient the question of possible lifelong anticoagulation. the patient has had extensive negative testing for hypercoagulable states, including during this work-up with negative anticardiolipin, antiphospholipid, beta-2 glycoprotein and at3 antibodies. protein c and s levels were unremarkable. although her clots seem to have all occured in the setting of lines, her continued thrombosis is likey due to hypercoagulability from her lupus (in absence of lupus anticoagulant). her inr will be followed first by dr. [**last name (stitle) 4883**], her nephrologist, and then by the coumadin clinic of [**company 191**]. it will be especially important that her coumadin be well titrated given her risk of intracranial bleed with hypertension. this was communicated tothe patient and she understands and plans to be compliant with frequent blood draws for inr testing and varying her coumadin dose as directed. . # hypertension: the patient has chronically labile hypertension, with frequent episodes of hypertensive urgency over systolic 200, as well as lows as far as the 80s during this admission. it remains unclear why her blood pressure is so chronically labile. the hope is that once she starts dialysis this will help to stabilize her blood pressure, however in the interim various adjustments were made to her regimen. the patient received frequent extra doses during her stay (especially of hydralazine), however, this occasionally causes her blood pressure to swing too low to tolerate her subsequent standing dose of medication. we stopped her ace and [**last name (un) **] as above. we discharged her to home on a regimen that was reviewed with her nephrologist, dr. [**last name (stitle) 4883**]. she is discharged on clonidine patch 0.3mg qweek, labetalol 900mg po tid, nifedipine cr 90mg po bid, hydralazine 35mg po tid. these medications were reviewed extensively with the patient and she was given prescriptions for all meds. she is discharged with home vna for blood pressure checks and assistance with meds. she has purchased a portable bp cuff and will keep a bp diary to bring to subsequent appointments as well. the importance of bp control, especially in the setting of new anticoagulation, was discussed extensively with the patient. her goal sbp is 140-160 at this time. . # esrd: the patient has esrd due to lupus nephritis. pd catheter was placed before admission and the patient received morphine prn pain at her catheter site. the renal team followed her closely throughout her stay. she was treated for hypocalcemia as well as hyperkalemia. her regimen was changed to calcitriol 0.25mcg po qday, sodium bicarb 1300mg po qday, cholecalciferol 400units po qday, ergocalciferol 50,000 units po qweek for ten weeks. she plans to start hd within 1-2 weeks of discharge. she will call [**doctor first name 3040**] the pd nurse tomorrow to set up an appointment to have her catheter flushed and to start pd. she will be closely followed by dr. [**last name (stitle) 4883**] at pd. # sle: the patient was maintained on her home dose of prednisone 15mg po qday throughout her stay. she has no symptoms of acute sle flare, so her nephrologist and outpatient physicians may attempt to wean this down as an outpatient. . # abnormal pap smear: the pt is noted to have an abnormal pap and colpo two years ago with cin 2 and high risk hpv. this has never been repeated, as the patient failed to schedule appointments and dnk others. we discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. the patient was discharged to home with a clear plan to call [**doctor first name 3040**], the pd nurse on the day after discharge to set up an appointment to have her pd catheter flushed later this week, as well as to set a date to start her pd. she will see dr. [**last name (stitle) 44539**] in [**hospital **] clinic within the next 1-2 weeks. she will have her blood drawn for inr in two days and faxed to dr. [**last name (stitle) 4883**], subsequently this will be faxed to the [**company 191**] coumadin clinic and her dose will be adjusted for inr [**2-12**]. we have also given her the phone number to call [**company 191**] and establish care with a new pcp, [**name10 (nameis) 3**] her old pcp has now graduated and her complex management makes a pcp [**name initial (pre) 44540**]. (her pcp must be at [**company 191**] for the [**company 191**] coumadin clinic to follow her as well.) finally, the patient was given an appointment with ob/gyn to have a follow up pap smear, as her last pap and colpo two years ago showed cin 2 with high risk hpv and this has not been followed. the above plan and appoitnments were reviewed with the pt and her mother extensively. [**name2 (ni) **] medication hcanges were also extensively reviewed. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Compression of vein; Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Hyperpotassemia; Hyperparathyroidism, unspecified; Other iatrogenic hypotension; Nausea with vomiting; ; Abnormal glandular Papanicolaou smear of cervix; Abdominal pain, other specified site; Other specified disorders of pancreatic internal secretion; Adrenal cortical steroids causing adverse effects in therapeutic use]","known lastname **] is a 23yo woman with a history of sle, esrd and htn who presented with acute onset bilateral facial swelling and hypertensive urgency, which developed into l sided facial, l arm and l breast swelling throughout her stay. mra could not visualize the l brachiocephalic vein. it remains unclear why her blood pressure is so chronically labile. we stopped her ace and [**last name (un) **] as above. the importance of bp control, especially in the setting of new anticoagulation, was discussed extensively with the patient. # esrd: the patient has esrd due to lupus nephritis. the renal team followed her closely throughout her stay. she will call [**doctor first name 3040**] the pd nurse tomorrow to set up an appointment to have her catheter flushed and to start pd. we discussed the importance of following this up with the patient, and at her request scheduled her for an ob/gyn appointment as an outpatient shortly after discharge. the above plan and appoitnments were reviewed with the pt and her mother extensively. [**","a 23yo woman with a history of sle, esrd and htn presented with bilateral facial swelling. she developed l sided facial, l arm and l breast swelling throughout her stay. most likely etiology of her swelling is an acute-on-chronic (now occlusive) thrombus of l brachiocephalic vein." 109,113189.0,14806,2142-02-17,14796,139061.0,2141-09-14,Discharge summary,"Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Right leg pain. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 24 y.o. F with lupus, Chronic Kidney Disease V (not currently on HD or PD), and multiple admissions for hypertensive urgency/emergency, who presented to the ED for continued R leg pain that starts in her R buttocks and refers down her R leg. She describes it as feeling like the pain is deep within her bone. The pain was [**10-20**] in the AM, and she felt like she couldn't get out of bed. Denies any swelling of her RLE. When getting VS in [**Name (NI) **], pt noted to be very hypertensive at 263/176. The patient reportedly has baseline SBPs in 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM on day of admission. She denies any recent recrational drug use including cocaine and amphetamines. She denies headache, vision changes, double vision, chest pain, shortness of breath, abdominal pain, BRBPR, dysuria. During MD interview, the patient was nauseous and had small amount of emesis of a recent Coolata. Pt states that flushing her PD cath causes a large amount of stomach pain. . Of note, the patient was recently admitted from 08.26-29.08. The patient initially presented to the ED after referral from her nephrologist's office where she had complaints of right leg pain and was found to be hypertensive to 250/145. She was admitted after initiation of a labetalol drip and nitropaste with improvement in sbp to 180. The patient did receive 2 U of PRBC's during this hospitalization for baseline anemia. The patient did have a work-up for her right leg pain complaints with plain films of the right hip and MRI of the L-spine which did not reveal an explanation for her symptoms and did rule out avascular necrosis. The patient received dilaudid for pain control and was ambulating without pain prior to discharge. In addition, the patient completed a course of ciprofloxacin for a positive UA with negative cultures. The patient was unable to tolerate peritoneal dialysis for unclear reasons. Peritoneal dialysate culture was negative for infection. . In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in ED ranged from [**Telephone/Fax (3) 43494**]-175 with HR in 96-108. Initially given labetalol 10 mg IV x 1 and then started on labetalol gtt for her elevated blood pressures and titrated to 3 mg/min. LENI of R leg was negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per ED, cannot do V/Q scan due to volume overload after talking with radiology. Renal c/s initiated. A-line placed. Past Medical History: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] . PAST SURGICAL HISTORY: - Placement of multiple catheters including dialysis. - Tonsillectomy. - Left eye enucleation in [**2140-4-10**]. - PD catheter placement in [**2141-5-11**]. Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 98.9 [**Telephone/Fax (2) 43495**] 99$% RA GEN: NAD, pleasant female sitting in bed with moon facies HEENT: EOMI of R eye, L eye prosthesis, no exudate, no erythema, MMM, no LAD CHEST: CTAB except at R base with decreased breath sounds; no w/r/r CV: tachy, normal S1S2, II/VI systolic murmur accentuated with Valsalva ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i EXT: no c/c/e, strength of LEs [**5-15**] and symmetric bilaterally. Negative straight leg test, no pain with internal rotation, external rotation, extension, adduction or abduction. Some pain on flexion at the hip. NEURO: II - XII intact to direct testing. No deficit in light tough sensation. Gait normal. DERM: no rashes noted Pertinent Results: LABS AT ADMISSION: [**2141-9-11**] 11:43AM GLUCOSE-86 UREA N-49* CREAT-8.1* SODIUM-139 POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-16* ANION GAP-18 [**2141-9-11**] 11:43AM CALCIUM-6.2* PHOSPHATE-5.8* MAGNESIUM-1.6 [**2141-9-11**] 11:43AM PT-18.4* PTT-42.8* INR(PT)-1.7* [**2141-9-11**] 07:00AM WBC-5.5 RBC-2.88* HGB-8.1* HCT-24.7* MCV-86 MCH-28.1 MCHC-32.8 RDW-18.0* [**2141-9-11**] 07:00AM NEUTS-74.7* LYMPHS-17.5* MONOS-4.2 EOS-3.3 BASOS-0.2 [**2141-9-11**] 07:00AM PLT COUNT-101* UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50 WBC . MICROBIOLOGY: Urine culture ([**2141-9-11**]): Mixed flora . STUDIES: Cardiology Report ECG Study Date of [**2141-9-11**] 6:55:16 AM Sinus tachycardia. The tracing is marred by baseline artifact. There is left atrial enlargement. Compared to the previous tracing of [**2141-9-5**] the rate has increased. The axis is more rightward. Otherwise, no diagnostic interim change. . UNILAT LOWER EXT VEINS RIGHT Study Date of [**2141-9-11**] 8:54 AM [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and popliteal veins demonstrate normal flow, compressibility, augmentation, waveforms. Appropriate color flow and compression is noted within the calf veins. No intraluminal thrombus is present. IMPRESSION: No evidence of right lower extremity DVT. . TTE ([**2140-8-26**]): The left atrium is normal in size. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . R HIP XR [**2141-9-6**]: No acute fracture or dislocation. . MRI L-SPINE [**2141-9-6**]: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. LAB RESULTS AT DISCHARGE: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-9-14**] 06:15AM 4.0 2.63* 7.6* 23.1* 88 29.1 33.0 18.0* 100* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-9-14**] 06:15AM 100 44* 8.1* 137 4.8 109* 17* 16 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2141-9-14**] 06:15AM 6.8* 5.4* 1.6 CALCIUM freeCa [**2141-9-14**] 11:30AM 0.94* Brief Hospital Course: ICU course: EKG showed no change from prior, and CXR showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home medication regimen. The patient was found to by hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. . [**Hospital1 **] history: . 1. Hypertensive urgency: During the patient's [**Hospital1 **] stay, her SBPs ranged from 140s-160s during the day, which is her baseline systolic blood pressure. She was maintained on her home oral medication regimen. At night, she became more hypertensive, with SBP to the 170s-180s, which was controlled with both IV hydralazine and PO nifedipine. PO nifedipine was most successful at bringing her SBP back to her baseline. SBP at discharge was 140. Throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. The renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. Right leg pain: Upon arrival on the floor, the patient complained of [**2143-4-15**] pain in R buttock and posterior thigh, much exacerbated with standing. Of note, lumbar spine MRI and R hip XR on most recent admission were both negative. Her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. Her pain when she was symptomatic was controlled well with PO dilaudid. If the pain recurs, an MRI of the right hip can be considered to evaluate for osteonecrosis. . 3. UTI: The patient had a urinalysis suggestive of UTI, though she remained asymptomatic throughout. She was treated with a three day course of ciprofloxacin. Her urine culture showed mixed flora consistent with skin contamination. . 4. ESRD: The patient has end-stage renal disease due to her lupus. The patient's creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. She was followed by the renal consult service. Her potassium remained stable. Her calcium was low during admission, and supplemental calcium was given in addition to starting Calcitriol. She was not dialyzed through her PD catheter secondary to discomfort, but may reinitiate PD as an outpatient. Her laboratories will be checked as an outpatient in renal clinic. . 5. Anemia: The patient's hematocrit remained near her baseline low 20s throughout her stay. She has anemia from chronic kidney disease and chronic disease. The patient is not on Epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. Prior SVC thrombus: The patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with INR goal 2.5 to 3.0. . 7. Systemic lupus erythematosus: No active issues. The patient's home prednisone regimen was continued. Medications on Admission: - Prednisone 5 mg Daily - Coumadin 2 mg at bedtime - Nifedipine 60 mg Sustained Release Daily - Hydralazine 50 mg every 8 hours - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY - Aliskiren 150 mg Twice daily - Docusate Sodium 100 mg 2 times a day - Labetalol 900 mg three times a day - Lactulose 15-30 ml once a day: goal is [**1-11**] soft bowel movements per day Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 7. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: - Hypertensive urgency - Right lower extremity pain - Urinary tract infection Secondary diagnosis: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) - HOCM: Last noted on echo [**8-17**] - Anemia - History of left eye enucleation [**2139-4-20**] for fungal infection - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Discharge Condition: Stable systolic blood pressure over past 24 hours. Discharge Instructions: You were admitted to the hospital for uncontrolled high blood pressure. You spent one day in the intensive care unit, where you were treated with intravenous medication to lower your blood pressure. You were then transferred to a regular hospital floor, where your blood pressure was managed with your home oral medications. You were also treated for urinary tract infection with antibiotics. Your right leg pain improved during admission, and we are unsure of the cause of this pain. You should discuss the need for an MRI of the hip if the pain returns when you meet with your primary care doctor. Please call your physician or return to the emergency room if you experience fever, chills, chest pain, difficulty breathing, abdominal pain, headache, changes in your vision, or any other symptoms that are concerning. Please take your medications as prescribed. - Calcitriol was added to your medications. - You should hold Coumadin for two days and restart Saturday, [**2141-9-16**]. You should have your INR checked at your visit in kidney clinic [**2141-9-18**]. - You can take Dilaudid 2-4 mg every eight hours as needed for pain. You should be vigilant about taking lactulose if you need to take Dilaudid. - You should continue Lactulose as per Dr.[**Name (NI) 12913**] instructions. - No other changes were made. Please keep follow up appointments as described below. Followup Instructions: Please call the office of your kidney doctor, Dr. [**Last Name (STitle) 4883**], at ([**Telephone/Fax (1) 773**] to schedule an appointment for [**Last Name (LF) 766**], [**9-19**] as discussed. Follow up with your lung doctor: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-9-21**] 1:00 Follow up with your new primary care doctor: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 ",156,2141-09-11 10:12:00,2141-09-14 20:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home medication regimen. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. . [**hospital1 **] history: . 1. hypertensive urgency: during the patients [**hospital1 **] stay, her sbps ranged from 140s-160s during the day, which is her baseline systolic blood pressure. she was maintained on her home oral medication regimen. at night, she became more hypertensive, with sbp to the 170s-180s, which was controlled with both iv hydralazine and po nifedipine. po nifedipine was most successful at bringing her sbp back to her baseline. sbp at discharge was 140. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. the renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. her pain when she was symptomatic was controlled well with po dilaudid. if the pain recurs, an mri of the right hip can be considered to evaluate for osteonecrosis. . 3. uti: the patient had a urinalysis suggestive of uti, though she remained asymptomatic throughout. she was treated with a three day course of ciprofloxacin. her urine culture showed mixed flora consistent with skin contamination. . 4. esrd: the patient has end-stage renal disease due to her lupus. the patients creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. she was followed by the renal consult service. her potassium remained stable. her calcium was low during admission, and supplemental calcium was given in addition to starting calcitriol. she was not dialyzed through her pd catheter secondary to discomfort, but may reinitiate pd as an outpatient. her laboratories will be checked as an outpatient in renal clinic. . 5. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay. she has anemia from chronic kidney disease and chronic disease. the patient is not on epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. prior svc thrombus: the patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with inr goal 2.5 to 3.0. . 7. systemic lupus erythematosus: no active issues. the patients home prednisone regimen was continued. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Urinary tract infection, site not specified; Other primary cardiomyopathies; Systemic lupus erythematosus; Sciatica; Hyperpotassemia; Thrombocytopenia, unspecified; Abnormal coagulation profile; Hyperparathyroidism, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism]","icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the renal team was consulted, and recommended no change to home medication regimen. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. she was treated with a three day course of ciprofloxacin. esrd: the patient has end-stage renal disease due to her lupus. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay.","ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. she became more hypertensive, with sbps to the 170s-180s during the day. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency." 109,113189.0,14806,2142-02-17,14797,172335.0,2141-09-24,Discharge summary,"Admission Date: [**2141-9-18**] Discharge Date: [**2141-9-24**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1936**] Chief Complaint: hip pain Major Surgical or Invasive Procedure: None History of Present Illness: 24yo woman with hx SLE, CKD(not currently on HD or PD), labile HTN here with right leg pain and HTN urgency. Patient was recently d/ced on [**9-14**] following admission for the same complaints. . Patient took her hydralazine dose on am of admission. BP at presentation to the ER was 250/140 (The patient reportedly has baseline SBPs in 130-170s) She was given 900 labetolol and 50 hydralazine in the ED. BP following this was 175/124. Her EKG was unchanged. K was 5.7. . Patient also complaining of [**10-20**] right hip pain. Patient was d/ced on [**9-14**] with oral dilaudid for hip/leg pain. She took this only for one day due to severe itching. Denies any parasthesias/weakness. Her RLE/hip pain has been extensively worked up with negative LENIs, Lumbar spine MRI and hip plain films in the past. She was given 4mg IV morphine in the ER. . On admission to the floor, leg/hip pain somwhat improved with morphine.She denies any headache, vision changes, double vision, chest pain or SOB. Feels warm but no chills. Past Medical History: Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 97.3 HR 81 BP 135/91 RR 16 100%RA Gen:NAD, happy, pleasant female HEENT:NC/AT, L eye prosthesis, R PERRL, EOMI, MMM, facial swelling, L side>R, scerla anicteric Neck: supple, no JVD, no LAD, scars from prior CVL and HD lines CV:S1S2+, 2/6 SEM LUSB, loud P2, RRR, no ectopy Pulm: CTA B/L, good inspiratory effort Abd: +BS, soft, nontender, slightly distended and resonant to percussion, PD catheter in place in left abdomen ext: no c/c/e, 2+DP b/L, L foream swollen>R, R hip is mobile without pain elicited on passive or active movement neuro: AAOx3, nonfocal exam, CN 2-12 intact, moves all 4 extremities psych: mood/affect appropriate Pertinent Results: MRI Right Hip ([**9-18**]): There is no signal abnormality on the fluid-sensitive sequences in the proximal femur, acetabulum, or other osseous structure. On T1- weighted images, there is a focal rounded region within the right femoral head measuring approximately 9 mm in a subchondral location, which is nonspecific but may represent an unusual focus of red marrow. No sclerosis is seen on the corresponding plain films. There is a small right hip joint effusion and a small amount of fluid in the left hip joint as well, at the upper limits of normal. There is no soft tissue abnormality, no muscular edema, and no fluid collections. IMPRESSION: 1. Small right hip joint effusion. 2. No bone marrow edema in the proximal femurs or the pelvis. 3. Nonspecific small focus of low signal on T1-weighted images in the right femoral head is nonspecific but may represent an unusual focus of red marrow. TTE ([**9-21**]): The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF 80%). A mild (18 mmHg) mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. There is no systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Severe symmetric left ventricular hypertrophy with hyperdynamic systolic function and mild mid-cavitary gradient. Mild aortic regurgitation. Moderate pulmonary hypertension. Findings consistent with hyperrtophic cardiomyopathy. Compared with the prior study (images reviewed) of [**2140-8-26**], pulmonary hypertension has developed (also present on the study from [**2140-5-20**]). Pericardial effusion is also new. V/Q scan ([**9-21**]): Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate no focal defects with improved ventilation to the posterior right basal segment. Perfusion images in the same 8 views show improved perfusion to the posterior right basal segement with a persistent small defect but no new findings. Chest x-ray shows cardiomgealy and left basilar atelectasis. IMPRESSION: Improved V/Q scan from [**9-/2139**] with no findings to suggest acute pulmonary embolism. B/L upper ext U/S ([**9-21**]): Grayscale and Doppler son[**Name (NI) 867**] of the right and left internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. There is nonocclusive focal thrombus seen in the left subclavian vein, where the vein is not fully compressible. Flow is seen in the region, indicating that the thrombus is nonocclusive. Elsewhere, normal flow, augmentation, compressibility were appropriate and waveforms are demonstrated. IMPRESSION: 1. Focal nonocclusive thrombus in the left subclavian vein. 2. Otherwise, patent upper extremity veins as described. [**2141-9-18**] 02:15PM POTASSIUM-5.1 [**2141-9-18**] 02:15PM HCT-21.2* [**2141-9-18**] 08:45AM POTASSIUM-5.7* [**2141-9-18**] 07:30AM GLUCOSE-88 UREA N-54* CREAT-8.6* SODIUM-136 POTASSIUM-5.8* CHLORIDE-108 TOTAL CO2-15* ANION GAP-19 [**2141-9-18**] 07:30AM estGFR-Using this [**2141-9-18**] 07:30AM CALCIUM-7.3* PHOSPHATE-5.3* MAGNESIUM-1.6 [**2141-9-18**] 07:30AM WBC-5.2 RBC-2.32* HGB-6.5* HCT-20.1* MCV-87 MCH-28.1 MCHC-32.4 RDW-18.4* [**2141-9-18**] 07:30AM NEUTS-78.0* LYMPHS-14.7* MONOS-3.9 EOS-3.2 BASOS-0.3 [**2141-9-18**] 07:30AM PLT COUNT-107* [**2141-9-18**] 07:30AM PT-20.8* PTT-43.3* INR(PT)-2.0* . [**2141-9-21**] CXR: There is no significant change when compared to the recent previous examination. The previously described left retrocardiac opacity is unchanged in appearance. Cardiomegaly is also unchanged. The mediastinal contour, bony thorax and pulmonary vasculature are normal. IMPRESSION: No significant change compared to study done roughly 7 hours prior. Brief Hospital Course: 24 yo with h/o of Lupus, HTN, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for R hip pain. Patient was on the floor on [**9-20**], given morphine for the hip pain. She then had an episode of hypotension and unresponsiveness and transferred to the MICU for closer monitoring. The patient got 2L IVFs and narcan and improved, in fact, found to be hypertensive upon arrival to MICU. . MICU Course: On [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. Concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. Mental status cleared somewhat with narcan. Renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. V/Q scan demonstrated improvement since prior study. Patient's home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. She was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. PD fluid was not c/w SBP. CXR was clear. Urine culture and blood cultures are pending. Patient's BP was in the 110s so hydralazine was stopped. Her other BP meds were otherwise continued. Plan was/is to follow renal recs for PD. If, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. Would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. If patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. Would add neurontin 100mg TID with room to titrate up to 300mg TID. Neuro also recommended PT with TENS unit and referral to pain clinic although patient's pain is currently absent. . FYI **** per Dr. [**Last Name (STitle) **] --- Because of ? increase in cardiomegaly on CXR, she got an echo yesterday. In addition to her known HOCM, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm Hg. They probably need to be followed up over time (particularly the pulmonary hypertension). We did evaluated the PHTN with a VQ scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. It would be good if we could arrange a PULMONARY CLINIC FOLLOW UP for Ms. [**Known lastname **] after discharge with either [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].**** . She underwent CT head, and V/Q scan which were unremarkable. Her steroid dose was increased to 15mg given concern for need for stress dose steroids. After transfer from the MICU, her steroids were dropped back to 5mg, her home dose with the approval of [**Last Name (un) **]. . Her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. Her hydralazine was discontinued. On day 2 of her MICU stay, she developed a fever to 102. She was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. Broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. There was question of retrocardiac opacity on CXR, though not clear. Rheum consult obtained given hip discomfort, who felt septic joint unlikely. Neurology consult obtained who felt autonomic seizure unlikely. . Pt initiated peritoneal dialysis. In this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising BPs. She is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. Her hip pain has resolved completely without further intervention. . Floor course: Fever: Spike fever in MICU to 102. Started on Levoquin, Aztreonam, and Vanc. Source unclear at this point, but CXR with question of retrocardiac opacity. There is a possibility of aspiration pneumonitis. Other etiologies include peritoneal fluid (PD cath), urine, and blood (though patient does not have any indwelling lines). Hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. Peritoneal dialysis cultures negative so far. Continued levo/vanco/aztreonam for 2 days empirically. Then d/ced the Abx as no infectious etiologies were found. Steroids back to home dosage. BCx, UCx (final neg), Peritoneal cultures negative at discharge. . # Labile blood pressure: h/o of difficult to control BP with episodes of hypertensive emergency in the past. Normal SBP runs in 170s. Having nausea in setting of new PD, no evidence of intracranial bleeding on clinical exam, though INR had been supratherapeutic so remains in differential, though not bradycardic. Continue home BP meds :Labetalol 900 mg PO TID but difficult for patient to tolerate due to nausea, Aliskiren *NF* 150 mg Oral [**Hospital1 **], NIFEdipine CR 60 mg PO DAILY, clonidine patch, hydralazine given hypertensive in setting of nausa. . # Right leg/hip pain: no evidence of avascular necrosis or fracture on MRI though there is a small effusion. Pain resolved without intervention. Continued to monitor and would avoid narcotics, restart slowly if pain resumes. Physical therapy to follow as an outpatient. [**Last Name (un) 18183**] followed. Please see consult note. . # Hyperkalemia: Chronic issue. Patient takes kayexalate intermittently per her report (last dose [**Last Name (un) 766**]). Monitored K but patient did not need it on floor. # CKD V: Renal following. Did well with PD on [**9-22**] but did report some nause and cramping. She was not tolerating all 1.5L in exchanges on discharge. # Anemia: Hct stable around 20. S/p 1 U PRBCs in MICU with Hct 20.1 to 21.9. Likely due to chronic hemolysis consistent with SLE> #. Prior SVC thrombus: Physical exam with L arm swelling consistent with this. No flow limitations. INR 3.5 on ICU admission. Held warfarin but restarted home 2mg daily the day before discharge. # Systemic lupus erythematosus: Home prednisone dose 5mg. Currently on 15mg in setting of acute illness (day 2). # General care: FEN: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, PD initiated, Proph: INR therapeutic, no indication for PPI, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. Code: Full code, confirmed with patient Communication: with the patient and her mother [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (2) 43497**]contact. Access: 2 PIVs Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly dilaudid PO prn benadryl prn lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily coumadin 2mg PO qday calcitriol 1 mcg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Hypertensive urgency Transient Hypotension due to Narcotics Sciatica . Secondary: End stage renal disease Systemic Lupus Erythematosus Anemia Discharge Condition: Stable. Blood pressures at baseline. Hip/leg pain resolved. Ambulating without assistance. Discharge Instructions: You were admitted to the hospital with high blood pressure and right leg/hip pain. We gave you pain medications and blood pressure lowering medications. Your blood pressure then dropped which was caused by the pain medication, and you were transferred to the Intensive Care Unit(ICU) where you recovered quickly. During your stay in the ICU, you developed a fever and were started on antibiotics. However, the cultures that were obtained were negative, and we discontinued the Antibiotics. During your hospitalization, your blood pressure normalized on your home regimen, and your right leg/hip pain resolved. You had an MRI of your hip done, which did not show an acute infection. You were seen by the kidney doctors and they recommended starting peritoneal dialysis. You were also given some blood for your anemia. Please follow up with the Peritoneal Dialysis nurse at the scheduled day/time. Please make an appointment to meet with your PCP in the next couple of weeks. Your Hip pain may benefit from physical therapy or outpatient anesthetic joint injection. Please discuss these options with your rheumatologist. . Please call the number given below to schedule outpatient physical therapy. . Please restart your home medications. You were also started on Sodium Bicarb 650mg by mouth three times a day. . If you develop fevers, chills, trouble breathing, chest pain, worsening of hip pain, headaches, changes in your vision or any other symptoms that concern you please return to the emergency room or call your doctor. Followup Instructions: Please follow up with your Peritoneal Dialysis nurse ([**Doctor First Name 3040**]) on [**Doctor First Name 766**] [**2141-9-25**] . Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 . Please call to schedule Outpatient Physical Therapy:[**Telephone/Fax (1) 2484**] Completed by:[**2141-9-25**]",146,2141-09-18 10:32:00,2141-09-24 13:53:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,LEG PAIN," 24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. patient was on the floor on [**9-20**], given morphine for the hip pain. she then had an episode of hypotension and unresponsiveness and transferred to the micu for closer monitoring. the patient got 2l ivfs and narcan and improved, in fact, found to be hypertensive upon arrival to micu. . micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. mental status cleared somewhat with narcan. renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. v/q scan demonstrated improvement since prior study. patients home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. she was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. pd fluid was not c/w sbp. cxr was clear. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. plan was/is to follow renal recs for pd. if, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. would add neurontin 100mg tid with room to titrate up to 300mg tid. neuro also recommended pt with tens unit and referral to pain clinic although patients pain is currently absent. . fyi **** per dr. [**last name (stitle) **] --- because of ? increase in cardiomegaly on cxr, she got an echo yesterday. in addition to her known hocm, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm hg. they probably need to be followed up over time (particularly the pulmonary hypertension). we did evaluated the phtn with a vq scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. it would be good if we could arrange a pulmonary clinic follow up for ms. [**known lastname **] after discharge with either [**first name4 (namepattern1) **] [**last name (namepattern1) **] or [**first name4 (namepattern1) **] [**last name (namepattern1) **].**** . she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. after transfer from the micu, her steroids were dropped back to 5mg, her home dose with the approval of [**last name (un) **]. . her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. her hydralazine was discontinued. on day 2 of her micu stay, she developed a fever to 102. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. there was question of retrocardiac opacity on cxr, though not clear. rheum consult obtained given hip discomfort, who felt septic joint unlikely. neurology consult obtained who felt autonomic seizure unlikely. . pt initiated peritoneal dialysis. in this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising bps. she is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. her hip pain has resolved completely without further intervention. . fever: spike fever in micu to 102. started on levoquin, aztreonam, and vanc. source unclear at this point, but cxr with question of retrocardiac opacity. there is a possibility of aspiration pneumonitis. other etiologies include peritoneal fluid (pd cath), urine, and blood (though patient does not have any indwelling lines). hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. peritoneal dialysis cultures negative so far. continued levo/vanco/aztreonam for 2 days empirically. then d/ced the abx as no infectious etiologies were found. steroids back to home dosage. bcx, ucx (final neg), peritoneal cultures negative at discharge. . # labile blood pressure: h/o of difficult to control bp with episodes of hypertensive emergency in the past. normal sbp runs in 170s. having nausea in setting of new pd, no evidence of intracranial bleeding on clinical exam, though inr had been supratherapeutic so remains in differential, though not bradycardic. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. . # right leg/hip pain: no evidence of avascular necrosis or fracture on mri though there is a small effusion. pain resolved without intervention. continued to monitor and would avoid narcotics, restart slowly if pain resumes. physical therapy to follow as an outpatient. [**last name (un) 18183**] followed. please see consult note. . # hyperkalemia: chronic issue. patient takes kayexalate intermittently per her report (last dose [**last name (un) 766**]). monitored k but patient did not need it on floor. # ckd v: renal following. did well with pd on [**9-22**] but did report some nause and cramping. she was not tolerating all 1.5l in exchanges on discharge. # anemia: hct stable around 20. s/p 1 u prbcs in micu with hct 20.1 to 21.9. likely due to chronic hemolysis consistent with sle> #. prior svc thrombus: physical exam with l arm swelling consistent with this. no flow limitations. inr 3.5 on icu admission. held warfarin but restarted home 2mg daily the day before discharge. # systemic lupus erythematosus: home prednisone dose 5mg. currently on 15mg in setting of acute illness (day 2). # general care: fen: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, pd initiated, proph: inr therapeutic, no indication for ppi, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. code: full code, confirmed with patient communication: with the patient and her mother [**name (ni) **] [**name (ni) **], [**telephone/fax (2) 43497**]contact. access: 2 pivs ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Pneumonia, organism unspecified; Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Hyperpotassemia; Sciatica; Other iatrogenic hypotension; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Anemia of other chronic disease; Hypocalcemia]","24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. it would be good if we could arrange a pulmonary clinic follow up for ms. [** she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. source unclear at this point, but cxr with question of retrocardiac opacity. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. did well with pd on [**9-22**] but did report some nause and cramping. # systemic lupus erythematosus: home prednisone dose 5mg.","lupus nephropathy patient on peitoneal dialysis with htn and lupus nephropathy. triggered for hypotension (82/45), hypothermia (92.9), altered mental status. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis." 109,113189.0,14806,2142-02-17,14798,126055.0,2141-11-03,Discharge summary,"Admission Date: [**2141-10-13**] Discharge Date: [**2141-11-3**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 6734**] Chief Complaint: Nausea, Vomitting, Abdominal Pain, HTN Urgenc Major Surgical or Invasive Procedure: Upper GI endoscopy Exploratory laparotomy Tunneled hemodialysis catheter in R femoral vein Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 24 y/o F with h/o ESRD, HTN who started peritoneal dialysis during the week of [**2141-10-8**] and presented with a 1 day history of acute onset N/V, sharp abdominal pain on [**2141-10-13**]. (Of note, the patient had presented to the ED on [**10-11**] with hypotension, SBPs in the 80s off after approximately 1.5L was taken off during dialysis in the setting of taking her PO Anti-HTNs. On [**2141-10-11**] she received 0.5L IVF, labs WNL, and was d/c'd home). On the day of admission on [**2141-10-13**], the patient reported that the previous night, she was awoken from sleep with severe, sharp abdominal pain, 6 episodes of frothy emesis, 10+ yellowish BMs without melena or BRBRP.She was admitted for further work- up of this abdminal pain. . In the ED here vitals were as follows: T: 97.0 HR: 101 BP: 240/180 RR: 17 O2sat: 100%RA. She received Labetolol 20mg IV and was subsequently placed on a labetolol drip. She also received ceftriaxone 1gm IV, Flagyl 500mg IV, Dilaudid 0.5-1mg IV q1hr and Zofran. Her abdominal CT showed multifocal areas of small bowel wall thickening. Her peritoneal Cell count was negtaive for SBP. She had some signs of peritonitis and thus surgery was consulted. Her lactate was normal. . Upon arrival to the MICU the patient was mentating well with complaints of diffuse sharp abdominal pain that radiated to the back and diarrhea. She had no headache or visual changes. Past Medical History: - SLE DX ([**2134**] - 16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter Placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). - Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS: 98.4 HR 98 192/131 21 100%RA GEN: Mild Distress, AOx3 HEENT: PEERLA, EOMI NECK: Supple, No LAD, No bruit RESP: CTAB CARD: 2/6 systolic ejection murmur ABD: soft, moderately tender with +/- guarding, BS+ EXTR: Warm well perfused NEURO: Motor Grossly Intact RECTAL: Yellow Stool BACK: B CVAT Pertinent Results: [**2141-11-3**] 08:50AM BLOOD WBC-3.5* RBC-2.55* Hgb-7.8* Hct-23.6* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.8* Plt Ct-176 [**2141-11-3**] 03:55PM BLOOD PT-15.5* PTT-50.8* INR(PT)-1.4* [**2141-11-3**] 08:50AM BLOOD Glucose-121* UreaN-33* Creat-5.2*# Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [**2141-10-26**] 06:15AM BLOOD ALT-11 AST-49* AlkPhos-122* Amylase-186* TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2141-10-26**] 06:15AM BLOOD Lipase-30 [**2141-11-3**] 08:50AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.9 [**2141-10-30**] 06:55AM BLOOD HBsAg-NEGATIVE [**2141-10-17**] 10:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2141-10-25**] 11:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2141-10-25**] 11:56AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2141-10-25**] 11:56AM URINE RBC-0-2 WBC-[**3-15**] Bacteri-FEW Yeast-NONE Epi-21-50 Blood cultures: all negative EKG ([**2141-10-13**]): Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of [**2141-10-2**] there is no significant diagnostic change. CXR ([**2141-10-13**]): No acute cardiopulmonary abnormality. No free air under the diaphragms. CT chest/abdomen/pelvis ([**2141-10-13**]): There is a moderate-sized pericardial effusion, similar in appearance from [**2141-10-13**]. The great vessels are normal in caliber, without aneurysmal dilatation. Evaluation of the great vessels is limited without IV contrast. Interstitial thickening, particularly within the perihilar regions, is suggestive of fluid overload. There is bibasilar atelectasis with a small focus of consolidation in the right lower lobe (2:35) unchanged from [**2141-10-13**], and may reflect aspiration or pneumonia. Scattered bilateral nodules are largely stable from as far back as [**2139-10-9**]. Specifically, there is a 5 mm nodule in the right middle lobe (2:25), two adjacent nodules in the right lower lobe measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule within the left lower lobe. A nodular density seen adjacent and anterior to the right main pulmonary artery (2:23) may reflect a vessel. There is a small right pleural effusion. Axillary lymphadenopathy, with axillary nodes measuring up to approximately 10 mm in short axis, is seen. Ill- defined soft tissue thickening within the hilus bilaterally may reflect hilar lymphadenopathy, but assessment is limited without IV contrast. A catheter is visualized within the visualized right upper extremity, which may reflect a PICC line that terminates within the right subclavian vein. The esophagus is distended and filled with contrast, with marked wall thickening and edema throughout its entire length, a new finding. There is a moderate- sized hiatal hernia. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval development of a moderate amount of free intraperitoneal air, that layers anteriorly and along the anterior abdominal wall. Additional small clustered foci of extraluminal air is seen adjacent to the proximal stomach and the gastroesophageal junction, with a focus of air tracking into the fissure of ligamentum venosum. Additionally, there appears to be air tracking into the anterior subcutaneous tissues in the region of the umbilicus. These findings are all new from the prior CT on [**2141-10-13**], but free air was present on chest radiograph performed [**2141-10-25**]. There is no obvious evidence of extravasation of oral contrast into the peritoneum. Of note, a peritoneal dialysis catheter is in place that could represent a route of entry of intraperitoneal air. The stomach, small bowel, and colon are filled with contrast, without evidence of obstruction. Evaluation for wall thickening is limited without IV contrast. Limited non-contrast views of the liver demonstrates a rounded 1.6 cm x 1.2 cm hypodensity in the right lobe of the liver, previously characterized as a hemangioma. The liver is otherwise unremarkable. The gallbladder, spleen, pancreas, and adrenal glands demonstrate no gross abnormality. Both kidneys are atrophic. Evaluation of solid organs is limited by lack of IV contrast. There is a peritoneal dialysis catheter, coiled within the pelvis, unchanged. There is a large amount of free fluid throughout the abdomen, similar in appearance to the prior study. CT OF THE PELVIS WITHOUT IV CONTRAST: Uterus and rectum are grossly unremarkable. However, assessment of the rectal wall is limited without IV contrast. OSSEOUS STRUCTURES: Bones are diffusely sclerotic, which may be related to renal osteodystrophy. There is bilateral sacroiliitis. IMPRESSION: 1. Interval development of a moderate amount of free intraperitoneal air, new from [**2141-10-13**]. A peritoneal dialysis catheter is in place and could represent the route of entry of free intraperitoneal air. However, as foci of air is seen in the region of the proximal stomach and GE junction in the setting of a recent endoscopy, perforation cannot be excluded, though no frank extravasation of contrast is identified. 2. New dilation and wall thickening of the entire esophagus, a nonspecific finding that could relate to infectious or inflammatory esophagitis; clinical correlation is recommended. Esophagus is contrast-filled possibly representing reflux. Hiatal hernia. 3. Anasarca, with moderate-sized pericardial effusion, pulmonary edema, and small right pleural effusion. 4. Large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. Imaging cannot exclude SBP, which should be evaluated for clinically. 5. Focus of consolidation within the right lower lobe, could represent aspiration or pneumonia, but unchanged from the prior study. Gastric Biopsies ([**2141-10-18**]): Antrum: Corpus-type mucosa, no diagnostic abnormalities recognized. Jejunum: Small intestinal mucosa, no diagnostic abnormalities recognized. UE Venous U/S: No evidence of DVT of the left upper extremity, without thrombus identified within the left subclavian vein. Brief Hospital Course: This is a 24 year old woman with ESRD secondary to SLE (started peritoneal dialysis approximately one week prior to admission), malignant HTN, h/o SVC syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. Her hospital course was complicated by multiple transfers between the MICU and the floor secondary to hypertensive urgency. # Abdominal Pain/Diarrhea: During the patient's admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. Infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. However, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. The patient was empirically placed on IV flagyl, but this was discontinued when stool samples were negative for C.difficile. Serial abdominal exams showed no peritoneal signs. Peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. CT of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. Other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to SLE vasculitis, malignant HTN, or microthrombosis and SLE enteritis. Surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. A heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible GI bleed. With regards to SLE vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to SLE. On [**10-18**], GI performed an EGD which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. Approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. Both cardiac, GI, and pulmonary etiologies were considered for the origin of her epigastric pain. Pericarditis was considered, but her EKG was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. Her lungs were also essentially unchanged from [**2141-10-13**]. However, her abdominal CT on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. As a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. There were no major findings: no evidence of perforation, obstruction, or infection. The patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. At discharge, the patient only complained of some mild incisional pain. # Hypertensive urgency: The patient was initially admitted to the MICU with a blood pressure of 240/180. Her hospital course was complicated by extremely labile HTN and was transferred back and forth between the MICU and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of SBPs > 260. Throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. Her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. Multiple medication regimens were attempted and changed throughout her hospital course. However, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for SBPs > 180. At discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg PO. Her regimen as per Dr. [**Last Name (STitle) 4883**]: Nifedipine SR 90 mg daily Aliskiren 150 mg [**Hospital1 **] Labetalol 300 mg TID Hydralazine 75 mg TID Clonidine patch 0.3 mg/24 hr patch qWed When SBP>180, she then uses a hydralazine sliding scale. When SBP>180, give 25 mg PO hydral every 30 min until SBP<150. You can use this for up to 2-3 hours. In between PO hydral doses, can then also use 10 IV hydralazine. # ESRD: The etiology of the patient's ESRD is secondary to SLE. Her Creatinine on admission was 7.9, which was near her baseline of 8 - 9. During her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. Prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2L per PD. After her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. Initially, the patient adamantly refused hemodialysis. However, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. As a result, after a long coversation with her primary renal physician, [**Name10 (NameIs) **] agreed to restart hemodialysis. A tunneled catheter was placed in her R femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. She underwent hemodialysis two more times prior to discharge. Upon discharge, her electrolytes were back to her baseline. She is expected to undergo hemodialysis (Tues/[**Last Name (un) **]/SAT) as an outpatient. # Anemia: During her admission, the patient's HCT was monitored daily with HCT to low-mid 20's. On [**2141-10-17**], she was found to have guaiac positive stools and her HCT was found to have dropped to a low of 18.6. The patient was transfused a total of 2 units of [**Date Range **] between [**2141-10-17**] and [**2141-10-18**]. Epo Alfa SC was also given on [**2141-10-17**]. She remained hemodynamically stable. GI consulted and EGD results were as stated above. The patient's HCT remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. Between [**2141-10-23**] - [**2141-10-24**], the patient had a HCT drop from 26 to 20 in the setting of occult positive emesis. She received two units of [**Month/Day/Year **] and her HCT returned to 28. GI was aware and planned to perform a non-urgent EGD on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her HCT returned to baseline. However, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her HCt remained stable and near baseline for the remiainder of her hospital course. # H/O Thrombosis: The patient was initially placed on her home dose of warfarin 2mg qd. Her INR on admission was 1.2. She was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. However, this was stopped for her EGD and after she had evidence of a GI bleed. The heparin drip was discontinued on [**10-22**]. The patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in HCT and in preparation for a possible GI intervention. After her surgery, her coumadin was held and she was off the heparin drip, but her INR continued to drift up, getting as high as 2.6 on [**2141-10-30**]. This was mostly attributed to nutritional deficiency [**2-11**] poor PO intake, but there was concern for possible synthetic dysfunction as well. As a result, she was given a test dose of vitamin K, which she responded to well (Her INR came back down to 1.4). As a result, her home dose of coumadin at 2 mg qday was restarted. At discharge, her INR was still sub- therapeutic at 1.4. Of note, the patient has a history of SVC syndrome and had a L subclavian venous thrombosis. During the last few days of her hospital stay, the patient complained of increased tongue swelling and her L face was noted to be slightly more swollen than previously noted. As a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a DVT within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # SLE: Rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. Her outside rheumatologist was also consulted. Both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # Obstructive sleep apnea: The patient was noted to have OSA based on clinical nocturnal exam during admission. Patient attempted 1 trial of CPAP at 2L/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. The paitent stated that she would pursue further work-up and treatment for OSA as an outpatient. While the mask and CPAP machine were at her bedside throughout her hospital course, the patient rarely used it. # Metabolic Acidosis: The patient's bicarbonate on admission was 13. Her baseline is normally between 16-20. She received 150mEq NaHCO3 over 24hrs from [**Date range (1) 43500**]. During her brief returns to the MICU, her HC03 was 18-19, which was presumed to be her baseline at home secondary to her CRF. At discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. Medications on Admission: Nifedipine 60 mg PO daily Labetalol 900 mg PO TID Hydralazine 50 mg PO TID Clonidine 0.3 mg/24hr patch qWED Lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 4 mg daily Warfarin 2mg PO daily Calcitriol 1 mcg daily Calcium carbonate 500mg QID Dilaudid 2mg PO Q4-6hr prn pain Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*30 Patch Weekly(s)* Refills:*2* 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. [**Hospital1 **]:*1500 ML(s)* Refills:*0* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Twice daily (). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): In addition to 75 mg TID, if SBP>180, take 1 tab every 30 min until BP decreases to 150. If no improvement after 2 hours, call your doctor. [**Last Name (Titles) **]:*300 Tablet(s)* Refills:*6* 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). [**Last Name (Titles) **]:*1500 ML(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet Sustained Release(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 5 days. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. [**Last Name (Titles) **]:*30 Capsule(s)* Refills:*2* 13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO once a day. [**Last Name (Titles) **]:*30 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: end stage renal disease malignant hypertension abdominal free air subclavian deep vein thrombosis initiation of hemodialysis Secondary: SLE Anemia Discharge Condition: stable, pain well controlled, blood pressure at baseline Discharge Instructions: You were admitted for abdominal pain and then subsequently had a very long hospital course with high blood pressures, severe abdominal pain, some free air in your abdomen resulting in an exploratory laparotomy. You have also been initiated on hemodialysis on Tuesday/Thursday/Saturday schedule. Please take all medications as prescribed in the list that you will be given at discharge. There have been some changes to your medications. Please call your doctor if you have any worsening abdominal pain, fevers, chills, nausea, vomiting, headache, palpitations, diarrhea or any other concerning symptoms. Followup Instructions: You will see Dr. [**Last Name (STitle) 4883**] at hemodialysis on Tuesday, [**11-7**], [**2141**]. You should have your coumadin level checked at this appointment. Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] to schedule an appointment in [**1-11**] weeks to have your staples removed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**] ",106,2141-10-13 23:10:00,2141-11-03 18:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. her hospital course was complicated by multiple transfers between the micu and the floor secondary to hypertensive urgency. # abdominal pain/diarrhea: during the patients admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. the patient was empirically placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. serial abdominal exams showed no peritoneal signs. peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. ct of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to sle vasculitis, malignant htn, or microthrombosis and sle enteritis. surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible gi bleed. with regards to sle vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to sle. on [**10-18**], gi performed an egd which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. both cardiac, gi, and pulmonary etiologies were considered for the origin of her epigastric pain. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. her lungs were also essentially unchanged from [**2141-10-13**]. however, her abdominal ct on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. as a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. there were no major findings: no evidence of perforation, obstruction, or infection. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. at discharge, the patient only complained of some mild incisional pain. # hypertensive urgency: the patient was initially admitted to the micu with a blood pressure of 240/180. her hospital course was complicated by extremely labile htn and was transferred back and forth between the micu and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of sbps > 260. throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. multiple medication regimens were attempted and changed throughout her hospital course. however, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for sbps > 180. at discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg po. her regimen as per dr. [**last name (stitle) 4883**]: nifedipine sr 90 mg daily aliskiren 150 mg [**hospital1 **] labetalol 300 mg tid hydralazine 75 mg tid clonidine patch 0.3 mg/24 hr patch qwed when sbp>180, she then uses a hydralazine sliding scale. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. you can use this for up to 2-3 hours. in between po hydral doses, can then also use 10 iv hydralazine. # esrd: the etiology of the patients esrd is secondary to sle. her creatinine on admission was 7.9, which was near her baseline of 8 - 9. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2l per pd. after her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. initially, the patient adamantly refused hemodialysis. however, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. as a result, after a long coversation with her primary renal physician, [**name10 (nameis) **] agreed to restart hemodialysis. a tunneled catheter was placed in her r femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. she underwent hemodialysis two more times prior to discharge. upon discharge, her electrolytes were back to her baseline. she is expected to undergo hemodialysis (tues/[**last name (un) **]/sat) as an outpatient. # anemia: during her admission, the patients hct was monitored daily with hct to low-mid 20s. on [**2141-10-17**], she was found to have guaiac positive stools and her hct was found to have dropped to a low of 18.6. the patient was transfused a total of 2 units of [**date range **] between [**2141-10-17**] and [**2141-10-18**]. epo alfa sc was also given on [**2141-10-17**]. she remained hemodynamically stable. gi consulted and egd results were as stated above. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. she received two units of [**month/day/year **] and her hct returned to 28. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. however, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her hct remained stable and near baseline for the remiainder of her hospital course. # h/o thrombosis: the patient was initially placed on her home dose of warfarin 2mg qd. her inr on admission was 1.2. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. however, this was stopped for her egd and after she had evidence of a gi bleed. the heparin drip was discontinued on [**10-22**]. the patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in hct and in preparation for a possible gi intervention. after her surgery, her coumadin was held and she was off the heparin drip, but her inr continued to drift up, getting as high as 2.6 on [**2141-10-30**]. this was mostly attributed to nutritional deficiency [**2-11**] poor po intake, but there was concern for possible synthetic dysfunction as well. as a result, she was given a test dose of vitamin k, which she responded to well (her inr came back down to 1.4). as a result, her home dose of coumadin at 2 mg qday was restarted. at discharge, her inr was still sub- therapeutic at 1.4. of note, the patient has a history of svc syndrome and had a l subclavian venous thrombosis. during the last few days of her hospital stay, the patient complained of increased tongue swelling and her l face was noted to be slightly more swollen than previously noted. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. her outside rheumatologist was also consulted. both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission. patient attempted 1 trial of cpap at 2l/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. the paitent stated that she would pursue further work-up and treatment for osa as an outpatient. while the mask and cpap machine were at her bedside throughout her hospital course, the patient rarely used it. # metabolic acidosis: the patients bicarbonate on admission was 13. her baseline is normally between 16-20. she received 150meq nahco3 over 24hrs from [**date range (1) 43500**]. during her brief returns to the micu, her hc03 was 18-19, which was presumed to be her baseline at home secondary to her crf. at discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. ","PRIMARY: [Malignant essential hypertension] SECONDARY: [Renal dialysis status; Epilepsy, unspecified, without mention of intractable epilepsy; Constipation, unspecified; Anemia in chronic kidney disease; Abnormal coagulation profile; Obstructive sleep apnea (adult)(pediatric); Other diseases of lung, not elsewhere classified; Other chest pain; Fever, unspecified; Rash and other nonspecific skin eruption; Other chronic pulmonary heart diseases; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified disease of pericardium; Other ascites; Acidosis; Hyposmolality and/or hyponatremia; Abdominal pain, other specified site; Abdominal pain, epigastric; Nausea with vomiting; Diarrhea; Systemic lupus erythematosus; Hyperparathyroidism, unspecified; Anemia, unspecified; Thrombocytopenia, unspecified; Esophageal reflux]","this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. multiple medication regimens were attempted and changed throughout her hospital course. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. upon discharge, her electrolytes were back to her baseline. epo alfa sc was also given on [**2141-10-17**]. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission.","esrd secondary to sle, malignant htn, h/o svc syndrome, and multiple thrombotic events were considered. the patient was placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia." 109,113189.0,14806,2142-02-17,14799,125288.0,2141-11-23,Discharge summary,"Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypertensive Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: (from MICU admit note) 24yoF ESRD-HD, SLE, HTN presents with 1 month abdominal pain and hypertension. Pt has had work-up over recent months for abd pain, including exploratory laparotomy, all of which essentially (-). Was admitted [**Date range (1) 34629**], for abdominal pain, then returned [**11-16**] for sob with (-)CTA, dc'ed [**11-17**]. In [**Hospital1 18**] ED, T98.5 hr95 BP 220/110 then 183/133 RR13 O2 100% on RA, rectal exam negative, guaiac(-), pelvic exam unremarkable with no cervical motion tenderness. Renal was consulted, taken for hemodialysis. CT abd showed large ascites, no other pathology; CT head improved from prior with no acute ICH; cxr(-). Given iv dilaudid for abdominal pain. BP treated with 10mg iv labetalol. Blood and urine cultures drawn, peritoneal fluid cx sent from catheter. Admitted to MICU for hypertension management. Access: R-HD catheter, 1 pIV in hand, 1 non-functioning peritoneal dialysis catheter. Past Medical History: PMH: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSH: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: PE: T:99.4 BP:158/108 HR:95 RR:12 O2 100% RA GEN: NAD/ pt eyes closed due to pain/ pleasant despite pain HEENT: AT, NC, PERRLA, EOMI on R eye, L eye prosthesis, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD CV: S1 & S2, RRR II/VI HSM at R/L USB, no rubs/gallops PULM: CTAB, no w/r/r ABD: soft, mildly tender at PD catheter, ND, + BS, midline incision with steri-stripes, PD catheter dressing C/I/D EXT: warm, dry, +2 distal pulses BL, no edema NEURO: alert & oriented, CN II-XII grossly intact (except L eye), 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: Admission Labs: [**2141-11-18**] 07:00AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.7* Hct-30.7* MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* Plt Ct-142* [**2141-11-18**] 07:00AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.3* [**2141-11-18**] 07:00AM BLOOD Glucose-86 UreaN-22* Creat-5.0* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2141-11-18**] 07:00AM BLOOD ALT-8 AST-39 AlkPhos-92 TotBili-0.3 [**2141-11-18**] 07:00AM BLOOD Lipase-76* [**2141-11-18**] 07:00AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.9 [**2141-11-18**] 11:00PM ASCITES WBC-1265* RBC-1680* Polys-43* Lymphs-1* Monos-2* Mesothe-11* Macroph-43* [**2141-11-18**] 10:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2141-11-18**] 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2141-11-18**] 10:05AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-[**3-15**] Discharge Labs: [**2141-11-23**] 04:40AM BLOOD WBC-2.9* RBC-3.08* Hgb-9.0* Hct-28.3* MCV-92 MCH-29.2 MCHC-31.8 RDW-17.5* Plt Ct-182 [**2141-11-23**] 04:40AM BLOOD PT-20.8* PTT-76.1* INR(PT)-2.0* [**2141-11-23**] 04:40AM BLOOD Glucose-80 UreaN-21* Creat-4.7* Na-139 K-4.8 Cl-106 HCO3-24 AnGap-14 [**2141-11-23**] 04:40AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8 [**2141-11-22**] 04:55AM BLOOD TSH-6.1* [**2141-11-23**] 04:40AM BLOOD Free T4-1.2 Blood cx ([**11-18**], [**11-19**]): 1/4 bottles with coag neg Staph, [**3-14**] NGTD Urine cx ([**11-18**]): mixed flora c/w contamination Peritoneal fluid ([**11-18**]): Gram stain 2+ polys. Culture no growth. Imaging: CXR Portable ([**11-18**]): Since [**2141-11-16**], heart size enlargement is unchanged due to known pericardial effusion. Lungs are otherwise clear. Hilar contours are normal. Incidentally, widening of both acromioclavicular joints is unchanged. CT A/P ([**11-18**]): 1. No evidence of bowel obstruction or rim-enhancing fluid collection. 2. Large ascites, slightly increased from [**2141-11-13**], with peritoneal dialysis catheter in place. Interval removal of surgical skin staples along the abdomen. 3. Moderate pericardial effusion as before. 4. Symmetric heterogeneous attenuation of the kidneys could be related to renal failure; however, pyelonephritis could also give this appearance. Appearance of the kidneys is unchanged from [**2141-11-13**]. CT Head w/o contrast ([**11-18**]): 1. No evidence of acute intracranial hemorrhage. 2. Regions of hypoattenuation in the bifrontal white matter and left posterior temporal lobe have resolved since [**2141-6-11**]. No new regions of hypoattenuation seen. Brief Hospital Course: 1) Hypertension: Patient has history of extremely labile hypertension on an aggressive outpatient regimen. Overnight in the MICU, patient required IV and PO labetalol for SBP > 200. Her hydralazine was increased from 75mg to 100mg TID with mild improvement. Her labetalol was also increased from 300mg to 400mg TID. Her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. TSH was sent and elevated, although free T4 was normal. Plasma metanephrines were sent and pending at discharge. 2) Abdominal pain: CT scan showed increasing ascites, but no acute pathology. Peritoneal fluid was obtained and contained 544 polys. Treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing GPC pairs/clusters. Blood cultures ended up growing 1 out of 4 bottles coag-neg Staph, likely contaminant, so vancomycin was stopped. Since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. The peritoneal cultures remained negative. Her PD catheter was left in place as the patient refuses HD any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) SVC/brachiocephalic thrombosis: Patient's INR was subtherapeutic on admission at 1.3. Due to the proximal location of her old venous thrombi, she was started on a heparin gtt. This was continued during her admission and her warfarin was increased to 5mg daily. Her INR reached 2.0 at discharge (therapeutic range 2-3). The dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) Anxiety: Patient noted feeling short of breath and anxious around the time of her recent admissions. Her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. They felt her symptoms were suggestive of anxiety and panic attacks, recommended checking TSH and metanephrines as above, and starting citalopram 20mg, which was done. She was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h PRN. Patient is agreeable to outpatient follow up with [**Company 191**] social work, and potential CBT. These can be arranged by her PCP. Medications on Admission: 1. Aliskiren 150 mg [**Hospital1 **] 2. Clonidine 0.3 mg/24 qwk 3. Prochlorperazine Maleate 10 mg prn 4. Hydromorphone 2 mg Tablet Sig: [**1-11**] q6 prn 5. Bisacodyl 10mg [**Hospital1 **] 6. Ergocalciferol (Vitamin D2) 50,000 qmonth 7. Hydralazine 75mg tid 8. Hydralazine scale prn 9. Labetalol 300 mg tid 10. Nifedipine 90 mg qd 11. Prednisone 4mg qd 12. Warfarin 2 mg qd at 4pm Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Hospital1 766**]). 5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day. [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 7 days. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO q30 min prn as needed for hypertension: for SBP > 180. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive urgency Headache Abdominal pain Anxiety Secondary Diagnosis: HTN SLE ESRD on HD SVC and IJ thrombosis, chronic Anemia Discharge Condition: Stable, BPs improved. Discharge Instructions: You were admitted with elevated blood pressures, headache, and abdominal pain. You were found to have increased amounts of white blood cells in your abdominal cavity, but this was not infected. Your abdominal pain resolved and you continued to have intermittent headaches. Your blood pressure medications were adjusted as below. You were also seen by psychiatry who recommended starting new medications for your anxiety. The following changes were made to your medication regimen: - We increased your hydralazine to 100 mg three times a day. - We also increased your labetalol to 400 mg three times a day. - We have started a medication called celexa 20 mg daily as well as ativan 1 mg three times a day as needed for anxiety. - We have increased your coumadin to 4 mg daily. - Please continue taking all other medications as previously prescribed. Call your doctor or return to the emergency room if you experience any of the following: worsening abdominal pain, nausea, vomiting, blurry vision, worsening headache, fever > 101. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. Please continue to follow with your nephrologist and go to outpatient dialysis as previously arranged. Please discuss with your PCP the possibility of talking to a social worker at [**Name (NI) 191**]. You will need to continue to have your INR monitored at [**Hospital 191**] [**Hospital 2786**] clinic. Please have this level checked on [**Hospital 766**], [**11-27**]. Completed by:[**2141-11-23**]",86,2141-11-18 14:00:00,2141-11-23 16:42:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. her hydralazine was increased from 75mg to 100mg tid with mild improvement. her labetalol was also increased from 300mg to 400mg tid. her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. tsh was sent and elevated, although free t4 was normal. plasma metanephrines were sent and pending at discharge. 2) abdominal pain: ct scan showed increasing ascites, but no acute pathology. peritoneal fluid was obtained and contained 544 polys. treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing gpc pairs/clusters. blood cultures ended up growing 1 out of 4 bottles coag-neg staph, likely contaminant, so vancomycin was stopped. since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. the peritoneal cultures remained negative. her pd catheter was left in place as the patient refuses hd any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) svc/brachiocephalic thrombosis: patients inr was subtherapeutic on admission at 1.3. due to the proximal location of her old venous thrombi, she was started on a heparin gtt. this was continued during her admission and her warfarin was increased to 5mg daily. her inr reached 2.0 at discharge (therapeutic range 2-3). the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) anxiety: patient noted feeling short of breath and anxious around the time of her recent admissions. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. they felt her symptoms were suggestive of anxiety and panic attacks, recommended checking tsh and metanephrines as above, and starting citalopram 20mg, which was done. she was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h prn. patient is agreeable to outpatient follow up with [**company 191**] social work, and potential cbt. these can be arranged by her pcp. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Abdominal pain, unspecified site; Anemia, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. her hydralazine was increased from 75mg to 100mg tid with mild improvement. peritoneal fluid was obtained and contained 544 polys. the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted.","patient has history of extremely labile hypertension on aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. ct scan showed increasing ascites, but no acute pathology." 109,113189.0,14806,2142-02-17,14800,161950.0,2141-12-01,Discharge summary,"Admission Date: [**2141-11-24**] Discharge Date: [**2141-12-1**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Headache, abdominal pain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24yo F w/PMHx of ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning, awakening her from sleep. Had been previously discharged from [**Hospital1 **] yesterday after being admitted for hypertension and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Upon discharge yesterday she states her abdominal pain had subsided. She had HD yesterday without complications. She awoke at 6am with a headache and crampy, stabbing abdominal pain. Took 2mg PO Dilaudid without relief and came to ED. No nausea/vomiting, no changes in vision, no fevers, chills, night sweats. No chest pain, SOB, diarrhea. In the ED, initial vitals were T98.7, BP260/130, HR70, RR16. Was initially given 10mg IV Labetalol X 2, 4mg Zofran for nausea. No improvement in BP and started on Labetolol gtt. Got 1mg IV Dilaudid for pain. Currently, patient continues to complain of headache and abdominal pain, both [**7-17**]. No vision changes, chest pain or shortness of breath. Has been feeling increased anxiety recently and saw psychiatrist, was put on Celexa. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T98.2, BP176/135, HR94, RR 22, 100% RA Gen: well-appearing african-american woman, lying comfortably HEENT: anicteric, L eye prosthetic non-reactive, R pupil reactive, MMM, neck supple with submanibular LAD CV: RRR, II/VI SEM best heard at apex Pulm: CTA b/l Abd: hyperactive bowel sounds, midline scar well-healed, soft, diffusely tender to palpation, +rebound, no guarding. PD catheter in LLQ without erythema or purulent material draining. +dullness on percusion with evidence of clinical ascites. Ext: no edema, no clubbing, 2+ peripheral pulses DP and radial. R femoral HD [**Last Name (un) **] in place without erythema, purulance Neuro: A&O X 3, CN intact II-XII, [**5-15**] motor strength in upper and lower extremities Pertinent Results: Admission labs: CBC: [**2141-11-26**] 05:21AM BLOOD WBC-3.5* RBC-3.07* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-17.6* Plt Ct-180 CHEM 10: [**2141-11-26**] 01:16PM BLOOD Glucose-87 UreaN-17 Creat-4.0* Na-136 K-5.2* Cl-106 HCO3-23 AnGap-12 [**2141-11-26**] 09:20PM BLOOD Calcium-7.6* Phos-3.8 Mg-1.8 COAGS: [**2141-11-26**] 01:16PM BLOOD PT-23.9* PTT-40.2* INR(PT)-2.3* STUDIES: 1)Peritoneal fluid ([**11-26**]): negative for malignant cells. Reactive mesothelial cells, macrophages, eosinophils and lymphocytes. 2)BILAT UP EXT VEINS US ([**11-26**]): No evidence of deep vein thrombosis of the right or left upper extremity. 3) MRI/MRA ([**11-30**]): FINDINGS: Examination is somewhat limited by patient motion. T2/FLAIR sequences are unremarkable with interval resolve of previously noted posterior abnormalities. The major vessels appear patent proximally. There are stable areas of low signal in the left frontal and right occipetal/temporal lobes. IMPRESSION: 1. Interval resolution of previously noted posterior white matter abnormalities. 2. Stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions. 3. Very limited MRA as above. Brief Hospital Course: 24yo F with SLE, ESRD on HD and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**Hospital Unit Name 153**] course: The patient was admitted for blood pressure management and evaluation of abd pain. An A-line was placed. EKG showed no change from prior, and Abd x-ray showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home med regimen. The patient was found to be hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. Upon transfer to the floor, the following was her course: 1. Hypertensive Urgency: Pt had had hemodialysis one day prior to admission, so unlikely that she was volume overloaded. Unclear what precipitated this episode of hypertensive urgency, although suspect secondary to abdominal pain leading to an anxiety which then precipitates hypertension. She may not have been taking her medications secondary to pain. Negative serum tox. On the floor, we continued hemodialysis Tu, Th, Sat. She was initially continued on PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine 90mg PO qday and clonidine; she received hydralazine 10mg IV for goal BP < 180/100. Renal team followed patient during this hospitalization. Per renal team recs, labetalol was increased to 800mg TID due to poor blood pressure control. Pt discharged on clonidine 0.3mg patch, Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, Nifedipine 90mg daily and lobatalol 800mg TID. This regimen worked well. 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT scan during prior admission which did not show source of abdominal pain. On admission, LFTs were normal except for slightly low albumin, lipase was slightly elevated and KUB was negative for free air or evidence of SBO. Peritoneal fluid was negative for malignant cells but showed reactive mesothelial cells, macrophages, eosinophils and lymphocytes. Negative gram stain or peritoneal fluid cultures, excluding SBP as a cause of the abdominal pain. PD catheter was not removed. Pt was continued on PO dilaudid 1-2mg Q6h and pain resolved. She denied N/V/diarrhea or constipation. 3. ESRD: Pt on hemodialysis, on T/Th/Sat schedule. Renal following patient closely throughout this hospitalization. Lytes were checked frequently and kayexalate given prn. 4. Hx of SVC/brachiocephalic DVT: Pt was initially subtherapeutic on coumadin. Unclear if she had not been taking Coumadin although patient reported that she has been taking all home meds. We started heparin gtt to bridge to Coumadin. Once therapeutic, continued Coumadin 5mg PO qday. 5. Anxiety: Likely contributing to medical problems and could have very well been the etiology of this admission. Although pt stated she was taking her current medications, she did report increased anxiety which can lead to medication non-compliance and hypertension. Pt recently saw psychiatrist who started her on Celexa. She was continued on celexa 20mg PO qday, ativan 1mg PO q8hours PRN and psychiatry was re-consulted. Per psych recs, started standing clonazepam. Pt refused psych VNA. Outpatient PCP followup recommended. 6. Headache NOS: Pt complained of R-sided HA for several weeks, radiating to R jaw where patient had previous tooth extraction. Right upper extremity ultrasound was negative for DVT. She did not have any focal neuro findings, no visual deficits. She was initially treated with tylenol PRN Q6h; pt requested IV dilaudid for HA, but use of this medication by IV route was limited by team. It was felt by the pain service that her HA did not fit migraine, tension type HA or rebound HA. They recommended increasing dilaudid to 4-6mg Q6h PRN, continuing tylenol and starting neurontin 300mg Qhs which was slowly titrated to 300mg [**Hospital1 **] for better control. Per pain recs, a neurology consult was also obtained during this admission. MRI/MRA showed interval resolution of previously noted posterior white matter abnormalities and stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions, but very limited MRA as above. Per pain recs, dilaudid was further increased to 4mg q4h for better control of her HA. Neurology recommended outpt f/u and Pt scheduled with [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**]. 7. Anemia: Likely related to ESRD. No evidence of acute bleeding. Hct remained stable during this hospitalization. 8. SLE: no acute issues. continued Prednisone 4mg PO qday 9. FEN: tolerated regular diet, repleted lytes PRN 9. Prophylaxis: Heparin gtt, then coumadin, bowel regigmen Medications on Admission: (from prior discharge summary) Bisacodyl 10mg PO qday PRN Prednisone 4mg PO qday Aliskiren 150mg PO BID Clonidine 0.3mg / 24 hr patch weekly qmonday Labetalol 400mg PO TID Warfarin 4mg PO qday Nifedipine 90mg PO qday Hydralazine 100mg PO q8H Hydromorphone 2-4mg PO q4H PRN Lorazepam 1mg PO q8H Celexa 20mg PO qday Prochlorperazine 10mg PO q6H Colace 100mg PO BID Hydralazine 25mg PO q30min PRN for HTN Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Year (4 digits) 766**]). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). [**Year (4 digits) **]:*100 Tablet(s)* Refills:*2* 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*90 Capsule(s)* Refills:*2* 9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for headache. [**Year (4 digits) **]:*84 Tablet(s)* Refills:*0* 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*60 Capsule(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours. [**Year (4 digits) **]:*360 Tablet(s)* Refills:*2* 16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. [**Year (4 digits) **]:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive Emergency 2. SLE 3. Headache, NOS 4. Abdominal pain Discharge Condition: BP better controlled. Headache managed on oral meds Discharge Instructions: You were admitted with abdominal pain, high blood pressure, and headache. Your abdominal pain resolved - no serious cause of this pain was found. Your blood pressure medications were continued, and with an increased in one medication, the labetalol. Your blood pressure improved. You should continue the clonidine 0.3mg patch changed on [**Year (4 digits) 766**], Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, and Nifedipine 90mg daily. The dose of Labetalol was increased to 800 mg three times daily by you kidney doctor and you are given a new prescription. Please take all medications as listed below. For your headache, you had an MRI and MRA of the head, which did not show a new or serious abnormality. You were seen by the neurology and pain services. You should follow up at [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**] at 6:30 PM (in the evening). Your pain was managed by oral dilaudid, 4mg. You should take this medication every 4 hours as needed. You were also started on Gabapentin (also called Neurontin) for the headache. The dose was slowly increased to twice a day. You may not need as much dilaudid for your headache and should wean this medication as tolerated, given it's potential for side effects (constipation, lethargy, dependence). Finally, you will likely need medications for constipation while you take dilaudid. Take colace (a stool softener), senna (a laxative), and bisacodyl (another laxative), as needed. It is really important that you have a primary care doctor. You are scheduled with Dr. [**Last Name (STitle) **] (see below) next Tuesday. You will need your INR checked since you are on coumadin. Call your doctor if you have worsened headache, chest pain, confusion, or any other concerning symptom. Followup Instructions: Please make sure you attend the following doctor appointments: 1) Dr. [**Last Name (STitle) 4883**] (nephrologist) on Tuesday, [**2141-12-5**] at 10AM. Phone number [**Telephone/Fax (1) 60**]. 2) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Location (un) **], [**Hospital Ward Name 23**] center, [**Location (un) **]. Phone:[**Telephone/Fax (1) 250**]. Date/Time:[**2141-12-5**] 3:20 3) Neurology: Dr. [**Last Name (STitle) 43502**] [**Name (STitle) **]. He is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-12-12**] 6:30 PM [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2141-12-2**]",78,2141-11-24 16:11:00,2141-12-01 19:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**hospital unit name 153**] the patient was admitted for blood pressure management and evaluation of abd pain. an a-line was placed. ekg showed no change from prior, and abd x-ray showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home med regimen. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. upon transfer to the floor, the following was her ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other ascites; ; Systemic lupus erythematosus; Headache; Anemia in chronic kidney disease; Anxiety state, unspecified; Other chest pain; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Renal dialysis status; Acquired absence of organ, eye]","24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. the renal team was consulted, and recommended no change to home med regimen.","a 24yo f with sle, esrd on hd and malignant hypertension presented with abdominal pain and headache. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. she successfully switched to po meds and was transferred to the floor." 109,113189.0,14806,2142-02-17,14801,173633.0,2141-12-14,Discharge summary,"Admission Date: [**2141-12-8**] Discharge Date: [**2141-12-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 8104**] Chief Complaint: abdominal pain & hypertension Major Surgical or Invasive Procedure: Hemodialysis PICC Line [**12-11**] History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with a history of CKD V (on HD) from lupus nephritis, chronic intermittent abdominal pain, and multiple prior ICU admissions for hypertensive urgency who presented to the ED complaining of two days' of abdominal pain, nausea, and loose stools. She was feeling well until after her hemodialysis session on Wednesday. Thereafter, she complained of nausea with occasional vomitting and has been unable to keep down any of her oral medications. She also has had diffuse abdominal pain consistent with her prior flares of pain as well as her typical diffuse headache. The headache in particular was worsening and, for her, this is a sign of poorly-controlled hypertension so she came to the [**Hospital1 18**] ED. Upon arrival to the ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room air. She was given 4 mg of IV ondansetron, [**1-11**] inch intropaste, 1 mg of IV hydromorphone x3, 1000cc of NS, and was put on a labetalol drip which had to be increased up to 2 mg/min. A head CT showed no acute abnormality (including hemorrhage) and an abdominal CT showed some possible mild colitis, though it is unclear if this is due to her recent peritoneal dialysis. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 97.9 BP 165/120 HR 93 RR 12 Sat 100% ra Gen: mildly fatigued, but no distress HEENT: oropharynx clear Neck: no JVP, no LAD Chest: clear to auscultation throughout, no w/r/r CV: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard Abdomen: soft, tender diffusely to moderate palpation without rebound or guarding; hyperactive bowel sounds; no masses or HSM, PD catheter in palce Extr: no edema, 2+ PT pulses Neuro: alert, appropriate, strength grossly intact in all four limbs Skin: no rashes Pertinent Results: [**2141-12-14**] 05:53AM BLOOD WBC-4.3 RBC-2.81* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.7 MCHC-33.8 RDW-19.3* Plt Ct-148* [**2141-12-14**] 05:53AM BLOOD PT-42.6* PTT-51.0* INR(PT)-4.7* [**2141-12-10**] 05:10AM BLOOD Ret Aut-2.5 [**2141-12-14**] 05:53AM BLOOD Glucose-83 UreaN-21* Creat-5.1*# Na-138 K-5.3* Cl-105 HCO3-24 AnGap-14 [**2141-12-10**] 05:10AM BLOOD LD(LDH)-234 Amylase-347* TotBili-0.1 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-10**] 05:10AM BLOOD Lipase-72* [**2141-12-14**] 05:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 [**2141-12-10**] 05:10AM BLOOD Hapto-142 [**2141-12-8**] 04:02AM BLOOD calTIBC-138* VitB12-445 Folate-18.5 Ferritn-220* TRF-106* ON ADMISSION: [**2141-12-7**] 09:50PM BLOOD WBC-4.5 RBC-2.78* Hgb-8.4* Hct-25.2* MCV-91 MCH-30.2 MCHC-33.3 RDW-19.2* Plt Ct-158 [**2141-12-7**] 09:50PM BLOOD Neuts-65.2 Lymphs-23.4 Monos-8.0 Eos-2.9 Baso-0.4 [**2141-12-7**] 09:50PM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3* [**2141-12-8**] 04:02AM BLOOD Ret Aut-2.5 [**2141-12-7**] 09:50PM BLOOD Glucose-89 UreaN-25* Creat-5.1*# Na-139 K-4.8 Cl-104 HCO3-26 AnGap-14 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-7**] 09:50PM BLOOD Lipase-89* [**2141-12-7**] 09:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9* Mg-1.9 [**2141-12-7**] 09:54PM BLOOD Glucose-75 Lactate-1.3 Na-139 K-4.8 Cl-101 calHCO3-23 Micro: Blood Cx: [**12-7**], [**12-7**], [**12-11**], [**12-11**] No growth FECAL CULTURE (Final [**2141-12-10**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2141-12-10**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2141-12-8**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-12-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CT HEAD [**2141-12-8**]: IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. The hypodensities noted in the parietal white matter are stable. However in the setting of the hypertension, PRES cannot be excluded. If further evaluation is required MR can be obtained. CT Abdomin/Pelvis [**2141-12-8**] IMPRESSION: 1. Moderate amount of free fluid in the pelvis is compatible with the patient's known peritoneal dialysis. Unchanged peritoneal enhancement. 2. Stable liver hemangioma. CXR [**12-11**] IMPRESSION: Small left pleural effusion. Left lower lobe opacity which is either atelectasis versus pneumonia. Brief Hospital Course: 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. MICU course: Current plan on transfer 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. 1. Hypertensive urgency: The patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. Initially her blood pressure over-corrected to SBPs in the 80s (patient was asymptomatic). Her clonidine patch and hydralazine was held and she again became hypertensive with SBPs 190s. The patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. The following dialysis the patient asymptomatic with SBPs in 80s, MAPs 60s asymptomatic again. Her hydralazine was stopped and continued on all her other home medications at the advice of renal. The patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. On [**12-11**] the patient's SBP dropped to the 80's and due to her pain medications she was extremely lethargic, but arousable. A PICC line was placed because lack of access and she was bolused 250cc NS. The patient's pressures responded and additional narcotics were held due to her mental status. The patient's blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. The patient did require IV hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. A possible component to the patient's malignant hypertension is likely due to OSA. An inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on BiPAP for OSA. The patient was continuned on her admission hypertensive regimen. . 2. Abdominal pain: The etiology of her abdominal pain is unclear, but has been a chronic issue for her. A CT scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. The patient also had diarrhea, but stool studies were negative. The patient's pain was initially treated with hydromorphone, but because of the patient's lethargy on [**12-11**] they were initially held. She continued to complain of severe abdominal pain. She was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. Surgery was consulted in regards to removal of her PD catheter, but given that she may return to PD it was deferred to the outpatient setting. 3. CKD V from lupus nephritis: The patient was continued on HD during her admission. She was also continued on her home prednisone dose. She was closely followed by the renal team. . 4. History of SVC/subclavian vein thrombus: The patient was found to have a subtherapeutic INR on admission 1.3. She was started on a heparin gtt and continued on coumadin. The patient's heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her PICC line was placed. She was therapetuic the same day and her heparin gtt was stopped. On discharge her coumadin was supratherapeutic (4.7) and was held. She will have her INR checked at HD. . 5. Anemia: The patient's Hct slowly trended down. She was guaiac negative and hemolysis labs were negative. She was transfused 1U pRBC at HD on [**12-12**]. She was also given epo at HD. Medications on Admission: prednisone 4 mg daily clonidine 0.3 mg/day patch qWeek ergocalciferol 50,000 units qMonth nifedipine SR 90 mg daily hydralazine 100 mg q8h citalopram 20 mg daily warfarin 2 mg qhs gabapentin 300 mg [**Hospital1 **] hydromorphone 4 mg q4h prn clonazepam 0.5 mg [**Hospital1 **] alikiren 150 mg [**Hospital1 **] docusate 100 mg [**Hospital1 **] senna 8.6 mg [**Hospital1 **] prn acetaminophen prn labetalol 800 mg q8h bisacodyl 5 mg daily prn Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. [**Hospital1 **]:*84 Tablet(s)* Refills:*0* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed: please take as needed for anxiety prior to CPAP at bedtime. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 14. CPAP Home CPAP Dx: OSA Prefer: AutoCPAP/ Pressure setting [**5-20**] Alt: Straight CPAP/ Pressure setting 7 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency Abdominal Pain ESRD on HD SVC Thrombus Secondary: Systemic lupus erythematosus Malignant hypertension Thrombocytopenia HOCM Anemia History of left eye enucleation History of vaginal bleeding Thrombotic microangiopathy Discharge Condition: Stable Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because of elevated blood pressure and abdominal pain. You were initially admitted to the ICU and your blood pressure was controlled. You were stabilized and transferred back to th floor. Your pressures remained stable throughout the rest of your stay. Additionally, you had abdominal pain and diarrhea. Your stool was tested for infections and was negative. Your diarrhea resolved without intervention. Your abdominal pain was controlled with pain medications. You had a sleep study in the hospital which showed that you had sleep apnea. Please continue to take your medications as prescribed. 1. Please do not take your coumadin until your doctor tells you to. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: You will have dialysis at [**Location (un) **] Dialysis on your normal schedule. You need to go to dialysis on Saturday. Please follow-up with the Sleep Clinic in [**12-19**] @ 11:45 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Completed by:[**2141-12-16**]",65,2141-12-08 01:40:00,2141-12-14 17:16:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. micu course: current plan on transfer 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. 1. hypertensive urgency: the patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). her clonidine patch and hydralazine was held and she again became hypertensive with sbps 190s. the patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. the following dialysis the patient asymptomatic with sbps in 80s, maps 60s asymptomatic again. her hydralazine was stopped and continued on all her other home medications at the advice of renal. the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. on [**12-11**] the patients sbp dropped to the 80s and due to her pain medications she was extremely lethargic, but arousable. a picc line was placed because lack of access and she was bolused 250cc ns. the patients pressures responded and additional narcotics were held due to her mental status. the patients blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. the patient did require iv hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. a possible component to the patients malignant hypertension is likely due to osa. an inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on bipap for osa. the patient was continuned on her admission hypertensive regimen. . 2. abdominal pain: the etiology of her abdominal pain is unclear, but has been a chronic issue for her. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. the patient also had diarrhea, but stool studies were negative. the patients pain was initially treated with hydromorphone, but because of the patients lethargy on [**12-11**] they were initially held. she continued to complain of severe abdominal pain. she was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. surgery was consulted in regards to removal of her pd catheter, but given that she may return to pd it was deferred to the outpatient setting. 3. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was also continued on her home prednisone dose. she was closely followed by the renal team. . 4. history of svc/subclavian vein thrombus: the patient was found to have a subtherapeutic inr on admission 1.3. she was started on a heparin gtt and continued on coumadin. the patients heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her picc line was placed. she was therapetuic the same day and her heparin gtt was stopped. on discharge her coumadin was supratherapeutic (4.7) and was held. she will have her inr checked at hd. . 5. anemia: the patients hct slowly trended down. she was guaiac negative and hemolysis labs were negative. she was transfused 1u prbc at hd on [**12-12**]. she was also given epo at hd. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Systemic lupus erythematosus; Other and unspecified noninfectious gastroenteritis and colitis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other iatrogenic hypotension; Obstructive sleep apnea (adult)(pediatric); Hemangioma of intra-abdominal structures; Other chronic pain; Abdominal pain, unspecified site; Abnormal coagulation profile; Renal dialysis status; Personal history of venous thrombosis and embolism]","24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. the patient was continuned on her admission hypertensive regimen. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was therapetuic the same day and her heparin gtt was stopped.",24 year old woman with ckd v and severe hypertension due to sle admitted. patient was initially maintained on a labetalol drip and hydralazine iv prn. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic) 109,113189.0,14806,2142-02-17,14802,140167.0,2141-12-23,Discharge summary,"Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1973**] Chief Complaint: Malignant hypertension Major Surgical or Invasive Procedure: None History of Present Illness: 24 year old female with ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning. Patient had her hemodialysis day before yesterday. She has had multiple admissions to [**Hospital1 18**] with hypertensive urgency with symptoms of headache and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Patient states that her headache and abdominal pain are similar in characteristics to her previous admission. Patient denies any fever, chills, nightsweats, chest pain, shortness of breath, abdominal pain, nausea, vomitting, diarrhea, constipation, blood in stool, dysuria, hematuria, change in vision, hearing, weakness or numbness. In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was initially given 10mg IV Labetalol once and then started on drip at 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea. Her BP elevated as high as 270/174 and his labetolol was switched to nicardipine 1mg/kg/min. On arrival to the MICU her vitals were T 96.4 HR 99 BP 175/120 RR 15 100%RA. Patient was comfortable. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Vitals: 97.5 122/80 88 18 100%RA. Gen: sleeping, easily arousable, appears comfortable. HEENT: AT/NC, L eye prosthetic non-reactive, R pupil reactive, MMM. Heart: S1S2 RRR, III/VI SEM heard best at apex, + S3 Pulm: CTA b/l, no w/r/r. Abd: normal bowel sounds, midline scar well-healed, soft, nontender, prior PD site with dry dressing, patient with tenderness to palpation over prior PD cath site, no guarding/rebound Ext: no edema, no clubbing, WWP. R femoral HD catheter in place. Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: Admission: [**2141-12-18**] 02:00AM BLOOD WBC-5.8 RBC-3.30* Hgb-10.1* Hct-30.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-20.7* Plt Ct-199 [**2141-12-18**] 02:00AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.2* [**2141-12-18**] 02:00AM BLOOD UreaN-35* Creat-5.0* Na-138 K-5.5* Cl-103 HCO3-21* AnGap-20 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-18**] 02:00AM BLOOD Lipase-73* [**2141-12-18**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2141-12-19**] 06:45AM BLOOD Calcium-8.1* Phos-5.1* Mg-1.8 [**2141-12-18**] 03:52PM BLOOD dsDNA-NEGATIVE [**2141-12-18**] 03:52PM BLOOD CRP-11.5* [**2141-12-18**] 03:52PM BLOOD C3-68* C4-19 [**2141-12-20**] 12:09PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 [**2141-12-18**] 02:08AM BLOOD pO2-52* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 Comment-GREEN TOP [**2141-12-20**] 12:09PM BLOOD Lactate-0.9 [**2141-12-18**] 02:08AM BLOOD Glucose-68* Lactate-1.3 Na-140 K-4.8 Cl-103 [**2141-12-23**] 03:00PM BLOOD WBC-4.7 RBC-2.35* Hgb-7.1* Hct-22.3* MCV-95 MCH-30.3 MCHC-31.9 RDW-20.6* Plt Ct-131* [**2141-12-23**] 12:55AM BLOOD PT-14.7* PTT-66.2* INR(PT)-1.3* [**2141-12-18**] 03:52PM BLOOD ESR-21* [**2141-12-23**] 03:00PM BLOOD Glucose-97 UreaN-42* Creat-6.6* Na-138 K-4.3 Cl-106 HCO3-23 AnGap-13 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-23**] 03:00PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8 [**2141-12-18**] 04:23PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2141-12-18**] 04:23PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2141-12-18**] 04:23PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-12 TransE-<1 Micro: Blood Cx- [**12-18**]: No growth Urine Cx- [**12-18**]: No growth [**12-18**] TTE The left atrium and right atrium are normal in cavity size. A possible secundum type atrial septal defect is seen by color Doppler (clip [**Clip Number (Radiology) **]) There is severe symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. There is no significant resting LVOT gradient, but a mild gradient (30mmHg peak) is seen with Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Marked symmetric left ventricular hypertrophy with normal regional/global systolic function and mild inducible LVOT gradient. Mild aortic regurgitation. Mild pulmonary artery systolic hypertension. Possible secundum type atrial septal defect. Compared with the prior study (images reviewed) of [**2141-10-19**], a possible secundum type atrial septal defect is now suggested. If clinically indicated, a follow-up study with saline contrast and/or a TEE would be better able to characterize the possible atrial septal defect. CLINICAL IMPLICATIONS: Based on [**2140**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**12-18**] CXR IMPRESSION: 1. Cardiomegaly with findings suggestive of mild pulmonary edema. 2. Bibasilar linear opacities suggesting atelectasis, although developing pneumonia cannot be excluded. 3. No evidence of free intraperitoneal air. [**12-20**] MRV IMPRESSION: No appreciable change since the MRV chest exam dated [**2141-5-30**]. SVC is patent. Again seen is occlusion of the right internal jugular and left brachiocephalic veins. Right external jugular vein is provides the major venous drainage from the neck. Brief Hospital Course: 24 year old Female with SLE, ESRD on HD and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ED. 1. Malignant Hypertension: The patient had her hemodialysis two days prior to admission. Initially in the ED her BP was 253/170. She was given 10mg IV Labetalol and started on a labatelol drip. She also received hydralazine IV 10 mg once and 2 inches of nitropaste. She had morphine 4mg and 4mg Zofran for nausea. Her BP remained elevated so she was switched to nicardipine 1mg/kg/min. The patient was transferred to the MICU. In the ICU she was continued on the Nicardapine drip and her pressures decreased to 175/120. Nephrology was consulted and dialysis initiated in the AM. The Nicardapine drip dc'd on [**12-19**] and pt transferred to floor. While on the floor the patient had question of angioedema and markedly elevated BP. She was readmitted to the MICU on [**2141-12-20**]. Patient's Aliskerin was also held for conern for angioedema. The renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. The patient's PD catheter was removed. The patient was briefly on a nitro drip for hypertension. The patient's nifedepine was increased to 120mg. The patient was transferred to the floor with stable blood pressures, BP 124/72 on [**12-21**]. The morning of [**12-22**], the patient was noted to have a BP up to 247/120 at 0800. Hypertension persisted throughout the morning with BPs 210s-240s systolic. HR during this time was in the 90s. She received a total of 60 mg IV hydralazine over the course of the morning as well as 0.1 mg PO clonidine. She was also given her normal AM BP meds and restarted on aliskarin. Due to persistent hypertension, she was transferred to the ICU for further care. On arrival to the ICU, the patient reported severe abdominal pain over the site of recently removed PD catheter. She denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. She reports bilateral calf cramping but no leg swelling. She denies any difficulty breathing or chest pain. She took her AM BP meds without difficulty. Her blood pressure decreased to 130s-140s/60s without further intervention. She was transferred back to the floor on [**12-23**] and signed out AMA. 2. Angioedema: On [**12-20**] the patietn developed facial swelling and evidence of angioedema by ENT. The patient reported that her face is more swollen which was confirmed by her mother on the floor. The patient was give lasix IV as she has been unable to have any negative filtration with HD. The patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. Her tekturna was discontinued for concern that it might be causing angioedema. She denied difficulty with her breathing at that time, but was very somnulent. On arrival to the MICU her vitals were stable and oxygenating well at 100% on face mask. The patient's airway was supported with a nasal trumpet. The patient underwent MRV that showed no progression of her clot. Patient was diuresed with lasix and dialysis with significant improvement in her symptoms. She was treated with prednisone and decadron, famotidine and benadryl for angioedema. The patient was maintained on her heparin drip for her SVC syndrome. 3. Abdominal Pain: The patient has had extensive prior workup that has been unrevealing. The Transplant surgery team removed the PD cath on [**12-21**]. She continued to have abdominal pain post-op. She was continued on PO dilaudid 2mg po prn. She continuned to complain of abdominal pain throughout her admission and continued to requested IV dilaudid. 4. ESRD: The patient is on a T/Th/Sat schedule. She was closely followed by the renal team. She had dialysis on [**12-19**]. The patient's tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. The patient also had her PD catheter removed on [**12-21**] secondary to chronic abdominal pain. The patient was scheduled to have dialysis on [**12-23**]. 5. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last admission for supratherapeutic INR. She was admitted with a subtherpeutic INR of 1.2 She was started on a heparin drip. She was also started on Coumadin 2mg PO qday, but was held on [**12-19**] in prep her PD catheter removal. She was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by IR. However, the patient signed out AMA and thus it was not placed. 6. Anxiety: Pt recently saw psychiatrist who started her on Celexa. She was continued on Celexa 20mg PO daily. 7. Anemi of CKDa: The patient's Hct was 30.3 on admission. It trended down to 22.3 on discharge when she left AMA. There was no evidence of active, acute bleeding. THis is likely seoncdary to her ESRD. The patient was closely monitored. 8. Systemic Lupus Erythematosis: Rheumatology was consulted and does not suspect acute flare and dsDNA, C3, C4 nl, ESR and CRP slightly elevated. Her Echo did not suggest worsening pericarditis. She was continued on her home prednisone dose of 4mg daily. 9. Obstructive Sleep Apnea: CPAP for sleep with 7 pressure. Medications on Admission: Aliskiren 150 mg [**Hospital1 **] Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Warfarin held on discharge [**2141-12-14**] due to supratherap INR Discharge Medications: As patient signed out AMA, no medications were issued. She was told to resume her admission medications, however no instructions were taken by the patient. Discharge Disposition: Home Discharge Diagnosis: 1) Hypertensive urgency 2) Abdominal pain 3) End stage renal disease on hemodialysis 4) Venous thromboembolism Discharge Condition: Signed out AMA Discharge Instructions: Pt signed out AMA Return to the hospital with any concerning symptoms. Be sure to call your doctor's office on [**Month/Day/Year 766**] to arrange hemodialysis and review your medications and discuss follow-up plan. Followup Instructions: Follow-up with your Dr. [**Last Name (STitle) **] next week, and call [**Last Name (STitle) 766**] to arrange your hemodialysis. Completed by:[**2141-12-26**]",56,2141-12-18 03:50:00,2141-12-23 19:51:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. 1. malignant hypertension: the patient had her hemodialysis two days prior to admission. initially in the ed her bp was 253/170. she was given 10mg iv labetalol and started on a labatelol drip. she also received hydralazine iv 10 mg once and 2 inches of nitropaste. she had morphine 4mg and 4mg zofran for nausea. her bp remained elevated so she was switched to nicardipine 1mg/kg/min. the patient was transferred to the micu. in the icu she was continued on the nicardapine drip and her pressures decreased to 175/120. nephrology was consulted and dialysis initiated in the am. the nicardapine drip dcd on [**12-19**] and pt transferred to floor. while on the floor the patient had question of angioedema and markedly elevated bp. she was readmitted to the micu on [**2141-12-20**]. patients aliskerin was also held for conern for angioedema. the renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. the patients pd catheter was removed. the patient was briefly on a nitro drip for hypertension. the patients nifedepine was increased to 120mg. the patient was transferred to the floor with stable blood pressures, bp 124/72 on [**12-21**]. the morning of [**12-22**], the patient was noted to have a bp up to 247/120 at 0800. hypertension persisted throughout the morning with bps 210s-240s systolic. hr during this time was in the 90s. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she was also given her normal am bp meds and restarted on aliskarin. due to persistent hypertension, she was transferred to the icu for further care. on arrival to the icu, the patient reported severe abdominal pain over the site of recently removed pd catheter. she denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. she reports bilateral calf cramping but no leg swelling. she denies any difficulty breathing or chest pain. she took her am bp meds without difficulty. her blood pressure decreased to 130s-140s/60s without further intervention. she was transferred back to the floor on [**12-23**] and signed out ama. 2. angioedema: on [**12-20**] the patietn developed facial swelling and evidence of angioedema by ent. the patient reported that her face is more swollen which was confirmed by her mother on the floor. the patient was give lasix iv as she has been unable to have any negative filtration with hd. the patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. her tekturna was discontinued for concern that it might be causing angioedema. she denied difficulty with her breathing at that time, but was very somnulent. on arrival to the micu her vitals were stable and oxygenating well at 100% on face mask. the patients airway was supported with a nasal trumpet. the patient underwent mrv that showed no progression of her clot. patient was diuresed with lasix and dialysis with significant improvement in her symptoms. she was treated with prednisone and decadron, famotidine and benadryl for angioedema. the patient was maintained on her heparin drip for her svc syndrome. 3. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the transplant surgery team removed the pd cath on [**12-21**]. she continued to have abdominal pain post-op. she was continued on po dilaudid 2mg po prn. she continuned to complain of abdominal pain throughout her admission and continued to requested iv dilaudid. 4. esrd: the patient is on a t/th/sat schedule. she was closely followed by the renal team. she had dialysis on [**12-19**]. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient also had her pd catheter removed on [**12-21**] secondary to chronic abdominal pain. the patient was scheduled to have dialysis on [**12-23**]. 5. hx of svc/brachiocephalic dvt: her coumadin was held during last admission for supratherapeutic inr. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. she was also started on coumadin 2mg po qday, but was held on [**12-19**] in prep her pd catheter removal. she was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by ir. however, the patient signed out ama and thus it was not placed. 6. anxiety: pt recently saw psychiatrist who started her on celexa. she was continued on celexa 20mg po daily. 7. anemi of ckda: the patients hct was 30.3 on admission. it trended down to 22.3 on discharge when she left ama. there was no evidence of active, acute bleeding. this is likely seoncdary to her esrd. the patient was closely monitored. 8. systemic lupus erythematosis: rheumatology was consulted and does not suspect acute flare and dsdna, c3, c4 nl, esr and crp slightly elevated. her echo did not suggest worsening pericarditis. she was continued on her home prednisone dose of 4mg daily. 9. obstructive sleep apnea: cpap for sleep with 7 pressure. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Mechanical complication due to peritoneal dialysis catheter; ; Unspecified disease of pericardium; Angioneurotic edema, not elsewhere classified; Abdominal pain, other specified site; Systemic lupus erythematosus; ; Anemia in chronic kidney disease; Dysthymic disorder; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of steroids; Long-term (current) use of anticoagulants; Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation; Other antihypertensive agents causing adverse effects in therapeutic use]","24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. she was given 10mg iv labetalol and started on a labatelol drip. nephrology was consulted and dialysis initiated in the am. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she reports bilateral calf cramping but no leg swelling. she took her am bp meds without difficulty. her tekturna was discontinued for concern that it might be causing angioedema. the patient was maintained on her heparin drip for her svc syndrome. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient was scheduled to have dialysis on [**12-23**]. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. there was no evidence of active, acute bleeding.","24 year old female with sle, esrd on hd presents with abdominal pain and headache consistent with her usual hypertensive urgency. she was found to be in hypertensive urgency in ed. she received hydralazine iv 10 mg once and 2 inches of nitropaste." 109,113189.0,14806,2142-02-17,14803,135923.0,2142-01-12,Discharge summary,"Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-13**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypertensive Urgency and HA Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with HA in the setting of hypertension. Upon arrival to the ED, her vitals were 284/140, HR 67, RR 28, 100% on 4LNC. She was started on a nicardipine drip. She denied shortness of breath or chest pain. She is due for HD today. She has a left groin catheter which was recently placed [**2141-12-21**] and is causing her pain. She was also given dilaudid IV 1 mg x 2 with some relief. CXR was performed and showed no pulmonary edema. . Upon arrival to the MICU, patient denies HA, CP, SOB, fevers, chills. Patient reports mild abdominal pain at sight of left anterior abdominal wall hematoma and left groin pain at site of femoral HD line. She reports that she was taking her medications as directed, including coumadin for SVC thrombus. Briefly, 24 yo F with ESRD on HD, SLE, malignant HTN admitted for HA in the setting of HTN to 284/140 in ED. Initially, she was treated with a nicardipine gtt to control her BP. Her cardiac enzymes were flat, no new ECG changes. She was started on a heparin gtt with transition to coumadin for a SVC thrombosis. HTN secondary to med noncompliance. She was restarted on her oral BP. She missed her PM meds yesterday, so nicardipine was restarted, and then turned off this AM. She received all her AM BP meds. Her BPs have been in the 160s/90s. She had no neurological deficits. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 176/105, 87, 18, 100% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: 2/6 systolic murmur LUSB Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: left ant wall abd hematoma, TTP Extremities: Right: Trace, Left: Trace, left fem HD line without oozing or drainage Skin: Warm Neurologic: AAO x 3 Pertinent Results: [**2142-1-8**] 05:15AM PT-13.7* PTT-33.6 INR(PT)-1.2* [**2142-1-8**] 05:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-1+ STIPPLED-OCCASIONAL TEARDROP-1+ BITE-NORMAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2142-1-8**] 05:15AM cTropnT-0.08* [**2142-1-8**] 05:15AM CK(CPK)-119 [**2142-1-8**] 04:12PM PTT-120.8* [**2142-1-8**] 10:41PM PTT-144.8* [**2142-1-8**] 02:55PM CK-MB-NotDone cTropnT-0.06* Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. Patient was initially observed in the MICU and placed on a nicardipine drip. Patient was stablized on home medicaitons, suggesting medication non-compliance. Additionally, patient presented subtheraputic on coumadin for SVC thrombosis. Patient was started on heparin ggt. After the nicardipine drip was turned off, patient was called out to the floor. Heparin drip was continued until INR [**2-13**]. Pressures were managed to her baseline. Pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with Narcan. Patient received dialysis 3x/wk as per outpatient schedule. # Hypertension: Pt with extensive history of repeated admissions for hypertension. Patient's BP improved with nicardipine drip and after HD off drip on home PO medication regimen. Resumed oral antihypertensives with improved BP control. HTn likely from renal disease, possible medication noncompliance, lupus. No evidence of MI. Continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. Renal increased clonidine patch, and added Nicardipine with improvement of BP control. Pt is to follow up with an appointment in the next week to establish care at [**Company 191**], and to re-check her BP and adjust medications further. # SLE: Stable, continued prednisone at 4 mg PO daily. # Left groin pain. Permanent HD line was placed on [**12-25**]. Line and hematoma from prior peritoneal line on abdomen okay. No leukocytosis or fevers to suggest infection. Patient was oversedated on Dilaudid and had episode of oxygen desaturation which was reversed with Narcan. Patient was solmolent with morphine SR so that was d/c'ed as well, patient was given standing tylenlol and Morphine IR PRN. Transplant surgery removed remaining sutures today from L groin. Pt has a follow-up appointment in the next week with Dr. [**First Name (STitle) **] (Transplant Surgery). She will be sent home with low-dose Morphine IR and Tylenol PRN pain. If L groin pain should become uncontrollable on current meds, pt should return to the ED for re-evaluation. It is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #ESRD: Renal following, continuing HD Th/Th/Sat. CaCO3 was started for elevated calcium-phosphate product. Pt will follow-up with Dr. [**Last Name (STitle) 7473**] in the next 1-2 weeks. # Anemia: Pt's baseline is 26. This is likely secondary to AOCD and renal failure. Hct was stable on day of discharge at 25.9. # SVC thrombus: Pt has a history of an SVC thrombus, and is on coumadin. She is supposed to be on lifelong anticoagulation due to recurrent thrombosis but INR subtherapeutic on arrival. Heparin drip was stopped on the floor once the INR was theraputic. INR was therapeutic on day of discharge. Pt will need an INR check in the next week at her follow-up with her PCP. # HOCM: Pt has evidence of myocardial hypertrophy on Echo. She is currently not symptomatic. Echo did not show evidence of worsening pericardial effusion. She was continued on her beta-blocker and other BP medications. # Depression/anxiety: Stable. She was continued on Celexa and Clonazepam. # OSA: Pt as continued on CPAP for sleep with 7 pressure. # FEN: regular diet # PPX: heparin drip --> coumadin, bowel regimen # ACCESS: PIV x2 / permanent dialysis cath L fem # CODE: FULL # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] # DISPO: home with PCP and Renal [**Name9 (PRE) 702**] to re-check BP, INR level. Follow-up with Transplant Surgery. Medications on Admission: Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Aliskiren 150 [**Hospital1 **] Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Nicardipine 30 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain for 2 weeks. [**Hospital1 **]:*20 Tablet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Urgency End Stage Renal Disease Discharge Condition: stable, blood pressure moderately controlled, afebrile, tolerating POs Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. Some of medications were increased as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to take the coumadin as prescribed by your doctor, and have your INR checked frequently per your PCP's recommendations. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Renal) Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-1-15**] 3:00 - Will follow-up Vitamin D [**2-4**] level Provider: [**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD ([**Company 191**]) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-1-16**] 3:30 - Will re-check your INR level Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Transplant Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-1-19**] 2:50p [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-1-12**]",36,2142-01-08 06:36:00,2142-01-13 21:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE URGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was initially observed in the micu and placed on a nicardipine drip. patient was stablized on home medicaitons, suggesting medication non-compliance. additionally, patient presented subtheraputic on coumadin for svc thrombosis. patient was started on heparin ggt. after the nicardipine drip was turned off, patient was called out to the floor. heparin drip was continued until inr [**2-13**]. pressures were managed to her baseline. pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with narcan. patient received dialysis 3x/wk as per outpatient schedule. # hypertension: pt with extensive history of repeated admissions for hypertension. patients bp improved with nicardipine drip and after hd off drip on home po medication regimen. resumed oral antihypertensives with improved bp control. htn likely from renal disease, possible medication noncompliance, lupus. no evidence of mi. continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. renal increased clonidine patch, and added nicardipine with improvement of bp control. pt is to follow up with an appointment in the next week to establish care at [**company 191**], and to re-check her bp and adjust medications further. # sle: stable, continued prednisone at 4 mg po daily. # left groin pain. permanent hd line was placed on [**12-25**]. line and hematoma from prior peritoneal line on abdomen okay. no leukocytosis or fevers to suggest infection. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. patient was solmolent with morphine sr so that was d/ced as well, patient was given standing tylenlol and morphine ir prn. transplant surgery removed remaining sutures today from l groin. pt has a follow-up appointment in the next week with dr. [**first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. it is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #esrd: renal following, continuing hd th/th/sat. caco3 was started for elevated calcium-phosphate product. pt will follow-up with dr. [**last name (stitle) 7473**] in the next 1-2 weeks. # anemia: pts baseline is 26. this is likely secondary to aocd and renal failure. hct was stable on day of discharge at 25.9. # svc thrombus: pt has a history of an svc thrombus, and is on coumadin. she is supposed to be on lifelong anticoagulation due to recurrent thrombosis but inr subtherapeutic on arrival. heparin drip was stopped on the floor once the inr was theraputic. inr was therapeutic on day of discharge. pt will need an inr check in the next week at her follow-up with her pcp. # hocm: pt has evidence of myocardial hypertrophy on echo. she is currently not symptomatic. echo did not show evidence of worsening pericardial effusion. she was continued on her beta-blocker and other bp medications. # depression/anxiety: stable. she was continued on celexa and clonazepam. # osa: pt as continued on cpap for sleep with 7 pressure. # fen: regular diet # ppx: heparin drip --> coumadin, bowel regimen # access: piv x2 / permanent dialysis cath l fem # code: full # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] # dispo: home with pcp and renal [**name9 (pre) 702**] to re-check bp, inr level. follow-up with transplant surgery. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Hypoxemia; Other opiates and related narcotics causing adverse effects in therapeutic use; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Abdominal pain, other specified site; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Renal dialysis status; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Other postprocedural status]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. # hypertension: pt with extensive history of repeated admissions for hypertension. # sle: stable, continued prednisone at 4 mg po daily. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. this is likely secondary to aocd and renal failure. pt will need an inr check in the next week at her follow-up with her pcp.","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was stablized on home medicaitons, suggesting medication non-compliance. patient was oversedated on dilaudid and had episode of oxygen desaturation." 109,113189.0,14806,2142-02-17,14804,124657.0,2142-01-20,Discharge summary,"Admission Date: [**2142-1-14**] Discharge Date: [**2142-1-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 4028**] Chief Complaint: headache Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with mild headache, mild shortness of breath and consistent abdominal pain at the site of her known left abdominal wall hematoma in the setting of hypertension. Her last HD was yesterday. . Upon arrival to the ED, her vitals were BP 240's systolic, HR 90's, 93% on RA. A head CT scan was done which showed no acute process. An abdominal CT was done given her femoral line pain, which also was normal. She was given nitropaste X2 initially, then switched to labetalol 100mg x2, then 200mg x2, then finally started on nicardipine drip when she showed benefit with a decrease in her BP to 170/123 and improvement in her headache. . Upon arrival to the MICU, patient denies any current symptoms. She reports that her headache, shortness of breath and abdominal pain all resolved with blood pressure management and pain medications. . Pt was transferred to the floor when blood pressure was controlled. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: HR 96 BP 171/111 RR 12 O2 98% on RA Physical Exam: General in NAD HEENT NC, AT, EOMI, PERRLA, MMM CVS RRR, 3/6 systolic murmur in all heart fields RESP CTA BL, no crackles or wheezes ABD soft, hematoma raised on left anterior abdominal wall, +BS, mildly tender over hematoma EXT left sided femoral HD line in place, no erythema, no edema NEURO A+Ox3, CN2-12 intact, pt has left sided artificial eye, motor and sensory intact Pertinent Results: ***LABS ON ADMISSION*** [**2142-1-13**] 07:03AM WBC-5.2 RBC-2.79* HGB-8.5* HCT-26.3* MCV-94 MCH-30.3 MCHC-32.2 RDW-19.2* [**2142-1-13**] 07:03AM PLT COUNT-154 [**2142-1-13**] 07:03AM PT-29.5* PTT-49.2* INR(PT)-3.0* [**2142-1-13**] 07:03AM GLUCOSE-94 UREA N-53* CREAT-7.0* SODIUM-136 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [**2142-1-13**] 07:03AM CALCIUM-8.8 PHOSPHATE-5.0* MAGNESIUM-1.9 [**2142-1-14**] 12:00PM PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-14**] 12:00PM LIPASE-42 [**2142-1-14**] 12:00PM ALT(SGPT)-12 AST(SGOT)-43* ALK PHOS-96 TOT BILI-0.4 [**2142-1-14**] 03:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-1-14**] 03:25PM URINE RBC-[**3-15**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-[**3-15**] [**2142-1-14**] 12:00PM BLOOD PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-19**] 06:40AM BLOOD PT-18.6* PTT-38.7* INR(PT)-1.7* . ***LABS ON DAY OF DISCHARGE*** [**2142-1-20**] 06:35AM BLOOD WBC-5.7 RBC-2.39* Hgb-7.1* Hct-22.1* MCV-93 MCH-29.8 MCHC-32.2 RDW-18.6* Plt Ct-136* [**2142-1-20**] 06:35AM BLOOD Glucose-107* UreaN-34* Creat-4.8* Na-137 K-5.2* Cl-101 HCO3-27 AnGap-14 [**2142-1-20**] 06:35AM BLOOD PT-22.8* PTT-42.3* INR(PT)-2.2* . IMAGING [**2142-1-14**] EKG Sinus rhythm. Possible left atrial abnormality. Borderline voltage criteria for left ventricular hypertrophy. Inferolateral ST-T wave changes may be related to left ventricular hypertrophy. Compared to the previous tracing of [**2142-1-8**] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 99 190 86 368/436 13 100 24 [**2142-1-14**] CT ABD/PELV IMPRESSION: 1. Interval decrease in size to subcutaneous anterior abdominal wall hematoma. 2. Infectious versus inflammatory process within the right lower lobe of the lung. Small right simple pleural effusion. 3. Cardiomegaly with slight decrease in size of moderate pericardial effusion. 4. Right lobe liver hemangioma, unchanged. [**2142-1-14**] CT HEAD IMPRESSION: 1. Mildly limited study given administration of small amount of IV contrast material. However, no evidence of hemorrhage or mass effect. NOTE ADDED AT ATTENDING REVIEW: This patient was administered contrast for the abdominal CT, and the head CT was performed after part of this dose. Therefore, this is neither a noncontrast examination, nor a proper contrast CT. [**2142-1-14**] CXR CONCLUSION: Persistent cardiomegaly and mild pulmonary edema. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. . # Hypertensive Urgency: Pt with extensive history of hypertension. Patient's BP improved with nicardipine drip. Became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. Restarted all home oral antihypertensives including nicardipine 30 Q8H, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Blood pressure remains labile and renal continues to follow patient. Pt was transferred to the floor as blood pressure stabilized. BP has remained stable with systolics 140s-170s. In the MICU, Nifedipine extended release was added in place of Nicardipine as pt's blood pressures seemed to rise prior to Nicardipine doses. . # Hyperkalemia: Ocurred on the day after admission. Resolved with administration of kayexalate. Pt continued hemodialysis on TuThSat. . # Left abdominal wall hematoma: Abd CT showed a mild decrease in the size. Pt reported that morphine did not help pain, and was switched to dilaudid PO in the MICU. However, given pt's recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/c'ed on the floor. Pt was continued on gabapentin, tylenol around the clock, and low-dose Morphine as needed for pain. Narcotics should be avoided in the future. Pain should also resolve in the next few weeks as hematoma resolves. . # SLE: Pt was continued on prednisone at 4 mg PO daily. . #ESRD: Renal was following during her stay. She continued HD on her T, Th, Sat schedule. # Anemia: Hct was mildly decreased from baseline during admission. This is likely secondary to AOCD and in the setting of renal failure. . # SVC thrombus: Patient is on anticoagulation, likely lifelong. Patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. Then INR became subtherapeutic, so heparin gtt was used to bridge. On day of discharge, INR became therapeutic, and pt was discharged home on Coumadin 4mg PO daily, with INR to be checked next at hemodialysis . # HOCM: Pt has evidence of myocardial hypertrophy on recent Echo. She was not symptomatic during her stay. She was continued on her beta blocker. . # Depression/anxiety. She was continued on celexa and clonazepam PRN. . # OSA: CPAP for sleep with 7 pressure. . # FEN: repleted lytes prn / regular diet . # PPX: coumadin, bowel regimen . # ACCESS: PIV/ permanent dialysis cath L fem . # CODE: FULL . # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nicardipine 30mg PO TID Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for breakthrough pain for 2 weeks. 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*1* 13. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*260 Tablet(s)* Refills:*1* 14. Respiratory Therapy Please adjust settings of CPAP machine to a lower volume as it is uncomfortable for the patient. Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Discharge Condition: Good, hemodynamically stable, afebrile, pain controlled Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. One new medication was added as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to continue your Coumadin at 4mg daily and have your INR checked AT DIALYSIS next week. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep ALL scheduled appointments. Medications changes include: 1. STOP NICARDIPINE 2. Start Nifedipine CR 90mg by mouth daily 3. INCREASE Labetalol to 900mg by mouth 3 times daily 4. Continue at Warfarin 4mg by mouth daily If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to set up a follow-up appointment in 1-2weeks. Please continue your HD TuThSat. Completed by:[**2142-1-20**]",28,2142-01-14 17:34:00,2142-01-20 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. . # hypertensive urgency: pt with extensive history of hypertension. patients bp improved with nicardipine drip. became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. restarted all home oral antihypertensives including nicardipine 30 q8h, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. blood pressure remains labile and renal continues to follow patient. pt was transferred to the floor as blood pressure stabilized. bp has remained stable with systolics 140s-170s. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. . # hyperkalemia: ocurred on the day after admission. resolved with administration of kayexalate. pt continued hemodialysis on tuthsat. . # left abdominal wall hematoma: abd ct showed a mild decrease in the size. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu. however, given pts recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/ced on the floor. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. narcotics should be avoided in the future. pain should also resolve in the next few weeks as hematoma resolves. . # sle: pt was continued on prednisone at 4 mg po daily. . #esrd: renal was following during her stay. she continued hd on her t, th, sat schedule. # anemia: hct was mildly decreased from baseline during admission. this is likely secondary to aocd and in the setting of renal failure. . # svc thrombus: patient is on anticoagulation, likely lifelong. patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. then inr became subtherapeutic, so heparin gtt was used to bridge. on day of discharge, inr became therapeutic, and pt was discharged home on coumadin 4mg po daily, with inr to be checked next at hemodialysis . # hocm: pt has evidence of myocardial hypertrophy on recent echo. she was not symptomatic during her stay. she was continued on her beta blocker. . # depression/anxiety. she was continued on celexa and clonazepam prn. . # osa: cpap for sleep with 7 pressure. . # fen: repleted lytes prn / regular diet . # ppx: coumadin, bowel regimen . # access: piv/ permanent dialysis cath l fem . # code: full . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Other vascular complications of medical care, not elsewhere classified; Systemic lupus erythematosus; Hyperpotassemia; Phlebitis and thrombophlebitis of upper extremities, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. # anemia: hct was mildly decreased from baseline during admission. # hocm: pt has evidence of myocardial hypertrophy on recent echo. # fen: repleted lytes prn / regular diet . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. pt was transferred to the floor as blood pressure stabilized. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu." 109,113189.0,14806,2142-02-17,14805,176760.0,2142-01-23,Discharge summary,"Admission Date: [**2142-1-21**] Discharge Date: [**2142-1-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Hypertensive Urgency and fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with hypertensive urgency, subjective fevers, and pain. . Of note, she had been hospitalized [**Date range (1) 43505**] with hypertensive urgency. Her nicardipine was changed to nifedipine in hospital and her labetalol was increased to 900mg TID from 800mg TID.BPs were reportedly stable in the 140's-170's on the medical floor on nifedipine, aliskerin, labetalol, clonidine, and hydralazine prior to discharge. Last HD was [**1-20**]. . She reports feeling well at time of discharge [**1-20**], however woke this evening feeling sweaty, hot, and mildly SOB. She did not check her temperature and denies any rigors. She had total body aching (worst in her left wrist at site of recent IV and abdomen at site of known hematoma). +Palpitations overnight now resolved. No CP, SOB, cough, diarrhea, dysuria, erythema/tenderness/drainage from HD catheter. Denies recent joint symptoms with her lupus. No sick contacts. Says she took her BP meds. . Upon arrival to the ED, her vitals were 99.9 104 254/145 16 96% on RA. She was started on a nicardipine drip, given 1"" nitropaste with improvement in her BP. Did spike a fever while in the ED, currently 101F 101 173/106 Given vancomycin and zoysn for ?pna as CXR with right sided haziness. Also received 3mg IV dilaudid for body pains. LUE ultrasound without evidence of DVT. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 98.5 P 92 Bp 173/116 RR 16 O2 100% on RA General Pleasant young woman appearing comfortable HEENT Cushingoid faces, L eye prosthesis, MMM Pulm Lungs clear bilaterally, no rales or wheezing CV Regular S1 S2 ?soft systolic murmur Abd Soft +hematoma left abdomen unchanged from prior exam Extrem Warm full distal pulses. Left hand with slight edema ++ tender to palpation of wrist patient unable to make fist secondary to pain, no erythema +warmth ?purulence at site of old PIV Skin No peripehral stigmata of endocarditis Lines Left groin HD catheter site without erythema, purulence, or tenderness Neuro Alert and awake, moving all extremities Pertinent Results: CXR [**1-21**]: In comparison with the earlier study of this date, the diffuse pulmonary edema has substantially decreased, possibly following hemodialysis. Enlargement of the cardiac silhouette persists and there is no definite pleural effusion. Suggestion of an area of increased opacification at the right base. This could merely represent asymmetric edema, though the possibility of a developing consolidation cannot be unequivocally excluded. . LUE US [**1-21**]: IMPRESSION: No DVT in the left upper extremity. . L wrist xray [**1-21**]: There is prominent soft tissue swelling about the wrist, relatively diffuse, but quite prominent along the dorsum of the wrist. No fracture, dislocation, degenerative change, focal lytic or sclerotic lesion, or erosion is identified. No soft tissue calcification or radiopaque foreign body is identified. A tiny (1.7 mm) linear density is seen along the dorsum of the wrist on the oblique view is seen only on that view and is consistent with a small film artifact. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency and left wrist pain. . 1. Hypertensive urgency: Patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. Patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. She was started on nicardipine drip and 1"" nitropaste and admitted to the ICU for further treatment. There was no evidence of end-organ ischemia. Upon arrival to the ICU she was given her usual home antihypertensives and the nicardipine was quickly weaned off. It was felt that pain and anxiety were both contributing to her elevated BPs. Her BP quickly stabilized and she was called out to the medical floor where her SBP ranged 110-150. She was continued on nifepidine 90mg daily, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Given her repeated admissions with hypertensive urgency a meeting was held between the patient's nephrologist Dr. [**Last Name (STitle) 4883**], her ICU physician and her [**Name9 (PRE) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the ICU where she quickly improves with simply continuing her home medications. The following plan was drafted and placed in a note in OMR titled "" Care Protocol"". . CARE PROTOCOL: . BLOOD PRESSURE MANAGEMENT: . For BP > 230/140 1. Hydralazine: 100 mg PO OR 10 mg IV q 20 minutes until blood pressure back to baseline*. . 2. Give daily blood pressure medications, if she has not already taken them before arrival. . 3. If after one hour of therapy AND/OR evidence of end organ damage, transfer to the ICU. . * Note: Her usual blood pressure is ~ 160/100. Efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. In the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . PAIN MANAGEMENT: . As an outpatient, Ms. [**Name13 (STitle) **] takes dilaudid 2-4 mg PO q 4 PRN.This is being slowly tapered, she should not be administered IV pain medications. . ANTICOAGULATION: . In the absence of bleeding, warfarin does not need to be stopped on admission. Similarly, in the absence of new thrombosis, subtherapeutic INR's do not require bridging with IV UFH. . 2. Fever: Possible sources included line infection, thombophlebitis, septic arthritis, PNA. Received vanc/zosyn in ED for possible PNA. UA without pyuria and urine culture negative. CXR also without convinving infiltrate on repeat PA/Lat so zosyn was discontinued. Patient was complaining of severe pain at her IV site and was noted to have a small abscess there which was felt to be the cause of her fever. She was continued on IV vanco with HD for 10day course. She remained afebrile and did not have a leukocytosis. . 3. Left wrist pain: Began following IV placement during recent hospitalization. Likely due to septic thrombophlebitis. Small abscess was too small to drain. This was treated with warm soaks and prn PO dilaudid. Vanco was continued for 10 day course. L wrist films were enremarkable. . 4. Left abdominal wall hematoma: Stable on exam from recent admission. She was continued on pain management with morphine 7.5mg TID, gabapentin and tylenol as needed for pain. . 5. SLE: Continued prednisone at 4 mg PO daily . 6. ESRD: Continued on regularly scheduled dialysis. . 7. Anemia: Baseline Hct 26. Her Hct was mildly decreased from baseline. Secondary to AOCD and renal failure. There was no evidence of bleeding. . 8. SVC thrombus: Known SVC thrombus, therapeutic on coumadin. Continued warfarin. . 9. HOCM: evidence of myocardial hypertrophy on recent Echo. Currently not symptomatic. Echo without evidence of worsening pericardial effusion. Continued beta blocker . 10. Depression/anxiety. Continued Celexa, clonazepam 0.5mg [**Hospital1 **] . 11. OSA: Continued CPAP Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nifedipine 90mg PO daily Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325-650 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*270 Tablet(s)* Refills:*2* 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 7 days. [**Hospital1 **]:*4 dose* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Septic thrombophlebitis Discharge Condition: Stable, afebrile, BP improved. Discharge Instructions: You were admitted to the hospital with hypertensive urgency. You required IV medications and were observed overnight in the ICU. Your usual oral blood pressure medications were continued and your blood pressure remained well-controlled. You were found to have an infection at your prior IV site on your left hand. For this you were given IV vancomycin. You will need 7 days more of antibiotics which will be given with dialysis. Please resume your usual dialysis schedule. Your last dialysis was [**1-23**]. Please continue to take your medications as prescribed. You should hold your coumadin today. You can resume this on wednesday at your normal dose. You should have your INR checked at dialyis as usual on thursday. . If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-12**] weeks. ",25,2142-01-21 11:23:00,2142-01-23 16:40:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE EMERGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. . 1. hypertensive urgency: patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. there was no evidence of end-organ ischemia. upon arrival to the icu she was given her usual home antihypertensives and the nicardipine was quickly weaned off. it was felt that pain and anxiety were both contributing to her elevated bps. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150. she was continued on nifepidine 90mg daily, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. given her repeated admissions with hypertensive urgency a meeting was held between the patients nephrologist dr. [**last name (stitle) 4883**], her icu physician and her [**name9 (pre) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the icu where she quickly improves with simply continuing her home medications. the following plan was drafted and placed in a note in omr titled "" care protocol"". . care protocol: . blood pressure management: . for bp > 230/140 1. hydralazine: 100 mg po or 10 mg iv q 20 minutes until blood pressure back to baseline*. . 2. give daily blood pressure medications, if she has not already taken them before arrival. . 3. if after one hour of therapy and/or evidence of end organ damage, transfer to the icu. . * note: her usual blood pressure is ~ 160/100. efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. in the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . pain management: . as an outpatient, ms. [**name13 (stitle) **] takes dilaudid 2-4 mg po q 4 prn.this is being slowly tapered, she should not be administered iv pain medications. . anticoagulation: . in the absence of bleeding, warfarin does not need to be stopped on admission. similarly, in the absence of new thrombosis, subtherapeutic inrs do not require bridging with iv ufh. . 2. fever: possible sources included line infection, thombophlebitis, septic arthritis, pna. received vanc/zosyn in ed for possible pna. ua without pyuria and urine culture negative. cxr also without convinving infiltrate on repeat pa/lat so zosyn was discontinued. patient was complaining of severe pain at her iv site and was noted to have a small abscess there which was felt to be the cause of her fever. she was continued on iv vanco with hd for 10day course. she remained afebrile and did not have a leukocytosis. . 3. left wrist pain: began following iv placement during recent hospitalization. likely due to septic thrombophlebitis. small abscess was too small to drain. this was treated with warm soaks and prn po dilaudid. vanco was continued for 10 day course. l wrist films were enremarkable. . 4. left abdominal wall hematoma: stable on exam from recent admission. she was continued on pain management with morphine 7.5mg tid, gabapentin and tylenol as needed for pain. . 5. sle: continued prednisone at 4 mg po daily . 6. esrd: continued on regularly scheduled dialysis. . 7. anemia: baseline hct 26. her hct was mildly decreased from baseline. secondary to aocd and renal failure. there was no evidence of bleeding. . 8. svc thrombus: known svc thrombus, therapeutic on coumadin. continued warfarin. . 9. hocm: evidence of myocardial hypertrophy on recent echo. currently not symptomatic. echo without evidence of worsening pericardial effusion. continued beta blocker . 10. depression/anxiety. continued celexa, clonazepam 0.5mg [**hospital1 **] . 11. osa: continued cpap ","PRIMARY: [Other vascular complications of medical care, not elsewhere classified] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; ; Systemic lupus erythematosus; Phlebitis and thrombophlebitis of upper extremities, unspecified]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. she was continued on iv vanco with hd for 10day course. esrd: continued on regularly scheduled dialysis. her hct was mildly decreased from baseline. hocm: evidence of myocardial hypertrophy on recent echo. echo without evidence of worsening pericardial effusion. continued celexa, clonazepam 0.5mg [**hospital1 **] .","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150." 109,113189.0,14806,2142-02-17,15330,131345.0,2141-09-08,Discharge summary,"Admission Date: [**2141-9-5**] Discharge Date: [**2141-9-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 348**] Chief Complaint: right leg pain, hypertension Major Surgical or Invasive Procedure: blood transfusion x2 History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. The pain is worst when she tried to bear weight on the leg, or when she uses it to roll over or adjust her position in bed. The pain begins in her buttock and travels down the posterior thigh and calf but stops before reaching the ankle. It occasionally feels like it is coming from her low back. She denies any parasthesias or weakness in the leg, and she denies any numbness in her foot or groin. She denies any fevers or incontinence. The pain was unrelieved by Vicodin that she had at home, so she scheduled an urgent visit with her nephrologist yesterday [**2141-9-4**]. At her nephrologist??????s office, she was hypertensive to 250/145 and so she was referred to the ED. She ended up leaving the ED against medical advice yesterday, but returned today because of persistent leg pain. She reports that she took all of her morning and noon BP meds. She denies any fevers, headaches, visual changes, nausea (prior to coming to the ED), or leg weakness. Upon arrival to the ED today, she was afebrile, BP 237/146, HR 97, RR 16, Sat 100% on room air. She received a total of 90 mg of IV labetalol and nitropaste, and was eventually put on a labetalol drip for her hypertension. With these interventions, her SBP dropped to the 180s, but she reported feeling nauseous and so the drip was discontinued. She was also given 4 mg of IV morphine and 1 mg of IV hydromorphone for her leg pain with decent relief. Due to a urinalysis suggestive of infection, she was given one tablet of DS TMP/SMX. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: MICU physical: Tmax: 36.3 ??????C (97.4 ??????F) Tcurrent: 36.3 ??????C (97.4 ??????F) HR: 92 (92 - 94) bpm BP: 209/138(152) {201/134(151) - 209/138(152)} mmHg RR: 19 (19 - 30) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Height: 59 Inch General: well-appearing young woman in no acute distress HEENT: no scleral icterus; prosthetic right eye Neck: supple Chest: clear to auscultation throughout, no wheezes/rales/ronchi CV: regular rate/rhythm, normal s1s2, no murmurs Abdomen: soft, nontender, nondistended, PD catheter in place in left abdomen Back: very mild spinal tenderness over approx L3 level of spine Extremities: no edema, 1+ PT pulses, warm Skin: no rashes or jaundice Neuro: alert, oriented x3, 5/5 strength in bilateral deltoids, biceps, triceps, hip flexors/extensors, ankle flexors/extensors; unable to elicit patellar reflexes bilaterally; negative straight leg raise bilaterally Pertinent Results: 138 111 54 -----------------< 83 5.4 14 8.2 . WBC: 3.7 HCT: 19 PLT: 101 N:69.3 L:23.4 M:5.5 E:1.7 Bas:0.1 PT: 21.9 PTT: 48.2 INR: 2.1 . Trends: HCT: 19 -> 22 w 1u then received another unit. INR 3.4 on discharge Discharge chem: Glucose-104 UreaN-51* Creat-8.4* Na-136 K-5.3* Cl-106 HCO3-18* AnGap-17 . [**2141-9-8**] 07:30AM BLOOD CK(CPK)-126 [**2141-9-5**] 02:50PM BLOOD HCG-<5 . [**2141-9-8**] 1:37 pm PERITONEAL FLUID GRAM STAIN (Final [**2141-9-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count . MRI L-spine: IMPRESSION: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. . CXR admit: IMPRESSION: Moderate cardiomegaly, bilateral pleural effusions, and pulmonary vascular prominence consistent with pulmonary edema. . Hip film: FINDINGS: No comparisons. No acute fracture or dislocation is seen. No lucent or sclerotic lesion is noted. There is a distal aspect of a catheter or shunt seen in the pelvis. Soft tissues are otherwise unremarkable. There is minimal degenerative change of the pubic symphysis. IMPRESSION: No acute fracture or dislocation. . Abdominal film: FINDINGS: A PD catheter is seen with its tip coiled in the pelvis. There is normal bowel gas. The underlying osseous structures are unremarkable. IMPRESSION: PD catheter with tip coiled in the pelvis . CXR [**9-8**]: IMPRESSION: Marked cardiomegaly, unchanged. Interval resolution of pulmonary edema. Brief Hospital Course: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. She was initially admitted to the MICU for hypertensive urgency and then transfered to the floor after a day. # Hypertensive urgency: had been on labetalol drip in the ED, but this was stopped due to nausea (presumed that her BP was coming down too fast). She was started on her home meds and tolerated these fairly well. Transferred to the floor and noted to have SPBs in the 90s. She required 1L IVF bolus since her baseline SBP is thought to run in the 130-170 range. She also had transient dizziness during this episode. BP meds were held and later that night her SBP was in the 220s. BP meds restarted. She remained stable thereafter with SBPs in the 130-170s. We opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # Right leg pain: no evidence of avascular necrosis or fracture on plain film. MRI and plain films were ordered and showed no acute pathology. The pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. CK was normal. Pain was treated with dilaudid initially. On day of discharge, she was able to ambulate without gait abnormality or pain. PT saw her and rec outpt PT followup. . # CKD V: PD catheter placement in place. Pt was tried on PD on a number of occasions but did not tolerate it [**2-11**] pain. KUB confirmed tip in place. Cx of peritoneal fluid not suggestive of peritonitis. K remained mildly elevated. Hyperpara treated with sevelamer (although patient refused) then tums. Pt will reconsider PD as outpatient. . # Anemia: chronic. Received 2u pRBC while inhouse for Hct in the 18-19 range. Had appropriate response. Not on Epo given hypertension . # ID: Rx with cipro for ? UTI although urine cx neg. Also had temp to 101 on evening prior to discharge. No clear source. PD fluid cultured and NGTD. Pt remainded HD stable on day of discharge. . # Prior SVC thrombus. Continued warfarin with appropriate INR checks. INR elevated on day of discharge. Rec holding coumadin for 2d . # Systemic lupus erythematosus: cont home prednisone dose . # Dispo status: ambulating, pain free, BP in the 150/90 range Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly Vicodin prn Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO WEEKLY (). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*20 Capsule(s)* Refills:*0* 9. Outpatient Physical Therapy Please provide PT for right hamstring injury 10. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*0* 11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold dose until [**9-10**]. Disp:*30 Tablet(s)* Refills:*0* 12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO once a day: goal is [**1-11**] soft bowel movements per day. Disp:*500 ml* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - HTN urgency - right leg pain - thought [**2-11**] hamstring injury - chronic kidney disease - not currently on dialysis - SLE - anemia [**2-11**] CKD and SLE - hx of SVC thrombosis on coumadin now Secondary: - hx hypertrophic obstructive cardiomyopathy - chronic thrombocytopenia Discharge Condition: ambulating without difficulty. tolerating oral diet. afebrile and SBP in the 130-150 range. Discharge Instructions: You came in with right leg pain and poorly controlled hypertension. Your blood pressure was controlled initially with IV medications then your home medications. Since your blood pressure was occasionally low, we recommend that you hold your labetalol if you are feeling lightheaded or have dizziness or have blood pressure less than 110/60. In terms of your leg pain, we performed xrays, ultrasound, and MRI without finding a cause. We suspect a hamstring injury given its location. Please take pain medications if needed. We recommend followup with physical therapy. You also had a fever which is suggestive of infection. We treated you with cipro in case you had a UTI. Otherwise, your cultures were unrevealing. We attempted peritoneal dialysis but this was unsuccessful. Please followup with your nephrologist. Please return to the ED if you experience headache, chest pain, shortness of breath, high fevers, or worsening leg pain. Please hold your coumadin for two days then restart as per previously written. Please take lactulose for constipation. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-9-12**] 5:00 Provider: [**Name10 (NameIs) 706**] NURSE Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 2:00 Provider: [**Name10 (NameIs) 7548**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 3:00 Please followup with your nephrologist and PCP. [**Name10 (NameIs) **] would like you to see your nephrologist within the next 1-2 weeks. ",162,2141-09-05 20:04:00,2141-09-08 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transfered to the floor after a day. # hypertensive urgency: had been on labetalol drip in the ed, but this was stopped due to nausea (presumed that her bp was coming down too fast). she was started on her home meds and tolerated these fairly well. transferred to the floor and noted to have spbs in the 90s. she required 1l ivf bolus since her baseline sbp is thought to run in the 130-170 range. she also had transient dizziness during this episode. bp meds were held and later that night her sbp was in the 220s. bp meds restarted. she remained stable thereafter with sbps in the 130-170s. we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # right leg pain: no evidence of avascular necrosis or fracture on plain film. mri and plain films were ordered and showed no acute pathology. the pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. ck was normal. pain was treated with dilaudid initially. on day of discharge, she was able to ambulate without gait abnormality or pain. pt saw her and rec outpt pt followup. . # ckd v: pd catheter placement in place. pt was tried on pd on a number of occasions but did not tolerate it [**2-11**] pain. kub confirmed tip in place. cx of peritoneal fluid not suggestive of peritonitis. k remained mildly elevated. hyperpara treated with sevelamer (although patient refused) then tums. pt will reconsider pd as outpatient. . # anemia: chronic. received 2u prbc while inhouse for hct in the 18-19 range. had appropriate response. not on epo given hypertension . # id: rx with cipro for ? uti although urine cx neg. also had temp to 101 on evening prior to discharge. no clear source. pd fluid cultured and ngtd. pt remainded hd stable on day of discharge. . # prior svc thrombus. continued warfarin with appropriate inr checks. inr elevated on day of discharge. rec holding coumadin for 2d . # systemic lupus erythematosus: cont home prednisone dose . # dispo status: ambulating, pain free, bp in the 150/90 range ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Nausea alone; Other antihypertensive agents causing adverse effects in therapeutic use; Hip and thigh injury; Unspecified accident; Hypotension, unspecified; Anemia, unspecified; Personal history of venous thrombosis and embolism; End stage renal disease; ; Urinary tract infection, site not specified; Hyperpotassemia; Acidosis; Disorders of phosphorus metabolism; Hypocalcemia; Secondary hyperparathyroidism (of renal origin)]","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. # right leg pain: no evidence of avascular necrosis or fracture on plain film. also had temp to 101 on evening prior to discharge. # systemic lupus erythematosus: cont home prednisone dose .","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension. she presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transferred to the floor after a day. she was started on her home meds and tolerated them fairly well." 109,176760.0,14805,2142-01-23,15330,131345.0,2141-09-08,Discharge summary,"Admission Date: [**2141-9-5**] Discharge Date: [**2141-9-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 348**] Chief Complaint: right leg pain, hypertension Major Surgical or Invasive Procedure: blood transfusion x2 History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. The pain is worst when she tried to bear weight on the leg, or when she uses it to roll over or adjust her position in bed. The pain begins in her buttock and travels down the posterior thigh and calf but stops before reaching the ankle. It occasionally feels like it is coming from her low back. She denies any parasthesias or weakness in the leg, and she denies any numbness in her foot or groin. She denies any fevers or incontinence. The pain was unrelieved by Vicodin that she had at home, so she scheduled an urgent visit with her nephrologist yesterday [**2141-9-4**]. At her nephrologist??????s office, she was hypertensive to 250/145 and so she was referred to the ED. She ended up leaving the ED against medical advice yesterday, but returned today because of persistent leg pain. She reports that she took all of her morning and noon BP meds. She denies any fevers, headaches, visual changes, nausea (prior to coming to the ED), or leg weakness. Upon arrival to the ED today, she was afebrile, BP 237/146, HR 97, RR 16, Sat 100% on room air. She received a total of 90 mg of IV labetalol and nitropaste, and was eventually put on a labetalol drip for her hypertension. With these interventions, her SBP dropped to the 180s, but she reported feeling nauseous and so the drip was discontinued. She was also given 4 mg of IV morphine and 1 mg of IV hydromorphone for her leg pain with decent relief. Due to a urinalysis suggestive of infection, she was given one tablet of DS TMP/SMX. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: MICU physical: Tmax: 36.3 ??????C (97.4 ??????F) Tcurrent: 36.3 ??????C (97.4 ??????F) HR: 92 (92 - 94) bpm BP: 209/138(152) {201/134(151) - 209/138(152)} mmHg RR: 19 (19 - 30) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Height: 59 Inch General: well-appearing young woman in no acute distress HEENT: no scleral icterus; prosthetic right eye Neck: supple Chest: clear to auscultation throughout, no wheezes/rales/ronchi CV: regular rate/rhythm, normal s1s2, no murmurs Abdomen: soft, nontender, nondistended, PD catheter in place in left abdomen Back: very mild spinal tenderness over approx L3 level of spine Extremities: no edema, 1+ PT pulses, warm Skin: no rashes or jaundice Neuro: alert, oriented x3, 5/5 strength in bilateral deltoids, biceps, triceps, hip flexors/extensors, ankle flexors/extensors; unable to elicit patellar reflexes bilaterally; negative straight leg raise bilaterally Pertinent Results: 138 111 54 -----------------< 83 5.4 14 8.2 . WBC: 3.7 HCT: 19 PLT: 101 N:69.3 L:23.4 M:5.5 E:1.7 Bas:0.1 PT: 21.9 PTT: 48.2 INR: 2.1 . Trends: HCT: 19 -> 22 w 1u then received another unit. INR 3.4 on discharge Discharge chem: Glucose-104 UreaN-51* Creat-8.4* Na-136 K-5.3* Cl-106 HCO3-18* AnGap-17 . [**2141-9-8**] 07:30AM BLOOD CK(CPK)-126 [**2141-9-5**] 02:50PM BLOOD HCG-<5 . [**2141-9-8**] 1:37 pm PERITONEAL FLUID GRAM STAIN (Final [**2141-9-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count . MRI L-spine: IMPRESSION: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. . CXR admit: IMPRESSION: Moderate cardiomegaly, bilateral pleural effusions, and pulmonary vascular prominence consistent with pulmonary edema. . Hip film: FINDINGS: No comparisons. No acute fracture or dislocation is seen. No lucent or sclerotic lesion is noted. There is a distal aspect of a catheter or shunt seen in the pelvis. Soft tissues are otherwise unremarkable. There is minimal degenerative change of the pubic symphysis. IMPRESSION: No acute fracture or dislocation. . Abdominal film: FINDINGS: A PD catheter is seen with its tip coiled in the pelvis. There is normal bowel gas. The underlying osseous structures are unremarkable. IMPRESSION: PD catheter with tip coiled in the pelvis . CXR [**9-8**]: IMPRESSION: Marked cardiomegaly, unchanged. Interval resolution of pulmonary edema. Brief Hospital Course: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. She was initially admitted to the MICU for hypertensive urgency and then transfered to the floor after a day. # Hypertensive urgency: had been on labetalol drip in the ED, but this was stopped due to nausea (presumed that her BP was coming down too fast). She was started on her home meds and tolerated these fairly well. Transferred to the floor and noted to have SPBs in the 90s. She required 1L IVF bolus since her baseline SBP is thought to run in the 130-170 range. She also had transient dizziness during this episode. BP meds were held and later that night her SBP was in the 220s. BP meds restarted. She remained stable thereafter with SBPs in the 130-170s. We opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # Right leg pain: no evidence of avascular necrosis or fracture on plain film. MRI and plain films were ordered and showed no acute pathology. The pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. CK was normal. Pain was treated with dilaudid initially. On day of discharge, she was able to ambulate without gait abnormality or pain. PT saw her and rec outpt PT followup. . # CKD V: PD catheter placement in place. Pt was tried on PD on a number of occasions but did not tolerate it [**2-11**] pain. KUB confirmed tip in place. Cx of peritoneal fluid not suggestive of peritonitis. K remained mildly elevated. Hyperpara treated with sevelamer (although patient refused) then tums. Pt will reconsider PD as outpatient. . # Anemia: chronic. Received 2u pRBC while inhouse for Hct in the 18-19 range. Had appropriate response. Not on Epo given hypertension . # ID: Rx with cipro for ? UTI although urine cx neg. Also had temp to 101 on evening prior to discharge. No clear source. PD fluid cultured and NGTD. Pt remainded HD stable on day of discharge. . # Prior SVC thrombus. Continued warfarin with appropriate INR checks. INR elevated on day of discharge. Rec holding coumadin for 2d . # Systemic lupus erythematosus: cont home prednisone dose . # Dispo status: ambulating, pain free, BP in the 150/90 range Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly Vicodin prn Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO WEEKLY (). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*20 Capsule(s)* Refills:*0* 9. Outpatient Physical Therapy Please provide PT for right hamstring injury 10. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*0* 11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold dose until [**9-10**]. Disp:*30 Tablet(s)* Refills:*0* 12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO once a day: goal is [**1-11**] soft bowel movements per day. Disp:*500 ml* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - HTN urgency - right leg pain - thought [**2-11**] hamstring injury - chronic kidney disease - not currently on dialysis - SLE - anemia [**2-11**] CKD and SLE - hx of SVC thrombosis on coumadin now Secondary: - hx hypertrophic obstructive cardiomyopathy - chronic thrombocytopenia Discharge Condition: ambulating without difficulty. tolerating oral diet. afebrile and SBP in the 130-150 range. Discharge Instructions: You came in with right leg pain and poorly controlled hypertension. Your blood pressure was controlled initially with IV medications then your home medications. Since your blood pressure was occasionally low, we recommend that you hold your labetalol if you are feeling lightheaded or have dizziness or have blood pressure less than 110/60. In terms of your leg pain, we performed xrays, ultrasound, and MRI without finding a cause. We suspect a hamstring injury given its location. Please take pain medications if needed. We recommend followup with physical therapy. You also had a fever which is suggestive of infection. We treated you with cipro in case you had a UTI. Otherwise, your cultures were unrevealing. We attempted peritoneal dialysis but this was unsuccessful. Please followup with your nephrologist. Please return to the ED if you experience headache, chest pain, shortness of breath, high fevers, or worsening leg pain. Please hold your coumadin for two days then restart as per previously written. Please take lactulose for constipation. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-9-12**] 5:00 Provider: [**Name10 (NameIs) 706**] NURSE Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 2:00 Provider: [**Name10 (NameIs) 7548**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 3:00 Please followup with your nephrologist and PCP. [**Name10 (NameIs) **] would like you to see your nephrologist within the next 1-2 weeks. ",137,2141-09-05 20:04:00,2141-09-08 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transfered to the floor after a day. # hypertensive urgency: had been on labetalol drip in the ed, but this was stopped due to nausea (presumed that her bp was coming down too fast). she was started on her home meds and tolerated these fairly well. transferred to the floor and noted to have spbs in the 90s. she required 1l ivf bolus since her baseline sbp is thought to run in the 130-170 range. she also had transient dizziness during this episode. bp meds were held and later that night her sbp was in the 220s. bp meds restarted. she remained stable thereafter with sbps in the 130-170s. we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # right leg pain: no evidence of avascular necrosis or fracture on plain film. mri and plain films were ordered and showed no acute pathology. the pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. ck was normal. pain was treated with dilaudid initially. on day of discharge, she was able to ambulate without gait abnormality or pain. pt saw her and rec outpt pt followup. . # ckd v: pd catheter placement in place. pt was tried on pd on a number of occasions but did not tolerate it [**2-11**] pain. kub confirmed tip in place. cx of peritoneal fluid not suggestive of peritonitis. k remained mildly elevated. hyperpara treated with sevelamer (although patient refused) then tums. pt will reconsider pd as outpatient. . # anemia: chronic. received 2u prbc while inhouse for hct in the 18-19 range. had appropriate response. not on epo given hypertension . # id: rx with cipro for ? uti although urine cx neg. also had temp to 101 on evening prior to discharge. no clear source. pd fluid cultured and ngtd. pt remainded hd stable on day of discharge. . # prior svc thrombus. continued warfarin with appropriate inr checks. inr elevated on day of discharge. rec holding coumadin for 2d . # systemic lupus erythematosus: cont home prednisone dose . # dispo status: ambulating, pain free, bp in the 150/90 range ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Nausea alone; Other antihypertensive agents causing adverse effects in therapeutic use; Hip and thigh injury; Unspecified accident; Hypotension, unspecified; Anemia, unspecified; Personal history of venous thrombosis and embolism; End stage renal disease; ; Urinary tract infection, site not specified; Hyperpotassemia; Acidosis; Disorders of phosphorus metabolism; Hypocalcemia; Secondary hyperparathyroidism (of renal origin)]","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. # right leg pain: no evidence of avascular necrosis or fracture on plain film. also had temp to 101 on evening prior to discharge. # systemic lupus erythematosus: cont home prednisone dose .","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension. she presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transferred to the floor after a day. she was started on her home meds and tolerated them fairly well." 109,176760.0,14805,2142-01-23,14796,139061.0,2141-09-14,Discharge summary,"Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Right leg pain. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 24 y.o. F with lupus, Chronic Kidney Disease V (not currently on HD or PD), and multiple admissions for hypertensive urgency/emergency, who presented to the ED for continued R leg pain that starts in her R buttocks and refers down her R leg. She describes it as feeling like the pain is deep within her bone. The pain was [**10-20**] in the AM, and she felt like she couldn't get out of bed. Denies any swelling of her RLE. When getting VS in [**Name (NI) **], pt noted to be very hypertensive at 263/176. The patient reportedly has baseline SBPs in 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM on day of admission. She denies any recent recrational drug use including cocaine and amphetamines. She denies headache, vision changes, double vision, chest pain, shortness of breath, abdominal pain, BRBPR, dysuria. During MD interview, the patient was nauseous and had small amount of emesis of a recent Coolata. Pt states that flushing her PD cath causes a large amount of stomach pain. . Of note, the patient was recently admitted from 08.26-29.08. The patient initially presented to the ED after referral from her nephrologist's office where she had complaints of right leg pain and was found to be hypertensive to 250/145. She was admitted after initiation of a labetalol drip and nitropaste with improvement in sbp to 180. The patient did receive 2 U of PRBC's during this hospitalization for baseline anemia. The patient did have a work-up for her right leg pain complaints with plain films of the right hip and MRI of the L-spine which did not reveal an explanation for her symptoms and did rule out avascular necrosis. The patient received dilaudid for pain control and was ambulating without pain prior to discharge. In addition, the patient completed a course of ciprofloxacin for a positive UA with negative cultures. The patient was unable to tolerate peritoneal dialysis for unclear reasons. Peritoneal dialysate culture was negative for infection. . In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in ED ranged from [**Telephone/Fax (3) 43494**]-175 with HR in 96-108. Initially given labetalol 10 mg IV x 1 and then started on labetalol gtt for her elevated blood pressures and titrated to 3 mg/min. LENI of R leg was negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per ED, cannot do V/Q scan due to volume overload after talking with radiology. Renal c/s initiated. A-line placed. Past Medical History: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] . PAST SURGICAL HISTORY: - Placement of multiple catheters including dialysis. - Tonsillectomy. - Left eye enucleation in [**2140-4-10**]. - PD catheter placement in [**2141-5-11**]. Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 98.9 [**Telephone/Fax (2) 43495**] 99$% RA GEN: NAD, pleasant female sitting in bed with moon facies HEENT: EOMI of R eye, L eye prosthesis, no exudate, no erythema, MMM, no LAD CHEST: CTAB except at R base with decreased breath sounds; no w/r/r CV: tachy, normal S1S2, II/VI systolic murmur accentuated with Valsalva ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i EXT: no c/c/e, strength of LEs [**5-15**] and symmetric bilaterally. Negative straight leg test, no pain with internal rotation, external rotation, extension, adduction or abduction. Some pain on flexion at the hip. NEURO: II - XII intact to direct testing. No deficit in light tough sensation. Gait normal. DERM: no rashes noted Pertinent Results: LABS AT ADMISSION: [**2141-9-11**] 11:43AM GLUCOSE-86 UREA N-49* CREAT-8.1* SODIUM-139 POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-16* ANION GAP-18 [**2141-9-11**] 11:43AM CALCIUM-6.2* PHOSPHATE-5.8* MAGNESIUM-1.6 [**2141-9-11**] 11:43AM PT-18.4* PTT-42.8* INR(PT)-1.7* [**2141-9-11**] 07:00AM WBC-5.5 RBC-2.88* HGB-8.1* HCT-24.7* MCV-86 MCH-28.1 MCHC-32.8 RDW-18.0* [**2141-9-11**] 07:00AM NEUTS-74.7* LYMPHS-17.5* MONOS-4.2 EOS-3.3 BASOS-0.2 [**2141-9-11**] 07:00AM PLT COUNT-101* UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50 WBC . MICROBIOLOGY: Urine culture ([**2141-9-11**]): Mixed flora . STUDIES: Cardiology Report ECG Study Date of [**2141-9-11**] 6:55:16 AM Sinus tachycardia. The tracing is marred by baseline artifact. There is left atrial enlargement. Compared to the previous tracing of [**2141-9-5**] the rate has increased. The axis is more rightward. Otherwise, no diagnostic interim change. . UNILAT LOWER EXT VEINS RIGHT Study Date of [**2141-9-11**] 8:54 AM [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and popliteal veins demonstrate normal flow, compressibility, augmentation, waveforms. Appropriate color flow and compression is noted within the calf veins. No intraluminal thrombus is present. IMPRESSION: No evidence of right lower extremity DVT. . TTE ([**2140-8-26**]): The left atrium is normal in size. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . R HIP XR [**2141-9-6**]: No acute fracture or dislocation. . MRI L-SPINE [**2141-9-6**]: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. LAB RESULTS AT DISCHARGE: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-9-14**] 06:15AM 4.0 2.63* 7.6* 23.1* 88 29.1 33.0 18.0* 100* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-9-14**] 06:15AM 100 44* 8.1* 137 4.8 109* 17* 16 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2141-9-14**] 06:15AM 6.8* 5.4* 1.6 CALCIUM freeCa [**2141-9-14**] 11:30AM 0.94* Brief Hospital Course: ICU course: EKG showed no change from prior, and CXR showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home medication regimen. The patient was found to by hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. . [**Hospital1 **] history: . 1. Hypertensive urgency: During the patient's [**Hospital1 **] stay, her SBPs ranged from 140s-160s during the day, which is her baseline systolic blood pressure. She was maintained on her home oral medication regimen. At night, she became more hypertensive, with SBP to the 170s-180s, which was controlled with both IV hydralazine and PO nifedipine. PO nifedipine was most successful at bringing her SBP back to her baseline. SBP at discharge was 140. Throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. The renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. Right leg pain: Upon arrival on the floor, the patient complained of [**2143-4-15**] pain in R buttock and posterior thigh, much exacerbated with standing. Of note, lumbar spine MRI and R hip XR on most recent admission were both negative. Her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. Her pain when she was symptomatic was controlled well with PO dilaudid. If the pain recurs, an MRI of the right hip can be considered to evaluate for osteonecrosis. . 3. UTI: The patient had a urinalysis suggestive of UTI, though she remained asymptomatic throughout. She was treated with a three day course of ciprofloxacin. Her urine culture showed mixed flora consistent with skin contamination. . 4. ESRD: The patient has end-stage renal disease due to her lupus. The patient's creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. She was followed by the renal consult service. Her potassium remained stable. Her calcium was low during admission, and supplemental calcium was given in addition to starting Calcitriol. She was not dialyzed through her PD catheter secondary to discomfort, but may reinitiate PD as an outpatient. Her laboratories will be checked as an outpatient in renal clinic. . 5. Anemia: The patient's hematocrit remained near her baseline low 20s throughout her stay. She has anemia from chronic kidney disease and chronic disease. The patient is not on Epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. Prior SVC thrombus: The patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with INR goal 2.5 to 3.0. . 7. Systemic lupus erythematosus: No active issues. The patient's home prednisone regimen was continued. Medications on Admission: - Prednisone 5 mg Daily - Coumadin 2 mg at bedtime - Nifedipine 60 mg Sustained Release Daily - Hydralazine 50 mg every 8 hours - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY - Aliskiren 150 mg Twice daily - Docusate Sodium 100 mg 2 times a day - Labetalol 900 mg three times a day - Lactulose 15-30 ml once a day: goal is [**1-11**] soft bowel movements per day Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 7. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: - Hypertensive urgency - Right lower extremity pain - Urinary tract infection Secondary diagnosis: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) - HOCM: Last noted on echo [**8-17**] - Anemia - History of left eye enucleation [**2139-4-20**] for fungal infection - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Discharge Condition: Stable systolic blood pressure over past 24 hours. Discharge Instructions: You were admitted to the hospital for uncontrolled high blood pressure. You spent one day in the intensive care unit, where you were treated with intravenous medication to lower your blood pressure. You were then transferred to a regular hospital floor, where your blood pressure was managed with your home oral medications. You were also treated for urinary tract infection with antibiotics. Your right leg pain improved during admission, and we are unsure of the cause of this pain. You should discuss the need for an MRI of the hip if the pain returns when you meet with your primary care doctor. Please call your physician or return to the emergency room if you experience fever, chills, chest pain, difficulty breathing, abdominal pain, headache, changes in your vision, or any other symptoms that are concerning. Please take your medications as prescribed. - Calcitriol was added to your medications. - You should hold Coumadin for two days and restart Saturday, [**2141-9-16**]. You should have your INR checked at your visit in kidney clinic [**2141-9-18**]. - You can take Dilaudid 2-4 mg every eight hours as needed for pain. You should be vigilant about taking lactulose if you need to take Dilaudid. - You should continue Lactulose as per Dr.[**Name (NI) 12913**] instructions. - No other changes were made. Please keep follow up appointments as described below. Followup Instructions: Please call the office of your kidney doctor, Dr. [**Last Name (STitle) 4883**], at ([**Telephone/Fax (1) 773**] to schedule an appointment for [**Last Name (LF) 766**], [**9-19**] as discussed. Follow up with your lung doctor: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-9-21**] 1:00 Follow up with your new primary care doctor: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 ",131,2141-09-11 10:12:00,2141-09-14 20:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home medication regimen. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. . [**hospital1 **] history: . 1. hypertensive urgency: during the patients [**hospital1 **] stay, her sbps ranged from 140s-160s during the day, which is her baseline systolic blood pressure. she was maintained on her home oral medication regimen. at night, she became more hypertensive, with sbp to the 170s-180s, which was controlled with both iv hydralazine and po nifedipine. po nifedipine was most successful at bringing her sbp back to her baseline. sbp at discharge was 140. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. the renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. her pain when she was symptomatic was controlled well with po dilaudid. if the pain recurs, an mri of the right hip can be considered to evaluate for osteonecrosis. . 3. uti: the patient had a urinalysis suggestive of uti, though she remained asymptomatic throughout. she was treated with a three day course of ciprofloxacin. her urine culture showed mixed flora consistent with skin contamination. . 4. esrd: the patient has end-stage renal disease due to her lupus. the patients creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. she was followed by the renal consult service. her potassium remained stable. her calcium was low during admission, and supplemental calcium was given in addition to starting calcitriol. she was not dialyzed through her pd catheter secondary to discomfort, but may reinitiate pd as an outpatient. her laboratories will be checked as an outpatient in renal clinic. . 5. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay. she has anemia from chronic kidney disease and chronic disease. the patient is not on epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. prior svc thrombus: the patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with inr goal 2.5 to 3.0. . 7. systemic lupus erythematosus: no active issues. the patients home prednisone regimen was continued. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Urinary tract infection, site not specified; Other primary cardiomyopathies; Systemic lupus erythematosus; Sciatica; Hyperpotassemia; Thrombocytopenia, unspecified; Abnormal coagulation profile; Hyperparathyroidism, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism]","icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the renal team was consulted, and recommended no change to home medication regimen. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. she was treated with a three day course of ciprofloxacin. esrd: the patient has end-stage renal disease due to her lupus. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay.","ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. she became more hypertensive, with sbps to the 170s-180s during the day. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency." 109,176760.0,14805,2142-01-23,14797,172335.0,2141-09-24,Discharge summary,"Admission Date: [**2141-9-18**] Discharge Date: [**2141-9-24**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1936**] Chief Complaint: hip pain Major Surgical or Invasive Procedure: None History of Present Illness: 24yo woman with hx SLE, CKD(not currently on HD or PD), labile HTN here with right leg pain and HTN urgency. Patient was recently d/ced on [**9-14**] following admission for the same complaints. . Patient took her hydralazine dose on am of admission. BP at presentation to the ER was 250/140 (The patient reportedly has baseline SBPs in 130-170s) She was given 900 labetolol and 50 hydralazine in the ED. BP following this was 175/124. Her EKG was unchanged. K was 5.7. . Patient also complaining of [**10-20**] right hip pain. Patient was d/ced on [**9-14**] with oral dilaudid for hip/leg pain. She took this only for one day due to severe itching. Denies any parasthesias/weakness. Her RLE/hip pain has been extensively worked up with negative LENIs, Lumbar spine MRI and hip plain films in the past. She was given 4mg IV morphine in the ER. . On admission to the floor, leg/hip pain somwhat improved with morphine.She denies any headache, vision changes, double vision, chest pain or SOB. Feels warm but no chills. Past Medical History: Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 97.3 HR 81 BP 135/91 RR 16 100%RA Gen:NAD, happy, pleasant female HEENT:NC/AT, L eye prosthesis, R PERRL, EOMI, MMM, facial swelling, L side>R, scerla anicteric Neck: supple, no JVD, no LAD, scars from prior CVL and HD lines CV:S1S2+, 2/6 SEM LUSB, loud P2, RRR, no ectopy Pulm: CTA B/L, good inspiratory effort Abd: +BS, soft, nontender, slightly distended and resonant to percussion, PD catheter in place in left abdomen ext: no c/c/e, 2+DP b/L, L foream swollen>R, R hip is mobile without pain elicited on passive or active movement neuro: AAOx3, nonfocal exam, CN 2-12 intact, moves all 4 extremities psych: mood/affect appropriate Pertinent Results: MRI Right Hip ([**9-18**]): There is no signal abnormality on the fluid-sensitive sequences in the proximal femur, acetabulum, or other osseous structure. On T1- weighted images, there is a focal rounded region within the right femoral head measuring approximately 9 mm in a subchondral location, which is nonspecific but may represent an unusual focus of red marrow. No sclerosis is seen on the corresponding plain films. There is a small right hip joint effusion and a small amount of fluid in the left hip joint as well, at the upper limits of normal. There is no soft tissue abnormality, no muscular edema, and no fluid collections. IMPRESSION: 1. Small right hip joint effusion. 2. No bone marrow edema in the proximal femurs or the pelvis. 3. Nonspecific small focus of low signal on T1-weighted images in the right femoral head is nonspecific but may represent an unusual focus of red marrow. TTE ([**9-21**]): The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF 80%). A mild (18 mmHg) mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. There is no systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Severe symmetric left ventricular hypertrophy with hyperdynamic systolic function and mild mid-cavitary gradient. Mild aortic regurgitation. Moderate pulmonary hypertension. Findings consistent with hyperrtophic cardiomyopathy. Compared with the prior study (images reviewed) of [**2140-8-26**], pulmonary hypertension has developed (also present on the study from [**2140-5-20**]). Pericardial effusion is also new. V/Q scan ([**9-21**]): Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate no focal defects with improved ventilation to the posterior right basal segment. Perfusion images in the same 8 views show improved perfusion to the posterior right basal segement with a persistent small defect but no new findings. Chest x-ray shows cardiomgealy and left basilar atelectasis. IMPRESSION: Improved V/Q scan from [**9-/2139**] with no findings to suggest acute pulmonary embolism. B/L upper ext U/S ([**9-21**]): Grayscale and Doppler son[**Name (NI) 867**] of the right and left internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. There is nonocclusive focal thrombus seen in the left subclavian vein, where the vein is not fully compressible. Flow is seen in the region, indicating that the thrombus is nonocclusive. Elsewhere, normal flow, augmentation, compressibility were appropriate and waveforms are demonstrated. IMPRESSION: 1. Focal nonocclusive thrombus in the left subclavian vein. 2. Otherwise, patent upper extremity veins as described. [**2141-9-18**] 02:15PM POTASSIUM-5.1 [**2141-9-18**] 02:15PM HCT-21.2* [**2141-9-18**] 08:45AM POTASSIUM-5.7* [**2141-9-18**] 07:30AM GLUCOSE-88 UREA N-54* CREAT-8.6* SODIUM-136 POTASSIUM-5.8* CHLORIDE-108 TOTAL CO2-15* ANION GAP-19 [**2141-9-18**] 07:30AM estGFR-Using this [**2141-9-18**] 07:30AM CALCIUM-7.3* PHOSPHATE-5.3* MAGNESIUM-1.6 [**2141-9-18**] 07:30AM WBC-5.2 RBC-2.32* HGB-6.5* HCT-20.1* MCV-87 MCH-28.1 MCHC-32.4 RDW-18.4* [**2141-9-18**] 07:30AM NEUTS-78.0* LYMPHS-14.7* MONOS-3.9 EOS-3.2 BASOS-0.3 [**2141-9-18**] 07:30AM PLT COUNT-107* [**2141-9-18**] 07:30AM PT-20.8* PTT-43.3* INR(PT)-2.0* . [**2141-9-21**] CXR: There is no significant change when compared to the recent previous examination. The previously described left retrocardiac opacity is unchanged in appearance. Cardiomegaly is also unchanged. The mediastinal contour, bony thorax and pulmonary vasculature are normal. IMPRESSION: No significant change compared to study done roughly 7 hours prior. Brief Hospital Course: 24 yo with h/o of Lupus, HTN, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for R hip pain. Patient was on the floor on [**9-20**], given morphine for the hip pain. She then had an episode of hypotension and unresponsiveness and transferred to the MICU for closer monitoring. The patient got 2L IVFs and narcan and improved, in fact, found to be hypertensive upon arrival to MICU. . MICU Course: On [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. Concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. Mental status cleared somewhat with narcan. Renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. V/Q scan demonstrated improvement since prior study. Patient's home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. She was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. PD fluid was not c/w SBP. CXR was clear. Urine culture and blood cultures are pending. Patient's BP was in the 110s so hydralazine was stopped. Her other BP meds were otherwise continued. Plan was/is to follow renal recs for PD. If, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. Would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. If patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. Would add neurontin 100mg TID with room to titrate up to 300mg TID. Neuro also recommended PT with TENS unit and referral to pain clinic although patient's pain is currently absent. . FYI **** per Dr. [**Last Name (STitle) **] --- Because of ? increase in cardiomegaly on CXR, she got an echo yesterday. In addition to her known HOCM, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm Hg. They probably need to be followed up over time (particularly the pulmonary hypertension). We did evaluated the PHTN with a VQ scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. It would be good if we could arrange a PULMONARY CLINIC FOLLOW UP for Ms. [**Known lastname **] after discharge with either [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].**** . She underwent CT head, and V/Q scan which were unremarkable. Her steroid dose was increased to 15mg given concern for need for stress dose steroids. After transfer from the MICU, her steroids were dropped back to 5mg, her home dose with the approval of [**Last Name (un) **]. . Her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. Her hydralazine was discontinued. On day 2 of her MICU stay, she developed a fever to 102. She was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. Broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. There was question of retrocardiac opacity on CXR, though not clear. Rheum consult obtained given hip discomfort, who felt septic joint unlikely. Neurology consult obtained who felt autonomic seizure unlikely. . Pt initiated peritoneal dialysis. In this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising BPs. She is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. Her hip pain has resolved completely without further intervention. . Floor course: Fever: Spike fever in MICU to 102. Started on Levoquin, Aztreonam, and Vanc. Source unclear at this point, but CXR with question of retrocardiac opacity. There is a possibility of aspiration pneumonitis. Other etiologies include peritoneal fluid (PD cath), urine, and blood (though patient does not have any indwelling lines). Hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. Peritoneal dialysis cultures negative so far. Continued levo/vanco/aztreonam for 2 days empirically. Then d/ced the Abx as no infectious etiologies were found. Steroids back to home dosage. BCx, UCx (final neg), Peritoneal cultures negative at discharge. . # Labile blood pressure: h/o of difficult to control BP with episodes of hypertensive emergency in the past. Normal SBP runs in 170s. Having nausea in setting of new PD, no evidence of intracranial bleeding on clinical exam, though INR had been supratherapeutic so remains in differential, though not bradycardic. Continue home BP meds :Labetalol 900 mg PO TID but difficult for patient to tolerate due to nausea, Aliskiren *NF* 150 mg Oral [**Hospital1 **], NIFEdipine CR 60 mg PO DAILY, clonidine patch, hydralazine given hypertensive in setting of nausa. . # Right leg/hip pain: no evidence of avascular necrosis or fracture on MRI though there is a small effusion. Pain resolved without intervention. Continued to monitor and would avoid narcotics, restart slowly if pain resumes. Physical therapy to follow as an outpatient. [**Last Name (un) 18183**] followed. Please see consult note. . # Hyperkalemia: Chronic issue. Patient takes kayexalate intermittently per her report (last dose [**Last Name (un) 766**]). Monitored K but patient did not need it on floor. # CKD V: Renal following. Did well with PD on [**9-22**] but did report some nause and cramping. She was not tolerating all 1.5L in exchanges on discharge. # Anemia: Hct stable around 20. S/p 1 U PRBCs in MICU with Hct 20.1 to 21.9. Likely due to chronic hemolysis consistent with SLE> #. Prior SVC thrombus: Physical exam with L arm swelling consistent with this. No flow limitations. INR 3.5 on ICU admission. Held warfarin but restarted home 2mg daily the day before discharge. # Systemic lupus erythematosus: Home prednisone dose 5mg. Currently on 15mg in setting of acute illness (day 2). # General care: FEN: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, PD initiated, Proph: INR therapeutic, no indication for PPI, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. Code: Full code, confirmed with patient Communication: with the patient and her mother [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (2) 43497**]contact. Access: 2 PIVs Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly dilaudid PO prn benadryl prn lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily coumadin 2mg PO qday calcitriol 1 mcg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Hypertensive urgency Transient Hypotension due to Narcotics Sciatica . Secondary: End stage renal disease Systemic Lupus Erythematosus Anemia Discharge Condition: Stable. Blood pressures at baseline. Hip/leg pain resolved. Ambulating without assistance. Discharge Instructions: You were admitted to the hospital with high blood pressure and right leg/hip pain. We gave you pain medications and blood pressure lowering medications. Your blood pressure then dropped which was caused by the pain medication, and you were transferred to the Intensive Care Unit(ICU) where you recovered quickly. During your stay in the ICU, you developed a fever and were started on antibiotics. However, the cultures that were obtained were negative, and we discontinued the Antibiotics. During your hospitalization, your blood pressure normalized on your home regimen, and your right leg/hip pain resolved. You had an MRI of your hip done, which did not show an acute infection. You were seen by the kidney doctors and they recommended starting peritoneal dialysis. You were also given some blood for your anemia. Please follow up with the Peritoneal Dialysis nurse at the scheduled day/time. Please make an appointment to meet with your PCP in the next couple of weeks. Your Hip pain may benefit from physical therapy or outpatient anesthetic joint injection. Please discuss these options with your rheumatologist. . Please call the number given below to schedule outpatient physical therapy. . Please restart your home medications. You were also started on Sodium Bicarb 650mg by mouth three times a day. . If you develop fevers, chills, trouble breathing, chest pain, worsening of hip pain, headaches, changes in your vision or any other symptoms that concern you please return to the emergency room or call your doctor. Followup Instructions: Please follow up with your Peritoneal Dialysis nurse ([**Doctor First Name 3040**]) on [**Doctor First Name 766**] [**2141-9-25**] . Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 . Please call to schedule Outpatient Physical Therapy:[**Telephone/Fax (1) 2484**] Completed by:[**2141-9-25**]",121,2141-09-18 10:32:00,2141-09-24 13:53:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,LEG PAIN," 24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. patient was on the floor on [**9-20**], given morphine for the hip pain. she then had an episode of hypotension and unresponsiveness and transferred to the micu for closer monitoring. the patient got 2l ivfs and narcan and improved, in fact, found to be hypertensive upon arrival to micu. . micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. mental status cleared somewhat with narcan. renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. v/q scan demonstrated improvement since prior study. patients home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. she was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. pd fluid was not c/w sbp. cxr was clear. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. plan was/is to follow renal recs for pd. if, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. would add neurontin 100mg tid with room to titrate up to 300mg tid. neuro also recommended pt with tens unit and referral to pain clinic although patients pain is currently absent. . fyi **** per dr. [**last name (stitle) **] --- because of ? increase in cardiomegaly on cxr, she got an echo yesterday. in addition to her known hocm, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm hg. they probably need to be followed up over time (particularly the pulmonary hypertension). we did evaluated the phtn with a vq scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. it would be good if we could arrange a pulmonary clinic follow up for ms. [**known lastname **] after discharge with either [**first name4 (namepattern1) **] [**last name (namepattern1) **] or [**first name4 (namepattern1) **] [**last name (namepattern1) **].**** . she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. after transfer from the micu, her steroids were dropped back to 5mg, her home dose with the approval of [**last name (un) **]. . her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. her hydralazine was discontinued. on day 2 of her micu stay, she developed a fever to 102. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. there was question of retrocardiac opacity on cxr, though not clear. rheum consult obtained given hip discomfort, who felt septic joint unlikely. neurology consult obtained who felt autonomic seizure unlikely. . pt initiated peritoneal dialysis. in this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising bps. she is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. her hip pain has resolved completely without further intervention. . fever: spike fever in micu to 102. started on levoquin, aztreonam, and vanc. source unclear at this point, but cxr with question of retrocardiac opacity. there is a possibility of aspiration pneumonitis. other etiologies include peritoneal fluid (pd cath), urine, and blood (though patient does not have any indwelling lines). hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. peritoneal dialysis cultures negative so far. continued levo/vanco/aztreonam for 2 days empirically. then d/ced the abx as no infectious etiologies were found. steroids back to home dosage. bcx, ucx (final neg), peritoneal cultures negative at discharge. . # labile blood pressure: h/o of difficult to control bp with episodes of hypertensive emergency in the past. normal sbp runs in 170s. having nausea in setting of new pd, no evidence of intracranial bleeding on clinical exam, though inr had been supratherapeutic so remains in differential, though not bradycardic. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. . # right leg/hip pain: no evidence of avascular necrosis or fracture on mri though there is a small effusion. pain resolved without intervention. continued to monitor and would avoid narcotics, restart slowly if pain resumes. physical therapy to follow as an outpatient. [**last name (un) 18183**] followed. please see consult note. . # hyperkalemia: chronic issue. patient takes kayexalate intermittently per her report (last dose [**last name (un) 766**]). monitored k but patient did not need it on floor. # ckd v: renal following. did well with pd on [**9-22**] but did report some nause and cramping. she was not tolerating all 1.5l in exchanges on discharge. # anemia: hct stable around 20. s/p 1 u prbcs in micu with hct 20.1 to 21.9. likely due to chronic hemolysis consistent with sle> #. prior svc thrombus: physical exam with l arm swelling consistent with this. no flow limitations. inr 3.5 on icu admission. held warfarin but restarted home 2mg daily the day before discharge. # systemic lupus erythematosus: home prednisone dose 5mg. currently on 15mg in setting of acute illness (day 2). # general care: fen: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, pd initiated, proph: inr therapeutic, no indication for ppi, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. code: full code, confirmed with patient communication: with the patient and her mother [**name (ni) **] [**name (ni) **], [**telephone/fax (2) 43497**]contact. access: 2 pivs ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Pneumonia, organism unspecified; Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Hyperpotassemia; Sciatica; Other iatrogenic hypotension; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Anemia of other chronic disease; Hypocalcemia]","24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. it would be good if we could arrange a pulmonary clinic follow up for ms. [** she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. source unclear at this point, but cxr with question of retrocardiac opacity. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. did well with pd on [**9-22**] but did report some nause and cramping. # systemic lupus erythematosus: home prednisone dose 5mg.","lupus nephropathy patient on peitoneal dialysis with htn and lupus nephropathy. triggered for hypotension (82/45), hypothermia (92.9), altered mental status. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis." 109,176760.0,14805,2142-01-23,14798,126055.0,2141-11-03,Discharge summary,"Admission Date: [**2141-10-13**] Discharge Date: [**2141-11-3**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 6734**] Chief Complaint: Nausea, Vomitting, Abdominal Pain, HTN Urgenc Major Surgical or Invasive Procedure: Upper GI endoscopy Exploratory laparotomy Tunneled hemodialysis catheter in R femoral vein Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 24 y/o F with h/o ESRD, HTN who started peritoneal dialysis during the week of [**2141-10-8**] and presented with a 1 day history of acute onset N/V, sharp abdominal pain on [**2141-10-13**]. (Of note, the patient had presented to the ED on [**10-11**] with hypotension, SBPs in the 80s off after approximately 1.5L was taken off during dialysis in the setting of taking her PO Anti-HTNs. On [**2141-10-11**] she received 0.5L IVF, labs WNL, and was d/c'd home). On the day of admission on [**2141-10-13**], the patient reported that the previous night, she was awoken from sleep with severe, sharp abdominal pain, 6 episodes of frothy emesis, 10+ yellowish BMs without melena or BRBRP.She was admitted for further work- up of this abdminal pain. . In the ED here vitals were as follows: T: 97.0 HR: 101 BP: 240/180 RR: 17 O2sat: 100%RA. She received Labetolol 20mg IV and was subsequently placed on a labetolol drip. She also received ceftriaxone 1gm IV, Flagyl 500mg IV, Dilaudid 0.5-1mg IV q1hr and Zofran. Her abdominal CT showed multifocal areas of small bowel wall thickening. Her peritoneal Cell count was negtaive for SBP. She had some signs of peritonitis and thus surgery was consulted. Her lactate was normal. . Upon arrival to the MICU the patient was mentating well with complaints of diffuse sharp abdominal pain that radiated to the back and diarrhea. She had no headache or visual changes. Past Medical History: - SLE DX ([**2134**] - 16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter Placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). - Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS: 98.4 HR 98 192/131 21 100%RA GEN: Mild Distress, AOx3 HEENT: PEERLA, EOMI NECK: Supple, No LAD, No bruit RESP: CTAB CARD: 2/6 systolic ejection murmur ABD: soft, moderately tender with +/- guarding, BS+ EXTR: Warm well perfused NEURO: Motor Grossly Intact RECTAL: Yellow Stool BACK: B CVAT Pertinent Results: [**2141-11-3**] 08:50AM BLOOD WBC-3.5* RBC-2.55* Hgb-7.8* Hct-23.6* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.8* Plt Ct-176 [**2141-11-3**] 03:55PM BLOOD PT-15.5* PTT-50.8* INR(PT)-1.4* [**2141-11-3**] 08:50AM BLOOD Glucose-121* UreaN-33* Creat-5.2*# Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [**2141-10-26**] 06:15AM BLOOD ALT-11 AST-49* AlkPhos-122* Amylase-186* TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2141-10-26**] 06:15AM BLOOD Lipase-30 [**2141-11-3**] 08:50AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.9 [**2141-10-30**] 06:55AM BLOOD HBsAg-NEGATIVE [**2141-10-17**] 10:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2141-10-25**] 11:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2141-10-25**] 11:56AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2141-10-25**] 11:56AM URINE RBC-0-2 WBC-[**3-15**] Bacteri-FEW Yeast-NONE Epi-21-50 Blood cultures: all negative EKG ([**2141-10-13**]): Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of [**2141-10-2**] there is no significant diagnostic change. CXR ([**2141-10-13**]): No acute cardiopulmonary abnormality. No free air under the diaphragms. CT chest/abdomen/pelvis ([**2141-10-13**]): There is a moderate-sized pericardial effusion, similar in appearance from [**2141-10-13**]. The great vessels are normal in caliber, without aneurysmal dilatation. Evaluation of the great vessels is limited without IV contrast. Interstitial thickening, particularly within the perihilar regions, is suggestive of fluid overload. There is bibasilar atelectasis with a small focus of consolidation in the right lower lobe (2:35) unchanged from [**2141-10-13**], and may reflect aspiration or pneumonia. Scattered bilateral nodules are largely stable from as far back as [**2139-10-9**]. Specifically, there is a 5 mm nodule in the right middle lobe (2:25), two adjacent nodules in the right lower lobe measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule within the left lower lobe. A nodular density seen adjacent and anterior to the right main pulmonary artery (2:23) may reflect a vessel. There is a small right pleural effusion. Axillary lymphadenopathy, with axillary nodes measuring up to approximately 10 mm in short axis, is seen. Ill- defined soft tissue thickening within the hilus bilaterally may reflect hilar lymphadenopathy, but assessment is limited without IV contrast. A catheter is visualized within the visualized right upper extremity, which may reflect a PICC line that terminates within the right subclavian vein. The esophagus is distended and filled with contrast, with marked wall thickening and edema throughout its entire length, a new finding. There is a moderate- sized hiatal hernia. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval development of a moderate amount of free intraperitoneal air, that layers anteriorly and along the anterior abdominal wall. Additional small clustered foci of extraluminal air is seen adjacent to the proximal stomach and the gastroesophageal junction, with a focus of air tracking into the fissure of ligamentum venosum. Additionally, there appears to be air tracking into the anterior subcutaneous tissues in the region of the umbilicus. These findings are all new from the prior CT on [**2141-10-13**], but free air was present on chest radiograph performed [**2141-10-25**]. There is no obvious evidence of extravasation of oral contrast into the peritoneum. Of note, a peritoneal dialysis catheter is in place that could represent a route of entry of intraperitoneal air. The stomach, small bowel, and colon are filled with contrast, without evidence of obstruction. Evaluation for wall thickening is limited without IV contrast. Limited non-contrast views of the liver demonstrates a rounded 1.6 cm x 1.2 cm hypodensity in the right lobe of the liver, previously characterized as a hemangioma. The liver is otherwise unremarkable. The gallbladder, spleen, pancreas, and adrenal glands demonstrate no gross abnormality. Both kidneys are atrophic. Evaluation of solid organs is limited by lack of IV contrast. There is a peritoneal dialysis catheter, coiled within the pelvis, unchanged. There is a large amount of free fluid throughout the abdomen, similar in appearance to the prior study. CT OF THE PELVIS WITHOUT IV CONTRAST: Uterus and rectum are grossly unremarkable. However, assessment of the rectal wall is limited without IV contrast. OSSEOUS STRUCTURES: Bones are diffusely sclerotic, which may be related to renal osteodystrophy. There is bilateral sacroiliitis. IMPRESSION: 1. Interval development of a moderate amount of free intraperitoneal air, new from [**2141-10-13**]. A peritoneal dialysis catheter is in place and could represent the route of entry of free intraperitoneal air. However, as foci of air is seen in the region of the proximal stomach and GE junction in the setting of a recent endoscopy, perforation cannot be excluded, though no frank extravasation of contrast is identified. 2. New dilation and wall thickening of the entire esophagus, a nonspecific finding that could relate to infectious or inflammatory esophagitis; clinical correlation is recommended. Esophagus is contrast-filled possibly representing reflux. Hiatal hernia. 3. Anasarca, with moderate-sized pericardial effusion, pulmonary edema, and small right pleural effusion. 4. Large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. Imaging cannot exclude SBP, which should be evaluated for clinically. 5. Focus of consolidation within the right lower lobe, could represent aspiration or pneumonia, but unchanged from the prior study. Gastric Biopsies ([**2141-10-18**]): Antrum: Corpus-type mucosa, no diagnostic abnormalities recognized. Jejunum: Small intestinal mucosa, no diagnostic abnormalities recognized. UE Venous U/S: No evidence of DVT of the left upper extremity, without thrombus identified within the left subclavian vein. Brief Hospital Course: This is a 24 year old woman with ESRD secondary to SLE (started peritoneal dialysis approximately one week prior to admission), malignant HTN, h/o SVC syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. Her hospital course was complicated by multiple transfers between the MICU and the floor secondary to hypertensive urgency. # Abdominal Pain/Diarrhea: During the patient's admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. Infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. However, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. The patient was empirically placed on IV flagyl, but this was discontinued when stool samples were negative for C.difficile. Serial abdominal exams showed no peritoneal signs. Peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. CT of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. Other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to SLE vasculitis, malignant HTN, or microthrombosis and SLE enteritis. Surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. A heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible GI bleed. With regards to SLE vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to SLE. On [**10-18**], GI performed an EGD which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. Approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. Both cardiac, GI, and pulmonary etiologies were considered for the origin of her epigastric pain. Pericarditis was considered, but her EKG was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. Her lungs were also essentially unchanged from [**2141-10-13**]. However, her abdominal CT on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. As a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. There were no major findings: no evidence of perforation, obstruction, or infection. The patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. At discharge, the patient only complained of some mild incisional pain. # Hypertensive urgency: The patient was initially admitted to the MICU with a blood pressure of 240/180. Her hospital course was complicated by extremely labile HTN and was transferred back and forth between the MICU and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of SBPs > 260. Throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. Her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. Multiple medication regimens were attempted and changed throughout her hospital course. However, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for SBPs > 180. At discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg PO. Her regimen as per Dr. [**Last Name (STitle) 4883**]: Nifedipine SR 90 mg daily Aliskiren 150 mg [**Hospital1 **] Labetalol 300 mg TID Hydralazine 75 mg TID Clonidine patch 0.3 mg/24 hr patch qWed When SBP>180, she then uses a hydralazine sliding scale. When SBP>180, give 25 mg PO hydral every 30 min until SBP<150. You can use this for up to 2-3 hours. In between PO hydral doses, can then also use 10 IV hydralazine. # ESRD: The etiology of the patient's ESRD is secondary to SLE. Her Creatinine on admission was 7.9, which was near her baseline of 8 - 9. During her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. Prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2L per PD. After her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. Initially, the patient adamantly refused hemodialysis. However, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. As a result, after a long coversation with her primary renal physician, [**Name10 (NameIs) **] agreed to restart hemodialysis. A tunneled catheter was placed in her R femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. She underwent hemodialysis two more times prior to discharge. Upon discharge, her electrolytes were back to her baseline. She is expected to undergo hemodialysis (Tues/[**Last Name (un) **]/SAT) as an outpatient. # Anemia: During her admission, the patient's HCT was monitored daily with HCT to low-mid 20's. On [**2141-10-17**], she was found to have guaiac positive stools and her HCT was found to have dropped to a low of 18.6. The patient was transfused a total of 2 units of [**Date Range **] between [**2141-10-17**] and [**2141-10-18**]. Epo Alfa SC was also given on [**2141-10-17**]. She remained hemodynamically stable. GI consulted and EGD results were as stated above. The patient's HCT remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. Between [**2141-10-23**] - [**2141-10-24**], the patient had a HCT drop from 26 to 20 in the setting of occult positive emesis. She received two units of [**Month/Day/Year **] and her HCT returned to 28. GI was aware and planned to perform a non-urgent EGD on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her HCT returned to baseline. However, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her HCt remained stable and near baseline for the remiainder of her hospital course. # H/O Thrombosis: The patient was initially placed on her home dose of warfarin 2mg qd. Her INR on admission was 1.2. She was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. However, this was stopped for her EGD and after she had evidence of a GI bleed. The heparin drip was discontinued on [**10-22**]. The patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in HCT and in preparation for a possible GI intervention. After her surgery, her coumadin was held and she was off the heparin drip, but her INR continued to drift up, getting as high as 2.6 on [**2141-10-30**]. This was mostly attributed to nutritional deficiency [**2-11**] poor PO intake, but there was concern for possible synthetic dysfunction as well. As a result, she was given a test dose of vitamin K, which she responded to well (Her INR came back down to 1.4). As a result, her home dose of coumadin at 2 mg qday was restarted. At discharge, her INR was still sub- therapeutic at 1.4. Of note, the patient has a history of SVC syndrome and had a L subclavian venous thrombosis. During the last few days of her hospital stay, the patient complained of increased tongue swelling and her L face was noted to be slightly more swollen than previously noted. As a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a DVT within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # SLE: Rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. Her outside rheumatologist was also consulted. Both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # Obstructive sleep apnea: The patient was noted to have OSA based on clinical nocturnal exam during admission. Patient attempted 1 trial of CPAP at 2L/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. The paitent stated that she would pursue further work-up and treatment for OSA as an outpatient. While the mask and CPAP machine were at her bedside throughout her hospital course, the patient rarely used it. # Metabolic Acidosis: The patient's bicarbonate on admission was 13. Her baseline is normally between 16-20. She received 150mEq NaHCO3 over 24hrs from [**Date range (1) 43500**]. During her brief returns to the MICU, her HC03 was 18-19, which was presumed to be her baseline at home secondary to her CRF. At discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. Medications on Admission: Nifedipine 60 mg PO daily Labetalol 900 mg PO TID Hydralazine 50 mg PO TID Clonidine 0.3 mg/24hr patch qWED Lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 4 mg daily Warfarin 2mg PO daily Calcitriol 1 mcg daily Calcium carbonate 500mg QID Dilaudid 2mg PO Q4-6hr prn pain Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*30 Patch Weekly(s)* Refills:*2* 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. [**Hospital1 **]:*1500 ML(s)* Refills:*0* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Twice daily (). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): In addition to 75 mg TID, if SBP>180, take 1 tab every 30 min until BP decreases to 150. If no improvement after 2 hours, call your doctor. [**Last Name (Titles) **]:*300 Tablet(s)* Refills:*6* 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). [**Last Name (Titles) **]:*1500 ML(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet Sustained Release(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 5 days. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. [**Last Name (Titles) **]:*30 Capsule(s)* Refills:*2* 13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO once a day. [**Last Name (Titles) **]:*30 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: end stage renal disease malignant hypertension abdominal free air subclavian deep vein thrombosis initiation of hemodialysis Secondary: SLE Anemia Discharge Condition: stable, pain well controlled, blood pressure at baseline Discharge Instructions: You were admitted for abdominal pain and then subsequently had a very long hospital course with high blood pressures, severe abdominal pain, some free air in your abdomen resulting in an exploratory laparotomy. You have also been initiated on hemodialysis on Tuesday/Thursday/Saturday schedule. Please take all medications as prescribed in the list that you will be given at discharge. There have been some changes to your medications. Please call your doctor if you have any worsening abdominal pain, fevers, chills, nausea, vomiting, headache, palpitations, diarrhea or any other concerning symptoms. Followup Instructions: You will see Dr. [**Last Name (STitle) 4883**] at hemodialysis on Tuesday, [**11-7**], [**2141**]. You should have your coumadin level checked at this appointment. Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] to schedule an appointment in [**1-11**] weeks to have your staples removed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**] ",81,2141-10-13 23:10:00,2141-11-03 18:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. her hospital course was complicated by multiple transfers between the micu and the floor secondary to hypertensive urgency. # abdominal pain/diarrhea: during the patients admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. the patient was empirically placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. serial abdominal exams showed no peritoneal signs. peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. ct of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to sle vasculitis, malignant htn, or microthrombosis and sle enteritis. surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible gi bleed. with regards to sle vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to sle. on [**10-18**], gi performed an egd which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. both cardiac, gi, and pulmonary etiologies were considered for the origin of her epigastric pain. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. her lungs were also essentially unchanged from [**2141-10-13**]. however, her abdominal ct on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. as a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. there were no major findings: no evidence of perforation, obstruction, or infection. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. at discharge, the patient only complained of some mild incisional pain. # hypertensive urgency: the patient was initially admitted to the micu with a blood pressure of 240/180. her hospital course was complicated by extremely labile htn and was transferred back and forth between the micu and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of sbps > 260. throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. multiple medication regimens were attempted and changed throughout her hospital course. however, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for sbps > 180. at discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg po. her regimen as per dr. [**last name (stitle) 4883**]: nifedipine sr 90 mg daily aliskiren 150 mg [**hospital1 **] labetalol 300 mg tid hydralazine 75 mg tid clonidine patch 0.3 mg/24 hr patch qwed when sbp>180, she then uses a hydralazine sliding scale. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. you can use this for up to 2-3 hours. in between po hydral doses, can then also use 10 iv hydralazine. # esrd: the etiology of the patients esrd is secondary to sle. her creatinine on admission was 7.9, which was near her baseline of 8 - 9. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2l per pd. after her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. initially, the patient adamantly refused hemodialysis. however, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. as a result, after a long coversation with her primary renal physician, [**name10 (nameis) **] agreed to restart hemodialysis. a tunneled catheter was placed in her r femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. she underwent hemodialysis two more times prior to discharge. upon discharge, her electrolytes were back to her baseline. she is expected to undergo hemodialysis (tues/[**last name (un) **]/sat) as an outpatient. # anemia: during her admission, the patients hct was monitored daily with hct to low-mid 20s. on [**2141-10-17**], she was found to have guaiac positive stools and her hct was found to have dropped to a low of 18.6. the patient was transfused a total of 2 units of [**date range **] between [**2141-10-17**] and [**2141-10-18**]. epo alfa sc was also given on [**2141-10-17**]. she remained hemodynamically stable. gi consulted and egd results were as stated above. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. she received two units of [**month/day/year **] and her hct returned to 28. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. however, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her hct remained stable and near baseline for the remiainder of her hospital course. # h/o thrombosis: the patient was initially placed on her home dose of warfarin 2mg qd. her inr on admission was 1.2. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. however, this was stopped for her egd and after she had evidence of a gi bleed. the heparin drip was discontinued on [**10-22**]. the patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in hct and in preparation for a possible gi intervention. after her surgery, her coumadin was held and she was off the heparin drip, but her inr continued to drift up, getting as high as 2.6 on [**2141-10-30**]. this was mostly attributed to nutritional deficiency [**2-11**] poor po intake, but there was concern for possible synthetic dysfunction as well. as a result, she was given a test dose of vitamin k, which she responded to well (her inr came back down to 1.4). as a result, her home dose of coumadin at 2 mg qday was restarted. at discharge, her inr was still sub- therapeutic at 1.4. of note, the patient has a history of svc syndrome and had a l subclavian venous thrombosis. during the last few days of her hospital stay, the patient complained of increased tongue swelling and her l face was noted to be slightly more swollen than previously noted. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. her outside rheumatologist was also consulted. both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission. patient attempted 1 trial of cpap at 2l/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. the paitent stated that she would pursue further work-up and treatment for osa as an outpatient. while the mask and cpap machine were at her bedside throughout her hospital course, the patient rarely used it. # metabolic acidosis: the patients bicarbonate on admission was 13. her baseline is normally between 16-20. she received 150meq nahco3 over 24hrs from [**date range (1) 43500**]. during her brief returns to the micu, her hc03 was 18-19, which was presumed to be her baseline at home secondary to her crf. at discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. ","PRIMARY: [Malignant essential hypertension] SECONDARY: [Renal dialysis status; Epilepsy, unspecified, without mention of intractable epilepsy; Constipation, unspecified; Anemia in chronic kidney disease; Abnormal coagulation profile; Obstructive sleep apnea (adult)(pediatric); Other diseases of lung, not elsewhere classified; Other chest pain; Fever, unspecified; Rash and other nonspecific skin eruption; Other chronic pulmonary heart diseases; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified disease of pericardium; Other ascites; Acidosis; Hyposmolality and/or hyponatremia; Abdominal pain, other specified site; Abdominal pain, epigastric; Nausea with vomiting; Diarrhea; Systemic lupus erythematosus; Hyperparathyroidism, unspecified; Anemia, unspecified; Thrombocytopenia, unspecified; Esophageal reflux]","this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. multiple medication regimens were attempted and changed throughout her hospital course. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. upon discharge, her electrolytes were back to her baseline. epo alfa sc was also given on [**2141-10-17**]. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission.","esrd secondary to sle, malignant htn, h/o svc syndrome, and multiple thrombotic events were considered. the patient was placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia." 109,176760.0,14805,2142-01-23,14799,125288.0,2141-11-23,Discharge summary,"Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypertensive Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: (from MICU admit note) 24yoF ESRD-HD, SLE, HTN presents with 1 month abdominal pain and hypertension. Pt has had work-up over recent months for abd pain, including exploratory laparotomy, all of which essentially (-). Was admitted [**Date range (1) 34629**], for abdominal pain, then returned [**11-16**] for sob with (-)CTA, dc'ed [**11-17**]. In [**Hospital1 18**] ED, T98.5 hr95 BP 220/110 then 183/133 RR13 O2 100% on RA, rectal exam negative, guaiac(-), pelvic exam unremarkable with no cervical motion tenderness. Renal was consulted, taken for hemodialysis. CT abd showed large ascites, no other pathology; CT head improved from prior with no acute ICH; cxr(-). Given iv dilaudid for abdominal pain. BP treated with 10mg iv labetalol. Blood and urine cultures drawn, peritoneal fluid cx sent from catheter. Admitted to MICU for hypertension management. Access: R-HD catheter, 1 pIV in hand, 1 non-functioning peritoneal dialysis catheter. Past Medical History: PMH: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSH: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: PE: T:99.4 BP:158/108 HR:95 RR:12 O2 100% RA GEN: NAD/ pt eyes closed due to pain/ pleasant despite pain HEENT: AT, NC, PERRLA, EOMI on R eye, L eye prosthesis, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD CV: S1 & S2, RRR II/VI HSM at R/L USB, no rubs/gallops PULM: CTAB, no w/r/r ABD: soft, mildly tender at PD catheter, ND, + BS, midline incision with steri-stripes, PD catheter dressing C/I/D EXT: warm, dry, +2 distal pulses BL, no edema NEURO: alert & oriented, CN II-XII grossly intact (except L eye), 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: Admission Labs: [**2141-11-18**] 07:00AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.7* Hct-30.7* MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* Plt Ct-142* [**2141-11-18**] 07:00AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.3* [**2141-11-18**] 07:00AM BLOOD Glucose-86 UreaN-22* Creat-5.0* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2141-11-18**] 07:00AM BLOOD ALT-8 AST-39 AlkPhos-92 TotBili-0.3 [**2141-11-18**] 07:00AM BLOOD Lipase-76* [**2141-11-18**] 07:00AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.9 [**2141-11-18**] 11:00PM ASCITES WBC-1265* RBC-1680* Polys-43* Lymphs-1* Monos-2* Mesothe-11* Macroph-43* [**2141-11-18**] 10:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2141-11-18**] 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2141-11-18**] 10:05AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-[**3-15**] Discharge Labs: [**2141-11-23**] 04:40AM BLOOD WBC-2.9* RBC-3.08* Hgb-9.0* Hct-28.3* MCV-92 MCH-29.2 MCHC-31.8 RDW-17.5* Plt Ct-182 [**2141-11-23**] 04:40AM BLOOD PT-20.8* PTT-76.1* INR(PT)-2.0* [**2141-11-23**] 04:40AM BLOOD Glucose-80 UreaN-21* Creat-4.7* Na-139 K-4.8 Cl-106 HCO3-24 AnGap-14 [**2141-11-23**] 04:40AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8 [**2141-11-22**] 04:55AM BLOOD TSH-6.1* [**2141-11-23**] 04:40AM BLOOD Free T4-1.2 Blood cx ([**11-18**], [**11-19**]): 1/4 bottles with coag neg Staph, [**3-14**] NGTD Urine cx ([**11-18**]): mixed flora c/w contamination Peritoneal fluid ([**11-18**]): Gram stain 2+ polys. Culture no growth. Imaging: CXR Portable ([**11-18**]): Since [**2141-11-16**], heart size enlargement is unchanged due to known pericardial effusion. Lungs are otherwise clear. Hilar contours are normal. Incidentally, widening of both acromioclavicular joints is unchanged. CT A/P ([**11-18**]): 1. No evidence of bowel obstruction or rim-enhancing fluid collection. 2. Large ascites, slightly increased from [**2141-11-13**], with peritoneal dialysis catheter in place. Interval removal of surgical skin staples along the abdomen. 3. Moderate pericardial effusion as before. 4. Symmetric heterogeneous attenuation of the kidneys could be related to renal failure; however, pyelonephritis could also give this appearance. Appearance of the kidneys is unchanged from [**2141-11-13**]. CT Head w/o contrast ([**11-18**]): 1. No evidence of acute intracranial hemorrhage. 2. Regions of hypoattenuation in the bifrontal white matter and left posterior temporal lobe have resolved since [**2141-6-11**]. No new regions of hypoattenuation seen. Brief Hospital Course: 1) Hypertension: Patient has history of extremely labile hypertension on an aggressive outpatient regimen. Overnight in the MICU, patient required IV and PO labetalol for SBP > 200. Her hydralazine was increased from 75mg to 100mg TID with mild improvement. Her labetalol was also increased from 300mg to 400mg TID. Her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. TSH was sent and elevated, although free T4 was normal. Plasma metanephrines were sent and pending at discharge. 2) Abdominal pain: CT scan showed increasing ascites, but no acute pathology. Peritoneal fluid was obtained and contained 544 polys. Treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing GPC pairs/clusters. Blood cultures ended up growing 1 out of 4 bottles coag-neg Staph, likely contaminant, so vancomycin was stopped. Since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. The peritoneal cultures remained negative. Her PD catheter was left in place as the patient refuses HD any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) SVC/brachiocephalic thrombosis: Patient's INR was subtherapeutic on admission at 1.3. Due to the proximal location of her old venous thrombi, she was started on a heparin gtt. This was continued during her admission and her warfarin was increased to 5mg daily. Her INR reached 2.0 at discharge (therapeutic range 2-3). The dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) Anxiety: Patient noted feeling short of breath and anxious around the time of her recent admissions. Her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. They felt her symptoms were suggestive of anxiety and panic attacks, recommended checking TSH and metanephrines as above, and starting citalopram 20mg, which was done. She was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h PRN. Patient is agreeable to outpatient follow up with [**Company 191**] social work, and potential CBT. These can be arranged by her PCP. Medications on Admission: 1. Aliskiren 150 mg [**Hospital1 **] 2. Clonidine 0.3 mg/24 qwk 3. Prochlorperazine Maleate 10 mg prn 4. Hydromorphone 2 mg Tablet Sig: [**1-11**] q6 prn 5. Bisacodyl 10mg [**Hospital1 **] 6. Ergocalciferol (Vitamin D2) 50,000 qmonth 7. Hydralazine 75mg tid 8. Hydralazine scale prn 9. Labetalol 300 mg tid 10. Nifedipine 90 mg qd 11. Prednisone 4mg qd 12. Warfarin 2 mg qd at 4pm Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Hospital1 766**]). 5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day. [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 7 days. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO q30 min prn as needed for hypertension: for SBP > 180. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive urgency Headache Abdominal pain Anxiety Secondary Diagnosis: HTN SLE ESRD on HD SVC and IJ thrombosis, chronic Anemia Discharge Condition: Stable, BPs improved. Discharge Instructions: You were admitted with elevated blood pressures, headache, and abdominal pain. You were found to have increased amounts of white blood cells in your abdominal cavity, but this was not infected. Your abdominal pain resolved and you continued to have intermittent headaches. Your blood pressure medications were adjusted as below. You were also seen by psychiatry who recommended starting new medications for your anxiety. The following changes were made to your medication regimen: - We increased your hydralazine to 100 mg three times a day. - We also increased your labetalol to 400 mg three times a day. - We have started a medication called celexa 20 mg daily as well as ativan 1 mg three times a day as needed for anxiety. - We have increased your coumadin to 4 mg daily. - Please continue taking all other medications as previously prescribed. Call your doctor or return to the emergency room if you experience any of the following: worsening abdominal pain, nausea, vomiting, blurry vision, worsening headache, fever > 101. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. Please continue to follow with your nephrologist and go to outpatient dialysis as previously arranged. Please discuss with your PCP the possibility of talking to a social worker at [**Name (NI) 191**]. You will need to continue to have your INR monitored at [**Hospital 191**] [**Hospital 2786**] clinic. Please have this level checked on [**Hospital 766**], [**11-27**]. Completed by:[**2141-11-23**]",61,2141-11-18 14:00:00,2141-11-23 16:42:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. her hydralazine was increased from 75mg to 100mg tid with mild improvement. her labetalol was also increased from 300mg to 400mg tid. her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. tsh was sent and elevated, although free t4 was normal. plasma metanephrines were sent and pending at discharge. 2) abdominal pain: ct scan showed increasing ascites, but no acute pathology. peritoneal fluid was obtained and contained 544 polys. treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing gpc pairs/clusters. blood cultures ended up growing 1 out of 4 bottles coag-neg staph, likely contaminant, so vancomycin was stopped. since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. the peritoneal cultures remained negative. her pd catheter was left in place as the patient refuses hd any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) svc/brachiocephalic thrombosis: patients inr was subtherapeutic on admission at 1.3. due to the proximal location of her old venous thrombi, she was started on a heparin gtt. this was continued during her admission and her warfarin was increased to 5mg daily. her inr reached 2.0 at discharge (therapeutic range 2-3). the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) anxiety: patient noted feeling short of breath and anxious around the time of her recent admissions. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. they felt her symptoms were suggestive of anxiety and panic attacks, recommended checking tsh and metanephrines as above, and starting citalopram 20mg, which was done. she was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h prn. patient is agreeable to outpatient follow up with [**company 191**] social work, and potential cbt. these can be arranged by her pcp. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Abdominal pain, unspecified site; Anemia, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. her hydralazine was increased from 75mg to 100mg tid with mild improvement. peritoneal fluid was obtained and contained 544 polys. the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted.","patient has history of extremely labile hypertension on aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. ct scan showed increasing ascites, but no acute pathology." 109,176760.0,14805,2142-01-23,14800,161950.0,2141-12-01,Discharge summary,"Admission Date: [**2141-11-24**] Discharge Date: [**2141-12-1**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Headache, abdominal pain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24yo F w/PMHx of ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning, awakening her from sleep. Had been previously discharged from [**Hospital1 **] yesterday after being admitted for hypertension and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Upon discharge yesterday she states her abdominal pain had subsided. She had HD yesterday without complications. She awoke at 6am with a headache and crampy, stabbing abdominal pain. Took 2mg PO Dilaudid without relief and came to ED. No nausea/vomiting, no changes in vision, no fevers, chills, night sweats. No chest pain, SOB, diarrhea. In the ED, initial vitals were T98.7, BP260/130, HR70, RR16. Was initially given 10mg IV Labetalol X 2, 4mg Zofran for nausea. No improvement in BP and started on Labetolol gtt. Got 1mg IV Dilaudid for pain. Currently, patient continues to complain of headache and abdominal pain, both [**7-17**]. No vision changes, chest pain or shortness of breath. Has been feeling increased anxiety recently and saw psychiatrist, was put on Celexa. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T98.2, BP176/135, HR94, RR 22, 100% RA Gen: well-appearing african-american woman, lying comfortably HEENT: anicteric, L eye prosthetic non-reactive, R pupil reactive, MMM, neck supple with submanibular LAD CV: RRR, II/VI SEM best heard at apex Pulm: CTA b/l Abd: hyperactive bowel sounds, midline scar well-healed, soft, diffusely tender to palpation, +rebound, no guarding. PD catheter in LLQ without erythema or purulent material draining. +dullness on percusion with evidence of clinical ascites. Ext: no edema, no clubbing, 2+ peripheral pulses DP and radial. R femoral HD [**Last Name (un) **] in place without erythema, purulance Neuro: A&O X 3, CN intact II-XII, [**5-15**] motor strength in upper and lower extremities Pertinent Results: Admission labs: CBC: [**2141-11-26**] 05:21AM BLOOD WBC-3.5* RBC-3.07* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-17.6* Plt Ct-180 CHEM 10: [**2141-11-26**] 01:16PM BLOOD Glucose-87 UreaN-17 Creat-4.0* Na-136 K-5.2* Cl-106 HCO3-23 AnGap-12 [**2141-11-26**] 09:20PM BLOOD Calcium-7.6* Phos-3.8 Mg-1.8 COAGS: [**2141-11-26**] 01:16PM BLOOD PT-23.9* PTT-40.2* INR(PT)-2.3* STUDIES: 1)Peritoneal fluid ([**11-26**]): negative for malignant cells. Reactive mesothelial cells, macrophages, eosinophils and lymphocytes. 2)BILAT UP EXT VEINS US ([**11-26**]): No evidence of deep vein thrombosis of the right or left upper extremity. 3) MRI/MRA ([**11-30**]): FINDINGS: Examination is somewhat limited by patient motion. T2/FLAIR sequences are unremarkable with interval resolve of previously noted posterior abnormalities. The major vessels appear patent proximally. There are stable areas of low signal in the left frontal and right occipetal/temporal lobes. IMPRESSION: 1. Interval resolution of previously noted posterior white matter abnormalities. 2. Stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions. 3. Very limited MRA as above. Brief Hospital Course: 24yo F with SLE, ESRD on HD and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**Hospital Unit Name 153**] course: The patient was admitted for blood pressure management and evaluation of abd pain. An A-line was placed. EKG showed no change from prior, and Abd x-ray showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home med regimen. The patient was found to be hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. Upon transfer to the floor, the following was her course: 1. Hypertensive Urgency: Pt had had hemodialysis one day prior to admission, so unlikely that she was volume overloaded. Unclear what precipitated this episode of hypertensive urgency, although suspect secondary to abdominal pain leading to an anxiety which then precipitates hypertension. She may not have been taking her medications secondary to pain. Negative serum tox. On the floor, we continued hemodialysis Tu, Th, Sat. She was initially continued on PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine 90mg PO qday and clonidine; she received hydralazine 10mg IV for goal BP < 180/100. Renal team followed patient during this hospitalization. Per renal team recs, labetalol was increased to 800mg TID due to poor blood pressure control. Pt discharged on clonidine 0.3mg patch, Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, Nifedipine 90mg daily and lobatalol 800mg TID. This regimen worked well. 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT scan during prior admission which did not show source of abdominal pain. On admission, LFTs were normal except for slightly low albumin, lipase was slightly elevated and KUB was negative for free air or evidence of SBO. Peritoneal fluid was negative for malignant cells but showed reactive mesothelial cells, macrophages, eosinophils and lymphocytes. Negative gram stain or peritoneal fluid cultures, excluding SBP as a cause of the abdominal pain. PD catheter was not removed. Pt was continued on PO dilaudid 1-2mg Q6h and pain resolved. She denied N/V/diarrhea or constipation. 3. ESRD: Pt on hemodialysis, on T/Th/Sat schedule. Renal following patient closely throughout this hospitalization. Lytes were checked frequently and kayexalate given prn. 4. Hx of SVC/brachiocephalic DVT: Pt was initially subtherapeutic on coumadin. Unclear if she had not been taking Coumadin although patient reported that she has been taking all home meds. We started heparin gtt to bridge to Coumadin. Once therapeutic, continued Coumadin 5mg PO qday. 5. Anxiety: Likely contributing to medical problems and could have very well been the etiology of this admission. Although pt stated she was taking her current medications, she did report increased anxiety which can lead to medication non-compliance and hypertension. Pt recently saw psychiatrist who started her on Celexa. She was continued on celexa 20mg PO qday, ativan 1mg PO q8hours PRN and psychiatry was re-consulted. Per psych recs, started standing clonazepam. Pt refused psych VNA. Outpatient PCP followup recommended. 6. Headache NOS: Pt complained of R-sided HA for several weeks, radiating to R jaw where patient had previous tooth extraction. Right upper extremity ultrasound was negative for DVT. She did not have any focal neuro findings, no visual deficits. She was initially treated with tylenol PRN Q6h; pt requested IV dilaudid for HA, but use of this medication by IV route was limited by team. It was felt by the pain service that her HA did not fit migraine, tension type HA or rebound HA. They recommended increasing dilaudid to 4-6mg Q6h PRN, continuing tylenol and starting neurontin 300mg Qhs which was slowly titrated to 300mg [**Hospital1 **] for better control. Per pain recs, a neurology consult was also obtained during this admission. MRI/MRA showed interval resolution of previously noted posterior white matter abnormalities and stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions, but very limited MRA as above. Per pain recs, dilaudid was further increased to 4mg q4h for better control of her HA. Neurology recommended outpt f/u and Pt scheduled with [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**]. 7. Anemia: Likely related to ESRD. No evidence of acute bleeding. Hct remained stable during this hospitalization. 8. SLE: no acute issues. continued Prednisone 4mg PO qday 9. FEN: tolerated regular diet, repleted lytes PRN 9. Prophylaxis: Heparin gtt, then coumadin, bowel regigmen Medications on Admission: (from prior discharge summary) Bisacodyl 10mg PO qday PRN Prednisone 4mg PO qday Aliskiren 150mg PO BID Clonidine 0.3mg / 24 hr patch weekly qmonday Labetalol 400mg PO TID Warfarin 4mg PO qday Nifedipine 90mg PO qday Hydralazine 100mg PO q8H Hydromorphone 2-4mg PO q4H PRN Lorazepam 1mg PO q8H Celexa 20mg PO qday Prochlorperazine 10mg PO q6H Colace 100mg PO BID Hydralazine 25mg PO q30min PRN for HTN Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Year (4 digits) 766**]). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). [**Year (4 digits) **]:*100 Tablet(s)* Refills:*2* 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*90 Capsule(s)* Refills:*2* 9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for headache. [**Year (4 digits) **]:*84 Tablet(s)* Refills:*0* 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*60 Capsule(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours. [**Year (4 digits) **]:*360 Tablet(s)* Refills:*2* 16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. [**Year (4 digits) **]:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive Emergency 2. SLE 3. Headache, NOS 4. Abdominal pain Discharge Condition: BP better controlled. Headache managed on oral meds Discharge Instructions: You were admitted with abdominal pain, high blood pressure, and headache. Your abdominal pain resolved - no serious cause of this pain was found. Your blood pressure medications were continued, and with an increased in one medication, the labetalol. Your blood pressure improved. You should continue the clonidine 0.3mg patch changed on [**Year (4 digits) 766**], Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, and Nifedipine 90mg daily. The dose of Labetalol was increased to 800 mg three times daily by you kidney doctor and you are given a new prescription. Please take all medications as listed below. For your headache, you had an MRI and MRA of the head, which did not show a new or serious abnormality. You were seen by the neurology and pain services. You should follow up at [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**] at 6:30 PM (in the evening). Your pain was managed by oral dilaudid, 4mg. You should take this medication every 4 hours as needed. You were also started on Gabapentin (also called Neurontin) for the headache. The dose was slowly increased to twice a day. You may not need as much dilaudid for your headache and should wean this medication as tolerated, given it's potential for side effects (constipation, lethargy, dependence). Finally, you will likely need medications for constipation while you take dilaudid. Take colace (a stool softener), senna (a laxative), and bisacodyl (another laxative), as needed. It is really important that you have a primary care doctor. You are scheduled with Dr. [**Last Name (STitle) **] (see below) next Tuesday. You will need your INR checked since you are on coumadin. Call your doctor if you have worsened headache, chest pain, confusion, or any other concerning symptom. Followup Instructions: Please make sure you attend the following doctor appointments: 1) Dr. [**Last Name (STitle) 4883**] (nephrologist) on Tuesday, [**2141-12-5**] at 10AM. Phone number [**Telephone/Fax (1) 60**]. 2) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Location (un) **], [**Hospital Ward Name 23**] center, [**Location (un) **]. Phone:[**Telephone/Fax (1) 250**]. Date/Time:[**2141-12-5**] 3:20 3) Neurology: Dr. [**Last Name (STitle) 43502**] [**Name (STitle) **]. He is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-12-12**] 6:30 PM [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2141-12-2**]",53,2141-11-24 16:11:00,2141-12-01 19:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**hospital unit name 153**] the patient was admitted for blood pressure management and evaluation of abd pain. an a-line was placed. ekg showed no change from prior, and abd x-ray showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home med regimen. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. upon transfer to the floor, the following was her ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other ascites; ; Systemic lupus erythematosus; Headache; Anemia in chronic kidney disease; Anxiety state, unspecified; Other chest pain; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Renal dialysis status; Acquired absence of organ, eye]","24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. the renal team was consulted, and recommended no change to home med regimen.","a 24yo f with sle, esrd on hd and malignant hypertension presented with abdominal pain and headache. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. she successfully switched to po meds and was transferred to the floor." 109,176760.0,14805,2142-01-23,14801,173633.0,2141-12-14,Discharge summary,"Admission Date: [**2141-12-8**] Discharge Date: [**2141-12-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 8104**] Chief Complaint: abdominal pain & hypertension Major Surgical or Invasive Procedure: Hemodialysis PICC Line [**12-11**] History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with a history of CKD V (on HD) from lupus nephritis, chronic intermittent abdominal pain, and multiple prior ICU admissions for hypertensive urgency who presented to the ED complaining of two days' of abdominal pain, nausea, and loose stools. She was feeling well until after her hemodialysis session on Wednesday. Thereafter, she complained of nausea with occasional vomitting and has been unable to keep down any of her oral medications. She also has had diffuse abdominal pain consistent with her prior flares of pain as well as her typical diffuse headache. The headache in particular was worsening and, for her, this is a sign of poorly-controlled hypertension so she came to the [**Hospital1 18**] ED. Upon arrival to the ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room air. She was given 4 mg of IV ondansetron, [**1-11**] inch intropaste, 1 mg of IV hydromorphone x3, 1000cc of NS, and was put on a labetalol drip which had to be increased up to 2 mg/min. A head CT showed no acute abnormality (including hemorrhage) and an abdominal CT showed some possible mild colitis, though it is unclear if this is due to her recent peritoneal dialysis. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 97.9 BP 165/120 HR 93 RR 12 Sat 100% ra Gen: mildly fatigued, but no distress HEENT: oropharynx clear Neck: no JVP, no LAD Chest: clear to auscultation throughout, no w/r/r CV: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard Abdomen: soft, tender diffusely to moderate palpation without rebound or guarding; hyperactive bowel sounds; no masses or HSM, PD catheter in palce Extr: no edema, 2+ PT pulses Neuro: alert, appropriate, strength grossly intact in all four limbs Skin: no rashes Pertinent Results: [**2141-12-14**] 05:53AM BLOOD WBC-4.3 RBC-2.81* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.7 MCHC-33.8 RDW-19.3* Plt Ct-148* [**2141-12-14**] 05:53AM BLOOD PT-42.6* PTT-51.0* INR(PT)-4.7* [**2141-12-10**] 05:10AM BLOOD Ret Aut-2.5 [**2141-12-14**] 05:53AM BLOOD Glucose-83 UreaN-21* Creat-5.1*# Na-138 K-5.3* Cl-105 HCO3-24 AnGap-14 [**2141-12-10**] 05:10AM BLOOD LD(LDH)-234 Amylase-347* TotBili-0.1 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-10**] 05:10AM BLOOD Lipase-72* [**2141-12-14**] 05:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 [**2141-12-10**] 05:10AM BLOOD Hapto-142 [**2141-12-8**] 04:02AM BLOOD calTIBC-138* VitB12-445 Folate-18.5 Ferritn-220* TRF-106* ON ADMISSION: [**2141-12-7**] 09:50PM BLOOD WBC-4.5 RBC-2.78* Hgb-8.4* Hct-25.2* MCV-91 MCH-30.2 MCHC-33.3 RDW-19.2* Plt Ct-158 [**2141-12-7**] 09:50PM BLOOD Neuts-65.2 Lymphs-23.4 Monos-8.0 Eos-2.9 Baso-0.4 [**2141-12-7**] 09:50PM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3* [**2141-12-8**] 04:02AM BLOOD Ret Aut-2.5 [**2141-12-7**] 09:50PM BLOOD Glucose-89 UreaN-25* Creat-5.1*# Na-139 K-4.8 Cl-104 HCO3-26 AnGap-14 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-7**] 09:50PM BLOOD Lipase-89* [**2141-12-7**] 09:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9* Mg-1.9 [**2141-12-7**] 09:54PM BLOOD Glucose-75 Lactate-1.3 Na-139 K-4.8 Cl-101 calHCO3-23 Micro: Blood Cx: [**12-7**], [**12-7**], [**12-11**], [**12-11**] No growth FECAL CULTURE (Final [**2141-12-10**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2141-12-10**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2141-12-8**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-12-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CT HEAD [**2141-12-8**]: IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. The hypodensities noted in the parietal white matter are stable. However in the setting of the hypertension, PRES cannot be excluded. If further evaluation is required MR can be obtained. CT Abdomin/Pelvis [**2141-12-8**] IMPRESSION: 1. Moderate amount of free fluid in the pelvis is compatible with the patient's known peritoneal dialysis. Unchanged peritoneal enhancement. 2. Stable liver hemangioma. CXR [**12-11**] IMPRESSION: Small left pleural effusion. Left lower lobe opacity which is either atelectasis versus pneumonia. Brief Hospital Course: 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. MICU course: Current plan on transfer 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. 1. Hypertensive urgency: The patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. Initially her blood pressure over-corrected to SBPs in the 80s (patient was asymptomatic). Her clonidine patch and hydralazine was held and she again became hypertensive with SBPs 190s. The patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. The following dialysis the patient asymptomatic with SBPs in 80s, MAPs 60s asymptomatic again. Her hydralazine was stopped and continued on all her other home medications at the advice of renal. The patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. On [**12-11**] the patient's SBP dropped to the 80's and due to her pain medications she was extremely lethargic, but arousable. A PICC line was placed because lack of access and she was bolused 250cc NS. The patient's pressures responded and additional narcotics were held due to her mental status. The patient's blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. The patient did require IV hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. A possible component to the patient's malignant hypertension is likely due to OSA. An inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on BiPAP for OSA. The patient was continuned on her admission hypertensive regimen. . 2. Abdominal pain: The etiology of her abdominal pain is unclear, but has been a chronic issue for her. A CT scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. The patient also had diarrhea, but stool studies were negative. The patient's pain was initially treated with hydromorphone, but because of the patient's lethargy on [**12-11**] they were initially held. She continued to complain of severe abdominal pain. She was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. Surgery was consulted in regards to removal of her PD catheter, but given that she may return to PD it was deferred to the outpatient setting. 3. CKD V from lupus nephritis: The patient was continued on HD during her admission. She was also continued on her home prednisone dose. She was closely followed by the renal team. . 4. History of SVC/subclavian vein thrombus: The patient was found to have a subtherapeutic INR on admission 1.3. She was started on a heparin gtt and continued on coumadin. The patient's heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her PICC line was placed. She was therapetuic the same day and her heparin gtt was stopped. On discharge her coumadin was supratherapeutic (4.7) and was held. She will have her INR checked at HD. . 5. Anemia: The patient's Hct slowly trended down. She was guaiac negative and hemolysis labs were negative. She was transfused 1U pRBC at HD on [**12-12**]. She was also given epo at HD. Medications on Admission: prednisone 4 mg daily clonidine 0.3 mg/day patch qWeek ergocalciferol 50,000 units qMonth nifedipine SR 90 mg daily hydralazine 100 mg q8h citalopram 20 mg daily warfarin 2 mg qhs gabapentin 300 mg [**Hospital1 **] hydromorphone 4 mg q4h prn clonazepam 0.5 mg [**Hospital1 **] alikiren 150 mg [**Hospital1 **] docusate 100 mg [**Hospital1 **] senna 8.6 mg [**Hospital1 **] prn acetaminophen prn labetalol 800 mg q8h bisacodyl 5 mg daily prn Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. [**Hospital1 **]:*84 Tablet(s)* Refills:*0* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed: please take as needed for anxiety prior to CPAP at bedtime. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 14. CPAP Home CPAP Dx: OSA Prefer: AutoCPAP/ Pressure setting [**5-20**] Alt: Straight CPAP/ Pressure setting 7 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency Abdominal Pain ESRD on HD SVC Thrombus Secondary: Systemic lupus erythematosus Malignant hypertension Thrombocytopenia HOCM Anemia History of left eye enucleation History of vaginal bleeding Thrombotic microangiopathy Discharge Condition: Stable Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because of elevated blood pressure and abdominal pain. You were initially admitted to the ICU and your blood pressure was controlled. You were stabilized and transferred back to th floor. Your pressures remained stable throughout the rest of your stay. Additionally, you had abdominal pain and diarrhea. Your stool was tested for infections and was negative. Your diarrhea resolved without intervention. Your abdominal pain was controlled with pain medications. You had a sleep study in the hospital which showed that you had sleep apnea. Please continue to take your medications as prescribed. 1. Please do not take your coumadin until your doctor tells you to. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: You will have dialysis at [**Location (un) **] Dialysis on your normal schedule. You need to go to dialysis on Saturday. Please follow-up with the Sleep Clinic in [**12-19**] @ 11:45 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Completed by:[**2141-12-16**]",40,2141-12-08 01:40:00,2141-12-14 17:16:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. micu course: current plan on transfer 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. 1. hypertensive urgency: the patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). her clonidine patch and hydralazine was held and she again became hypertensive with sbps 190s. the patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. the following dialysis the patient asymptomatic with sbps in 80s, maps 60s asymptomatic again. her hydralazine was stopped and continued on all her other home medications at the advice of renal. the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. on [**12-11**] the patients sbp dropped to the 80s and due to her pain medications she was extremely lethargic, but arousable. a picc line was placed because lack of access and she was bolused 250cc ns. the patients pressures responded and additional narcotics were held due to her mental status. the patients blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. the patient did require iv hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. a possible component to the patients malignant hypertension is likely due to osa. an inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on bipap for osa. the patient was continuned on her admission hypertensive regimen. . 2. abdominal pain: the etiology of her abdominal pain is unclear, but has been a chronic issue for her. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. the patient also had diarrhea, but stool studies were negative. the patients pain was initially treated with hydromorphone, but because of the patients lethargy on [**12-11**] they were initially held. she continued to complain of severe abdominal pain. she was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. surgery was consulted in regards to removal of her pd catheter, but given that she may return to pd it was deferred to the outpatient setting. 3. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was also continued on her home prednisone dose. she was closely followed by the renal team. . 4. history of svc/subclavian vein thrombus: the patient was found to have a subtherapeutic inr on admission 1.3. she was started on a heparin gtt and continued on coumadin. the patients heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her picc line was placed. she was therapetuic the same day and her heparin gtt was stopped. on discharge her coumadin was supratherapeutic (4.7) and was held. she will have her inr checked at hd. . 5. anemia: the patients hct slowly trended down. she was guaiac negative and hemolysis labs were negative. she was transfused 1u prbc at hd on [**12-12**]. she was also given epo at hd. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Systemic lupus erythematosus; Other and unspecified noninfectious gastroenteritis and colitis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other iatrogenic hypotension; Obstructive sleep apnea (adult)(pediatric); Hemangioma of intra-abdominal structures; Other chronic pain; Abdominal pain, unspecified site; Abnormal coagulation profile; Renal dialysis status; Personal history of venous thrombosis and embolism]","24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. the patient was continuned on her admission hypertensive regimen. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was therapetuic the same day and her heparin gtt was stopped.",24 year old woman with ckd v and severe hypertension due to sle admitted. patient was initially maintained on a labetalol drip and hydralazine iv prn. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic) 109,176760.0,14805,2142-01-23,14802,140167.0,2141-12-23,Discharge summary,"Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1973**] Chief Complaint: Malignant hypertension Major Surgical or Invasive Procedure: None History of Present Illness: 24 year old female with ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning. Patient had her hemodialysis day before yesterday. She has had multiple admissions to [**Hospital1 18**] with hypertensive urgency with symptoms of headache and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Patient states that her headache and abdominal pain are similar in characteristics to her previous admission. Patient denies any fever, chills, nightsweats, chest pain, shortness of breath, abdominal pain, nausea, vomitting, diarrhea, constipation, blood in stool, dysuria, hematuria, change in vision, hearing, weakness or numbness. In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was initially given 10mg IV Labetalol once and then started on drip at 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea. Her BP elevated as high as 270/174 and his labetolol was switched to nicardipine 1mg/kg/min. On arrival to the MICU her vitals were T 96.4 HR 99 BP 175/120 RR 15 100%RA. Patient was comfortable. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Vitals: 97.5 122/80 88 18 100%RA. Gen: sleeping, easily arousable, appears comfortable. HEENT: AT/NC, L eye prosthetic non-reactive, R pupil reactive, MMM. Heart: S1S2 RRR, III/VI SEM heard best at apex, + S3 Pulm: CTA b/l, no w/r/r. Abd: normal bowel sounds, midline scar well-healed, soft, nontender, prior PD site with dry dressing, patient with tenderness to palpation over prior PD cath site, no guarding/rebound Ext: no edema, no clubbing, WWP. R femoral HD catheter in place. Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: Admission: [**2141-12-18**] 02:00AM BLOOD WBC-5.8 RBC-3.30* Hgb-10.1* Hct-30.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-20.7* Plt Ct-199 [**2141-12-18**] 02:00AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.2* [**2141-12-18**] 02:00AM BLOOD UreaN-35* Creat-5.0* Na-138 K-5.5* Cl-103 HCO3-21* AnGap-20 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-18**] 02:00AM BLOOD Lipase-73* [**2141-12-18**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2141-12-19**] 06:45AM BLOOD Calcium-8.1* Phos-5.1* Mg-1.8 [**2141-12-18**] 03:52PM BLOOD dsDNA-NEGATIVE [**2141-12-18**] 03:52PM BLOOD CRP-11.5* [**2141-12-18**] 03:52PM BLOOD C3-68* C4-19 [**2141-12-20**] 12:09PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 [**2141-12-18**] 02:08AM BLOOD pO2-52* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 Comment-GREEN TOP [**2141-12-20**] 12:09PM BLOOD Lactate-0.9 [**2141-12-18**] 02:08AM BLOOD Glucose-68* Lactate-1.3 Na-140 K-4.8 Cl-103 [**2141-12-23**] 03:00PM BLOOD WBC-4.7 RBC-2.35* Hgb-7.1* Hct-22.3* MCV-95 MCH-30.3 MCHC-31.9 RDW-20.6* Plt Ct-131* [**2141-12-23**] 12:55AM BLOOD PT-14.7* PTT-66.2* INR(PT)-1.3* [**2141-12-18**] 03:52PM BLOOD ESR-21* [**2141-12-23**] 03:00PM BLOOD Glucose-97 UreaN-42* Creat-6.6* Na-138 K-4.3 Cl-106 HCO3-23 AnGap-13 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-23**] 03:00PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8 [**2141-12-18**] 04:23PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2141-12-18**] 04:23PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2141-12-18**] 04:23PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-12 TransE-<1 Micro: Blood Cx- [**12-18**]: No growth Urine Cx- [**12-18**]: No growth [**12-18**] TTE The left atrium and right atrium are normal in cavity size. A possible secundum type atrial septal defect is seen by color Doppler (clip [**Clip Number (Radiology) **]) There is severe symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. There is no significant resting LVOT gradient, but a mild gradient (30mmHg peak) is seen with Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Marked symmetric left ventricular hypertrophy with normal regional/global systolic function and mild inducible LVOT gradient. Mild aortic regurgitation. Mild pulmonary artery systolic hypertension. Possible secundum type atrial septal defect. Compared with the prior study (images reviewed) of [**2141-10-19**], a possible secundum type atrial septal defect is now suggested. If clinically indicated, a follow-up study with saline contrast and/or a TEE would be better able to characterize the possible atrial septal defect. CLINICAL IMPLICATIONS: Based on [**2140**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**12-18**] CXR IMPRESSION: 1. Cardiomegaly with findings suggestive of mild pulmonary edema. 2. Bibasilar linear opacities suggesting atelectasis, although developing pneumonia cannot be excluded. 3. No evidence of free intraperitoneal air. [**12-20**] MRV IMPRESSION: No appreciable change since the MRV chest exam dated [**2141-5-30**]. SVC is patent. Again seen is occlusion of the right internal jugular and left brachiocephalic veins. Right external jugular vein is provides the major venous drainage from the neck. Brief Hospital Course: 24 year old Female with SLE, ESRD on HD and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ED. 1. Malignant Hypertension: The patient had her hemodialysis two days prior to admission. Initially in the ED her BP was 253/170. She was given 10mg IV Labetalol and started on a labatelol drip. She also received hydralazine IV 10 mg once and 2 inches of nitropaste. She had morphine 4mg and 4mg Zofran for nausea. Her BP remained elevated so she was switched to nicardipine 1mg/kg/min. The patient was transferred to the MICU. In the ICU she was continued on the Nicardapine drip and her pressures decreased to 175/120. Nephrology was consulted and dialysis initiated in the AM. The Nicardapine drip dc'd on [**12-19**] and pt transferred to floor. While on the floor the patient had question of angioedema and markedly elevated BP. She was readmitted to the MICU on [**2141-12-20**]. Patient's Aliskerin was also held for conern for angioedema. The renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. The patient's PD catheter was removed. The patient was briefly on a nitro drip for hypertension. The patient's nifedepine was increased to 120mg. The patient was transferred to the floor with stable blood pressures, BP 124/72 on [**12-21**]. The morning of [**12-22**], the patient was noted to have a BP up to 247/120 at 0800. Hypertension persisted throughout the morning with BPs 210s-240s systolic. HR during this time was in the 90s. She received a total of 60 mg IV hydralazine over the course of the morning as well as 0.1 mg PO clonidine. She was also given her normal AM BP meds and restarted on aliskarin. Due to persistent hypertension, she was transferred to the ICU for further care. On arrival to the ICU, the patient reported severe abdominal pain over the site of recently removed PD catheter. She denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. She reports bilateral calf cramping but no leg swelling. She denies any difficulty breathing or chest pain. She took her AM BP meds without difficulty. Her blood pressure decreased to 130s-140s/60s without further intervention. She was transferred back to the floor on [**12-23**] and signed out AMA. 2. Angioedema: On [**12-20**] the patietn developed facial swelling and evidence of angioedema by ENT. The patient reported that her face is more swollen which was confirmed by her mother on the floor. The patient was give lasix IV as she has been unable to have any negative filtration with HD. The patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. Her tekturna was discontinued for concern that it might be causing angioedema. She denied difficulty with her breathing at that time, but was very somnulent. On arrival to the MICU her vitals were stable and oxygenating well at 100% on face mask. The patient's airway was supported with a nasal trumpet. The patient underwent MRV that showed no progression of her clot. Patient was diuresed with lasix and dialysis with significant improvement in her symptoms. She was treated with prednisone and decadron, famotidine and benadryl for angioedema. The patient was maintained on her heparin drip for her SVC syndrome. 3. Abdominal Pain: The patient has had extensive prior workup that has been unrevealing. The Transplant surgery team removed the PD cath on [**12-21**]. She continued to have abdominal pain post-op. She was continued on PO dilaudid 2mg po prn. She continuned to complain of abdominal pain throughout her admission and continued to requested IV dilaudid. 4. ESRD: The patient is on a T/Th/Sat schedule. She was closely followed by the renal team. She had dialysis on [**12-19**]. The patient's tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. The patient also had her PD catheter removed on [**12-21**] secondary to chronic abdominal pain. The patient was scheduled to have dialysis on [**12-23**]. 5. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last admission for supratherapeutic INR. She was admitted with a subtherpeutic INR of 1.2 She was started on a heparin drip. She was also started on Coumadin 2mg PO qday, but was held on [**12-19**] in prep her PD catheter removal. She was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by IR. However, the patient signed out AMA and thus it was not placed. 6. Anxiety: Pt recently saw psychiatrist who started her on Celexa. She was continued on Celexa 20mg PO daily. 7. Anemi of CKDa: The patient's Hct was 30.3 on admission. It trended down to 22.3 on discharge when she left AMA. There was no evidence of active, acute bleeding. THis is likely seoncdary to her ESRD. The patient was closely monitored. 8. Systemic Lupus Erythematosis: Rheumatology was consulted and does not suspect acute flare and dsDNA, C3, C4 nl, ESR and CRP slightly elevated. Her Echo did not suggest worsening pericarditis. She was continued on her home prednisone dose of 4mg daily. 9. Obstructive Sleep Apnea: CPAP for sleep with 7 pressure. Medications on Admission: Aliskiren 150 mg [**Hospital1 **] Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Warfarin held on discharge [**2141-12-14**] due to supratherap INR Discharge Medications: As patient signed out AMA, no medications were issued. She was told to resume her admission medications, however no instructions were taken by the patient. Discharge Disposition: Home Discharge Diagnosis: 1) Hypertensive urgency 2) Abdominal pain 3) End stage renal disease on hemodialysis 4) Venous thromboembolism Discharge Condition: Signed out AMA Discharge Instructions: Pt signed out AMA Return to the hospital with any concerning symptoms. Be sure to call your doctor's office on [**Month/Day/Year 766**] to arrange hemodialysis and review your medications and discuss follow-up plan. Followup Instructions: Follow-up with your Dr. [**Last Name (STitle) **] next week, and call [**Last Name (STitle) 766**] to arrange your hemodialysis. Completed by:[**2141-12-26**]",31,2141-12-18 03:50:00,2141-12-23 19:51:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. 1. malignant hypertension: the patient had her hemodialysis two days prior to admission. initially in the ed her bp was 253/170. she was given 10mg iv labetalol and started on a labatelol drip. she also received hydralazine iv 10 mg once and 2 inches of nitropaste. she had morphine 4mg and 4mg zofran for nausea. her bp remained elevated so she was switched to nicardipine 1mg/kg/min. the patient was transferred to the micu. in the icu she was continued on the nicardapine drip and her pressures decreased to 175/120. nephrology was consulted and dialysis initiated in the am. the nicardapine drip dcd on [**12-19**] and pt transferred to floor. while on the floor the patient had question of angioedema and markedly elevated bp. she was readmitted to the micu on [**2141-12-20**]. patients aliskerin was also held for conern for angioedema. the renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. the patients pd catheter was removed. the patient was briefly on a nitro drip for hypertension. the patients nifedepine was increased to 120mg. the patient was transferred to the floor with stable blood pressures, bp 124/72 on [**12-21**]. the morning of [**12-22**], the patient was noted to have a bp up to 247/120 at 0800. hypertension persisted throughout the morning with bps 210s-240s systolic. hr during this time was in the 90s. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she was also given her normal am bp meds and restarted on aliskarin. due to persistent hypertension, she was transferred to the icu for further care. on arrival to the icu, the patient reported severe abdominal pain over the site of recently removed pd catheter. she denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. she reports bilateral calf cramping but no leg swelling. she denies any difficulty breathing or chest pain. she took her am bp meds without difficulty. her blood pressure decreased to 130s-140s/60s without further intervention. she was transferred back to the floor on [**12-23**] and signed out ama. 2. angioedema: on [**12-20**] the patietn developed facial swelling and evidence of angioedema by ent. the patient reported that her face is more swollen which was confirmed by her mother on the floor. the patient was give lasix iv as she has been unable to have any negative filtration with hd. the patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. her tekturna was discontinued for concern that it might be causing angioedema. she denied difficulty with her breathing at that time, but was very somnulent. on arrival to the micu her vitals were stable and oxygenating well at 100% on face mask. the patients airway was supported with a nasal trumpet. the patient underwent mrv that showed no progression of her clot. patient was diuresed with lasix and dialysis with significant improvement in her symptoms. she was treated with prednisone and decadron, famotidine and benadryl for angioedema. the patient was maintained on her heparin drip for her svc syndrome. 3. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the transplant surgery team removed the pd cath on [**12-21**]. she continued to have abdominal pain post-op. she was continued on po dilaudid 2mg po prn. she continuned to complain of abdominal pain throughout her admission and continued to requested iv dilaudid. 4. esrd: the patient is on a t/th/sat schedule. she was closely followed by the renal team. she had dialysis on [**12-19**]. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient also had her pd catheter removed on [**12-21**] secondary to chronic abdominal pain. the patient was scheduled to have dialysis on [**12-23**]. 5. hx of svc/brachiocephalic dvt: her coumadin was held during last admission for supratherapeutic inr. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. she was also started on coumadin 2mg po qday, but was held on [**12-19**] in prep her pd catheter removal. she was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by ir. however, the patient signed out ama and thus it was not placed. 6. anxiety: pt recently saw psychiatrist who started her on celexa. she was continued on celexa 20mg po daily. 7. anemi of ckda: the patients hct was 30.3 on admission. it trended down to 22.3 on discharge when she left ama. there was no evidence of active, acute bleeding. this is likely seoncdary to her esrd. the patient was closely monitored. 8. systemic lupus erythematosis: rheumatology was consulted and does not suspect acute flare and dsdna, c3, c4 nl, esr and crp slightly elevated. her echo did not suggest worsening pericarditis. she was continued on her home prednisone dose of 4mg daily. 9. obstructive sleep apnea: cpap for sleep with 7 pressure. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Mechanical complication due to peritoneal dialysis catheter; ; Unspecified disease of pericardium; Angioneurotic edema, not elsewhere classified; Abdominal pain, other specified site; Systemic lupus erythematosus; ; Anemia in chronic kidney disease; Dysthymic disorder; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of steroids; Long-term (current) use of anticoagulants; Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation; Other antihypertensive agents causing adverse effects in therapeutic use]","24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. she was given 10mg iv labetalol and started on a labatelol drip. nephrology was consulted and dialysis initiated in the am. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she reports bilateral calf cramping but no leg swelling. she took her am bp meds without difficulty. her tekturna was discontinued for concern that it might be causing angioedema. the patient was maintained on her heparin drip for her svc syndrome. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient was scheduled to have dialysis on [**12-23**]. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. there was no evidence of active, acute bleeding.","24 year old female with sle, esrd on hd presents with abdominal pain and headache consistent with her usual hypertensive urgency. she was found to be in hypertensive urgency in ed. she received hydralazine iv 10 mg once and 2 inches of nitropaste." 109,176760.0,14805,2142-01-23,14803,135923.0,2142-01-12,Discharge summary,"Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-13**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypertensive Urgency and HA Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with HA in the setting of hypertension. Upon arrival to the ED, her vitals were 284/140, HR 67, RR 28, 100% on 4LNC. She was started on a nicardipine drip. She denied shortness of breath or chest pain. She is due for HD today. She has a left groin catheter which was recently placed [**2141-12-21**] and is causing her pain. She was also given dilaudid IV 1 mg x 2 with some relief. CXR was performed and showed no pulmonary edema. . Upon arrival to the MICU, patient denies HA, CP, SOB, fevers, chills. Patient reports mild abdominal pain at sight of left anterior abdominal wall hematoma and left groin pain at site of femoral HD line. She reports that she was taking her medications as directed, including coumadin for SVC thrombus. Briefly, 24 yo F with ESRD on HD, SLE, malignant HTN admitted for HA in the setting of HTN to 284/140 in ED. Initially, she was treated with a nicardipine gtt to control her BP. Her cardiac enzymes were flat, no new ECG changes. She was started on a heparin gtt with transition to coumadin for a SVC thrombosis. HTN secondary to med noncompliance. She was restarted on her oral BP. She missed her PM meds yesterday, so nicardipine was restarted, and then turned off this AM. She received all her AM BP meds. Her BPs have been in the 160s/90s. She had no neurological deficits. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 176/105, 87, 18, 100% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: 2/6 systolic murmur LUSB Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: left ant wall abd hematoma, TTP Extremities: Right: Trace, Left: Trace, left fem HD line without oozing or drainage Skin: Warm Neurologic: AAO x 3 Pertinent Results: [**2142-1-8**] 05:15AM PT-13.7* PTT-33.6 INR(PT)-1.2* [**2142-1-8**] 05:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-1+ STIPPLED-OCCASIONAL TEARDROP-1+ BITE-NORMAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2142-1-8**] 05:15AM cTropnT-0.08* [**2142-1-8**] 05:15AM CK(CPK)-119 [**2142-1-8**] 04:12PM PTT-120.8* [**2142-1-8**] 10:41PM PTT-144.8* [**2142-1-8**] 02:55PM CK-MB-NotDone cTropnT-0.06* Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. Patient was initially observed in the MICU and placed on a nicardipine drip. Patient was stablized on home medicaitons, suggesting medication non-compliance. Additionally, patient presented subtheraputic on coumadin for SVC thrombosis. Patient was started on heparin ggt. After the nicardipine drip was turned off, patient was called out to the floor. Heparin drip was continued until INR [**2-13**]. Pressures were managed to her baseline. Pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with Narcan. Patient received dialysis 3x/wk as per outpatient schedule. # Hypertension: Pt with extensive history of repeated admissions for hypertension. Patient's BP improved with nicardipine drip and after HD off drip on home PO medication regimen. Resumed oral antihypertensives with improved BP control. HTn likely from renal disease, possible medication noncompliance, lupus. No evidence of MI. Continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. Renal increased clonidine patch, and added Nicardipine with improvement of BP control. Pt is to follow up with an appointment in the next week to establish care at [**Company 191**], and to re-check her BP and adjust medications further. # SLE: Stable, continued prednisone at 4 mg PO daily. # Left groin pain. Permanent HD line was placed on [**12-25**]. Line and hematoma from prior peritoneal line on abdomen okay. No leukocytosis or fevers to suggest infection. Patient was oversedated on Dilaudid and had episode of oxygen desaturation which was reversed with Narcan. Patient was solmolent with morphine SR so that was d/c'ed as well, patient was given standing tylenlol and Morphine IR PRN. Transplant surgery removed remaining sutures today from L groin. Pt has a follow-up appointment in the next week with Dr. [**First Name (STitle) **] (Transplant Surgery). She will be sent home with low-dose Morphine IR and Tylenol PRN pain. If L groin pain should become uncontrollable on current meds, pt should return to the ED for re-evaluation. It is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #ESRD: Renal following, continuing HD Th/Th/Sat. CaCO3 was started for elevated calcium-phosphate product. Pt will follow-up with Dr. [**Last Name (STitle) 7473**] in the next 1-2 weeks. # Anemia: Pt's baseline is 26. This is likely secondary to AOCD and renal failure. Hct was stable on day of discharge at 25.9. # SVC thrombus: Pt has a history of an SVC thrombus, and is on coumadin. She is supposed to be on lifelong anticoagulation due to recurrent thrombosis but INR subtherapeutic on arrival. Heparin drip was stopped on the floor once the INR was theraputic. INR was therapeutic on day of discharge. Pt will need an INR check in the next week at her follow-up with her PCP. # HOCM: Pt has evidence of myocardial hypertrophy on Echo. She is currently not symptomatic. Echo did not show evidence of worsening pericardial effusion. She was continued on her beta-blocker and other BP medications. # Depression/anxiety: Stable. She was continued on Celexa and Clonazepam. # OSA: Pt as continued on CPAP for sleep with 7 pressure. # FEN: regular diet # PPX: heparin drip --> coumadin, bowel regimen # ACCESS: PIV x2 / permanent dialysis cath L fem # CODE: FULL # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] # DISPO: home with PCP and Renal [**Name9 (PRE) 702**] to re-check BP, INR level. Follow-up with Transplant Surgery. Medications on Admission: Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Aliskiren 150 [**Hospital1 **] Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Nicardipine 30 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain for 2 weeks. [**Hospital1 **]:*20 Tablet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Urgency End Stage Renal Disease Discharge Condition: stable, blood pressure moderately controlled, afebrile, tolerating POs Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. Some of medications were increased as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to take the coumadin as prescribed by your doctor, and have your INR checked frequently per your PCP's recommendations. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Renal) Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-1-15**] 3:00 - Will follow-up Vitamin D [**2-4**] level Provider: [**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD ([**Company 191**]) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-1-16**] 3:30 - Will re-check your INR level Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Transplant Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-1-19**] 2:50p [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-1-12**]",11,2142-01-08 06:36:00,2142-01-13 21:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE URGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was initially observed in the micu and placed on a nicardipine drip. patient was stablized on home medicaitons, suggesting medication non-compliance. additionally, patient presented subtheraputic on coumadin for svc thrombosis. patient was started on heparin ggt. after the nicardipine drip was turned off, patient was called out to the floor. heparin drip was continued until inr [**2-13**]. pressures were managed to her baseline. pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with narcan. patient received dialysis 3x/wk as per outpatient schedule. # hypertension: pt with extensive history of repeated admissions for hypertension. patients bp improved with nicardipine drip and after hd off drip on home po medication regimen. resumed oral antihypertensives with improved bp control. htn likely from renal disease, possible medication noncompliance, lupus. no evidence of mi. continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. renal increased clonidine patch, and added nicardipine with improvement of bp control. pt is to follow up with an appointment in the next week to establish care at [**company 191**], and to re-check her bp and adjust medications further. # sle: stable, continued prednisone at 4 mg po daily. # left groin pain. permanent hd line was placed on [**12-25**]. line and hematoma from prior peritoneal line on abdomen okay. no leukocytosis or fevers to suggest infection. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. patient was solmolent with morphine sr so that was d/ced as well, patient was given standing tylenlol and morphine ir prn. transplant surgery removed remaining sutures today from l groin. pt has a follow-up appointment in the next week with dr. [**first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. it is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #esrd: renal following, continuing hd th/th/sat. caco3 was started for elevated calcium-phosphate product. pt will follow-up with dr. [**last name (stitle) 7473**] in the next 1-2 weeks. # anemia: pts baseline is 26. this is likely secondary to aocd and renal failure. hct was stable on day of discharge at 25.9. # svc thrombus: pt has a history of an svc thrombus, and is on coumadin. she is supposed to be on lifelong anticoagulation due to recurrent thrombosis but inr subtherapeutic on arrival. heparin drip was stopped on the floor once the inr was theraputic. inr was therapeutic on day of discharge. pt will need an inr check in the next week at her follow-up with her pcp. # hocm: pt has evidence of myocardial hypertrophy on echo. she is currently not symptomatic. echo did not show evidence of worsening pericardial effusion. she was continued on her beta-blocker and other bp medications. # depression/anxiety: stable. she was continued on celexa and clonazepam. # osa: pt as continued on cpap for sleep with 7 pressure. # fen: regular diet # ppx: heparin drip --> coumadin, bowel regimen # access: piv x2 / permanent dialysis cath l fem # code: full # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] # dispo: home with pcp and renal [**name9 (pre) 702**] to re-check bp, inr level. follow-up with transplant surgery. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Hypoxemia; Other opiates and related narcotics causing adverse effects in therapeutic use; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Abdominal pain, other specified site; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Renal dialysis status; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Other postprocedural status]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. # hypertension: pt with extensive history of repeated admissions for hypertension. # sle: stable, continued prednisone at 4 mg po daily. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. this is likely secondary to aocd and renal failure. pt will need an inr check in the next week at her follow-up with her pcp.","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was stablized on home medicaitons, suggesting medication non-compliance. patient was oversedated on dilaudid and had episode of oxygen desaturation." 109,176760.0,14805,2142-01-23,14804,124657.0,2142-01-20,Discharge summary,"Admission Date: [**2142-1-14**] Discharge Date: [**2142-1-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 4028**] Chief Complaint: headache Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with mild headache, mild shortness of breath and consistent abdominal pain at the site of her known left abdominal wall hematoma in the setting of hypertension. Her last HD was yesterday. . Upon arrival to the ED, her vitals were BP 240's systolic, HR 90's, 93% on RA. A head CT scan was done which showed no acute process. An abdominal CT was done given her femoral line pain, which also was normal. She was given nitropaste X2 initially, then switched to labetalol 100mg x2, then 200mg x2, then finally started on nicardipine drip when she showed benefit with a decrease in her BP to 170/123 and improvement in her headache. . Upon arrival to the MICU, patient denies any current symptoms. She reports that her headache, shortness of breath and abdominal pain all resolved with blood pressure management and pain medications. . Pt was transferred to the floor when blood pressure was controlled. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: HR 96 BP 171/111 RR 12 O2 98% on RA Physical Exam: General in NAD HEENT NC, AT, EOMI, PERRLA, MMM CVS RRR, 3/6 systolic murmur in all heart fields RESP CTA BL, no crackles or wheezes ABD soft, hematoma raised on left anterior abdominal wall, +BS, mildly tender over hematoma EXT left sided femoral HD line in place, no erythema, no edema NEURO A+Ox3, CN2-12 intact, pt has left sided artificial eye, motor and sensory intact Pertinent Results: ***LABS ON ADMISSION*** [**2142-1-13**] 07:03AM WBC-5.2 RBC-2.79* HGB-8.5* HCT-26.3* MCV-94 MCH-30.3 MCHC-32.2 RDW-19.2* [**2142-1-13**] 07:03AM PLT COUNT-154 [**2142-1-13**] 07:03AM PT-29.5* PTT-49.2* INR(PT)-3.0* [**2142-1-13**] 07:03AM GLUCOSE-94 UREA N-53* CREAT-7.0* SODIUM-136 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [**2142-1-13**] 07:03AM CALCIUM-8.8 PHOSPHATE-5.0* MAGNESIUM-1.9 [**2142-1-14**] 12:00PM PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-14**] 12:00PM LIPASE-42 [**2142-1-14**] 12:00PM ALT(SGPT)-12 AST(SGOT)-43* ALK PHOS-96 TOT BILI-0.4 [**2142-1-14**] 03:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-1-14**] 03:25PM URINE RBC-[**3-15**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-[**3-15**] [**2142-1-14**] 12:00PM BLOOD PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-19**] 06:40AM BLOOD PT-18.6* PTT-38.7* INR(PT)-1.7* . ***LABS ON DAY OF DISCHARGE*** [**2142-1-20**] 06:35AM BLOOD WBC-5.7 RBC-2.39* Hgb-7.1* Hct-22.1* MCV-93 MCH-29.8 MCHC-32.2 RDW-18.6* Plt Ct-136* [**2142-1-20**] 06:35AM BLOOD Glucose-107* UreaN-34* Creat-4.8* Na-137 K-5.2* Cl-101 HCO3-27 AnGap-14 [**2142-1-20**] 06:35AM BLOOD PT-22.8* PTT-42.3* INR(PT)-2.2* . IMAGING [**2142-1-14**] EKG Sinus rhythm. Possible left atrial abnormality. Borderline voltage criteria for left ventricular hypertrophy. Inferolateral ST-T wave changes may be related to left ventricular hypertrophy. Compared to the previous tracing of [**2142-1-8**] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 99 190 86 368/436 13 100 24 [**2142-1-14**] CT ABD/PELV IMPRESSION: 1. Interval decrease in size to subcutaneous anterior abdominal wall hematoma. 2. Infectious versus inflammatory process within the right lower lobe of the lung. Small right simple pleural effusion. 3. Cardiomegaly with slight decrease in size of moderate pericardial effusion. 4. Right lobe liver hemangioma, unchanged. [**2142-1-14**] CT HEAD IMPRESSION: 1. Mildly limited study given administration of small amount of IV contrast material. However, no evidence of hemorrhage or mass effect. NOTE ADDED AT ATTENDING REVIEW: This patient was administered contrast for the abdominal CT, and the head CT was performed after part of this dose. Therefore, this is neither a noncontrast examination, nor a proper contrast CT. [**2142-1-14**] CXR CONCLUSION: Persistent cardiomegaly and mild pulmonary edema. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. . # Hypertensive Urgency: Pt with extensive history of hypertension. Patient's BP improved with nicardipine drip. Became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. Restarted all home oral antihypertensives including nicardipine 30 Q8H, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Blood pressure remains labile and renal continues to follow patient. Pt was transferred to the floor as blood pressure stabilized. BP has remained stable with systolics 140s-170s. In the MICU, Nifedipine extended release was added in place of Nicardipine as pt's blood pressures seemed to rise prior to Nicardipine doses. . # Hyperkalemia: Ocurred on the day after admission. Resolved with administration of kayexalate. Pt continued hemodialysis on TuThSat. . # Left abdominal wall hematoma: Abd CT showed a mild decrease in the size. Pt reported that morphine did not help pain, and was switched to dilaudid PO in the MICU. However, given pt's recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/c'ed on the floor. Pt was continued on gabapentin, tylenol around the clock, and low-dose Morphine as needed for pain. Narcotics should be avoided in the future. Pain should also resolve in the next few weeks as hematoma resolves. . # SLE: Pt was continued on prednisone at 4 mg PO daily. . #ESRD: Renal was following during her stay. She continued HD on her T, Th, Sat schedule. # Anemia: Hct was mildly decreased from baseline during admission. This is likely secondary to AOCD and in the setting of renal failure. . # SVC thrombus: Patient is on anticoagulation, likely lifelong. Patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. Then INR became subtherapeutic, so heparin gtt was used to bridge. On day of discharge, INR became therapeutic, and pt was discharged home on Coumadin 4mg PO daily, with INR to be checked next at hemodialysis . # HOCM: Pt has evidence of myocardial hypertrophy on recent Echo. She was not symptomatic during her stay. She was continued on her beta blocker. . # Depression/anxiety. She was continued on celexa and clonazepam PRN. . # OSA: CPAP for sleep with 7 pressure. . # FEN: repleted lytes prn / regular diet . # PPX: coumadin, bowel regimen . # ACCESS: PIV/ permanent dialysis cath L fem . # CODE: FULL . # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nicardipine 30mg PO TID Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for breakthrough pain for 2 weeks. 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*1* 13. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*260 Tablet(s)* Refills:*1* 14. Respiratory Therapy Please adjust settings of CPAP machine to a lower volume as it is uncomfortable for the patient. Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Discharge Condition: Good, hemodynamically stable, afebrile, pain controlled Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. One new medication was added as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to continue your Coumadin at 4mg daily and have your INR checked AT DIALYSIS next week. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep ALL scheduled appointments. Medications changes include: 1. STOP NICARDIPINE 2. Start Nifedipine CR 90mg by mouth daily 3. INCREASE Labetalol to 900mg by mouth 3 times daily 4. Continue at Warfarin 4mg by mouth daily If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to set up a follow-up appointment in 1-2weeks. Please continue your HD TuThSat. Completed by:[**2142-1-20**]",3,2142-01-14 17:34:00,2142-01-20 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. . # hypertensive urgency: pt with extensive history of hypertension. patients bp improved with nicardipine drip. became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. restarted all home oral antihypertensives including nicardipine 30 q8h, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. blood pressure remains labile and renal continues to follow patient. pt was transferred to the floor as blood pressure stabilized. bp has remained stable with systolics 140s-170s. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. . # hyperkalemia: ocurred on the day after admission. resolved with administration of kayexalate. pt continued hemodialysis on tuthsat. . # left abdominal wall hematoma: abd ct showed a mild decrease in the size. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu. however, given pts recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/ced on the floor. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. narcotics should be avoided in the future. pain should also resolve in the next few weeks as hematoma resolves. . # sle: pt was continued on prednisone at 4 mg po daily. . #esrd: renal was following during her stay. she continued hd on her t, th, sat schedule. # anemia: hct was mildly decreased from baseline during admission. this is likely secondary to aocd and in the setting of renal failure. . # svc thrombus: patient is on anticoagulation, likely lifelong. patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. then inr became subtherapeutic, so heparin gtt was used to bridge. on day of discharge, inr became therapeutic, and pt was discharged home on coumadin 4mg po daily, with inr to be checked next at hemodialysis . # hocm: pt has evidence of myocardial hypertrophy on recent echo. she was not symptomatic during her stay. she was continued on her beta blocker. . # depression/anxiety. she was continued on celexa and clonazepam prn. . # osa: cpap for sleep with 7 pressure. . # fen: repleted lytes prn / regular diet . # ppx: coumadin, bowel regimen . # access: piv/ permanent dialysis cath l fem . # code: full . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Other vascular complications of medical care, not elsewhere classified; Systemic lupus erythematosus; Hyperpotassemia; Phlebitis and thrombophlebitis of upper extremities, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. # anemia: hct was mildly decreased from baseline during admission. # hocm: pt has evidence of myocardial hypertrophy on recent echo. # fen: repleted lytes prn / regular diet . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. pt was transferred to the floor as blood pressure stabilized. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu." 109,158943.0,14808,2142-03-23,14798,126055.0,2141-11-03,Discharge summary,"Admission Date: [**2141-10-13**] Discharge Date: [**2141-11-3**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 6734**] Chief Complaint: Nausea, Vomitting, Abdominal Pain, HTN Urgenc Major Surgical or Invasive Procedure: Upper GI endoscopy Exploratory laparotomy Tunneled hemodialysis catheter in R femoral vein Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 24 y/o F with h/o ESRD, HTN who started peritoneal dialysis during the week of [**2141-10-8**] and presented with a 1 day history of acute onset N/V, sharp abdominal pain on [**2141-10-13**]. (Of note, the patient had presented to the ED on [**10-11**] with hypotension, SBPs in the 80s off after approximately 1.5L was taken off during dialysis in the setting of taking her PO Anti-HTNs. On [**2141-10-11**] she received 0.5L IVF, labs WNL, and was d/c'd home). On the day of admission on [**2141-10-13**], the patient reported that the previous night, she was awoken from sleep with severe, sharp abdominal pain, 6 episodes of frothy emesis, 10+ yellowish BMs without melena or BRBRP.She was admitted for further work- up of this abdminal pain. . In the ED here vitals were as follows: T: 97.0 HR: 101 BP: 240/180 RR: 17 O2sat: 100%RA. She received Labetolol 20mg IV and was subsequently placed on a labetolol drip. She also received ceftriaxone 1gm IV, Flagyl 500mg IV, Dilaudid 0.5-1mg IV q1hr and Zofran. Her abdominal CT showed multifocal areas of small bowel wall thickening. Her peritoneal Cell count was negtaive for SBP. She had some signs of peritonitis and thus surgery was consulted. Her lactate was normal. . Upon arrival to the MICU the patient was mentating well with complaints of diffuse sharp abdominal pain that radiated to the back and diarrhea. She had no headache or visual changes. Past Medical History: - SLE DX ([**2134**] - 16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter Placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). - Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS: 98.4 HR 98 192/131 21 100%RA GEN: Mild Distress, AOx3 HEENT: PEERLA, EOMI NECK: Supple, No LAD, No bruit RESP: CTAB CARD: 2/6 systolic ejection murmur ABD: soft, moderately tender with +/- guarding, BS+ EXTR: Warm well perfused NEURO: Motor Grossly Intact RECTAL: Yellow Stool BACK: B CVAT Pertinent Results: [**2141-11-3**] 08:50AM BLOOD WBC-3.5* RBC-2.55* Hgb-7.8* Hct-23.6* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.8* Plt Ct-176 [**2141-11-3**] 03:55PM BLOOD PT-15.5* PTT-50.8* INR(PT)-1.4* [**2141-11-3**] 08:50AM BLOOD Glucose-121* UreaN-33* Creat-5.2*# Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [**2141-10-26**] 06:15AM BLOOD ALT-11 AST-49* AlkPhos-122* Amylase-186* TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2141-10-26**] 06:15AM BLOOD Lipase-30 [**2141-11-3**] 08:50AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.9 [**2141-10-30**] 06:55AM BLOOD HBsAg-NEGATIVE [**2141-10-17**] 10:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2141-10-25**] 11:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2141-10-25**] 11:56AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2141-10-25**] 11:56AM URINE RBC-0-2 WBC-[**3-15**] Bacteri-FEW Yeast-NONE Epi-21-50 Blood cultures: all negative EKG ([**2141-10-13**]): Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of [**2141-10-2**] there is no significant diagnostic change. CXR ([**2141-10-13**]): No acute cardiopulmonary abnormality. No free air under the diaphragms. CT chest/abdomen/pelvis ([**2141-10-13**]): There is a moderate-sized pericardial effusion, similar in appearance from [**2141-10-13**]. The great vessels are normal in caliber, without aneurysmal dilatation. Evaluation of the great vessels is limited without IV contrast. Interstitial thickening, particularly within the perihilar regions, is suggestive of fluid overload. There is bibasilar atelectasis with a small focus of consolidation in the right lower lobe (2:35) unchanged from [**2141-10-13**], and may reflect aspiration or pneumonia. Scattered bilateral nodules are largely stable from as far back as [**2139-10-9**]. Specifically, there is a 5 mm nodule in the right middle lobe (2:25), two adjacent nodules in the right lower lobe measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule within the left lower lobe. A nodular density seen adjacent and anterior to the right main pulmonary artery (2:23) may reflect a vessel. There is a small right pleural effusion. Axillary lymphadenopathy, with axillary nodes measuring up to approximately 10 mm in short axis, is seen. Ill- defined soft tissue thickening within the hilus bilaterally may reflect hilar lymphadenopathy, but assessment is limited without IV contrast. A catheter is visualized within the visualized right upper extremity, which may reflect a PICC line that terminates within the right subclavian vein. The esophagus is distended and filled with contrast, with marked wall thickening and edema throughout its entire length, a new finding. There is a moderate- sized hiatal hernia. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval development of a moderate amount of free intraperitoneal air, that layers anteriorly and along the anterior abdominal wall. Additional small clustered foci of extraluminal air is seen adjacent to the proximal stomach and the gastroesophageal junction, with a focus of air tracking into the fissure of ligamentum venosum. Additionally, there appears to be air tracking into the anterior subcutaneous tissues in the region of the umbilicus. These findings are all new from the prior CT on [**2141-10-13**], but free air was present on chest radiograph performed [**2141-10-25**]. There is no obvious evidence of extravasation of oral contrast into the peritoneum. Of note, a peritoneal dialysis catheter is in place that could represent a route of entry of intraperitoneal air. The stomach, small bowel, and colon are filled with contrast, without evidence of obstruction. Evaluation for wall thickening is limited without IV contrast. Limited non-contrast views of the liver demonstrates a rounded 1.6 cm x 1.2 cm hypodensity in the right lobe of the liver, previously characterized as a hemangioma. The liver is otherwise unremarkable. The gallbladder, spleen, pancreas, and adrenal glands demonstrate no gross abnormality. Both kidneys are atrophic. Evaluation of solid organs is limited by lack of IV contrast. There is a peritoneal dialysis catheter, coiled within the pelvis, unchanged. There is a large amount of free fluid throughout the abdomen, similar in appearance to the prior study. CT OF THE PELVIS WITHOUT IV CONTRAST: Uterus and rectum are grossly unremarkable. However, assessment of the rectal wall is limited without IV contrast. OSSEOUS STRUCTURES: Bones are diffusely sclerotic, which may be related to renal osteodystrophy. There is bilateral sacroiliitis. IMPRESSION: 1. Interval development of a moderate amount of free intraperitoneal air, new from [**2141-10-13**]. A peritoneal dialysis catheter is in place and could represent the route of entry of free intraperitoneal air. However, as foci of air is seen in the region of the proximal stomach and GE junction in the setting of a recent endoscopy, perforation cannot be excluded, though no frank extravasation of contrast is identified. 2. New dilation and wall thickening of the entire esophagus, a nonspecific finding that could relate to infectious or inflammatory esophagitis; clinical correlation is recommended. Esophagus is contrast-filled possibly representing reflux. Hiatal hernia. 3. Anasarca, with moderate-sized pericardial effusion, pulmonary edema, and small right pleural effusion. 4. Large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. Imaging cannot exclude SBP, which should be evaluated for clinically. 5. Focus of consolidation within the right lower lobe, could represent aspiration or pneumonia, but unchanged from the prior study. Gastric Biopsies ([**2141-10-18**]): Antrum: Corpus-type mucosa, no diagnostic abnormalities recognized. Jejunum: Small intestinal mucosa, no diagnostic abnormalities recognized. UE Venous U/S: No evidence of DVT of the left upper extremity, without thrombus identified within the left subclavian vein. Brief Hospital Course: This is a 24 year old woman with ESRD secondary to SLE (started peritoneal dialysis approximately one week prior to admission), malignant HTN, h/o SVC syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. Her hospital course was complicated by multiple transfers between the MICU and the floor secondary to hypertensive urgency. # Abdominal Pain/Diarrhea: During the patient's admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. Infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. However, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. The patient was empirically placed on IV flagyl, but this was discontinued when stool samples were negative for C.difficile. Serial abdominal exams showed no peritoneal signs. Peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. CT of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. Other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to SLE vasculitis, malignant HTN, or microthrombosis and SLE enteritis. Surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. A heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible GI bleed. With regards to SLE vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to SLE. On [**10-18**], GI performed an EGD which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. Approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. Both cardiac, GI, and pulmonary etiologies were considered for the origin of her epigastric pain. Pericarditis was considered, but her EKG was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. Her lungs were also essentially unchanged from [**2141-10-13**]. However, her abdominal CT on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. As a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. There were no major findings: no evidence of perforation, obstruction, or infection. The patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. At discharge, the patient only complained of some mild incisional pain. # Hypertensive urgency: The patient was initially admitted to the MICU with a blood pressure of 240/180. Her hospital course was complicated by extremely labile HTN and was transferred back and forth between the MICU and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of SBPs > 260. Throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. Her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. Multiple medication regimens were attempted and changed throughout her hospital course. However, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for SBPs > 180. At discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg PO. Her regimen as per Dr. [**Last Name (STitle) 4883**]: Nifedipine SR 90 mg daily Aliskiren 150 mg [**Hospital1 **] Labetalol 300 mg TID Hydralazine 75 mg TID Clonidine patch 0.3 mg/24 hr patch qWed When SBP>180, she then uses a hydralazine sliding scale. When SBP>180, give 25 mg PO hydral every 30 min until SBP<150. You can use this for up to 2-3 hours. In between PO hydral doses, can then also use 10 IV hydralazine. # ESRD: The etiology of the patient's ESRD is secondary to SLE. Her Creatinine on admission was 7.9, which was near her baseline of 8 - 9. During her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. Prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2L per PD. After her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. Initially, the patient adamantly refused hemodialysis. However, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. As a result, after a long coversation with her primary renal physician, [**Name10 (NameIs) **] agreed to restart hemodialysis. A tunneled catheter was placed in her R femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. She underwent hemodialysis two more times prior to discharge. Upon discharge, her electrolytes were back to her baseline. She is expected to undergo hemodialysis (Tues/[**Last Name (un) **]/SAT) as an outpatient. # Anemia: During her admission, the patient's HCT was monitored daily with HCT to low-mid 20's. On [**2141-10-17**], she was found to have guaiac positive stools and her HCT was found to have dropped to a low of 18.6. The patient was transfused a total of 2 units of [**Date Range **] between [**2141-10-17**] and [**2141-10-18**]. Epo Alfa SC was also given on [**2141-10-17**]. She remained hemodynamically stable. GI consulted and EGD results were as stated above. The patient's HCT remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. Between [**2141-10-23**] - [**2141-10-24**], the patient had a HCT drop from 26 to 20 in the setting of occult positive emesis. She received two units of [**Month/Day/Year **] and her HCT returned to 28. GI was aware and planned to perform a non-urgent EGD on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her HCT returned to baseline. However, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her HCt remained stable and near baseline for the remiainder of her hospital course. # H/O Thrombosis: The patient was initially placed on her home dose of warfarin 2mg qd. Her INR on admission was 1.2. She was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. However, this was stopped for her EGD and after she had evidence of a GI bleed. The heparin drip was discontinued on [**10-22**]. The patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in HCT and in preparation for a possible GI intervention. After her surgery, her coumadin was held and she was off the heparin drip, but her INR continued to drift up, getting as high as 2.6 on [**2141-10-30**]. This was mostly attributed to nutritional deficiency [**2-11**] poor PO intake, but there was concern for possible synthetic dysfunction as well. As a result, she was given a test dose of vitamin K, which she responded to well (Her INR came back down to 1.4). As a result, her home dose of coumadin at 2 mg qday was restarted. At discharge, her INR was still sub- therapeutic at 1.4. Of note, the patient has a history of SVC syndrome and had a L subclavian venous thrombosis. During the last few days of her hospital stay, the patient complained of increased tongue swelling and her L face was noted to be slightly more swollen than previously noted. As a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a DVT within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # SLE: Rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. Her outside rheumatologist was also consulted. Both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # Obstructive sleep apnea: The patient was noted to have OSA based on clinical nocturnal exam during admission. Patient attempted 1 trial of CPAP at 2L/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. The paitent stated that she would pursue further work-up and treatment for OSA as an outpatient. While the mask and CPAP machine were at her bedside throughout her hospital course, the patient rarely used it. # Metabolic Acidosis: The patient's bicarbonate on admission was 13. Her baseline is normally between 16-20. She received 150mEq NaHCO3 over 24hrs from [**Date range (1) 43500**]. During her brief returns to the MICU, her HC03 was 18-19, which was presumed to be her baseline at home secondary to her CRF. At discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. Medications on Admission: Nifedipine 60 mg PO daily Labetalol 900 mg PO TID Hydralazine 50 mg PO TID Clonidine 0.3 mg/24hr patch qWED Lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 4 mg daily Warfarin 2mg PO daily Calcitriol 1 mcg daily Calcium carbonate 500mg QID Dilaudid 2mg PO Q4-6hr prn pain Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*30 Patch Weekly(s)* Refills:*2* 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. [**Hospital1 **]:*1500 ML(s)* Refills:*0* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Twice daily (). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): In addition to 75 mg TID, if SBP>180, take 1 tab every 30 min until BP decreases to 150. If no improvement after 2 hours, call your doctor. [**Last Name (Titles) **]:*300 Tablet(s)* Refills:*6* 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). [**Last Name (Titles) **]:*1500 ML(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet Sustained Release(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 5 days. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. [**Last Name (Titles) **]:*30 Capsule(s)* Refills:*2* 13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO once a day. [**Last Name (Titles) **]:*30 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: end stage renal disease malignant hypertension abdominal free air subclavian deep vein thrombosis initiation of hemodialysis Secondary: SLE Anemia Discharge Condition: stable, pain well controlled, blood pressure at baseline Discharge Instructions: You were admitted for abdominal pain and then subsequently had a very long hospital course with high blood pressures, severe abdominal pain, some free air in your abdomen resulting in an exploratory laparotomy. You have also been initiated on hemodialysis on Tuesday/Thursday/Saturday schedule. Please take all medications as prescribed in the list that you will be given at discharge. There have been some changes to your medications. Please call your doctor if you have any worsening abdominal pain, fevers, chills, nausea, vomiting, headache, palpitations, diarrhea or any other concerning symptoms. Followup Instructions: You will see Dr. [**Last Name (STitle) 4883**] at hemodialysis on Tuesday, [**11-7**], [**2141**]. You should have your coumadin level checked at this appointment. Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] to schedule an appointment in [**1-11**] weeks to have your staples removed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**] ",140,2141-10-13 23:10:00,2141-11-03 18:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. her hospital course was complicated by multiple transfers between the micu and the floor secondary to hypertensive urgency. # abdominal pain/diarrhea: during the patients admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. the patient was empirically placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. serial abdominal exams showed no peritoneal signs. peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. ct of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to sle vasculitis, malignant htn, or microthrombosis and sle enteritis. surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible gi bleed. with regards to sle vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to sle. on [**10-18**], gi performed an egd which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. both cardiac, gi, and pulmonary etiologies were considered for the origin of her epigastric pain. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. her lungs were also essentially unchanged from [**2141-10-13**]. however, her abdominal ct on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. as a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. there were no major findings: no evidence of perforation, obstruction, or infection. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. at discharge, the patient only complained of some mild incisional pain. # hypertensive urgency: the patient was initially admitted to the micu with a blood pressure of 240/180. her hospital course was complicated by extremely labile htn and was transferred back and forth between the micu and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of sbps > 260. throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. multiple medication regimens were attempted and changed throughout her hospital course. however, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for sbps > 180. at discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg po. her regimen as per dr. [**last name (stitle) 4883**]: nifedipine sr 90 mg daily aliskiren 150 mg [**hospital1 **] labetalol 300 mg tid hydralazine 75 mg tid clonidine patch 0.3 mg/24 hr patch qwed when sbp>180, she then uses a hydralazine sliding scale. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. you can use this for up to 2-3 hours. in between po hydral doses, can then also use 10 iv hydralazine. # esrd: the etiology of the patients esrd is secondary to sle. her creatinine on admission was 7.9, which was near her baseline of 8 - 9. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2l per pd. after her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. initially, the patient adamantly refused hemodialysis. however, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. as a result, after a long coversation with her primary renal physician, [**name10 (nameis) **] agreed to restart hemodialysis. a tunneled catheter was placed in her r femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. she underwent hemodialysis two more times prior to discharge. upon discharge, her electrolytes were back to her baseline. she is expected to undergo hemodialysis (tues/[**last name (un) **]/sat) as an outpatient. # anemia: during her admission, the patients hct was monitored daily with hct to low-mid 20s. on [**2141-10-17**], she was found to have guaiac positive stools and her hct was found to have dropped to a low of 18.6. the patient was transfused a total of 2 units of [**date range **] between [**2141-10-17**] and [**2141-10-18**]. epo alfa sc was also given on [**2141-10-17**]. she remained hemodynamically stable. gi consulted and egd results were as stated above. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. she received two units of [**month/day/year **] and her hct returned to 28. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. however, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her hct remained stable and near baseline for the remiainder of her hospital course. # h/o thrombosis: the patient was initially placed on her home dose of warfarin 2mg qd. her inr on admission was 1.2. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. however, this was stopped for her egd and after she had evidence of a gi bleed. the heparin drip was discontinued on [**10-22**]. the patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in hct and in preparation for a possible gi intervention. after her surgery, her coumadin was held and she was off the heparin drip, but her inr continued to drift up, getting as high as 2.6 on [**2141-10-30**]. this was mostly attributed to nutritional deficiency [**2-11**] poor po intake, but there was concern for possible synthetic dysfunction as well. as a result, she was given a test dose of vitamin k, which she responded to well (her inr came back down to 1.4). as a result, her home dose of coumadin at 2 mg qday was restarted. at discharge, her inr was still sub- therapeutic at 1.4. of note, the patient has a history of svc syndrome and had a l subclavian venous thrombosis. during the last few days of her hospital stay, the patient complained of increased tongue swelling and her l face was noted to be slightly more swollen than previously noted. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. her outside rheumatologist was also consulted. both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission. patient attempted 1 trial of cpap at 2l/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. the paitent stated that she would pursue further work-up and treatment for osa as an outpatient. while the mask and cpap machine were at her bedside throughout her hospital course, the patient rarely used it. # metabolic acidosis: the patients bicarbonate on admission was 13. her baseline is normally between 16-20. she received 150meq nahco3 over 24hrs from [**date range (1) 43500**]. during her brief returns to the micu, her hc03 was 18-19, which was presumed to be her baseline at home secondary to her crf. at discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. ","PRIMARY: [Malignant essential hypertension] SECONDARY: [Renal dialysis status; Epilepsy, unspecified, without mention of intractable epilepsy; Constipation, unspecified; Anemia in chronic kidney disease; Abnormal coagulation profile; Obstructive sleep apnea (adult)(pediatric); Other diseases of lung, not elsewhere classified; Other chest pain; Fever, unspecified; Rash and other nonspecific skin eruption; Other chronic pulmonary heart diseases; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified disease of pericardium; Other ascites; Acidosis; Hyposmolality and/or hyponatremia; Abdominal pain, other specified site; Abdominal pain, epigastric; Nausea with vomiting; Diarrhea; Systemic lupus erythematosus; Hyperparathyroidism, unspecified; Anemia, unspecified; Thrombocytopenia, unspecified; Esophageal reflux]","this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. multiple medication regimens were attempted and changed throughout her hospital course. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. upon discharge, her electrolytes were back to her baseline. epo alfa sc was also given on [**2141-10-17**]. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission.","esrd secondary to sle, malignant htn, h/o svc syndrome, and multiple thrombotic events were considered. the patient was placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia." 109,158943.0,14808,2142-03-23,14799,125288.0,2141-11-23,Discharge summary,"Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypertensive Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: (from MICU admit note) 24yoF ESRD-HD, SLE, HTN presents with 1 month abdominal pain and hypertension. Pt has had work-up over recent months for abd pain, including exploratory laparotomy, all of which essentially (-). Was admitted [**Date range (1) 34629**], for abdominal pain, then returned [**11-16**] for sob with (-)CTA, dc'ed [**11-17**]. In [**Hospital1 18**] ED, T98.5 hr95 BP 220/110 then 183/133 RR13 O2 100% on RA, rectal exam negative, guaiac(-), pelvic exam unremarkable with no cervical motion tenderness. Renal was consulted, taken for hemodialysis. CT abd showed large ascites, no other pathology; CT head improved from prior with no acute ICH; cxr(-). Given iv dilaudid for abdominal pain. BP treated with 10mg iv labetalol. Blood and urine cultures drawn, peritoneal fluid cx sent from catheter. Admitted to MICU for hypertension management. Access: R-HD catheter, 1 pIV in hand, 1 non-functioning peritoneal dialysis catheter. Past Medical History: PMH: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSH: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: PE: T:99.4 BP:158/108 HR:95 RR:12 O2 100% RA GEN: NAD/ pt eyes closed due to pain/ pleasant despite pain HEENT: AT, NC, PERRLA, EOMI on R eye, L eye prosthesis, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD CV: S1 & S2, RRR II/VI HSM at R/L USB, no rubs/gallops PULM: CTAB, no w/r/r ABD: soft, mildly tender at PD catheter, ND, + BS, midline incision with steri-stripes, PD catheter dressing C/I/D EXT: warm, dry, +2 distal pulses BL, no edema NEURO: alert & oriented, CN II-XII grossly intact (except L eye), 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: Admission Labs: [**2141-11-18**] 07:00AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.7* Hct-30.7* MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* Plt Ct-142* [**2141-11-18**] 07:00AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.3* [**2141-11-18**] 07:00AM BLOOD Glucose-86 UreaN-22* Creat-5.0* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2141-11-18**] 07:00AM BLOOD ALT-8 AST-39 AlkPhos-92 TotBili-0.3 [**2141-11-18**] 07:00AM BLOOD Lipase-76* [**2141-11-18**] 07:00AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.9 [**2141-11-18**] 11:00PM ASCITES WBC-1265* RBC-1680* Polys-43* Lymphs-1* Monos-2* Mesothe-11* Macroph-43* [**2141-11-18**] 10:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2141-11-18**] 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2141-11-18**] 10:05AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-[**3-15**] Discharge Labs: [**2141-11-23**] 04:40AM BLOOD WBC-2.9* RBC-3.08* Hgb-9.0* Hct-28.3* MCV-92 MCH-29.2 MCHC-31.8 RDW-17.5* Plt Ct-182 [**2141-11-23**] 04:40AM BLOOD PT-20.8* PTT-76.1* INR(PT)-2.0* [**2141-11-23**] 04:40AM BLOOD Glucose-80 UreaN-21* Creat-4.7* Na-139 K-4.8 Cl-106 HCO3-24 AnGap-14 [**2141-11-23**] 04:40AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8 [**2141-11-22**] 04:55AM BLOOD TSH-6.1* [**2141-11-23**] 04:40AM BLOOD Free T4-1.2 Blood cx ([**11-18**], [**11-19**]): 1/4 bottles with coag neg Staph, [**3-14**] NGTD Urine cx ([**11-18**]): mixed flora c/w contamination Peritoneal fluid ([**11-18**]): Gram stain 2+ polys. Culture no growth. Imaging: CXR Portable ([**11-18**]): Since [**2141-11-16**], heart size enlargement is unchanged due to known pericardial effusion. Lungs are otherwise clear. Hilar contours are normal. Incidentally, widening of both acromioclavicular joints is unchanged. CT A/P ([**11-18**]): 1. No evidence of bowel obstruction or rim-enhancing fluid collection. 2. Large ascites, slightly increased from [**2141-11-13**], with peritoneal dialysis catheter in place. Interval removal of surgical skin staples along the abdomen. 3. Moderate pericardial effusion as before. 4. Symmetric heterogeneous attenuation of the kidneys could be related to renal failure; however, pyelonephritis could also give this appearance. Appearance of the kidneys is unchanged from [**2141-11-13**]. CT Head w/o contrast ([**11-18**]): 1. No evidence of acute intracranial hemorrhage. 2. Regions of hypoattenuation in the bifrontal white matter and left posterior temporal lobe have resolved since [**2141-6-11**]. No new regions of hypoattenuation seen. Brief Hospital Course: 1) Hypertension: Patient has history of extremely labile hypertension on an aggressive outpatient regimen. Overnight in the MICU, patient required IV and PO labetalol for SBP > 200. Her hydralazine was increased from 75mg to 100mg TID with mild improvement. Her labetalol was also increased from 300mg to 400mg TID. Her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. TSH was sent and elevated, although free T4 was normal. Plasma metanephrines were sent and pending at discharge. 2) Abdominal pain: CT scan showed increasing ascites, but no acute pathology. Peritoneal fluid was obtained and contained 544 polys. Treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing GPC pairs/clusters. Blood cultures ended up growing 1 out of 4 bottles coag-neg Staph, likely contaminant, so vancomycin was stopped. Since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. The peritoneal cultures remained negative. Her PD catheter was left in place as the patient refuses HD any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) SVC/brachiocephalic thrombosis: Patient's INR was subtherapeutic on admission at 1.3. Due to the proximal location of her old venous thrombi, she was started on a heparin gtt. This was continued during her admission and her warfarin was increased to 5mg daily. Her INR reached 2.0 at discharge (therapeutic range 2-3). The dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) Anxiety: Patient noted feeling short of breath and anxious around the time of her recent admissions. Her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. They felt her symptoms were suggestive of anxiety and panic attacks, recommended checking TSH and metanephrines as above, and starting citalopram 20mg, which was done. She was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h PRN. Patient is agreeable to outpatient follow up with [**Company 191**] social work, and potential CBT. These can be arranged by her PCP. Medications on Admission: 1. Aliskiren 150 mg [**Hospital1 **] 2. Clonidine 0.3 mg/24 qwk 3. Prochlorperazine Maleate 10 mg prn 4. Hydromorphone 2 mg Tablet Sig: [**1-11**] q6 prn 5. Bisacodyl 10mg [**Hospital1 **] 6. Ergocalciferol (Vitamin D2) 50,000 qmonth 7. Hydralazine 75mg tid 8. Hydralazine scale prn 9. Labetalol 300 mg tid 10. Nifedipine 90 mg qd 11. Prednisone 4mg qd 12. Warfarin 2 mg qd at 4pm Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Hospital1 766**]). 5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day. [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 7 days. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO q30 min prn as needed for hypertension: for SBP > 180. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive urgency Headache Abdominal pain Anxiety Secondary Diagnosis: HTN SLE ESRD on HD SVC and IJ thrombosis, chronic Anemia Discharge Condition: Stable, BPs improved. Discharge Instructions: You were admitted with elevated blood pressures, headache, and abdominal pain. You were found to have increased amounts of white blood cells in your abdominal cavity, but this was not infected. Your abdominal pain resolved and you continued to have intermittent headaches. Your blood pressure medications were adjusted as below. You were also seen by psychiatry who recommended starting new medications for your anxiety. The following changes were made to your medication regimen: - We increased your hydralazine to 100 mg three times a day. - We also increased your labetalol to 400 mg three times a day. - We have started a medication called celexa 20 mg daily as well as ativan 1 mg three times a day as needed for anxiety. - We have increased your coumadin to 4 mg daily. - Please continue taking all other medications as previously prescribed. Call your doctor or return to the emergency room if you experience any of the following: worsening abdominal pain, nausea, vomiting, blurry vision, worsening headache, fever > 101. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. Please continue to follow with your nephrologist and go to outpatient dialysis as previously arranged. Please discuss with your PCP the possibility of talking to a social worker at [**Name (NI) 191**]. You will need to continue to have your INR monitored at [**Hospital 191**] [**Hospital 2786**] clinic. Please have this level checked on [**Hospital 766**], [**11-27**]. Completed by:[**2141-11-23**]",120,2141-11-18 14:00:00,2141-11-23 16:42:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. her hydralazine was increased from 75mg to 100mg tid with mild improvement. her labetalol was also increased from 300mg to 400mg tid. her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. tsh was sent and elevated, although free t4 was normal. plasma metanephrines were sent and pending at discharge. 2) abdominal pain: ct scan showed increasing ascites, but no acute pathology. peritoneal fluid was obtained and contained 544 polys. treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing gpc pairs/clusters. blood cultures ended up growing 1 out of 4 bottles coag-neg staph, likely contaminant, so vancomycin was stopped. since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. the peritoneal cultures remained negative. her pd catheter was left in place as the patient refuses hd any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) svc/brachiocephalic thrombosis: patients inr was subtherapeutic on admission at 1.3. due to the proximal location of her old venous thrombi, she was started on a heparin gtt. this was continued during her admission and her warfarin was increased to 5mg daily. her inr reached 2.0 at discharge (therapeutic range 2-3). the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) anxiety: patient noted feeling short of breath and anxious around the time of her recent admissions. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. they felt her symptoms were suggestive of anxiety and panic attacks, recommended checking tsh and metanephrines as above, and starting citalopram 20mg, which was done. she was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h prn. patient is agreeable to outpatient follow up with [**company 191**] social work, and potential cbt. these can be arranged by her pcp. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Abdominal pain, unspecified site; Anemia, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. her hydralazine was increased from 75mg to 100mg tid with mild improvement. peritoneal fluid was obtained and contained 544 polys. the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted.","patient has history of extremely labile hypertension on aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. ct scan showed increasing ascites, but no acute pathology." 109,158943.0,14808,2142-03-23,14800,161950.0,2141-12-01,Discharge summary,"Admission Date: [**2141-11-24**] Discharge Date: [**2141-12-1**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Headache, abdominal pain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24yo F w/PMHx of ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning, awakening her from sleep. Had been previously discharged from [**Hospital1 **] yesterday after being admitted for hypertension and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Upon discharge yesterday she states her abdominal pain had subsided. She had HD yesterday without complications. She awoke at 6am with a headache and crampy, stabbing abdominal pain. Took 2mg PO Dilaudid without relief and came to ED. No nausea/vomiting, no changes in vision, no fevers, chills, night sweats. No chest pain, SOB, diarrhea. In the ED, initial vitals were T98.7, BP260/130, HR70, RR16. Was initially given 10mg IV Labetalol X 2, 4mg Zofran for nausea. No improvement in BP and started on Labetolol gtt. Got 1mg IV Dilaudid for pain. Currently, patient continues to complain of headache and abdominal pain, both [**7-17**]. No vision changes, chest pain or shortness of breath. Has been feeling increased anxiety recently and saw psychiatrist, was put on Celexa. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T98.2, BP176/135, HR94, RR 22, 100% RA Gen: well-appearing african-american woman, lying comfortably HEENT: anicteric, L eye prosthetic non-reactive, R pupil reactive, MMM, neck supple with submanibular LAD CV: RRR, II/VI SEM best heard at apex Pulm: CTA b/l Abd: hyperactive bowel sounds, midline scar well-healed, soft, diffusely tender to palpation, +rebound, no guarding. PD catheter in LLQ without erythema or purulent material draining. +dullness on percusion with evidence of clinical ascites. Ext: no edema, no clubbing, 2+ peripheral pulses DP and radial. R femoral HD [**Last Name (un) **] in place without erythema, purulance Neuro: A&O X 3, CN intact II-XII, [**5-15**] motor strength in upper and lower extremities Pertinent Results: Admission labs: CBC: [**2141-11-26**] 05:21AM BLOOD WBC-3.5* RBC-3.07* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-17.6* Plt Ct-180 CHEM 10: [**2141-11-26**] 01:16PM BLOOD Glucose-87 UreaN-17 Creat-4.0* Na-136 K-5.2* Cl-106 HCO3-23 AnGap-12 [**2141-11-26**] 09:20PM BLOOD Calcium-7.6* Phos-3.8 Mg-1.8 COAGS: [**2141-11-26**] 01:16PM BLOOD PT-23.9* PTT-40.2* INR(PT)-2.3* STUDIES: 1)Peritoneal fluid ([**11-26**]): negative for malignant cells. Reactive mesothelial cells, macrophages, eosinophils and lymphocytes. 2)BILAT UP EXT VEINS US ([**11-26**]): No evidence of deep vein thrombosis of the right or left upper extremity. 3) MRI/MRA ([**11-30**]): FINDINGS: Examination is somewhat limited by patient motion. T2/FLAIR sequences are unremarkable with interval resolve of previously noted posterior abnormalities. The major vessels appear patent proximally. There are stable areas of low signal in the left frontal and right occipetal/temporal lobes. IMPRESSION: 1. Interval resolution of previously noted posterior white matter abnormalities. 2. Stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions. 3. Very limited MRA as above. Brief Hospital Course: 24yo F with SLE, ESRD on HD and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**Hospital Unit Name 153**] course: The patient was admitted for blood pressure management and evaluation of abd pain. An A-line was placed. EKG showed no change from prior, and Abd x-ray showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home med regimen. The patient was found to be hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. Upon transfer to the floor, the following was her course: 1. Hypertensive Urgency: Pt had had hemodialysis one day prior to admission, so unlikely that she was volume overloaded. Unclear what precipitated this episode of hypertensive urgency, although suspect secondary to abdominal pain leading to an anxiety which then precipitates hypertension. She may not have been taking her medications secondary to pain. Negative serum tox. On the floor, we continued hemodialysis Tu, Th, Sat. She was initially continued on PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine 90mg PO qday and clonidine; she received hydralazine 10mg IV for goal BP < 180/100. Renal team followed patient during this hospitalization. Per renal team recs, labetalol was increased to 800mg TID due to poor blood pressure control. Pt discharged on clonidine 0.3mg patch, Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, Nifedipine 90mg daily and lobatalol 800mg TID. This regimen worked well. 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT scan during prior admission which did not show source of abdominal pain. On admission, LFTs were normal except for slightly low albumin, lipase was slightly elevated and KUB was negative for free air or evidence of SBO. Peritoneal fluid was negative for malignant cells but showed reactive mesothelial cells, macrophages, eosinophils and lymphocytes. Negative gram stain or peritoneal fluid cultures, excluding SBP as a cause of the abdominal pain. PD catheter was not removed. Pt was continued on PO dilaudid 1-2mg Q6h and pain resolved. She denied N/V/diarrhea or constipation. 3. ESRD: Pt on hemodialysis, on T/Th/Sat schedule. Renal following patient closely throughout this hospitalization. Lytes were checked frequently and kayexalate given prn. 4. Hx of SVC/brachiocephalic DVT: Pt was initially subtherapeutic on coumadin. Unclear if she had not been taking Coumadin although patient reported that she has been taking all home meds. We started heparin gtt to bridge to Coumadin. Once therapeutic, continued Coumadin 5mg PO qday. 5. Anxiety: Likely contributing to medical problems and could have very well been the etiology of this admission. Although pt stated she was taking her current medications, she did report increased anxiety which can lead to medication non-compliance and hypertension. Pt recently saw psychiatrist who started her on Celexa. She was continued on celexa 20mg PO qday, ativan 1mg PO q8hours PRN and psychiatry was re-consulted. Per psych recs, started standing clonazepam. Pt refused psych VNA. Outpatient PCP followup recommended. 6. Headache NOS: Pt complained of R-sided HA for several weeks, radiating to R jaw where patient had previous tooth extraction. Right upper extremity ultrasound was negative for DVT. She did not have any focal neuro findings, no visual deficits. She was initially treated with tylenol PRN Q6h; pt requested IV dilaudid for HA, but use of this medication by IV route was limited by team. It was felt by the pain service that her HA did not fit migraine, tension type HA or rebound HA. They recommended increasing dilaudid to 4-6mg Q6h PRN, continuing tylenol and starting neurontin 300mg Qhs which was slowly titrated to 300mg [**Hospital1 **] for better control. Per pain recs, a neurology consult was also obtained during this admission. MRI/MRA showed interval resolution of previously noted posterior white matter abnormalities and stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions, but very limited MRA as above. Per pain recs, dilaudid was further increased to 4mg q4h for better control of her HA. Neurology recommended outpt f/u and Pt scheduled with [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**]. 7. Anemia: Likely related to ESRD. No evidence of acute bleeding. Hct remained stable during this hospitalization. 8. SLE: no acute issues. continued Prednisone 4mg PO qday 9. FEN: tolerated regular diet, repleted lytes PRN 9. Prophylaxis: Heparin gtt, then coumadin, bowel regigmen Medications on Admission: (from prior discharge summary) Bisacodyl 10mg PO qday PRN Prednisone 4mg PO qday Aliskiren 150mg PO BID Clonidine 0.3mg / 24 hr patch weekly qmonday Labetalol 400mg PO TID Warfarin 4mg PO qday Nifedipine 90mg PO qday Hydralazine 100mg PO q8H Hydromorphone 2-4mg PO q4H PRN Lorazepam 1mg PO q8H Celexa 20mg PO qday Prochlorperazine 10mg PO q6H Colace 100mg PO BID Hydralazine 25mg PO q30min PRN for HTN Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Year (4 digits) 766**]). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). [**Year (4 digits) **]:*100 Tablet(s)* Refills:*2* 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*90 Capsule(s)* Refills:*2* 9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for headache. [**Year (4 digits) **]:*84 Tablet(s)* Refills:*0* 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*60 Capsule(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours. [**Year (4 digits) **]:*360 Tablet(s)* Refills:*2* 16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. [**Year (4 digits) **]:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive Emergency 2. SLE 3. Headache, NOS 4. Abdominal pain Discharge Condition: BP better controlled. Headache managed on oral meds Discharge Instructions: You were admitted with abdominal pain, high blood pressure, and headache. Your abdominal pain resolved - no serious cause of this pain was found. Your blood pressure medications were continued, and with an increased in one medication, the labetalol. Your blood pressure improved. You should continue the clonidine 0.3mg patch changed on [**Year (4 digits) 766**], Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, and Nifedipine 90mg daily. The dose of Labetalol was increased to 800 mg three times daily by you kidney doctor and you are given a new prescription. Please take all medications as listed below. For your headache, you had an MRI and MRA of the head, which did not show a new or serious abnormality. You were seen by the neurology and pain services. You should follow up at [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**] at 6:30 PM (in the evening). Your pain was managed by oral dilaudid, 4mg. You should take this medication every 4 hours as needed. You were also started on Gabapentin (also called Neurontin) for the headache. The dose was slowly increased to twice a day. You may not need as much dilaudid for your headache and should wean this medication as tolerated, given it's potential for side effects (constipation, lethargy, dependence). Finally, you will likely need medications for constipation while you take dilaudid. Take colace (a stool softener), senna (a laxative), and bisacodyl (another laxative), as needed. It is really important that you have a primary care doctor. You are scheduled with Dr. [**Last Name (STitle) **] (see below) next Tuesday. You will need your INR checked since you are on coumadin. Call your doctor if you have worsened headache, chest pain, confusion, or any other concerning symptom. Followup Instructions: Please make sure you attend the following doctor appointments: 1) Dr. [**Last Name (STitle) 4883**] (nephrologist) on Tuesday, [**2141-12-5**] at 10AM. Phone number [**Telephone/Fax (1) 60**]. 2) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Location (un) **], [**Hospital Ward Name 23**] center, [**Location (un) **]. Phone:[**Telephone/Fax (1) 250**]. Date/Time:[**2141-12-5**] 3:20 3) Neurology: Dr. [**Last Name (STitle) 43502**] [**Name (STitle) **]. He is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-12-12**] 6:30 PM [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2141-12-2**]",112,2141-11-24 16:11:00,2141-12-01 19:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**hospital unit name 153**] the patient was admitted for blood pressure management and evaluation of abd pain. an a-line was placed. ekg showed no change from prior, and abd x-ray showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home med regimen. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. upon transfer to the floor, the following was her ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other ascites; ; Systemic lupus erythematosus; Headache; Anemia in chronic kidney disease; Anxiety state, unspecified; Other chest pain; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Renal dialysis status; Acquired absence of organ, eye]","24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. the renal team was consulted, and recommended no change to home med regimen.","a 24yo f with sle, esrd on hd and malignant hypertension presented with abdominal pain and headache. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. she successfully switched to po meds and was transferred to the floor." 109,158943.0,14808,2142-03-23,14801,173633.0,2141-12-14,Discharge summary,"Admission Date: [**2141-12-8**] Discharge Date: [**2141-12-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 8104**] Chief Complaint: abdominal pain & hypertension Major Surgical or Invasive Procedure: Hemodialysis PICC Line [**12-11**] History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with a history of CKD V (on HD) from lupus nephritis, chronic intermittent abdominal pain, and multiple prior ICU admissions for hypertensive urgency who presented to the ED complaining of two days' of abdominal pain, nausea, and loose stools. She was feeling well until after her hemodialysis session on Wednesday. Thereafter, she complained of nausea with occasional vomitting and has been unable to keep down any of her oral medications. She also has had diffuse abdominal pain consistent with her prior flares of pain as well as her typical diffuse headache. The headache in particular was worsening and, for her, this is a sign of poorly-controlled hypertension so she came to the [**Hospital1 18**] ED. Upon arrival to the ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room air. She was given 4 mg of IV ondansetron, [**1-11**] inch intropaste, 1 mg of IV hydromorphone x3, 1000cc of NS, and was put on a labetalol drip which had to be increased up to 2 mg/min. A head CT showed no acute abnormality (including hemorrhage) and an abdominal CT showed some possible mild colitis, though it is unclear if this is due to her recent peritoneal dialysis. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 97.9 BP 165/120 HR 93 RR 12 Sat 100% ra Gen: mildly fatigued, but no distress HEENT: oropharynx clear Neck: no JVP, no LAD Chest: clear to auscultation throughout, no w/r/r CV: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard Abdomen: soft, tender diffusely to moderate palpation without rebound or guarding; hyperactive bowel sounds; no masses or HSM, PD catheter in palce Extr: no edema, 2+ PT pulses Neuro: alert, appropriate, strength grossly intact in all four limbs Skin: no rashes Pertinent Results: [**2141-12-14**] 05:53AM BLOOD WBC-4.3 RBC-2.81* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.7 MCHC-33.8 RDW-19.3* Plt Ct-148* [**2141-12-14**] 05:53AM BLOOD PT-42.6* PTT-51.0* INR(PT)-4.7* [**2141-12-10**] 05:10AM BLOOD Ret Aut-2.5 [**2141-12-14**] 05:53AM BLOOD Glucose-83 UreaN-21* Creat-5.1*# Na-138 K-5.3* Cl-105 HCO3-24 AnGap-14 [**2141-12-10**] 05:10AM BLOOD LD(LDH)-234 Amylase-347* TotBili-0.1 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-10**] 05:10AM BLOOD Lipase-72* [**2141-12-14**] 05:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 [**2141-12-10**] 05:10AM BLOOD Hapto-142 [**2141-12-8**] 04:02AM BLOOD calTIBC-138* VitB12-445 Folate-18.5 Ferritn-220* TRF-106* ON ADMISSION: [**2141-12-7**] 09:50PM BLOOD WBC-4.5 RBC-2.78* Hgb-8.4* Hct-25.2* MCV-91 MCH-30.2 MCHC-33.3 RDW-19.2* Plt Ct-158 [**2141-12-7**] 09:50PM BLOOD Neuts-65.2 Lymphs-23.4 Monos-8.0 Eos-2.9 Baso-0.4 [**2141-12-7**] 09:50PM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3* [**2141-12-8**] 04:02AM BLOOD Ret Aut-2.5 [**2141-12-7**] 09:50PM BLOOD Glucose-89 UreaN-25* Creat-5.1*# Na-139 K-4.8 Cl-104 HCO3-26 AnGap-14 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-7**] 09:50PM BLOOD Lipase-89* [**2141-12-7**] 09:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9* Mg-1.9 [**2141-12-7**] 09:54PM BLOOD Glucose-75 Lactate-1.3 Na-139 K-4.8 Cl-101 calHCO3-23 Micro: Blood Cx: [**12-7**], [**12-7**], [**12-11**], [**12-11**] No growth FECAL CULTURE (Final [**2141-12-10**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2141-12-10**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2141-12-8**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-12-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CT HEAD [**2141-12-8**]: IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. The hypodensities noted in the parietal white matter are stable. However in the setting of the hypertension, PRES cannot be excluded. If further evaluation is required MR can be obtained. CT Abdomin/Pelvis [**2141-12-8**] IMPRESSION: 1. Moderate amount of free fluid in the pelvis is compatible with the patient's known peritoneal dialysis. Unchanged peritoneal enhancement. 2. Stable liver hemangioma. CXR [**12-11**] IMPRESSION: Small left pleural effusion. Left lower lobe opacity which is either atelectasis versus pneumonia. Brief Hospital Course: 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. MICU course: Current plan on transfer 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. 1. Hypertensive urgency: The patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. Initially her blood pressure over-corrected to SBPs in the 80s (patient was asymptomatic). Her clonidine patch and hydralazine was held and she again became hypertensive with SBPs 190s. The patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. The following dialysis the patient asymptomatic with SBPs in 80s, MAPs 60s asymptomatic again. Her hydralazine was stopped and continued on all her other home medications at the advice of renal. The patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. On [**12-11**] the patient's SBP dropped to the 80's and due to her pain medications she was extremely lethargic, but arousable. A PICC line was placed because lack of access and she was bolused 250cc NS. The patient's pressures responded and additional narcotics were held due to her mental status. The patient's blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. The patient did require IV hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. A possible component to the patient's malignant hypertension is likely due to OSA. An inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on BiPAP for OSA. The patient was continuned on her admission hypertensive regimen. . 2. Abdominal pain: The etiology of her abdominal pain is unclear, but has been a chronic issue for her. A CT scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. The patient also had diarrhea, but stool studies were negative. The patient's pain was initially treated with hydromorphone, but because of the patient's lethargy on [**12-11**] they were initially held. She continued to complain of severe abdominal pain. She was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. Surgery was consulted in regards to removal of her PD catheter, but given that she may return to PD it was deferred to the outpatient setting. 3. CKD V from lupus nephritis: The patient was continued on HD during her admission. She was also continued on her home prednisone dose. She was closely followed by the renal team. . 4. History of SVC/subclavian vein thrombus: The patient was found to have a subtherapeutic INR on admission 1.3. She was started on a heparin gtt and continued on coumadin. The patient's heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her PICC line was placed. She was therapetuic the same day and her heparin gtt was stopped. On discharge her coumadin was supratherapeutic (4.7) and was held. She will have her INR checked at HD. . 5. Anemia: The patient's Hct slowly trended down. She was guaiac negative and hemolysis labs were negative. She was transfused 1U pRBC at HD on [**12-12**]. She was also given epo at HD. Medications on Admission: prednisone 4 mg daily clonidine 0.3 mg/day patch qWeek ergocalciferol 50,000 units qMonth nifedipine SR 90 mg daily hydralazine 100 mg q8h citalopram 20 mg daily warfarin 2 mg qhs gabapentin 300 mg [**Hospital1 **] hydromorphone 4 mg q4h prn clonazepam 0.5 mg [**Hospital1 **] alikiren 150 mg [**Hospital1 **] docusate 100 mg [**Hospital1 **] senna 8.6 mg [**Hospital1 **] prn acetaminophen prn labetalol 800 mg q8h bisacodyl 5 mg daily prn Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. [**Hospital1 **]:*84 Tablet(s)* Refills:*0* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed: please take as needed for anxiety prior to CPAP at bedtime. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 14. CPAP Home CPAP Dx: OSA Prefer: AutoCPAP/ Pressure setting [**5-20**] Alt: Straight CPAP/ Pressure setting 7 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency Abdominal Pain ESRD on HD SVC Thrombus Secondary: Systemic lupus erythematosus Malignant hypertension Thrombocytopenia HOCM Anemia History of left eye enucleation History of vaginal bleeding Thrombotic microangiopathy Discharge Condition: Stable Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because of elevated blood pressure and abdominal pain. You were initially admitted to the ICU and your blood pressure was controlled. You were stabilized and transferred back to th floor. Your pressures remained stable throughout the rest of your stay. Additionally, you had abdominal pain and diarrhea. Your stool was tested for infections and was negative. Your diarrhea resolved without intervention. Your abdominal pain was controlled with pain medications. You had a sleep study in the hospital which showed that you had sleep apnea. Please continue to take your medications as prescribed. 1. Please do not take your coumadin until your doctor tells you to. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: You will have dialysis at [**Location (un) **] Dialysis on your normal schedule. You need to go to dialysis on Saturday. Please follow-up with the Sleep Clinic in [**12-19**] @ 11:45 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Completed by:[**2141-12-16**]",99,2141-12-08 01:40:00,2141-12-14 17:16:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. micu course: current plan on transfer 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. 1. hypertensive urgency: the patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). her clonidine patch and hydralazine was held and she again became hypertensive with sbps 190s. the patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. the following dialysis the patient asymptomatic with sbps in 80s, maps 60s asymptomatic again. her hydralazine was stopped and continued on all her other home medications at the advice of renal. the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. on [**12-11**] the patients sbp dropped to the 80s and due to her pain medications she was extremely lethargic, but arousable. a picc line was placed because lack of access and she was bolused 250cc ns. the patients pressures responded and additional narcotics were held due to her mental status. the patients blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. the patient did require iv hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. a possible component to the patients malignant hypertension is likely due to osa. an inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on bipap for osa. the patient was continuned on her admission hypertensive regimen. . 2. abdominal pain: the etiology of her abdominal pain is unclear, but has been a chronic issue for her. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. the patient also had diarrhea, but stool studies were negative. the patients pain was initially treated with hydromorphone, but because of the patients lethargy on [**12-11**] they were initially held. she continued to complain of severe abdominal pain. she was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. surgery was consulted in regards to removal of her pd catheter, but given that she may return to pd it was deferred to the outpatient setting. 3. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was also continued on her home prednisone dose. she was closely followed by the renal team. . 4. history of svc/subclavian vein thrombus: the patient was found to have a subtherapeutic inr on admission 1.3. she was started on a heparin gtt and continued on coumadin. the patients heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her picc line was placed. she was therapetuic the same day and her heparin gtt was stopped. on discharge her coumadin was supratherapeutic (4.7) and was held. she will have her inr checked at hd. . 5. anemia: the patients hct slowly trended down. she was guaiac negative and hemolysis labs were negative. she was transfused 1u prbc at hd on [**12-12**]. she was also given epo at hd. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Systemic lupus erythematosus; Other and unspecified noninfectious gastroenteritis and colitis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other iatrogenic hypotension; Obstructive sleep apnea (adult)(pediatric); Hemangioma of intra-abdominal structures; Other chronic pain; Abdominal pain, unspecified site; Abnormal coagulation profile; Renal dialysis status; Personal history of venous thrombosis and embolism]","24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. the patient was continuned on her admission hypertensive regimen. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was therapetuic the same day and her heparin gtt was stopped.",24 year old woman with ckd v and severe hypertension due to sle admitted. patient was initially maintained on a labetalol drip and hydralazine iv prn. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic) 109,158943.0,14808,2142-03-23,14802,140167.0,2141-12-23,Discharge summary,"Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1973**] Chief Complaint: Malignant hypertension Major Surgical or Invasive Procedure: None History of Present Illness: 24 year old female with ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning. Patient had her hemodialysis day before yesterday. She has had multiple admissions to [**Hospital1 18**] with hypertensive urgency with symptoms of headache and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Patient states that her headache and abdominal pain are similar in characteristics to her previous admission. Patient denies any fever, chills, nightsweats, chest pain, shortness of breath, abdominal pain, nausea, vomitting, diarrhea, constipation, blood in stool, dysuria, hematuria, change in vision, hearing, weakness or numbness. In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was initially given 10mg IV Labetalol once and then started on drip at 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea. Her BP elevated as high as 270/174 and his labetolol was switched to nicardipine 1mg/kg/min. On arrival to the MICU her vitals were T 96.4 HR 99 BP 175/120 RR 15 100%RA. Patient was comfortable. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Vitals: 97.5 122/80 88 18 100%RA. Gen: sleeping, easily arousable, appears comfortable. HEENT: AT/NC, L eye prosthetic non-reactive, R pupil reactive, MMM. Heart: S1S2 RRR, III/VI SEM heard best at apex, + S3 Pulm: CTA b/l, no w/r/r. Abd: normal bowel sounds, midline scar well-healed, soft, nontender, prior PD site with dry dressing, patient with tenderness to palpation over prior PD cath site, no guarding/rebound Ext: no edema, no clubbing, WWP. R femoral HD catheter in place. Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: Admission: [**2141-12-18**] 02:00AM BLOOD WBC-5.8 RBC-3.30* Hgb-10.1* Hct-30.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-20.7* Plt Ct-199 [**2141-12-18**] 02:00AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.2* [**2141-12-18**] 02:00AM BLOOD UreaN-35* Creat-5.0* Na-138 K-5.5* Cl-103 HCO3-21* AnGap-20 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-18**] 02:00AM BLOOD Lipase-73* [**2141-12-18**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2141-12-19**] 06:45AM BLOOD Calcium-8.1* Phos-5.1* Mg-1.8 [**2141-12-18**] 03:52PM BLOOD dsDNA-NEGATIVE [**2141-12-18**] 03:52PM BLOOD CRP-11.5* [**2141-12-18**] 03:52PM BLOOD C3-68* C4-19 [**2141-12-20**] 12:09PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 [**2141-12-18**] 02:08AM BLOOD pO2-52* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 Comment-GREEN TOP [**2141-12-20**] 12:09PM BLOOD Lactate-0.9 [**2141-12-18**] 02:08AM BLOOD Glucose-68* Lactate-1.3 Na-140 K-4.8 Cl-103 [**2141-12-23**] 03:00PM BLOOD WBC-4.7 RBC-2.35* Hgb-7.1* Hct-22.3* MCV-95 MCH-30.3 MCHC-31.9 RDW-20.6* Plt Ct-131* [**2141-12-23**] 12:55AM BLOOD PT-14.7* PTT-66.2* INR(PT)-1.3* [**2141-12-18**] 03:52PM BLOOD ESR-21* [**2141-12-23**] 03:00PM BLOOD Glucose-97 UreaN-42* Creat-6.6* Na-138 K-4.3 Cl-106 HCO3-23 AnGap-13 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-23**] 03:00PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8 [**2141-12-18**] 04:23PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2141-12-18**] 04:23PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2141-12-18**] 04:23PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-12 TransE-<1 Micro: Blood Cx- [**12-18**]: No growth Urine Cx- [**12-18**]: No growth [**12-18**] TTE The left atrium and right atrium are normal in cavity size. A possible secundum type atrial septal defect is seen by color Doppler (clip [**Clip Number (Radiology) **]) There is severe symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. There is no significant resting LVOT gradient, but a mild gradient (30mmHg peak) is seen with Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Marked symmetric left ventricular hypertrophy with normal regional/global systolic function and mild inducible LVOT gradient. Mild aortic regurgitation. Mild pulmonary artery systolic hypertension. Possible secundum type atrial septal defect. Compared with the prior study (images reviewed) of [**2141-10-19**], a possible secundum type atrial septal defect is now suggested. If clinically indicated, a follow-up study with saline contrast and/or a TEE would be better able to characterize the possible atrial septal defect. CLINICAL IMPLICATIONS: Based on [**2140**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**12-18**] CXR IMPRESSION: 1. Cardiomegaly with findings suggestive of mild pulmonary edema. 2. Bibasilar linear opacities suggesting atelectasis, although developing pneumonia cannot be excluded. 3. No evidence of free intraperitoneal air. [**12-20**] MRV IMPRESSION: No appreciable change since the MRV chest exam dated [**2141-5-30**]. SVC is patent. Again seen is occlusion of the right internal jugular and left brachiocephalic veins. Right external jugular vein is provides the major venous drainage from the neck. Brief Hospital Course: 24 year old Female with SLE, ESRD on HD and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ED. 1. Malignant Hypertension: The patient had her hemodialysis two days prior to admission. Initially in the ED her BP was 253/170. She was given 10mg IV Labetalol and started on a labatelol drip. She also received hydralazine IV 10 mg once and 2 inches of nitropaste. She had morphine 4mg and 4mg Zofran for nausea. Her BP remained elevated so she was switched to nicardipine 1mg/kg/min. The patient was transferred to the MICU. In the ICU she was continued on the Nicardapine drip and her pressures decreased to 175/120. Nephrology was consulted and dialysis initiated in the AM. The Nicardapine drip dc'd on [**12-19**] and pt transferred to floor. While on the floor the patient had question of angioedema and markedly elevated BP. She was readmitted to the MICU on [**2141-12-20**]. Patient's Aliskerin was also held for conern for angioedema. The renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. The patient's PD catheter was removed. The patient was briefly on a nitro drip for hypertension. The patient's nifedepine was increased to 120mg. The patient was transferred to the floor with stable blood pressures, BP 124/72 on [**12-21**]. The morning of [**12-22**], the patient was noted to have a BP up to 247/120 at 0800. Hypertension persisted throughout the morning with BPs 210s-240s systolic. HR during this time was in the 90s. She received a total of 60 mg IV hydralazine over the course of the morning as well as 0.1 mg PO clonidine. She was also given her normal AM BP meds and restarted on aliskarin. Due to persistent hypertension, she was transferred to the ICU for further care. On arrival to the ICU, the patient reported severe abdominal pain over the site of recently removed PD catheter. She denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. She reports bilateral calf cramping but no leg swelling. She denies any difficulty breathing or chest pain. She took her AM BP meds without difficulty. Her blood pressure decreased to 130s-140s/60s without further intervention. She was transferred back to the floor on [**12-23**] and signed out AMA. 2. Angioedema: On [**12-20**] the patietn developed facial swelling and evidence of angioedema by ENT. The patient reported that her face is more swollen which was confirmed by her mother on the floor. The patient was give lasix IV as she has been unable to have any negative filtration with HD. The patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. Her tekturna was discontinued for concern that it might be causing angioedema. She denied difficulty with her breathing at that time, but was very somnulent. On arrival to the MICU her vitals were stable and oxygenating well at 100% on face mask. The patient's airway was supported with a nasal trumpet. The patient underwent MRV that showed no progression of her clot. Patient was diuresed with lasix and dialysis with significant improvement in her symptoms. She was treated with prednisone and decadron, famotidine and benadryl for angioedema. The patient was maintained on her heparin drip for her SVC syndrome. 3. Abdominal Pain: The patient has had extensive prior workup that has been unrevealing. The Transplant surgery team removed the PD cath on [**12-21**]. She continued to have abdominal pain post-op. She was continued on PO dilaudid 2mg po prn. She continuned to complain of abdominal pain throughout her admission and continued to requested IV dilaudid. 4. ESRD: The patient is on a T/Th/Sat schedule. She was closely followed by the renal team. She had dialysis on [**12-19**]. The patient's tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. The patient also had her PD catheter removed on [**12-21**] secondary to chronic abdominal pain. The patient was scheduled to have dialysis on [**12-23**]. 5. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last admission for supratherapeutic INR. She was admitted with a subtherpeutic INR of 1.2 She was started on a heparin drip. She was also started on Coumadin 2mg PO qday, but was held on [**12-19**] in prep her PD catheter removal. She was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by IR. However, the patient signed out AMA and thus it was not placed. 6. Anxiety: Pt recently saw psychiatrist who started her on Celexa. She was continued on Celexa 20mg PO daily. 7. Anemi of CKDa: The patient's Hct was 30.3 on admission. It trended down to 22.3 on discharge when she left AMA. There was no evidence of active, acute bleeding. THis is likely seoncdary to her ESRD. The patient was closely monitored. 8. Systemic Lupus Erythematosis: Rheumatology was consulted and does not suspect acute flare and dsDNA, C3, C4 nl, ESR and CRP slightly elevated. Her Echo did not suggest worsening pericarditis. She was continued on her home prednisone dose of 4mg daily. 9. Obstructive Sleep Apnea: CPAP for sleep with 7 pressure. Medications on Admission: Aliskiren 150 mg [**Hospital1 **] Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Warfarin held on discharge [**2141-12-14**] due to supratherap INR Discharge Medications: As patient signed out AMA, no medications were issued. She was told to resume her admission medications, however no instructions were taken by the patient. Discharge Disposition: Home Discharge Diagnosis: 1) Hypertensive urgency 2) Abdominal pain 3) End stage renal disease on hemodialysis 4) Venous thromboembolism Discharge Condition: Signed out AMA Discharge Instructions: Pt signed out AMA Return to the hospital with any concerning symptoms. Be sure to call your doctor's office on [**Month/Day/Year 766**] to arrange hemodialysis and review your medications and discuss follow-up plan. Followup Instructions: Follow-up with your Dr. [**Last Name (STitle) **] next week, and call [**Last Name (STitle) 766**] to arrange your hemodialysis. Completed by:[**2141-12-26**]",90,2141-12-18 03:50:00,2141-12-23 19:51:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. 1. malignant hypertension: the patient had her hemodialysis two days prior to admission. initially in the ed her bp was 253/170. she was given 10mg iv labetalol and started on a labatelol drip. she also received hydralazine iv 10 mg once and 2 inches of nitropaste. she had morphine 4mg and 4mg zofran for nausea. her bp remained elevated so she was switched to nicardipine 1mg/kg/min. the patient was transferred to the micu. in the icu she was continued on the nicardapine drip and her pressures decreased to 175/120. nephrology was consulted and dialysis initiated in the am. the nicardapine drip dcd on [**12-19**] and pt transferred to floor. while on the floor the patient had question of angioedema and markedly elevated bp. she was readmitted to the micu on [**2141-12-20**]. patients aliskerin was also held for conern for angioedema. the renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. the patients pd catheter was removed. the patient was briefly on a nitro drip for hypertension. the patients nifedepine was increased to 120mg. the patient was transferred to the floor with stable blood pressures, bp 124/72 on [**12-21**]. the morning of [**12-22**], the patient was noted to have a bp up to 247/120 at 0800. hypertension persisted throughout the morning with bps 210s-240s systolic. hr during this time was in the 90s. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she was also given her normal am bp meds and restarted on aliskarin. due to persistent hypertension, she was transferred to the icu for further care. on arrival to the icu, the patient reported severe abdominal pain over the site of recently removed pd catheter. she denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. she reports bilateral calf cramping but no leg swelling. she denies any difficulty breathing or chest pain. she took her am bp meds without difficulty. her blood pressure decreased to 130s-140s/60s without further intervention. she was transferred back to the floor on [**12-23**] and signed out ama. 2. angioedema: on [**12-20**] the patietn developed facial swelling and evidence of angioedema by ent. the patient reported that her face is more swollen which was confirmed by her mother on the floor. the patient was give lasix iv as she has been unable to have any negative filtration with hd. the patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. her tekturna was discontinued for concern that it might be causing angioedema. she denied difficulty with her breathing at that time, but was very somnulent. on arrival to the micu her vitals were stable and oxygenating well at 100% on face mask. the patients airway was supported with a nasal trumpet. the patient underwent mrv that showed no progression of her clot. patient was diuresed with lasix and dialysis with significant improvement in her symptoms. she was treated with prednisone and decadron, famotidine and benadryl for angioedema. the patient was maintained on her heparin drip for her svc syndrome. 3. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the transplant surgery team removed the pd cath on [**12-21**]. she continued to have abdominal pain post-op. she was continued on po dilaudid 2mg po prn. she continuned to complain of abdominal pain throughout her admission and continued to requested iv dilaudid. 4. esrd: the patient is on a t/th/sat schedule. she was closely followed by the renal team. she had dialysis on [**12-19**]. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient also had her pd catheter removed on [**12-21**] secondary to chronic abdominal pain. the patient was scheduled to have dialysis on [**12-23**]. 5. hx of svc/brachiocephalic dvt: her coumadin was held during last admission for supratherapeutic inr. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. she was also started on coumadin 2mg po qday, but was held on [**12-19**] in prep her pd catheter removal. she was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by ir. however, the patient signed out ama and thus it was not placed. 6. anxiety: pt recently saw psychiatrist who started her on celexa. she was continued on celexa 20mg po daily. 7. anemi of ckda: the patients hct was 30.3 on admission. it trended down to 22.3 on discharge when she left ama. there was no evidence of active, acute bleeding. this is likely seoncdary to her esrd. the patient was closely monitored. 8. systemic lupus erythematosis: rheumatology was consulted and does not suspect acute flare and dsdna, c3, c4 nl, esr and crp slightly elevated. her echo did not suggest worsening pericarditis. she was continued on her home prednisone dose of 4mg daily. 9. obstructive sleep apnea: cpap for sleep with 7 pressure. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Mechanical complication due to peritoneal dialysis catheter; ; Unspecified disease of pericardium; Angioneurotic edema, not elsewhere classified; Abdominal pain, other specified site; Systemic lupus erythematosus; ; Anemia in chronic kidney disease; Dysthymic disorder; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of steroids; Long-term (current) use of anticoagulants; Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation; Other antihypertensive agents causing adverse effects in therapeutic use]","24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. she was given 10mg iv labetalol and started on a labatelol drip. nephrology was consulted and dialysis initiated in the am. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she reports bilateral calf cramping but no leg swelling. she took her am bp meds without difficulty. her tekturna was discontinued for concern that it might be causing angioedema. the patient was maintained on her heparin drip for her svc syndrome. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient was scheduled to have dialysis on [**12-23**]. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. there was no evidence of active, acute bleeding.","24 year old female with sle, esrd on hd presents with abdominal pain and headache consistent with her usual hypertensive urgency. she was found to be in hypertensive urgency in ed. she received hydralazine iv 10 mg once and 2 inches of nitropaste." 109,158943.0,14808,2142-03-23,14803,135923.0,2142-01-12,Discharge summary,"Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-13**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypertensive Urgency and HA Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with HA in the setting of hypertension. Upon arrival to the ED, her vitals were 284/140, HR 67, RR 28, 100% on 4LNC. She was started on a nicardipine drip. She denied shortness of breath or chest pain. She is due for HD today. She has a left groin catheter which was recently placed [**2141-12-21**] and is causing her pain. She was also given dilaudid IV 1 mg x 2 with some relief. CXR was performed and showed no pulmonary edema. . Upon arrival to the MICU, patient denies HA, CP, SOB, fevers, chills. Patient reports mild abdominal pain at sight of left anterior abdominal wall hematoma and left groin pain at site of femoral HD line. She reports that she was taking her medications as directed, including coumadin for SVC thrombus. Briefly, 24 yo F with ESRD on HD, SLE, malignant HTN admitted for HA in the setting of HTN to 284/140 in ED. Initially, she was treated with a nicardipine gtt to control her BP. Her cardiac enzymes were flat, no new ECG changes. She was started on a heparin gtt with transition to coumadin for a SVC thrombosis. HTN secondary to med noncompliance. She was restarted on her oral BP. She missed her PM meds yesterday, so nicardipine was restarted, and then turned off this AM. She received all her AM BP meds. Her BPs have been in the 160s/90s. She had no neurological deficits. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 176/105, 87, 18, 100% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: 2/6 systolic murmur LUSB Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: left ant wall abd hematoma, TTP Extremities: Right: Trace, Left: Trace, left fem HD line without oozing or drainage Skin: Warm Neurologic: AAO x 3 Pertinent Results: [**2142-1-8**] 05:15AM PT-13.7* PTT-33.6 INR(PT)-1.2* [**2142-1-8**] 05:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-1+ STIPPLED-OCCASIONAL TEARDROP-1+ BITE-NORMAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2142-1-8**] 05:15AM cTropnT-0.08* [**2142-1-8**] 05:15AM CK(CPK)-119 [**2142-1-8**] 04:12PM PTT-120.8* [**2142-1-8**] 10:41PM PTT-144.8* [**2142-1-8**] 02:55PM CK-MB-NotDone cTropnT-0.06* Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. Patient was initially observed in the MICU and placed on a nicardipine drip. Patient was stablized on home medicaitons, suggesting medication non-compliance. Additionally, patient presented subtheraputic on coumadin for SVC thrombosis. Patient was started on heparin ggt. After the nicardipine drip was turned off, patient was called out to the floor. Heparin drip was continued until INR [**2-13**]. Pressures were managed to her baseline. Pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with Narcan. Patient received dialysis 3x/wk as per outpatient schedule. # Hypertension: Pt with extensive history of repeated admissions for hypertension. Patient's BP improved with nicardipine drip and after HD off drip on home PO medication regimen. Resumed oral antihypertensives with improved BP control. HTn likely from renal disease, possible medication noncompliance, lupus. No evidence of MI. Continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. Renal increased clonidine patch, and added Nicardipine with improvement of BP control. Pt is to follow up with an appointment in the next week to establish care at [**Company 191**], and to re-check her BP and adjust medications further. # SLE: Stable, continued prednisone at 4 mg PO daily. # Left groin pain. Permanent HD line was placed on [**12-25**]. Line and hematoma from prior peritoneal line on abdomen okay. No leukocytosis or fevers to suggest infection. Patient was oversedated on Dilaudid and had episode of oxygen desaturation which was reversed with Narcan. Patient was solmolent with morphine SR so that was d/c'ed as well, patient was given standing tylenlol and Morphine IR PRN. Transplant surgery removed remaining sutures today from L groin. Pt has a follow-up appointment in the next week with Dr. [**First Name (STitle) **] (Transplant Surgery). She will be sent home with low-dose Morphine IR and Tylenol PRN pain. If L groin pain should become uncontrollable on current meds, pt should return to the ED for re-evaluation. It is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #ESRD: Renal following, continuing HD Th/Th/Sat. CaCO3 was started for elevated calcium-phosphate product. Pt will follow-up with Dr. [**Last Name (STitle) 7473**] in the next 1-2 weeks. # Anemia: Pt's baseline is 26. This is likely secondary to AOCD and renal failure. Hct was stable on day of discharge at 25.9. # SVC thrombus: Pt has a history of an SVC thrombus, and is on coumadin. She is supposed to be on lifelong anticoagulation due to recurrent thrombosis but INR subtherapeutic on arrival. Heparin drip was stopped on the floor once the INR was theraputic. INR was therapeutic on day of discharge. Pt will need an INR check in the next week at her follow-up with her PCP. # HOCM: Pt has evidence of myocardial hypertrophy on Echo. She is currently not symptomatic. Echo did not show evidence of worsening pericardial effusion. She was continued on her beta-blocker and other BP medications. # Depression/anxiety: Stable. She was continued on Celexa and Clonazepam. # OSA: Pt as continued on CPAP for sleep with 7 pressure. # FEN: regular diet # PPX: heparin drip --> coumadin, bowel regimen # ACCESS: PIV x2 / permanent dialysis cath L fem # CODE: FULL # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] # DISPO: home with PCP and Renal [**Name9 (PRE) 702**] to re-check BP, INR level. Follow-up with Transplant Surgery. Medications on Admission: Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Aliskiren 150 [**Hospital1 **] Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Nicardipine 30 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain for 2 weeks. [**Hospital1 **]:*20 Tablet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Urgency End Stage Renal Disease Discharge Condition: stable, blood pressure moderately controlled, afebrile, tolerating POs Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. Some of medications were increased as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to take the coumadin as prescribed by your doctor, and have your INR checked frequently per your PCP's recommendations. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Renal) Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-1-15**] 3:00 - Will follow-up Vitamin D [**2-4**] level Provider: [**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD ([**Company 191**]) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-1-16**] 3:30 - Will re-check your INR level Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Transplant Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-1-19**] 2:50p [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-1-12**]",70,2142-01-08 06:36:00,2142-01-13 21:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE URGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was initially observed in the micu and placed on a nicardipine drip. patient was stablized on home medicaitons, suggesting medication non-compliance. additionally, patient presented subtheraputic on coumadin for svc thrombosis. patient was started on heparin ggt. after the nicardipine drip was turned off, patient was called out to the floor. heparin drip was continued until inr [**2-13**]. pressures were managed to her baseline. pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with narcan. patient received dialysis 3x/wk as per outpatient schedule. # hypertension: pt with extensive history of repeated admissions for hypertension. patients bp improved with nicardipine drip and after hd off drip on home po medication regimen. resumed oral antihypertensives with improved bp control. htn likely from renal disease, possible medication noncompliance, lupus. no evidence of mi. continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. renal increased clonidine patch, and added nicardipine with improvement of bp control. pt is to follow up with an appointment in the next week to establish care at [**company 191**], and to re-check her bp and adjust medications further. # sle: stable, continued prednisone at 4 mg po daily. # left groin pain. permanent hd line was placed on [**12-25**]. line and hematoma from prior peritoneal line on abdomen okay. no leukocytosis or fevers to suggest infection. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. patient was solmolent with morphine sr so that was d/ced as well, patient was given standing tylenlol and morphine ir prn. transplant surgery removed remaining sutures today from l groin. pt has a follow-up appointment in the next week with dr. [**first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. it is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #esrd: renal following, continuing hd th/th/sat. caco3 was started for elevated calcium-phosphate product. pt will follow-up with dr. [**last name (stitle) 7473**] in the next 1-2 weeks. # anemia: pts baseline is 26. this is likely secondary to aocd and renal failure. hct was stable on day of discharge at 25.9. # svc thrombus: pt has a history of an svc thrombus, and is on coumadin. she is supposed to be on lifelong anticoagulation due to recurrent thrombosis but inr subtherapeutic on arrival. heparin drip was stopped on the floor once the inr was theraputic. inr was therapeutic on day of discharge. pt will need an inr check in the next week at her follow-up with her pcp. # hocm: pt has evidence of myocardial hypertrophy on echo. she is currently not symptomatic. echo did not show evidence of worsening pericardial effusion. she was continued on her beta-blocker and other bp medications. # depression/anxiety: stable. she was continued on celexa and clonazepam. # osa: pt as continued on cpap for sleep with 7 pressure. # fen: regular diet # ppx: heparin drip --> coumadin, bowel regimen # access: piv x2 / permanent dialysis cath l fem # code: full # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] # dispo: home with pcp and renal [**name9 (pre) 702**] to re-check bp, inr level. follow-up with transplant surgery. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Hypoxemia; Other opiates and related narcotics causing adverse effects in therapeutic use; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Abdominal pain, other specified site; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Renal dialysis status; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Other postprocedural status]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. # hypertension: pt with extensive history of repeated admissions for hypertension. # sle: stable, continued prednisone at 4 mg po daily. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. this is likely secondary to aocd and renal failure. pt will need an inr check in the next week at her follow-up with her pcp.","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was stablized on home medicaitons, suggesting medication non-compliance. patient was oversedated on dilaudid and had episode of oxygen desaturation." 109,158943.0,14808,2142-03-23,14804,124657.0,2142-01-20,Discharge summary,"Admission Date: [**2142-1-14**] Discharge Date: [**2142-1-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 4028**] Chief Complaint: headache Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with mild headache, mild shortness of breath and consistent abdominal pain at the site of her known left abdominal wall hematoma in the setting of hypertension. Her last HD was yesterday. . Upon arrival to the ED, her vitals were BP 240's systolic, HR 90's, 93% on RA. A head CT scan was done which showed no acute process. An abdominal CT was done given her femoral line pain, which also was normal. She was given nitropaste X2 initially, then switched to labetalol 100mg x2, then 200mg x2, then finally started on nicardipine drip when she showed benefit with a decrease in her BP to 170/123 and improvement in her headache. . Upon arrival to the MICU, patient denies any current symptoms. She reports that her headache, shortness of breath and abdominal pain all resolved with blood pressure management and pain medications. . Pt was transferred to the floor when blood pressure was controlled. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: HR 96 BP 171/111 RR 12 O2 98% on RA Physical Exam: General in NAD HEENT NC, AT, EOMI, PERRLA, MMM CVS RRR, 3/6 systolic murmur in all heart fields RESP CTA BL, no crackles or wheezes ABD soft, hematoma raised on left anterior abdominal wall, +BS, mildly tender over hematoma EXT left sided femoral HD line in place, no erythema, no edema NEURO A+Ox3, CN2-12 intact, pt has left sided artificial eye, motor and sensory intact Pertinent Results: ***LABS ON ADMISSION*** [**2142-1-13**] 07:03AM WBC-5.2 RBC-2.79* HGB-8.5* HCT-26.3* MCV-94 MCH-30.3 MCHC-32.2 RDW-19.2* [**2142-1-13**] 07:03AM PLT COUNT-154 [**2142-1-13**] 07:03AM PT-29.5* PTT-49.2* INR(PT)-3.0* [**2142-1-13**] 07:03AM GLUCOSE-94 UREA N-53* CREAT-7.0* SODIUM-136 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [**2142-1-13**] 07:03AM CALCIUM-8.8 PHOSPHATE-5.0* MAGNESIUM-1.9 [**2142-1-14**] 12:00PM PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-14**] 12:00PM LIPASE-42 [**2142-1-14**] 12:00PM ALT(SGPT)-12 AST(SGOT)-43* ALK PHOS-96 TOT BILI-0.4 [**2142-1-14**] 03:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-1-14**] 03:25PM URINE RBC-[**3-15**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-[**3-15**] [**2142-1-14**] 12:00PM BLOOD PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-19**] 06:40AM BLOOD PT-18.6* PTT-38.7* INR(PT)-1.7* . ***LABS ON DAY OF DISCHARGE*** [**2142-1-20**] 06:35AM BLOOD WBC-5.7 RBC-2.39* Hgb-7.1* Hct-22.1* MCV-93 MCH-29.8 MCHC-32.2 RDW-18.6* Plt Ct-136* [**2142-1-20**] 06:35AM BLOOD Glucose-107* UreaN-34* Creat-4.8* Na-137 K-5.2* Cl-101 HCO3-27 AnGap-14 [**2142-1-20**] 06:35AM BLOOD PT-22.8* PTT-42.3* INR(PT)-2.2* . IMAGING [**2142-1-14**] EKG Sinus rhythm. Possible left atrial abnormality. Borderline voltage criteria for left ventricular hypertrophy. Inferolateral ST-T wave changes may be related to left ventricular hypertrophy. Compared to the previous tracing of [**2142-1-8**] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 99 190 86 368/436 13 100 24 [**2142-1-14**] CT ABD/PELV IMPRESSION: 1. Interval decrease in size to subcutaneous anterior abdominal wall hematoma. 2. Infectious versus inflammatory process within the right lower lobe of the lung. Small right simple pleural effusion. 3. Cardiomegaly with slight decrease in size of moderate pericardial effusion. 4. Right lobe liver hemangioma, unchanged. [**2142-1-14**] CT HEAD IMPRESSION: 1. Mildly limited study given administration of small amount of IV contrast material. However, no evidence of hemorrhage or mass effect. NOTE ADDED AT ATTENDING REVIEW: This patient was administered contrast for the abdominal CT, and the head CT was performed after part of this dose. Therefore, this is neither a noncontrast examination, nor a proper contrast CT. [**2142-1-14**] CXR CONCLUSION: Persistent cardiomegaly and mild pulmonary edema. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. . # Hypertensive Urgency: Pt with extensive history of hypertension. Patient's BP improved with nicardipine drip. Became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. Restarted all home oral antihypertensives including nicardipine 30 Q8H, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Blood pressure remains labile and renal continues to follow patient. Pt was transferred to the floor as blood pressure stabilized. BP has remained stable with systolics 140s-170s. In the MICU, Nifedipine extended release was added in place of Nicardipine as pt's blood pressures seemed to rise prior to Nicardipine doses. . # Hyperkalemia: Ocurred on the day after admission. Resolved with administration of kayexalate. Pt continued hemodialysis on TuThSat. . # Left abdominal wall hematoma: Abd CT showed a mild decrease in the size. Pt reported that morphine did not help pain, and was switched to dilaudid PO in the MICU. However, given pt's recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/c'ed on the floor. Pt was continued on gabapentin, tylenol around the clock, and low-dose Morphine as needed for pain. Narcotics should be avoided in the future. Pain should also resolve in the next few weeks as hematoma resolves. . # SLE: Pt was continued on prednisone at 4 mg PO daily. . #ESRD: Renal was following during her stay. She continued HD on her T, Th, Sat schedule. # Anemia: Hct was mildly decreased from baseline during admission. This is likely secondary to AOCD and in the setting of renal failure. . # SVC thrombus: Patient is on anticoagulation, likely lifelong. Patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. Then INR became subtherapeutic, so heparin gtt was used to bridge. On day of discharge, INR became therapeutic, and pt was discharged home on Coumadin 4mg PO daily, with INR to be checked next at hemodialysis . # HOCM: Pt has evidence of myocardial hypertrophy on recent Echo. She was not symptomatic during her stay. She was continued on her beta blocker. . # Depression/anxiety. She was continued on celexa and clonazepam PRN. . # OSA: CPAP for sleep with 7 pressure. . # FEN: repleted lytes prn / regular diet . # PPX: coumadin, bowel regimen . # ACCESS: PIV/ permanent dialysis cath L fem . # CODE: FULL . # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nicardipine 30mg PO TID Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for breakthrough pain for 2 weeks. 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*1* 13. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*260 Tablet(s)* Refills:*1* 14. Respiratory Therapy Please adjust settings of CPAP machine to a lower volume as it is uncomfortable for the patient. Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Discharge Condition: Good, hemodynamically stable, afebrile, pain controlled Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. One new medication was added as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to continue your Coumadin at 4mg daily and have your INR checked AT DIALYSIS next week. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep ALL scheduled appointments. Medications changes include: 1. STOP NICARDIPINE 2. Start Nifedipine CR 90mg by mouth daily 3. INCREASE Labetalol to 900mg by mouth 3 times daily 4. Continue at Warfarin 4mg by mouth daily If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to set up a follow-up appointment in 1-2weeks. Please continue your HD TuThSat. Completed by:[**2142-1-20**]",62,2142-01-14 17:34:00,2142-01-20 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. . # hypertensive urgency: pt with extensive history of hypertension. patients bp improved with nicardipine drip. became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. restarted all home oral antihypertensives including nicardipine 30 q8h, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. blood pressure remains labile and renal continues to follow patient. pt was transferred to the floor as blood pressure stabilized. bp has remained stable with systolics 140s-170s. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. . # hyperkalemia: ocurred on the day after admission. resolved with administration of kayexalate. pt continued hemodialysis on tuthsat. . # left abdominal wall hematoma: abd ct showed a mild decrease in the size. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu. however, given pts recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/ced on the floor. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. narcotics should be avoided in the future. pain should also resolve in the next few weeks as hematoma resolves. . # sle: pt was continued on prednisone at 4 mg po daily. . #esrd: renal was following during her stay. she continued hd on her t, th, sat schedule. # anemia: hct was mildly decreased from baseline during admission. this is likely secondary to aocd and in the setting of renal failure. . # svc thrombus: patient is on anticoagulation, likely lifelong. patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. then inr became subtherapeutic, so heparin gtt was used to bridge. on day of discharge, inr became therapeutic, and pt was discharged home on coumadin 4mg po daily, with inr to be checked next at hemodialysis . # hocm: pt has evidence of myocardial hypertrophy on recent echo. she was not symptomatic during her stay. she was continued on her beta blocker. . # depression/anxiety. she was continued on celexa and clonazepam prn. . # osa: cpap for sleep with 7 pressure. . # fen: repleted lytes prn / regular diet . # ppx: coumadin, bowel regimen . # access: piv/ permanent dialysis cath l fem . # code: full . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Other vascular complications of medical care, not elsewhere classified; Systemic lupus erythematosus; Hyperpotassemia; Phlebitis and thrombophlebitis of upper extremities, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. # anemia: hct was mildly decreased from baseline during admission. # hocm: pt has evidence of myocardial hypertrophy on recent echo. # fen: repleted lytes prn / regular diet . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. pt was transferred to the floor as blood pressure stabilized. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu." 109,158943.0,14808,2142-03-23,14805,176760.0,2142-01-23,Discharge summary,"Admission Date: [**2142-1-21**] Discharge Date: [**2142-1-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Hypertensive Urgency and fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with hypertensive urgency, subjective fevers, and pain. . Of note, she had been hospitalized [**Date range (1) 43505**] with hypertensive urgency. Her nicardipine was changed to nifedipine in hospital and her labetalol was increased to 900mg TID from 800mg TID.BPs were reportedly stable in the 140's-170's on the medical floor on nifedipine, aliskerin, labetalol, clonidine, and hydralazine prior to discharge. Last HD was [**1-20**]. . She reports feeling well at time of discharge [**1-20**], however woke this evening feeling sweaty, hot, and mildly SOB. She did not check her temperature and denies any rigors. She had total body aching (worst in her left wrist at site of recent IV and abdomen at site of known hematoma). +Palpitations overnight now resolved. No CP, SOB, cough, diarrhea, dysuria, erythema/tenderness/drainage from HD catheter. Denies recent joint symptoms with her lupus. No sick contacts. Says she took her BP meds. . Upon arrival to the ED, her vitals were 99.9 104 254/145 16 96% on RA. She was started on a nicardipine drip, given 1"" nitropaste with improvement in her BP. Did spike a fever while in the ED, currently 101F 101 173/106 Given vancomycin and zoysn for ?pna as CXR with right sided haziness. Also received 3mg IV dilaudid for body pains. LUE ultrasound without evidence of DVT. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 98.5 P 92 Bp 173/116 RR 16 O2 100% on RA General Pleasant young woman appearing comfortable HEENT Cushingoid faces, L eye prosthesis, MMM Pulm Lungs clear bilaterally, no rales or wheezing CV Regular S1 S2 ?soft systolic murmur Abd Soft +hematoma left abdomen unchanged from prior exam Extrem Warm full distal pulses. Left hand with slight edema ++ tender to palpation of wrist patient unable to make fist secondary to pain, no erythema +warmth ?purulence at site of old PIV Skin No peripehral stigmata of endocarditis Lines Left groin HD catheter site without erythema, purulence, or tenderness Neuro Alert and awake, moving all extremities Pertinent Results: CXR [**1-21**]: In comparison with the earlier study of this date, the diffuse pulmonary edema has substantially decreased, possibly following hemodialysis. Enlargement of the cardiac silhouette persists and there is no definite pleural effusion. Suggestion of an area of increased opacification at the right base. This could merely represent asymmetric edema, though the possibility of a developing consolidation cannot be unequivocally excluded. . LUE US [**1-21**]: IMPRESSION: No DVT in the left upper extremity. . L wrist xray [**1-21**]: There is prominent soft tissue swelling about the wrist, relatively diffuse, but quite prominent along the dorsum of the wrist. No fracture, dislocation, degenerative change, focal lytic or sclerotic lesion, or erosion is identified. No soft tissue calcification or radiopaque foreign body is identified. A tiny (1.7 mm) linear density is seen along the dorsum of the wrist on the oblique view is seen only on that view and is consistent with a small film artifact. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency and left wrist pain. . 1. Hypertensive urgency: Patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. Patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. She was started on nicardipine drip and 1"" nitropaste and admitted to the ICU for further treatment. There was no evidence of end-organ ischemia. Upon arrival to the ICU she was given her usual home antihypertensives and the nicardipine was quickly weaned off. It was felt that pain and anxiety were both contributing to her elevated BPs. Her BP quickly stabilized and she was called out to the medical floor where her SBP ranged 110-150. She was continued on nifepidine 90mg daily, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Given her repeated admissions with hypertensive urgency a meeting was held between the patient's nephrologist Dr. [**Last Name (STitle) 4883**], her ICU physician and her [**Name9 (PRE) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the ICU where she quickly improves with simply continuing her home medications. The following plan was drafted and placed in a note in OMR titled "" Care Protocol"". . CARE PROTOCOL: . BLOOD PRESSURE MANAGEMENT: . For BP > 230/140 1. Hydralazine: 100 mg PO OR 10 mg IV q 20 minutes until blood pressure back to baseline*. . 2. Give daily blood pressure medications, if she has not already taken them before arrival. . 3. If after one hour of therapy AND/OR evidence of end organ damage, transfer to the ICU. . * Note: Her usual blood pressure is ~ 160/100. Efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. In the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . PAIN MANAGEMENT: . As an outpatient, Ms. [**Name13 (STitle) **] takes dilaudid 2-4 mg PO q 4 PRN.This is being slowly tapered, she should not be administered IV pain medications. . ANTICOAGULATION: . In the absence of bleeding, warfarin does not need to be stopped on admission. Similarly, in the absence of new thrombosis, subtherapeutic INR's do not require bridging with IV UFH. . 2. Fever: Possible sources included line infection, thombophlebitis, septic arthritis, PNA. Received vanc/zosyn in ED for possible PNA. UA without pyuria and urine culture negative. CXR also without convinving infiltrate on repeat PA/Lat so zosyn was discontinued. Patient was complaining of severe pain at her IV site and was noted to have a small abscess there which was felt to be the cause of her fever. She was continued on IV vanco with HD for 10day course. She remained afebrile and did not have a leukocytosis. . 3. Left wrist pain: Began following IV placement during recent hospitalization. Likely due to septic thrombophlebitis. Small abscess was too small to drain. This was treated with warm soaks and prn PO dilaudid. Vanco was continued for 10 day course. L wrist films were enremarkable. . 4. Left abdominal wall hematoma: Stable on exam from recent admission. She was continued on pain management with morphine 7.5mg TID, gabapentin and tylenol as needed for pain. . 5. SLE: Continued prednisone at 4 mg PO daily . 6. ESRD: Continued on regularly scheduled dialysis. . 7. Anemia: Baseline Hct 26. Her Hct was mildly decreased from baseline. Secondary to AOCD and renal failure. There was no evidence of bleeding. . 8. SVC thrombus: Known SVC thrombus, therapeutic on coumadin. Continued warfarin. . 9. HOCM: evidence of myocardial hypertrophy on recent Echo. Currently not symptomatic. Echo without evidence of worsening pericardial effusion. Continued beta blocker . 10. Depression/anxiety. Continued Celexa, clonazepam 0.5mg [**Hospital1 **] . 11. OSA: Continued CPAP Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nifedipine 90mg PO daily Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325-650 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*270 Tablet(s)* Refills:*2* 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 7 days. [**Hospital1 **]:*4 dose* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Septic thrombophlebitis Discharge Condition: Stable, afebrile, BP improved. Discharge Instructions: You were admitted to the hospital with hypertensive urgency. You required IV medications and were observed overnight in the ICU. Your usual oral blood pressure medications were continued and your blood pressure remained well-controlled. You were found to have an infection at your prior IV site on your left hand. For this you were given IV vancomycin. You will need 7 days more of antibiotics which will be given with dialysis. Please resume your usual dialysis schedule. Your last dialysis was [**1-23**]. Please continue to take your medications as prescribed. You should hold your coumadin today. You can resume this on wednesday at your normal dose. You should have your INR checked at dialyis as usual on thursday. . If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-12**] weeks. ",59,2142-01-21 11:23:00,2142-01-23 16:40:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE EMERGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. . 1. hypertensive urgency: patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. there was no evidence of end-organ ischemia. upon arrival to the icu she was given her usual home antihypertensives and the nicardipine was quickly weaned off. it was felt that pain and anxiety were both contributing to her elevated bps. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150. she was continued on nifepidine 90mg daily, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. given her repeated admissions with hypertensive urgency a meeting was held between the patients nephrologist dr. [**last name (stitle) 4883**], her icu physician and her [**name9 (pre) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the icu where she quickly improves with simply continuing her home medications. the following plan was drafted and placed in a note in omr titled "" care protocol"". . care protocol: . blood pressure management: . for bp > 230/140 1. hydralazine: 100 mg po or 10 mg iv q 20 minutes until blood pressure back to baseline*. . 2. give daily blood pressure medications, if she has not already taken them before arrival. . 3. if after one hour of therapy and/or evidence of end organ damage, transfer to the icu. . * note: her usual blood pressure is ~ 160/100. efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. in the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . pain management: . as an outpatient, ms. [**name13 (stitle) **] takes dilaudid 2-4 mg po q 4 prn.this is being slowly tapered, she should not be administered iv pain medications. . anticoagulation: . in the absence of bleeding, warfarin does not need to be stopped on admission. similarly, in the absence of new thrombosis, subtherapeutic inrs do not require bridging with iv ufh. . 2. fever: possible sources included line infection, thombophlebitis, septic arthritis, pna. received vanc/zosyn in ed for possible pna. ua without pyuria and urine culture negative. cxr also without convinving infiltrate on repeat pa/lat so zosyn was discontinued. patient was complaining of severe pain at her iv site and was noted to have a small abscess there which was felt to be the cause of her fever. she was continued on iv vanco with hd for 10day course. she remained afebrile and did not have a leukocytosis. . 3. left wrist pain: began following iv placement during recent hospitalization. likely due to septic thrombophlebitis. small abscess was too small to drain. this was treated with warm soaks and prn po dilaudid. vanco was continued for 10 day course. l wrist films were enremarkable. . 4. left abdominal wall hematoma: stable on exam from recent admission. she was continued on pain management with morphine 7.5mg tid, gabapentin and tylenol as needed for pain. . 5. sle: continued prednisone at 4 mg po daily . 6. esrd: continued on regularly scheduled dialysis. . 7. anemia: baseline hct 26. her hct was mildly decreased from baseline. secondary to aocd and renal failure. there was no evidence of bleeding. . 8. svc thrombus: known svc thrombus, therapeutic on coumadin. continued warfarin. . 9. hocm: evidence of myocardial hypertrophy on recent echo. currently not symptomatic. echo without evidence of worsening pericardial effusion. continued beta blocker . 10. depression/anxiety. continued celexa, clonazepam 0.5mg [**hospital1 **] . 11. osa: continued cpap ","PRIMARY: [Other vascular complications of medical care, not elsewhere classified] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; ; Systemic lupus erythematosus; Phlebitis and thrombophlebitis of upper extremities, unspecified]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. she was continued on iv vanco with hd for 10day course. esrd: continued on regularly scheduled dialysis. her hct was mildly decreased from baseline. hocm: evidence of myocardial hypertrophy on recent echo. echo without evidence of worsening pericardial effusion. continued celexa, clonazepam 0.5mg [**hospital1 **] .","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150." 109,158943.0,14808,2142-03-23,14807,158995.0,2142-02-26,Discharge summary,"Admission Date: [**2142-2-25**] Discharge Date: [**2142-2-26**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 338**] 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 History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, hx of malignant HTN admitted with change in mental status. Patient missed HD on [**2142-2-24**] and was found unresponsive and diaphoretic by mother this morning after she took some dilaudid. EMS was called, 1 mg of narcan was administered with slight improvement in mental status. On arrival to the ED her vitals were 112/64 62 16 99RA she was noted to be hyperkalemic in the absence of EKG changes and was given calcium, D5, 10U regular insulin, 30 mg po kayxalate and repeat K was 5.4. ABG: 7.29/38/199. Repeat glucose was 41 and 1amp D50 was given. She was sent to the ICU for monitoring. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including [**Month/Year (2) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: HR: 80 (79 - 80) bpm BP: 127/59(76) {127/59(76) - 139/64(82)} mmHg RR: 34 (21 - 34) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Physical Examination Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact Pertinent Results: [**2142-2-25**] 01:50PM PT-14.9* PTT-36.8* INR(PT)-1.3* [**2142-2-25**] 01:50PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2142-2-25**] 01:50PM WBC-5.0 RBC-2.21* HGB-6.4* HCT-20.7* MCV-94 MCH-29.1 MCHC-31.1 RDW-19.6* [**2142-2-25**] 10:30PM GLUCOSE-87 UREA N-66* CREAT-8.4* SODIUM-142 POTASSIUM-5.9* CHLORIDE-110* TOTAL CO2-16* ANION GAP-22* HISTORY: Altered mental status. Evaluate underlying for pneumonia. UPRIGHT PORTABLE CHEST: Comparison is made to [**2-14**] and [**2142-2-19**], exams. Study is slightly limited by patient motion. In the interval, the degree of pulmonary edema appears improved with slightly decreased prominence of the pulmonary vascularity. There is unchanged extensive retrocardiac consolidation obscuring the majority of the left hemidiaphragm with persistent blunting of the left CP angle, likely related to small effusion. Exam is otherwise unchanged from prior with persistent cardiomegaly. A catheter is seen projecting over the abdomen, partially imaged. IMPRESSION: Slight improvement in pulmonary edema with persistent retrocardiac opacity, which again may represent atelectasis versus underlying pneumonia. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted hypotension and decreased mental status. Hypotension and altered mental status were in the setting of excessive narcotic use. Patient's narcotics were held, pressors returned to [**Location 213**] and patient was mentating fine. Hct was below baseline and patient was transfused 1u PRBC and was given HD before discharge. Patient is to continue anti-hypertensive medications as previously scheduled. Patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # Change in mental status: Resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. Patient received 1 dose of narcan with slight improvement in BP and mental status. patient without fevers or leuckocytosis which argue against infection. # Hypertension ?????? resumed outpatient regimen. Patient did not have any hypertensive episodes requiring hydralizine 10mg IV. # Hypotension: resolved, Patient normotensive on arrival to ICU. Relative hypotension likely due to dilaudid. Other considerations include sepsis, although patient without objective signs of infection. Held pain medications and hypotension resolved. Resumed hypertensive medications. # Abdominal pain ?????? from previous peritoneal [**Location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # Hyperkalemia: Likely due to missed HD session. She received calcium, D5, insulin and kayexalate in ED. HD in am ESRD: Renal following, had HD the day of discharge, transfused while there. Will continue normal schedule as an outpatient with HD T/Th/F this week. # Metabolic Acidosis: likely due to renal failure and missed HD. # SLE: continued prednisone at 4 mg PO daily. # OSA: CPAP for sleep with 7 pressure, however patient refuses. Continued to offer as inpatient. Should try to follow up with sleep medicine. Medications on Admission: Prednisone 4mg qd Citalopram 20 mg daily Gabapentin 300 mg [**Hospital1 **] Warfarin 4mg daily Pantoprazole 40 mg qd Clonidine 0.1 mg/24 QWED Clonidine 0.3 mg/24 hr QWED Labetalol 900 mg tid Nifedipine 90 mg qd Aliskiren 150 mg [**Hospital1 **] Hydralazine 100 mg q8h Morphine 7.5 mg q8h prn pain Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Home Discharge Diagnosis: Primary: narcotic overdose relative hypotension anemia Secondary: ESRD on HD [**2-12**] SLE malignant hypertension Discharge Condition: stable - received HD prior to discharge Discharge Instructions: You were admitted for altered mental status after missing hemodialysis. It was likely from the dilaudid you took as well as missing your scheduled [**Month/Day (2) 2286**]. You were also relatively hypotensive in the setting of excessive narcotic medicaiton usage. Narcotic medications were held and hypotension and altered mental status resolved. Please use narcotic medications with caution. You are recommended to use morphine for pain control rather than dilaudid. No medication changes were made. Please return to the ED if you have any altered mental status or miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] or have symptoms such as vision changes or headache from your history of malignant hypertension. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-3-20**] 3:00 HD as previously scheduled Completed by:[**2142-2-26**]",25,2142-02-25 15:49:00,2142-02-26 16:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ALTERED MENTAL STATUS," 24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. patients narcotics were held, pressors returned to [**location 213**] and patient was mentating fine. hct was below baseline and patient was transfused 1u prbc and was given hd before discharge. patient is to continue anti-hypertensive medications as previously scheduled. patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # change in mental status: resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. patient received 1 dose of narcan with slight improvement in bp and mental status. patient without fevers or leuckocytosis which argue against infection. # hypertension ?????? resumed outpatient regimen. patient did not have any hypertensive episodes requiring hydralizine 10mg iv. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. other considerations include sepsis, although patient without objective signs of infection. held pain medications and hypotension resolved. resumed hypertensive medications. # abdominal pain ?????? from previous peritoneal [**location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # hyperkalemia: likely due to missed hd session. she received calcium, d5, insulin and kayexalate in ed. hd in am esrd: renal following, had hd the day of discharge, transfused while there. will continue normal schedule as an outpatient with hd t/th/f this week. # metabolic acidosis: likely due to renal failure and missed hd. # sle: continued prednisone at 4 mg po daily. # osa: cpap for sleep with 7 pressure, however patient refuses. continued to offer as inpatient. should try to follow up with sleep medicine. ","PRIMARY: [Poisoning by other opiates and related narcotics] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Thrombotic microangiopathy; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Altered mental status; Other iatrogenic hypotension; Accidental poisoning by other opiates and related narcotics; Hyperpotassemia; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Nontraumatic hematoma of soft tissue; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. from previous peritoneal [**location 2286**] hematoma ??????","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. narcotics were held, pressors returned to and patient was mentating fine. patient was encouraged to take less pain medications and to use morphine." 109,158943.0,14808,2142-03-23,14806,113189.0,2142-02-17,Discharge summary,"Admission Date: [**2142-2-14**] Discharge Date: [**2142-2-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: From admission note: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome admitted with HTN and SOB in the setting of missed HD. The patient reported missing HD yesterday because she thinks she is being overdiuresed. She reports persistent pain at site of rectus sheath hematoma. Denies N/V/D. Pt recently admitted from [**Date range (1) 13924**] with consistent abdominal pain at the site of her known left abdominal wall hematoma, hypertensive to 230's and hyperkalemic to 6.2 after missing her last two dialysis sessions. At this time the pt. was dialyzed, received a blood transfusion, and was administered her daily antihypertensive medications. Pt. left AMA after her transfusion despite the primary team's concerns to look for an active area of bleeding. In the ED, patient complain of mild dyspnea, sating well on RA. CXR mild volume overload. KUB with no evidence of obstruction. She was started on a labetalol gtt. ECG - RAD, LVH no change from prior. HCT stable at 21. The renal team evaluated pt and recommended HD, however the patient refused. She was transferred to ICU for BP control. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: [**2142-2-14**] 07:40AM WBC-3.9* RBC-2.38* HGB-7.0* HCT-21.3* MCV-90 MCH-29.5 MCHC-33.0 RDW-18.9* [**2142-2-14**] 07:40AM NEUTS-74.9* LYMPHS-18.7 MONOS-3.1 EOS-3.0 BASOS-0.2 [**2142-2-14**] 07:40AM PLT COUNT-101* [**2142-2-14**] 07:40AM PT-16.3* PTT-36.6* INR(PT)-1.5* [**2142-2-14**] 07:40AM CK-MB-6 [**2142-2-14**] 07:40AM cTropnT-0.09* [**2142-2-14**] 07:40AM LIPASE-80* [**2142-2-14**] 07:40AM ALT(SGPT)-34 AST(SGOT)-72* CK(CPK)-120 ALK PHOS-124* TOT BILI-0.4 [**2142-2-14**] 07:40AM GLUCOSE-85 UREA N-32* CREAT-7.0* SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-19* ANION GAP-17 [**2142-2-14**] 07:44AM LACTATE-1.3 [**2142-2-14**] CXR: Stable cardiomegaly with mild CHF and a small left pleural effusion. Left basilar air space disease which may represent pneumonia. Clinical correlation and a follow up chest x-ray to clearance is recommended. [**2142-2-14**] KUB: 1. Nonspecific bowel gas pattern with no evidence of obstruction. 2. Left basilar airspace disease which may represent pneumonia and a small left pleural effusion. Please ensure follow-up to clearance. Brief Hospital Course: 24 y.o female with SLE, ESRD on HD and malignant hypertension who presents with HTN and SOB aftering missing HD. . # Malignant hypertension/hypertensive urgency: The patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and HD compliance. Has previously presented with BP up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. Pt was treated per OMR hypertensive protocol created by the patient's primary providers, with a goal SBP of 160-180. With short course of IV antihypertensives and hemodialysis, pt's BP fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # ESRD: Pt was followed by the renal service and underwent HD without any complications. Pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting HD. She will discuss this further with the Renal team as an outpatient. . # SLE: Pt was continued on her home dose of prednisone with no sign of SLE flair. . # Coagulopathy/history of DVT: Patient on lifetime anticoagulation for hx of multiple thrombotic events. Pt was continued on coumadin. . # Pain management: Pt was treated with PO dilaudid for her abdominal pain, as recommended per her OMR protocol. She asked for IV dilaudid multiple times but there was no clinical indication. She was also continued on gabapentin. . # Anemia: Secondary to AOCD and renal failure. The patietns Hct remained stable in the low 20s during admission. No PRBC infusions were needed. . # Depression/anxiety: Continued Celexa, clonazepam 0.5mg [**Hospital1 **] Medications on Admission: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain. 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Disposition: Home Discharge Diagnosis: Primary: Malignant Hypertension Secondary: SLE, End stage renal disease on hemodialysis, SVC syndrome Discharge Condition: Stable. SBP in 160s. Discharge Instructions: You were admitted with dangerously high hypertension and some shortness of breath in the setting of missing several dialysis sessions. You were admitted and treated with your usual regimen of blood pressure meds and a short course of IV meds. With dialysis, your symptoms improved. You also had some abdominal pain, which was well controlled on your usual pain medications. We made no changes to your medications. Please take everything as prescribed. Please call your PCP or return to the hospital if you develop any headaches, visual changes, confusion or chest pain, or any other concerning symptoms. Followup Instructions: Please schedule a follow up with Dr [**Last Name (STitle) **] in [**Month (only) 958**] as scheduled. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2142-2-21**]",34,2142-02-14 10:42:00,2142-02-17 18:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. . # malignant hypertension/hypertensive urgency: the patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and hd compliance. has previously presented with bp up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. with short course of iv antihypertensives and hemodialysis, pts bp fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # esrd: pt was followed by the renal service and underwent hd without any complications. pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting hd. she will discuss this further with the renal team as an outpatient. . # sle: pt was continued on her home dose of prednisone with no sign of sle flair. . # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events. pt was continued on coumadin. . # pain management: pt was treated with po dilaudid for her abdominal pain, as recommended per her omr protocol. she asked for iv dilaudid multiple times but there was no clinical indication. she was also continued on gabapentin. . # anemia: secondary to aocd and renal failure. the patietns hct remained stable in the low 20s during admission. no prbc infusions were needed. . # depression/anxiety: continued celexa, clonazepam 0.5mg [**hospital1 **] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Thrombotic microangiopathy; Systemic lupus erythematosus; Anemia in chronic kidney disease; Thrombocytopenia, unspecified; Obstructive sleep apnea (adult)(pediatric); Nontraumatic hematoma of soft tissue; Dysthymic disorder; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events.","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob after missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. she was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine." 109,158995.0,14807,2142-02-26,15330,131345.0,2141-09-08,Discharge summary,"Admission Date: [**2141-9-5**] Discharge Date: [**2141-9-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 348**] Chief Complaint: right leg pain, hypertension Major Surgical or Invasive Procedure: blood transfusion x2 History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. The pain is worst when she tried to bear weight on the leg, or when she uses it to roll over or adjust her position in bed. The pain begins in her buttock and travels down the posterior thigh and calf but stops before reaching the ankle. It occasionally feels like it is coming from her low back. She denies any parasthesias or weakness in the leg, and she denies any numbness in her foot or groin. She denies any fevers or incontinence. The pain was unrelieved by Vicodin that she had at home, so she scheduled an urgent visit with her nephrologist yesterday [**2141-9-4**]. At her nephrologist??????s office, she was hypertensive to 250/145 and so she was referred to the ED. She ended up leaving the ED against medical advice yesterday, but returned today because of persistent leg pain. She reports that she took all of her morning and noon BP meds. She denies any fevers, headaches, visual changes, nausea (prior to coming to the ED), or leg weakness. Upon arrival to the ED today, she was afebrile, BP 237/146, HR 97, RR 16, Sat 100% on room air. She received a total of 90 mg of IV labetalol and nitropaste, and was eventually put on a labetalol drip for her hypertension. With these interventions, her SBP dropped to the 180s, but she reported feeling nauseous and so the drip was discontinued. She was also given 4 mg of IV morphine and 1 mg of IV hydromorphone for her leg pain with decent relief. Due to a urinalysis suggestive of infection, she was given one tablet of DS TMP/SMX. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] - PD catheter placement [**5-18**] 3. Malignant hypertension - Baseline BPs 180's - 120's - History of hypertensive crisis with seizures - History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] PAST SURGICAL HISTORY: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: MICU physical: Tmax: 36.3 ??????C (97.4 ??????F) Tcurrent: 36.3 ??????C (97.4 ??????F) HR: 92 (92 - 94) bpm BP: 209/138(152) {201/134(151) - 209/138(152)} mmHg RR: 19 (19 - 30) insp/min SpO2: 91% Heart rhythm: SR (Sinus Rhythm) Height: 59 Inch General: well-appearing young woman in no acute distress HEENT: no scleral icterus; prosthetic right eye Neck: supple Chest: clear to auscultation throughout, no wheezes/rales/ronchi CV: regular rate/rhythm, normal s1s2, no murmurs Abdomen: soft, nontender, nondistended, PD catheter in place in left abdomen Back: very mild spinal tenderness over approx L3 level of spine Extremities: no edema, 1+ PT pulses, warm Skin: no rashes or jaundice Neuro: alert, oriented x3, 5/5 strength in bilateral deltoids, biceps, triceps, hip flexors/extensors, ankle flexors/extensors; unable to elicit patellar reflexes bilaterally; negative straight leg raise bilaterally Pertinent Results: 138 111 54 -----------------< 83 5.4 14 8.2 . WBC: 3.7 HCT: 19 PLT: 101 N:69.3 L:23.4 M:5.5 E:1.7 Bas:0.1 PT: 21.9 PTT: 48.2 INR: 2.1 . Trends: HCT: 19 -> 22 w 1u then received another unit. INR 3.4 on discharge Discharge chem: Glucose-104 UreaN-51* Creat-8.4* Na-136 K-5.3* Cl-106 HCO3-18* AnGap-17 . [**2141-9-8**] 07:30AM BLOOD CK(CPK)-126 [**2141-9-5**] 02:50PM BLOOD HCG-<5 . [**2141-9-8**] 1:37 pm PERITONEAL FLUID GRAM STAIN (Final [**2141-9-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count . MRI L-spine: IMPRESSION: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. . CXR admit: IMPRESSION: Moderate cardiomegaly, bilateral pleural effusions, and pulmonary vascular prominence consistent with pulmonary edema. . Hip film: FINDINGS: No comparisons. No acute fracture or dislocation is seen. No lucent or sclerotic lesion is noted. There is a distal aspect of a catheter or shunt seen in the pelvis. Soft tissues are otherwise unremarkable. There is minimal degenerative change of the pubic symphysis. IMPRESSION: No acute fracture or dislocation. . Abdominal film: FINDINGS: A PD catheter is seen with its tip coiled in the pelvis. There is normal bowel gas. The underlying osseous structures are unremarkable. IMPRESSION: PD catheter with tip coiled in the pelvis . CXR [**9-8**]: IMPRESSION: Marked cardiomegaly, unchanged. Interval resolution of pulmonary edema. Brief Hospital Course: Ms [**Known lastname **] is a 24 year old woman with SLE, CKD V, and multiple admissions for labile hypertension who presented to the ED complaining of about a weeks?????? worth of right leg pain. She was initially admitted to the MICU for hypertensive urgency and then transfered to the floor after a day. # Hypertensive urgency: had been on labetalol drip in the ED, but this was stopped due to nausea (presumed that her BP was coming down too fast). She was started on her home meds and tolerated these fairly well. Transferred to the floor and noted to have SPBs in the 90s. She required 1L IVF bolus since her baseline SBP is thought to run in the 130-170 range. She also had transient dizziness during this episode. BP meds were held and later that night her SBP was in the 220s. BP meds restarted. She remained stable thereafter with SBPs in the 130-170s. We opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # Right leg pain: no evidence of avascular necrosis or fracture on plain film. MRI and plain films were ordered and showed no acute pathology. The pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. CK was normal. Pain was treated with dilaudid initially. On day of discharge, she was able to ambulate without gait abnormality or pain. PT saw her and rec outpt PT followup. . # CKD V: PD catheter placement in place. Pt was tried on PD on a number of occasions but did not tolerate it [**2-11**] pain. KUB confirmed tip in place. Cx of peritoneal fluid not suggestive of peritonitis. K remained mildly elevated. Hyperpara treated with sevelamer (although patient refused) then tums. Pt will reconsider PD as outpatient. . # Anemia: chronic. Received 2u pRBC while inhouse for Hct in the 18-19 range. Had appropriate response. Not on Epo given hypertension . # ID: Rx with cipro for ? UTI although urine cx neg. Also had temp to 101 on evening prior to discharge. No clear source. PD fluid cultured and NGTD. Pt remainded HD stable on day of discharge. . # Prior SVC thrombus. Continued warfarin with appropriate INR checks. INR elevated on day of discharge. Rec holding coumadin for 2d . # Systemic lupus erythematosus: cont home prednisone dose . # Dispo status: ambulating, pain free, BP in the 150/90 range Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly Vicodin prn Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime. 3. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). 4. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO WEEKLY (). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*20 Capsule(s)* Refills:*0* 9. Outpatient Physical Therapy Please provide PT for right hamstring injury 10. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. Disp:*270 Tablet(s)* Refills:*0* 11. Coumadin 2 mg Tablet Sig: One (1) Tablet PO at bedtime: hold dose until [**9-10**]. Disp:*30 Tablet(s)* Refills:*0* 12. Lactulose 10 gram/15 mL Solution Sig: 15-30 ml PO once a day: goal is [**1-11**] soft bowel movements per day. Disp:*500 ml* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: - HTN urgency - right leg pain - thought [**2-11**] hamstring injury - chronic kidney disease - not currently on dialysis - SLE - anemia [**2-11**] CKD and SLE - hx of SVC thrombosis on coumadin now Secondary: - hx hypertrophic obstructive cardiomyopathy - chronic thrombocytopenia Discharge Condition: ambulating without difficulty. tolerating oral diet. afebrile and SBP in the 130-150 range. Discharge Instructions: You came in with right leg pain and poorly controlled hypertension. Your blood pressure was controlled initially with IV medications then your home medications. Since your blood pressure was occasionally low, we recommend that you hold your labetalol if you are feeling lightheaded or have dizziness or have blood pressure less than 110/60. In terms of your leg pain, we performed xrays, ultrasound, and MRI without finding a cause. We suspect a hamstring injury given its location. Please take pain medications if needed. We recommend followup with physical therapy. You also had a fever which is suggestive of infection. We treated you with cipro in case you had a UTI. Otherwise, your cultures were unrevealing. We attempted peritoneal dialysis but this was unsuccessful. Please followup with your nephrologist. Please return to the ED if you experience headache, chest pain, shortness of breath, high fevers, or worsening leg pain. Please hold your coumadin for two days then restart as per previously written. Please take lactulose for constipation. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-9-12**] 5:00 Provider: [**Name10 (NameIs) 706**] NURSE Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 2:00 Provider: [**Name10 (NameIs) 7548**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-9-14**] 3:00 Please followup with your nephrologist and PCP. [**Name10 (NameIs) **] would like you to see your nephrologist within the next 1-2 weeks. ",171,2141-09-05 20:04:00,2141-09-08 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transfered to the floor after a day. # hypertensive urgency: had been on labetalol drip in the ed, but this was stopped due to nausea (presumed that her bp was coming down too fast). she was started on her home meds and tolerated these fairly well. transferred to the floor and noted to have spbs in the 90s. she required 1l ivf bolus since her baseline sbp is thought to run in the 130-170 range. she also had transient dizziness during this episode. bp meds were held and later that night her sbp was in the 220s. bp meds restarted. she remained stable thereafter with sbps in the 130-170s. we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. . # right leg pain: no evidence of avascular necrosis or fracture on plain film. mri and plain films were ordered and showed no acute pathology. the pain was in the distribution of her right hamstring and was worsened when it was stretched thus suggesting a muscle injury. ck was normal. pain was treated with dilaudid initially. on day of discharge, she was able to ambulate without gait abnormality or pain. pt saw her and rec outpt pt followup. . # ckd v: pd catheter placement in place. pt was tried on pd on a number of occasions but did not tolerate it [**2-11**] pain. kub confirmed tip in place. cx of peritoneal fluid not suggestive of peritonitis. k remained mildly elevated. hyperpara treated with sevelamer (although patient refused) then tums. pt will reconsider pd as outpatient. . # anemia: chronic. received 2u prbc while inhouse for hct in the 18-19 range. had appropriate response. not on epo given hypertension . # id: rx with cipro for ? uti although urine cx neg. also had temp to 101 on evening prior to discharge. no clear source. pd fluid cultured and ngtd. pt remainded hd stable on day of discharge. . # prior svc thrombus. continued warfarin with appropriate inr checks. inr elevated on day of discharge. rec holding coumadin for 2d . # systemic lupus erythematosus: cont home prednisone dose . # dispo status: ambulating, pain free, bp in the 150/90 range ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Nausea alone; Other antihypertensive agents causing adverse effects in therapeutic use; Hip and thigh injury; Unspecified accident; Hypotension, unspecified; Anemia, unspecified; Personal history of venous thrombosis and embolism; End stage renal disease; ; Urinary tract infection, site not specified; Hyperpotassemia; Acidosis; Disorders of phosphorus metabolism; Hypocalcemia; Secondary hyperparathyroidism (of renal origin)]","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension who presented to the ed complaining of about a weeks?????? we opted to discharge her on her home regimen (without decreasing doses) since she is more often having issues with elevated blood pressures. # right leg pain: no evidence of avascular necrosis or fracture on plain film. also had temp to 101 on evening prior to discharge. # systemic lupus erythematosus: cont home prednisone dose .","ms [**known lastname **] is a 24 year old woman with sle, ckd v, and multiple admissions for labile hypertension. she presented to the ed complaining of about a weeks?????? worth of right leg pain. she was initially admitted to the micu for hypertensive urgency and then transferred to the floor after a day. she was started on her home meds and tolerated them fairly well." 109,158995.0,14807,2142-02-26,14796,139061.0,2141-09-14,Discharge summary,"Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Right leg pain. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 24 y.o. F with lupus, Chronic Kidney Disease V (not currently on HD or PD), and multiple admissions for hypertensive urgency/emergency, who presented to the ED for continued R leg pain that starts in her R buttocks and refers down her R leg. She describes it as feeling like the pain is deep within her bone. The pain was [**10-20**] in the AM, and she felt like she couldn't get out of bed. Denies any swelling of her RLE. When getting VS in [**Name (NI) **], pt noted to be very hypertensive at 263/176. The patient reportedly has baseline SBPs in 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM on day of admission. She denies any recent recrational drug use including cocaine and amphetamines. She denies headache, vision changes, double vision, chest pain, shortness of breath, abdominal pain, BRBPR, dysuria. During MD interview, the patient was nauseous and had small amount of emesis of a recent Coolata. Pt states that flushing her PD cath causes a large amount of stomach pain. . Of note, the patient was recently admitted from 08.26-29.08. The patient initially presented to the ED after referral from her nephrologist's office where she had complaints of right leg pain and was found to be hypertensive to 250/145. She was admitted after initiation of a labetalol drip and nitropaste with improvement in sbp to 180. The patient did receive 2 U of PRBC's during this hospitalization for baseline anemia. The patient did have a work-up for her right leg pain complaints with plain films of the right hip and MRI of the L-spine which did not reveal an explanation for her symptoms and did rule out avascular necrosis. The patient received dilaudid for pain control and was ambulating without pain prior to discharge. In addition, the patient completed a course of ciprofloxacin for a positive UA with negative cultures. The patient was unable to tolerate peritoneal dialysis for unclear reasons. Peritoneal dialysate culture was negative for infection. . In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in ED ranged from [**Telephone/Fax (3) 43494**]-175 with HR in 96-108. Initially given labetalol 10 mg IV x 1 and then started on labetalol gtt for her elevated blood pressures and titrated to 3 mg/min. LENI of R leg was negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per ED, cannot do V/Q scan due to volume overload after talking with radiology. Renal c/s initiated. A-line placed. Past Medical History: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] . PAST SURGICAL HISTORY: - Placement of multiple catheters including dialysis. - Tonsillectomy. - Left eye enucleation in [**2140-4-10**]. - PD catheter placement in [**2141-5-11**]. Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 98.9 [**Telephone/Fax (2) 43495**] 99$% RA GEN: NAD, pleasant female sitting in bed with moon facies HEENT: EOMI of R eye, L eye prosthesis, no exudate, no erythema, MMM, no LAD CHEST: CTAB except at R base with decreased breath sounds; no w/r/r CV: tachy, normal S1S2, II/VI systolic murmur accentuated with Valsalva ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i EXT: no c/c/e, strength of LEs [**5-15**] and symmetric bilaterally. Negative straight leg test, no pain with internal rotation, external rotation, extension, adduction or abduction. Some pain on flexion at the hip. NEURO: II - XII intact to direct testing. No deficit in light tough sensation. Gait normal. DERM: no rashes noted Pertinent Results: LABS AT ADMISSION: [**2141-9-11**] 11:43AM GLUCOSE-86 UREA N-49* CREAT-8.1* SODIUM-139 POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-16* ANION GAP-18 [**2141-9-11**] 11:43AM CALCIUM-6.2* PHOSPHATE-5.8* MAGNESIUM-1.6 [**2141-9-11**] 11:43AM PT-18.4* PTT-42.8* INR(PT)-1.7* [**2141-9-11**] 07:00AM WBC-5.5 RBC-2.88* HGB-8.1* HCT-24.7* MCV-86 MCH-28.1 MCHC-32.8 RDW-18.0* [**2141-9-11**] 07:00AM NEUTS-74.7* LYMPHS-17.5* MONOS-4.2 EOS-3.3 BASOS-0.2 [**2141-9-11**] 07:00AM PLT COUNT-101* UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50 WBC . MICROBIOLOGY: Urine culture ([**2141-9-11**]): Mixed flora . STUDIES: Cardiology Report ECG Study Date of [**2141-9-11**] 6:55:16 AM Sinus tachycardia. The tracing is marred by baseline artifact. There is left atrial enlargement. Compared to the previous tracing of [**2141-9-5**] the rate has increased. The axis is more rightward. Otherwise, no diagnostic interim change. . UNILAT LOWER EXT VEINS RIGHT Study Date of [**2141-9-11**] 8:54 AM [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and popliteal veins demonstrate normal flow, compressibility, augmentation, waveforms. Appropriate color flow and compression is noted within the calf veins. No intraluminal thrombus is present. IMPRESSION: No evidence of right lower extremity DVT. . TTE ([**2140-8-26**]): The left atrium is normal in size. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . R HIP XR [**2141-9-6**]: No acute fracture or dislocation. . MRI L-SPINE [**2141-9-6**]: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. LAB RESULTS AT DISCHARGE: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-9-14**] 06:15AM 4.0 2.63* 7.6* 23.1* 88 29.1 33.0 18.0* 100* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-9-14**] 06:15AM 100 44* 8.1* 137 4.8 109* 17* 16 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2141-9-14**] 06:15AM 6.8* 5.4* 1.6 CALCIUM freeCa [**2141-9-14**] 11:30AM 0.94* Brief Hospital Course: ICU course: EKG showed no change from prior, and CXR showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home medication regimen. The patient was found to by hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. . [**Hospital1 **] history: . 1. Hypertensive urgency: During the patient's [**Hospital1 **] stay, her SBPs ranged from 140s-160s during the day, which is her baseline systolic blood pressure. She was maintained on her home oral medication regimen. At night, she became more hypertensive, with SBP to the 170s-180s, which was controlled with both IV hydralazine and PO nifedipine. PO nifedipine was most successful at bringing her SBP back to her baseline. SBP at discharge was 140. Throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. The renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. Right leg pain: Upon arrival on the floor, the patient complained of [**2143-4-15**] pain in R buttock and posterior thigh, much exacerbated with standing. Of note, lumbar spine MRI and R hip XR on most recent admission were both negative. Her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. Her pain when she was symptomatic was controlled well with PO dilaudid. If the pain recurs, an MRI of the right hip can be considered to evaluate for osteonecrosis. . 3. UTI: The patient had a urinalysis suggestive of UTI, though she remained asymptomatic throughout. She was treated with a three day course of ciprofloxacin. Her urine culture showed mixed flora consistent with skin contamination. . 4. ESRD: The patient has end-stage renal disease due to her lupus. The patient's creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. She was followed by the renal consult service. Her potassium remained stable. Her calcium was low during admission, and supplemental calcium was given in addition to starting Calcitriol. She was not dialyzed through her PD catheter secondary to discomfort, but may reinitiate PD as an outpatient. Her laboratories will be checked as an outpatient in renal clinic. . 5. Anemia: The patient's hematocrit remained near her baseline low 20s throughout her stay. She has anemia from chronic kidney disease and chronic disease. The patient is not on Epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. Prior SVC thrombus: The patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with INR goal 2.5 to 3.0. . 7. Systemic lupus erythematosus: No active issues. The patient's home prednisone regimen was continued. Medications on Admission: - Prednisone 5 mg Daily - Coumadin 2 mg at bedtime - Nifedipine 60 mg Sustained Release Daily - Hydralazine 50 mg every 8 hours - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY - Aliskiren 150 mg Twice daily - Docusate Sodium 100 mg 2 times a day - Labetalol 900 mg three times a day - Lactulose 15-30 ml once a day: goal is [**1-11**] soft bowel movements per day Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 7. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: - Hypertensive urgency - Right lower extremity pain - Urinary tract infection Secondary diagnosis: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) - HOCM: Last noted on echo [**8-17**] - Anemia - History of left eye enucleation [**2139-4-20**] for fungal infection - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Discharge Condition: Stable systolic blood pressure over past 24 hours. Discharge Instructions: You were admitted to the hospital for uncontrolled high blood pressure. You spent one day in the intensive care unit, where you were treated with intravenous medication to lower your blood pressure. You were then transferred to a regular hospital floor, where your blood pressure was managed with your home oral medications. You were also treated for urinary tract infection with antibiotics. Your right leg pain improved during admission, and we are unsure of the cause of this pain. You should discuss the need for an MRI of the hip if the pain returns when you meet with your primary care doctor. Please call your physician or return to the emergency room if you experience fever, chills, chest pain, difficulty breathing, abdominal pain, headache, changes in your vision, or any other symptoms that are concerning. Please take your medications as prescribed. - Calcitriol was added to your medications. - You should hold Coumadin for two days and restart Saturday, [**2141-9-16**]. You should have your INR checked at your visit in kidney clinic [**2141-9-18**]. - You can take Dilaudid 2-4 mg every eight hours as needed for pain. You should be vigilant about taking lactulose if you need to take Dilaudid. - You should continue Lactulose as per Dr.[**Name (NI) 12913**] instructions. - No other changes were made. Please keep follow up appointments as described below. Followup Instructions: Please call the office of your kidney doctor, Dr. [**Last Name (STitle) 4883**], at ([**Telephone/Fax (1) 773**] to schedule an appointment for [**Last Name (LF) 766**], [**9-19**] as discussed. Follow up with your lung doctor: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-9-21**] 1:00 Follow up with your new primary care doctor: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 ",165,2141-09-11 10:12:00,2141-09-14 20:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home medication regimen. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. . [**hospital1 **] history: . 1. hypertensive urgency: during the patients [**hospital1 **] stay, her sbps ranged from 140s-160s during the day, which is her baseline systolic blood pressure. she was maintained on her home oral medication regimen. at night, she became more hypertensive, with sbp to the 170s-180s, which was controlled with both iv hydralazine and po nifedipine. po nifedipine was most successful at bringing her sbp back to her baseline. sbp at discharge was 140. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. the renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. her pain when she was symptomatic was controlled well with po dilaudid. if the pain recurs, an mri of the right hip can be considered to evaluate for osteonecrosis. . 3. uti: the patient had a urinalysis suggestive of uti, though she remained asymptomatic throughout. she was treated with a three day course of ciprofloxacin. her urine culture showed mixed flora consistent with skin contamination. . 4. esrd: the patient has end-stage renal disease due to her lupus. the patients creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. she was followed by the renal consult service. her potassium remained stable. her calcium was low during admission, and supplemental calcium was given in addition to starting calcitriol. she was not dialyzed through her pd catheter secondary to discomfort, but may reinitiate pd as an outpatient. her laboratories will be checked as an outpatient in renal clinic. . 5. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay. she has anemia from chronic kidney disease and chronic disease. the patient is not on epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. prior svc thrombus: the patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with inr goal 2.5 to 3.0. . 7. systemic lupus erythematosus: no active issues. the patients home prednisone regimen was continued. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Urinary tract infection, site not specified; Other primary cardiomyopathies; Systemic lupus erythematosus; Sciatica; Hyperpotassemia; Thrombocytopenia, unspecified; Abnormal coagulation profile; Hyperparathyroidism, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism]","icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the renal team was consulted, and recommended no change to home medication regimen. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. she was treated with a three day course of ciprofloxacin. esrd: the patient has end-stage renal disease due to her lupus. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay.","ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. she became more hypertensive, with sbps to the 170s-180s during the day. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency." 109,158995.0,14807,2142-02-26,14797,172335.0,2141-09-24,Discharge summary,"Admission Date: [**2141-9-18**] Discharge Date: [**2141-9-24**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1936**] Chief Complaint: hip pain Major Surgical or Invasive Procedure: None History of Present Illness: 24yo woman with hx SLE, CKD(not currently on HD or PD), labile HTN here with right leg pain and HTN urgency. Patient was recently d/ced on [**9-14**] following admission for the same complaints. . Patient took her hydralazine dose on am of admission. BP at presentation to the ER was 250/140 (The patient reportedly has baseline SBPs in 130-170s) She was given 900 labetolol and 50 hydralazine in the ED. BP following this was 175/124. Her EKG was unchanged. K was 5.7. . Patient also complaining of [**10-20**] right hip pain. Patient was d/ced on [**9-14**] with oral dilaudid for hip/leg pain. She took this only for one day due to severe itching. Denies any parasthesias/weakness. Her RLE/hip pain has been extensively worked up with negative LENIs, Lumbar spine MRI and hip plain films in the past. She was given 4mg IV morphine in the ER. . On admission to the floor, leg/hip pain somwhat improved with morphine.She denies any headache, vision changes, double vision, chest pain or SOB. Feels warm but no chills. Past Medical History: Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 97.3 HR 81 BP 135/91 RR 16 100%RA Gen:NAD, happy, pleasant female HEENT:NC/AT, L eye prosthesis, R PERRL, EOMI, MMM, facial swelling, L side>R, scerla anicteric Neck: supple, no JVD, no LAD, scars from prior CVL and HD lines CV:S1S2+, 2/6 SEM LUSB, loud P2, RRR, no ectopy Pulm: CTA B/L, good inspiratory effort Abd: +BS, soft, nontender, slightly distended and resonant to percussion, PD catheter in place in left abdomen ext: no c/c/e, 2+DP b/L, L foream swollen>R, R hip is mobile without pain elicited on passive or active movement neuro: AAOx3, nonfocal exam, CN 2-12 intact, moves all 4 extremities psych: mood/affect appropriate Pertinent Results: MRI Right Hip ([**9-18**]): There is no signal abnormality on the fluid-sensitive sequences in the proximal femur, acetabulum, or other osseous structure. On T1- weighted images, there is a focal rounded region within the right femoral head measuring approximately 9 mm in a subchondral location, which is nonspecific but may represent an unusual focus of red marrow. No sclerosis is seen on the corresponding plain films. There is a small right hip joint effusion and a small amount of fluid in the left hip joint as well, at the upper limits of normal. There is no soft tissue abnormality, no muscular edema, and no fluid collections. IMPRESSION: 1. Small right hip joint effusion. 2. No bone marrow edema in the proximal femurs or the pelvis. 3. Nonspecific small focus of low signal on T1-weighted images in the right femoral head is nonspecific but may represent an unusual focus of red marrow. TTE ([**9-21**]): The left atrium is moderately dilated. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF 80%). A mild (18 mmHg) mid-cavitary gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. Mild (1+) aortic regurgitation is seen. There is no systolic anterior motion of the mitral valve leaflets. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. IMPRESSION: Severe symmetric left ventricular hypertrophy with hyperdynamic systolic function and mild mid-cavitary gradient. Mild aortic regurgitation. Moderate pulmonary hypertension. Findings consistent with hyperrtophic cardiomyopathy. Compared with the prior study (images reviewed) of [**2140-8-26**], pulmonary hypertension has developed (also present on the study from [**2140-5-20**]). Pericardial effusion is also new. V/Q scan ([**9-21**]): Ventilation images obtained with Tc-[**Age over 90 **]m aerosol in 8 views demonstrate no focal defects with improved ventilation to the posterior right basal segment. Perfusion images in the same 8 views show improved perfusion to the posterior right basal segement with a persistent small defect but no new findings. Chest x-ray shows cardiomgealy and left basilar atelectasis. IMPRESSION: Improved V/Q scan from [**9-/2139**] with no findings to suggest acute pulmonary embolism. B/L upper ext U/S ([**9-21**]): Grayscale and Doppler son[**Name (NI) 867**] of the right and left internal jugular, subclavian, axillary, brachial, basilic and cephalic veins were performed. There is nonocclusive focal thrombus seen in the left subclavian vein, where the vein is not fully compressible. Flow is seen in the region, indicating that the thrombus is nonocclusive. Elsewhere, normal flow, augmentation, compressibility were appropriate and waveforms are demonstrated. IMPRESSION: 1. Focal nonocclusive thrombus in the left subclavian vein. 2. Otherwise, patent upper extremity veins as described. [**2141-9-18**] 02:15PM POTASSIUM-5.1 [**2141-9-18**] 02:15PM HCT-21.2* [**2141-9-18**] 08:45AM POTASSIUM-5.7* [**2141-9-18**] 07:30AM GLUCOSE-88 UREA N-54* CREAT-8.6* SODIUM-136 POTASSIUM-5.8* CHLORIDE-108 TOTAL CO2-15* ANION GAP-19 [**2141-9-18**] 07:30AM estGFR-Using this [**2141-9-18**] 07:30AM CALCIUM-7.3* PHOSPHATE-5.3* MAGNESIUM-1.6 [**2141-9-18**] 07:30AM WBC-5.2 RBC-2.32* HGB-6.5* HCT-20.1* MCV-87 MCH-28.1 MCHC-32.4 RDW-18.4* [**2141-9-18**] 07:30AM NEUTS-78.0* LYMPHS-14.7* MONOS-3.9 EOS-3.2 BASOS-0.3 [**2141-9-18**] 07:30AM PLT COUNT-107* [**2141-9-18**] 07:30AM PT-20.8* PTT-43.3* INR(PT)-2.0* . [**2141-9-21**] CXR: There is no significant change when compared to the recent previous examination. The previously described left retrocardiac opacity is unchanged in appearance. Cardiomegaly is also unchanged. The mediastinal contour, bony thorax and pulmonary vasculature are normal. IMPRESSION: No significant change compared to study done roughly 7 hours prior. Brief Hospital Course: 24 yo with h/o of Lupus, HTN, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for R hip pain. Patient was on the floor on [**9-20**], given morphine for the hip pain. She then had an episode of hypotension and unresponsiveness and transferred to the MICU for closer monitoring. The patient got 2L IVFs and narcan and improved, in fact, found to be hypertensive upon arrival to MICU. . MICU Course: On [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. Concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. Mental status cleared somewhat with narcan. Renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. V/Q scan demonstrated improvement since prior study. Patient's home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. She was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. PD fluid was not c/w SBP. CXR was clear. Urine culture and blood cultures are pending. Patient's BP was in the 110s so hydralazine was stopped. Her other BP meds were otherwise continued. Plan was/is to follow renal recs for PD. If, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. Would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. If patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. Would add neurontin 100mg TID with room to titrate up to 300mg TID. Neuro also recommended PT with TENS unit and referral to pain clinic although patient's pain is currently absent. . FYI **** per Dr. [**Last Name (STitle) **] --- Because of ? increase in cardiomegaly on CXR, she got an echo yesterday. In addition to her known HOCM, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm Hg. They probably need to be followed up over time (particularly the pulmonary hypertension). We did evaluated the PHTN with a VQ scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. It would be good if we could arrange a PULMONARY CLINIC FOLLOW UP for Ms. [**Known lastname **] after discharge with either [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] or [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **].**** . She underwent CT head, and V/Q scan which were unremarkable. Her steroid dose was increased to 15mg given concern for need for stress dose steroids. After transfer from the MICU, her steroids were dropped back to 5mg, her home dose with the approval of [**Last Name (un) **]. . Her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. Her hydralazine was discontinued. On day 2 of her MICU stay, she developed a fever to 102. She was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. Broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. There was question of retrocardiac opacity on CXR, though not clear. Rheum consult obtained given hip discomfort, who felt septic joint unlikely. Neurology consult obtained who felt autonomic seizure unlikely. . Pt initiated peritoneal dialysis. In this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising BPs. She is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. Her hip pain has resolved completely without further intervention. . Floor course: Fever: Spike fever in MICU to 102. Started on Levoquin, Aztreonam, and Vanc. Source unclear at this point, but CXR with question of retrocardiac opacity. There is a possibility of aspiration pneumonitis. Other etiologies include peritoneal fluid (PD cath), urine, and blood (though patient does not have any indwelling lines). Hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. Peritoneal dialysis cultures negative so far. Continued levo/vanco/aztreonam for 2 days empirically. Then d/ced the Abx as no infectious etiologies were found. Steroids back to home dosage. BCx, UCx (final neg), Peritoneal cultures negative at discharge. . # Labile blood pressure: h/o of difficult to control BP with episodes of hypertensive emergency in the past. Normal SBP runs in 170s. Having nausea in setting of new PD, no evidence of intracranial bleeding on clinical exam, though INR had been supratherapeutic so remains in differential, though not bradycardic. Continue home BP meds :Labetalol 900 mg PO TID but difficult for patient to tolerate due to nausea, Aliskiren *NF* 150 mg Oral [**Hospital1 **], NIFEdipine CR 60 mg PO DAILY, clonidine patch, hydralazine given hypertensive in setting of nausa. . # Right leg/hip pain: no evidence of avascular necrosis or fracture on MRI though there is a small effusion. Pain resolved without intervention. Continued to monitor and would avoid narcotics, restart slowly if pain resumes. Physical therapy to follow as an outpatient. [**Last Name (un) 18183**] followed. Please see consult note. . # Hyperkalemia: Chronic issue. Patient takes kayexalate intermittently per her report (last dose [**Last Name (un) 766**]). Monitored K but patient did not need it on floor. # CKD V: Renal following. Did well with PD on [**9-22**] but did report some nause and cramping. She was not tolerating all 1.5L in exchanges on discharge. # Anemia: Hct stable around 20. S/p 1 U PRBCs in MICU with Hct 20.1 to 21.9. Likely due to chronic hemolysis consistent with SLE> #. Prior SVC thrombus: Physical exam with L arm swelling consistent with this. No flow limitations. INR 3.5 on ICU admission. Held warfarin but restarted home 2mg daily the day before discharge. # Systemic lupus erythematosus: Home prednisone dose 5mg. Currently on 15mg in setting of acute illness (day 2). # General care: FEN: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, PD initiated, Proph: INR therapeutic, no indication for PPI, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. Code: Full code, confirmed with patient Communication: with the patient and her mother [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (2) 43497**]contact. Access: 2 PIVs Medications on Admission: Nifedipine 60 mg PO qhs Labetalol 900 mg PO tid Hydralazine 50 mg PO tid Clonidine 0.3 mg/hr patch qWED Vitamin D once weekly dilaudid PO prn benadryl prn lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 5 mg daily coumadin 2mg PO qday calcitriol 1 mcg daily Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. 10. Sodium Bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Calcitriol 0.25 mcg Capsule Sig: Four (4) Capsule PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Hypertensive urgency Transient Hypotension due to Narcotics Sciatica . Secondary: End stage renal disease Systemic Lupus Erythematosus Anemia Discharge Condition: Stable. Blood pressures at baseline. Hip/leg pain resolved. Ambulating without assistance. Discharge Instructions: You were admitted to the hospital with high blood pressure and right leg/hip pain. We gave you pain medications and blood pressure lowering medications. Your blood pressure then dropped which was caused by the pain medication, and you were transferred to the Intensive Care Unit(ICU) where you recovered quickly. During your stay in the ICU, you developed a fever and were started on antibiotics. However, the cultures that were obtained were negative, and we discontinued the Antibiotics. During your hospitalization, your blood pressure normalized on your home regimen, and your right leg/hip pain resolved. You had an MRI of your hip done, which did not show an acute infection. You were seen by the kidney doctors and they recommended starting peritoneal dialysis. You were also given some blood for your anemia. Please follow up with the Peritoneal Dialysis nurse at the scheduled day/time. Please make an appointment to meet with your PCP in the next couple of weeks. Your Hip pain may benefit from physical therapy or outpatient anesthetic joint injection. Please discuss these options with your rheumatologist. . Please call the number given below to schedule outpatient physical therapy. . Please restart your home medications. You were also started on Sodium Bicarb 650mg by mouth three times a day. . If you develop fevers, chills, trouble breathing, chest pain, worsening of hip pain, headaches, changes in your vision or any other symptoms that concern you please return to the emergency room or call your doctor. Followup Instructions: Please follow up with your Peritoneal Dialysis nurse ([**Doctor First Name 3040**]) on [**Doctor First Name 766**] [**2141-9-25**] . Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 . Please call to schedule Outpatient Physical Therapy:[**Telephone/Fax (1) 2484**] Completed by:[**2141-9-25**]",155,2141-09-18 10:32:00,2141-09-24 13:53:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,LEG PAIN," 24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. patient was on the floor on [**9-20**], given morphine for the hip pain. she then had an episode of hypotension and unresponsiveness and transferred to the micu for closer monitoring. the patient got 2l ivfs and narcan and improved, in fact, found to be hypertensive upon arrival to micu. . micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis. mental status cleared somewhat with narcan. renal c/s felt episode likely [**2-11**] accumulation of morphine active metabolites. v/q scan demonstrated improvement since prior study. patients home prednisone dose was increased from 5 to 15mg with thought that patient may be stressed in setting of acute illness. she was febrile on [**9-21**] and resultingly started in vancomycin, aztreonam, and levofloxacin. pd fluid was not c/w sbp. cxr was clear. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. plan was/is to follow renal recs for pd. if, in 24-48 hours (once cultures have had 48-72 hours to grow) no source has been located, would d/c antibiotics except for levofloxacin. would continue levoflox for total 5 day course for pneumonia possibly ? aspiration pneumonitis during episode of altered mental status. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. would add neurontin 100mg tid with room to titrate up to 300mg tid. neuro also recommended pt with tens unit and referral to pain clinic although patients pain is currently absent. . fyi **** per dr. [**last name (stitle) **] --- because of ? increase in cardiomegaly on cxr, she got an echo yesterday. in addition to her known hocm, this showed (1) a small pericardial effusion, and (2) pulmonary hypertension with an estimated tricuspid gradient of 50 mm hg. they probably need to be followed up over time (particularly the pulmonary hypertension). we did evaluated the phtn with a vq scan which was unremarkable, making chronic thromboembolic disease much lower on the differential. it would be good if we could arrange a pulmonary clinic follow up for ms. [**known lastname **] after discharge with either [**first name4 (namepattern1) **] [**last name (namepattern1) **] or [**first name4 (namepattern1) **] [**last name (namepattern1) **].**** . she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. after transfer from the micu, her steroids were dropped back to 5mg, her home dose with the approval of [**last name (un) **]. . her hypotensive episode was thought to be due to a delayed clearing of the morphine due to her renal failure. her hydralazine was discontinued. on day 2 of her micu stay, she developed a fever to 102. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. broad spectrum abx were started (vanco, cipro, aztreonam (pcn allergy)) empirically. there was question of retrocardiac opacity on cxr, though not clear. rheum consult obtained given hip discomfort, who felt septic joint unlikely. neurology consult obtained who felt autonomic seizure unlikely. . pt initiated peritoneal dialysis. in this setting she has been having some nausea, which has made taking her home labetalol difficult, resulting in some rising bps. she is called out to medical service for ongoing management and workup of fever, nausea, and hypertension. her hip pain has resolved completely without further intervention. . fever: spike fever in micu to 102. started on levoquin, aztreonam, and vanc. source unclear at this point, but cxr with question of retrocardiac opacity. there is a possibility of aspiration pneumonitis. other etiologies include peritoneal fluid (pd cath), urine, and blood (though patient does not have any indwelling lines). hip, due to small effusion, could be septic arthritis but no pain with movement on exam makes this less likely. peritoneal dialysis cultures negative so far. continued levo/vanco/aztreonam for 2 days empirically. then d/ced the abx as no infectious etiologies were found. steroids back to home dosage. bcx, ucx (final neg), peritoneal cultures negative at discharge. . # labile blood pressure: h/o of difficult to control bp with episodes of hypertensive emergency in the past. normal sbp runs in 170s. having nausea in setting of new pd, no evidence of intracranial bleeding on clinical exam, though inr had been supratherapeutic so remains in differential, though not bradycardic. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. . # right leg/hip pain: no evidence of avascular necrosis or fracture on mri though there is a small effusion. pain resolved without intervention. continued to monitor and would avoid narcotics, restart slowly if pain resumes. physical therapy to follow as an outpatient. [**last name (un) 18183**] followed. please see consult note. . # hyperkalemia: chronic issue. patient takes kayexalate intermittently per her report (last dose [**last name (un) 766**]). monitored k but patient did not need it on floor. # ckd v: renal following. did well with pd on [**9-22**] but did report some nause and cramping. she was not tolerating all 1.5l in exchanges on discharge. # anemia: hct stable around 20. s/p 1 u prbcs in micu with hct 20.1 to 21.9. likely due to chronic hemolysis consistent with sle> #. prior svc thrombus: physical exam with l arm swelling consistent with this. no flow limitations. inr 3.5 on icu admission. held warfarin but restarted home 2mg daily the day before discharge. # systemic lupus erythematosus: home prednisone dose 5mg. currently on 15mg in setting of acute illness (day 2). # general care: fen: low sodium, renal diet; treatment of hyperkalemia as above, replete other lytes prn, pd initiated, proph: inr therapeutic, no indication for ppi, kayexalate as needed for hyperkalemia and lactulose prn as per home regimen. code: full code, confirmed with patient communication: with the patient and her mother [**name (ni) **] [**name (ni) **], [**telephone/fax (2) 43497**]contact. access: 2 pivs ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Pneumonia, organism unspecified; Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Hyperpotassemia; Sciatica; Other iatrogenic hypotension; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Anemia of other chronic disease; Hypocalcemia]","24 yo with h/o of lupus, htn, and lupus nephropathy started on peitoneal dialysis during this admissionwho was admitted initially for r hip pain. micu course: on [**9-20**], the patient triggered for hypotension (82/45), hypothermia (92.9) and altered mental status with difficult arousability in setting of recent blood transfusion. urine culture and blood cultures are pending. patients bp was in the 110s so hydralazine was stopped. her other bp meds were otherwise continued. if patient has leg pain again, may consider neurogenic source such a piriformis syndrome as suggested by neurology. it would be good if we could arrange a pulmonary clinic follow up for ms. [** she underwent ct head, and v/q scan which were unremarkable. her steroid dose was increased to 15mg given concern for need for stress dose steroids. she was pan-cultured (blood, urine, peritoneal dialysate) without obvious source of infection. source unclear at this point, but cxr with question of retrocardiac opacity. continue home bp meds :labetalol 900 mg po tid but difficult for patient to tolerate due to nausea, aliskiren *nf* 150 mg oral [**hospital1 **], nifedipine cr 60 mg po daily, clonidine patch, hydralazine given hypertensive in setting of nausa. did well with pd on [**9-22**] but did report some nause and cramping. # systemic lupus erythematosus: home prednisone dose 5mg.","lupus nephropathy patient on peitoneal dialysis with htn and lupus nephropathy. triggered for hypotension (82/45), hypothermia (92.9), altered mental status. concern was for sepsis, autonomic seizure, transfusion reaction, pulmonary embolus and/or narcosis." 109,158995.0,14807,2142-02-26,14798,126055.0,2141-11-03,Discharge summary,"Admission Date: [**2141-10-13**] Discharge Date: [**2141-11-3**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 6734**] Chief Complaint: Nausea, Vomitting, Abdominal Pain, HTN Urgenc Major Surgical or Invasive Procedure: Upper GI endoscopy Exploratory laparotomy Tunneled hemodialysis catheter in R femoral vein Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 24 y/o F with h/o ESRD, HTN who started peritoneal dialysis during the week of [**2141-10-8**] and presented with a 1 day history of acute onset N/V, sharp abdominal pain on [**2141-10-13**]. (Of note, the patient had presented to the ED on [**10-11**] with hypotension, SBPs in the 80s off after approximately 1.5L was taken off during dialysis in the setting of taking her PO Anti-HTNs. On [**2141-10-11**] she received 0.5L IVF, labs WNL, and was d/c'd home). On the day of admission on [**2141-10-13**], the patient reported that the previous night, she was awoken from sleep with severe, sharp abdominal pain, 6 episodes of frothy emesis, 10+ yellowish BMs without melena or BRBRP.She was admitted for further work- up of this abdminal pain. . In the ED here vitals were as follows: T: 97.0 HR: 101 BP: 240/180 RR: 17 O2sat: 100%RA. She received Labetolol 20mg IV and was subsequently placed on a labetolol drip. She also received ceftriaxone 1gm IV, Flagyl 500mg IV, Dilaudid 0.5-1mg IV q1hr and Zofran. Her abdominal CT showed multifocal areas of small bowel wall thickening. Her peritoneal Cell count was negtaive for SBP. She had some signs of peritonitis and thus surgery was consulted. Her lactate was normal. . Upon arrival to the MICU the patient was mentating well with complaints of diffuse sharp abdominal pain that radiated to the back and diarrhea. She had no headache or visual changes. Past Medical History: - SLE DX ([**2134**] - 16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter Placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). - Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VITALS: 98.4 HR 98 192/131 21 100%RA GEN: Mild Distress, AOx3 HEENT: PEERLA, EOMI NECK: Supple, No LAD, No bruit RESP: CTAB CARD: 2/6 systolic ejection murmur ABD: soft, moderately tender with +/- guarding, BS+ EXTR: Warm well perfused NEURO: Motor Grossly Intact RECTAL: Yellow Stool BACK: B CVAT Pertinent Results: [**2141-11-3**] 08:50AM BLOOD WBC-3.5* RBC-2.55* Hgb-7.8* Hct-23.6* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.8* Plt Ct-176 [**2141-11-3**] 03:55PM BLOOD PT-15.5* PTT-50.8* INR(PT)-1.4* [**2141-11-3**] 08:50AM BLOOD Glucose-121* UreaN-33* Creat-5.2*# Na-140 K-4.2 Cl-104 HCO3-28 AnGap-12 [**2141-10-26**] 06:15AM BLOOD ALT-11 AST-49* AlkPhos-122* Amylase-186* TotBili-0.2 DirBili-0.1 IndBili-0.1 [**2141-10-26**] 06:15AM BLOOD Lipase-30 [**2141-11-3**] 08:50AM BLOOD Albumin-2.5* Calcium-7.8* Phos-4.1 Mg-1.9 [**2141-10-30**] 06:55AM BLOOD HBsAg-NEGATIVE [**2141-10-17**] 10:48AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2141-10-25**] 11:56AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2141-10-25**] 11:56AM URINE Blood-TR Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2141-10-25**] 11:56AM URINE RBC-0-2 WBC-[**3-15**] Bacteri-FEW Yeast-NONE Epi-21-50 Blood cultures: all negative EKG ([**2141-10-13**]): Sinus rhythm. Findings are within normal limits. Compared to the previous tracing of [**2141-10-2**] there is no significant diagnostic change. CXR ([**2141-10-13**]): No acute cardiopulmonary abnormality. No free air under the diaphragms. CT chest/abdomen/pelvis ([**2141-10-13**]): There is a moderate-sized pericardial effusion, similar in appearance from [**2141-10-13**]. The great vessels are normal in caliber, without aneurysmal dilatation. Evaluation of the great vessels is limited without IV contrast. Interstitial thickening, particularly within the perihilar regions, is suggestive of fluid overload. There is bibasilar atelectasis with a small focus of consolidation in the right lower lobe (2:35) unchanged from [**2141-10-13**], and may reflect aspiration or pneumonia. Scattered bilateral nodules are largely stable from as far back as [**2139-10-9**]. Specifically, there is a 5 mm nodule in the right middle lobe (2:25), two adjacent nodules in the right lower lobe measuring 5 mm and 2 mm (2:24), and a 4 mm pleural based nodule within the left lower lobe. A nodular density seen adjacent and anterior to the right main pulmonary artery (2:23) may reflect a vessel. There is a small right pleural effusion. Axillary lymphadenopathy, with axillary nodes measuring up to approximately 10 mm in short axis, is seen. Ill- defined soft tissue thickening within the hilus bilaterally may reflect hilar lymphadenopathy, but assessment is limited without IV contrast. A catheter is visualized within the visualized right upper extremity, which may reflect a PICC line that terminates within the right subclavian vein. The esophagus is distended and filled with contrast, with marked wall thickening and edema throughout its entire length, a new finding. There is a moderate- sized hiatal hernia. CT OF THE ABDOMEN WITHOUT IV CONTRAST: There has been interval development of a moderate amount of free intraperitoneal air, that layers anteriorly and along the anterior abdominal wall. Additional small clustered foci of extraluminal air is seen adjacent to the proximal stomach and the gastroesophageal junction, with a focus of air tracking into the fissure of ligamentum venosum. Additionally, there appears to be air tracking into the anterior subcutaneous tissues in the region of the umbilicus. These findings are all new from the prior CT on [**2141-10-13**], but free air was present on chest radiograph performed [**2141-10-25**]. There is no obvious evidence of extravasation of oral contrast into the peritoneum. Of note, a peritoneal dialysis catheter is in place that could represent a route of entry of intraperitoneal air. The stomach, small bowel, and colon are filled with contrast, without evidence of obstruction. Evaluation for wall thickening is limited without IV contrast. Limited non-contrast views of the liver demonstrates a rounded 1.6 cm x 1.2 cm hypodensity in the right lobe of the liver, previously characterized as a hemangioma. The liver is otherwise unremarkable. The gallbladder, spleen, pancreas, and adrenal glands demonstrate no gross abnormality. Both kidneys are atrophic. Evaluation of solid organs is limited by lack of IV contrast. There is a peritoneal dialysis catheter, coiled within the pelvis, unchanged. There is a large amount of free fluid throughout the abdomen, similar in appearance to the prior study. CT OF THE PELVIS WITHOUT IV CONTRAST: Uterus and rectum are grossly unremarkable. However, assessment of the rectal wall is limited without IV contrast. OSSEOUS STRUCTURES: Bones are diffusely sclerotic, which may be related to renal osteodystrophy. There is bilateral sacroiliitis. IMPRESSION: 1. Interval development of a moderate amount of free intraperitoneal air, new from [**2141-10-13**]. A peritoneal dialysis catheter is in place and could represent the route of entry of free intraperitoneal air. However, as foci of air is seen in the region of the proximal stomach and GE junction in the setting of a recent endoscopy, perforation cannot be excluded, though no frank extravasation of contrast is identified. 2. New dilation and wall thickening of the entire esophagus, a nonspecific finding that could relate to infectious or inflammatory esophagitis; clinical correlation is recommended. Esophagus is contrast-filled possibly representing reflux. Hiatal hernia. 3. Anasarca, with moderate-sized pericardial effusion, pulmonary edema, and small right pleural effusion. 4. Large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. Imaging cannot exclude SBP, which should be evaluated for clinically. 5. Focus of consolidation within the right lower lobe, could represent aspiration or pneumonia, but unchanged from the prior study. Gastric Biopsies ([**2141-10-18**]): Antrum: Corpus-type mucosa, no diagnostic abnormalities recognized. Jejunum: Small intestinal mucosa, no diagnostic abnormalities recognized. UE Venous U/S: No evidence of DVT of the left upper extremity, without thrombus identified within the left subclavian vein. Brief Hospital Course: This is a 24 year old woman with ESRD secondary to SLE (started peritoneal dialysis approximately one week prior to admission), malignant HTN, h/o SVC syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. Her hospital course was complicated by multiple transfers between the MICU and the floor secondary to hypertensive urgency. # Abdominal Pain/Diarrhea: During the patient's admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. Infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. However, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. The patient was empirically placed on IV flagyl, but this was discontinued when stool samples were negative for C.difficile. Serial abdominal exams showed no peritoneal signs. Peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. CT of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. Other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to SLE vasculitis, malignant HTN, or microthrombosis and SLE enteritis. Surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. A heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible GI bleed. With regards to SLE vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to SLE. On [**10-18**], GI performed an EGD which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. Approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. Both cardiac, GI, and pulmonary etiologies were considered for the origin of her epigastric pain. Pericarditis was considered, but her EKG was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. Her lungs were also essentially unchanged from [**2141-10-13**]. However, her abdominal CT on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. As a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. There were no major findings: no evidence of perforation, obstruction, or infection. The patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. At discharge, the patient only complained of some mild incisional pain. # Hypertensive urgency: The patient was initially admitted to the MICU with a blood pressure of 240/180. Her hospital course was complicated by extremely labile HTN and was transferred back and forth between the MICU and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of SBPs > 260. Throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. Her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. Multiple medication regimens were attempted and changed throughout her hospital course. However, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for SBPs > 180. At discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg PO. Her regimen as per Dr. [**Last Name (STitle) 4883**]: Nifedipine SR 90 mg daily Aliskiren 150 mg [**Hospital1 **] Labetalol 300 mg TID Hydralazine 75 mg TID Clonidine patch 0.3 mg/24 hr patch qWed When SBP>180, she then uses a hydralazine sliding scale. When SBP>180, give 25 mg PO hydral every 30 min until SBP<150. You can use this for up to 2-3 hours. In between PO hydral doses, can then also use 10 IV hydralazine. # ESRD: The etiology of the patient's ESRD is secondary to SLE. Her Creatinine on admission was 7.9, which was near her baseline of 8 - 9. During her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. Prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2L per PD. After her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. Initially, the patient adamantly refused hemodialysis. However, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. As a result, after a long coversation with her primary renal physician, [**Name10 (NameIs) **] agreed to restart hemodialysis. A tunneled catheter was placed in her R femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. She underwent hemodialysis two more times prior to discharge. Upon discharge, her electrolytes were back to her baseline. She is expected to undergo hemodialysis (Tues/[**Last Name (un) **]/SAT) as an outpatient. # Anemia: During her admission, the patient's HCT was monitored daily with HCT to low-mid 20's. On [**2141-10-17**], she was found to have guaiac positive stools and her HCT was found to have dropped to a low of 18.6. The patient was transfused a total of 2 units of [**Date Range **] between [**2141-10-17**] and [**2141-10-18**]. Epo Alfa SC was also given on [**2141-10-17**]. She remained hemodynamically stable. GI consulted and EGD results were as stated above. The patient's HCT remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. Between [**2141-10-23**] - [**2141-10-24**], the patient had a HCT drop from 26 to 20 in the setting of occult positive emesis. She received two units of [**Month/Day/Year **] and her HCT returned to 28. GI was aware and planned to perform a non-urgent EGD on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her HCT returned to baseline. However, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her HCt remained stable and near baseline for the remiainder of her hospital course. # H/O Thrombosis: The patient was initially placed on her home dose of warfarin 2mg qd. Her INR on admission was 1.2. She was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. However, this was stopped for her EGD and after she had evidence of a GI bleed. The heparin drip was discontinued on [**10-22**]. The patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in HCT and in preparation for a possible GI intervention. After her surgery, her coumadin was held and she was off the heparin drip, but her INR continued to drift up, getting as high as 2.6 on [**2141-10-30**]. This was mostly attributed to nutritional deficiency [**2-11**] poor PO intake, but there was concern for possible synthetic dysfunction as well. As a result, she was given a test dose of vitamin K, which she responded to well (Her INR came back down to 1.4). As a result, her home dose of coumadin at 2 mg qday was restarted. At discharge, her INR was still sub- therapeutic at 1.4. Of note, the patient has a history of SVC syndrome and had a L subclavian venous thrombosis. During the last few days of her hospital stay, the patient complained of increased tongue swelling and her L face was noted to be slightly more swollen than previously noted. As a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a DVT within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # SLE: Rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. Her outside rheumatologist was also consulted. Both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # Obstructive sleep apnea: The patient was noted to have OSA based on clinical nocturnal exam during admission. Patient attempted 1 trial of CPAP at 2L/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. The paitent stated that she would pursue further work-up and treatment for OSA as an outpatient. While the mask and CPAP machine were at her bedside throughout her hospital course, the patient rarely used it. # Metabolic Acidosis: The patient's bicarbonate on admission was 13. Her baseline is normally between 16-20. She received 150mEq NaHCO3 over 24hrs from [**Date range (1) 43500**]. During her brief returns to the MICU, her HC03 was 18-19, which was presumed to be her baseline at home secondary to her CRF. At discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. Medications on Admission: Nifedipine 60 mg PO daily Labetalol 900 mg PO TID Hydralazine 50 mg PO TID Clonidine 0.3 mg/24hr patch qWED Lactulose 30 ml TID Aliskiren 150 mg [**Hospital1 **] Prednisone 4 mg daily Warfarin 2mg PO daily Calcitriol 1 mcg daily Calcium carbonate 500mg QID Dilaudid 2mg PO Q4-6hr prn pain Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*30 Patch Weekly(s)* Refills:*2* 2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Hospital1 **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. [**Hospital1 **]:*1500 ML(s)* Refills:*0* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO Twice daily (). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 8. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): In addition to 75 mg TID, if SBP>180, take 1 tab every 30 min until BP decreases to 150. If no improvement after 2 hours, call your doctor. [**Last Name (Titles) **]:*300 Tablet(s)* Refills:*6* 9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). [**Last Name (Titles) **]:*1500 ML(s)* Refills:*2* 10. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (Titles) **]:*30 Tablet Sustained Release(s)* Refills:*2* 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain for 5 days. [**Last Name (Titles) **]:*30 Tablet(s)* Refills:*0* 12. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day. [**Last Name (Titles) **]:*30 Capsule(s)* Refills:*2* 13. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) PO once a day. [**Last Name (Titles) **]:*30 packets* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary: end stage renal disease malignant hypertension abdominal free air subclavian deep vein thrombosis initiation of hemodialysis Secondary: SLE Anemia Discharge Condition: stable, pain well controlled, blood pressure at baseline Discharge Instructions: You were admitted for abdominal pain and then subsequently had a very long hospital course with high blood pressures, severe abdominal pain, some free air in your abdomen resulting in an exploratory laparotomy. You have also been initiated on hemodialysis on Tuesday/Thursday/Saturday schedule. Please take all medications as prescribed in the list that you will be given at discharge. There have been some changes to your medications. Please call your doctor if you have any worsening abdominal pain, fevers, chills, nausea, vomiting, headache, palpitations, diarrhea or any other concerning symptoms. Followup Instructions: You will see Dr. [**Last Name (STitle) 4883**] at hemodialysis on Tuesday, [**11-7**], [**2141**]. You should have your coumadin level checked at this appointment. Call Dr.[**Name (NI) 6045**] office at [**Telephone/Fax (1) 5189**] to schedule an appointment in [**1-11**] weeks to have your staples removed. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6735**] ",115,2141-10-13 23:10:00,2141-11-03 18:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. her hospital course was complicated by multiple transfers between the micu and the floor secondary to hypertensive urgency. # abdominal pain/diarrhea: during the patients admission, her complaints of abdominal pain, nausea, diarrhea, and vomiting progressively improved although no clear source of the symptoms was found. infectious causes, including viral gastroenteritis, peritonitis or c. dif colitis, were considered. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. the patient was empirically placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. serial abdominal exams showed no peritoneal signs. peritoneal dialysis fluid analysis was negative for leukocytosis without organisms on gram stain. ct of the abdomen on [**10-13**] showed evidence of multifocal small bowel thickening and gastric wall edema, but no acute process. other etiologies of her abdomoinal pain were also considered including mesenteric ischemia bowel secondary to sle vasculitis, malignant htn, or microthrombosis and sle enteritis. surgery was consulted and felt that the patient did not have an ischemic bowel as serial lactates were negative and serial abdominal exams showed improvement in pain. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia, although this was stopped when the patient had evidence of a possible gi bleed. with regards to sle vasculitis/enteritis, rheumatology was consulted and they did not believe her symptoms were related to sle. on [**10-18**], gi performed an egd which showed erosion in the gastroesophageal junction yet an otherwise normal small bowel enteroscopy to third part of the duodenum; biopsies of stomach antrum and proximal jejunum were negative. approximately halfway through her hospital course, the patient complained of severe epigastric pain in addition to her lower abdominal pain. both cardiac, gi, and pulmonary etiologies were considered for the origin of her epigastric pain. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. her lungs were also essentially unchanged from [**2141-10-13**]. however, her abdominal ct on [**2141-10-26**] showed a large amount of free intra-abdominal fluid in the setting of peritoneal dialysis. as a result, the patient underwent an exploaratory laparotomy on [**2141-10-27**]. there were no major findings: no evidence of perforation, obstruction, or infection. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. at discharge, the patient only complained of some mild incisional pain. # hypertensive urgency: the patient was initially admitted to the micu with a blood pressure of 240/180. her hospital course was complicated by extremely labile htn and was transferred back and forth between the micu and the floor on three separate occasions ([**10-19**], [**10-21**], and [**10-22**]) for identical episodes of sbps > 260. throughout all of these episodes of hypertensive urgency, the patient remained asymptomatic from a neuro and cardiac standpoint except for occasional headache. her final transfer to the floor occured [**2141-10-25**], where she remained for the rest of her hospital course. multiple medication regimens were attempted and changed throughout her hospital course. however, her blood pressures finally stabilized when she was placed back on her oral home regimen, which includes nifedipine, clonidine patch, labetalol, aliskiren, and hydralazine, with a hydralazine sliding scale for sbps > 180. at discharge, the only change from her home regimen that was made was increasing her nifedipine to 90 mg po. her regimen as per dr. [**last name (stitle) 4883**]: nifedipine sr 90 mg daily aliskiren 150 mg [**hospital1 **] labetalol 300 mg tid hydralazine 75 mg tid clonidine patch 0.3 mg/24 hr patch qwed when sbp>180, she then uses a hydralazine sliding scale. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. you can use this for up to 2-3 hours. in between po hydral doses, can then also use 10 iv hydralazine. # esrd: the etiology of the patients esrd is secondary to sle. her creatinine on admission was 7.9, which was near her baseline of 8 - 9. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. prior to her exploratory laparotomy, she was scheduled to have peritoneal dialysis four times per day over 4hrs with 2% solution at 1.2l per pd. after her exploratory laparotomy, surgery strongly advised the medical team that she should not restart peritoneal dialysis until she was at least 3 weeks out from her surgery. initially, the patient adamantly refused hemodialysis. however, over several days, she became hyperkalemic and increased swelling was noted bilaterally in her ankles and feet. as a result, after a long coversation with her primary renal physician, [**name10 (nameis) **] agreed to restart hemodialysis. a tunneled catheter was placed in her r femoral vein on [**2141-11-1**] and she subsequently started hemodialysis the same day, which she tolerated well. she underwent hemodialysis two more times prior to discharge. upon discharge, her electrolytes were back to her baseline. she is expected to undergo hemodialysis (tues/[**last name (un) **]/sat) as an outpatient. # anemia: during her admission, the patients hct was monitored daily with hct to low-mid 20s. on [**2141-10-17**], she was found to have guaiac positive stools and her hct was found to have dropped to a low of 18.6. the patient was transfused a total of 2 units of [**date range **] between [**2141-10-17**] and [**2141-10-18**]. epo alfa sc was also given on [**2141-10-17**]. she remained hemodynamically stable. gi consulted and egd results were as stated above. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. she received two units of [**month/day/year **] and her hct returned to 28. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. however, this did not occur as the patient went for an exploratory laparotomy on [**2141-10-27**] and her hct remained stable and near baseline for the remiainder of her hospital course. # h/o thrombosis: the patient was initially placed on her home dose of warfarin 2mg qd. her inr on admission was 1.2. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. however, this was stopped for her egd and after she had evidence of a gi bleed. the heparin drip was discontinued on [**10-22**]. the patient remained off heparin and coumadin from [**2141-10-23**] - [**2141-10-25**] given her drop in hct and in preparation for a possible gi intervention. after her surgery, her coumadin was held and she was off the heparin drip, but her inr continued to drift up, getting as high as 2.6 on [**2141-10-30**]. this was mostly attributed to nutritional deficiency [**2-11**] poor po intake, but there was concern for possible synthetic dysfunction as well. as a result, she was given a test dose of vitamin k, which she responded to well (her inr came back down to 1.4). as a result, her home dose of coumadin at 2 mg qday was restarted. at discharge, her inr was still sub- therapeutic at 1.4. of note, the patient has a history of svc syndrome and had a l subclavian venous thrombosis. during the last few days of her hospital stay, the patient complained of increased tongue swelling and her l face was noted to be slightly more swollen than previously noted. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. her outside rheumatologist was also consulted. both parties wanted to keep the patient on her home dose of prednisone of 4 mg qday, which was continued throughout her entire hospital course. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission. patient attempted 1 trial of cpap at 2l/min for 1-2 hrs with nasal mask, however did not tolerate as she complained of claustrophobia. the paitent stated that she would pursue further work-up and treatment for osa as an outpatient. while the mask and cpap machine were at her bedside throughout her hospital course, the patient rarely used it. # metabolic acidosis: the patients bicarbonate on admission was 13. her baseline is normally between 16-20. she received 150meq nahco3 over 24hrs from [**date range (1) 43500**]. during her brief returns to the micu, her hc03 was 18-19, which was presumed to be her baseline at home secondary to her crf. at discharge, having undergone three rounds of hemodialysis, her bicarbonate was within normal limits at 28. ","PRIMARY: [Malignant essential hypertension] SECONDARY: [Renal dialysis status; Epilepsy, unspecified, without mention of intractable epilepsy; Constipation, unspecified; Anemia in chronic kidney disease; Abnormal coagulation profile; Obstructive sleep apnea (adult)(pediatric); Other diseases of lung, not elsewhere classified; Other chest pain; Fever, unspecified; Rash and other nonspecific skin eruption; Other chronic pulmonary heart diseases; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified disease of pericardium; Other ascites; Acidosis; Hyposmolality and/or hyponatremia; Abdominal pain, other specified site; Abdominal pain, epigastric; Nausea with vomiting; Diarrhea; Systemic lupus erythematosus; Hyperparathyroidism, unspecified; Anemia, unspecified; Thrombocytopenia, unspecified; Esophageal reflux]","this is a 24 year old woman with esrd secondary to sle (started peritoneal dialysis approximately one week prior to admission), malignant htn, h/o svc syndrome, and multiple thrombotic events (on warfarin) who is presenting with persistent suprapubic/lower abdominal pain and new onset severe epigastric pain w/ nausea and vomiting, and hypertension. however, during the initial part of her admission, the patient remained afebrile with an initial relative leukocytosis which trended to within baseline limits. pericarditis was considered, but her ekg was unchanged from prior studies and there had been on interval increase in her pericardial effusion since [**2141-10-13**]. the patient tolerated the procedure well and immediately reported that both her epigastric and suprapubic pain were gone after the surgery. multiple medication regimens were attempted and changed throughout her hospital course. when sbp>180, give 25 mg po hydral every 30 min until sbp<150. during her admission, the patient underwent multiple trials of peritoneal dialysis, but was unable to tolerate it on a consistent basis secondary to abdominal pain. upon discharge, her electrolytes were back to her baseline. epo alfa sc was also given on [**2141-10-17**]. the patients hct remained stable (hovering between 25 - 27) from [**2141-10-19**] - [**2141-10-23**]. between [**2141-10-23**] - [**2141-10-24**], the patient had a hct drop from 26 to 20 in the setting of occult positive emesis. gi was aware and planned to perform a non-urgent egd on [**10-25**] or [**10-26**] as the patient was hemodynamically stable and her hct returned to baseline. she was also started heparin drip secondary to concern for ischemic bowel [**2-11**] microthrombotic disease. as a result, she underwent upper extremity venous ultrasound on [**2141-11-2**], which showed no evidence of a dvt within the left upper extremity and the previously noted thrombus within the left subclavian vein was not seen as well. # sle: rheumatology was consulted several times throughout her hospital course, but they did not think that a lupus flare was contributing to her presentation. # obstructive sleep apnea: the patient was noted to have osa based on clinical nocturnal exam during admission.","esrd secondary to sle, malignant htn, h/o svc syndrome, and multiple thrombotic events were considered. the patient was placed on iv flagyl, but this was discontinued when stool samples were negative for c.difficile. a heparin drip and warfarin were started for treatment of possible microthrombotic ischemia." 109,158995.0,14807,2142-02-26,14799,125288.0,2141-11-23,Discharge summary,"Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypertensive Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: (from MICU admit note) 24yoF ESRD-HD, SLE, HTN presents with 1 month abdominal pain and hypertension. Pt has had work-up over recent months for abd pain, including exploratory laparotomy, all of which essentially (-). Was admitted [**Date range (1) 34629**], for abdominal pain, then returned [**11-16**] for sob with (-)CTA, dc'ed [**11-17**]. In [**Hospital1 18**] ED, T98.5 hr95 BP 220/110 then 183/133 RR13 O2 100% on RA, rectal exam negative, guaiac(-), pelvic exam unremarkable with no cervical motion tenderness. Renal was consulted, taken for hemodialysis. CT abd showed large ascites, no other pathology; CT head improved from prior with no acute ICH; cxr(-). Given iv dilaudid for abdominal pain. BP treated with 10mg iv labetalol. Blood and urine cultures drawn, peritoneal fluid cx sent from catheter. Admitted to MICU for hypertension management. Access: R-HD catheter, 1 pIV in hand, 1 non-functioning peritoneal dialysis catheter. Past Medical History: PMH: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSH: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: PE: T:99.4 BP:158/108 HR:95 RR:12 O2 100% RA GEN: NAD/ pt eyes closed due to pain/ pleasant despite pain HEENT: AT, NC, PERRLA, EOMI on R eye, L eye prosthesis, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD CV: S1 & S2, RRR II/VI HSM at R/L USB, no rubs/gallops PULM: CTAB, no w/r/r ABD: soft, mildly tender at PD catheter, ND, + BS, midline incision with steri-stripes, PD catheter dressing C/I/D EXT: warm, dry, +2 distal pulses BL, no edema NEURO: alert & oriented, CN II-XII grossly intact (except L eye), 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: Admission Labs: [**2141-11-18**] 07:00AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.7* Hct-30.7* MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* Plt Ct-142* [**2141-11-18**] 07:00AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.3* [**2141-11-18**] 07:00AM BLOOD Glucose-86 UreaN-22* Creat-5.0* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2141-11-18**] 07:00AM BLOOD ALT-8 AST-39 AlkPhos-92 TotBili-0.3 [**2141-11-18**] 07:00AM BLOOD Lipase-76* [**2141-11-18**] 07:00AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.9 [**2141-11-18**] 11:00PM ASCITES WBC-1265* RBC-1680* Polys-43* Lymphs-1* Monos-2* Mesothe-11* Macroph-43* [**2141-11-18**] 10:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2141-11-18**] 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2141-11-18**] 10:05AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-[**3-15**] Discharge Labs: [**2141-11-23**] 04:40AM BLOOD WBC-2.9* RBC-3.08* Hgb-9.0* Hct-28.3* MCV-92 MCH-29.2 MCHC-31.8 RDW-17.5* Plt Ct-182 [**2141-11-23**] 04:40AM BLOOD PT-20.8* PTT-76.1* INR(PT)-2.0* [**2141-11-23**] 04:40AM BLOOD Glucose-80 UreaN-21* Creat-4.7* Na-139 K-4.8 Cl-106 HCO3-24 AnGap-14 [**2141-11-23**] 04:40AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8 [**2141-11-22**] 04:55AM BLOOD TSH-6.1* [**2141-11-23**] 04:40AM BLOOD Free T4-1.2 Blood cx ([**11-18**], [**11-19**]): 1/4 bottles with coag neg Staph, [**3-14**] NGTD Urine cx ([**11-18**]): mixed flora c/w contamination Peritoneal fluid ([**11-18**]): Gram stain 2+ polys. Culture no growth. Imaging: CXR Portable ([**11-18**]): Since [**2141-11-16**], heart size enlargement is unchanged due to known pericardial effusion. Lungs are otherwise clear. Hilar contours are normal. Incidentally, widening of both acromioclavicular joints is unchanged. CT A/P ([**11-18**]): 1. No evidence of bowel obstruction or rim-enhancing fluid collection. 2. Large ascites, slightly increased from [**2141-11-13**], with peritoneal dialysis catheter in place. Interval removal of surgical skin staples along the abdomen. 3. Moderate pericardial effusion as before. 4. Symmetric heterogeneous attenuation of the kidneys could be related to renal failure; however, pyelonephritis could also give this appearance. Appearance of the kidneys is unchanged from [**2141-11-13**]. CT Head w/o contrast ([**11-18**]): 1. No evidence of acute intracranial hemorrhage. 2. Regions of hypoattenuation in the bifrontal white matter and left posterior temporal lobe have resolved since [**2141-6-11**]. No new regions of hypoattenuation seen. Brief Hospital Course: 1) Hypertension: Patient has history of extremely labile hypertension on an aggressive outpatient regimen. Overnight in the MICU, patient required IV and PO labetalol for SBP > 200. Her hydralazine was increased from 75mg to 100mg TID with mild improvement. Her labetalol was also increased from 300mg to 400mg TID. Her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. TSH was sent and elevated, although free T4 was normal. Plasma metanephrines were sent and pending at discharge. 2) Abdominal pain: CT scan showed increasing ascites, but no acute pathology. Peritoneal fluid was obtained and contained 544 polys. Treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing GPC pairs/clusters. Blood cultures ended up growing 1 out of 4 bottles coag-neg Staph, likely contaminant, so vancomycin was stopped. Since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. The peritoneal cultures remained negative. Her PD catheter was left in place as the patient refuses HD any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) SVC/brachiocephalic thrombosis: Patient's INR was subtherapeutic on admission at 1.3. Due to the proximal location of her old venous thrombi, she was started on a heparin gtt. This was continued during her admission and her warfarin was increased to 5mg daily. Her INR reached 2.0 at discharge (therapeutic range 2-3). The dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) Anxiety: Patient noted feeling short of breath and anxious around the time of her recent admissions. Her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. They felt her symptoms were suggestive of anxiety and panic attacks, recommended checking TSH and metanephrines as above, and starting citalopram 20mg, which was done. She was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h PRN. Patient is agreeable to outpatient follow up with [**Company 191**] social work, and potential CBT. These can be arranged by her PCP. Medications on Admission: 1. Aliskiren 150 mg [**Hospital1 **] 2. Clonidine 0.3 mg/24 qwk 3. Prochlorperazine Maleate 10 mg prn 4. Hydromorphone 2 mg Tablet Sig: [**1-11**] q6 prn 5. Bisacodyl 10mg [**Hospital1 **] 6. Ergocalciferol (Vitamin D2) 50,000 qmonth 7. Hydralazine 75mg tid 8. Hydralazine scale prn 9. Labetalol 300 mg tid 10. Nifedipine 90 mg qd 11. Prednisone 4mg qd 12. Warfarin 2 mg qd at 4pm Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Hospital1 766**]). 5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day. [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 7 days. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO q30 min prn as needed for hypertension: for SBP > 180. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive urgency Headache Abdominal pain Anxiety Secondary Diagnosis: HTN SLE ESRD on HD SVC and IJ thrombosis, chronic Anemia Discharge Condition: Stable, BPs improved. Discharge Instructions: You were admitted with elevated blood pressures, headache, and abdominal pain. You were found to have increased amounts of white blood cells in your abdominal cavity, but this was not infected. Your abdominal pain resolved and you continued to have intermittent headaches. Your blood pressure medications were adjusted as below. You were also seen by psychiatry who recommended starting new medications for your anxiety. The following changes were made to your medication regimen: - We increased your hydralazine to 100 mg three times a day. - We also increased your labetalol to 400 mg three times a day. - We have started a medication called celexa 20 mg daily as well as ativan 1 mg three times a day as needed for anxiety. - We have increased your coumadin to 4 mg daily. - Please continue taking all other medications as previously prescribed. Call your doctor or return to the emergency room if you experience any of the following: worsening abdominal pain, nausea, vomiting, blurry vision, worsening headache, fever > 101. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. Please continue to follow with your nephrologist and go to outpatient dialysis as previously arranged. Please discuss with your PCP the possibility of talking to a social worker at [**Name (NI) 191**]. You will need to continue to have your INR monitored at [**Hospital 191**] [**Hospital 2786**] clinic. Please have this level checked on [**Hospital 766**], [**11-27**]. Completed by:[**2141-11-23**]",95,2141-11-18 14:00:00,2141-11-23 16:42:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. her hydralazine was increased from 75mg to 100mg tid with mild improvement. her labetalol was also increased from 300mg to 400mg tid. her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. tsh was sent and elevated, although free t4 was normal. plasma metanephrines were sent and pending at discharge. 2) abdominal pain: ct scan showed increasing ascites, but no acute pathology. peritoneal fluid was obtained and contained 544 polys. treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing gpc pairs/clusters. blood cultures ended up growing 1 out of 4 bottles coag-neg staph, likely contaminant, so vancomycin was stopped. since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. the peritoneal cultures remained negative. her pd catheter was left in place as the patient refuses hd any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) svc/brachiocephalic thrombosis: patients inr was subtherapeutic on admission at 1.3. due to the proximal location of her old venous thrombi, she was started on a heparin gtt. this was continued during her admission and her warfarin was increased to 5mg daily. her inr reached 2.0 at discharge (therapeutic range 2-3). the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) anxiety: patient noted feeling short of breath and anxious around the time of her recent admissions. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. they felt her symptoms were suggestive of anxiety and panic attacks, recommended checking tsh and metanephrines as above, and starting citalopram 20mg, which was done. she was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h prn. patient is agreeable to outpatient follow up with [**company 191**] social work, and potential cbt. these can be arranged by her pcp. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Abdominal pain, unspecified site; Anemia, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. her hydralazine was increased from 75mg to 100mg tid with mild improvement. peritoneal fluid was obtained and contained 544 polys. the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted.","patient has history of extremely labile hypertension on aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. ct scan showed increasing ascites, but no acute pathology." 109,158995.0,14807,2142-02-26,14800,161950.0,2141-12-01,Discharge summary,"Admission Date: [**2141-11-24**] Discharge Date: [**2141-12-1**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Headache, abdominal pain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24yo F w/PMHx of ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning, awakening her from sleep. Had been previously discharged from [**Hospital1 **] yesterday after being admitted for hypertension and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Upon discharge yesterday she states her abdominal pain had subsided. She had HD yesterday without complications. She awoke at 6am with a headache and crampy, stabbing abdominal pain. Took 2mg PO Dilaudid without relief and came to ED. No nausea/vomiting, no changes in vision, no fevers, chills, night sweats. No chest pain, SOB, diarrhea. In the ED, initial vitals were T98.7, BP260/130, HR70, RR16. Was initially given 10mg IV Labetalol X 2, 4mg Zofran for nausea. No improvement in BP and started on Labetolol gtt. Got 1mg IV Dilaudid for pain. Currently, patient continues to complain of headache and abdominal pain, both [**7-17**]. No vision changes, chest pain or shortness of breath. Has been feeling increased anxiety recently and saw psychiatrist, was put on Celexa. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T98.2, BP176/135, HR94, RR 22, 100% RA Gen: well-appearing african-american woman, lying comfortably HEENT: anicteric, L eye prosthetic non-reactive, R pupil reactive, MMM, neck supple with submanibular LAD CV: RRR, II/VI SEM best heard at apex Pulm: CTA b/l Abd: hyperactive bowel sounds, midline scar well-healed, soft, diffusely tender to palpation, +rebound, no guarding. PD catheter in LLQ without erythema or purulent material draining. +dullness on percusion with evidence of clinical ascites. Ext: no edema, no clubbing, 2+ peripheral pulses DP and radial. R femoral HD [**Last Name (un) **] in place without erythema, purulance Neuro: A&O X 3, CN intact II-XII, [**5-15**] motor strength in upper and lower extremities Pertinent Results: Admission labs: CBC: [**2141-11-26**] 05:21AM BLOOD WBC-3.5* RBC-3.07* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-17.6* Plt Ct-180 CHEM 10: [**2141-11-26**] 01:16PM BLOOD Glucose-87 UreaN-17 Creat-4.0* Na-136 K-5.2* Cl-106 HCO3-23 AnGap-12 [**2141-11-26**] 09:20PM BLOOD Calcium-7.6* Phos-3.8 Mg-1.8 COAGS: [**2141-11-26**] 01:16PM BLOOD PT-23.9* PTT-40.2* INR(PT)-2.3* STUDIES: 1)Peritoneal fluid ([**11-26**]): negative for malignant cells. Reactive mesothelial cells, macrophages, eosinophils and lymphocytes. 2)BILAT UP EXT VEINS US ([**11-26**]): No evidence of deep vein thrombosis of the right or left upper extremity. 3) MRI/MRA ([**11-30**]): FINDINGS: Examination is somewhat limited by patient motion. T2/FLAIR sequences are unremarkable with interval resolve of previously noted posterior abnormalities. The major vessels appear patent proximally. There are stable areas of low signal in the left frontal and right occipetal/temporal lobes. IMPRESSION: 1. Interval resolution of previously noted posterior white matter abnormalities. 2. Stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions. 3. Very limited MRA as above. Brief Hospital Course: 24yo F with SLE, ESRD on HD and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**Hospital Unit Name 153**] course: The patient was admitted for blood pressure management and evaluation of abd pain. An A-line was placed. EKG showed no change from prior, and Abd x-ray showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home med regimen. The patient was found to be hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. Upon transfer to the floor, the following was her course: 1. Hypertensive Urgency: Pt had had hemodialysis one day prior to admission, so unlikely that she was volume overloaded. Unclear what precipitated this episode of hypertensive urgency, although suspect secondary to abdominal pain leading to an anxiety which then precipitates hypertension. She may not have been taking her medications secondary to pain. Negative serum tox. On the floor, we continued hemodialysis Tu, Th, Sat. She was initially continued on PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine 90mg PO qday and clonidine; she received hydralazine 10mg IV for goal BP < 180/100. Renal team followed patient during this hospitalization. Per renal team recs, labetalol was increased to 800mg TID due to poor blood pressure control. Pt discharged on clonidine 0.3mg patch, Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, Nifedipine 90mg daily and lobatalol 800mg TID. This regimen worked well. 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT scan during prior admission which did not show source of abdominal pain. On admission, LFTs were normal except for slightly low albumin, lipase was slightly elevated and KUB was negative for free air or evidence of SBO. Peritoneal fluid was negative for malignant cells but showed reactive mesothelial cells, macrophages, eosinophils and lymphocytes. Negative gram stain or peritoneal fluid cultures, excluding SBP as a cause of the abdominal pain. PD catheter was not removed. Pt was continued on PO dilaudid 1-2mg Q6h and pain resolved. She denied N/V/diarrhea or constipation. 3. ESRD: Pt on hemodialysis, on T/Th/Sat schedule. Renal following patient closely throughout this hospitalization. Lytes were checked frequently and kayexalate given prn. 4. Hx of SVC/brachiocephalic DVT: Pt was initially subtherapeutic on coumadin. Unclear if she had not been taking Coumadin although patient reported that she has been taking all home meds. We started heparin gtt to bridge to Coumadin. Once therapeutic, continued Coumadin 5mg PO qday. 5. Anxiety: Likely contributing to medical problems and could have very well been the etiology of this admission. Although pt stated she was taking her current medications, she did report increased anxiety which can lead to medication non-compliance and hypertension. Pt recently saw psychiatrist who started her on Celexa. She was continued on celexa 20mg PO qday, ativan 1mg PO q8hours PRN and psychiatry was re-consulted. Per psych recs, started standing clonazepam. Pt refused psych VNA. Outpatient PCP followup recommended. 6. Headache NOS: Pt complained of R-sided HA for several weeks, radiating to R jaw where patient had previous tooth extraction. Right upper extremity ultrasound was negative for DVT. She did not have any focal neuro findings, no visual deficits. She was initially treated with tylenol PRN Q6h; pt requested IV dilaudid for HA, but use of this medication by IV route was limited by team. It was felt by the pain service that her HA did not fit migraine, tension type HA or rebound HA. They recommended increasing dilaudid to 4-6mg Q6h PRN, continuing tylenol and starting neurontin 300mg Qhs which was slowly titrated to 300mg [**Hospital1 **] for better control. Per pain recs, a neurology consult was also obtained during this admission. MRI/MRA showed interval resolution of previously noted posterior white matter abnormalities and stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions, but very limited MRA as above. Per pain recs, dilaudid was further increased to 4mg q4h for better control of her HA. Neurology recommended outpt f/u and Pt scheduled with [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**]. 7. Anemia: Likely related to ESRD. No evidence of acute bleeding. Hct remained stable during this hospitalization. 8. SLE: no acute issues. continued Prednisone 4mg PO qday 9. FEN: tolerated regular diet, repleted lytes PRN 9. Prophylaxis: Heparin gtt, then coumadin, bowel regigmen Medications on Admission: (from prior discharge summary) Bisacodyl 10mg PO qday PRN Prednisone 4mg PO qday Aliskiren 150mg PO BID Clonidine 0.3mg / 24 hr patch weekly qmonday Labetalol 400mg PO TID Warfarin 4mg PO qday Nifedipine 90mg PO qday Hydralazine 100mg PO q8H Hydromorphone 2-4mg PO q4H PRN Lorazepam 1mg PO q8H Celexa 20mg PO qday Prochlorperazine 10mg PO q6H Colace 100mg PO BID Hydralazine 25mg PO q30min PRN for HTN Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Year (4 digits) 766**]). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). [**Year (4 digits) **]:*100 Tablet(s)* Refills:*2* 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*90 Capsule(s)* Refills:*2* 9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for headache. [**Year (4 digits) **]:*84 Tablet(s)* Refills:*0* 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*60 Capsule(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours. [**Year (4 digits) **]:*360 Tablet(s)* Refills:*2* 16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. [**Year (4 digits) **]:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive Emergency 2. SLE 3. Headache, NOS 4. Abdominal pain Discharge Condition: BP better controlled. Headache managed on oral meds Discharge Instructions: You were admitted with abdominal pain, high blood pressure, and headache. Your abdominal pain resolved - no serious cause of this pain was found. Your blood pressure medications were continued, and with an increased in one medication, the labetalol. Your blood pressure improved. You should continue the clonidine 0.3mg patch changed on [**Year (4 digits) 766**], Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, and Nifedipine 90mg daily. The dose of Labetalol was increased to 800 mg three times daily by you kidney doctor and you are given a new prescription. Please take all medications as listed below. For your headache, you had an MRI and MRA of the head, which did not show a new or serious abnormality. You were seen by the neurology and pain services. You should follow up at [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**] at 6:30 PM (in the evening). Your pain was managed by oral dilaudid, 4mg. You should take this medication every 4 hours as needed. You were also started on Gabapentin (also called Neurontin) for the headache. The dose was slowly increased to twice a day. You may not need as much dilaudid for your headache and should wean this medication as tolerated, given it's potential for side effects (constipation, lethargy, dependence). Finally, you will likely need medications for constipation while you take dilaudid. Take colace (a stool softener), senna (a laxative), and bisacodyl (another laxative), as needed. It is really important that you have a primary care doctor. You are scheduled with Dr. [**Last Name (STitle) **] (see below) next Tuesday. You will need your INR checked since you are on coumadin. Call your doctor if you have worsened headache, chest pain, confusion, or any other concerning symptom. Followup Instructions: Please make sure you attend the following doctor appointments: 1) Dr. [**Last Name (STitle) 4883**] (nephrologist) on Tuesday, [**2141-12-5**] at 10AM. Phone number [**Telephone/Fax (1) 60**]. 2) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Location (un) **], [**Hospital Ward Name 23**] center, [**Location (un) **]. Phone:[**Telephone/Fax (1) 250**]. Date/Time:[**2141-12-5**] 3:20 3) Neurology: Dr. [**Last Name (STitle) 43502**] [**Name (STitle) **]. He is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-12-12**] 6:30 PM [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2141-12-2**]",87,2141-11-24 16:11:00,2141-12-01 19:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**hospital unit name 153**] the patient was admitted for blood pressure management and evaluation of abd pain. an a-line was placed. ekg showed no change from prior, and abd x-ray showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home med regimen. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. upon transfer to the floor, the following was her ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other ascites; ; Systemic lupus erythematosus; Headache; Anemia in chronic kidney disease; Anxiety state, unspecified; Other chest pain; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Renal dialysis status; Acquired absence of organ, eye]","24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. the renal team was consulted, and recommended no change to home med regimen.","a 24yo f with sle, esrd on hd and malignant hypertension presented with abdominal pain and headache. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. she successfully switched to po meds and was transferred to the floor." 109,158995.0,14807,2142-02-26,14801,173633.0,2141-12-14,Discharge summary,"Admission Date: [**2141-12-8**] Discharge Date: [**2141-12-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 8104**] Chief Complaint: abdominal pain & hypertension Major Surgical or Invasive Procedure: Hemodialysis PICC Line [**12-11**] History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with a history of CKD V (on HD) from lupus nephritis, chronic intermittent abdominal pain, and multiple prior ICU admissions for hypertensive urgency who presented to the ED complaining of two days' of abdominal pain, nausea, and loose stools. She was feeling well until after her hemodialysis session on Wednesday. Thereafter, she complained of nausea with occasional vomitting and has been unable to keep down any of her oral medications. She also has had diffuse abdominal pain consistent with her prior flares of pain as well as her typical diffuse headache. The headache in particular was worsening and, for her, this is a sign of poorly-controlled hypertension so she came to the [**Hospital1 18**] ED. Upon arrival to the ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room air. She was given 4 mg of IV ondansetron, [**1-11**] inch intropaste, 1 mg of IV hydromorphone x3, 1000cc of NS, and was put on a labetalol drip which had to be increased up to 2 mg/min. A head CT showed no acute abnormality (including hemorrhage) and an abdominal CT showed some possible mild colitis, though it is unclear if this is due to her recent peritoneal dialysis. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 97.9 BP 165/120 HR 93 RR 12 Sat 100% ra Gen: mildly fatigued, but no distress HEENT: oropharynx clear Neck: no JVP, no LAD Chest: clear to auscultation throughout, no w/r/r CV: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard Abdomen: soft, tender diffusely to moderate palpation without rebound or guarding; hyperactive bowel sounds; no masses or HSM, PD catheter in palce Extr: no edema, 2+ PT pulses Neuro: alert, appropriate, strength grossly intact in all four limbs Skin: no rashes Pertinent Results: [**2141-12-14**] 05:53AM BLOOD WBC-4.3 RBC-2.81* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.7 MCHC-33.8 RDW-19.3* Plt Ct-148* [**2141-12-14**] 05:53AM BLOOD PT-42.6* PTT-51.0* INR(PT)-4.7* [**2141-12-10**] 05:10AM BLOOD Ret Aut-2.5 [**2141-12-14**] 05:53AM BLOOD Glucose-83 UreaN-21* Creat-5.1*# Na-138 K-5.3* Cl-105 HCO3-24 AnGap-14 [**2141-12-10**] 05:10AM BLOOD LD(LDH)-234 Amylase-347* TotBili-0.1 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-10**] 05:10AM BLOOD Lipase-72* [**2141-12-14**] 05:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 [**2141-12-10**] 05:10AM BLOOD Hapto-142 [**2141-12-8**] 04:02AM BLOOD calTIBC-138* VitB12-445 Folate-18.5 Ferritn-220* TRF-106* ON ADMISSION: [**2141-12-7**] 09:50PM BLOOD WBC-4.5 RBC-2.78* Hgb-8.4* Hct-25.2* MCV-91 MCH-30.2 MCHC-33.3 RDW-19.2* Plt Ct-158 [**2141-12-7**] 09:50PM BLOOD Neuts-65.2 Lymphs-23.4 Monos-8.0 Eos-2.9 Baso-0.4 [**2141-12-7**] 09:50PM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3* [**2141-12-8**] 04:02AM BLOOD Ret Aut-2.5 [**2141-12-7**] 09:50PM BLOOD Glucose-89 UreaN-25* Creat-5.1*# Na-139 K-4.8 Cl-104 HCO3-26 AnGap-14 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-7**] 09:50PM BLOOD Lipase-89* [**2141-12-7**] 09:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9* Mg-1.9 [**2141-12-7**] 09:54PM BLOOD Glucose-75 Lactate-1.3 Na-139 K-4.8 Cl-101 calHCO3-23 Micro: Blood Cx: [**12-7**], [**12-7**], [**12-11**], [**12-11**] No growth FECAL CULTURE (Final [**2141-12-10**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2141-12-10**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2141-12-8**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-12-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CT HEAD [**2141-12-8**]: IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. The hypodensities noted in the parietal white matter are stable. However in the setting of the hypertension, PRES cannot be excluded. If further evaluation is required MR can be obtained. CT Abdomin/Pelvis [**2141-12-8**] IMPRESSION: 1. Moderate amount of free fluid in the pelvis is compatible with the patient's known peritoneal dialysis. Unchanged peritoneal enhancement. 2. Stable liver hemangioma. CXR [**12-11**] IMPRESSION: Small left pleural effusion. Left lower lobe opacity which is either atelectasis versus pneumonia. Brief Hospital Course: 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. MICU course: Current plan on transfer 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. 1. Hypertensive urgency: The patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. Initially her blood pressure over-corrected to SBPs in the 80s (patient was asymptomatic). Her clonidine patch and hydralazine was held and she again became hypertensive with SBPs 190s. The patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. The following dialysis the patient asymptomatic with SBPs in 80s, MAPs 60s asymptomatic again. Her hydralazine was stopped and continued on all her other home medications at the advice of renal. The patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. On [**12-11**] the patient's SBP dropped to the 80's and due to her pain medications she was extremely lethargic, but arousable. A PICC line was placed because lack of access and she was bolused 250cc NS. The patient's pressures responded and additional narcotics were held due to her mental status. The patient's blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. The patient did require IV hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. A possible component to the patient's malignant hypertension is likely due to OSA. An inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on BiPAP for OSA. The patient was continuned on her admission hypertensive regimen. . 2. Abdominal pain: The etiology of her abdominal pain is unclear, but has been a chronic issue for her. A CT scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. The patient also had diarrhea, but stool studies were negative. The patient's pain was initially treated with hydromorphone, but because of the patient's lethargy on [**12-11**] they were initially held. She continued to complain of severe abdominal pain. She was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. Surgery was consulted in regards to removal of her PD catheter, but given that she may return to PD it was deferred to the outpatient setting. 3. CKD V from lupus nephritis: The patient was continued on HD during her admission. She was also continued on her home prednisone dose. She was closely followed by the renal team. . 4. History of SVC/subclavian vein thrombus: The patient was found to have a subtherapeutic INR on admission 1.3. She was started on a heparin gtt and continued on coumadin. The patient's heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her PICC line was placed. She was therapetuic the same day and her heparin gtt was stopped. On discharge her coumadin was supratherapeutic (4.7) and was held. She will have her INR checked at HD. . 5. Anemia: The patient's Hct slowly trended down. She was guaiac negative and hemolysis labs were negative. She was transfused 1U pRBC at HD on [**12-12**]. She was also given epo at HD. Medications on Admission: prednisone 4 mg daily clonidine 0.3 mg/day patch qWeek ergocalciferol 50,000 units qMonth nifedipine SR 90 mg daily hydralazine 100 mg q8h citalopram 20 mg daily warfarin 2 mg qhs gabapentin 300 mg [**Hospital1 **] hydromorphone 4 mg q4h prn clonazepam 0.5 mg [**Hospital1 **] alikiren 150 mg [**Hospital1 **] docusate 100 mg [**Hospital1 **] senna 8.6 mg [**Hospital1 **] prn acetaminophen prn labetalol 800 mg q8h bisacodyl 5 mg daily prn Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. [**Hospital1 **]:*84 Tablet(s)* Refills:*0* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed: please take as needed for anxiety prior to CPAP at bedtime. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 14. CPAP Home CPAP Dx: OSA Prefer: AutoCPAP/ Pressure setting [**5-20**] Alt: Straight CPAP/ Pressure setting 7 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency Abdominal Pain ESRD on HD SVC Thrombus Secondary: Systemic lupus erythematosus Malignant hypertension Thrombocytopenia HOCM Anemia History of left eye enucleation History of vaginal bleeding Thrombotic microangiopathy Discharge Condition: Stable Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because of elevated blood pressure and abdominal pain. You were initially admitted to the ICU and your blood pressure was controlled. You were stabilized and transferred back to th floor. Your pressures remained stable throughout the rest of your stay. Additionally, you had abdominal pain and diarrhea. Your stool was tested for infections and was negative. Your diarrhea resolved without intervention. Your abdominal pain was controlled with pain medications. You had a sleep study in the hospital which showed that you had sleep apnea. Please continue to take your medications as prescribed. 1. Please do not take your coumadin until your doctor tells you to. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: You will have dialysis at [**Location (un) **] Dialysis on your normal schedule. You need to go to dialysis on Saturday. Please follow-up with the Sleep Clinic in [**12-19**] @ 11:45 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Completed by:[**2141-12-16**]",74,2141-12-08 01:40:00,2141-12-14 17:16:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. micu course: current plan on transfer 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. 1. hypertensive urgency: the patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). her clonidine patch and hydralazine was held and she again became hypertensive with sbps 190s. the patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. the following dialysis the patient asymptomatic with sbps in 80s, maps 60s asymptomatic again. her hydralazine was stopped and continued on all her other home medications at the advice of renal. the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. on [**12-11**] the patients sbp dropped to the 80s and due to her pain medications she was extremely lethargic, but arousable. a picc line was placed because lack of access and she was bolused 250cc ns. the patients pressures responded and additional narcotics were held due to her mental status. the patients blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. the patient did require iv hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. a possible component to the patients malignant hypertension is likely due to osa. an inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on bipap for osa. the patient was continuned on her admission hypertensive regimen. . 2. abdominal pain: the etiology of her abdominal pain is unclear, but has been a chronic issue for her. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. the patient also had diarrhea, but stool studies were negative. the patients pain was initially treated with hydromorphone, but because of the patients lethargy on [**12-11**] they were initially held. she continued to complain of severe abdominal pain. she was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. surgery was consulted in regards to removal of her pd catheter, but given that she may return to pd it was deferred to the outpatient setting. 3. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was also continued on her home prednisone dose. she was closely followed by the renal team. . 4. history of svc/subclavian vein thrombus: the patient was found to have a subtherapeutic inr on admission 1.3. she was started on a heparin gtt and continued on coumadin. the patients heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her picc line was placed. she was therapetuic the same day and her heparin gtt was stopped. on discharge her coumadin was supratherapeutic (4.7) and was held. she will have her inr checked at hd. . 5. anemia: the patients hct slowly trended down. she was guaiac negative and hemolysis labs were negative. she was transfused 1u prbc at hd on [**12-12**]. she was also given epo at hd. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Systemic lupus erythematosus; Other and unspecified noninfectious gastroenteritis and colitis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other iatrogenic hypotension; Obstructive sleep apnea (adult)(pediatric); Hemangioma of intra-abdominal structures; Other chronic pain; Abdominal pain, unspecified site; Abnormal coagulation profile; Renal dialysis status; Personal history of venous thrombosis and embolism]","24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. the patient was continuned on her admission hypertensive regimen. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was therapetuic the same day and her heparin gtt was stopped.",24 year old woman with ckd v and severe hypertension due to sle admitted. patient was initially maintained on a labetalol drip and hydralazine iv prn. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic) 109,158995.0,14807,2142-02-26,14802,140167.0,2141-12-23,Discharge summary,"Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1973**] Chief Complaint: Malignant hypertension Major Surgical or Invasive Procedure: None History of Present Illness: 24 year old female with ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning. Patient had her hemodialysis day before yesterday. She has had multiple admissions to [**Hospital1 18**] with hypertensive urgency with symptoms of headache and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Patient states that her headache and abdominal pain are similar in characteristics to her previous admission. Patient denies any fever, chills, nightsweats, chest pain, shortness of breath, abdominal pain, nausea, vomitting, diarrhea, constipation, blood in stool, dysuria, hematuria, change in vision, hearing, weakness or numbness. In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was initially given 10mg IV Labetalol once and then started on drip at 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea. Her BP elevated as high as 270/174 and his labetolol was switched to nicardipine 1mg/kg/min. On arrival to the MICU her vitals were T 96.4 HR 99 BP 175/120 RR 15 100%RA. Patient was comfortable. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Vitals: 97.5 122/80 88 18 100%RA. Gen: sleeping, easily arousable, appears comfortable. HEENT: AT/NC, L eye prosthetic non-reactive, R pupil reactive, MMM. Heart: S1S2 RRR, III/VI SEM heard best at apex, + S3 Pulm: CTA b/l, no w/r/r. Abd: normal bowel sounds, midline scar well-healed, soft, nontender, prior PD site with dry dressing, patient with tenderness to palpation over prior PD cath site, no guarding/rebound Ext: no edema, no clubbing, WWP. R femoral HD catheter in place. Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: Admission: [**2141-12-18**] 02:00AM BLOOD WBC-5.8 RBC-3.30* Hgb-10.1* Hct-30.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-20.7* Plt Ct-199 [**2141-12-18**] 02:00AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.2* [**2141-12-18**] 02:00AM BLOOD UreaN-35* Creat-5.0* Na-138 K-5.5* Cl-103 HCO3-21* AnGap-20 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-18**] 02:00AM BLOOD Lipase-73* [**2141-12-18**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2141-12-19**] 06:45AM BLOOD Calcium-8.1* Phos-5.1* Mg-1.8 [**2141-12-18**] 03:52PM BLOOD dsDNA-NEGATIVE [**2141-12-18**] 03:52PM BLOOD CRP-11.5* [**2141-12-18**] 03:52PM BLOOD C3-68* C4-19 [**2141-12-20**] 12:09PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 [**2141-12-18**] 02:08AM BLOOD pO2-52* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 Comment-GREEN TOP [**2141-12-20**] 12:09PM BLOOD Lactate-0.9 [**2141-12-18**] 02:08AM BLOOD Glucose-68* Lactate-1.3 Na-140 K-4.8 Cl-103 [**2141-12-23**] 03:00PM BLOOD WBC-4.7 RBC-2.35* Hgb-7.1* Hct-22.3* MCV-95 MCH-30.3 MCHC-31.9 RDW-20.6* Plt Ct-131* [**2141-12-23**] 12:55AM BLOOD PT-14.7* PTT-66.2* INR(PT)-1.3* [**2141-12-18**] 03:52PM BLOOD ESR-21* [**2141-12-23**] 03:00PM BLOOD Glucose-97 UreaN-42* Creat-6.6* Na-138 K-4.3 Cl-106 HCO3-23 AnGap-13 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-23**] 03:00PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8 [**2141-12-18**] 04:23PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2141-12-18**] 04:23PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2141-12-18**] 04:23PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-12 TransE-<1 Micro: Blood Cx- [**12-18**]: No growth Urine Cx- [**12-18**]: No growth [**12-18**] TTE The left atrium and right atrium are normal in cavity size. A possible secundum type atrial septal defect is seen by color Doppler (clip [**Clip Number (Radiology) **]) There is severe symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. There is no significant resting LVOT gradient, but a mild gradient (30mmHg peak) is seen with Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Marked symmetric left ventricular hypertrophy with normal regional/global systolic function and mild inducible LVOT gradient. Mild aortic regurgitation. Mild pulmonary artery systolic hypertension. Possible secundum type atrial septal defect. Compared with the prior study (images reviewed) of [**2141-10-19**], a possible secundum type atrial septal defect is now suggested. If clinically indicated, a follow-up study with saline contrast and/or a TEE would be better able to characterize the possible atrial septal defect. CLINICAL IMPLICATIONS: Based on [**2140**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**12-18**] CXR IMPRESSION: 1. Cardiomegaly with findings suggestive of mild pulmonary edema. 2. Bibasilar linear opacities suggesting atelectasis, although developing pneumonia cannot be excluded. 3. No evidence of free intraperitoneal air. [**12-20**] MRV IMPRESSION: No appreciable change since the MRV chest exam dated [**2141-5-30**]. SVC is patent. Again seen is occlusion of the right internal jugular and left brachiocephalic veins. Right external jugular vein is provides the major venous drainage from the neck. Brief Hospital Course: 24 year old Female with SLE, ESRD on HD and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ED. 1. Malignant Hypertension: The patient had her hemodialysis two days prior to admission. Initially in the ED her BP was 253/170. She was given 10mg IV Labetalol and started on a labatelol drip. She also received hydralazine IV 10 mg once and 2 inches of nitropaste. She had morphine 4mg and 4mg Zofran for nausea. Her BP remained elevated so she was switched to nicardipine 1mg/kg/min. The patient was transferred to the MICU. In the ICU she was continued on the Nicardapine drip and her pressures decreased to 175/120. Nephrology was consulted and dialysis initiated in the AM. The Nicardapine drip dc'd on [**12-19**] and pt transferred to floor. While on the floor the patient had question of angioedema and markedly elevated BP. She was readmitted to the MICU on [**2141-12-20**]. Patient's Aliskerin was also held for conern for angioedema. The renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. The patient's PD catheter was removed. The patient was briefly on a nitro drip for hypertension. The patient's nifedepine was increased to 120mg. The patient was transferred to the floor with stable blood pressures, BP 124/72 on [**12-21**]. The morning of [**12-22**], the patient was noted to have a BP up to 247/120 at 0800. Hypertension persisted throughout the morning with BPs 210s-240s systolic. HR during this time was in the 90s. She received a total of 60 mg IV hydralazine over the course of the morning as well as 0.1 mg PO clonidine. She was also given her normal AM BP meds and restarted on aliskarin. Due to persistent hypertension, she was transferred to the ICU for further care. On arrival to the ICU, the patient reported severe abdominal pain over the site of recently removed PD catheter. She denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. She reports bilateral calf cramping but no leg swelling. She denies any difficulty breathing or chest pain. She took her AM BP meds without difficulty. Her blood pressure decreased to 130s-140s/60s without further intervention. She was transferred back to the floor on [**12-23**] and signed out AMA. 2. Angioedema: On [**12-20**] the patietn developed facial swelling and evidence of angioedema by ENT. The patient reported that her face is more swollen which was confirmed by her mother on the floor. The patient was give lasix IV as she has been unable to have any negative filtration with HD. The patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. Her tekturna was discontinued for concern that it might be causing angioedema. She denied difficulty with her breathing at that time, but was very somnulent. On arrival to the MICU her vitals were stable and oxygenating well at 100% on face mask. The patient's airway was supported with a nasal trumpet. The patient underwent MRV that showed no progression of her clot. Patient was diuresed with lasix and dialysis with significant improvement in her symptoms. She was treated with prednisone and decadron, famotidine and benadryl for angioedema. The patient was maintained on her heparin drip for her SVC syndrome. 3. Abdominal Pain: The patient has had extensive prior workup that has been unrevealing. The Transplant surgery team removed the PD cath on [**12-21**]. She continued to have abdominal pain post-op. She was continued on PO dilaudid 2mg po prn. She continuned to complain of abdominal pain throughout her admission and continued to requested IV dilaudid. 4. ESRD: The patient is on a T/Th/Sat schedule. She was closely followed by the renal team. She had dialysis on [**12-19**]. The patient's tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. The patient also had her PD catheter removed on [**12-21**] secondary to chronic abdominal pain. The patient was scheduled to have dialysis on [**12-23**]. 5. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last admission for supratherapeutic INR. She was admitted with a subtherpeutic INR of 1.2 She was started on a heparin drip. She was also started on Coumadin 2mg PO qday, but was held on [**12-19**] in prep her PD catheter removal. She was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by IR. However, the patient signed out AMA and thus it was not placed. 6. Anxiety: Pt recently saw psychiatrist who started her on Celexa. She was continued on Celexa 20mg PO daily. 7. Anemi of CKDa: The patient's Hct was 30.3 on admission. It trended down to 22.3 on discharge when she left AMA. There was no evidence of active, acute bleeding. THis is likely seoncdary to her ESRD. The patient was closely monitored. 8. Systemic Lupus Erythematosis: Rheumatology was consulted and does not suspect acute flare and dsDNA, C3, C4 nl, ESR and CRP slightly elevated. Her Echo did not suggest worsening pericarditis. She was continued on her home prednisone dose of 4mg daily. 9. Obstructive Sleep Apnea: CPAP for sleep with 7 pressure. Medications on Admission: Aliskiren 150 mg [**Hospital1 **] Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Warfarin held on discharge [**2141-12-14**] due to supratherap INR Discharge Medications: As patient signed out AMA, no medications were issued. She was told to resume her admission medications, however no instructions were taken by the patient. Discharge Disposition: Home Discharge Diagnosis: 1) Hypertensive urgency 2) Abdominal pain 3) End stage renal disease on hemodialysis 4) Venous thromboembolism Discharge Condition: Signed out AMA Discharge Instructions: Pt signed out AMA Return to the hospital with any concerning symptoms. Be sure to call your doctor's office on [**Month/Day/Year 766**] to arrange hemodialysis and review your medications and discuss follow-up plan. Followup Instructions: Follow-up with your Dr. [**Last Name (STitle) **] next week, and call [**Last Name (STitle) 766**] to arrange your hemodialysis. Completed by:[**2141-12-26**]",65,2141-12-18 03:50:00,2141-12-23 19:51:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. 1. malignant hypertension: the patient had her hemodialysis two days prior to admission. initially in the ed her bp was 253/170. she was given 10mg iv labetalol and started on a labatelol drip. she also received hydralazine iv 10 mg once and 2 inches of nitropaste. she had morphine 4mg and 4mg zofran for nausea. her bp remained elevated so she was switched to nicardipine 1mg/kg/min. the patient was transferred to the micu. in the icu she was continued on the nicardapine drip and her pressures decreased to 175/120. nephrology was consulted and dialysis initiated in the am. the nicardapine drip dcd on [**12-19**] and pt transferred to floor. while on the floor the patient had question of angioedema and markedly elevated bp. she was readmitted to the micu on [**2141-12-20**]. patients aliskerin was also held for conern for angioedema. the renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. the patients pd catheter was removed. the patient was briefly on a nitro drip for hypertension. the patients nifedepine was increased to 120mg. the patient was transferred to the floor with stable blood pressures, bp 124/72 on [**12-21**]. the morning of [**12-22**], the patient was noted to have a bp up to 247/120 at 0800. hypertension persisted throughout the morning with bps 210s-240s systolic. hr during this time was in the 90s. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she was also given her normal am bp meds and restarted on aliskarin. due to persistent hypertension, she was transferred to the icu for further care. on arrival to the icu, the patient reported severe abdominal pain over the site of recently removed pd catheter. she denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. she reports bilateral calf cramping but no leg swelling. she denies any difficulty breathing or chest pain. she took her am bp meds without difficulty. her blood pressure decreased to 130s-140s/60s without further intervention. she was transferred back to the floor on [**12-23**] and signed out ama. 2. angioedema: on [**12-20**] the patietn developed facial swelling and evidence of angioedema by ent. the patient reported that her face is more swollen which was confirmed by her mother on the floor. the patient was give lasix iv as she has been unable to have any negative filtration with hd. the patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. her tekturna was discontinued for concern that it might be causing angioedema. she denied difficulty with her breathing at that time, but was very somnulent. on arrival to the micu her vitals were stable and oxygenating well at 100% on face mask. the patients airway was supported with a nasal trumpet. the patient underwent mrv that showed no progression of her clot. patient was diuresed with lasix and dialysis with significant improvement in her symptoms. she was treated with prednisone and decadron, famotidine and benadryl for angioedema. the patient was maintained on her heparin drip for her svc syndrome. 3. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the transplant surgery team removed the pd cath on [**12-21**]. she continued to have abdominal pain post-op. she was continued on po dilaudid 2mg po prn. she continuned to complain of abdominal pain throughout her admission and continued to requested iv dilaudid. 4. esrd: the patient is on a t/th/sat schedule. she was closely followed by the renal team. she had dialysis on [**12-19**]. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient also had her pd catheter removed on [**12-21**] secondary to chronic abdominal pain. the patient was scheduled to have dialysis on [**12-23**]. 5. hx of svc/brachiocephalic dvt: her coumadin was held during last admission for supratherapeutic inr. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. she was also started on coumadin 2mg po qday, but was held on [**12-19**] in prep her pd catheter removal. she was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by ir. however, the patient signed out ama and thus it was not placed. 6. anxiety: pt recently saw psychiatrist who started her on celexa. she was continued on celexa 20mg po daily. 7. anemi of ckda: the patients hct was 30.3 on admission. it trended down to 22.3 on discharge when she left ama. there was no evidence of active, acute bleeding. this is likely seoncdary to her esrd. the patient was closely monitored. 8. systemic lupus erythematosis: rheumatology was consulted and does not suspect acute flare and dsdna, c3, c4 nl, esr and crp slightly elevated. her echo did not suggest worsening pericarditis. she was continued on her home prednisone dose of 4mg daily. 9. obstructive sleep apnea: cpap for sleep with 7 pressure. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Mechanical complication due to peritoneal dialysis catheter; ; Unspecified disease of pericardium; Angioneurotic edema, not elsewhere classified; Abdominal pain, other specified site; Systemic lupus erythematosus; ; Anemia in chronic kidney disease; Dysthymic disorder; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of steroids; Long-term (current) use of anticoagulants; Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation; Other antihypertensive agents causing adverse effects in therapeutic use]","24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. she was given 10mg iv labetalol and started on a labatelol drip. nephrology was consulted and dialysis initiated in the am. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she reports bilateral calf cramping but no leg swelling. she took her am bp meds without difficulty. her tekturna was discontinued for concern that it might be causing angioedema. the patient was maintained on her heparin drip for her svc syndrome. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient was scheduled to have dialysis on [**12-23**]. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. there was no evidence of active, acute bleeding.","24 year old female with sle, esrd on hd presents with abdominal pain and headache consistent with her usual hypertensive urgency. she was found to be in hypertensive urgency in ed. she received hydralazine iv 10 mg once and 2 inches of nitropaste." 109,158995.0,14807,2142-02-26,14803,135923.0,2142-01-12,Discharge summary,"Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-13**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypertensive Urgency and HA Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with HA in the setting of hypertension. Upon arrival to the ED, her vitals were 284/140, HR 67, RR 28, 100% on 4LNC. She was started on a nicardipine drip. She denied shortness of breath or chest pain. She is due for HD today. She has a left groin catheter which was recently placed [**2141-12-21**] and is causing her pain. She was also given dilaudid IV 1 mg x 2 with some relief. CXR was performed and showed no pulmonary edema. . Upon arrival to the MICU, patient denies HA, CP, SOB, fevers, chills. Patient reports mild abdominal pain at sight of left anterior abdominal wall hematoma and left groin pain at site of femoral HD line. She reports that she was taking her medications as directed, including coumadin for SVC thrombus. Briefly, 24 yo F with ESRD on HD, SLE, malignant HTN admitted for HA in the setting of HTN to 284/140 in ED. Initially, she was treated with a nicardipine gtt to control her BP. Her cardiac enzymes were flat, no new ECG changes. She was started on a heparin gtt with transition to coumadin for a SVC thrombosis. HTN secondary to med noncompliance. She was restarted on her oral BP. She missed her PM meds yesterday, so nicardipine was restarted, and then turned off this AM. She received all her AM BP meds. Her BPs have been in the 160s/90s. She had no neurological deficits. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 176/105, 87, 18, 100% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: 2/6 systolic murmur LUSB Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: left ant wall abd hematoma, TTP Extremities: Right: Trace, Left: Trace, left fem HD line without oozing or drainage Skin: Warm Neurologic: AAO x 3 Pertinent Results: [**2142-1-8**] 05:15AM PT-13.7* PTT-33.6 INR(PT)-1.2* [**2142-1-8**] 05:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-1+ STIPPLED-OCCASIONAL TEARDROP-1+ BITE-NORMAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2142-1-8**] 05:15AM cTropnT-0.08* [**2142-1-8**] 05:15AM CK(CPK)-119 [**2142-1-8**] 04:12PM PTT-120.8* [**2142-1-8**] 10:41PM PTT-144.8* [**2142-1-8**] 02:55PM CK-MB-NotDone cTropnT-0.06* Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. Patient was initially observed in the MICU and placed on a nicardipine drip. Patient was stablized on home medicaitons, suggesting medication non-compliance. Additionally, patient presented subtheraputic on coumadin for SVC thrombosis. Patient was started on heparin ggt. After the nicardipine drip was turned off, patient was called out to the floor. Heparin drip was continued until INR [**2-13**]. Pressures were managed to her baseline. Pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with Narcan. Patient received dialysis 3x/wk as per outpatient schedule. # Hypertension: Pt with extensive history of repeated admissions for hypertension. Patient's BP improved with nicardipine drip and after HD off drip on home PO medication regimen. Resumed oral antihypertensives with improved BP control. HTn likely from renal disease, possible medication noncompliance, lupus. No evidence of MI. Continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. Renal increased clonidine patch, and added Nicardipine with improvement of BP control. Pt is to follow up with an appointment in the next week to establish care at [**Company 191**], and to re-check her BP and adjust medications further. # SLE: Stable, continued prednisone at 4 mg PO daily. # Left groin pain. Permanent HD line was placed on [**12-25**]. Line and hematoma from prior peritoneal line on abdomen okay. No leukocytosis or fevers to suggest infection. Patient was oversedated on Dilaudid and had episode of oxygen desaturation which was reversed with Narcan. Patient was solmolent with morphine SR so that was d/c'ed as well, patient was given standing tylenlol and Morphine IR PRN. Transplant surgery removed remaining sutures today from L groin. Pt has a follow-up appointment in the next week with Dr. [**First Name (STitle) **] (Transplant Surgery). She will be sent home with low-dose Morphine IR and Tylenol PRN pain. If L groin pain should become uncontrollable on current meds, pt should return to the ED for re-evaluation. It is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #ESRD: Renal following, continuing HD Th/Th/Sat. CaCO3 was started for elevated calcium-phosphate product. Pt will follow-up with Dr. [**Last Name (STitle) 7473**] in the next 1-2 weeks. # Anemia: Pt's baseline is 26. This is likely secondary to AOCD and renal failure. Hct was stable on day of discharge at 25.9. # SVC thrombus: Pt has a history of an SVC thrombus, and is on coumadin. She is supposed to be on lifelong anticoagulation due to recurrent thrombosis but INR subtherapeutic on arrival. Heparin drip was stopped on the floor once the INR was theraputic. INR was therapeutic on day of discharge. Pt will need an INR check in the next week at her follow-up with her PCP. # HOCM: Pt has evidence of myocardial hypertrophy on Echo. She is currently not symptomatic. Echo did not show evidence of worsening pericardial effusion. She was continued on her beta-blocker and other BP medications. # Depression/anxiety: Stable. She was continued on Celexa and Clonazepam. # OSA: Pt as continued on CPAP for sleep with 7 pressure. # FEN: regular diet # PPX: heparin drip --> coumadin, bowel regimen # ACCESS: PIV x2 / permanent dialysis cath L fem # CODE: FULL # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] # DISPO: home with PCP and Renal [**Name9 (PRE) 702**] to re-check BP, INR level. Follow-up with Transplant Surgery. Medications on Admission: Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Aliskiren 150 [**Hospital1 **] Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Nicardipine 30 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain for 2 weeks. [**Hospital1 **]:*20 Tablet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Urgency End Stage Renal Disease Discharge Condition: stable, blood pressure moderately controlled, afebrile, tolerating POs Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. Some of medications were increased as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to take the coumadin as prescribed by your doctor, and have your INR checked frequently per your PCP's recommendations. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Renal) Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-1-15**] 3:00 - Will follow-up Vitamin D [**2-4**] level Provider: [**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD ([**Company 191**]) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-1-16**] 3:30 - Will re-check your INR level Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Transplant Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-1-19**] 2:50p [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-1-12**]",45,2142-01-08 06:36:00,2142-01-13 21:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE URGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was initially observed in the micu and placed on a nicardipine drip. patient was stablized on home medicaitons, suggesting medication non-compliance. additionally, patient presented subtheraputic on coumadin for svc thrombosis. patient was started on heparin ggt. after the nicardipine drip was turned off, patient was called out to the floor. heparin drip was continued until inr [**2-13**]. pressures were managed to her baseline. pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with narcan. patient received dialysis 3x/wk as per outpatient schedule. # hypertension: pt with extensive history of repeated admissions for hypertension. patients bp improved with nicardipine drip and after hd off drip on home po medication regimen. resumed oral antihypertensives with improved bp control. htn likely from renal disease, possible medication noncompliance, lupus. no evidence of mi. continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. renal increased clonidine patch, and added nicardipine with improvement of bp control. pt is to follow up with an appointment in the next week to establish care at [**company 191**], and to re-check her bp and adjust medications further. # sle: stable, continued prednisone at 4 mg po daily. # left groin pain. permanent hd line was placed on [**12-25**]. line and hematoma from prior peritoneal line on abdomen okay. no leukocytosis or fevers to suggest infection. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. patient was solmolent with morphine sr so that was d/ced as well, patient was given standing tylenlol and morphine ir prn. transplant surgery removed remaining sutures today from l groin. pt has a follow-up appointment in the next week with dr. [**first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. it is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #esrd: renal following, continuing hd th/th/sat. caco3 was started for elevated calcium-phosphate product. pt will follow-up with dr. [**last name (stitle) 7473**] in the next 1-2 weeks. # anemia: pts baseline is 26. this is likely secondary to aocd and renal failure. hct was stable on day of discharge at 25.9. # svc thrombus: pt has a history of an svc thrombus, and is on coumadin. she is supposed to be on lifelong anticoagulation due to recurrent thrombosis but inr subtherapeutic on arrival. heparin drip was stopped on the floor once the inr was theraputic. inr was therapeutic on day of discharge. pt will need an inr check in the next week at her follow-up with her pcp. # hocm: pt has evidence of myocardial hypertrophy on echo. she is currently not symptomatic. echo did not show evidence of worsening pericardial effusion. she was continued on her beta-blocker and other bp medications. # depression/anxiety: stable. she was continued on celexa and clonazepam. # osa: pt as continued on cpap for sleep with 7 pressure. # fen: regular diet # ppx: heparin drip --> coumadin, bowel regimen # access: piv x2 / permanent dialysis cath l fem # code: full # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] # dispo: home with pcp and renal [**name9 (pre) 702**] to re-check bp, inr level. follow-up with transplant surgery. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Hypoxemia; Other opiates and related narcotics causing adverse effects in therapeutic use; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Abdominal pain, other specified site; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Renal dialysis status; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Other postprocedural status]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. # hypertension: pt with extensive history of repeated admissions for hypertension. # sle: stable, continued prednisone at 4 mg po daily. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. this is likely secondary to aocd and renal failure. pt will need an inr check in the next week at her follow-up with her pcp.","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was stablized on home medicaitons, suggesting medication non-compliance. patient was oversedated on dilaudid and had episode of oxygen desaturation." 109,158995.0,14807,2142-02-26,14804,124657.0,2142-01-20,Discharge summary,"Admission Date: [**2142-1-14**] Discharge Date: [**2142-1-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 4028**] Chief Complaint: headache Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with mild headache, mild shortness of breath and consistent abdominal pain at the site of her known left abdominal wall hematoma in the setting of hypertension. Her last HD was yesterday. . Upon arrival to the ED, her vitals were BP 240's systolic, HR 90's, 93% on RA. A head CT scan was done which showed no acute process. An abdominal CT was done given her femoral line pain, which also was normal. She was given nitropaste X2 initially, then switched to labetalol 100mg x2, then 200mg x2, then finally started on nicardipine drip when she showed benefit with a decrease in her BP to 170/123 and improvement in her headache. . Upon arrival to the MICU, patient denies any current symptoms. She reports that her headache, shortness of breath and abdominal pain all resolved with blood pressure management and pain medications. . Pt was transferred to the floor when blood pressure was controlled. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: HR 96 BP 171/111 RR 12 O2 98% on RA Physical Exam: General in NAD HEENT NC, AT, EOMI, PERRLA, MMM CVS RRR, 3/6 systolic murmur in all heart fields RESP CTA BL, no crackles or wheezes ABD soft, hematoma raised on left anterior abdominal wall, +BS, mildly tender over hematoma EXT left sided femoral HD line in place, no erythema, no edema NEURO A+Ox3, CN2-12 intact, pt has left sided artificial eye, motor and sensory intact Pertinent Results: ***LABS ON ADMISSION*** [**2142-1-13**] 07:03AM WBC-5.2 RBC-2.79* HGB-8.5* HCT-26.3* MCV-94 MCH-30.3 MCHC-32.2 RDW-19.2* [**2142-1-13**] 07:03AM PLT COUNT-154 [**2142-1-13**] 07:03AM PT-29.5* PTT-49.2* INR(PT)-3.0* [**2142-1-13**] 07:03AM GLUCOSE-94 UREA N-53* CREAT-7.0* SODIUM-136 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [**2142-1-13**] 07:03AM CALCIUM-8.8 PHOSPHATE-5.0* MAGNESIUM-1.9 [**2142-1-14**] 12:00PM PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-14**] 12:00PM LIPASE-42 [**2142-1-14**] 12:00PM ALT(SGPT)-12 AST(SGOT)-43* ALK PHOS-96 TOT BILI-0.4 [**2142-1-14**] 03:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-1-14**] 03:25PM URINE RBC-[**3-15**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-[**3-15**] [**2142-1-14**] 12:00PM BLOOD PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-19**] 06:40AM BLOOD PT-18.6* PTT-38.7* INR(PT)-1.7* . ***LABS ON DAY OF DISCHARGE*** [**2142-1-20**] 06:35AM BLOOD WBC-5.7 RBC-2.39* Hgb-7.1* Hct-22.1* MCV-93 MCH-29.8 MCHC-32.2 RDW-18.6* Plt Ct-136* [**2142-1-20**] 06:35AM BLOOD Glucose-107* UreaN-34* Creat-4.8* Na-137 K-5.2* Cl-101 HCO3-27 AnGap-14 [**2142-1-20**] 06:35AM BLOOD PT-22.8* PTT-42.3* INR(PT)-2.2* . IMAGING [**2142-1-14**] EKG Sinus rhythm. Possible left atrial abnormality. Borderline voltage criteria for left ventricular hypertrophy. Inferolateral ST-T wave changes may be related to left ventricular hypertrophy. Compared to the previous tracing of [**2142-1-8**] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 99 190 86 368/436 13 100 24 [**2142-1-14**] CT ABD/PELV IMPRESSION: 1. Interval decrease in size to subcutaneous anterior abdominal wall hematoma. 2. Infectious versus inflammatory process within the right lower lobe of the lung. Small right simple pleural effusion. 3. Cardiomegaly with slight decrease in size of moderate pericardial effusion. 4. Right lobe liver hemangioma, unchanged. [**2142-1-14**] CT HEAD IMPRESSION: 1. Mildly limited study given administration of small amount of IV contrast material. However, no evidence of hemorrhage or mass effect. NOTE ADDED AT ATTENDING REVIEW: This patient was administered contrast for the abdominal CT, and the head CT was performed after part of this dose. Therefore, this is neither a noncontrast examination, nor a proper contrast CT. [**2142-1-14**] CXR CONCLUSION: Persistent cardiomegaly and mild pulmonary edema. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. . # Hypertensive Urgency: Pt with extensive history of hypertension. Patient's BP improved with nicardipine drip. Became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. Restarted all home oral antihypertensives including nicardipine 30 Q8H, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Blood pressure remains labile and renal continues to follow patient. Pt was transferred to the floor as blood pressure stabilized. BP has remained stable with systolics 140s-170s. In the MICU, Nifedipine extended release was added in place of Nicardipine as pt's blood pressures seemed to rise prior to Nicardipine doses. . # Hyperkalemia: Ocurred on the day after admission. Resolved with administration of kayexalate. Pt continued hemodialysis on TuThSat. . # Left abdominal wall hematoma: Abd CT showed a mild decrease in the size. Pt reported that morphine did not help pain, and was switched to dilaudid PO in the MICU. However, given pt's recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/c'ed on the floor. Pt was continued on gabapentin, tylenol around the clock, and low-dose Morphine as needed for pain. Narcotics should be avoided in the future. Pain should also resolve in the next few weeks as hematoma resolves. . # SLE: Pt was continued on prednisone at 4 mg PO daily. . #ESRD: Renal was following during her stay. She continued HD on her T, Th, Sat schedule. # Anemia: Hct was mildly decreased from baseline during admission. This is likely secondary to AOCD and in the setting of renal failure. . # SVC thrombus: Patient is on anticoagulation, likely lifelong. Patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. Then INR became subtherapeutic, so heparin gtt was used to bridge. On day of discharge, INR became therapeutic, and pt was discharged home on Coumadin 4mg PO daily, with INR to be checked next at hemodialysis . # HOCM: Pt has evidence of myocardial hypertrophy on recent Echo. She was not symptomatic during her stay. She was continued on her beta blocker. . # Depression/anxiety. She was continued on celexa and clonazepam PRN. . # OSA: CPAP for sleep with 7 pressure. . # FEN: repleted lytes prn / regular diet . # PPX: coumadin, bowel regimen . # ACCESS: PIV/ permanent dialysis cath L fem . # CODE: FULL . # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nicardipine 30mg PO TID Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for breakthrough pain for 2 weeks. 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*1* 13. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*260 Tablet(s)* Refills:*1* 14. Respiratory Therapy Please adjust settings of CPAP machine to a lower volume as it is uncomfortable for the patient. Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Discharge Condition: Good, hemodynamically stable, afebrile, pain controlled Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. One new medication was added as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to continue your Coumadin at 4mg daily and have your INR checked AT DIALYSIS next week. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep ALL scheduled appointments. Medications changes include: 1. STOP NICARDIPINE 2. Start Nifedipine CR 90mg by mouth daily 3. INCREASE Labetalol to 900mg by mouth 3 times daily 4. Continue at Warfarin 4mg by mouth daily If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to set up a follow-up appointment in 1-2weeks. Please continue your HD TuThSat. Completed by:[**2142-1-20**]",37,2142-01-14 17:34:00,2142-01-20 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. . # hypertensive urgency: pt with extensive history of hypertension. patients bp improved with nicardipine drip. became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. restarted all home oral antihypertensives including nicardipine 30 q8h, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. blood pressure remains labile and renal continues to follow patient. pt was transferred to the floor as blood pressure stabilized. bp has remained stable with systolics 140s-170s. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. . # hyperkalemia: ocurred on the day after admission. resolved with administration of kayexalate. pt continued hemodialysis on tuthsat. . # left abdominal wall hematoma: abd ct showed a mild decrease in the size. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu. however, given pts recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/ced on the floor. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. narcotics should be avoided in the future. pain should also resolve in the next few weeks as hematoma resolves. . # sle: pt was continued on prednisone at 4 mg po daily. . #esrd: renal was following during her stay. she continued hd on her t, th, sat schedule. # anemia: hct was mildly decreased from baseline during admission. this is likely secondary to aocd and in the setting of renal failure. . # svc thrombus: patient is on anticoagulation, likely lifelong. patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. then inr became subtherapeutic, so heparin gtt was used to bridge. on day of discharge, inr became therapeutic, and pt was discharged home on coumadin 4mg po daily, with inr to be checked next at hemodialysis . # hocm: pt has evidence of myocardial hypertrophy on recent echo. she was not symptomatic during her stay. she was continued on her beta blocker. . # depression/anxiety. she was continued on celexa and clonazepam prn. . # osa: cpap for sleep with 7 pressure. . # fen: repleted lytes prn / regular diet . # ppx: coumadin, bowel regimen . # access: piv/ permanent dialysis cath l fem . # code: full . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Other vascular complications of medical care, not elsewhere classified; Systemic lupus erythematosus; Hyperpotassemia; Phlebitis and thrombophlebitis of upper extremities, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. # anemia: hct was mildly decreased from baseline during admission. # hocm: pt has evidence of myocardial hypertrophy on recent echo. # fen: repleted lytes prn / regular diet . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. pt was transferred to the floor as blood pressure stabilized. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu." 109,158995.0,14807,2142-02-26,14805,176760.0,2142-01-23,Discharge summary,"Admission Date: [**2142-1-21**] Discharge Date: [**2142-1-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Hypertensive Urgency and fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with hypertensive urgency, subjective fevers, and pain. . Of note, she had been hospitalized [**Date range (1) 43505**] with hypertensive urgency. Her nicardipine was changed to nifedipine in hospital and her labetalol was increased to 900mg TID from 800mg TID.BPs were reportedly stable in the 140's-170's on the medical floor on nifedipine, aliskerin, labetalol, clonidine, and hydralazine prior to discharge. Last HD was [**1-20**]. . She reports feeling well at time of discharge [**1-20**], however woke this evening feeling sweaty, hot, and mildly SOB. She did not check her temperature and denies any rigors. She had total body aching (worst in her left wrist at site of recent IV and abdomen at site of known hematoma). +Palpitations overnight now resolved. No CP, SOB, cough, diarrhea, dysuria, erythema/tenderness/drainage from HD catheter. Denies recent joint symptoms with her lupus. No sick contacts. Says she took her BP meds. . Upon arrival to the ED, her vitals were 99.9 104 254/145 16 96% on RA. She was started on a nicardipine drip, given 1"" nitropaste with improvement in her BP. Did spike a fever while in the ED, currently 101F 101 173/106 Given vancomycin and zoysn for ?pna as CXR with right sided haziness. Also received 3mg IV dilaudid for body pains. LUE ultrasound without evidence of DVT. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 98.5 P 92 Bp 173/116 RR 16 O2 100% on RA General Pleasant young woman appearing comfortable HEENT Cushingoid faces, L eye prosthesis, MMM Pulm Lungs clear bilaterally, no rales or wheezing CV Regular S1 S2 ?soft systolic murmur Abd Soft +hematoma left abdomen unchanged from prior exam Extrem Warm full distal pulses. Left hand with slight edema ++ tender to palpation of wrist patient unable to make fist secondary to pain, no erythema +warmth ?purulence at site of old PIV Skin No peripehral stigmata of endocarditis Lines Left groin HD catheter site without erythema, purulence, or tenderness Neuro Alert and awake, moving all extremities Pertinent Results: CXR [**1-21**]: In comparison with the earlier study of this date, the diffuse pulmonary edema has substantially decreased, possibly following hemodialysis. Enlargement of the cardiac silhouette persists and there is no definite pleural effusion. Suggestion of an area of increased opacification at the right base. This could merely represent asymmetric edema, though the possibility of a developing consolidation cannot be unequivocally excluded. . LUE US [**1-21**]: IMPRESSION: No DVT in the left upper extremity. . L wrist xray [**1-21**]: There is prominent soft tissue swelling about the wrist, relatively diffuse, but quite prominent along the dorsum of the wrist. No fracture, dislocation, degenerative change, focal lytic or sclerotic lesion, or erosion is identified. No soft tissue calcification or radiopaque foreign body is identified. A tiny (1.7 mm) linear density is seen along the dorsum of the wrist on the oblique view is seen only on that view and is consistent with a small film artifact. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency and left wrist pain. . 1. Hypertensive urgency: Patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. Patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. She was started on nicardipine drip and 1"" nitropaste and admitted to the ICU for further treatment. There was no evidence of end-organ ischemia. Upon arrival to the ICU she was given her usual home antihypertensives and the nicardipine was quickly weaned off. It was felt that pain and anxiety were both contributing to her elevated BPs. Her BP quickly stabilized and she was called out to the medical floor where her SBP ranged 110-150. She was continued on nifepidine 90mg daily, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Given her repeated admissions with hypertensive urgency a meeting was held between the patient's nephrologist Dr. [**Last Name (STitle) 4883**], her ICU physician and her [**Name9 (PRE) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the ICU where she quickly improves with simply continuing her home medications. The following plan was drafted and placed in a note in OMR titled "" Care Protocol"". . CARE PROTOCOL: . BLOOD PRESSURE MANAGEMENT: . For BP > 230/140 1. Hydralazine: 100 mg PO OR 10 mg IV q 20 minutes until blood pressure back to baseline*. . 2. Give daily blood pressure medications, if she has not already taken them before arrival. . 3. If after one hour of therapy AND/OR evidence of end organ damage, transfer to the ICU. . * Note: Her usual blood pressure is ~ 160/100. Efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. In the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . PAIN MANAGEMENT: . As an outpatient, Ms. [**Name13 (STitle) **] takes dilaudid 2-4 mg PO q 4 PRN.This is being slowly tapered, she should not be administered IV pain medications. . ANTICOAGULATION: . In the absence of bleeding, warfarin does not need to be stopped on admission. Similarly, in the absence of new thrombosis, subtherapeutic INR's do not require bridging with IV UFH. . 2. Fever: Possible sources included line infection, thombophlebitis, septic arthritis, PNA. Received vanc/zosyn in ED for possible PNA. UA without pyuria and urine culture negative. CXR also without convinving infiltrate on repeat PA/Lat so zosyn was discontinued. Patient was complaining of severe pain at her IV site and was noted to have a small abscess there which was felt to be the cause of her fever. She was continued on IV vanco with HD for 10day course. She remained afebrile and did not have a leukocytosis. . 3. Left wrist pain: Began following IV placement during recent hospitalization. Likely due to septic thrombophlebitis. Small abscess was too small to drain. This was treated with warm soaks and prn PO dilaudid. Vanco was continued for 10 day course. L wrist films were enremarkable. . 4. Left abdominal wall hematoma: Stable on exam from recent admission. She was continued on pain management with morphine 7.5mg TID, gabapentin and tylenol as needed for pain. . 5. SLE: Continued prednisone at 4 mg PO daily . 6. ESRD: Continued on regularly scheduled dialysis. . 7. Anemia: Baseline Hct 26. Her Hct was mildly decreased from baseline. Secondary to AOCD and renal failure. There was no evidence of bleeding. . 8. SVC thrombus: Known SVC thrombus, therapeutic on coumadin. Continued warfarin. . 9. HOCM: evidence of myocardial hypertrophy on recent Echo. Currently not symptomatic. Echo without evidence of worsening pericardial effusion. Continued beta blocker . 10. Depression/anxiety. Continued Celexa, clonazepam 0.5mg [**Hospital1 **] . 11. OSA: Continued CPAP Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nifedipine 90mg PO daily Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325-650 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*270 Tablet(s)* Refills:*2* 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 7 days. [**Hospital1 **]:*4 dose* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Septic thrombophlebitis Discharge Condition: Stable, afebrile, BP improved. Discharge Instructions: You were admitted to the hospital with hypertensive urgency. You required IV medications and were observed overnight in the ICU. Your usual oral blood pressure medications were continued and your blood pressure remained well-controlled. You were found to have an infection at your prior IV site on your left hand. For this you were given IV vancomycin. You will need 7 days more of antibiotics which will be given with dialysis. Please resume your usual dialysis schedule. Your last dialysis was [**1-23**]. Please continue to take your medications as prescribed. You should hold your coumadin today. You can resume this on wednesday at your normal dose. You should have your INR checked at dialyis as usual on thursday. . If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-12**] weeks. ",34,2142-01-21 11:23:00,2142-01-23 16:40:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE EMERGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. . 1. hypertensive urgency: patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. there was no evidence of end-organ ischemia. upon arrival to the icu she was given her usual home antihypertensives and the nicardipine was quickly weaned off. it was felt that pain and anxiety were both contributing to her elevated bps. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150. she was continued on nifepidine 90mg daily, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. given her repeated admissions with hypertensive urgency a meeting was held between the patients nephrologist dr. [**last name (stitle) 4883**], her icu physician and her [**name9 (pre) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the icu where she quickly improves with simply continuing her home medications. the following plan was drafted and placed in a note in omr titled "" care protocol"". . care protocol: . blood pressure management: . for bp > 230/140 1. hydralazine: 100 mg po or 10 mg iv q 20 minutes until blood pressure back to baseline*. . 2. give daily blood pressure medications, if she has not already taken them before arrival. . 3. if after one hour of therapy and/or evidence of end organ damage, transfer to the icu. . * note: her usual blood pressure is ~ 160/100. efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. in the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . pain management: . as an outpatient, ms. [**name13 (stitle) **] takes dilaudid 2-4 mg po q 4 prn.this is being slowly tapered, she should not be administered iv pain medications. . anticoagulation: . in the absence of bleeding, warfarin does not need to be stopped on admission. similarly, in the absence of new thrombosis, subtherapeutic inrs do not require bridging with iv ufh. . 2. fever: possible sources included line infection, thombophlebitis, septic arthritis, pna. received vanc/zosyn in ed for possible pna. ua without pyuria and urine culture negative. cxr also without convinving infiltrate on repeat pa/lat so zosyn was discontinued. patient was complaining of severe pain at her iv site and was noted to have a small abscess there which was felt to be the cause of her fever. she was continued on iv vanco with hd for 10day course. she remained afebrile and did not have a leukocytosis. . 3. left wrist pain: began following iv placement during recent hospitalization. likely due to septic thrombophlebitis. small abscess was too small to drain. this was treated with warm soaks and prn po dilaudid. vanco was continued for 10 day course. l wrist films were enremarkable. . 4. left abdominal wall hematoma: stable on exam from recent admission. she was continued on pain management with morphine 7.5mg tid, gabapentin and tylenol as needed for pain. . 5. sle: continued prednisone at 4 mg po daily . 6. esrd: continued on regularly scheduled dialysis. . 7. anemia: baseline hct 26. her hct was mildly decreased from baseline. secondary to aocd and renal failure. there was no evidence of bleeding. . 8. svc thrombus: known svc thrombus, therapeutic on coumadin. continued warfarin. . 9. hocm: evidence of myocardial hypertrophy on recent echo. currently not symptomatic. echo without evidence of worsening pericardial effusion. continued beta blocker . 10. depression/anxiety. continued celexa, clonazepam 0.5mg [**hospital1 **] . 11. osa: continued cpap ","PRIMARY: [Other vascular complications of medical care, not elsewhere classified] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; ; Systemic lupus erythematosus; Phlebitis and thrombophlebitis of upper extremities, unspecified]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. she was continued on iv vanco with hd for 10day course. esrd: continued on regularly scheduled dialysis. her hct was mildly decreased from baseline. hocm: evidence of myocardial hypertrophy on recent echo. echo without evidence of worsening pericardial effusion. continued celexa, clonazepam 0.5mg [**hospital1 **] .","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150." 109,158995.0,14807,2142-02-26,14806,113189.0,2142-02-17,Discharge summary,"Admission Date: [**2142-2-14**] Discharge Date: [**2142-2-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: From admission note: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome admitted with HTN and SOB in the setting of missed HD. The patient reported missing HD yesterday because she thinks she is being overdiuresed. She reports persistent pain at site of rectus sheath hematoma. Denies N/V/D. Pt recently admitted from [**Date range (1) 13924**] with consistent abdominal pain at the site of her known left abdominal wall hematoma, hypertensive to 230's and hyperkalemic to 6.2 after missing her last two dialysis sessions. At this time the pt. was dialyzed, received a blood transfusion, and was administered her daily antihypertensive medications. Pt. left AMA after her transfusion despite the primary team's concerns to look for an active area of bleeding. In the ED, patient complain of mild dyspnea, sating well on RA. CXR mild volume overload. KUB with no evidence of obstruction. She was started on a labetalol gtt. ECG - RAD, LVH no change from prior. HCT stable at 21. The renal team evaluated pt and recommended HD, however the patient refused. She was transferred to ICU for BP control. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: [**2142-2-14**] 07:40AM WBC-3.9* RBC-2.38* HGB-7.0* HCT-21.3* MCV-90 MCH-29.5 MCHC-33.0 RDW-18.9* [**2142-2-14**] 07:40AM NEUTS-74.9* LYMPHS-18.7 MONOS-3.1 EOS-3.0 BASOS-0.2 [**2142-2-14**] 07:40AM PLT COUNT-101* [**2142-2-14**] 07:40AM PT-16.3* PTT-36.6* INR(PT)-1.5* [**2142-2-14**] 07:40AM CK-MB-6 [**2142-2-14**] 07:40AM cTropnT-0.09* [**2142-2-14**] 07:40AM LIPASE-80* [**2142-2-14**] 07:40AM ALT(SGPT)-34 AST(SGOT)-72* CK(CPK)-120 ALK PHOS-124* TOT BILI-0.4 [**2142-2-14**] 07:40AM GLUCOSE-85 UREA N-32* CREAT-7.0* SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-19* ANION GAP-17 [**2142-2-14**] 07:44AM LACTATE-1.3 [**2142-2-14**] CXR: Stable cardiomegaly with mild CHF and a small left pleural effusion. Left basilar air space disease which may represent pneumonia. Clinical correlation and a follow up chest x-ray to clearance is recommended. [**2142-2-14**] KUB: 1. Nonspecific bowel gas pattern with no evidence of obstruction. 2. Left basilar airspace disease which may represent pneumonia and a small left pleural effusion. Please ensure follow-up to clearance. Brief Hospital Course: 24 y.o female with SLE, ESRD on HD and malignant hypertension who presents with HTN and SOB aftering missing HD. . # Malignant hypertension/hypertensive urgency: The patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and HD compliance. Has previously presented with BP up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. Pt was treated per OMR hypertensive protocol created by the patient's primary providers, with a goal SBP of 160-180. With short course of IV antihypertensives and hemodialysis, pt's BP fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # ESRD: Pt was followed by the renal service and underwent HD without any complications. Pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting HD. She will discuss this further with the Renal team as an outpatient. . # SLE: Pt was continued on her home dose of prednisone with no sign of SLE flair. . # Coagulopathy/history of DVT: Patient on lifetime anticoagulation for hx of multiple thrombotic events. Pt was continued on coumadin. . # Pain management: Pt was treated with PO dilaudid for her abdominal pain, as recommended per her OMR protocol. She asked for IV dilaudid multiple times but there was no clinical indication. She was also continued on gabapentin. . # Anemia: Secondary to AOCD and renal failure. The patietns Hct remained stable in the low 20s during admission. No PRBC infusions were needed. . # Depression/anxiety: Continued Celexa, clonazepam 0.5mg [**Hospital1 **] Medications on Admission: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain. 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Disposition: Home Discharge Diagnosis: Primary: Malignant Hypertension Secondary: SLE, End stage renal disease on hemodialysis, SVC syndrome Discharge Condition: Stable. SBP in 160s. Discharge Instructions: You were admitted with dangerously high hypertension and some shortness of breath in the setting of missing several dialysis sessions. You were admitted and treated with your usual regimen of blood pressure meds and a short course of IV meds. With dialysis, your symptoms improved. You also had some abdominal pain, which was well controlled on your usual pain medications. We made no changes to your medications. Please take everything as prescribed. Please call your PCP or return to the hospital if you develop any headaches, visual changes, confusion or chest pain, or any other concerning symptoms. Followup Instructions: Please schedule a follow up with Dr [**Last Name (STitle) **] in [**Month (only) 958**] as scheduled. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2142-2-21**]",9,2142-02-14 10:42:00,2142-02-17 18:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. . # malignant hypertension/hypertensive urgency: the patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and hd compliance. has previously presented with bp up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. with short course of iv antihypertensives and hemodialysis, pts bp fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # esrd: pt was followed by the renal service and underwent hd without any complications. pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting hd. she will discuss this further with the renal team as an outpatient. . # sle: pt was continued on her home dose of prednisone with no sign of sle flair. . # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events. pt was continued on coumadin. . # pain management: pt was treated with po dilaudid for her abdominal pain, as recommended per her omr protocol. she asked for iv dilaudid multiple times but there was no clinical indication. she was also continued on gabapentin. . # anemia: secondary to aocd and renal failure. the patietns hct remained stable in the low 20s during admission. no prbc infusions were needed. . # depression/anxiety: continued celexa, clonazepam 0.5mg [**hospital1 **] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Thrombotic microangiopathy; Systemic lupus erythematosus; Anemia in chronic kidney disease; Thrombocytopenia, unspecified; Obstructive sleep apnea (adult)(pediatric); Nontraumatic hematoma of soft tissue; Dysthymic disorder; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events.","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob after missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. she was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine." 109,124657.0,14804,2142-01-20,14796,139061.0,2141-09-14,Discharge summary,"Admission Date: [**2141-9-11**] Discharge Date: [**2141-9-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Right leg pain. Major Surgical or Invasive Procedure: None. History of Present Illness: Ms. [**Known lastname **] is a 24 y.o. F with lupus, Chronic Kidney Disease V (not currently on HD or PD), and multiple admissions for hypertensive urgency/emergency, who presented to the ED for continued R leg pain that starts in her R buttocks and refers down her R leg. She describes it as feeling like the pain is deep within her bone. The pain was [**10-20**] in the AM, and she felt like she couldn't get out of bed. Denies any swelling of her RLE. When getting VS in [**Name (NI) **], pt noted to be very hypertensive at 263/176. The patient reportedly has baseline SBPs in 130-170s. She took her hydralazine, aliskirien, and labetalol at 5 AM on day of admission. She denies any recent recrational drug use including cocaine and amphetamines. She denies headache, vision changes, double vision, chest pain, shortness of breath, abdominal pain, BRBPR, dysuria. During MD interview, the patient was nauseous and had small amount of emesis of a recent Coolata. Pt states that flushing her PD cath causes a large amount of stomach pain. . Of note, the patient was recently admitted from 08.26-29.08. The patient initially presented to the ED after referral from her nephrologist's office where she had complaints of right leg pain and was found to be hypertensive to 250/145. She was admitted after initiation of a labetalol drip and nitropaste with improvement in sbp to 180. The patient did receive 2 U of PRBC's during this hospitalization for baseline anemia. The patient did have a work-up for her right leg pain complaints with plain films of the right hip and MRI of the L-spine which did not reveal an explanation for her symptoms and did rule out avascular necrosis. The patient received dilaudid for pain control and was ambulating without pain prior to discharge. In addition, the patient completed a course of ciprofloxacin for a positive UA with negative cultures. The patient was unable to tolerate peritoneal dialysis for unclear reasons. Peritoneal dialysate culture was negative for infection. . In the ED: VS T 98.2 HR 101 BP 263/176 RR 20 O2 sat 100% RA. BPs in ED ranged from [**Telephone/Fax (3) 43494**]-175 with HR in 96-108. Initially given labetalol 10 mg IV x 1 and then started on labetalol gtt for her elevated blood pressures and titrated to 3 mg/min. LENI of R leg was negative. CXR performed. Given morphine 4 mg IV x 1 for leg pain. Per ED, cannot do V/Q scan due to volume overload after talking with radiology. Renal c/s initiated. A-line placed. Past Medical History: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]). - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD. - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome. - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN. - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], 8/[**2140**]). - HOCM: Last noted on echo [**8-17**]. - Anemia. - History of left eye enucleation [**2139-4-20**] for fungal infection. - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] . PAST SURGICAL HISTORY: - Placement of multiple catheters including dialysis. - Tonsillectomy. - Left eye enucleation in [**2140-4-10**]. - PD catheter placement in [**2141-5-11**]. Social History: Single. Recently moved into her own apartment. On disability. Denies EtOH, tobacco or recreational drug use. Family History: Negative for autoimmune diseases, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: T 98.9 [**Telephone/Fax (2) 43495**] 99$% RA GEN: NAD, pleasant female sitting in bed with moon facies HEENT: EOMI of R eye, L eye prosthesis, no exudate, no erythema, MMM, no LAD CHEST: CTAB except at R base with decreased breath sounds; no w/r/r CV: tachy, normal S1S2, II/VI systolic murmur accentuated with Valsalva ABD: NDNT, soft, NABS, PD cathether placed in LLQ, dressing c/d/i EXT: no c/c/e, strength of LEs [**5-15**] and symmetric bilaterally. Negative straight leg test, no pain with internal rotation, external rotation, extension, adduction or abduction. Some pain on flexion at the hip. NEURO: II - XII intact to direct testing. No deficit in light tough sensation. Gait normal. DERM: no rashes noted Pertinent Results: LABS AT ADMISSION: [**2141-9-11**] 11:43AM GLUCOSE-86 UREA N-49* CREAT-8.1* SODIUM-139 POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-16* ANION GAP-18 [**2141-9-11**] 11:43AM CALCIUM-6.2* PHOSPHATE-5.8* MAGNESIUM-1.6 [**2141-9-11**] 11:43AM PT-18.4* PTT-42.8* INR(PT)-1.7* [**2141-9-11**] 07:00AM WBC-5.5 RBC-2.88* HGB-8.1* HCT-24.7* MCV-86 MCH-28.1 MCHC-32.8 RDW-18.0* [**2141-9-11**] 07:00AM NEUTS-74.7* LYMPHS-17.5* MONOS-4.2 EOS-3.3 BASOS-0.2 [**2141-9-11**] 07:00AM PLT COUNT-101* UA: moderate leuk, small blood, negative nitrite, protein 100, 21-50 WBC . MICROBIOLOGY: Urine culture ([**2141-9-11**]): Mixed flora . STUDIES: Cardiology Report ECG Study Date of [**2141-9-11**] 6:55:16 AM Sinus tachycardia. The tracing is marred by baseline artifact. There is left atrial enlargement. Compared to the previous tracing of [**2141-9-5**] the rate has increased. The axis is more rightward. Otherwise, no diagnostic interim change. . UNILAT LOWER EXT VEINS RIGHT Study Date of [**2141-9-11**] 8:54 AM [**Doctor Last Name **]-scale and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and popliteal veins demonstrate normal flow, compressibility, augmentation, waveforms. Appropriate color flow and compression is noted within the calf veins. No intraluminal thrombus is present. IMPRESSION: No evidence of right lower extremity DVT. . TTE ([**2140-8-26**]): The left atrium is normal in size. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. The findings are consistent with hypertrophic obstructive cardiomyopathy (HOCM). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. . R HIP XR [**2141-9-6**]: No acute fracture or dislocation. . MRI L-SPINE [**2141-9-6**]: Diffuse low-signal intensity is identified in the bone marrow of the lumbar and lower thoracic spine as described above, possibly related with anemic changes, please correlate clinically. There is no evidence of spinal canal stenosis or neural foraminal narrowing at the different intervertebral disc spaces. LAB RESULTS AT DISCHARGE: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2141-9-14**] 06:15AM 4.0 2.63* 7.6* 23.1* 88 29.1 33.0 18.0* 100* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2141-9-14**] 06:15AM 100 44* 8.1* 137 4.8 109* 17* 16 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2141-9-14**] 06:15AM 6.8* 5.4* 1.6 CALCIUM freeCa [**2141-9-14**] 11:30AM 0.94* Brief Hospital Course: ICU course: EKG showed no change from prior, and CXR showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home medication regimen. The patient was found to by hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. . [**Hospital1 **] history: . 1. Hypertensive urgency: During the patient's [**Hospital1 **] stay, her SBPs ranged from 140s-160s during the day, which is her baseline systolic blood pressure. She was maintained on her home oral medication regimen. At night, she became more hypertensive, with SBP to the 170s-180s, which was controlled with both IV hydralazine and PO nifedipine. PO nifedipine was most successful at bringing her SBP back to her baseline. SBP at discharge was 140. Throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. The renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. Right leg pain: Upon arrival on the floor, the patient complained of [**2143-4-15**] pain in R buttock and posterior thigh, much exacerbated with standing. Of note, lumbar spine MRI and R hip XR on most recent admission were both negative. Her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. Her pain when she was symptomatic was controlled well with PO dilaudid. If the pain recurs, an MRI of the right hip can be considered to evaluate for osteonecrosis. . 3. UTI: The patient had a urinalysis suggestive of UTI, though she remained asymptomatic throughout. She was treated with a three day course of ciprofloxacin. Her urine culture showed mixed flora consistent with skin contamination. . 4. ESRD: The patient has end-stage renal disease due to her lupus. The patient's creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. She was followed by the renal consult service. Her potassium remained stable. Her calcium was low during admission, and supplemental calcium was given in addition to starting Calcitriol. She was not dialyzed through her PD catheter secondary to discomfort, but may reinitiate PD as an outpatient. Her laboratories will be checked as an outpatient in renal clinic. . 5. Anemia: The patient's hematocrit remained near her baseline low 20s throughout her stay. She has anemia from chronic kidney disease and chronic disease. The patient is not on Epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. Prior SVC thrombus: The patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with INR goal 2.5 to 3.0. . 7. Systemic lupus erythematosus: No active issues. The patient's home prednisone regimen was continued. Medications on Admission: - Prednisone 5 mg Daily - Coumadin 2 mg at bedtime - Nifedipine 60 mg Sustained Release Daily - Hydralazine 50 mg every 8 hours - Clonidine 0.3 mg/24 hr Patch Weekly every Wednesday - Ergocalciferol (Vitamin D2) 50,000 unit WEEKLY - Aliskiren 150 mg Twice daily - Docusate Sodium 100 mg 2 times a day - Labetalol 900 mg three times a day - Lactulose 15-30 ml once a day: goal is [**1-11**] soft bowel movements per day Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 5. Calcitriol 0.5 mcg Capsule Sig: Two (2) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*0* 6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for Pain. 7. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for itching. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: - Hypertensive urgency - Right lower extremity pain - Urinary tract infection Secondary diagnosis: - Systemic lupus erythematosus. Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias. Previous treatment with cytoxan, cellcept; currently on prednisone. Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) - CKD/ESRD. Diagosed [**2135**]. Initiated dialysis [**2137**]. PD catheter placement [**5-18**]. Pt reluctant to start PD - Malignant hypertension. Baseline BPs 180's - 120's. History of hypertensive crisis with seizures. History of two intraparenchymal hemorrhages that were thought to be due to the posterior reversible leukoencephalopathy syndrome - Thrombocytopenia. TTP (got plasmapheresisis) versus malignant HTN - Thrombotic events. SVC thrombosis ([**2139**]); related to a catheter. Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], 9/[**2140**]). Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]). Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) - HOCM: Last noted on echo [**8-17**] - Anemia - History of left eye enucleation [**2139-4-20**] for fungal infection - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion. - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] Discharge Condition: Stable systolic blood pressure over past 24 hours. Discharge Instructions: You were admitted to the hospital for uncontrolled high blood pressure. You spent one day in the intensive care unit, where you were treated with intravenous medication to lower your blood pressure. You were then transferred to a regular hospital floor, where your blood pressure was managed with your home oral medications. You were also treated for urinary tract infection with antibiotics. Your right leg pain improved during admission, and we are unsure of the cause of this pain. You should discuss the need for an MRI of the hip if the pain returns when you meet with your primary care doctor. Please call your physician or return to the emergency room if you experience fever, chills, chest pain, difficulty breathing, abdominal pain, headache, changes in your vision, or any other symptoms that are concerning. Please take your medications as prescribed. - Calcitriol was added to your medications. - You should hold Coumadin for two days and restart Saturday, [**2141-9-16**]. You should have your INR checked at your visit in kidney clinic [**2141-9-18**]. - You can take Dilaudid 2-4 mg every eight hours as needed for pain. You should be vigilant about taking lactulose if you need to take Dilaudid. - You should continue Lactulose as per Dr.[**Name (NI) 12913**] instructions. - No other changes were made. Please keep follow up appointments as described below. Followup Instructions: Please call the office of your kidney doctor, Dr. [**Last Name (STitle) 4883**], at ([**Telephone/Fax (1) 773**] to schedule an appointment for [**Last Name (LF) 766**], [**9-19**] as discussed. Follow up with your lung doctor: Provider: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2141-9-21**] 1:00 Follow up with your new primary care doctor: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-9-28**] 10:00 ",128,2141-09-11 10:12:00,2141-09-14 20:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home medication regimen. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. . [**hospital1 **] history: . 1. hypertensive urgency: during the patients [**hospital1 **] stay, her sbps ranged from 140s-160s during the day, which is her baseline systolic blood pressure. she was maintained on her home oral medication regimen. at night, she became more hypertensive, with sbp to the 170s-180s, which was controlled with both iv hydralazine and po nifedipine. po nifedipine was most successful at bringing her sbp back to her baseline. sbp at discharge was 140. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency, including no seizures, no acute worsening of renal function, no headache, nausea, visual and mental status disturbances, chest pain, abdominal pain, or urinary symptoms. the renal service followed her throughout her course and did not recommend any changes to her regimen, but will follow her closely as an outpatient. . 2. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. her pain was intermittent, likely secondary to sciatica, and had resolved by the time of her discharge. her pain when she was symptomatic was controlled well with po dilaudid. if the pain recurs, an mri of the right hip can be considered to evaluate for osteonecrosis. . 3. uti: the patient had a urinalysis suggestive of uti, though she remained asymptomatic throughout. she was treated with a three day course of ciprofloxacin. her urine culture showed mixed flora consistent with skin contamination. . 4. esrd: the patient has end-stage renal disease due to her lupus. the patients creatinine remained stable at 7.9-8.4 throughout her hospitalization, which was similar to her baseline renal function. she was followed by the renal consult service. her potassium remained stable. her calcium was low during admission, and supplemental calcium was given in addition to starting calcitriol. she was not dialyzed through her pd catheter secondary to discomfort, but may reinitiate pd as an outpatient. her laboratories will be checked as an outpatient in renal clinic. . 5. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay. she has anemia from chronic kidney disease and chronic disease. the patient is not on epopoeitin as an outpatient, likely due to her malignant hypertension. . 6. prior svc thrombus: the patient has a reported history of prior thrombus related to catheter placement in [**2139**], and was maintained on warfarin with inr goal 2.5 to 3.0. . 7. systemic lupus erythematosus: no active issues. the patients home prednisone regimen was continued. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [Chronic glomerulonephritis in diseases classified elsewhere; Chronic kidney disease, Stage V; Urinary tract infection, site not specified; Other primary cardiomyopathies; Systemic lupus erythematosus; Sciatica; Hyperpotassemia; Thrombocytopenia, unspecified; Abnormal coagulation profile; Hyperparathyroidism, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism]","icu course: ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the renal team was consulted, and recommended no change to home medication regimen. right leg pain: upon arrival on the floor, the patient complained of [**2143-4-15**] pain in r buttock and posterior thigh, much exacerbated with standing. of note, lumbar spine mri and r hip xr on most recent admission were both negative. she was treated with a three day course of ciprofloxacin. esrd: the patient has end-stage renal disease due to her lupus. anemia: the patients hematocrit remained near her baseline low 20s throughout her stay.","ekg showed no change from prior, and cxr showed a suggestion of rll/r diaphragm haziness. the patient was found to by hypocalcemic, and was started on calcium replacement therapy. she became more hypertensive, with sbps to the 170s-180s during the day. throughout her hospitalization, the patient had no symptoms/signs of hypertensive emergency." 109,131376.0,14862,2142-07-08,14803,135923.0,2142-01-12,Discharge summary,"Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-13**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypertensive Urgency and HA Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with HA in the setting of hypertension. Upon arrival to the ED, her vitals were 284/140, HR 67, RR 28, 100% on 4LNC. She was started on a nicardipine drip. She denied shortness of breath or chest pain. She is due for HD today. She has a left groin catheter which was recently placed [**2141-12-21**] and is causing her pain. She was also given dilaudid IV 1 mg x 2 with some relief. CXR was performed and showed no pulmonary edema. . Upon arrival to the MICU, patient denies HA, CP, SOB, fevers, chills. Patient reports mild abdominal pain at sight of left anterior abdominal wall hematoma and left groin pain at site of femoral HD line. She reports that she was taking her medications as directed, including coumadin for SVC thrombus. Briefly, 24 yo F with ESRD on HD, SLE, malignant HTN admitted for HA in the setting of HTN to 284/140 in ED. Initially, she was treated with a nicardipine gtt to control her BP. Her cardiac enzymes were flat, no new ECG changes. She was started on a heparin gtt with transition to coumadin for a SVC thrombosis. HTN secondary to med noncompliance. She was restarted on her oral BP. She missed her PM meds yesterday, so nicardipine was restarted, and then turned off this AM. She received all her AM BP meds. Her BPs have been in the 160s/90s. She had no neurological deficits. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 176/105, 87, 18, 100% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: 2/6 systolic murmur LUSB Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: left ant wall abd hematoma, TTP Extremities: Right: Trace, Left: Trace, left fem HD line without oozing or drainage Skin: Warm Neurologic: AAO x 3 Pertinent Results: [**2142-1-8**] 05:15AM PT-13.7* PTT-33.6 INR(PT)-1.2* [**2142-1-8**] 05:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-1+ STIPPLED-OCCASIONAL TEARDROP-1+ BITE-NORMAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2142-1-8**] 05:15AM cTropnT-0.08* [**2142-1-8**] 05:15AM CK(CPK)-119 [**2142-1-8**] 04:12PM PTT-120.8* [**2142-1-8**] 10:41PM PTT-144.8* [**2142-1-8**] 02:55PM CK-MB-NotDone cTropnT-0.06* Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. Patient was initially observed in the MICU and placed on a nicardipine drip. Patient was stablized on home medicaitons, suggesting medication non-compliance. Additionally, patient presented subtheraputic on coumadin for SVC thrombosis. Patient was started on heparin ggt. After the nicardipine drip was turned off, patient was called out to the floor. Heparin drip was continued until INR [**2-13**]. Pressures were managed to her baseline. Pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with Narcan. Patient received dialysis 3x/wk as per outpatient schedule. # Hypertension: Pt with extensive history of repeated admissions for hypertension. Patient's BP improved with nicardipine drip and after HD off drip on home PO medication regimen. Resumed oral antihypertensives with improved BP control. HTn likely from renal disease, possible medication noncompliance, lupus. No evidence of MI. Continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. Renal increased clonidine patch, and added Nicardipine with improvement of BP control. Pt is to follow up with an appointment in the next week to establish care at [**Company 191**], and to re-check her BP and adjust medications further. # SLE: Stable, continued prednisone at 4 mg PO daily. # Left groin pain. Permanent HD line was placed on [**12-25**]. Line and hematoma from prior peritoneal line on abdomen okay. No leukocytosis or fevers to suggest infection. Patient was oversedated on Dilaudid and had episode of oxygen desaturation which was reversed with Narcan. Patient was solmolent with morphine SR so that was d/c'ed as well, patient was given standing tylenlol and Morphine IR PRN. Transplant surgery removed remaining sutures today from L groin. Pt has a follow-up appointment in the next week with Dr. [**First Name (STitle) **] (Transplant Surgery). She will be sent home with low-dose Morphine IR and Tylenol PRN pain. If L groin pain should become uncontrollable on current meds, pt should return to the ED for re-evaluation. It is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #ESRD: Renal following, continuing HD Th/Th/Sat. CaCO3 was started for elevated calcium-phosphate product. Pt will follow-up with Dr. [**Last Name (STitle) 7473**] in the next 1-2 weeks. # Anemia: Pt's baseline is 26. This is likely secondary to AOCD and renal failure. Hct was stable on day of discharge at 25.9. # SVC thrombus: Pt has a history of an SVC thrombus, and is on coumadin. She is supposed to be on lifelong anticoagulation due to recurrent thrombosis but INR subtherapeutic on arrival. Heparin drip was stopped on the floor once the INR was theraputic. INR was therapeutic on day of discharge. Pt will need an INR check in the next week at her follow-up with her PCP. # HOCM: Pt has evidence of myocardial hypertrophy on Echo. She is currently not symptomatic. Echo did not show evidence of worsening pericardial effusion. She was continued on her beta-blocker and other BP medications. # Depression/anxiety: Stable. She was continued on Celexa and Clonazepam. # OSA: Pt as continued on CPAP for sleep with 7 pressure. # FEN: regular diet # PPX: heparin drip --> coumadin, bowel regimen # ACCESS: PIV x2 / permanent dialysis cath L fem # CODE: FULL # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] # DISPO: home with PCP and Renal [**Name9 (PRE) 702**] to re-check BP, INR level. Follow-up with Transplant Surgery. Medications on Admission: Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Aliskiren 150 [**Hospital1 **] Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Nicardipine 30 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain for 2 weeks. [**Hospital1 **]:*20 Tablet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Urgency End Stage Renal Disease Discharge Condition: stable, blood pressure moderately controlled, afebrile, tolerating POs Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. Some of medications were increased as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to take the coumadin as prescribed by your doctor, and have your INR checked frequently per your PCP's recommendations. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Renal) Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-1-15**] 3:00 - Will follow-up Vitamin D [**2-4**] level Provider: [**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD ([**Company 191**]) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-1-16**] 3:30 - Will re-check your INR level Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Transplant Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-1-19**] 2:50p [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-1-12**]",177,2142-01-08 06:36:00,2142-01-13 21:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE URGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was initially observed in the micu and placed on a nicardipine drip. patient was stablized on home medicaitons, suggesting medication non-compliance. additionally, patient presented subtheraputic on coumadin for svc thrombosis. patient was started on heparin ggt. after the nicardipine drip was turned off, patient was called out to the floor. heparin drip was continued until inr [**2-13**]. pressures were managed to her baseline. pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with narcan. patient received dialysis 3x/wk as per outpatient schedule. # hypertension: pt with extensive history of repeated admissions for hypertension. patients bp improved with nicardipine drip and after hd off drip on home po medication regimen. resumed oral antihypertensives with improved bp control. htn likely from renal disease, possible medication noncompliance, lupus. no evidence of mi. continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. renal increased clonidine patch, and added nicardipine with improvement of bp control. pt is to follow up with an appointment in the next week to establish care at [**company 191**], and to re-check her bp and adjust medications further. # sle: stable, continued prednisone at 4 mg po daily. # left groin pain. permanent hd line was placed on [**12-25**]. line and hematoma from prior peritoneal line on abdomen okay. no leukocytosis or fevers to suggest infection. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. patient was solmolent with morphine sr so that was d/ced as well, patient was given standing tylenlol and morphine ir prn. transplant surgery removed remaining sutures today from l groin. pt has a follow-up appointment in the next week with dr. [**first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. it is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #esrd: renal following, continuing hd th/th/sat. caco3 was started for elevated calcium-phosphate product. pt will follow-up with dr. [**last name (stitle) 7473**] in the next 1-2 weeks. # anemia: pts baseline is 26. this is likely secondary to aocd and renal failure. hct was stable on day of discharge at 25.9. # svc thrombus: pt has a history of an svc thrombus, and is on coumadin. she is supposed to be on lifelong anticoagulation due to recurrent thrombosis but inr subtherapeutic on arrival. heparin drip was stopped on the floor once the inr was theraputic. inr was therapeutic on day of discharge. pt will need an inr check in the next week at her follow-up with her pcp. # hocm: pt has evidence of myocardial hypertrophy on echo. she is currently not symptomatic. echo did not show evidence of worsening pericardial effusion. she was continued on her beta-blocker and other bp medications. # depression/anxiety: stable. she was continued on celexa and clonazepam. # osa: pt as continued on cpap for sleep with 7 pressure. # fen: regular diet # ppx: heparin drip --> coumadin, bowel regimen # access: piv x2 / permanent dialysis cath l fem # code: full # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] # dispo: home with pcp and renal [**name9 (pre) 702**] to re-check bp, inr level. follow-up with transplant surgery. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Hypoxemia; Other opiates and related narcotics causing adverse effects in therapeutic use; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Abdominal pain, other specified site; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Renal dialysis status; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Other postprocedural status]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. # hypertension: pt with extensive history of repeated admissions for hypertension. # sle: stable, continued prednisone at 4 mg po daily. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. this is likely secondary to aocd and renal failure. pt will need an inr check in the next week at her follow-up with her pcp.","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was stablized on home medicaitons, suggesting medication non-compliance. patient was oversedated on dilaudid and had episode of oxygen desaturation." 109,131376.0,14862,2142-07-08,14804,124657.0,2142-01-20,Discharge summary,"Admission Date: [**2142-1-14**] Discharge Date: [**2142-1-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 4028**] Chief Complaint: headache Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with mild headache, mild shortness of breath and consistent abdominal pain at the site of her known left abdominal wall hematoma in the setting of hypertension. Her last HD was yesterday. . Upon arrival to the ED, her vitals were BP 240's systolic, HR 90's, 93% on RA. A head CT scan was done which showed no acute process. An abdominal CT was done given her femoral line pain, which also was normal. She was given nitropaste X2 initially, then switched to labetalol 100mg x2, then 200mg x2, then finally started on nicardipine drip when she showed benefit with a decrease in her BP to 170/123 and improvement in her headache. . Upon arrival to the MICU, patient denies any current symptoms. She reports that her headache, shortness of breath and abdominal pain all resolved with blood pressure management and pain medications. . Pt was transferred to the floor when blood pressure was controlled. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: HR 96 BP 171/111 RR 12 O2 98% on RA Physical Exam: General in NAD HEENT NC, AT, EOMI, PERRLA, MMM CVS RRR, 3/6 systolic murmur in all heart fields RESP CTA BL, no crackles or wheezes ABD soft, hematoma raised on left anterior abdominal wall, +BS, mildly tender over hematoma EXT left sided femoral HD line in place, no erythema, no edema NEURO A+Ox3, CN2-12 intact, pt has left sided artificial eye, motor and sensory intact Pertinent Results: ***LABS ON ADMISSION*** [**2142-1-13**] 07:03AM WBC-5.2 RBC-2.79* HGB-8.5* HCT-26.3* MCV-94 MCH-30.3 MCHC-32.2 RDW-19.2* [**2142-1-13**] 07:03AM PLT COUNT-154 [**2142-1-13**] 07:03AM PT-29.5* PTT-49.2* INR(PT)-3.0* [**2142-1-13**] 07:03AM GLUCOSE-94 UREA N-53* CREAT-7.0* SODIUM-136 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [**2142-1-13**] 07:03AM CALCIUM-8.8 PHOSPHATE-5.0* MAGNESIUM-1.9 [**2142-1-14**] 12:00PM PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-14**] 12:00PM LIPASE-42 [**2142-1-14**] 12:00PM ALT(SGPT)-12 AST(SGOT)-43* ALK PHOS-96 TOT BILI-0.4 [**2142-1-14**] 03:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-1-14**] 03:25PM URINE RBC-[**3-15**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-[**3-15**] [**2142-1-14**] 12:00PM BLOOD PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-19**] 06:40AM BLOOD PT-18.6* PTT-38.7* INR(PT)-1.7* . ***LABS ON DAY OF DISCHARGE*** [**2142-1-20**] 06:35AM BLOOD WBC-5.7 RBC-2.39* Hgb-7.1* Hct-22.1* MCV-93 MCH-29.8 MCHC-32.2 RDW-18.6* Plt Ct-136* [**2142-1-20**] 06:35AM BLOOD Glucose-107* UreaN-34* Creat-4.8* Na-137 K-5.2* Cl-101 HCO3-27 AnGap-14 [**2142-1-20**] 06:35AM BLOOD PT-22.8* PTT-42.3* INR(PT)-2.2* . IMAGING [**2142-1-14**] EKG Sinus rhythm. Possible left atrial abnormality. Borderline voltage criteria for left ventricular hypertrophy. Inferolateral ST-T wave changes may be related to left ventricular hypertrophy. Compared to the previous tracing of [**2142-1-8**] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 99 190 86 368/436 13 100 24 [**2142-1-14**] CT ABD/PELV IMPRESSION: 1. Interval decrease in size to subcutaneous anterior abdominal wall hematoma. 2. Infectious versus inflammatory process within the right lower lobe of the lung. Small right simple pleural effusion. 3. Cardiomegaly with slight decrease in size of moderate pericardial effusion. 4. Right lobe liver hemangioma, unchanged. [**2142-1-14**] CT HEAD IMPRESSION: 1. Mildly limited study given administration of small amount of IV contrast material. However, no evidence of hemorrhage or mass effect. NOTE ADDED AT ATTENDING REVIEW: This patient was administered contrast for the abdominal CT, and the head CT was performed after part of this dose. Therefore, this is neither a noncontrast examination, nor a proper contrast CT. [**2142-1-14**] CXR CONCLUSION: Persistent cardiomegaly and mild pulmonary edema. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. . # Hypertensive Urgency: Pt with extensive history of hypertension. Patient's BP improved with nicardipine drip. Became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. Restarted all home oral antihypertensives including nicardipine 30 Q8H, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Blood pressure remains labile and renal continues to follow patient. Pt was transferred to the floor as blood pressure stabilized. BP has remained stable with systolics 140s-170s. In the MICU, Nifedipine extended release was added in place of Nicardipine as pt's blood pressures seemed to rise prior to Nicardipine doses. . # Hyperkalemia: Ocurred on the day after admission. Resolved with administration of kayexalate. Pt continued hemodialysis on TuThSat. . # Left abdominal wall hematoma: Abd CT showed a mild decrease in the size. Pt reported that morphine did not help pain, and was switched to dilaudid PO in the MICU. However, given pt's recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/c'ed on the floor. Pt was continued on gabapentin, tylenol around the clock, and low-dose Morphine as needed for pain. Narcotics should be avoided in the future. Pain should also resolve in the next few weeks as hematoma resolves. . # SLE: Pt was continued on prednisone at 4 mg PO daily. . #ESRD: Renal was following during her stay. She continued HD on her T, Th, Sat schedule. # Anemia: Hct was mildly decreased from baseline during admission. This is likely secondary to AOCD and in the setting of renal failure. . # SVC thrombus: Patient is on anticoagulation, likely lifelong. Patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. Then INR became subtherapeutic, so heparin gtt was used to bridge. On day of discharge, INR became therapeutic, and pt was discharged home on Coumadin 4mg PO daily, with INR to be checked next at hemodialysis . # HOCM: Pt has evidence of myocardial hypertrophy on recent Echo. She was not symptomatic during her stay. She was continued on her beta blocker. . # Depression/anxiety. She was continued on celexa and clonazepam PRN. . # OSA: CPAP for sleep with 7 pressure. . # FEN: repleted lytes prn / regular diet . # PPX: coumadin, bowel regimen . # ACCESS: PIV/ permanent dialysis cath L fem . # CODE: FULL . # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nicardipine 30mg PO TID Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for breakthrough pain for 2 weeks. 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*1* 13. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*260 Tablet(s)* Refills:*1* 14. Respiratory Therapy Please adjust settings of CPAP machine to a lower volume as it is uncomfortable for the patient. Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Discharge Condition: Good, hemodynamically stable, afebrile, pain controlled Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. One new medication was added as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to continue your Coumadin at 4mg daily and have your INR checked AT DIALYSIS next week. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep ALL scheduled appointments. Medications changes include: 1. STOP NICARDIPINE 2. Start Nifedipine CR 90mg by mouth daily 3. INCREASE Labetalol to 900mg by mouth 3 times daily 4. Continue at Warfarin 4mg by mouth daily If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to set up a follow-up appointment in 1-2weeks. Please continue your HD TuThSat. Completed by:[**2142-1-20**]",169,2142-01-14 17:34:00,2142-01-20 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. . # hypertensive urgency: pt with extensive history of hypertension. patients bp improved with nicardipine drip. became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. restarted all home oral antihypertensives including nicardipine 30 q8h, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. blood pressure remains labile and renal continues to follow patient. pt was transferred to the floor as blood pressure stabilized. bp has remained stable with systolics 140s-170s. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. . # hyperkalemia: ocurred on the day after admission. resolved with administration of kayexalate. pt continued hemodialysis on tuthsat. . # left abdominal wall hematoma: abd ct showed a mild decrease in the size. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu. however, given pts recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/ced on the floor. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. narcotics should be avoided in the future. pain should also resolve in the next few weeks as hematoma resolves. . # sle: pt was continued on prednisone at 4 mg po daily. . #esrd: renal was following during her stay. she continued hd on her t, th, sat schedule. # anemia: hct was mildly decreased from baseline during admission. this is likely secondary to aocd and in the setting of renal failure. . # svc thrombus: patient is on anticoagulation, likely lifelong. patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. then inr became subtherapeutic, so heparin gtt was used to bridge. on day of discharge, inr became therapeutic, and pt was discharged home on coumadin 4mg po daily, with inr to be checked next at hemodialysis . # hocm: pt has evidence of myocardial hypertrophy on recent echo. she was not symptomatic during her stay. she was continued on her beta blocker. . # depression/anxiety. she was continued on celexa and clonazepam prn. . # osa: cpap for sleep with 7 pressure. . # fen: repleted lytes prn / regular diet . # ppx: coumadin, bowel regimen . # access: piv/ permanent dialysis cath l fem . # code: full . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Other vascular complications of medical care, not elsewhere classified; Systemic lupus erythematosus; Hyperpotassemia; Phlebitis and thrombophlebitis of upper extremities, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. # anemia: hct was mildly decreased from baseline during admission. # hocm: pt has evidence of myocardial hypertrophy on recent echo. # fen: repleted lytes prn / regular diet . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. pt was transferred to the floor as blood pressure stabilized. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu." 109,131376.0,14862,2142-07-08,14805,176760.0,2142-01-23,Discharge summary,"Admission Date: [**2142-1-21**] Discharge Date: [**2142-1-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Hypertensive Urgency and fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with hypertensive urgency, subjective fevers, and pain. . Of note, she had been hospitalized [**Date range (1) 43505**] with hypertensive urgency. Her nicardipine was changed to nifedipine in hospital and her labetalol was increased to 900mg TID from 800mg TID.BPs were reportedly stable in the 140's-170's on the medical floor on nifedipine, aliskerin, labetalol, clonidine, and hydralazine prior to discharge. Last HD was [**1-20**]. . She reports feeling well at time of discharge [**1-20**], however woke this evening feeling sweaty, hot, and mildly SOB. She did not check her temperature and denies any rigors. She had total body aching (worst in her left wrist at site of recent IV and abdomen at site of known hematoma). +Palpitations overnight now resolved. No CP, SOB, cough, diarrhea, dysuria, erythema/tenderness/drainage from HD catheter. Denies recent joint symptoms with her lupus. No sick contacts. Says she took her BP meds. . Upon arrival to the ED, her vitals were 99.9 104 254/145 16 96% on RA. She was started on a nicardipine drip, given 1"" nitropaste with improvement in her BP. Did spike a fever while in the ED, currently 101F 101 173/106 Given vancomycin and zoysn for ?pna as CXR with right sided haziness. Also received 3mg IV dilaudid for body pains. LUE ultrasound without evidence of DVT. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 98.5 P 92 Bp 173/116 RR 16 O2 100% on RA General Pleasant young woman appearing comfortable HEENT Cushingoid faces, L eye prosthesis, MMM Pulm Lungs clear bilaterally, no rales or wheezing CV Regular S1 S2 ?soft systolic murmur Abd Soft +hematoma left abdomen unchanged from prior exam Extrem Warm full distal pulses. Left hand with slight edema ++ tender to palpation of wrist patient unable to make fist secondary to pain, no erythema +warmth ?purulence at site of old PIV Skin No peripehral stigmata of endocarditis Lines Left groin HD catheter site without erythema, purulence, or tenderness Neuro Alert and awake, moving all extremities Pertinent Results: CXR [**1-21**]: In comparison with the earlier study of this date, the diffuse pulmonary edema has substantially decreased, possibly following hemodialysis. Enlargement of the cardiac silhouette persists and there is no definite pleural effusion. Suggestion of an area of increased opacification at the right base. This could merely represent asymmetric edema, though the possibility of a developing consolidation cannot be unequivocally excluded. . LUE US [**1-21**]: IMPRESSION: No DVT in the left upper extremity. . L wrist xray [**1-21**]: There is prominent soft tissue swelling about the wrist, relatively diffuse, but quite prominent along the dorsum of the wrist. No fracture, dislocation, degenerative change, focal lytic or sclerotic lesion, or erosion is identified. No soft tissue calcification or radiopaque foreign body is identified. A tiny (1.7 mm) linear density is seen along the dorsum of the wrist on the oblique view is seen only on that view and is consistent with a small film artifact. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency and left wrist pain. . 1. Hypertensive urgency: Patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. Patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. She was started on nicardipine drip and 1"" nitropaste and admitted to the ICU for further treatment. There was no evidence of end-organ ischemia. Upon arrival to the ICU she was given her usual home antihypertensives and the nicardipine was quickly weaned off. It was felt that pain and anxiety were both contributing to her elevated BPs. Her BP quickly stabilized and she was called out to the medical floor where her SBP ranged 110-150. She was continued on nifepidine 90mg daily, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Given her repeated admissions with hypertensive urgency a meeting was held between the patient's nephrologist Dr. [**Last Name (STitle) 4883**], her ICU physician and her [**Name9 (PRE) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the ICU where she quickly improves with simply continuing her home medications. The following plan was drafted and placed in a note in OMR titled "" Care Protocol"". . CARE PROTOCOL: . BLOOD PRESSURE MANAGEMENT: . For BP > 230/140 1. Hydralazine: 100 mg PO OR 10 mg IV q 20 minutes until blood pressure back to baseline*. . 2. Give daily blood pressure medications, if she has not already taken them before arrival. . 3. If after one hour of therapy AND/OR evidence of end organ damage, transfer to the ICU. . * Note: Her usual blood pressure is ~ 160/100. Efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. In the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . PAIN MANAGEMENT: . As an outpatient, Ms. [**Name13 (STitle) **] takes dilaudid 2-4 mg PO q 4 PRN.This is being slowly tapered, she should not be administered IV pain medications. . ANTICOAGULATION: . In the absence of bleeding, warfarin does not need to be stopped on admission. Similarly, in the absence of new thrombosis, subtherapeutic INR's do not require bridging with IV UFH. . 2. Fever: Possible sources included line infection, thombophlebitis, septic arthritis, PNA. Received vanc/zosyn in ED for possible PNA. UA without pyuria and urine culture negative. CXR also without convinving infiltrate on repeat PA/Lat so zosyn was discontinued. Patient was complaining of severe pain at her IV site and was noted to have a small abscess there which was felt to be the cause of her fever. She was continued on IV vanco with HD for 10day course. She remained afebrile and did not have a leukocytosis. . 3. Left wrist pain: Began following IV placement during recent hospitalization. Likely due to septic thrombophlebitis. Small abscess was too small to drain. This was treated with warm soaks and prn PO dilaudid. Vanco was continued for 10 day course. L wrist films were enremarkable. . 4. Left abdominal wall hematoma: Stable on exam from recent admission. She was continued on pain management with morphine 7.5mg TID, gabapentin and tylenol as needed for pain. . 5. SLE: Continued prednisone at 4 mg PO daily . 6. ESRD: Continued on regularly scheduled dialysis. . 7. Anemia: Baseline Hct 26. Her Hct was mildly decreased from baseline. Secondary to AOCD and renal failure. There was no evidence of bleeding. . 8. SVC thrombus: Known SVC thrombus, therapeutic on coumadin. Continued warfarin. . 9. HOCM: evidence of myocardial hypertrophy on recent Echo. Currently not symptomatic. Echo without evidence of worsening pericardial effusion. Continued beta blocker . 10. Depression/anxiety. Continued Celexa, clonazepam 0.5mg [**Hospital1 **] . 11. OSA: Continued CPAP Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nifedipine 90mg PO daily Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325-650 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*270 Tablet(s)* Refills:*2* 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 7 days. [**Hospital1 **]:*4 dose* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Septic thrombophlebitis Discharge Condition: Stable, afebrile, BP improved. Discharge Instructions: You were admitted to the hospital with hypertensive urgency. You required IV medications and were observed overnight in the ICU. Your usual oral blood pressure medications were continued and your blood pressure remained well-controlled. You were found to have an infection at your prior IV site on your left hand. For this you were given IV vancomycin. You will need 7 days more of antibiotics which will be given with dialysis. Please resume your usual dialysis schedule. Your last dialysis was [**1-23**]. Please continue to take your medications as prescribed. You should hold your coumadin today. You can resume this on wednesday at your normal dose. You should have your INR checked at dialyis as usual on thursday. . If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-12**] weeks. ",166,2142-01-21 11:23:00,2142-01-23 16:40:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE EMERGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. . 1. hypertensive urgency: patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. there was no evidence of end-organ ischemia. upon arrival to the icu she was given her usual home antihypertensives and the nicardipine was quickly weaned off. it was felt that pain and anxiety were both contributing to her elevated bps. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150. she was continued on nifepidine 90mg daily, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. given her repeated admissions with hypertensive urgency a meeting was held between the patients nephrologist dr. [**last name (stitle) 4883**], her icu physician and her [**name9 (pre) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the icu where she quickly improves with simply continuing her home medications. the following plan was drafted and placed in a note in omr titled "" care protocol"". . care protocol: . blood pressure management: . for bp > 230/140 1. hydralazine: 100 mg po or 10 mg iv q 20 minutes until blood pressure back to baseline*. . 2. give daily blood pressure medications, if she has not already taken them before arrival. . 3. if after one hour of therapy and/or evidence of end organ damage, transfer to the icu. . * note: her usual blood pressure is ~ 160/100. efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. in the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . pain management: . as an outpatient, ms. [**name13 (stitle) **] takes dilaudid 2-4 mg po q 4 prn.this is being slowly tapered, she should not be administered iv pain medications. . anticoagulation: . in the absence of bleeding, warfarin does not need to be stopped on admission. similarly, in the absence of new thrombosis, subtherapeutic inrs do not require bridging with iv ufh. . 2. fever: possible sources included line infection, thombophlebitis, septic arthritis, pna. received vanc/zosyn in ed for possible pna. ua without pyuria and urine culture negative. cxr also without convinving infiltrate on repeat pa/lat so zosyn was discontinued. patient was complaining of severe pain at her iv site and was noted to have a small abscess there which was felt to be the cause of her fever. she was continued on iv vanco with hd for 10day course. she remained afebrile and did not have a leukocytosis. . 3. left wrist pain: began following iv placement during recent hospitalization. likely due to septic thrombophlebitis. small abscess was too small to drain. this was treated with warm soaks and prn po dilaudid. vanco was continued for 10 day course. l wrist films were enremarkable. . 4. left abdominal wall hematoma: stable on exam from recent admission. she was continued on pain management with morphine 7.5mg tid, gabapentin and tylenol as needed for pain. . 5. sle: continued prednisone at 4 mg po daily . 6. esrd: continued on regularly scheduled dialysis. . 7. anemia: baseline hct 26. her hct was mildly decreased from baseline. secondary to aocd and renal failure. there was no evidence of bleeding. . 8. svc thrombus: known svc thrombus, therapeutic on coumadin. continued warfarin. . 9. hocm: evidence of myocardial hypertrophy on recent echo. currently not symptomatic. echo without evidence of worsening pericardial effusion. continued beta blocker . 10. depression/anxiety. continued celexa, clonazepam 0.5mg [**hospital1 **] . 11. osa: continued cpap ","PRIMARY: [Other vascular complications of medical care, not elsewhere classified] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; ; Systemic lupus erythematosus; Phlebitis and thrombophlebitis of upper extremities, unspecified]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. she was continued on iv vanco with hd for 10day course. esrd: continued on regularly scheduled dialysis. her hct was mildly decreased from baseline. hocm: evidence of myocardial hypertrophy on recent echo. echo without evidence of worsening pericardial effusion. continued celexa, clonazepam 0.5mg [**hospital1 **] .","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150." 109,131376.0,14862,2142-07-08,14806,113189.0,2142-02-17,Discharge summary,"Admission Date: [**2142-2-14**] Discharge Date: [**2142-2-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: From admission note: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome admitted with HTN and SOB in the setting of missed HD. The patient reported missing HD yesterday because she thinks she is being overdiuresed. She reports persistent pain at site of rectus sheath hematoma. Denies N/V/D. Pt recently admitted from [**Date range (1) 13924**] with consistent abdominal pain at the site of her known left abdominal wall hematoma, hypertensive to 230's and hyperkalemic to 6.2 after missing her last two dialysis sessions. At this time the pt. was dialyzed, received a blood transfusion, and was administered her daily antihypertensive medications. Pt. left AMA after her transfusion despite the primary team's concerns to look for an active area of bleeding. In the ED, patient complain of mild dyspnea, sating well on RA. CXR mild volume overload. KUB with no evidence of obstruction. She was started on a labetalol gtt. ECG - RAD, LVH no change from prior. HCT stable at 21. The renal team evaluated pt and recommended HD, however the patient refused. She was transferred to ICU for BP control. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: [**2142-2-14**] 07:40AM WBC-3.9* RBC-2.38* HGB-7.0* HCT-21.3* MCV-90 MCH-29.5 MCHC-33.0 RDW-18.9* [**2142-2-14**] 07:40AM NEUTS-74.9* LYMPHS-18.7 MONOS-3.1 EOS-3.0 BASOS-0.2 [**2142-2-14**] 07:40AM PLT COUNT-101* [**2142-2-14**] 07:40AM PT-16.3* PTT-36.6* INR(PT)-1.5* [**2142-2-14**] 07:40AM CK-MB-6 [**2142-2-14**] 07:40AM cTropnT-0.09* [**2142-2-14**] 07:40AM LIPASE-80* [**2142-2-14**] 07:40AM ALT(SGPT)-34 AST(SGOT)-72* CK(CPK)-120 ALK PHOS-124* TOT BILI-0.4 [**2142-2-14**] 07:40AM GLUCOSE-85 UREA N-32* CREAT-7.0* SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-19* ANION GAP-17 [**2142-2-14**] 07:44AM LACTATE-1.3 [**2142-2-14**] CXR: Stable cardiomegaly with mild CHF and a small left pleural effusion. Left basilar air space disease which may represent pneumonia. Clinical correlation and a follow up chest x-ray to clearance is recommended. [**2142-2-14**] KUB: 1. Nonspecific bowel gas pattern with no evidence of obstruction. 2. Left basilar airspace disease which may represent pneumonia and a small left pleural effusion. Please ensure follow-up to clearance. Brief Hospital Course: 24 y.o female with SLE, ESRD on HD and malignant hypertension who presents with HTN and SOB aftering missing HD. . # Malignant hypertension/hypertensive urgency: The patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and HD compliance. Has previously presented with BP up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. Pt was treated per OMR hypertensive protocol created by the patient's primary providers, with a goal SBP of 160-180. With short course of IV antihypertensives and hemodialysis, pt's BP fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # ESRD: Pt was followed by the renal service and underwent HD without any complications. Pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting HD. She will discuss this further with the Renal team as an outpatient. . # SLE: Pt was continued on her home dose of prednisone with no sign of SLE flair. . # Coagulopathy/history of DVT: Patient on lifetime anticoagulation for hx of multiple thrombotic events. Pt was continued on coumadin. . # Pain management: Pt was treated with PO dilaudid for her abdominal pain, as recommended per her OMR protocol. She asked for IV dilaudid multiple times but there was no clinical indication. She was also continued on gabapentin. . # Anemia: Secondary to AOCD and renal failure. The patietns Hct remained stable in the low 20s during admission. No PRBC infusions were needed. . # Depression/anxiety: Continued Celexa, clonazepam 0.5mg [**Hospital1 **] Medications on Admission: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain. 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Disposition: Home Discharge Diagnosis: Primary: Malignant Hypertension Secondary: SLE, End stage renal disease on hemodialysis, SVC syndrome Discharge Condition: Stable. SBP in 160s. Discharge Instructions: You were admitted with dangerously high hypertension and some shortness of breath in the setting of missing several dialysis sessions. You were admitted and treated with your usual regimen of blood pressure meds and a short course of IV meds. With dialysis, your symptoms improved. You also had some abdominal pain, which was well controlled on your usual pain medications. We made no changes to your medications. Please take everything as prescribed. Please call your PCP or return to the hospital if you develop any headaches, visual changes, confusion or chest pain, or any other concerning symptoms. Followup Instructions: Please schedule a follow up with Dr [**Last Name (STitle) **] in [**Month (only) 958**] as scheduled. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2142-2-21**]",141,2142-02-14 10:42:00,2142-02-17 18:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. . # malignant hypertension/hypertensive urgency: the patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and hd compliance. has previously presented with bp up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. with short course of iv antihypertensives and hemodialysis, pts bp fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # esrd: pt was followed by the renal service and underwent hd without any complications. pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting hd. she will discuss this further with the renal team as an outpatient. . # sle: pt was continued on her home dose of prednisone with no sign of sle flair. . # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events. pt was continued on coumadin. . # pain management: pt was treated with po dilaudid for her abdominal pain, as recommended per her omr protocol. she asked for iv dilaudid multiple times but there was no clinical indication. she was also continued on gabapentin. . # anemia: secondary to aocd and renal failure. the patietns hct remained stable in the low 20s during admission. no prbc infusions were needed. . # depression/anxiety: continued celexa, clonazepam 0.5mg [**hospital1 **] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Thrombotic microangiopathy; Systemic lupus erythematosus; Anemia in chronic kidney disease; Thrombocytopenia, unspecified; Obstructive sleep apnea (adult)(pediatric); Nontraumatic hematoma of soft tissue; Dysthymic disorder; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events.","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob after missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. she was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine." 109,131376.0,14862,2142-07-08,14807,158995.0,2142-02-26,Discharge summary,"Admission Date: [**2142-2-25**] Discharge Date: [**2142-2-26**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 338**] 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 History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, hx of malignant HTN admitted with change in mental status. Patient missed HD on [**2142-2-24**] and was found unresponsive and diaphoretic by mother this morning after she took some dilaudid. EMS was called, 1 mg of narcan was administered with slight improvement in mental status. On arrival to the ED her vitals were 112/64 62 16 99RA she was noted to be hyperkalemic in the absence of EKG changes and was given calcium, D5, 10U regular insulin, 30 mg po kayxalate and repeat K was 5.4. ABG: 7.29/38/199. Repeat glucose was 41 and 1amp D50 was given. She was sent to the ICU for monitoring. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including [**Month/Year (2) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: HR: 80 (79 - 80) bpm BP: 127/59(76) {127/59(76) - 139/64(82)} mmHg RR: 34 (21 - 34) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Physical Examination Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact Pertinent Results: [**2142-2-25**] 01:50PM PT-14.9* PTT-36.8* INR(PT)-1.3* [**2142-2-25**] 01:50PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2142-2-25**] 01:50PM WBC-5.0 RBC-2.21* HGB-6.4* HCT-20.7* MCV-94 MCH-29.1 MCHC-31.1 RDW-19.6* [**2142-2-25**] 10:30PM GLUCOSE-87 UREA N-66* CREAT-8.4* SODIUM-142 POTASSIUM-5.9* CHLORIDE-110* TOTAL CO2-16* ANION GAP-22* HISTORY: Altered mental status. Evaluate underlying for pneumonia. UPRIGHT PORTABLE CHEST: Comparison is made to [**2-14**] and [**2142-2-19**], exams. Study is slightly limited by patient motion. In the interval, the degree of pulmonary edema appears improved with slightly decreased prominence of the pulmonary vascularity. There is unchanged extensive retrocardiac consolidation obscuring the majority of the left hemidiaphragm with persistent blunting of the left CP angle, likely related to small effusion. Exam is otherwise unchanged from prior with persistent cardiomegaly. A catheter is seen projecting over the abdomen, partially imaged. IMPRESSION: Slight improvement in pulmonary edema with persistent retrocardiac opacity, which again may represent atelectasis versus underlying pneumonia. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted hypotension and decreased mental status. Hypotension and altered mental status were in the setting of excessive narcotic use. Patient's narcotics were held, pressors returned to [**Location 213**] and patient was mentating fine. Hct was below baseline and patient was transfused 1u PRBC and was given HD before discharge. Patient is to continue anti-hypertensive medications as previously scheduled. Patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # Change in mental status: Resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. Patient received 1 dose of narcan with slight improvement in BP and mental status. patient without fevers or leuckocytosis which argue against infection. # Hypertension ?????? resumed outpatient regimen. Patient did not have any hypertensive episodes requiring hydralizine 10mg IV. # Hypotension: resolved, Patient normotensive on arrival to ICU. Relative hypotension likely due to dilaudid. Other considerations include sepsis, although patient without objective signs of infection. Held pain medications and hypotension resolved. Resumed hypertensive medications. # Abdominal pain ?????? from previous peritoneal [**Location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # Hyperkalemia: Likely due to missed HD session. She received calcium, D5, insulin and kayexalate in ED. HD in am ESRD: Renal following, had HD the day of discharge, transfused while there. Will continue normal schedule as an outpatient with HD T/Th/F this week. # Metabolic Acidosis: likely due to renal failure and missed HD. # SLE: continued prednisone at 4 mg PO daily. # OSA: CPAP for sleep with 7 pressure, however patient refuses. Continued to offer as inpatient. Should try to follow up with sleep medicine. Medications on Admission: Prednisone 4mg qd Citalopram 20 mg daily Gabapentin 300 mg [**Hospital1 **] Warfarin 4mg daily Pantoprazole 40 mg qd Clonidine 0.1 mg/24 QWED Clonidine 0.3 mg/24 hr QWED Labetalol 900 mg tid Nifedipine 90 mg qd Aliskiren 150 mg [**Hospital1 **] Hydralazine 100 mg q8h Morphine 7.5 mg q8h prn pain Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Home Discharge Diagnosis: Primary: narcotic overdose relative hypotension anemia Secondary: ESRD on HD [**2-12**] SLE malignant hypertension Discharge Condition: stable - received HD prior to discharge Discharge Instructions: You were admitted for altered mental status after missing hemodialysis. It was likely from the dilaudid you took as well as missing your scheduled [**Month/Day (2) 2286**]. You were also relatively hypotensive in the setting of excessive narcotic medicaiton usage. Narcotic medications were held and hypotension and altered mental status resolved. Please use narcotic medications with caution. You are recommended to use morphine for pain control rather than dilaudid. No medication changes were made. Please return to the ED if you have any altered mental status or miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] or have symptoms such as vision changes or headache from your history of malignant hypertension. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-3-20**] 3:00 HD as previously scheduled Completed by:[**2142-2-26**]",132,2142-02-25 15:49:00,2142-02-26 16:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ALTERED MENTAL STATUS," 24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. patients narcotics were held, pressors returned to [**location 213**] and patient was mentating fine. hct was below baseline and patient was transfused 1u prbc and was given hd before discharge. patient is to continue anti-hypertensive medications as previously scheduled. patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # change in mental status: resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. patient received 1 dose of narcan with slight improvement in bp and mental status. patient without fevers or leuckocytosis which argue against infection. # hypertension ?????? resumed outpatient regimen. patient did not have any hypertensive episodes requiring hydralizine 10mg iv. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. other considerations include sepsis, although patient without objective signs of infection. held pain medications and hypotension resolved. resumed hypertensive medications. # abdominal pain ?????? from previous peritoneal [**location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # hyperkalemia: likely due to missed hd session. she received calcium, d5, insulin and kayexalate in ed. hd in am esrd: renal following, had hd the day of discharge, transfused while there. will continue normal schedule as an outpatient with hd t/th/f this week. # metabolic acidosis: likely due to renal failure and missed hd. # sle: continued prednisone at 4 mg po daily. # osa: cpap for sleep with 7 pressure, however patient refuses. continued to offer as inpatient. should try to follow up with sleep medicine. ","PRIMARY: [Poisoning by other opiates and related narcotics] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Thrombotic microangiopathy; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Altered mental status; Other iatrogenic hypotension; Accidental poisoning by other opiates and related narcotics; Hyperpotassemia; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Nontraumatic hematoma of soft tissue; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. from previous peritoneal [**location 2286**] hematoma ??????","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. narcotics were held, pressors returned to and patient was mentating fine. patient was encouraged to take less pain medications and to use morphine." 109,131376.0,14862,2142-07-08,14808,158943.0,2142-03-23,Discharge summary,"Admission Date: [**2142-3-21**] Discharge Date: [**2142-3-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: Abdominal Pain, Shortness of breath, Chest discomfort Major Surgical or Invasive Procedure: HD [**2142-3-21**] and [**2142-3-23**] History of Present Illness: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] 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 [**Telephone/Fax (3) 43508**]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. [**Telephone/Fax (3) **] was discussed with renal and it was not felt that HTN is a volume issue so no need for emergent [**Telephone/Fax (3) 2286**]. . 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 [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**], getting Vanc with HD. . PSHx: 1. Placement of multiple catheters including [**Year (4 digits) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] 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: [**2142-3-21**] 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* [**2142-3-21**] 02:20AM NEUTS-76.1* BANDS-0 LYMPHS-17.9* MONOS-4.5 EOS-1.1 BASOS-0.5 [**2142-3-21**] 02:20AM PLT SMR-NORMAL PLT COUNT-168 [**2142-3-21**] 02:20AM PT-21.8* PTT-34.7 INR(PT)-2.1* [**2142-3-21**] 02:20AM cTropnT-0.12* [**2142-3-21**] 02:20AM ALT(SGPT)-46* AST(SGOT)-94* CK(CPK)-76 ALK PHOS-173* TOT BILI-0.4 [**2142-3-21**] 02:20AM GLUCOSE-74 UREA N-47* CREAT-7.3* SODIUM-140 POTASSIUM-5.8* CHLORIDE-109* TOTAL CO2-19* ANION GAP-18 [**2142-3-21**] 04:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-21**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2142-3-21**] 12:58PM CK-MB-NotDone cTropnT-0.12* . CT C/A/P - [**2142-3-20**] - 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: [**2142-3-23**] 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* [**2142-3-23**] 12:00PM BLOOD Plt Ct-130* [**2142-3-23**] 12:00PM BLOOD PT-28.8* PTT-58.6* INR(PT)-2.9* [**2142-3-23**] 12:00PM BLOOD Glucose-77 UreaN-31* Creat-6.0*# Na-137 K-4.8 Cl-104 HCO3-24 AnGap-14 [**2142-3-23**] 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 [**3-22**] 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 [**2142-3-21**] . # abdominal pain: Consistent with patient's baseline chronic abdominal pain. Medication effect also possible. CT prelim neg for small bowel obstruction. LFTs doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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). [**Month/Year (2) **]:*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 [**Month/Year (2) 2286**] sessions as directed by the nephrology team- your next session should be on Tuesday. Completed by:[**2142-3-26**]",107,2142-03-21 09:25:00,2142-03-23 18:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,CHEST PAIN;TELEMETRY," 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 (200s/100s) that nevertheless are within levels shes 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 [**3-22**] and transferred to the medicine floor. the next day, her bp remained within goal of 120s/80s. 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. ces were cycled and were negative. cpap was continued as tolerated at home settings. sob resolved after hd on [**2142-3-21**] . # abdominal pain: consistent with patients baseline chronic abdominal pain. medication effect also possible. ct prelim neg for small bowel obstruction. lfts doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Compression of vein; Unspecified disease of pericardium; Infection and inflammatory reaction due to other vascular device, implant, and graft; Bacteremia; Primary hypercoagulable state; Other primary cardiomyopathies; ; Abdominal pain, unspecified site; Urinary tract infection, site not specified; Acidosis; Other chest pain; Other chronic pain; Systemic lupus erythematosus; Noncompliance with renal dialysis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Hyperpotassemia; 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; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","this is a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. ct prelim neg for small bowel obstruction. on arrival to the floor, abd pain was back to baseline and well controlled on dilaudid 2mg po q 4hrs .","a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. initial attempts were made to control her bp with hydralazine and labetalol iv but after these failed to control her blood pressure. she was successfully transitioned to home medications of clonidine, labetalol, aliskiren, nifedipine" 109,131376.0,14862,2142-07-08,14809,124398.0,2142-03-31,Discharge summary,"Admission Date: [**2142-3-24**] Discharge Date: [**2142-3-31**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: HTN, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 24F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] after admission for abdominal pain, MSSA bacteremia, paroxysmal hypertension and ESRD line, followed by readmission [**3-22**], now presents with usual central crampy abdominal pain, 3 loose nonbloody stools this AM, SOB, and HTN to 270s. Pt was d/c'd from [**Hospital1 18**] yesterday after HD session, went home, states she took her PM meds, took her 8 AM medds (hydral, labetalol), then developed these symptoms which precluded her from taking her usual home meds (no afternoon meds - nifedipine, labetalol, hydral). The abd pain comes and goes and is unchanged from her baseline. While she has nausea, she is asking for dinner. . In the ED, initial BP 272/148. CXR w/o evidence of volume overload. No CT scan performed. Started on NTG gtt, given Hydralazine 10 x 1, Dilaudid 2 mg, labetaolo 20mg IV x 1. . Upon arrival to the floor, her BP was 240/135. She continued to complain of abdominal pain but was eating crackers, breathing felt better. RR 17. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: 98.2 97 [**Telephone/Fax (2) 43509**]0% on 2 L nC Gen: pleasant, comfortable HEENT: L eye enucleated. moon facies. Right pupil reactive Heart: hrrr, no m/r/g Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, diffuse TTP, no rebound/guarding Ext: no c/c/e Neuro: aox4, cn 2-12 intact grossly. Pertinent Results: [**2142-3-24**] 07:17PM PT-22.4* PTT-43.64* INR(PT)-2.1* [**2142-3-24**] 04:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2142-3-24**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-24**] 04:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**11-30**] [**2142-3-24**] 02:05PM GLUCOSE-76 UREA N-21* CREAT-4.8*# SODIUM-139 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2142-3-24**] 02:05PM ALT(SGPT)-78* AST(SGOT)-181* CK(CPK)-55 ALK PHOS-192* TOT BILI-0.5 [**2142-3-24**] 02:05PM cTropnT-0.12* [**2142-3-24**] 02:05PM CK-MB-5 [**2142-3-24**] 02:05PM WBC-3.6* RBC-2.90* HGB-8.9* HCT-26.6* MCV-92 MCH-30.7 MCHC-33.4 RDW-19.8* [**2142-3-24**] 02:05PM NEUTS-73.9* BANDS-0 LYMPHS-18.5 MONOS-3.8 EOS-3.0 BASOS-0.8 [**2142-3-24**] 02:05PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-1+ TARGET-1+ SCHISTOCY-OCCASIONAL TEARDROP-1+ ELLIPTOCY-OCCASIONAL [**2142-3-24**] 02:05PM PLT SMR-LOW PLT COUNT-129* [**2142-3-23**] 12:00PM GLUCOSE-77 UREA N-31* CREAT-6.0*# SODIUM-137 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14 [**2142-3-23**] 12:00PM estGFR-Using this [**2142-3-23**] 12:00PM CALCIUM-8.4 PHOSPHATE-5.7* MAGNESIUM-1.9 [**2142-3-23**] 12:00PM WBC-3.7* RBC-2.87* HGB-8.7* HCT-26.1* MCV-91 MCH-30.3 MCHC-33.3 RDW-19.4* [**2142-3-23**] 12:00PM PLT COUNT-130* [**2142-3-23**] 12:00PM PT-28.8* PTT-58.6* INR(PT)-2.9* Brief Hospital Course: The patient was admitted to the MICU on a NTG gtt from the ED. Her abdominal pain had imporved and she was eating crackers and peanut butter. She was given her usual afternoon home medications, and transitioned to a Nicardipine gtt, which has worked well for her in the past. Her BP goal was for a systolic of 180-200. The Nicardipine gtt was titrated off quickly and she was transfered to the floor. . On arrival to the floor, she in fact missed her morning medications on [**Month/Day/Year 766**]. This resulted in elevate blood pressures requiring IV hydralazing for control. She went to dialyisis Tuesday [**3-27**] and again had markedly elevated blood pressures while at [**Month/Year (2) 2286**] from missing her AM doses. Instructions were written for explicit AM administration and Nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. She was continued on labetalol 900mg TID, Aliskerin, Hydralazine 100mg po TID, and clonidine patch 0.4mg/24 weekly patch. . HEr BP remained relativly stable. She established a three three times weekly Dialysus regemin. A PAP smear was attempted due to her history of CIN I and no PCP follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . Her abdominal pain was also a chronic issue, which appeared stable. She was not administered IV narcotics, only PO. It was wihtout clear percipitating events or etiology. She will need GI follow up. She was contact[**Name (NI) **] by phone several times to arrange a GI follow up appointment but did not return messages. She has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . She was discharged to followup with her nephrologist, Dr. [**Last Name (STitle) 4883**]. . 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. Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Last Name (STitle) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2* 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). [**Last Name (STitle) **]:*405 Tablet(s)* Refills:*2* 5. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*2* 6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). [**Last Name (STitle) **]:*60 Tablet(s)* Refills:*2* 9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patches Transdermal once a week: Place two patches every week on Fridays. [**Last Name (STitle) **]:*8 Patches* Refills:*2* 10. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*0* 11. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO twice a day as needed for prn SBP>200: if nauseated and cannot keep down meds, may use 1 sublingual clonidine if sbp>200. . [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0* 12. Kayexalate Powder Sig: Thirty (30) grams PO once a day for 2 days: please take [**2142-4-1**] and [**2142-4-2**] for elevated potassium. [**Month/Day/Year **]:*240 grams* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Systemic Lupus Erythematosus End Stage Renal Disease Hypertension Abdominal Pain Discharge Condition: Blood pressure stable and abdominal pain at baseline Discharge Instructions: You were admitted with high blood pressure. You were in the ICU overnight for treatment. Some of your medications were changed and you were increased to three times weekly [**Location (un) 2286**]. Your abdominal pain is a difficult problem, as the reason for the pain is unclear. [**Name2 (NI) **] were continued on oral dilaudid. IV dilaudid is strongly discouraged and will continue to be in the future. You are now taking Nifedipine SR 30mg at night in addition to 90mg in the morning. Your other medications were the same. At home, if your blood pressure is above 200, then take 100mg hydralazine. If after 1 hour, your blood pressure does not decrease to below 200 with this, then take another 100mg hydralazine. If you are nauseated and cannot take in oral meds, then take sublingual clonidine, then wait 1 hour and repeat if BP still > 200. Finally, your potassium has been high. Please take kayexalate 30gm tomorrow and the next day. Followup Instructions: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-3-31**] 7:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule appointment We will attempt to contact you on [**Name (NI) 766**] with appointment times for you. ",99,2142-03-24 16:34:00,2142-03-31 15:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," the patient was admitted to the micu on a ntg gtt from the ed. her abdominal pain had imporved and she was eating crackers and peanut butter. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. her bp goal was for a systolic of 180-200. the nicardipine gtt was titrated off quickly and she was transfered to the floor. . on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**]. this resulted in elevate blood pressures requiring iv hydralazing for control. she went to dialyisis tuesday [**3-27**] and again had markedly elevated blood pressures while at [**month/year (2) 2286**] from missing her am doses. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she was continued on labetalol 900mg tid, aliskerin, hydralazine 100mg po tid, and clonidine patch 0.4mg/24 weekly patch. . her bp remained relativly stable. she established a three three times weekly dialysus regemin. a pap smear was attempted due to her history of cin i and no pcp follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . her abdominal pain was also a chronic issue, which appeared stable. she was not administered iv narcotics, only po. it was wihtout clear percipitating events or etiology. she will need gi follow up. she was contact[**name (ni) **] by phone several times to arrange a gi follow up appointment but did not return messages. she has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . she was discharged to followup with her nephrologist, dr. [**last name (stitle) 4883**]. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Long-term (current) use of steroids; Other chronic pain; Obstructive sleep apnea (adult)(pediatric); Abdominal pain, generalized; Hyperpotassemia]","the patient was admitted to the micu on a ntg gtt from the ed. her bp goal was for a systolic of 180-200. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she established a three three times weekly dialysus regemin.","the patient was admitted to the micu on a nicardipine gtt from the ed. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**] this resulted in elevate blood pressures requiring iv hydralazing for control " 109,131376.0,14862,2142-07-08,14810,137510.0,2142-04-22,Discharge summary,"Admission Date: [**2142-4-20**] Discharge Date: [**2142-4-22**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 1253**] Chief Complaint: Dyspnea, malignant hypertension Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented with abdominal pain and shortness of breath. On [**2142-4-19**] she refused ultrafiltration at HD because she was at her dry weight. Awoke at 3 AM feeling more short of breath. She also had worsening abdominal pain and vomiting without hematemasis. She took all of her medications as prescribed including two new lidocaine patches, fentanyl patch and clonidine. She developed a slight frontal headache but no blurry vision or neurologic symptoms. ROS largely negative. . In the emergency room her initial vitals were T: 99.1 BP: 280/140 HR: 79 RR: 16 O2: 100% on RA. She had two large bore peripheral IVs placed. She received 100 mg PO hydralazine, 200 mg PO labetolol, zofran 4 mg IV, vancomycin 1 gram IV, levofloxacin 750 mg IV x 1 and was started on labetolol and nitroglycerin drips with control of her blood pressure to the 180s systolic. She had a CXR which was concerning for volume overload. She was admitted the MICU for further evaluation. . In the MICU she was stablized and transitioned to her home meds. Nephrology gave her HD with 2L UF and subjective improvement in SOB. . Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: On Admission per MICU team: Vitals: T: 96.5 BP: 162/120 HR: 79 RR: 13 O2: 100% on 4L General: Pleasant, comfortable, no distress HEENT: L eye enucleated. Moon facies. Right pupil reactive Heart: Regular rate and rhythm, s1 + s2, soft systolic murmur at RLSB, no rubs or gallops Respiratory: Crackles at bases bilaterally, no wheezes, rales, ronchi GI: soft, non-tender, non-distended, +BS GU: no foley Ext: Warm and well perfused, no clubbing, cyanosis or edema . Pertinent Results: [**2142-4-19**] 08:35AM WBC-3.8* RBC-2.53* HGB-7.6* HCT-23.4* MCV-93 MCH-29.9 MCHC-32.3 RDW-19.9* [**2142-4-19**] 08:35AM PLT COUNT-93* . [**2142-4-19**] 08:35AM GLUCOSE-88 UREA N-36* CREAT-6.0* SODIUM-135 POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-25 ANION GAP-15 [**2142-4-19**] 08:35AM CALCIUM-9.4 PHOSPHATE-5.3* MAGNESIUM-2.0 . [**2142-4-20**] 08:40AM PT-28.3* PTT-45.3* INR(PT)-2.9* . CXR PA and LAT: IMPRESSION: 1. Persistent cardiomegaly with prominence of pulmonary vasculature suggesting overhydration. Minimal costophrenic angle blunting may suggest small effusions. 2. No definite consolidation, although increased retrocardiac density is noted, most likely due to atelectasis and vascular congestion. Repeat imaging following diuresis could be considered. . INR trend: [**2142-4-19**] 09:30AM BLOOD PT-30.4* INR(PT)-3.1* [**2142-4-20**] 08:40AM BLOOD PT-28.3* PTT-45.3* INR(PT)-2.9* [**2142-4-21**] 04:07AM BLOOD PT-29.9* PTT-48.9* INR(PT)-3.1* [**2142-4-22**] 05:55AM BLOOD PT-33.3* PTT-54.1* INR(PT)-3.5* Brief Hospital Course: 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented to the ICU for hypertensive emergency, dyspnea, and headache, now resolved. . Hypertensive Emergency: Patient's blood pressure normalized with transient nitroglycerin and labetalol drips. Likely precipitated by lack of ultrafiltration at [**Year/Month/Day 2286**] yesterday. She has received [**Year/Month/Day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - Nifedipine 150 mg Tablet SR daily - Hydralazine 100 mg Tablet Q8H - Labetalol 1000 mg Tablet TID - Aliskiren 150 mg Tablet PO BID - Clonidine 0.2 mg/24 hr Patch Weekly - Hydralazine 100 mg PO PRN for SBP > 200 - continue regular [**Year/Month/Day 2286**] schedule . Social Issues/repeated admissions: The ICU and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. These episodes may be due to medication non-compliance and it may benefit Ms. [**Known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. Ms. [**Known lastname **] [**Last Name (Titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. Of note, she has missed [**Last Name (Titles) 2286**] sessions and often requests durations and flow rates for her [**Last Name (Titles) 2286**] that contradict recommendations by her nephrologist. This issue was left unresolved on discharge. . Chronic Abdominal Pain: Currently managed with PO dilaudid, fentanyl patch and lidocaine patch. Per MICU team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue PO dilaudid - continue lidocaine patch . Lupus Erythematous: Complicated by uveitis and ESRD. - continued prednisone . ESRD: On [**Last Name (Titles) 2286**]. Ultrafiltrate of 2 L on initial HD - continue outpatient regimen . Thrombocytopenia: Remained at baseline 80s to 130s. . Thrombotic Events: History of SVC thrombosis with negative workup. INR drifted up and was 3.5 on discharge. She was asked to hold her warfarin dose this PM and recheck her INR with VNA services on [**2142-4-23**] to be faxed to coumadin clinic in [**Company 191**]. - continued coumadin . Anemia: Hematocrit 24.5 initially. Baseline 23 to 28. . Medications on Admission: Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H Prednisone 1 mg Tablet Citalopram 20 mg Tablet Pantoprazole 40 mg Tablet, Warfarin 3 mg daily Gabapentin 300 mg TID Nifedipine 90 mg Tablet SR daily Nifedipine 60 mg Tablet SR daily Hydralazine 100 mg Tablet Q8H Labetalol 1000 mg Tablet TID Aliskiren 150 mg Tablet PO BID Clonidine 0.2 mg/24 hr Patch Weekly Docusate Sodium 100 mg Capsule PO BID Senna 8.6 mg Tablet Fentanyl 25 mcg/hr Patch 72 hr Lidocaine 5 %(700 mg/patch) daily Hydralazine 100 mg PO:PRN for SBP > 200 Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) 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 3 mg Tablet Sig: One (1) Tablet PO once a day: DO NOT TAKE DOSE ON [**2142-4-22**]. Then restart per your PCP. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QHS (once a day (at bedtime)). 9. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 10. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 17. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed: For systolic blood pressure > 200. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Malignant Hypertension Systemic Lupus Erythematosus End Stage Renal Disease Abdominal Pain Discharge Condition: good, VSS, on room air, pain controlled. Discharge Instructions: You came to the hospital for shortness of breath and hypertension. You were given antihypertensive drips and during [**Location (un) 2286**] 2 liters were taken off with good improvement in your shortness of breath. You will need to take your medications as prescribed and follow-up with all of your doctors to prevent coming into the hospital. . Medication changes: - Please do not take your coumadin tonight because your INR is too high. You will need to have it checked by VNA services and adjusted. - Please take ALL of your medications as prescribed. . Please call your doctor or return to the ED if you have intractable headaches, shortness of breath, intractable pain or other concerns. Followup Instructions: Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-4-26**] 3:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Completed by:[**2142-4-23**]",77,2142-04-20 13:39:00,2142-04-22 15:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,PULMONARY EDEMA;HYPERTENSION," 24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. . hypertensive emergency: patients blood pressure normalized with transient nitroglycerin and labetalol drips. likely precipitated by lack of ultrafiltration at [**year/month/day 2286**] yesterday. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - nifedipine 150 mg tablet sr daily - hydralazine 100 mg tablet q8h - labetalol 1000 mg tablet tid - aliskiren 150 mg tablet po bid - clonidine 0.2 mg/24 hr patch weekly - hydralazine 100 mg po prn for sbp > 200 - continue regular [**year/month/day 2286**] schedule . social issues/repeated admissions: the icu and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. these episodes may be due to medication non-compliance and it may benefit ms. [**known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. ms. [**known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. this issue was left unresolved on discharge. . chronic abdominal pain: currently managed with po dilaudid, fentanyl patch and lidocaine patch. per micu team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue po dilaudid - continue lidocaine patch . lupus erythematous: complicated by uveitis and esrd. - continued prednisone . esrd: on [**last name (titles) 2286**]. ultrafiltrate of 2 l on initial hd - continue outpatient regimen . thrombocytopenia: remained at baseline 80s to 130s. . thrombotic events: history of svc thrombosis with negative workup. inr drifted up and was 3.5 on discharge. she was asked to hold her warfarin dose this pm and recheck her inr with vna services on [**2142-4-23**] to be faxed to coumadin clinic in [**company 191**]. - continued coumadin . anemia: hematocrit 24.5 initially. baseline 23 to 28. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Unspecified iridocyclitis; Other primary cardiomyopathies; Unspecified disease of pericardium; ; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Noncompliance with renal dialysis; Personal history of noncompliance with medical treatment, presenting hazards to health; Surgical or other procedure not carried out because of patient's decision; Abdominal pain, left lower quadrant; Renal dialysis status; Thrombocytopenia, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Peripheral vascular disease, unspecified; Acquired absence of organ, eye; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus]","24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. ultrafiltrate of 2 l on initial hd - continue outpatient regimen .","malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips." 109,196721.0,14863,2142-07-23,14858,151240.0,2142-05-18,Discharge summary,"Admission Date: [**2142-5-15**] Discharge Date: [**2142-5-18**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 613**] Chief Complaint: Headache, Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis x 2 History of Present Illness: 24 year old female with SLE, ESRD on HD, hx malignant HTN, h/o SVC syndrome, h/o posterior reversible encephalopathy syndrome (PRES) and prior intracerebral hemorrhage, recently admitted [**Date range (1) 17717**] with diarrhea, hypertensive urgency. Treated at that time with nicardipine drip for a short period and then to her home regimen. Yesterday onset of nausea with emesis and inability to tolerate home meds including antihypertensives. Diarrhea mild as prior. No fever, chills, no hematemesis or hematochezia. No melena. Today reports onset of headache therefore to the ED. In the ED, initial vs were 280/160, 99.4, 105, RR 18. She was given dilaudid 2 mg PO x 2. Hydral 20 mg x 3 for BP. Calcium gluconate 1 gram. Insulin 10 units, D 50 [**1-12**] amp, sodium bicarbonate, kayexalate for K 6.7 (dialysis dependent Tues/thurs/sat) but with report of peaked T waves. Renal dialysis fellow was not contact[**Name (NI) **]. HCT 33.4, WBC 4.6, trop 0.10. Admitted for hypertensive urgency to ICU. No gtt was started. Of note usualy BP 160/100. Review of sytems: patient tearful complaining of frontal headache and nausea Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: Vitals: BP 240/146, 101, 98.6, General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardic, 3/6 SEM RUSB Abdomen: soft, diffusely tender, no rebound or gaurding. Ext: cachectic, warm, 2+ DP pulse no clubbing, cyanosis or edema Pertinent Results: [**2142-5-15**] 05:45AM GLUCOSE-83 UREA N-54* CREAT-7.6* SODIUM-138 POTASSIUM-6.7* CHLORIDE-103 TOTAL CO2-23 ANION GAP-19 [**2142-5-15**] 05:45AM CK(CPK)-96 [**2142-5-15**] 05:45AM cTropnT-0.10* [**2142-5-15**] 05:45AM CK-MB-NotDone [**2142-5-15**] 05:45AM WBC-4.6 RBC-3.66* HGB-10.8* HCT-33.4* MCV-91 MCH-29.6 MCHC-32.4 RDW-17.9* [**2142-5-15**] 05:45AM NEUTS-65.4 LYMPHS-25.1 MONOS-4.8 EOS-4.1* BASOS-0.7 [**2142-5-15**] 05:45AM PLT COUNT-128* [**2142-5-15**] 05:45AM PT-14.2* PTT-36.4* INR(PT)-1.2* [**2142-5-15**] 07:14AM K+-6.0* [**2142-5-15**] 12:17PM K+-5.3 Images: CXR: Persistent severe cardiomegaly. Head CT: Normal brain CT. Brief Hospital Course: 24 yo female with ESRD on HD, malignant hypertension with hx of intracerebral hemorrhage, SLE, chronic abdominal pain, and SVC syndrome admitted due to hypertensive urgency after developing N/V and being unable to take her po medications. # Hypertensive urgency: The patient was admitted to the MICU the night of admission where she was placed on a labetolol drip and her home medications were restarted. head CT was negative for intracranial bleed. She was continued on her home regimen of Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet Sustained Release QAM, and Hydralazine 100 mg PO Q8H. During her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. Blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). She was discharged on her home regimen. # Nausea/vomiting: The patient did not experience further vomiting, but occasionally complained of nausea. The cause of her nausea was unclear. She was able to tolerate po intake prior to discharge. # Abdominal pain/Diarrhea: The patient has chronic abdominal pain with previous negative workups. During this hospitalization her pain was at its baseline. Since admission she denied diarrhea. She was continued on her outpatient regimen of [**2-14**] mg po dilaudid q4h as needed. # ESRD on HD: She was hyperkalemic in the emergency room and was given kayexalate. She underwent two sessions of dialysis during this hospitalization. # SLE: Stable, without symptoms. She was continued on 4 mg of prednisone daily. # History of thrombotic events/SVC syndrome: She is anticoagulated with warfarin as an outpatient, however her INR was subtherapeutic on admission at 1.2. Previous documentation in OMR states she does not need to be bridged while subtherapeutic. She was initally continued on coumadin 4 mg po daily, however her INR rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # OSA: She is on CPAP at a setting of 7 as an outpatient and was continued on this during her hospitalization. Medications on Admission: Medications: as per last discharge summary -Aliskiren 150 mg Tablet [**Hospital1 **] -Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday) -Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). -Labetalol 200 mg Tablet Sig 5 tab TID -Nifedipine 60 mg Tablet Sustained Release QPM -Nifedipine 90 mg Tablet Sustained Release QAM -Citalopram 20 mg Tablet Sig daily -Hydromorphone 2 mg Tablet Sig [**1-12**] Q4 PRN -Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). -Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H -Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID PRN -Prednisone 4 mg daily -Coumadin 4 mg daily at 4 PM Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QPM (once a day (in the evening)). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 10. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO twice a day as needed for hypertension. 13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary - Hypertensive urgency End-stage renal disease on dialysis Secondary - Systemic lupus erythematous History of thombosis and Superior vena cava syndrome Obstructive sleep apnea Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital due to dangerously elevated blood pressure due to inability to take your medications secondary to nausea. It is very important that you take your blood pressure medications reguarly. Your nausea was controlled with medication and your blood pressure decreased once back on your home medication regimen. You underwent two sessions of dialysis during your hospitalization. It is extremely important that you attend dialysis three times weekly as an outpatient. Medication changes: You should be taking 3 mg of coumadin daily. You will need to have your INR checked at dialysis. Otherwise continue your outpatient medications as prescribed. Call your primary doctor, or go to the emergency room if you experience fevers, chills, worsening headache, vision change, inability to take your medications, blood in your stool, or dark black stool. Followup Instructions: It is very important that you keep your previously scheduled appointments: You have an appointment with gynecology to evaluate an abnormality recently seen on PAP smear. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-6-1**] 2:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-5-19**]",66,2142-05-15 10:45:00,2142-05-18 15:58:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSIVE CRISIS," 24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. # hypertensive urgency: the patient was admitted to the micu the night of admission where she was placed on a labetolol drip and her home medications were restarted. head ct was negative for intracranial bleed. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, and hydralazine 100 mg po q8h. during her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). she was discharged on her home regimen. # nausea/vomiting: the patient did not experience further vomiting, but occasionally complained of nausea. the cause of her nausea was unclear. she was able to tolerate po intake prior to discharge. # abdominal pain/diarrhea: the patient has chronic abdominal pain with previous negative workups. during this hospitalization her pain was at its baseline. since admission she denied diarrhea. she was continued on her outpatient regimen of [**2-14**] mg po dilaudid q4h as needed. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. she underwent two sessions of dialysis during this hospitalization. # sle: stable, without symptoms. she was continued on 4 mg of prednisone daily. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient, however her inr was subtherapeutic on admission at 1.2. previous documentation in omr states she does not need to be bridged while subtherapeutic. she was initally continued on coumadin 4 mg po daily, however her inr rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # osa: she is on cpap at a setting of 7 as an outpatient and was continued on this during her hospitalization. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other primary cardiomyopathies; Unspecified disease of pericardium; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Hyperpotassemia; Nausea with vomiting; Diarrhea; Disorders of phosphorus metabolism; Anemia of other chronic disease; Abdominal pain, left lower quadrant; Other chronic pain; Thrombocytopenia, unspecified; Other specified peripheral vascular diseases; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus; Long-term (current) use of anticoagulants; Noncompliance with renal dialysis; Renal dialysis status; Personal history of noncompliance with medical treatment, presenting hazards to health]","24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. she was able to tolerate po intake prior to discharge. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. previous documentation in omr states she does not need to be bridged while subtherapeutic.","24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg" 109,196721.0,14863,2142-07-23,14859,102024.0,2142-06-05,Discharge summary,"Admission Date: [**2142-5-20**] Discharge Date: [**2142-6-5**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 3705**] Chief Complaint: abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname **] is a 24 yo F with lupus since age 16, with ESRD on HD, malignant HTN, history of SVC syndrome, and history of Posterior Reversible Encephalopathy Syndrome (PRES) and intracerebral hemorrhage, who has had multiple recent admissions [**Date range (1) 43604**], [**Date range (1) 17717**], [**Date range (1) **], [**4-26**], [**Date range (1) 42063**], [**Date range (1) 43605**] mostly for hypertension, but most recently for diarrhea in addition to hypertension. . In the ED, vitals were 98 90 102/65 20 98% RA. She was complaining of abdominal pain X 3 hours, more severe than usual [**7-20**], no N/V/D. She received dilaudid 4 mg PO X 3, zofran 8mg IV, hyperkalemia 6.2=>5.3 w/ Kayexalate. Initially, she was felt stable for floor; however, BP rose during ED course to SBP 270. She then received hydral 50 PO X 1, home aliskeren, labetalol 1000 PO X 1, 20 IV hydral X 2, labetalol 100 Iv X 1, nicardipine 2.5 mg IV X 1 and started on nicardipine gtt. . Upon arrival to the floor, she complains of severe abd pain which started earlier today, it is sharp all over her abd and constant. It feels different from her usual abd pain, although she is not able to characterize it more. She has been having some nausea and bilious emesis X 1 earlier today. She has been having some mild diarrhea 2-3 episodes of loose, greenish stools for the past few weeks. She denies any chest pain, headache, vision changes. She was not able to take all of the medications due to her GI distress. . While in the MICU she was weaned off a nicardipine drip and her diarrhea resolved. Her BP remained WNL while on her home regimen and she was transferred to the floor in stable condition. Last HD was [**2142-5-21**]. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**] and [**2142-4-12**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting - has appt scheduled with gyn on [**5-25**] 17. History of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] which has resolved Social History: Denies any substance abuse (EtOH, tobacco, illicits). She lives with her mother and brother. 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: 100/63 81 18 100RA GENERAL: Pleasant, thin young female sitting in the bed in NAD watching TV. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. s/p left eye enucleation. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD. CARDIAC: RRR. 4/6 systolic murmur heard best at the RUSB. LUNGS: Breathing comfortably, CTAB, good air movement biaterally. ABDOMEN: + BS, soft ND, tenderness to palpation in her LUQ. No rebound or guarding. EXTREMITIES: No edema. Right femoral HD line nontender, nonerythematous. SKIN: Several subcutaneous cysts of different sizes 1 - 3 cm scattered along her lower extremities. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation to light touch throughout. 5/5 strength in her upper and lower extremities PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2142-5-20**] 09:14PM LACTATE-0.9 [**2142-5-20**] 09:13PM WBC-6.8 RBC-3.65* HGB-10.7* HCT-33.7* MCV-93 MCH-29.2 MCHC-31.6 RDW-18.8* [**2142-5-20**] 09:13PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ TEARDROP-OCCASIONAL [**2142-5-20**] 09:13PM PLT COUNT-145* [**2142-5-20**] 08:55PM GLUCOSE-98 UREA N-44* CREAT-7.7* SODIUM-137 POTASSIUM-6.3* CHLORIDE-102 TOTAL CO2-20* ANION GAP-21* [**2142-5-20**] 08:55PM CALCIUM-9.9 PHOSPHATE-5.8* MAGNESIUM-2.1 [**2142-5-20**] 08:55PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2142-5-20**] 08:55PM WBC-7.0 RBC-3.69* HGB-11.1* HCT-34.2* MCV-93 MCH-30.2 MCHC-32.5 RDW-19.2* [**2142-5-20**] 08:55PM PLT COUNT-126* [**2142-5-20**] 08:55PM PT-14.1* PTT-32.4 INR(PT)-1.2* [**2142-5-20**] 07:40AM ALT(SGPT)-18 AST(SGOT)-55* ALK PHOS-118* TOT BILI-0.4 [**2142-5-20**] 07:40AM LIPASE-58 Brief Hospital Course: KUB: SBO Head CT: (prelim read from radiology). unchanged from prior head CT, no intracranial hemorrhage EKG: NSR, right axis, LVH, nl intervals, ST elevations V2-3 (old), TW inversion V6 (new) compared to prior EKG [**5-15**]. CT CHEST/ABD: Preliminary Read Normal aorta without dissection or acute abnormality. No PE. Stable trace ascites and small right pleural effusion. Unchanged small pulmonary nodules and lymphadenopathy in the chest. No acute abnormalities in the abdomen to explain epigastric pain. EGD: Ulcer at GE junction. # Hypertensive urgency: This is a chronic issue related to ESRD. Head CT was negative for intracranial bleed. Weaned off Nicardipine gtt and BP well controlled on home regimen. Continued her home regimen of: Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet Sustained Release QAM, Hydralazine 100 mg PO Q8H. When BPs were lower (see below) patient's BP meds were held occasionally, but as she was transfused and the BPs started to trend back up the meds were re-initiated. She then developed hypotension in the setting of poor PO intake during her SBO. BP meds were held and then re-initiated as the pressure came back up once she was able to eat. # Abdominal pain/UGIB: The patient has chronic abdominal pain with previous negative workups. At first the pain resolved and she was continued on her outpatient regimen of: 2-4 mg po dilaudid q4 h as needed. GI was c/s re: abd pain and rec CTA-abdomen to eval for mesenteric ischemia vs. partial SBO, however with ESRD did not initially want to get CTA so KUB was ordered. This showed no SBO. They recommended checking urine porphyrobilinogen and serum lead levels which were negative and LFTs were at baseline. The patient then developed a different type of pain associated with her incision site. Pain service was consulted and did a bupivicaine injection at the site which did help. They will continue to follow her. She then developed a third type of pain associated with a burning sensation in her chest. EKG was unchanged from prior. A few hours later she had 3 episodes of coffee-ground emesis. She was placed on IV PPI and transfused two units of blood. Afterward the pain resolved and her hct remained stable. GI felt that the patient would need general anesthesia in order to undergo an EGD which showed an ulcer at the GE junction. She was started on empiric treatment for H. Pylori and serologies were sent which came back negative so the antibiotics were stopped. Her pain was controlled with her outpatient regimen of PO dilaudid. She will follow up with Dr. [**Last Name (STitle) **] in [**6-18**] weeks to have another EGD under MAC to see if there has been resolution of the ulcer. # SBO: Continued to be nauseous and vomited intermittently. she was started on reglan and continued on zofran and compazine PRN howeve she continued to have n/v. A KUB was done which showed an SBO. Surgery was consulted, NGT was placed, she was made NPO and serial abdominal exams were done. Eventually she was able to transition to clear diet and then tolerated a regular diet without pain or vomiting. #. Fever: On hospital day #6 she spiked a fever to 101. Blood and urine cultures were sent and a cxr were negative, however she then had a seizure and in the post-ictal state aspirated after vomiting. She had an episode of hypoxia with this and was transferred to the ICU. In the ICU LP was attempted to rule out meningitis as a possible cause of a seizure but this was unsuccessful. Broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. She improved over the next few days and antibiotics were discontinued because the suspicion for a bacterial meningitis was low. #. Seizure: This occured in the setting of fever, hypotension, and initiation of reglan for vomiting. Neurology was consulted and felt she should be continued on keppra indefinitely. EEG was non-revealing. She should be continued on keppra 1gm with dialysis three times weekly. # ESRD on HD: Hyperkalemia resolved with kayexalate. Underwent dialysis on normal schedule. # SLE: She was continued on prednisone 4mg daily. With multiple abdominal symptoms it was thought she may have lupus flare in the abdomen. C3, c4 were equivocal for active lupus flare, and [**Doctor First Name **] was positive, as would be expected in lupus. # Anemia: Has anemia of chronic renal disease and her Hct was high on admission and epo was held per renal. However, her Hct trended all the way down to 20 and she was borderline hypotensive for her (ie SBP 120) and she developed coffee ground emesis so she was transfused 2 units. Afterward her Hct was stable at 25. She was also re-started on EPO per renal for her chronic anemia. Hemolysis labs were negative. # History of thrombotic events/SVC syndrome: She is anticoagulated with warfarin as an outpatient. Previous documentation in OMR states she does not need to be bridged while subtherapeutic. Continued coumadin 4 mg po daily however INR became supratherapeutic and the coumadin was then held. She was started on heparin gtt while awaiting EGD. After EGD the coumadin was re-started at 3mg daily however, in setting of poor po intake her INR was supratherapeutic - likely [**2-12**] nutritional deficiency of vitamin k. coumadin will be restarted when INR [**2-13**] at dialysis. # OSA: She is on CPAP at a setting of 7 as an outpatient. Continued CPAP #. CIN1: On last pap had CIN1. OB/GYN service was called re: doing colposcopy in hospital as patient rarely makes o/p appointments, hwoever they do not do this procedure in hospital especially because it does not have to be done emergently - just within one year. Will need outpatient colposcopy at some point in next few months as they do not do this procedure in the hospital. # RLL nodule: A new 10 x 5 mm nodularity was found incidentally within the right lower lobe of the lung on an abdominal CT. This should be reassessed in 3 months. # ACCESS: PIV, right groin HD line # CODE: Full code Medications on Admission: 1. Aliskiren 150 mg PO bid 2. Citalopram 20 mg PO DAILY 3. Clonidine 0.2 mg/24 hr Patch Weekly QSAT 4. Hydromorphone 2 mg 1-2 Tablets PO Q4H 5. Fentanyl 25 mcg/hr Patch 72 hr 6. Gabapentin 300 mg PO TID 7. Hydralazine 100 mg PO Q8H 8. Hydralazine 100 mg PO BID PRn fro SBP> 180. 9. Prednisone 4 mg PO DAILY 10. Pantoprazole 40 mg PO Q24H 11. Labetalol 1000 mg PO TID 12. Nifedipine 90 mg PO QAM 13. Nifedipine 60 mg PO QHS 14. Warfarin 3 mg PO Once Daily 15. Lidocaine 5 %(700 mg/patch) Topical once a day. 16. Nifedipine 90 mg PO once a day as needed for for SBP persistently above 200. Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 2. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QHS (once a day (at bedtime)). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 30 days. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 16. LeVETiracetam 1,000 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: UGIB- Ulcer at GE junction Hypertensive Emergency Anemia ESRD on HD SBO Discharge Condition: The patient was afebrile and hemodynamically stable prior to discharge. Discharge Instructions: You were admitted to the hospital with abdominal pain. You had an injection of lidocaine to help the pain around your surgery sites. You then had some blood in your vomit. You were treated for a bleed in your stomach with a blood transfusion and medications. You stopped bleeding and felt better. You had a scope of your abdomen that showed an ulcer. You were treated with medications for this and need to have another scope of your abdomen in 6 weeks. You also had high blood pressures while you were here because you could not take your medicines with your nausea and vomiting. Once you were on your home medicines your blood pressure was better. Medication Changes: CHANGE: Pantoprazole to 40mg TWICE daily Please call your PCP or come to the emergency room if you have fevers, chills, worsening abdominal pain, nausea, vomiting, blood in your vomit, blood in your stools, black/tarry stools or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] (gastroenterology) in [**6-18**] weeks for an EGD to re-look at your ulcer. Please follow up with the OB/[**Hospital **] clinic for a colposcopy on Wednesday [**2142-8-8**] at 3:15pm in the [**Hospital Ward Name 23**] Building on the [**Location (un) **]. Their number is [**Telephone/Fax (1) 2664**]. Please follow up with Dr.[**Name (NI) **] at [**Hospital6 733**] in the Shapria building on the [**Location (un) **] on [**2142-6-27**] at 2:00pm. Completed by:[**2142-6-6**]",48,2142-05-20 12:59:00,2142-06-05 16:18:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," kub: sbo head ct: (prelim read from radiology). unchanged from prior head ct, no intracranial hemorrhage ekg: nsr, right axis, lvh, nl intervals, st elevations v2-3 (old), tw inversion v6 (new) compared to prior ekg [**5-15**]. ct chest/abd: preliminary read normal aorta without dissection or acute abnormality. no pe. stable trace ascites and small right pleural effusion. unchanged small pulmonary nodules and lymphadenopathy in the chest. no acute abnormalities in the abdomen to explain epigastric pain. egd: ulcer at ge junction. # hypertensive urgency: this is a chronic issue related to esrd. head ct was negative for intracranial bleed. weaned off nicardipine gtt and bp well controlled on home regimen. continued her home regimen of: aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, hydralazine 100 mg po q8h. when bps were lower (see below) patients bp meds were held occasionally, but as she was transfused and the bps started to trend back up the meds were re-initiated. she then developed hypotension in the setting of poor po intake during her sbo. bp meds were held and then re-initiated as the pressure came back up once she was able to eat. # abdominal pain/ugib: the patient has chronic abdominal pain with previous negative workups. at first the pain resolved and she was continued on her outpatient regimen of: 2-4 mg po dilaudid q4 h as needed. gi was c/s re: abd pain and rec cta-abdomen to eval for mesenteric ischemia vs. partial sbo, however with esrd did not initially want to get cta so kub was ordered. this showed no sbo. they recommended checking urine porphyrobilinogen and serum lead levels which were negative and lfts were at baseline. the patient then developed a different type of pain associated with her incision site. pain service was consulted and did a bupivicaine injection at the site which did help. they will continue to follow her. she then developed a third type of pain associated with a burning sensation in her chest. ekg was unchanged from prior. a few hours later she had 3 episodes of coffee-ground emesis. she was placed on iv ppi and transfused two units of blood. afterward the pain resolved and her hct remained stable. gi felt that the patient would need general anesthesia in order to undergo an egd which showed an ulcer at the ge junction. she was started on empiric treatment for h. pylori and serologies were sent which came back negative so the antibiotics were stopped. her pain was controlled with her outpatient regimen of po dilaudid. she will follow up with dr. [**last name (stitle) **] in [**6-18**] weeks to have another egd under mac to see if there has been resolution of the ulcer. # sbo: continued to be nauseous and vomited intermittently. she was started on reglan and continued on zofran and compazine prn howeve she continued to have n/v. a kub was done which showed an sbo. surgery was consulted, ngt was placed, she was made npo and serial abdominal exams were done. eventually she was able to transition to clear diet and then tolerated a regular diet without pain or vomiting. #. fever: on hospital day #6 she spiked a fever to 101. blood and urine cultures were sent and a cxr were negative, however she then had a seizure and in the post-ictal state aspirated after vomiting. she had an episode of hypoxia with this and was transferred to the icu. in the icu lp was attempted to rule out meningitis as a possible cause of a seizure but this was unsuccessful. broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. she improved over the next few days and antibiotics were discontinued because the suspicion for a bacterial meningitis was low. #. seizure: this occured in the setting of fever, hypotension, and initiation of reglan for vomiting. neurology was consulted and felt she should be continued on keppra indefinitely. eeg was non-revealing. she should be continued on keppra 1gm with dialysis three times weekly. # esrd on hd: hyperkalemia resolved with kayexalate. underwent dialysis on normal schedule. # sle: she was continued on prednisone 4mg daily. with multiple abdominal symptoms it was thought she may have lupus flare in the abdomen. c3, c4 were equivocal for active lupus flare, and [**doctor first name **] was positive, as would be expected in lupus. # anemia: has anemia of chronic renal disease and her hct was high on admission and epo was held per renal. however, her hct trended all the way down to 20 and she was borderline hypotensive for her (ie sbp 120) and she developed coffee ground emesis so she was transfused 2 units. afterward her hct was stable at 25. she was also re-started on epo per renal for her chronic anemia. hemolysis labs were negative. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient. previous documentation in omr states she does not need to be bridged while subtherapeutic. continued coumadin 4 mg po daily however inr became supratherapeutic and the coumadin was then held. she was started on heparin gtt while awaiting egd. after egd the coumadin was re-started at 3mg daily however, in setting of poor po intake her inr was supratherapeutic - likely [**2-12**] nutritional deficiency of vitamin k. coumadin will be restarted when inr [**2-13**] at dialysis. # osa: she is on cpap at a setting of 7 as an outpatient. continued cpap #. cin1: on last pap had cin1. ob/gyn service was called re: doing colposcopy in hospital as patient rarely makes o/p appointments, hwoever they do not do this procedure in hospital especially because it does not have to be done emergently - just within one year. will need outpatient colposcopy at some point in next few months as they do not do this procedure in the hospital. # rll nodule: a new 10 x 5 mm nodularity was found incidentally within the right lower lobe of the lung on an abdominal ct. this should be reassessed in 3 months. # access: piv, right groin hd line # code: full code ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction; Acute posthemorrhagic anemia; Unspecified intestinal obstruction; Other primary cardiomyopathies; Unspecified disease of pericardium; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Disorders of phosphorus metabolism; Hypotension, unspecified; Hyperpotassemia; Mononeuritis of unspecified site; Anemia of other chronic disease; Abdominal pain, left lower quadrant; Other chronic pain; Thrombocytopenia, unspecified; Diaphragmatic hernia without mention of obstruction or gangrene; Other specified peripheral vascular diseases; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus; Noncompliance with renal dialysis; Renal dialysis status; Long-term (current) use of anticoagulants; Personal history of noncompliance with medical treatment, presenting hazards to health]","kub: sbo head ct: (prelim read from radiology). ct chest/abd: preliminary read normal aorta without dissection or acute abnormality. bp meds were held and then re-initiated as the pressure came back up once she was able to eat. gi was c/s re: abd pain and rec cta-abdomen to eval for mesenteric ischemia vs. partial sbo, however with esrd did not initially want to get cta so kub was ordered. a few hours later she had 3 episodes of coffee-ground emesis. afterward the pain resolved and her hct remained stable. gi felt that the patient would need general anesthesia in order to undergo an egd which showed an ulcer at the ge junction. her pain was controlled with her outpatient regimen of po dilaudid. broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. she should be continued on keppra 1gm with dialysis three times weekly. c3, c4 were equivocal for active lupus flare, and [**doctor first name **] was positive, as would be expected in lupus. # anemia: has anemia of chronic renal disease and her hct was high on admission and epo was held per renal.","sbo head ct was negative for intracranial hemorrhage. no intracranial hemorrhage ekg: nsr, right axis, lvh, nl intervals, st elevations v2-3 (old), tw inversion v6 (new) no acute abnormalities in the abdomen to explain epigastric pain." 109,196721.0,14863,2142-07-23,14860,136572.0,2142-06-20,Discharge summary,"Admission Date: [**2142-6-18**] Discharge Date: [**2142-6-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 2145**] Chief Complaint: Acute Onset Dyspnea Major Surgical or Invasive Procedure: Dialysis History of Present Illness: Please see MICU note for full details. In brief this is a 24 y.o. woman with SLE, ESRD on HD, hx malignant HTN, h/o SVC syndrome, h/o posterior reversible encephalopathy syndrome (PRES) and prior intracerebral hemorrhage, frequently admitted with hypertensive urgency/emergency who was admitted with acute onset dyspnea after 2 weeks without dialysis given to unable to get transportation ? despite Dr. [**Last Name (STitle) 7473**] attempting to arrange transport for her (? refused to come). She was admitted therefore on [**6-18**] to micu with VS: T 100.4 HR 108 BP 240/180 RR 28 POx100 RA. She was treated with nitro gtt, labetolol gtt and dilaudid-these gtts were stopped at 0700. In the micu she was dialyzed with 1.7L fluid removal (though + 300cc given tranfusion). Her SOB is improved. Her hct was also noted to be low (18->from 22 [**2142-6-5**]) so transfused 2 units PRBC's, recent EGD with gastric ulcer [**5-29**], guaiac negative in ED, no BM in unit, hemolysis w/u negative. BP in icu 140/106 currently but of note was hypotensive on HD to 86/62. She notes sob improved rapidly on arrival. ROS: Currently she has no complaints. She notes at home her abdominal pain is at baseline for her, felt mid epigastric, for which she takes dilaudid 4mg up to [**Hospital1 **]. She has been getting HD via right femoral catheter which is not painful, no discharge from the sight. She denies HA, visual changes, cough, chest pain or pressure, orthostatic changes, palpitations, nausea, vomiting, constipation, diarrhea, melena, brbpr, dysuria, hematuria, rash, swelling, orthopnea, pnd. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Physical Exam: Vitals - T: 97.7, BP: 140/99 P: 88 R: 19 O2: 98% on RA General: Sleeping comfortably but awakens easily, alert, oriented x3 HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear, nonerythematous, MMM, moon facies Neck: supple, JVP flat, no LAD, full ROM, left EJ in place Lungs: coarse BS throughout, no W/R/R, no decreased BS at bases CV: S1, S2 nl, no m/r/g appreciated Abdomen: Firm, non-tender to palpation, no masses or organomegally Ext: Warm, well perfused, 1+ DP/PT, no clubbing, cyanosis or edema Neuro: a&o x3, motor [**5-15**] UE/LE bilaterally Pertinent Results: [**2142-6-18**] 05:28PM HCT-26.0*# [**2142-6-18**] 11:38AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL [**2142-6-18**] 05:04AM GLUCOSE-85 UREA N-72* CREAT-10.4* SODIUM-139 POTASSIUM-5.5* CHLORIDE-109* TOTAL CO2-14* ANION GAP-22* [**2142-6-18**] 05:04AM LD(LDH)-264* TOT BILI-0.2 [**2142-6-18**] 05:04AM CALCIUM-6.6* PHOSPHATE-6.5* MAGNESIUM-1.6 [**2142-6-18**] 05:04AM HAPTOGLOB-142 [**2142-6-18**] 05:04AM WBC-3.4* RBC-1.93* HGB-5.8* HCT-17.0* MCV-88 MCH-30.0 MCHC-34.2 RDW-18.4* [**2142-6-18**] 05:04AM PLT COUNT-97* [**2142-6-18**] 01:34AM GLUCOSE-84 UREA N-70* CREAT-10.5*# SODIUM-136 POTASSIUM-5.6* CHLORIDE-108 TOTAL CO2-14* ANION GAP-20 [**2142-6-18**] 01:34AM estGFR-Using this [**2142-6-18**] 01:34AM ALT(SGPT)-10 AST(SGOT)-39 ALK PHOS-108 TOT BILI-0.2 [**2142-6-18**] 01:34AM LIPASE-115* [**2142-6-18**] 01:34AM ALBUMIN-3.2* CALCIUM-6.6* PHOSPHATE-6.8* MAGNESIUM-1.7 [**2142-6-18**] 01:34AM WBC-4.5 RBC-2.08* HGB-6.0* HCT-18.3* MCV-88 MCH-28.6 MCHC-32.5 RDW-18.6* [**2142-6-18**] 01:34AM NEUTS-78.5* LYMPHS-16.5* MONOS-3.0 EOS-1.4 BASOS-0.6 [**2142-6-18**] 01:34AM PLT COUNT-104* [**2142-6-18**] 01:34AM PT-15.0* PTT-33.6 INR(PT)-1.3* Brief Hospital Course: # Dyspnea: Pt's dypsnea improved on admission to the ED prior to HD. Based on her imaging studies her dyspnea was likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. Upon transfer to the floor she was continued on her dialysis regimen and discharged on room air. # Anemia: Pt's baseline 1 month ago noted to be low 30s, since then her Hct has trended down to 22 several week prior to admission. As she missed dialysis she was not able to reserve her Eopgen which likely complicated her anemia. Pt underwent hemolysis workup in the ICU which was ultimately negative. She was given several units of PRBC and bumped her Hct appropriately. She was noted to be guaiac negative on examination. # Hypertension: Pt was initially admitted with hypertension. Following transition to the floor she was placed on her home regimen. She was noted to be hypotensive in dialysis which is likely due to her being on Labetalol, Nitro gtt on dialysis. Pt was discharged on her home BP regimen with follow up with her nephrologist. # Chronic Abdominal Pain: Pt had noted some intermittent abdominal pain which has been chronic. Lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. Pt was able to tolerate a PO diet prior to her discharge. Pt was continued on her outpatient regimen of Dilaudid, Fentanyl patch, Neurontin. # GE junction Ulcer: Pt was continued on her PPI regimen [**Hospital1 **]. # SLE: Pt was continued on her home regimen of Prednisone 4mg daily # History of DVT: Pt had a sub-therapeutic INR on admission. She was discharged on Warfarin 3mg daily. # ESRD on HD: Pt was admitted for dyspnea in the setting of missing 2 weeks of HD. The renal team followed Ms. [**Known lastname **] during her hospitalization and she was continued on her outpatient regimen of hemodialysis. Pt was continued on Sevelamer and Epogen. # Seizure D/O: Pt was continued on her home regimen of keppra. # Depression: Pt was continued on her home regimen of Celexa. Medications on Admission: 1. Nifedipine 90 mg Tablet Sustained Release PO QAM 2. Nifedipine 60 mg Tablet Sustained Release PO QHS 3. Lidocaine 5 % transdermal one daily 4. Aliskiren 150 mg PO BID 5. Citalopram 20 mg PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch Q72H (every 72 hours). 7. Prednisone 4mg PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Transdermal QSAT 9. Clonidine 0.3 mg/24 hr Patch Weekly Transdermal QSAT 10. Sevelamer HCl 400 mg Four (4) Tablet PO TID W/MEALS 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID 13. Hydralazine 100 mg PO Q8H 14. Hydromorphone 2 mg 1-2 Tablets PO Q6H as needed for pain. 15. Pantoprazole 40 mg PO Q12H 16. LeVETiracetam 1,000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24 H (). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK (TU,TH,SA). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Malignant HTN, ESRD on HD, Shortness of breath Secondary: Lupus Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted to the hospital after you noticed some shortness of breath. Whilst in the hospital you were noted to have a low blood level (anemia) and you some fluid in your lungs. We think your blood level was low because you were not receiving your Epo shots, we think the fluid is from not receiving dialysis. Before you were discharged from the hospital your breathing was better. We recommend that you continue going to dialysis. We made no changes to your medications. If you notice any fevers, chills, nausea, vomiting, shortness of breath, lightheadedness please return to the ED. Followup Instructions: Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 Provider: [**First Name4 (NamePattern1) **] [**Name Initial (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-6-27**] 2:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] ",33,2142-06-18 03:11:00,2142-06-20 16:34:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ANEMIA," # dyspnea: pts dypsnea improved on admission to the ed prior to hd. based on her imaging studies her dyspnea was likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. upon transfer to the floor she was continued on her dialysis regimen and discharged on room air. # anemia: pts baseline 1 month ago noted to be low 30s, since then her hct has trended down to 22 several week prior to admission. as she missed dialysis she was not able to reserve her eopgen which likely complicated her anemia. pt underwent hemolysis workup in the icu which was ultimately negative. she was given several units of prbc and bumped her hct appropriately. she was noted to be guaiac negative on examination. # hypertension: pt was initially admitted with hypertension. following transition to the floor she was placed on her home regimen. she was noted to be hypotensive in dialysis which is likely due to her being on labetalol, nitro gtt on dialysis. pt was discharged on her home bp regimen with follow up with her nephrologist. # chronic abdominal pain: pt had noted some intermittent abdominal pain which has been chronic. lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. pt was able to tolerate a po diet prior to her discharge. pt was continued on her outpatient regimen of dilaudid, fentanyl patch, neurontin. # ge junction ulcer: pt was continued on her ppi regimen [**hospital1 **]. # sle: pt was continued on her home regimen of prednisone 4mg daily # history of dvt: pt had a sub-therapeutic inr on admission. she was discharged on warfarin 3mg daily. # esrd on hd: pt was admitted for dyspnea in the setting of missing 2 weeks of hd. the renal team followed ms. [**known lastname **] during her hospitalization and she was continued on her outpatient regimen of hemodialysis. pt was continued on sevelamer and epogen. # seizure d/o: pt was continued on her home regimen of keppra. # depression: pt was continued on her home regimen of celexa. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Other primary cardiomyopathies; Unspecified disease of pericardium; Anemia of other chronic disease; Hyperpotassemia; Systemic lupus erythematosus; Abdominal pain, other specified site; Other chronic pain; Hypotension, unspecified; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Epilepsy, unspecified, without mention of intractable epilepsy; Depressive disorder, not elsewhere classified; Personal history of venous thrombosis and embolism; Noncompliance with renal dialysis]","# dyspnea: pts dypsnea improved on admission to the ed prior to hd. lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. # sle: pt was continued on her home regimen of prednisone 4mg daily # history of dvt: pt had a sub-therapeutic inr on admission. she was discharged on warfarin 3mg daily. # depression: pt was continued on her home regimen of celexa.",pts dypsnea improved on admission to the ed prior to hd. dyspnea likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. 109,196721.0,14863,2142-07-23,14861,174489.0,2142-07-04,Discharge summary,"Admission Date: [**2142-7-3**] Discharge Date: [**2142-7-4**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 2817**] Chief Complaint: dyspnea, hypertension Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24F h/o SLE, ESRD on HD, h/o malignant HTN, SVC syndrome, PRES, prior ICH, with frequent admission for hypertensive urgency/emergency, with chronic abdominal pain. She was recently discharged on [**7-1**] after presenting for hypertensive urgency and dyspnea for which she received iv medication in the ED, but was otherwised managed with oral antihypertensives and CPAP. . She was doing well until the evening of [**7-2**] when she notes the gradual onset of dyspnea. She denied f/c/cp/ha/abd pain/diarrhea, or constipation. She was having regular, soft, daily BMs. . On [**7-3**] she awoke, and describes n/v x 2, with increasing dyspnea, and headache. She did not want to wait until dialysis at 4PM and therefore presented to [**Hospital1 18**]. . In ED VS= 97.7 [**Telephone/Fax (2) 43606**] 100%RA. Labs were notable for HCT 23, PLT 66, WBC 3.3, all roughly at baseline. CXR without acute process, ECG unchanged from prior. No UA sent, though she does make some urine. She was started on nitro gtt with modest improvement of SBPs to 210s, then labetalol 20mg iv x1 followed by labetalol gtt with BP 221/130 at the time of transfer. She refused abdominal CT. Renal was consulted, but felt HD not indicated today. . . ROS: Negative for fevers, chills, chest pain, diarrhea, rash, joint pains. +n/v as above. +abdominal pain unchanged from her baseline. +dyspnea, +HA. denies visual changes, slurrring speech, numbness, weeakness. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Physical Exam: Vitals - 97.7 88 220/150 19 100%2L BC. General: A&Ox3. NAD, oriented x3. HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear, nonerythematous, MMM. Neck: supple, no LAD, full ROM. Lungs: CTA B, with few crackles at bases. CV: RR, nl S1, S2 +S3, no rubs appreciated. Abdomen: soft, minimally distended, diffuse mild tenderness to palpation, negative [**Doctor Last Name **], no rebound, gaurding. Ext: WWP, 1+ dp/pt pluses, no clubbing, cyanosis or edema. Neuro: CN 2-12 intact. moving all four extremities spontaneously. Pertinent Results: Lab Results on Admission: [**2142-7-3**] 11:37AM GLUCOSE-95 UREA N-40* CREAT-7.4*# SODIUM-140 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16 ALT(SGPT)-14 AST(SGOT)-44* LD(LDH)-264* ALK PHOS-115 TOT BILI-0.4 ALBUMIN-3.2* WBC-3.6* RBC-2.61* HGB-7.6* HCT-23.4* MCV-90 MCH-29.0 MCHC-32.4 RDW-18.3* [**2142-7-3**] 11:37AM NEUTS-71.6* LYMPHS-23.0 MONOS-3.7 EOS-1.5 BASOS-0.2 PLT COUNT-66* PT-14.0* PTT-34.5 INR(PT)-1.2* [**2142-7-3**] 06:00PM CK-MB-5 cTropnT-0.17*CK(CPK)-58 [**2142-7-3**] CXR: IMPRESSION: Unchanged moderate cardiomegaly with pulmonary edema. Again underlying pneumonia in the lung bases cannot be completely excluded and evaluation after appropriate diuresis could be performed if pneumonia remains a clinical concern. Brief Hospital Course: 24F with h/o SLE, ESRD on HD, malignant HTN, h/o SVC syndrome, PRES, prior ICH, and recent SBO, p/w n/v, and hypertensive urgency. . # hypertensive urgency - On presentation she denies chest pain, but continues to have mild headache, and resolving shortness of breath, likely [**2-12**] hypertension. states she did take her PO meds. Hypertensive urgency was treated as follows with nitro and labetalol gtt which were quickly weaned as blood pressures dropped below SBP 120. She evenutally became hypotensive to SBP of 90 which resolved on its own. She was continued on CPAP overnight and discontinued in the am. She was continued on her home regimen of oral labetolol, nifedipine, hydralazine, aliskerin. She remained normotensive the following morning and was taken to hemodialysis after which she was discharged home on all of her old home medications. . # abdominal pain - On presentation she was without n/v, soft abdomen, passing flatus, and having daily bowel movements. She did have hypoactive bowel sounds on admission. She was maintained on outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch, neurontin with HD with plan to follow BMs closley. Her pain improved the am of discharge and she had no further vomiting. . # ESRD on HD - She is currently getting HD SaTuTh, though did not get HD on the day of presenation. As there was no acute indication for HD on presentation, she received HD on the following am, day of discharge. She was continued on sevelamer. . # anemia - chronic anemia, likely [**2-12**] CKD and SLE, currently above baseline, though has h/o GIB. She received 2 unit PRBCs and epo with hemodialysis. . # h/o gastric ulcer - she was continued on her outpatient dose of PPI [**Hospital1 **]. . # SLE - continue home regimen of prednisone 4mg po qdaily. . # h/o SVC thrombosis - pt with goal INR [**2-13**], but this was stopped after recent admission [**2-12**] supratherapeutic INR. INR currently sub-therapeutic and she was resumed on warfarin at 3 mg qdaily without heparin bridge. . # seizure disorder - continued on keppra 1000 mg PO 3X/WEEK (TU,TH,SA). . # depression - continued on celexa. Medications on Admission: 1.Nifedipine 90 mg PO DAILY (Daily). 2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime). 3.Lidocaine 5 % PATCH Q24HR. 4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID 5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H 7.Prednisone 4 mg PO DAILY (Daily). 8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday). 9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday). 10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD 12.Labetalol 1000 mg Tablet Tablet PO TID 13.Hydralazine 100 mg Tablet PO Q8H 14.Warfarin 3 mg Tablet PO Once Daily at 4 PM. 15.Pantoprazole 40 mg PO Q12H (every 12 hours). 16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. 6. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for hypertension. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 12. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 13. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). Tablet(s) 14. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 15. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QTUTHSA (TU,TH,SA). Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Primary: hypertensive emergency anemia, erythropoetin deficiency Secondary: chronic renal failure on hemodialysis lupus nephritis Discharge Condition: Hemodynamically stable. Discharge Instructions: You were admitted for hypertensive urgency and treated in the intensvie care unit with IV medications to decrease your blood pressure. You also received 2 units of blood and hemodialysis before you were discharged home. It is essential that you take all of your prescribed blood pressure medications and present regularly for your Tuesday, Thursday, Saturday dialysis. Please return to the emergency department or call your primary care physician if you develop any chest pain, shortness of breath, fevers, or any other concerning symptoms. Followup Instructions: You have the following appointment scheduled. Please contact your provider if you are unable to make these appointments. Your dialysis is scheduled for Tuesday, Thursday, Saturday. Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-7-30**] 2:00 Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 ",19,2142-07-03 14:48:00,2142-07-04 17:23:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24f with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, p/w n/v, and hypertensive urgency. . # hypertensive urgency - on presentation she denies chest pain, but continues to have mild headache, and resolving shortness of breath, likely [**2-12**] hypertension. states she did take her po meds. hypertensive urgency was treated as follows with nitro and labetalol gtt which were quickly weaned as blood pressures dropped below sbp 120. she evenutally became hypotensive to sbp of 90 which resolved on its own. she was continued on cpap overnight and discontinued in the am. she was continued on her home regimen of oral labetolol, nifedipine, hydralazine, aliskerin. she remained normotensive the following morning and was taken to hemodialysis after which she was discharged home on all of her old home medications. . # abdominal pain - on presentation she was without n/v, soft abdomen, passing flatus, and having daily bowel movements. she did have hypoactive bowel sounds on admission. she was maintained on outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch, neurontin with hd with plan to follow bms closley. her pain improved the am of discharge and she had no further vomiting. . # esrd on hd - she is currently getting hd satuth, though did not get hd on the day of presenation. as there was no acute indication for hd on presentation, she received hd on the following am, day of discharge. she was continued on sevelamer. . # anemia - chronic anemia, likely [**2-12**] ckd and sle, currently above baseline, though has h/o gib. she received 2 unit prbcs and epo with hemodialysis. . # h/o gastric ulcer - she was continued on her outpatient dose of ppi [**hospital1 **]. . # sle - continue home regimen of prednisone 4mg po qdaily. . # h/o svc thrombosis - pt with goal inr [**2-13**], but this was stopped after recent admission [**2-12**] supratherapeutic inr. inr currently sub-therapeutic and she was resumed on warfarin at 3 mg qdaily without heparin bridge. . # seizure disorder - continued on keppra 1000 mg po 3x/week (tu,th,sa). . # depression - continued on celexa. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified iridocyclitis; Other primary cardiomyopathies; Abdominal pain, unspecified site; Other chronic pain; Nausea with vomiting; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other specified peripheral vascular diseases; Obstructive sleep apnea (adult)(pediatric); Anemia of other chronic disease; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Epilepsy, unspecified, without mention of intractable epilepsy; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism; Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits]","24f with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, p/w n/v, and hypertensive urgency. she remained normotensive the following morning and was taken to hemodialysis after which she was discharged home on all of her old home medications. # abdominal pain - on presentation she was without n/v, soft abdomen, passing flatus, and having daily bowel movements. # seizure disorder - continued on keppra 1000 mg po 3x/week (tu,th,sa).","malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, p/w n/v, and hypertensive urgency. hypertensive urgency was treated as follows with nitro and labetalol gtt which were quickly weaned as blood pressures dropped below sbp 120. she evenutally became hypotensive to sbp of 90 which resolved on its own " 109,174489.0,14861,2142-07-04,14805,176760.0,2142-01-23,Discharge summary,"Admission Date: [**2142-1-21**] Discharge Date: [**2142-1-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Hypertensive Urgency and fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with hypertensive urgency, subjective fevers, and pain. . Of note, she had been hospitalized [**Date range (1) 43505**] with hypertensive urgency. Her nicardipine was changed to nifedipine in hospital and her labetalol was increased to 900mg TID from 800mg TID.BPs were reportedly stable in the 140's-170's on the medical floor on nifedipine, aliskerin, labetalol, clonidine, and hydralazine prior to discharge. Last HD was [**1-20**]. . She reports feeling well at time of discharge [**1-20**], however woke this evening feeling sweaty, hot, and mildly SOB. She did not check her temperature and denies any rigors. She had total body aching (worst in her left wrist at site of recent IV and abdomen at site of known hematoma). +Palpitations overnight now resolved. No CP, SOB, cough, diarrhea, dysuria, erythema/tenderness/drainage from HD catheter. Denies recent joint symptoms with her lupus. No sick contacts. Says she took her BP meds. . Upon arrival to the ED, her vitals were 99.9 104 254/145 16 96% on RA. She was started on a nicardipine drip, given 1"" nitropaste with improvement in her BP. Did spike a fever while in the ED, currently 101F 101 173/106 Given vancomycin and zoysn for ?pna as CXR with right sided haziness. Also received 3mg IV dilaudid for body pains. LUE ultrasound without evidence of DVT. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 98.5 P 92 Bp 173/116 RR 16 O2 100% on RA General Pleasant young woman appearing comfortable HEENT Cushingoid faces, L eye prosthesis, MMM Pulm Lungs clear bilaterally, no rales or wheezing CV Regular S1 S2 ?soft systolic murmur Abd Soft +hematoma left abdomen unchanged from prior exam Extrem Warm full distal pulses. Left hand with slight edema ++ tender to palpation of wrist patient unable to make fist secondary to pain, no erythema +warmth ?purulence at site of old PIV Skin No peripehral stigmata of endocarditis Lines Left groin HD catheter site without erythema, purulence, or tenderness Neuro Alert and awake, moving all extremities Pertinent Results: CXR [**1-21**]: In comparison with the earlier study of this date, the diffuse pulmonary edema has substantially decreased, possibly following hemodialysis. Enlargement of the cardiac silhouette persists and there is no definite pleural effusion. Suggestion of an area of increased opacification at the right base. This could merely represent asymmetric edema, though the possibility of a developing consolidation cannot be unequivocally excluded. . LUE US [**1-21**]: IMPRESSION: No DVT in the left upper extremity. . L wrist xray [**1-21**]: There is prominent soft tissue swelling about the wrist, relatively diffuse, but quite prominent along the dorsum of the wrist. No fracture, dislocation, degenerative change, focal lytic or sclerotic lesion, or erosion is identified. No soft tissue calcification or radiopaque foreign body is identified. A tiny (1.7 mm) linear density is seen along the dorsum of the wrist on the oblique view is seen only on that view and is consistent with a small film artifact. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency and left wrist pain. . 1. Hypertensive urgency: Patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. Patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. She was started on nicardipine drip and 1"" nitropaste and admitted to the ICU for further treatment. There was no evidence of end-organ ischemia. Upon arrival to the ICU she was given her usual home antihypertensives and the nicardipine was quickly weaned off. It was felt that pain and anxiety were both contributing to her elevated BPs. Her BP quickly stabilized and she was called out to the medical floor where her SBP ranged 110-150. She was continued on nifepidine 90mg daily, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Given her repeated admissions with hypertensive urgency a meeting was held between the patient's nephrologist Dr. [**Last Name (STitle) 4883**], her ICU physician and her [**Name9 (PRE) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the ICU where she quickly improves with simply continuing her home medications. The following plan was drafted and placed in a note in OMR titled "" Care Protocol"". . CARE PROTOCOL: . BLOOD PRESSURE MANAGEMENT: . For BP > 230/140 1. Hydralazine: 100 mg PO OR 10 mg IV q 20 minutes until blood pressure back to baseline*. . 2. Give daily blood pressure medications, if she has not already taken them before arrival. . 3. If after one hour of therapy AND/OR evidence of end organ damage, transfer to the ICU. . * Note: Her usual blood pressure is ~ 160/100. Efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. In the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . PAIN MANAGEMENT: . As an outpatient, Ms. [**Name13 (STitle) **] takes dilaudid 2-4 mg PO q 4 PRN.This is being slowly tapered, she should not be administered IV pain medications. . ANTICOAGULATION: . In the absence of bleeding, warfarin does not need to be stopped on admission. Similarly, in the absence of new thrombosis, subtherapeutic INR's do not require bridging with IV UFH. . 2. Fever: Possible sources included line infection, thombophlebitis, septic arthritis, PNA. Received vanc/zosyn in ED for possible PNA. UA without pyuria and urine culture negative. CXR also without convinving infiltrate on repeat PA/Lat so zosyn was discontinued. Patient was complaining of severe pain at her IV site and was noted to have a small abscess there which was felt to be the cause of her fever. She was continued on IV vanco with HD for 10day course. She remained afebrile and did not have a leukocytosis. . 3. Left wrist pain: Began following IV placement during recent hospitalization. Likely due to septic thrombophlebitis. Small abscess was too small to drain. This was treated with warm soaks and prn PO dilaudid. Vanco was continued for 10 day course. L wrist films were enremarkable. . 4. Left abdominal wall hematoma: Stable on exam from recent admission. She was continued on pain management with morphine 7.5mg TID, gabapentin and tylenol as needed for pain. . 5. SLE: Continued prednisone at 4 mg PO daily . 6. ESRD: Continued on regularly scheduled dialysis. . 7. Anemia: Baseline Hct 26. Her Hct was mildly decreased from baseline. Secondary to AOCD and renal failure. There was no evidence of bleeding. . 8. SVC thrombus: Known SVC thrombus, therapeutic on coumadin. Continued warfarin. . 9. HOCM: evidence of myocardial hypertrophy on recent Echo. Currently not symptomatic. Echo without evidence of worsening pericardial effusion. Continued beta blocker . 10. Depression/anxiety. Continued Celexa, clonazepam 0.5mg [**Hospital1 **] . 11. OSA: Continued CPAP Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nifedipine 90mg PO daily Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325-650 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*270 Tablet(s)* Refills:*2* 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 7 days. [**Hospital1 **]:*4 dose* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Septic thrombophlebitis Discharge Condition: Stable, afebrile, BP improved. Discharge Instructions: You were admitted to the hospital with hypertensive urgency. You required IV medications and were observed overnight in the ICU. Your usual oral blood pressure medications were continued and your blood pressure remained well-controlled. You were found to have an infection at your prior IV site on your left hand. For this you were given IV vancomycin. You will need 7 days more of antibiotics which will be given with dialysis. Please resume your usual dialysis schedule. Your last dialysis was [**1-23**]. Please continue to take your medications as prescribed. You should hold your coumadin today. You can resume this on wednesday at your normal dose. You should have your INR checked at dialyis as usual on thursday. . If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-12**] weeks. ",162,2142-01-21 11:23:00,2142-01-23 16:40:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE EMERGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. . 1. hypertensive urgency: patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. there was no evidence of end-organ ischemia. upon arrival to the icu she was given her usual home antihypertensives and the nicardipine was quickly weaned off. it was felt that pain and anxiety were both contributing to her elevated bps. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150. she was continued on nifepidine 90mg daily, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. given her repeated admissions with hypertensive urgency a meeting was held between the patients nephrologist dr. [**last name (stitle) 4883**], her icu physician and her [**name9 (pre) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the icu where she quickly improves with simply continuing her home medications. the following plan was drafted and placed in a note in omr titled "" care protocol"". . care protocol: . blood pressure management: . for bp > 230/140 1. hydralazine: 100 mg po or 10 mg iv q 20 minutes until blood pressure back to baseline*. . 2. give daily blood pressure medications, if she has not already taken them before arrival. . 3. if after one hour of therapy and/or evidence of end organ damage, transfer to the icu. . * note: her usual blood pressure is ~ 160/100. efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. in the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . pain management: . as an outpatient, ms. [**name13 (stitle) **] takes dilaudid 2-4 mg po q 4 prn.this is being slowly tapered, she should not be administered iv pain medications. . anticoagulation: . in the absence of bleeding, warfarin does not need to be stopped on admission. similarly, in the absence of new thrombosis, subtherapeutic inrs do not require bridging with iv ufh. . 2. fever: possible sources included line infection, thombophlebitis, septic arthritis, pna. received vanc/zosyn in ed for possible pna. ua without pyuria and urine culture negative. cxr also without convinving infiltrate on repeat pa/lat so zosyn was discontinued. patient was complaining of severe pain at her iv site and was noted to have a small abscess there which was felt to be the cause of her fever. she was continued on iv vanco with hd for 10day course. she remained afebrile and did not have a leukocytosis. . 3. left wrist pain: began following iv placement during recent hospitalization. likely due to septic thrombophlebitis. small abscess was too small to drain. this was treated with warm soaks and prn po dilaudid. vanco was continued for 10 day course. l wrist films were enremarkable. . 4. left abdominal wall hematoma: stable on exam from recent admission. she was continued on pain management with morphine 7.5mg tid, gabapentin and tylenol as needed for pain. . 5. sle: continued prednisone at 4 mg po daily . 6. esrd: continued on regularly scheduled dialysis. . 7. anemia: baseline hct 26. her hct was mildly decreased from baseline. secondary to aocd and renal failure. there was no evidence of bleeding. . 8. svc thrombus: known svc thrombus, therapeutic on coumadin. continued warfarin. . 9. hocm: evidence of myocardial hypertrophy on recent echo. currently not symptomatic. echo without evidence of worsening pericardial effusion. continued beta blocker . 10. depression/anxiety. continued celexa, clonazepam 0.5mg [**hospital1 **] . 11. osa: continued cpap ","PRIMARY: [Other vascular complications of medical care, not elsewhere classified] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; ; Systemic lupus erythematosus; Phlebitis and thrombophlebitis of upper extremities, unspecified]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. she was continued on iv vanco with hd for 10day course. esrd: continued on regularly scheduled dialysis. her hct was mildly decreased from baseline. hocm: evidence of myocardial hypertrophy on recent echo. echo without evidence of worsening pericardial effusion. continued celexa, clonazepam 0.5mg [**hospital1 **] .","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150." 109,174489.0,14861,2142-07-04,14806,113189.0,2142-02-17,Discharge summary,"Admission Date: [**2142-2-14**] Discharge Date: [**2142-2-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: From admission note: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome admitted with HTN and SOB in the setting of missed HD. The patient reported missing HD yesterday because she thinks she is being overdiuresed. She reports persistent pain at site of rectus sheath hematoma. Denies N/V/D. Pt recently admitted from [**Date range (1) 13924**] with consistent abdominal pain at the site of her known left abdominal wall hematoma, hypertensive to 230's and hyperkalemic to 6.2 after missing her last two dialysis sessions. At this time the pt. was dialyzed, received a blood transfusion, and was administered her daily antihypertensive medications. Pt. left AMA after her transfusion despite the primary team's concerns to look for an active area of bleeding. In the ED, patient complain of mild dyspnea, sating well on RA. CXR mild volume overload. KUB with no evidence of obstruction. She was started on a labetalol gtt. ECG - RAD, LVH no change from prior. HCT stable at 21. The renal team evaluated pt and recommended HD, however the patient refused. She was transferred to ICU for BP control. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: [**2142-2-14**] 07:40AM WBC-3.9* RBC-2.38* HGB-7.0* HCT-21.3* MCV-90 MCH-29.5 MCHC-33.0 RDW-18.9* [**2142-2-14**] 07:40AM NEUTS-74.9* LYMPHS-18.7 MONOS-3.1 EOS-3.0 BASOS-0.2 [**2142-2-14**] 07:40AM PLT COUNT-101* [**2142-2-14**] 07:40AM PT-16.3* PTT-36.6* INR(PT)-1.5* [**2142-2-14**] 07:40AM CK-MB-6 [**2142-2-14**] 07:40AM cTropnT-0.09* [**2142-2-14**] 07:40AM LIPASE-80* [**2142-2-14**] 07:40AM ALT(SGPT)-34 AST(SGOT)-72* CK(CPK)-120 ALK PHOS-124* TOT BILI-0.4 [**2142-2-14**] 07:40AM GLUCOSE-85 UREA N-32* CREAT-7.0* SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-19* ANION GAP-17 [**2142-2-14**] 07:44AM LACTATE-1.3 [**2142-2-14**] CXR: Stable cardiomegaly with mild CHF and a small left pleural effusion. Left basilar air space disease which may represent pneumonia. Clinical correlation and a follow up chest x-ray to clearance is recommended. [**2142-2-14**] KUB: 1. Nonspecific bowel gas pattern with no evidence of obstruction. 2. Left basilar airspace disease which may represent pneumonia and a small left pleural effusion. Please ensure follow-up to clearance. Brief Hospital Course: 24 y.o female with SLE, ESRD on HD and malignant hypertension who presents with HTN and SOB aftering missing HD. . # Malignant hypertension/hypertensive urgency: The patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and HD compliance. Has previously presented with BP up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. Pt was treated per OMR hypertensive protocol created by the patient's primary providers, with a goal SBP of 160-180. With short course of IV antihypertensives and hemodialysis, pt's BP fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # ESRD: Pt was followed by the renal service and underwent HD without any complications. Pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting HD. She will discuss this further with the Renal team as an outpatient. . # SLE: Pt was continued on her home dose of prednisone with no sign of SLE flair. . # Coagulopathy/history of DVT: Patient on lifetime anticoagulation for hx of multiple thrombotic events. Pt was continued on coumadin. . # Pain management: Pt was treated with PO dilaudid for her abdominal pain, as recommended per her OMR protocol. She asked for IV dilaudid multiple times but there was no clinical indication. She was also continued on gabapentin. . # Anemia: Secondary to AOCD and renal failure. The patietns Hct remained stable in the low 20s during admission. No PRBC infusions were needed. . # Depression/anxiety: Continued Celexa, clonazepam 0.5mg [**Hospital1 **] Medications on Admission: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain. 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Disposition: Home Discharge Diagnosis: Primary: Malignant Hypertension Secondary: SLE, End stage renal disease on hemodialysis, SVC syndrome Discharge Condition: Stable. SBP in 160s. Discharge Instructions: You were admitted with dangerously high hypertension and some shortness of breath in the setting of missing several dialysis sessions. You were admitted and treated with your usual regimen of blood pressure meds and a short course of IV meds. With dialysis, your symptoms improved. You also had some abdominal pain, which was well controlled on your usual pain medications. We made no changes to your medications. Please take everything as prescribed. Please call your PCP or return to the hospital if you develop any headaches, visual changes, confusion or chest pain, or any other concerning symptoms. Followup Instructions: Please schedule a follow up with Dr [**Last Name (STitle) **] in [**Month (only) 958**] as scheduled. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2142-2-21**]",137,2142-02-14 10:42:00,2142-02-17 18:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. . # malignant hypertension/hypertensive urgency: the patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and hd compliance. has previously presented with bp up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. with short course of iv antihypertensives and hemodialysis, pts bp fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # esrd: pt was followed by the renal service and underwent hd without any complications. pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting hd. she will discuss this further with the renal team as an outpatient. . # sle: pt was continued on her home dose of prednisone with no sign of sle flair. . # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events. pt was continued on coumadin. . # pain management: pt was treated with po dilaudid for her abdominal pain, as recommended per her omr protocol. she asked for iv dilaudid multiple times but there was no clinical indication. she was also continued on gabapentin. . # anemia: secondary to aocd and renal failure. the patietns hct remained stable in the low 20s during admission. no prbc infusions were needed. . # depression/anxiety: continued celexa, clonazepam 0.5mg [**hospital1 **] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Thrombotic microangiopathy; Systemic lupus erythematosus; Anemia in chronic kidney disease; Thrombocytopenia, unspecified; Obstructive sleep apnea (adult)(pediatric); Nontraumatic hematoma of soft tissue; Dysthymic disorder; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events.","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob after missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. she was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine." 109,174489.0,14861,2142-07-04,14807,158995.0,2142-02-26,Discharge summary,"Admission Date: [**2142-2-25**] Discharge Date: [**2142-2-26**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 338**] 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 History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, hx of malignant HTN admitted with change in mental status. Patient missed HD on [**2142-2-24**] and was found unresponsive and diaphoretic by mother this morning after she took some dilaudid. EMS was called, 1 mg of narcan was administered with slight improvement in mental status. On arrival to the ED her vitals were 112/64 62 16 99RA she was noted to be hyperkalemic in the absence of EKG changes and was given calcium, D5, 10U regular insulin, 30 mg po kayxalate and repeat K was 5.4. ABG: 7.29/38/199. Repeat glucose was 41 and 1amp D50 was given. She was sent to the ICU for monitoring. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including [**Month/Year (2) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: HR: 80 (79 - 80) bpm BP: 127/59(76) {127/59(76) - 139/64(82)} mmHg RR: 34 (21 - 34) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Physical Examination Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact Pertinent Results: [**2142-2-25**] 01:50PM PT-14.9* PTT-36.8* INR(PT)-1.3* [**2142-2-25**] 01:50PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2142-2-25**] 01:50PM WBC-5.0 RBC-2.21* HGB-6.4* HCT-20.7* MCV-94 MCH-29.1 MCHC-31.1 RDW-19.6* [**2142-2-25**] 10:30PM GLUCOSE-87 UREA N-66* CREAT-8.4* SODIUM-142 POTASSIUM-5.9* CHLORIDE-110* TOTAL CO2-16* ANION GAP-22* HISTORY: Altered mental status. Evaluate underlying for pneumonia. UPRIGHT PORTABLE CHEST: Comparison is made to [**2-14**] and [**2142-2-19**], exams. Study is slightly limited by patient motion. In the interval, the degree of pulmonary edema appears improved with slightly decreased prominence of the pulmonary vascularity. There is unchanged extensive retrocardiac consolidation obscuring the majority of the left hemidiaphragm with persistent blunting of the left CP angle, likely related to small effusion. Exam is otherwise unchanged from prior with persistent cardiomegaly. A catheter is seen projecting over the abdomen, partially imaged. IMPRESSION: Slight improvement in pulmonary edema with persistent retrocardiac opacity, which again may represent atelectasis versus underlying pneumonia. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted hypotension and decreased mental status. Hypotension and altered mental status were in the setting of excessive narcotic use. Patient's narcotics were held, pressors returned to [**Location 213**] and patient was mentating fine. Hct was below baseline and patient was transfused 1u PRBC and was given HD before discharge. Patient is to continue anti-hypertensive medications as previously scheduled. Patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # Change in mental status: Resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. Patient received 1 dose of narcan with slight improvement in BP and mental status. patient without fevers or leuckocytosis which argue against infection. # Hypertension ?????? resumed outpatient regimen. Patient did not have any hypertensive episodes requiring hydralizine 10mg IV. # Hypotension: resolved, Patient normotensive on arrival to ICU. Relative hypotension likely due to dilaudid. Other considerations include sepsis, although patient without objective signs of infection. Held pain medications and hypotension resolved. Resumed hypertensive medications. # Abdominal pain ?????? from previous peritoneal [**Location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # Hyperkalemia: Likely due to missed HD session. She received calcium, D5, insulin and kayexalate in ED. HD in am ESRD: Renal following, had HD the day of discharge, transfused while there. Will continue normal schedule as an outpatient with HD T/Th/F this week. # Metabolic Acidosis: likely due to renal failure and missed HD. # SLE: continued prednisone at 4 mg PO daily. # OSA: CPAP for sleep with 7 pressure, however patient refuses. Continued to offer as inpatient. Should try to follow up with sleep medicine. Medications on Admission: Prednisone 4mg qd Citalopram 20 mg daily Gabapentin 300 mg [**Hospital1 **] Warfarin 4mg daily Pantoprazole 40 mg qd Clonidine 0.1 mg/24 QWED Clonidine 0.3 mg/24 hr QWED Labetalol 900 mg tid Nifedipine 90 mg qd Aliskiren 150 mg [**Hospital1 **] Hydralazine 100 mg q8h Morphine 7.5 mg q8h prn pain Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Home Discharge Diagnosis: Primary: narcotic overdose relative hypotension anemia Secondary: ESRD on HD [**2-12**] SLE malignant hypertension Discharge Condition: stable - received HD prior to discharge Discharge Instructions: You were admitted for altered mental status after missing hemodialysis. It was likely from the dilaudid you took as well as missing your scheduled [**Month/Day (2) 2286**]. You were also relatively hypotensive in the setting of excessive narcotic medicaiton usage. Narcotic medications were held and hypotension and altered mental status resolved. Please use narcotic medications with caution. You are recommended to use morphine for pain control rather than dilaudid. No medication changes were made. Please return to the ED if you have any altered mental status or miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] or have symptoms such as vision changes or headache from your history of malignant hypertension. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-3-20**] 3:00 HD as previously scheduled Completed by:[**2142-2-26**]",128,2142-02-25 15:49:00,2142-02-26 16:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ALTERED MENTAL STATUS," 24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. patients narcotics were held, pressors returned to [**location 213**] and patient was mentating fine. hct was below baseline and patient was transfused 1u prbc and was given hd before discharge. patient is to continue anti-hypertensive medications as previously scheduled. patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # change in mental status: resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. patient received 1 dose of narcan with slight improvement in bp and mental status. patient without fevers or leuckocytosis which argue against infection. # hypertension ?????? resumed outpatient regimen. patient did not have any hypertensive episodes requiring hydralizine 10mg iv. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. other considerations include sepsis, although patient without objective signs of infection. held pain medications and hypotension resolved. resumed hypertensive medications. # abdominal pain ?????? from previous peritoneal [**location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # hyperkalemia: likely due to missed hd session. she received calcium, d5, insulin and kayexalate in ed. hd in am esrd: renal following, had hd the day of discharge, transfused while there. will continue normal schedule as an outpatient with hd t/th/f this week. # metabolic acidosis: likely due to renal failure and missed hd. # sle: continued prednisone at 4 mg po daily. # osa: cpap for sleep with 7 pressure, however patient refuses. continued to offer as inpatient. should try to follow up with sleep medicine. ","PRIMARY: [Poisoning by other opiates and related narcotics] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Thrombotic microangiopathy; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Altered mental status; Other iatrogenic hypotension; Accidental poisoning by other opiates and related narcotics; Hyperpotassemia; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Nontraumatic hematoma of soft tissue; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. from previous peritoneal [**location 2286**] hematoma ??????","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. narcotics were held, pressors returned to and patient was mentating fine. patient was encouraged to take less pain medications and to use morphine." 109,174489.0,14861,2142-07-04,14808,158943.0,2142-03-23,Discharge summary,"Admission Date: [**2142-3-21**] Discharge Date: [**2142-3-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: Abdominal Pain, Shortness of breath, Chest discomfort Major Surgical or Invasive Procedure: HD [**2142-3-21**] and [**2142-3-23**] History of Present Illness: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] 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 [**Telephone/Fax (3) 43508**]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. [**Telephone/Fax (3) **] was discussed with renal and it was not felt that HTN is a volume issue so no need for emergent [**Telephone/Fax (3) 2286**]. . 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 [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**], getting Vanc with HD. . PSHx: 1. Placement of multiple catheters including [**Year (4 digits) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] 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: [**2142-3-21**] 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* [**2142-3-21**] 02:20AM NEUTS-76.1* BANDS-0 LYMPHS-17.9* MONOS-4.5 EOS-1.1 BASOS-0.5 [**2142-3-21**] 02:20AM PLT SMR-NORMAL PLT COUNT-168 [**2142-3-21**] 02:20AM PT-21.8* PTT-34.7 INR(PT)-2.1* [**2142-3-21**] 02:20AM cTropnT-0.12* [**2142-3-21**] 02:20AM ALT(SGPT)-46* AST(SGOT)-94* CK(CPK)-76 ALK PHOS-173* TOT BILI-0.4 [**2142-3-21**] 02:20AM GLUCOSE-74 UREA N-47* CREAT-7.3* SODIUM-140 POTASSIUM-5.8* CHLORIDE-109* TOTAL CO2-19* ANION GAP-18 [**2142-3-21**] 04:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-21**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2142-3-21**] 12:58PM CK-MB-NotDone cTropnT-0.12* . CT C/A/P - [**2142-3-20**] - 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: [**2142-3-23**] 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* [**2142-3-23**] 12:00PM BLOOD Plt Ct-130* [**2142-3-23**] 12:00PM BLOOD PT-28.8* PTT-58.6* INR(PT)-2.9* [**2142-3-23**] 12:00PM BLOOD Glucose-77 UreaN-31* Creat-6.0*# Na-137 K-4.8 Cl-104 HCO3-24 AnGap-14 [**2142-3-23**] 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 [**3-22**] 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 [**2142-3-21**] . # abdominal pain: Consistent with patient's baseline chronic abdominal pain. Medication effect also possible. CT prelim neg for small bowel obstruction. LFTs doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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). [**Month/Year (2) **]:*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 [**Month/Year (2) 2286**] sessions as directed by the nephrology team- your next session should be on Tuesday. Completed by:[**2142-3-26**]",103,2142-03-21 09:25:00,2142-03-23 18:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,CHEST PAIN;TELEMETRY," 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 (200s/100s) that nevertheless are within levels shes 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 [**3-22**] and transferred to the medicine floor. the next day, her bp remained within goal of 120s/80s. 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. ces were cycled and were negative. cpap was continued as tolerated at home settings. sob resolved after hd on [**2142-3-21**] . # abdominal pain: consistent with patients baseline chronic abdominal pain. medication effect also possible. ct prelim neg for small bowel obstruction. lfts doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Compression of vein; Unspecified disease of pericardium; Infection and inflammatory reaction due to other vascular device, implant, and graft; Bacteremia; Primary hypercoagulable state; Other primary cardiomyopathies; ; Abdominal pain, unspecified site; Urinary tract infection, site not specified; Acidosis; Other chest pain; Other chronic pain; Systemic lupus erythematosus; Noncompliance with renal dialysis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Hyperpotassemia; 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; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","this is a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. ct prelim neg for small bowel obstruction. on arrival to the floor, abd pain was back to baseline and well controlled on dilaudid 2mg po q 4hrs .","a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. initial attempts were made to control her bp with hydralazine and labetalol iv but after these failed to control her blood pressure. she was successfully transitioned to home medications of clonidine, labetalol, aliskiren, nifedipine" 109,174489.0,14861,2142-07-04,14809,124398.0,2142-03-31,Discharge summary,"Admission Date: [**2142-3-24**] Discharge Date: [**2142-3-31**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: HTN, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 24F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] after admission for abdominal pain, MSSA bacteremia, paroxysmal hypertension and ESRD line, followed by readmission [**3-22**], now presents with usual central crampy abdominal pain, 3 loose nonbloody stools this AM, SOB, and HTN to 270s. Pt was d/c'd from [**Hospital1 18**] yesterday after HD session, went home, states she took her PM meds, took her 8 AM medds (hydral, labetalol), then developed these symptoms which precluded her from taking her usual home meds (no afternoon meds - nifedipine, labetalol, hydral). The abd pain comes and goes and is unchanged from her baseline. While she has nausea, she is asking for dinner. . In the ED, initial BP 272/148. CXR w/o evidence of volume overload. No CT scan performed. Started on NTG gtt, given Hydralazine 10 x 1, Dilaudid 2 mg, labetaolo 20mg IV x 1. . Upon arrival to the floor, her BP was 240/135. She continued to complain of abdominal pain but was eating crackers, breathing felt better. RR 17. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: 98.2 97 [**Telephone/Fax (2) 43509**]0% on 2 L nC Gen: pleasant, comfortable HEENT: L eye enucleated. moon facies. Right pupil reactive Heart: hrrr, no m/r/g Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, diffuse TTP, no rebound/guarding Ext: no c/c/e Neuro: aox4, cn 2-12 intact grossly. Pertinent Results: [**2142-3-24**] 07:17PM PT-22.4* PTT-43.64* INR(PT)-2.1* [**2142-3-24**] 04:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2142-3-24**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-24**] 04:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**11-30**] [**2142-3-24**] 02:05PM GLUCOSE-76 UREA N-21* CREAT-4.8*# SODIUM-139 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2142-3-24**] 02:05PM ALT(SGPT)-78* AST(SGOT)-181* CK(CPK)-55 ALK PHOS-192* TOT BILI-0.5 [**2142-3-24**] 02:05PM cTropnT-0.12* [**2142-3-24**] 02:05PM CK-MB-5 [**2142-3-24**] 02:05PM WBC-3.6* RBC-2.90* HGB-8.9* HCT-26.6* MCV-92 MCH-30.7 MCHC-33.4 RDW-19.8* [**2142-3-24**] 02:05PM NEUTS-73.9* BANDS-0 LYMPHS-18.5 MONOS-3.8 EOS-3.0 BASOS-0.8 [**2142-3-24**] 02:05PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-1+ TARGET-1+ SCHISTOCY-OCCASIONAL TEARDROP-1+ ELLIPTOCY-OCCASIONAL [**2142-3-24**] 02:05PM PLT SMR-LOW PLT COUNT-129* [**2142-3-23**] 12:00PM GLUCOSE-77 UREA N-31* CREAT-6.0*# SODIUM-137 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14 [**2142-3-23**] 12:00PM estGFR-Using this [**2142-3-23**] 12:00PM CALCIUM-8.4 PHOSPHATE-5.7* MAGNESIUM-1.9 [**2142-3-23**] 12:00PM WBC-3.7* RBC-2.87* HGB-8.7* HCT-26.1* MCV-91 MCH-30.3 MCHC-33.3 RDW-19.4* [**2142-3-23**] 12:00PM PLT COUNT-130* [**2142-3-23**] 12:00PM PT-28.8* PTT-58.6* INR(PT)-2.9* Brief Hospital Course: The patient was admitted to the MICU on a NTG gtt from the ED. Her abdominal pain had imporved and she was eating crackers and peanut butter. She was given her usual afternoon home medications, and transitioned to a Nicardipine gtt, which has worked well for her in the past. Her BP goal was for a systolic of 180-200. The Nicardipine gtt was titrated off quickly and she was transfered to the floor. . On arrival to the floor, she in fact missed her morning medications on [**Month/Day/Year 766**]. This resulted in elevate blood pressures requiring IV hydralazing for control. She went to dialyisis Tuesday [**3-27**] and again had markedly elevated blood pressures while at [**Month/Year (2) 2286**] from missing her AM doses. Instructions were written for explicit AM administration and Nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. She was continued on labetalol 900mg TID, Aliskerin, Hydralazine 100mg po TID, and clonidine patch 0.4mg/24 weekly patch. . HEr BP remained relativly stable. She established a three three times weekly Dialysus regemin. A PAP smear was attempted due to her history of CIN I and no PCP follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . Her abdominal pain was also a chronic issue, which appeared stable. She was not administered IV narcotics, only PO. It was wihtout clear percipitating events or etiology. She will need GI follow up. She was contact[**Name (NI) **] by phone several times to arrange a GI follow up appointment but did not return messages. She has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . She was discharged to followup with her nephrologist, Dr. [**Last Name (STitle) 4883**]. . 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. Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Last Name (STitle) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2* 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). [**Last Name (STitle) **]:*405 Tablet(s)* Refills:*2* 5. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*2* 6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). [**Last Name (STitle) **]:*60 Tablet(s)* Refills:*2* 9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patches Transdermal once a week: Place two patches every week on Fridays. [**Last Name (STitle) **]:*8 Patches* Refills:*2* 10. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*0* 11. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO twice a day as needed for prn SBP>200: if nauseated and cannot keep down meds, may use 1 sublingual clonidine if sbp>200. . [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0* 12. Kayexalate Powder Sig: Thirty (30) grams PO once a day for 2 days: please take [**2142-4-1**] and [**2142-4-2**] for elevated potassium. [**Month/Day/Year **]:*240 grams* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Systemic Lupus Erythematosus End Stage Renal Disease Hypertension Abdominal Pain Discharge Condition: Blood pressure stable and abdominal pain at baseline Discharge Instructions: You were admitted with high blood pressure. You were in the ICU overnight for treatment. Some of your medications were changed and you were increased to three times weekly [**Location (un) 2286**]. Your abdominal pain is a difficult problem, as the reason for the pain is unclear. [**Name2 (NI) **] were continued on oral dilaudid. IV dilaudid is strongly discouraged and will continue to be in the future. You are now taking Nifedipine SR 30mg at night in addition to 90mg in the morning. Your other medications were the same. At home, if your blood pressure is above 200, then take 100mg hydralazine. If after 1 hour, your blood pressure does not decrease to below 200 with this, then take another 100mg hydralazine. If you are nauseated and cannot take in oral meds, then take sublingual clonidine, then wait 1 hour and repeat if BP still > 200. Finally, your potassium has been high. Please take kayexalate 30gm tomorrow and the next day. Followup Instructions: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-3-31**] 7:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule appointment We will attempt to contact you on [**Name (NI) 766**] with appointment times for you. ",95,2142-03-24 16:34:00,2142-03-31 15:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," the patient was admitted to the micu on a ntg gtt from the ed. her abdominal pain had imporved and she was eating crackers and peanut butter. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. her bp goal was for a systolic of 180-200. the nicardipine gtt was titrated off quickly and she was transfered to the floor. . on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**]. this resulted in elevate blood pressures requiring iv hydralazing for control. she went to dialyisis tuesday [**3-27**] and again had markedly elevated blood pressures while at [**month/year (2) 2286**] from missing her am doses. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she was continued on labetalol 900mg tid, aliskerin, hydralazine 100mg po tid, and clonidine patch 0.4mg/24 weekly patch. . her bp remained relativly stable. she established a three three times weekly dialysus regemin. a pap smear was attempted due to her history of cin i and no pcp follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . her abdominal pain was also a chronic issue, which appeared stable. she was not administered iv narcotics, only po. it was wihtout clear percipitating events or etiology. she will need gi follow up. she was contact[**name (ni) **] by phone several times to arrange a gi follow up appointment but did not return messages. she has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . she was discharged to followup with her nephrologist, dr. [**last name (stitle) 4883**]. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Long-term (current) use of steroids; Other chronic pain; Obstructive sleep apnea (adult)(pediatric); Abdominal pain, generalized; Hyperpotassemia]","the patient was admitted to the micu on a ntg gtt from the ed. her bp goal was for a systolic of 180-200. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she established a three three times weekly dialysus regemin.","the patient was admitted to the micu on a nicardipine gtt from the ed. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**] this resulted in elevate blood pressures requiring iv hydralazing for control " 109,174489.0,14861,2142-07-04,14810,137510.0,2142-04-22,Discharge summary,"Admission Date: [**2142-4-20**] Discharge Date: [**2142-4-22**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 1253**] Chief Complaint: Dyspnea, malignant hypertension Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented with abdominal pain and shortness of breath. On [**2142-4-19**] she refused ultrafiltration at HD because she was at her dry weight. Awoke at 3 AM feeling more short of breath. She also had worsening abdominal pain and vomiting without hematemasis. She took all of her medications as prescribed including two new lidocaine patches, fentanyl patch and clonidine. She developed a slight frontal headache but no blurry vision or neurologic symptoms. ROS largely negative. . In the emergency room her initial vitals were T: 99.1 BP: 280/140 HR: 79 RR: 16 O2: 100% on RA. She had two large bore peripheral IVs placed. She received 100 mg PO hydralazine, 200 mg PO labetolol, zofran 4 mg IV, vancomycin 1 gram IV, levofloxacin 750 mg IV x 1 and was started on labetolol and nitroglycerin drips with control of her blood pressure to the 180s systolic. She had a CXR which was concerning for volume overload. She was admitted the MICU for further evaluation. . In the MICU she was stablized and transitioned to her home meds. Nephrology gave her HD with 2L UF and subjective improvement in SOB. . Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: On Admission per MICU team: Vitals: T: 96.5 BP: 162/120 HR: 79 RR: 13 O2: 100% on 4L General: Pleasant, comfortable, no distress HEENT: L eye enucleated. Moon facies. Right pupil reactive Heart: Regular rate and rhythm, s1 + s2, soft systolic murmur at RLSB, no rubs or gallops Respiratory: Crackles at bases bilaterally, no wheezes, rales, ronchi GI: soft, non-tender, non-distended, +BS GU: no foley Ext: Warm and well perfused, no clubbing, cyanosis or edema . Pertinent Results: [**2142-4-19**] 08:35AM WBC-3.8* RBC-2.53* HGB-7.6* HCT-23.4* MCV-93 MCH-29.9 MCHC-32.3 RDW-19.9* [**2142-4-19**] 08:35AM PLT COUNT-93* . [**2142-4-19**] 08:35AM GLUCOSE-88 UREA N-36* CREAT-6.0* SODIUM-135 POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-25 ANION GAP-15 [**2142-4-19**] 08:35AM CALCIUM-9.4 PHOSPHATE-5.3* MAGNESIUM-2.0 . [**2142-4-20**] 08:40AM PT-28.3* PTT-45.3* INR(PT)-2.9* . CXR PA and LAT: IMPRESSION: 1. Persistent cardiomegaly with prominence of pulmonary vasculature suggesting overhydration. Minimal costophrenic angle blunting may suggest small effusions. 2. No definite consolidation, although increased retrocardiac density is noted, most likely due to atelectasis and vascular congestion. Repeat imaging following diuresis could be considered. . INR trend: [**2142-4-19**] 09:30AM BLOOD PT-30.4* INR(PT)-3.1* [**2142-4-20**] 08:40AM BLOOD PT-28.3* PTT-45.3* INR(PT)-2.9* [**2142-4-21**] 04:07AM BLOOD PT-29.9* PTT-48.9* INR(PT)-3.1* [**2142-4-22**] 05:55AM BLOOD PT-33.3* PTT-54.1* INR(PT)-3.5* Brief Hospital Course: 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented to the ICU for hypertensive emergency, dyspnea, and headache, now resolved. . Hypertensive Emergency: Patient's blood pressure normalized with transient nitroglycerin and labetalol drips. Likely precipitated by lack of ultrafiltration at [**Year/Month/Day 2286**] yesterday. She has received [**Year/Month/Day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - Nifedipine 150 mg Tablet SR daily - Hydralazine 100 mg Tablet Q8H - Labetalol 1000 mg Tablet TID - Aliskiren 150 mg Tablet PO BID - Clonidine 0.2 mg/24 hr Patch Weekly - Hydralazine 100 mg PO PRN for SBP > 200 - continue regular [**Year/Month/Day 2286**] schedule . Social Issues/repeated admissions: The ICU and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. These episodes may be due to medication non-compliance and it may benefit Ms. [**Known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. Ms. [**Known lastname **] [**Last Name (Titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. Of note, she has missed [**Last Name (Titles) 2286**] sessions and often requests durations and flow rates for her [**Last Name (Titles) 2286**] that contradict recommendations by her nephrologist. This issue was left unresolved on discharge. . Chronic Abdominal Pain: Currently managed with PO dilaudid, fentanyl patch and lidocaine patch. Per MICU team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue PO dilaudid - continue lidocaine patch . Lupus Erythematous: Complicated by uveitis and ESRD. - continued prednisone . ESRD: On [**Last Name (Titles) 2286**]. Ultrafiltrate of 2 L on initial HD - continue outpatient regimen . Thrombocytopenia: Remained at baseline 80s to 130s. . Thrombotic Events: History of SVC thrombosis with negative workup. INR drifted up and was 3.5 on discharge. She was asked to hold her warfarin dose this PM and recheck her INR with VNA services on [**2142-4-23**] to be faxed to coumadin clinic in [**Company 191**]. - continued coumadin . Anemia: Hematocrit 24.5 initially. Baseline 23 to 28. . Medications on Admission: Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H Prednisone 1 mg Tablet Citalopram 20 mg Tablet Pantoprazole 40 mg Tablet, Warfarin 3 mg daily Gabapentin 300 mg TID Nifedipine 90 mg Tablet SR daily Nifedipine 60 mg Tablet SR daily Hydralazine 100 mg Tablet Q8H Labetalol 1000 mg Tablet TID Aliskiren 150 mg Tablet PO BID Clonidine 0.2 mg/24 hr Patch Weekly Docusate Sodium 100 mg Capsule PO BID Senna 8.6 mg Tablet Fentanyl 25 mcg/hr Patch 72 hr Lidocaine 5 %(700 mg/patch) daily Hydralazine 100 mg PO:PRN for SBP > 200 Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) 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 3 mg Tablet Sig: One (1) Tablet PO once a day: DO NOT TAKE DOSE ON [**2142-4-22**]. Then restart per your PCP. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QHS (once a day (at bedtime)). 9. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 10. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 17. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed: For systolic blood pressure > 200. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Malignant Hypertension Systemic Lupus Erythematosus End Stage Renal Disease Abdominal Pain Discharge Condition: good, VSS, on room air, pain controlled. Discharge Instructions: You came to the hospital for shortness of breath and hypertension. You were given antihypertensive drips and during [**Location (un) 2286**] 2 liters were taken off with good improvement in your shortness of breath. You will need to take your medications as prescribed and follow-up with all of your doctors to prevent coming into the hospital. . Medication changes: - Please do not take your coumadin tonight because your INR is too high. You will need to have it checked by VNA services and adjusted. - Please take ALL of your medications as prescribed. . Please call your doctor or return to the ED if you have intractable headaches, shortness of breath, intractable pain or other concerns. Followup Instructions: Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-4-26**] 3:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Completed by:[**2142-4-23**]",73,2142-04-20 13:39:00,2142-04-22 15:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,PULMONARY EDEMA;HYPERTENSION," 24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. . hypertensive emergency: patients blood pressure normalized with transient nitroglycerin and labetalol drips. likely precipitated by lack of ultrafiltration at [**year/month/day 2286**] yesterday. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - nifedipine 150 mg tablet sr daily - hydralazine 100 mg tablet q8h - labetalol 1000 mg tablet tid - aliskiren 150 mg tablet po bid - clonidine 0.2 mg/24 hr patch weekly - hydralazine 100 mg po prn for sbp > 200 - continue regular [**year/month/day 2286**] schedule . social issues/repeated admissions: the icu and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. these episodes may be due to medication non-compliance and it may benefit ms. [**known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. ms. [**known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. this issue was left unresolved on discharge. . chronic abdominal pain: currently managed with po dilaudid, fentanyl patch and lidocaine patch. per micu team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue po dilaudid - continue lidocaine patch . lupus erythematous: complicated by uveitis and esrd. - continued prednisone . esrd: on [**last name (titles) 2286**]. ultrafiltrate of 2 l on initial hd - continue outpatient regimen . thrombocytopenia: remained at baseline 80s to 130s. . thrombotic events: history of svc thrombosis with negative workup. inr drifted up and was 3.5 on discharge. she was asked to hold her warfarin dose this pm and recheck her inr with vna services on [**2142-4-23**] to be faxed to coumadin clinic in [**company 191**]. - continued coumadin . anemia: hematocrit 24.5 initially. baseline 23 to 28. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Unspecified iridocyclitis; Other primary cardiomyopathies; Unspecified disease of pericardium; ; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Noncompliance with renal dialysis; Personal history of noncompliance with medical treatment, presenting hazards to health; Surgical or other procedure not carried out because of patient's decision; Abdominal pain, left lower quadrant; Renal dialysis status; Thrombocytopenia, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Peripheral vascular disease, unspecified; Acquired absence of organ, eye; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus]","24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. ultrafiltrate of 2 l on initial hd - continue outpatient regimen .","malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips." 109,196721.0,14863,2142-07-23,14862,131376.0,2142-07-08,Discharge summary,"Admission Date: [**2142-7-7**] Discharge Date: [**2142-7-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**Last Name (NamePattern1) 293**] Chief Complaint: dyspnea, Hypertension Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24F h/o SLE, ESRD on HD, h/o malignant HTN, SVC syndrome, PRES, prior ICH, with frequent admission for hypertensive urgency/emergency, with chronic abdominal pain. She was recently admitted [**Date range (1) 43607**] after presenting for hypertensive urgency and dyspnea for which she was started on nitroglycerin and labetalol drips, which were weaned off in the ICU. She was also received 2U PRBCs during HD. She was discahrged home without any changes to her medical regimen. . On the afternoon of [**7-4**] she notes increased dyspnea, she therefore went to HD on Wednesday, and again on Thursday [**7-5**]. After HD, her BP remained elevated, and she took an extra dose of labetalol 1000mg x 1. On [**7-6**] her VNA noted SBP 250s. She took extra doses of hydralazine, but otherwise felt well. She then woke up this morning with HA. She took all of her BP meds this morning, but remained with HA and SOB, thus prompting her presentation to the ED. . No fevers, productive cough, taking all meds, had chronic diarrhea that is unchanged, some n/v at baseline, no coffee ground emesis, has some abdominal pain unchanged from baseline Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Pertinent Results: 08:00a ALK,ALT,AST,CK,CPIS,LIP,BILI,TNT ADDED 12:29PM 141 103 29 82 AGap=13 3.4 28 6.5 ∆ CK: 59 MB: Notdone Trop-T: 0.18 ALT: 21 AP: 126 Tbili: 0.4 Alb: AST: 51 LDH: Dbili: TProt: [**Doctor First Name **]: Lip: 56 PT: 15.0 PTT: 35.5 INR: 1.3 N:69.8 L:21.9 M:5.5 E:2.5 Bas:0.3 Hypochr: 1+ Anisocy: 2+ Macrocy: 1+ Microcy: 1+ Polychr: 1+ Brief Hospital Course: # Hypertensive Urgency - At the time of admission, the patient denied chest pain but continued to have mild headache. She also had resolving shortness of breath, likely secondary to hypertension. She stated that she did take her PO meds. She was started on a labetalol drip and continued on her home regimen of oral labetolol, nifedipine, hydralazine, and aliskerin. A sent of cardiac enzymes was sent and revealed a CPK of 59 and a troponin of 0.18. The patient also underwent dialysis in the ICU. After dialysis the labetalol drip was weaned off. Overnight, SBP's ranged 109 to 182 mmHg. The following day, her SBP's ranged 133 to 200. Ultimately, she was discharged home on her normal medication regimen. # Abdominal Pain - The patient also presented complaining of adbominal pain. She had recently been treated for SBO; however, at the time of admit, she was without nausea or vomiting. She had a soft abdomen, was passing flatus, and was having daily bowel movements. She did have hypoactive bowel sounds. She was continued of her outpatient pain regimen of PO dilaudid, fentanyl patch, and lidoacine patch. An ultrasound of her abd was also performed and showed ascites in all 4 quadrants with the largest in the left lower quadrant measuring 5.5cm. Considering her history of thrombosis, renal recommended getting an abdominal ultrasound with doppler flow studies. This ultrasound showed mild to moderate ascites, a 9mm hemangioma, and no evidence of thrombosis. After the results of this ultrasound were reviewed, the patient was discharged home with a plan to follow-up with liver regarding her ascites and whether it can be attributed to her recent SBO. # ESRD on HD - The patient gets hemodialysis on a Tu/Th/Sa schedule. On admit, the patient was continued on her home does of sevalemer. Renal was consulted, and the patient received dialysis on [**7-7**] in the ICU. # Anemia/Pancytopenia - The patient has a chronic anemia and baseline pancytopenia that are likely secondary to her CKD and SLE. On admit she was actually above baseline. She was continued on her home does of epogen. # H/o Gastric Ulcer - The patient was continued on her PPI [**Hospital1 **]. # SLE - The patient was continued on her home regimen of prednisone 4mg po daily. # H/o SVC Thrombosis - The patient has a goal INR of [**2-13**]. However, naticoagulation was stopped after a recent admission secondary to a supratherapeutic INR. On admit, her INR was sub-therapeutic. Therefore, her warfarin was restarted at 3 mg daily. # Seizure Disorder - The patient was continued on her home regimen of keppra 1000 mg PO 3 times a week (Tu/Th/Sa). # Depression - The patient was continued on her home dose of celexa. Medications on Admission: 1.Nifedipine 90 mg PO DAILY (Daily). 2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime). 3.Lidocaine 5 % PATCH Q24HR. 4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID 5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H 7.Prednisone 4 mg PO DAILY (Daily). 8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday). 9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday). 10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD 12.Labetalol 1000 mg Tablet Tablet PO TID 13.Hydralazine 100 mg Tablet PO Q8H 14.Warfarin 3 mg Tablet PO Once Daily at 4 PM. 15.Pantoprazole 40 mg PO Q12H (every 12 hours). 16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24HR (). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). Disp:*QS Tablet(s)* Refills:*2* 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QTUTHSA (TU,TH,SA). 17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for abdominal pain. Discharge Disposition: Home Discharge Diagnosis: Hypertensive Urgency Lupus Nephritis End stage renal disease on hemodialysis Ascites Discharge Condition: hemodynamically stable with blood pressures 130-140/70-80s. Discharge Instructions: You were evaluated and treated for you hypertension. You were started on IV medications and transitioned to your home regimen and received a session of hemodialysis. You also had an ultrasound to evaluate the fluid in your belly. There was no evidence of blood clot contributing to the build up of the fluid. Please continue to follow a low sodium diet at home and take all of your blood pressure medications in addition to going to dialysis. Followup Instructions: You have the following appointments scheduled: Please also keep your Tuesday/Thursday/Saturday Dialysis schedule Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-7-30**] 2:00 Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 ",15,2142-07-07 10:01:00,2142-07-08 18:05:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," # hypertensive urgency - at the time of admission, the patient denied chest pain but continued to have mild headache. she also had resolving shortness of breath, likely secondary to hypertension. she stated that she did take her po meds. she was started on a labetalol drip and continued on her home regimen of oral labetolol, nifedipine, hydralazine, and aliskerin. a sent of cardiac enzymes was sent and revealed a cpk of 59 and a troponin of 0.18. the patient also underwent dialysis in the icu. after dialysis the labetalol drip was weaned off. overnight, sbps ranged 109 to 182 mmhg. the following day, her sbps ranged 133 to 200. ultimately, she was discharged home on her normal medication regimen. # abdominal pain - the patient also presented complaining of adbominal pain. she had recently been treated for sbo; however, at the time of admit, she was without nausea or vomiting. she had a soft abdomen, was passing flatus, and was having daily bowel movements. she did have hypoactive bowel sounds. she was continued of her outpatient pain regimen of po dilaudid, fentanyl patch, and lidoacine patch. an ultrasound of her abd was also performed and showed ascites in all 4 quadrants with the largest in the left lower quadrant measuring 5.5cm. considering her history of thrombosis, renal recommended getting an abdominal ultrasound with doppler flow studies. this ultrasound showed mild to moderate ascites, a 9mm hemangioma, and no evidence of thrombosis. after the results of this ultrasound were reviewed, the patient was discharged home with a plan to follow-up with liver regarding her ascites and whether it can be attributed to her recent sbo. # esrd on hd - the patient gets hemodialysis on a tu/th/sa schedule. on admit, the patient was continued on her home does of sevalemer. renal was consulted, and the patient received dialysis on [**7-7**] in the icu. # anemia/pancytopenia - the patient has a chronic anemia and baseline pancytopenia that are likely secondary to her ckd and sle. on admit she was actually above baseline. she was continued on her home does of epogen. # h/o gastric ulcer - the patient was continued on her ppi [**hospital1 **]. # sle - the patient was continued on her home regimen of prednisone 4mg po daily. # h/o svc thrombosis - the patient has a goal inr of [**2-13**]. however, naticoagulation was stopped after a recent admission secondary to a supratherapeutic inr. on admit, her inr was sub-therapeutic. therefore, her warfarin was restarted at 3 mg daily. # seizure disorder - the patient was continued on her home regimen of keppra 1000 mg po 3 times a week (tu/th/sa). # depression - the patient was continued on her home dose of celexa. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Unspecified iridocyclitis; ; Other ascites; Other chronic pain; Abdominal pain, unspecified site; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Other specified peripheral vascular diseases; Anemia of other chronic disease; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Epilepsy, unspecified, without mention of intractable epilepsy; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism; Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits]","# hypertensive urgency - at the time of admission, the patient denied chest pain but continued to have mild headache. she stated that she did take her po meds. # abdominal pain - the patient also presented complaining of adbominal pain. on admit, the patient was continued on her home does of sevalemer. # h/o gastric ulcer - the patient was continued on her ppi [**hospital1 **]. # sle - the patient was continued on her home regimen of prednisone 4mg po daily.","at the time of admission, the patient denied chest pain but continued to have mild headache. she also had resolving shortness of breath, likely secondary to hypertension. she had recently been treated for sbo; however, she was without nausea or vomiting." 109,131376.0,14862,2142-07-08,14858,151240.0,2142-05-18,Discharge summary,"Admission Date: [**2142-5-15**] Discharge Date: [**2142-5-18**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 613**] Chief Complaint: Headache, Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis x 2 History of Present Illness: 24 year old female with SLE, ESRD on HD, hx malignant HTN, h/o SVC syndrome, h/o posterior reversible encephalopathy syndrome (PRES) and prior intracerebral hemorrhage, recently admitted [**Date range (1) 17717**] with diarrhea, hypertensive urgency. Treated at that time with nicardipine drip for a short period and then to her home regimen. Yesterday onset of nausea with emesis and inability to tolerate home meds including antihypertensives. Diarrhea mild as prior. No fever, chills, no hematemesis or hematochezia. No melena. Today reports onset of headache therefore to the ED. In the ED, initial vs were 280/160, 99.4, 105, RR 18. She was given dilaudid 2 mg PO x 2. Hydral 20 mg x 3 for BP. Calcium gluconate 1 gram. Insulin 10 units, D 50 [**1-12**] amp, sodium bicarbonate, kayexalate for K 6.7 (dialysis dependent Tues/thurs/sat) but with report of peaked T waves. Renal dialysis fellow was not contact[**Name (NI) **]. HCT 33.4, WBC 4.6, trop 0.10. Admitted for hypertensive urgency to ICU. No gtt was started. Of note usualy BP 160/100. Review of sytems: patient tearful complaining of frontal headache and nausea Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: Vitals: BP 240/146, 101, 98.6, General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardic, 3/6 SEM RUSB Abdomen: soft, diffusely tender, no rebound or gaurding. Ext: cachectic, warm, 2+ DP pulse no clubbing, cyanosis or edema Pertinent Results: [**2142-5-15**] 05:45AM GLUCOSE-83 UREA N-54* CREAT-7.6* SODIUM-138 POTASSIUM-6.7* CHLORIDE-103 TOTAL CO2-23 ANION GAP-19 [**2142-5-15**] 05:45AM CK(CPK)-96 [**2142-5-15**] 05:45AM cTropnT-0.10* [**2142-5-15**] 05:45AM CK-MB-NotDone [**2142-5-15**] 05:45AM WBC-4.6 RBC-3.66* HGB-10.8* HCT-33.4* MCV-91 MCH-29.6 MCHC-32.4 RDW-17.9* [**2142-5-15**] 05:45AM NEUTS-65.4 LYMPHS-25.1 MONOS-4.8 EOS-4.1* BASOS-0.7 [**2142-5-15**] 05:45AM PLT COUNT-128* [**2142-5-15**] 05:45AM PT-14.2* PTT-36.4* INR(PT)-1.2* [**2142-5-15**] 07:14AM K+-6.0* [**2142-5-15**] 12:17PM K+-5.3 Images: CXR: Persistent severe cardiomegaly. Head CT: Normal brain CT. Brief Hospital Course: 24 yo female with ESRD on HD, malignant hypertension with hx of intracerebral hemorrhage, SLE, chronic abdominal pain, and SVC syndrome admitted due to hypertensive urgency after developing N/V and being unable to take her po medications. # Hypertensive urgency: The patient was admitted to the MICU the night of admission where she was placed on a labetolol drip and her home medications were restarted. head CT was negative for intracranial bleed. She was continued on her home regimen of Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet Sustained Release QAM, and Hydralazine 100 mg PO Q8H. During her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. Blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). She was discharged on her home regimen. # Nausea/vomiting: The patient did not experience further vomiting, but occasionally complained of nausea. The cause of her nausea was unclear. She was able to tolerate po intake prior to discharge. # Abdominal pain/Diarrhea: The patient has chronic abdominal pain with previous negative workups. During this hospitalization her pain was at its baseline. Since admission she denied diarrhea. She was continued on her outpatient regimen of [**2-14**] mg po dilaudid q4h as needed. # ESRD on HD: She was hyperkalemic in the emergency room and was given kayexalate. She underwent two sessions of dialysis during this hospitalization. # SLE: Stable, without symptoms. She was continued on 4 mg of prednisone daily. # History of thrombotic events/SVC syndrome: She is anticoagulated with warfarin as an outpatient, however her INR was subtherapeutic on admission at 1.2. Previous documentation in OMR states she does not need to be bridged while subtherapeutic. She was initally continued on coumadin 4 mg po daily, however her INR rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # OSA: She is on CPAP at a setting of 7 as an outpatient and was continued on this during her hospitalization. Medications on Admission: Medications: as per last discharge summary -Aliskiren 150 mg Tablet [**Hospital1 **] -Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday) -Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). -Labetalol 200 mg Tablet Sig 5 tab TID -Nifedipine 60 mg Tablet Sustained Release QPM -Nifedipine 90 mg Tablet Sustained Release QAM -Citalopram 20 mg Tablet Sig daily -Hydromorphone 2 mg Tablet Sig [**1-12**] Q4 PRN -Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). -Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H -Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID PRN -Prednisone 4 mg daily -Coumadin 4 mg daily at 4 PM Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QPM (once a day (in the evening)). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 10. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO twice a day as needed for hypertension. 13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary - Hypertensive urgency End-stage renal disease on dialysis Secondary - Systemic lupus erythematous History of thombosis and Superior vena cava syndrome Obstructive sleep apnea Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital due to dangerously elevated blood pressure due to inability to take your medications secondary to nausea. It is very important that you take your blood pressure medications reguarly. Your nausea was controlled with medication and your blood pressure decreased once back on your home medication regimen. You underwent two sessions of dialysis during your hospitalization. It is extremely important that you attend dialysis three times weekly as an outpatient. Medication changes: You should be taking 3 mg of coumadin daily. You will need to have your INR checked at dialysis. Otherwise continue your outpatient medications as prescribed. Call your primary doctor, or go to the emergency room if you experience fevers, chills, worsening headache, vision change, inability to take your medications, blood in your stool, or dark black stool. Followup Instructions: It is very important that you keep your previously scheduled appointments: You have an appointment with gynecology to evaluate an abnormality recently seen on PAP smear. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-6-1**] 2:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-5-19**]",51,2142-05-15 10:45:00,2142-05-18 15:58:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSIVE CRISIS," 24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. # hypertensive urgency: the patient was admitted to the micu the night of admission where she was placed on a labetolol drip and her home medications were restarted. head ct was negative for intracranial bleed. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, and hydralazine 100 mg po q8h. during her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). she was discharged on her home regimen. # nausea/vomiting: the patient did not experience further vomiting, but occasionally complained of nausea. the cause of her nausea was unclear. she was able to tolerate po intake prior to discharge. # abdominal pain/diarrhea: the patient has chronic abdominal pain with previous negative workups. during this hospitalization her pain was at its baseline. since admission she denied diarrhea. she was continued on her outpatient regimen of [**2-14**] mg po dilaudid q4h as needed. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. she underwent two sessions of dialysis during this hospitalization. # sle: stable, without symptoms. she was continued on 4 mg of prednisone daily. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient, however her inr was subtherapeutic on admission at 1.2. previous documentation in omr states she does not need to be bridged while subtherapeutic. she was initally continued on coumadin 4 mg po daily, however her inr rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # osa: she is on cpap at a setting of 7 as an outpatient and was continued on this during her hospitalization. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other primary cardiomyopathies; Unspecified disease of pericardium; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Hyperpotassemia; Nausea with vomiting; Diarrhea; Disorders of phosphorus metabolism; Anemia of other chronic disease; Abdominal pain, left lower quadrant; Other chronic pain; Thrombocytopenia, unspecified; Other specified peripheral vascular diseases; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus; Long-term (current) use of anticoagulants; Noncompliance with renal dialysis; Renal dialysis status; Personal history of noncompliance with medical treatment, presenting hazards to health]","24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. she was able to tolerate po intake prior to discharge. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. previous documentation in omr states she does not need to be bridged while subtherapeutic.","24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg" 109,131376.0,14862,2142-07-08,14859,102024.0,2142-06-05,Discharge summary,"Admission Date: [**2142-5-20**] Discharge Date: [**2142-6-5**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 3705**] Chief Complaint: abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname **] is a 24 yo F with lupus since age 16, with ESRD on HD, malignant HTN, history of SVC syndrome, and history of Posterior Reversible Encephalopathy Syndrome (PRES) and intracerebral hemorrhage, who has had multiple recent admissions [**Date range (1) 43604**], [**Date range (1) 17717**], [**Date range (1) **], [**4-26**], [**Date range (1) 42063**], [**Date range (1) 43605**] mostly for hypertension, but most recently for diarrhea in addition to hypertension. . In the ED, vitals were 98 90 102/65 20 98% RA. She was complaining of abdominal pain X 3 hours, more severe than usual [**7-20**], no N/V/D. She received dilaudid 4 mg PO X 3, zofran 8mg IV, hyperkalemia 6.2=>5.3 w/ Kayexalate. Initially, she was felt stable for floor; however, BP rose during ED course to SBP 270. She then received hydral 50 PO X 1, home aliskeren, labetalol 1000 PO X 1, 20 IV hydral X 2, labetalol 100 Iv X 1, nicardipine 2.5 mg IV X 1 and started on nicardipine gtt. . Upon arrival to the floor, she complains of severe abd pain which started earlier today, it is sharp all over her abd and constant. It feels different from her usual abd pain, although she is not able to characterize it more. She has been having some nausea and bilious emesis X 1 earlier today. She has been having some mild diarrhea 2-3 episodes of loose, greenish stools for the past few weeks. She denies any chest pain, headache, vision changes. She was not able to take all of the medications due to her GI distress. . While in the MICU she was weaned off a nicardipine drip and her diarrhea resolved. Her BP remained WNL while on her home regimen and she was transferred to the floor in stable condition. Last HD was [**2142-5-21**]. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**] and [**2142-4-12**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting - has appt scheduled with gyn on [**5-25**] 17. History of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] which has resolved Social History: Denies any substance abuse (EtOH, tobacco, illicits). She lives with her mother and brother. 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: 100/63 81 18 100RA GENERAL: Pleasant, thin young female sitting in the bed in NAD watching TV. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. s/p left eye enucleation. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD. CARDIAC: RRR. 4/6 systolic murmur heard best at the RUSB. LUNGS: Breathing comfortably, CTAB, good air movement biaterally. ABDOMEN: + BS, soft ND, tenderness to palpation in her LUQ. No rebound or guarding. EXTREMITIES: No edema. Right femoral HD line nontender, nonerythematous. SKIN: Several subcutaneous cysts of different sizes 1 - 3 cm scattered along her lower extremities. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation to light touch throughout. 5/5 strength in her upper and lower extremities PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2142-5-20**] 09:14PM LACTATE-0.9 [**2142-5-20**] 09:13PM WBC-6.8 RBC-3.65* HGB-10.7* HCT-33.7* MCV-93 MCH-29.2 MCHC-31.6 RDW-18.8* [**2142-5-20**] 09:13PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ TEARDROP-OCCASIONAL [**2142-5-20**] 09:13PM PLT COUNT-145* [**2142-5-20**] 08:55PM GLUCOSE-98 UREA N-44* CREAT-7.7* SODIUM-137 POTASSIUM-6.3* CHLORIDE-102 TOTAL CO2-20* ANION GAP-21* [**2142-5-20**] 08:55PM CALCIUM-9.9 PHOSPHATE-5.8* MAGNESIUM-2.1 [**2142-5-20**] 08:55PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2142-5-20**] 08:55PM WBC-7.0 RBC-3.69* HGB-11.1* HCT-34.2* MCV-93 MCH-30.2 MCHC-32.5 RDW-19.2* [**2142-5-20**] 08:55PM PLT COUNT-126* [**2142-5-20**] 08:55PM PT-14.1* PTT-32.4 INR(PT)-1.2* [**2142-5-20**] 07:40AM ALT(SGPT)-18 AST(SGOT)-55* ALK PHOS-118* TOT BILI-0.4 [**2142-5-20**] 07:40AM LIPASE-58 Brief Hospital Course: KUB: SBO Head CT: (prelim read from radiology). unchanged from prior head CT, no intracranial hemorrhage EKG: NSR, right axis, LVH, nl intervals, ST elevations V2-3 (old), TW inversion V6 (new) compared to prior EKG [**5-15**]. CT CHEST/ABD: Preliminary Read Normal aorta without dissection or acute abnormality. No PE. Stable trace ascites and small right pleural effusion. Unchanged small pulmonary nodules and lymphadenopathy in the chest. No acute abnormalities in the abdomen to explain epigastric pain. EGD: Ulcer at GE junction. # Hypertensive urgency: This is a chronic issue related to ESRD. Head CT was negative for intracranial bleed. Weaned off Nicardipine gtt and BP well controlled on home regimen. Continued her home regimen of: Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet Sustained Release QAM, Hydralazine 100 mg PO Q8H. When BPs were lower (see below) patient's BP meds were held occasionally, but as she was transfused and the BPs started to trend back up the meds were re-initiated. She then developed hypotension in the setting of poor PO intake during her SBO. BP meds were held and then re-initiated as the pressure came back up once she was able to eat. # Abdominal pain/UGIB: The patient has chronic abdominal pain with previous negative workups. At first the pain resolved and she was continued on her outpatient regimen of: 2-4 mg po dilaudid q4 h as needed. GI was c/s re: abd pain and rec CTA-abdomen to eval for mesenteric ischemia vs. partial SBO, however with ESRD did not initially want to get CTA so KUB was ordered. This showed no SBO. They recommended checking urine porphyrobilinogen and serum lead levels which were negative and LFTs were at baseline. The patient then developed a different type of pain associated with her incision site. Pain service was consulted and did a bupivicaine injection at the site which did help. They will continue to follow her. She then developed a third type of pain associated with a burning sensation in her chest. EKG was unchanged from prior. A few hours later she had 3 episodes of coffee-ground emesis. She was placed on IV PPI and transfused two units of blood. Afterward the pain resolved and her hct remained stable. GI felt that the patient would need general anesthesia in order to undergo an EGD which showed an ulcer at the GE junction. She was started on empiric treatment for H. Pylori and serologies were sent which came back negative so the antibiotics were stopped. Her pain was controlled with her outpatient regimen of PO dilaudid. She will follow up with Dr. [**Last Name (STitle) **] in [**6-18**] weeks to have another EGD under MAC to see if there has been resolution of the ulcer. # SBO: Continued to be nauseous and vomited intermittently. she was started on reglan and continued on zofran and compazine PRN howeve she continued to have n/v. A KUB was done which showed an SBO. Surgery was consulted, NGT was placed, she was made NPO and serial abdominal exams were done. Eventually she was able to transition to clear diet and then tolerated a regular diet without pain or vomiting. #. Fever: On hospital day #6 she spiked a fever to 101. Blood and urine cultures were sent and a cxr were negative, however she then had a seizure and in the post-ictal state aspirated after vomiting. She had an episode of hypoxia with this and was transferred to the ICU. In the ICU LP was attempted to rule out meningitis as a possible cause of a seizure but this was unsuccessful. Broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. She improved over the next few days and antibiotics were discontinued because the suspicion for a bacterial meningitis was low. #. Seizure: This occured in the setting of fever, hypotension, and initiation of reglan for vomiting. Neurology was consulted and felt she should be continued on keppra indefinitely. EEG was non-revealing. She should be continued on keppra 1gm with dialysis three times weekly. # ESRD on HD: Hyperkalemia resolved with kayexalate. Underwent dialysis on normal schedule. # SLE: She was continued on prednisone 4mg daily. With multiple abdominal symptoms it was thought she may have lupus flare in the abdomen. C3, c4 were equivocal for active lupus flare, and [**Doctor First Name **] was positive, as would be expected in lupus. # Anemia: Has anemia of chronic renal disease and her Hct was high on admission and epo was held per renal. However, her Hct trended all the way down to 20 and she was borderline hypotensive for her (ie SBP 120) and she developed coffee ground emesis so she was transfused 2 units. Afterward her Hct was stable at 25. She was also re-started on EPO per renal for her chronic anemia. Hemolysis labs were negative. # History of thrombotic events/SVC syndrome: She is anticoagulated with warfarin as an outpatient. Previous documentation in OMR states she does not need to be bridged while subtherapeutic. Continued coumadin 4 mg po daily however INR became supratherapeutic and the coumadin was then held. She was started on heparin gtt while awaiting EGD. After EGD the coumadin was re-started at 3mg daily however, in setting of poor po intake her INR was supratherapeutic - likely [**2-12**] nutritional deficiency of vitamin k. coumadin will be restarted when INR [**2-13**] at dialysis. # OSA: She is on CPAP at a setting of 7 as an outpatient. Continued CPAP #. CIN1: On last pap had CIN1. OB/GYN service was called re: doing colposcopy in hospital as patient rarely makes o/p appointments, hwoever they do not do this procedure in hospital especially because it does not have to be done emergently - just within one year. Will need outpatient colposcopy at some point in next few months as they do not do this procedure in the hospital. # RLL nodule: A new 10 x 5 mm nodularity was found incidentally within the right lower lobe of the lung on an abdominal CT. This should be reassessed in 3 months. # ACCESS: PIV, right groin HD line # CODE: Full code Medications on Admission: 1. Aliskiren 150 mg PO bid 2. Citalopram 20 mg PO DAILY 3. Clonidine 0.2 mg/24 hr Patch Weekly QSAT 4. Hydromorphone 2 mg 1-2 Tablets PO Q4H 5. Fentanyl 25 mcg/hr Patch 72 hr 6. Gabapentin 300 mg PO TID 7. Hydralazine 100 mg PO Q8H 8. Hydralazine 100 mg PO BID PRn fro SBP> 180. 9. Prednisone 4 mg PO DAILY 10. Pantoprazole 40 mg PO Q24H 11. Labetalol 1000 mg PO TID 12. Nifedipine 90 mg PO QAM 13. Nifedipine 60 mg PO QHS 14. Warfarin 3 mg PO Once Daily 15. Lidocaine 5 %(700 mg/patch) Topical once a day. 16. Nifedipine 90 mg PO once a day as needed for for SBP persistently above 200. Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 2. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QHS (once a day (at bedtime)). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 30 days. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 16. LeVETiracetam 1,000 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: UGIB- Ulcer at GE junction Hypertensive Emergency Anemia ESRD on HD SBO Discharge Condition: The patient was afebrile and hemodynamically stable prior to discharge. Discharge Instructions: You were admitted to the hospital with abdominal pain. You had an injection of lidocaine to help the pain around your surgery sites. You then had some blood in your vomit. You were treated for a bleed in your stomach with a blood transfusion and medications. You stopped bleeding and felt better. You had a scope of your abdomen that showed an ulcer. You were treated with medications for this and need to have another scope of your abdomen in 6 weeks. You also had high blood pressures while you were here because you could not take your medicines with your nausea and vomiting. Once you were on your home medicines your blood pressure was better. Medication Changes: CHANGE: Pantoprazole to 40mg TWICE daily Please call your PCP or come to the emergency room if you have fevers, chills, worsening abdominal pain, nausea, vomiting, blood in your vomit, blood in your stools, black/tarry stools or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] (gastroenterology) in [**6-18**] weeks for an EGD to re-look at your ulcer. Please follow up with the OB/[**Hospital **] clinic for a colposcopy on Wednesday [**2142-8-8**] at 3:15pm in the [**Hospital Ward Name 23**] Building on the [**Location (un) **]. Their number is [**Telephone/Fax (1) 2664**]. Please follow up with Dr.[**Name (NI) **] at [**Hospital6 733**] in the Shapria building on the [**Location (un) **] on [**2142-6-27**] at 2:00pm. Completed by:[**2142-6-6**]",33,2142-05-20 12:59:00,2142-06-05 16:18:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," kub: sbo head ct: (prelim read from radiology). unchanged from prior head ct, no intracranial hemorrhage ekg: nsr, right axis, lvh, nl intervals, st elevations v2-3 (old), tw inversion v6 (new) compared to prior ekg [**5-15**]. ct chest/abd: preliminary read normal aorta without dissection or acute abnormality. no pe. stable trace ascites and small right pleural effusion. unchanged small pulmonary nodules and lymphadenopathy in the chest. no acute abnormalities in the abdomen to explain epigastric pain. egd: ulcer at ge junction. # hypertensive urgency: this is a chronic issue related to esrd. head ct was negative for intracranial bleed. weaned off nicardipine gtt and bp well controlled on home regimen. continued her home regimen of: aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, hydralazine 100 mg po q8h. when bps were lower (see below) patients bp meds were held occasionally, but as she was transfused and the bps started to trend back up the meds were re-initiated. she then developed hypotension in the setting of poor po intake during her sbo. bp meds were held and then re-initiated as the pressure came back up once she was able to eat. # abdominal pain/ugib: the patient has chronic abdominal pain with previous negative workups. at first the pain resolved and she was continued on her outpatient regimen of: 2-4 mg po dilaudid q4 h as needed. gi was c/s re: abd pain and rec cta-abdomen to eval for mesenteric ischemia vs. partial sbo, however with esrd did not initially want to get cta so kub was ordered. this showed no sbo. they recommended checking urine porphyrobilinogen and serum lead levels which were negative and lfts were at baseline. the patient then developed a different type of pain associated with her incision site. pain service was consulted and did a bupivicaine injection at the site which did help. they will continue to follow her. she then developed a third type of pain associated with a burning sensation in her chest. ekg was unchanged from prior. a few hours later she had 3 episodes of coffee-ground emesis. she was placed on iv ppi and transfused two units of blood. afterward the pain resolved and her hct remained stable. gi felt that the patient would need general anesthesia in order to undergo an egd which showed an ulcer at the ge junction. she was started on empiric treatment for h. pylori and serologies were sent which came back negative so the antibiotics were stopped. her pain was controlled with her outpatient regimen of po dilaudid. she will follow up with dr. [**last name (stitle) **] in [**6-18**] weeks to have another egd under mac to see if there has been resolution of the ulcer. # sbo: continued to be nauseous and vomited intermittently. she was started on reglan and continued on zofran and compazine prn howeve she continued to have n/v. a kub was done which showed an sbo. surgery was consulted, ngt was placed, she was made npo and serial abdominal exams were done. eventually she was able to transition to clear diet and then tolerated a regular diet without pain or vomiting. #. fever: on hospital day #6 she spiked a fever to 101. blood and urine cultures were sent and a cxr were negative, however she then had a seizure and in the post-ictal state aspirated after vomiting. she had an episode of hypoxia with this and was transferred to the icu. in the icu lp was attempted to rule out meningitis as a possible cause of a seizure but this was unsuccessful. broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. she improved over the next few days and antibiotics were discontinued because the suspicion for a bacterial meningitis was low. #. seizure: this occured in the setting of fever, hypotension, and initiation of reglan for vomiting. neurology was consulted and felt she should be continued on keppra indefinitely. eeg was non-revealing. she should be continued on keppra 1gm with dialysis three times weekly. # esrd on hd: hyperkalemia resolved with kayexalate. underwent dialysis on normal schedule. # sle: she was continued on prednisone 4mg daily. with multiple abdominal symptoms it was thought she may have lupus flare in the abdomen. c3, c4 were equivocal for active lupus flare, and [**doctor first name **] was positive, as would be expected in lupus. # anemia: has anemia of chronic renal disease and her hct was high on admission and epo was held per renal. however, her hct trended all the way down to 20 and she was borderline hypotensive for her (ie sbp 120) and she developed coffee ground emesis so she was transfused 2 units. afterward her hct was stable at 25. she was also re-started on epo per renal for her chronic anemia. hemolysis labs were negative. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient. previous documentation in omr states she does not need to be bridged while subtherapeutic. continued coumadin 4 mg po daily however inr became supratherapeutic and the coumadin was then held. she was started on heparin gtt while awaiting egd. after egd the coumadin was re-started at 3mg daily however, in setting of poor po intake her inr was supratherapeutic - likely [**2-12**] nutritional deficiency of vitamin k. coumadin will be restarted when inr [**2-13**] at dialysis. # osa: she is on cpap at a setting of 7 as an outpatient. continued cpap #. cin1: on last pap had cin1. ob/gyn service was called re: doing colposcopy in hospital as patient rarely makes o/p appointments, hwoever they do not do this procedure in hospital especially because it does not have to be done emergently - just within one year. will need outpatient colposcopy at some point in next few months as they do not do this procedure in the hospital. # rll nodule: a new 10 x 5 mm nodularity was found incidentally within the right lower lobe of the lung on an abdominal ct. this should be reassessed in 3 months. # access: piv, right groin hd line # code: full code ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction; Acute posthemorrhagic anemia; Unspecified intestinal obstruction; Other primary cardiomyopathies; Unspecified disease of pericardium; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Disorders of phosphorus metabolism; Hypotension, unspecified; Hyperpotassemia; Mononeuritis of unspecified site; Anemia of other chronic disease; Abdominal pain, left lower quadrant; Other chronic pain; Thrombocytopenia, unspecified; Diaphragmatic hernia without mention of obstruction or gangrene; Other specified peripheral vascular diseases; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus; Noncompliance with renal dialysis; Renal dialysis status; Long-term (current) use of anticoagulants; Personal history of noncompliance with medical treatment, presenting hazards to health]","kub: sbo head ct: (prelim read from radiology). ct chest/abd: preliminary read normal aorta without dissection or acute abnormality. bp meds were held and then re-initiated as the pressure came back up once she was able to eat. gi was c/s re: abd pain and rec cta-abdomen to eval for mesenteric ischemia vs. partial sbo, however with esrd did not initially want to get cta so kub was ordered. a few hours later she had 3 episodes of coffee-ground emesis. afterward the pain resolved and her hct remained stable. gi felt that the patient would need general anesthesia in order to undergo an egd which showed an ulcer at the ge junction. her pain was controlled with her outpatient regimen of po dilaudid. broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. she should be continued on keppra 1gm with dialysis three times weekly. c3, c4 were equivocal for active lupus flare, and [**doctor first name **] was positive, as would be expected in lupus. # anemia: has anemia of chronic renal disease and her hct was high on admission and epo was held per renal.","sbo head ct was negative for intracranial hemorrhage. no intracranial hemorrhage ekg: nsr, right axis, lvh, nl intervals, st elevations v2-3 (old), tw inversion v6 (new) no acute abnormalities in the abdomen to explain epigastric pain." 109,131376.0,14862,2142-07-08,14860,136572.0,2142-06-20,Discharge summary,"Admission Date: [**2142-6-18**] Discharge Date: [**2142-6-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 2145**] Chief Complaint: Acute Onset Dyspnea Major Surgical or Invasive Procedure: Dialysis History of Present Illness: Please see MICU note for full details. In brief this is a 24 y.o. woman with SLE, ESRD on HD, hx malignant HTN, h/o SVC syndrome, h/o posterior reversible encephalopathy syndrome (PRES) and prior intracerebral hemorrhage, frequently admitted with hypertensive urgency/emergency who was admitted with acute onset dyspnea after 2 weeks without dialysis given to unable to get transportation ? despite Dr. [**Last Name (STitle) 7473**] attempting to arrange transport for her (? refused to come). She was admitted therefore on [**6-18**] to micu with VS: T 100.4 HR 108 BP 240/180 RR 28 POx100 RA. She was treated with nitro gtt, labetolol gtt and dilaudid-these gtts were stopped at 0700. In the micu she was dialyzed with 1.7L fluid removal (though + 300cc given tranfusion). Her SOB is improved. Her hct was also noted to be low (18->from 22 [**2142-6-5**]) so transfused 2 units PRBC's, recent EGD with gastric ulcer [**5-29**], guaiac negative in ED, no BM in unit, hemolysis w/u negative. BP in icu 140/106 currently but of note was hypotensive on HD to 86/62. She notes sob improved rapidly on arrival. ROS: Currently she has no complaints. She notes at home her abdominal pain is at baseline for her, felt mid epigastric, for which she takes dilaudid 4mg up to [**Hospital1 **]. She has been getting HD via right femoral catheter which is not painful, no discharge from the sight. She denies HA, visual changes, cough, chest pain or pressure, orthostatic changes, palpitations, nausea, vomiting, constipation, diarrhea, melena, brbpr, dysuria, hematuria, rash, swelling, orthopnea, pnd. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Physical Exam: Vitals - T: 97.7, BP: 140/99 P: 88 R: 19 O2: 98% on RA General: Sleeping comfortably but awakens easily, alert, oriented x3 HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear, nonerythematous, MMM, moon facies Neck: supple, JVP flat, no LAD, full ROM, left EJ in place Lungs: coarse BS throughout, no W/R/R, no decreased BS at bases CV: S1, S2 nl, no m/r/g appreciated Abdomen: Firm, non-tender to palpation, no masses or organomegally Ext: Warm, well perfused, 1+ DP/PT, no clubbing, cyanosis or edema Neuro: a&o x3, motor [**5-15**] UE/LE bilaterally Pertinent Results: [**2142-6-18**] 05:28PM HCT-26.0*# [**2142-6-18**] 11:38AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL [**2142-6-18**] 05:04AM GLUCOSE-85 UREA N-72* CREAT-10.4* SODIUM-139 POTASSIUM-5.5* CHLORIDE-109* TOTAL CO2-14* ANION GAP-22* [**2142-6-18**] 05:04AM LD(LDH)-264* TOT BILI-0.2 [**2142-6-18**] 05:04AM CALCIUM-6.6* PHOSPHATE-6.5* MAGNESIUM-1.6 [**2142-6-18**] 05:04AM HAPTOGLOB-142 [**2142-6-18**] 05:04AM WBC-3.4* RBC-1.93* HGB-5.8* HCT-17.0* MCV-88 MCH-30.0 MCHC-34.2 RDW-18.4* [**2142-6-18**] 05:04AM PLT COUNT-97* [**2142-6-18**] 01:34AM GLUCOSE-84 UREA N-70* CREAT-10.5*# SODIUM-136 POTASSIUM-5.6* CHLORIDE-108 TOTAL CO2-14* ANION GAP-20 [**2142-6-18**] 01:34AM estGFR-Using this [**2142-6-18**] 01:34AM ALT(SGPT)-10 AST(SGOT)-39 ALK PHOS-108 TOT BILI-0.2 [**2142-6-18**] 01:34AM LIPASE-115* [**2142-6-18**] 01:34AM ALBUMIN-3.2* CALCIUM-6.6* PHOSPHATE-6.8* MAGNESIUM-1.7 [**2142-6-18**] 01:34AM WBC-4.5 RBC-2.08* HGB-6.0* HCT-18.3* MCV-88 MCH-28.6 MCHC-32.5 RDW-18.6* [**2142-6-18**] 01:34AM NEUTS-78.5* LYMPHS-16.5* MONOS-3.0 EOS-1.4 BASOS-0.6 [**2142-6-18**] 01:34AM PLT COUNT-104* [**2142-6-18**] 01:34AM PT-15.0* PTT-33.6 INR(PT)-1.3* Brief Hospital Course: # Dyspnea: Pt's dypsnea improved on admission to the ED prior to HD. Based on her imaging studies her dyspnea was likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. Upon transfer to the floor she was continued on her dialysis regimen and discharged on room air. # Anemia: Pt's baseline 1 month ago noted to be low 30s, since then her Hct has trended down to 22 several week prior to admission. As she missed dialysis she was not able to reserve her Eopgen which likely complicated her anemia. Pt underwent hemolysis workup in the ICU which was ultimately negative. She was given several units of PRBC and bumped her Hct appropriately. She was noted to be guaiac negative on examination. # Hypertension: Pt was initially admitted with hypertension. Following transition to the floor she was placed on her home regimen. She was noted to be hypotensive in dialysis which is likely due to her being on Labetalol, Nitro gtt on dialysis. Pt was discharged on her home BP regimen with follow up with her nephrologist. # Chronic Abdominal Pain: Pt had noted some intermittent abdominal pain which has been chronic. Lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. Pt was able to tolerate a PO diet prior to her discharge. Pt was continued on her outpatient regimen of Dilaudid, Fentanyl patch, Neurontin. # GE junction Ulcer: Pt was continued on her PPI regimen [**Hospital1 **]. # SLE: Pt was continued on her home regimen of Prednisone 4mg daily # History of DVT: Pt had a sub-therapeutic INR on admission. She was discharged on Warfarin 3mg daily. # ESRD on HD: Pt was admitted for dyspnea in the setting of missing 2 weeks of HD. The renal team followed Ms. [**Known lastname **] during her hospitalization and she was continued on her outpatient regimen of hemodialysis. Pt was continued on Sevelamer and Epogen. # Seizure D/O: Pt was continued on her home regimen of keppra. # Depression: Pt was continued on her home regimen of Celexa. Medications on Admission: 1. Nifedipine 90 mg Tablet Sustained Release PO QAM 2. Nifedipine 60 mg Tablet Sustained Release PO QHS 3. Lidocaine 5 % transdermal one daily 4. Aliskiren 150 mg PO BID 5. Citalopram 20 mg PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch Q72H (every 72 hours). 7. Prednisone 4mg PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Transdermal QSAT 9. Clonidine 0.3 mg/24 hr Patch Weekly Transdermal QSAT 10. Sevelamer HCl 400 mg Four (4) Tablet PO TID W/MEALS 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID 13. Hydralazine 100 mg PO Q8H 14. Hydromorphone 2 mg 1-2 Tablets PO Q6H as needed for pain. 15. Pantoprazole 40 mg PO Q12H 16. LeVETiracetam 1,000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24 H (). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK (TU,TH,SA). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Malignant HTN, ESRD on HD, Shortness of breath Secondary: Lupus Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted to the hospital after you noticed some shortness of breath. Whilst in the hospital you were noted to have a low blood level (anemia) and you some fluid in your lungs. We think your blood level was low because you were not receiving your Epo shots, we think the fluid is from not receiving dialysis. Before you were discharged from the hospital your breathing was better. We recommend that you continue going to dialysis. We made no changes to your medications. If you notice any fevers, chills, nausea, vomiting, shortness of breath, lightheadedness please return to the ED. Followup Instructions: Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 Provider: [**First Name4 (NamePattern1) **] [**Name Initial (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-6-27**] 2:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] ",18,2142-06-18 03:11:00,2142-06-20 16:34:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ANEMIA," # dyspnea: pts dypsnea improved on admission to the ed prior to hd. based on her imaging studies her dyspnea was likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. upon transfer to the floor she was continued on her dialysis regimen and discharged on room air. # anemia: pts baseline 1 month ago noted to be low 30s, since then her hct has trended down to 22 several week prior to admission. as she missed dialysis she was not able to reserve her eopgen which likely complicated her anemia. pt underwent hemolysis workup in the icu which was ultimately negative. she was given several units of prbc and bumped her hct appropriately. she was noted to be guaiac negative on examination. # hypertension: pt was initially admitted with hypertension. following transition to the floor she was placed on her home regimen. she was noted to be hypotensive in dialysis which is likely due to her being on labetalol, nitro gtt on dialysis. pt was discharged on her home bp regimen with follow up with her nephrologist. # chronic abdominal pain: pt had noted some intermittent abdominal pain which has been chronic. lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. pt was able to tolerate a po diet prior to her discharge. pt was continued on her outpatient regimen of dilaudid, fentanyl patch, neurontin. # ge junction ulcer: pt was continued on her ppi regimen [**hospital1 **]. # sle: pt was continued on her home regimen of prednisone 4mg daily # history of dvt: pt had a sub-therapeutic inr on admission. she was discharged on warfarin 3mg daily. # esrd on hd: pt was admitted for dyspnea in the setting of missing 2 weeks of hd. the renal team followed ms. [**known lastname **] during her hospitalization and she was continued on her outpatient regimen of hemodialysis. pt was continued on sevelamer and epogen. # seizure d/o: pt was continued on her home regimen of keppra. # depression: pt was continued on her home regimen of celexa. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Other primary cardiomyopathies; Unspecified disease of pericardium; Anemia of other chronic disease; Hyperpotassemia; Systemic lupus erythematosus; Abdominal pain, other specified site; Other chronic pain; Hypotension, unspecified; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Epilepsy, unspecified, without mention of intractable epilepsy; Depressive disorder, not elsewhere classified; Personal history of venous thrombosis and embolism; Noncompliance with renal dialysis]","# dyspnea: pts dypsnea improved on admission to the ed prior to hd. lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. # sle: pt was continued on her home regimen of prednisone 4mg daily # history of dvt: pt had a sub-therapeutic inr on admission. she was discharged on warfarin 3mg daily. # depression: pt was continued on her home regimen of celexa.",pts dypsnea improved on admission to the ed prior to hd. dyspnea likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. 109,131376.0,14862,2142-07-08,14861,174489.0,2142-07-04,Discharge summary,"Admission Date: [**2142-7-3**] Discharge Date: [**2142-7-4**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 2817**] Chief Complaint: dyspnea, hypertension Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24F h/o SLE, ESRD on HD, h/o malignant HTN, SVC syndrome, PRES, prior ICH, with frequent admission for hypertensive urgency/emergency, with chronic abdominal pain. She was recently discharged on [**7-1**] after presenting for hypertensive urgency and dyspnea for which she received iv medication in the ED, but was otherwised managed with oral antihypertensives and CPAP. . She was doing well until the evening of [**7-2**] when she notes the gradual onset of dyspnea. She denied f/c/cp/ha/abd pain/diarrhea, or constipation. She was having regular, soft, daily BMs. . On [**7-3**] she awoke, and describes n/v x 2, with increasing dyspnea, and headache. She did not want to wait until dialysis at 4PM and therefore presented to [**Hospital1 18**]. . In ED VS= 97.7 [**Telephone/Fax (2) 43606**] 100%RA. Labs were notable for HCT 23, PLT 66, WBC 3.3, all roughly at baseline. CXR without acute process, ECG unchanged from prior. No UA sent, though she does make some urine. She was started on nitro gtt with modest improvement of SBPs to 210s, then labetalol 20mg iv x1 followed by labetalol gtt with BP 221/130 at the time of transfer. She refused abdominal CT. Renal was consulted, but felt HD not indicated today. . . ROS: Negative for fevers, chills, chest pain, diarrhea, rash, joint pains. +n/v as above. +abdominal pain unchanged from her baseline. +dyspnea, +HA. denies visual changes, slurrring speech, numbness, weeakness. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Physical Exam: Vitals - 97.7 88 220/150 19 100%2L BC. General: A&Ox3. NAD, oriented x3. HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear, nonerythematous, MMM. Neck: supple, no LAD, full ROM. Lungs: CTA B, with few crackles at bases. CV: RR, nl S1, S2 +S3, no rubs appreciated. Abdomen: soft, minimally distended, diffuse mild tenderness to palpation, negative [**Doctor Last Name **], no rebound, gaurding. Ext: WWP, 1+ dp/pt pluses, no clubbing, cyanosis or edema. Neuro: CN 2-12 intact. moving all four extremities spontaneously. Pertinent Results: Lab Results on Admission: [**2142-7-3**] 11:37AM GLUCOSE-95 UREA N-40* CREAT-7.4*# SODIUM-140 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16 ALT(SGPT)-14 AST(SGOT)-44* LD(LDH)-264* ALK PHOS-115 TOT BILI-0.4 ALBUMIN-3.2* WBC-3.6* RBC-2.61* HGB-7.6* HCT-23.4* MCV-90 MCH-29.0 MCHC-32.4 RDW-18.3* [**2142-7-3**] 11:37AM NEUTS-71.6* LYMPHS-23.0 MONOS-3.7 EOS-1.5 BASOS-0.2 PLT COUNT-66* PT-14.0* PTT-34.5 INR(PT)-1.2* [**2142-7-3**] 06:00PM CK-MB-5 cTropnT-0.17*CK(CPK)-58 [**2142-7-3**] CXR: IMPRESSION: Unchanged moderate cardiomegaly with pulmonary edema. Again underlying pneumonia in the lung bases cannot be completely excluded and evaluation after appropriate diuresis could be performed if pneumonia remains a clinical concern. Brief Hospital Course: 24F with h/o SLE, ESRD on HD, malignant HTN, h/o SVC syndrome, PRES, prior ICH, and recent SBO, p/w n/v, and hypertensive urgency. . # hypertensive urgency - On presentation she denies chest pain, but continues to have mild headache, and resolving shortness of breath, likely [**2-12**] hypertension. states she did take her PO meds. Hypertensive urgency was treated as follows with nitro and labetalol gtt which were quickly weaned as blood pressures dropped below SBP 120. She evenutally became hypotensive to SBP of 90 which resolved on its own. She was continued on CPAP overnight and discontinued in the am. She was continued on her home regimen of oral labetolol, nifedipine, hydralazine, aliskerin. She remained normotensive the following morning and was taken to hemodialysis after which she was discharged home on all of her old home medications. . # abdominal pain - On presentation she was without n/v, soft abdomen, passing flatus, and having daily bowel movements. She did have hypoactive bowel sounds on admission. She was maintained on outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch, neurontin with HD with plan to follow BMs closley. Her pain improved the am of discharge and she had no further vomiting. . # ESRD on HD - She is currently getting HD SaTuTh, though did not get HD on the day of presenation. As there was no acute indication for HD on presentation, she received HD on the following am, day of discharge. She was continued on sevelamer. . # anemia - chronic anemia, likely [**2-12**] CKD and SLE, currently above baseline, though has h/o GIB. She received 2 unit PRBCs and epo with hemodialysis. . # h/o gastric ulcer - she was continued on her outpatient dose of PPI [**Hospital1 **]. . # SLE - continue home regimen of prednisone 4mg po qdaily. . # h/o SVC thrombosis - pt with goal INR [**2-13**], but this was stopped after recent admission [**2-12**] supratherapeutic INR. INR currently sub-therapeutic and she was resumed on warfarin at 3 mg qdaily without heparin bridge. . # seizure disorder - continued on keppra 1000 mg PO 3X/WEEK (TU,TH,SA). . # depression - continued on celexa. Medications on Admission: 1.Nifedipine 90 mg PO DAILY (Daily). 2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime). 3.Lidocaine 5 % PATCH Q24HR. 4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID 5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H 7.Prednisone 4 mg PO DAILY (Daily). 8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday). 9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday). 10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD 12.Labetalol 1000 mg Tablet Tablet PO TID 13.Hydralazine 100 mg Tablet PO Q8H 14.Warfarin 3 mg Tablet PO Once Daily at 4 PM. 15.Pantoprazole 40 mg PO Q12H (every 12 hours). 16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. 6. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for hypertension. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 12. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 13. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). Tablet(s) 14. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 15. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QTUTHSA (TU,TH,SA). Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Primary: hypertensive emergency anemia, erythropoetin deficiency Secondary: chronic renal failure on hemodialysis lupus nephritis Discharge Condition: Hemodynamically stable. Discharge Instructions: You were admitted for hypertensive urgency and treated in the intensvie care unit with IV medications to decrease your blood pressure. You also received 2 units of blood and hemodialysis before you were discharged home. It is essential that you take all of your prescribed blood pressure medications and present regularly for your Tuesday, Thursday, Saturday dialysis. Please return to the emergency department or call your primary care physician if you develop any chest pain, shortness of breath, fevers, or any other concerning symptoms. Followup Instructions: You have the following appointment scheduled. Please contact your provider if you are unable to make these appointments. Your dialysis is scheduled for Tuesday, Thursday, Saturday. Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-7-30**] 2:00 Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 ",4,2142-07-03 14:48:00,2142-07-04 17:23:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24f with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, p/w n/v, and hypertensive urgency. . # hypertensive urgency - on presentation she denies chest pain, but continues to have mild headache, and resolving shortness of breath, likely [**2-12**] hypertension. states she did take her po meds. hypertensive urgency was treated as follows with nitro and labetalol gtt which were quickly weaned as blood pressures dropped below sbp 120. she evenutally became hypotensive to sbp of 90 which resolved on its own. she was continued on cpap overnight and discontinued in the am. she was continued on her home regimen of oral labetolol, nifedipine, hydralazine, aliskerin. she remained normotensive the following morning and was taken to hemodialysis after which she was discharged home on all of her old home medications. . # abdominal pain - on presentation she was without n/v, soft abdomen, passing flatus, and having daily bowel movements. she did have hypoactive bowel sounds on admission. she was maintained on outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch, neurontin with hd with plan to follow bms closley. her pain improved the am of discharge and she had no further vomiting. . # esrd on hd - she is currently getting hd satuth, though did not get hd on the day of presenation. as there was no acute indication for hd on presentation, she received hd on the following am, day of discharge. she was continued on sevelamer. . # anemia - chronic anemia, likely [**2-12**] ckd and sle, currently above baseline, though has h/o gib. she received 2 unit prbcs and epo with hemodialysis. . # h/o gastric ulcer - she was continued on her outpatient dose of ppi [**hospital1 **]. . # sle - continue home regimen of prednisone 4mg po qdaily. . # h/o svc thrombosis - pt with goal inr [**2-13**], but this was stopped after recent admission [**2-12**] supratherapeutic inr. inr currently sub-therapeutic and she was resumed on warfarin at 3 mg qdaily without heparin bridge. . # seizure disorder - continued on keppra 1000 mg po 3x/week (tu,th,sa). . # depression - continued on celexa. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified iridocyclitis; Other primary cardiomyopathies; Abdominal pain, unspecified site; Other chronic pain; Nausea with vomiting; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other specified peripheral vascular diseases; Obstructive sleep apnea (adult)(pediatric); Anemia of other chronic disease; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Epilepsy, unspecified, without mention of intractable epilepsy; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism; Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits]","24f with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, p/w n/v, and hypertensive urgency. she remained normotensive the following morning and was taken to hemodialysis after which she was discharged home on all of her old home medications. # abdominal pain - on presentation she was without n/v, soft abdomen, passing flatus, and having daily bowel movements. # seizure disorder - continued on keppra 1000 mg po 3x/week (tu,th,sa).","malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, p/w n/v, and hypertensive urgency. hypertensive urgency was treated as follows with nitro and labetalol gtt which were quickly weaned as blood pressures dropped below sbp 120. she evenutally became hypotensive to sbp of 90 which resolved on its own " 109,174489.0,14861,2142-07-04,14804,124657.0,2142-01-20,Discharge summary,"Admission Date: [**2142-1-14**] Discharge Date: [**2142-1-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 4028**] Chief Complaint: headache Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with mild headache, mild shortness of breath and consistent abdominal pain at the site of her known left abdominal wall hematoma in the setting of hypertension. Her last HD was yesterday. . Upon arrival to the ED, her vitals were BP 240's systolic, HR 90's, 93% on RA. A head CT scan was done which showed no acute process. An abdominal CT was done given her femoral line pain, which also was normal. She was given nitropaste X2 initially, then switched to labetalol 100mg x2, then 200mg x2, then finally started on nicardipine drip when she showed benefit with a decrease in her BP to 170/123 and improvement in her headache. . Upon arrival to the MICU, patient denies any current symptoms. She reports that her headache, shortness of breath and abdominal pain all resolved with blood pressure management and pain medications. . Pt was transferred to the floor when blood pressure was controlled. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: HR 96 BP 171/111 RR 12 O2 98% on RA Physical Exam: General in NAD HEENT NC, AT, EOMI, PERRLA, MMM CVS RRR, 3/6 systolic murmur in all heart fields RESP CTA BL, no crackles or wheezes ABD soft, hematoma raised on left anterior abdominal wall, +BS, mildly tender over hematoma EXT left sided femoral HD line in place, no erythema, no edema NEURO A+Ox3, CN2-12 intact, pt has left sided artificial eye, motor and sensory intact Pertinent Results: ***LABS ON ADMISSION*** [**2142-1-13**] 07:03AM WBC-5.2 RBC-2.79* HGB-8.5* HCT-26.3* MCV-94 MCH-30.3 MCHC-32.2 RDW-19.2* [**2142-1-13**] 07:03AM PLT COUNT-154 [**2142-1-13**] 07:03AM PT-29.5* PTT-49.2* INR(PT)-3.0* [**2142-1-13**] 07:03AM GLUCOSE-94 UREA N-53* CREAT-7.0* SODIUM-136 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [**2142-1-13**] 07:03AM CALCIUM-8.8 PHOSPHATE-5.0* MAGNESIUM-1.9 [**2142-1-14**] 12:00PM PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-14**] 12:00PM LIPASE-42 [**2142-1-14**] 12:00PM ALT(SGPT)-12 AST(SGOT)-43* ALK PHOS-96 TOT BILI-0.4 [**2142-1-14**] 03:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-1-14**] 03:25PM URINE RBC-[**3-15**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-[**3-15**] [**2142-1-14**] 12:00PM BLOOD PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-19**] 06:40AM BLOOD PT-18.6* PTT-38.7* INR(PT)-1.7* . ***LABS ON DAY OF DISCHARGE*** [**2142-1-20**] 06:35AM BLOOD WBC-5.7 RBC-2.39* Hgb-7.1* Hct-22.1* MCV-93 MCH-29.8 MCHC-32.2 RDW-18.6* Plt Ct-136* [**2142-1-20**] 06:35AM BLOOD Glucose-107* UreaN-34* Creat-4.8* Na-137 K-5.2* Cl-101 HCO3-27 AnGap-14 [**2142-1-20**] 06:35AM BLOOD PT-22.8* PTT-42.3* INR(PT)-2.2* . IMAGING [**2142-1-14**] EKG Sinus rhythm. Possible left atrial abnormality. Borderline voltage criteria for left ventricular hypertrophy. Inferolateral ST-T wave changes may be related to left ventricular hypertrophy. Compared to the previous tracing of [**2142-1-8**] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 99 190 86 368/436 13 100 24 [**2142-1-14**] CT ABD/PELV IMPRESSION: 1. Interval decrease in size to subcutaneous anterior abdominal wall hematoma. 2. Infectious versus inflammatory process within the right lower lobe of the lung. Small right simple pleural effusion. 3. Cardiomegaly with slight decrease in size of moderate pericardial effusion. 4. Right lobe liver hemangioma, unchanged. [**2142-1-14**] CT HEAD IMPRESSION: 1. Mildly limited study given administration of small amount of IV contrast material. However, no evidence of hemorrhage or mass effect. NOTE ADDED AT ATTENDING REVIEW: This patient was administered contrast for the abdominal CT, and the head CT was performed after part of this dose. Therefore, this is neither a noncontrast examination, nor a proper contrast CT. [**2142-1-14**] CXR CONCLUSION: Persistent cardiomegaly and mild pulmonary edema. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. . # Hypertensive Urgency: Pt with extensive history of hypertension. Patient's BP improved with nicardipine drip. Became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. Restarted all home oral antihypertensives including nicardipine 30 Q8H, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Blood pressure remains labile and renal continues to follow patient. Pt was transferred to the floor as blood pressure stabilized. BP has remained stable with systolics 140s-170s. In the MICU, Nifedipine extended release was added in place of Nicardipine as pt's blood pressures seemed to rise prior to Nicardipine doses. . # Hyperkalemia: Ocurred on the day after admission. Resolved with administration of kayexalate. Pt continued hemodialysis on TuThSat. . # Left abdominal wall hematoma: Abd CT showed a mild decrease in the size. Pt reported that morphine did not help pain, and was switched to dilaudid PO in the MICU. However, given pt's recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/c'ed on the floor. Pt was continued on gabapentin, tylenol around the clock, and low-dose Morphine as needed for pain. Narcotics should be avoided in the future. Pain should also resolve in the next few weeks as hematoma resolves. . # SLE: Pt was continued on prednisone at 4 mg PO daily. . #ESRD: Renal was following during her stay. She continued HD on her T, Th, Sat schedule. # Anemia: Hct was mildly decreased from baseline during admission. This is likely secondary to AOCD and in the setting of renal failure. . # SVC thrombus: Patient is on anticoagulation, likely lifelong. Patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. Then INR became subtherapeutic, so heparin gtt was used to bridge. On day of discharge, INR became therapeutic, and pt was discharged home on Coumadin 4mg PO daily, with INR to be checked next at hemodialysis . # HOCM: Pt has evidence of myocardial hypertrophy on recent Echo. She was not symptomatic during her stay. She was continued on her beta blocker. . # Depression/anxiety. She was continued on celexa and clonazepam PRN. . # OSA: CPAP for sleep with 7 pressure. . # FEN: repleted lytes prn / regular diet . # PPX: coumadin, bowel regimen . # ACCESS: PIV/ permanent dialysis cath L fem . # CODE: FULL . # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nicardipine 30mg PO TID Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for breakthrough pain for 2 weeks. 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*1* 13. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*260 Tablet(s)* Refills:*1* 14. Respiratory Therapy Please adjust settings of CPAP machine to a lower volume as it is uncomfortable for the patient. Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Discharge Condition: Good, hemodynamically stable, afebrile, pain controlled Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. One new medication was added as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to continue your Coumadin at 4mg daily and have your INR checked AT DIALYSIS next week. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep ALL scheduled appointments. Medications changes include: 1. STOP NICARDIPINE 2. Start Nifedipine CR 90mg by mouth daily 3. INCREASE Labetalol to 900mg by mouth 3 times daily 4. Continue at Warfarin 4mg by mouth daily If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to set up a follow-up appointment in 1-2weeks. Please continue your HD TuThSat. Completed by:[**2142-1-20**]",165,2142-01-14 17:34:00,2142-01-20 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. . # hypertensive urgency: pt with extensive history of hypertension. patients bp improved with nicardipine drip. became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. restarted all home oral antihypertensives including nicardipine 30 q8h, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. blood pressure remains labile and renal continues to follow patient. pt was transferred to the floor as blood pressure stabilized. bp has remained stable with systolics 140s-170s. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. . # hyperkalemia: ocurred on the day after admission. resolved with administration of kayexalate. pt continued hemodialysis on tuthsat. . # left abdominal wall hematoma: abd ct showed a mild decrease in the size. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu. however, given pts recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/ced on the floor. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. narcotics should be avoided in the future. pain should also resolve in the next few weeks as hematoma resolves. . # sle: pt was continued on prednisone at 4 mg po daily. . #esrd: renal was following during her stay. she continued hd on her t, th, sat schedule. # anemia: hct was mildly decreased from baseline during admission. this is likely secondary to aocd and in the setting of renal failure. . # svc thrombus: patient is on anticoagulation, likely lifelong. patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. then inr became subtherapeutic, so heparin gtt was used to bridge. on day of discharge, inr became therapeutic, and pt was discharged home on coumadin 4mg po daily, with inr to be checked next at hemodialysis . # hocm: pt has evidence of myocardial hypertrophy on recent echo. she was not symptomatic during her stay. she was continued on her beta blocker. . # depression/anxiety. she was continued on celexa and clonazepam prn. . # osa: cpap for sleep with 7 pressure. . # fen: repleted lytes prn / regular diet . # ppx: coumadin, bowel regimen . # access: piv/ permanent dialysis cath l fem . # code: full . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Other vascular complications of medical care, not elsewhere classified; Systemic lupus erythematosus; Hyperpotassemia; Phlebitis and thrombophlebitis of upper extremities, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. # anemia: hct was mildly decreased from baseline during admission. # hocm: pt has evidence of myocardial hypertrophy on recent echo. # fen: repleted lytes prn / regular diet . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. pt was transferred to the floor as blood pressure stabilized. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu." 109,155726.0,14864,2142-08-16,14862,131376.0,2142-07-08,Discharge summary,"Admission Date: [**2142-7-7**] Discharge Date: [**2142-7-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**Last Name (NamePattern1) 293**] Chief Complaint: dyspnea, Hypertension Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24F h/o SLE, ESRD on HD, h/o malignant HTN, SVC syndrome, PRES, prior ICH, with frequent admission for hypertensive urgency/emergency, with chronic abdominal pain. She was recently admitted [**Date range (1) 43607**] after presenting for hypertensive urgency and dyspnea for which she was started on nitroglycerin and labetalol drips, which were weaned off in the ICU. She was also received 2U PRBCs during HD. She was discahrged home without any changes to her medical regimen. . On the afternoon of [**7-4**] she notes increased dyspnea, she therefore went to HD on Wednesday, and again on Thursday [**7-5**]. After HD, her BP remained elevated, and she took an extra dose of labetalol 1000mg x 1. On [**7-6**] her VNA noted SBP 250s. She took extra doses of hydralazine, but otherwise felt well. She then woke up this morning with HA. She took all of her BP meds this morning, but remained with HA and SOB, thus prompting her presentation to the ED. . No fevers, productive cough, taking all meds, had chronic diarrhea that is unchanged, some n/v at baseline, no coffee ground emesis, has some abdominal pain unchanged from baseline Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Pertinent Results: 08:00a ALK,ALT,AST,CK,CPIS,LIP,BILI,TNT ADDED 12:29PM 141 103 29 82 AGap=13 3.4 28 6.5 ∆ CK: 59 MB: Notdone Trop-T: 0.18 ALT: 21 AP: 126 Tbili: 0.4 Alb: AST: 51 LDH: Dbili: TProt: [**Doctor First Name **]: Lip: 56 PT: 15.0 PTT: 35.5 INR: 1.3 N:69.8 L:21.9 M:5.5 E:2.5 Bas:0.3 Hypochr: 1+ Anisocy: 2+ Macrocy: 1+ Microcy: 1+ Polychr: 1+ Brief Hospital Course: # Hypertensive Urgency - At the time of admission, the patient denied chest pain but continued to have mild headache. She also had resolving shortness of breath, likely secondary to hypertension. She stated that she did take her PO meds. She was started on a labetalol drip and continued on her home regimen of oral labetolol, nifedipine, hydralazine, and aliskerin. A sent of cardiac enzymes was sent and revealed a CPK of 59 and a troponin of 0.18. The patient also underwent dialysis in the ICU. After dialysis the labetalol drip was weaned off. Overnight, SBP's ranged 109 to 182 mmHg. The following day, her SBP's ranged 133 to 200. Ultimately, she was discharged home on her normal medication regimen. # Abdominal Pain - The patient also presented complaining of adbominal pain. She had recently been treated for SBO; however, at the time of admit, she was without nausea or vomiting. She had a soft abdomen, was passing flatus, and was having daily bowel movements. She did have hypoactive bowel sounds. She was continued of her outpatient pain regimen of PO dilaudid, fentanyl patch, and lidoacine patch. An ultrasound of her abd was also performed and showed ascites in all 4 quadrants with the largest in the left lower quadrant measuring 5.5cm. Considering her history of thrombosis, renal recommended getting an abdominal ultrasound with doppler flow studies. This ultrasound showed mild to moderate ascites, a 9mm hemangioma, and no evidence of thrombosis. After the results of this ultrasound were reviewed, the patient was discharged home with a plan to follow-up with liver regarding her ascites and whether it can be attributed to her recent SBO. # ESRD on HD - The patient gets hemodialysis on a Tu/Th/Sa schedule. On admit, the patient was continued on her home does of sevalemer. Renal was consulted, and the patient received dialysis on [**7-7**] in the ICU. # Anemia/Pancytopenia - The patient has a chronic anemia and baseline pancytopenia that are likely secondary to her CKD and SLE. On admit she was actually above baseline. She was continued on her home does of epogen. # H/o Gastric Ulcer - The patient was continued on her PPI [**Hospital1 **]. # SLE - The patient was continued on her home regimen of prednisone 4mg po daily. # H/o SVC Thrombosis - The patient has a goal INR of [**2-13**]. However, naticoagulation was stopped after a recent admission secondary to a supratherapeutic INR. On admit, her INR was sub-therapeutic. Therefore, her warfarin was restarted at 3 mg daily. # Seizure Disorder - The patient was continued on her home regimen of keppra 1000 mg PO 3 times a week (Tu/Th/Sa). # Depression - The patient was continued on her home dose of celexa. Medications on Admission: 1.Nifedipine 90 mg PO DAILY (Daily). 2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime). 3.Lidocaine 5 % PATCH Q24HR. 4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID 5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H 7.Prednisone 4 mg PO DAILY (Daily). 8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday). 9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday). 10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD 12.Labetalol 1000 mg Tablet Tablet PO TID 13.Hydralazine 100 mg Tablet PO Q8H 14.Warfarin 3 mg Tablet PO Once Daily at 4 PM. 15.Pantoprazole 40 mg PO Q12H (every 12 hours). 16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24HR (). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). Disp:*QS Tablet(s)* Refills:*2* 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QTUTHSA (TU,TH,SA). 17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for abdominal pain. Discharge Disposition: Home Discharge Diagnosis: Hypertensive Urgency Lupus Nephritis End stage renal disease on hemodialysis Ascites Discharge Condition: hemodynamically stable with blood pressures 130-140/70-80s. Discharge Instructions: You were evaluated and treated for you hypertension. You were started on IV medications and transitioned to your home regimen and received a session of hemodialysis. You also had an ultrasound to evaluate the fluid in your belly. There was no evidence of blood clot contributing to the build up of the fluid. Please continue to follow a low sodium diet at home and take all of your blood pressure medications in addition to going to dialysis. Followup Instructions: You have the following appointments scheduled: Please also keep your Tuesday/Thursday/Saturday Dialysis schedule Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-7-30**] 2:00 Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 ",39,2142-07-07 10:01:00,2142-07-08 18:05:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," # hypertensive urgency - at the time of admission, the patient denied chest pain but continued to have mild headache. she also had resolving shortness of breath, likely secondary to hypertension. she stated that she did take her po meds. she was started on a labetalol drip and continued on her home regimen of oral labetolol, nifedipine, hydralazine, and aliskerin. a sent of cardiac enzymes was sent and revealed a cpk of 59 and a troponin of 0.18. the patient also underwent dialysis in the icu. after dialysis the labetalol drip was weaned off. overnight, sbps ranged 109 to 182 mmhg. the following day, her sbps ranged 133 to 200. ultimately, she was discharged home on her normal medication regimen. # abdominal pain - the patient also presented complaining of adbominal pain. she had recently been treated for sbo; however, at the time of admit, she was without nausea or vomiting. she had a soft abdomen, was passing flatus, and was having daily bowel movements. she did have hypoactive bowel sounds. she was continued of her outpatient pain regimen of po dilaudid, fentanyl patch, and lidoacine patch. an ultrasound of her abd was also performed and showed ascites in all 4 quadrants with the largest in the left lower quadrant measuring 5.5cm. considering her history of thrombosis, renal recommended getting an abdominal ultrasound with doppler flow studies. this ultrasound showed mild to moderate ascites, a 9mm hemangioma, and no evidence of thrombosis. after the results of this ultrasound were reviewed, the patient was discharged home with a plan to follow-up with liver regarding her ascites and whether it can be attributed to her recent sbo. # esrd on hd - the patient gets hemodialysis on a tu/th/sa schedule. on admit, the patient was continued on her home does of sevalemer. renal was consulted, and the patient received dialysis on [**7-7**] in the icu. # anemia/pancytopenia - the patient has a chronic anemia and baseline pancytopenia that are likely secondary to her ckd and sle. on admit she was actually above baseline. she was continued on her home does of epogen. # h/o gastric ulcer - the patient was continued on her ppi [**hospital1 **]. # sle - the patient was continued on her home regimen of prednisone 4mg po daily. # h/o svc thrombosis - the patient has a goal inr of [**2-13**]. however, naticoagulation was stopped after a recent admission secondary to a supratherapeutic inr. on admit, her inr was sub-therapeutic. therefore, her warfarin was restarted at 3 mg daily. # seizure disorder - the patient was continued on her home regimen of keppra 1000 mg po 3 times a week (tu/th/sa). # depression - the patient was continued on her home dose of celexa. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Unspecified iridocyclitis; ; Other ascites; Other chronic pain; Abdominal pain, unspecified site; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Other specified peripheral vascular diseases; Anemia of other chronic disease; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Epilepsy, unspecified, without mention of intractable epilepsy; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism; Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits]","# hypertensive urgency - at the time of admission, the patient denied chest pain but continued to have mild headache. she stated that she did take her po meds. # abdominal pain - the patient also presented complaining of adbominal pain. on admit, the patient was continued on her home does of sevalemer. # h/o gastric ulcer - the patient was continued on her ppi [**hospital1 **]. # sle - the patient was continued on her home regimen of prednisone 4mg po daily.","at the time of admission, the patient denied chest pain but continued to have mild headache. she also had resolving shortness of breath, likely secondary to hypertension. she had recently been treated for sbo; however, she was without nausea or vomiting." 109,155726.0,14864,2142-08-16,14863,196721.0,2142-07-23,Discharge summary,"Admission Date: [**2142-7-12**] Discharge Date: [**2142-7-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 759**] Chief Complaint: Dyspnea, hypertension Major Surgical or Invasive Procedure: 1. Ultrasound Guided Tap 2. Venogram History of Present Illness: Ms. [**Known lastname **] is a 24 year old female with a history of SLE, ESRD on HD, h/o malignant HTN, SVC syndrome, PRES, prior ICH, with frequent admission for hypertensive urgency/emergency, with chronic abdominal pain that presented to the ED [**7-12**] with critically high blood pressure and dyspnea. She was recently discharged on [**7-8**] for hypertensive urgency and dyspnea. She was treated with labetolol gtt, [**Month/Year (2) 2286**], and her home medications with improvement of her BP. She was discharged home in stable condition on [**7-8**]. She had been doing well at home, but missed her HD session on [**7-10**] due to transportation issues. She has been taking her medications without any difficulty. On the morning of admission, she noted increase dyspnea, and had a dry cough, although this is not particularly new. She presented to the ER for dyspnea. She continues to have the chronic abdominal pain which is unchanged, and is controlled right now. In the emergency department, VS= 98.1, 240/140, 128, 30, 96%RA. On initial evaluation, she was noted to have SBP 70s on the right arm, 240s on the left arm. She did not complain of any pain. She underwent CTA torso to eval for dissection which was negative for dissection or PE. The imaging showed persistent SVC thrombus. There was also note of bilateral ground glass and nodularities therefore was given levofloxacin 750 mg IV x 1. She was given labetalol IV, then started on a labetalol gtt. Her BP remained elevated, therefore she was transferred to the ICU for BP control and then [**Month/Year (2) 2286**]. She was also given dilaudid 1 mg IV x 1 as well. Ms. [**Known lastname **] was taken to the MICU and treated for malignant hypertension. She was given hemodialysis and her blood pressure stabilized. She was transferred to the medical floor. She continued to receive [**Known lastname 2286**] Tuesday, Thursday, and Saturday. On [**7-16**], she had a paracentesis of her abdomen. She is complaining of focal tenderness around the point of insertion. On [**7-17**], she was transferred back to the MICU because of stridor that was treated with Heliox. She was stabilized, and came back to the floor on [**7-19**]. On [**7-19**], Ms. [**Known lastname **] had a venogram. On [**7-23**], an angiography intervention for an occlusion of her left brachiocephalic vein was discontinued because her occlusion was not as drastic as prior imaging indicated when tested with a 22 gauge needle. Ms. [**Known lastname **] was discharged on [**7-23**] with stable blood pressures and abdominal pain controlled. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Physical Exam: General: A&Ox3. NAD, oriented x3. HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear, Neck: supple, no LAD Lungs: CTA B, with few crackles at bases. CV: RRR, S1, S2 Abdomen: soft, minimally distended, diffuse mild tenderness to palpation Ext: palpable DP/PT pulses, no clubbing, cyanosis or edema. Neuro: CN 2-12 intact. moving all four extremities spontaneously. Pertinent Results: [**2142-7-22**] 07:50AM BLOOD WBC-2.8* RBC-2.51* Hgb-7.3* Hct-23.1* MCV-92 MCH-29.1 MCHC-31.8 RDW-21.1* Plt Ct-134* [**2142-7-21**] 10:30AM BLOOD WBC-3.5* RBC-2.36* Hgb-6.8* Hct-21.6* MCV-92 MCH-28.9 MCHC-31.6 RDW-20.5* Plt Ct-121* [**2142-7-22**] 07:50AM BLOOD PT-14.7* PTT-35.0 INR(PT)-1.3* [**2142-7-22**] 07:50AM BLOOD Glucose-154* UreaN-20 Creat-4.4* Na-138 K-4.0 Cl-103 HCO3-23 AnGap-16 [**2142-7-21**] 10:30AM BLOOD Vanco-17.8 [**2142-7-20**] 09:35AM BLOOD WBC-3.8* RBC-2.39* Hgb-7.0* Hct-21.6* MCV-90 MCH-29.2 MCHC-32.4 RDW-19.8* Plt Ct-120* [**2142-7-19**] 12:30PM BLOOD WBC-3.6* RBC-2.49* Hgb-7.0* Hct-22.5* MCV-90 MCH-28.3 MCHC-31.3 RDW-18.8* Plt Ct-121* [**2142-7-20**] 09:35AM BLOOD Plt Ct-120* [**2142-7-20**] 09:35AM BLOOD PT-19.7* PTT-38.4* INR(PT)-1.8* [**2142-7-19**] 12:30PM BLOOD Plt Ct-121* [**2142-7-19**] 12:30PM BLOOD PT-29.5* PTT-43.9* INR(PT)-2.9* [**2142-7-20**] 09:35AM BLOOD Glucose-90 UreaN-19 Creat-4.2*# Na-138 K-4.2 Cl-102 HCO3-25 AnGap-15 [**2142-7-19**] 12:30PM BLOOD Glucose-72 UreaN-34* Creat-6.0*# Na-137 K-4.5 Cl-102 HCO3-24 AnGap-16 [**2142-7-19**] 12:30PM BLOOD Calcium-8.2* Phos-4.6* Mg-1.6 [**2142-7-18**] 05:44AM BLOOD Calcium-8.9 Phos-5.1* Mg-1.7 [**2142-7-12**] 12:27PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:80 [**Last Name (un) **] [**2142-7-12**] 12:27PM BLOOD C3-69* C4-17 [**2142-7-19**] 12:30PM BLOOD Vanco-16.7 [**2142-7-17**] 08:57AM BLOOD Vanco-15.9 [**2142-7-14**] 04:16AM BLOOD Vanco-19.2 [**2142-7-17**] 07:27AM BLOOD Type-ART pO2-66* pCO2-52* pH-7.30* calTCO2-27 Base XS--1 [**2142-7-12**] 02:06PM BLOOD Lactate-1.0 Brief Hospital Course: 24 y/o female with h/o SLE, ESRD on HD, malignant HTN, h/o SVC syndrome, PRES, prior ICH, and recent SBO, presented to ED on [**7-12**] for dyspnea and hypertensive urgency. 1. hypertensive urgency - pt presented to ER with SBP in 240s and c/o dyspnea. Her blood pressures were reported as unequal and CTA in ER was done. This study showed no signs of dissection. Pt's blood pressure was controlled with labetalol gtt. At time of transfer, she denied CP and SOB. CE's were flat. She was started on her home BP regimen of oral labetalol on [**2142-7-15**], and nifedipine/hydralazine/aliskerin soon after admission. Pt was also continued on her HD regimen for ESRD, for volume control. . 2. angioedema - pt developed facial swelling and shortness of breath while on medical floor. She was taken to ICU and responded favorably to Heliox. Patient returned to floor and has been comfortably breathing since. Given history of SVC, venogram was ordered that did not indicate a complete occlusion of the left brachiocephalic vein, as previously thought, with help of 22 gauge needle. 3. cough: pt presented with chronic cough/dyspnea without fevers. Chest CT revealed bilateral infiltrates and nodularities, noted possibly infectious vs edema. Pt was started on vanc/zosyn given recent hospitalization, brief temp spike, and pulm infiltrates. Abx were stopped after cultures were neg. At time of transfer, pt's dyspnea was largely resolved and these findings were felt to be more consistent with edema given hypertensive urgency. . 4. chronic abdominal pain - pt has had chronic abdominal pain, which was well controlled at time of transfer. She was continued on her current outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch. Her LFTs and lipase were wnl. She had no signs of SBO. . 5. bacteremia - GPC in pairs and clusters; started on vanco on [**2142-7-12**]. . 6. Ascites - unclear etiology and new findings for her. Pt is to get workup with liver team as outpatient. Her [**Date Range 2286**] seems to have slightly improved this finding. Her coags were unremarkable. She was seen by Hepatology in house who did not have any specific recommendations at this time but asked to see her in follow up as an outpatient. . 7. ESRD on HD - HD SaTuTh,. Pt was continued on her HD regimen while in house. Sevelamer was continued as well. . 8. anemia/pancytopenia - chronic anemia, baseline pancytopenia, likely [**2-12**] CKD and SLE, currently above baseline, though has h/o GIB. Pt's pancytopenia remained stable; C3 and C4 studies were performed and it was felt that her SLE was not active at this time. Guiac stools were neg. EPO was continued at HD. . 9. h/o gastric ulcer - PPI was continued throughout hospitalization. . 10. SLE - pt was continued on home regimen of prednisone 4mg po qdaily. . 11. h/o SVC thrombosis - patient's warfarin was discontinued after discussion with Dr. [**Last Name (STitle) 4883**]. She frequently is outside of therapeutic range on this medication and given the suspected problems with medication compliance, it was felt it was safer to discontinue it altogether. . 12. seizure disorder - pt was continued on home regimen keppra 1000 mg PO 3X/WEEK (TU,TH,SA). . 13. depression - pt was continued on her home celexa. . Medications on Admission: 1.Nifedipine 90 mg PO DAILY (Daily). 2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime). 3.Lidocaine 5 % PATCH Q24HR. 4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID 5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H 7.Prednisone 4 mg PO DAILY (Daily). 8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday). 9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday). 10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD 12.Labetalol 1000 mg Tablet Tablet PO TID 13.Hydralazine 100 mg Tablet PO Q8H 14.Warfarin 3 mg Tablet PO Once Daily at 4 PM. 15.Pantoprazole 40 mg PO Q12H (every 12 hours). 16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours. 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). 3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO at bedtime. 4. Nifedipine 30 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO QAM (once a day (in the morning)). 5. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 9. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 10. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal every Thursday. 11. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 13. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day): Please hold if systolic blood pressure < 100 or HR < 55. 14. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 15. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK (TU,TH,SA). 16. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 17. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous HD PROTOCOL (HD Protochol). 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*60 Tablet(s)* Refills:*2* 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 20. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: do not drive or operate heavy machinery with this medication as it can cause drowsiness. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Malignant Hypertension Angioedema Ascites End Stage Renal Disease Secondary: Chronic Abdominal Pain Anemia/Pancytopenia Lupus Gastric Ulcer SVC Thrombosis Seizure Disorder Depression Discharge Condition: Hemodynamically stable with blood pressures 130-140 / 60-90 Discharge Instructions: You were admitted to [**Hospital1 18**] on [**2142-7-12**] because of critically high blood pressure. While here, you were given IV antihypertensive medications, and then you were switched to antihypertnsive medications by mouth. You received multiple sessions of hemodialysis. You had a distended, tender belly, and you underwent a ultrasound guided tap to remove the fluid in your abdomen. On [**2142-7-17**], you developed throat and facial swelling, and you were transferred from the medical floor to the ICU. You were given medication to help open your airway; you were stabilized and went to hemodialysis several times. You were transferred back to the medical floor. You had a venogram on [**2142-7-20**], and the results at this time are still pending. You had blood cultures drawn that were positive for bacteria. You received IV antibiotics while at hemodialysis. You will continue to receive these antibiotics at your appointments. Please keep all of your medical appointments. Please go to the nearest emergency room if you experience any of the following: 1. Chest Pain 2. Headaches 3. Lightheadedness 4. Changes in vision 5. Nausea and Vomiting Followup Instructions: Please continue your regular hemodialysis schedule. You have the following appointments scheduled. Please call if you need to cancel or change your appointments. Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-7-21**] 12:00 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-7-30**] 2:00 Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 Completed by:[**2142-7-24**]",24,2142-07-12 15:27:00,2142-07-23 18:41:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,SHORTNESS OF BREATH," 24 y/o female with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, presented to ed on [**7-12**] for dyspnea and hypertensive urgency. 1. hypertensive urgency - pt presented to er with sbp in 240s and c/o dyspnea. her blood pressures were reported as unequal and cta in er was done. this study showed no signs of dissection. pts blood pressure was controlled with labetalol gtt. at time of transfer, she denied cp and sob. ces were flat. she was started on her home bp regimen of oral labetalol on [**2142-7-15**], and nifedipine/hydralazine/aliskerin soon after admission. pt was also continued on her hd regimen for esrd, for volume control. . 2. angioedema - pt developed facial swelling and shortness of breath while on medical floor. she was taken to icu and responded favorably to heliox. patient returned to floor and has been comfortably breathing since. given history of svc, venogram was ordered that did not indicate a complete occlusion of the left brachiocephalic vein, as previously thought, with help of 22 gauge needle. 3. cough: pt presented with chronic cough/dyspnea without fevers. chest ct revealed bilateral infiltrates and nodularities, noted possibly infectious vs edema. pt was started on vanc/zosyn given recent hospitalization, brief temp spike, and pulm infiltrates. abx were stopped after cultures were neg. at time of transfer, pts dyspnea was largely resolved and these findings were felt to be more consistent with edema given hypertensive urgency. . 4. chronic abdominal pain - pt has had chronic abdominal pain, which was well controlled at time of transfer. she was continued on her current outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch. her lfts and lipase were wnl. she had no signs of sbo. . 5. bacteremia - gpc in pairs and clusters; started on vanco on [**2142-7-12**]. . 6. ascites - unclear etiology and new findings for her. pt is to get workup with liver team as outpatient. her [**date range 2286**] seems to have slightly improved this finding. her coags were unremarkable. she was seen by hepatology in house who did not have any specific recommendations at this time but asked to see her in follow up as an outpatient. . 7. esrd on hd - hd satuth,. pt was continued on her hd regimen while in house. sevelamer was continued as well. . 8. anemia/pancytopenia - chronic anemia, baseline pancytopenia, likely [**2-12**] ckd and sle, currently above baseline, though has h/o gib. pts pancytopenia remained stable; c3 and c4 studies were performed and it was felt that her sle was not active at this time. guiac stools were neg. epo was continued at hd. . 9. h/o gastric ulcer - ppi was continued throughout hospitalization. . 10. sle - pt was continued on home regimen of prednisone 4mg po qdaily. . 11. h/o svc thrombosis - patients warfarin was discontinued after discussion with dr. [**last name (stitle) 4883**]. she frequently is outside of therapeutic range on this medication and given the suspected problems with medication compliance, it was felt it was safer to discontinue it altogether. . 12. seizure disorder - pt was continued on home regimen keppra 1000 mg po 3x/week (tu,th,sa). . 13. depression - pt was continued on her home celexa. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Other ascites; Infection and inflammatory reaction due to other vascular device, implant, and graft; Bacteremia; Other primary cardiomyopathies; Unspecified disease of pericardium; Compression of vein; Systemic lupus erythematosus; Abdominal pain, unspecified site; Other chronic pain; Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus; Stridor; Angioneurotic edema, not elsewhere classified; Unspecified accident; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Other specified peripheral vascular diseases; Anemia of other chronic disease; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Epilepsy, unspecified, without mention of intractable epilepsy; ; Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism; Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits]","24 y/o female with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, presented to ed on [**7-12**] for dyspnea and hypertensive urgency. she was taken to icu and responded favorably to heliox. patient returned to floor and has been comfortably breathing since. at time of transfer, pts dyspnea was largely resolved and these findings were felt to be more consistent with edema given hypertensive urgency. ascites - unclear etiology and new findings for her. h/o gastric ulcer - ppi was continued throughout hospitalization. she frequently is outside of therapeutic range on this medication and given the suspected problems with medication compliance, it was felt it was safer to discontinue it altogether.","24 y/o female with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, presented to ed on [**7-12**] for dyspnea and hypertensive urgency. she was started on her home bp regimen of oral labetalol on [**2142-7-15**], and nife" 109,155726.0,14864,2142-08-16,14807,158995.0,2142-02-26,Discharge summary,"Admission Date: [**2142-2-25**] Discharge Date: [**2142-2-26**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 338**] 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 History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, hx of malignant HTN admitted with change in mental status. Patient missed HD on [**2142-2-24**] and was found unresponsive and diaphoretic by mother this morning after she took some dilaudid. EMS was called, 1 mg of narcan was administered with slight improvement in mental status. On arrival to the ED her vitals were 112/64 62 16 99RA she was noted to be hyperkalemic in the absence of EKG changes and was given calcium, D5, 10U regular insulin, 30 mg po kayxalate and repeat K was 5.4. ABG: 7.29/38/199. Repeat glucose was 41 and 1amp D50 was given. She was sent to the ICU for monitoring. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including [**Month/Year (2) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: HR: 80 (79 - 80) bpm BP: 127/59(76) {127/59(76) - 139/64(82)} mmHg RR: 34 (21 - 34) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Physical Examination Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact Pertinent Results: [**2142-2-25**] 01:50PM PT-14.9* PTT-36.8* INR(PT)-1.3* [**2142-2-25**] 01:50PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2142-2-25**] 01:50PM WBC-5.0 RBC-2.21* HGB-6.4* HCT-20.7* MCV-94 MCH-29.1 MCHC-31.1 RDW-19.6* [**2142-2-25**] 10:30PM GLUCOSE-87 UREA N-66* CREAT-8.4* SODIUM-142 POTASSIUM-5.9* CHLORIDE-110* TOTAL CO2-16* ANION GAP-22* HISTORY: Altered mental status. Evaluate underlying for pneumonia. UPRIGHT PORTABLE CHEST: Comparison is made to [**2-14**] and [**2142-2-19**], exams. Study is slightly limited by patient motion. In the interval, the degree of pulmonary edema appears improved with slightly decreased prominence of the pulmonary vascularity. There is unchanged extensive retrocardiac consolidation obscuring the majority of the left hemidiaphragm with persistent blunting of the left CP angle, likely related to small effusion. Exam is otherwise unchanged from prior with persistent cardiomegaly. A catheter is seen projecting over the abdomen, partially imaged. IMPRESSION: Slight improvement in pulmonary edema with persistent retrocardiac opacity, which again may represent atelectasis versus underlying pneumonia. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted hypotension and decreased mental status. Hypotension and altered mental status were in the setting of excessive narcotic use. Patient's narcotics were held, pressors returned to [**Location 213**] and patient was mentating fine. Hct was below baseline and patient was transfused 1u PRBC and was given HD before discharge. Patient is to continue anti-hypertensive medications as previously scheduled. Patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # Change in mental status: Resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. Patient received 1 dose of narcan with slight improvement in BP and mental status. patient without fevers or leuckocytosis which argue against infection. # Hypertension ?????? resumed outpatient regimen. Patient did not have any hypertensive episodes requiring hydralizine 10mg IV. # Hypotension: resolved, Patient normotensive on arrival to ICU. Relative hypotension likely due to dilaudid. Other considerations include sepsis, although patient without objective signs of infection. Held pain medications and hypotension resolved. Resumed hypertensive medications. # Abdominal pain ?????? from previous peritoneal [**Location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # Hyperkalemia: Likely due to missed HD session. She received calcium, D5, insulin and kayexalate in ED. HD in am ESRD: Renal following, had HD the day of discharge, transfused while there. Will continue normal schedule as an outpatient with HD T/Th/F this week. # Metabolic Acidosis: likely due to renal failure and missed HD. # SLE: continued prednisone at 4 mg PO daily. # OSA: CPAP for sleep with 7 pressure, however patient refuses. Continued to offer as inpatient. Should try to follow up with sleep medicine. Medications on Admission: Prednisone 4mg qd Citalopram 20 mg daily Gabapentin 300 mg [**Hospital1 **] Warfarin 4mg daily Pantoprazole 40 mg qd Clonidine 0.1 mg/24 QWED Clonidine 0.3 mg/24 hr QWED Labetalol 900 mg tid Nifedipine 90 mg qd Aliskiren 150 mg [**Hospital1 **] Hydralazine 100 mg q8h Morphine 7.5 mg q8h prn pain Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Home Discharge Diagnosis: Primary: narcotic overdose relative hypotension anemia Secondary: ESRD on HD [**2-12**] SLE malignant hypertension Discharge Condition: stable - received HD prior to discharge Discharge Instructions: You were admitted for altered mental status after missing hemodialysis. It was likely from the dilaudid you took as well as missing your scheduled [**Month/Day (2) 2286**]. You were also relatively hypotensive in the setting of excessive narcotic medicaiton usage. Narcotic medications were held and hypotension and altered mental status resolved. Please use narcotic medications with caution. You are recommended to use morphine for pain control rather than dilaudid. No medication changes were made. Please return to the ED if you have any altered mental status or miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] or have symptoms such as vision changes or headache from your history of malignant hypertension. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-3-20**] 3:00 HD as previously scheduled Completed by:[**2142-2-26**]",171,2142-02-25 15:49:00,2142-02-26 16:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ALTERED MENTAL STATUS," 24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. patients narcotics were held, pressors returned to [**location 213**] and patient was mentating fine. hct was below baseline and patient was transfused 1u prbc and was given hd before discharge. patient is to continue anti-hypertensive medications as previously scheduled. patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # change in mental status: resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. patient received 1 dose of narcan with slight improvement in bp and mental status. patient without fevers or leuckocytosis which argue against infection. # hypertension ?????? resumed outpatient regimen. patient did not have any hypertensive episodes requiring hydralizine 10mg iv. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. other considerations include sepsis, although patient without objective signs of infection. held pain medications and hypotension resolved. resumed hypertensive medications. # abdominal pain ?????? from previous peritoneal [**location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # hyperkalemia: likely due to missed hd session. she received calcium, d5, insulin and kayexalate in ed. hd in am esrd: renal following, had hd the day of discharge, transfused while there. will continue normal schedule as an outpatient with hd t/th/f this week. # metabolic acidosis: likely due to renal failure and missed hd. # sle: continued prednisone at 4 mg po daily. # osa: cpap for sleep with 7 pressure, however patient refuses. continued to offer as inpatient. should try to follow up with sleep medicine. ","PRIMARY: [Poisoning by other opiates and related narcotics] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Thrombotic microangiopathy; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Altered mental status; Other iatrogenic hypotension; Accidental poisoning by other opiates and related narcotics; Hyperpotassemia; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Nontraumatic hematoma of soft tissue; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. from previous peritoneal [**location 2286**] hematoma ??????","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. narcotics were held, pressors returned to and patient was mentating fine. patient was encouraged to take less pain medications and to use morphine." 109,155726.0,14864,2142-08-16,14808,158943.0,2142-03-23,Discharge summary,"Admission Date: [**2142-3-21**] Discharge Date: [**2142-3-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: Abdominal Pain, Shortness of breath, Chest discomfort Major Surgical or Invasive Procedure: HD [**2142-3-21**] and [**2142-3-23**] History of Present Illness: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] 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 [**Telephone/Fax (3) 43508**]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. [**Telephone/Fax (3) **] was discussed with renal and it was not felt that HTN is a volume issue so no need for emergent [**Telephone/Fax (3) 2286**]. . 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 [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**], getting Vanc with HD. . PSHx: 1. Placement of multiple catheters including [**Year (4 digits) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] 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: [**2142-3-21**] 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* [**2142-3-21**] 02:20AM NEUTS-76.1* BANDS-0 LYMPHS-17.9* MONOS-4.5 EOS-1.1 BASOS-0.5 [**2142-3-21**] 02:20AM PLT SMR-NORMAL PLT COUNT-168 [**2142-3-21**] 02:20AM PT-21.8* PTT-34.7 INR(PT)-2.1* [**2142-3-21**] 02:20AM cTropnT-0.12* [**2142-3-21**] 02:20AM ALT(SGPT)-46* AST(SGOT)-94* CK(CPK)-76 ALK PHOS-173* TOT BILI-0.4 [**2142-3-21**] 02:20AM GLUCOSE-74 UREA N-47* CREAT-7.3* SODIUM-140 POTASSIUM-5.8* CHLORIDE-109* TOTAL CO2-19* ANION GAP-18 [**2142-3-21**] 04:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-21**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2142-3-21**] 12:58PM CK-MB-NotDone cTropnT-0.12* . CT C/A/P - [**2142-3-20**] - 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: [**2142-3-23**] 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* [**2142-3-23**] 12:00PM BLOOD Plt Ct-130* [**2142-3-23**] 12:00PM BLOOD PT-28.8* PTT-58.6* INR(PT)-2.9* [**2142-3-23**] 12:00PM BLOOD Glucose-77 UreaN-31* Creat-6.0*# Na-137 K-4.8 Cl-104 HCO3-24 AnGap-14 [**2142-3-23**] 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 [**3-22**] 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 [**2142-3-21**] . # abdominal pain: Consistent with patient's baseline chronic abdominal pain. Medication effect also possible. CT prelim neg for small bowel obstruction. LFTs doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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). [**Month/Year (2) **]:*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 [**Month/Year (2) 2286**] sessions as directed by the nephrology team- your next session should be on Tuesday. Completed by:[**2142-3-26**]",146,2142-03-21 09:25:00,2142-03-23 18:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,CHEST PAIN;TELEMETRY," 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 (200s/100s) that nevertheless are within levels shes 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 [**3-22**] and transferred to the medicine floor. the next day, her bp remained within goal of 120s/80s. 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. ces were cycled and were negative. cpap was continued as tolerated at home settings. sob resolved after hd on [**2142-3-21**] . # abdominal pain: consistent with patients baseline chronic abdominal pain. medication effect also possible. ct prelim neg for small bowel obstruction. lfts doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Compression of vein; Unspecified disease of pericardium; Infection and inflammatory reaction due to other vascular device, implant, and graft; Bacteremia; Primary hypercoagulable state; Other primary cardiomyopathies; ; Abdominal pain, unspecified site; Urinary tract infection, site not specified; Acidosis; Other chest pain; Other chronic pain; Systemic lupus erythematosus; Noncompliance with renal dialysis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Hyperpotassemia; 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; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","this is a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. ct prelim neg for small bowel obstruction. on arrival to the floor, abd pain was back to baseline and well controlled on dilaudid 2mg po q 4hrs .","a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. initial attempts were made to control her bp with hydralazine and labetalol iv but after these failed to control her blood pressure. she was successfully transitioned to home medications of clonidine, labetalol, aliskiren, nifedipine" 109,155726.0,14864,2142-08-16,14809,124398.0,2142-03-31,Discharge summary,"Admission Date: [**2142-3-24**] Discharge Date: [**2142-3-31**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: HTN, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 24F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] after admission for abdominal pain, MSSA bacteremia, paroxysmal hypertension and ESRD line, followed by readmission [**3-22**], now presents with usual central crampy abdominal pain, 3 loose nonbloody stools this AM, SOB, and HTN to 270s. Pt was d/c'd from [**Hospital1 18**] yesterday after HD session, went home, states she took her PM meds, took her 8 AM medds (hydral, labetalol), then developed these symptoms which precluded her from taking her usual home meds (no afternoon meds - nifedipine, labetalol, hydral). The abd pain comes and goes and is unchanged from her baseline. While she has nausea, she is asking for dinner. . In the ED, initial BP 272/148. CXR w/o evidence of volume overload. No CT scan performed. Started on NTG gtt, given Hydralazine 10 x 1, Dilaudid 2 mg, labetaolo 20mg IV x 1. . Upon arrival to the floor, her BP was 240/135. She continued to complain of abdominal pain but was eating crackers, breathing felt better. RR 17. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: 98.2 97 [**Telephone/Fax (2) 43509**]0% on 2 L nC Gen: pleasant, comfortable HEENT: L eye enucleated. moon facies. Right pupil reactive Heart: hrrr, no m/r/g Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, diffuse TTP, no rebound/guarding Ext: no c/c/e Neuro: aox4, cn 2-12 intact grossly. Pertinent Results: [**2142-3-24**] 07:17PM PT-22.4* PTT-43.64* INR(PT)-2.1* [**2142-3-24**] 04:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2142-3-24**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-24**] 04:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**11-30**] [**2142-3-24**] 02:05PM GLUCOSE-76 UREA N-21* CREAT-4.8*# SODIUM-139 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2142-3-24**] 02:05PM ALT(SGPT)-78* AST(SGOT)-181* CK(CPK)-55 ALK PHOS-192* TOT BILI-0.5 [**2142-3-24**] 02:05PM cTropnT-0.12* [**2142-3-24**] 02:05PM CK-MB-5 [**2142-3-24**] 02:05PM WBC-3.6* RBC-2.90* HGB-8.9* HCT-26.6* MCV-92 MCH-30.7 MCHC-33.4 RDW-19.8* [**2142-3-24**] 02:05PM NEUTS-73.9* BANDS-0 LYMPHS-18.5 MONOS-3.8 EOS-3.0 BASOS-0.8 [**2142-3-24**] 02:05PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-1+ TARGET-1+ SCHISTOCY-OCCASIONAL TEARDROP-1+ ELLIPTOCY-OCCASIONAL [**2142-3-24**] 02:05PM PLT SMR-LOW PLT COUNT-129* [**2142-3-23**] 12:00PM GLUCOSE-77 UREA N-31* CREAT-6.0*# SODIUM-137 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14 [**2142-3-23**] 12:00PM estGFR-Using this [**2142-3-23**] 12:00PM CALCIUM-8.4 PHOSPHATE-5.7* MAGNESIUM-1.9 [**2142-3-23**] 12:00PM WBC-3.7* RBC-2.87* HGB-8.7* HCT-26.1* MCV-91 MCH-30.3 MCHC-33.3 RDW-19.4* [**2142-3-23**] 12:00PM PLT COUNT-130* [**2142-3-23**] 12:00PM PT-28.8* PTT-58.6* INR(PT)-2.9* Brief Hospital Course: The patient was admitted to the MICU on a NTG gtt from the ED. Her abdominal pain had imporved and she was eating crackers and peanut butter. She was given her usual afternoon home medications, and transitioned to a Nicardipine gtt, which has worked well for her in the past. Her BP goal was for a systolic of 180-200. The Nicardipine gtt was titrated off quickly and she was transfered to the floor. . On arrival to the floor, she in fact missed her morning medications on [**Month/Day/Year 766**]. This resulted in elevate blood pressures requiring IV hydralazing for control. She went to dialyisis Tuesday [**3-27**] and again had markedly elevated blood pressures while at [**Month/Year (2) 2286**] from missing her AM doses. Instructions were written for explicit AM administration and Nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. She was continued on labetalol 900mg TID, Aliskerin, Hydralazine 100mg po TID, and clonidine patch 0.4mg/24 weekly patch. . HEr BP remained relativly stable. She established a three three times weekly Dialysus regemin. A PAP smear was attempted due to her history of CIN I and no PCP follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . Her abdominal pain was also a chronic issue, which appeared stable. She was not administered IV narcotics, only PO. It was wihtout clear percipitating events or etiology. She will need GI follow up. She was contact[**Name (NI) **] by phone several times to arrange a GI follow up appointment but did not return messages. She has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . She was discharged to followup with her nephrologist, Dr. [**Last Name (STitle) 4883**]. . 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. Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Last Name (STitle) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2* 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). [**Last Name (STitle) **]:*405 Tablet(s)* Refills:*2* 5. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*2* 6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). [**Last Name (STitle) **]:*60 Tablet(s)* Refills:*2* 9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patches Transdermal once a week: Place two patches every week on Fridays. [**Last Name (STitle) **]:*8 Patches* Refills:*2* 10. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*0* 11. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO twice a day as needed for prn SBP>200: if nauseated and cannot keep down meds, may use 1 sublingual clonidine if sbp>200. . [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0* 12. Kayexalate Powder Sig: Thirty (30) grams PO once a day for 2 days: please take [**2142-4-1**] and [**2142-4-2**] for elevated potassium. [**Month/Day/Year **]:*240 grams* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Systemic Lupus Erythematosus End Stage Renal Disease Hypertension Abdominal Pain Discharge Condition: Blood pressure stable and abdominal pain at baseline Discharge Instructions: You were admitted with high blood pressure. You were in the ICU overnight for treatment. Some of your medications were changed and you were increased to three times weekly [**Location (un) 2286**]. Your abdominal pain is a difficult problem, as the reason for the pain is unclear. [**Name2 (NI) **] were continued on oral dilaudid. IV dilaudid is strongly discouraged and will continue to be in the future. You are now taking Nifedipine SR 30mg at night in addition to 90mg in the morning. Your other medications were the same. At home, if your blood pressure is above 200, then take 100mg hydralazine. If after 1 hour, your blood pressure does not decrease to below 200 with this, then take another 100mg hydralazine. If you are nauseated and cannot take in oral meds, then take sublingual clonidine, then wait 1 hour and repeat if BP still > 200. Finally, your potassium has been high. Please take kayexalate 30gm tomorrow and the next day. Followup Instructions: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-3-31**] 7:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule appointment We will attempt to contact you on [**Name (NI) 766**] with appointment times for you. ",138,2142-03-24 16:34:00,2142-03-31 15:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," the patient was admitted to the micu on a ntg gtt from the ed. her abdominal pain had imporved and she was eating crackers and peanut butter. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. her bp goal was for a systolic of 180-200. the nicardipine gtt was titrated off quickly and she was transfered to the floor. . on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**]. this resulted in elevate blood pressures requiring iv hydralazing for control. she went to dialyisis tuesday [**3-27**] and again had markedly elevated blood pressures while at [**month/year (2) 2286**] from missing her am doses. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she was continued on labetalol 900mg tid, aliskerin, hydralazine 100mg po tid, and clonidine patch 0.4mg/24 weekly patch. . her bp remained relativly stable. she established a three three times weekly dialysus regemin. a pap smear was attempted due to her history of cin i and no pcp follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . her abdominal pain was also a chronic issue, which appeared stable. she was not administered iv narcotics, only po. it was wihtout clear percipitating events or etiology. she will need gi follow up. she was contact[**name (ni) **] by phone several times to arrange a gi follow up appointment but did not return messages. she has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . she was discharged to followup with her nephrologist, dr. [**last name (stitle) 4883**]. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Long-term (current) use of steroids; Other chronic pain; Obstructive sleep apnea (adult)(pediatric); Abdominal pain, generalized; Hyperpotassemia]","the patient was admitted to the micu on a ntg gtt from the ed. her bp goal was for a systolic of 180-200. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she established a three three times weekly dialysus regemin.","the patient was admitted to the micu on a nicardipine gtt from the ed. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**] this resulted in elevate blood pressures requiring iv hydralazing for control " 109,155726.0,14864,2142-08-16,14810,137510.0,2142-04-22,Discharge summary,"Admission Date: [**2142-4-20**] Discharge Date: [**2142-4-22**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 1253**] Chief Complaint: Dyspnea, malignant hypertension Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented with abdominal pain and shortness of breath. On [**2142-4-19**] she refused ultrafiltration at HD because she was at her dry weight. Awoke at 3 AM feeling more short of breath. She also had worsening abdominal pain and vomiting without hematemasis. She took all of her medications as prescribed including two new lidocaine patches, fentanyl patch and clonidine. She developed a slight frontal headache but no blurry vision or neurologic symptoms. ROS largely negative. . In the emergency room her initial vitals were T: 99.1 BP: 280/140 HR: 79 RR: 16 O2: 100% on RA. She had two large bore peripheral IVs placed. She received 100 mg PO hydralazine, 200 mg PO labetolol, zofran 4 mg IV, vancomycin 1 gram IV, levofloxacin 750 mg IV x 1 and was started on labetolol and nitroglycerin drips with control of her blood pressure to the 180s systolic. She had a CXR which was concerning for volume overload. She was admitted the MICU for further evaluation. . In the MICU she was stablized and transitioned to her home meds. Nephrology gave her HD with 2L UF and subjective improvement in SOB. . Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: On Admission per MICU team: Vitals: T: 96.5 BP: 162/120 HR: 79 RR: 13 O2: 100% on 4L General: Pleasant, comfortable, no distress HEENT: L eye enucleated. Moon facies. Right pupil reactive Heart: Regular rate and rhythm, s1 + s2, soft systolic murmur at RLSB, no rubs or gallops Respiratory: Crackles at bases bilaterally, no wheezes, rales, ronchi GI: soft, non-tender, non-distended, +BS GU: no foley Ext: Warm and well perfused, no clubbing, cyanosis or edema . Pertinent Results: [**2142-4-19**] 08:35AM WBC-3.8* RBC-2.53* HGB-7.6* HCT-23.4* MCV-93 MCH-29.9 MCHC-32.3 RDW-19.9* [**2142-4-19**] 08:35AM PLT COUNT-93* . [**2142-4-19**] 08:35AM GLUCOSE-88 UREA N-36* CREAT-6.0* SODIUM-135 POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-25 ANION GAP-15 [**2142-4-19**] 08:35AM CALCIUM-9.4 PHOSPHATE-5.3* MAGNESIUM-2.0 . [**2142-4-20**] 08:40AM PT-28.3* PTT-45.3* INR(PT)-2.9* . CXR PA and LAT: IMPRESSION: 1. Persistent cardiomegaly with prominence of pulmonary vasculature suggesting overhydration. Minimal costophrenic angle blunting may suggest small effusions. 2. No definite consolidation, although increased retrocardiac density is noted, most likely due to atelectasis and vascular congestion. Repeat imaging following diuresis could be considered. . INR trend: [**2142-4-19**] 09:30AM BLOOD PT-30.4* INR(PT)-3.1* [**2142-4-20**] 08:40AM BLOOD PT-28.3* PTT-45.3* INR(PT)-2.9* [**2142-4-21**] 04:07AM BLOOD PT-29.9* PTT-48.9* INR(PT)-3.1* [**2142-4-22**] 05:55AM BLOOD PT-33.3* PTT-54.1* INR(PT)-3.5* Brief Hospital Course: 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented to the ICU for hypertensive emergency, dyspnea, and headache, now resolved. . Hypertensive Emergency: Patient's blood pressure normalized with transient nitroglycerin and labetalol drips. Likely precipitated by lack of ultrafiltration at [**Year/Month/Day 2286**] yesterday. She has received [**Year/Month/Day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - Nifedipine 150 mg Tablet SR daily - Hydralazine 100 mg Tablet Q8H - Labetalol 1000 mg Tablet TID - Aliskiren 150 mg Tablet PO BID - Clonidine 0.2 mg/24 hr Patch Weekly - Hydralazine 100 mg PO PRN for SBP > 200 - continue regular [**Year/Month/Day 2286**] schedule . Social Issues/repeated admissions: The ICU and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. These episodes may be due to medication non-compliance and it may benefit Ms. [**Known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. Ms. [**Known lastname **] [**Last Name (Titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. Of note, she has missed [**Last Name (Titles) 2286**] sessions and often requests durations and flow rates for her [**Last Name (Titles) 2286**] that contradict recommendations by her nephrologist. This issue was left unresolved on discharge. . Chronic Abdominal Pain: Currently managed with PO dilaudid, fentanyl patch and lidocaine patch. Per MICU team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue PO dilaudid - continue lidocaine patch . Lupus Erythematous: Complicated by uveitis and ESRD. - continued prednisone . ESRD: On [**Last Name (Titles) 2286**]. Ultrafiltrate of 2 L on initial HD - continue outpatient regimen . Thrombocytopenia: Remained at baseline 80s to 130s. . Thrombotic Events: History of SVC thrombosis with negative workup. INR drifted up and was 3.5 on discharge. She was asked to hold her warfarin dose this PM and recheck her INR with VNA services on [**2142-4-23**] to be faxed to coumadin clinic in [**Company 191**]. - continued coumadin . Anemia: Hematocrit 24.5 initially. Baseline 23 to 28. . Medications on Admission: Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H Prednisone 1 mg Tablet Citalopram 20 mg Tablet Pantoprazole 40 mg Tablet, Warfarin 3 mg daily Gabapentin 300 mg TID Nifedipine 90 mg Tablet SR daily Nifedipine 60 mg Tablet SR daily Hydralazine 100 mg Tablet Q8H Labetalol 1000 mg Tablet TID Aliskiren 150 mg Tablet PO BID Clonidine 0.2 mg/24 hr Patch Weekly Docusate Sodium 100 mg Capsule PO BID Senna 8.6 mg Tablet Fentanyl 25 mcg/hr Patch 72 hr Lidocaine 5 %(700 mg/patch) daily Hydralazine 100 mg PO:PRN for SBP > 200 Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) 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 3 mg Tablet Sig: One (1) Tablet PO once a day: DO NOT TAKE DOSE ON [**2142-4-22**]. Then restart per your PCP. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QHS (once a day (at bedtime)). 9. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 10. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 17. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed: For systolic blood pressure > 200. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Malignant Hypertension Systemic Lupus Erythematosus End Stage Renal Disease Abdominal Pain Discharge Condition: good, VSS, on room air, pain controlled. Discharge Instructions: You came to the hospital for shortness of breath and hypertension. You were given antihypertensive drips and during [**Location (un) 2286**] 2 liters were taken off with good improvement in your shortness of breath. You will need to take your medications as prescribed and follow-up with all of your doctors to prevent coming into the hospital. . Medication changes: - Please do not take your coumadin tonight because your INR is too high. You will need to have it checked by VNA services and adjusted. - Please take ALL of your medications as prescribed. . Please call your doctor or return to the ED if you have intractable headaches, shortness of breath, intractable pain or other concerns. Followup Instructions: Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-4-26**] 3:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Completed by:[**2142-4-23**]",116,2142-04-20 13:39:00,2142-04-22 15:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,PULMONARY EDEMA;HYPERTENSION," 24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. . hypertensive emergency: patients blood pressure normalized with transient nitroglycerin and labetalol drips. likely precipitated by lack of ultrafiltration at [**year/month/day 2286**] yesterday. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - nifedipine 150 mg tablet sr daily - hydralazine 100 mg tablet q8h - labetalol 1000 mg tablet tid - aliskiren 150 mg tablet po bid - clonidine 0.2 mg/24 hr patch weekly - hydralazine 100 mg po prn for sbp > 200 - continue regular [**year/month/day 2286**] schedule . social issues/repeated admissions: the icu and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. these episodes may be due to medication non-compliance and it may benefit ms. [**known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. ms. [**known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. this issue was left unresolved on discharge. . chronic abdominal pain: currently managed with po dilaudid, fentanyl patch and lidocaine patch. per micu team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue po dilaudid - continue lidocaine patch . lupus erythematous: complicated by uveitis and esrd. - continued prednisone . esrd: on [**last name (titles) 2286**]. ultrafiltrate of 2 l on initial hd - continue outpatient regimen . thrombocytopenia: remained at baseline 80s to 130s. . thrombotic events: history of svc thrombosis with negative workup. inr drifted up and was 3.5 on discharge. she was asked to hold her warfarin dose this pm and recheck her inr with vna services on [**2142-4-23**] to be faxed to coumadin clinic in [**company 191**]. - continued coumadin . anemia: hematocrit 24.5 initially. baseline 23 to 28. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Unspecified iridocyclitis; Other primary cardiomyopathies; Unspecified disease of pericardium; ; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Noncompliance with renal dialysis; Personal history of noncompliance with medical treatment, presenting hazards to health; Surgical or other procedure not carried out because of patient's decision; Abdominal pain, left lower quadrant; Renal dialysis status; Thrombocytopenia, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Peripheral vascular disease, unspecified; Acquired absence of organ, eye; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus]","24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. ultrafiltrate of 2 l on initial hd - continue outpatient regimen .","malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips." 109,155726.0,14864,2142-08-16,14861,174489.0,2142-07-04,Discharge summary,"Admission Date: [**2142-7-3**] Discharge Date: [**2142-7-4**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 2817**] Chief Complaint: dyspnea, hypertension Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24F h/o SLE, ESRD on HD, h/o malignant HTN, SVC syndrome, PRES, prior ICH, with frequent admission for hypertensive urgency/emergency, with chronic abdominal pain. She was recently discharged on [**7-1**] after presenting for hypertensive urgency and dyspnea for which she received iv medication in the ED, but was otherwised managed with oral antihypertensives and CPAP. . She was doing well until the evening of [**7-2**] when she notes the gradual onset of dyspnea. She denied f/c/cp/ha/abd pain/diarrhea, or constipation. She was having regular, soft, daily BMs. . On [**7-3**] she awoke, and describes n/v x 2, with increasing dyspnea, and headache. She did not want to wait until dialysis at 4PM and therefore presented to [**Hospital1 18**]. . In ED VS= 97.7 [**Telephone/Fax (2) 43606**] 100%RA. Labs were notable for HCT 23, PLT 66, WBC 3.3, all roughly at baseline. CXR without acute process, ECG unchanged from prior. No UA sent, though she does make some urine. She was started on nitro gtt with modest improvement of SBPs to 210s, then labetalol 20mg iv x1 followed by labetalol gtt with BP 221/130 at the time of transfer. She refused abdominal CT. Renal was consulted, but felt HD not indicated today. . . ROS: Negative for fevers, chills, chest pain, diarrhea, rash, joint pains. +n/v as above. +abdominal pain unchanged from her baseline. +dyspnea, +HA. denies visual changes, slurrring speech, numbness, weeakness. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Physical Exam: Vitals - 97.7 88 220/150 19 100%2L BC. General: A&Ox3. NAD, oriented x3. HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear, nonerythematous, MMM. Neck: supple, no LAD, full ROM. Lungs: CTA B, with few crackles at bases. CV: RR, nl S1, S2 +S3, no rubs appreciated. Abdomen: soft, minimally distended, diffuse mild tenderness to palpation, negative [**Doctor Last Name **], no rebound, gaurding. Ext: WWP, 1+ dp/pt pluses, no clubbing, cyanosis or edema. Neuro: CN 2-12 intact. moving all four extremities spontaneously. Pertinent Results: Lab Results on Admission: [**2142-7-3**] 11:37AM GLUCOSE-95 UREA N-40* CREAT-7.4*# SODIUM-140 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16 ALT(SGPT)-14 AST(SGOT)-44* LD(LDH)-264* ALK PHOS-115 TOT BILI-0.4 ALBUMIN-3.2* WBC-3.6* RBC-2.61* HGB-7.6* HCT-23.4* MCV-90 MCH-29.0 MCHC-32.4 RDW-18.3* [**2142-7-3**] 11:37AM NEUTS-71.6* LYMPHS-23.0 MONOS-3.7 EOS-1.5 BASOS-0.2 PLT COUNT-66* PT-14.0* PTT-34.5 INR(PT)-1.2* [**2142-7-3**] 06:00PM CK-MB-5 cTropnT-0.17*CK(CPK)-58 [**2142-7-3**] CXR: IMPRESSION: Unchanged moderate cardiomegaly with pulmonary edema. Again underlying pneumonia in the lung bases cannot be completely excluded and evaluation after appropriate diuresis could be performed if pneumonia remains a clinical concern. Brief Hospital Course: 24F with h/o SLE, ESRD on HD, malignant HTN, h/o SVC syndrome, PRES, prior ICH, and recent SBO, p/w n/v, and hypertensive urgency. . # hypertensive urgency - On presentation she denies chest pain, but continues to have mild headache, and resolving shortness of breath, likely [**2-12**] hypertension. states she did take her PO meds. Hypertensive urgency was treated as follows with nitro and labetalol gtt which were quickly weaned as blood pressures dropped below SBP 120. She evenutally became hypotensive to SBP of 90 which resolved on its own. She was continued on CPAP overnight and discontinued in the am. She was continued on her home regimen of oral labetolol, nifedipine, hydralazine, aliskerin. She remained normotensive the following morning and was taken to hemodialysis after which she was discharged home on all of her old home medications. . # abdominal pain - On presentation she was without n/v, soft abdomen, passing flatus, and having daily bowel movements. She did have hypoactive bowel sounds on admission. She was maintained on outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch, neurontin with HD with plan to follow BMs closley. Her pain improved the am of discharge and she had no further vomiting. . # ESRD on HD - She is currently getting HD SaTuTh, though did not get HD on the day of presenation. As there was no acute indication for HD on presentation, she received HD on the following am, day of discharge. She was continued on sevelamer. . # anemia - chronic anemia, likely [**2-12**] CKD and SLE, currently above baseline, though has h/o GIB. She received 2 unit PRBCs and epo with hemodialysis. . # h/o gastric ulcer - she was continued on her outpatient dose of PPI [**Hospital1 **]. . # SLE - continue home regimen of prednisone 4mg po qdaily. . # h/o SVC thrombosis - pt with goal INR [**2-13**], but this was stopped after recent admission [**2-12**] supratherapeutic INR. INR currently sub-therapeutic and she was resumed on warfarin at 3 mg qdaily without heparin bridge. . # seizure disorder - continued on keppra 1000 mg PO 3X/WEEK (TU,TH,SA). . # depression - continued on celexa. Medications on Admission: 1.Nifedipine 90 mg PO DAILY (Daily). 2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime). 3.Lidocaine 5 % PATCH Q24HR. 4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID 5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H 7.Prednisone 4 mg PO DAILY (Daily). 8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday). 9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday). 10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD 12.Labetalol 1000 mg Tablet Tablet PO TID 13.Hydralazine 100 mg Tablet PO Q8H 14.Warfarin 3 mg Tablet PO Once Daily at 4 PM. 15.Pantoprazole 40 mg PO Q12H (every 12 hours). 16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. 6. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for hypertension. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 12. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 13. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). Tablet(s) 14. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 15. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QTUTHSA (TU,TH,SA). Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Primary: hypertensive emergency anemia, erythropoetin deficiency Secondary: chronic renal failure on hemodialysis lupus nephritis Discharge Condition: Hemodynamically stable. Discharge Instructions: You were admitted for hypertensive urgency and treated in the intensvie care unit with IV medications to decrease your blood pressure. You also received 2 units of blood and hemodialysis before you were discharged home. It is essential that you take all of your prescribed blood pressure medications and present regularly for your Tuesday, Thursday, Saturday dialysis. Please return to the emergency department or call your primary care physician if you develop any chest pain, shortness of breath, fevers, or any other concerning symptoms. Followup Instructions: You have the following appointment scheduled. Please contact your provider if you are unable to make these appointments. Your dialysis is scheduled for Tuesday, Thursday, Saturday. Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-7-30**] 2:00 Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 ",43,2142-07-03 14:48:00,2142-07-04 17:23:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24f with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, p/w n/v, and hypertensive urgency. . # hypertensive urgency - on presentation she denies chest pain, but continues to have mild headache, and resolving shortness of breath, likely [**2-12**] hypertension. states she did take her po meds. hypertensive urgency was treated as follows with nitro and labetalol gtt which were quickly weaned as blood pressures dropped below sbp 120. she evenutally became hypotensive to sbp of 90 which resolved on its own. she was continued on cpap overnight and discontinued in the am. she was continued on her home regimen of oral labetolol, nifedipine, hydralazine, aliskerin. she remained normotensive the following morning and was taken to hemodialysis after which she was discharged home on all of her old home medications. . # abdominal pain - on presentation she was without n/v, soft abdomen, passing flatus, and having daily bowel movements. she did have hypoactive bowel sounds on admission. she was maintained on outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch, neurontin with hd with plan to follow bms closley. her pain improved the am of discharge and she had no further vomiting. . # esrd on hd - she is currently getting hd satuth, though did not get hd on the day of presenation. as there was no acute indication for hd on presentation, she received hd on the following am, day of discharge. she was continued on sevelamer. . # anemia - chronic anemia, likely [**2-12**] ckd and sle, currently above baseline, though has h/o gib. she received 2 unit prbcs and epo with hemodialysis. . # h/o gastric ulcer - she was continued on her outpatient dose of ppi [**hospital1 **]. . # sle - continue home regimen of prednisone 4mg po qdaily. . # h/o svc thrombosis - pt with goal inr [**2-13**], but this was stopped after recent admission [**2-12**] supratherapeutic inr. inr currently sub-therapeutic and she was resumed on warfarin at 3 mg qdaily without heparin bridge. . # seizure disorder - continued on keppra 1000 mg po 3x/week (tu,th,sa). . # depression - continued on celexa. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified iridocyclitis; Other primary cardiomyopathies; Abdominal pain, unspecified site; Other chronic pain; Nausea with vomiting; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other specified peripheral vascular diseases; Obstructive sleep apnea (adult)(pediatric); Anemia of other chronic disease; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Epilepsy, unspecified, without mention of intractable epilepsy; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism; Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits]","24f with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, p/w n/v, and hypertensive urgency. she remained normotensive the following morning and was taken to hemodialysis after which she was discharged home on all of her old home medications. # abdominal pain - on presentation she was without n/v, soft abdomen, passing flatus, and having daily bowel movements. # seizure disorder - continued on keppra 1000 mg po 3x/week (tu,th,sa).","malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, p/w n/v, and hypertensive urgency. hypertensive urgency was treated as follows with nitro and labetalol gtt which were quickly weaned as blood pressures dropped below sbp 120. she evenutally became hypotensive to sbp of 90 which resolved on its own " 109,155726.0,14864,2142-08-16,14860,136572.0,2142-06-20,Discharge summary,"Admission Date: [**2142-6-18**] Discharge Date: [**2142-6-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 2145**] Chief Complaint: Acute Onset Dyspnea Major Surgical or Invasive Procedure: Dialysis History of Present Illness: Please see MICU note for full details. In brief this is a 24 y.o. woman with SLE, ESRD on HD, hx malignant HTN, h/o SVC syndrome, h/o posterior reversible encephalopathy syndrome (PRES) and prior intracerebral hemorrhage, frequently admitted with hypertensive urgency/emergency who was admitted with acute onset dyspnea after 2 weeks without dialysis given to unable to get transportation ? despite Dr. [**Last Name (STitle) 7473**] attempting to arrange transport for her (? refused to come). She was admitted therefore on [**6-18**] to micu with VS: T 100.4 HR 108 BP 240/180 RR 28 POx100 RA. She was treated with nitro gtt, labetolol gtt and dilaudid-these gtts were stopped at 0700. In the micu she was dialyzed with 1.7L fluid removal (though + 300cc given tranfusion). Her SOB is improved. Her hct was also noted to be low (18->from 22 [**2142-6-5**]) so transfused 2 units PRBC's, recent EGD with gastric ulcer [**5-29**], guaiac negative in ED, no BM in unit, hemolysis w/u negative. BP in icu 140/106 currently but of note was hypotensive on HD to 86/62. She notes sob improved rapidly on arrival. ROS: Currently she has no complaints. She notes at home her abdominal pain is at baseline for her, felt mid epigastric, for which she takes dilaudid 4mg up to [**Hospital1 **]. She has been getting HD via right femoral catheter which is not painful, no discharge from the sight. She denies HA, visual changes, cough, chest pain or pressure, orthostatic changes, palpitations, nausea, vomiting, constipation, diarrhea, melena, brbpr, dysuria, hematuria, rash, swelling, orthopnea, pnd. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Physical Exam: Vitals - T: 97.7, BP: 140/99 P: 88 R: 19 O2: 98% on RA General: Sleeping comfortably but awakens easily, alert, oriented x3 HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear, nonerythematous, MMM, moon facies Neck: supple, JVP flat, no LAD, full ROM, left EJ in place Lungs: coarse BS throughout, no W/R/R, no decreased BS at bases CV: S1, S2 nl, no m/r/g appreciated Abdomen: Firm, non-tender to palpation, no masses or organomegally Ext: Warm, well perfused, 1+ DP/PT, no clubbing, cyanosis or edema Neuro: a&o x3, motor [**5-15**] UE/LE bilaterally Pertinent Results: [**2142-6-18**] 05:28PM HCT-26.0*# [**2142-6-18**] 11:38AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL [**2142-6-18**] 05:04AM GLUCOSE-85 UREA N-72* CREAT-10.4* SODIUM-139 POTASSIUM-5.5* CHLORIDE-109* TOTAL CO2-14* ANION GAP-22* [**2142-6-18**] 05:04AM LD(LDH)-264* TOT BILI-0.2 [**2142-6-18**] 05:04AM CALCIUM-6.6* PHOSPHATE-6.5* MAGNESIUM-1.6 [**2142-6-18**] 05:04AM HAPTOGLOB-142 [**2142-6-18**] 05:04AM WBC-3.4* RBC-1.93* HGB-5.8* HCT-17.0* MCV-88 MCH-30.0 MCHC-34.2 RDW-18.4* [**2142-6-18**] 05:04AM PLT COUNT-97* [**2142-6-18**] 01:34AM GLUCOSE-84 UREA N-70* CREAT-10.5*# SODIUM-136 POTASSIUM-5.6* CHLORIDE-108 TOTAL CO2-14* ANION GAP-20 [**2142-6-18**] 01:34AM estGFR-Using this [**2142-6-18**] 01:34AM ALT(SGPT)-10 AST(SGOT)-39 ALK PHOS-108 TOT BILI-0.2 [**2142-6-18**] 01:34AM LIPASE-115* [**2142-6-18**] 01:34AM ALBUMIN-3.2* CALCIUM-6.6* PHOSPHATE-6.8* MAGNESIUM-1.7 [**2142-6-18**] 01:34AM WBC-4.5 RBC-2.08* HGB-6.0* HCT-18.3* MCV-88 MCH-28.6 MCHC-32.5 RDW-18.6* [**2142-6-18**] 01:34AM NEUTS-78.5* LYMPHS-16.5* MONOS-3.0 EOS-1.4 BASOS-0.6 [**2142-6-18**] 01:34AM PLT COUNT-104* [**2142-6-18**] 01:34AM PT-15.0* PTT-33.6 INR(PT)-1.3* Brief Hospital Course: # Dyspnea: Pt's dypsnea improved on admission to the ED prior to HD. Based on her imaging studies her dyspnea was likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. Upon transfer to the floor she was continued on her dialysis regimen and discharged on room air. # Anemia: Pt's baseline 1 month ago noted to be low 30s, since then her Hct has trended down to 22 several week prior to admission. As she missed dialysis she was not able to reserve her Eopgen which likely complicated her anemia. Pt underwent hemolysis workup in the ICU which was ultimately negative. She was given several units of PRBC and bumped her Hct appropriately. She was noted to be guaiac negative on examination. # Hypertension: Pt was initially admitted with hypertension. Following transition to the floor she was placed on her home regimen. She was noted to be hypotensive in dialysis which is likely due to her being on Labetalol, Nitro gtt on dialysis. Pt was discharged on her home BP regimen with follow up with her nephrologist. # Chronic Abdominal Pain: Pt had noted some intermittent abdominal pain which has been chronic. Lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. Pt was able to tolerate a PO diet prior to her discharge. Pt was continued on her outpatient regimen of Dilaudid, Fentanyl patch, Neurontin. # GE junction Ulcer: Pt was continued on her PPI regimen [**Hospital1 **]. # SLE: Pt was continued on her home regimen of Prednisone 4mg daily # History of DVT: Pt had a sub-therapeutic INR on admission. She was discharged on Warfarin 3mg daily. # ESRD on HD: Pt was admitted for dyspnea in the setting of missing 2 weeks of HD. The renal team followed Ms. [**Known lastname **] during her hospitalization and she was continued on her outpatient regimen of hemodialysis. Pt was continued on Sevelamer and Epogen. # Seizure D/O: Pt was continued on her home regimen of keppra. # Depression: Pt was continued on her home regimen of Celexa. Medications on Admission: 1. Nifedipine 90 mg Tablet Sustained Release PO QAM 2. Nifedipine 60 mg Tablet Sustained Release PO QHS 3. Lidocaine 5 % transdermal one daily 4. Aliskiren 150 mg PO BID 5. Citalopram 20 mg PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch Q72H (every 72 hours). 7. Prednisone 4mg PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Transdermal QSAT 9. Clonidine 0.3 mg/24 hr Patch Weekly Transdermal QSAT 10. Sevelamer HCl 400 mg Four (4) Tablet PO TID W/MEALS 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID 13. Hydralazine 100 mg PO Q8H 14. Hydromorphone 2 mg 1-2 Tablets PO Q6H as needed for pain. 15. Pantoprazole 40 mg PO Q12H 16. LeVETiracetam 1,000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24 H (). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK (TU,TH,SA). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Malignant HTN, ESRD on HD, Shortness of breath Secondary: Lupus Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted to the hospital after you noticed some shortness of breath. Whilst in the hospital you were noted to have a low blood level (anemia) and you some fluid in your lungs. We think your blood level was low because you were not receiving your Epo shots, we think the fluid is from not receiving dialysis. Before you were discharged from the hospital your breathing was better. We recommend that you continue going to dialysis. We made no changes to your medications. If you notice any fevers, chills, nausea, vomiting, shortness of breath, lightheadedness please return to the ED. Followup Instructions: Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 Provider: [**First Name4 (NamePattern1) **] [**Name Initial (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-6-27**] 2:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] ",57,2142-06-18 03:11:00,2142-06-20 16:34:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ANEMIA," # dyspnea: pts dypsnea improved on admission to the ed prior to hd. based on her imaging studies her dyspnea was likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. upon transfer to the floor she was continued on her dialysis regimen and discharged on room air. # anemia: pts baseline 1 month ago noted to be low 30s, since then her hct has trended down to 22 several week prior to admission. as she missed dialysis she was not able to reserve her eopgen which likely complicated her anemia. pt underwent hemolysis workup in the icu which was ultimately negative. she was given several units of prbc and bumped her hct appropriately. she was noted to be guaiac negative on examination. # hypertension: pt was initially admitted with hypertension. following transition to the floor she was placed on her home regimen. she was noted to be hypotensive in dialysis which is likely due to her being on labetalol, nitro gtt on dialysis. pt was discharged on her home bp regimen with follow up with her nephrologist. # chronic abdominal pain: pt had noted some intermittent abdominal pain which has been chronic. lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. pt was able to tolerate a po diet prior to her discharge. pt was continued on her outpatient regimen of dilaudid, fentanyl patch, neurontin. # ge junction ulcer: pt was continued on her ppi regimen [**hospital1 **]. # sle: pt was continued on her home regimen of prednisone 4mg daily # history of dvt: pt had a sub-therapeutic inr on admission. she was discharged on warfarin 3mg daily. # esrd on hd: pt was admitted for dyspnea in the setting of missing 2 weeks of hd. the renal team followed ms. [**known lastname **] during her hospitalization and she was continued on her outpatient regimen of hemodialysis. pt was continued on sevelamer and epogen. # seizure d/o: pt was continued on her home regimen of keppra. # depression: pt was continued on her home regimen of celexa. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Other primary cardiomyopathies; Unspecified disease of pericardium; Anemia of other chronic disease; Hyperpotassemia; Systemic lupus erythematosus; Abdominal pain, other specified site; Other chronic pain; Hypotension, unspecified; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Epilepsy, unspecified, without mention of intractable epilepsy; Depressive disorder, not elsewhere classified; Personal history of venous thrombosis and embolism; Noncompliance with renal dialysis]","# dyspnea: pts dypsnea improved on admission to the ed prior to hd. lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. # sle: pt was continued on her home regimen of prednisone 4mg daily # history of dvt: pt had a sub-therapeutic inr on admission. she was discharged on warfarin 3mg daily. # depression: pt was continued on her home regimen of celexa.",pts dypsnea improved on admission to the ed prior to hd. dyspnea likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. 109,155726.0,14864,2142-08-16,14859,102024.0,2142-06-05,Discharge summary,"Admission Date: [**2142-5-20**] Discharge Date: [**2142-6-5**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 3705**] Chief Complaint: abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname **] is a 24 yo F with lupus since age 16, with ESRD on HD, malignant HTN, history of SVC syndrome, and history of Posterior Reversible Encephalopathy Syndrome (PRES) and intracerebral hemorrhage, who has had multiple recent admissions [**Date range (1) 43604**], [**Date range (1) 17717**], [**Date range (1) **], [**4-26**], [**Date range (1) 42063**], [**Date range (1) 43605**] mostly for hypertension, but most recently for diarrhea in addition to hypertension. . In the ED, vitals were 98 90 102/65 20 98% RA. She was complaining of abdominal pain X 3 hours, more severe than usual [**7-20**], no N/V/D. She received dilaudid 4 mg PO X 3, zofran 8mg IV, hyperkalemia 6.2=>5.3 w/ Kayexalate. Initially, she was felt stable for floor; however, BP rose during ED course to SBP 270. She then received hydral 50 PO X 1, home aliskeren, labetalol 1000 PO X 1, 20 IV hydral X 2, labetalol 100 Iv X 1, nicardipine 2.5 mg IV X 1 and started on nicardipine gtt. . Upon arrival to the floor, she complains of severe abd pain which started earlier today, it is sharp all over her abd and constant. It feels different from her usual abd pain, although she is not able to characterize it more. She has been having some nausea and bilious emesis X 1 earlier today. She has been having some mild diarrhea 2-3 episodes of loose, greenish stools for the past few weeks. She denies any chest pain, headache, vision changes. She was not able to take all of the medications due to her GI distress. . While in the MICU she was weaned off a nicardipine drip and her diarrhea resolved. Her BP remained WNL while on her home regimen and she was transferred to the floor in stable condition. Last HD was [**2142-5-21**]. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**] and [**2142-4-12**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting - has appt scheduled with gyn on [**5-25**] 17. History of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] which has resolved Social History: Denies any substance abuse (EtOH, tobacco, illicits). She lives with her mother and brother. 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: 100/63 81 18 100RA GENERAL: Pleasant, thin young female sitting in the bed in NAD watching TV. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. s/p left eye enucleation. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD. CARDIAC: RRR. 4/6 systolic murmur heard best at the RUSB. LUNGS: Breathing comfortably, CTAB, good air movement biaterally. ABDOMEN: + BS, soft ND, tenderness to palpation in her LUQ. No rebound or guarding. EXTREMITIES: No edema. Right femoral HD line nontender, nonerythematous. SKIN: Several subcutaneous cysts of different sizes 1 - 3 cm scattered along her lower extremities. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation to light touch throughout. 5/5 strength in her upper and lower extremities PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2142-5-20**] 09:14PM LACTATE-0.9 [**2142-5-20**] 09:13PM WBC-6.8 RBC-3.65* HGB-10.7* HCT-33.7* MCV-93 MCH-29.2 MCHC-31.6 RDW-18.8* [**2142-5-20**] 09:13PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ TEARDROP-OCCASIONAL [**2142-5-20**] 09:13PM PLT COUNT-145* [**2142-5-20**] 08:55PM GLUCOSE-98 UREA N-44* CREAT-7.7* SODIUM-137 POTASSIUM-6.3* CHLORIDE-102 TOTAL CO2-20* ANION GAP-21* [**2142-5-20**] 08:55PM CALCIUM-9.9 PHOSPHATE-5.8* MAGNESIUM-2.1 [**2142-5-20**] 08:55PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2142-5-20**] 08:55PM WBC-7.0 RBC-3.69* HGB-11.1* HCT-34.2* MCV-93 MCH-30.2 MCHC-32.5 RDW-19.2* [**2142-5-20**] 08:55PM PLT COUNT-126* [**2142-5-20**] 08:55PM PT-14.1* PTT-32.4 INR(PT)-1.2* [**2142-5-20**] 07:40AM ALT(SGPT)-18 AST(SGOT)-55* ALK PHOS-118* TOT BILI-0.4 [**2142-5-20**] 07:40AM LIPASE-58 Brief Hospital Course: KUB: SBO Head CT: (prelim read from radiology). unchanged from prior head CT, no intracranial hemorrhage EKG: NSR, right axis, LVH, nl intervals, ST elevations V2-3 (old), TW inversion V6 (new) compared to prior EKG [**5-15**]. CT CHEST/ABD: Preliminary Read Normal aorta without dissection or acute abnormality. No PE. Stable trace ascites and small right pleural effusion. Unchanged small pulmonary nodules and lymphadenopathy in the chest. No acute abnormalities in the abdomen to explain epigastric pain. EGD: Ulcer at GE junction. # Hypertensive urgency: This is a chronic issue related to ESRD. Head CT was negative for intracranial bleed. Weaned off Nicardipine gtt and BP well controlled on home regimen. Continued her home regimen of: Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet Sustained Release QAM, Hydralazine 100 mg PO Q8H. When BPs were lower (see below) patient's BP meds were held occasionally, but as she was transfused and the BPs started to trend back up the meds were re-initiated. She then developed hypotension in the setting of poor PO intake during her SBO. BP meds were held and then re-initiated as the pressure came back up once she was able to eat. # Abdominal pain/UGIB: The patient has chronic abdominal pain with previous negative workups. At first the pain resolved and she was continued on her outpatient regimen of: 2-4 mg po dilaudid q4 h as needed. GI was c/s re: abd pain and rec CTA-abdomen to eval for mesenteric ischemia vs. partial SBO, however with ESRD did not initially want to get CTA so KUB was ordered. This showed no SBO. They recommended checking urine porphyrobilinogen and serum lead levels which were negative and LFTs were at baseline. The patient then developed a different type of pain associated with her incision site. Pain service was consulted and did a bupivicaine injection at the site which did help. They will continue to follow her. She then developed a third type of pain associated with a burning sensation in her chest. EKG was unchanged from prior. A few hours later she had 3 episodes of coffee-ground emesis. She was placed on IV PPI and transfused two units of blood. Afterward the pain resolved and her hct remained stable. GI felt that the patient would need general anesthesia in order to undergo an EGD which showed an ulcer at the GE junction. She was started on empiric treatment for H. Pylori and serologies were sent which came back negative so the antibiotics were stopped. Her pain was controlled with her outpatient regimen of PO dilaudid. She will follow up with Dr. [**Last Name (STitle) **] in [**6-18**] weeks to have another EGD under MAC to see if there has been resolution of the ulcer. # SBO: Continued to be nauseous and vomited intermittently. she was started on reglan and continued on zofran and compazine PRN howeve she continued to have n/v. A KUB was done which showed an SBO. Surgery was consulted, NGT was placed, she was made NPO and serial abdominal exams were done. Eventually she was able to transition to clear diet and then tolerated a regular diet without pain or vomiting. #. Fever: On hospital day #6 she spiked a fever to 101. Blood and urine cultures were sent and a cxr were negative, however she then had a seizure and in the post-ictal state aspirated after vomiting. She had an episode of hypoxia with this and was transferred to the ICU. In the ICU LP was attempted to rule out meningitis as a possible cause of a seizure but this was unsuccessful. Broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. She improved over the next few days and antibiotics were discontinued because the suspicion for a bacterial meningitis was low. #. Seizure: This occured in the setting of fever, hypotension, and initiation of reglan for vomiting. Neurology was consulted and felt she should be continued on keppra indefinitely. EEG was non-revealing. She should be continued on keppra 1gm with dialysis three times weekly. # ESRD on HD: Hyperkalemia resolved with kayexalate. Underwent dialysis on normal schedule. # SLE: She was continued on prednisone 4mg daily. With multiple abdominal symptoms it was thought she may have lupus flare in the abdomen. C3, c4 were equivocal for active lupus flare, and [**Doctor First Name **] was positive, as would be expected in lupus. # Anemia: Has anemia of chronic renal disease and her Hct was high on admission and epo was held per renal. However, her Hct trended all the way down to 20 and she was borderline hypotensive for her (ie SBP 120) and she developed coffee ground emesis so she was transfused 2 units. Afterward her Hct was stable at 25. She was also re-started on EPO per renal for her chronic anemia. Hemolysis labs were negative. # History of thrombotic events/SVC syndrome: She is anticoagulated with warfarin as an outpatient. Previous documentation in OMR states she does not need to be bridged while subtherapeutic. Continued coumadin 4 mg po daily however INR became supratherapeutic and the coumadin was then held. She was started on heparin gtt while awaiting EGD. After EGD the coumadin was re-started at 3mg daily however, in setting of poor po intake her INR was supratherapeutic - likely [**2-12**] nutritional deficiency of vitamin k. coumadin will be restarted when INR [**2-13**] at dialysis. # OSA: She is on CPAP at a setting of 7 as an outpatient. Continued CPAP #. CIN1: On last pap had CIN1. OB/GYN service was called re: doing colposcopy in hospital as patient rarely makes o/p appointments, hwoever they do not do this procedure in hospital especially because it does not have to be done emergently - just within one year. Will need outpatient colposcopy at some point in next few months as they do not do this procedure in the hospital. # RLL nodule: A new 10 x 5 mm nodularity was found incidentally within the right lower lobe of the lung on an abdominal CT. This should be reassessed in 3 months. # ACCESS: PIV, right groin HD line # CODE: Full code Medications on Admission: 1. Aliskiren 150 mg PO bid 2. Citalopram 20 mg PO DAILY 3. Clonidine 0.2 mg/24 hr Patch Weekly QSAT 4. Hydromorphone 2 mg 1-2 Tablets PO Q4H 5. Fentanyl 25 mcg/hr Patch 72 hr 6. Gabapentin 300 mg PO TID 7. Hydralazine 100 mg PO Q8H 8. Hydralazine 100 mg PO BID PRn fro SBP> 180. 9. Prednisone 4 mg PO DAILY 10. Pantoprazole 40 mg PO Q24H 11. Labetalol 1000 mg PO TID 12. Nifedipine 90 mg PO QAM 13. Nifedipine 60 mg PO QHS 14. Warfarin 3 mg PO Once Daily 15. Lidocaine 5 %(700 mg/patch) Topical once a day. 16. Nifedipine 90 mg PO once a day as needed for for SBP persistently above 200. Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 2. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QHS (once a day (at bedtime)). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 30 days. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 16. LeVETiracetam 1,000 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: UGIB- Ulcer at GE junction Hypertensive Emergency Anemia ESRD on HD SBO Discharge Condition: The patient was afebrile and hemodynamically stable prior to discharge. Discharge Instructions: You were admitted to the hospital with abdominal pain. You had an injection of lidocaine to help the pain around your surgery sites. You then had some blood in your vomit. You were treated for a bleed in your stomach with a blood transfusion and medications. You stopped bleeding and felt better. You had a scope of your abdomen that showed an ulcer. You were treated with medications for this and need to have another scope of your abdomen in 6 weeks. You also had high blood pressures while you were here because you could not take your medicines with your nausea and vomiting. Once you were on your home medicines your blood pressure was better. Medication Changes: CHANGE: Pantoprazole to 40mg TWICE daily Please call your PCP or come to the emergency room if you have fevers, chills, worsening abdominal pain, nausea, vomiting, blood in your vomit, blood in your stools, black/tarry stools or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] (gastroenterology) in [**6-18**] weeks for an EGD to re-look at your ulcer. Please follow up with the OB/[**Hospital **] clinic for a colposcopy on Wednesday [**2142-8-8**] at 3:15pm in the [**Hospital Ward Name 23**] Building on the [**Location (un) **]. Their number is [**Telephone/Fax (1) 2664**]. Please follow up with Dr.[**Name (NI) **] at [**Hospital6 733**] in the Shapria building on the [**Location (un) **] on [**2142-6-27**] at 2:00pm. Completed by:[**2142-6-6**]",72,2142-05-20 12:59:00,2142-06-05 16:18:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," kub: sbo head ct: (prelim read from radiology). unchanged from prior head ct, no intracranial hemorrhage ekg: nsr, right axis, lvh, nl intervals, st elevations v2-3 (old), tw inversion v6 (new) compared to prior ekg [**5-15**]. ct chest/abd: preliminary read normal aorta without dissection or acute abnormality. no pe. stable trace ascites and small right pleural effusion. unchanged small pulmonary nodules and lymphadenopathy in the chest. no acute abnormalities in the abdomen to explain epigastric pain. egd: ulcer at ge junction. # hypertensive urgency: this is a chronic issue related to esrd. head ct was negative for intracranial bleed. weaned off nicardipine gtt and bp well controlled on home regimen. continued her home regimen of: aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, hydralazine 100 mg po q8h. when bps were lower (see below) patients bp meds were held occasionally, but as she was transfused and the bps started to trend back up the meds were re-initiated. she then developed hypotension in the setting of poor po intake during her sbo. bp meds were held and then re-initiated as the pressure came back up once she was able to eat. # abdominal pain/ugib: the patient has chronic abdominal pain with previous negative workups. at first the pain resolved and she was continued on her outpatient regimen of: 2-4 mg po dilaudid q4 h as needed. gi was c/s re: abd pain and rec cta-abdomen to eval for mesenteric ischemia vs. partial sbo, however with esrd did not initially want to get cta so kub was ordered. this showed no sbo. they recommended checking urine porphyrobilinogen and serum lead levels which were negative and lfts were at baseline. the patient then developed a different type of pain associated with her incision site. pain service was consulted and did a bupivicaine injection at the site which did help. they will continue to follow her. she then developed a third type of pain associated with a burning sensation in her chest. ekg was unchanged from prior. a few hours later she had 3 episodes of coffee-ground emesis. she was placed on iv ppi and transfused two units of blood. afterward the pain resolved and her hct remained stable. gi felt that the patient would need general anesthesia in order to undergo an egd which showed an ulcer at the ge junction. she was started on empiric treatment for h. pylori and serologies were sent which came back negative so the antibiotics were stopped. her pain was controlled with her outpatient regimen of po dilaudid. she will follow up with dr. [**last name (stitle) **] in [**6-18**] weeks to have another egd under mac to see if there has been resolution of the ulcer. # sbo: continued to be nauseous and vomited intermittently. she was started on reglan and continued on zofran and compazine prn howeve she continued to have n/v. a kub was done which showed an sbo. surgery was consulted, ngt was placed, she was made npo and serial abdominal exams were done. eventually she was able to transition to clear diet and then tolerated a regular diet without pain or vomiting. #. fever: on hospital day #6 she spiked a fever to 101. blood and urine cultures were sent and a cxr were negative, however she then had a seizure and in the post-ictal state aspirated after vomiting. she had an episode of hypoxia with this and was transferred to the icu. in the icu lp was attempted to rule out meningitis as a possible cause of a seizure but this was unsuccessful. broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. she improved over the next few days and antibiotics were discontinued because the suspicion for a bacterial meningitis was low. #. seizure: this occured in the setting of fever, hypotension, and initiation of reglan for vomiting. neurology was consulted and felt she should be continued on keppra indefinitely. eeg was non-revealing. she should be continued on keppra 1gm with dialysis three times weekly. # esrd on hd: hyperkalemia resolved with kayexalate. underwent dialysis on normal schedule. # sle: she was continued on prednisone 4mg daily. with multiple abdominal symptoms it was thought she may have lupus flare in the abdomen. c3, c4 were equivocal for active lupus flare, and [**doctor first name **] was positive, as would be expected in lupus. # anemia: has anemia of chronic renal disease and her hct was high on admission and epo was held per renal. however, her hct trended all the way down to 20 and she was borderline hypotensive for her (ie sbp 120) and she developed coffee ground emesis so she was transfused 2 units. afterward her hct was stable at 25. she was also re-started on epo per renal for her chronic anemia. hemolysis labs were negative. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient. previous documentation in omr states she does not need to be bridged while subtherapeutic. continued coumadin 4 mg po daily however inr became supratherapeutic and the coumadin was then held. she was started on heparin gtt while awaiting egd. after egd the coumadin was re-started at 3mg daily however, in setting of poor po intake her inr was supratherapeutic - likely [**2-12**] nutritional deficiency of vitamin k. coumadin will be restarted when inr [**2-13**] at dialysis. # osa: she is on cpap at a setting of 7 as an outpatient. continued cpap #. cin1: on last pap had cin1. ob/gyn service was called re: doing colposcopy in hospital as patient rarely makes o/p appointments, hwoever they do not do this procedure in hospital especially because it does not have to be done emergently - just within one year. will need outpatient colposcopy at some point in next few months as they do not do this procedure in the hospital. # rll nodule: a new 10 x 5 mm nodularity was found incidentally within the right lower lobe of the lung on an abdominal ct. this should be reassessed in 3 months. # access: piv, right groin hd line # code: full code ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction; Acute posthemorrhagic anemia; Unspecified intestinal obstruction; Other primary cardiomyopathies; Unspecified disease of pericardium; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Disorders of phosphorus metabolism; Hypotension, unspecified; Hyperpotassemia; Mononeuritis of unspecified site; Anemia of other chronic disease; Abdominal pain, left lower quadrant; Other chronic pain; Thrombocytopenia, unspecified; Diaphragmatic hernia without mention of obstruction or gangrene; Other specified peripheral vascular diseases; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus; Noncompliance with renal dialysis; Renal dialysis status; Long-term (current) use of anticoagulants; Personal history of noncompliance with medical treatment, presenting hazards to health]","kub: sbo head ct: (prelim read from radiology). ct chest/abd: preliminary read normal aorta without dissection or acute abnormality. bp meds were held and then re-initiated as the pressure came back up once she was able to eat. gi was c/s re: abd pain and rec cta-abdomen to eval for mesenteric ischemia vs. partial sbo, however with esrd did not initially want to get cta so kub was ordered. a few hours later she had 3 episodes of coffee-ground emesis. afterward the pain resolved and her hct remained stable. gi felt that the patient would need general anesthesia in order to undergo an egd which showed an ulcer at the ge junction. her pain was controlled with her outpatient regimen of po dilaudid. broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. she should be continued on keppra 1gm with dialysis three times weekly. c3, c4 were equivocal for active lupus flare, and [**doctor first name **] was positive, as would be expected in lupus. # anemia: has anemia of chronic renal disease and her hct was high on admission and epo was held per renal.","sbo head ct was negative for intracranial hemorrhage. no intracranial hemorrhage ekg: nsr, right axis, lvh, nl intervals, st elevations v2-3 (old), tw inversion v6 (new) no acute abnormalities in the abdomen to explain epigastric pain." 109,155726.0,14864,2142-08-16,14858,151240.0,2142-05-18,Discharge summary,"Admission Date: [**2142-5-15**] Discharge Date: [**2142-5-18**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 613**] Chief Complaint: Headache, Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis x 2 History of Present Illness: 24 year old female with SLE, ESRD on HD, hx malignant HTN, h/o SVC syndrome, h/o posterior reversible encephalopathy syndrome (PRES) and prior intracerebral hemorrhage, recently admitted [**Date range (1) 17717**] with diarrhea, hypertensive urgency. Treated at that time with nicardipine drip for a short period and then to her home regimen. Yesterday onset of nausea with emesis and inability to tolerate home meds including antihypertensives. Diarrhea mild as prior. No fever, chills, no hematemesis or hematochezia. No melena. Today reports onset of headache therefore to the ED. In the ED, initial vs were 280/160, 99.4, 105, RR 18. She was given dilaudid 2 mg PO x 2. Hydral 20 mg x 3 for BP. Calcium gluconate 1 gram. Insulin 10 units, D 50 [**1-12**] amp, sodium bicarbonate, kayexalate for K 6.7 (dialysis dependent Tues/thurs/sat) but with report of peaked T waves. Renal dialysis fellow was not contact[**Name (NI) **]. HCT 33.4, WBC 4.6, trop 0.10. Admitted for hypertensive urgency to ICU. No gtt was started. Of note usualy BP 160/100. Review of sytems: patient tearful complaining of frontal headache and nausea Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: Vitals: BP 240/146, 101, 98.6, General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardic, 3/6 SEM RUSB Abdomen: soft, diffusely tender, no rebound or gaurding. Ext: cachectic, warm, 2+ DP pulse no clubbing, cyanosis or edema Pertinent Results: [**2142-5-15**] 05:45AM GLUCOSE-83 UREA N-54* CREAT-7.6* SODIUM-138 POTASSIUM-6.7* CHLORIDE-103 TOTAL CO2-23 ANION GAP-19 [**2142-5-15**] 05:45AM CK(CPK)-96 [**2142-5-15**] 05:45AM cTropnT-0.10* [**2142-5-15**] 05:45AM CK-MB-NotDone [**2142-5-15**] 05:45AM WBC-4.6 RBC-3.66* HGB-10.8* HCT-33.4* MCV-91 MCH-29.6 MCHC-32.4 RDW-17.9* [**2142-5-15**] 05:45AM NEUTS-65.4 LYMPHS-25.1 MONOS-4.8 EOS-4.1* BASOS-0.7 [**2142-5-15**] 05:45AM PLT COUNT-128* [**2142-5-15**] 05:45AM PT-14.2* PTT-36.4* INR(PT)-1.2* [**2142-5-15**] 07:14AM K+-6.0* [**2142-5-15**] 12:17PM K+-5.3 Images: CXR: Persistent severe cardiomegaly. Head CT: Normal brain CT. Brief Hospital Course: 24 yo female with ESRD on HD, malignant hypertension with hx of intracerebral hemorrhage, SLE, chronic abdominal pain, and SVC syndrome admitted due to hypertensive urgency after developing N/V and being unable to take her po medications. # Hypertensive urgency: The patient was admitted to the MICU the night of admission where she was placed on a labetolol drip and her home medications were restarted. head CT was negative for intracranial bleed. She was continued on her home regimen of Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet Sustained Release QAM, and Hydralazine 100 mg PO Q8H. During her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. Blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). She was discharged on her home regimen. # Nausea/vomiting: The patient did not experience further vomiting, but occasionally complained of nausea. The cause of her nausea was unclear. She was able to tolerate po intake prior to discharge. # Abdominal pain/Diarrhea: The patient has chronic abdominal pain with previous negative workups. During this hospitalization her pain was at its baseline. Since admission she denied diarrhea. She was continued on her outpatient regimen of [**2-14**] mg po dilaudid q4h as needed. # ESRD on HD: She was hyperkalemic in the emergency room and was given kayexalate. She underwent two sessions of dialysis during this hospitalization. # SLE: Stable, without symptoms. She was continued on 4 mg of prednisone daily. # History of thrombotic events/SVC syndrome: She is anticoagulated with warfarin as an outpatient, however her INR was subtherapeutic on admission at 1.2. Previous documentation in OMR states she does not need to be bridged while subtherapeutic. She was initally continued on coumadin 4 mg po daily, however her INR rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # OSA: She is on CPAP at a setting of 7 as an outpatient and was continued on this during her hospitalization. Medications on Admission: Medications: as per last discharge summary -Aliskiren 150 mg Tablet [**Hospital1 **] -Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday) -Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). -Labetalol 200 mg Tablet Sig 5 tab TID -Nifedipine 60 mg Tablet Sustained Release QPM -Nifedipine 90 mg Tablet Sustained Release QAM -Citalopram 20 mg Tablet Sig daily -Hydromorphone 2 mg Tablet Sig [**1-12**] Q4 PRN -Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). -Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H -Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID PRN -Prednisone 4 mg daily -Coumadin 4 mg daily at 4 PM Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QPM (once a day (in the evening)). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 10. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO twice a day as needed for hypertension. 13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary - Hypertensive urgency End-stage renal disease on dialysis Secondary - Systemic lupus erythematous History of thombosis and Superior vena cava syndrome Obstructive sleep apnea Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital due to dangerously elevated blood pressure due to inability to take your medications secondary to nausea. It is very important that you take your blood pressure medications reguarly. Your nausea was controlled with medication and your blood pressure decreased once back on your home medication regimen. You underwent two sessions of dialysis during your hospitalization. It is extremely important that you attend dialysis three times weekly as an outpatient. Medication changes: You should be taking 3 mg of coumadin daily. You will need to have your INR checked at dialysis. Otherwise continue your outpatient medications as prescribed. Call your primary doctor, or go to the emergency room if you experience fevers, chills, worsening headache, vision change, inability to take your medications, blood in your stool, or dark black stool. Followup Instructions: It is very important that you keep your previously scheduled appointments: You have an appointment with gynecology to evaluate an abnormality recently seen on PAP smear. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-6-1**] 2:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-5-19**]",90,2142-05-15 10:45:00,2142-05-18 15:58:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSIVE CRISIS," 24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. # hypertensive urgency: the patient was admitted to the micu the night of admission where she was placed on a labetolol drip and her home medications were restarted. head ct was negative for intracranial bleed. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, and hydralazine 100 mg po q8h. during her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). she was discharged on her home regimen. # nausea/vomiting: the patient did not experience further vomiting, but occasionally complained of nausea. the cause of her nausea was unclear. she was able to tolerate po intake prior to discharge. # abdominal pain/diarrhea: the patient has chronic abdominal pain with previous negative workups. during this hospitalization her pain was at its baseline. since admission she denied diarrhea. she was continued on her outpatient regimen of [**2-14**] mg po dilaudid q4h as needed. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. she underwent two sessions of dialysis during this hospitalization. # sle: stable, without symptoms. she was continued on 4 mg of prednisone daily. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient, however her inr was subtherapeutic on admission at 1.2. previous documentation in omr states she does not need to be bridged while subtherapeutic. she was initally continued on coumadin 4 mg po daily, however her inr rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # osa: she is on cpap at a setting of 7 as an outpatient and was continued on this during her hospitalization. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other primary cardiomyopathies; Unspecified disease of pericardium; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Hyperpotassemia; Nausea with vomiting; Diarrhea; Disorders of phosphorus metabolism; Anemia of other chronic disease; Abdominal pain, left lower quadrant; Other chronic pain; Thrombocytopenia, unspecified; Other specified peripheral vascular diseases; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus; Long-term (current) use of anticoagulants; Noncompliance with renal dialysis; Renal dialysis status; Personal history of noncompliance with medical treatment, presenting hazards to health]","24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. she was able to tolerate po intake prior to discharge. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. previous documentation in omr states she does not need to be bridged while subtherapeutic.","24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg" 109,196721.0,14863,2142-07-23,14806,113189.0,2142-02-17,Discharge summary,"Admission Date: [**2142-2-14**] Discharge Date: [**2142-2-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: From admission note: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome admitted with HTN and SOB in the setting of missed HD. The patient reported missing HD yesterday because she thinks she is being overdiuresed. She reports persistent pain at site of rectus sheath hematoma. Denies N/V/D. Pt recently admitted from [**Date range (1) 13924**] with consistent abdominal pain at the site of her known left abdominal wall hematoma, hypertensive to 230's and hyperkalemic to 6.2 after missing her last two dialysis sessions. At this time the pt. was dialyzed, received a blood transfusion, and was administered her daily antihypertensive medications. Pt. left AMA after her transfusion despite the primary team's concerns to look for an active area of bleeding. In the ED, patient complain of mild dyspnea, sating well on RA. CXR mild volume overload. KUB with no evidence of obstruction. She was started on a labetalol gtt. ECG - RAD, LVH no change from prior. HCT stable at 21. The renal team evaluated pt and recommended HD, however the patient refused. She was transferred to ICU for BP control. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: [**2142-2-14**] 07:40AM WBC-3.9* RBC-2.38* HGB-7.0* HCT-21.3* MCV-90 MCH-29.5 MCHC-33.0 RDW-18.9* [**2142-2-14**] 07:40AM NEUTS-74.9* LYMPHS-18.7 MONOS-3.1 EOS-3.0 BASOS-0.2 [**2142-2-14**] 07:40AM PLT COUNT-101* [**2142-2-14**] 07:40AM PT-16.3* PTT-36.6* INR(PT)-1.5* [**2142-2-14**] 07:40AM CK-MB-6 [**2142-2-14**] 07:40AM cTropnT-0.09* [**2142-2-14**] 07:40AM LIPASE-80* [**2142-2-14**] 07:40AM ALT(SGPT)-34 AST(SGOT)-72* CK(CPK)-120 ALK PHOS-124* TOT BILI-0.4 [**2142-2-14**] 07:40AM GLUCOSE-85 UREA N-32* CREAT-7.0* SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-19* ANION GAP-17 [**2142-2-14**] 07:44AM LACTATE-1.3 [**2142-2-14**] CXR: Stable cardiomegaly with mild CHF and a small left pleural effusion. Left basilar air space disease which may represent pneumonia. Clinical correlation and a follow up chest x-ray to clearance is recommended. [**2142-2-14**] KUB: 1. Nonspecific bowel gas pattern with no evidence of obstruction. 2. Left basilar airspace disease which may represent pneumonia and a small left pleural effusion. Please ensure follow-up to clearance. Brief Hospital Course: 24 y.o female with SLE, ESRD on HD and malignant hypertension who presents with HTN and SOB aftering missing HD. . # Malignant hypertension/hypertensive urgency: The patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and HD compliance. Has previously presented with BP up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. Pt was treated per OMR hypertensive protocol created by the patient's primary providers, with a goal SBP of 160-180. With short course of IV antihypertensives and hemodialysis, pt's BP fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # ESRD: Pt was followed by the renal service and underwent HD without any complications. Pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting HD. She will discuss this further with the Renal team as an outpatient. . # SLE: Pt was continued on her home dose of prednisone with no sign of SLE flair. . # Coagulopathy/history of DVT: Patient on lifetime anticoagulation for hx of multiple thrombotic events. Pt was continued on coumadin. . # Pain management: Pt was treated with PO dilaudid for her abdominal pain, as recommended per her OMR protocol. She asked for IV dilaudid multiple times but there was no clinical indication. She was also continued on gabapentin. . # Anemia: Secondary to AOCD and renal failure. The patietns Hct remained stable in the low 20s during admission. No PRBC infusions were needed. . # Depression/anxiety: Continued Celexa, clonazepam 0.5mg [**Hospital1 **] Medications on Admission: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain. 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Disposition: Home Discharge Diagnosis: Primary: Malignant Hypertension Secondary: SLE, End stage renal disease on hemodialysis, SVC syndrome Discharge Condition: Stable. SBP in 160s. Discharge Instructions: You were admitted with dangerously high hypertension and some shortness of breath in the setting of missing several dialysis sessions. You were admitted and treated with your usual regimen of blood pressure meds and a short course of IV meds. With dialysis, your symptoms improved. You also had some abdominal pain, which was well controlled on your usual pain medications. We made no changes to your medications. Please take everything as prescribed. Please call your PCP or return to the hospital if you develop any headaches, visual changes, confusion or chest pain, or any other concerning symptoms. Followup Instructions: Please schedule a follow up with Dr [**Last Name (STitle) **] in [**Month (only) 958**] as scheduled. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2142-2-21**]",156,2142-02-14 10:42:00,2142-02-17 18:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. . # malignant hypertension/hypertensive urgency: the patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and hd compliance. has previously presented with bp up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. with short course of iv antihypertensives and hemodialysis, pts bp fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # esrd: pt was followed by the renal service and underwent hd without any complications. pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting hd. she will discuss this further with the renal team as an outpatient. . # sle: pt was continued on her home dose of prednisone with no sign of sle flair. . # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events. pt was continued on coumadin. . # pain management: pt was treated with po dilaudid for her abdominal pain, as recommended per her omr protocol. she asked for iv dilaudid multiple times but there was no clinical indication. she was also continued on gabapentin. . # anemia: secondary to aocd and renal failure. the patietns hct remained stable in the low 20s during admission. no prbc infusions were needed. . # depression/anxiety: continued celexa, clonazepam 0.5mg [**hospital1 **] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Thrombotic microangiopathy; Systemic lupus erythematosus; Anemia in chronic kidney disease; Thrombocytopenia, unspecified; Obstructive sleep apnea (adult)(pediatric); Nontraumatic hematoma of soft tissue; Dysthymic disorder; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events.","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob after missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. she was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine." 109,196721.0,14863,2142-07-23,14807,158995.0,2142-02-26,Discharge summary,"Admission Date: [**2142-2-25**] Discharge Date: [**2142-2-26**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 338**] 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 History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, hx of malignant HTN admitted with change in mental status. Patient missed HD on [**2142-2-24**] and was found unresponsive and diaphoretic by mother this morning after she took some dilaudid. EMS was called, 1 mg of narcan was administered with slight improvement in mental status. On arrival to the ED her vitals were 112/64 62 16 99RA she was noted to be hyperkalemic in the absence of EKG changes and was given calcium, D5, 10U regular insulin, 30 mg po kayxalate and repeat K was 5.4. ABG: 7.29/38/199. Repeat glucose was 41 and 1amp D50 was given. She was sent to the ICU for monitoring. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including [**Month/Year (2) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: HR: 80 (79 - 80) bpm BP: 127/59(76) {127/59(76) - 139/64(82)} mmHg RR: 34 (21 - 34) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Physical Examination Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact Pertinent Results: [**2142-2-25**] 01:50PM PT-14.9* PTT-36.8* INR(PT)-1.3* [**2142-2-25**] 01:50PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2142-2-25**] 01:50PM WBC-5.0 RBC-2.21* HGB-6.4* HCT-20.7* MCV-94 MCH-29.1 MCHC-31.1 RDW-19.6* [**2142-2-25**] 10:30PM GLUCOSE-87 UREA N-66* CREAT-8.4* SODIUM-142 POTASSIUM-5.9* CHLORIDE-110* TOTAL CO2-16* ANION GAP-22* HISTORY: Altered mental status. Evaluate underlying for pneumonia. UPRIGHT PORTABLE CHEST: Comparison is made to [**2-14**] and [**2142-2-19**], exams. Study is slightly limited by patient motion. In the interval, the degree of pulmonary edema appears improved with slightly decreased prominence of the pulmonary vascularity. There is unchanged extensive retrocardiac consolidation obscuring the majority of the left hemidiaphragm with persistent blunting of the left CP angle, likely related to small effusion. Exam is otherwise unchanged from prior with persistent cardiomegaly. A catheter is seen projecting over the abdomen, partially imaged. IMPRESSION: Slight improvement in pulmonary edema with persistent retrocardiac opacity, which again may represent atelectasis versus underlying pneumonia. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted hypotension and decreased mental status. Hypotension and altered mental status were in the setting of excessive narcotic use. Patient's narcotics were held, pressors returned to [**Location 213**] and patient was mentating fine. Hct was below baseline and patient was transfused 1u PRBC and was given HD before discharge. Patient is to continue anti-hypertensive medications as previously scheduled. Patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # Change in mental status: Resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. Patient received 1 dose of narcan with slight improvement in BP and mental status. patient without fevers or leuckocytosis which argue against infection. # Hypertension ?????? resumed outpatient regimen. Patient did not have any hypertensive episodes requiring hydralizine 10mg IV. # Hypotension: resolved, Patient normotensive on arrival to ICU. Relative hypotension likely due to dilaudid. Other considerations include sepsis, although patient without objective signs of infection. Held pain medications and hypotension resolved. Resumed hypertensive medications. # Abdominal pain ?????? from previous peritoneal [**Location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # Hyperkalemia: Likely due to missed HD session. She received calcium, D5, insulin and kayexalate in ED. HD in am ESRD: Renal following, had HD the day of discharge, transfused while there. Will continue normal schedule as an outpatient with HD T/Th/F this week. # Metabolic Acidosis: likely due to renal failure and missed HD. # SLE: continued prednisone at 4 mg PO daily. # OSA: CPAP for sleep with 7 pressure, however patient refuses. Continued to offer as inpatient. Should try to follow up with sleep medicine. Medications on Admission: Prednisone 4mg qd Citalopram 20 mg daily Gabapentin 300 mg [**Hospital1 **] Warfarin 4mg daily Pantoprazole 40 mg qd Clonidine 0.1 mg/24 QWED Clonidine 0.3 mg/24 hr QWED Labetalol 900 mg tid Nifedipine 90 mg qd Aliskiren 150 mg [**Hospital1 **] Hydralazine 100 mg q8h Morphine 7.5 mg q8h prn pain Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Home Discharge Diagnosis: Primary: narcotic overdose relative hypotension anemia Secondary: ESRD on HD [**2-12**] SLE malignant hypertension Discharge Condition: stable - received HD prior to discharge Discharge Instructions: You were admitted for altered mental status after missing hemodialysis. It was likely from the dilaudid you took as well as missing your scheduled [**Month/Day (2) 2286**]. You were also relatively hypotensive in the setting of excessive narcotic medicaiton usage. Narcotic medications were held and hypotension and altered mental status resolved. Please use narcotic medications with caution. You are recommended to use morphine for pain control rather than dilaudid. No medication changes were made. Please return to the ED if you have any altered mental status or miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] or have symptoms such as vision changes or headache from your history of malignant hypertension. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-3-20**] 3:00 HD as previously scheduled Completed by:[**2142-2-26**]",147,2142-02-25 15:49:00,2142-02-26 16:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ALTERED MENTAL STATUS," 24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. patients narcotics were held, pressors returned to [**location 213**] and patient was mentating fine. hct was below baseline and patient was transfused 1u prbc and was given hd before discharge. patient is to continue anti-hypertensive medications as previously scheduled. patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # change in mental status: resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. patient received 1 dose of narcan with slight improvement in bp and mental status. patient without fevers or leuckocytosis which argue against infection. # hypertension ?????? resumed outpatient regimen. patient did not have any hypertensive episodes requiring hydralizine 10mg iv. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. other considerations include sepsis, although patient without objective signs of infection. held pain medications and hypotension resolved. resumed hypertensive medications. # abdominal pain ?????? from previous peritoneal [**location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # hyperkalemia: likely due to missed hd session. she received calcium, d5, insulin and kayexalate in ed. hd in am esrd: renal following, had hd the day of discharge, transfused while there. will continue normal schedule as an outpatient with hd t/th/f this week. # metabolic acidosis: likely due to renal failure and missed hd. # sle: continued prednisone at 4 mg po daily. # osa: cpap for sleep with 7 pressure, however patient refuses. continued to offer as inpatient. should try to follow up with sleep medicine. ","PRIMARY: [Poisoning by other opiates and related narcotics] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Thrombotic microangiopathy; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Altered mental status; Other iatrogenic hypotension; Accidental poisoning by other opiates and related narcotics; Hyperpotassemia; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Nontraumatic hematoma of soft tissue; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. from previous peritoneal [**location 2286**] hematoma ??????","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. narcotics were held, pressors returned to and patient was mentating fine. patient was encouraged to take less pain medications and to use morphine." 109,196721.0,14863,2142-07-23,14808,158943.0,2142-03-23,Discharge summary,"Admission Date: [**2142-3-21**] Discharge Date: [**2142-3-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: Abdominal Pain, Shortness of breath, Chest discomfort Major Surgical or Invasive Procedure: HD [**2142-3-21**] and [**2142-3-23**] History of Present Illness: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] 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 [**Telephone/Fax (3) 43508**]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. [**Telephone/Fax (3) **] was discussed with renal and it was not felt that HTN is a volume issue so no need for emergent [**Telephone/Fax (3) 2286**]. . 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 [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**], getting Vanc with HD. . PSHx: 1. Placement of multiple catheters including [**Year (4 digits) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] 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: [**2142-3-21**] 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* [**2142-3-21**] 02:20AM NEUTS-76.1* BANDS-0 LYMPHS-17.9* MONOS-4.5 EOS-1.1 BASOS-0.5 [**2142-3-21**] 02:20AM PLT SMR-NORMAL PLT COUNT-168 [**2142-3-21**] 02:20AM PT-21.8* PTT-34.7 INR(PT)-2.1* [**2142-3-21**] 02:20AM cTropnT-0.12* [**2142-3-21**] 02:20AM ALT(SGPT)-46* AST(SGOT)-94* CK(CPK)-76 ALK PHOS-173* TOT BILI-0.4 [**2142-3-21**] 02:20AM GLUCOSE-74 UREA N-47* CREAT-7.3* SODIUM-140 POTASSIUM-5.8* CHLORIDE-109* TOTAL CO2-19* ANION GAP-18 [**2142-3-21**] 04:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-21**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2142-3-21**] 12:58PM CK-MB-NotDone cTropnT-0.12* . CT C/A/P - [**2142-3-20**] - 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: [**2142-3-23**] 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* [**2142-3-23**] 12:00PM BLOOD Plt Ct-130* [**2142-3-23**] 12:00PM BLOOD PT-28.8* PTT-58.6* INR(PT)-2.9* [**2142-3-23**] 12:00PM BLOOD Glucose-77 UreaN-31* Creat-6.0*# Na-137 K-4.8 Cl-104 HCO3-24 AnGap-14 [**2142-3-23**] 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 [**3-22**] 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 [**2142-3-21**] . # abdominal pain: Consistent with patient's baseline chronic abdominal pain. Medication effect also possible. CT prelim neg for small bowel obstruction. LFTs doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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). [**Month/Year (2) **]:*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 [**Month/Year (2) 2286**] sessions as directed by the nephrology team- your next session should be on Tuesday. Completed by:[**2142-3-26**]",122,2142-03-21 09:25:00,2142-03-23 18:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,CHEST PAIN;TELEMETRY," 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 (200s/100s) that nevertheless are within levels shes 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 [**3-22**] and transferred to the medicine floor. the next day, her bp remained within goal of 120s/80s. 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. ces were cycled and were negative. cpap was continued as tolerated at home settings. sob resolved after hd on [**2142-3-21**] . # abdominal pain: consistent with patients baseline chronic abdominal pain. medication effect also possible. ct prelim neg for small bowel obstruction. lfts doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Compression of vein; Unspecified disease of pericardium; Infection and inflammatory reaction due to other vascular device, implant, and graft; Bacteremia; Primary hypercoagulable state; Other primary cardiomyopathies; ; Abdominal pain, unspecified site; Urinary tract infection, site not specified; Acidosis; Other chest pain; Other chronic pain; Systemic lupus erythematosus; Noncompliance with renal dialysis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Hyperpotassemia; 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; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","this is a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. ct prelim neg for small bowel obstruction. on arrival to the floor, abd pain was back to baseline and well controlled on dilaudid 2mg po q 4hrs .","a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. initial attempts were made to control her bp with hydralazine and labetalol iv but after these failed to control her blood pressure. she was successfully transitioned to home medications of clonidine, labetalol, aliskiren, nifedipine" 109,196721.0,14863,2142-07-23,14810,137510.0,2142-04-22,Discharge summary,"Admission Date: [**2142-4-20**] Discharge Date: [**2142-4-22**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 1253**] Chief Complaint: Dyspnea, malignant hypertension Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented with abdominal pain and shortness of breath. On [**2142-4-19**] she refused ultrafiltration at HD because she was at her dry weight. Awoke at 3 AM feeling more short of breath. She also had worsening abdominal pain and vomiting without hematemasis. She took all of her medications as prescribed including two new lidocaine patches, fentanyl patch and clonidine. She developed a slight frontal headache but no blurry vision or neurologic symptoms. ROS largely negative. . In the emergency room her initial vitals were T: 99.1 BP: 280/140 HR: 79 RR: 16 O2: 100% on RA. She had two large bore peripheral IVs placed. She received 100 mg PO hydralazine, 200 mg PO labetolol, zofran 4 mg IV, vancomycin 1 gram IV, levofloxacin 750 mg IV x 1 and was started on labetolol and nitroglycerin drips with control of her blood pressure to the 180s systolic. She had a CXR which was concerning for volume overload. She was admitted the MICU for further evaluation. . In the MICU she was stablized and transitioned to her home meds. Nephrology gave her HD with 2L UF and subjective improvement in SOB. . Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: On Admission per MICU team: Vitals: T: 96.5 BP: 162/120 HR: 79 RR: 13 O2: 100% on 4L General: Pleasant, comfortable, no distress HEENT: L eye enucleated. Moon facies. Right pupil reactive Heart: Regular rate and rhythm, s1 + s2, soft systolic murmur at RLSB, no rubs or gallops Respiratory: Crackles at bases bilaterally, no wheezes, rales, ronchi GI: soft, non-tender, non-distended, +BS GU: no foley Ext: Warm and well perfused, no clubbing, cyanosis or edema . Pertinent Results: [**2142-4-19**] 08:35AM WBC-3.8* RBC-2.53* HGB-7.6* HCT-23.4* MCV-93 MCH-29.9 MCHC-32.3 RDW-19.9* [**2142-4-19**] 08:35AM PLT COUNT-93* . [**2142-4-19**] 08:35AM GLUCOSE-88 UREA N-36* CREAT-6.0* SODIUM-135 POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-25 ANION GAP-15 [**2142-4-19**] 08:35AM CALCIUM-9.4 PHOSPHATE-5.3* MAGNESIUM-2.0 . [**2142-4-20**] 08:40AM PT-28.3* PTT-45.3* INR(PT)-2.9* . CXR PA and LAT: IMPRESSION: 1. Persistent cardiomegaly with prominence of pulmonary vasculature suggesting overhydration. Minimal costophrenic angle blunting may suggest small effusions. 2. No definite consolidation, although increased retrocardiac density is noted, most likely due to atelectasis and vascular congestion. Repeat imaging following diuresis could be considered. . INR trend: [**2142-4-19**] 09:30AM BLOOD PT-30.4* INR(PT)-3.1* [**2142-4-20**] 08:40AM BLOOD PT-28.3* PTT-45.3* INR(PT)-2.9* [**2142-4-21**] 04:07AM BLOOD PT-29.9* PTT-48.9* INR(PT)-3.1* [**2142-4-22**] 05:55AM BLOOD PT-33.3* PTT-54.1* INR(PT)-3.5* Brief Hospital Course: 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented to the ICU for hypertensive emergency, dyspnea, and headache, now resolved. . Hypertensive Emergency: Patient's blood pressure normalized with transient nitroglycerin and labetalol drips. Likely precipitated by lack of ultrafiltration at [**Year/Month/Day 2286**] yesterday. She has received [**Year/Month/Day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - Nifedipine 150 mg Tablet SR daily - Hydralazine 100 mg Tablet Q8H - Labetalol 1000 mg Tablet TID - Aliskiren 150 mg Tablet PO BID - Clonidine 0.2 mg/24 hr Patch Weekly - Hydralazine 100 mg PO PRN for SBP > 200 - continue regular [**Year/Month/Day 2286**] schedule . Social Issues/repeated admissions: The ICU and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. These episodes may be due to medication non-compliance and it may benefit Ms. [**Known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. Ms. [**Known lastname **] [**Last Name (Titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. Of note, she has missed [**Last Name (Titles) 2286**] sessions and often requests durations and flow rates for her [**Last Name (Titles) 2286**] that contradict recommendations by her nephrologist. This issue was left unresolved on discharge. . Chronic Abdominal Pain: Currently managed with PO dilaudid, fentanyl patch and lidocaine patch. Per MICU team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue PO dilaudid - continue lidocaine patch . Lupus Erythematous: Complicated by uveitis and ESRD. - continued prednisone . ESRD: On [**Last Name (Titles) 2286**]. Ultrafiltrate of 2 L on initial HD - continue outpatient regimen . Thrombocytopenia: Remained at baseline 80s to 130s. . Thrombotic Events: History of SVC thrombosis with negative workup. INR drifted up and was 3.5 on discharge. She was asked to hold her warfarin dose this PM and recheck her INR with VNA services on [**2142-4-23**] to be faxed to coumadin clinic in [**Company 191**]. - continued coumadin . Anemia: Hematocrit 24.5 initially. Baseline 23 to 28. . Medications on Admission: Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H Prednisone 1 mg Tablet Citalopram 20 mg Tablet Pantoprazole 40 mg Tablet, Warfarin 3 mg daily Gabapentin 300 mg TID Nifedipine 90 mg Tablet SR daily Nifedipine 60 mg Tablet SR daily Hydralazine 100 mg Tablet Q8H Labetalol 1000 mg Tablet TID Aliskiren 150 mg Tablet PO BID Clonidine 0.2 mg/24 hr Patch Weekly Docusate Sodium 100 mg Capsule PO BID Senna 8.6 mg Tablet Fentanyl 25 mcg/hr Patch 72 hr Lidocaine 5 %(700 mg/patch) daily Hydralazine 100 mg PO:PRN for SBP > 200 Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) 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 3 mg Tablet Sig: One (1) Tablet PO once a day: DO NOT TAKE DOSE ON [**2142-4-22**]. Then restart per your PCP. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QHS (once a day (at bedtime)). 9. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 10. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 17. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed: For systolic blood pressure > 200. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Malignant Hypertension Systemic Lupus Erythematosus End Stage Renal Disease Abdominal Pain Discharge Condition: good, VSS, on room air, pain controlled. Discharge Instructions: You came to the hospital for shortness of breath and hypertension. You were given antihypertensive drips and during [**Location (un) 2286**] 2 liters were taken off with good improvement in your shortness of breath. You will need to take your medications as prescribed and follow-up with all of your doctors to prevent coming into the hospital. . Medication changes: - Please do not take your coumadin tonight because your INR is too high. You will need to have it checked by VNA services and adjusted. - Please take ALL of your medications as prescribed. . Please call your doctor or return to the ED if you have intractable headaches, shortness of breath, intractable pain or other concerns. Followup Instructions: Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-4-26**] 3:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Completed by:[**2142-4-23**]",92,2142-04-20 13:39:00,2142-04-22 15:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,PULMONARY EDEMA;HYPERTENSION," 24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. . hypertensive emergency: patients blood pressure normalized with transient nitroglycerin and labetalol drips. likely precipitated by lack of ultrafiltration at [**year/month/day 2286**] yesterday. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - nifedipine 150 mg tablet sr daily - hydralazine 100 mg tablet q8h - labetalol 1000 mg tablet tid - aliskiren 150 mg tablet po bid - clonidine 0.2 mg/24 hr patch weekly - hydralazine 100 mg po prn for sbp > 200 - continue regular [**year/month/day 2286**] schedule . social issues/repeated admissions: the icu and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. these episodes may be due to medication non-compliance and it may benefit ms. [**known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. ms. [**known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. this issue was left unresolved on discharge. . chronic abdominal pain: currently managed with po dilaudid, fentanyl patch and lidocaine patch. per micu team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue po dilaudid - continue lidocaine patch . lupus erythematous: complicated by uveitis and esrd. - continued prednisone . esrd: on [**last name (titles) 2286**]. ultrafiltrate of 2 l on initial hd - continue outpatient regimen . thrombocytopenia: remained at baseline 80s to 130s. . thrombotic events: history of svc thrombosis with negative workup. inr drifted up and was 3.5 on discharge. she was asked to hold her warfarin dose this pm and recheck her inr with vna services on [**2142-4-23**] to be faxed to coumadin clinic in [**company 191**]. - continued coumadin . anemia: hematocrit 24.5 initially. baseline 23 to 28. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Unspecified iridocyclitis; Other primary cardiomyopathies; Unspecified disease of pericardium; ; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Noncompliance with renal dialysis; Personal history of noncompliance with medical treatment, presenting hazards to health; Surgical or other procedure not carried out because of patient's decision; Abdominal pain, left lower quadrant; Renal dialysis status; Thrombocytopenia, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Peripheral vascular disease, unspecified; Acquired absence of organ, eye; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus]","24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. ultrafiltrate of 2 l on initial hd - continue outpatient regimen .","malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips." 109,196721.0,14863,2142-07-23,14809,124398.0,2142-03-31,Discharge summary,"Admission Date: [**2142-3-24**] Discharge Date: [**2142-3-31**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: HTN, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 24F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] after admission for abdominal pain, MSSA bacteremia, paroxysmal hypertension and ESRD line, followed by readmission [**3-22**], now presents with usual central crampy abdominal pain, 3 loose nonbloody stools this AM, SOB, and HTN to 270s. Pt was d/c'd from [**Hospital1 18**] yesterday after HD session, went home, states she took her PM meds, took her 8 AM medds (hydral, labetalol), then developed these symptoms which precluded her from taking her usual home meds (no afternoon meds - nifedipine, labetalol, hydral). The abd pain comes and goes and is unchanged from her baseline. While she has nausea, she is asking for dinner. . In the ED, initial BP 272/148. CXR w/o evidence of volume overload. No CT scan performed. Started on NTG gtt, given Hydralazine 10 x 1, Dilaudid 2 mg, labetaolo 20mg IV x 1. . Upon arrival to the floor, her BP was 240/135. She continued to complain of abdominal pain but was eating crackers, breathing felt better. RR 17. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: 98.2 97 [**Telephone/Fax (2) 43509**]0% on 2 L nC Gen: pleasant, comfortable HEENT: L eye enucleated. moon facies. Right pupil reactive Heart: hrrr, no m/r/g Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, diffuse TTP, no rebound/guarding Ext: no c/c/e Neuro: aox4, cn 2-12 intact grossly. Pertinent Results: [**2142-3-24**] 07:17PM PT-22.4* PTT-43.64* INR(PT)-2.1* [**2142-3-24**] 04:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2142-3-24**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-24**] 04:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**11-30**] [**2142-3-24**] 02:05PM GLUCOSE-76 UREA N-21* CREAT-4.8*# SODIUM-139 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2142-3-24**] 02:05PM ALT(SGPT)-78* AST(SGOT)-181* CK(CPK)-55 ALK PHOS-192* TOT BILI-0.5 [**2142-3-24**] 02:05PM cTropnT-0.12* [**2142-3-24**] 02:05PM CK-MB-5 [**2142-3-24**] 02:05PM WBC-3.6* RBC-2.90* HGB-8.9* HCT-26.6* MCV-92 MCH-30.7 MCHC-33.4 RDW-19.8* [**2142-3-24**] 02:05PM NEUTS-73.9* BANDS-0 LYMPHS-18.5 MONOS-3.8 EOS-3.0 BASOS-0.8 [**2142-3-24**] 02:05PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-1+ TARGET-1+ SCHISTOCY-OCCASIONAL TEARDROP-1+ ELLIPTOCY-OCCASIONAL [**2142-3-24**] 02:05PM PLT SMR-LOW PLT COUNT-129* [**2142-3-23**] 12:00PM GLUCOSE-77 UREA N-31* CREAT-6.0*# SODIUM-137 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14 [**2142-3-23**] 12:00PM estGFR-Using this [**2142-3-23**] 12:00PM CALCIUM-8.4 PHOSPHATE-5.7* MAGNESIUM-1.9 [**2142-3-23**] 12:00PM WBC-3.7* RBC-2.87* HGB-8.7* HCT-26.1* MCV-91 MCH-30.3 MCHC-33.3 RDW-19.4* [**2142-3-23**] 12:00PM PLT COUNT-130* [**2142-3-23**] 12:00PM PT-28.8* PTT-58.6* INR(PT)-2.9* Brief Hospital Course: The patient was admitted to the MICU on a NTG gtt from the ED. Her abdominal pain had imporved and she was eating crackers and peanut butter. She was given her usual afternoon home medications, and transitioned to a Nicardipine gtt, which has worked well for her in the past. Her BP goal was for a systolic of 180-200. The Nicardipine gtt was titrated off quickly and she was transfered to the floor. . On arrival to the floor, she in fact missed her morning medications on [**Month/Day/Year 766**]. This resulted in elevate blood pressures requiring IV hydralazing for control. She went to dialyisis Tuesday [**3-27**] and again had markedly elevated blood pressures while at [**Month/Year (2) 2286**] from missing her AM doses. Instructions were written for explicit AM administration and Nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. She was continued on labetalol 900mg TID, Aliskerin, Hydralazine 100mg po TID, and clonidine patch 0.4mg/24 weekly patch. . HEr BP remained relativly stable. She established a three three times weekly Dialysus regemin. A PAP smear was attempted due to her history of CIN I and no PCP follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . Her abdominal pain was also a chronic issue, which appeared stable. She was not administered IV narcotics, only PO. It was wihtout clear percipitating events or etiology. She will need GI follow up. She was contact[**Name (NI) **] by phone several times to arrange a GI follow up appointment but did not return messages. She has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . She was discharged to followup with her nephrologist, Dr. [**Last Name (STitle) 4883**]. . 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. Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Last Name (STitle) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2* 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). [**Last Name (STitle) **]:*405 Tablet(s)* Refills:*2* 5. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*2* 6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). [**Last Name (STitle) **]:*60 Tablet(s)* Refills:*2* 9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patches Transdermal once a week: Place two patches every week on Fridays. [**Last Name (STitle) **]:*8 Patches* Refills:*2* 10. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*0* 11. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO twice a day as needed for prn SBP>200: if nauseated and cannot keep down meds, may use 1 sublingual clonidine if sbp>200. . [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0* 12. Kayexalate Powder Sig: Thirty (30) grams PO once a day for 2 days: please take [**2142-4-1**] and [**2142-4-2**] for elevated potassium. [**Month/Day/Year **]:*240 grams* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Systemic Lupus Erythematosus End Stage Renal Disease Hypertension Abdominal Pain Discharge Condition: Blood pressure stable and abdominal pain at baseline Discharge Instructions: You were admitted with high blood pressure. You were in the ICU overnight for treatment. Some of your medications were changed and you were increased to three times weekly [**Location (un) 2286**]. Your abdominal pain is a difficult problem, as the reason for the pain is unclear. [**Name2 (NI) **] were continued on oral dilaudid. IV dilaudid is strongly discouraged and will continue to be in the future. You are now taking Nifedipine SR 30mg at night in addition to 90mg in the morning. Your other medications were the same. At home, if your blood pressure is above 200, then take 100mg hydralazine. If after 1 hour, your blood pressure does not decrease to below 200 with this, then take another 100mg hydralazine. If you are nauseated and cannot take in oral meds, then take sublingual clonidine, then wait 1 hour and repeat if BP still > 200. Finally, your potassium has been high. Please take kayexalate 30gm tomorrow and the next day. Followup Instructions: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-3-31**] 7:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule appointment We will attempt to contact you on [**Name (NI) 766**] with appointment times for you. ",114,2142-03-24 16:34:00,2142-03-31 15:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," the patient was admitted to the micu on a ntg gtt from the ed. her abdominal pain had imporved and she was eating crackers and peanut butter. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. her bp goal was for a systolic of 180-200. the nicardipine gtt was titrated off quickly and she was transfered to the floor. . on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**]. this resulted in elevate blood pressures requiring iv hydralazing for control. she went to dialyisis tuesday [**3-27**] and again had markedly elevated blood pressures while at [**month/year (2) 2286**] from missing her am doses. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she was continued on labetalol 900mg tid, aliskerin, hydralazine 100mg po tid, and clonidine patch 0.4mg/24 weekly patch. . her bp remained relativly stable. she established a three three times weekly dialysus regemin. a pap smear was attempted due to her history of cin i and no pcp follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . her abdominal pain was also a chronic issue, which appeared stable. she was not administered iv narcotics, only po. it was wihtout clear percipitating events or etiology. she will need gi follow up. she was contact[**name (ni) **] by phone several times to arrange a gi follow up appointment but did not return messages. she has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . she was discharged to followup with her nephrologist, dr. [**last name (stitle) 4883**]. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Long-term (current) use of steroids; Other chronic pain; Obstructive sleep apnea (adult)(pediatric); Abdominal pain, generalized; Hyperpotassemia]","the patient was admitted to the micu on a ntg gtt from the ed. her bp goal was for a systolic of 180-200. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she established a three three times weekly dialysus regemin.","the patient was admitted to the micu on a nicardipine gtt from the ed. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**] this resulted in elevate blood pressures requiring iv hydralazing for control " 109,174489.0,14861,2142-07-04,14803,135923.0,2142-01-12,Discharge summary,"Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-13**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypertensive Urgency and HA Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with HA in the setting of hypertension. Upon arrival to the ED, her vitals were 284/140, HR 67, RR 28, 100% on 4LNC. She was started on a nicardipine drip. She denied shortness of breath or chest pain. She is due for HD today. She has a left groin catheter which was recently placed [**2141-12-21**] and is causing her pain. She was also given dilaudid IV 1 mg x 2 with some relief. CXR was performed and showed no pulmonary edema. . Upon arrival to the MICU, patient denies HA, CP, SOB, fevers, chills. Patient reports mild abdominal pain at sight of left anterior abdominal wall hematoma and left groin pain at site of femoral HD line. She reports that she was taking her medications as directed, including coumadin for SVC thrombus. Briefly, 24 yo F with ESRD on HD, SLE, malignant HTN admitted for HA in the setting of HTN to 284/140 in ED. Initially, she was treated with a nicardipine gtt to control her BP. Her cardiac enzymes were flat, no new ECG changes. She was started on a heparin gtt with transition to coumadin for a SVC thrombosis. HTN secondary to med noncompliance. She was restarted on her oral BP. She missed her PM meds yesterday, so nicardipine was restarted, and then turned off this AM. She received all her AM BP meds. Her BPs have been in the 160s/90s. She had no neurological deficits. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 176/105, 87, 18, 100% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: 2/6 systolic murmur LUSB Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: left ant wall abd hematoma, TTP Extremities: Right: Trace, Left: Trace, left fem HD line without oozing or drainage Skin: Warm Neurologic: AAO x 3 Pertinent Results: [**2142-1-8**] 05:15AM PT-13.7* PTT-33.6 INR(PT)-1.2* [**2142-1-8**] 05:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-1+ STIPPLED-OCCASIONAL TEARDROP-1+ BITE-NORMAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2142-1-8**] 05:15AM cTropnT-0.08* [**2142-1-8**] 05:15AM CK(CPK)-119 [**2142-1-8**] 04:12PM PTT-120.8* [**2142-1-8**] 10:41PM PTT-144.8* [**2142-1-8**] 02:55PM CK-MB-NotDone cTropnT-0.06* Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. Patient was initially observed in the MICU and placed on a nicardipine drip. Patient was stablized on home medicaitons, suggesting medication non-compliance. Additionally, patient presented subtheraputic on coumadin for SVC thrombosis. Patient was started on heparin ggt. After the nicardipine drip was turned off, patient was called out to the floor. Heparin drip was continued until INR [**2-13**]. Pressures were managed to her baseline. Pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with Narcan. Patient received dialysis 3x/wk as per outpatient schedule. # Hypertension: Pt with extensive history of repeated admissions for hypertension. Patient's BP improved with nicardipine drip and after HD off drip on home PO medication regimen. Resumed oral antihypertensives with improved BP control. HTn likely from renal disease, possible medication noncompliance, lupus. No evidence of MI. Continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. Renal increased clonidine patch, and added Nicardipine with improvement of BP control. Pt is to follow up with an appointment in the next week to establish care at [**Company 191**], and to re-check her BP and adjust medications further. # SLE: Stable, continued prednisone at 4 mg PO daily. # Left groin pain. Permanent HD line was placed on [**12-25**]. Line and hematoma from prior peritoneal line on abdomen okay. No leukocytosis or fevers to suggest infection. Patient was oversedated on Dilaudid and had episode of oxygen desaturation which was reversed with Narcan. Patient was solmolent with morphine SR so that was d/c'ed as well, patient was given standing tylenlol and Morphine IR PRN. Transplant surgery removed remaining sutures today from L groin. Pt has a follow-up appointment in the next week with Dr. [**First Name (STitle) **] (Transplant Surgery). She will be sent home with low-dose Morphine IR and Tylenol PRN pain. If L groin pain should become uncontrollable on current meds, pt should return to the ED for re-evaluation. It is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #ESRD: Renal following, continuing HD Th/Th/Sat. CaCO3 was started for elevated calcium-phosphate product. Pt will follow-up with Dr. [**Last Name (STitle) 7473**] in the next 1-2 weeks. # Anemia: Pt's baseline is 26. This is likely secondary to AOCD and renal failure. Hct was stable on day of discharge at 25.9. # SVC thrombus: Pt has a history of an SVC thrombus, and is on coumadin. She is supposed to be on lifelong anticoagulation due to recurrent thrombosis but INR subtherapeutic on arrival. Heparin drip was stopped on the floor once the INR was theraputic. INR was therapeutic on day of discharge. Pt will need an INR check in the next week at her follow-up with her PCP. # HOCM: Pt has evidence of myocardial hypertrophy on Echo. She is currently not symptomatic. Echo did not show evidence of worsening pericardial effusion. She was continued on her beta-blocker and other BP medications. # Depression/anxiety: Stable. She was continued on Celexa and Clonazepam. # OSA: Pt as continued on CPAP for sleep with 7 pressure. # FEN: regular diet # PPX: heparin drip --> coumadin, bowel regimen # ACCESS: PIV x2 / permanent dialysis cath L fem # CODE: FULL # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] # DISPO: home with PCP and Renal [**Name9 (PRE) 702**] to re-check BP, INR level. Follow-up with Transplant Surgery. Medications on Admission: Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Aliskiren 150 [**Hospital1 **] Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Nicardipine 30 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain for 2 weeks. [**Hospital1 **]:*20 Tablet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Urgency End Stage Renal Disease Discharge Condition: stable, blood pressure moderately controlled, afebrile, tolerating POs Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. Some of medications were increased as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to take the coumadin as prescribed by your doctor, and have your INR checked frequently per your PCP's recommendations. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Renal) Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-1-15**] 3:00 - Will follow-up Vitamin D [**2-4**] level Provider: [**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD ([**Company 191**]) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-1-16**] 3:30 - Will re-check your INR level Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Transplant Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-1-19**] 2:50p [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-1-12**]",173,2142-01-08 06:36:00,2142-01-13 21:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE URGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was initially observed in the micu and placed on a nicardipine drip. patient was stablized on home medicaitons, suggesting medication non-compliance. additionally, patient presented subtheraputic on coumadin for svc thrombosis. patient was started on heparin ggt. after the nicardipine drip was turned off, patient was called out to the floor. heparin drip was continued until inr [**2-13**]. pressures were managed to her baseline. pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with narcan. patient received dialysis 3x/wk as per outpatient schedule. # hypertension: pt with extensive history of repeated admissions for hypertension. patients bp improved with nicardipine drip and after hd off drip on home po medication regimen. resumed oral antihypertensives with improved bp control. htn likely from renal disease, possible medication noncompliance, lupus. no evidence of mi. continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. renal increased clonidine patch, and added nicardipine with improvement of bp control. pt is to follow up with an appointment in the next week to establish care at [**company 191**], and to re-check her bp and adjust medications further. # sle: stable, continued prednisone at 4 mg po daily. # left groin pain. permanent hd line was placed on [**12-25**]. line and hematoma from prior peritoneal line on abdomen okay. no leukocytosis or fevers to suggest infection. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. patient was solmolent with morphine sr so that was d/ced as well, patient was given standing tylenlol and morphine ir prn. transplant surgery removed remaining sutures today from l groin. pt has a follow-up appointment in the next week with dr. [**first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. it is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #esrd: renal following, continuing hd th/th/sat. caco3 was started for elevated calcium-phosphate product. pt will follow-up with dr. [**last name (stitle) 7473**] in the next 1-2 weeks. # anemia: pts baseline is 26. this is likely secondary to aocd and renal failure. hct was stable on day of discharge at 25.9. # svc thrombus: pt has a history of an svc thrombus, and is on coumadin. she is supposed to be on lifelong anticoagulation due to recurrent thrombosis but inr subtherapeutic on arrival. heparin drip was stopped on the floor once the inr was theraputic. inr was therapeutic on day of discharge. pt will need an inr check in the next week at her follow-up with her pcp. # hocm: pt has evidence of myocardial hypertrophy on echo. she is currently not symptomatic. echo did not show evidence of worsening pericardial effusion. she was continued on her beta-blocker and other bp medications. # depression/anxiety: stable. she was continued on celexa and clonazepam. # osa: pt as continued on cpap for sleep with 7 pressure. # fen: regular diet # ppx: heparin drip --> coumadin, bowel regimen # access: piv x2 / permanent dialysis cath l fem # code: full # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] # dispo: home with pcp and renal [**name9 (pre) 702**] to re-check bp, inr level. follow-up with transplant surgery. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Hypoxemia; Other opiates and related narcotics causing adverse effects in therapeutic use; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Abdominal pain, other specified site; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Renal dialysis status; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Other postprocedural status]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. # hypertension: pt with extensive history of repeated admissions for hypertension. # sle: stable, continued prednisone at 4 mg po daily. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. this is likely secondary to aocd and renal failure. pt will need an inr check in the next week at her follow-up with her pcp.","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was stablized on home medicaitons, suggesting medication non-compliance. patient was oversedated on dilaudid and had episode of oxygen desaturation." 109,102024.0,14859,2142-06-05,14858,151240.0,2142-05-18,Discharge summary,"Admission Date: [**2142-5-15**] Discharge Date: [**2142-5-18**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 613**] Chief Complaint: Headache, Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis x 2 History of Present Illness: 24 year old female with SLE, ESRD on HD, hx malignant HTN, h/o SVC syndrome, h/o posterior reversible encephalopathy syndrome (PRES) and prior intracerebral hemorrhage, recently admitted [**Date range (1) 17717**] with diarrhea, hypertensive urgency. Treated at that time with nicardipine drip for a short period and then to her home regimen. Yesterday onset of nausea with emesis and inability to tolerate home meds including antihypertensives. Diarrhea mild as prior. No fever, chills, no hematemesis or hematochezia. No melena. Today reports onset of headache therefore to the ED. In the ED, initial vs were 280/160, 99.4, 105, RR 18. She was given dilaudid 2 mg PO x 2. Hydral 20 mg x 3 for BP. Calcium gluconate 1 gram. Insulin 10 units, D 50 [**1-12**] amp, sodium bicarbonate, kayexalate for K 6.7 (dialysis dependent Tues/thurs/sat) but with report of peaked T waves. Renal dialysis fellow was not contact[**Name (NI) **]. HCT 33.4, WBC 4.6, trop 0.10. Admitted for hypertensive urgency to ICU. No gtt was started. Of note usualy BP 160/100. Review of sytems: patient tearful complaining of frontal headache and nausea Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: Vitals: BP 240/146, 101, 98.6, General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardic, 3/6 SEM RUSB Abdomen: soft, diffusely tender, no rebound or gaurding. Ext: cachectic, warm, 2+ DP pulse no clubbing, cyanosis or edema Pertinent Results: [**2142-5-15**] 05:45AM GLUCOSE-83 UREA N-54* CREAT-7.6* SODIUM-138 POTASSIUM-6.7* CHLORIDE-103 TOTAL CO2-23 ANION GAP-19 [**2142-5-15**] 05:45AM CK(CPK)-96 [**2142-5-15**] 05:45AM cTropnT-0.10* [**2142-5-15**] 05:45AM CK-MB-NotDone [**2142-5-15**] 05:45AM WBC-4.6 RBC-3.66* HGB-10.8* HCT-33.4* MCV-91 MCH-29.6 MCHC-32.4 RDW-17.9* [**2142-5-15**] 05:45AM NEUTS-65.4 LYMPHS-25.1 MONOS-4.8 EOS-4.1* BASOS-0.7 [**2142-5-15**] 05:45AM PLT COUNT-128* [**2142-5-15**] 05:45AM PT-14.2* PTT-36.4* INR(PT)-1.2* [**2142-5-15**] 07:14AM K+-6.0* [**2142-5-15**] 12:17PM K+-5.3 Images: CXR: Persistent severe cardiomegaly. Head CT: Normal brain CT. Brief Hospital Course: 24 yo female with ESRD on HD, malignant hypertension with hx of intracerebral hemorrhage, SLE, chronic abdominal pain, and SVC syndrome admitted due to hypertensive urgency after developing N/V and being unable to take her po medications. # Hypertensive urgency: The patient was admitted to the MICU the night of admission where she was placed on a labetolol drip and her home medications were restarted. head CT was negative for intracranial bleed. She was continued on her home regimen of Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet Sustained Release QAM, and Hydralazine 100 mg PO Q8H. During her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. Blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). She was discharged on her home regimen. # Nausea/vomiting: The patient did not experience further vomiting, but occasionally complained of nausea. The cause of her nausea was unclear. She was able to tolerate po intake prior to discharge. # Abdominal pain/Diarrhea: The patient has chronic abdominal pain with previous negative workups. During this hospitalization her pain was at its baseline. Since admission she denied diarrhea. She was continued on her outpatient regimen of [**2-14**] mg po dilaudid q4h as needed. # ESRD on HD: She was hyperkalemic in the emergency room and was given kayexalate. She underwent two sessions of dialysis during this hospitalization. # SLE: Stable, without symptoms. She was continued on 4 mg of prednisone daily. # History of thrombotic events/SVC syndrome: She is anticoagulated with warfarin as an outpatient, however her INR was subtherapeutic on admission at 1.2. Previous documentation in OMR states she does not need to be bridged while subtherapeutic. She was initally continued on coumadin 4 mg po daily, however her INR rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # OSA: She is on CPAP at a setting of 7 as an outpatient and was continued on this during her hospitalization. Medications on Admission: Medications: as per last discharge summary -Aliskiren 150 mg Tablet [**Hospital1 **] -Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday) -Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). -Labetalol 200 mg Tablet Sig 5 tab TID -Nifedipine 60 mg Tablet Sustained Release QPM -Nifedipine 90 mg Tablet Sustained Release QAM -Citalopram 20 mg Tablet Sig daily -Hydromorphone 2 mg Tablet Sig [**1-12**] Q4 PRN -Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). -Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H -Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID PRN -Prednisone 4 mg daily -Coumadin 4 mg daily at 4 PM Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QPM (once a day (in the evening)). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 10. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO twice a day as needed for hypertension. 13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary - Hypertensive urgency End-stage renal disease on dialysis Secondary - Systemic lupus erythematous History of thombosis and Superior vena cava syndrome Obstructive sleep apnea Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital due to dangerously elevated blood pressure due to inability to take your medications secondary to nausea. It is very important that you take your blood pressure medications reguarly. Your nausea was controlled with medication and your blood pressure decreased once back on your home medication regimen. You underwent two sessions of dialysis during your hospitalization. It is extremely important that you attend dialysis three times weekly as an outpatient. Medication changes: You should be taking 3 mg of coumadin daily. You will need to have your INR checked at dialysis. Otherwise continue your outpatient medications as prescribed. Call your primary doctor, or go to the emergency room if you experience fevers, chills, worsening headache, vision change, inability to take your medications, blood in your stool, or dark black stool. Followup Instructions: It is very important that you keep your previously scheduled appointments: You have an appointment with gynecology to evaluate an abnormality recently seen on PAP smear. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-6-1**] 2:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-5-19**]",18,2142-05-15 10:45:00,2142-05-18 15:58:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSIVE CRISIS," 24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. # hypertensive urgency: the patient was admitted to the micu the night of admission where she was placed on a labetolol drip and her home medications were restarted. head ct was negative for intracranial bleed. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, and hydralazine 100 mg po q8h. during her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). she was discharged on her home regimen. # nausea/vomiting: the patient did not experience further vomiting, but occasionally complained of nausea. the cause of her nausea was unclear. she was able to tolerate po intake prior to discharge. # abdominal pain/diarrhea: the patient has chronic abdominal pain with previous negative workups. during this hospitalization her pain was at its baseline. since admission she denied diarrhea. she was continued on her outpatient regimen of [**2-14**] mg po dilaudid q4h as needed. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. she underwent two sessions of dialysis during this hospitalization. # sle: stable, without symptoms. she was continued on 4 mg of prednisone daily. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient, however her inr was subtherapeutic on admission at 1.2. previous documentation in omr states she does not need to be bridged while subtherapeutic. she was initally continued on coumadin 4 mg po daily, however her inr rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # osa: she is on cpap at a setting of 7 as an outpatient and was continued on this during her hospitalization. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other primary cardiomyopathies; Unspecified disease of pericardium; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Hyperpotassemia; Nausea with vomiting; Diarrhea; Disorders of phosphorus metabolism; Anemia of other chronic disease; Abdominal pain, left lower quadrant; Other chronic pain; Thrombocytopenia, unspecified; Other specified peripheral vascular diseases; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus; Long-term (current) use of anticoagulants; Noncompliance with renal dialysis; Renal dialysis status; Personal history of noncompliance with medical treatment, presenting hazards to health]","24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. she was able to tolerate po intake prior to discharge. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. previous documentation in omr states she does not need to be bridged while subtherapeutic.","24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg" 109,102024.0,14859,2142-06-05,14801,173633.0,2141-12-14,Discharge summary,"Admission Date: [**2141-12-8**] Discharge Date: [**2141-12-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 8104**] Chief Complaint: abdominal pain & hypertension Major Surgical or Invasive Procedure: Hemodialysis PICC Line [**12-11**] History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with a history of CKD V (on HD) from lupus nephritis, chronic intermittent abdominal pain, and multiple prior ICU admissions for hypertensive urgency who presented to the ED complaining of two days' of abdominal pain, nausea, and loose stools. She was feeling well until after her hemodialysis session on Wednesday. Thereafter, she complained of nausea with occasional vomitting and has been unable to keep down any of her oral medications. She also has had diffuse abdominal pain consistent with her prior flares of pain as well as her typical diffuse headache. The headache in particular was worsening and, for her, this is a sign of poorly-controlled hypertension so she came to the [**Hospital1 18**] ED. Upon arrival to the ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room air. She was given 4 mg of IV ondansetron, [**1-11**] inch intropaste, 1 mg of IV hydromorphone x3, 1000cc of NS, and was put on a labetalol drip which had to be increased up to 2 mg/min. A head CT showed no acute abnormality (including hemorrhage) and an abdominal CT showed some possible mild colitis, though it is unclear if this is due to her recent peritoneal dialysis. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 97.9 BP 165/120 HR 93 RR 12 Sat 100% ra Gen: mildly fatigued, but no distress HEENT: oropharynx clear Neck: no JVP, no LAD Chest: clear to auscultation throughout, no w/r/r CV: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard Abdomen: soft, tender diffusely to moderate palpation without rebound or guarding; hyperactive bowel sounds; no masses or HSM, PD catheter in palce Extr: no edema, 2+ PT pulses Neuro: alert, appropriate, strength grossly intact in all four limbs Skin: no rashes Pertinent Results: [**2141-12-14**] 05:53AM BLOOD WBC-4.3 RBC-2.81* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.7 MCHC-33.8 RDW-19.3* Plt Ct-148* [**2141-12-14**] 05:53AM BLOOD PT-42.6* PTT-51.0* INR(PT)-4.7* [**2141-12-10**] 05:10AM BLOOD Ret Aut-2.5 [**2141-12-14**] 05:53AM BLOOD Glucose-83 UreaN-21* Creat-5.1*# Na-138 K-5.3* Cl-105 HCO3-24 AnGap-14 [**2141-12-10**] 05:10AM BLOOD LD(LDH)-234 Amylase-347* TotBili-0.1 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-10**] 05:10AM BLOOD Lipase-72* [**2141-12-14**] 05:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 [**2141-12-10**] 05:10AM BLOOD Hapto-142 [**2141-12-8**] 04:02AM BLOOD calTIBC-138* VitB12-445 Folate-18.5 Ferritn-220* TRF-106* ON ADMISSION: [**2141-12-7**] 09:50PM BLOOD WBC-4.5 RBC-2.78* Hgb-8.4* Hct-25.2* MCV-91 MCH-30.2 MCHC-33.3 RDW-19.2* Plt Ct-158 [**2141-12-7**] 09:50PM BLOOD Neuts-65.2 Lymphs-23.4 Monos-8.0 Eos-2.9 Baso-0.4 [**2141-12-7**] 09:50PM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3* [**2141-12-8**] 04:02AM BLOOD Ret Aut-2.5 [**2141-12-7**] 09:50PM BLOOD Glucose-89 UreaN-25* Creat-5.1*# Na-139 K-4.8 Cl-104 HCO3-26 AnGap-14 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-7**] 09:50PM BLOOD Lipase-89* [**2141-12-7**] 09:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9* Mg-1.9 [**2141-12-7**] 09:54PM BLOOD Glucose-75 Lactate-1.3 Na-139 K-4.8 Cl-101 calHCO3-23 Micro: Blood Cx: [**12-7**], [**12-7**], [**12-11**], [**12-11**] No growth FECAL CULTURE (Final [**2141-12-10**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2141-12-10**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2141-12-8**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-12-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CT HEAD [**2141-12-8**]: IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. The hypodensities noted in the parietal white matter are stable. However in the setting of the hypertension, PRES cannot be excluded. If further evaluation is required MR can be obtained. CT Abdomin/Pelvis [**2141-12-8**] IMPRESSION: 1. Moderate amount of free fluid in the pelvis is compatible with the patient's known peritoneal dialysis. Unchanged peritoneal enhancement. 2. Stable liver hemangioma. CXR [**12-11**] IMPRESSION: Small left pleural effusion. Left lower lobe opacity which is either atelectasis versus pneumonia. Brief Hospital Course: 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. MICU course: Current plan on transfer 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. 1. Hypertensive urgency: The patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. Initially her blood pressure over-corrected to SBPs in the 80s (patient was asymptomatic). Her clonidine patch and hydralazine was held and she again became hypertensive with SBPs 190s. The patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. The following dialysis the patient asymptomatic with SBPs in 80s, MAPs 60s asymptomatic again. Her hydralazine was stopped and continued on all her other home medications at the advice of renal. The patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. On [**12-11**] the patient's SBP dropped to the 80's and due to her pain medications she was extremely lethargic, but arousable. A PICC line was placed because lack of access and she was bolused 250cc NS. The patient's pressures responded and additional narcotics were held due to her mental status. The patient's blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. The patient did require IV hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. A possible component to the patient's malignant hypertension is likely due to OSA. An inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on BiPAP for OSA. The patient was continuned on her admission hypertensive regimen. . 2. Abdominal pain: The etiology of her abdominal pain is unclear, but has been a chronic issue for her. A CT scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. The patient also had diarrhea, but stool studies were negative. The patient's pain was initially treated with hydromorphone, but because of the patient's lethargy on [**12-11**] they were initially held. She continued to complain of severe abdominal pain. She was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. Surgery was consulted in regards to removal of her PD catheter, but given that she may return to PD it was deferred to the outpatient setting. 3. CKD V from lupus nephritis: The patient was continued on HD during her admission. She was also continued on her home prednisone dose. She was closely followed by the renal team. . 4. History of SVC/subclavian vein thrombus: The patient was found to have a subtherapeutic INR on admission 1.3. She was started on a heparin gtt and continued on coumadin. The patient's heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her PICC line was placed. She was therapetuic the same day and her heparin gtt was stopped. On discharge her coumadin was supratherapeutic (4.7) and was held. She will have her INR checked at HD. . 5. Anemia: The patient's Hct slowly trended down. She was guaiac negative and hemolysis labs were negative. She was transfused 1U pRBC at HD on [**12-12**]. She was also given epo at HD. Medications on Admission: prednisone 4 mg daily clonidine 0.3 mg/day patch qWeek ergocalciferol 50,000 units qMonth nifedipine SR 90 mg daily hydralazine 100 mg q8h citalopram 20 mg daily warfarin 2 mg qhs gabapentin 300 mg [**Hospital1 **] hydromorphone 4 mg q4h prn clonazepam 0.5 mg [**Hospital1 **] alikiren 150 mg [**Hospital1 **] docusate 100 mg [**Hospital1 **] senna 8.6 mg [**Hospital1 **] prn acetaminophen prn labetalol 800 mg q8h bisacodyl 5 mg daily prn Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. [**Hospital1 **]:*84 Tablet(s)* Refills:*0* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed: please take as needed for anxiety prior to CPAP at bedtime. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 14. CPAP Home CPAP Dx: OSA Prefer: AutoCPAP/ Pressure setting [**5-20**] Alt: Straight CPAP/ Pressure setting 7 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency Abdominal Pain ESRD on HD SVC Thrombus Secondary: Systemic lupus erythematosus Malignant hypertension Thrombocytopenia HOCM Anemia History of left eye enucleation History of vaginal bleeding Thrombotic microangiopathy Discharge Condition: Stable Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because of elevated blood pressure and abdominal pain. You were initially admitted to the ICU and your blood pressure was controlled. You were stabilized and transferred back to th floor. Your pressures remained stable throughout the rest of your stay. Additionally, you had abdominal pain and diarrhea. Your stool was tested for infections and was negative. Your diarrhea resolved without intervention. Your abdominal pain was controlled with pain medications. You had a sleep study in the hospital which showed that you had sleep apnea. Please continue to take your medications as prescribed. 1. Please do not take your coumadin until your doctor tells you to. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: You will have dialysis at [**Location (un) **] Dialysis on your normal schedule. You need to go to dialysis on Saturday. Please follow-up with the Sleep Clinic in [**12-19**] @ 11:45 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Completed by:[**2141-12-16**]",173,2141-12-08 01:40:00,2141-12-14 17:16:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. micu course: current plan on transfer 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. 1. hypertensive urgency: the patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). her clonidine patch and hydralazine was held and she again became hypertensive with sbps 190s. the patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. the following dialysis the patient asymptomatic with sbps in 80s, maps 60s asymptomatic again. her hydralazine was stopped and continued on all her other home medications at the advice of renal. the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. on [**12-11**] the patients sbp dropped to the 80s and due to her pain medications she was extremely lethargic, but arousable. a picc line was placed because lack of access and she was bolused 250cc ns. the patients pressures responded and additional narcotics were held due to her mental status. the patients blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. the patient did require iv hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. a possible component to the patients malignant hypertension is likely due to osa. an inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on bipap for osa. the patient was continuned on her admission hypertensive regimen. . 2. abdominal pain: the etiology of her abdominal pain is unclear, but has been a chronic issue for her. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. the patient also had diarrhea, but stool studies were negative. the patients pain was initially treated with hydromorphone, but because of the patients lethargy on [**12-11**] they were initially held. she continued to complain of severe abdominal pain. she was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. surgery was consulted in regards to removal of her pd catheter, but given that she may return to pd it was deferred to the outpatient setting. 3. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was also continued on her home prednisone dose. she was closely followed by the renal team. . 4. history of svc/subclavian vein thrombus: the patient was found to have a subtherapeutic inr on admission 1.3. she was started on a heparin gtt and continued on coumadin. the patients heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her picc line was placed. she was therapetuic the same day and her heparin gtt was stopped. on discharge her coumadin was supratherapeutic (4.7) and was held. she will have her inr checked at hd. . 5. anemia: the patients hct slowly trended down. she was guaiac negative and hemolysis labs were negative. she was transfused 1u prbc at hd on [**12-12**]. she was also given epo at hd. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Systemic lupus erythematosus; Other and unspecified noninfectious gastroenteritis and colitis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other iatrogenic hypotension; Obstructive sleep apnea (adult)(pediatric); Hemangioma of intra-abdominal structures; Other chronic pain; Abdominal pain, unspecified site; Abnormal coagulation profile; Renal dialysis status; Personal history of venous thrombosis and embolism]","24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. the patient was continuned on her admission hypertensive regimen. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was therapetuic the same day and her heparin gtt was stopped.",24 year old woman with ckd v and severe hypertension due to sle admitted. patient was initially maintained on a labetalol drip and hydralazine iv prn. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic) 109,102024.0,14859,2142-06-05,14802,140167.0,2141-12-23,Discharge summary,"Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1973**] Chief Complaint: Malignant hypertension Major Surgical or Invasive Procedure: None History of Present Illness: 24 year old female with ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning. Patient had her hemodialysis day before yesterday. She has had multiple admissions to [**Hospital1 18**] with hypertensive urgency with symptoms of headache and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Patient states that her headache and abdominal pain are similar in characteristics to her previous admission. Patient denies any fever, chills, nightsweats, chest pain, shortness of breath, abdominal pain, nausea, vomitting, diarrhea, constipation, blood in stool, dysuria, hematuria, change in vision, hearing, weakness or numbness. In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was initially given 10mg IV Labetalol once and then started on drip at 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea. Her BP elevated as high as 270/174 and his labetolol was switched to nicardipine 1mg/kg/min. On arrival to the MICU her vitals were T 96.4 HR 99 BP 175/120 RR 15 100%RA. Patient was comfortable. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Vitals: 97.5 122/80 88 18 100%RA. Gen: sleeping, easily arousable, appears comfortable. HEENT: AT/NC, L eye prosthetic non-reactive, R pupil reactive, MMM. Heart: S1S2 RRR, III/VI SEM heard best at apex, + S3 Pulm: CTA b/l, no w/r/r. Abd: normal bowel sounds, midline scar well-healed, soft, nontender, prior PD site with dry dressing, patient with tenderness to palpation over prior PD cath site, no guarding/rebound Ext: no edema, no clubbing, WWP. R femoral HD catheter in place. Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: Admission: [**2141-12-18**] 02:00AM BLOOD WBC-5.8 RBC-3.30* Hgb-10.1* Hct-30.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-20.7* Plt Ct-199 [**2141-12-18**] 02:00AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.2* [**2141-12-18**] 02:00AM BLOOD UreaN-35* Creat-5.0* Na-138 K-5.5* Cl-103 HCO3-21* AnGap-20 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-18**] 02:00AM BLOOD Lipase-73* [**2141-12-18**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2141-12-19**] 06:45AM BLOOD Calcium-8.1* Phos-5.1* Mg-1.8 [**2141-12-18**] 03:52PM BLOOD dsDNA-NEGATIVE [**2141-12-18**] 03:52PM BLOOD CRP-11.5* [**2141-12-18**] 03:52PM BLOOD C3-68* C4-19 [**2141-12-20**] 12:09PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 [**2141-12-18**] 02:08AM BLOOD pO2-52* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 Comment-GREEN TOP [**2141-12-20**] 12:09PM BLOOD Lactate-0.9 [**2141-12-18**] 02:08AM BLOOD Glucose-68* Lactate-1.3 Na-140 K-4.8 Cl-103 [**2141-12-23**] 03:00PM BLOOD WBC-4.7 RBC-2.35* Hgb-7.1* Hct-22.3* MCV-95 MCH-30.3 MCHC-31.9 RDW-20.6* Plt Ct-131* [**2141-12-23**] 12:55AM BLOOD PT-14.7* PTT-66.2* INR(PT)-1.3* [**2141-12-18**] 03:52PM BLOOD ESR-21* [**2141-12-23**] 03:00PM BLOOD Glucose-97 UreaN-42* Creat-6.6* Na-138 K-4.3 Cl-106 HCO3-23 AnGap-13 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-23**] 03:00PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8 [**2141-12-18**] 04:23PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2141-12-18**] 04:23PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2141-12-18**] 04:23PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-12 TransE-<1 Micro: Blood Cx- [**12-18**]: No growth Urine Cx- [**12-18**]: No growth [**12-18**] TTE The left atrium and right atrium are normal in cavity size. A possible secundum type atrial septal defect is seen by color Doppler (clip [**Clip Number (Radiology) **]) There is severe symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. There is no significant resting LVOT gradient, but a mild gradient (30mmHg peak) is seen with Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Marked symmetric left ventricular hypertrophy with normal regional/global systolic function and mild inducible LVOT gradient. Mild aortic regurgitation. Mild pulmonary artery systolic hypertension. Possible secundum type atrial septal defect. Compared with the prior study (images reviewed) of [**2141-10-19**], a possible secundum type atrial septal defect is now suggested. If clinically indicated, a follow-up study with saline contrast and/or a TEE would be better able to characterize the possible atrial septal defect. CLINICAL IMPLICATIONS: Based on [**2140**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**12-18**] CXR IMPRESSION: 1. Cardiomegaly with findings suggestive of mild pulmonary edema. 2. Bibasilar linear opacities suggesting atelectasis, although developing pneumonia cannot be excluded. 3. No evidence of free intraperitoneal air. [**12-20**] MRV IMPRESSION: No appreciable change since the MRV chest exam dated [**2141-5-30**]. SVC is patent. Again seen is occlusion of the right internal jugular and left brachiocephalic veins. Right external jugular vein is provides the major venous drainage from the neck. Brief Hospital Course: 24 year old Female with SLE, ESRD on HD and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ED. 1. Malignant Hypertension: The patient had her hemodialysis two days prior to admission. Initially in the ED her BP was 253/170. She was given 10mg IV Labetalol and started on a labatelol drip. She also received hydralazine IV 10 mg once and 2 inches of nitropaste. She had morphine 4mg and 4mg Zofran for nausea. Her BP remained elevated so she was switched to nicardipine 1mg/kg/min. The patient was transferred to the MICU. In the ICU she was continued on the Nicardapine drip and her pressures decreased to 175/120. Nephrology was consulted and dialysis initiated in the AM. The Nicardapine drip dc'd on [**12-19**] and pt transferred to floor. While on the floor the patient had question of angioedema and markedly elevated BP. She was readmitted to the MICU on [**2141-12-20**]. Patient's Aliskerin was also held for conern for angioedema. The renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. The patient's PD catheter was removed. The patient was briefly on a nitro drip for hypertension. The patient's nifedepine was increased to 120mg. The patient was transferred to the floor with stable blood pressures, BP 124/72 on [**12-21**]. The morning of [**12-22**], the patient was noted to have a BP up to 247/120 at 0800. Hypertension persisted throughout the morning with BPs 210s-240s systolic. HR during this time was in the 90s. She received a total of 60 mg IV hydralazine over the course of the morning as well as 0.1 mg PO clonidine. She was also given her normal AM BP meds and restarted on aliskarin. Due to persistent hypertension, she was transferred to the ICU for further care. On arrival to the ICU, the patient reported severe abdominal pain over the site of recently removed PD catheter. She denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. She reports bilateral calf cramping but no leg swelling. She denies any difficulty breathing or chest pain. She took her AM BP meds without difficulty. Her blood pressure decreased to 130s-140s/60s without further intervention. She was transferred back to the floor on [**12-23**] and signed out AMA. 2. Angioedema: On [**12-20**] the patietn developed facial swelling and evidence of angioedema by ENT. The patient reported that her face is more swollen which was confirmed by her mother on the floor. The patient was give lasix IV as she has been unable to have any negative filtration with HD. The patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. Her tekturna was discontinued for concern that it might be causing angioedema. She denied difficulty with her breathing at that time, but was very somnulent. On arrival to the MICU her vitals were stable and oxygenating well at 100% on face mask. The patient's airway was supported with a nasal trumpet. The patient underwent MRV that showed no progression of her clot. Patient was diuresed with lasix and dialysis with significant improvement in her symptoms. She was treated with prednisone and decadron, famotidine and benadryl for angioedema. The patient was maintained on her heparin drip for her SVC syndrome. 3. Abdominal Pain: The patient has had extensive prior workup that has been unrevealing. The Transplant surgery team removed the PD cath on [**12-21**]. She continued to have abdominal pain post-op. She was continued on PO dilaudid 2mg po prn. She continuned to complain of abdominal pain throughout her admission and continued to requested IV dilaudid. 4. ESRD: The patient is on a T/Th/Sat schedule. She was closely followed by the renal team. She had dialysis on [**12-19**]. The patient's tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. The patient also had her PD catheter removed on [**12-21**] secondary to chronic abdominal pain. The patient was scheduled to have dialysis on [**12-23**]. 5. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last admission for supratherapeutic INR. She was admitted with a subtherpeutic INR of 1.2 She was started on a heparin drip. She was also started on Coumadin 2mg PO qday, but was held on [**12-19**] in prep her PD catheter removal. She was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by IR. However, the patient signed out AMA and thus it was not placed. 6. Anxiety: Pt recently saw psychiatrist who started her on Celexa. She was continued on Celexa 20mg PO daily. 7. Anemi of CKDa: The patient's Hct was 30.3 on admission. It trended down to 22.3 on discharge when she left AMA. There was no evidence of active, acute bleeding. THis is likely seoncdary to her ESRD. The patient was closely monitored. 8. Systemic Lupus Erythematosis: Rheumatology was consulted and does not suspect acute flare and dsDNA, C3, C4 nl, ESR and CRP slightly elevated. Her Echo did not suggest worsening pericarditis. She was continued on her home prednisone dose of 4mg daily. 9. Obstructive Sleep Apnea: CPAP for sleep with 7 pressure. Medications on Admission: Aliskiren 150 mg [**Hospital1 **] Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Warfarin held on discharge [**2141-12-14**] due to supratherap INR Discharge Medications: As patient signed out AMA, no medications were issued. She was told to resume her admission medications, however no instructions were taken by the patient. Discharge Disposition: Home Discharge Diagnosis: 1) Hypertensive urgency 2) Abdominal pain 3) End stage renal disease on hemodialysis 4) Venous thromboembolism Discharge Condition: Signed out AMA Discharge Instructions: Pt signed out AMA Return to the hospital with any concerning symptoms. Be sure to call your doctor's office on [**Month/Day/Year 766**] to arrange hemodialysis and review your medications and discuss follow-up plan. Followup Instructions: Follow-up with your Dr. [**Last Name (STitle) **] next week, and call [**Last Name (STitle) 766**] to arrange your hemodialysis. Completed by:[**2141-12-26**]",164,2141-12-18 03:50:00,2141-12-23 19:51:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. 1. malignant hypertension: the patient had her hemodialysis two days prior to admission. initially in the ed her bp was 253/170. she was given 10mg iv labetalol and started on a labatelol drip. she also received hydralazine iv 10 mg once and 2 inches of nitropaste. she had morphine 4mg and 4mg zofran for nausea. her bp remained elevated so she was switched to nicardipine 1mg/kg/min. the patient was transferred to the micu. in the icu she was continued on the nicardapine drip and her pressures decreased to 175/120. nephrology was consulted and dialysis initiated in the am. the nicardapine drip dcd on [**12-19**] and pt transferred to floor. while on the floor the patient had question of angioedema and markedly elevated bp. she was readmitted to the micu on [**2141-12-20**]. patients aliskerin was also held for conern for angioedema. the renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. the patients pd catheter was removed. the patient was briefly on a nitro drip for hypertension. the patients nifedepine was increased to 120mg. the patient was transferred to the floor with stable blood pressures, bp 124/72 on [**12-21**]. the morning of [**12-22**], the patient was noted to have a bp up to 247/120 at 0800. hypertension persisted throughout the morning with bps 210s-240s systolic. hr during this time was in the 90s. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she was also given her normal am bp meds and restarted on aliskarin. due to persistent hypertension, she was transferred to the icu for further care. on arrival to the icu, the patient reported severe abdominal pain over the site of recently removed pd catheter. she denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. she reports bilateral calf cramping but no leg swelling. she denies any difficulty breathing or chest pain. she took her am bp meds without difficulty. her blood pressure decreased to 130s-140s/60s without further intervention. she was transferred back to the floor on [**12-23**] and signed out ama. 2. angioedema: on [**12-20**] the patietn developed facial swelling and evidence of angioedema by ent. the patient reported that her face is more swollen which was confirmed by her mother on the floor. the patient was give lasix iv as she has been unable to have any negative filtration with hd. the patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. her tekturna was discontinued for concern that it might be causing angioedema. she denied difficulty with her breathing at that time, but was very somnulent. on arrival to the micu her vitals were stable and oxygenating well at 100% on face mask. the patients airway was supported with a nasal trumpet. the patient underwent mrv that showed no progression of her clot. patient was diuresed with lasix and dialysis with significant improvement in her symptoms. she was treated with prednisone and decadron, famotidine and benadryl for angioedema. the patient was maintained on her heparin drip for her svc syndrome. 3. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the transplant surgery team removed the pd cath on [**12-21**]. she continued to have abdominal pain post-op. she was continued on po dilaudid 2mg po prn. she continuned to complain of abdominal pain throughout her admission and continued to requested iv dilaudid. 4. esrd: the patient is on a t/th/sat schedule. she was closely followed by the renal team. she had dialysis on [**12-19**]. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient also had her pd catheter removed on [**12-21**] secondary to chronic abdominal pain. the patient was scheduled to have dialysis on [**12-23**]. 5. hx of svc/brachiocephalic dvt: her coumadin was held during last admission for supratherapeutic inr. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. she was also started on coumadin 2mg po qday, but was held on [**12-19**] in prep her pd catheter removal. she was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by ir. however, the patient signed out ama and thus it was not placed. 6. anxiety: pt recently saw psychiatrist who started her on celexa. she was continued on celexa 20mg po daily. 7. anemi of ckda: the patients hct was 30.3 on admission. it trended down to 22.3 on discharge when she left ama. there was no evidence of active, acute bleeding. this is likely seoncdary to her esrd. the patient was closely monitored. 8. systemic lupus erythematosis: rheumatology was consulted and does not suspect acute flare and dsdna, c3, c4 nl, esr and crp slightly elevated. her echo did not suggest worsening pericarditis. she was continued on her home prednisone dose of 4mg daily. 9. obstructive sleep apnea: cpap for sleep with 7 pressure. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Mechanical complication due to peritoneal dialysis catheter; ; Unspecified disease of pericardium; Angioneurotic edema, not elsewhere classified; Abdominal pain, other specified site; Systemic lupus erythematosus; ; Anemia in chronic kidney disease; Dysthymic disorder; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of steroids; Long-term (current) use of anticoagulants; Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation; Other antihypertensive agents causing adverse effects in therapeutic use]","24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. she was given 10mg iv labetalol and started on a labatelol drip. nephrology was consulted and dialysis initiated in the am. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she reports bilateral calf cramping but no leg swelling. she took her am bp meds without difficulty. her tekturna was discontinued for concern that it might be causing angioedema. the patient was maintained on her heparin drip for her svc syndrome. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient was scheduled to have dialysis on [**12-23**]. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. there was no evidence of active, acute bleeding.","24 year old female with sle, esrd on hd presents with abdominal pain and headache consistent with her usual hypertensive urgency. she was found to be in hypertensive urgency in ed. she received hydralazine iv 10 mg once and 2 inches of nitropaste." 109,102024.0,14859,2142-06-05,14803,135923.0,2142-01-12,Discharge summary,"Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-13**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypertensive Urgency and HA Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with HA in the setting of hypertension. Upon arrival to the ED, her vitals were 284/140, HR 67, RR 28, 100% on 4LNC. She was started on a nicardipine drip. She denied shortness of breath or chest pain. She is due for HD today. She has a left groin catheter which was recently placed [**2141-12-21**] and is causing her pain. She was also given dilaudid IV 1 mg x 2 with some relief. CXR was performed and showed no pulmonary edema. . Upon arrival to the MICU, patient denies HA, CP, SOB, fevers, chills. Patient reports mild abdominal pain at sight of left anterior abdominal wall hematoma and left groin pain at site of femoral HD line. She reports that she was taking her medications as directed, including coumadin for SVC thrombus. Briefly, 24 yo F with ESRD on HD, SLE, malignant HTN admitted for HA in the setting of HTN to 284/140 in ED. Initially, she was treated with a nicardipine gtt to control her BP. Her cardiac enzymes were flat, no new ECG changes. She was started on a heparin gtt with transition to coumadin for a SVC thrombosis. HTN secondary to med noncompliance. She was restarted on her oral BP. She missed her PM meds yesterday, so nicardipine was restarted, and then turned off this AM. She received all her AM BP meds. Her BPs have been in the 160s/90s. She had no neurological deficits. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 176/105, 87, 18, 100% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: 2/6 systolic murmur LUSB Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: left ant wall abd hematoma, TTP Extremities: Right: Trace, Left: Trace, left fem HD line without oozing or drainage Skin: Warm Neurologic: AAO x 3 Pertinent Results: [**2142-1-8**] 05:15AM PT-13.7* PTT-33.6 INR(PT)-1.2* [**2142-1-8**] 05:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-1+ STIPPLED-OCCASIONAL TEARDROP-1+ BITE-NORMAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2142-1-8**] 05:15AM cTropnT-0.08* [**2142-1-8**] 05:15AM CK(CPK)-119 [**2142-1-8**] 04:12PM PTT-120.8* [**2142-1-8**] 10:41PM PTT-144.8* [**2142-1-8**] 02:55PM CK-MB-NotDone cTropnT-0.06* Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. Patient was initially observed in the MICU and placed on a nicardipine drip. Patient was stablized on home medicaitons, suggesting medication non-compliance. Additionally, patient presented subtheraputic on coumadin for SVC thrombosis. Patient was started on heparin ggt. After the nicardipine drip was turned off, patient was called out to the floor. Heparin drip was continued until INR [**2-13**]. Pressures were managed to her baseline. Pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with Narcan. Patient received dialysis 3x/wk as per outpatient schedule. # Hypertension: Pt with extensive history of repeated admissions for hypertension. Patient's BP improved with nicardipine drip and after HD off drip on home PO medication regimen. Resumed oral antihypertensives with improved BP control. HTn likely from renal disease, possible medication noncompliance, lupus. No evidence of MI. Continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. Renal increased clonidine patch, and added Nicardipine with improvement of BP control. Pt is to follow up with an appointment in the next week to establish care at [**Company 191**], and to re-check her BP and adjust medications further. # SLE: Stable, continued prednisone at 4 mg PO daily. # Left groin pain. Permanent HD line was placed on [**12-25**]. Line and hematoma from prior peritoneal line on abdomen okay. No leukocytosis or fevers to suggest infection. Patient was oversedated on Dilaudid and had episode of oxygen desaturation which was reversed with Narcan. Patient was solmolent with morphine SR so that was d/c'ed as well, patient was given standing tylenlol and Morphine IR PRN. Transplant surgery removed remaining sutures today from L groin. Pt has a follow-up appointment in the next week with Dr. [**First Name (STitle) **] (Transplant Surgery). She will be sent home with low-dose Morphine IR and Tylenol PRN pain. If L groin pain should become uncontrollable on current meds, pt should return to the ED for re-evaluation. It is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #ESRD: Renal following, continuing HD Th/Th/Sat. CaCO3 was started for elevated calcium-phosphate product. Pt will follow-up with Dr. [**Last Name (STitle) 7473**] in the next 1-2 weeks. # Anemia: Pt's baseline is 26. This is likely secondary to AOCD and renal failure. Hct was stable on day of discharge at 25.9. # SVC thrombus: Pt has a history of an SVC thrombus, and is on coumadin. She is supposed to be on lifelong anticoagulation due to recurrent thrombosis but INR subtherapeutic on arrival. Heparin drip was stopped on the floor once the INR was theraputic. INR was therapeutic on day of discharge. Pt will need an INR check in the next week at her follow-up with her PCP. # HOCM: Pt has evidence of myocardial hypertrophy on Echo. She is currently not symptomatic. Echo did not show evidence of worsening pericardial effusion. She was continued on her beta-blocker and other BP medications. # Depression/anxiety: Stable. She was continued on Celexa and Clonazepam. # OSA: Pt as continued on CPAP for sleep with 7 pressure. # FEN: regular diet # PPX: heparin drip --> coumadin, bowel regimen # ACCESS: PIV x2 / permanent dialysis cath L fem # CODE: FULL # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] # DISPO: home with PCP and Renal [**Name9 (PRE) 702**] to re-check BP, INR level. Follow-up with Transplant Surgery. Medications on Admission: Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Aliskiren 150 [**Hospital1 **] Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Nicardipine 30 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain for 2 weeks. [**Hospital1 **]:*20 Tablet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Urgency End Stage Renal Disease Discharge Condition: stable, blood pressure moderately controlled, afebrile, tolerating POs Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. Some of medications were increased as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to take the coumadin as prescribed by your doctor, and have your INR checked frequently per your PCP's recommendations. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Renal) Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-1-15**] 3:00 - Will follow-up Vitamin D [**2-4**] level Provider: [**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD ([**Company 191**]) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-1-16**] 3:30 - Will re-check your INR level Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Transplant Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-1-19**] 2:50p [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-1-12**]",144,2142-01-08 06:36:00,2142-01-13 21:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE URGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was initially observed in the micu and placed on a nicardipine drip. patient was stablized on home medicaitons, suggesting medication non-compliance. additionally, patient presented subtheraputic on coumadin for svc thrombosis. patient was started on heparin ggt. after the nicardipine drip was turned off, patient was called out to the floor. heparin drip was continued until inr [**2-13**]. pressures were managed to her baseline. pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with narcan. patient received dialysis 3x/wk as per outpatient schedule. # hypertension: pt with extensive history of repeated admissions for hypertension. patients bp improved with nicardipine drip and after hd off drip on home po medication regimen. resumed oral antihypertensives with improved bp control. htn likely from renal disease, possible medication noncompliance, lupus. no evidence of mi. continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. renal increased clonidine patch, and added nicardipine with improvement of bp control. pt is to follow up with an appointment in the next week to establish care at [**company 191**], and to re-check her bp and adjust medications further. # sle: stable, continued prednisone at 4 mg po daily. # left groin pain. permanent hd line was placed on [**12-25**]. line and hematoma from prior peritoneal line on abdomen okay. no leukocytosis or fevers to suggest infection. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. patient was solmolent with morphine sr so that was d/ced as well, patient was given standing tylenlol and morphine ir prn. transplant surgery removed remaining sutures today from l groin. pt has a follow-up appointment in the next week with dr. [**first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. it is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #esrd: renal following, continuing hd th/th/sat. caco3 was started for elevated calcium-phosphate product. pt will follow-up with dr. [**last name (stitle) 7473**] in the next 1-2 weeks. # anemia: pts baseline is 26. this is likely secondary to aocd and renal failure. hct was stable on day of discharge at 25.9. # svc thrombus: pt has a history of an svc thrombus, and is on coumadin. she is supposed to be on lifelong anticoagulation due to recurrent thrombosis but inr subtherapeutic on arrival. heparin drip was stopped on the floor once the inr was theraputic. inr was therapeutic on day of discharge. pt will need an inr check in the next week at her follow-up with her pcp. # hocm: pt has evidence of myocardial hypertrophy on echo. she is currently not symptomatic. echo did not show evidence of worsening pericardial effusion. she was continued on her beta-blocker and other bp medications. # depression/anxiety: stable. she was continued on celexa and clonazepam. # osa: pt as continued on cpap for sleep with 7 pressure. # fen: regular diet # ppx: heparin drip --> coumadin, bowel regimen # access: piv x2 / permanent dialysis cath l fem # code: full # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] # dispo: home with pcp and renal [**name9 (pre) 702**] to re-check bp, inr level. follow-up with transplant surgery. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Hypoxemia; Other opiates and related narcotics causing adverse effects in therapeutic use; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Abdominal pain, other specified site; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Renal dialysis status; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Other postprocedural status]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. # hypertension: pt with extensive history of repeated admissions for hypertension. # sle: stable, continued prednisone at 4 mg po daily. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. this is likely secondary to aocd and renal failure. pt will need an inr check in the next week at her follow-up with her pcp.","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was stablized on home medicaitons, suggesting medication non-compliance. patient was oversedated on dilaudid and had episode of oxygen desaturation." 109,102024.0,14859,2142-06-05,14804,124657.0,2142-01-20,Discharge summary,"Admission Date: [**2142-1-14**] Discharge Date: [**2142-1-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 4028**] Chief Complaint: headache Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with mild headache, mild shortness of breath and consistent abdominal pain at the site of her known left abdominal wall hematoma in the setting of hypertension. Her last HD was yesterday. . Upon arrival to the ED, her vitals were BP 240's systolic, HR 90's, 93% on RA. A head CT scan was done which showed no acute process. An abdominal CT was done given her femoral line pain, which also was normal. She was given nitropaste X2 initially, then switched to labetalol 100mg x2, then 200mg x2, then finally started on nicardipine drip when she showed benefit with a decrease in her BP to 170/123 and improvement in her headache. . Upon arrival to the MICU, patient denies any current symptoms. She reports that her headache, shortness of breath and abdominal pain all resolved with blood pressure management and pain medications. . Pt was transferred to the floor when blood pressure was controlled. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: HR 96 BP 171/111 RR 12 O2 98% on RA Physical Exam: General in NAD HEENT NC, AT, EOMI, PERRLA, MMM CVS RRR, 3/6 systolic murmur in all heart fields RESP CTA BL, no crackles or wheezes ABD soft, hematoma raised on left anterior abdominal wall, +BS, mildly tender over hematoma EXT left sided femoral HD line in place, no erythema, no edema NEURO A+Ox3, CN2-12 intact, pt has left sided artificial eye, motor and sensory intact Pertinent Results: ***LABS ON ADMISSION*** [**2142-1-13**] 07:03AM WBC-5.2 RBC-2.79* HGB-8.5* HCT-26.3* MCV-94 MCH-30.3 MCHC-32.2 RDW-19.2* [**2142-1-13**] 07:03AM PLT COUNT-154 [**2142-1-13**] 07:03AM PT-29.5* PTT-49.2* INR(PT)-3.0* [**2142-1-13**] 07:03AM GLUCOSE-94 UREA N-53* CREAT-7.0* SODIUM-136 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [**2142-1-13**] 07:03AM CALCIUM-8.8 PHOSPHATE-5.0* MAGNESIUM-1.9 [**2142-1-14**] 12:00PM PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-14**] 12:00PM LIPASE-42 [**2142-1-14**] 12:00PM ALT(SGPT)-12 AST(SGOT)-43* ALK PHOS-96 TOT BILI-0.4 [**2142-1-14**] 03:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-1-14**] 03:25PM URINE RBC-[**3-15**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-[**3-15**] [**2142-1-14**] 12:00PM BLOOD PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-19**] 06:40AM BLOOD PT-18.6* PTT-38.7* INR(PT)-1.7* . ***LABS ON DAY OF DISCHARGE*** [**2142-1-20**] 06:35AM BLOOD WBC-5.7 RBC-2.39* Hgb-7.1* Hct-22.1* MCV-93 MCH-29.8 MCHC-32.2 RDW-18.6* Plt Ct-136* [**2142-1-20**] 06:35AM BLOOD Glucose-107* UreaN-34* Creat-4.8* Na-137 K-5.2* Cl-101 HCO3-27 AnGap-14 [**2142-1-20**] 06:35AM BLOOD PT-22.8* PTT-42.3* INR(PT)-2.2* . IMAGING [**2142-1-14**] EKG Sinus rhythm. Possible left atrial abnormality. Borderline voltage criteria for left ventricular hypertrophy. Inferolateral ST-T wave changes may be related to left ventricular hypertrophy. Compared to the previous tracing of [**2142-1-8**] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 99 190 86 368/436 13 100 24 [**2142-1-14**] CT ABD/PELV IMPRESSION: 1. Interval decrease in size to subcutaneous anterior abdominal wall hematoma. 2. Infectious versus inflammatory process within the right lower lobe of the lung. Small right simple pleural effusion. 3. Cardiomegaly with slight decrease in size of moderate pericardial effusion. 4. Right lobe liver hemangioma, unchanged. [**2142-1-14**] CT HEAD IMPRESSION: 1. Mildly limited study given administration of small amount of IV contrast material. However, no evidence of hemorrhage or mass effect. NOTE ADDED AT ATTENDING REVIEW: This patient was administered contrast for the abdominal CT, and the head CT was performed after part of this dose. Therefore, this is neither a noncontrast examination, nor a proper contrast CT. [**2142-1-14**] CXR CONCLUSION: Persistent cardiomegaly and mild pulmonary edema. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. . # Hypertensive Urgency: Pt with extensive history of hypertension. Patient's BP improved with nicardipine drip. Became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. Restarted all home oral antihypertensives including nicardipine 30 Q8H, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Blood pressure remains labile and renal continues to follow patient. Pt was transferred to the floor as blood pressure stabilized. BP has remained stable with systolics 140s-170s. In the MICU, Nifedipine extended release was added in place of Nicardipine as pt's blood pressures seemed to rise prior to Nicardipine doses. . # Hyperkalemia: Ocurred on the day after admission. Resolved with administration of kayexalate. Pt continued hemodialysis on TuThSat. . # Left abdominal wall hematoma: Abd CT showed a mild decrease in the size. Pt reported that morphine did not help pain, and was switched to dilaudid PO in the MICU. However, given pt's recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/c'ed on the floor. Pt was continued on gabapentin, tylenol around the clock, and low-dose Morphine as needed for pain. Narcotics should be avoided in the future. Pain should also resolve in the next few weeks as hematoma resolves. . # SLE: Pt was continued on prednisone at 4 mg PO daily. . #ESRD: Renal was following during her stay. She continued HD on her T, Th, Sat schedule. # Anemia: Hct was mildly decreased from baseline during admission. This is likely secondary to AOCD and in the setting of renal failure. . # SVC thrombus: Patient is on anticoagulation, likely lifelong. Patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. Then INR became subtherapeutic, so heparin gtt was used to bridge. On day of discharge, INR became therapeutic, and pt was discharged home on Coumadin 4mg PO daily, with INR to be checked next at hemodialysis . # HOCM: Pt has evidence of myocardial hypertrophy on recent Echo. She was not symptomatic during her stay. She was continued on her beta blocker. . # Depression/anxiety. She was continued on celexa and clonazepam PRN. . # OSA: CPAP for sleep with 7 pressure. . # FEN: repleted lytes prn / regular diet . # PPX: coumadin, bowel regimen . # ACCESS: PIV/ permanent dialysis cath L fem . # CODE: FULL . # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nicardipine 30mg PO TID Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for breakthrough pain for 2 weeks. 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*1* 13. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*260 Tablet(s)* Refills:*1* 14. Respiratory Therapy Please adjust settings of CPAP machine to a lower volume as it is uncomfortable for the patient. Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Discharge Condition: Good, hemodynamically stable, afebrile, pain controlled Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. One new medication was added as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to continue your Coumadin at 4mg daily and have your INR checked AT DIALYSIS next week. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep ALL scheduled appointments. Medications changes include: 1. STOP NICARDIPINE 2. Start Nifedipine CR 90mg by mouth daily 3. INCREASE Labetalol to 900mg by mouth 3 times daily 4. Continue at Warfarin 4mg by mouth daily If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to set up a follow-up appointment in 1-2weeks. Please continue your HD TuThSat. Completed by:[**2142-1-20**]",136,2142-01-14 17:34:00,2142-01-20 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. . # hypertensive urgency: pt with extensive history of hypertension. patients bp improved with nicardipine drip. became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. restarted all home oral antihypertensives including nicardipine 30 q8h, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. blood pressure remains labile and renal continues to follow patient. pt was transferred to the floor as blood pressure stabilized. bp has remained stable with systolics 140s-170s. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. . # hyperkalemia: ocurred on the day after admission. resolved with administration of kayexalate. pt continued hemodialysis on tuthsat. . # left abdominal wall hematoma: abd ct showed a mild decrease in the size. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu. however, given pts recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/ced on the floor. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. narcotics should be avoided in the future. pain should also resolve in the next few weeks as hematoma resolves. . # sle: pt was continued on prednisone at 4 mg po daily. . #esrd: renal was following during her stay. she continued hd on her t, th, sat schedule. # anemia: hct was mildly decreased from baseline during admission. this is likely secondary to aocd and in the setting of renal failure. . # svc thrombus: patient is on anticoagulation, likely lifelong. patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. then inr became subtherapeutic, so heparin gtt was used to bridge. on day of discharge, inr became therapeutic, and pt was discharged home on coumadin 4mg po daily, with inr to be checked next at hemodialysis . # hocm: pt has evidence of myocardial hypertrophy on recent echo. she was not symptomatic during her stay. she was continued on her beta blocker. . # depression/anxiety. she was continued on celexa and clonazepam prn. . # osa: cpap for sleep with 7 pressure. . # fen: repleted lytes prn / regular diet . # ppx: coumadin, bowel regimen . # access: piv/ permanent dialysis cath l fem . # code: full . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Other vascular complications of medical care, not elsewhere classified; Systemic lupus erythematosus; Hyperpotassemia; Phlebitis and thrombophlebitis of upper extremities, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. # anemia: hct was mildly decreased from baseline during admission. # hocm: pt has evidence of myocardial hypertrophy on recent echo. # fen: repleted lytes prn / regular diet . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. pt was transferred to the floor as blood pressure stabilized. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu." 109,102024.0,14859,2142-06-05,14805,176760.0,2142-01-23,Discharge summary,"Admission Date: [**2142-1-21**] Discharge Date: [**2142-1-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Hypertensive Urgency and fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with hypertensive urgency, subjective fevers, and pain. . Of note, she had been hospitalized [**Date range (1) 43505**] with hypertensive urgency. Her nicardipine was changed to nifedipine in hospital and her labetalol was increased to 900mg TID from 800mg TID.BPs were reportedly stable in the 140's-170's on the medical floor on nifedipine, aliskerin, labetalol, clonidine, and hydralazine prior to discharge. Last HD was [**1-20**]. . She reports feeling well at time of discharge [**1-20**], however woke this evening feeling sweaty, hot, and mildly SOB. She did not check her temperature and denies any rigors. She had total body aching (worst in her left wrist at site of recent IV and abdomen at site of known hematoma). +Palpitations overnight now resolved. No CP, SOB, cough, diarrhea, dysuria, erythema/tenderness/drainage from HD catheter. Denies recent joint symptoms with her lupus. No sick contacts. Says she took her BP meds. . Upon arrival to the ED, her vitals were 99.9 104 254/145 16 96% on RA. She was started on a nicardipine drip, given 1"" nitropaste with improvement in her BP. Did spike a fever while in the ED, currently 101F 101 173/106 Given vancomycin and zoysn for ?pna as CXR with right sided haziness. Also received 3mg IV dilaudid for body pains. LUE ultrasound without evidence of DVT. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 98.5 P 92 Bp 173/116 RR 16 O2 100% on RA General Pleasant young woman appearing comfortable HEENT Cushingoid faces, L eye prosthesis, MMM Pulm Lungs clear bilaterally, no rales or wheezing CV Regular S1 S2 ?soft systolic murmur Abd Soft +hematoma left abdomen unchanged from prior exam Extrem Warm full distal pulses. Left hand with slight edema ++ tender to palpation of wrist patient unable to make fist secondary to pain, no erythema +warmth ?purulence at site of old PIV Skin No peripehral stigmata of endocarditis Lines Left groin HD catheter site without erythema, purulence, or tenderness Neuro Alert and awake, moving all extremities Pertinent Results: CXR [**1-21**]: In comparison with the earlier study of this date, the diffuse pulmonary edema has substantially decreased, possibly following hemodialysis. Enlargement of the cardiac silhouette persists and there is no definite pleural effusion. Suggestion of an area of increased opacification at the right base. This could merely represent asymmetric edema, though the possibility of a developing consolidation cannot be unequivocally excluded. . LUE US [**1-21**]: IMPRESSION: No DVT in the left upper extremity. . L wrist xray [**1-21**]: There is prominent soft tissue swelling about the wrist, relatively diffuse, but quite prominent along the dorsum of the wrist. No fracture, dislocation, degenerative change, focal lytic or sclerotic lesion, or erosion is identified. No soft tissue calcification or radiopaque foreign body is identified. A tiny (1.7 mm) linear density is seen along the dorsum of the wrist on the oblique view is seen only on that view and is consistent with a small film artifact. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency and left wrist pain. . 1. Hypertensive urgency: Patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. Patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. She was started on nicardipine drip and 1"" nitropaste and admitted to the ICU for further treatment. There was no evidence of end-organ ischemia. Upon arrival to the ICU she was given her usual home antihypertensives and the nicardipine was quickly weaned off. It was felt that pain and anxiety were both contributing to her elevated BPs. Her BP quickly stabilized and she was called out to the medical floor where her SBP ranged 110-150. She was continued on nifepidine 90mg daily, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Given her repeated admissions with hypertensive urgency a meeting was held between the patient's nephrologist Dr. [**Last Name (STitle) 4883**], her ICU physician and her [**Name9 (PRE) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the ICU where she quickly improves with simply continuing her home medications. The following plan was drafted and placed in a note in OMR titled "" Care Protocol"". . CARE PROTOCOL: . BLOOD PRESSURE MANAGEMENT: . For BP > 230/140 1. Hydralazine: 100 mg PO OR 10 mg IV q 20 minutes until blood pressure back to baseline*. . 2. Give daily blood pressure medications, if she has not already taken them before arrival. . 3. If after one hour of therapy AND/OR evidence of end organ damage, transfer to the ICU. . * Note: Her usual blood pressure is ~ 160/100. Efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. In the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . PAIN MANAGEMENT: . As an outpatient, Ms. [**Name13 (STitle) **] takes dilaudid 2-4 mg PO q 4 PRN.This is being slowly tapered, she should not be administered IV pain medications. . ANTICOAGULATION: . In the absence of bleeding, warfarin does not need to be stopped on admission. Similarly, in the absence of new thrombosis, subtherapeutic INR's do not require bridging with IV UFH. . 2. Fever: Possible sources included line infection, thombophlebitis, septic arthritis, PNA. Received vanc/zosyn in ED for possible PNA. UA without pyuria and urine culture negative. CXR also without convinving infiltrate on repeat PA/Lat so zosyn was discontinued. Patient was complaining of severe pain at her IV site and was noted to have a small abscess there which was felt to be the cause of her fever. She was continued on IV vanco with HD for 10day course. She remained afebrile and did not have a leukocytosis. . 3. Left wrist pain: Began following IV placement during recent hospitalization. Likely due to septic thrombophlebitis. Small abscess was too small to drain. This was treated with warm soaks and prn PO dilaudid. Vanco was continued for 10 day course. L wrist films were enremarkable. . 4. Left abdominal wall hematoma: Stable on exam from recent admission. She was continued on pain management with morphine 7.5mg TID, gabapentin and tylenol as needed for pain. . 5. SLE: Continued prednisone at 4 mg PO daily . 6. ESRD: Continued on regularly scheduled dialysis. . 7. Anemia: Baseline Hct 26. Her Hct was mildly decreased from baseline. Secondary to AOCD and renal failure. There was no evidence of bleeding. . 8. SVC thrombus: Known SVC thrombus, therapeutic on coumadin. Continued warfarin. . 9. HOCM: evidence of myocardial hypertrophy on recent Echo. Currently not symptomatic. Echo without evidence of worsening pericardial effusion. Continued beta blocker . 10. Depression/anxiety. Continued Celexa, clonazepam 0.5mg [**Hospital1 **] . 11. OSA: Continued CPAP Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nifedipine 90mg PO daily Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325-650 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*270 Tablet(s)* Refills:*2* 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 7 days. [**Hospital1 **]:*4 dose* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Septic thrombophlebitis Discharge Condition: Stable, afebrile, BP improved. Discharge Instructions: You were admitted to the hospital with hypertensive urgency. You required IV medications and were observed overnight in the ICU. Your usual oral blood pressure medications were continued and your blood pressure remained well-controlled. You were found to have an infection at your prior IV site on your left hand. For this you were given IV vancomycin. You will need 7 days more of antibiotics which will be given with dialysis. Please resume your usual dialysis schedule. Your last dialysis was [**1-23**]. Please continue to take your medications as prescribed. You should hold your coumadin today. You can resume this on wednesday at your normal dose. You should have your INR checked at dialyis as usual on thursday. . If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-12**] weeks. ",133,2142-01-21 11:23:00,2142-01-23 16:40:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE EMERGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. . 1. hypertensive urgency: patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. there was no evidence of end-organ ischemia. upon arrival to the icu she was given her usual home antihypertensives and the nicardipine was quickly weaned off. it was felt that pain and anxiety were both contributing to her elevated bps. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150. she was continued on nifepidine 90mg daily, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. given her repeated admissions with hypertensive urgency a meeting was held between the patients nephrologist dr. [**last name (stitle) 4883**], her icu physician and her [**name9 (pre) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the icu where she quickly improves with simply continuing her home medications. the following plan was drafted and placed in a note in omr titled "" care protocol"". . care protocol: . blood pressure management: . for bp > 230/140 1. hydralazine: 100 mg po or 10 mg iv q 20 minutes until blood pressure back to baseline*. . 2. give daily blood pressure medications, if she has not already taken them before arrival. . 3. if after one hour of therapy and/or evidence of end organ damage, transfer to the icu. . * note: her usual blood pressure is ~ 160/100. efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. in the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . pain management: . as an outpatient, ms. [**name13 (stitle) **] takes dilaudid 2-4 mg po q 4 prn.this is being slowly tapered, she should not be administered iv pain medications. . anticoagulation: . in the absence of bleeding, warfarin does not need to be stopped on admission. similarly, in the absence of new thrombosis, subtherapeutic inrs do not require bridging with iv ufh. . 2. fever: possible sources included line infection, thombophlebitis, septic arthritis, pna. received vanc/zosyn in ed for possible pna. ua without pyuria and urine culture negative. cxr also without convinving infiltrate on repeat pa/lat so zosyn was discontinued. patient was complaining of severe pain at her iv site and was noted to have a small abscess there which was felt to be the cause of her fever. she was continued on iv vanco with hd for 10day course. she remained afebrile and did not have a leukocytosis. . 3. left wrist pain: began following iv placement during recent hospitalization. likely due to septic thrombophlebitis. small abscess was too small to drain. this was treated with warm soaks and prn po dilaudid. vanco was continued for 10 day course. l wrist films were enremarkable. . 4. left abdominal wall hematoma: stable on exam from recent admission. she was continued on pain management with morphine 7.5mg tid, gabapentin and tylenol as needed for pain. . 5. sle: continued prednisone at 4 mg po daily . 6. esrd: continued on regularly scheduled dialysis. . 7. anemia: baseline hct 26. her hct was mildly decreased from baseline. secondary to aocd and renal failure. there was no evidence of bleeding. . 8. svc thrombus: known svc thrombus, therapeutic on coumadin. continued warfarin. . 9. hocm: evidence of myocardial hypertrophy on recent echo. currently not symptomatic. echo without evidence of worsening pericardial effusion. continued beta blocker . 10. depression/anxiety. continued celexa, clonazepam 0.5mg [**hospital1 **] . 11. osa: continued cpap ","PRIMARY: [Other vascular complications of medical care, not elsewhere classified] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; ; Systemic lupus erythematosus; Phlebitis and thrombophlebitis of upper extremities, unspecified]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. she was continued on iv vanco with hd for 10day course. esrd: continued on regularly scheduled dialysis. her hct was mildly decreased from baseline. hocm: evidence of myocardial hypertrophy on recent echo. echo without evidence of worsening pericardial effusion. continued celexa, clonazepam 0.5mg [**hospital1 **] .","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150." 109,102024.0,14859,2142-06-05,14806,113189.0,2142-02-17,Discharge summary,"Admission Date: [**2142-2-14**] Discharge Date: [**2142-2-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: From admission note: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome admitted with HTN and SOB in the setting of missed HD. The patient reported missing HD yesterday because she thinks she is being overdiuresed. She reports persistent pain at site of rectus sheath hematoma. Denies N/V/D. Pt recently admitted from [**Date range (1) 13924**] with consistent abdominal pain at the site of her known left abdominal wall hematoma, hypertensive to 230's and hyperkalemic to 6.2 after missing her last two dialysis sessions. At this time the pt. was dialyzed, received a blood transfusion, and was administered her daily antihypertensive medications. Pt. left AMA after her transfusion despite the primary team's concerns to look for an active area of bleeding. In the ED, patient complain of mild dyspnea, sating well on RA. CXR mild volume overload. KUB with no evidence of obstruction. She was started on a labetalol gtt. ECG - RAD, LVH no change from prior. HCT stable at 21. The renal team evaluated pt and recommended HD, however the patient refused. She was transferred to ICU for BP control. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: [**2142-2-14**] 07:40AM WBC-3.9* RBC-2.38* HGB-7.0* HCT-21.3* MCV-90 MCH-29.5 MCHC-33.0 RDW-18.9* [**2142-2-14**] 07:40AM NEUTS-74.9* LYMPHS-18.7 MONOS-3.1 EOS-3.0 BASOS-0.2 [**2142-2-14**] 07:40AM PLT COUNT-101* [**2142-2-14**] 07:40AM PT-16.3* PTT-36.6* INR(PT)-1.5* [**2142-2-14**] 07:40AM CK-MB-6 [**2142-2-14**] 07:40AM cTropnT-0.09* [**2142-2-14**] 07:40AM LIPASE-80* [**2142-2-14**] 07:40AM ALT(SGPT)-34 AST(SGOT)-72* CK(CPK)-120 ALK PHOS-124* TOT BILI-0.4 [**2142-2-14**] 07:40AM GLUCOSE-85 UREA N-32* CREAT-7.0* SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-19* ANION GAP-17 [**2142-2-14**] 07:44AM LACTATE-1.3 [**2142-2-14**] CXR: Stable cardiomegaly with mild CHF and a small left pleural effusion. Left basilar air space disease which may represent pneumonia. Clinical correlation and a follow up chest x-ray to clearance is recommended. [**2142-2-14**] KUB: 1. Nonspecific bowel gas pattern with no evidence of obstruction. 2. Left basilar airspace disease which may represent pneumonia and a small left pleural effusion. Please ensure follow-up to clearance. Brief Hospital Course: 24 y.o female with SLE, ESRD on HD and malignant hypertension who presents with HTN and SOB aftering missing HD. . # Malignant hypertension/hypertensive urgency: The patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and HD compliance. Has previously presented with BP up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. Pt was treated per OMR hypertensive protocol created by the patient's primary providers, with a goal SBP of 160-180. With short course of IV antihypertensives and hemodialysis, pt's BP fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # ESRD: Pt was followed by the renal service and underwent HD without any complications. Pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting HD. She will discuss this further with the Renal team as an outpatient. . # SLE: Pt was continued on her home dose of prednisone with no sign of SLE flair. . # Coagulopathy/history of DVT: Patient on lifetime anticoagulation for hx of multiple thrombotic events. Pt was continued on coumadin. . # Pain management: Pt was treated with PO dilaudid for her abdominal pain, as recommended per her OMR protocol. She asked for IV dilaudid multiple times but there was no clinical indication. She was also continued on gabapentin. . # Anemia: Secondary to AOCD and renal failure. The patietns Hct remained stable in the low 20s during admission. No PRBC infusions were needed. . # Depression/anxiety: Continued Celexa, clonazepam 0.5mg [**Hospital1 **] Medications on Admission: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain. 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Disposition: Home Discharge Diagnosis: Primary: Malignant Hypertension Secondary: SLE, End stage renal disease on hemodialysis, SVC syndrome Discharge Condition: Stable. SBP in 160s. Discharge Instructions: You were admitted with dangerously high hypertension and some shortness of breath in the setting of missing several dialysis sessions. You were admitted and treated with your usual regimen of blood pressure meds and a short course of IV meds. With dialysis, your symptoms improved. You also had some abdominal pain, which was well controlled on your usual pain medications. We made no changes to your medications. Please take everything as prescribed. Please call your PCP or return to the hospital if you develop any headaches, visual changes, confusion or chest pain, or any other concerning symptoms. Followup Instructions: Please schedule a follow up with Dr [**Last Name (STitle) **] in [**Month (only) 958**] as scheduled. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2142-2-21**]",108,2142-02-14 10:42:00,2142-02-17 18:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. . # malignant hypertension/hypertensive urgency: the patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and hd compliance. has previously presented with bp up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. with short course of iv antihypertensives and hemodialysis, pts bp fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # esrd: pt was followed by the renal service and underwent hd without any complications. pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting hd. she will discuss this further with the renal team as an outpatient. . # sle: pt was continued on her home dose of prednisone with no sign of sle flair. . # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events. pt was continued on coumadin. . # pain management: pt was treated with po dilaudid for her abdominal pain, as recommended per her omr protocol. she asked for iv dilaudid multiple times but there was no clinical indication. she was also continued on gabapentin. . # anemia: secondary to aocd and renal failure. the patietns hct remained stable in the low 20s during admission. no prbc infusions were needed. . # depression/anxiety: continued celexa, clonazepam 0.5mg [**hospital1 **] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Thrombotic microangiopathy; Systemic lupus erythematosus; Anemia in chronic kidney disease; Thrombocytopenia, unspecified; Obstructive sleep apnea (adult)(pediatric); Nontraumatic hematoma of soft tissue; Dysthymic disorder; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events.","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob after missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. she was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine." 109,102024.0,14859,2142-06-05,14807,158995.0,2142-02-26,Discharge summary,"Admission Date: [**2142-2-25**] Discharge Date: [**2142-2-26**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 338**] 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 History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, hx of malignant HTN admitted with change in mental status. Patient missed HD on [**2142-2-24**] and was found unresponsive and diaphoretic by mother this morning after she took some dilaudid. EMS was called, 1 mg of narcan was administered with slight improvement in mental status. On arrival to the ED her vitals were 112/64 62 16 99RA she was noted to be hyperkalemic in the absence of EKG changes and was given calcium, D5, 10U regular insulin, 30 mg po kayxalate and repeat K was 5.4. ABG: 7.29/38/199. Repeat glucose was 41 and 1amp D50 was given. She was sent to the ICU for monitoring. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including [**Month/Year (2) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: HR: 80 (79 - 80) bpm BP: 127/59(76) {127/59(76) - 139/64(82)} mmHg RR: 34 (21 - 34) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Physical Examination Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact Pertinent Results: [**2142-2-25**] 01:50PM PT-14.9* PTT-36.8* INR(PT)-1.3* [**2142-2-25**] 01:50PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2142-2-25**] 01:50PM WBC-5.0 RBC-2.21* HGB-6.4* HCT-20.7* MCV-94 MCH-29.1 MCHC-31.1 RDW-19.6* [**2142-2-25**] 10:30PM GLUCOSE-87 UREA N-66* CREAT-8.4* SODIUM-142 POTASSIUM-5.9* CHLORIDE-110* TOTAL CO2-16* ANION GAP-22* HISTORY: Altered mental status. Evaluate underlying for pneumonia. UPRIGHT PORTABLE CHEST: Comparison is made to [**2-14**] and [**2142-2-19**], exams. Study is slightly limited by patient motion. In the interval, the degree of pulmonary edema appears improved with slightly decreased prominence of the pulmonary vascularity. There is unchanged extensive retrocardiac consolidation obscuring the majority of the left hemidiaphragm with persistent blunting of the left CP angle, likely related to small effusion. Exam is otherwise unchanged from prior with persistent cardiomegaly. A catheter is seen projecting over the abdomen, partially imaged. IMPRESSION: Slight improvement in pulmonary edema with persistent retrocardiac opacity, which again may represent atelectasis versus underlying pneumonia. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted hypotension and decreased mental status. Hypotension and altered mental status were in the setting of excessive narcotic use. Patient's narcotics were held, pressors returned to [**Location 213**] and patient was mentating fine. Hct was below baseline and patient was transfused 1u PRBC and was given HD before discharge. Patient is to continue anti-hypertensive medications as previously scheduled. Patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # Change in mental status: Resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. Patient received 1 dose of narcan with slight improvement in BP and mental status. patient without fevers or leuckocytosis which argue against infection. # Hypertension ?????? resumed outpatient regimen. Patient did not have any hypertensive episodes requiring hydralizine 10mg IV. # Hypotension: resolved, Patient normotensive on arrival to ICU. Relative hypotension likely due to dilaudid. Other considerations include sepsis, although patient without objective signs of infection. Held pain medications and hypotension resolved. Resumed hypertensive medications. # Abdominal pain ?????? from previous peritoneal [**Location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # Hyperkalemia: Likely due to missed HD session. She received calcium, D5, insulin and kayexalate in ED. HD in am ESRD: Renal following, had HD the day of discharge, transfused while there. Will continue normal schedule as an outpatient with HD T/Th/F this week. # Metabolic Acidosis: likely due to renal failure and missed HD. # SLE: continued prednisone at 4 mg PO daily. # OSA: CPAP for sleep with 7 pressure, however patient refuses. Continued to offer as inpatient. Should try to follow up with sleep medicine. Medications on Admission: Prednisone 4mg qd Citalopram 20 mg daily Gabapentin 300 mg [**Hospital1 **] Warfarin 4mg daily Pantoprazole 40 mg qd Clonidine 0.1 mg/24 QWED Clonidine 0.3 mg/24 hr QWED Labetalol 900 mg tid Nifedipine 90 mg qd Aliskiren 150 mg [**Hospital1 **] Hydralazine 100 mg q8h Morphine 7.5 mg q8h prn pain Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Home Discharge Diagnosis: Primary: narcotic overdose relative hypotension anemia Secondary: ESRD on HD [**2-12**] SLE malignant hypertension Discharge Condition: stable - received HD prior to discharge Discharge Instructions: You were admitted for altered mental status after missing hemodialysis. It was likely from the dilaudid you took as well as missing your scheduled [**Month/Day (2) 2286**]. You were also relatively hypotensive in the setting of excessive narcotic medicaiton usage. Narcotic medications were held and hypotension and altered mental status resolved. Please use narcotic medications with caution. You are recommended to use morphine for pain control rather than dilaudid. No medication changes were made. Please return to the ED if you have any altered mental status or miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] or have symptoms such as vision changes or headache from your history of malignant hypertension. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-3-20**] 3:00 HD as previously scheduled Completed by:[**2142-2-26**]",99,2142-02-25 15:49:00,2142-02-26 16:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ALTERED MENTAL STATUS," 24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. patients narcotics were held, pressors returned to [**location 213**] and patient was mentating fine. hct was below baseline and patient was transfused 1u prbc and was given hd before discharge. patient is to continue anti-hypertensive medications as previously scheduled. patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # change in mental status: resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. patient received 1 dose of narcan with slight improvement in bp and mental status. patient without fevers or leuckocytosis which argue against infection. # hypertension ?????? resumed outpatient regimen. patient did not have any hypertensive episodes requiring hydralizine 10mg iv. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. other considerations include sepsis, although patient without objective signs of infection. held pain medications and hypotension resolved. resumed hypertensive medications. # abdominal pain ?????? from previous peritoneal [**location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # hyperkalemia: likely due to missed hd session. she received calcium, d5, insulin and kayexalate in ed. hd in am esrd: renal following, had hd the day of discharge, transfused while there. will continue normal schedule as an outpatient with hd t/th/f this week. # metabolic acidosis: likely due to renal failure and missed hd. # sle: continued prednisone at 4 mg po daily. # osa: cpap for sleep with 7 pressure, however patient refuses. continued to offer as inpatient. should try to follow up with sleep medicine. ","PRIMARY: [Poisoning by other opiates and related narcotics] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Thrombotic microangiopathy; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Altered mental status; Other iatrogenic hypotension; Accidental poisoning by other opiates and related narcotics; Hyperpotassemia; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Nontraumatic hematoma of soft tissue; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. from previous peritoneal [**location 2286**] hematoma ??????","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. narcotics were held, pressors returned to and patient was mentating fine. patient was encouraged to take less pain medications and to use morphine." 109,102024.0,14859,2142-06-05,14808,158943.0,2142-03-23,Discharge summary,"Admission Date: [**2142-3-21**] Discharge Date: [**2142-3-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: Abdominal Pain, Shortness of breath, Chest discomfort Major Surgical or Invasive Procedure: HD [**2142-3-21**] and [**2142-3-23**] History of Present Illness: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] 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 [**Telephone/Fax (3) 43508**]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. [**Telephone/Fax (3) **] was discussed with renal and it was not felt that HTN is a volume issue so no need for emergent [**Telephone/Fax (3) 2286**]. . 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 [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**], getting Vanc with HD. . PSHx: 1. Placement of multiple catheters including [**Year (4 digits) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] 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: [**2142-3-21**] 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* [**2142-3-21**] 02:20AM NEUTS-76.1* BANDS-0 LYMPHS-17.9* MONOS-4.5 EOS-1.1 BASOS-0.5 [**2142-3-21**] 02:20AM PLT SMR-NORMAL PLT COUNT-168 [**2142-3-21**] 02:20AM PT-21.8* PTT-34.7 INR(PT)-2.1* [**2142-3-21**] 02:20AM cTropnT-0.12* [**2142-3-21**] 02:20AM ALT(SGPT)-46* AST(SGOT)-94* CK(CPK)-76 ALK PHOS-173* TOT BILI-0.4 [**2142-3-21**] 02:20AM GLUCOSE-74 UREA N-47* CREAT-7.3* SODIUM-140 POTASSIUM-5.8* CHLORIDE-109* TOTAL CO2-19* ANION GAP-18 [**2142-3-21**] 04:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-21**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2142-3-21**] 12:58PM CK-MB-NotDone cTropnT-0.12* . CT C/A/P - [**2142-3-20**] - 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: [**2142-3-23**] 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* [**2142-3-23**] 12:00PM BLOOD Plt Ct-130* [**2142-3-23**] 12:00PM BLOOD PT-28.8* PTT-58.6* INR(PT)-2.9* [**2142-3-23**] 12:00PM BLOOD Glucose-77 UreaN-31* Creat-6.0*# Na-137 K-4.8 Cl-104 HCO3-24 AnGap-14 [**2142-3-23**] 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 [**3-22**] 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 [**2142-3-21**] . # abdominal pain: Consistent with patient's baseline chronic abdominal pain. Medication effect also possible. CT prelim neg for small bowel obstruction. LFTs doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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). [**Month/Year (2) **]:*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 [**Month/Year (2) 2286**] sessions as directed by the nephrology team- your next session should be on Tuesday. Completed by:[**2142-3-26**]",74,2142-03-21 09:25:00,2142-03-23 18:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,CHEST PAIN;TELEMETRY," 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 (200s/100s) that nevertheless are within levels shes 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 [**3-22**] and transferred to the medicine floor. the next day, her bp remained within goal of 120s/80s. 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. ces were cycled and were negative. cpap was continued as tolerated at home settings. sob resolved after hd on [**2142-3-21**] . # abdominal pain: consistent with patients baseline chronic abdominal pain. medication effect also possible. ct prelim neg for small bowel obstruction. lfts doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Compression of vein; Unspecified disease of pericardium; Infection and inflammatory reaction due to other vascular device, implant, and graft; Bacteremia; Primary hypercoagulable state; Other primary cardiomyopathies; ; Abdominal pain, unspecified site; Urinary tract infection, site not specified; Acidosis; Other chest pain; Other chronic pain; Systemic lupus erythematosus; Noncompliance with renal dialysis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Hyperpotassemia; 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; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","this is a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. ct prelim neg for small bowel obstruction. on arrival to the floor, abd pain was back to baseline and well controlled on dilaudid 2mg po q 4hrs .","a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. initial attempts were made to control her bp with hydralazine and labetalol iv but after these failed to control her blood pressure. she was successfully transitioned to home medications of clonidine, labetalol, aliskiren, nifedipine" 109,102024.0,14859,2142-06-05,14809,124398.0,2142-03-31,Discharge summary,"Admission Date: [**2142-3-24**] Discharge Date: [**2142-3-31**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: HTN, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 24F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] after admission for abdominal pain, MSSA bacteremia, paroxysmal hypertension and ESRD line, followed by readmission [**3-22**], now presents with usual central crampy abdominal pain, 3 loose nonbloody stools this AM, SOB, and HTN to 270s. Pt was d/c'd from [**Hospital1 18**] yesterday after HD session, went home, states she took her PM meds, took her 8 AM medds (hydral, labetalol), then developed these symptoms which precluded her from taking her usual home meds (no afternoon meds - nifedipine, labetalol, hydral). The abd pain comes and goes and is unchanged from her baseline. While she has nausea, she is asking for dinner. . In the ED, initial BP 272/148. CXR w/o evidence of volume overload. No CT scan performed. Started on NTG gtt, given Hydralazine 10 x 1, Dilaudid 2 mg, labetaolo 20mg IV x 1. . Upon arrival to the floor, her BP was 240/135. She continued to complain of abdominal pain but was eating crackers, breathing felt better. RR 17. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: 98.2 97 [**Telephone/Fax (2) 43509**]0% on 2 L nC Gen: pleasant, comfortable HEENT: L eye enucleated. moon facies. Right pupil reactive Heart: hrrr, no m/r/g Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, diffuse TTP, no rebound/guarding Ext: no c/c/e Neuro: aox4, cn 2-12 intact grossly. Pertinent Results: [**2142-3-24**] 07:17PM PT-22.4* PTT-43.64* INR(PT)-2.1* [**2142-3-24**] 04:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2142-3-24**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-24**] 04:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**11-30**] [**2142-3-24**] 02:05PM GLUCOSE-76 UREA N-21* CREAT-4.8*# SODIUM-139 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2142-3-24**] 02:05PM ALT(SGPT)-78* AST(SGOT)-181* CK(CPK)-55 ALK PHOS-192* TOT BILI-0.5 [**2142-3-24**] 02:05PM cTropnT-0.12* [**2142-3-24**] 02:05PM CK-MB-5 [**2142-3-24**] 02:05PM WBC-3.6* RBC-2.90* HGB-8.9* HCT-26.6* MCV-92 MCH-30.7 MCHC-33.4 RDW-19.8* [**2142-3-24**] 02:05PM NEUTS-73.9* BANDS-0 LYMPHS-18.5 MONOS-3.8 EOS-3.0 BASOS-0.8 [**2142-3-24**] 02:05PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-1+ TARGET-1+ SCHISTOCY-OCCASIONAL TEARDROP-1+ ELLIPTOCY-OCCASIONAL [**2142-3-24**] 02:05PM PLT SMR-LOW PLT COUNT-129* [**2142-3-23**] 12:00PM GLUCOSE-77 UREA N-31* CREAT-6.0*# SODIUM-137 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14 [**2142-3-23**] 12:00PM estGFR-Using this [**2142-3-23**] 12:00PM CALCIUM-8.4 PHOSPHATE-5.7* MAGNESIUM-1.9 [**2142-3-23**] 12:00PM WBC-3.7* RBC-2.87* HGB-8.7* HCT-26.1* MCV-91 MCH-30.3 MCHC-33.3 RDW-19.4* [**2142-3-23**] 12:00PM PLT COUNT-130* [**2142-3-23**] 12:00PM PT-28.8* PTT-58.6* INR(PT)-2.9* Brief Hospital Course: The patient was admitted to the MICU on a NTG gtt from the ED. Her abdominal pain had imporved and she was eating crackers and peanut butter. She was given her usual afternoon home medications, and transitioned to a Nicardipine gtt, which has worked well for her in the past. Her BP goal was for a systolic of 180-200. The Nicardipine gtt was titrated off quickly and she was transfered to the floor. . On arrival to the floor, she in fact missed her morning medications on [**Month/Day/Year 766**]. This resulted in elevate blood pressures requiring IV hydralazing for control. She went to dialyisis Tuesday [**3-27**] and again had markedly elevated blood pressures while at [**Month/Year (2) 2286**] from missing her AM doses. Instructions were written for explicit AM administration and Nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. She was continued on labetalol 900mg TID, Aliskerin, Hydralazine 100mg po TID, and clonidine patch 0.4mg/24 weekly patch. . HEr BP remained relativly stable. She established a three three times weekly Dialysus regemin. A PAP smear was attempted due to her history of CIN I and no PCP follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . Her abdominal pain was also a chronic issue, which appeared stable. She was not administered IV narcotics, only PO. It was wihtout clear percipitating events or etiology. She will need GI follow up. She was contact[**Name (NI) **] by phone several times to arrange a GI follow up appointment but did not return messages. She has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . She was discharged to followup with her nephrologist, Dr. [**Last Name (STitle) 4883**]. . 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. Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Last Name (STitle) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2* 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). [**Last Name (STitle) **]:*405 Tablet(s)* Refills:*2* 5. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*2* 6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). [**Last Name (STitle) **]:*60 Tablet(s)* Refills:*2* 9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patches Transdermal once a week: Place two patches every week on Fridays. [**Last Name (STitle) **]:*8 Patches* Refills:*2* 10. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*0* 11. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO twice a day as needed for prn SBP>200: if nauseated and cannot keep down meds, may use 1 sublingual clonidine if sbp>200. . [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0* 12. Kayexalate Powder Sig: Thirty (30) grams PO once a day for 2 days: please take [**2142-4-1**] and [**2142-4-2**] for elevated potassium. [**Month/Day/Year **]:*240 grams* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Systemic Lupus Erythematosus End Stage Renal Disease Hypertension Abdominal Pain Discharge Condition: Blood pressure stable and abdominal pain at baseline Discharge Instructions: You were admitted with high blood pressure. You were in the ICU overnight for treatment. Some of your medications were changed and you were increased to three times weekly [**Location (un) 2286**]. Your abdominal pain is a difficult problem, as the reason for the pain is unclear. [**Name2 (NI) **] were continued on oral dilaudid. IV dilaudid is strongly discouraged and will continue to be in the future. You are now taking Nifedipine SR 30mg at night in addition to 90mg in the morning. Your other medications were the same. At home, if your blood pressure is above 200, then take 100mg hydralazine. If after 1 hour, your blood pressure does not decrease to below 200 with this, then take another 100mg hydralazine. If you are nauseated and cannot take in oral meds, then take sublingual clonidine, then wait 1 hour and repeat if BP still > 200. Finally, your potassium has been high. Please take kayexalate 30gm tomorrow and the next day. Followup Instructions: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-3-31**] 7:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule appointment We will attempt to contact you on [**Name (NI) 766**] with appointment times for you. ",66,2142-03-24 16:34:00,2142-03-31 15:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," the patient was admitted to the micu on a ntg gtt from the ed. her abdominal pain had imporved and she was eating crackers and peanut butter. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. her bp goal was for a systolic of 180-200. the nicardipine gtt was titrated off quickly and she was transfered to the floor. . on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**]. this resulted in elevate blood pressures requiring iv hydralazing for control. she went to dialyisis tuesday [**3-27**] and again had markedly elevated blood pressures while at [**month/year (2) 2286**] from missing her am doses. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she was continued on labetalol 900mg tid, aliskerin, hydralazine 100mg po tid, and clonidine patch 0.4mg/24 weekly patch. . her bp remained relativly stable. she established a three three times weekly dialysus regemin. a pap smear was attempted due to her history of cin i and no pcp follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . her abdominal pain was also a chronic issue, which appeared stable. she was not administered iv narcotics, only po. it was wihtout clear percipitating events or etiology. she will need gi follow up. she was contact[**name (ni) **] by phone several times to arrange a gi follow up appointment but did not return messages. she has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . she was discharged to followup with her nephrologist, dr. [**last name (stitle) 4883**]. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Long-term (current) use of steroids; Other chronic pain; Obstructive sleep apnea (adult)(pediatric); Abdominal pain, generalized; Hyperpotassemia]","the patient was admitted to the micu on a ntg gtt from the ed. her bp goal was for a systolic of 180-200. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she established a three three times weekly dialysus regemin.","the patient was admitted to the micu on a nicardipine gtt from the ed. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**] this resulted in elevate blood pressures requiring iv hydralazing for control " 109,151240.0,14858,2142-05-18,14799,125288.0,2141-11-23,Discharge summary,"Admission Date: [**2141-11-18**] Discharge Date: [**2141-11-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1990**] Chief Complaint: Hypertensive Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: (from MICU admit note) 24yoF ESRD-HD, SLE, HTN presents with 1 month abdominal pain and hypertension. Pt has had work-up over recent months for abd pain, including exploratory laparotomy, all of which essentially (-). Was admitted [**Date range (1) 34629**], for abdominal pain, then returned [**11-16**] for sob with (-)CTA, dc'ed [**11-17**]. In [**Hospital1 18**] ED, T98.5 hr95 BP 220/110 then 183/133 RR13 O2 100% on RA, rectal exam negative, guaiac(-), pelvic exam unremarkable with no cervical motion tenderness. Renal was consulted, taken for hemodialysis. CT abd showed large ascites, no other pathology; CT head improved from prior with no acute ICH; cxr(-). Given iv dilaudid for abdominal pain. BP treated with 10mg iv labetalol. Blood and urine cultures drawn, peritoneal fluid cx sent from catheter. Admitted to MICU for hypertension management. Access: R-HD catheter, 1 pIV in hand, 1 non-functioning peritoneal dialysis catheter. Past Medical History: PMH: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSH: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: PE: T:99.4 BP:158/108 HR:95 RR:12 O2 100% RA GEN: NAD/ pt eyes closed due to pain/ pleasant despite pain HEENT: AT, NC, PERRLA, EOMI on R eye, L eye prosthesis, no conjuctival injection, anicteric, OP clear, MMM Neck: supple, no LAD CV: S1 & S2, RRR II/VI HSM at R/L USB, no rubs/gallops PULM: CTAB, no w/r/r ABD: soft, mildly tender at PD catheter, ND, + BS, midline incision with steri-stripes, PD catheter dressing C/I/D EXT: warm, dry, +2 distal pulses BL, no edema NEURO: alert & oriented, CN II-XII grossly intact (except L eye), 5/5 strength throughout. No sensory deficits to light touch appreciated. No asterixis PSYCH: appropriate affect Pertinent Results: Admission Labs: [**2141-11-18**] 07:00AM BLOOD WBC-3.7* RBC-3.35* Hgb-9.7* Hct-30.7* MCV-92 MCH-28.9 MCHC-31.5 RDW-17.7* Plt Ct-142* [**2141-11-18**] 07:00AM BLOOD PT-14.4* PTT-30.0 INR(PT)-1.3* [**2141-11-18**] 07:00AM BLOOD Glucose-86 UreaN-22* Creat-5.0* Na-140 K-4.3 Cl-105 HCO3-25 AnGap-14 [**2141-11-18**] 07:00AM BLOOD ALT-8 AST-39 AlkPhos-92 TotBili-0.3 [**2141-11-18**] 07:00AM BLOOD Lipase-76* [**2141-11-18**] 07:00AM BLOOD Calcium-7.6* Phos-4.7* Mg-1.9 [**2141-11-18**] 11:00PM ASCITES WBC-1265* RBC-1680* Polys-43* Lymphs-1* Monos-2* Mesothe-11* Macroph-43* [**2141-11-18**] 10:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2141-11-18**] 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2141-11-18**] 10:05AM URINE RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-[**3-15**] Discharge Labs: [**2141-11-23**] 04:40AM BLOOD WBC-2.9* RBC-3.08* Hgb-9.0* Hct-28.3* MCV-92 MCH-29.2 MCHC-31.8 RDW-17.5* Plt Ct-182 [**2141-11-23**] 04:40AM BLOOD PT-20.8* PTT-76.1* INR(PT)-2.0* [**2141-11-23**] 04:40AM BLOOD Glucose-80 UreaN-21* Creat-4.7* Na-139 K-4.8 Cl-106 HCO3-24 AnGap-14 [**2141-11-23**] 04:40AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.8 [**2141-11-22**] 04:55AM BLOOD TSH-6.1* [**2141-11-23**] 04:40AM BLOOD Free T4-1.2 Blood cx ([**11-18**], [**11-19**]): 1/4 bottles with coag neg Staph, [**3-14**] NGTD Urine cx ([**11-18**]): mixed flora c/w contamination Peritoneal fluid ([**11-18**]): Gram stain 2+ polys. Culture no growth. Imaging: CXR Portable ([**11-18**]): Since [**2141-11-16**], heart size enlargement is unchanged due to known pericardial effusion. Lungs are otherwise clear. Hilar contours are normal. Incidentally, widening of both acromioclavicular joints is unchanged. CT A/P ([**11-18**]): 1. No evidence of bowel obstruction or rim-enhancing fluid collection. 2. Large ascites, slightly increased from [**2141-11-13**], with peritoneal dialysis catheter in place. Interval removal of surgical skin staples along the abdomen. 3. Moderate pericardial effusion as before. 4. Symmetric heterogeneous attenuation of the kidneys could be related to renal failure; however, pyelonephritis could also give this appearance. Appearance of the kidneys is unchanged from [**2141-11-13**]. CT Head w/o contrast ([**11-18**]): 1. No evidence of acute intracranial hemorrhage. 2. Regions of hypoattenuation in the bifrontal white matter and left posterior temporal lobe have resolved since [**2141-6-11**]. No new regions of hypoattenuation seen. Brief Hospital Course: 1) Hypertension: Patient has history of extremely labile hypertension on an aggressive outpatient regimen. Overnight in the MICU, patient required IV and PO labetalol for SBP > 200. Her hydralazine was increased from 75mg to 100mg TID with mild improvement. Her labetalol was also increased from 300mg to 400mg TID. Her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. TSH was sent and elevated, although free T4 was normal. Plasma metanephrines were sent and pending at discharge. 2) Abdominal pain: CT scan showed increasing ascites, but no acute pathology. Peritoneal fluid was obtained and contained 544 polys. Treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing GPC pairs/clusters. Blood cultures ended up growing 1 out of 4 bottles coag-neg Staph, likely contaminant, so vancomycin was stopped. Since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. The peritoneal cultures remained negative. Her PD catheter was left in place as the patient refuses HD any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) SVC/brachiocephalic thrombosis: Patient's INR was subtherapeutic on admission at 1.3. Due to the proximal location of her old venous thrombi, she was started on a heparin gtt. This was continued during her admission and her warfarin was increased to 5mg daily. Her INR reached 2.0 at discharge (therapeutic range 2-3). The dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) Anxiety: Patient noted feeling short of breath and anxious around the time of her recent admissions. Her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. They felt her symptoms were suggestive of anxiety and panic attacks, recommended checking TSH and metanephrines as above, and starting citalopram 20mg, which was done. She was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h PRN. Patient is agreeable to outpatient follow up with [**Company 191**] social work, and potential CBT. These can be arranged by her PCP. Medications on Admission: 1. Aliskiren 150 mg [**Hospital1 **] 2. Clonidine 0.3 mg/24 qwk 3. Prochlorperazine Maleate 10 mg prn 4. Hydromorphone 2 mg Tablet Sig: [**1-11**] q6 prn 5. Bisacodyl 10mg [**Hospital1 **] 6. Ergocalciferol (Vitamin D2) 50,000 qmonth 7. Hydralazine 75mg tid 8. Hydralazine scale prn 9. Labetalol 300 mg tid 10. Nifedipine 90 mg qd 11. Prednisone 4mg qd 12. Warfarin 2 mg qd at 4pm Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 4. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Hospital1 766**]). 5. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO three times a day. [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 6. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 8. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 9. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Hospital1 **]:*180 Tablet(s)* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for 7 days. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 12. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO q30 min prn as needed for hypertension: for SBP > 180. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive urgency Headache Abdominal pain Anxiety Secondary Diagnosis: HTN SLE ESRD on HD SVC and IJ thrombosis, chronic Anemia Discharge Condition: Stable, BPs improved. Discharge Instructions: You were admitted with elevated blood pressures, headache, and abdominal pain. You were found to have increased amounts of white blood cells in your abdominal cavity, but this was not infected. Your abdominal pain resolved and you continued to have intermittent headaches. Your blood pressure medications were adjusted as below. You were also seen by psychiatry who recommended starting new medications for your anxiety. The following changes were made to your medication regimen: - We increased your hydralazine to 100 mg three times a day. - We also increased your labetalol to 400 mg three times a day. - We have started a medication called celexa 20 mg daily as well as ativan 1 mg three times a day as needed for anxiety. - We have increased your coumadin to 4 mg daily. - Please continue taking all other medications as previously prescribed. Call your doctor or return to the emergency room if you experience any of the following: worsening abdominal pain, nausea, vomiting, blurry vision, worsening headache, fever > 101. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. Please continue to follow with your nephrologist and go to outpatient dialysis as previously arranged. Please discuss with your PCP the possibility of talking to a social worker at [**Name (NI) 191**]. You will need to continue to have your INR monitored at [**Hospital 191**] [**Hospital 2786**] clinic. Please have this level checked on [**Hospital 766**], [**11-27**]. Completed by:[**2141-11-23**]",176,2141-11-18 14:00:00,2141-11-23 16:42:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. her hydralazine was increased from 75mg to 100mg tid with mild improvement. her labetalol was also increased from 300mg to 400mg tid. her blood pressure also seemed to improve when her pain decreased and was normal in the middle of the night. tsh was sent and elevated, although free t4 was normal. plasma metanephrines were sent and pending at discharge. 2) abdominal pain: ct scan showed increasing ascites, but no acute pathology. peritoneal fluid was obtained and contained 544 polys. treatment was started with metronidazole and levofloxacin, as well as vancomycin as 1 blood culture was growing gpc pairs/clusters. blood cultures ended up growing 1 out of 4 bottles coag-neg staph, likely contaminant, so vancomycin was stopped. since nephrology felt her peritoneal fluid polys were inflammatory but not infectious, the levofloxacin and metronidazole were stopped. the peritoneal cultures remained negative. her pd catheter was left in place as the patient refuses hd any longer than necessitated by the healing of her recent laparotomy (see prior d/c summaries). 3) svc/brachiocephalic thrombosis: patients inr was subtherapeutic on admission at 1.3. due to the proximal location of her old venous thrombi, she was started on a heparin gtt. this was continued during her admission and her warfarin was increased to 5mg daily. her inr reached 2.0 at discharge (therapeutic range 2-3). the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. 4) anxiety: patient noted feeling short of breath and anxious around the time of her recent admissions. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted. they felt her symptoms were suggestive of anxiety and panic attacks, recommended checking tsh and metanephrines as above, and starting citalopram 20mg, which was done. she was advised on breathing exercises, which seemed to have benefit, and given lorazepam 1mg q8h prn. patient is agreeable to outpatient follow up with [**company 191**] social work, and potential cbt. these can be arranged by her pcp. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Abdominal pain, unspecified site; Anemia, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","1) hypertension: patient has history of extremely labile hypertension on an aggressive outpatient regimen. her hydralazine was increased from 75mg to 100mg tid with mild improvement. peritoneal fluid was obtained and contained 544 polys. the dose was lowered to 4mg daily at discharge to prevent overshooting the therapeutic range, but the patient will have close follow up with coumadin clinic, with dose titrations as needed. her nephrologist felt this may be contributing to her recurrent pain and hypertension, so psychiatry was consulted.","patient has history of extremely labile hypertension on aggressive outpatient regimen. overnight in the micu, patient required iv and po labetalol for sbp > 200. ct scan showed increasing ascites, but no acute pathology." 109,102024.0,14859,2142-06-05,14810,137510.0,2142-04-22,Discharge summary,"Admission Date: [**2142-4-20**] Discharge Date: [**2142-4-22**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 1253**] Chief Complaint: Dyspnea, malignant hypertension Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented with abdominal pain and shortness of breath. On [**2142-4-19**] she refused ultrafiltration at HD because she was at her dry weight. Awoke at 3 AM feeling more short of breath. She also had worsening abdominal pain and vomiting without hematemasis. She took all of her medications as prescribed including two new lidocaine patches, fentanyl patch and clonidine. She developed a slight frontal headache but no blurry vision or neurologic symptoms. ROS largely negative. . In the emergency room her initial vitals were T: 99.1 BP: 280/140 HR: 79 RR: 16 O2: 100% on RA. She had two large bore peripheral IVs placed. She received 100 mg PO hydralazine, 200 mg PO labetolol, zofran 4 mg IV, vancomycin 1 gram IV, levofloxacin 750 mg IV x 1 and was started on labetolol and nitroglycerin drips with control of her blood pressure to the 180s systolic. She had a CXR which was concerning for volume overload. She was admitted the MICU for further evaluation. . In the MICU she was stablized and transitioned to her home meds. Nephrology gave her HD with 2L UF and subjective improvement in SOB. . Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: On Admission per MICU team: Vitals: T: 96.5 BP: 162/120 HR: 79 RR: 13 O2: 100% on 4L General: Pleasant, comfortable, no distress HEENT: L eye enucleated. Moon facies. Right pupil reactive Heart: Regular rate and rhythm, s1 + s2, soft systolic murmur at RLSB, no rubs or gallops Respiratory: Crackles at bases bilaterally, no wheezes, rales, ronchi GI: soft, non-tender, non-distended, +BS GU: no foley Ext: Warm and well perfused, no clubbing, cyanosis or edema . Pertinent Results: [**2142-4-19**] 08:35AM WBC-3.8* RBC-2.53* HGB-7.6* HCT-23.4* MCV-93 MCH-29.9 MCHC-32.3 RDW-19.9* [**2142-4-19**] 08:35AM PLT COUNT-93* . [**2142-4-19**] 08:35AM GLUCOSE-88 UREA N-36* CREAT-6.0* SODIUM-135 POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-25 ANION GAP-15 [**2142-4-19**] 08:35AM CALCIUM-9.4 PHOSPHATE-5.3* MAGNESIUM-2.0 . [**2142-4-20**] 08:40AM PT-28.3* PTT-45.3* INR(PT)-2.9* . CXR PA and LAT: IMPRESSION: 1. Persistent cardiomegaly with prominence of pulmonary vasculature suggesting overhydration. Minimal costophrenic angle blunting may suggest small effusions. 2. No definite consolidation, although increased retrocardiac density is noted, most likely due to atelectasis and vascular congestion. Repeat imaging following diuresis could be considered. . INR trend: [**2142-4-19**] 09:30AM BLOOD PT-30.4* INR(PT)-3.1* [**2142-4-20**] 08:40AM BLOOD PT-28.3* PTT-45.3* INR(PT)-2.9* [**2142-4-21**] 04:07AM BLOOD PT-29.9* PTT-48.9* INR(PT)-3.1* [**2142-4-22**] 05:55AM BLOOD PT-33.3* PTT-54.1* INR(PT)-3.5* Brief Hospital Course: 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented to the ICU for hypertensive emergency, dyspnea, and headache, now resolved. . Hypertensive Emergency: Patient's blood pressure normalized with transient nitroglycerin and labetalol drips. Likely precipitated by lack of ultrafiltration at [**Year/Month/Day 2286**] yesterday. She has received [**Year/Month/Day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - Nifedipine 150 mg Tablet SR daily - Hydralazine 100 mg Tablet Q8H - Labetalol 1000 mg Tablet TID - Aliskiren 150 mg Tablet PO BID - Clonidine 0.2 mg/24 hr Patch Weekly - Hydralazine 100 mg PO PRN for SBP > 200 - continue regular [**Year/Month/Day 2286**] schedule . Social Issues/repeated admissions: The ICU and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. These episodes may be due to medication non-compliance and it may benefit Ms. [**Known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. Ms. [**Known lastname **] [**Last Name (Titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. Of note, she has missed [**Last Name (Titles) 2286**] sessions and often requests durations and flow rates for her [**Last Name (Titles) 2286**] that contradict recommendations by her nephrologist. This issue was left unresolved on discharge. . Chronic Abdominal Pain: Currently managed with PO dilaudid, fentanyl patch and lidocaine patch. Per MICU team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue PO dilaudid - continue lidocaine patch . Lupus Erythematous: Complicated by uveitis and ESRD. - continued prednisone . ESRD: On [**Last Name (Titles) 2286**]. Ultrafiltrate of 2 L on initial HD - continue outpatient regimen . Thrombocytopenia: Remained at baseline 80s to 130s. . Thrombotic Events: History of SVC thrombosis with negative workup. INR drifted up and was 3.5 on discharge. She was asked to hold her warfarin dose this PM and recheck her INR with VNA services on [**2142-4-23**] to be faxed to coumadin clinic in [**Company 191**]. - continued coumadin . Anemia: Hematocrit 24.5 initially. Baseline 23 to 28. . Medications on Admission: Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H Prednisone 1 mg Tablet Citalopram 20 mg Tablet Pantoprazole 40 mg Tablet, Warfarin 3 mg daily Gabapentin 300 mg TID Nifedipine 90 mg Tablet SR daily Nifedipine 60 mg Tablet SR daily Hydralazine 100 mg Tablet Q8H Labetalol 1000 mg Tablet TID Aliskiren 150 mg Tablet PO BID Clonidine 0.2 mg/24 hr Patch Weekly Docusate Sodium 100 mg Capsule PO BID Senna 8.6 mg Tablet Fentanyl 25 mcg/hr Patch 72 hr Lidocaine 5 %(700 mg/patch) daily Hydralazine 100 mg PO:PRN for SBP > 200 Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) 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 3 mg Tablet Sig: One (1) Tablet PO once a day: DO NOT TAKE DOSE ON [**2142-4-22**]. Then restart per your PCP. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QHS (once a day (at bedtime)). 9. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 10. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 17. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed: For systolic blood pressure > 200. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Malignant Hypertension Systemic Lupus Erythematosus End Stage Renal Disease Abdominal Pain Discharge Condition: good, VSS, on room air, pain controlled. Discharge Instructions: You came to the hospital for shortness of breath and hypertension. You were given antihypertensive drips and during [**Location (un) 2286**] 2 liters were taken off with good improvement in your shortness of breath. You will need to take your medications as prescribed and follow-up with all of your doctors to prevent coming into the hospital. . Medication changes: - Please do not take your coumadin tonight because your INR is too high. You will need to have it checked by VNA services and adjusted. - Please take ALL of your medications as prescribed. . Please call your doctor or return to the ED if you have intractable headaches, shortness of breath, intractable pain or other concerns. Followup Instructions: Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-4-26**] 3:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Completed by:[**2142-4-23**]",44,2142-04-20 13:39:00,2142-04-22 15:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,PULMONARY EDEMA;HYPERTENSION," 24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. . hypertensive emergency: patients blood pressure normalized with transient nitroglycerin and labetalol drips. likely precipitated by lack of ultrafiltration at [**year/month/day 2286**] yesterday. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - nifedipine 150 mg tablet sr daily - hydralazine 100 mg tablet q8h - labetalol 1000 mg tablet tid - aliskiren 150 mg tablet po bid - clonidine 0.2 mg/24 hr patch weekly - hydralazine 100 mg po prn for sbp > 200 - continue regular [**year/month/day 2286**] schedule . social issues/repeated admissions: the icu and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. these episodes may be due to medication non-compliance and it may benefit ms. [**known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. ms. [**known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. this issue was left unresolved on discharge. . chronic abdominal pain: currently managed with po dilaudid, fentanyl patch and lidocaine patch. per micu team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue po dilaudid - continue lidocaine patch . lupus erythematous: complicated by uveitis and esrd. - continued prednisone . esrd: on [**last name (titles) 2286**]. ultrafiltrate of 2 l on initial hd - continue outpatient regimen . thrombocytopenia: remained at baseline 80s to 130s. . thrombotic events: history of svc thrombosis with negative workup. inr drifted up and was 3.5 on discharge. she was asked to hold her warfarin dose this pm and recheck her inr with vna services on [**2142-4-23**] to be faxed to coumadin clinic in [**company 191**]. - continued coumadin . anemia: hematocrit 24.5 initially. baseline 23 to 28. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Unspecified iridocyclitis; Other primary cardiomyopathies; Unspecified disease of pericardium; ; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Noncompliance with renal dialysis; Personal history of noncompliance with medical treatment, presenting hazards to health; Surgical or other procedure not carried out because of patient's decision; Abdominal pain, left lower quadrant; Renal dialysis status; Thrombocytopenia, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Peripheral vascular disease, unspecified; Acquired absence of organ, eye; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus]","24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. ultrafiltrate of 2 l on initial hd - continue outpatient regimen .","malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips." 109,151240.0,14858,2142-05-18,14800,161950.0,2141-12-01,Discharge summary,"Admission Date: [**2141-11-24**] Discharge Date: [**2141-12-1**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Headache, abdominal pain Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24yo F w/PMHx of ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning, awakening her from sleep. Had been previously discharged from [**Hospital1 **] yesterday after being admitted for hypertension and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Upon discharge yesterday she states her abdominal pain had subsided. She had HD yesterday without complications. She awoke at 6am with a headache and crampy, stabbing abdominal pain. Took 2mg PO Dilaudid without relief and came to ED. No nausea/vomiting, no changes in vision, no fevers, chills, night sweats. No chest pain, SOB, diarrhea. In the ED, initial vitals were T98.7, BP260/130, HR70, RR16. Was initially given 10mg IV Labetalol X 2, 4mg Zofran for nausea. No improvement in BP and started on Labetolol gtt. Got 1mg IV Dilaudid for pain. Currently, patient continues to complain of headache and abdominal pain, both [**7-17**]. No vision changes, chest pain or shortness of breath. Has been feeling increased anxiety recently and saw psychiatrist, was put on Celexa. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T98.2, BP176/135, HR94, RR 22, 100% RA Gen: well-appearing african-american woman, lying comfortably HEENT: anicteric, L eye prosthetic non-reactive, R pupil reactive, MMM, neck supple with submanibular LAD CV: RRR, II/VI SEM best heard at apex Pulm: CTA b/l Abd: hyperactive bowel sounds, midline scar well-healed, soft, diffusely tender to palpation, +rebound, no guarding. PD catheter in LLQ without erythema or purulent material draining. +dullness on percusion with evidence of clinical ascites. Ext: no edema, no clubbing, 2+ peripheral pulses DP and radial. R femoral HD [**Last Name (un) **] in place without erythema, purulance Neuro: A&O X 3, CN intact II-XII, [**5-15**] motor strength in upper and lower extremities Pertinent Results: Admission labs: CBC: [**2141-11-26**] 05:21AM BLOOD WBC-3.5* RBC-3.07* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.1 MCHC-33.6 RDW-17.6* Plt Ct-180 CHEM 10: [**2141-11-26**] 01:16PM BLOOD Glucose-87 UreaN-17 Creat-4.0* Na-136 K-5.2* Cl-106 HCO3-23 AnGap-12 [**2141-11-26**] 09:20PM BLOOD Calcium-7.6* Phos-3.8 Mg-1.8 COAGS: [**2141-11-26**] 01:16PM BLOOD PT-23.9* PTT-40.2* INR(PT)-2.3* STUDIES: 1)Peritoneal fluid ([**11-26**]): negative for malignant cells. Reactive mesothelial cells, macrophages, eosinophils and lymphocytes. 2)BILAT UP EXT VEINS US ([**11-26**]): No evidence of deep vein thrombosis of the right or left upper extremity. 3) MRI/MRA ([**11-30**]): FINDINGS: Examination is somewhat limited by patient motion. T2/FLAIR sequences are unremarkable with interval resolve of previously noted posterior abnormalities. The major vessels appear patent proximally. There are stable areas of low signal in the left frontal and right occipetal/temporal lobes. IMPRESSION: 1. Interval resolution of previously noted posterior white matter abnormalities. 2. Stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions. 3. Very limited MRA as above. Brief Hospital Course: 24yo F with SLE, ESRD on HD and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**Hospital Unit Name 153**] course: The patient was admitted for blood pressure management and evaluation of abd pain. An A-line was placed. EKG showed no change from prior, and Abd x-ray showed a suggestion of RLL/R diaphragm haziness. IV labetalol was started, and SBPS dropped from 200s to 130s-160s. The patient had no symptoms of end-organ damage. The renal team was consulted, and recommended no change to home med regimen. The patient was found to be hypocalcemic, and was started on calcium replacement therapy. When stable, patient succesfully switched to PO meds and transferred to the floor. Upon transfer to the floor, the following was her course: 1. Hypertensive Urgency: Pt had had hemodialysis one day prior to admission, so unlikely that she was volume overloaded. Unclear what precipitated this episode of hypertensive urgency, although suspect secondary to abdominal pain leading to an anxiety which then precipitates hypertension. She may not have been taking her medications secondary to pain. Negative serum tox. On the floor, we continued hemodialysis Tu, Th, Sat. She was initially continued on PO Labetolol 400mg TID, Hydralazine 100mg PO q8H, Nifedipine 90mg PO qday and clonidine; she received hydralazine 10mg IV for goal BP < 180/100. Renal team followed patient during this hospitalization. Per renal team recs, labetalol was increased to 800mg TID due to poor blood pressure control. Pt discharged on clonidine 0.3mg patch, Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, Nifedipine 90mg daily and lobatalol 800mg TID. This regimen worked well. 2. Abdominal Pain: Extensive prior workup unrevealing. Pt had recent CT scan during prior admission which did not show source of abdominal pain. On admission, LFTs were normal except for slightly low albumin, lipase was slightly elevated and KUB was negative for free air or evidence of SBO. Peritoneal fluid was negative for malignant cells but showed reactive mesothelial cells, macrophages, eosinophils and lymphocytes. Negative gram stain or peritoneal fluid cultures, excluding SBP as a cause of the abdominal pain. PD catheter was not removed. Pt was continued on PO dilaudid 1-2mg Q6h and pain resolved. She denied N/V/diarrhea or constipation. 3. ESRD: Pt on hemodialysis, on T/Th/Sat schedule. Renal following patient closely throughout this hospitalization. Lytes were checked frequently and kayexalate given prn. 4. Hx of SVC/brachiocephalic DVT: Pt was initially subtherapeutic on coumadin. Unclear if she had not been taking Coumadin although patient reported that she has been taking all home meds. We started heparin gtt to bridge to Coumadin. Once therapeutic, continued Coumadin 5mg PO qday. 5. Anxiety: Likely contributing to medical problems and could have very well been the etiology of this admission. Although pt stated she was taking her current medications, she did report increased anxiety which can lead to medication non-compliance and hypertension. Pt recently saw psychiatrist who started her on Celexa. She was continued on celexa 20mg PO qday, ativan 1mg PO q8hours PRN and psychiatry was re-consulted. Per psych recs, started standing clonazepam. Pt refused psych VNA. Outpatient PCP followup recommended. 6. Headache NOS: Pt complained of R-sided HA for several weeks, radiating to R jaw where patient had previous tooth extraction. Right upper extremity ultrasound was negative for DVT. She did not have any focal neuro findings, no visual deficits. She was initially treated with tylenol PRN Q6h; pt requested IV dilaudid for HA, but use of this medication by IV route was limited by team. It was felt by the pain service that her HA did not fit migraine, tension type HA or rebound HA. They recommended increasing dilaudid to 4-6mg Q6h PRN, continuing tylenol and starting neurontin 300mg Qhs which was slowly titrated to 300mg [**Hospital1 **] for better control. Per pain recs, a neurology consult was also obtained during this admission. MRI/MRA showed interval resolution of previously noted posterior white matter abnormalities and stable prior areas of hemorrhage within the left frontal and right occipital/temporal regions, but very limited MRA as above. Per pain recs, dilaudid was further increased to 4mg q4h for better control of her HA. Neurology recommended outpt f/u and Pt scheduled with [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**]. 7. Anemia: Likely related to ESRD. No evidence of acute bleeding. Hct remained stable during this hospitalization. 8. SLE: no acute issues. continued Prednisone 4mg PO qday 9. FEN: tolerated regular diet, repleted lytes PRN 9. Prophylaxis: Heparin gtt, then coumadin, bowel regigmen Medications on Admission: (from prior discharge summary) Bisacodyl 10mg PO qday PRN Prednisone 4mg PO qday Aliskiren 150mg PO BID Clonidine 0.3mg / 24 hr patch weekly qmonday Labetalol 400mg PO TID Warfarin 4mg PO qday Nifedipine 90mg PO qday Hydralazine 100mg PO q8H Hydromorphone 2-4mg PO q4H PRN Lorazepam 1mg PO q8H Celexa 20mg PO qday Prochlorperazine 10mg PO q6H Colace 100mg PO BID Hydralazine 25mg PO q30min PRN for HTN Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every [**Year (4 digits) 766**]). 3. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QMONTH (). 4. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 5. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). [**Year (4 digits) **]:*100 Tablet(s)* Refills:*2* 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*90 Capsule(s)* Refills:*2* 9. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for headache. [**Year (4 digits) **]:*84 Tablet(s)* Refills:*0* 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). [**Year (4 digits) **]:*60 Capsule(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. [**Year (4 digits) **]:*60 Tablet(s)* Refills:*0* 14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO every eight (8) hours. [**Year (4 digits) **]:*360 Tablet(s)* Refills:*2* 16. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as needed for constipation. [**Year (4 digits) **]:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. Hypertensive Emergency 2. SLE 3. Headache, NOS 4. Abdominal pain Discharge Condition: BP better controlled. Headache managed on oral meds Discharge Instructions: You were admitted with abdominal pain, high blood pressure, and headache. Your abdominal pain resolved - no serious cause of this pain was found. Your blood pressure medications were continued, and with an increased in one medication, the labetalol. Your blood pressure improved. You should continue the clonidine 0.3mg patch changed on [**Year (4 digits) 766**], Hydralazine 100mg three times a day, Aliskiren 150mg twice a day, and Nifedipine 90mg daily. The dose of Labetalol was increased to 800 mg three times daily by you kidney doctor and you are given a new prescription. Please take all medications as listed below. For your headache, you had an MRI and MRA of the head, which did not show a new or serious abnormality. You were seen by the neurology and pain services. You should follow up at [**Hospital 878**] clinic with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**2141-12-12**] at 6:30 PM (in the evening). Your pain was managed by oral dilaudid, 4mg. You should take this medication every 4 hours as needed. You were also started on Gabapentin (also called Neurontin) for the headache. The dose was slowly increased to twice a day. You may not need as much dilaudid for your headache and should wean this medication as tolerated, given it's potential for side effects (constipation, lethargy, dependence). Finally, you will likely need medications for constipation while you take dilaudid. Take colace (a stool softener), senna (a laxative), and bisacodyl (another laxative), as needed. It is really important that you have a primary care doctor. You are scheduled with Dr. [**Last Name (STitle) **] (see below) next Tuesday. You will need your INR checked since you are on coumadin. Call your doctor if you have worsened headache, chest pain, confusion, or any other concerning symptom. Followup Instructions: Please make sure you attend the following doctor appointments: 1) Dr. [**Last Name (STitle) 4883**] (nephrologist) on Tuesday, [**2141-12-5**] at 10AM. Phone number [**Telephone/Fax (1) 60**]. 2) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Location (un) **], [**Hospital Ward Name 23**] center, [**Location (un) **]. Phone:[**Telephone/Fax (1) 250**]. Date/Time:[**2141-12-5**] 3:20 3) Neurology: Dr. [**Last Name (STitle) 43502**] [**Name (STitle) **]. He is located on the [**Location (un) **] of the [**Hospital Ward Name 23**] building. Phone:[**Telephone/Fax (1) 2574**] Date/Time:[**2141-12-12**] 6:30 PM [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2141-12-2**]",168,2141-11-24 16:11:00,2141-12-01 19:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," 24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. [**hospital unit name 153**] the patient was admitted for blood pressure management and evaluation of abd pain. an a-line was placed. ekg showed no change from prior, and abd x-ray showed a suggestion of rll/r diaphragm haziness. iv labetalol was started, and sbps dropped from 200s to 130s-160s. the patient had no symptoms of end-organ damage. the renal team was consulted, and recommended no change to home med regimen. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. when stable, patient succesfully switched to po meds and transferred to the floor. upon transfer to the floor, the following was her ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other ascites; ; Systemic lupus erythematosus; Headache; Anemia in chronic kidney disease; Anxiety state, unspecified; Other chest pain; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Renal dialysis status; Acquired absence of organ, eye]","24yo f with sle, esrd on hd and malignant hypertension who presented with abdominal pain and headache and was admitted for hypertensive urgency. the renal team was consulted, and recommended no change to home med regimen.","a 24yo f with sle, esrd on hd and malignant hypertension presented with abdominal pain and headache. the patient was found to be hypocalcemic, and was started on calcium replacement therapy. she successfully switched to po meds and was transferred to the floor." 109,151240.0,14858,2142-05-18,14802,140167.0,2141-12-23,Discharge summary,"Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1973**] Chief Complaint: Malignant hypertension Major Surgical or Invasive Procedure: None History of Present Illness: 24 year old female with ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning. Patient had her hemodialysis day before yesterday. She has had multiple admissions to [**Hospital1 18**] with hypertensive urgency with symptoms of headache and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Patient states that her headache and abdominal pain are similar in characteristics to her previous admission. Patient denies any fever, chills, nightsweats, chest pain, shortness of breath, abdominal pain, nausea, vomitting, diarrhea, constipation, blood in stool, dysuria, hematuria, change in vision, hearing, weakness or numbness. In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was initially given 10mg IV Labetalol once and then started on drip at 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea. Her BP elevated as high as 270/174 and his labetolol was switched to nicardipine 1mg/kg/min. On arrival to the MICU her vitals were T 96.4 HR 99 BP 175/120 RR 15 100%RA. Patient was comfortable. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Vitals: 97.5 122/80 88 18 100%RA. Gen: sleeping, easily arousable, appears comfortable. HEENT: AT/NC, L eye prosthetic non-reactive, R pupil reactive, MMM. Heart: S1S2 RRR, III/VI SEM heard best at apex, + S3 Pulm: CTA b/l, no w/r/r. Abd: normal bowel sounds, midline scar well-healed, soft, nontender, prior PD site with dry dressing, patient with tenderness to palpation over prior PD cath site, no guarding/rebound Ext: no edema, no clubbing, WWP. R femoral HD catheter in place. Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: Admission: [**2141-12-18**] 02:00AM BLOOD WBC-5.8 RBC-3.30* Hgb-10.1* Hct-30.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-20.7* Plt Ct-199 [**2141-12-18**] 02:00AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.2* [**2141-12-18**] 02:00AM BLOOD UreaN-35* Creat-5.0* Na-138 K-5.5* Cl-103 HCO3-21* AnGap-20 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-18**] 02:00AM BLOOD Lipase-73* [**2141-12-18**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2141-12-19**] 06:45AM BLOOD Calcium-8.1* Phos-5.1* Mg-1.8 [**2141-12-18**] 03:52PM BLOOD dsDNA-NEGATIVE [**2141-12-18**] 03:52PM BLOOD CRP-11.5* [**2141-12-18**] 03:52PM BLOOD C3-68* C4-19 [**2141-12-20**] 12:09PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 [**2141-12-18**] 02:08AM BLOOD pO2-52* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 Comment-GREEN TOP [**2141-12-20**] 12:09PM BLOOD Lactate-0.9 [**2141-12-18**] 02:08AM BLOOD Glucose-68* Lactate-1.3 Na-140 K-4.8 Cl-103 [**2141-12-23**] 03:00PM BLOOD WBC-4.7 RBC-2.35* Hgb-7.1* Hct-22.3* MCV-95 MCH-30.3 MCHC-31.9 RDW-20.6* Plt Ct-131* [**2141-12-23**] 12:55AM BLOOD PT-14.7* PTT-66.2* INR(PT)-1.3* [**2141-12-18**] 03:52PM BLOOD ESR-21* [**2141-12-23**] 03:00PM BLOOD Glucose-97 UreaN-42* Creat-6.6* Na-138 K-4.3 Cl-106 HCO3-23 AnGap-13 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-23**] 03:00PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8 [**2141-12-18**] 04:23PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2141-12-18**] 04:23PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2141-12-18**] 04:23PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-12 TransE-<1 Micro: Blood Cx- [**12-18**]: No growth Urine Cx- [**12-18**]: No growth [**12-18**] TTE The left atrium and right atrium are normal in cavity size. A possible secundum type atrial septal defect is seen by color Doppler (clip [**Clip Number (Radiology) **]) There is severe symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. There is no significant resting LVOT gradient, but a mild gradient (30mmHg peak) is seen with Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Marked symmetric left ventricular hypertrophy with normal regional/global systolic function and mild inducible LVOT gradient. Mild aortic regurgitation. Mild pulmonary artery systolic hypertension. Possible secundum type atrial septal defect. Compared with the prior study (images reviewed) of [**2141-10-19**], a possible secundum type atrial septal defect is now suggested. If clinically indicated, a follow-up study with saline contrast and/or a TEE would be better able to characterize the possible atrial septal defect. CLINICAL IMPLICATIONS: Based on [**2140**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**12-18**] CXR IMPRESSION: 1. Cardiomegaly with findings suggestive of mild pulmonary edema. 2. Bibasilar linear opacities suggesting atelectasis, although developing pneumonia cannot be excluded. 3. No evidence of free intraperitoneal air. [**12-20**] MRV IMPRESSION: No appreciable change since the MRV chest exam dated [**2141-5-30**]. SVC is patent. Again seen is occlusion of the right internal jugular and left brachiocephalic veins. Right external jugular vein is provides the major venous drainage from the neck. Brief Hospital Course: 24 year old Female with SLE, ESRD on HD and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ED. 1. Malignant Hypertension: The patient had her hemodialysis two days prior to admission. Initially in the ED her BP was 253/170. She was given 10mg IV Labetalol and started on a labatelol drip. She also received hydralazine IV 10 mg once and 2 inches of nitropaste. She had morphine 4mg and 4mg Zofran for nausea. Her BP remained elevated so she was switched to nicardipine 1mg/kg/min. The patient was transferred to the MICU. In the ICU she was continued on the Nicardapine drip and her pressures decreased to 175/120. Nephrology was consulted and dialysis initiated in the AM. The Nicardapine drip dc'd on [**12-19**] and pt transferred to floor. While on the floor the patient had question of angioedema and markedly elevated BP. She was readmitted to the MICU on [**2141-12-20**]. Patient's Aliskerin was also held for conern for angioedema. The renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. The patient's PD catheter was removed. The patient was briefly on a nitro drip for hypertension. The patient's nifedepine was increased to 120mg. The patient was transferred to the floor with stable blood pressures, BP 124/72 on [**12-21**]. The morning of [**12-22**], the patient was noted to have a BP up to 247/120 at 0800. Hypertension persisted throughout the morning with BPs 210s-240s systolic. HR during this time was in the 90s. She received a total of 60 mg IV hydralazine over the course of the morning as well as 0.1 mg PO clonidine. She was also given her normal AM BP meds and restarted on aliskarin. Due to persistent hypertension, she was transferred to the ICU for further care. On arrival to the ICU, the patient reported severe abdominal pain over the site of recently removed PD catheter. She denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. She reports bilateral calf cramping but no leg swelling. She denies any difficulty breathing or chest pain. She took her AM BP meds without difficulty. Her blood pressure decreased to 130s-140s/60s without further intervention. She was transferred back to the floor on [**12-23**] and signed out AMA. 2. Angioedema: On [**12-20**] the patietn developed facial swelling and evidence of angioedema by ENT. The patient reported that her face is more swollen which was confirmed by her mother on the floor. The patient was give lasix IV as she has been unable to have any negative filtration with HD. The patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. Her tekturna was discontinued for concern that it might be causing angioedema. She denied difficulty with her breathing at that time, but was very somnulent. On arrival to the MICU her vitals were stable and oxygenating well at 100% on face mask. The patient's airway was supported with a nasal trumpet. The patient underwent MRV that showed no progression of her clot. Patient was diuresed with lasix and dialysis with significant improvement in her symptoms. She was treated with prednisone and decadron, famotidine and benadryl for angioedema. The patient was maintained on her heparin drip for her SVC syndrome. 3. Abdominal Pain: The patient has had extensive prior workup that has been unrevealing. The Transplant surgery team removed the PD cath on [**12-21**]. She continued to have abdominal pain post-op. She was continued on PO dilaudid 2mg po prn. She continuned to complain of abdominal pain throughout her admission and continued to requested IV dilaudid. 4. ESRD: The patient is on a T/Th/Sat schedule. She was closely followed by the renal team. She had dialysis on [**12-19**]. The patient's tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. The patient also had her PD catheter removed on [**12-21**] secondary to chronic abdominal pain. The patient was scheduled to have dialysis on [**12-23**]. 5. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last admission for supratherapeutic INR. She was admitted with a subtherpeutic INR of 1.2 She was started on a heparin drip. She was also started on Coumadin 2mg PO qday, but was held on [**12-19**] in prep her PD catheter removal. She was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by IR. However, the patient signed out AMA and thus it was not placed. 6. Anxiety: Pt recently saw psychiatrist who started her on Celexa. She was continued on Celexa 20mg PO daily. 7. Anemi of CKDa: The patient's Hct was 30.3 on admission. It trended down to 22.3 on discharge when she left AMA. There was no evidence of active, acute bleeding. THis is likely seoncdary to her ESRD. The patient was closely monitored. 8. Systemic Lupus Erythematosis: Rheumatology was consulted and does not suspect acute flare and dsDNA, C3, C4 nl, ESR and CRP slightly elevated. Her Echo did not suggest worsening pericarditis. She was continued on her home prednisone dose of 4mg daily. 9. Obstructive Sleep Apnea: CPAP for sleep with 7 pressure. Medications on Admission: Aliskiren 150 mg [**Hospital1 **] Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Warfarin held on discharge [**2141-12-14**] due to supratherap INR Discharge Medications: As patient signed out AMA, no medications were issued. She was told to resume her admission medications, however no instructions were taken by the patient. Discharge Disposition: Home Discharge Diagnosis: 1) Hypertensive urgency 2) Abdominal pain 3) End stage renal disease on hemodialysis 4) Venous thromboembolism Discharge Condition: Signed out AMA Discharge Instructions: Pt signed out AMA Return to the hospital with any concerning symptoms. Be sure to call your doctor's office on [**Month/Day/Year 766**] to arrange hemodialysis and review your medications and discuss follow-up plan. Followup Instructions: Follow-up with your Dr. [**Last Name (STitle) **] next week, and call [**Last Name (STitle) 766**] to arrange your hemodialysis. Completed by:[**2141-12-26**]",146,2141-12-18 03:50:00,2141-12-23 19:51:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. 1. malignant hypertension: the patient had her hemodialysis two days prior to admission. initially in the ed her bp was 253/170. she was given 10mg iv labetalol and started on a labatelol drip. she also received hydralazine iv 10 mg once and 2 inches of nitropaste. she had morphine 4mg and 4mg zofran for nausea. her bp remained elevated so she was switched to nicardipine 1mg/kg/min. the patient was transferred to the micu. in the icu she was continued on the nicardapine drip and her pressures decreased to 175/120. nephrology was consulted and dialysis initiated in the am. the nicardapine drip dcd on [**12-19**] and pt transferred to floor. while on the floor the patient had question of angioedema and markedly elevated bp. she was readmitted to the micu on [**2141-12-20**]. patients aliskerin was also held for conern for angioedema. the renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. the patients pd catheter was removed. the patient was briefly on a nitro drip for hypertension. the patients nifedepine was increased to 120mg. the patient was transferred to the floor with stable blood pressures, bp 124/72 on [**12-21**]. the morning of [**12-22**], the patient was noted to have a bp up to 247/120 at 0800. hypertension persisted throughout the morning with bps 210s-240s systolic. hr during this time was in the 90s. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she was also given her normal am bp meds and restarted on aliskarin. due to persistent hypertension, she was transferred to the icu for further care. on arrival to the icu, the patient reported severe abdominal pain over the site of recently removed pd catheter. she denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. she reports bilateral calf cramping but no leg swelling. she denies any difficulty breathing or chest pain. she took her am bp meds without difficulty. her blood pressure decreased to 130s-140s/60s without further intervention. she was transferred back to the floor on [**12-23**] and signed out ama. 2. angioedema: on [**12-20**] the patietn developed facial swelling and evidence of angioedema by ent. the patient reported that her face is more swollen which was confirmed by her mother on the floor. the patient was give lasix iv as she has been unable to have any negative filtration with hd. the patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. her tekturna was discontinued for concern that it might be causing angioedema. she denied difficulty with her breathing at that time, but was very somnulent. on arrival to the micu her vitals were stable and oxygenating well at 100% on face mask. the patients airway was supported with a nasal trumpet. the patient underwent mrv that showed no progression of her clot. patient was diuresed with lasix and dialysis with significant improvement in her symptoms. she was treated with prednisone and decadron, famotidine and benadryl for angioedema. the patient was maintained on her heparin drip for her svc syndrome. 3. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the transplant surgery team removed the pd cath on [**12-21**]. she continued to have abdominal pain post-op. she was continued on po dilaudid 2mg po prn. she continuned to complain of abdominal pain throughout her admission and continued to requested iv dilaudid. 4. esrd: the patient is on a t/th/sat schedule. she was closely followed by the renal team. she had dialysis on [**12-19**]. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient also had her pd catheter removed on [**12-21**] secondary to chronic abdominal pain. the patient was scheduled to have dialysis on [**12-23**]. 5. hx of svc/brachiocephalic dvt: her coumadin was held during last admission for supratherapeutic inr. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. she was also started on coumadin 2mg po qday, but was held on [**12-19**] in prep her pd catheter removal. she was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by ir. however, the patient signed out ama and thus it was not placed. 6. anxiety: pt recently saw psychiatrist who started her on celexa. she was continued on celexa 20mg po daily. 7. anemi of ckda: the patients hct was 30.3 on admission. it trended down to 22.3 on discharge when she left ama. there was no evidence of active, acute bleeding. this is likely seoncdary to her esrd. the patient was closely monitored. 8. systemic lupus erythematosis: rheumatology was consulted and does not suspect acute flare and dsdna, c3, c4 nl, esr and crp slightly elevated. her echo did not suggest worsening pericarditis. she was continued on her home prednisone dose of 4mg daily. 9. obstructive sleep apnea: cpap for sleep with 7 pressure. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Mechanical complication due to peritoneal dialysis catheter; ; Unspecified disease of pericardium; Angioneurotic edema, not elsewhere classified; Abdominal pain, other specified site; Systemic lupus erythematosus; ; Anemia in chronic kidney disease; Dysthymic disorder; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of steroids; Long-term (current) use of anticoagulants; Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation; Other antihypertensive agents causing adverse effects in therapeutic use]","24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. she was given 10mg iv labetalol and started on a labatelol drip. nephrology was consulted and dialysis initiated in the am. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she reports bilateral calf cramping but no leg swelling. she took her am bp meds without difficulty. her tekturna was discontinued for concern that it might be causing angioedema. the patient was maintained on her heparin drip for her svc syndrome. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient was scheduled to have dialysis on [**12-23**]. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. there was no evidence of active, acute bleeding.","24 year old female with sle, esrd on hd presents with abdominal pain and headache consistent with her usual hypertensive urgency. she was found to be in hypertensive urgency in ed. she received hydralazine iv 10 mg once and 2 inches of nitropaste." 109,151240.0,14858,2142-05-18,14803,135923.0,2142-01-12,Discharge summary,"Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-13**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypertensive Urgency and HA Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with HA in the setting of hypertension. Upon arrival to the ED, her vitals were 284/140, HR 67, RR 28, 100% on 4LNC. She was started on a nicardipine drip. She denied shortness of breath or chest pain. She is due for HD today. She has a left groin catheter which was recently placed [**2141-12-21**] and is causing her pain. She was also given dilaudid IV 1 mg x 2 with some relief. CXR was performed and showed no pulmonary edema. . Upon arrival to the MICU, patient denies HA, CP, SOB, fevers, chills. Patient reports mild abdominal pain at sight of left anterior abdominal wall hematoma and left groin pain at site of femoral HD line. She reports that she was taking her medications as directed, including coumadin for SVC thrombus. Briefly, 24 yo F with ESRD on HD, SLE, malignant HTN admitted for HA in the setting of HTN to 284/140 in ED. Initially, she was treated with a nicardipine gtt to control her BP. Her cardiac enzymes were flat, no new ECG changes. She was started on a heparin gtt with transition to coumadin for a SVC thrombosis. HTN secondary to med noncompliance. She was restarted on her oral BP. She missed her PM meds yesterday, so nicardipine was restarted, and then turned off this AM. She received all her AM BP meds. Her BPs have been in the 160s/90s. She had no neurological deficits. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 176/105, 87, 18, 100% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: 2/6 systolic murmur LUSB Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: left ant wall abd hematoma, TTP Extremities: Right: Trace, Left: Trace, left fem HD line without oozing or drainage Skin: Warm Neurologic: AAO x 3 Pertinent Results: [**2142-1-8**] 05:15AM PT-13.7* PTT-33.6 INR(PT)-1.2* [**2142-1-8**] 05:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-1+ STIPPLED-OCCASIONAL TEARDROP-1+ BITE-NORMAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2142-1-8**] 05:15AM cTropnT-0.08* [**2142-1-8**] 05:15AM CK(CPK)-119 [**2142-1-8**] 04:12PM PTT-120.8* [**2142-1-8**] 10:41PM PTT-144.8* [**2142-1-8**] 02:55PM CK-MB-NotDone cTropnT-0.06* Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. Patient was initially observed in the MICU and placed on a nicardipine drip. Patient was stablized on home medicaitons, suggesting medication non-compliance. Additionally, patient presented subtheraputic on coumadin for SVC thrombosis. Patient was started on heparin ggt. After the nicardipine drip was turned off, patient was called out to the floor. Heparin drip was continued until INR [**2-13**]. Pressures were managed to her baseline. Pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with Narcan. Patient received dialysis 3x/wk as per outpatient schedule. # Hypertension: Pt with extensive history of repeated admissions for hypertension. Patient's BP improved with nicardipine drip and after HD off drip on home PO medication regimen. Resumed oral antihypertensives with improved BP control. HTn likely from renal disease, possible medication noncompliance, lupus. No evidence of MI. Continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. Renal increased clonidine patch, and added Nicardipine with improvement of BP control. Pt is to follow up with an appointment in the next week to establish care at [**Company 191**], and to re-check her BP and adjust medications further. # SLE: Stable, continued prednisone at 4 mg PO daily. # Left groin pain. Permanent HD line was placed on [**12-25**]. Line and hematoma from prior peritoneal line on abdomen okay. No leukocytosis or fevers to suggest infection. Patient was oversedated on Dilaudid and had episode of oxygen desaturation which was reversed with Narcan. Patient was solmolent with morphine SR so that was d/c'ed as well, patient was given standing tylenlol and Morphine IR PRN. Transplant surgery removed remaining sutures today from L groin. Pt has a follow-up appointment in the next week with Dr. [**First Name (STitle) **] (Transplant Surgery). She will be sent home with low-dose Morphine IR and Tylenol PRN pain. If L groin pain should become uncontrollable on current meds, pt should return to the ED for re-evaluation. It is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #ESRD: Renal following, continuing HD Th/Th/Sat. CaCO3 was started for elevated calcium-phosphate product. Pt will follow-up with Dr. [**Last Name (STitle) 7473**] in the next 1-2 weeks. # Anemia: Pt's baseline is 26. This is likely secondary to AOCD and renal failure. Hct was stable on day of discharge at 25.9. # SVC thrombus: Pt has a history of an SVC thrombus, and is on coumadin. She is supposed to be on lifelong anticoagulation due to recurrent thrombosis but INR subtherapeutic on arrival. Heparin drip was stopped on the floor once the INR was theraputic. INR was therapeutic on day of discharge. Pt will need an INR check in the next week at her follow-up with her PCP. # HOCM: Pt has evidence of myocardial hypertrophy on Echo. She is currently not symptomatic. Echo did not show evidence of worsening pericardial effusion. She was continued on her beta-blocker and other BP medications. # Depression/anxiety: Stable. She was continued on Celexa and Clonazepam. # OSA: Pt as continued on CPAP for sleep with 7 pressure. # FEN: regular diet # PPX: heparin drip --> coumadin, bowel regimen # ACCESS: PIV x2 / permanent dialysis cath L fem # CODE: FULL # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] # DISPO: home with PCP and Renal [**Name9 (PRE) 702**] to re-check BP, INR level. Follow-up with Transplant Surgery. Medications on Admission: Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Aliskiren 150 [**Hospital1 **] Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Nicardipine 30 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain for 2 weeks. [**Hospital1 **]:*20 Tablet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Urgency End Stage Renal Disease Discharge Condition: stable, blood pressure moderately controlled, afebrile, tolerating POs Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. Some of medications were increased as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to take the coumadin as prescribed by your doctor, and have your INR checked frequently per your PCP's recommendations. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Renal) Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-1-15**] 3:00 - Will follow-up Vitamin D [**2-4**] level Provider: [**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD ([**Company 191**]) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-1-16**] 3:30 - Will re-check your INR level Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Transplant Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-1-19**] 2:50p [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-1-12**]",126,2142-01-08 06:36:00,2142-01-13 21:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE URGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was initially observed in the micu and placed on a nicardipine drip. patient was stablized on home medicaitons, suggesting medication non-compliance. additionally, patient presented subtheraputic on coumadin for svc thrombosis. patient was started on heparin ggt. after the nicardipine drip was turned off, patient was called out to the floor. heparin drip was continued until inr [**2-13**]. pressures were managed to her baseline. pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with narcan. patient received dialysis 3x/wk as per outpatient schedule. # hypertension: pt with extensive history of repeated admissions for hypertension. patients bp improved with nicardipine drip and after hd off drip on home po medication regimen. resumed oral antihypertensives with improved bp control. htn likely from renal disease, possible medication noncompliance, lupus. no evidence of mi. continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. renal increased clonidine patch, and added nicardipine with improvement of bp control. pt is to follow up with an appointment in the next week to establish care at [**company 191**], and to re-check her bp and adjust medications further. # sle: stable, continued prednisone at 4 mg po daily. # left groin pain. permanent hd line was placed on [**12-25**]. line and hematoma from prior peritoneal line on abdomen okay. no leukocytosis or fevers to suggest infection. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. patient was solmolent with morphine sr so that was d/ced as well, patient was given standing tylenlol and morphine ir prn. transplant surgery removed remaining sutures today from l groin. pt has a follow-up appointment in the next week with dr. [**first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. it is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #esrd: renal following, continuing hd th/th/sat. caco3 was started for elevated calcium-phosphate product. pt will follow-up with dr. [**last name (stitle) 7473**] in the next 1-2 weeks. # anemia: pts baseline is 26. this is likely secondary to aocd and renal failure. hct was stable on day of discharge at 25.9. # svc thrombus: pt has a history of an svc thrombus, and is on coumadin. she is supposed to be on lifelong anticoagulation due to recurrent thrombosis but inr subtherapeutic on arrival. heparin drip was stopped on the floor once the inr was theraputic. inr was therapeutic on day of discharge. pt will need an inr check in the next week at her follow-up with her pcp. # hocm: pt has evidence of myocardial hypertrophy on echo. she is currently not symptomatic. echo did not show evidence of worsening pericardial effusion. she was continued on her beta-blocker and other bp medications. # depression/anxiety: stable. she was continued on celexa and clonazepam. # osa: pt as continued on cpap for sleep with 7 pressure. # fen: regular diet # ppx: heparin drip --> coumadin, bowel regimen # access: piv x2 / permanent dialysis cath l fem # code: full # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] # dispo: home with pcp and renal [**name9 (pre) 702**] to re-check bp, inr level. follow-up with transplant surgery. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Hypoxemia; Other opiates and related narcotics causing adverse effects in therapeutic use; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Abdominal pain, other specified site; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Renal dialysis status; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Other postprocedural status]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. # hypertension: pt with extensive history of repeated admissions for hypertension. # sle: stable, continued prednisone at 4 mg po daily. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. this is likely secondary to aocd and renal failure. pt will need an inr check in the next week at her follow-up with her pcp.","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was stablized on home medicaitons, suggesting medication non-compliance. patient was oversedated on dilaudid and had episode of oxygen desaturation." 109,151240.0,14858,2142-05-18,14804,124657.0,2142-01-20,Discharge summary,"Admission Date: [**2142-1-14**] Discharge Date: [**2142-1-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 4028**] Chief Complaint: headache Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with mild headache, mild shortness of breath and consistent abdominal pain at the site of her known left abdominal wall hematoma in the setting of hypertension. Her last HD was yesterday. . Upon arrival to the ED, her vitals were BP 240's systolic, HR 90's, 93% on RA. A head CT scan was done which showed no acute process. An abdominal CT was done given her femoral line pain, which also was normal. She was given nitropaste X2 initially, then switched to labetalol 100mg x2, then 200mg x2, then finally started on nicardipine drip when she showed benefit with a decrease in her BP to 170/123 and improvement in her headache. . Upon arrival to the MICU, patient denies any current symptoms. She reports that her headache, shortness of breath and abdominal pain all resolved with blood pressure management and pain medications. . Pt was transferred to the floor when blood pressure was controlled. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: HR 96 BP 171/111 RR 12 O2 98% on RA Physical Exam: General in NAD HEENT NC, AT, EOMI, PERRLA, MMM CVS RRR, 3/6 systolic murmur in all heart fields RESP CTA BL, no crackles or wheezes ABD soft, hematoma raised on left anterior abdominal wall, +BS, mildly tender over hematoma EXT left sided femoral HD line in place, no erythema, no edema NEURO A+Ox3, CN2-12 intact, pt has left sided artificial eye, motor and sensory intact Pertinent Results: ***LABS ON ADMISSION*** [**2142-1-13**] 07:03AM WBC-5.2 RBC-2.79* HGB-8.5* HCT-26.3* MCV-94 MCH-30.3 MCHC-32.2 RDW-19.2* [**2142-1-13**] 07:03AM PLT COUNT-154 [**2142-1-13**] 07:03AM PT-29.5* PTT-49.2* INR(PT)-3.0* [**2142-1-13**] 07:03AM GLUCOSE-94 UREA N-53* CREAT-7.0* SODIUM-136 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [**2142-1-13**] 07:03AM CALCIUM-8.8 PHOSPHATE-5.0* MAGNESIUM-1.9 [**2142-1-14**] 12:00PM PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-14**] 12:00PM LIPASE-42 [**2142-1-14**] 12:00PM ALT(SGPT)-12 AST(SGOT)-43* ALK PHOS-96 TOT BILI-0.4 [**2142-1-14**] 03:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-1-14**] 03:25PM URINE RBC-[**3-15**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-[**3-15**] [**2142-1-14**] 12:00PM BLOOD PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-19**] 06:40AM BLOOD PT-18.6* PTT-38.7* INR(PT)-1.7* . ***LABS ON DAY OF DISCHARGE*** [**2142-1-20**] 06:35AM BLOOD WBC-5.7 RBC-2.39* Hgb-7.1* Hct-22.1* MCV-93 MCH-29.8 MCHC-32.2 RDW-18.6* Plt Ct-136* [**2142-1-20**] 06:35AM BLOOD Glucose-107* UreaN-34* Creat-4.8* Na-137 K-5.2* Cl-101 HCO3-27 AnGap-14 [**2142-1-20**] 06:35AM BLOOD PT-22.8* PTT-42.3* INR(PT)-2.2* . IMAGING [**2142-1-14**] EKG Sinus rhythm. Possible left atrial abnormality. Borderline voltage criteria for left ventricular hypertrophy. Inferolateral ST-T wave changes may be related to left ventricular hypertrophy. Compared to the previous tracing of [**2142-1-8**] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 99 190 86 368/436 13 100 24 [**2142-1-14**] CT ABD/PELV IMPRESSION: 1. Interval decrease in size to subcutaneous anterior abdominal wall hematoma. 2. Infectious versus inflammatory process within the right lower lobe of the lung. Small right simple pleural effusion. 3. Cardiomegaly with slight decrease in size of moderate pericardial effusion. 4. Right lobe liver hemangioma, unchanged. [**2142-1-14**] CT HEAD IMPRESSION: 1. Mildly limited study given administration of small amount of IV contrast material. However, no evidence of hemorrhage or mass effect. NOTE ADDED AT ATTENDING REVIEW: This patient was administered contrast for the abdominal CT, and the head CT was performed after part of this dose. Therefore, this is neither a noncontrast examination, nor a proper contrast CT. [**2142-1-14**] CXR CONCLUSION: Persistent cardiomegaly and mild pulmonary edema. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. . # Hypertensive Urgency: Pt with extensive history of hypertension. Patient's BP improved with nicardipine drip. Became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. Restarted all home oral antihypertensives including nicardipine 30 Q8H, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Blood pressure remains labile and renal continues to follow patient. Pt was transferred to the floor as blood pressure stabilized. BP has remained stable with systolics 140s-170s. In the MICU, Nifedipine extended release was added in place of Nicardipine as pt's blood pressures seemed to rise prior to Nicardipine doses. . # Hyperkalemia: Ocurred on the day after admission. Resolved with administration of kayexalate. Pt continued hemodialysis on TuThSat. . # Left abdominal wall hematoma: Abd CT showed a mild decrease in the size. Pt reported that morphine did not help pain, and was switched to dilaudid PO in the MICU. However, given pt's recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/c'ed on the floor. Pt was continued on gabapentin, tylenol around the clock, and low-dose Morphine as needed for pain. Narcotics should be avoided in the future. Pain should also resolve in the next few weeks as hematoma resolves. . # SLE: Pt was continued on prednisone at 4 mg PO daily. . #ESRD: Renal was following during her stay. She continued HD on her T, Th, Sat schedule. # Anemia: Hct was mildly decreased from baseline during admission. This is likely secondary to AOCD and in the setting of renal failure. . # SVC thrombus: Patient is on anticoagulation, likely lifelong. Patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. Then INR became subtherapeutic, so heparin gtt was used to bridge. On day of discharge, INR became therapeutic, and pt was discharged home on Coumadin 4mg PO daily, with INR to be checked next at hemodialysis . # HOCM: Pt has evidence of myocardial hypertrophy on recent Echo. She was not symptomatic during her stay. She was continued on her beta blocker. . # Depression/anxiety. She was continued on celexa and clonazepam PRN. . # OSA: CPAP for sleep with 7 pressure. . # FEN: repleted lytes prn / regular diet . # PPX: coumadin, bowel regimen . # ACCESS: PIV/ permanent dialysis cath L fem . # CODE: FULL . # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nicardipine 30mg PO TID Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for breakthrough pain for 2 weeks. 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*1* 13. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*260 Tablet(s)* Refills:*1* 14. Respiratory Therapy Please adjust settings of CPAP machine to a lower volume as it is uncomfortable for the patient. Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Discharge Condition: Good, hemodynamically stable, afebrile, pain controlled Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. One new medication was added as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to continue your Coumadin at 4mg daily and have your INR checked AT DIALYSIS next week. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep ALL scheduled appointments. Medications changes include: 1. STOP NICARDIPINE 2. Start Nifedipine CR 90mg by mouth daily 3. INCREASE Labetalol to 900mg by mouth 3 times daily 4. Continue at Warfarin 4mg by mouth daily If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to set up a follow-up appointment in 1-2weeks. Please continue your HD TuThSat. Completed by:[**2142-1-20**]",118,2142-01-14 17:34:00,2142-01-20 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. . # hypertensive urgency: pt with extensive history of hypertension. patients bp improved with nicardipine drip. became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. restarted all home oral antihypertensives including nicardipine 30 q8h, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. blood pressure remains labile and renal continues to follow patient. pt was transferred to the floor as blood pressure stabilized. bp has remained stable with systolics 140s-170s. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. . # hyperkalemia: ocurred on the day after admission. resolved with administration of kayexalate. pt continued hemodialysis on tuthsat. . # left abdominal wall hematoma: abd ct showed a mild decrease in the size. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu. however, given pts recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/ced on the floor. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. narcotics should be avoided in the future. pain should also resolve in the next few weeks as hematoma resolves. . # sle: pt was continued on prednisone at 4 mg po daily. . #esrd: renal was following during her stay. she continued hd on her t, th, sat schedule. # anemia: hct was mildly decreased from baseline during admission. this is likely secondary to aocd and in the setting of renal failure. . # svc thrombus: patient is on anticoagulation, likely lifelong. patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. then inr became subtherapeutic, so heparin gtt was used to bridge. on day of discharge, inr became therapeutic, and pt was discharged home on coumadin 4mg po daily, with inr to be checked next at hemodialysis . # hocm: pt has evidence of myocardial hypertrophy on recent echo. she was not symptomatic during her stay. she was continued on her beta blocker. . # depression/anxiety. she was continued on celexa and clonazepam prn. . # osa: cpap for sleep with 7 pressure. . # fen: repleted lytes prn / regular diet . # ppx: coumadin, bowel regimen . # access: piv/ permanent dialysis cath l fem . # code: full . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Other vascular complications of medical care, not elsewhere classified; Systemic lupus erythematosus; Hyperpotassemia; Phlebitis and thrombophlebitis of upper extremities, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. # anemia: hct was mildly decreased from baseline during admission. # hocm: pt has evidence of myocardial hypertrophy on recent echo. # fen: repleted lytes prn / regular diet . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. pt was transferred to the floor as blood pressure stabilized. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu." 109,151240.0,14858,2142-05-18,14805,176760.0,2142-01-23,Discharge summary,"Admission Date: [**2142-1-21**] Discharge Date: [**2142-1-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Hypertensive Urgency and fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with hypertensive urgency, subjective fevers, and pain. . Of note, she had been hospitalized [**Date range (1) 43505**] with hypertensive urgency. Her nicardipine was changed to nifedipine in hospital and her labetalol was increased to 900mg TID from 800mg TID.BPs were reportedly stable in the 140's-170's on the medical floor on nifedipine, aliskerin, labetalol, clonidine, and hydralazine prior to discharge. Last HD was [**1-20**]. . She reports feeling well at time of discharge [**1-20**], however woke this evening feeling sweaty, hot, and mildly SOB. She did not check her temperature and denies any rigors. She had total body aching (worst in her left wrist at site of recent IV and abdomen at site of known hematoma). +Palpitations overnight now resolved. No CP, SOB, cough, diarrhea, dysuria, erythema/tenderness/drainage from HD catheter. Denies recent joint symptoms with her lupus. No sick contacts. Says she took her BP meds. . Upon arrival to the ED, her vitals were 99.9 104 254/145 16 96% on RA. She was started on a nicardipine drip, given 1"" nitropaste with improvement in her BP. Did spike a fever while in the ED, currently 101F 101 173/106 Given vancomycin and zoysn for ?pna as CXR with right sided haziness. Also received 3mg IV dilaudid for body pains. LUE ultrasound without evidence of DVT. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 98.5 P 92 Bp 173/116 RR 16 O2 100% on RA General Pleasant young woman appearing comfortable HEENT Cushingoid faces, L eye prosthesis, MMM Pulm Lungs clear bilaterally, no rales or wheezing CV Regular S1 S2 ?soft systolic murmur Abd Soft +hematoma left abdomen unchanged from prior exam Extrem Warm full distal pulses. Left hand with slight edema ++ tender to palpation of wrist patient unable to make fist secondary to pain, no erythema +warmth ?purulence at site of old PIV Skin No peripehral stigmata of endocarditis Lines Left groin HD catheter site without erythema, purulence, or tenderness Neuro Alert and awake, moving all extremities Pertinent Results: CXR [**1-21**]: In comparison with the earlier study of this date, the diffuse pulmonary edema has substantially decreased, possibly following hemodialysis. Enlargement of the cardiac silhouette persists and there is no definite pleural effusion. Suggestion of an area of increased opacification at the right base. This could merely represent asymmetric edema, though the possibility of a developing consolidation cannot be unequivocally excluded. . LUE US [**1-21**]: IMPRESSION: No DVT in the left upper extremity. . L wrist xray [**1-21**]: There is prominent soft tissue swelling about the wrist, relatively diffuse, but quite prominent along the dorsum of the wrist. No fracture, dislocation, degenerative change, focal lytic or sclerotic lesion, or erosion is identified. No soft tissue calcification or radiopaque foreign body is identified. A tiny (1.7 mm) linear density is seen along the dorsum of the wrist on the oblique view is seen only on that view and is consistent with a small film artifact. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency and left wrist pain. . 1. Hypertensive urgency: Patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. Patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. She was started on nicardipine drip and 1"" nitropaste and admitted to the ICU for further treatment. There was no evidence of end-organ ischemia. Upon arrival to the ICU she was given her usual home antihypertensives and the nicardipine was quickly weaned off. It was felt that pain and anxiety were both contributing to her elevated BPs. Her BP quickly stabilized and she was called out to the medical floor where her SBP ranged 110-150. She was continued on nifepidine 90mg daily, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Given her repeated admissions with hypertensive urgency a meeting was held between the patient's nephrologist Dr. [**Last Name (STitle) 4883**], her ICU physician and her [**Name9 (PRE) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the ICU where she quickly improves with simply continuing her home medications. The following plan was drafted and placed in a note in OMR titled "" Care Protocol"". . CARE PROTOCOL: . BLOOD PRESSURE MANAGEMENT: . For BP > 230/140 1. Hydralazine: 100 mg PO OR 10 mg IV q 20 minutes until blood pressure back to baseline*. . 2. Give daily blood pressure medications, if she has not already taken them before arrival. . 3. If after one hour of therapy AND/OR evidence of end organ damage, transfer to the ICU. . * Note: Her usual blood pressure is ~ 160/100. Efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. In the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . PAIN MANAGEMENT: . As an outpatient, Ms. [**Name13 (STitle) **] takes dilaudid 2-4 mg PO q 4 PRN.This is being slowly tapered, she should not be administered IV pain medications. . ANTICOAGULATION: . In the absence of bleeding, warfarin does not need to be stopped on admission. Similarly, in the absence of new thrombosis, subtherapeutic INR's do not require bridging with IV UFH. . 2. Fever: Possible sources included line infection, thombophlebitis, septic arthritis, PNA. Received vanc/zosyn in ED for possible PNA. UA without pyuria and urine culture negative. CXR also without convinving infiltrate on repeat PA/Lat so zosyn was discontinued. Patient was complaining of severe pain at her IV site and was noted to have a small abscess there which was felt to be the cause of her fever. She was continued on IV vanco with HD for 10day course. She remained afebrile and did not have a leukocytosis. . 3. Left wrist pain: Began following IV placement during recent hospitalization. Likely due to septic thrombophlebitis. Small abscess was too small to drain. This was treated with warm soaks and prn PO dilaudid. Vanco was continued for 10 day course. L wrist films were enremarkable. . 4. Left abdominal wall hematoma: Stable on exam from recent admission. She was continued on pain management with morphine 7.5mg TID, gabapentin and tylenol as needed for pain. . 5. SLE: Continued prednisone at 4 mg PO daily . 6. ESRD: Continued on regularly scheduled dialysis. . 7. Anemia: Baseline Hct 26. Her Hct was mildly decreased from baseline. Secondary to AOCD and renal failure. There was no evidence of bleeding. . 8. SVC thrombus: Known SVC thrombus, therapeutic on coumadin. Continued warfarin. . 9. HOCM: evidence of myocardial hypertrophy on recent Echo. Currently not symptomatic. Echo without evidence of worsening pericardial effusion. Continued beta blocker . 10. Depression/anxiety. Continued Celexa, clonazepam 0.5mg [**Hospital1 **] . 11. OSA: Continued CPAP Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nifedipine 90mg PO daily Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325-650 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*270 Tablet(s)* Refills:*2* 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 7 days. [**Hospital1 **]:*4 dose* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Septic thrombophlebitis Discharge Condition: Stable, afebrile, BP improved. Discharge Instructions: You were admitted to the hospital with hypertensive urgency. You required IV medications and were observed overnight in the ICU. Your usual oral blood pressure medications were continued and your blood pressure remained well-controlled. You were found to have an infection at your prior IV site on your left hand. For this you were given IV vancomycin. You will need 7 days more of antibiotics which will be given with dialysis. Please resume your usual dialysis schedule. Your last dialysis was [**1-23**]. Please continue to take your medications as prescribed. You should hold your coumadin today. You can resume this on wednesday at your normal dose. You should have your INR checked at dialyis as usual on thursday. . If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-12**] weeks. ",115,2142-01-21 11:23:00,2142-01-23 16:40:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE EMERGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. . 1. hypertensive urgency: patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. there was no evidence of end-organ ischemia. upon arrival to the icu she was given her usual home antihypertensives and the nicardipine was quickly weaned off. it was felt that pain and anxiety were both contributing to her elevated bps. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150. she was continued on nifepidine 90mg daily, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. given her repeated admissions with hypertensive urgency a meeting was held between the patients nephrologist dr. [**last name (stitle) 4883**], her icu physician and her [**name9 (pre) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the icu where she quickly improves with simply continuing her home medications. the following plan was drafted and placed in a note in omr titled "" care protocol"". . care protocol: . blood pressure management: . for bp > 230/140 1. hydralazine: 100 mg po or 10 mg iv q 20 minutes until blood pressure back to baseline*. . 2. give daily blood pressure medications, if she has not already taken them before arrival. . 3. if after one hour of therapy and/or evidence of end organ damage, transfer to the icu. . * note: her usual blood pressure is ~ 160/100. efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. in the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . pain management: . as an outpatient, ms. [**name13 (stitle) **] takes dilaudid 2-4 mg po q 4 prn.this is being slowly tapered, she should not be administered iv pain medications. . anticoagulation: . in the absence of bleeding, warfarin does not need to be stopped on admission. similarly, in the absence of new thrombosis, subtherapeutic inrs do not require bridging with iv ufh. . 2. fever: possible sources included line infection, thombophlebitis, septic arthritis, pna. received vanc/zosyn in ed for possible pna. ua without pyuria and urine culture negative. cxr also without convinving infiltrate on repeat pa/lat so zosyn was discontinued. patient was complaining of severe pain at her iv site and was noted to have a small abscess there which was felt to be the cause of her fever. she was continued on iv vanco with hd for 10day course. she remained afebrile and did not have a leukocytosis. . 3. left wrist pain: began following iv placement during recent hospitalization. likely due to septic thrombophlebitis. small abscess was too small to drain. this was treated with warm soaks and prn po dilaudid. vanco was continued for 10 day course. l wrist films were enremarkable. . 4. left abdominal wall hematoma: stable on exam from recent admission. she was continued on pain management with morphine 7.5mg tid, gabapentin and tylenol as needed for pain. . 5. sle: continued prednisone at 4 mg po daily . 6. esrd: continued on regularly scheduled dialysis. . 7. anemia: baseline hct 26. her hct was mildly decreased from baseline. secondary to aocd and renal failure. there was no evidence of bleeding. . 8. svc thrombus: known svc thrombus, therapeutic on coumadin. continued warfarin. . 9. hocm: evidence of myocardial hypertrophy on recent echo. currently not symptomatic. echo without evidence of worsening pericardial effusion. continued beta blocker . 10. depression/anxiety. continued celexa, clonazepam 0.5mg [**hospital1 **] . 11. osa: continued cpap ","PRIMARY: [Other vascular complications of medical care, not elsewhere classified] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; ; Systemic lupus erythematosus; Phlebitis and thrombophlebitis of upper extremities, unspecified]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. she was continued on iv vanco with hd for 10day course. esrd: continued on regularly scheduled dialysis. her hct was mildly decreased from baseline. hocm: evidence of myocardial hypertrophy on recent echo. echo without evidence of worsening pericardial effusion. continued celexa, clonazepam 0.5mg [**hospital1 **] .","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150." 109,151240.0,14858,2142-05-18,14806,113189.0,2142-02-17,Discharge summary,"Admission Date: [**2142-2-14**] Discharge Date: [**2142-2-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: From admission note: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome admitted with HTN and SOB in the setting of missed HD. The patient reported missing HD yesterday because she thinks she is being overdiuresed. She reports persistent pain at site of rectus sheath hematoma. Denies N/V/D. Pt recently admitted from [**Date range (1) 13924**] with consistent abdominal pain at the site of her known left abdominal wall hematoma, hypertensive to 230's and hyperkalemic to 6.2 after missing her last two dialysis sessions. At this time the pt. was dialyzed, received a blood transfusion, and was administered her daily antihypertensive medications. Pt. left AMA after her transfusion despite the primary team's concerns to look for an active area of bleeding. In the ED, patient complain of mild dyspnea, sating well on RA. CXR mild volume overload. KUB with no evidence of obstruction. She was started on a labetalol gtt. ECG - RAD, LVH no change from prior. HCT stable at 21. The renal team evaluated pt and recommended HD, however the patient refused. She was transferred to ICU for BP control. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: [**2142-2-14**] 07:40AM WBC-3.9* RBC-2.38* HGB-7.0* HCT-21.3* MCV-90 MCH-29.5 MCHC-33.0 RDW-18.9* [**2142-2-14**] 07:40AM NEUTS-74.9* LYMPHS-18.7 MONOS-3.1 EOS-3.0 BASOS-0.2 [**2142-2-14**] 07:40AM PLT COUNT-101* [**2142-2-14**] 07:40AM PT-16.3* PTT-36.6* INR(PT)-1.5* [**2142-2-14**] 07:40AM CK-MB-6 [**2142-2-14**] 07:40AM cTropnT-0.09* [**2142-2-14**] 07:40AM LIPASE-80* [**2142-2-14**] 07:40AM ALT(SGPT)-34 AST(SGOT)-72* CK(CPK)-120 ALK PHOS-124* TOT BILI-0.4 [**2142-2-14**] 07:40AM GLUCOSE-85 UREA N-32* CREAT-7.0* SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-19* ANION GAP-17 [**2142-2-14**] 07:44AM LACTATE-1.3 [**2142-2-14**] CXR: Stable cardiomegaly with mild CHF and a small left pleural effusion. Left basilar air space disease which may represent pneumonia. Clinical correlation and a follow up chest x-ray to clearance is recommended. [**2142-2-14**] KUB: 1. Nonspecific bowel gas pattern with no evidence of obstruction. 2. Left basilar airspace disease which may represent pneumonia and a small left pleural effusion. Please ensure follow-up to clearance. Brief Hospital Course: 24 y.o female with SLE, ESRD on HD and malignant hypertension who presents with HTN and SOB aftering missing HD. . # Malignant hypertension/hypertensive urgency: The patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and HD compliance. Has previously presented with BP up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. Pt was treated per OMR hypertensive protocol created by the patient's primary providers, with a goal SBP of 160-180. With short course of IV antihypertensives and hemodialysis, pt's BP fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # ESRD: Pt was followed by the renal service and underwent HD without any complications. Pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting HD. She will discuss this further with the Renal team as an outpatient. . # SLE: Pt was continued on her home dose of prednisone with no sign of SLE flair. . # Coagulopathy/history of DVT: Patient on lifetime anticoagulation for hx of multiple thrombotic events. Pt was continued on coumadin. . # Pain management: Pt was treated with PO dilaudid for her abdominal pain, as recommended per her OMR protocol. She asked for IV dilaudid multiple times but there was no clinical indication. She was also continued on gabapentin. . # Anemia: Secondary to AOCD and renal failure. The patietns Hct remained stable in the low 20s during admission. No PRBC infusions were needed. . # Depression/anxiety: Continued Celexa, clonazepam 0.5mg [**Hospital1 **] Medications on Admission: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain. 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Disposition: Home Discharge Diagnosis: Primary: Malignant Hypertension Secondary: SLE, End stage renal disease on hemodialysis, SVC syndrome Discharge Condition: Stable. SBP in 160s. Discharge Instructions: You were admitted with dangerously high hypertension and some shortness of breath in the setting of missing several dialysis sessions. You were admitted and treated with your usual regimen of blood pressure meds and a short course of IV meds. With dialysis, your symptoms improved. You also had some abdominal pain, which was well controlled on your usual pain medications. We made no changes to your medications. Please take everything as prescribed. Please call your PCP or return to the hospital if you develop any headaches, visual changes, confusion or chest pain, or any other concerning symptoms. Followup Instructions: Please schedule a follow up with Dr [**Last Name (STitle) **] in [**Month (only) 958**] as scheduled. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2142-2-21**]",90,2142-02-14 10:42:00,2142-02-17 18:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. . # malignant hypertension/hypertensive urgency: the patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and hd compliance. has previously presented with bp up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. with short course of iv antihypertensives and hemodialysis, pts bp fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # esrd: pt was followed by the renal service and underwent hd without any complications. pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting hd. she will discuss this further with the renal team as an outpatient. . # sle: pt was continued on her home dose of prednisone with no sign of sle flair. . # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events. pt was continued on coumadin. . # pain management: pt was treated with po dilaudid for her abdominal pain, as recommended per her omr protocol. she asked for iv dilaudid multiple times but there was no clinical indication. she was also continued on gabapentin. . # anemia: secondary to aocd and renal failure. the patietns hct remained stable in the low 20s during admission. no prbc infusions were needed. . # depression/anxiety: continued celexa, clonazepam 0.5mg [**hospital1 **] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Thrombotic microangiopathy; Systemic lupus erythematosus; Anemia in chronic kidney disease; Thrombocytopenia, unspecified; Obstructive sleep apnea (adult)(pediatric); Nontraumatic hematoma of soft tissue; Dysthymic disorder; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events.","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob after missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. she was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine." 109,151240.0,14858,2142-05-18,14807,158995.0,2142-02-26,Discharge summary,"Admission Date: [**2142-2-25**] Discharge Date: [**2142-2-26**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 338**] 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 History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, hx of malignant HTN admitted with change in mental status. Patient missed HD on [**2142-2-24**] and was found unresponsive and diaphoretic by mother this morning after she took some dilaudid. EMS was called, 1 mg of narcan was administered with slight improvement in mental status. On arrival to the ED her vitals were 112/64 62 16 99RA she was noted to be hyperkalemic in the absence of EKG changes and was given calcium, D5, 10U regular insulin, 30 mg po kayxalate and repeat K was 5.4. ABG: 7.29/38/199. Repeat glucose was 41 and 1amp D50 was given. She was sent to the ICU for monitoring. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including [**Month/Year (2) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: HR: 80 (79 - 80) bpm BP: 127/59(76) {127/59(76) - 139/64(82)} mmHg RR: 34 (21 - 34) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Physical Examination Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact Pertinent Results: [**2142-2-25**] 01:50PM PT-14.9* PTT-36.8* INR(PT)-1.3* [**2142-2-25**] 01:50PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2142-2-25**] 01:50PM WBC-5.0 RBC-2.21* HGB-6.4* HCT-20.7* MCV-94 MCH-29.1 MCHC-31.1 RDW-19.6* [**2142-2-25**] 10:30PM GLUCOSE-87 UREA N-66* CREAT-8.4* SODIUM-142 POTASSIUM-5.9* CHLORIDE-110* TOTAL CO2-16* ANION GAP-22* HISTORY: Altered mental status. Evaluate underlying for pneumonia. UPRIGHT PORTABLE CHEST: Comparison is made to [**2-14**] and [**2142-2-19**], exams. Study is slightly limited by patient motion. In the interval, the degree of pulmonary edema appears improved with slightly decreased prominence of the pulmonary vascularity. There is unchanged extensive retrocardiac consolidation obscuring the majority of the left hemidiaphragm with persistent blunting of the left CP angle, likely related to small effusion. Exam is otherwise unchanged from prior with persistent cardiomegaly. A catheter is seen projecting over the abdomen, partially imaged. IMPRESSION: Slight improvement in pulmonary edema with persistent retrocardiac opacity, which again may represent atelectasis versus underlying pneumonia. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted hypotension and decreased mental status. Hypotension and altered mental status were in the setting of excessive narcotic use. Patient's narcotics were held, pressors returned to [**Location 213**] and patient was mentating fine. Hct was below baseline and patient was transfused 1u PRBC and was given HD before discharge. Patient is to continue anti-hypertensive medications as previously scheduled. Patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # Change in mental status: Resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. Patient received 1 dose of narcan with slight improvement in BP and mental status. patient without fevers or leuckocytosis which argue against infection. # Hypertension ?????? resumed outpatient regimen. Patient did not have any hypertensive episodes requiring hydralizine 10mg IV. # Hypotension: resolved, Patient normotensive on arrival to ICU. Relative hypotension likely due to dilaudid. Other considerations include sepsis, although patient without objective signs of infection. Held pain medications and hypotension resolved. Resumed hypertensive medications. # Abdominal pain ?????? from previous peritoneal [**Location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # Hyperkalemia: Likely due to missed HD session. She received calcium, D5, insulin and kayexalate in ED. HD in am ESRD: Renal following, had HD the day of discharge, transfused while there. Will continue normal schedule as an outpatient with HD T/Th/F this week. # Metabolic Acidosis: likely due to renal failure and missed HD. # SLE: continued prednisone at 4 mg PO daily. # OSA: CPAP for sleep with 7 pressure, however patient refuses. Continued to offer as inpatient. Should try to follow up with sleep medicine. Medications on Admission: Prednisone 4mg qd Citalopram 20 mg daily Gabapentin 300 mg [**Hospital1 **] Warfarin 4mg daily Pantoprazole 40 mg qd Clonidine 0.1 mg/24 QWED Clonidine 0.3 mg/24 hr QWED Labetalol 900 mg tid Nifedipine 90 mg qd Aliskiren 150 mg [**Hospital1 **] Hydralazine 100 mg q8h Morphine 7.5 mg q8h prn pain Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Home Discharge Diagnosis: Primary: narcotic overdose relative hypotension anemia Secondary: ESRD on HD [**2-12**] SLE malignant hypertension Discharge Condition: stable - received HD prior to discharge Discharge Instructions: You were admitted for altered mental status after missing hemodialysis. It was likely from the dilaudid you took as well as missing your scheduled [**Month/Day (2) 2286**]. You were also relatively hypotensive in the setting of excessive narcotic medicaiton usage. Narcotic medications were held and hypotension and altered mental status resolved. Please use narcotic medications with caution. You are recommended to use morphine for pain control rather than dilaudid. No medication changes were made. Please return to the ED if you have any altered mental status or miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] or have symptoms such as vision changes or headache from your history of malignant hypertension. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-3-20**] 3:00 HD as previously scheduled Completed by:[**2142-2-26**]",81,2142-02-25 15:49:00,2142-02-26 16:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ALTERED MENTAL STATUS," 24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. patients narcotics were held, pressors returned to [**location 213**] and patient was mentating fine. hct was below baseline and patient was transfused 1u prbc and was given hd before discharge. patient is to continue anti-hypertensive medications as previously scheduled. patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # change in mental status: resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. patient received 1 dose of narcan with slight improvement in bp and mental status. patient without fevers or leuckocytosis which argue against infection. # hypertension ?????? resumed outpatient regimen. patient did not have any hypertensive episodes requiring hydralizine 10mg iv. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. other considerations include sepsis, although patient without objective signs of infection. held pain medications and hypotension resolved. resumed hypertensive medications. # abdominal pain ?????? from previous peritoneal [**location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # hyperkalemia: likely due to missed hd session. she received calcium, d5, insulin and kayexalate in ed. hd in am esrd: renal following, had hd the day of discharge, transfused while there. will continue normal schedule as an outpatient with hd t/th/f this week. # metabolic acidosis: likely due to renal failure and missed hd. # sle: continued prednisone at 4 mg po daily. # osa: cpap for sleep with 7 pressure, however patient refuses. continued to offer as inpatient. should try to follow up with sleep medicine. ","PRIMARY: [Poisoning by other opiates and related narcotics] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Thrombotic microangiopathy; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Altered mental status; Other iatrogenic hypotension; Accidental poisoning by other opiates and related narcotics; Hyperpotassemia; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Nontraumatic hematoma of soft tissue; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. from previous peritoneal [**location 2286**] hematoma ??????","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. narcotics were held, pressors returned to and patient was mentating fine. patient was encouraged to take less pain medications and to use morphine." 109,151240.0,14858,2142-05-18,14808,158943.0,2142-03-23,Discharge summary,"Admission Date: [**2142-3-21**] Discharge Date: [**2142-3-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: Abdominal Pain, Shortness of breath, Chest discomfort Major Surgical or Invasive Procedure: HD [**2142-3-21**] and [**2142-3-23**] History of Present Illness: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] 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 [**Telephone/Fax (3) 43508**]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. [**Telephone/Fax (3) **] was discussed with renal and it was not felt that HTN is a volume issue so no need for emergent [**Telephone/Fax (3) 2286**]. . 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 [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**], getting Vanc with HD. . PSHx: 1. Placement of multiple catheters including [**Year (4 digits) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] 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: [**2142-3-21**] 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* [**2142-3-21**] 02:20AM NEUTS-76.1* BANDS-0 LYMPHS-17.9* MONOS-4.5 EOS-1.1 BASOS-0.5 [**2142-3-21**] 02:20AM PLT SMR-NORMAL PLT COUNT-168 [**2142-3-21**] 02:20AM PT-21.8* PTT-34.7 INR(PT)-2.1* [**2142-3-21**] 02:20AM cTropnT-0.12* [**2142-3-21**] 02:20AM ALT(SGPT)-46* AST(SGOT)-94* CK(CPK)-76 ALK PHOS-173* TOT BILI-0.4 [**2142-3-21**] 02:20AM GLUCOSE-74 UREA N-47* CREAT-7.3* SODIUM-140 POTASSIUM-5.8* CHLORIDE-109* TOTAL CO2-19* ANION GAP-18 [**2142-3-21**] 04:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-21**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2142-3-21**] 12:58PM CK-MB-NotDone cTropnT-0.12* . CT C/A/P - [**2142-3-20**] - 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: [**2142-3-23**] 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* [**2142-3-23**] 12:00PM BLOOD Plt Ct-130* [**2142-3-23**] 12:00PM BLOOD PT-28.8* PTT-58.6* INR(PT)-2.9* [**2142-3-23**] 12:00PM BLOOD Glucose-77 UreaN-31* Creat-6.0*# Na-137 K-4.8 Cl-104 HCO3-24 AnGap-14 [**2142-3-23**] 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 [**3-22**] 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 [**2142-3-21**] . # abdominal pain: Consistent with patient's baseline chronic abdominal pain. Medication effect also possible. CT prelim neg for small bowel obstruction. LFTs doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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). [**Month/Year (2) **]:*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 [**Month/Year (2) 2286**] sessions as directed by the nephrology team- your next session should be on Tuesday. Completed by:[**2142-3-26**]",56,2142-03-21 09:25:00,2142-03-23 18:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,CHEST PAIN;TELEMETRY," 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 (200s/100s) that nevertheless are within levels shes 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 [**3-22**] and transferred to the medicine floor. the next day, her bp remained within goal of 120s/80s. 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. ces were cycled and were negative. cpap was continued as tolerated at home settings. sob resolved after hd on [**2142-3-21**] . # abdominal pain: consistent with patients baseline chronic abdominal pain. medication effect also possible. ct prelim neg for small bowel obstruction. lfts doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Compression of vein; Unspecified disease of pericardium; Infection and inflammatory reaction due to other vascular device, implant, and graft; Bacteremia; Primary hypercoagulable state; Other primary cardiomyopathies; ; Abdominal pain, unspecified site; Urinary tract infection, site not specified; Acidosis; Other chest pain; Other chronic pain; Systemic lupus erythematosus; Noncompliance with renal dialysis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Hyperpotassemia; 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; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","this is a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. ct prelim neg for small bowel obstruction. on arrival to the floor, abd pain was back to baseline and well controlled on dilaudid 2mg po q 4hrs .","a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. initial attempts were made to control her bp with hydralazine and labetalol iv but after these failed to control her blood pressure. she was successfully transitioned to home medications of clonidine, labetalol, aliskiren, nifedipine" 109,151240.0,14858,2142-05-18,14809,124398.0,2142-03-31,Discharge summary,"Admission Date: [**2142-3-24**] Discharge Date: [**2142-3-31**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: HTN, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 24F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] after admission for abdominal pain, MSSA bacteremia, paroxysmal hypertension and ESRD line, followed by readmission [**3-22**], now presents with usual central crampy abdominal pain, 3 loose nonbloody stools this AM, SOB, and HTN to 270s. Pt was d/c'd from [**Hospital1 18**] yesterday after HD session, went home, states she took her PM meds, took her 8 AM medds (hydral, labetalol), then developed these symptoms which precluded her from taking her usual home meds (no afternoon meds - nifedipine, labetalol, hydral). The abd pain comes and goes and is unchanged from her baseline. While she has nausea, she is asking for dinner. . In the ED, initial BP 272/148. CXR w/o evidence of volume overload. No CT scan performed. Started on NTG gtt, given Hydralazine 10 x 1, Dilaudid 2 mg, labetaolo 20mg IV x 1. . Upon arrival to the floor, her BP was 240/135. She continued to complain of abdominal pain but was eating crackers, breathing felt better. RR 17. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: 98.2 97 [**Telephone/Fax (2) 43509**]0% on 2 L nC Gen: pleasant, comfortable HEENT: L eye enucleated. moon facies. Right pupil reactive Heart: hrrr, no m/r/g Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, diffuse TTP, no rebound/guarding Ext: no c/c/e Neuro: aox4, cn 2-12 intact grossly. Pertinent Results: [**2142-3-24**] 07:17PM PT-22.4* PTT-43.64* INR(PT)-2.1* [**2142-3-24**] 04:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2142-3-24**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-24**] 04:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**11-30**] [**2142-3-24**] 02:05PM GLUCOSE-76 UREA N-21* CREAT-4.8*# SODIUM-139 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2142-3-24**] 02:05PM ALT(SGPT)-78* AST(SGOT)-181* CK(CPK)-55 ALK PHOS-192* TOT BILI-0.5 [**2142-3-24**] 02:05PM cTropnT-0.12* [**2142-3-24**] 02:05PM CK-MB-5 [**2142-3-24**] 02:05PM WBC-3.6* RBC-2.90* HGB-8.9* HCT-26.6* MCV-92 MCH-30.7 MCHC-33.4 RDW-19.8* [**2142-3-24**] 02:05PM NEUTS-73.9* BANDS-0 LYMPHS-18.5 MONOS-3.8 EOS-3.0 BASOS-0.8 [**2142-3-24**] 02:05PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-1+ TARGET-1+ SCHISTOCY-OCCASIONAL TEARDROP-1+ ELLIPTOCY-OCCASIONAL [**2142-3-24**] 02:05PM PLT SMR-LOW PLT COUNT-129* [**2142-3-23**] 12:00PM GLUCOSE-77 UREA N-31* CREAT-6.0*# SODIUM-137 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14 [**2142-3-23**] 12:00PM estGFR-Using this [**2142-3-23**] 12:00PM CALCIUM-8.4 PHOSPHATE-5.7* MAGNESIUM-1.9 [**2142-3-23**] 12:00PM WBC-3.7* RBC-2.87* HGB-8.7* HCT-26.1* MCV-91 MCH-30.3 MCHC-33.3 RDW-19.4* [**2142-3-23**] 12:00PM PLT COUNT-130* [**2142-3-23**] 12:00PM PT-28.8* PTT-58.6* INR(PT)-2.9* Brief Hospital Course: The patient was admitted to the MICU on a NTG gtt from the ED. Her abdominal pain had imporved and she was eating crackers and peanut butter. She was given her usual afternoon home medications, and transitioned to a Nicardipine gtt, which has worked well for her in the past. Her BP goal was for a systolic of 180-200. The Nicardipine gtt was titrated off quickly and she was transfered to the floor. . On arrival to the floor, she in fact missed her morning medications on [**Month/Day/Year 766**]. This resulted in elevate blood pressures requiring IV hydralazing for control. She went to dialyisis Tuesday [**3-27**] and again had markedly elevated blood pressures while at [**Month/Year (2) 2286**] from missing her AM doses. Instructions were written for explicit AM administration and Nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. She was continued on labetalol 900mg TID, Aliskerin, Hydralazine 100mg po TID, and clonidine patch 0.4mg/24 weekly patch. . HEr BP remained relativly stable. She established a three three times weekly Dialysus regemin. A PAP smear was attempted due to her history of CIN I and no PCP follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . Her abdominal pain was also a chronic issue, which appeared stable. She was not administered IV narcotics, only PO. It was wihtout clear percipitating events or etiology. She will need GI follow up. She was contact[**Name (NI) **] by phone several times to arrange a GI follow up appointment but did not return messages. She has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . She was discharged to followup with her nephrologist, Dr. [**Last Name (STitle) 4883**]. . 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. Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Last Name (STitle) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2* 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). [**Last Name (STitle) **]:*405 Tablet(s)* Refills:*2* 5. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*2* 6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). [**Last Name (STitle) **]:*60 Tablet(s)* Refills:*2* 9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patches Transdermal once a week: Place two patches every week on Fridays. [**Last Name (STitle) **]:*8 Patches* Refills:*2* 10. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*0* 11. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO twice a day as needed for prn SBP>200: if nauseated and cannot keep down meds, may use 1 sublingual clonidine if sbp>200. . [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0* 12. Kayexalate Powder Sig: Thirty (30) grams PO once a day for 2 days: please take [**2142-4-1**] and [**2142-4-2**] for elevated potassium. [**Month/Day/Year **]:*240 grams* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Systemic Lupus Erythematosus End Stage Renal Disease Hypertension Abdominal Pain Discharge Condition: Blood pressure stable and abdominal pain at baseline Discharge Instructions: You were admitted with high blood pressure. You were in the ICU overnight for treatment. Some of your medications were changed and you were increased to three times weekly [**Location (un) 2286**]. Your abdominal pain is a difficult problem, as the reason for the pain is unclear. [**Name2 (NI) **] were continued on oral dilaudid. IV dilaudid is strongly discouraged and will continue to be in the future. You are now taking Nifedipine SR 30mg at night in addition to 90mg in the morning. Your other medications were the same. At home, if your blood pressure is above 200, then take 100mg hydralazine. If after 1 hour, your blood pressure does not decrease to below 200 with this, then take another 100mg hydralazine. If you are nauseated and cannot take in oral meds, then take sublingual clonidine, then wait 1 hour and repeat if BP still > 200. Finally, your potassium has been high. Please take kayexalate 30gm tomorrow and the next day. Followup Instructions: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-3-31**] 7:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule appointment We will attempt to contact you on [**Name (NI) 766**] with appointment times for you. ",48,2142-03-24 16:34:00,2142-03-31 15:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," the patient was admitted to the micu on a ntg gtt from the ed. her abdominal pain had imporved and she was eating crackers and peanut butter. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. her bp goal was for a systolic of 180-200. the nicardipine gtt was titrated off quickly and she was transfered to the floor. . on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**]. this resulted in elevate blood pressures requiring iv hydralazing for control. she went to dialyisis tuesday [**3-27**] and again had markedly elevated blood pressures while at [**month/year (2) 2286**] from missing her am doses. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she was continued on labetalol 900mg tid, aliskerin, hydralazine 100mg po tid, and clonidine patch 0.4mg/24 weekly patch. . her bp remained relativly stable. she established a three three times weekly dialysus regemin. a pap smear was attempted due to her history of cin i and no pcp follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . her abdominal pain was also a chronic issue, which appeared stable. she was not administered iv narcotics, only po. it was wihtout clear percipitating events or etiology. she will need gi follow up. she was contact[**name (ni) **] by phone several times to arrange a gi follow up appointment but did not return messages. she has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . she was discharged to followup with her nephrologist, dr. [**last name (stitle) 4883**]. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Long-term (current) use of steroids; Other chronic pain; Obstructive sleep apnea (adult)(pediatric); Abdominal pain, generalized; Hyperpotassemia]","the patient was admitted to the micu on a ntg gtt from the ed. her bp goal was for a systolic of 180-200. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she established a three three times weekly dialysus regemin.","the patient was admitted to the micu on a nicardipine gtt from the ed. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**] this resulted in elevate blood pressures requiring iv hydralazing for control " 109,151240.0,14858,2142-05-18,14810,137510.0,2142-04-22,Discharge summary,"Admission Date: [**2142-4-20**] Discharge Date: [**2142-4-22**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 1253**] Chief Complaint: Dyspnea, malignant hypertension Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented with abdominal pain and shortness of breath. On [**2142-4-19**] she refused ultrafiltration at HD because she was at her dry weight. Awoke at 3 AM feeling more short of breath. She also had worsening abdominal pain and vomiting without hematemasis. She took all of her medications as prescribed including two new lidocaine patches, fentanyl patch and clonidine. She developed a slight frontal headache but no blurry vision or neurologic symptoms. ROS largely negative. . In the emergency room her initial vitals were T: 99.1 BP: 280/140 HR: 79 RR: 16 O2: 100% on RA. She had two large bore peripheral IVs placed. She received 100 mg PO hydralazine, 200 mg PO labetolol, zofran 4 mg IV, vancomycin 1 gram IV, levofloxacin 750 mg IV x 1 and was started on labetolol and nitroglycerin drips with control of her blood pressure to the 180s systolic. She had a CXR which was concerning for volume overload. She was admitted the MICU for further evaluation. . In the MICU she was stablized and transitioned to her home meds. Nephrology gave her HD with 2L UF and subjective improvement in SOB. . Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: On Admission per MICU team: Vitals: T: 96.5 BP: 162/120 HR: 79 RR: 13 O2: 100% on 4L General: Pleasant, comfortable, no distress HEENT: L eye enucleated. Moon facies. Right pupil reactive Heart: Regular rate and rhythm, s1 + s2, soft systolic murmur at RLSB, no rubs or gallops Respiratory: Crackles at bases bilaterally, no wheezes, rales, ronchi GI: soft, non-tender, non-distended, +BS GU: no foley Ext: Warm and well perfused, no clubbing, cyanosis or edema . Pertinent Results: [**2142-4-19**] 08:35AM WBC-3.8* RBC-2.53* HGB-7.6* HCT-23.4* MCV-93 MCH-29.9 MCHC-32.3 RDW-19.9* [**2142-4-19**] 08:35AM PLT COUNT-93* . [**2142-4-19**] 08:35AM GLUCOSE-88 UREA N-36* CREAT-6.0* SODIUM-135 POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-25 ANION GAP-15 [**2142-4-19**] 08:35AM CALCIUM-9.4 PHOSPHATE-5.3* MAGNESIUM-2.0 . [**2142-4-20**] 08:40AM PT-28.3* PTT-45.3* INR(PT)-2.9* . CXR PA and LAT: IMPRESSION: 1. Persistent cardiomegaly with prominence of pulmonary vasculature suggesting overhydration. Minimal costophrenic angle blunting may suggest small effusions. 2. No definite consolidation, although increased retrocardiac density is noted, most likely due to atelectasis and vascular congestion. Repeat imaging following diuresis could be considered. . INR trend: [**2142-4-19**] 09:30AM BLOOD PT-30.4* INR(PT)-3.1* [**2142-4-20**] 08:40AM BLOOD PT-28.3* PTT-45.3* INR(PT)-2.9* [**2142-4-21**] 04:07AM BLOOD PT-29.9* PTT-48.9* INR(PT)-3.1* [**2142-4-22**] 05:55AM BLOOD PT-33.3* PTT-54.1* INR(PT)-3.5* Brief Hospital Course: 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented to the ICU for hypertensive emergency, dyspnea, and headache, now resolved. . Hypertensive Emergency: Patient's blood pressure normalized with transient nitroglycerin and labetalol drips. Likely precipitated by lack of ultrafiltration at [**Year/Month/Day 2286**] yesterday. She has received [**Year/Month/Day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - Nifedipine 150 mg Tablet SR daily - Hydralazine 100 mg Tablet Q8H - Labetalol 1000 mg Tablet TID - Aliskiren 150 mg Tablet PO BID - Clonidine 0.2 mg/24 hr Patch Weekly - Hydralazine 100 mg PO PRN for SBP > 200 - continue regular [**Year/Month/Day 2286**] schedule . Social Issues/repeated admissions: The ICU and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. These episodes may be due to medication non-compliance and it may benefit Ms. [**Known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. Ms. [**Known lastname **] [**Last Name (Titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. Of note, she has missed [**Last Name (Titles) 2286**] sessions and often requests durations and flow rates for her [**Last Name (Titles) 2286**] that contradict recommendations by her nephrologist. This issue was left unresolved on discharge. . Chronic Abdominal Pain: Currently managed with PO dilaudid, fentanyl patch and lidocaine patch. Per MICU team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue PO dilaudid - continue lidocaine patch . Lupus Erythematous: Complicated by uveitis and ESRD. - continued prednisone . ESRD: On [**Last Name (Titles) 2286**]. Ultrafiltrate of 2 L on initial HD - continue outpatient regimen . Thrombocytopenia: Remained at baseline 80s to 130s. . Thrombotic Events: History of SVC thrombosis with negative workup. INR drifted up and was 3.5 on discharge. She was asked to hold her warfarin dose this PM and recheck her INR with VNA services on [**2142-4-23**] to be faxed to coumadin clinic in [**Company 191**]. - continued coumadin . Anemia: Hematocrit 24.5 initially. Baseline 23 to 28. . Medications on Admission: Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H Prednisone 1 mg Tablet Citalopram 20 mg Tablet Pantoprazole 40 mg Tablet, Warfarin 3 mg daily Gabapentin 300 mg TID Nifedipine 90 mg Tablet SR daily Nifedipine 60 mg Tablet SR daily Hydralazine 100 mg Tablet Q8H Labetalol 1000 mg Tablet TID Aliskiren 150 mg Tablet PO BID Clonidine 0.2 mg/24 hr Patch Weekly Docusate Sodium 100 mg Capsule PO BID Senna 8.6 mg Tablet Fentanyl 25 mcg/hr Patch 72 hr Lidocaine 5 %(700 mg/patch) daily Hydralazine 100 mg PO:PRN for SBP > 200 Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) 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 3 mg Tablet Sig: One (1) Tablet PO once a day: DO NOT TAKE DOSE ON [**2142-4-22**]. Then restart per your PCP. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QHS (once a day (at bedtime)). 9. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 10. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 17. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed: For systolic blood pressure > 200. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Malignant Hypertension Systemic Lupus Erythematosus End Stage Renal Disease Abdominal Pain Discharge Condition: good, VSS, on room air, pain controlled. Discharge Instructions: You came to the hospital for shortness of breath and hypertension. You were given antihypertensive drips and during [**Location (un) 2286**] 2 liters were taken off with good improvement in your shortness of breath. You will need to take your medications as prescribed and follow-up with all of your doctors to prevent coming into the hospital. . Medication changes: - Please do not take your coumadin tonight because your INR is too high. You will need to have it checked by VNA services and adjusted. - Please take ALL of your medications as prescribed. . Please call your doctor or return to the ED if you have intractable headaches, shortness of breath, intractable pain or other concerns. Followup Instructions: Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-4-26**] 3:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Completed by:[**2142-4-23**]",26,2142-04-20 13:39:00,2142-04-22 15:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,PULMONARY EDEMA;HYPERTENSION," 24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. . hypertensive emergency: patients blood pressure normalized with transient nitroglycerin and labetalol drips. likely precipitated by lack of ultrafiltration at [**year/month/day 2286**] yesterday. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - nifedipine 150 mg tablet sr daily - hydralazine 100 mg tablet q8h - labetalol 1000 mg tablet tid - aliskiren 150 mg tablet po bid - clonidine 0.2 mg/24 hr patch weekly - hydralazine 100 mg po prn for sbp > 200 - continue regular [**year/month/day 2286**] schedule . social issues/repeated admissions: the icu and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. these episodes may be due to medication non-compliance and it may benefit ms. [**known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. ms. [**known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. this issue was left unresolved on discharge. . chronic abdominal pain: currently managed with po dilaudid, fentanyl patch and lidocaine patch. per micu team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue po dilaudid - continue lidocaine patch . lupus erythematous: complicated by uveitis and esrd. - continued prednisone . esrd: on [**last name (titles) 2286**]. ultrafiltrate of 2 l on initial hd - continue outpatient regimen . thrombocytopenia: remained at baseline 80s to 130s. . thrombotic events: history of svc thrombosis with negative workup. inr drifted up and was 3.5 on discharge. she was asked to hold her warfarin dose this pm and recheck her inr with vna services on [**2142-4-23**] to be faxed to coumadin clinic in [**company 191**]. - continued coumadin . anemia: hematocrit 24.5 initially. baseline 23 to 28. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Unspecified iridocyclitis; Other primary cardiomyopathies; Unspecified disease of pericardium; ; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Noncompliance with renal dialysis; Personal history of noncompliance with medical treatment, presenting hazards to health; Surgical or other procedure not carried out because of patient's decision; Abdominal pain, left lower quadrant; Renal dialysis status; Thrombocytopenia, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Peripheral vascular disease, unspecified; Acquired absence of organ, eye; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus]","24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. ultrafiltrate of 2 l on initial hd - continue outpatient regimen .","malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips." 109,151240.0,14858,2142-05-18,14801,173633.0,2141-12-14,Discharge summary,"Admission Date: [**2141-12-8**] Discharge Date: [**2141-12-14**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 8104**] Chief Complaint: abdominal pain & hypertension Major Surgical or Invasive Procedure: Hemodialysis PICC Line [**12-11**] History of Present Illness: Ms [**Known lastname **] is a 24 year old woman with a history of CKD V (on HD) from lupus nephritis, chronic intermittent abdominal pain, and multiple prior ICU admissions for hypertensive urgency who presented to the ED complaining of two days' of abdominal pain, nausea, and loose stools. She was feeling well until after her hemodialysis session on Wednesday. Thereafter, she complained of nausea with occasional vomitting and has been unable to keep down any of her oral medications. She also has had diffuse abdominal pain consistent with her prior flares of pain as well as her typical diffuse headache. The headache in particular was worsening and, for her, this is a sign of poorly-controlled hypertension so she came to the [**Hospital1 18**] ED. Upon arrival to the ED, she was afebrile, BP 240/184, HR 109, RR 16, Sat 99% on room air. She was given 4 mg of IV ondansetron, [**1-11**] inch intropaste, 1 mg of IV hydromorphone x3, 1000cc of NS, and was put on a labetalol drip which had to be increased up to 2 mg/min. A head CT showed no acute abnormality (including hemorrhage) and an abdominal CT showed some possible mild colitis, though it is unclear if this is due to her recent peritoneal dialysis. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 97.9 BP 165/120 HR 93 RR 12 Sat 100% ra Gen: mildly fatigued, but no distress HEENT: oropharynx clear Neck: no JVP, no LAD Chest: clear to auscultation throughout, no w/r/r CV: reg rate/rhythm, nl s1s2, ? s4, no murmurs or rubs heard Abdomen: soft, tender diffusely to moderate palpation without rebound or guarding; hyperactive bowel sounds; no masses or HSM, PD catheter in palce Extr: no edema, 2+ PT pulses Neuro: alert, appropriate, strength grossly intact in all four limbs Skin: no rashes Pertinent Results: [**2141-12-14**] 05:53AM BLOOD WBC-4.3 RBC-2.81* Hgb-8.6* Hct-25.6* MCV-91 MCH-30.7 MCHC-33.8 RDW-19.3* Plt Ct-148* [**2141-12-14**] 05:53AM BLOOD PT-42.6* PTT-51.0* INR(PT)-4.7* [**2141-12-10**] 05:10AM BLOOD Ret Aut-2.5 [**2141-12-14**] 05:53AM BLOOD Glucose-83 UreaN-21* Creat-5.1*# Na-138 K-5.3* Cl-105 HCO3-24 AnGap-14 [**2141-12-10**] 05:10AM BLOOD LD(LDH)-234 Amylase-347* TotBili-0.1 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-10**] 05:10AM BLOOD Lipase-72* [**2141-12-14**] 05:53AM BLOOD Calcium-8.2* Phos-4.5 Mg-1.7 [**2141-12-10**] 05:10AM BLOOD Hapto-142 [**2141-12-8**] 04:02AM BLOOD calTIBC-138* VitB12-445 Folate-18.5 Ferritn-220* TRF-106* ON ADMISSION: [**2141-12-7**] 09:50PM BLOOD WBC-4.5 RBC-2.78* Hgb-8.4* Hct-25.2* MCV-91 MCH-30.2 MCHC-33.3 RDW-19.2* Plt Ct-158 [**2141-12-7**] 09:50PM BLOOD Neuts-65.2 Lymphs-23.4 Monos-8.0 Eos-2.9 Baso-0.4 [**2141-12-7**] 09:50PM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3* [**2141-12-8**] 04:02AM BLOOD Ret Aut-2.5 [**2141-12-7**] 09:50PM BLOOD Glucose-89 UreaN-25* Creat-5.1*# Na-139 K-4.8 Cl-104 HCO3-26 AnGap-14 [**2141-12-7**] 09:50PM BLOOD ALT-14 AST-51* AlkPhos-94 TotBili-0.3 [**2141-12-7**] 09:50PM BLOOD Lipase-89* [**2141-12-7**] 09:50PM BLOOD Albumin-3.3* Calcium-8.3* Phos-4.9* Mg-1.9 [**2141-12-7**] 09:54PM BLOOD Glucose-75 Lactate-1.3 Na-139 K-4.8 Cl-101 calHCO3-23 Micro: Blood Cx: [**12-7**], [**12-7**], [**12-11**], [**12-11**] No growth FECAL CULTURE (Final [**2141-12-10**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2141-12-10**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2141-12-8**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2141-12-8**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). CT HEAD [**2141-12-8**]: IMPRESSION: 1. No acute intracranial pathology including no hemorrhage. 2. The hypodensities noted in the parietal white matter are stable. However in the setting of the hypertension, PRES cannot be excluded. If further evaluation is required MR can be obtained. CT Abdomin/Pelvis [**2141-12-8**] IMPRESSION: 1. Moderate amount of free fluid in the pelvis is compatible with the patient's known peritoneal dialysis. Unchanged peritoneal enhancement. 2. Stable liver hemangioma. CXR [**12-11**] IMPRESSION: Small left pleural effusion. Left lower lobe opacity which is either atelectasis versus pneumonia. Brief Hospital Course: 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. MICU course: Current plan on transfer 24 year old woman with CKD V and severe hypertension due to SLE admitted with flare of chronic abdominal pain and hypertensive urgency. 1. Hypertensive urgency: The patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. Initially her blood pressure over-corrected to SBPs in the 80s (patient was asymptomatic). Her clonidine patch and hydralazine was held and she again became hypertensive with SBPs 190s. The patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. The following dialysis the patient asymptomatic with SBPs in 80s, MAPs 60s asymptomatic again. Her hydralazine was stopped and continued on all her other home medications at the advice of renal. The patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. On [**12-11**] the patient's SBP dropped to the 80's and due to her pain medications she was extremely lethargic, but arousable. A PICC line was placed because lack of access and she was bolused 250cc NS. The patient's pressures responded and additional narcotics were held due to her mental status. The patient's blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. The patient did require IV hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. A possible component to the patient's malignant hypertension is likely due to OSA. An inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on BiPAP for OSA. The patient was continuned on her admission hypertensive regimen. . 2. Abdominal pain: The etiology of her abdominal pain is unclear, but has been a chronic issue for her. A CT scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. The patient also had diarrhea, but stool studies were negative. The patient's pain was initially treated with hydromorphone, but because of the patient's lethargy on [**12-11**] they were initially held. She continued to complain of severe abdominal pain. She was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. Surgery was consulted in regards to removal of her PD catheter, but given that she may return to PD it was deferred to the outpatient setting. 3. CKD V from lupus nephritis: The patient was continued on HD during her admission. She was also continued on her home prednisone dose. She was closely followed by the renal team. . 4. History of SVC/subclavian vein thrombus: The patient was found to have a subtherapeutic INR on admission 1.3. She was started on a heparin gtt and continued on coumadin. The patient's heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her PICC line was placed. She was therapetuic the same day and her heparin gtt was stopped. On discharge her coumadin was supratherapeutic (4.7) and was held. She will have her INR checked at HD. . 5. Anemia: The patient's Hct slowly trended down. She was guaiac negative and hemolysis labs were negative. She was transfused 1U pRBC at HD on [**12-12**]. She was also given epo at HD. Medications on Admission: prednisone 4 mg daily clonidine 0.3 mg/day patch qWeek ergocalciferol 50,000 units qMonth nifedipine SR 90 mg daily hydralazine 100 mg q8h citalopram 20 mg daily warfarin 2 mg qhs gabapentin 300 mg [**Hospital1 **] hydromorphone 4 mg q4h prn clonazepam 0.5 mg [**Hospital1 **] alikiren 150 mg [**Hospital1 **] docusate 100 mg [**Hospital1 **] senna 8.6 mg [**Hospital1 **] prn acetaminophen prn labetalol 800 mg q8h bisacodyl 5 mg daily prn Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Hydromorphone 4 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. [**Hospital1 **]:*84 Tablet(s)* Refills:*0* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever. 10. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed: please take as needed for anxiety prior to CPAP at bedtime. [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 14. CPAP Home CPAP Dx: OSA Prefer: AutoCPAP/ Pressure setting [**5-20**] Alt: Straight CPAP/ Pressure setting 7 Discharge Disposition: Home Discharge Diagnosis: Primary: Hypertensive Urgency Abdominal Pain ESRD on HD SVC Thrombus Secondary: Systemic lupus erythematosus Malignant hypertension Thrombocytopenia HOCM Anemia History of left eye enucleation History of vaginal bleeding Thrombotic microangiopathy Discharge Condition: Stable Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because of elevated blood pressure and abdominal pain. You were initially admitted to the ICU and your blood pressure was controlled. You were stabilized and transferred back to th floor. Your pressures remained stable throughout the rest of your stay. Additionally, you had abdominal pain and diarrhea. Your stool was tested for infections and was negative. Your diarrhea resolved without intervention. Your abdominal pain was controlled with pain medications. You had a sleep study in the hospital which showed that you had sleep apnea. Please continue to take your medications as prescribed. 1. Please do not take your coumadin until your doctor tells you to. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: You will have dialysis at [**Location (un) **] Dialysis on your normal schedule. You need to go to dialysis on Saturday. Please follow-up with the Sleep Clinic in [**12-19**] @ 11:45 Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**] Please follow-up with your PCP [**Last Name (NamePattern4) **] [**1-11**] weeks PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Completed by:[**2141-12-16**]",155,2141-12-08 01:40:00,2141-12-14 17:16:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. micu course: current plan on transfer 24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. 1. hypertensive urgency: the patient was initially maintained on a labetalol drip and hydralazine iv prn until oral anti-hypertensives lowered her blood pressure. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). her clonidine patch and hydralazine was held and she again became hypertensive with sbps 190s. the patient was restarted on a low dose clonidine 0.1 mg/24 hr patch, and hydralazine. the following dialysis the patient asymptomatic with sbps in 80s, maps 60s asymptomatic again. her hydralazine was stopped and continued on all her other home medications at the advice of renal. the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. on [**12-11**] the patients sbp dropped to the 80s and due to her pain medications she was extremely lethargic, but arousable. a picc line was placed because lack of access and she was bolused 250cc ns. the patients pressures responded and additional narcotics were held due to her mental status. the patients blood pressures continued to be labile and her clonidine patch was increased to 0.3mg/24hr and her hydralazine was titrated back to 100mg daily. the patient did require iv hydralazine prn for control of her blood pressures initially, but was stablized back on her home regimen. a possible component to the patients malignant hypertension is likely due to osa. an inpatient sleep study was performed overnight on [**12-13**] and the patient was sent home on bipap for osa. the patient was continuned on her admission hypertensive regimen. . 2. abdominal pain: the etiology of her abdominal pain is unclear, but has been a chronic issue for her. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. the patient also had diarrhea, but stool studies were negative. the patients pain was initially treated with hydromorphone, but because of the patients lethargy on [**12-11**] they were initially held. she continued to complain of severe abdominal pain. she was slowly restarted back on her home regimen was 4mg po hydromorphone q6 as her mental status improved. surgery was consulted in regards to removal of her pd catheter, but given that she may return to pd it was deferred to the outpatient setting. 3. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was also continued on her home prednisone dose. she was closely followed by the renal team. . 4. history of svc/subclavian vein thrombus: the patient was found to have a subtherapeutic inr on admission 1.3. she was started on a heparin gtt and continued on coumadin. the patients heparin gtt was hled on [**12-10**] because of access issues, but was restarted on [**12-11**] after her picc line was placed. she was therapetuic the same day and her heparin gtt was stopped. on discharge her coumadin was supratherapeutic (4.7) and was held. she will have her inr checked at hd. . 5. anemia: the patients hct slowly trended down. she was guaiac negative and hemolysis labs were negative. she was transfused 1u prbc at hd on [**12-12**]. she was also given epo at hd. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Systemic lupus erythematosus; Other and unspecified noninfectious gastroenteritis and colitis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other iatrogenic hypotension; Obstructive sleep apnea (adult)(pediatric); Hemangioma of intra-abdominal structures; Other chronic pain; Abdominal pain, unspecified site; Abnormal coagulation profile; Renal dialysis status; Personal history of venous thrombosis and embolism]","24 year old woman with ckd v and severe hypertension due to sle admitted with flare of chronic abdominal pain and hypertensive urgency. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic). the patient was transferred to the floor on [**12-10**] after resolution of her hypertensive urgency with a decreased blood pressure regimen due to her hypotension in response to home doses of her medications. the patient was continuned on her admission hypertensive regimen. a ct scan was performed that showed bowel wall changes that are likely secondary to recent peritoneal dialysis and unrelated to pain. ckd v from lupus nephritis: the patient was continued on hd during her admission. she was therapetuic the same day and her heparin gtt was stopped.",24 year old woman with ckd v and severe hypertension due to sle admitted. patient was initially maintained on a labetalol drip and hydralazine iv prn. initially her blood pressure over-corrected to sbps in the 80s (patient was asymptomatic) 109,136572.0,14860,2142-06-20,14810,137510.0,2142-04-22,Discharge summary,"Admission Date: [**2142-4-20**] Discharge Date: [**2142-4-22**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 1253**] Chief Complaint: Dyspnea, malignant hypertension Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented with abdominal pain and shortness of breath. On [**2142-4-19**] she refused ultrafiltration at HD because she was at her dry weight. Awoke at 3 AM feeling more short of breath. She also had worsening abdominal pain and vomiting without hematemasis. She took all of her medications as prescribed including two new lidocaine patches, fentanyl patch and clonidine. She developed a slight frontal headache but no blurry vision or neurologic symptoms. ROS largely negative. . In the emergency room her initial vitals were T: 99.1 BP: 280/140 HR: 79 RR: 16 O2: 100% on RA. She had two large bore peripheral IVs placed. She received 100 mg PO hydralazine, 200 mg PO labetolol, zofran 4 mg IV, vancomycin 1 gram IV, levofloxacin 750 mg IV x 1 and was started on labetolol and nitroglycerin drips with control of her blood pressure to the 180s systolic. She had a CXR which was concerning for volume overload. She was admitted the MICU for further evaluation. . In the MICU she was stablized and transitioned to her home meds. Nephrology gave her HD with 2L UF and subjective improvement in SOB. . Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: On Admission per MICU team: Vitals: T: 96.5 BP: 162/120 HR: 79 RR: 13 O2: 100% on 4L General: Pleasant, comfortable, no distress HEENT: L eye enucleated. Moon facies. Right pupil reactive Heart: Regular rate and rhythm, s1 + s2, soft systolic murmur at RLSB, no rubs or gallops Respiratory: Crackles at bases bilaterally, no wheezes, rales, ronchi GI: soft, non-tender, non-distended, +BS GU: no foley Ext: Warm and well perfused, no clubbing, cyanosis or edema . Pertinent Results: [**2142-4-19**] 08:35AM WBC-3.8* RBC-2.53* HGB-7.6* HCT-23.4* MCV-93 MCH-29.9 MCHC-32.3 RDW-19.9* [**2142-4-19**] 08:35AM PLT COUNT-93* . [**2142-4-19**] 08:35AM GLUCOSE-88 UREA N-36* CREAT-6.0* SODIUM-135 POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-25 ANION GAP-15 [**2142-4-19**] 08:35AM CALCIUM-9.4 PHOSPHATE-5.3* MAGNESIUM-2.0 . [**2142-4-20**] 08:40AM PT-28.3* PTT-45.3* INR(PT)-2.9* . CXR PA and LAT: IMPRESSION: 1. Persistent cardiomegaly with prominence of pulmonary vasculature suggesting overhydration. Minimal costophrenic angle blunting may suggest small effusions. 2. No definite consolidation, although increased retrocardiac density is noted, most likely due to atelectasis and vascular congestion. Repeat imaging following diuresis could be considered. . INR trend: [**2142-4-19**] 09:30AM BLOOD PT-30.4* INR(PT)-3.1* [**2142-4-20**] 08:40AM BLOOD PT-28.3* PTT-45.3* INR(PT)-2.9* [**2142-4-21**] 04:07AM BLOOD PT-29.9* PTT-48.9* INR(PT)-3.1* [**2142-4-22**] 05:55AM BLOOD PT-33.3* PTT-54.1* INR(PT)-3.5* Brief Hospital Course: 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented to the ICU for hypertensive emergency, dyspnea, and headache, now resolved. . Hypertensive Emergency: Patient's blood pressure normalized with transient nitroglycerin and labetalol drips. Likely precipitated by lack of ultrafiltration at [**Year/Month/Day 2286**] yesterday. She has received [**Year/Month/Day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - Nifedipine 150 mg Tablet SR daily - Hydralazine 100 mg Tablet Q8H - Labetalol 1000 mg Tablet TID - Aliskiren 150 mg Tablet PO BID - Clonidine 0.2 mg/24 hr Patch Weekly - Hydralazine 100 mg PO PRN for SBP > 200 - continue regular [**Year/Month/Day 2286**] schedule . Social Issues/repeated admissions: The ICU and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. These episodes may be due to medication non-compliance and it may benefit Ms. [**Known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. Ms. [**Known lastname **] [**Last Name (Titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. Of note, she has missed [**Last Name (Titles) 2286**] sessions and often requests durations and flow rates for her [**Last Name (Titles) 2286**] that contradict recommendations by her nephrologist. This issue was left unresolved on discharge. . Chronic Abdominal Pain: Currently managed with PO dilaudid, fentanyl patch and lidocaine patch. Per MICU team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue PO dilaudid - continue lidocaine patch . Lupus Erythematous: Complicated by uveitis and ESRD. - continued prednisone . ESRD: On [**Last Name (Titles) 2286**]. Ultrafiltrate of 2 L on initial HD - continue outpatient regimen . Thrombocytopenia: Remained at baseline 80s to 130s. . Thrombotic Events: History of SVC thrombosis with negative workup. INR drifted up and was 3.5 on discharge. She was asked to hold her warfarin dose this PM and recheck her INR with VNA services on [**2142-4-23**] to be faxed to coumadin clinic in [**Company 191**]. - continued coumadin . Anemia: Hematocrit 24.5 initially. Baseline 23 to 28. . Medications on Admission: Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H Prednisone 1 mg Tablet Citalopram 20 mg Tablet Pantoprazole 40 mg Tablet, Warfarin 3 mg daily Gabapentin 300 mg TID Nifedipine 90 mg Tablet SR daily Nifedipine 60 mg Tablet SR daily Hydralazine 100 mg Tablet Q8H Labetalol 1000 mg Tablet TID Aliskiren 150 mg Tablet PO BID Clonidine 0.2 mg/24 hr Patch Weekly Docusate Sodium 100 mg Capsule PO BID Senna 8.6 mg Tablet Fentanyl 25 mcg/hr Patch 72 hr Lidocaine 5 %(700 mg/patch) daily Hydralazine 100 mg PO:PRN for SBP > 200 Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) 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 3 mg Tablet Sig: One (1) Tablet PO once a day: DO NOT TAKE DOSE ON [**2142-4-22**]. Then restart per your PCP. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QHS (once a day (at bedtime)). 9. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 10. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 17. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed: For systolic blood pressure > 200. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Malignant Hypertension Systemic Lupus Erythematosus End Stage Renal Disease Abdominal Pain Discharge Condition: good, VSS, on room air, pain controlled. Discharge Instructions: You came to the hospital for shortness of breath and hypertension. You were given antihypertensive drips and during [**Location (un) 2286**] 2 liters were taken off with good improvement in your shortness of breath. You will need to take your medications as prescribed and follow-up with all of your doctors to prevent coming into the hospital. . Medication changes: - Please do not take your coumadin tonight because your INR is too high. You will need to have it checked by VNA services and adjusted. - Please take ALL of your medications as prescribed. . Please call your doctor or return to the ED if you have intractable headaches, shortness of breath, intractable pain or other concerns. Followup Instructions: Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-4-26**] 3:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Completed by:[**2142-4-23**]",59,2142-04-20 13:39:00,2142-04-22 15:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,PULMONARY EDEMA;HYPERTENSION," 24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. . hypertensive emergency: patients blood pressure normalized with transient nitroglycerin and labetalol drips. likely precipitated by lack of ultrafiltration at [**year/month/day 2286**] yesterday. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - nifedipine 150 mg tablet sr daily - hydralazine 100 mg tablet q8h - labetalol 1000 mg tablet tid - aliskiren 150 mg tablet po bid - clonidine 0.2 mg/24 hr patch weekly - hydralazine 100 mg po prn for sbp > 200 - continue regular [**year/month/day 2286**] schedule . social issues/repeated admissions: the icu and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. these episodes may be due to medication non-compliance and it may benefit ms. [**known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. ms. [**known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. this issue was left unresolved on discharge. . chronic abdominal pain: currently managed with po dilaudid, fentanyl patch and lidocaine patch. per micu team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue po dilaudid - continue lidocaine patch . lupus erythematous: complicated by uveitis and esrd. - continued prednisone . esrd: on [**last name (titles) 2286**]. ultrafiltrate of 2 l on initial hd - continue outpatient regimen . thrombocytopenia: remained at baseline 80s to 130s. . thrombotic events: history of svc thrombosis with negative workup. inr drifted up and was 3.5 on discharge. she was asked to hold her warfarin dose this pm and recheck her inr with vna services on [**2142-4-23**] to be faxed to coumadin clinic in [**company 191**]. - continued coumadin . anemia: hematocrit 24.5 initially. baseline 23 to 28. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Unspecified iridocyclitis; Other primary cardiomyopathies; Unspecified disease of pericardium; ; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Noncompliance with renal dialysis; Personal history of noncompliance with medical treatment, presenting hazards to health; Surgical or other procedure not carried out because of patient's decision; Abdominal pain, left lower quadrant; Renal dialysis status; Thrombocytopenia, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Peripheral vascular disease, unspecified; Acquired absence of organ, eye; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus]","24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. ultrafiltrate of 2 l on initial hd - continue outpatient regimen .","malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips." 109,174489.0,14861,2142-07-04,14858,151240.0,2142-05-18,Discharge summary,"Admission Date: [**2142-5-15**] Discharge Date: [**2142-5-18**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 613**] Chief Complaint: Headache, Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis x 2 History of Present Illness: 24 year old female with SLE, ESRD on HD, hx malignant HTN, h/o SVC syndrome, h/o posterior reversible encephalopathy syndrome (PRES) and prior intracerebral hemorrhage, recently admitted [**Date range (1) 17717**] with diarrhea, hypertensive urgency. Treated at that time with nicardipine drip for a short period and then to her home regimen. Yesterday onset of nausea with emesis and inability to tolerate home meds including antihypertensives. Diarrhea mild as prior. No fever, chills, no hematemesis or hematochezia. No melena. Today reports onset of headache therefore to the ED. In the ED, initial vs were 280/160, 99.4, 105, RR 18. She was given dilaudid 2 mg PO x 2. Hydral 20 mg x 3 for BP. Calcium gluconate 1 gram. Insulin 10 units, D 50 [**1-12**] amp, sodium bicarbonate, kayexalate for K 6.7 (dialysis dependent Tues/thurs/sat) but with report of peaked T waves. Renal dialysis fellow was not contact[**Name (NI) **]. HCT 33.4, WBC 4.6, trop 0.10. Admitted for hypertensive urgency to ICU. No gtt was started. Of note usualy BP 160/100. Review of sytems: patient tearful complaining of frontal headache and nausea Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: Vitals: BP 240/146, 101, 98.6, General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardic, 3/6 SEM RUSB Abdomen: soft, diffusely tender, no rebound or gaurding. Ext: cachectic, warm, 2+ DP pulse no clubbing, cyanosis or edema Pertinent Results: [**2142-5-15**] 05:45AM GLUCOSE-83 UREA N-54* CREAT-7.6* SODIUM-138 POTASSIUM-6.7* CHLORIDE-103 TOTAL CO2-23 ANION GAP-19 [**2142-5-15**] 05:45AM CK(CPK)-96 [**2142-5-15**] 05:45AM cTropnT-0.10* [**2142-5-15**] 05:45AM CK-MB-NotDone [**2142-5-15**] 05:45AM WBC-4.6 RBC-3.66* HGB-10.8* HCT-33.4* MCV-91 MCH-29.6 MCHC-32.4 RDW-17.9* [**2142-5-15**] 05:45AM NEUTS-65.4 LYMPHS-25.1 MONOS-4.8 EOS-4.1* BASOS-0.7 [**2142-5-15**] 05:45AM PLT COUNT-128* [**2142-5-15**] 05:45AM PT-14.2* PTT-36.4* INR(PT)-1.2* [**2142-5-15**] 07:14AM K+-6.0* [**2142-5-15**] 12:17PM K+-5.3 Images: CXR: Persistent severe cardiomegaly. Head CT: Normal brain CT. Brief Hospital Course: 24 yo female with ESRD on HD, malignant hypertension with hx of intracerebral hemorrhage, SLE, chronic abdominal pain, and SVC syndrome admitted due to hypertensive urgency after developing N/V and being unable to take her po medications. # Hypertensive urgency: The patient was admitted to the MICU the night of admission where she was placed on a labetolol drip and her home medications were restarted. head CT was negative for intracranial bleed. She was continued on her home regimen of Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet Sustained Release QAM, and Hydralazine 100 mg PO Q8H. During her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. Blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). She was discharged on her home regimen. # Nausea/vomiting: The patient did not experience further vomiting, but occasionally complained of nausea. The cause of her nausea was unclear. She was able to tolerate po intake prior to discharge. # Abdominal pain/Diarrhea: The patient has chronic abdominal pain with previous negative workups. During this hospitalization her pain was at its baseline. Since admission she denied diarrhea. She was continued on her outpatient regimen of [**2-14**] mg po dilaudid q4h as needed. # ESRD on HD: She was hyperkalemic in the emergency room and was given kayexalate. She underwent two sessions of dialysis during this hospitalization. # SLE: Stable, without symptoms. She was continued on 4 mg of prednisone daily. # History of thrombotic events/SVC syndrome: She is anticoagulated with warfarin as an outpatient, however her INR was subtherapeutic on admission at 1.2. Previous documentation in OMR states she does not need to be bridged while subtherapeutic. She was initally continued on coumadin 4 mg po daily, however her INR rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # OSA: She is on CPAP at a setting of 7 as an outpatient and was continued on this during her hospitalization. Medications on Admission: Medications: as per last discharge summary -Aliskiren 150 mg Tablet [**Hospital1 **] -Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday) -Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). -Labetalol 200 mg Tablet Sig 5 tab TID -Nifedipine 60 mg Tablet Sustained Release QPM -Nifedipine 90 mg Tablet Sustained Release QAM -Citalopram 20 mg Tablet Sig daily -Hydromorphone 2 mg Tablet Sig [**1-12**] Q4 PRN -Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). -Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H -Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID PRN -Prednisone 4 mg daily -Coumadin 4 mg daily at 4 PM Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QPM (once a day (in the evening)). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 10. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO twice a day as needed for hypertension. 13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary - Hypertensive urgency End-stage renal disease on dialysis Secondary - Systemic lupus erythematous History of thombosis and Superior vena cava syndrome Obstructive sleep apnea Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital due to dangerously elevated blood pressure due to inability to take your medications secondary to nausea. It is very important that you take your blood pressure medications reguarly. Your nausea was controlled with medication and your blood pressure decreased once back on your home medication regimen. You underwent two sessions of dialysis during your hospitalization. It is extremely important that you attend dialysis three times weekly as an outpatient. Medication changes: You should be taking 3 mg of coumadin daily. You will need to have your INR checked at dialysis. Otherwise continue your outpatient medications as prescribed. Call your primary doctor, or go to the emergency room if you experience fevers, chills, worsening headache, vision change, inability to take your medications, blood in your stool, or dark black stool. Followup Instructions: It is very important that you keep your previously scheduled appointments: You have an appointment with gynecology to evaluate an abnormality recently seen on PAP smear. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-6-1**] 2:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-5-19**]",47,2142-05-15 10:45:00,2142-05-18 15:58:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSIVE CRISIS," 24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. # hypertensive urgency: the patient was admitted to the micu the night of admission where she was placed on a labetolol drip and her home medications were restarted. head ct was negative for intracranial bleed. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, and hydralazine 100 mg po q8h. during her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). she was discharged on her home regimen. # nausea/vomiting: the patient did not experience further vomiting, but occasionally complained of nausea. the cause of her nausea was unclear. she was able to tolerate po intake prior to discharge. # abdominal pain/diarrhea: the patient has chronic abdominal pain with previous negative workups. during this hospitalization her pain was at its baseline. since admission she denied diarrhea. she was continued on her outpatient regimen of [**2-14**] mg po dilaudid q4h as needed. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. she underwent two sessions of dialysis during this hospitalization. # sle: stable, without symptoms. she was continued on 4 mg of prednisone daily. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient, however her inr was subtherapeutic on admission at 1.2. previous documentation in omr states she does not need to be bridged while subtherapeutic. she was initally continued on coumadin 4 mg po daily, however her inr rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # osa: she is on cpap at a setting of 7 as an outpatient and was continued on this during her hospitalization. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other primary cardiomyopathies; Unspecified disease of pericardium; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Hyperpotassemia; Nausea with vomiting; Diarrhea; Disorders of phosphorus metabolism; Anemia of other chronic disease; Abdominal pain, left lower quadrant; Other chronic pain; Thrombocytopenia, unspecified; Other specified peripheral vascular diseases; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus; Long-term (current) use of anticoagulants; Noncompliance with renal dialysis; Renal dialysis status; Personal history of noncompliance with medical treatment, presenting hazards to health]","24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. she was able to tolerate po intake prior to discharge. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. previous documentation in omr states she does not need to be bridged while subtherapeutic.","24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg" 109,174489.0,14861,2142-07-04,14859,102024.0,2142-06-05,Discharge summary,"Admission Date: [**2142-5-20**] Discharge Date: [**2142-6-5**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 3705**] Chief Complaint: abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname **] is a 24 yo F with lupus since age 16, with ESRD on HD, malignant HTN, history of SVC syndrome, and history of Posterior Reversible Encephalopathy Syndrome (PRES) and intracerebral hemorrhage, who has had multiple recent admissions [**Date range (1) 43604**], [**Date range (1) 17717**], [**Date range (1) **], [**4-26**], [**Date range (1) 42063**], [**Date range (1) 43605**] mostly for hypertension, but most recently for diarrhea in addition to hypertension. . In the ED, vitals were 98 90 102/65 20 98% RA. She was complaining of abdominal pain X 3 hours, more severe than usual [**7-20**], no N/V/D. She received dilaudid 4 mg PO X 3, zofran 8mg IV, hyperkalemia 6.2=>5.3 w/ Kayexalate. Initially, she was felt stable for floor; however, BP rose during ED course to SBP 270. She then received hydral 50 PO X 1, home aliskeren, labetalol 1000 PO X 1, 20 IV hydral X 2, labetalol 100 Iv X 1, nicardipine 2.5 mg IV X 1 and started on nicardipine gtt. . Upon arrival to the floor, she complains of severe abd pain which started earlier today, it is sharp all over her abd and constant. It feels different from her usual abd pain, although she is not able to characterize it more. She has been having some nausea and bilious emesis X 1 earlier today. She has been having some mild diarrhea 2-3 episodes of loose, greenish stools for the past few weeks. She denies any chest pain, headache, vision changes. She was not able to take all of the medications due to her GI distress. . While in the MICU she was weaned off a nicardipine drip and her diarrhea resolved. Her BP remained WNL while on her home regimen and she was transferred to the floor in stable condition. Last HD was [**2142-5-21**]. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**] and [**2142-4-12**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting - has appt scheduled with gyn on [**5-25**] 17. History of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] which has resolved Social History: Denies any substance abuse (EtOH, tobacco, illicits). She lives with her mother and brother. 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: 100/63 81 18 100RA GENERAL: Pleasant, thin young female sitting in the bed in NAD watching TV. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. s/p left eye enucleation. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD. CARDIAC: RRR. 4/6 systolic murmur heard best at the RUSB. LUNGS: Breathing comfortably, CTAB, good air movement biaterally. ABDOMEN: + BS, soft ND, tenderness to palpation in her LUQ. No rebound or guarding. EXTREMITIES: No edema. Right femoral HD line nontender, nonerythematous. SKIN: Several subcutaneous cysts of different sizes 1 - 3 cm scattered along her lower extremities. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation to light touch throughout. 5/5 strength in her upper and lower extremities PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2142-5-20**] 09:14PM LACTATE-0.9 [**2142-5-20**] 09:13PM WBC-6.8 RBC-3.65* HGB-10.7* HCT-33.7* MCV-93 MCH-29.2 MCHC-31.6 RDW-18.8* [**2142-5-20**] 09:13PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ TEARDROP-OCCASIONAL [**2142-5-20**] 09:13PM PLT COUNT-145* [**2142-5-20**] 08:55PM GLUCOSE-98 UREA N-44* CREAT-7.7* SODIUM-137 POTASSIUM-6.3* CHLORIDE-102 TOTAL CO2-20* ANION GAP-21* [**2142-5-20**] 08:55PM CALCIUM-9.9 PHOSPHATE-5.8* MAGNESIUM-2.1 [**2142-5-20**] 08:55PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2142-5-20**] 08:55PM WBC-7.0 RBC-3.69* HGB-11.1* HCT-34.2* MCV-93 MCH-30.2 MCHC-32.5 RDW-19.2* [**2142-5-20**] 08:55PM PLT COUNT-126* [**2142-5-20**] 08:55PM PT-14.1* PTT-32.4 INR(PT)-1.2* [**2142-5-20**] 07:40AM ALT(SGPT)-18 AST(SGOT)-55* ALK PHOS-118* TOT BILI-0.4 [**2142-5-20**] 07:40AM LIPASE-58 Brief Hospital Course: KUB: SBO Head CT: (prelim read from radiology). unchanged from prior head CT, no intracranial hemorrhage EKG: NSR, right axis, LVH, nl intervals, ST elevations V2-3 (old), TW inversion V6 (new) compared to prior EKG [**5-15**]. CT CHEST/ABD: Preliminary Read Normal aorta without dissection or acute abnormality. No PE. Stable trace ascites and small right pleural effusion. Unchanged small pulmonary nodules and lymphadenopathy in the chest. No acute abnormalities in the abdomen to explain epigastric pain. EGD: Ulcer at GE junction. # Hypertensive urgency: This is a chronic issue related to ESRD. Head CT was negative for intracranial bleed. Weaned off Nicardipine gtt and BP well controlled on home regimen. Continued her home regimen of: Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet Sustained Release QAM, Hydralazine 100 mg PO Q8H. When BPs were lower (see below) patient's BP meds were held occasionally, but as she was transfused and the BPs started to trend back up the meds were re-initiated. She then developed hypotension in the setting of poor PO intake during her SBO. BP meds were held and then re-initiated as the pressure came back up once she was able to eat. # Abdominal pain/UGIB: The patient has chronic abdominal pain with previous negative workups. At first the pain resolved and she was continued on her outpatient regimen of: 2-4 mg po dilaudid q4 h as needed. GI was c/s re: abd pain and rec CTA-abdomen to eval for mesenteric ischemia vs. partial SBO, however with ESRD did not initially want to get CTA so KUB was ordered. This showed no SBO. They recommended checking urine porphyrobilinogen and serum lead levels which were negative and LFTs were at baseline. The patient then developed a different type of pain associated with her incision site. Pain service was consulted and did a bupivicaine injection at the site which did help. They will continue to follow her. She then developed a third type of pain associated with a burning sensation in her chest. EKG was unchanged from prior. A few hours later she had 3 episodes of coffee-ground emesis. She was placed on IV PPI and transfused two units of blood. Afterward the pain resolved and her hct remained stable. GI felt that the patient would need general anesthesia in order to undergo an EGD which showed an ulcer at the GE junction. She was started on empiric treatment for H. Pylori and serologies were sent which came back negative so the antibiotics were stopped. Her pain was controlled with her outpatient regimen of PO dilaudid. She will follow up with Dr. [**Last Name (STitle) **] in [**6-18**] weeks to have another EGD under MAC to see if there has been resolution of the ulcer. # SBO: Continued to be nauseous and vomited intermittently. she was started on reglan and continued on zofran and compazine PRN howeve she continued to have n/v. A KUB was done which showed an SBO. Surgery was consulted, NGT was placed, she was made NPO and serial abdominal exams were done. Eventually she was able to transition to clear diet and then tolerated a regular diet without pain or vomiting. #. Fever: On hospital day #6 she spiked a fever to 101. Blood and urine cultures were sent and a cxr were negative, however she then had a seizure and in the post-ictal state aspirated after vomiting. She had an episode of hypoxia with this and was transferred to the ICU. In the ICU LP was attempted to rule out meningitis as a possible cause of a seizure but this was unsuccessful. Broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. She improved over the next few days and antibiotics were discontinued because the suspicion for a bacterial meningitis was low. #. Seizure: This occured in the setting of fever, hypotension, and initiation of reglan for vomiting. Neurology was consulted and felt she should be continued on keppra indefinitely. EEG was non-revealing. She should be continued on keppra 1gm with dialysis three times weekly. # ESRD on HD: Hyperkalemia resolved with kayexalate. Underwent dialysis on normal schedule. # SLE: She was continued on prednisone 4mg daily. With multiple abdominal symptoms it was thought she may have lupus flare in the abdomen. C3, c4 were equivocal for active lupus flare, and [**Doctor First Name **] was positive, as would be expected in lupus. # Anemia: Has anemia of chronic renal disease and her Hct was high on admission and epo was held per renal. However, her Hct trended all the way down to 20 and she was borderline hypotensive for her (ie SBP 120) and she developed coffee ground emesis so she was transfused 2 units. Afterward her Hct was stable at 25. She was also re-started on EPO per renal for her chronic anemia. Hemolysis labs were negative. # History of thrombotic events/SVC syndrome: She is anticoagulated with warfarin as an outpatient. Previous documentation in OMR states she does not need to be bridged while subtherapeutic. Continued coumadin 4 mg po daily however INR became supratherapeutic and the coumadin was then held. She was started on heparin gtt while awaiting EGD. After EGD the coumadin was re-started at 3mg daily however, in setting of poor po intake her INR was supratherapeutic - likely [**2-12**] nutritional deficiency of vitamin k. coumadin will be restarted when INR [**2-13**] at dialysis. # OSA: She is on CPAP at a setting of 7 as an outpatient. Continued CPAP #. CIN1: On last pap had CIN1. OB/GYN service was called re: doing colposcopy in hospital as patient rarely makes o/p appointments, hwoever they do not do this procedure in hospital especially because it does not have to be done emergently - just within one year. Will need outpatient colposcopy at some point in next few months as they do not do this procedure in the hospital. # RLL nodule: A new 10 x 5 mm nodularity was found incidentally within the right lower lobe of the lung on an abdominal CT. This should be reassessed in 3 months. # ACCESS: PIV, right groin HD line # CODE: Full code Medications on Admission: 1. Aliskiren 150 mg PO bid 2. Citalopram 20 mg PO DAILY 3. Clonidine 0.2 mg/24 hr Patch Weekly QSAT 4. Hydromorphone 2 mg 1-2 Tablets PO Q4H 5. Fentanyl 25 mcg/hr Patch 72 hr 6. Gabapentin 300 mg PO TID 7. Hydralazine 100 mg PO Q8H 8. Hydralazine 100 mg PO BID PRn fro SBP> 180. 9. Prednisone 4 mg PO DAILY 10. Pantoprazole 40 mg PO Q24H 11. Labetalol 1000 mg PO TID 12. Nifedipine 90 mg PO QAM 13. Nifedipine 60 mg PO QHS 14. Warfarin 3 mg PO Once Daily 15. Lidocaine 5 %(700 mg/patch) Topical once a day. 16. Nifedipine 90 mg PO once a day as needed for for SBP persistently above 200. Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 2. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QHS (once a day (at bedtime)). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 30 days. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 16. LeVETiracetam 1,000 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: UGIB- Ulcer at GE junction Hypertensive Emergency Anemia ESRD on HD SBO Discharge Condition: The patient was afebrile and hemodynamically stable prior to discharge. Discharge Instructions: You were admitted to the hospital with abdominal pain. You had an injection of lidocaine to help the pain around your surgery sites. You then had some blood in your vomit. You were treated for a bleed in your stomach with a blood transfusion and medications. You stopped bleeding and felt better. You had a scope of your abdomen that showed an ulcer. You were treated with medications for this and need to have another scope of your abdomen in 6 weeks. You also had high blood pressures while you were here because you could not take your medicines with your nausea and vomiting. Once you were on your home medicines your blood pressure was better. Medication Changes: CHANGE: Pantoprazole to 40mg TWICE daily Please call your PCP or come to the emergency room if you have fevers, chills, worsening abdominal pain, nausea, vomiting, blood in your vomit, blood in your stools, black/tarry stools or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] (gastroenterology) in [**6-18**] weeks for an EGD to re-look at your ulcer. Please follow up with the OB/[**Hospital **] clinic for a colposcopy on Wednesday [**2142-8-8**] at 3:15pm in the [**Hospital Ward Name 23**] Building on the [**Location (un) **]. Their number is [**Telephone/Fax (1) 2664**]. Please follow up with Dr.[**Name (NI) **] at [**Hospital6 733**] in the Shapria building on the [**Location (un) **] on [**2142-6-27**] at 2:00pm. Completed by:[**2142-6-6**]",29,2142-05-20 12:59:00,2142-06-05 16:18:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," kub: sbo head ct: (prelim read from radiology). unchanged from prior head ct, no intracranial hemorrhage ekg: nsr, right axis, lvh, nl intervals, st elevations v2-3 (old), tw inversion v6 (new) compared to prior ekg [**5-15**]. ct chest/abd: preliminary read normal aorta without dissection or acute abnormality. no pe. stable trace ascites and small right pleural effusion. unchanged small pulmonary nodules and lymphadenopathy in the chest. no acute abnormalities in the abdomen to explain epigastric pain. egd: ulcer at ge junction. # hypertensive urgency: this is a chronic issue related to esrd. head ct was negative for intracranial bleed. weaned off nicardipine gtt and bp well controlled on home regimen. continued her home regimen of: aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, hydralazine 100 mg po q8h. when bps were lower (see below) patients bp meds were held occasionally, but as she was transfused and the bps started to trend back up the meds were re-initiated. she then developed hypotension in the setting of poor po intake during her sbo. bp meds were held and then re-initiated as the pressure came back up once she was able to eat. # abdominal pain/ugib: the patient has chronic abdominal pain with previous negative workups. at first the pain resolved and she was continued on her outpatient regimen of: 2-4 mg po dilaudid q4 h as needed. gi was c/s re: abd pain and rec cta-abdomen to eval for mesenteric ischemia vs. partial sbo, however with esrd did not initially want to get cta so kub was ordered. this showed no sbo. they recommended checking urine porphyrobilinogen and serum lead levels which were negative and lfts were at baseline. the patient then developed a different type of pain associated with her incision site. pain service was consulted and did a bupivicaine injection at the site which did help. they will continue to follow her. she then developed a third type of pain associated with a burning sensation in her chest. ekg was unchanged from prior. a few hours later she had 3 episodes of coffee-ground emesis. she was placed on iv ppi and transfused two units of blood. afterward the pain resolved and her hct remained stable. gi felt that the patient would need general anesthesia in order to undergo an egd which showed an ulcer at the ge junction. she was started on empiric treatment for h. pylori and serologies were sent which came back negative so the antibiotics were stopped. her pain was controlled with her outpatient regimen of po dilaudid. she will follow up with dr. [**last name (stitle) **] in [**6-18**] weeks to have another egd under mac to see if there has been resolution of the ulcer. # sbo: continued to be nauseous and vomited intermittently. she was started on reglan and continued on zofran and compazine prn howeve she continued to have n/v. a kub was done which showed an sbo. surgery was consulted, ngt was placed, she was made npo and serial abdominal exams were done. eventually she was able to transition to clear diet and then tolerated a regular diet without pain or vomiting. #. fever: on hospital day #6 she spiked a fever to 101. blood and urine cultures were sent and a cxr were negative, however she then had a seizure and in the post-ictal state aspirated after vomiting. she had an episode of hypoxia with this and was transferred to the icu. in the icu lp was attempted to rule out meningitis as a possible cause of a seizure but this was unsuccessful. broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. she improved over the next few days and antibiotics were discontinued because the suspicion for a bacterial meningitis was low. #. seizure: this occured in the setting of fever, hypotension, and initiation of reglan for vomiting. neurology was consulted and felt she should be continued on keppra indefinitely. eeg was non-revealing. she should be continued on keppra 1gm with dialysis three times weekly. # esrd on hd: hyperkalemia resolved with kayexalate. underwent dialysis on normal schedule. # sle: she was continued on prednisone 4mg daily. with multiple abdominal symptoms it was thought she may have lupus flare in the abdomen. c3, c4 were equivocal for active lupus flare, and [**doctor first name **] was positive, as would be expected in lupus. # anemia: has anemia of chronic renal disease and her hct was high on admission and epo was held per renal. however, her hct trended all the way down to 20 and she was borderline hypotensive for her (ie sbp 120) and she developed coffee ground emesis so she was transfused 2 units. afterward her hct was stable at 25. she was also re-started on epo per renal for her chronic anemia. hemolysis labs were negative. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient. previous documentation in omr states she does not need to be bridged while subtherapeutic. continued coumadin 4 mg po daily however inr became supratherapeutic and the coumadin was then held. she was started on heparin gtt while awaiting egd. after egd the coumadin was re-started at 3mg daily however, in setting of poor po intake her inr was supratherapeutic - likely [**2-12**] nutritional deficiency of vitamin k. coumadin will be restarted when inr [**2-13**] at dialysis. # osa: she is on cpap at a setting of 7 as an outpatient. continued cpap #. cin1: on last pap had cin1. ob/gyn service was called re: doing colposcopy in hospital as patient rarely makes o/p appointments, hwoever they do not do this procedure in hospital especially because it does not have to be done emergently - just within one year. will need outpatient colposcopy at some point in next few months as they do not do this procedure in the hospital. # rll nodule: a new 10 x 5 mm nodularity was found incidentally within the right lower lobe of the lung on an abdominal ct. this should be reassessed in 3 months. # access: piv, right groin hd line # code: full code ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction; Acute posthemorrhagic anemia; Unspecified intestinal obstruction; Other primary cardiomyopathies; Unspecified disease of pericardium; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Disorders of phosphorus metabolism; Hypotension, unspecified; Hyperpotassemia; Mononeuritis of unspecified site; Anemia of other chronic disease; Abdominal pain, left lower quadrant; Other chronic pain; Thrombocytopenia, unspecified; Diaphragmatic hernia without mention of obstruction or gangrene; Other specified peripheral vascular diseases; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus; Noncompliance with renal dialysis; Renal dialysis status; Long-term (current) use of anticoagulants; Personal history of noncompliance with medical treatment, presenting hazards to health]","kub: sbo head ct: (prelim read from radiology). ct chest/abd: preliminary read normal aorta without dissection or acute abnormality. bp meds were held and then re-initiated as the pressure came back up once she was able to eat. gi was c/s re: abd pain and rec cta-abdomen to eval for mesenteric ischemia vs. partial sbo, however with esrd did not initially want to get cta so kub was ordered. a few hours later she had 3 episodes of coffee-ground emesis. afterward the pain resolved and her hct remained stable. gi felt that the patient would need general anesthesia in order to undergo an egd which showed an ulcer at the ge junction. her pain was controlled with her outpatient regimen of po dilaudid. broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. she should be continued on keppra 1gm with dialysis three times weekly. c3, c4 were equivocal for active lupus flare, and [**doctor first name **] was positive, as would be expected in lupus. # anemia: has anemia of chronic renal disease and her hct was high on admission and epo was held per renal.","sbo head ct was negative for intracranial hemorrhage. no intracranial hemorrhage ekg: nsr, right axis, lvh, nl intervals, st elevations v2-3 (old), tw inversion v6 (new) no acute abnormalities in the abdomen to explain epigastric pain." 109,174489.0,14861,2142-07-04,14860,136572.0,2142-06-20,Discharge summary,"Admission Date: [**2142-6-18**] Discharge Date: [**2142-6-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 2145**] Chief Complaint: Acute Onset Dyspnea Major Surgical or Invasive Procedure: Dialysis History of Present Illness: Please see MICU note for full details. In brief this is a 24 y.o. woman with SLE, ESRD on HD, hx malignant HTN, h/o SVC syndrome, h/o posterior reversible encephalopathy syndrome (PRES) and prior intracerebral hemorrhage, frequently admitted with hypertensive urgency/emergency who was admitted with acute onset dyspnea after 2 weeks without dialysis given to unable to get transportation ? despite Dr. [**Last Name (STitle) 7473**] attempting to arrange transport for her (? refused to come). She was admitted therefore on [**6-18**] to micu with VS: T 100.4 HR 108 BP 240/180 RR 28 POx100 RA. She was treated with nitro gtt, labetolol gtt and dilaudid-these gtts were stopped at 0700. In the micu she was dialyzed with 1.7L fluid removal (though + 300cc given tranfusion). Her SOB is improved. Her hct was also noted to be low (18->from 22 [**2142-6-5**]) so transfused 2 units PRBC's, recent EGD with gastric ulcer [**5-29**], guaiac negative in ED, no BM in unit, hemolysis w/u negative. BP in icu 140/106 currently but of note was hypotensive on HD to 86/62. She notes sob improved rapidly on arrival. ROS: Currently she has no complaints. She notes at home her abdominal pain is at baseline for her, felt mid epigastric, for which she takes dilaudid 4mg up to [**Hospital1 **]. She has been getting HD via right femoral catheter which is not painful, no discharge from the sight. She denies HA, visual changes, cough, chest pain or pressure, orthostatic changes, palpitations, nausea, vomiting, constipation, diarrhea, melena, brbpr, dysuria, hematuria, rash, swelling, orthopnea, pnd. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Physical Exam: Vitals - T: 97.7, BP: 140/99 P: 88 R: 19 O2: 98% on RA General: Sleeping comfortably but awakens easily, alert, oriented x3 HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear, nonerythematous, MMM, moon facies Neck: supple, JVP flat, no LAD, full ROM, left EJ in place Lungs: coarse BS throughout, no W/R/R, no decreased BS at bases CV: S1, S2 nl, no m/r/g appreciated Abdomen: Firm, non-tender to palpation, no masses or organomegally Ext: Warm, well perfused, 1+ DP/PT, no clubbing, cyanosis or edema Neuro: a&o x3, motor [**5-15**] UE/LE bilaterally Pertinent Results: [**2142-6-18**] 05:28PM HCT-26.0*# [**2142-6-18**] 11:38AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL [**2142-6-18**] 05:04AM GLUCOSE-85 UREA N-72* CREAT-10.4* SODIUM-139 POTASSIUM-5.5* CHLORIDE-109* TOTAL CO2-14* ANION GAP-22* [**2142-6-18**] 05:04AM LD(LDH)-264* TOT BILI-0.2 [**2142-6-18**] 05:04AM CALCIUM-6.6* PHOSPHATE-6.5* MAGNESIUM-1.6 [**2142-6-18**] 05:04AM HAPTOGLOB-142 [**2142-6-18**] 05:04AM WBC-3.4* RBC-1.93* HGB-5.8* HCT-17.0* MCV-88 MCH-30.0 MCHC-34.2 RDW-18.4* [**2142-6-18**] 05:04AM PLT COUNT-97* [**2142-6-18**] 01:34AM GLUCOSE-84 UREA N-70* CREAT-10.5*# SODIUM-136 POTASSIUM-5.6* CHLORIDE-108 TOTAL CO2-14* ANION GAP-20 [**2142-6-18**] 01:34AM estGFR-Using this [**2142-6-18**] 01:34AM ALT(SGPT)-10 AST(SGOT)-39 ALK PHOS-108 TOT BILI-0.2 [**2142-6-18**] 01:34AM LIPASE-115* [**2142-6-18**] 01:34AM ALBUMIN-3.2* CALCIUM-6.6* PHOSPHATE-6.8* MAGNESIUM-1.7 [**2142-6-18**] 01:34AM WBC-4.5 RBC-2.08* HGB-6.0* HCT-18.3* MCV-88 MCH-28.6 MCHC-32.5 RDW-18.6* [**2142-6-18**] 01:34AM NEUTS-78.5* LYMPHS-16.5* MONOS-3.0 EOS-1.4 BASOS-0.6 [**2142-6-18**] 01:34AM PLT COUNT-104* [**2142-6-18**] 01:34AM PT-15.0* PTT-33.6 INR(PT)-1.3* Brief Hospital Course: # Dyspnea: Pt's dypsnea improved on admission to the ED prior to HD. Based on her imaging studies her dyspnea was likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. Upon transfer to the floor she was continued on her dialysis regimen and discharged on room air. # Anemia: Pt's baseline 1 month ago noted to be low 30s, since then her Hct has trended down to 22 several week prior to admission. As she missed dialysis she was not able to reserve her Eopgen which likely complicated her anemia. Pt underwent hemolysis workup in the ICU which was ultimately negative. She was given several units of PRBC and bumped her Hct appropriately. She was noted to be guaiac negative on examination. # Hypertension: Pt was initially admitted with hypertension. Following transition to the floor she was placed on her home regimen. She was noted to be hypotensive in dialysis which is likely due to her being on Labetalol, Nitro gtt on dialysis. Pt was discharged on her home BP regimen with follow up with her nephrologist. # Chronic Abdominal Pain: Pt had noted some intermittent abdominal pain which has been chronic. Lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. Pt was able to tolerate a PO diet prior to her discharge. Pt was continued on her outpatient regimen of Dilaudid, Fentanyl patch, Neurontin. # GE junction Ulcer: Pt was continued on her PPI regimen [**Hospital1 **]. # SLE: Pt was continued on her home regimen of Prednisone 4mg daily # History of DVT: Pt had a sub-therapeutic INR on admission. She was discharged on Warfarin 3mg daily. # ESRD on HD: Pt was admitted for dyspnea in the setting of missing 2 weeks of HD. The renal team followed Ms. [**Known lastname **] during her hospitalization and she was continued on her outpatient regimen of hemodialysis. Pt was continued on Sevelamer and Epogen. # Seizure D/O: Pt was continued on her home regimen of keppra. # Depression: Pt was continued on her home regimen of Celexa. Medications on Admission: 1. Nifedipine 90 mg Tablet Sustained Release PO QAM 2. Nifedipine 60 mg Tablet Sustained Release PO QHS 3. Lidocaine 5 % transdermal one daily 4. Aliskiren 150 mg PO BID 5. Citalopram 20 mg PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch Q72H (every 72 hours). 7. Prednisone 4mg PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Transdermal QSAT 9. Clonidine 0.3 mg/24 hr Patch Weekly Transdermal QSAT 10. Sevelamer HCl 400 mg Four (4) Tablet PO TID W/MEALS 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID 13. Hydralazine 100 mg PO Q8H 14. Hydromorphone 2 mg 1-2 Tablets PO Q6H as needed for pain. 15. Pantoprazole 40 mg PO Q12H 16. LeVETiracetam 1,000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24 H (). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK (TU,TH,SA). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Malignant HTN, ESRD on HD, Shortness of breath Secondary: Lupus Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted to the hospital after you noticed some shortness of breath. Whilst in the hospital you were noted to have a low blood level (anemia) and you some fluid in your lungs. We think your blood level was low because you were not receiving your Epo shots, we think the fluid is from not receiving dialysis. Before you were discharged from the hospital your breathing was better. We recommend that you continue going to dialysis. We made no changes to your medications. If you notice any fevers, chills, nausea, vomiting, shortness of breath, lightheadedness please return to the ED. Followup Instructions: Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 Provider: [**First Name4 (NamePattern1) **] [**Name Initial (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-6-27**] 2:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] ",14,2142-06-18 03:11:00,2142-06-20 16:34:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ANEMIA," # dyspnea: pts dypsnea improved on admission to the ed prior to hd. based on her imaging studies her dyspnea was likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. upon transfer to the floor she was continued on her dialysis regimen and discharged on room air. # anemia: pts baseline 1 month ago noted to be low 30s, since then her hct has trended down to 22 several week prior to admission. as she missed dialysis she was not able to reserve her eopgen which likely complicated her anemia. pt underwent hemolysis workup in the icu which was ultimately negative. she was given several units of prbc and bumped her hct appropriately. she was noted to be guaiac negative on examination. # hypertension: pt was initially admitted with hypertension. following transition to the floor she was placed on her home regimen. she was noted to be hypotensive in dialysis which is likely due to her being on labetalol, nitro gtt on dialysis. pt was discharged on her home bp regimen with follow up with her nephrologist. # chronic abdominal pain: pt had noted some intermittent abdominal pain which has been chronic. lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. pt was able to tolerate a po diet prior to her discharge. pt was continued on her outpatient regimen of dilaudid, fentanyl patch, neurontin. # ge junction ulcer: pt was continued on her ppi regimen [**hospital1 **]. # sle: pt was continued on her home regimen of prednisone 4mg daily # history of dvt: pt had a sub-therapeutic inr on admission. she was discharged on warfarin 3mg daily. # esrd on hd: pt was admitted for dyspnea in the setting of missing 2 weeks of hd. the renal team followed ms. [**known lastname **] during her hospitalization and she was continued on her outpatient regimen of hemodialysis. pt was continued on sevelamer and epogen. # seizure d/o: pt was continued on her home regimen of keppra. # depression: pt was continued on her home regimen of celexa. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Other primary cardiomyopathies; Unspecified disease of pericardium; Anemia of other chronic disease; Hyperpotassemia; Systemic lupus erythematosus; Abdominal pain, other specified site; Other chronic pain; Hypotension, unspecified; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Epilepsy, unspecified, without mention of intractable epilepsy; Depressive disorder, not elsewhere classified; Personal history of venous thrombosis and embolism; Noncompliance with renal dialysis]","# dyspnea: pts dypsnea improved on admission to the ed prior to hd. lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. # sle: pt was continued on her home regimen of prednisone 4mg daily # history of dvt: pt had a sub-therapeutic inr on admission. she was discharged on warfarin 3mg daily. # depression: pt was continued on her home regimen of celexa.",pts dypsnea improved on admission to the ed prior to hd. dyspnea likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. 109,136572.0,14860,2142-06-20,14809,124398.0,2142-03-31,Discharge summary,"Admission Date: [**2142-3-24**] Discharge Date: [**2142-3-31**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: HTN, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 24F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] after admission for abdominal pain, MSSA bacteremia, paroxysmal hypertension and ESRD line, followed by readmission [**3-22**], now presents with usual central crampy abdominal pain, 3 loose nonbloody stools this AM, SOB, and HTN to 270s. Pt was d/c'd from [**Hospital1 18**] yesterday after HD session, went home, states she took her PM meds, took her 8 AM medds (hydral, labetalol), then developed these symptoms which precluded her from taking her usual home meds (no afternoon meds - nifedipine, labetalol, hydral). The abd pain comes and goes and is unchanged from her baseline. While she has nausea, she is asking for dinner. . In the ED, initial BP 272/148. CXR w/o evidence of volume overload. No CT scan performed. Started on NTG gtt, given Hydralazine 10 x 1, Dilaudid 2 mg, labetaolo 20mg IV x 1. . Upon arrival to the floor, her BP was 240/135. She continued to complain of abdominal pain but was eating crackers, breathing felt better. RR 17. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: 98.2 97 [**Telephone/Fax (2) 43509**]0% on 2 L nC Gen: pleasant, comfortable HEENT: L eye enucleated. moon facies. Right pupil reactive Heart: hrrr, no m/r/g Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, diffuse TTP, no rebound/guarding Ext: no c/c/e Neuro: aox4, cn 2-12 intact grossly. Pertinent Results: [**2142-3-24**] 07:17PM PT-22.4* PTT-43.64* INR(PT)-2.1* [**2142-3-24**] 04:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2142-3-24**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-24**] 04:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**11-30**] [**2142-3-24**] 02:05PM GLUCOSE-76 UREA N-21* CREAT-4.8*# SODIUM-139 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2142-3-24**] 02:05PM ALT(SGPT)-78* AST(SGOT)-181* CK(CPK)-55 ALK PHOS-192* TOT BILI-0.5 [**2142-3-24**] 02:05PM cTropnT-0.12* [**2142-3-24**] 02:05PM CK-MB-5 [**2142-3-24**] 02:05PM WBC-3.6* RBC-2.90* HGB-8.9* HCT-26.6* MCV-92 MCH-30.7 MCHC-33.4 RDW-19.8* [**2142-3-24**] 02:05PM NEUTS-73.9* BANDS-0 LYMPHS-18.5 MONOS-3.8 EOS-3.0 BASOS-0.8 [**2142-3-24**] 02:05PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-1+ TARGET-1+ SCHISTOCY-OCCASIONAL TEARDROP-1+ ELLIPTOCY-OCCASIONAL [**2142-3-24**] 02:05PM PLT SMR-LOW PLT COUNT-129* [**2142-3-23**] 12:00PM GLUCOSE-77 UREA N-31* CREAT-6.0*# SODIUM-137 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14 [**2142-3-23**] 12:00PM estGFR-Using this [**2142-3-23**] 12:00PM CALCIUM-8.4 PHOSPHATE-5.7* MAGNESIUM-1.9 [**2142-3-23**] 12:00PM WBC-3.7* RBC-2.87* HGB-8.7* HCT-26.1* MCV-91 MCH-30.3 MCHC-33.3 RDW-19.4* [**2142-3-23**] 12:00PM PLT COUNT-130* [**2142-3-23**] 12:00PM PT-28.8* PTT-58.6* INR(PT)-2.9* Brief Hospital Course: The patient was admitted to the MICU on a NTG gtt from the ED. Her abdominal pain had imporved and she was eating crackers and peanut butter. She was given her usual afternoon home medications, and transitioned to a Nicardipine gtt, which has worked well for her in the past. Her BP goal was for a systolic of 180-200. The Nicardipine gtt was titrated off quickly and she was transfered to the floor. . On arrival to the floor, she in fact missed her morning medications on [**Month/Day/Year 766**]. This resulted in elevate blood pressures requiring IV hydralazing for control. She went to dialyisis Tuesday [**3-27**] and again had markedly elevated blood pressures while at [**Month/Year (2) 2286**] from missing her AM doses. Instructions were written for explicit AM administration and Nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. She was continued on labetalol 900mg TID, Aliskerin, Hydralazine 100mg po TID, and clonidine patch 0.4mg/24 weekly patch. . HEr BP remained relativly stable. She established a three three times weekly Dialysus regemin. A PAP smear was attempted due to her history of CIN I and no PCP follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . Her abdominal pain was also a chronic issue, which appeared stable. She was not administered IV narcotics, only PO. It was wihtout clear percipitating events or etiology. She will need GI follow up. She was contact[**Name (NI) **] by phone several times to arrange a GI follow up appointment but did not return messages. She has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . She was discharged to followup with her nephrologist, Dr. [**Last Name (STitle) 4883**]. . 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. Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Last Name (STitle) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2* 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). [**Last Name (STitle) **]:*405 Tablet(s)* Refills:*2* 5. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*2* 6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). [**Last Name (STitle) **]:*60 Tablet(s)* Refills:*2* 9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patches Transdermal once a week: Place two patches every week on Fridays. [**Last Name (STitle) **]:*8 Patches* Refills:*2* 10. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*0* 11. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO twice a day as needed for prn SBP>200: if nauseated and cannot keep down meds, may use 1 sublingual clonidine if sbp>200. . [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0* 12. Kayexalate Powder Sig: Thirty (30) grams PO once a day for 2 days: please take [**2142-4-1**] and [**2142-4-2**] for elevated potassium. [**Month/Day/Year **]:*240 grams* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Systemic Lupus Erythematosus End Stage Renal Disease Hypertension Abdominal Pain Discharge Condition: Blood pressure stable and abdominal pain at baseline Discharge Instructions: You were admitted with high blood pressure. You were in the ICU overnight for treatment. Some of your medications were changed and you were increased to three times weekly [**Location (un) 2286**]. Your abdominal pain is a difficult problem, as the reason for the pain is unclear. [**Name2 (NI) **] were continued on oral dilaudid. IV dilaudid is strongly discouraged and will continue to be in the future. You are now taking Nifedipine SR 30mg at night in addition to 90mg in the morning. Your other medications were the same. At home, if your blood pressure is above 200, then take 100mg hydralazine. If after 1 hour, your blood pressure does not decrease to below 200 with this, then take another 100mg hydralazine. If you are nauseated and cannot take in oral meds, then take sublingual clonidine, then wait 1 hour and repeat if BP still > 200. Finally, your potassium has been high. Please take kayexalate 30gm tomorrow and the next day. Followup Instructions: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-3-31**] 7:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule appointment We will attempt to contact you on [**Name (NI) 766**] with appointment times for you. ",81,2142-03-24 16:34:00,2142-03-31 15:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," the patient was admitted to the micu on a ntg gtt from the ed. her abdominal pain had imporved and she was eating crackers and peanut butter. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. her bp goal was for a systolic of 180-200. the nicardipine gtt was titrated off quickly and she was transfered to the floor. . on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**]. this resulted in elevate blood pressures requiring iv hydralazing for control. she went to dialyisis tuesday [**3-27**] and again had markedly elevated blood pressures while at [**month/year (2) 2286**] from missing her am doses. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she was continued on labetalol 900mg tid, aliskerin, hydralazine 100mg po tid, and clonidine patch 0.4mg/24 weekly patch. . her bp remained relativly stable. she established a three three times weekly dialysus regemin. a pap smear was attempted due to her history of cin i and no pcp follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . her abdominal pain was also a chronic issue, which appeared stable. she was not administered iv narcotics, only po. it was wihtout clear percipitating events or etiology. she will need gi follow up. she was contact[**name (ni) **] by phone several times to arrange a gi follow up appointment but did not return messages. she has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . she was discharged to followup with her nephrologist, dr. [**last name (stitle) 4883**]. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Long-term (current) use of steroids; Other chronic pain; Obstructive sleep apnea (adult)(pediatric); Abdominal pain, generalized; Hyperpotassemia]","the patient was admitted to the micu on a ntg gtt from the ed. her bp goal was for a systolic of 180-200. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she established a three three times weekly dialysus regemin.","the patient was admitted to the micu on a nicardipine gtt from the ed. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**] this resulted in elevate blood pressures requiring iv hydralazing for control " 109,136572.0,14860,2142-06-20,14808,158943.0,2142-03-23,Discharge summary,"Admission Date: [**2142-3-21**] Discharge Date: [**2142-3-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: Abdominal Pain, Shortness of breath, Chest discomfort Major Surgical or Invasive Procedure: HD [**2142-3-21**] and [**2142-3-23**] History of Present Illness: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] 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 [**Telephone/Fax (3) 43508**]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. [**Telephone/Fax (3) **] was discussed with renal and it was not felt that HTN is a volume issue so no need for emergent [**Telephone/Fax (3) 2286**]. . 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 [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**], getting Vanc with HD. . PSHx: 1. Placement of multiple catheters including [**Year (4 digits) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] 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: [**2142-3-21**] 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* [**2142-3-21**] 02:20AM NEUTS-76.1* BANDS-0 LYMPHS-17.9* MONOS-4.5 EOS-1.1 BASOS-0.5 [**2142-3-21**] 02:20AM PLT SMR-NORMAL PLT COUNT-168 [**2142-3-21**] 02:20AM PT-21.8* PTT-34.7 INR(PT)-2.1* [**2142-3-21**] 02:20AM cTropnT-0.12* [**2142-3-21**] 02:20AM ALT(SGPT)-46* AST(SGOT)-94* CK(CPK)-76 ALK PHOS-173* TOT BILI-0.4 [**2142-3-21**] 02:20AM GLUCOSE-74 UREA N-47* CREAT-7.3* SODIUM-140 POTASSIUM-5.8* CHLORIDE-109* TOTAL CO2-19* ANION GAP-18 [**2142-3-21**] 04:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-21**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2142-3-21**] 12:58PM CK-MB-NotDone cTropnT-0.12* . CT C/A/P - [**2142-3-20**] - 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: [**2142-3-23**] 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* [**2142-3-23**] 12:00PM BLOOD Plt Ct-130* [**2142-3-23**] 12:00PM BLOOD PT-28.8* PTT-58.6* INR(PT)-2.9* [**2142-3-23**] 12:00PM BLOOD Glucose-77 UreaN-31* Creat-6.0*# Na-137 K-4.8 Cl-104 HCO3-24 AnGap-14 [**2142-3-23**] 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 [**3-22**] 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 [**2142-3-21**] . # abdominal pain: Consistent with patient's baseline chronic abdominal pain. Medication effect also possible. CT prelim neg for small bowel obstruction. LFTs doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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). [**Month/Year (2) **]:*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 [**Month/Year (2) 2286**] sessions as directed by the nephrology team- your next session should be on Tuesday. Completed by:[**2142-3-26**]",89,2142-03-21 09:25:00,2142-03-23 18:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,CHEST PAIN;TELEMETRY," 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 (200s/100s) that nevertheless are within levels shes 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 [**3-22**] and transferred to the medicine floor. the next day, her bp remained within goal of 120s/80s. 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. ces were cycled and were negative. cpap was continued as tolerated at home settings. sob resolved after hd on [**2142-3-21**] . # abdominal pain: consistent with patients baseline chronic abdominal pain. medication effect also possible. ct prelim neg for small bowel obstruction. lfts doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Compression of vein; Unspecified disease of pericardium; Infection and inflammatory reaction due to other vascular device, implant, and graft; Bacteremia; Primary hypercoagulable state; Other primary cardiomyopathies; ; Abdominal pain, unspecified site; Urinary tract infection, site not specified; Acidosis; Other chest pain; Other chronic pain; Systemic lupus erythematosus; Noncompliance with renal dialysis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Hyperpotassemia; 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; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","this is a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. ct prelim neg for small bowel obstruction. on arrival to the floor, abd pain was back to baseline and well controlled on dilaudid 2mg po q 4hrs .","a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. initial attempts were made to control her bp with hydralazine and labetalol iv but after these failed to control her blood pressure. she was successfully transitioned to home medications of clonidine, labetalol, aliskiren, nifedipine" 109,136572.0,14860,2142-06-20,14807,158995.0,2142-02-26,Discharge summary,"Admission Date: [**2142-2-25**] Discharge Date: [**2142-2-26**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 338**] 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 History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, hx of malignant HTN admitted with change in mental status. Patient missed HD on [**2142-2-24**] and was found unresponsive and diaphoretic by mother this morning after she took some dilaudid. EMS was called, 1 mg of narcan was administered with slight improvement in mental status. On arrival to the ED her vitals were 112/64 62 16 99RA she was noted to be hyperkalemic in the absence of EKG changes and was given calcium, D5, 10U regular insulin, 30 mg po kayxalate and repeat K was 5.4. ABG: 7.29/38/199. Repeat glucose was 41 and 1amp D50 was given. She was sent to the ICU for monitoring. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including [**Month/Year (2) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: HR: 80 (79 - 80) bpm BP: 127/59(76) {127/59(76) - 139/64(82)} mmHg RR: 34 (21 - 34) insp/min SpO2: 100% Heart rhythm: SR (Sinus Rhythm) Physical Examination Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact Pertinent Results: [**2142-2-25**] 01:50PM PT-14.9* PTT-36.8* INR(PT)-1.3* [**2142-2-25**] 01:50PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2142-2-25**] 01:50PM WBC-5.0 RBC-2.21* HGB-6.4* HCT-20.7* MCV-94 MCH-29.1 MCHC-31.1 RDW-19.6* [**2142-2-25**] 10:30PM GLUCOSE-87 UREA N-66* CREAT-8.4* SODIUM-142 POTASSIUM-5.9* CHLORIDE-110* TOTAL CO2-16* ANION GAP-22* HISTORY: Altered mental status. Evaluate underlying for pneumonia. UPRIGHT PORTABLE CHEST: Comparison is made to [**2-14**] and [**2142-2-19**], exams. Study is slightly limited by patient motion. In the interval, the degree of pulmonary edema appears improved with slightly decreased prominence of the pulmonary vascularity. There is unchanged extensive retrocardiac consolidation obscuring the majority of the left hemidiaphragm with persistent blunting of the left CP angle, likely related to small effusion. Exam is otherwise unchanged from prior with persistent cardiomegaly. A catheter is seen projecting over the abdomen, partially imaged. IMPRESSION: Slight improvement in pulmonary edema with persistent retrocardiac opacity, which again may represent atelectasis versus underlying pneumonia. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted hypotension and decreased mental status. Hypotension and altered mental status were in the setting of excessive narcotic use. Patient's narcotics were held, pressors returned to [**Location 213**] and patient was mentating fine. Hct was below baseline and patient was transfused 1u PRBC and was given HD before discharge. Patient is to continue anti-hypertensive medications as previously scheduled. Patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # Change in mental status: Resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. Patient received 1 dose of narcan with slight improvement in BP and mental status. patient without fevers or leuckocytosis which argue against infection. # Hypertension ?????? resumed outpatient regimen. Patient did not have any hypertensive episodes requiring hydralizine 10mg IV. # Hypotension: resolved, Patient normotensive on arrival to ICU. Relative hypotension likely due to dilaudid. Other considerations include sepsis, although patient without objective signs of infection. Held pain medications and hypotension resolved. Resumed hypertensive medications. # Abdominal pain ?????? from previous peritoneal [**Location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # Hyperkalemia: Likely due to missed HD session. She received calcium, D5, insulin and kayexalate in ED. HD in am ESRD: Renal following, had HD the day of discharge, transfused while there. Will continue normal schedule as an outpatient with HD T/Th/F this week. # Metabolic Acidosis: likely due to renal failure and missed HD. # SLE: continued prednisone at 4 mg PO daily. # OSA: CPAP for sleep with 7 pressure, however patient refuses. Continued to offer as inpatient. Should try to follow up with sleep medicine. Medications on Admission: Prednisone 4mg qd Citalopram 20 mg daily Gabapentin 300 mg [**Hospital1 **] Warfarin 4mg daily Pantoprazole 40 mg qd Clonidine 0.1 mg/24 QWED Clonidine 0.3 mg/24 hr QWED Labetalol 900 mg tid Nifedipine 90 mg qd Aliskiren 150 mg [**Hospital1 **] Hydralazine 100 mg q8h Morphine 7.5 mg q8h prn pain Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Discharge Disposition: Home Discharge Diagnosis: Primary: narcotic overdose relative hypotension anemia Secondary: ESRD on HD [**2-12**] SLE malignant hypertension Discharge Condition: stable - received HD prior to discharge Discharge Instructions: You were admitted for altered mental status after missing hemodialysis. It was likely from the dilaudid you took as well as missing your scheduled [**Month/Day (2) 2286**]. You were also relatively hypotensive in the setting of excessive narcotic medicaiton usage. Narcotic medications were held and hypotension and altered mental status resolved. Please use narcotic medications with caution. You are recommended to use morphine for pain control rather than dilaudid. No medication changes were made. Please return to the ED if you have any altered mental status or miss [**First Name (Titles) **] [**Last Name (Titles) 2286**] or have symptoms such as vision changes or headache from your history of malignant hypertension. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 488**] [**Last Name (NamePattern4) 43496**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-3-20**] 3:00 HD as previously scheduled Completed by:[**2142-2-26**]",114,2142-02-25 15:49:00,2142-02-26 16:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ALTERED MENTAL STATUS," 24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. patients narcotics were held, pressors returned to [**location 213**] and patient was mentating fine. hct was below baseline and patient was transfused 1u prbc and was given hd before discharge. patient is to continue anti-hypertensive medications as previously scheduled. patient was encouraged to take less pain medications and to use morphine (already previously written for) rather than dilaudid for pain control. # change in mental status: resolved, patient took dilaudid this morning and was noticed to be unresponsive shortly thereafter. patient received 1 dose of narcan with slight improvement in bp and mental status. patient without fevers or leuckocytosis which argue against infection. # hypertension ?????? resumed outpatient regimen. patient did not have any hypertensive episodes requiring hydralizine 10mg iv. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. other considerations include sepsis, although patient without objective signs of infection. held pain medications and hypotension resolved. resumed hypertensive medications. # abdominal pain ?????? from previous peritoneal [**location 2286**] hematoma ?????? pain under control patient should use morphine instead of dilaudid # hyperkalemia: likely due to missed hd session. she received calcium, d5, insulin and kayexalate in ed. hd in am esrd: renal following, had hd the day of discharge, transfused while there. will continue normal schedule as an outpatient with hd t/th/f this week. # metabolic acidosis: likely due to renal failure and missed hd. # sle: continued prednisone at 4 mg po daily. # osa: cpap for sleep with 7 pressure, however patient refuses. continued to offer as inpatient. should try to follow up with sleep medicine. ","PRIMARY: [Poisoning by other opiates and related narcotics] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Thrombotic microangiopathy; Other primary cardiomyopathies; Acidosis; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Altered mental status; Other iatrogenic hypotension; Accidental poisoning by other opiates and related narcotics; Hyperpotassemia; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Nontraumatic hematoma of soft tissue; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. hypotension and altered mental status were in the setting of excessive narcotic use. # hypotension: resolved, patient normotensive on arrival to icu. relative hypotension likely due to dilaudid. from previous peritoneal [**location 2286**] hematoma ??????","24 yo woman with hx of sle, ersd on hd, admitted hypotension and decreased mental status. narcotics were held, pressors returned to and patient was mentating fine. patient was encouraged to take less pain medications and to use morphine." 109,136572.0,14860,2142-06-20,14806,113189.0,2142-02-17,Discharge summary,"Admission Date: [**2142-2-14**] Discharge Date: [**2142-2-17**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 5119**] Chief Complaint: Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: From admission note: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome admitted with HTN and SOB in the setting of missed HD. The patient reported missing HD yesterday because she thinks she is being overdiuresed. She reports persistent pain at site of rectus sheath hematoma. Denies N/V/D. Pt recently admitted from [**Date range (1) 13924**] with consistent abdominal pain at the site of her known left abdominal wall hematoma, hypertensive to 230's and hyperkalemic to 6.2 after missing her last two dialysis sessions. At this time the pt. was dialyzed, received a blood transfusion, and was administered her daily antihypertensive medications. Pt. left AMA after her transfusion despite the primary team's concerns to look for an active area of bleeding. In the ED, patient complain of mild dyspnea, sating well on RA. CXR mild volume overload. KUB with no evidence of obstruction. She was started on a labetalol gtt. ECG - RAD, LVH no change from prior. HCT stable at 21. The renal team evaluated pt and recommended HD, however the patient refused. She was transferred to ICU for BP control. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Gen: sleeping comfortably, easily awoken by verbal stimuli HEENT: L eye prosthetic non-reactive, R pupil reactive, MMM Heart: S1S2 RRR, III/VI SEM throughout the precordium Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, mild L TTP, no rebound/guarding Ext: no edema, no clubbing, WWP. R femoral HD [**Last Name (un) **] in place Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: [**2142-2-14**] 07:40AM WBC-3.9* RBC-2.38* HGB-7.0* HCT-21.3* MCV-90 MCH-29.5 MCHC-33.0 RDW-18.9* [**2142-2-14**] 07:40AM NEUTS-74.9* LYMPHS-18.7 MONOS-3.1 EOS-3.0 BASOS-0.2 [**2142-2-14**] 07:40AM PLT COUNT-101* [**2142-2-14**] 07:40AM PT-16.3* PTT-36.6* INR(PT)-1.5* [**2142-2-14**] 07:40AM CK-MB-6 [**2142-2-14**] 07:40AM cTropnT-0.09* [**2142-2-14**] 07:40AM LIPASE-80* [**2142-2-14**] 07:40AM ALT(SGPT)-34 AST(SGOT)-72* CK(CPK)-120 ALK PHOS-124* TOT BILI-0.4 [**2142-2-14**] 07:40AM GLUCOSE-85 UREA N-32* CREAT-7.0* SODIUM-142 POTASSIUM-4.3 CHLORIDE-110* TOTAL CO2-19* ANION GAP-17 [**2142-2-14**] 07:44AM LACTATE-1.3 [**2142-2-14**] CXR: Stable cardiomegaly with mild CHF and a small left pleural effusion. Left basilar air space disease which may represent pneumonia. Clinical correlation and a follow up chest x-ray to clearance is recommended. [**2142-2-14**] KUB: 1. Nonspecific bowel gas pattern with no evidence of obstruction. 2. Left basilar airspace disease which may represent pneumonia and a small left pleural effusion. Please ensure follow-up to clearance. Brief Hospital Course: 24 y.o female with SLE, ESRD on HD and malignant hypertension who presents with HTN and SOB aftering missing HD. . # Malignant hypertension/hypertensive urgency: The patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and HD compliance. Has previously presented with BP up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. Pt was treated per OMR hypertensive protocol created by the patient's primary providers, with a goal SBP of 160-180. With short course of IV antihypertensives and hemodialysis, pt's BP fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # ESRD: Pt was followed by the renal service and underwent HD without any complications. Pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting HD. She will discuss this further with the Renal team as an outpatient. . # SLE: Pt was continued on her home dose of prednisone with no sign of SLE flair. . # Coagulopathy/history of DVT: Patient on lifetime anticoagulation for hx of multiple thrombotic events. Pt was continued on coumadin. . # Pain management: Pt was treated with PO dilaudid for her abdominal pain, as recommended per her OMR protocol. She asked for IV dilaudid multiple times but there was no clinical indication. She was also continued on gabapentin. . # Anemia: Secondary to AOCD and renal failure. The patietns Hct remained stable in the low 20s during admission. No PRBC infusions were needed. . # Depression/anxiety: Continued Celexa, clonazepam 0.5mg [**Hospital1 **] Medications on Admission: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Medications: 1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 8. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 10. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain. 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. Discharge Disposition: Home Discharge Diagnosis: Primary: Malignant Hypertension Secondary: SLE, End stage renal disease on hemodialysis, SVC syndrome Discharge Condition: Stable. SBP in 160s. Discharge Instructions: You were admitted with dangerously high hypertension and some shortness of breath in the setting of missing several dialysis sessions. You were admitted and treated with your usual regimen of blood pressure meds and a short course of IV meds. With dialysis, your symptoms improved. You also had some abdominal pain, which was well controlled on your usual pain medications. We made no changes to your medications. Please take everything as prescribed. Please call your PCP or return to the hospital if you develop any headaches, visual changes, confusion or chest pain, or any other concerning symptoms. Followup Instructions: Please schedule a follow up with Dr [**Last Name (STitle) **] in [**Month (only) 958**] as scheduled. [**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**] Completed by:[**2142-2-21**]",123,2142-02-14 10:42:00,2142-02-17 18:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. . # malignant hypertension/hypertensive urgency: the patient has a well-documented history of paroxysmal hypertension believed to possibly be related to pain, anxiety, narcotic withdrawal and poor medication and hd compliance. has previously presented with bp up to 260/160 but most often without evidence of end-organ ischemia, as she did for this admission. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. with short course of iv antihypertensives and hemodialysis, pts bp fell appropriately and was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine. . # esrd: pt was followed by the renal service and underwent hd without any complications. pt states she would like to reconsider peritoneal dialysis as she is experiencing increased fatigue since instituting hd. she will discuss this further with the renal team as an outpatient. . # sle: pt was continued on her home dose of prednisone with no sign of sle flair. . # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events. pt was continued on coumadin. . # pain management: pt was treated with po dilaudid for her abdominal pain, as recommended per her omr protocol. she asked for iv dilaudid multiple times but there was no clinical indication. she was also continued on gabapentin. . # anemia: secondary to aocd and renal failure. the patietns hct remained stable in the low 20s during admission. no prbc infusions were needed. . # depression/anxiety: continued celexa, clonazepam 0.5mg [**hospital1 **] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Thrombotic microangiopathy; Systemic lupus erythematosus; Anemia in chronic kidney disease; Thrombocytopenia, unspecified; Obstructive sleep apnea (adult)(pediatric); Nontraumatic hematoma of soft tissue; Dysthymic disorder; Noncompliance with renal dialysis; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob aftering missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. # coagulopathy/history of dvt: patient on lifetime anticoagulation for hx of multiple thrombotic events.","24 y.o female with sle, esrd on hd and malignant hypertension who presents with htn and sob after missing hd. pt was treated per omr hypertensive protocol created by the patients primary providers, with a goal sbp of 160-180. she was well maintained on oral outpt regimen of clonidine, labetalol, aliskiren, nifedipine." 109,136572.0,14860,2142-06-20,14858,151240.0,2142-05-18,Discharge summary,"Admission Date: [**2142-5-15**] Discharge Date: [**2142-5-18**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 613**] Chief Complaint: Headache, Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis x 2 History of Present Illness: 24 year old female with SLE, ESRD on HD, hx malignant HTN, h/o SVC syndrome, h/o posterior reversible encephalopathy syndrome (PRES) and prior intracerebral hemorrhage, recently admitted [**Date range (1) 17717**] with diarrhea, hypertensive urgency. Treated at that time with nicardipine drip for a short period and then to her home regimen. Yesterday onset of nausea with emesis and inability to tolerate home meds including antihypertensives. Diarrhea mild as prior. No fever, chills, no hematemesis or hematochezia. No melena. Today reports onset of headache therefore to the ED. In the ED, initial vs were 280/160, 99.4, 105, RR 18. She was given dilaudid 2 mg PO x 2. Hydral 20 mg x 3 for BP. Calcium gluconate 1 gram. Insulin 10 units, D 50 [**1-12**] amp, sodium bicarbonate, kayexalate for K 6.7 (dialysis dependent Tues/thurs/sat) but with report of peaked T waves. Renal dialysis fellow was not contact[**Name (NI) **]. HCT 33.4, WBC 4.6, trop 0.10. Admitted for hypertensive urgency to ICU. No gtt was started. Of note usualy BP 160/100. Review of sytems: patient tearful complaining of frontal headache and nausea Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: Vitals: BP 240/146, 101, 98.6, General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardic, 3/6 SEM RUSB Abdomen: soft, diffusely tender, no rebound or gaurding. Ext: cachectic, warm, 2+ DP pulse no clubbing, cyanosis or edema Pertinent Results: [**2142-5-15**] 05:45AM GLUCOSE-83 UREA N-54* CREAT-7.6* SODIUM-138 POTASSIUM-6.7* CHLORIDE-103 TOTAL CO2-23 ANION GAP-19 [**2142-5-15**] 05:45AM CK(CPK)-96 [**2142-5-15**] 05:45AM cTropnT-0.10* [**2142-5-15**] 05:45AM CK-MB-NotDone [**2142-5-15**] 05:45AM WBC-4.6 RBC-3.66* HGB-10.8* HCT-33.4* MCV-91 MCH-29.6 MCHC-32.4 RDW-17.9* [**2142-5-15**] 05:45AM NEUTS-65.4 LYMPHS-25.1 MONOS-4.8 EOS-4.1* BASOS-0.7 [**2142-5-15**] 05:45AM PLT COUNT-128* [**2142-5-15**] 05:45AM PT-14.2* PTT-36.4* INR(PT)-1.2* [**2142-5-15**] 07:14AM K+-6.0* [**2142-5-15**] 12:17PM K+-5.3 Images: CXR: Persistent severe cardiomegaly. Head CT: Normal brain CT. Brief Hospital Course: 24 yo female with ESRD on HD, malignant hypertension with hx of intracerebral hemorrhage, SLE, chronic abdominal pain, and SVC syndrome admitted due to hypertensive urgency after developing N/V and being unable to take her po medications. # Hypertensive urgency: The patient was admitted to the MICU the night of admission where she was placed on a labetolol drip and her home medications were restarted. head CT was negative for intracranial bleed. She was continued on her home regimen of Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet Sustained Release QAM, and Hydralazine 100 mg PO Q8H. During her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. Blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). She was discharged on her home regimen. # Nausea/vomiting: The patient did not experience further vomiting, but occasionally complained of nausea. The cause of her nausea was unclear. She was able to tolerate po intake prior to discharge. # Abdominal pain/Diarrhea: The patient has chronic abdominal pain with previous negative workups. During this hospitalization her pain was at its baseline. Since admission she denied diarrhea. She was continued on her outpatient regimen of [**2-14**] mg po dilaudid q4h as needed. # ESRD on HD: She was hyperkalemic in the emergency room and was given kayexalate. She underwent two sessions of dialysis during this hospitalization. # SLE: Stable, without symptoms. She was continued on 4 mg of prednisone daily. # History of thrombotic events/SVC syndrome: She is anticoagulated with warfarin as an outpatient, however her INR was subtherapeutic on admission at 1.2. Previous documentation in OMR states she does not need to be bridged while subtherapeutic. She was initally continued on coumadin 4 mg po daily, however her INR rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # OSA: She is on CPAP at a setting of 7 as an outpatient and was continued on this during her hospitalization. Medications on Admission: Medications: as per last discharge summary -Aliskiren 150 mg Tablet [**Hospital1 **] -Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday) -Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). -Labetalol 200 mg Tablet Sig 5 tab TID -Nifedipine 60 mg Tablet Sustained Release QPM -Nifedipine 90 mg Tablet Sustained Release QAM -Citalopram 20 mg Tablet Sig daily -Hydromorphone 2 mg Tablet Sig [**1-12**] Q4 PRN -Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). -Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H -Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID PRN -Prednisone 4 mg daily -Coumadin 4 mg daily at 4 PM Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QPM (once a day (in the evening)). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 10. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO twice a day as needed for hypertension. 13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary - Hypertensive urgency End-stage renal disease on dialysis Secondary - Systemic lupus erythematous History of thombosis and Superior vena cava syndrome Obstructive sleep apnea Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital due to dangerously elevated blood pressure due to inability to take your medications secondary to nausea. It is very important that you take your blood pressure medications reguarly. Your nausea was controlled with medication and your blood pressure decreased once back on your home medication regimen. You underwent two sessions of dialysis during your hospitalization. It is extremely important that you attend dialysis three times weekly as an outpatient. Medication changes: You should be taking 3 mg of coumadin daily. You will need to have your INR checked at dialysis. Otherwise continue your outpatient medications as prescribed. Call your primary doctor, or go to the emergency room if you experience fevers, chills, worsening headache, vision change, inability to take your medications, blood in your stool, or dark black stool. Followup Instructions: It is very important that you keep your previously scheduled appointments: You have an appointment with gynecology to evaluate an abnormality recently seen on PAP smear. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-6-1**] 2:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-5-19**]",33,2142-05-15 10:45:00,2142-05-18 15:58:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSIVE CRISIS," 24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. # hypertensive urgency: the patient was admitted to the micu the night of admission where she was placed on a labetolol drip and her home medications were restarted. head ct was negative for intracranial bleed. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, and hydralazine 100 mg po q8h. during her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). she was discharged on her home regimen. # nausea/vomiting: the patient did not experience further vomiting, but occasionally complained of nausea. the cause of her nausea was unclear. she was able to tolerate po intake prior to discharge. # abdominal pain/diarrhea: the patient has chronic abdominal pain with previous negative workups. during this hospitalization her pain was at its baseline. since admission she denied diarrhea. she was continued on her outpatient regimen of [**2-14**] mg po dilaudid q4h as needed. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. she underwent two sessions of dialysis during this hospitalization. # sle: stable, without symptoms. she was continued on 4 mg of prednisone daily. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient, however her inr was subtherapeutic on admission at 1.2. previous documentation in omr states she does not need to be bridged while subtherapeutic. she was initally continued on coumadin 4 mg po daily, however her inr rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # osa: she is on cpap at a setting of 7 as an outpatient and was continued on this during her hospitalization. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other primary cardiomyopathies; Unspecified disease of pericardium; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Hyperpotassemia; Nausea with vomiting; Diarrhea; Disorders of phosphorus metabolism; Anemia of other chronic disease; Abdominal pain, left lower quadrant; Other chronic pain; Thrombocytopenia, unspecified; Other specified peripheral vascular diseases; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus; Long-term (current) use of anticoagulants; Noncompliance with renal dialysis; Renal dialysis status; Personal history of noncompliance with medical treatment, presenting hazards to health]","24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. she was able to tolerate po intake prior to discharge. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. previous documentation in omr states she does not need to be bridged while subtherapeutic.","24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg" 109,136572.0,14860,2142-06-20,14859,102024.0,2142-06-05,Discharge summary,"Admission Date: [**2142-5-20**] Discharge Date: [**2142-6-5**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 3705**] Chief Complaint: abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname **] is a 24 yo F with lupus since age 16, with ESRD on HD, malignant HTN, history of SVC syndrome, and history of Posterior Reversible Encephalopathy Syndrome (PRES) and intracerebral hemorrhage, who has had multiple recent admissions [**Date range (1) 43604**], [**Date range (1) 17717**], [**Date range (1) **], [**4-26**], [**Date range (1) 42063**], [**Date range (1) 43605**] mostly for hypertension, but most recently for diarrhea in addition to hypertension. . In the ED, vitals were 98 90 102/65 20 98% RA. She was complaining of abdominal pain X 3 hours, more severe than usual [**7-20**], no N/V/D. She received dilaudid 4 mg PO X 3, zofran 8mg IV, hyperkalemia 6.2=>5.3 w/ Kayexalate. Initially, she was felt stable for floor; however, BP rose during ED course to SBP 270. She then received hydral 50 PO X 1, home aliskeren, labetalol 1000 PO X 1, 20 IV hydral X 2, labetalol 100 Iv X 1, nicardipine 2.5 mg IV X 1 and started on nicardipine gtt. . Upon arrival to the floor, she complains of severe abd pain which started earlier today, it is sharp all over her abd and constant. It feels different from her usual abd pain, although she is not able to characterize it more. She has been having some nausea and bilious emesis X 1 earlier today. She has been having some mild diarrhea 2-3 episodes of loose, greenish stools for the past few weeks. She denies any chest pain, headache, vision changes. She was not able to take all of the medications due to her GI distress. . While in the MICU she was weaned off a nicardipine drip and her diarrhea resolved. Her BP remained WNL while on her home regimen and she was transferred to the floor in stable condition. Last HD was [**2142-5-21**]. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**] and [**2142-4-12**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting - has appt scheduled with gyn on [**5-25**] 17. History of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] which has resolved Social History: Denies any substance abuse (EtOH, tobacco, illicits). She lives with her mother and brother. 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: 100/63 81 18 100RA GENERAL: Pleasant, thin young female sitting in the bed in NAD watching TV. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. s/p left eye enucleation. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD. CARDIAC: RRR. 4/6 systolic murmur heard best at the RUSB. LUNGS: Breathing comfortably, CTAB, good air movement biaterally. ABDOMEN: + BS, soft ND, tenderness to palpation in her LUQ. No rebound or guarding. EXTREMITIES: No edema. Right femoral HD line nontender, nonerythematous. SKIN: Several subcutaneous cysts of different sizes 1 - 3 cm scattered along her lower extremities. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation to light touch throughout. 5/5 strength in her upper and lower extremities PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2142-5-20**] 09:14PM LACTATE-0.9 [**2142-5-20**] 09:13PM WBC-6.8 RBC-3.65* HGB-10.7* HCT-33.7* MCV-93 MCH-29.2 MCHC-31.6 RDW-18.8* [**2142-5-20**] 09:13PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ TEARDROP-OCCASIONAL [**2142-5-20**] 09:13PM PLT COUNT-145* [**2142-5-20**] 08:55PM GLUCOSE-98 UREA N-44* CREAT-7.7* SODIUM-137 POTASSIUM-6.3* CHLORIDE-102 TOTAL CO2-20* ANION GAP-21* [**2142-5-20**] 08:55PM CALCIUM-9.9 PHOSPHATE-5.8* MAGNESIUM-2.1 [**2142-5-20**] 08:55PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2142-5-20**] 08:55PM WBC-7.0 RBC-3.69* HGB-11.1* HCT-34.2* MCV-93 MCH-30.2 MCHC-32.5 RDW-19.2* [**2142-5-20**] 08:55PM PLT COUNT-126* [**2142-5-20**] 08:55PM PT-14.1* PTT-32.4 INR(PT)-1.2* [**2142-5-20**] 07:40AM ALT(SGPT)-18 AST(SGOT)-55* ALK PHOS-118* TOT BILI-0.4 [**2142-5-20**] 07:40AM LIPASE-58 Brief Hospital Course: KUB: SBO Head CT: (prelim read from radiology). unchanged from prior head CT, no intracranial hemorrhage EKG: NSR, right axis, LVH, nl intervals, ST elevations V2-3 (old), TW inversion V6 (new) compared to prior EKG [**5-15**]. CT CHEST/ABD: Preliminary Read Normal aorta without dissection or acute abnormality. No PE. Stable trace ascites and small right pleural effusion. Unchanged small pulmonary nodules and lymphadenopathy in the chest. No acute abnormalities in the abdomen to explain epigastric pain. EGD: Ulcer at GE junction. # Hypertensive urgency: This is a chronic issue related to ESRD. Head CT was negative for intracranial bleed. Weaned off Nicardipine gtt and BP well controlled on home regimen. Continued her home regimen of: Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet Sustained Release QAM, Hydralazine 100 mg PO Q8H. When BPs were lower (see below) patient's BP meds were held occasionally, but as she was transfused and the BPs started to trend back up the meds were re-initiated. She then developed hypotension in the setting of poor PO intake during her SBO. BP meds were held and then re-initiated as the pressure came back up once she was able to eat. # Abdominal pain/UGIB: The patient has chronic abdominal pain with previous negative workups. At first the pain resolved and she was continued on her outpatient regimen of: 2-4 mg po dilaudid q4 h as needed. GI was c/s re: abd pain and rec CTA-abdomen to eval for mesenteric ischemia vs. partial SBO, however with ESRD did not initially want to get CTA so KUB was ordered. This showed no SBO. They recommended checking urine porphyrobilinogen and serum lead levels which were negative and LFTs were at baseline. The patient then developed a different type of pain associated with her incision site. Pain service was consulted and did a bupivicaine injection at the site which did help. They will continue to follow her. She then developed a third type of pain associated with a burning sensation in her chest. EKG was unchanged from prior. A few hours later she had 3 episodes of coffee-ground emesis. She was placed on IV PPI and transfused two units of blood. Afterward the pain resolved and her hct remained stable. GI felt that the patient would need general anesthesia in order to undergo an EGD which showed an ulcer at the GE junction. She was started on empiric treatment for H. Pylori and serologies were sent which came back negative so the antibiotics were stopped. Her pain was controlled with her outpatient regimen of PO dilaudid. She will follow up with Dr. [**Last Name (STitle) **] in [**6-18**] weeks to have another EGD under MAC to see if there has been resolution of the ulcer. # SBO: Continued to be nauseous and vomited intermittently. she was started on reglan and continued on zofran and compazine PRN howeve she continued to have n/v. A KUB was done which showed an SBO. Surgery was consulted, NGT was placed, she was made NPO and serial abdominal exams were done. Eventually she was able to transition to clear diet and then tolerated a regular diet without pain or vomiting. #. Fever: On hospital day #6 she spiked a fever to 101. Blood and urine cultures were sent and a cxr were negative, however she then had a seizure and in the post-ictal state aspirated after vomiting. She had an episode of hypoxia with this and was transferred to the ICU. In the ICU LP was attempted to rule out meningitis as a possible cause of a seizure but this was unsuccessful. Broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. She improved over the next few days and antibiotics were discontinued because the suspicion for a bacterial meningitis was low. #. Seizure: This occured in the setting of fever, hypotension, and initiation of reglan for vomiting. Neurology was consulted and felt she should be continued on keppra indefinitely. EEG was non-revealing. She should be continued on keppra 1gm with dialysis three times weekly. # ESRD on HD: Hyperkalemia resolved with kayexalate. Underwent dialysis on normal schedule. # SLE: She was continued on prednisone 4mg daily. With multiple abdominal symptoms it was thought she may have lupus flare in the abdomen. C3, c4 were equivocal for active lupus flare, and [**Doctor First Name **] was positive, as would be expected in lupus. # Anemia: Has anemia of chronic renal disease and her Hct was high on admission and epo was held per renal. However, her Hct trended all the way down to 20 and she was borderline hypotensive for her (ie SBP 120) and she developed coffee ground emesis so she was transfused 2 units. Afterward her Hct was stable at 25. She was also re-started on EPO per renal for her chronic anemia. Hemolysis labs were negative. # History of thrombotic events/SVC syndrome: She is anticoagulated with warfarin as an outpatient. Previous documentation in OMR states she does not need to be bridged while subtherapeutic. Continued coumadin 4 mg po daily however INR became supratherapeutic and the coumadin was then held. She was started on heparin gtt while awaiting EGD. After EGD the coumadin was re-started at 3mg daily however, in setting of poor po intake her INR was supratherapeutic - likely [**2-12**] nutritional deficiency of vitamin k. coumadin will be restarted when INR [**2-13**] at dialysis. # OSA: She is on CPAP at a setting of 7 as an outpatient. Continued CPAP #. CIN1: On last pap had CIN1. OB/GYN service was called re: doing colposcopy in hospital as patient rarely makes o/p appointments, hwoever they do not do this procedure in hospital especially because it does not have to be done emergently - just within one year. Will need outpatient colposcopy at some point in next few months as they do not do this procedure in the hospital. # RLL nodule: A new 10 x 5 mm nodularity was found incidentally within the right lower lobe of the lung on an abdominal CT. This should be reassessed in 3 months. # ACCESS: PIV, right groin HD line # CODE: Full code Medications on Admission: 1. Aliskiren 150 mg PO bid 2. Citalopram 20 mg PO DAILY 3. Clonidine 0.2 mg/24 hr Patch Weekly QSAT 4. Hydromorphone 2 mg 1-2 Tablets PO Q4H 5. Fentanyl 25 mcg/hr Patch 72 hr 6. Gabapentin 300 mg PO TID 7. Hydralazine 100 mg PO Q8H 8. Hydralazine 100 mg PO BID PRn fro SBP> 180. 9. Prednisone 4 mg PO DAILY 10. Pantoprazole 40 mg PO Q24H 11. Labetalol 1000 mg PO TID 12. Nifedipine 90 mg PO QAM 13. Nifedipine 60 mg PO QHS 14. Warfarin 3 mg PO Once Daily 15. Lidocaine 5 %(700 mg/patch) Topical once a day. 16. Nifedipine 90 mg PO once a day as needed for for SBP persistently above 200. Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 2. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QHS (once a day (at bedtime)). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 30 days. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 16. LeVETiracetam 1,000 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: UGIB- Ulcer at GE junction Hypertensive Emergency Anemia ESRD on HD SBO Discharge Condition: The patient was afebrile and hemodynamically stable prior to discharge. Discharge Instructions: You were admitted to the hospital with abdominal pain. You had an injection of lidocaine to help the pain around your surgery sites. You then had some blood in your vomit. You were treated for a bleed in your stomach with a blood transfusion and medications. You stopped bleeding and felt better. You had a scope of your abdomen that showed an ulcer. You were treated with medications for this and need to have another scope of your abdomen in 6 weeks. You also had high blood pressures while you were here because you could not take your medicines with your nausea and vomiting. Once you were on your home medicines your blood pressure was better. Medication Changes: CHANGE: Pantoprazole to 40mg TWICE daily Please call your PCP or come to the emergency room if you have fevers, chills, worsening abdominal pain, nausea, vomiting, blood in your vomit, blood in your stools, black/tarry stools or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] (gastroenterology) in [**6-18**] weeks for an EGD to re-look at your ulcer. Please follow up with the OB/[**Hospital **] clinic for a colposcopy on Wednesday [**2142-8-8**] at 3:15pm in the [**Hospital Ward Name 23**] Building on the [**Location (un) **]. Their number is [**Telephone/Fax (1) 2664**]. Please follow up with Dr.[**Name (NI) **] at [**Hospital6 733**] in the Shapria building on the [**Location (un) **] on [**2142-6-27**] at 2:00pm. Completed by:[**2142-6-6**]",15,2142-05-20 12:59:00,2142-06-05 16:18:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," kub: sbo head ct: (prelim read from radiology). unchanged from prior head ct, no intracranial hemorrhage ekg: nsr, right axis, lvh, nl intervals, st elevations v2-3 (old), tw inversion v6 (new) compared to prior ekg [**5-15**]. ct chest/abd: preliminary read normal aorta without dissection or acute abnormality. no pe. stable trace ascites and small right pleural effusion. unchanged small pulmonary nodules and lymphadenopathy in the chest. no acute abnormalities in the abdomen to explain epigastric pain. egd: ulcer at ge junction. # hypertensive urgency: this is a chronic issue related to esrd. head ct was negative for intracranial bleed. weaned off nicardipine gtt and bp well controlled on home regimen. continued her home regimen of: aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, hydralazine 100 mg po q8h. when bps were lower (see below) patients bp meds were held occasionally, but as she was transfused and the bps started to trend back up the meds were re-initiated. she then developed hypotension in the setting of poor po intake during her sbo. bp meds were held and then re-initiated as the pressure came back up once she was able to eat. # abdominal pain/ugib: the patient has chronic abdominal pain with previous negative workups. at first the pain resolved and she was continued on her outpatient regimen of: 2-4 mg po dilaudid q4 h as needed. gi was c/s re: abd pain and rec cta-abdomen to eval for mesenteric ischemia vs. partial sbo, however with esrd did not initially want to get cta so kub was ordered. this showed no sbo. they recommended checking urine porphyrobilinogen and serum lead levels which were negative and lfts were at baseline. the patient then developed a different type of pain associated with her incision site. pain service was consulted and did a bupivicaine injection at the site which did help. they will continue to follow her. she then developed a third type of pain associated with a burning sensation in her chest. ekg was unchanged from prior. a few hours later she had 3 episodes of coffee-ground emesis. she was placed on iv ppi and transfused two units of blood. afterward the pain resolved and her hct remained stable. gi felt that the patient would need general anesthesia in order to undergo an egd which showed an ulcer at the ge junction. she was started on empiric treatment for h. pylori and serologies were sent which came back negative so the antibiotics were stopped. her pain was controlled with her outpatient regimen of po dilaudid. she will follow up with dr. [**last name (stitle) **] in [**6-18**] weeks to have another egd under mac to see if there has been resolution of the ulcer. # sbo: continued to be nauseous and vomited intermittently. she was started on reglan and continued on zofran and compazine prn howeve she continued to have n/v. a kub was done which showed an sbo. surgery was consulted, ngt was placed, she was made npo and serial abdominal exams were done. eventually she was able to transition to clear diet and then tolerated a regular diet without pain or vomiting. #. fever: on hospital day #6 she spiked a fever to 101. blood and urine cultures were sent and a cxr were negative, however she then had a seizure and in the post-ictal state aspirated after vomiting. she had an episode of hypoxia with this and was transferred to the icu. in the icu lp was attempted to rule out meningitis as a possible cause of a seizure but this was unsuccessful. broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. she improved over the next few days and antibiotics were discontinued because the suspicion for a bacterial meningitis was low. #. seizure: this occured in the setting of fever, hypotension, and initiation of reglan for vomiting. neurology was consulted and felt she should be continued on keppra indefinitely. eeg was non-revealing. she should be continued on keppra 1gm with dialysis three times weekly. # esrd on hd: hyperkalemia resolved with kayexalate. underwent dialysis on normal schedule. # sle: she was continued on prednisone 4mg daily. with multiple abdominal symptoms it was thought she may have lupus flare in the abdomen. c3, c4 were equivocal for active lupus flare, and [**doctor first name **] was positive, as would be expected in lupus. # anemia: has anemia of chronic renal disease and her hct was high on admission and epo was held per renal. however, her hct trended all the way down to 20 and she was borderline hypotensive for her (ie sbp 120) and she developed coffee ground emesis so she was transfused 2 units. afterward her hct was stable at 25. she was also re-started on epo per renal for her chronic anemia. hemolysis labs were negative. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient. previous documentation in omr states she does not need to be bridged while subtherapeutic. continued coumadin 4 mg po daily however inr became supratherapeutic and the coumadin was then held. she was started on heparin gtt while awaiting egd. after egd the coumadin was re-started at 3mg daily however, in setting of poor po intake her inr was supratherapeutic - likely [**2-12**] nutritional deficiency of vitamin k. coumadin will be restarted when inr [**2-13**] at dialysis. # osa: she is on cpap at a setting of 7 as an outpatient. continued cpap #. cin1: on last pap had cin1. ob/gyn service was called re: doing colposcopy in hospital as patient rarely makes o/p appointments, hwoever they do not do this procedure in hospital especially because it does not have to be done emergently - just within one year. will need outpatient colposcopy at some point in next few months as they do not do this procedure in the hospital. # rll nodule: a new 10 x 5 mm nodularity was found incidentally within the right lower lobe of the lung on an abdominal ct. this should be reassessed in 3 months. # access: piv, right groin hd line # code: full code ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction; Acute posthemorrhagic anemia; Unspecified intestinal obstruction; Other primary cardiomyopathies; Unspecified disease of pericardium; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Disorders of phosphorus metabolism; Hypotension, unspecified; Hyperpotassemia; Mononeuritis of unspecified site; Anemia of other chronic disease; Abdominal pain, left lower quadrant; Other chronic pain; Thrombocytopenia, unspecified; Diaphragmatic hernia without mention of obstruction or gangrene; Other specified peripheral vascular diseases; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus; Noncompliance with renal dialysis; Renal dialysis status; Long-term (current) use of anticoagulants; Personal history of noncompliance with medical treatment, presenting hazards to health]","kub: sbo head ct: (prelim read from radiology). ct chest/abd: preliminary read normal aorta without dissection or acute abnormality. bp meds were held and then re-initiated as the pressure came back up once she was able to eat. gi was c/s re: abd pain and rec cta-abdomen to eval for mesenteric ischemia vs. partial sbo, however with esrd did not initially want to get cta so kub was ordered. a few hours later she had 3 episodes of coffee-ground emesis. afterward the pain resolved and her hct remained stable. gi felt that the patient would need general anesthesia in order to undergo an egd which showed an ulcer at the ge junction. her pain was controlled with her outpatient regimen of po dilaudid. broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. she should be continued on keppra 1gm with dialysis three times weekly. c3, c4 were equivocal for active lupus flare, and [**doctor first name **] was positive, as would be expected in lupus. # anemia: has anemia of chronic renal disease and her hct was high on admission and epo was held per renal.","sbo head ct was negative for intracranial hemorrhage. no intracranial hemorrhage ekg: nsr, right axis, lvh, nl intervals, st elevations v2-3 (old), tw inversion v6 (new) no acute abnormalities in the abdomen to explain epigastric pain." 109,136572.0,14860,2142-06-20,14802,140167.0,2141-12-23,Discharge summary,"Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 1973**] Chief Complaint: Malignant hypertension Major Surgical or Invasive Procedure: None History of Present Illness: 24 year old female with ESRD on HD, SLE, malignant HTN presents with headache and abdominal pain beginning this morning. Patient had her hemodialysis day before yesterday. She has had multiple admissions to [**Hospital1 18**] with hypertensive urgency with symptoms of headache and abdominal pain. Has had extensive work-up for abdominal pain including ex-lap on [**2141-10-27**] which was negative. Patient states that her headache and abdominal pain are similar in characteristics to her previous admission. Patient denies any fever, chills, nightsweats, chest pain, shortness of breath, abdominal pain, nausea, vomitting, diarrhea, constipation, blood in stool, dysuria, hematuria, change in vision, hearing, weakness or numbness. In the ED, initial vitals were T97, BP253/170, HR100, RR24 100%RA. Was initially given 10mg IV Labetalol once and then started on drip at 2mg/hour. She also received hydralazine IV 10 mg once and 2 inch nitropaste. She morphine 4mg once for pain and 4mg Zofran for nausea. Her BP elevated as high as 270/174 and his labetolol was switched to nicardipine 1mg/kg/min. On arrival to the MICU her vitals were T 96.4 HR 99 BP 175/120 RR 15 100%RA. Patient was comfortable. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile . PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: Vitals: 97.5 122/80 88 18 100%RA. Gen: sleeping, easily arousable, appears comfortable. HEENT: AT/NC, L eye prosthetic non-reactive, R pupil reactive, MMM. Heart: S1S2 RRR, III/VI SEM heard best at apex, + S3 Pulm: CTA b/l, no w/r/r. Abd: normal bowel sounds, midline scar well-healed, soft, nontender, prior PD site with dry dressing, patient with tenderness to palpation over prior PD cath site, no guarding/rebound Ext: no edema, no clubbing, WWP. R femoral HD catheter in place. Neuro: following commands, answers appropriately, [**5-15**] motor strength, sensation is intact. Pertinent Results: Admission: [**2141-12-18**] 02:00AM BLOOD WBC-5.8 RBC-3.30* Hgb-10.1* Hct-30.3* MCV-92 MCH-30.7 MCHC-33.5 RDW-20.7* Plt Ct-199 [**2141-12-18**] 02:00AM BLOOD PT-14.2* PTT-32.1 INR(PT)-1.2* [**2141-12-18**] 02:00AM BLOOD UreaN-35* Creat-5.0* Na-138 K-5.5* Cl-103 HCO3-21* AnGap-20 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-18**] 02:00AM BLOOD Lipase-73* [**2141-12-18**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.07* [**2141-12-19**] 06:45AM BLOOD Calcium-8.1* Phos-5.1* Mg-1.8 [**2141-12-18**] 03:52PM BLOOD dsDNA-NEGATIVE [**2141-12-18**] 03:52PM BLOOD CRP-11.5* [**2141-12-18**] 03:52PM BLOOD C3-68* C4-19 [**2141-12-20**] 12:09PM BLOOD Type-ART pO2-158* pCO2-42 pH-7.36 calTCO2-25 Base XS--1 [**2141-12-18**] 02:08AM BLOOD pO2-52* pCO2-38 pH-7.39 calTCO2-24 Base XS--1 Comment-GREEN TOP [**2141-12-20**] 12:09PM BLOOD Lactate-0.9 [**2141-12-18**] 02:08AM BLOOD Glucose-68* Lactate-1.3 Na-140 K-4.8 Cl-103 [**2141-12-23**] 03:00PM BLOOD WBC-4.7 RBC-2.35* Hgb-7.1* Hct-22.3* MCV-95 MCH-30.3 MCHC-31.9 RDW-20.6* Plt Ct-131* [**2141-12-23**] 12:55AM BLOOD PT-14.7* PTT-66.2* INR(PT)-1.3* [**2141-12-18**] 03:52PM BLOOD ESR-21* [**2141-12-23**] 03:00PM BLOOD Glucose-97 UreaN-42* Creat-6.6* Na-138 K-4.3 Cl-106 HCO3-23 AnGap-13 [**2141-12-18**] 02:00AM BLOOD ALT-16 AST-69* CK(CPK)-89 AlkPhos-109 TotBili-0.4 [**2141-12-23**] 03:00PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8 [**2141-12-18**] 04:23PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008 [**2141-12-18**] 04:23PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG [**2141-12-18**] 04:23PM URINE RBC-<1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-12 TransE-<1 Micro: Blood Cx- [**12-18**]: No growth Urine Cx- [**12-18**]: No growth [**12-18**] TTE The left atrium and right atrium are normal in cavity size. A possible secundum type atrial septal defect is seen by color Doppler (clip [**Clip Number (Radiology) **]) There is severe symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function. There is no significant resting LVOT gradient, but a mild gradient (30mmHg peak) is seen with Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Marked symmetric left ventricular hypertrophy with normal regional/global systolic function and mild inducible LVOT gradient. Mild aortic regurgitation. Mild pulmonary artery systolic hypertension. Possible secundum type atrial septal defect. Compared with the prior study (images reviewed) of [**2141-10-19**], a possible secundum type atrial septal defect is now suggested. If clinically indicated, a follow-up study with saline contrast and/or a TEE would be better able to characterize the possible atrial septal defect. CLINICAL IMPLICATIONS: Based on [**2140**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**12-18**] CXR IMPRESSION: 1. Cardiomegaly with findings suggestive of mild pulmonary edema. 2. Bibasilar linear opacities suggesting atelectasis, although developing pneumonia cannot be excluded. 3. No evidence of free intraperitoneal air. [**12-20**] MRV IMPRESSION: No appreciable change since the MRV chest exam dated [**2141-5-30**]. SVC is patent. Again seen is occlusion of the right internal jugular and left brachiocephalic veins. Right external jugular vein is provides the major venous drainage from the neck. Brief Hospital Course: 24 year old Female with SLE, ESRD on HD and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ED. 1. Malignant Hypertension: The patient had her hemodialysis two days prior to admission. Initially in the ED her BP was 253/170. She was given 10mg IV Labetalol and started on a labatelol drip. She also received hydralazine IV 10 mg once and 2 inches of nitropaste. She had morphine 4mg and 4mg Zofran for nausea. Her BP remained elevated so she was switched to nicardipine 1mg/kg/min. The patient was transferred to the MICU. In the ICU she was continued on the Nicardapine drip and her pressures decreased to 175/120. Nephrology was consulted and dialysis initiated in the AM. The Nicardapine drip dc'd on [**12-19**] and pt transferred to floor. While on the floor the patient had question of angioedema and markedly elevated BP. She was readmitted to the MICU on [**2141-12-20**]. Patient's Aliskerin was also held for conern for angioedema. The renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. The patient's PD catheter was removed. The patient was briefly on a nitro drip for hypertension. The patient's nifedepine was increased to 120mg. The patient was transferred to the floor with stable blood pressures, BP 124/72 on [**12-21**]. The morning of [**12-22**], the patient was noted to have a BP up to 247/120 at 0800. Hypertension persisted throughout the morning with BPs 210s-240s systolic. HR during this time was in the 90s. She received a total of 60 mg IV hydralazine over the course of the morning as well as 0.1 mg PO clonidine. She was also given her normal AM BP meds and restarted on aliskarin. Due to persistent hypertension, she was transferred to the ICU for further care. On arrival to the ICU, the patient reported severe abdominal pain over the site of recently removed PD catheter. She denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. She reports bilateral calf cramping but no leg swelling. She denies any difficulty breathing or chest pain. She took her AM BP meds without difficulty. Her blood pressure decreased to 130s-140s/60s without further intervention. She was transferred back to the floor on [**12-23**] and signed out AMA. 2. Angioedema: On [**12-20**] the patietn developed facial swelling and evidence of angioedema by ENT. The patient reported that her face is more swollen which was confirmed by her mother on the floor. The patient was give lasix IV as she has been unable to have any negative filtration with HD. The patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. Her tekturna was discontinued for concern that it might be causing angioedema. She denied difficulty with her breathing at that time, but was very somnulent. On arrival to the MICU her vitals were stable and oxygenating well at 100% on face mask. The patient's airway was supported with a nasal trumpet. The patient underwent MRV that showed no progression of her clot. Patient was diuresed with lasix and dialysis with significant improvement in her symptoms. She was treated with prednisone and decadron, famotidine and benadryl for angioedema. The patient was maintained on her heparin drip for her SVC syndrome. 3. Abdominal Pain: The patient has had extensive prior workup that has been unrevealing. The Transplant surgery team removed the PD cath on [**12-21**]. She continued to have abdominal pain post-op. She was continued on PO dilaudid 2mg po prn. She continuned to complain of abdominal pain throughout her admission and continued to requested IV dilaudid. 4. ESRD: The patient is on a T/Th/Sat schedule. She was closely followed by the renal team. She had dialysis on [**12-19**]. The patient's tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. The patient also had her PD catheter removed on [**12-21**] secondary to chronic abdominal pain. The patient was scheduled to have dialysis on [**12-23**]. 5. Hx of SVC/brachiocephalic DVT: Her coumadin was held during last admission for supratherapeutic INR. She was admitted with a subtherpeutic INR of 1.2 She was started on a heparin drip. She was also started on Coumadin 2mg PO qday, but was held on [**12-19**] in prep her PD catheter removal. She was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by IR. However, the patient signed out AMA and thus it was not placed. 6. Anxiety: Pt recently saw psychiatrist who started her on Celexa. She was continued on Celexa 20mg PO daily. 7. Anemi of CKDa: The patient's Hct was 30.3 on admission. It trended down to 22.3 on discharge when she left AMA. There was no evidence of active, acute bleeding. THis is likely seoncdary to her ESRD. The patient was closely monitored. 8. Systemic Lupus Erythematosis: Rheumatology was consulted and does not suspect acute flare and dsDNA, C3, C4 nl, ESR and CRP slightly elevated. Her Echo did not suggest worsening pericarditis. She was continued on her home prednisone dose of 4mg daily. 9. Obstructive Sleep Apnea: CPAP for sleep with 7 pressure. Medications on Admission: Aliskiren 150 mg [**Hospital1 **] Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Warfarin held on discharge [**2141-12-14**] due to supratherap INR Discharge Medications: As patient signed out AMA, no medications were issued. She was told to resume her admission medications, however no instructions were taken by the patient. Discharge Disposition: Home Discharge Diagnosis: 1) Hypertensive urgency 2) Abdominal pain 3) End stage renal disease on hemodialysis 4) Venous thromboembolism Discharge Condition: Signed out AMA Discharge Instructions: Pt signed out AMA Return to the hospital with any concerning symptoms. Be sure to call your doctor's office on [**Month/Day/Year 766**] to arrange hemodialysis and review your medications and discuss follow-up plan. Followup Instructions: Follow-up with your Dr. [**Last Name (STitle) **] next week, and call [**Last Name (STitle) 766**] to arrange your hemodialysis. Completed by:[**2141-12-26**]",179,2141-12-18 03:50:00,2141-12-23 19:51:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. 1. malignant hypertension: the patient had her hemodialysis two days prior to admission. initially in the ed her bp was 253/170. she was given 10mg iv labetalol and started on a labatelol drip. she also received hydralazine iv 10 mg once and 2 inches of nitropaste. she had morphine 4mg and 4mg zofran for nausea. her bp remained elevated so she was switched to nicardipine 1mg/kg/min. the patient was transferred to the micu. in the icu she was continued on the nicardapine drip and her pressures decreased to 175/120. nephrology was consulted and dialysis initiated in the am. the nicardapine drip dcd on [**12-19**] and pt transferred to floor. while on the floor the patient had question of angioedema and markedly elevated bp. she was readmitted to the micu on [**2141-12-20**]. patients aliskerin was also held for conern for angioedema. the renal team removed her tunneled dialysis catheter that had a cuff out, and replaced it with a temporary femoral line. the patients pd catheter was removed. the patient was briefly on a nitro drip for hypertension. the patients nifedepine was increased to 120mg. the patient was transferred to the floor with stable blood pressures, bp 124/72 on [**12-21**]. the morning of [**12-22**], the patient was noted to have a bp up to 247/120 at 0800. hypertension persisted throughout the morning with bps 210s-240s systolic. hr during this time was in the 90s. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she was also given her normal am bp meds and restarted on aliskarin. due to persistent hypertension, she was transferred to the icu for further care. on arrival to the icu, the patient reported severe abdominal pain over the site of recently removed pd catheter. she denied any headache, nausea, vomiting, diarrhea, constipation, or lower extremity swelling. she reports bilateral calf cramping but no leg swelling. she denies any difficulty breathing or chest pain. she took her am bp meds without difficulty. her blood pressure decreased to 130s-140s/60s without further intervention. she was transferred back to the floor on [**12-23**] and signed out ama. 2. angioedema: on [**12-20**] the patietn developed facial swelling and evidence of angioedema by ent. the patient reported that her face is more swollen which was confirmed by her mother on the floor. the patient was give lasix iv as she has been unable to have any negative filtration with hd. the patient was started on decadron 10mg q8hr, famotidine, diphenhydramine for the edema. her tekturna was discontinued for concern that it might be causing angioedema. she denied difficulty with her breathing at that time, but was very somnulent. on arrival to the micu her vitals were stable and oxygenating well at 100% on face mask. the patients airway was supported with a nasal trumpet. the patient underwent mrv that showed no progression of her clot. patient was diuresed with lasix and dialysis with significant improvement in her symptoms. she was treated with prednisone and decadron, famotidine and benadryl for angioedema. the patient was maintained on her heparin drip for her svc syndrome. 3. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the transplant surgery team removed the pd cath on [**12-21**]. she continued to have abdominal pain post-op. she was continued on po dilaudid 2mg po prn. she continuned to complain of abdominal pain throughout her admission and continued to requested iv dilaudid. 4. esrd: the patient is on a t/th/sat schedule. she was closely followed by the renal team. she had dialysis on [**12-19**]. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient also had her pd catheter removed on [**12-21**] secondary to chronic abdominal pain. the patient was scheduled to have dialysis on [**12-23**]. 5. hx of svc/brachiocephalic dvt: her coumadin was held during last admission for supratherapeutic inr. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. she was also started on coumadin 2mg po qday, but was held on [**12-19**] in prep her pd catheter removal. she was continuned on the heparin drip and her coumadin continued to be held in preparation for placement of a tunneled dialysis catheter by ir. however, the patient signed out ama and thus it was not placed. 6. anxiety: pt recently saw psychiatrist who started her on celexa. she was continued on celexa 20mg po daily. 7. anemi of ckda: the patients hct was 30.3 on admission. it trended down to 22.3 on discharge when she left ama. there was no evidence of active, acute bleeding. this is likely seoncdary to her esrd. the patient was closely monitored. 8. systemic lupus erythematosis: rheumatology was consulted and does not suspect acute flare and dsdna, c3, c4 nl, esr and crp slightly elevated. her echo did not suggest worsening pericarditis. she was continued on her home prednisone dose of 4mg daily. 9. obstructive sleep apnea: cpap for sleep with 7 pressure. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Mechanical complication due to peritoneal dialysis catheter; ; Unspecified disease of pericardium; Angioneurotic edema, not elsewhere classified; Abdominal pain, other specified site; Systemic lupus erythematosus; ; Anemia in chronic kidney disease; Dysthymic disorder; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of steroids; Long-term (current) use of anticoagulants; Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation; Other antihypertensive agents causing adverse effects in therapeutic use]","24 year old female with sle, esrd on hd and malignant hypertension presents with abdominal pain and headache consistent with her usual hypertensive urgency and was found to be in hypertensive urgency in ed. she was given 10mg iv labetalol and started on a labatelol drip. nephrology was consulted and dialysis initiated in the am. she received a total of 60 mg iv hydralazine over the course of the morning as well as 0.1 mg po clonidine. she reports bilateral calf cramping but no leg swelling. she took her am bp meds without difficulty. her tekturna was discontinued for concern that it might be causing angioedema. the patient was maintained on her heparin drip for her svc syndrome. abdominal pain: the patient has had extensive prior workup that has been unrevealing. the patients tunneled dialysis catheter had a cuff that was out and qas subsequently replaced with a temporary femoral line on [**12-21**]. the patient was scheduled to have dialysis on [**12-23**]. she was admitted with a subtherpeutic inr of 1.2 she was started on a heparin drip. there was no evidence of active, acute bleeding.","24 year old female with sle, esrd on hd presents with abdominal pain and headache consistent with her usual hypertensive urgency. she was found to be in hypertensive urgency in ed. she received hydralazine iv 10 mg once and 2 inches of nitropaste." 109,136572.0,14860,2142-06-20,14803,135923.0,2142-01-12,Discharge summary,"Admission Date: [**2142-1-8**] Discharge Date: [**2142-1-13**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 613**] Chief Complaint: Hypertensive Urgency and HA Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with HA in the setting of hypertension. Upon arrival to the ED, her vitals were 284/140, HR 67, RR 28, 100% on 4LNC. She was started on a nicardipine drip. She denied shortness of breath or chest pain. She is due for HD today. She has a left groin catheter which was recently placed [**2141-12-21**] and is causing her pain. She was also given dilaudid IV 1 mg x 2 with some relief. CXR was performed and showed no pulmonary edema. . Upon arrival to the MICU, patient denies HA, CP, SOB, fevers, chills. Patient reports mild abdominal pain at sight of left anterior abdominal wall hematoma and left groin pain at site of femoral HD line. She reports that she was taking her medications as directed, including coumadin for SVC thrombus. Briefly, 24 yo F with ESRD on HD, SLE, malignant HTN admitted for HA in the setting of HTN to 284/140 in ED. Initially, she was treated with a nicardipine gtt to control her BP. Her cardiac enzymes were flat, no new ECG changes. She was started on a heparin gtt with transition to coumadin for a SVC thrombosis. HTN secondary to med noncompliance. She was restarted on her oral BP. She missed her PM meds yesterday, so nicardipine was restarted, and then turned off this AM. She received all her AM BP meds. Her BPs have been in the 160s/90s. She had no neurological deficits. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: 176/105, 87, 18, 100% RA General Appearance: Well nourished, No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: 2/6 systolic murmur LUSB Respiratory / Chest: (Breath Sounds: Clear : ) Abdominal: left ant wall abd hematoma, TTP Extremities: Right: Trace, Left: Trace, left fem HD line without oozing or drainage Skin: Warm Neurologic: AAO x 3 Pertinent Results: [**2142-1-8**] 05:15AM PT-13.7* PTT-33.6 INR(PT)-1.2* [**2142-1-8**] 05:15AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-1+ STIPPLED-OCCASIONAL TEARDROP-1+ BITE-NORMAL FRAGMENT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2142-1-8**] 05:15AM cTropnT-0.08* [**2142-1-8**] 05:15AM CK(CPK)-119 [**2142-1-8**] 04:12PM PTT-120.8* [**2142-1-8**] 10:41PM PTT-144.8* [**2142-1-8**] 02:55PM CK-MB-NotDone cTropnT-0.06* Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. Patient was initially observed in the MICU and placed on a nicardipine drip. Patient was stablized on home medicaitons, suggesting medication non-compliance. Additionally, patient presented subtheraputic on coumadin for SVC thrombosis. Patient was started on heparin ggt. After the nicardipine drip was turned off, patient was called out to the floor. Heparin drip was continued until INR [**2-13**]. Pressures were managed to her baseline. Pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with Narcan. Patient received dialysis 3x/wk as per outpatient schedule. # Hypertension: Pt with extensive history of repeated admissions for hypertension. Patient's BP improved with nicardipine drip and after HD off drip on home PO medication regimen. Resumed oral antihypertensives with improved BP control. HTn likely from renal disease, possible medication noncompliance, lupus. No evidence of MI. Continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. Renal increased clonidine patch, and added Nicardipine with improvement of BP control. Pt is to follow up with an appointment in the next week to establish care at [**Company 191**], and to re-check her BP and adjust medications further. # SLE: Stable, continued prednisone at 4 mg PO daily. # Left groin pain. Permanent HD line was placed on [**12-25**]. Line and hematoma from prior peritoneal line on abdomen okay. No leukocytosis or fevers to suggest infection. Patient was oversedated on Dilaudid and had episode of oxygen desaturation which was reversed with Narcan. Patient was solmolent with morphine SR so that was d/c'ed as well, patient was given standing tylenlol and Morphine IR PRN. Transplant surgery removed remaining sutures today from L groin. Pt has a follow-up appointment in the next week with Dr. [**First Name (STitle) **] (Transplant Surgery). She will be sent home with low-dose Morphine IR and Tylenol PRN pain. If L groin pain should become uncontrollable on current meds, pt should return to the ED for re-evaluation. It is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #ESRD: Renal following, continuing HD Th/Th/Sat. CaCO3 was started for elevated calcium-phosphate product. Pt will follow-up with Dr. [**Last Name (STitle) 7473**] in the next 1-2 weeks. # Anemia: Pt's baseline is 26. This is likely secondary to AOCD and renal failure. Hct was stable on day of discharge at 25.9. # SVC thrombus: Pt has a history of an SVC thrombus, and is on coumadin. She is supposed to be on lifelong anticoagulation due to recurrent thrombosis but INR subtherapeutic on arrival. Heparin drip was stopped on the floor once the INR was theraputic. INR was therapeutic on day of discharge. Pt will need an INR check in the next week at her follow-up with her PCP. # HOCM: Pt has evidence of myocardial hypertrophy on Echo. She is currently not symptomatic. Echo did not show evidence of worsening pericardial effusion. She was continued on her beta-blocker and other BP medications. # Depression/anxiety: Stable. She was continued on Celexa and Clonazepam. # OSA: Pt as continued on CPAP for sleep with 7 pressure. # FEN: regular diet # PPX: heparin drip --> coumadin, bowel regimen # ACCESS: PIV x2 / permanent dialysis cath L fem # CODE: FULL # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] # DISPO: home with PCP and Renal [**Name9 (PRE) 702**] to re-check BP, INR level. Follow-up with Transplant Surgery. Medications on Admission: Clonidine 0.3mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 800mg PO TID Hydromorphone 4mg PO q4H PRN Nifedipine ER 90mg PO qday Prednisone 4mg PO qday Lorazepam 0.5mg PO qHS Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Aliskiren 150 [**Hospital1 **] Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM. 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Nicardipine 30 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 11. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for pain for 2 weeks. [**Hospital1 **]:*20 Tablet(s)* Refills:*0* 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours. 13. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Hypertensive Urgency End Stage Renal Disease Discharge Condition: stable, blood pressure moderately controlled, afebrile, tolerating POs Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. Some of medications were increased as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to take the coumadin as prescribed by your doctor, and have your INR checked frequently per your PCP's recommendations. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep all scheduled appointments. If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Renal) Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2142-1-15**] 3:00 - Will follow-up Vitamin D [**2-4**] level Provider: [**First Name11 (Name Pattern1) 9604**] [**Last Name (NamePattern4) 43504**], MD ([**Company 191**]) Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-1-16**] 3:30 - Will re-check your INR level Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD (Transplant Surgery) Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-1-19**] 2:50p [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-1-12**]",159,2142-01-08 06:36:00,2142-01-13 21:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE URGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was initially observed in the micu and placed on a nicardipine drip. patient was stablized on home medicaitons, suggesting medication non-compliance. additionally, patient presented subtheraputic on coumadin for svc thrombosis. patient was started on heparin ggt. after the nicardipine drip was turned off, patient was called out to the floor. heparin drip was continued until inr [**2-13**]. pressures were managed to her baseline. pain medications were decreased as patient has hypoxia and altered mental status from over sedation, which was reversed with narcan. patient received dialysis 3x/wk as per outpatient schedule. # hypertension: pt with extensive history of repeated admissions for hypertension. patients bp improved with nicardipine drip and after hd off drip on home po medication regimen. resumed oral antihypertensives with improved bp control. htn likely from renal disease, possible medication noncompliance, lupus. no evidence of mi. continued nifedipine, aliskerin labetalol, hydralazine, and clonidine at current doses. renal increased clonidine patch, and added nicardipine with improvement of bp control. pt is to follow up with an appointment in the next week to establish care at [**company 191**], and to re-check her bp and adjust medications further. # sle: stable, continued prednisone at 4 mg po daily. # left groin pain. permanent hd line was placed on [**12-25**]. line and hematoma from prior peritoneal line on abdomen okay. no leukocytosis or fevers to suggest infection. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. patient was solmolent with morphine sr so that was d/ced as well, patient was given standing tylenlol and morphine ir prn. transplant surgery removed remaining sutures today from l groin. pt has a follow-up appointment in the next week with dr. [**first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. it is anticipated that pain should resolve, as line placement occured over 2 weeks ago. #esrd: renal following, continuing hd th/th/sat. caco3 was started for elevated calcium-phosphate product. pt will follow-up with dr. [**last name (stitle) 7473**] in the next 1-2 weeks. # anemia: pts baseline is 26. this is likely secondary to aocd and renal failure. hct was stable on day of discharge at 25.9. # svc thrombus: pt has a history of an svc thrombus, and is on coumadin. she is supposed to be on lifelong anticoagulation due to recurrent thrombosis but inr subtherapeutic on arrival. heparin drip was stopped on the floor once the inr was theraputic. inr was therapeutic on day of discharge. pt will need an inr check in the next week at her follow-up with her pcp. # hocm: pt has evidence of myocardial hypertrophy on echo. she is currently not symptomatic. echo did not show evidence of worsening pericardial effusion. she was continued on her beta-blocker and other bp medications. # depression/anxiety: stable. she was continued on celexa and clonazepam. # osa: pt as continued on cpap for sleep with 7 pressure. # fen: regular diet # ppx: heparin drip --> coumadin, bowel regimen # access: piv x2 / permanent dialysis cath l fem # code: full # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] # dispo: home with pcp and renal [**name9 (pre) 702**] to re-check bp, inr level. follow-up with transplant surgery. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Systemic lupus erythematosus; Hypoxemia; Other opiates and related narcotics causing adverse effects in therapeutic use; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Abdominal pain, other specified site; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Renal dialysis status; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Other postprocedural status]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. # hypertension: pt with extensive history of repeated admissions for hypertension. # sle: stable, continued prednisone at 4 mg po daily. patient was oversedated on dilaudid and had episode of oxygen desaturation which was reversed with narcan. first name (stitle) **] (transplant surgery). she will be sent home with low-dose morphine ir and tylenol prn pain. if l groin pain should become uncontrollable on current meds, pt should return to the ed for re-evaluation. this is likely secondary to aocd and renal failure. pt will need an inr check in the next week at her follow-up with her pcp.","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. patient was stablized on home medicaitons, suggesting medication non-compliance. patient was oversedated on dilaudid and had episode of oxygen desaturation." 109,136572.0,14860,2142-06-20,14804,124657.0,2142-01-20,Discharge summary,"Admission Date: [**2142-1-14**] Discharge Date: [**2142-1-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 4028**] Chief Complaint: headache Major Surgical or Invasive Procedure: HD History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with mild headache, mild shortness of breath and consistent abdominal pain at the site of her known left abdominal wall hematoma in the setting of hypertension. Her last HD was yesterday. . Upon arrival to the ED, her vitals were BP 240's systolic, HR 90's, 93% on RA. A head CT scan was done which showed no acute process. An abdominal CT was done given her femoral line pain, which also was normal. She was given nitropaste X2 initially, then switched to labetalol 100mg x2, then 200mg x2, then finally started on nicardipine drip when she showed benefit with a decrease in her BP to 170/123 and improvement in her headache. . Upon arrival to the MICU, patient denies any current symptoms. She reports that her headache, shortness of breath and abdominal pain all resolved with blood pressure management and pain medications. . Pt was transferred to the floor when blood pressure was controlled. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: VS: HR 96 BP 171/111 RR 12 O2 98% on RA Physical Exam: General in NAD HEENT NC, AT, EOMI, PERRLA, MMM CVS RRR, 3/6 systolic murmur in all heart fields RESP CTA BL, no crackles or wheezes ABD soft, hematoma raised on left anterior abdominal wall, +BS, mildly tender over hematoma EXT left sided femoral HD line in place, no erythema, no edema NEURO A+Ox3, CN2-12 intact, pt has left sided artificial eye, motor and sensory intact Pertinent Results: ***LABS ON ADMISSION*** [**2142-1-13**] 07:03AM WBC-5.2 RBC-2.79* HGB-8.5* HCT-26.3* MCV-94 MCH-30.3 MCHC-32.2 RDW-19.2* [**2142-1-13**] 07:03AM PLT COUNT-154 [**2142-1-13**] 07:03AM PT-29.5* PTT-49.2* INR(PT)-3.0* [**2142-1-13**] 07:03AM GLUCOSE-94 UREA N-53* CREAT-7.0* SODIUM-136 POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16 [**2142-1-13**] 07:03AM CALCIUM-8.8 PHOSPHATE-5.0* MAGNESIUM-1.9 [**2142-1-14**] 12:00PM PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-14**] 12:00PM LIPASE-42 [**2142-1-14**] 12:00PM ALT(SGPT)-12 AST(SGOT)-43* ALK PHOS-96 TOT BILI-0.4 [**2142-1-14**] 03:25PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-1-14**] 03:25PM URINE RBC-[**3-15**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-[**3-15**] [**2142-1-14**] 12:00PM BLOOD PT-43.8* PTT-56.1* INR(PT)-4.9* [**2142-1-19**] 06:40AM BLOOD PT-18.6* PTT-38.7* INR(PT)-1.7* . ***LABS ON DAY OF DISCHARGE*** [**2142-1-20**] 06:35AM BLOOD WBC-5.7 RBC-2.39* Hgb-7.1* Hct-22.1* MCV-93 MCH-29.8 MCHC-32.2 RDW-18.6* Plt Ct-136* [**2142-1-20**] 06:35AM BLOOD Glucose-107* UreaN-34* Creat-4.8* Na-137 K-5.2* Cl-101 HCO3-27 AnGap-14 [**2142-1-20**] 06:35AM BLOOD PT-22.8* PTT-42.3* INR(PT)-2.2* . IMAGING [**2142-1-14**] EKG Sinus rhythm. Possible left atrial abnormality. Borderline voltage criteria for left ventricular hypertrophy. Inferolateral ST-T wave changes may be related to left ventricular hypertrophy. Compared to the previous tracing of [**2142-1-8**] there is no significant diagnostic change. Intervals Axes Rate PR QRS QT/QTc P QRS T 99 190 86 368/436 13 100 24 [**2142-1-14**] CT ABD/PELV IMPRESSION: 1. Interval decrease in size to subcutaneous anterior abdominal wall hematoma. 2. Infectious versus inflammatory process within the right lower lobe of the lung. Small right simple pleural effusion. 3. Cardiomegaly with slight decrease in size of moderate pericardial effusion. 4. Right lobe liver hemangioma, unchanged. [**2142-1-14**] CT HEAD IMPRESSION: 1. Mildly limited study given administration of small amount of IV contrast material. However, no evidence of hemorrhage or mass effect. NOTE ADDED AT ATTENDING REVIEW: This patient was administered contrast for the abdominal CT, and the head CT was performed after part of this dose. Therefore, this is neither a noncontrast examination, nor a proper contrast CT. [**2142-1-14**] CXR CONCLUSION: Persistent cardiomegaly and mild pulmonary edema. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency. . # Hypertensive Urgency: Pt with extensive history of hypertension. Patient's BP improved with nicardipine drip. Became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. Restarted all home oral antihypertensives including nicardipine 30 Q8H, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Blood pressure remains labile and renal continues to follow patient. Pt was transferred to the floor as blood pressure stabilized. BP has remained stable with systolics 140s-170s. In the MICU, Nifedipine extended release was added in place of Nicardipine as pt's blood pressures seemed to rise prior to Nicardipine doses. . # Hyperkalemia: Ocurred on the day after admission. Resolved with administration of kayexalate. Pt continued hemodialysis on TuThSat. . # Left abdominal wall hematoma: Abd CT showed a mild decrease in the size. Pt reported that morphine did not help pain, and was switched to dilaudid PO in the MICU. However, given pt's recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/c'ed on the floor. Pt was continued on gabapentin, tylenol around the clock, and low-dose Morphine as needed for pain. Narcotics should be avoided in the future. Pain should also resolve in the next few weeks as hematoma resolves. . # SLE: Pt was continued on prednisone at 4 mg PO daily. . #ESRD: Renal was following during her stay. She continued HD on her T, Th, Sat schedule. # Anemia: Hct was mildly decreased from baseline during admission. This is likely secondary to AOCD and in the setting of renal failure. . # SVC thrombus: Patient is on anticoagulation, likely lifelong. Patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. Then INR became subtherapeutic, so heparin gtt was used to bridge. On day of discharge, INR became therapeutic, and pt was discharged home on Coumadin 4mg PO daily, with INR to be checked next at hemodialysis . # HOCM: Pt has evidence of myocardial hypertrophy on recent Echo. She was not symptomatic during her stay. She was continued on her beta blocker. . # Depression/anxiety. She was continued on celexa and clonazepam PRN. . # OSA: CPAP for sleep with 7 pressure. . # FEN: repleted lytes prn / regular diet . # PPX: coumadin, bowel regimen . # ACCESS: PIV/ permanent dialysis cath L fem . # CODE: FULL . # CONTACT: [**First Name8 (NamePattern2) **] [**Name (NI) **] (mother) [**Telephone/Fax (1) 43503**] Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nicardipine 30mg PO TID Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO every eight (8) hours as needed for breakthrough pain for 2 weeks. 2. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 10. Warfarin 1 mg Tablet Sig: Four (4) Tablet PO once a day. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 12. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*1* 13. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*260 Tablet(s)* Refills:*1* 14. Respiratory Therapy Please adjust settings of CPAP machine to a lower volume as it is uncomfortable for the patient. Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Discharge Condition: Good, hemodynamically stable, afebrile, pain controlled Discharge Instructions: You were admitted for headaches and very high blood pressures. You were started on an IV medication for your blood pressure which controlled it. You were then started back on your home medications with improvement of your blood pressure. One new medication was added as your hypertension was difficult to control. You were also started on a heparin drip while restarting your coumadin since you have a known clot in your veins. You will need to continue your Coumadin at 4mg daily and have your INR checked AT DIALYSIS next week. Please take all medications as prescribed. It is important that you do not miss doses of your medications since your blood pressure is very sensitive to missed doses. Please keep ALL scheduled appointments. Medications changes include: 1. STOP NICARDIPINE 2. Start Nifedipine CR 90mg by mouth daily 3. INCREASE Labetalol to 900mg by mouth 3 times daily 4. Continue at Warfarin 4mg by mouth daily If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 250**] to set up a follow-up appointment in 1-2weeks. Please continue your HD TuThSat. Completed by:[**2142-1-20**]",151,2142-01-14 17:34:00,2142-01-20 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. . # hypertensive urgency: pt with extensive history of hypertension. patients bp improved with nicardipine drip. became increased yesterday when the patient missed a dose of oral nicardipine, but came down after a replacement dose. restarted all home oral antihypertensives including nicardipine 30 q8h, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. blood pressure remains labile and renal continues to follow patient. pt was transferred to the floor as blood pressure stabilized. bp has remained stable with systolics 140s-170s. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. . # hyperkalemia: ocurred on the day after admission. resolved with administration of kayexalate. pt continued hemodialysis on tuthsat. . # left abdominal wall hematoma: abd ct showed a mild decrease in the size. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu. however, given pts recent prior admission required narcan following sensitivity to narcotics, dilaudid was d/ced on the floor. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. narcotics should be avoided in the future. pain should also resolve in the next few weeks as hematoma resolves. . # sle: pt was continued on prednisone at 4 mg po daily. . #esrd: renal was following during her stay. she continued hd on her t, th, sat schedule. # anemia: hct was mildly decreased from baseline during admission. this is likely secondary to aocd and in the setting of renal failure. . # svc thrombus: patient is on anticoagulation, likely lifelong. patient was supratherapeutic on coumadin on admission and coumadin was subsequently held. then inr became subtherapeutic, so heparin gtt was used to bridge. on day of discharge, inr became therapeutic, and pt was discharged home on coumadin 4mg po daily, with inr to be checked next at hemodialysis . # hocm: pt has evidence of myocardial hypertrophy on recent echo. she was not symptomatic during her stay. she was continued on her beta blocker. . # depression/anxiety. she was continued on celexa and clonazepam prn. . # osa: cpap for sleep with 7 pressure. . # fen: repleted lytes prn / regular diet . # ppx: coumadin, bowel regimen . # access: piv/ permanent dialysis cath l fem . # code: full . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**] ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; ; Other vascular complications of medical care, not elsewhere classified; Systemic lupus erythematosus; Hyperpotassemia; Phlebitis and thrombophlebitis of upper extremities, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. in the micu, nifedipine extended release was added in place of nicardipine as pts blood pressures seemed to rise prior to nicardipine doses. pt was continued on gabapentin, tylenol around the clock, and low-dose morphine as needed for pain. # anemia: hct was mildly decreased from baseline during admission. # hocm: pt has evidence of myocardial hypertrophy on recent echo. # fen: repleted lytes prn / regular diet . # contact: [**first name8 (namepattern2) **] [**name (ni) **] (mother) [**telephone/fax (1) 43503**]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency. pt was transferred to the floor as blood pressure stabilized. pt reported that morphine did not help pain, and was switched to dilaudid po in the micu." 109,136572.0,14860,2142-06-20,14805,176760.0,2142-01-23,Discharge summary,"Admission Date: [**2142-1-21**] Discharge Date: [**2142-1-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 30**] Chief Complaint: Hypertensive Urgency and fevers Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname **] is a 24 year old woman with ESRD on HD, SLE, malignant HTN admitted with hypertensive urgency, subjective fevers, and pain. . Of note, she had been hospitalized [**Date range (1) 43505**] with hypertensive urgency. Her nicardipine was changed to nifedipine in hospital and her labetalol was increased to 900mg TID from 800mg TID.BPs were reportedly stable in the 140's-170's on the medical floor on nifedipine, aliskerin, labetalol, clonidine, and hydralazine prior to discharge. Last HD was [**1-20**]. . She reports feeling well at time of discharge [**1-20**], however woke this evening feeling sweaty, hot, and mildly SOB. She did not check her temperature and denies any rigors. She had total body aching (worst in her left wrist at site of recent IV and abdomen at site of known hematoma). +Palpitations overnight now resolved. No CP, SOB, cough, diarrhea, dysuria, erythema/tenderness/drainage from HD catheter. Denies recent joint symptoms with her lupus. No sick contacts. Says she took her BP meds. . Upon arrival to the ED, her vitals were 99.9 104 254/145 16 96% on RA. She was started on a nicardipine drip, given 1"" nitropaste with improvement in her BP. Did spike a fever while in the ED, currently 101F 101 173/106 Given vancomycin and zoysn for ?pna as CXR with right sided haziness. Also received 3mg IV dilaudid for body pains. LUE ultrasound without evidence of DVT. Past Medical History: 1. Systemic lupus erythematosus: - Diagnosed [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated dialysis [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 PSHx: 1. Placement of multiple catheters including dialysis. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] Social History: Single and lives with her mother and a brother. She graduated from high school. The patient is on disability. The patient does not drink alcohol or smoke, and has never used recreational drugs. Family History: Negative for autoimmune diseases including sle, thrombophilic disorders. Maternal grandfather with HTN, MI, stroke in 70s. Physical Exam: T 98.5 P 92 Bp 173/116 RR 16 O2 100% on RA General Pleasant young woman appearing comfortable HEENT Cushingoid faces, L eye prosthesis, MMM Pulm Lungs clear bilaterally, no rales or wheezing CV Regular S1 S2 ?soft systolic murmur Abd Soft +hematoma left abdomen unchanged from prior exam Extrem Warm full distal pulses. Left hand with slight edema ++ tender to palpation of wrist patient unable to make fist secondary to pain, no erythema +warmth ?purulence at site of old PIV Skin No peripehral stigmata of endocarditis Lines Left groin HD catheter site without erythema, purulence, or tenderness Neuro Alert and awake, moving all extremities Pertinent Results: CXR [**1-21**]: In comparison with the earlier study of this date, the diffuse pulmonary edema has substantially decreased, possibly following hemodialysis. Enlargement of the cardiac silhouette persists and there is no definite pleural effusion. Suggestion of an area of increased opacification at the right base. This could merely represent asymmetric edema, though the possibility of a developing consolidation cannot be unequivocally excluded. . LUE US [**1-21**]: IMPRESSION: No DVT in the left upper extremity. . L wrist xray [**1-21**]: There is prominent soft tissue swelling about the wrist, relatively diffuse, but quite prominent along the dorsum of the wrist. No fracture, dislocation, degenerative change, focal lytic or sclerotic lesion, or erosion is identified. No soft tissue calcification or radiopaque foreign body is identified. A tiny (1.7 mm) linear density is seen along the dorsum of the wrist on the oblique view is seen only on that view and is consistent with a small film artifact. Brief Hospital Course: 24 yo woman with hx of SLE, ERSD on HD, admitted with hypertensive urgency and left wrist pain. . 1. Hypertensive urgency: Patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. Patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. She was started on nicardipine drip and 1"" nitropaste and admitted to the ICU for further treatment. There was no evidence of end-organ ischemia. Upon arrival to the ICU she was given her usual home antihypertensives and the nicardipine was quickly weaned off. It was felt that pain and anxiety were both contributing to her elevated BPs. Her BP quickly stabilized and she was called out to the medical floor where her SBP ranged 110-150. She was continued on nifepidine 90mg daily, aliskerin 150mg [**Hospital1 **], labetalol 900mg TID, hydralazine 100mg TID, and clonidine 0.3mg + 0.1mg weekly at current doses. Given her repeated admissions with hypertensive urgency a meeting was held between the patient's nephrologist Dr. [**Last Name (STitle) 4883**], her ICU physician and her [**Name9 (PRE) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the ICU where she quickly improves with simply continuing her home medications. The following plan was drafted and placed in a note in OMR titled "" Care Protocol"". . CARE PROTOCOL: . BLOOD PRESSURE MANAGEMENT: . For BP > 230/140 1. Hydralazine: 100 mg PO OR 10 mg IV q 20 minutes until blood pressure back to baseline*. . 2. Give daily blood pressure medications, if she has not already taken them before arrival. . 3. If after one hour of therapy AND/OR evidence of end organ damage, transfer to the ICU. . * Note: Her usual blood pressure is ~ 160/100. Efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. In the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . PAIN MANAGEMENT: . As an outpatient, Ms. [**Name13 (STitle) **] takes dilaudid 2-4 mg PO q 4 PRN.This is being slowly tapered, she should not be administered IV pain medications. . ANTICOAGULATION: . In the absence of bleeding, warfarin does not need to be stopped on admission. Similarly, in the absence of new thrombosis, subtherapeutic INR's do not require bridging with IV UFH. . 2. Fever: Possible sources included line infection, thombophlebitis, septic arthritis, PNA. Received vanc/zosyn in ED for possible PNA. UA without pyuria and urine culture negative. CXR also without convinving infiltrate on repeat PA/Lat so zosyn was discontinued. Patient was complaining of severe pain at her IV site and was noted to have a small abscess there which was felt to be the cause of her fever. She was continued on IV vanco with HD for 10day course. She remained afebrile and did not have a leukocytosis. . 3. Left wrist pain: Began following IV placement during recent hospitalization. Likely due to septic thrombophlebitis. Small abscess was too small to drain. This was treated with warm soaks and prn PO dilaudid. Vanco was continued for 10 day course. L wrist films were enremarkable. . 4. Left abdominal wall hematoma: Stable on exam from recent admission. She was continued on pain management with morphine 7.5mg TID, gabapentin and tylenol as needed for pain. . 5. SLE: Continued prednisone at 4 mg PO daily . 6. ESRD: Continued on regularly scheduled dialysis. . 7. Anemia: Baseline Hct 26. Her Hct was mildly decreased from baseline. Secondary to AOCD and renal failure. There was no evidence of bleeding. . 8. SVC thrombus: Known SVC thrombus, therapeutic on coumadin. Continued warfarin. . 9. HOCM: evidence of myocardial hypertrophy on recent Echo. Currently not symptomatic. Echo without evidence of worsening pericardial effusion. Continued beta blocker . 10. Depression/anxiety. Continued Celexa, clonazepam 0.5mg [**Hospital1 **] . 11. OSA: Continued CPAP Medications on Admission: Clonidine 0.3mg + 0.1mg / 24 hr patch weekly qwednesday Hydralazine 100mg PO q8H Labetalol 900mg PO TID Morphine 7.5mg Q8H PRN Nifedipine 90mg PO daily Aliskiren 150 [**Hospital1 **] Prednisone 4mg PO qday Clonazepam 0.5 mg [**Hospital1 **] Celexa 20mg PO qday Gabapentin 300 mg [**Hospital1 **] Acetaminophen 325-650 mg q6H PRN Ergocalciferol (Vitamin D2) 50,000 unit PO once a month Coumadin 4 mg daily Discharge Medications: 1. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. [**Hospital1 **]:*90 Tablet(s)* Refills:*2* 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). [**Hospital1 **]:*4 Patch Weekly(s)* Refills:*2* 4. Labetalol 300 mg Tablet Sig: Three (3) Tablet PO three times a day. [**Hospital1 **]:*270 Tablet(s)* Refills:*2* 5. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for pain. [**Hospital1 **]:*15 Tablet(s)* Refills:*0* 6. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Hospital1 **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Hospital1 **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 13. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 7 days. [**Hospital1 **]:*4 dose* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hypertensive urgency Septic thrombophlebitis Discharge Condition: Stable, afebrile, BP improved. Discharge Instructions: You were admitted to the hospital with hypertensive urgency. You required IV medications and were observed overnight in the ICU. Your usual oral blood pressure medications were continued and your blood pressure remained well-controlled. You were found to have an infection at your prior IV site on your left hand. For this you were given IV vancomycin. You will need 7 days more of antibiotics which will be given with dialysis. Please resume your usual dialysis schedule. Your last dialysis was [**1-23**]. Please continue to take your medications as prescribed. You should hold your coumadin today. You can resume this on wednesday at your normal dose. You should have your INR checked at dialyis as usual on thursday. . If you develop any of the following concerning symptoms, please call your PCP or go to the ED: fevers, chills, chest pains, shortness of breath, nausea, vomiting, or headaches. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-12**] weeks. ",148,2142-01-21 11:23:00,2142-01-23 16:40:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSIVE EMERGENCY," 24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. . 1. hypertensive urgency: patient has an history of malignant hypertension, with multiple recurrent admissions for hypertensive urgency. patient represented the evening after her discharge from the hospital and was found to be hypertensive to 254/145. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. there was no evidence of end-organ ischemia. upon arrival to the icu she was given her usual home antihypertensives and the nicardipine was quickly weaned off. it was felt that pain and anxiety were both contributing to her elevated bps. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150. she was continued on nifepidine 90mg daily, aliskerin 150mg [**hospital1 **], labetalol 900mg tid, hydralazine 100mg tid, and clonidine 0.3mg + 0.1mg weekly at current doses. given her repeated admissions with hypertensive urgency a meeting was held between the patients nephrologist dr. [**last name (stitle) 4883**], her icu physician and her [**name9 (pre) **] to come up with a plan for treatment in order to try and avoid repeated admissions to the icu where she quickly improves with simply continuing her home medications. the following plan was drafted and placed in a note in omr titled "" care protocol"". . care protocol: . blood pressure management: . for bp > 230/140 1. hydralazine: 100 mg po or 10 mg iv q 20 minutes until blood pressure back to baseline*. . 2. give daily blood pressure medications, if she has not already taken them before arrival. . 3. if after one hour of therapy and/or evidence of end organ damage, transfer to the icu. . * note: her usual blood pressure is ~ 160/100. efforts should not be made to lower blood pressure further, as this may precipitate end organ hypoperfusion. in the absence of clear end-organ damage, parenteral blood pressure medications (other than hydralazine) are generally not required. . pain management: . as an outpatient, ms. [**name13 (stitle) **] takes dilaudid 2-4 mg po q 4 prn.this is being slowly tapered, she should not be administered iv pain medications. . anticoagulation: . in the absence of bleeding, warfarin does not need to be stopped on admission. similarly, in the absence of new thrombosis, subtherapeutic inrs do not require bridging with iv ufh. . 2. fever: possible sources included line infection, thombophlebitis, septic arthritis, pna. received vanc/zosyn in ed for possible pna. ua without pyuria and urine culture negative. cxr also without convinving infiltrate on repeat pa/lat so zosyn was discontinued. patient was complaining of severe pain at her iv site and was noted to have a small abscess there which was felt to be the cause of her fever. she was continued on iv vanco with hd for 10day course. she remained afebrile and did not have a leukocytosis. . 3. left wrist pain: began following iv placement during recent hospitalization. likely due to septic thrombophlebitis. small abscess was too small to drain. this was treated with warm soaks and prn po dilaudid. vanco was continued for 10 day course. l wrist films were enremarkable. . 4. left abdominal wall hematoma: stable on exam from recent admission. she was continued on pain management with morphine 7.5mg tid, gabapentin and tylenol as needed for pain. . 5. sle: continued prednisone at 4 mg po daily . 6. esrd: continued on regularly scheduled dialysis. . 7. anemia: baseline hct 26. her hct was mildly decreased from baseline. secondary to aocd and renal failure. there was no evidence of bleeding. . 8. svc thrombus: known svc thrombus, therapeutic on coumadin. continued warfarin. . 9. hocm: evidence of myocardial hypertrophy on recent echo. currently not symptomatic. echo without evidence of worsening pericardial effusion. continued beta blocker . 10. depression/anxiety. continued celexa, clonazepam 0.5mg [**hospital1 **] . 11. osa: continued cpap ","PRIMARY: [Other vascular complications of medical care, not elsewhere classified] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; ; Systemic lupus erythematosus; Phlebitis and thrombophlebitis of upper extremities, unspecified]","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. she was continued on iv vanco with hd for 10day course. esrd: continued on regularly scheduled dialysis. her hct was mildly decreased from baseline. hocm: evidence of myocardial hypertrophy on recent echo. echo without evidence of worsening pericardial effusion. continued celexa, clonazepam 0.5mg [**hospital1 **] .","24 yo woman with hx of sle, ersd on hd, admitted with hypertensive urgency and left wrist pain. she was started on nicardipine drip and 1"" nitropaste and admitted to the icu for further treatment. her bp quickly stabilized and she was called out to the medical floor where her sbp ranged 110-150." 109,189332.0,14865,2142-08-30,14808,158943.0,2142-03-23,Discharge summary,"Admission Date: [**2142-3-21**] Discharge Date: [**2142-3-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: Abdominal Pain, Shortness of breath, Chest discomfort Major Surgical or Invasive Procedure: HD [**2142-3-21**] and [**2142-3-23**] History of Present Illness: The pt is a 24 y.o. F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] 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 [**Telephone/Fax (3) 43508**]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. [**Telephone/Fax (3) **] was discussed with renal and it was not felt that HTN is a volume issue so no need for emergent [**Telephone/Fax (3) 2286**]. . 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 [**2134**] (16 years old) when she had swollen fingers, arm rash and arthralgias - Previous treatment with cytoxan, cellcept; currently on prednisone - Complicated by uveitis ([**2139**]) and ESRD ([**2135**]) 2. CKD/ESRD: - Diagosed [**2135**] - Initiated [**Year (4 digits) 2286**] [**2137**] but refused it as of [**2140**], has survived despite this - PD catheter placement [**5-18**] 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 [**2140**] that resolved 4. Thrombocytopenia: - TTP (got plasmapheresisis) versus malignant HTN 5. Thrombotic events: - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy: may be etiology of episodes of worse hypertension given appears quite labile 12. Obstructive sleep apnea, AutoCPAP/ Pressure setting [**5-20**], Straight CPAP/ Pressure setting 7 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**], getting Vanc with HD. . PSHx: 1. Placement of multiple catheters including [**Year (4 digits) 2286**]. 2. Tonsillectomy. 3. Left eye enucleation in [**2140-4-10**]. 4. PD catheter placement in [**2141-5-11**]. 5. S/P Ex-lap for free air in abdomen, ex-lap normal [**2141-10-27**] 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: [**2142-3-21**] 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* [**2142-3-21**] 02:20AM NEUTS-76.1* BANDS-0 LYMPHS-17.9* MONOS-4.5 EOS-1.1 BASOS-0.5 [**2142-3-21**] 02:20AM PLT SMR-NORMAL PLT COUNT-168 [**2142-3-21**] 02:20AM PT-21.8* PTT-34.7 INR(PT)-2.1* [**2142-3-21**] 02:20AM cTropnT-0.12* [**2142-3-21**] 02:20AM ALT(SGPT)-46* AST(SGOT)-94* CK(CPK)-76 ALK PHOS-173* TOT BILI-0.4 [**2142-3-21**] 02:20AM GLUCOSE-74 UREA N-47* CREAT-7.3* SODIUM-140 POTASSIUM-5.8* CHLORIDE-109* TOTAL CO2-19* ANION GAP-18 [**2142-3-21**] 04:00AM URINE BLOOD-TR NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-21**] 08:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2142-3-21**] 12:58PM CK-MB-NotDone cTropnT-0.12* . CT C/A/P - [**2142-3-20**] - 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: [**2142-3-23**] 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* [**2142-3-23**] 12:00PM BLOOD Plt Ct-130* [**2142-3-23**] 12:00PM BLOOD PT-28.8* PTT-58.6* INR(PT)-2.9* [**2142-3-23**] 12:00PM BLOOD Glucose-77 UreaN-31* Creat-6.0*# Na-137 K-4.8 Cl-104 HCO3-24 AnGap-14 [**2142-3-23**] 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 [**3-22**] 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 [**2142-3-21**] . # abdominal pain: Consistent with patient's baseline chronic abdominal pain. Medication effect also possible. CT prelim neg for small bowel obstruction. LFTs doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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). [**Month/Year (2) **]:*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 [**Month/Year (2) 2286**] sessions as directed by the nephrology team- your next session should be on Tuesday. Completed by:[**2142-3-26**]",160,2142-03-21 09:25:00,2142-03-23 18:11:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,CHEST PAIN;TELEMETRY," 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 (200s/100s) that nevertheless are within levels shes 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 [**3-22**] and transferred to the medicine floor. the next day, her bp remained within goal of 120s/80s. 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. ces were cycled and were negative. cpap was continued as tolerated at home settings. sob resolved after hd on [**2142-3-21**] . # abdominal pain: consistent with patients baseline chronic abdominal pain. medication effect also possible. ct prelim neg for small bowel obstruction. lfts doubled from [**2142-3-18**]. 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 [**3-21**] and [**3-23**] . # 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. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Compression of vein; Unspecified disease of pericardium; Infection and inflammatory reaction due to other vascular device, implant, and graft; Bacteremia; Primary hypercoagulable state; Other primary cardiomyopathies; ; Abdominal pain, unspecified site; Urinary tract infection, site not specified; Acidosis; Other chest pain; Other chronic pain; Systemic lupus erythematosus; Noncompliance with renal dialysis; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Hyperpotassemia; 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; Obstructive sleep apnea (adult)(pediatric); Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","this is a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. ct prelim neg for small bowel obstruction. on arrival to the floor, abd pain was back to baseline and well controlled on dilaudid 2mg po q 4hrs .","a 24 y.o f with sle, esrd on hd and malignant hypertension presenting with abd pain, diarrhea, and htn. initial attempts were made to control her bp with hydralazine and labetalol iv but after these failed to control her blood pressure. she was successfully transitioned to home medications of clonidine, labetalol, aliskiren, nifedipine" 109,189332.0,14865,2142-08-30,14809,124398.0,2142-03-31,Discharge summary,"Admission Date: [**2142-3-24**] Discharge Date: [**2142-3-31**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet Attending:[**First Name3 (LF) 2167**] Chief Complaint: HTN, abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 24F with ESRD on HD, SLE, malignant HTN, history of SVC syndrome, PRES, recently discharged on [**2142-3-18**] after admission for abdominal pain, MSSA bacteremia, paroxysmal hypertension and ESRD line, followed by readmission [**3-22**], now presents with usual central crampy abdominal pain, 3 loose nonbloody stools this AM, SOB, and HTN to 270s. Pt was d/c'd from [**Hospital1 18**] yesterday after HD session, went home, states she took her PM meds, took her 8 AM medds (hydral, labetalol), then developed these symptoms which precluded her from taking her usual home meds (no afternoon meds - nifedipine, labetalol, hydral). The abd pain comes and goes and is unchanged from her baseline. While she has nausea, she is asking for dinner. . In the ED, initial BP 272/148. CXR w/o evidence of volume overload. No CT scan performed. Started on NTG gtt, given Hydralazine 10 x 1, Dilaudid 2 mg, labetaolo 20mg IV x 1. . Upon arrival to the floor, her BP was 240/135. She continued to complain of abdominal pain but was eating crackers, breathing felt better. RR 17. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: 98.2 97 [**Telephone/Fax (2) 43509**]0% on 2 L nC Gen: pleasant, comfortable HEENT: L eye enucleated. moon facies. Right pupil reactive Heart: hrrr, no m/r/g Pulm: CTA b/l Abd: NABS, midline scar well-healed, soft, diffuse TTP, no rebound/guarding Ext: no c/c/e Neuro: aox4, cn 2-12 intact grossly. Pertinent Results: [**2142-3-24**] 07:17PM PT-22.4* PTT-43.64* INR(PT)-2.1* [**2142-3-24**] 04:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2142-3-24**] 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2142-3-24**] 04:45PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-[**11-30**] [**2142-3-24**] 02:05PM GLUCOSE-76 UREA N-21* CREAT-4.8*# SODIUM-139 POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2142-3-24**] 02:05PM ALT(SGPT)-78* AST(SGOT)-181* CK(CPK)-55 ALK PHOS-192* TOT BILI-0.5 [**2142-3-24**] 02:05PM cTropnT-0.12* [**2142-3-24**] 02:05PM CK-MB-5 [**2142-3-24**] 02:05PM WBC-3.6* RBC-2.90* HGB-8.9* HCT-26.6* MCV-92 MCH-30.7 MCHC-33.4 RDW-19.8* [**2142-3-24**] 02:05PM NEUTS-73.9* BANDS-0 LYMPHS-18.5 MONOS-3.8 EOS-3.0 BASOS-0.8 [**2142-3-24**] 02:05PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-2+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-1+ TARGET-1+ SCHISTOCY-OCCASIONAL TEARDROP-1+ ELLIPTOCY-OCCASIONAL [**2142-3-24**] 02:05PM PLT SMR-LOW PLT COUNT-129* [**2142-3-23**] 12:00PM GLUCOSE-77 UREA N-31* CREAT-6.0*# SODIUM-137 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-14 [**2142-3-23**] 12:00PM estGFR-Using this [**2142-3-23**] 12:00PM CALCIUM-8.4 PHOSPHATE-5.7* MAGNESIUM-1.9 [**2142-3-23**] 12:00PM WBC-3.7* RBC-2.87* HGB-8.7* HCT-26.1* MCV-91 MCH-30.3 MCHC-33.3 RDW-19.4* [**2142-3-23**] 12:00PM PLT COUNT-130* [**2142-3-23**] 12:00PM PT-28.8* PTT-58.6* INR(PT)-2.9* Brief Hospital Course: The patient was admitted to the MICU on a NTG gtt from the ED. Her abdominal pain had imporved and she was eating crackers and peanut butter. She was given her usual afternoon home medications, and transitioned to a Nicardipine gtt, which has worked well for her in the past. Her BP goal was for a systolic of 180-200. The Nicardipine gtt was titrated off quickly and she was transfered to the floor. . On arrival to the floor, she in fact missed her morning medications on [**Month/Day/Year 766**]. This resulted in elevate blood pressures requiring IV hydralazing for control. She went to dialyisis Tuesday [**3-27**] and again had markedly elevated blood pressures while at [**Month/Year (2) 2286**] from missing her AM doses. Instructions were written for explicit AM administration and Nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. She was continued on labetalol 900mg TID, Aliskerin, Hydralazine 100mg po TID, and clonidine patch 0.4mg/24 weekly patch. . HEr BP remained relativly stable. She established a three three times weekly Dialysus regemin. A PAP smear was attempted due to her history of CIN I and no PCP follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . Her abdominal pain was also a chronic issue, which appeared stable. She was not administered IV narcotics, only PO. It was wihtout clear percipitating events or etiology. She will need GI follow up. She was contact[**Name (NI) **] by phone several times to arrange a GI follow up appointment but did not return messages. She has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . She was discharged to followup with her nephrologist, Dr. [**Last Name (STitle) 4883**]. . 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. Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). [**Last Name (STitle) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2* 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). [**Last Name (STitle) **]:*120 Tablet(s)* Refills:*2* 4. Labetalol 200 mg Tablet Sig: 4.5 Tablets PO TID (3 times a day). [**Last Name (STitle) **]:*405 Tablet(s)* Refills:*2* 5. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*2* 6. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). [**Last Name (STitle) **]:*30 Tablet Sustained Release(s)* Refills:*2* 8. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO bid (). [**Last Name (STitle) **]:*60 Tablet(s)* Refills:*2* 9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: Two (2) Patches Transdermal once a week: Place two patches every week on Fridays. [**Last Name (STitle) **]:*8 Patches* Refills:*2* 10. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours. [**Last Name (STitle) **]:*180 Tablet(s)* Refills:*0* 11. Clonidine 0.3 mg Tablet Sig: One (1) Tablet PO twice a day as needed for prn SBP>200: if nauseated and cannot keep down meds, may use 1 sublingual clonidine if sbp>200. . [**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0* 12. Kayexalate Powder Sig: Thirty (30) grams PO once a day for 2 days: please take [**2142-4-1**] and [**2142-4-2**] for elevated potassium. [**Month/Day/Year **]:*240 grams* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Systemic Lupus Erythematosus End Stage Renal Disease Hypertension Abdominal Pain Discharge Condition: Blood pressure stable and abdominal pain at baseline Discharge Instructions: You were admitted with high blood pressure. You were in the ICU overnight for treatment. Some of your medications were changed and you were increased to three times weekly [**Location (un) 2286**]. Your abdominal pain is a difficult problem, as the reason for the pain is unclear. [**Name2 (NI) **] were continued on oral dilaudid. IV dilaudid is strongly discouraged and will continue to be in the future. You are now taking Nifedipine SR 30mg at night in addition to 90mg in the morning. Your other medications were the same. At home, if your blood pressure is above 200, then take 100mg hydralazine. If after 1 hour, your blood pressure does not decrease to below 200 with this, then take another 100mg hydralazine. If you are nauseated and cannot take in oral meds, then take sublingual clonidine, then wait 1 hour and repeat if BP still > 200. Finally, your potassium has been high. Please take kayexalate 30gm tomorrow and the next day. Followup Instructions: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-3-31**] 7:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 250**] Call to schedule appointment We will attempt to contact you on [**Name (NI) 766**] with appointment times for you. ",152,2142-03-24 16:34:00,2142-03-31 15:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," the patient was admitted to the micu on a ntg gtt from the ed. her abdominal pain had imporved and she was eating crackers and peanut butter. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. her bp goal was for a systolic of 180-200. the nicardipine gtt was titrated off quickly and she was transfered to the floor. . on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**]. this resulted in elevate blood pressures requiring iv hydralazing for control. she went to dialyisis tuesday [**3-27**] and again had markedly elevated blood pressures while at [**month/year (2) 2286**] from missing her am doses. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she was continued on labetalol 900mg tid, aliskerin, hydralazine 100mg po tid, and clonidine patch 0.4mg/24 weekly patch. . her bp remained relativly stable. she established a three three times weekly dialysus regemin. a pap smear was attempted due to her history of cin i and no pcp follow up, but was unsucesfull due to a very small vaginal introutus and no small specuilum available. . her abdominal pain was also a chronic issue, which appeared stable. she was not administered iv narcotics, only po. it was wihtout clear percipitating events or etiology. she will need gi follow up. she was contact[**name (ni) **] by phone several times to arrange a gi follow up appointment but did not return messages. she has a history of multiple missed appointments and no appoitment was made without confirming with the patient that she would attend. . she was discharged to followup with her nephrologist, dr. [**last name (stitle) 4883**]. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; ; Systemic lupus erythematosus; Anemia in chronic kidney disease; Long-term (current) use of steroids; Other chronic pain; Obstructive sleep apnea (adult)(pediatric); Abdominal pain, generalized; Hyperpotassemia]","the patient was admitted to the micu on a ntg gtt from the ed. her bp goal was for a systolic of 180-200. instructions were written for explicit am administration and nifedipine long acting 30mg was added at night, in addition to the 90mg long acting she was taking in the morning. she established a three three times weekly dialysus regemin.","the patient was admitted to the micu on a nicardipine gtt from the ed. she was given her usual afternoon home medications, and transitioned to a nicardipine gtt, which has worked well for her in the past. on arrival to the floor, she in fact missed her morning medications on [**month/day/year 766**] this resulted in elevate blood pressures requiring iv hydralazing for control " 109,189332.0,14865,2142-08-30,14810,137510.0,2142-04-22,Discharge summary,"Admission Date: [**2142-4-20**] Discharge Date: [**2142-4-22**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 1253**] Chief Complaint: Dyspnea, malignant hypertension Major Surgical or Invasive Procedure: none History of Present Illness: Briefly, 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented with abdominal pain and shortness of breath. On [**2142-4-19**] she refused ultrafiltration at HD because she was at her dry weight. Awoke at 3 AM feeling more short of breath. She also had worsening abdominal pain and vomiting without hematemasis. She took all of her medications as prescribed including two new lidocaine patches, fentanyl patch and clonidine. She developed a slight frontal headache but no blurry vision or neurologic symptoms. ROS largely negative. . In the emergency room her initial vitals were T: 99.1 BP: 280/140 HR: 79 RR: 16 O2: 100% on RA. She had two large bore peripheral IVs placed. She received 100 mg PO hydralazine, 200 mg PO labetolol, zofran 4 mg IV, vancomycin 1 gram IV, levofloxacin 750 mg IV x 1 and was started on labetolol and nitroglycerin drips with control of her blood pressure to the 180s systolic. She had a CXR which was concerning for volume overload. She was admitted the MICU for further evaluation. . In the MICU she was stablized and transitioned to her home meds. Nephrology gave her HD with 2L UF and subjective improvement in SOB. . Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of [**Year (4 digits) 2286**], currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: On Admission per MICU team: Vitals: T: 96.5 BP: 162/120 HR: 79 RR: 13 O2: 100% on 4L General: Pleasant, comfortable, no distress HEENT: L eye enucleated. Moon facies. Right pupil reactive Heart: Regular rate and rhythm, s1 + s2, soft systolic murmur at RLSB, no rubs or gallops Respiratory: Crackles at bases bilaterally, no wheezes, rales, ronchi GI: soft, non-tender, non-distended, +BS GU: no foley Ext: Warm and well perfused, no clubbing, cyanosis or edema . Pertinent Results: [**2142-4-19**] 08:35AM WBC-3.8* RBC-2.53* HGB-7.6* HCT-23.4* MCV-93 MCH-29.9 MCHC-32.3 RDW-19.9* [**2142-4-19**] 08:35AM PLT COUNT-93* . [**2142-4-19**] 08:35AM GLUCOSE-88 UREA N-36* CREAT-6.0* SODIUM-135 POTASSIUM-5.7* CHLORIDE-101 TOTAL CO2-25 ANION GAP-15 [**2142-4-19**] 08:35AM CALCIUM-9.4 PHOSPHATE-5.3* MAGNESIUM-2.0 . [**2142-4-20**] 08:40AM PT-28.3* PTT-45.3* INR(PT)-2.9* . CXR PA and LAT: IMPRESSION: 1. Persistent cardiomegaly with prominence of pulmonary vasculature suggesting overhydration. Minimal costophrenic angle blunting may suggest small effusions. 2. No definite consolidation, although increased retrocardiac density is noted, most likely due to atelectasis and vascular congestion. Repeat imaging following diuresis could be considered. . INR trend: [**2142-4-19**] 09:30AM BLOOD PT-30.4* INR(PT)-3.1* [**2142-4-20**] 08:40AM BLOOD PT-28.3* PTT-45.3* INR(PT)-2.9* [**2142-4-21**] 04:07AM BLOOD PT-29.9* PTT-48.9* INR(PT)-3.1* [**2142-4-22**] 05:55AM BLOOD PT-33.3* PTT-54.1* INR(PT)-3.5* Brief Hospital Course: 24 F with ESRD on hemodialysis, SLE, malignant hypertension, history of SVC syndrome, PRES who presented to the ICU for hypertensive emergency, dyspnea, and headache, now resolved. . Hypertensive Emergency: Patient's blood pressure normalized with transient nitroglycerin and labetalol drips. Likely precipitated by lack of ultrafiltration at [**Year/Month/Day 2286**] yesterday. She has received [**Year/Month/Day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - Nifedipine 150 mg Tablet SR daily - Hydralazine 100 mg Tablet Q8H - Labetalol 1000 mg Tablet TID - Aliskiren 150 mg Tablet PO BID - Clonidine 0.2 mg/24 hr Patch Weekly - Hydralazine 100 mg PO PRN for SBP > 200 - continue regular [**Year/Month/Day 2286**] schedule . Social Issues/repeated admissions: The ICU and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. These episodes may be due to medication non-compliance and it may benefit Ms. [**Known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. Ms. [**Known lastname **] [**Last Name (Titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. Of note, she has missed [**Last Name (Titles) 2286**] sessions and often requests durations and flow rates for her [**Last Name (Titles) 2286**] that contradict recommendations by her nephrologist. This issue was left unresolved on discharge. . Chronic Abdominal Pain: Currently managed with PO dilaudid, fentanyl patch and lidocaine patch. Per MICU team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue PO dilaudid - continue lidocaine patch . Lupus Erythematous: Complicated by uveitis and ESRD. - continued prednisone . ESRD: On [**Last Name (Titles) 2286**]. Ultrafiltrate of 2 L on initial HD - continue outpatient regimen . Thrombocytopenia: Remained at baseline 80s to 130s. . Thrombotic Events: History of SVC thrombosis with negative workup. INR drifted up and was 3.5 on discharge. She was asked to hold her warfarin dose this PM and recheck her INR with VNA services on [**2142-4-23**] to be faxed to coumadin clinic in [**Company 191**]. - continued coumadin . Anemia: Hematocrit 24.5 initially. Baseline 23 to 28. . Medications on Admission: Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H Prednisone 1 mg Tablet Citalopram 20 mg Tablet Pantoprazole 40 mg Tablet, Warfarin 3 mg daily Gabapentin 300 mg TID Nifedipine 90 mg Tablet SR daily Nifedipine 60 mg Tablet SR daily Hydralazine 100 mg Tablet Q8H Labetalol 1000 mg Tablet TID Aliskiren 150 mg Tablet PO BID Clonidine 0.2 mg/24 hr Patch Weekly Docusate Sodium 100 mg Capsule PO BID Senna 8.6 mg Tablet Fentanyl 25 mcg/hr Patch 72 hr Lidocaine 5 %(700 mg/patch) daily Hydralazine 100 mg PO:PRN for SBP > 200 Discharge Medications: 1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 2. Prednisone 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) 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 3 mg Tablet Sig: One (1) Tablet PO once a day: DO NOT TAKE DOSE ON [**2142-4-22**]. Then restart per your PCP. 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QHS (once a day (at bedtime)). 9. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 10. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 11. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 15. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 16. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 17. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed: For systolic blood pressure > 200. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Malignant Hypertension Systemic Lupus Erythematosus End Stage Renal Disease Abdominal Pain Discharge Condition: good, VSS, on room air, pain controlled. Discharge Instructions: You came to the hospital for shortness of breath and hypertension. You were given antihypertensive drips and during [**Location (un) 2286**] 2 liters were taken off with good improvement in your shortness of breath. You will need to take your medications as prescribed and follow-up with all of your doctors to prevent coming into the hospital. . Medication changes: - Please do not take your coumadin tonight because your INR is too high. You will need to have it checked by VNA services and adjusted. - Please take ALL of your medications as prescribed. . Please call your doctor or return to the ED if you have intractable headaches, shortness of breath, intractable pain or other concerns. Followup Instructions: Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-4-26**] 3:30 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Completed by:[**2142-4-23**]",130,2142-04-20 13:39:00,2142-04-22 15:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,PULMONARY EDEMA;HYPERTENSION," 24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. . hypertensive emergency: patients blood pressure normalized with transient nitroglycerin and labetalol drips. likely precipitated by lack of ultrafiltration at [**year/month/day 2286**] yesterday. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips. - continue home blood pressure regimen - nifedipine 150 mg tablet sr daily - hydralazine 100 mg tablet q8h - labetalol 1000 mg tablet tid - aliskiren 150 mg tablet po bid - clonidine 0.2 mg/24 hr patch weekly - hydralazine 100 mg po prn for sbp > 200 - continue regular [**year/month/day 2286**] schedule . social issues/repeated admissions: the icu and medicine floor addendings felt it important to express concern over her repeated, frequent admissions for hypertensive urgency. these episodes may be due to medication non-compliance and it may benefit ms. [**known lastname **] to be evaluated by an extended care facility to ensure proper blood pressure monitoring and health care in general. ms. [**known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. this issue was left unresolved on discharge. . chronic abdominal pain: currently managed with po dilaudid, fentanyl patch and lidocaine patch. per micu team, prior authorization paperwork for fentanyl was sent during last admission and is pending. - continue fentanyl patch - continue po dilaudid - continue lidocaine patch . lupus erythematous: complicated by uveitis and esrd. - continued prednisone . esrd: on [**last name (titles) 2286**]. ultrafiltrate of 2 l on initial hd - continue outpatient regimen . thrombocytopenia: remained at baseline 80s to 130s. . thrombotic events: history of svc thrombosis with negative workup. inr drifted up and was 3.5 on discharge. she was asked to hold her warfarin dose this pm and recheck her inr with vna services on [**2142-4-23**] to be faxed to coumadin clinic in [**company 191**]. - continued coumadin . anemia: hematocrit 24.5 initially. baseline 23 to 28. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Unspecified iridocyclitis; Other primary cardiomyopathies; Unspecified disease of pericardium; ; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Noncompliance with renal dialysis; Personal history of noncompliance with medical treatment, presenting hazards to health; Surgical or other procedure not carried out because of patient's decision; Abdominal pain, left lower quadrant; Renal dialysis status; Thrombocytopenia, unspecified; Anemia of other chronic disease; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Peripheral vascular disease, unspecified; Acquired absence of organ, eye; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus]","24 f with esrd on hemodialysis, sle, malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. known lastname **] [**last name (titles) 323**] refused to go to a ""home"" and declined to talk to social work at this time. of note, she has missed [**last name (titles) 2286**] sessions and often requests durations and flow rates for her [**last name (titles) 2286**] that contradict recommendations by her nephrologist. ultrafiltrate of 2 l on initial hd - continue outpatient regimen .","malignant hypertension, history of svc syndrome, pres who presented to the icu for hypertensive emergency, dyspnea, and headache, now resolved. she has received [**year/month/day 2286**] and her blood pressures remained at her baseline off the drips." 109,189332.0,14865,2142-08-30,14862,131376.0,2142-07-08,Discharge summary,"Admission Date: [**2142-7-7**] Discharge Date: [**2142-7-8**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**Last Name (NamePattern1) 293**] Chief Complaint: dyspnea, Hypertension Urgency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24F h/o SLE, ESRD on HD, h/o malignant HTN, SVC syndrome, PRES, prior ICH, with frequent admission for hypertensive urgency/emergency, with chronic abdominal pain. She was recently admitted [**Date range (1) 43607**] after presenting for hypertensive urgency and dyspnea for which she was started on nitroglycerin and labetalol drips, which were weaned off in the ICU. She was also received 2U PRBCs during HD. She was discahrged home without any changes to her medical regimen. . On the afternoon of [**7-4**] she notes increased dyspnea, she therefore went to HD on Wednesday, and again on Thursday [**7-5**]. After HD, her BP remained elevated, and she took an extra dose of labetalol 1000mg x 1. On [**7-6**] her VNA noted SBP 250s. She took extra doses of hydralazine, but otherwise felt well. She then woke up this morning with HA. She took all of her BP meds this morning, but remained with HA and SOB, thus prompting her presentation to the ED. . No fevers, productive cough, taking all meds, had chronic diarrhea that is unchanged, some n/v at baseline, no coffee ground emesis, has some abdominal pain unchanged from baseline Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Pertinent Results: 08:00a ALK,ALT,AST,CK,CPIS,LIP,BILI,TNT ADDED 12:29PM 141 103 29 82 AGap=13 3.4 28 6.5 ∆ CK: 59 MB: Notdone Trop-T: 0.18 ALT: 21 AP: 126 Tbili: 0.4 Alb: AST: 51 LDH: Dbili: TProt: [**Doctor First Name **]: Lip: 56 PT: 15.0 PTT: 35.5 INR: 1.3 N:69.8 L:21.9 M:5.5 E:2.5 Bas:0.3 Hypochr: 1+ Anisocy: 2+ Macrocy: 1+ Microcy: 1+ Polychr: 1+ Brief Hospital Course: # Hypertensive Urgency - At the time of admission, the patient denied chest pain but continued to have mild headache. She also had resolving shortness of breath, likely secondary to hypertension. She stated that she did take her PO meds. She was started on a labetalol drip and continued on her home regimen of oral labetolol, nifedipine, hydralazine, and aliskerin. A sent of cardiac enzymes was sent and revealed a CPK of 59 and a troponin of 0.18. The patient also underwent dialysis in the ICU. After dialysis the labetalol drip was weaned off. Overnight, SBP's ranged 109 to 182 mmHg. The following day, her SBP's ranged 133 to 200. Ultimately, she was discharged home on her normal medication regimen. # Abdominal Pain - The patient also presented complaining of adbominal pain. She had recently been treated for SBO; however, at the time of admit, she was without nausea or vomiting. She had a soft abdomen, was passing flatus, and was having daily bowel movements. She did have hypoactive bowel sounds. She was continued of her outpatient pain regimen of PO dilaudid, fentanyl patch, and lidoacine patch. An ultrasound of her abd was also performed and showed ascites in all 4 quadrants with the largest in the left lower quadrant measuring 5.5cm. Considering her history of thrombosis, renal recommended getting an abdominal ultrasound with doppler flow studies. This ultrasound showed mild to moderate ascites, a 9mm hemangioma, and no evidence of thrombosis. After the results of this ultrasound were reviewed, the patient was discharged home with a plan to follow-up with liver regarding her ascites and whether it can be attributed to her recent SBO. # ESRD on HD - The patient gets hemodialysis on a Tu/Th/Sa schedule. On admit, the patient was continued on her home does of sevalemer. Renal was consulted, and the patient received dialysis on [**7-7**] in the ICU. # Anemia/Pancytopenia - The patient has a chronic anemia and baseline pancytopenia that are likely secondary to her CKD and SLE. On admit she was actually above baseline. She was continued on her home does of epogen. # H/o Gastric Ulcer - The patient was continued on her PPI [**Hospital1 **]. # SLE - The patient was continued on her home regimen of prednisone 4mg po daily. # H/o SVC Thrombosis - The patient has a goal INR of [**2-13**]. However, naticoagulation was stopped after a recent admission secondary to a supratherapeutic INR. On admit, her INR was sub-therapeutic. Therefore, her warfarin was restarted at 3 mg daily. # Seizure Disorder - The patient was continued on her home regimen of keppra 1000 mg PO 3 times a week (Tu/Th/Sa). # Depression - The patient was continued on her home dose of celexa. Medications on Admission: 1.Nifedipine 90 mg PO DAILY (Daily). 2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime). 3.Lidocaine 5 % PATCH Q24HR. 4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID 5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H 7.Prednisone 4 mg PO DAILY (Daily). 8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday). 9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday). 10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD 12.Labetalol 1000 mg Tablet Tablet PO TID 13.Hydralazine 100 mg Tablet PO Q8H 14.Warfarin 3 mg Tablet PO Once Daily at 4 PM. 15.Pantoprazole 40 mg PO Q12H (every 12 hours). 16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24HR (). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). Disp:*QS Tablet(s)* Refills:*2* 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QTUTHSA (TU,TH,SA). 17. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for abdominal pain. Discharge Disposition: Home Discharge Diagnosis: Hypertensive Urgency Lupus Nephritis End stage renal disease on hemodialysis Ascites Discharge Condition: hemodynamically stable with blood pressures 130-140/70-80s. Discharge Instructions: You were evaluated and treated for you hypertension. You were started on IV medications and transitioned to your home regimen and received a session of hemodialysis. You also had an ultrasound to evaluate the fluid in your belly. There was no evidence of blood clot contributing to the build up of the fluid. Please continue to follow a low sodium diet at home and take all of your blood pressure medications in addition to going to dialysis. Followup Instructions: You have the following appointments scheduled: Please also keep your Tuesday/Thursday/Saturday Dialysis schedule Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-7-30**] 2:00 Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 ",53,2142-07-07 10:01:00,2142-07-08 18:05:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,HYPERTENSION," # hypertensive urgency - at the time of admission, the patient denied chest pain but continued to have mild headache. she also had resolving shortness of breath, likely secondary to hypertension. she stated that she did take her po meds. she was started on a labetalol drip and continued on her home regimen of oral labetolol, nifedipine, hydralazine, and aliskerin. a sent of cardiac enzymes was sent and revealed a cpk of 59 and a troponin of 0.18. the patient also underwent dialysis in the icu. after dialysis the labetalol drip was weaned off. overnight, sbps ranged 109 to 182 mmhg. the following day, her sbps ranged 133 to 200. ultimately, she was discharged home on her normal medication regimen. # abdominal pain - the patient also presented complaining of adbominal pain. she had recently been treated for sbo; however, at the time of admit, she was without nausea or vomiting. she had a soft abdomen, was passing flatus, and was having daily bowel movements. she did have hypoactive bowel sounds. she was continued of her outpatient pain regimen of po dilaudid, fentanyl patch, and lidoacine patch. an ultrasound of her abd was also performed and showed ascites in all 4 quadrants with the largest in the left lower quadrant measuring 5.5cm. considering her history of thrombosis, renal recommended getting an abdominal ultrasound with doppler flow studies. this ultrasound showed mild to moderate ascites, a 9mm hemangioma, and no evidence of thrombosis. after the results of this ultrasound were reviewed, the patient was discharged home with a plan to follow-up with liver regarding her ascites and whether it can be attributed to her recent sbo. # esrd on hd - the patient gets hemodialysis on a tu/th/sa schedule. on admit, the patient was continued on her home does of sevalemer. renal was consulted, and the patient received dialysis on [**7-7**] in the icu. # anemia/pancytopenia - the patient has a chronic anemia and baseline pancytopenia that are likely secondary to her ckd and sle. on admit she was actually above baseline. she was continued on her home does of epogen. # h/o gastric ulcer - the patient was continued on her ppi [**hospital1 **]. # sle - the patient was continued on her home regimen of prednisone 4mg po daily. # h/o svc thrombosis - the patient has a goal inr of [**2-13**]. however, naticoagulation was stopped after a recent admission secondary to a supratherapeutic inr. on admit, her inr was sub-therapeutic. therefore, her warfarin was restarted at 3 mg daily. # seizure disorder - the patient was continued on her home regimen of keppra 1000 mg po 3 times a week (tu/th/sa). # depression - the patient was continued on her home dose of celexa. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Unspecified iridocyclitis; ; Other ascites; Other chronic pain; Abdominal pain, unspecified site; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Other specified peripheral vascular diseases; Anemia of other chronic disease; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Epilepsy, unspecified, without mention of intractable epilepsy; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism; Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits]","# hypertensive urgency - at the time of admission, the patient denied chest pain but continued to have mild headache. she stated that she did take her po meds. # abdominal pain - the patient also presented complaining of adbominal pain. on admit, the patient was continued on her home does of sevalemer. # h/o gastric ulcer - the patient was continued on her ppi [**hospital1 **]. # sle - the patient was continued on her home regimen of prednisone 4mg po daily.","at the time of admission, the patient denied chest pain but continued to have mild headache. she also had resolving shortness of breath, likely secondary to hypertension. she had recently been treated for sbo; however, she was without nausea or vomiting." 109,189332.0,14865,2142-08-30,14860,136572.0,2142-06-20,Discharge summary,"Admission Date: [**2142-6-18**] Discharge Date: [**2142-6-20**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 2145**] Chief Complaint: Acute Onset Dyspnea Major Surgical or Invasive Procedure: Dialysis History of Present Illness: Please see MICU note for full details. In brief this is a 24 y.o. woman with SLE, ESRD on HD, hx malignant HTN, h/o SVC syndrome, h/o posterior reversible encephalopathy syndrome (PRES) and prior intracerebral hemorrhage, frequently admitted with hypertensive urgency/emergency who was admitted with acute onset dyspnea after 2 weeks without dialysis given to unable to get transportation ? despite Dr. [**Last Name (STitle) 7473**] attempting to arrange transport for her (? refused to come). She was admitted therefore on [**6-18**] to micu with VS: T 100.4 HR 108 BP 240/180 RR 28 POx100 RA. She was treated with nitro gtt, labetolol gtt and dilaudid-these gtts were stopped at 0700. In the micu she was dialyzed with 1.7L fluid removal (though + 300cc given tranfusion). Her SOB is improved. Her hct was also noted to be low (18->from 22 [**2142-6-5**]) so transfused 2 units PRBC's, recent EGD with gastric ulcer [**5-29**], guaiac negative in ED, no BM in unit, hemolysis w/u negative. BP in icu 140/106 currently but of note was hypotensive on HD to 86/62. She notes sob improved rapidly on arrival. ROS: Currently she has no complaints. She notes at home her abdominal pain is at baseline for her, felt mid epigastric, for which she takes dilaudid 4mg up to [**Hospital1 **]. She has been getting HD via right femoral catheter which is not painful, no discharge from the sight. She denies HA, visual changes, cough, chest pain or pressure, orthostatic changes, palpitations, nausea, vomiting, constipation, diarrhea, melena, brbpr, dysuria, hematuria, rash, swelling, orthopnea, pnd. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Physical Exam: Vitals - T: 97.7, BP: 140/99 P: 88 R: 19 O2: 98% on RA General: Sleeping comfortably but awakens easily, alert, oriented x3 HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear, nonerythematous, MMM, moon facies Neck: supple, JVP flat, no LAD, full ROM, left EJ in place Lungs: coarse BS throughout, no W/R/R, no decreased BS at bases CV: S1, S2 nl, no m/r/g appreciated Abdomen: Firm, non-tender to palpation, no masses or organomegally Ext: Warm, well perfused, 1+ DP/PT, no clubbing, cyanosis or edema Neuro: a&o x3, motor [**5-15**] UE/LE bilaterally Pertinent Results: [**2142-6-18**] 05:28PM HCT-26.0*# [**2142-6-18**] 11:38AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-OCCASIONAL POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL [**2142-6-18**] 05:04AM GLUCOSE-85 UREA N-72* CREAT-10.4* SODIUM-139 POTASSIUM-5.5* CHLORIDE-109* TOTAL CO2-14* ANION GAP-22* [**2142-6-18**] 05:04AM LD(LDH)-264* TOT BILI-0.2 [**2142-6-18**] 05:04AM CALCIUM-6.6* PHOSPHATE-6.5* MAGNESIUM-1.6 [**2142-6-18**] 05:04AM HAPTOGLOB-142 [**2142-6-18**] 05:04AM WBC-3.4* RBC-1.93* HGB-5.8* HCT-17.0* MCV-88 MCH-30.0 MCHC-34.2 RDW-18.4* [**2142-6-18**] 05:04AM PLT COUNT-97* [**2142-6-18**] 01:34AM GLUCOSE-84 UREA N-70* CREAT-10.5*# SODIUM-136 POTASSIUM-5.6* CHLORIDE-108 TOTAL CO2-14* ANION GAP-20 [**2142-6-18**] 01:34AM estGFR-Using this [**2142-6-18**] 01:34AM ALT(SGPT)-10 AST(SGOT)-39 ALK PHOS-108 TOT BILI-0.2 [**2142-6-18**] 01:34AM LIPASE-115* [**2142-6-18**] 01:34AM ALBUMIN-3.2* CALCIUM-6.6* PHOSPHATE-6.8* MAGNESIUM-1.7 [**2142-6-18**] 01:34AM WBC-4.5 RBC-2.08* HGB-6.0* HCT-18.3* MCV-88 MCH-28.6 MCHC-32.5 RDW-18.6* [**2142-6-18**] 01:34AM NEUTS-78.5* LYMPHS-16.5* MONOS-3.0 EOS-1.4 BASOS-0.6 [**2142-6-18**] 01:34AM PLT COUNT-104* [**2142-6-18**] 01:34AM PT-15.0* PTT-33.6 INR(PT)-1.3* Brief Hospital Course: # Dyspnea: Pt's dypsnea improved on admission to the ED prior to HD. Based on her imaging studies her dyspnea was likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. Upon transfer to the floor she was continued on her dialysis regimen and discharged on room air. # Anemia: Pt's baseline 1 month ago noted to be low 30s, since then her Hct has trended down to 22 several week prior to admission. As she missed dialysis she was not able to reserve her Eopgen which likely complicated her anemia. Pt underwent hemolysis workup in the ICU which was ultimately negative. She was given several units of PRBC and bumped her Hct appropriately. She was noted to be guaiac negative on examination. # Hypertension: Pt was initially admitted with hypertension. Following transition to the floor she was placed on her home regimen. She was noted to be hypotensive in dialysis which is likely due to her being on Labetalol, Nitro gtt on dialysis. Pt was discharged on her home BP regimen with follow up with her nephrologist. # Chronic Abdominal Pain: Pt had noted some intermittent abdominal pain which has been chronic. Lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. Pt was able to tolerate a PO diet prior to her discharge. Pt was continued on her outpatient regimen of Dilaudid, Fentanyl patch, Neurontin. # GE junction Ulcer: Pt was continued on her PPI regimen [**Hospital1 **]. # SLE: Pt was continued on her home regimen of Prednisone 4mg daily # History of DVT: Pt had a sub-therapeutic INR on admission. She was discharged on Warfarin 3mg daily. # ESRD on HD: Pt was admitted for dyspnea in the setting of missing 2 weeks of HD. The renal team followed Ms. [**Known lastname **] during her hospitalization and she was continued on her outpatient regimen of hemodialysis. Pt was continued on Sevelamer and Epogen. # Seizure D/O: Pt was continued on her home regimen of keppra. # Depression: Pt was continued on her home regimen of Celexa. Medications on Admission: 1. Nifedipine 90 mg Tablet Sustained Release PO QAM 2. Nifedipine 60 mg Tablet Sustained Release PO QHS 3. Lidocaine 5 % transdermal one daily 4. Aliskiren 150 mg PO BID 5. Citalopram 20 mg PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch Q72H (every 72 hours). 7. Prednisone 4mg PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Transdermal QSAT 9. Clonidine 0.3 mg/24 hr Patch Weekly Transdermal QSAT 10. Sevelamer HCl 400 mg Four (4) Tablet PO TID W/MEALS 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID 13. Hydralazine 100 mg PO Q8H 14. Hydromorphone 2 mg 1-2 Tablets PO Q6H as needed for pain. 15. Pantoprazole 40 mg PO Q12H 16. LeVETiracetam 1,000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24 H (). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK (TU,TH,SA). Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Malignant HTN, ESRD on HD, Shortness of breath Secondary: Lupus Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted to the hospital after you noticed some shortness of breath. Whilst in the hospital you were noted to have a low blood level (anemia) and you some fluid in your lungs. We think your blood level was low because you were not receiving your Epo shots, we think the fluid is from not receiving dialysis. Before you were discharged from the hospital your breathing was better. We recommend that you continue going to dialysis. We made no changes to your medications. If you notice any fevers, chills, nausea, vomiting, shortness of breath, lightheadedness please return to the ED. Followup Instructions: Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 Provider: [**First Name4 (NamePattern1) **] [**Name Initial (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-6-27**] 2:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] ",71,2142-06-18 03:11:00,2142-06-20 16:34:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ANEMIA," # dyspnea: pts dypsnea improved on admission to the ed prior to hd. based on her imaging studies her dyspnea was likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. upon transfer to the floor she was continued on her dialysis regimen and discharged on room air. # anemia: pts baseline 1 month ago noted to be low 30s, since then her hct has trended down to 22 several week prior to admission. as she missed dialysis she was not able to reserve her eopgen which likely complicated her anemia. pt underwent hemolysis workup in the icu which was ultimately negative. she was given several units of prbc and bumped her hct appropriately. she was noted to be guaiac negative on examination. # hypertension: pt was initially admitted with hypertension. following transition to the floor she was placed on her home regimen. she was noted to be hypotensive in dialysis which is likely due to her being on labetalol, nitro gtt on dialysis. pt was discharged on her home bp regimen with follow up with her nephrologist. # chronic abdominal pain: pt had noted some intermittent abdominal pain which has been chronic. lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. pt was able to tolerate a po diet prior to her discharge. pt was continued on her outpatient regimen of dilaudid, fentanyl patch, neurontin. # ge junction ulcer: pt was continued on her ppi regimen [**hospital1 **]. # sle: pt was continued on her home regimen of prednisone 4mg daily # history of dvt: pt had a sub-therapeutic inr on admission. she was discharged on warfarin 3mg daily. # esrd on hd: pt was admitted for dyspnea in the setting of missing 2 weeks of hd. the renal team followed ms. [**known lastname **] during her hospitalization and she was continued on her outpatient regimen of hemodialysis. pt was continued on sevelamer and epogen. # seizure d/o: pt was continued on her home regimen of keppra. # depression: pt was continued on her home regimen of celexa. ","PRIMARY: [] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Other primary cardiomyopathies; Unspecified disease of pericardium; Anemia of other chronic disease; Hyperpotassemia; Systemic lupus erythematosus; Abdominal pain, other specified site; Other chronic pain; Hypotension, unspecified; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Epilepsy, unspecified, without mention of intractable epilepsy; Depressive disorder, not elsewhere classified; Personal history of venous thrombosis and embolism; Noncompliance with renal dialysis]","# dyspnea: pts dypsnea improved on admission to the ed prior to hd. lipases were noted to be mildl elevated however no other concerning physical exam signs of pancreatitis. # sle: pt was continued on her home regimen of prednisone 4mg daily # history of dvt: pt had a sub-therapeutic inr on admission. she was discharged on warfarin 3mg daily. # depression: pt was continued on her home regimen of celexa.",pts dypsnea improved on admission to the ed prior to hd. dyspnea likely related to fluid overload (pt missed 2 weeks of dialysis) and her level of anemia. 109,189332.0,14865,2142-08-30,14861,174489.0,2142-07-04,Discharge summary,"Admission Date: [**2142-7-3**] Discharge Date: [**2142-7-4**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 2817**] Chief Complaint: dyspnea, hypertension Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: 24F h/o SLE, ESRD on HD, h/o malignant HTN, SVC syndrome, PRES, prior ICH, with frequent admission for hypertensive urgency/emergency, with chronic abdominal pain. She was recently discharged on [**7-1**] after presenting for hypertensive urgency and dyspnea for which she received iv medication in the ED, but was otherwised managed with oral antihypertensives and CPAP. . She was doing well until the evening of [**7-2**] when she notes the gradual onset of dyspnea. She denied f/c/cp/ha/abd pain/diarrhea, or constipation. She was having regular, soft, daily BMs. . On [**7-3**] she awoke, and describes n/v x 2, with increasing dyspnea, and headache. She did not want to wait until dialysis at 4PM and therefore presented to [**Hospital1 18**]. . In ED VS= 97.7 [**Telephone/Fax (2) 43606**] 100%RA. Labs were notable for HCT 23, PLT 66, WBC 3.3, all roughly at baseline. CXR without acute process, ECG unchanged from prior. No UA sent, though she does make some urine. She was started on nitro gtt with modest improvement of SBPs to 210s, then labetalol 20mg iv x1 followed by labetalol gtt with BP 221/130 at the time of transfer. She refused abdominal CT. Renal was consulted, but felt HD not indicated today. . . ROS: Negative for fevers, chills, chest pain, diarrhea, rash, joint pains. +n/v as above. +abdominal pain unchanged from her baseline. +dyspnea, +HA. denies visual changes, slurrring speech, numbness, weeakness. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Physical Exam: Vitals - 97.7 88 220/150 19 100%2L BC. General: A&Ox3. NAD, oriented x3. HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear, nonerythematous, MMM. Neck: supple, no LAD, full ROM. Lungs: CTA B, with few crackles at bases. CV: RR, nl S1, S2 +S3, no rubs appreciated. Abdomen: soft, minimally distended, diffuse mild tenderness to palpation, negative [**Doctor Last Name **], no rebound, gaurding. Ext: WWP, 1+ dp/pt pluses, no clubbing, cyanosis or edema. Neuro: CN 2-12 intact. moving all four extremities spontaneously. Pertinent Results: Lab Results on Admission: [**2142-7-3**] 11:37AM GLUCOSE-95 UREA N-40* CREAT-7.4*# SODIUM-140 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16 ALT(SGPT)-14 AST(SGOT)-44* LD(LDH)-264* ALK PHOS-115 TOT BILI-0.4 ALBUMIN-3.2* WBC-3.6* RBC-2.61* HGB-7.6* HCT-23.4* MCV-90 MCH-29.0 MCHC-32.4 RDW-18.3* [**2142-7-3**] 11:37AM NEUTS-71.6* LYMPHS-23.0 MONOS-3.7 EOS-1.5 BASOS-0.2 PLT COUNT-66* PT-14.0* PTT-34.5 INR(PT)-1.2* [**2142-7-3**] 06:00PM CK-MB-5 cTropnT-0.17*CK(CPK)-58 [**2142-7-3**] CXR: IMPRESSION: Unchanged moderate cardiomegaly with pulmonary edema. Again underlying pneumonia in the lung bases cannot be completely excluded and evaluation after appropriate diuresis could be performed if pneumonia remains a clinical concern. Brief Hospital Course: 24F with h/o SLE, ESRD on HD, malignant HTN, h/o SVC syndrome, PRES, prior ICH, and recent SBO, p/w n/v, and hypertensive urgency. . # hypertensive urgency - On presentation she denies chest pain, but continues to have mild headache, and resolving shortness of breath, likely [**2-12**] hypertension. states she did take her PO meds. Hypertensive urgency was treated as follows with nitro and labetalol gtt which were quickly weaned as blood pressures dropped below SBP 120. She evenutally became hypotensive to SBP of 90 which resolved on its own. She was continued on CPAP overnight and discontinued in the am. She was continued on her home regimen of oral labetolol, nifedipine, hydralazine, aliskerin. She remained normotensive the following morning and was taken to hemodialysis after which she was discharged home on all of her old home medications. . # abdominal pain - On presentation she was without n/v, soft abdomen, passing flatus, and having daily bowel movements. She did have hypoactive bowel sounds on admission. She was maintained on outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch, neurontin with HD with plan to follow BMs closley. Her pain improved the am of discharge and she had no further vomiting. . # ESRD on HD - She is currently getting HD SaTuTh, though did not get HD on the day of presenation. As there was no acute indication for HD on presentation, she received HD on the following am, day of discharge. She was continued on sevelamer. . # anemia - chronic anemia, likely [**2-12**] CKD and SLE, currently above baseline, though has h/o GIB. She received 2 unit PRBCs and epo with hemodialysis. . # h/o gastric ulcer - she was continued on her outpatient dose of PPI [**Hospital1 **]. . # SLE - continue home regimen of prednisone 4mg po qdaily. . # h/o SVC thrombosis - pt with goal INR [**2-13**], but this was stopped after recent admission [**2-12**] supratherapeutic INR. INR currently sub-therapeutic and she was resumed on warfarin at 3 mg qdaily without heparin bridge. . # seizure disorder - continued on keppra 1000 mg PO 3X/WEEK (TU,TH,SA). . # depression - continued on celexa. Medications on Admission: 1.Nifedipine 90 mg PO DAILY (Daily). 2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime). 3.Lidocaine 5 % PATCH Q24HR. 4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID 5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H 7.Prednisone 4 mg PO DAILY (Daily). 8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday). 9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday). 10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD 12.Labetalol 1000 mg Tablet Tablet PO TID 13.Hydralazine 100 mg Tablet PO Q8H 14.Warfarin 3 mg Tablet PO Once Daily at 4 PM. 15.Pantoprazole 40 mg PO Q12H (every 12 hours). 16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 2. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24H (every 24 hours). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) patch Transdermal every seventy-two (72) hours. 6. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 7. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for hypertension. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. 12. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 13. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). Tablet(s) 14. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 15. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QTUTHSA (TU,TH,SA). Discharge Disposition: Home With Service Facility: VNA Discharge Diagnosis: Primary: hypertensive emergency anemia, erythropoetin deficiency Secondary: chronic renal failure on hemodialysis lupus nephritis Discharge Condition: Hemodynamically stable. Discharge Instructions: You were admitted for hypertensive urgency and treated in the intensvie care unit with IV medications to decrease your blood pressure. You also received 2 units of blood and hemodialysis before you were discharged home. It is essential that you take all of your prescribed blood pressure medications and present regularly for your Tuesday, Thursday, Saturday dialysis. Please return to the emergency department or call your primary care physician if you develop any chest pain, shortness of breath, fevers, or any other concerning symptoms. Followup Instructions: You have the following appointment scheduled. Please contact your provider if you are unable to make these appointments. Your dialysis is scheduled for Tuesday, Thursday, Saturday. Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-7-30**] 2:00 Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 ",57,2142-07-03 14:48:00,2142-07-04 17:23:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSION," 24f with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, p/w n/v, and hypertensive urgency. . # hypertensive urgency - on presentation she denies chest pain, but continues to have mild headache, and resolving shortness of breath, likely [**2-12**] hypertension. states she did take her po meds. hypertensive urgency was treated as follows with nitro and labetalol gtt which were quickly weaned as blood pressures dropped below sbp 120. she evenutally became hypotensive to sbp of 90 which resolved on its own. she was continued on cpap overnight and discontinued in the am. she was continued on her home regimen of oral labetolol, nifedipine, hydralazine, aliskerin. she remained normotensive the following morning and was taken to hemodialysis after which she was discharged home on all of her old home medications. . # abdominal pain - on presentation she was without n/v, soft abdomen, passing flatus, and having daily bowel movements. she did have hypoactive bowel sounds on admission. she was maintained on outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch, neurontin with hd with plan to follow bms closley. her pain improved the am of discharge and she had no further vomiting. . # esrd on hd - she is currently getting hd satuth, though did not get hd on the day of presenation. as there was no acute indication for hd on presentation, she received hd on the following am, day of discharge. she was continued on sevelamer. . # anemia - chronic anemia, likely [**2-12**] ckd and sle, currently above baseline, though has h/o gib. she received 2 unit prbcs and epo with hemodialysis. . # h/o gastric ulcer - she was continued on her outpatient dose of ppi [**hospital1 **]. . # sle - continue home regimen of prednisone 4mg po qdaily. . # h/o svc thrombosis - pt with goal inr [**2-13**], but this was stopped after recent admission [**2-12**] supratherapeutic inr. inr currently sub-therapeutic and she was resumed on warfarin at 3 mg qdaily without heparin bridge. . # seizure disorder - continued on keppra 1000 mg po 3x/week (tu,th,sa). . # depression - continued on celexa. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Unspecified iridocyclitis; Other primary cardiomyopathies; Abdominal pain, unspecified site; Other chronic pain; Nausea with vomiting; Systemic lupus erythematosus; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Other specified peripheral vascular diseases; Obstructive sleep apnea (adult)(pediatric); Anemia of other chronic disease; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Epilepsy, unspecified, without mention of intractable epilepsy; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism; Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits]","24f with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, p/w n/v, and hypertensive urgency. she remained normotensive the following morning and was taken to hemodialysis after which she was discharged home on all of her old home medications. # abdominal pain - on presentation she was without n/v, soft abdomen, passing flatus, and having daily bowel movements. # seizure disorder - continued on keppra 1000 mg po 3x/week (tu,th,sa).","malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, p/w n/v, and hypertensive urgency. hypertensive urgency was treated as follows with nitro and labetalol gtt which were quickly weaned as blood pressures dropped below sbp 120. she evenutally became hypotensive to sbp of 90 which resolved on its own " 109,189332.0,14865,2142-08-30,14858,151240.0,2142-05-18,Discharge summary,"Admission Date: [**2142-5-15**] Discharge Date: [**2142-5-18**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 613**] Chief Complaint: Headache, Hypertensive urgency Major Surgical or Invasive Procedure: Hemodialysis x 2 History of Present Illness: 24 year old female with SLE, ESRD on HD, hx malignant HTN, h/o SVC syndrome, h/o posterior reversible encephalopathy syndrome (PRES) and prior intracerebral hemorrhage, recently admitted [**Date range (1) 17717**] with diarrhea, hypertensive urgency. Treated at that time with nicardipine drip for a short period and then to her home regimen. Yesterday onset of nausea with emesis and inability to tolerate home meds including antihypertensives. Diarrhea mild as prior. No fever, chills, no hematemesis or hematochezia. No melena. Today reports onset of headache therefore to the ED. In the ED, initial vs were 280/160, 99.4, 105, RR 18. She was given dilaudid 2 mg PO x 2. Hydral 20 mg x 3 for BP. Calcium gluconate 1 gram. Insulin 10 units, D 50 [**1-12**] amp, sodium bicarbonate, kayexalate for K 6.7 (dialysis dependent Tues/thurs/sat) but with report of peaked T waves. Renal dialysis fellow was not contact[**Name (NI) **]. HCT 33.4, WBC 4.6, trop 0.10. Admitted for hypertensive urgency to ICU. No gtt was started. Of note usualy BP 160/100. Review of sytems: patient tearful complaining of frontal headache and nausea Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension with baseline SBP's 180's-120's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 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: Vitals: BP 240/146, 101, 98.6, General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardic, 3/6 SEM RUSB Abdomen: soft, diffusely tender, no rebound or gaurding. Ext: cachectic, warm, 2+ DP pulse no clubbing, cyanosis or edema Pertinent Results: [**2142-5-15**] 05:45AM GLUCOSE-83 UREA N-54* CREAT-7.6* SODIUM-138 POTASSIUM-6.7* CHLORIDE-103 TOTAL CO2-23 ANION GAP-19 [**2142-5-15**] 05:45AM CK(CPK)-96 [**2142-5-15**] 05:45AM cTropnT-0.10* [**2142-5-15**] 05:45AM CK-MB-NotDone [**2142-5-15**] 05:45AM WBC-4.6 RBC-3.66* HGB-10.8* HCT-33.4* MCV-91 MCH-29.6 MCHC-32.4 RDW-17.9* [**2142-5-15**] 05:45AM NEUTS-65.4 LYMPHS-25.1 MONOS-4.8 EOS-4.1* BASOS-0.7 [**2142-5-15**] 05:45AM PLT COUNT-128* [**2142-5-15**] 05:45AM PT-14.2* PTT-36.4* INR(PT)-1.2* [**2142-5-15**] 07:14AM K+-6.0* [**2142-5-15**] 12:17PM K+-5.3 Images: CXR: Persistent severe cardiomegaly. Head CT: Normal brain CT. Brief Hospital Course: 24 yo female with ESRD on HD, malignant hypertension with hx of intracerebral hemorrhage, SLE, chronic abdominal pain, and SVC syndrome admitted due to hypertensive urgency after developing N/V and being unable to take her po medications. # Hypertensive urgency: The patient was admitted to the MICU the night of admission where she was placed on a labetolol drip and her home medications were restarted. head CT was negative for intracranial bleed. She was continued on her home regimen of Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet Sustained Release QAM, and Hydralazine 100 mg PO Q8H. During her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. Blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). She was discharged on her home regimen. # Nausea/vomiting: The patient did not experience further vomiting, but occasionally complained of nausea. The cause of her nausea was unclear. She was able to tolerate po intake prior to discharge. # Abdominal pain/Diarrhea: The patient has chronic abdominal pain with previous negative workups. During this hospitalization her pain was at its baseline. Since admission she denied diarrhea. She was continued on her outpatient regimen of [**2-14**] mg po dilaudid q4h as needed. # ESRD on HD: She was hyperkalemic in the emergency room and was given kayexalate. She underwent two sessions of dialysis during this hospitalization. # SLE: Stable, without symptoms. She was continued on 4 mg of prednisone daily. # History of thrombotic events/SVC syndrome: She is anticoagulated with warfarin as an outpatient, however her INR was subtherapeutic on admission at 1.2. Previous documentation in OMR states she does not need to be bridged while subtherapeutic. She was initally continued on coumadin 4 mg po daily, however her INR rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # OSA: She is on CPAP at a setting of 7 as an outpatient and was continued on this during her hospitalization. Medications on Admission: Medications: as per last discharge summary -Aliskiren 150 mg Tablet [**Hospital1 **] -Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday) -Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). -Labetalol 200 mg Tablet Sig 5 tab TID -Nifedipine 60 mg Tablet Sustained Release QPM -Nifedipine 90 mg Tablet Sustained Release QAM -Citalopram 20 mg Tablet Sig daily -Hydromorphone 2 mg Tablet Sig [**1-12**] Q4 PRN -Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). -Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H -Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO BID PRN -Prednisone 4 mg daily -Coumadin 4 mg daily at 4 PM Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 2. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 3. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QPM (once a day (in the evening)). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 10. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 11. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 12. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO twice a day as needed for hypertension. 13. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary - Hypertensive urgency End-stage renal disease on dialysis Secondary - Systemic lupus erythematous History of thombosis and Superior vena cava syndrome Obstructive sleep apnea Discharge Condition: Stable Discharge Instructions: You were admitted to the hospital due to dangerously elevated blood pressure due to inability to take your medications secondary to nausea. It is very important that you take your blood pressure medications reguarly. Your nausea was controlled with medication and your blood pressure decreased once back on your home medication regimen. You underwent two sessions of dialysis during your hospitalization. It is extremely important that you attend dialysis three times weekly as an outpatient. Medication changes: You should be taking 3 mg of coumadin daily. You will need to have your INR checked at dialysis. Otherwise continue your outpatient medications as prescribed. Call your primary doctor, or go to the emergency room if you experience fevers, chills, worsening headache, vision change, inability to take your medications, blood in your stool, or dark black stool. Followup Instructions: It is very important that you keep your previously scheduled appointments: You have an appointment with gynecology to evaluate an abnormality recently seen on PAP smear. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-5-25**] 9:30 Provider: [**First Name8 (NamePattern2) 2353**] [**Last Name (NamePattern1) 4758**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-6-1**] 2:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2142-5-19**]",104,2142-05-15 10:45:00,2142-05-18 15:58:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPERTENSIVE CRISIS," 24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. # hypertensive urgency: the patient was admitted to the micu the night of admission where she was placed on a labetolol drip and her home medications were restarted. head ct was negative for intracranial bleed. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, and hydralazine 100 mg po q8h. during her stay her blood pressure fluctuated, occasionally becoming relatively low due to grouping of her medications together. blood cultures were sent but have been no growth to date and she remained without signs of infection (afebrile with no leukocytosis). she was discharged on her home regimen. # nausea/vomiting: the patient did not experience further vomiting, but occasionally complained of nausea. the cause of her nausea was unclear. she was able to tolerate po intake prior to discharge. # abdominal pain/diarrhea: the patient has chronic abdominal pain with previous negative workups. during this hospitalization her pain was at its baseline. since admission she denied diarrhea. she was continued on her outpatient regimen of [**2-14**] mg po dilaudid q4h as needed. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. she underwent two sessions of dialysis during this hospitalization. # sle: stable, without symptoms. she was continued on 4 mg of prednisone daily. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient, however her inr was subtherapeutic on admission at 1.2. previous documentation in omr states she does not need to be bridged while subtherapeutic. she was initally continued on coumadin 4 mg po daily, however her inr rose quickly to the therapeutic range, so this was decreased to 3 mg po daily. # osa: she is on cpap at a setting of 7 as an outpatient and was continued on this during her hospitalization. ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Other primary cardiomyopathies; Unspecified disease of pericardium; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Hyperpotassemia; Nausea with vomiting; Diarrhea; Disorders of phosphorus metabolism; Anemia of other chronic disease; Abdominal pain, left lower quadrant; Other chronic pain; Thrombocytopenia, unspecified; Other specified peripheral vascular diseases; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus; Long-term (current) use of anticoagulants; Noncompliance with renal dialysis; Renal dialysis status; Personal history of noncompliance with medical treatment, presenting hazards to health]","24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency after developing n/v and being unable to take her po medications. she was able to tolerate po intake prior to discharge. # esrd on hd: she was hyperkalemic in the emergency room and was given kayexalate. previous documentation in omr states she does not need to be bridged while subtherapeutic.","24 yo female with esrd on hd, malignant hypertension with hx of intracerebral hemorrhage, sle, chronic abdominal pain, and svc syndrome admitted due to hypertensive urgency. she was continued on her home regimen of aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg" 109,189332.0,14865,2142-08-30,14863,196721.0,2142-07-23,Discharge summary,"Admission Date: [**2142-7-12**] Discharge Date: [**2142-7-23**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 759**] Chief Complaint: Dyspnea, hypertension Major Surgical or Invasive Procedure: 1. Ultrasound Guided Tap 2. Venogram History of Present Illness: Ms. [**Known lastname **] is a 24 year old female with a history of SLE, ESRD on HD, h/o malignant HTN, SVC syndrome, PRES, prior ICH, with frequent admission for hypertensive urgency/emergency, with chronic abdominal pain that presented to the ED [**7-12**] with critically high blood pressure and dyspnea. She was recently discharged on [**7-8**] for hypertensive urgency and dyspnea. She was treated with labetolol gtt, [**Month/Year (2) 2286**], and her home medications with improvement of her BP. She was discharged home in stable condition on [**7-8**]. She had been doing well at home, but missed her HD session on [**7-10**] due to transportation issues. She has been taking her medications without any difficulty. On the morning of admission, she noted increase dyspnea, and had a dry cough, although this is not particularly new. She presented to the ER for dyspnea. She continues to have the chronic abdominal pain which is unchanged, and is controlled right now. In the emergency department, VS= 98.1, 240/140, 128, 30, 96%RA. On initial evaluation, she was noted to have SBP 70s on the right arm, 240s on the left arm. She did not complain of any pain. She underwent CTA torso to eval for dissection which was negative for dissection or PE. The imaging showed persistent SVC thrombus. There was also note of bilateral ground glass and nodularities therefore was given levofloxacin 750 mg IV x 1. She was given labetalol IV, then started on a labetalol gtt. Her BP remained elevated, therefore she was transferred to the ICU for BP control and then [**Month/Year (2) 2286**]. She was also given dilaudid 1 mg IV x 1 as well. Ms. [**Known lastname **] was taken to the MICU and treated for malignant hypertension. She was given hemodialysis and her blood pressure stabilized. She was transferred to the medical floor. She continued to receive [**Known lastname 2286**] Tuesday, Thursday, and Saturday. On [**7-16**], she had a paracentesis of her abdomen. She is complaining of focal tenderness around the point of insertion. On [**7-17**], she was transferred back to the MICU because of stridor that was treated with Heliox. She was stabilized, and came back to the floor on [**7-19**]. On [**7-19**], Ms. [**Known lastname **] had a venogram. On [**7-23**], an angiography intervention for an occlusion of her left brachiocephalic vein was discontinued because her occlusion was not as drastic as prior imaging indicated when tested with a 22 gauge needle. Ms. [**Known lastname **] was discharged on [**7-23**] with stable blood pressures and abdominal pain controlled. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Denies tobacco, alcohol or illicit drug use. Lives with mother and is on disability for multiple medical problems. Family History: No known autoimmune disease. Physical Exam: General: A&Ox3. NAD, oriented x3. HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear, Neck: supple, no LAD Lungs: CTA B, with few crackles at bases. CV: RRR, S1, S2 Abdomen: soft, minimally distended, diffuse mild tenderness to palpation Ext: palpable DP/PT pulses, no clubbing, cyanosis or edema. Neuro: CN 2-12 intact. moving all four extremities spontaneously. Pertinent Results: [**2142-7-22**] 07:50AM BLOOD WBC-2.8* RBC-2.51* Hgb-7.3* Hct-23.1* MCV-92 MCH-29.1 MCHC-31.8 RDW-21.1* Plt Ct-134* [**2142-7-21**] 10:30AM BLOOD WBC-3.5* RBC-2.36* Hgb-6.8* Hct-21.6* MCV-92 MCH-28.9 MCHC-31.6 RDW-20.5* Plt Ct-121* [**2142-7-22**] 07:50AM BLOOD PT-14.7* PTT-35.0 INR(PT)-1.3* [**2142-7-22**] 07:50AM BLOOD Glucose-154* UreaN-20 Creat-4.4* Na-138 K-4.0 Cl-103 HCO3-23 AnGap-16 [**2142-7-21**] 10:30AM BLOOD Vanco-17.8 [**2142-7-20**] 09:35AM BLOOD WBC-3.8* RBC-2.39* Hgb-7.0* Hct-21.6* MCV-90 MCH-29.2 MCHC-32.4 RDW-19.8* Plt Ct-120* [**2142-7-19**] 12:30PM BLOOD WBC-3.6* RBC-2.49* Hgb-7.0* Hct-22.5* MCV-90 MCH-28.3 MCHC-31.3 RDW-18.8* Plt Ct-121* [**2142-7-20**] 09:35AM BLOOD Plt Ct-120* [**2142-7-20**] 09:35AM BLOOD PT-19.7* PTT-38.4* INR(PT)-1.8* [**2142-7-19**] 12:30PM BLOOD Plt Ct-121* [**2142-7-19**] 12:30PM BLOOD PT-29.5* PTT-43.9* INR(PT)-2.9* [**2142-7-20**] 09:35AM BLOOD Glucose-90 UreaN-19 Creat-4.2*# Na-138 K-4.2 Cl-102 HCO3-25 AnGap-15 [**2142-7-19**] 12:30PM BLOOD Glucose-72 UreaN-34* Creat-6.0*# Na-137 K-4.5 Cl-102 HCO3-24 AnGap-16 [**2142-7-19**] 12:30PM BLOOD Calcium-8.2* Phos-4.6* Mg-1.6 [**2142-7-18**] 05:44AM BLOOD Calcium-8.9 Phos-5.1* Mg-1.7 [**2142-7-12**] 12:27PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:80 [**Last Name (un) **] [**2142-7-12**] 12:27PM BLOOD C3-69* C4-17 [**2142-7-19**] 12:30PM BLOOD Vanco-16.7 [**2142-7-17**] 08:57AM BLOOD Vanco-15.9 [**2142-7-14**] 04:16AM BLOOD Vanco-19.2 [**2142-7-17**] 07:27AM BLOOD Type-ART pO2-66* pCO2-52* pH-7.30* calTCO2-27 Base XS--1 [**2142-7-12**] 02:06PM BLOOD Lactate-1.0 Brief Hospital Course: 24 y/o female with h/o SLE, ESRD on HD, malignant HTN, h/o SVC syndrome, PRES, prior ICH, and recent SBO, presented to ED on [**7-12**] for dyspnea and hypertensive urgency. 1. hypertensive urgency - pt presented to ER with SBP in 240s and c/o dyspnea. Her blood pressures were reported as unequal and CTA in ER was done. This study showed no signs of dissection. Pt's blood pressure was controlled with labetalol gtt. At time of transfer, she denied CP and SOB. CE's were flat. She was started on her home BP regimen of oral labetalol on [**2142-7-15**], and nifedipine/hydralazine/aliskerin soon after admission. Pt was also continued on her HD regimen for ESRD, for volume control. . 2. angioedema - pt developed facial swelling and shortness of breath while on medical floor. She was taken to ICU and responded favorably to Heliox. Patient returned to floor and has been comfortably breathing since. Given history of SVC, venogram was ordered that did not indicate a complete occlusion of the left brachiocephalic vein, as previously thought, with help of 22 gauge needle. 3. cough: pt presented with chronic cough/dyspnea without fevers. Chest CT revealed bilateral infiltrates and nodularities, noted possibly infectious vs edema. Pt was started on vanc/zosyn given recent hospitalization, brief temp spike, and pulm infiltrates. Abx were stopped after cultures were neg. At time of transfer, pt's dyspnea was largely resolved and these findings were felt to be more consistent with edema given hypertensive urgency. . 4. chronic abdominal pain - pt has had chronic abdominal pain, which was well controlled at time of transfer. She was continued on her current outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch. Her LFTs and lipase were wnl. She had no signs of SBO. . 5. bacteremia - GPC in pairs and clusters; started on vanco on [**2142-7-12**]. . 6. Ascites - unclear etiology and new findings for her. Pt is to get workup with liver team as outpatient. Her [**Date Range 2286**] seems to have slightly improved this finding. Her coags were unremarkable. She was seen by Hepatology in house who did not have any specific recommendations at this time but asked to see her in follow up as an outpatient. . 7. ESRD on HD - HD SaTuTh,. Pt was continued on her HD regimen while in house. Sevelamer was continued as well. . 8. anemia/pancytopenia - chronic anemia, baseline pancytopenia, likely [**2-12**] CKD and SLE, currently above baseline, though has h/o GIB. Pt's pancytopenia remained stable; C3 and C4 studies were performed and it was felt that her SLE was not active at this time. Guiac stools were neg. EPO was continued at HD. . 9. h/o gastric ulcer - PPI was continued throughout hospitalization. . 10. SLE - pt was continued on home regimen of prednisone 4mg po qdaily. . 11. h/o SVC thrombosis - patient's warfarin was discontinued after discussion with Dr. [**Last Name (STitle) 4883**]. She frequently is outside of therapeutic range on this medication and given the suspected problems with medication compliance, it was felt it was safer to discontinue it altogether. . 12. seizure disorder - pt was continued on home regimen keppra 1000 mg PO 3X/WEEK (TU,TH,SA). . 13. depression - pt was continued on her home celexa. . Medications on Admission: 1.Nifedipine 90 mg PO DAILY (Daily). 2.Nifedipine 60 mg Tablet Sustained Release PO HS (at bedtime). 3.Lidocaine 5 % PATCH Q24HR. 4.Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID 5.Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6.Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch Q72H 7.Prednisone 4 mg PO DAILY (Daily). 8.Clonidine 0.1 mg/24 hr Patch QSAT (every Saturday). 9.Clonidine 0.3 mg/24 hr Patch QSAT (every Saturday). 10.Sevelamer HCl 1600 mg PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11.Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD 12.Labetalol 1000 mg Tablet Tablet PO TID 13.Hydralazine 100 mg Tablet PO Q8H 14.Warfarin 3 mg Tablet PO Once Daily at 4 PM. 15.Pantoprazole 40 mg PO Q12H (every 12 hours). 16.Levetiracetam 1000 mg PO 3X/WEEK (TU,TH,SA). Discharge Medications: 1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours. 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). 3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO at bedtime. 4. Nifedipine 30 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO QAM (once a day (in the morning)). 5. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 9. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 10. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal every Thursday. 11. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 13. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day): Please hold if systolic blood pressure < 100 or HR < 55. 14. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 15. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO 3X/WEEK (TU,TH,SA). 16. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 17. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous HD PROTOCOL (HD Protochol). 18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*60 Tablet(s)* Refills:*2* 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 20. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: do not drive or operate heavy machinery with this medication as it can cause drowsiness. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Malignant Hypertension Angioedema Ascites End Stage Renal Disease Secondary: Chronic Abdominal Pain Anemia/Pancytopenia Lupus Gastric Ulcer SVC Thrombosis Seizure Disorder Depression Discharge Condition: Hemodynamically stable with blood pressures 130-140 / 60-90 Discharge Instructions: You were admitted to [**Hospital1 18**] on [**2142-7-12**] because of critically high blood pressure. While here, you were given IV antihypertensive medications, and then you were switched to antihypertnsive medications by mouth. You received multiple sessions of hemodialysis. You had a distended, tender belly, and you underwent a ultrasound guided tap to remove the fluid in your abdomen. On [**2142-7-17**], you developed throat and facial swelling, and you were transferred from the medical floor to the ICU. You were given medication to help open your airway; you were stabilized and went to hemodialysis several times. You were transferred back to the medical floor. You had a venogram on [**2142-7-20**], and the results at this time are still pending. You had blood cultures drawn that were positive for bacteria. You received IV antibiotics while at hemodialysis. You will continue to receive these antibiotics at your appointments. Please keep all of your medical appointments. Please go to the nearest emergency room if you experience any of the following: 1. Chest Pain 2. Headaches 3. Lightheadedness 4. Changes in vision 5. Nausea and Vomiting Followup Instructions: Please continue your regular hemodialysis schedule. You have the following appointments scheduled. Please call if you need to cancel or change your appointments. Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-7-21**] 12:00 Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2142-7-30**] 2:00 Provider: [**Name10 (NameIs) 14201**] CLINIC Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2142-8-8**] 3:15 Completed by:[**2142-7-24**]",38,2142-07-12 15:27:00,2142-07-23 18:41:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,SHORTNESS OF BREATH," 24 y/o female with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, presented to ed on [**7-12**] for dyspnea and hypertensive urgency. 1. hypertensive urgency - pt presented to er with sbp in 240s and c/o dyspnea. her blood pressures were reported as unequal and cta in er was done. this study showed no signs of dissection. pts blood pressure was controlled with labetalol gtt. at time of transfer, she denied cp and sob. ces were flat. she was started on her home bp regimen of oral labetalol on [**2142-7-15**], and nifedipine/hydralazine/aliskerin soon after admission. pt was also continued on her hd regimen for esrd, for volume control. . 2. angioedema - pt developed facial swelling and shortness of breath while on medical floor. she was taken to icu and responded favorably to heliox. patient returned to floor and has been comfortably breathing since. given history of svc, venogram was ordered that did not indicate a complete occlusion of the left brachiocephalic vein, as previously thought, with help of 22 gauge needle. 3. cough: pt presented with chronic cough/dyspnea without fevers. chest ct revealed bilateral infiltrates and nodularities, noted possibly infectious vs edema. pt was started on vanc/zosyn given recent hospitalization, brief temp spike, and pulm infiltrates. abx were stopped after cultures were neg. at time of transfer, pts dyspnea was largely resolved and these findings were felt to be more consistent with edema given hypertensive urgency. . 4. chronic abdominal pain - pt has had chronic abdominal pain, which was well controlled at time of transfer. she was continued on her current outpt pain regimen of po dilaudid, fentanyl patch, lidoacine patch. her lfts and lipase were wnl. she had no signs of sbo. . 5. bacteremia - gpc in pairs and clusters; started on vanco on [**2142-7-12**]. . 6. ascites - unclear etiology and new findings for her. pt is to get workup with liver team as outpatient. her [**date range 2286**] seems to have slightly improved this finding. her coags were unremarkable. she was seen by hepatology in house who did not have any specific recommendations at this time but asked to see her in follow up as an outpatient. . 7. esrd on hd - hd satuth,. pt was continued on her hd regimen while in house. sevelamer was continued as well. . 8. anemia/pancytopenia - chronic anemia, baseline pancytopenia, likely [**2-12**] ckd and sle, currently above baseline, though has h/o gib. pts pancytopenia remained stable; c3 and c4 studies were performed and it was felt that her sle was not active at this time. guiac stools were neg. epo was continued at hd. . 9. h/o gastric ulcer - ppi was continued throughout hospitalization. . 10. sle - pt was continued on home regimen of prednisone 4mg po qdaily. . 11. h/o svc thrombosis - patients warfarin was discontinued after discussion with dr. [**last name (stitle) 4883**]. she frequently is outside of therapeutic range on this medication and given the suspected problems with medication compliance, it was felt it was safer to discontinue it altogether. . 12. seizure disorder - pt was continued on home regimen keppra 1000 mg po 3x/week (tu,th,sa). . 13. depression - pt was continued on her home celexa. . ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Other ascites; Infection and inflammatory reaction due to other vascular device, implant, and graft; Bacteremia; Other primary cardiomyopathies; Unspecified disease of pericardium; Compression of vein; Systemic lupus erythematosus; Abdominal pain, unspecified site; Other chronic pain; Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus; Stridor; Angioneurotic edema, not elsewhere classified; Unspecified accident; Thrombocytopenia, unspecified; Anemia in chronic kidney disease; Obstructive sleep apnea (adult)(pediatric); Other specified peripheral vascular diseases; Anemia of other chronic disease; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Epilepsy, unspecified, without mention of intractable epilepsy; ; Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism; Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits]","24 y/o female with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, presented to ed on [**7-12**] for dyspnea and hypertensive urgency. she was taken to icu and responded favorably to heliox. patient returned to floor and has been comfortably breathing since. at time of transfer, pts dyspnea was largely resolved and these findings were felt to be more consistent with edema given hypertensive urgency. ascites - unclear etiology and new findings for her. h/o gastric ulcer - ppi was continued throughout hospitalization. she frequently is outside of therapeutic range on this medication and given the suspected problems with medication compliance, it was felt it was safer to discontinue it altogether.","24 y/o female with h/o sle, esrd on hd, malignant htn, h/o svc syndrome, pres, prior ich, and recent sbo, presented to ed on [**7-12**] for dyspnea and hypertensive urgency. she was started on her home bp regimen of oral labetalol on [**2142-7-15**], and nife" 109,189332.0,14865,2142-08-30,14864,155726.0,2142-08-16,Discharge summary,"Admission Date: [**2142-8-13**] Discharge Date: [**2142-8-16**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 5123**] Chief Complaint: Dyspnea and hypertensive emergency Major Surgical or Invasive Procedure: Hemodialysis History of Present Illness: Ms. [**Known lastname **] is a 25 year old female with a history of SLE, end stage renal disease on [**Known lastname 2286**], malignant hypertension, SVC syndrome, PRES, prior ICH and frequent admissions for hypertensive emergency now presenting with dyspnea and cough productive of white sputum x 1-2 days with initial SBP 280s in ED. Denies F/C, CP, HA, numbness, weakness, visual changes, N/V, confusion. Reports compliance with meds but has noticed that clonidine patches have fallen off last 24-48 hours. Her usual crampy abdominal pain at baseline. Last BM yesterday normal. Pt last dialyzed Saturday (day prior to admission). Most recently admitted [**Date range (1) 43608**] with groin pain [**2-12**] HD site, [**Date range (1) 41780**] with line infection, hypertension, last admitted to MICU [**7-12**] for hypertensive emergency and discharged [**2142-7-23**]. . In ED, initial VS SBP 280/140s T100.3 HR 110 RR 28 SaO2 100%. She recieved Hydralazine 40mg IV, was maxed out on Nitro drip and SBP 240s. Also reportedly had fever to 101, CXR with retrocardiac opacity and received Vancomycin 1g IV and Levofloxacin 500mg. Has 18g PIV. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD 3. Malignant hypertension with baseline SBP's 180's-220's and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting 17. Gastric ulcer 18. PRES Social History: Home: lives with mother Occupation: on disability, previously employed with various temp jobs EtOH: Denies Drugs: Denies Tobacco: Denies Family History: No history of autoimmune disease Physical Exam: General: A&Ox3. NAD, oriented x3. HEENT: NC/AT; PERRLA on right, enucleated eye on left; OP clear, nonerythematous, MMM. Neck: supple, no LAD, full ROM. Lungs: CTAB, with decreased BS right base, scant crackles. No egophony, slight dullness to percussion bases. CV: Regular, tachy, Prominent heart sounds, S1, S2 +S3, no rubs appreciated. Abdomen: Soft, minimally distended, diffuse mild tenderness to deep palpation, no rebound, guarding. Ext: WWP, 2+ dp/pt pluses, no clubbing, cyanosis or edema. Neuro: AAOx3. CN 2-12 intact. 5./5 Pertinent Results: [**2142-8-13**] 02:15AM BLOOD WBC-6.1# RBC-2.66* Hgb-7.4* Hct-23.8* MCV-90 MCH-27.9 MCHC-31.1 RDW-19.1* Plt Ct-169# [**2142-8-13**] 07:52AM BLOOD WBC-4.9 RBC-2.45* Hgb-7.0* Hct-22.0* MCV-90 MCH-28.7 MCHC-32.0 RDW-20.1* Plt Ct-150 [**2142-8-14**] 11:44AM BLOOD WBC-3.8* RBC-2.40* Hgb-6.9* Hct-21.7* MCV-90 MCH-28.8 MCHC-32.0 RDW-20.0* Plt Ct-154 [**2142-8-13**] 02:15AM BLOOD Neuts-82.4* Bands-0 Lymphs-12.6* Monos-3.2 Eos-1.6 Baso-0.3 [**2142-8-13**] 07:52AM BLOOD Neuts-80.6* Lymphs-13.6* Monos-3.9 Eos-1.7 Baso-0.3 [**2142-8-14**] 11:44AM BLOOD Neuts-81.3* Lymphs-11.5* Monos-4.4 Eos-2.4 Baso-0.4 [**2142-8-13**] 02:15AM BLOOD PT-14.1* PTT-34.0 INR(PT)-1.2* [**2142-8-13**] 07:52AM BLOOD PT-14.2* PTT-36.1* INR(PT)-1.2* [**2142-8-14**] 11:44AM BLOOD PT-13.7* PTT-34.7 INR(PT)-1.2* [**2142-8-13**] 02:15AM BLOOD Glucose-80 UreaN-35* Creat-5.8* Na-137 K-4.8 Cl-100 HCO3-23 AnGap-19 [**2142-8-13**] 07:52AM BLOOD Glucose-87 UreaN-37* Creat-6.2* Na-137 K-4.0 Cl-100 HCO3-24 AnGap-17 [**2142-8-14**] 11:44AM BLOOD Glucose-131* UreaN-46* Creat-7.1* Na-136 K-5.5* Cl-102 HCO3-21* AnGap-19 [**2142-8-13**] 07:52AM BLOOD Calcium-8.5 Phos-5.6* Mg-1.7 [**2142-8-14**] 11:44AM BLOOD Calcium-8.0* Phos-6.7* Mg-1.7 [**2142-8-13**] 07:52AM BLOOD Vanco-4.9* [**2142-8-14**] 11:44AM BLOOD Vanco-5.1* Brief Hospital Course: 24F with h/o SLE, ESRD on HD, malignant HTN, h/o SVC syndrome was admitted to the MICU with dyspnea and hypertensive emergency with SBP 280s. She has frequent admissions for hypertensive emergency. See below for specific hospital course on each problem. . # HTN Urgency/Emergency: Patient was admitted directly to the ICU with shortness of breath and hypertension. One of her clonidine patches had fallen off and it was likely that this could have caused some of the elevation in BP. She was started on a nitro gtt in the ED, but in the MICU she was placed on a labetolol drip. Lactate on admission was 0.9 and there was no evidence of new end organ damage. She was restarted on all of her home meds (except her qhs nifedipine) and transferred to the floor the next day with SBP in the 160s. During her admission renal was follwing and recommended that she be given a home blood pressure cuff. For SBP > 200, she will have hydralazine 100mg PO. She will re-check in 30 mins with instructions to repeat up to three times before seeking medical attention in the Emergency room. She was also given dilaudid prn for her pain, which is a continuation of her outpatient pain regimen. She did not require hydralazine IV prn on the floor. Prior to discharge her evening dose of nifedipine was restarted and she recieved hemodialysis. She remained normotensive during the rest of her admission and was discharged with stable vital signs. # Dyspnea: Patient was admitted with dyspnea, which improved with resolution of her hypertension. She required supplementary oxygen intermitantly during the admission but was saturation >92 % on RA at discharge. There was concern for infection in the ED and was given as above, likely secondary to pulmonary edema +/- infection given fever, cough and infiltrate. She was started on vancomycin in the ED, but that was discontinued and she was not put on additional antibiotics. She remaine afebrile throughout the rest of her stay. Blood cultures were negative at time of discharge. . # Fever: Concerning for PNA given complaints of dyspnea and cough and infiltrate on CXR. Other possible etiologies onclude line infection given indwelling femoral HD line, however, the femoral line had been exchanged during previous admission. See above course in dyspnea section. . # Chronic abdominal pain - abdominal pain was well controlled throughout the admission with PO dilaudid. She was moving her bowels throughout the stay. Lidocaine patch was also continued.ontinue neurontin per HD. . # ESRD on HD - HD SaTuTh. Sevelamer was continued during the hospitalization. She recieved hemodialysis on Thursday, [**8-16**] prior to discharge. . # anemia - Pt has chronic anemia, baseline pancytopenia, likely [**2-12**] CKD and SLE, currently at/slightly below baseline, though has h/o GIB. HCT 23 here, most recently 22 on discharge [**8-7**]. We continued EPO per renal and was administered 2 units PRBC's prior to hemodialysis. . # h/o gastric ulcer - continue PPI. . # SLE - continue home regimen of prednisone 4mg po qdaily. . # h/o SVC thrombosis - Now off anticoagulation secondary to noncompliance with coumadin . # seizure disorder - continue keppra 1000 mg PO 3X/WEEK (TU,TH,SA). . # depression - continue celexa. . # FEN: - low salt diet. . # Prophylaxis: heparin SC, PPI. # Access: PIVx2. # Code: FULL # Communication: Patient Medications on Admission: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 3. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY 6. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY 7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 9. Sevelamer HCl 400 mg Tablet Sig: One Tablet PO TID 10. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD 11. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID 12. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H 13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. 14. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO DAYS (TU,TH,SA). 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID 17. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Anxiety. 18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for fever. 19. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO HS (at bedtime). Discharge Medications: 1. Blood pressure machine For home blood pressure monitoring three times daily 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 3. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 4. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 5. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QHS (once a day (at bedtime)). 6. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. 10. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 15. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO QT, TH SAT (). 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 18. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 20. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 21. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO once as needed for systolic blood pressure > 200: Take one tablet if systolic blood pressure > 200. Re-check blood pressure in 30 mins. Repeat up to 3 times. . Disp:*30 Tablet(s)* Refills:*3* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Hypertensive Emergency 2. Dyspnea 3. End-Stage Renal Disease (renal failure) Secondary Diagnosis: - Systemic lupus erythematosus - End Stage Renal Disease on [**Month/Year (2) 2286**] - Malignant hypertension - Thrombocytopenia - Thrombotic events with negative hypercoagulability work-up - HOCM - Anemia - History of left eye enucleation [**2139-4-20**] for fungal infection - History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion - History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] - Thrombotic microangiopathy - Obstructive sleep apnea on CPAP - Left abdominal wall hematoma - MSSA bacteremia associated with HD line [**Month (only) 956**]-[**2142-3-11**]. Discharge Condition: Stable, Vitals stable, asymptommatic Discharge Instructions: You were admitted to the hospital because of high blood pressure. You were admitted to the Intensive Care Unit for IV medications to stabilize your blood pressure while your home medications were restarted. You the were transferred to the floor for continued management. You recieved hemodialysis while in the hospital. Changes to medication/management: You have been given a blood pressure cuff to take your blood presure at home. If your blood pressure is greater than 200, take Hydralazine 100 mg by mouth. Recheck blood pressure in 30 minutes. Repeat up to 3 times. Followup Instructions: Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2142-8-16**] 12:00 Provider: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2142-8-22**] 8:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26**] [**Last Name (NamePattern1) 8402**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2142-8-28**] 2:45 ",14,2142-08-13 04:03:00,2142-08-16 18:17:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,DYSPNEA," 24f with h/o sle, esrd on hd, malignant htn, h/o svc syndrome was admitted to the micu with dyspnea and hypertensive emergency with sbp 280s. she has frequent admissions for hypertensive emergency. see below for specific hospital course on each problem. . # htn urgency/emergency: patient was admitted directly to the icu with shortness of breath and hypertension. one of her clonidine patches had fallen off and it was likely that this could have caused some of the elevation in bp. she was started on a nitro gtt in the ed, but in the micu she was placed on a labetolol drip. lactate on admission was 0.9 and there was no evidence of new end organ damage. she was restarted on all of her home meds (except her qhs nifedipine) and transferred to the floor the next day with sbp in the 160s. during her admission renal was follwing and recommended that she be given a home blood pressure cuff. for sbp > 200, she will have hydralazine 100mg po. she will re-check in 30 mins with instructions to repeat up to three times before seeking medical attention in the emergency room. she was also given dilaudid prn for her pain, which is a continuation of her outpatient pain regimen. she did not require hydralazine iv prn on the floor. prior to discharge her evening dose of nifedipine was restarted and she recieved hemodialysis. she remained normotensive during the rest of her admission and was discharged with stable vital signs. # dyspnea: patient was admitted with dyspnea, which improved with resolution of her hypertension. she required supplementary oxygen intermitantly during the admission but was saturation >92 % on ra at discharge. there was concern for infection in the ed and was given as above, likely secondary to pulmonary edema +/- infection given fever, cough and infiltrate. she was started on vancomycin in the ed, but that was discontinued and she was not put on additional antibiotics. she remaine afebrile throughout the rest of her stay. blood cultures were negative at time of discharge. . # fever: concerning for pna given complaints of dyspnea and cough and infiltrate on cxr. other possible etiologies onclude line infection given indwelling femoral hd line, however, the femoral line had been exchanged during previous admission. see above course in dyspnea section. . # chronic abdominal pain - abdominal pain was well controlled throughout the admission with po dilaudid. she was moving her bowels throughout the stay. lidocaine patch was also continued.ontinue neurontin per hd. . # esrd on hd - hd satuth. sevelamer was continued during the hospitalization. she recieved hemodialysis on thursday, [**8-16**] prior to discharge. . # anemia - pt has chronic anemia, baseline pancytopenia, likely [**2-12**] ckd and sle, currently at/slightly below baseline, though has h/o gib. hct 23 here, most recently 22 on discharge [**8-7**]. we continued epo per renal and was administered 2 units prbcs prior to hemodialysis. . # h/o gastric ulcer - continue ppi. . # sle - continue home regimen of prednisone 4mg po qdaily. . # h/o svc thrombosis - now off anticoagulation secondary to noncompliance with coumadin . # seizure disorder - continue keppra 1000 mg po 3x/week (tu,th,sa). . # depression - continue celexa. . # fen: - low salt diet. . # prophylaxis: heparin sc, ppi. # access: pivx2. # code: full # communication: patient ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic glomerulonephritis in diseases classified elsewhere; Other primary cardiomyopathies; Other ascites; Thrombocytopenia, unspecified; Compression of vein; ; Systemic lupus erythematosus; Abdominal pain, unspecified site; Other acute pain; Other chronic pain; Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, without mention of obstruction; Esophageal reflux; Depressive disorder, not elsewhere classified; Anemia in chronic kidney disease; Anemia of other chronic disease; Epilepsy, unspecified, without mention of intractable epilepsy; Other disorders of bone and cartilage; Obstructive sleep apnea (adult)(pediatric); Other specified peripheral vascular diseases; Mild dysplasia of cervix; Noncompliance with renal dialysis; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","24f with h/o sle, esrd on hd, malignant htn, h/o svc syndrome was admitted to the micu with dyspnea and hypertensive emergency with sbp 280s. she has frequent admissions for hypertensive emergency. for sbp > 200, she will have hydralazine 100mg po. there was concern for infection in the ed and was given as above, likely secondary to pulmonary edema +/- infection given fever, cough and infiltrate. blood cultures were negative at time of discharge. other possible etiologies onclude line infection given indwelling femoral hd line, however, the femoral line had been exchanged during previous admission. # sle - continue home regimen of prednisone 4mg po qdaily.","malignant htn, h/o svc syndrome was admitted to the micu with dyspnea and hypertensive emergency with sbp 280s. she was started on a nitro gtt in the ed, but in the micu she was placed on a labetolol drip. lactate on admission was 0.9 and there was no evidence of new end organ damage. she was restarted on all of her home med" 109,189332.0,14865,2142-08-30,14859,102024.0,2142-06-05,Discharge summary,"Admission Date: [**2142-5-20**] Discharge Date: [**2142-6-5**] Date of Birth: [**2117-8-7**] Sex: F Service: MEDICINE Allergies: Penicillins / Percocet / Morphine Attending:[**First Name3 (LF) 3705**] Chief Complaint: abdominal pain, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname **] is a 24 yo F with lupus since age 16, with ESRD on HD, malignant HTN, history of SVC syndrome, and history of Posterior Reversible Encephalopathy Syndrome (PRES) and intracerebral hemorrhage, who has had multiple recent admissions [**Date range (1) 43604**], [**Date range (1) 17717**], [**Date range (1) **], [**4-26**], [**Date range (1) 42063**], [**Date range (1) 43605**] mostly for hypertension, but most recently for diarrhea in addition to hypertension. . In the ED, vitals were 98 90 102/65 20 98% RA. She was complaining of abdominal pain X 3 hours, more severe than usual [**7-20**], no N/V/D. She received dilaudid 4 mg PO X 3, zofran 8mg IV, hyperkalemia 6.2=>5.3 w/ Kayexalate. Initially, she was felt stable for floor; however, BP rose during ED course to SBP 270. She then received hydral 50 PO X 1, home aliskeren, labetalol 1000 PO X 1, 20 IV hydral X 2, labetalol 100 Iv X 1, nicardipine 2.5 mg IV X 1 and started on nicardipine gtt. . Upon arrival to the floor, she complains of severe abd pain which started earlier today, it is sharp all over her abd and constant. It feels different from her usual abd pain, although she is not able to characterize it more. She has been having some nausea and bilious emesis X 1 earlier today. She has been having some mild diarrhea 2-3 episodes of loose, greenish stools for the past few weeks. She denies any chest pain, headache, vision changes. She was not able to take all of the medications due to her GI distress. . While in the MICU she was weaned off a nicardipine drip and her diarrhea resolved. Her BP remained WNL while on her home regimen and she was transferred to the floor in stable condition. Last HD was [**2142-5-21**]. Past Medical History: 1. Systemic lupus erythematosus since age 16 complicated by uveitis and end stage renal disease since [**2135**]. -s/p treatment with cyclophosphamide and mycophenolate and now maintained on prednisone 2. CKD/ESRD: Diagnosed in [**2135**] and has previously been on PD and now HD with intermittent refusal of dialysis, currently only agrees to be dialyzed one time/wk 3. Malignant hypertension and history of hypertensive crisis with seizures. 4. Thrombocytopenia 5. Thrombotic events with negative hypercoagulability work-up - SVC thrombosis ([**2139**]); related to a catheter - Negative lupus anticoagulant ([**4-/2138**], [**8-/2138**], [**9-/2140**]) - Negative anticardiolipin antibodies IgG and IgM x4 ([**2137**]-[**2140**]) - Negative Beta-2 glycoprotein antibody ([**4-/2138**], [**8-/2140**]) 6. HOCM: Last noted on echo [**8-17**] 7. Anemia 8. History of left eye enucleation [**2139-4-20**] for fungal infection 9. History of vaginal bleeding [**2139**] lasting 2 months s/p DepoProvera injection requiring transfusion 10. History of Coag negative Staph bacteremia and HD line infection - [**6-16**] and [**5-17**] 11. Thrombotic microangiopathy 12. Obstructive sleep apnea on CPAP 13. Left abdominal wall hematoma 14. MSSA bacteremia associated with HD line [**Month (only) 956**]-[**Month (only) 958**], [**2142**]. 15. Pericardial effusion 16. CIN I noted in [**2139**] and [**2142-4-12**], not further worked up due to frequent hospitalizations and inability to see in outpatient setting - has appt scheduled with gyn on [**5-25**] 17. History of two intraparenchymal hemorrhages that were thought due to the posterior reversible leukoencephalopathy syndrome, associated with LE paresis in [**2140**] which has resolved Social History: Denies any substance abuse (EtOH, tobacco, illicits). She lives with her mother and brother. 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: 100/63 81 18 100RA GENERAL: Pleasant, thin young female sitting in the bed in NAD watching TV. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. s/p left eye enucleation. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD. CARDIAC: RRR. 4/6 systolic murmur heard best at the RUSB. LUNGS: Breathing comfortably, CTAB, good air movement biaterally. ABDOMEN: + BS, soft ND, tenderness to palpation in her LUQ. No rebound or guarding. EXTREMITIES: No edema. Right femoral HD line nontender, nonerythematous. SKIN: Several subcutaneous cysts of different sizes 1 - 3 cm scattered along her lower extremities. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation to light touch throughout. 5/5 strength in her upper and lower extremities PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2142-5-20**] 09:14PM LACTATE-0.9 [**2142-5-20**] 09:13PM WBC-6.8 RBC-3.65* HGB-10.7* HCT-33.7* MCV-93 MCH-29.2 MCHC-31.6 RDW-18.8* [**2142-5-20**] 09:13PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+ TEARDROP-OCCASIONAL [**2142-5-20**] 09:13PM PLT COUNT-145* [**2142-5-20**] 08:55PM GLUCOSE-98 UREA N-44* CREAT-7.7* SODIUM-137 POTASSIUM-6.3* CHLORIDE-102 TOTAL CO2-20* ANION GAP-21* [**2142-5-20**] 08:55PM CALCIUM-9.9 PHOSPHATE-5.8* MAGNESIUM-2.1 [**2142-5-20**] 08:55PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2142-5-20**] 08:55PM WBC-7.0 RBC-3.69* HGB-11.1* HCT-34.2* MCV-93 MCH-30.2 MCHC-32.5 RDW-19.2* [**2142-5-20**] 08:55PM PLT COUNT-126* [**2142-5-20**] 08:55PM PT-14.1* PTT-32.4 INR(PT)-1.2* [**2142-5-20**] 07:40AM ALT(SGPT)-18 AST(SGOT)-55* ALK PHOS-118* TOT BILI-0.4 [**2142-5-20**] 07:40AM LIPASE-58 Brief Hospital Course: KUB: SBO Head CT: (prelim read from radiology). unchanged from prior head CT, no intracranial hemorrhage EKG: NSR, right axis, LVH, nl intervals, ST elevations V2-3 (old), TW inversion V6 (new) compared to prior EKG [**5-15**]. CT CHEST/ABD: Preliminary Read Normal aorta without dissection or acute abnormality. No PE. Stable trace ascites and small right pleural effusion. Unchanged small pulmonary nodules and lymphadenopathy in the chest. No acute abnormalities in the abdomen to explain epigastric pain. EGD: Ulcer at GE junction. # Hypertensive urgency: This is a chronic issue related to ESRD. Head CT was negative for intracranial bleed. Weaned off Nicardipine gtt and BP well controlled on home regimen. Continued her home regimen of: Aliskiren 150 mg po bid, Clonidine 0.4 mg/24 hr Patch Weekly, Labetalol 1000 mg po TID, Nifedipine 60 mg Tablet Sustained Release QPM and 90 mg Tablet Sustained Release QAM, Hydralazine 100 mg PO Q8H. When BPs were lower (see below) patient's BP meds were held occasionally, but as she was transfused and the BPs started to trend back up the meds were re-initiated. She then developed hypotension in the setting of poor PO intake during her SBO. BP meds were held and then re-initiated as the pressure came back up once she was able to eat. # Abdominal pain/UGIB: The patient has chronic abdominal pain with previous negative workups. At first the pain resolved and she was continued on her outpatient regimen of: 2-4 mg po dilaudid q4 h as needed. GI was c/s re: abd pain and rec CTA-abdomen to eval for mesenteric ischemia vs. partial SBO, however with ESRD did not initially want to get CTA so KUB was ordered. This showed no SBO. They recommended checking urine porphyrobilinogen and serum lead levels which were negative and LFTs were at baseline. The patient then developed a different type of pain associated with her incision site. Pain service was consulted and did a bupivicaine injection at the site which did help. They will continue to follow her. She then developed a third type of pain associated with a burning sensation in her chest. EKG was unchanged from prior. A few hours later she had 3 episodes of coffee-ground emesis. She was placed on IV PPI and transfused two units of blood. Afterward the pain resolved and her hct remained stable. GI felt that the patient would need general anesthesia in order to undergo an EGD which showed an ulcer at the GE junction. She was started on empiric treatment for H. Pylori and serologies were sent which came back negative so the antibiotics were stopped. Her pain was controlled with her outpatient regimen of PO dilaudid. She will follow up with Dr. [**Last Name (STitle) **] in [**6-18**] weeks to have another EGD under MAC to see if there has been resolution of the ulcer. # SBO: Continued to be nauseous and vomited intermittently. she was started on reglan and continued on zofran and compazine PRN howeve she continued to have n/v. A KUB was done which showed an SBO. Surgery was consulted, NGT was placed, she was made NPO and serial abdominal exams were done. Eventually she was able to transition to clear diet and then tolerated a regular diet without pain or vomiting. #. Fever: On hospital day #6 she spiked a fever to 101. Blood and urine cultures were sent and a cxr were negative, however she then had a seizure and in the post-ictal state aspirated after vomiting. She had an episode of hypoxia with this and was transferred to the ICU. In the ICU LP was attempted to rule out meningitis as a possible cause of a seizure but this was unsuccessful. Broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. She improved over the next few days and antibiotics were discontinued because the suspicion for a bacterial meningitis was low. #. Seizure: This occured in the setting of fever, hypotension, and initiation of reglan for vomiting. Neurology was consulted and felt she should be continued on keppra indefinitely. EEG was non-revealing. She should be continued on keppra 1gm with dialysis three times weekly. # ESRD on HD: Hyperkalemia resolved with kayexalate. Underwent dialysis on normal schedule. # SLE: She was continued on prednisone 4mg daily. With multiple abdominal symptoms it was thought she may have lupus flare in the abdomen. C3, c4 were equivocal for active lupus flare, and [**Doctor First Name **] was positive, as would be expected in lupus. # Anemia: Has anemia of chronic renal disease and her Hct was high on admission and epo was held per renal. However, her Hct trended all the way down to 20 and she was borderline hypotensive for her (ie SBP 120) and she developed coffee ground emesis so she was transfused 2 units. Afterward her Hct was stable at 25. She was also re-started on EPO per renal for her chronic anemia. Hemolysis labs were negative. # History of thrombotic events/SVC syndrome: She is anticoagulated with warfarin as an outpatient. Previous documentation in OMR states she does not need to be bridged while subtherapeutic. Continued coumadin 4 mg po daily however INR became supratherapeutic and the coumadin was then held. She was started on heparin gtt while awaiting EGD. After EGD the coumadin was re-started at 3mg daily however, in setting of poor po intake her INR was supratherapeutic - likely [**2-12**] nutritional deficiency of vitamin k. coumadin will be restarted when INR [**2-13**] at dialysis. # OSA: She is on CPAP at a setting of 7 as an outpatient. Continued CPAP #. CIN1: On last pap had CIN1. OB/GYN service was called re: doing colposcopy in hospital as patient rarely makes o/p appointments, hwoever they do not do this procedure in hospital especially because it does not have to be done emergently - just within one year. Will need outpatient colposcopy at some point in next few months as they do not do this procedure in the hospital. # RLL nodule: A new 10 x 5 mm nodularity was found incidentally within the right lower lobe of the lung on an abdominal CT. This should be reassessed in 3 months. # ACCESS: PIV, right groin HD line # CODE: Full code Medications on Admission: 1. Aliskiren 150 mg PO bid 2. Citalopram 20 mg PO DAILY 3. Clonidine 0.2 mg/24 hr Patch Weekly QSAT 4. Hydromorphone 2 mg 1-2 Tablets PO Q4H 5. Fentanyl 25 mcg/hr Patch 72 hr 6. Gabapentin 300 mg PO TID 7. Hydralazine 100 mg PO Q8H 8. Hydralazine 100 mg PO BID PRn fro SBP> 180. 9. Prednisone 4 mg PO DAILY 10. Pantoprazole 40 mg PO Q24H 11. Labetalol 1000 mg PO TID 12. Nifedipine 90 mg PO QAM 13. Nifedipine 60 mg PO QHS 14. Warfarin 3 mg PO Once Daily 15. Lidocaine 5 %(700 mg/patch) Topical once a day. 16. Nifedipine 90 mg PO once a day as needed for for SBP persistently above 200. Discharge Medications: 1. Nifedipine 90 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 2. Nifedipine 30 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO QHS (once a day (at bedtime)). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 4. Aliskiren 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 7. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 9. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QSAT (every Saturday). 10. Sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO TID (3 times a day). 13. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 30 days. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 16. LeVETiracetam 1,000 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: UGIB- Ulcer at GE junction Hypertensive Emergency Anemia ESRD on HD SBO Discharge Condition: The patient was afebrile and hemodynamically stable prior to discharge. Discharge Instructions: You were admitted to the hospital with abdominal pain. You had an injection of lidocaine to help the pain around your surgery sites. You then had some blood in your vomit. You were treated for a bleed in your stomach with a blood transfusion and medications. You stopped bleeding and felt better. You had a scope of your abdomen that showed an ulcer. You were treated with medications for this and need to have another scope of your abdomen in 6 weeks. You also had high blood pressures while you were here because you could not take your medicines with your nausea and vomiting. Once you were on your home medicines your blood pressure was better. Medication Changes: CHANGE: Pantoprazole to 40mg TWICE daily Please call your PCP or come to the emergency room if you have fevers, chills, worsening abdominal pain, nausea, vomiting, blood in your vomit, blood in your stools, black/tarry stools or any other concerning symptoms. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] (gastroenterology) in [**6-18**] weeks for an EGD to re-look at your ulcer. Please follow up with the OB/[**Hospital **] clinic for a colposcopy on Wednesday [**2142-8-8**] at 3:15pm in the [**Hospital Ward Name 23**] Building on the [**Location (un) **]. Their number is [**Telephone/Fax (1) 2664**]. Please follow up with Dr.[**Name (NI) **] at [**Hospital6 733**] in the Shapria building on the [**Location (un) **] on [**2142-6-27**] at 2:00pm. Completed by:[**2142-6-6**]",86,2142-05-20 12:59:00,2142-06-05 16:18:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ABDOMINAL PAIN," kub: sbo head ct: (prelim read from radiology). unchanged from prior head ct, no intracranial hemorrhage ekg: nsr, right axis, lvh, nl intervals, st elevations v2-3 (old), tw inversion v6 (new) compared to prior ekg [**5-15**]. ct chest/abd: preliminary read normal aorta without dissection or acute abnormality. no pe. stable trace ascites and small right pleural effusion. unchanged small pulmonary nodules and lymphadenopathy in the chest. no acute abnormalities in the abdomen to explain epigastric pain. egd: ulcer at ge junction. # hypertensive urgency: this is a chronic issue related to esrd. head ct was negative for intracranial bleed. weaned off nicardipine gtt and bp well controlled on home regimen. continued her home regimen of: aliskiren 150 mg po bid, clonidine 0.4 mg/24 hr patch weekly, labetalol 1000 mg po tid, nifedipine 60 mg tablet sustained release qpm and 90 mg tablet sustained release qam, hydralazine 100 mg po q8h. when bps were lower (see below) patients bp meds were held occasionally, but as she was transfused and the bps started to trend back up the meds were re-initiated. she then developed hypotension in the setting of poor po intake during her sbo. bp meds were held and then re-initiated as the pressure came back up once she was able to eat. # abdominal pain/ugib: the patient has chronic abdominal pain with previous negative workups. at first the pain resolved and she was continued on her outpatient regimen of: 2-4 mg po dilaudid q4 h as needed. gi was c/s re: abd pain and rec cta-abdomen to eval for mesenteric ischemia vs. partial sbo, however with esrd did not initially want to get cta so kub was ordered. this showed no sbo. they recommended checking urine porphyrobilinogen and serum lead levels which were negative and lfts were at baseline. the patient then developed a different type of pain associated with her incision site. pain service was consulted and did a bupivicaine injection at the site which did help. they will continue to follow her. she then developed a third type of pain associated with a burning sensation in her chest. ekg was unchanged from prior. a few hours later she had 3 episodes of coffee-ground emesis. she was placed on iv ppi and transfused two units of blood. afterward the pain resolved and her hct remained stable. gi felt that the patient would need general anesthesia in order to undergo an egd which showed an ulcer at the ge junction. she was started on empiric treatment for h. pylori and serologies were sent which came back negative so the antibiotics were stopped. her pain was controlled with her outpatient regimen of po dilaudid. she will follow up with dr. [**last name (stitle) **] in [**6-18**] weeks to have another egd under mac to see if there has been resolution of the ulcer. # sbo: continued to be nauseous and vomited intermittently. she was started on reglan and continued on zofran and compazine prn howeve she continued to have n/v. a kub was done which showed an sbo. surgery was consulted, ngt was placed, she was made npo and serial abdominal exams were done. eventually she was able to transition to clear diet and then tolerated a regular diet without pain or vomiting. #. fever: on hospital day #6 she spiked a fever to 101. blood and urine cultures were sent and a cxr were negative, however she then had a seizure and in the post-ictal state aspirated after vomiting. she had an episode of hypoxia with this and was transferred to the icu. in the icu lp was attempted to rule out meningitis as a possible cause of a seizure but this was unsuccessful. broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. she improved over the next few days and antibiotics were discontinued because the suspicion for a bacterial meningitis was low. #. seizure: this occured in the setting of fever, hypotension, and initiation of reglan for vomiting. neurology was consulted and felt she should be continued on keppra indefinitely. eeg was non-revealing. she should be continued on keppra 1gm with dialysis three times weekly. # esrd on hd: hyperkalemia resolved with kayexalate. underwent dialysis on normal schedule. # sle: she was continued on prednisone 4mg daily. with multiple abdominal symptoms it was thought she may have lupus flare in the abdomen. c3, c4 were equivocal for active lupus flare, and [**doctor first name **] was positive, as would be expected in lupus. # anemia: has anemia of chronic renal disease and her hct was high on admission and epo was held per renal. however, her hct trended all the way down to 20 and she was borderline hypotensive for her (ie sbp 120) and she developed coffee ground emesis so she was transfused 2 units. afterward her hct was stable at 25. she was also re-started on epo per renal for her chronic anemia. hemolysis labs were negative. # history of thrombotic events/svc syndrome: she is anticoagulated with warfarin as an outpatient. previous documentation in omr states she does not need to be bridged while subtherapeutic. continued coumadin 4 mg po daily however inr became supratherapeutic and the coumadin was then held. she was started on heparin gtt while awaiting egd. after egd the coumadin was re-started at 3mg daily however, in setting of poor po intake her inr was supratherapeutic - likely [**2-12**] nutritional deficiency of vitamin k. coumadin will be restarted when inr [**2-13**] at dialysis. # osa: she is on cpap at a setting of 7 as an outpatient. continued cpap #. cin1: on last pap had cin1. ob/gyn service was called re: doing colposcopy in hospital as patient rarely makes o/p appointments, hwoever they do not do this procedure in hospital especially because it does not have to be done emergently - just within one year. will need outpatient colposcopy at some point in next few months as they do not do this procedure in the hospital. # rll nodule: a new 10 x 5 mm nodularity was found incidentally within the right lower lobe of the lung on an abdominal ct. this should be reassessed in 3 months. # access: piv, right groin hd line # code: full code ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease] SECONDARY: [End stage renal disease; Chronic or unspecified gastric ulcer with hemorrhage, without mention of obstruction; Acute posthemorrhagic anemia; Unspecified intestinal obstruction; Other primary cardiomyopathies; Unspecified disease of pericardium; Systemic lupus erythematosus; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Disorders of phosphorus metabolism; Hypotension, unspecified; Hyperpotassemia; Mononeuritis of unspecified site; Anemia of other chronic disease; Abdominal pain, left lower quadrant; Other chronic pain; Thrombocytopenia, unspecified; Diaphragmatic hernia without mention of obstruction or gangrene; Other specified peripheral vascular diseases; Carrier or suspected carrier of Methicillin resistant Staphylococcus aureus; Noncompliance with renal dialysis; Renal dialysis status; Long-term (current) use of anticoagulants; Personal history of noncompliance with medical treatment, presenting hazards to health]","kub: sbo head ct: (prelim read from radiology). ct chest/abd: preliminary read normal aorta without dissection or acute abnormality. bp meds were held and then re-initiated as the pressure came back up once she was able to eat. gi was c/s re: abd pain and rec cta-abdomen to eval for mesenteric ischemia vs. partial sbo, however with esrd did not initially want to get cta so kub was ordered. a few hours later she had 3 episodes of coffee-ground emesis. afterward the pain resolved and her hct remained stable. gi felt that the patient would need general anesthesia in order to undergo an egd which showed an ulcer at the ge junction. her pain was controlled with her outpatient regimen of po dilaudid. broad spectrum antibiotics were initiated (vanc ctx) at meningeal dosing. she should be continued on keppra 1gm with dialysis three times weekly. c3, c4 were equivocal for active lupus flare, and [**doctor first name **] was positive, as would be expected in lupus. # anemia: has anemia of chronic renal disease and her hct was high on admission and epo was held per renal.","sbo head ct was negative for intracranial hemorrhage. no intracranial hemorrhage ekg: nsr, right axis, lvh, nl intervals, st elevations v2-3 (old), tw inversion v6 (new) no acute abnormalities in the abdomen to explain epigastric pain." 2208,144187.0,23610,2190-09-28,23609,162248.0,2190-08-24,Discharge summary,"Admission Date: [**2190-8-18**] Discharge Date: [**2190-8-24**] Date of Birth: [**2120-10-4**] Sex: M Service: MEDICINE Allergies: Penicillins / Hydralazine Attending:[**First Name3 (LF) 13541**] Chief Complaint: Vomiting Major Surgical or Invasive Procedure: 1. Intraosseous access obtained. 2. Right internal jugular central venous catheter placed. 3. Left PICC placed. 4. Endotracheal intubation History of Present Illness: 69 year old male with h/o CVA and baseline non-communicative, aspiration pna, hydrocephalus s/p VP shunt who was brought in from NH by son for nausea and vomiting. Also noted to have increased yellow secretions. Per sone, his father has been pulling at his g-tube for past few days; unable to communicate though so son unclear whether it was painful. Did not know whether tube feeds have been a problem. Pt reports MS [**First Name (Titles) **] [**Last Name (Titles) 10252**]e; unchanged. On arrival to [**Name (NI) **], pt non-communicative (but at baseline), Fever 102. HR 120s, SBP 120. CXR was done which was wnl. WBC 22. Lactate 1.9. CT head was done given h/o hydrocephalus and new onset vomiting. CT was concerning for enlarged 3rd ventricle thus neurosurgery evaluated pt and felt unlikely to represent signficant change. CT Abd/Pelvis done which showed bibasilar opacities c/w aspiration pneumonia. Pt given Vanc/Levo/Flagyl for aspiration pna. In addition, central access was attempted x3; unsuccess femoral line attempts on both R/L and subclavian secondary to return of arterial blood; thus intraosseous access obtained. Also of note, during the multiple line attemps, pt became increasing tachycardic, hypotensive, vomiting with ?aspiration. NGT placed with coffee-ground return. Pt hydrated with 4L NS. BP remained stable however was tachycardic to 120s persistantly despite fluids. 2 PIVs subsequently obtained. Of note, pt was admitted [**Date range (1) 39587**] with fever,cough and intially tx for aspiration pna but subsequently found to have C.diff and Proteus UTI; d/c'd with 10D meropenem and 14D flagyl. He was then readmitted [**Date range (1) 27450**] for recurrent c.diff, VRE UTI and yeast UTI and d/c'd on flagyl, fluconazole and tetracycline. Of note, all c.diff toxin cultures from [**Month (only) **] were negative. Past Medical History: Alzheimer's dementia Bipolar disorder PVD DM type II Hydrocephalus s/p VP shunt (son says it was placed 3-5 years ago at [**Hospital3 **] with no revisions, unknown cause of hydrocephalus) H/o subdural hemorrhages (unknown if before or after shunt placed) Hearing loss with hearing aids Cataracts Hypertension Hypercholesterolemia h/o SIADH with fluid restriction of 1L per day h/o aspiration PNAs s/p recent CVA ([**2190-6-3**]) Recent C. diff infection h/o VRE UTI Social History: Resides in NH. Used to work as an accountant, 100 pack year smoking history, He is nonverbal at baseline with a PEG tube. He is dependent on others for ADLs. Family History: Type 2 diabetes mellitus, Alzheimer's and Bipolar Disease. Physical Exam: T:98 BP: 123/61 HR: 129 R 20 O2Sats 98% on Vent support Gen: Intubated, sedated, NG tube with some coffee-grounds. VP shunt - scalp site easily compressible HEENT: Pupils: 6-4 mm B/L Neck: Supple. Lungs: Coarse crackles B/L. Cardiac: Heart sounds are irregularly irregular, with a pansystolic murmur radiating to the axilla. Abd: PEG site clean. Foley in situ. Hypoactive bowel sounds Extrem: Cold peripheries. Neuro: Intubated and sedated, therefore could not be assessed, therefore, mental status could not be assessed. Pupils equally round and reactive to light. Pertinent Results: [**2190-8-18**] 04:15PM GLUCOSE-178* UREA N-82* CREAT-0.7 SODIUM-142 POTASSIUM-5.4* CHLORIDE-100 TOTAL CO2-26 ANION GAP-21* [**2190-8-24**] 06:15AM Glucose-216* UreaN-10 Creat-0.3* Na-139 K-5.0 Cl-107 HCO3-22 AnGap-15 [**2190-8-18**] 04:15PM CALCIUM-11.4* PHOSPHATE-4.9* MAGNESIUM-2.8* [**2190-8-18**] 04:15PM WBC-22.8*# RBC-5.03# HGB-13.9*# HCT-41.9 MCV-83# MCH-27.7 MCHC-33.3 RDW-16.0* PLTS: 422 [**2190-8-18**] 04:15PM NEUTS-80.4* LYMPHS-13.9* MONOS-4.9 EOS-0.3 BASOS-0.5 WBC: 22.8 -> 11.0 HCT: 41.9 ([**8-18**]) -> 23.1 ([**8-22**]) -> 31.9 ([**8-24**], after 2 units RBCs) Lactate: 1.9 INR: 1.3 -> 1.7 -> 1.3 Imaging: CT ABDOMEN/PELVIS ([**8-18**]): IMPRESSION: 1. Extensive tree-in-[**Male First Name (un) 239**] opacities at the lung bases are suggestive of aspiration. 2. Poorly defined areas of hypodensity in the left kidney are new from a prior study from [**2188**] and raise concern for infectious or ischemic process. 3. No evidence of acute bowel process. 4. VP shunt catheter tip in the right hemiabdomen appearing unremarkable. CT Head ([**8-18**]): Continued evolution of blood products of left MCA territory infarction. No midline shift. Enlarged 3rd ventricle. Persistent dilatation of the lateral ventricles. These findings may be chronic but correlation with signs of increased cranial pressure recommended. Renal U/S ([**8-19**]): IMPRESSION: No definite son[**Name (NI) 493**] correlates identified for bilateral renal hypodensities seen on previous CT, with no solid masses identified. The nephrographic abnormalities on recent CT are suspicious for infectious or ischemic process and their lack of visualization may relate to limitations of this study. CXR ([**8-21**]): FINDINGS: Comparison with study of [**8-20**], there are lower lung volumes. There is still some right infrahilar and left suprahilar opacification consistent with aspiration. However, some of this may also reflect crowding of vessels due to poor inspiration. Right UE U/S ([**8-23**]): IMPRESSION: No DVT in the right upper extremity. Right cephalic vein was not definitely identified. Brief Hospital Course: # Aspiration pneumonia Initially febrile with leukocytosis. Patient was intubated in the ED for concerns regarding airway protection and continued vomiting. He also received Vanc/Levo/ Flagyl in the ED. Vent settings were gradually weaned and he was easily extubated on [**2190-8-20**]. He had sputum cultures sent, which grew MRSA and Klebsiella pneumonia. He was on aspiration precautions and treated with a regimen of vanco and ceftriaxone. However, the ceftriaxone was switched to meropenem given ESBL Klebsiella in the urine. He will complete a 10d course of vanco and a 14d course of meropenem. At time of discharge, his fevers and leukocytosis have resolved, he continues to have SpO2 in the upper 90s on room air, and his secretions have improved. # Hypovolemia Labs initially suggestive of significant volume depletion with hypotension, increased calcium, BUN, hematocrit. He is unable to independently take POs, and had been vomiting. He received 4L IV NS in the ED via intraosseous line as no peripherals or central lines could be placed. Also, he was tachycardic, likely both from volume depletion and holding his antihypertensives due to hypotension. Once in the MICU, a R IJ TLC was placed. His blood pressure and heart rate normalized with volume resuscitation, and his TLC was d/c'd once PICC access was obtained with IR assistance. # Hypertension Occurred a few days after his hypovolemia and hypotension were corrected. Likely due to a rebound effect from being off his home antihypertensives, especially clonidine. The hypertension resolved after these medications were resumed, albeit at lower doses and with clonidine given PO. His EKG showed stable LVH and new TWI in the anteroseptal leads. This is nonspecific, but due to the possibility of ischemia, cardiac markers were checked and were not elevated when compared to his baseline. He was also continued on his home aspirin. - Please note that he does NOT currently have a clonidine patch. This was written in the discharge medications, but can be placed at the ECF. - Also, his other antihypertensives are at lower doses - please titrate to his prior regimen as tolerated. # N/V CT showed no acute abdominal pathology. LFTs WNL. Neurosurgery was consulted initially for concern of worsening ICP in a patient with a VP shunt, but felt his head CT was not suggestive of this. [**Name (NI) **] son felt that his mental status was at baseline. Following extubation, TFs were restarted gradually with high residuals, so he was started on reglan for presumed diabetic gastroparesis as the cause of his vomiting. There may have also been contribution by his UTI, as this has caused these symptoms in him previously. # UTI. Urine growing Proteus, ESBL Klebsiella, both sensitive to meropenem. His inital ceftriaxone and bactrim were switched to meropenem 500mg q6h and will be continued to complete a 14 day course. His foley was d/c'd and replaced by a condom cath. # Anemia Hematocrit initially 41.9 due to hemoconcentration from dehydration. It gradually trended down to a nadir of 23.1. He received 2 units pRBCs, and it remained stable around 32 subsequently. No coffee grounds were noted since the ED, and his stool was guaiac negative x2. He was started on lansoprazole. # FEN Initially had to hold TF for high residuals, but after reglan was started, we were able to advance him to a goal of 45ml/hr, which was well tolerated. He received 35 units glargine qhs due to initial decreased enteral intake, but this was increased to 60 units glargine qhs at discharge as he is at goal with TFs and having glucose levels upper 200s, lower 300s. - Please uptitrate the glargine to his prior regimen (listed as 78 units qhs) as tolerated. # R UE swelling Doppler U/S performed and showed no evidence of DVT. # Dispo His other chronic issues remained stable and were treated as previously. He will be discharged back to the extended care facility from which he was admitted. Medications on Admission: Heparin (Porcine) 5,000 unit/mL Solution [**Name (NI) **]: 5000 (5000) units Injection TID (3 times a day). Chlorhexidine Gluconate 0.12 % Mouthwash [**Name (NI) **]: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). Clonidine 0.3 mg/24 hr Patch Weekly [**Hospital1 **]: One (1) Patch Weekly Transdermal QTHUR (every Thursday). Metoprolol Tartrate 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). Lisinopril 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg PO BID (2 times a day). Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal DAILY (Daily) as needed for constipation: Give if no bowel movement within the last 24 hours. Lantus 100 unit/mL Solution [**Hospital1 **]: Seventy-eight (78) units Subcutaneous at bedtime. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: As directed Injection every six (6) hours: Insulin sliding scale. Acetaminophen 650mg q4h PRN Furosemide 40mg PO daily MVI 1 tab daily Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 3. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day) as needed. 6. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO every four (4) hours as needed for fever or pain: Max 4g/day. 7. Levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO three times a day: Hold for SBP < 100, HR < 60. 9. Metoclopramide 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4 times a day). 10. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Sixty (60) units Subcutaneous at bedtime: plus sliding scale, see attached. 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing on exam. 12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 13. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: One (1) Intravenous Q 12H (Every 12 Hours) for 4 days: 10 day course to finish on [**2190-8-27**]. 14. Clonidine 0.3 mg/24 hr Patch Weekly [**Date Range **]: One (1) Patch Weekly Transdermal Q WEDNESDAY. 15. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 16. Meropenem 500 mg Recon Soln [**Date Range **]: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 13 days: 14 day course to complete on [**2190-9-5**]. 17. Ondansetron 4 mg Tablet, Rapid Dissolve [**Date Range **]: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 18. Lisinopril 10 mg Tablet [**Date Range **]: One (1) Tablet PO once a day: hold for SBP < 95. 19. insulin see attached sliding scale for regular insulin Discharge Disposition: Extended Care Facility: Roscommon Discharge Diagnosis: Primary: Aspiration pneumonia Complicated cystitis. Secondary diagnoses: Diabetes mellitus type 2, controlled, with complications Peripheral vascular disease Hypertension Prior cerebrovascular accident Chronic anemia Hydrocephalus with ventriculoperitoneal shunt Discharge Condition: Stable. Discharge Instructions: You were admitted to [**Hospital1 18**] with vomiting. This was likely because the tube feeds were passing through your bowels very slowly, perhaps due to diabetes. Some of the vomit entered your lungs and lead to a pneumonia. We also found a bladder infection, and treated both infections with IV antibiotics. Your blood pressure was initially low, which improved with fluids. It became high later, but improved when we restarted your outpatient medications. We also gave you 2 units of blood because your red blood cell level was low. We will discharge you back to your extended care facility. Please take all medications as prescribed and go to all follow up appointments. We started another medication, reglan, to help prevent your stomach from slowing down. We also started lansoprazole due to concern about stomach irritation. If you experience any nausea, vomiting, difficulty breathing, fevers, chills, increased sputum, blood in the vomit or stool, or any other concerning symptoms, please seek medical attention or come to the emergency room immediately. Followup Instructions: Please follow up with your primary care provider at [**Name9 (PRE) 10246**] within 1-2 weeks. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**] Completed by:[**2190-8-24**]",35,2190-08-18 22:14:00,2190-08-24 15:27:00,EMERGENCY,EMERGENCY ROOM ADMIT,SNF,PNEUMONIA," # aspiration pneumonia initially febrile with leukocytosis. patient was intubated in the ed for concerns regarding airway protection and continued vomiting. he also received vanc/levo/ flagyl in the ed. vent settings were gradually weaned and he was easily extubated on [**2190-8-20**]. he had sputum cultures sent, which grew mrsa and klebsiella pneumonia. he was on aspiration precautions and treated with a regimen of vanco and ceftriaxone. however, the ceftriaxone was switched to meropenem given esbl klebsiella in the urine. he will complete a 10d course of vanco and a 14d course of meropenem. at time of discharge, his fevers and leukocytosis have resolved, he continues to have spo2 in the upper 90s on room air, and his secretions have improved. # hypovolemia labs initially suggestive of significant volume depletion with hypotension, increased calcium, bun, hematocrit. he is unable to independently take pos, and had been vomiting. he received 4l iv ns in the ed via intraosseous line as no peripherals or central lines could be placed. also, he was tachycardic, likely both from volume depletion and holding his antihypertensives due to hypotension. once in the micu, a r ij tlc was placed. his blood pressure and heart rate normalized with volume resuscitation, and his tlc was d/cd once picc access was obtained with ir assistance. # hypertension occurred a few days after his hypovolemia and hypotension were corrected. likely due to a rebound effect from being off his home antihypertensives, especially clonidine. the hypertension resolved after these medications were resumed, albeit at lower doses and with clonidine given po. his ekg showed stable lvh and new twi in the anteroseptal leads. this is nonspecific, but due to the possibility of ischemia, cardiac markers were checked and were not elevated when compared to his baseline. he was also continued on his home aspirin. - please note that he does not currently have a clonidine patch. this was written in the discharge medications, but can be placed at the ecf. - also, his other antihypertensives are at lower doses - please titrate to his prior regimen as tolerated. # n/v ct showed no acute abdominal pathology. lfts wnl. neurosurgery was consulted initially for concern of worsening icp in a patient with a vp shunt, but felt his head ct was not suggestive of this. [**name (ni) **] son felt that his mental status was at baseline. following extubation, tfs were restarted gradually with high residuals, so he was started on reglan for presumed diabetic gastroparesis as the cause of his vomiting. there may have also been contribution by his uti, as this has caused these symptoms in him previously. # uti. urine growing proteus, esbl klebsiella, both sensitive to meropenem. his inital ceftriaxone and bactrim were switched to meropenem 500mg q6h and will be continued to complete a 14 day course. his foley was d/cd and replaced by a condom cath. # anemia hematocrit initially 41.9 due to hemoconcentration from dehydration. it gradually trended down to a nadir of 23.1. he received 2 units prbcs, and it remained stable around 32 subsequently. no coffee grounds were noted since the ed, and his stool was guaiac negative x2. he was started on lansoprazole. # fen initially had to hold tf for high residuals, but after reglan was started, we were able to advance him to a goal of 45ml/hr, which was well tolerated. he received 35 units glargine qhs due to initial decreased enteral intake, but this was increased to 60 units glargine qhs at discharge as he is at goal with tfs and having glucose levels upper 200s, lower 300s. - please uptitrate the glargine to his prior regimen (listed as 78 units qhs) as tolerated. # r ue swelling doppler u/s performed and showed no evidence of dvt. # dispo his other chronic issues remained stable and were treated as previously. he will be discharged back to the extended care facility from which he was admitted. ","PRIMARY: [Pneumonitis due to inhalation of food or vomitus] SECONDARY: [Urinary tract infection, site not specified; Pressure ulcer, heel; Pressure ulcer, lower back; Alzheimer's disease; Dementia in conditions classified elsewhere without behavioral disturbance; Unspecified essential hypertension; Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled; Atherosclerosis of native arteries of the extremities, unspecified; Presence of cerebrospinal fluid drainage device; Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site; Hypovolemia; Tachycardia, unspecified; Anemia, unspecified; Gastrostomy status; Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled; Gastroparesis; Proteus (mirabilis) (morganii) infection in conditions classified elsewhere and of unspecified site; Abnormal coagulation profile]","# aspiration pneumonia initially febrile with leukocytosis. at time of discharge, his fevers and leukocytosis have resolved, he continues to have spo2 in the upper 90s on room air, and his secretions have improved. his ekg showed stable lvh and new twi in the anteroseptal leads. this is nonspecific, but due to the possibility of ischemia, cardiac markers were checked and were not elevated when compared to his baseline. - also, his other antihypertensives are at lower doses - please titrate to his prior regimen as tolerated. name (ni) **] son felt that his mental status was at baseline. his foley was d/cd and replaced by a condom cath. it gradually trended down to a nadir of 23.1. # r ue swelling doppler u/s performed and showed no evidence of dvt.","the patient was on aspiration precautions and treated with a regimen of vanco and ceftriaxone. his fevers and leukocytosis have resolved, he continues to have spo2 in the upper 90s on room air. he is unable to independently take pos, and had been vomiting." 2338,184485.0,9336,2159-09-19,9335,147143.0,2159-08-27,Discharge summary,"Admission Date: [**2159-8-24**] Discharge Date: [**2159-8-27**] Date of Birth: [**2097-9-24**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2181**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea. Pt states that yesterday evening he noted sudden onset of shortness of breath. He denies any fevers, chills, nausea, vomiting, chest pain, melena, hemetemesis, hematochezia, diarrhea, constipation. In the [**Name (NI) **] pt's initial VS were noted to be T96.2, HR 68, BP 118/84, RR 24, Sat 96%. His initial EKG was concerning for possible V tach however on further review it was noted to be A. fib with aberrancy, pt was given 5mg IV Lopressor which resulted in decrease of HR from 130s to the low 100s, SBP down to the mid 90s. Pt underwent CXR which showed fluid overload and he was thus given Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to concern for possible PNA. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos 257 with a TB of 5.1. His glc was noted to be 42 with an anion gap acidosis. His INR was noted to be 3.4, Digoxin level 0.3, BNP 6682. He received a RUQ U/S which showed edematous gallbladder wall but no cholecystitis, pt also had cholelithiasis. He also had a right IJ placed and underwent a CT abdomen/pelvis without contrast to eval for source of high lactate. CT scna was negative for bowel wall thickening, pneumotosis but did showed ground glass opacities in the lung. Prior to the CT scan he was given Levofloxacin and Zosyn given his acutely ill appearance and elevated lactate. Past Medical History: CAD s/p CABG Anterior MI [**2144**] h/o massive UGIB in [**2154**] [**1-1**] gastritis [**1-1**] NSAIDs and coumadin(intubated, c/b MRSA VAP, had tracheostomy) CHF (EF 25% by last echo) with BiV pacer and ICD placement L hip arthritis Hyperlipidimia Hypothyroidism h/o Afib in past (not currently on coumadin) Social History: Married > 25 years. Has three adult children. Lives with his wife. Used to work in computers but on disability for health reasons. Denies tobacco, occasional etoh. No illicits. Family History: FH: Father died of MI at age 52 Physical Exam: At Admission: General: Chronically sick appearing Male, appears jaundices lying down in NARD. HEENT: Left Sclera icteric, EOMI, PERRL Neck: JVP noted at mandible Lungs: Crackles noted over right hemithorax and left base. CV: Distant S1, S2, irregularly irregular, no murmurs, rubs, gallops Abdomen: Soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, no murphys Ext: Lower extremities cool to touch, sensation intact, movement intact. Healing wound noted on LLE. Pertinent Results: [**2159-8-24**] 12:10AM PT-33.9* PTT-35.9* INR(PT)-3.4* [**2159-8-24**] 12:10AM PLT COUNT-234 [**2159-8-24**] 12:10AM NEUTS-68.8 LYMPHS-24.3 MONOS-6.2 EOS-0.2 BASOS-0.5 [**2159-8-24**] 12:10AM WBC-12.3* RBC-4.98# HGB-12.2* HCT-42.1 MCV-84# MCH-24.4*# MCHC-28.9*# RDW-18.3* [**2159-8-24**] 12:10AM DIGOXIN-0.3* [**2159-8-24**] 12:10AM CALCIUM-8.8 [**2159-8-24**] 12:10AM CK-MB-6 proBNP-6682* [**2159-8-24**] 12:10AM cTropnT-0.05* [**2159-8-24**] 12:10AM LIPASE-25 [**2159-8-24**] 12:10AM ALT(SGPT)-133* AST(SGOT)-243* CK(CPK)-116 ALK PHOS-257* TOT BILI-5.1* DIR BILI-2.0* INDIR BIL-3.1 [**2159-8-24**] 12:10AM GLUCOSE-42* UREA N-22* CREAT-1.5* SODIUM-137 POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-17* ANION GAP-31* [**2159-8-24**] 12:19AM K+-4.2 [**2159-8-24**] 01:10AM URINE HYALINE-0-2 [**2159-8-24**] 01:10AM URINE RBC-0-2 WBC-[**2-1**] BACTERIA-MOD YEAST-NONE EPI-0-2 [**2159-8-24**] 01:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-12* PH-6.5 LEUK-NEG [**2159-8-24**] 01:10AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2159-8-24**] 01:36AM LACTATE-13.7* [**2159-8-24**] 05:42AM PT-43.7* PTT-42.5* INR(PT)-4.7* [**2159-8-24**] 05:44AM PLT COUNT-182 [**2159-8-24**] 05:44AM WBC-11.5* RBC-4.54* HGB-10.8* HCT-38.0* MCV-84 MCH-23.7* MCHC-28.3* RDW-18.6* [**2159-8-24**] 05:44AM ALBUMIN-3.5 CALCIUM-8.1* PHOSPHATE-4.4# MAGNESIUM-2.0 [**2159-8-24**] 05:44AM CK-MB-NotDone cTropnT-0.05* [**2159-8-24**] 05:44AM ALT(SGPT)-284* AST(SGOT)-770* LD(LDH)-1290* CK(CPK)-90 ALK PHOS-219* TOT BILI-5.2* [**2159-8-24**] 05:44AM GLUCOSE-90 UREA N-24* CREAT-1.4* SODIUM-134 POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-17* ANION GAP-27* [**2159-8-24**] 05:53AM O2 SAT-73 [**2159-8-24**] 05:53AM LACTATE-11.2* [**2159-8-24**] 07:18AM TSH-2.8 [**2159-8-24**] 07:18AM OSMOLAL-291 [**2159-8-24**] 07:23AM O2 SAT-96 CARBOXYHB-2 [**2159-8-24**] 07:23AM LACTATE-9.0* [**2159-8-24**] 07:23AM TYPE-ART PO2-106* PCO2-33* PH-7.39 TOTAL CO2-21 BASE XS--3 COMMENTS-ADD ON CAR [**2159-8-24**] 08:33AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2159-8-24**] 09:23AM URINE RBC-[**5-9**]* WBC-[**5-9**]* BACTERIA-MOD YEAST-NONE EPI-0-2 [**2159-8-24**] 09:23AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-NEG [**2159-8-24**] 09:23AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.023 [**2159-8-24**] 12:49PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2159-8-24**] 12:49PM ALT(SGPT)-589* AST(SGOT)-[**2160**]* LD(LDH)-2362* ALK PHOS-185* TOT BILI-3.8* [**2159-8-24**] 12:49PM GLUCOSE-99 UREA N-27* CREAT-1.3* SODIUM-135 POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16 [**2159-8-24**] 12:59PM HGB-10.7* calcHCT-32 O2 SAT-59 [**2159-8-24**] 12:59PM LACTATE-4.8* [**2159-8-24**] 12:59PM TYPE-[**Last Name (un) **] PO2-37* PCO2-41 PH-7.37 TOTAL CO2-25 BASE XS--1 [**2159-8-24**] 01:33PM O2 SAT-63 [**2159-8-24**] 07:31PM PLT COUNT-138* [**2159-8-24**] 07:31PM WBC-10.0 RBC-4.22* HGB-10.4* HCT-34.4* MCV-82 MCH-24.7* MCHC-30.2* RDW-19.7* [**2159-8-24**] 07:31PM CALCIUM-8.0* PHOSPHATE-2.6*# MAGNESIUM-1.9 [**2159-8-24**] 07:31PM ALT(SGPT)-711* AST(SGOT)-2094* LD(LDH)-1775* ALK PHOS-201* TOT BILI-3.4* [**2159-8-24**] 07:31PM GLUCOSE-75 UREA N-28* CREAT-1.4* SODIUM-135 POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-28 ANION GAP-15 [**2159-8-24**] 08:36PM LACTATE-3.4* Brief Hospital Course: Patient was admitted on [**2159-8-24**] for acute onset dyspnea. Patient is a 61 yom with h.o. of severe systolic and diastolic function s/p AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w acute onset dyspnea, elevated lactate, transaminitis and fluid overloaded on exam. ##. Elevated Lactate: Pt noted to have an elevated lactate of 13.7 on admission. Unclear as to the exact etiology of the Lactate level. Initial workup included osmolar gap (1), serum tox (negative), co-oximetry (negative), and cyanide (pending). Level was followed an rapidly trended down to 3.4 with fluids and diuresis. Infection was considered however in the setting of a mild leukocytosis and lack of fever and unconvincing history, this seemed less likely. Patient was pan cultured and a CXR was performed demonstrating substantial fluid overload. It was later felt that the lactate resulted from hypoperfusion stemming from prolonged SVT with abberancy. Lactate level was 1.7 on the day of discharge. ##. Dyspnea/CHF exacerbation: Pt presented to ED with complaint of SOB of sudden onset with no chest pain. On physical examination pt noted to have JVP, elevated elevated BNP and CXR which suggest fluid overload. CHF exacerbation was immediately suspected, flash pulmonary edema during episode of AF with RVR. Cardiac enzymes were cylced and were negative and dyspnea quickly resolved with diuresis. He responded well to IV lasix (negative > 3 liters on [**2159-8-26**]), and given the concern for further excess fluid, he was instructed to take 60 mg PO daily for two days after returning home instead of his usual 40 mg. ##. Transaminitis/hyperbilirubinemia: Pt noted to have elevated AST, ALT, TB on admission in the ED. In the ED he received a RUQ ultrasound which showed cholelithiasis with GB wall edema, per Radiology was not cholecystitis, as well as moderate ascites. Pt does have cholelithiasis although no mention is made of any CBD or prominence. Pt also fluid overloaded on examination, transaminitis was thought to have resulted from congestive hepatopathy with possible component of shock liver in setting of hypoperfusion. Hepatitis serologies were drawn and statin was held. Liver enzymes trended down over the course of the admission. Therefore, medications with caution in hepatic failure were held at discharge (including lorazepam, clonazepam, simvastatin, midodrine, and zolpidem). ##. Anion Gap Acidosis: Pt's noted to have metabolic acidosis with an AG of 26. Likely due to lactic acidosis given his lactate of 13.7. The gap resolved completely as lactate trended down. ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED. Although he received 10 of IV Lopressor, no response noted. Pt has history of A. fib, not anticoagulated due to a prior GI bleed whilst on Coumadin. Coumadin was held and sotalol was continued. EP was consulted and pacer was interrogated demonstrating no ventricular arrhythmias and multiple episodes of SVT with aberrancy. They recommended starting amiodarone; however, patient had allergic reaction to this [**Date Range 4085**] in past. At discharge, patient was in a paced rhythm at 72 bpm. ##. Hypothyroidism: patient was continued on synthroid ##. Systolic/diastolic dysfunction: Pt received an Echo in [**11/2158**] which was notable for an EF of 20% as well as Grade III/IV LV diastolic dysfunction. Patient was continued on digoxin. ##. Depression: Patient continued on home regimen of Citalopram and Bupropion. ##. Insomnia: Patient was taking lorazepam and zolpidem QHS at home. As these medications should be used with caution in hepatic impairment, they were held during this admission. The patient received a single dose of trazodone 25 mg PO. He was discharged with a prescription for 14 days of trazodone 25 mg to assist with insomnia until his LFTs can be re-evaluated and a decision made about a long-term sleeping aid. *** FOLLOW UP CARE *** Mr. [**Known lastname 31930**] will return home with visiting nurse services to attend to his wound care as well as to monitor his vitals (low blood pressure 90s/60s during this admission, but asymptomatic) and fluid status (assess for volume overload). Mr. [**Known lastname 31930**] will see a health provider [**Last Name (NamePattern4) **] 1 week, and should have his LFTs, electrolytes and CBC assessed at that time given the abnormalities noted prior to discharge to confirm that these values continue to stabilize. If LFTs have returned to [**Location 213**], consider restarting prior home medications which were held in the setting of transaminitis (statin, zolpidem, clonazepam, lorazepam, midodrine). He should also have BP checked (orthostatics performed, given his history) and volume status assessed - he may require increase in baseline lasix. Medications on Admission: Bupropion 100 mg po bid Citalopram 10 mg daily Clonazepam 0.5 mg po bid Digoxin 125 mcg, 1 tab/2 tabs alterating Lasix 40 mg daily Levothyroxine 50 mcg daily Lorazepam 4 mg qhs Midodrine 1 mg po tid Simvastatin 40 mg daily Sotalol 120 mg po bid Spironolactone 12.5 mg daily Triamcinolone 0.1% ointment Zolpidem 10 mg qhs Discharge Medications: 1. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Digoxin 125 mcg Tablet Sig: 1-2 Tablets PO Alternate 1 or 2 tabs every other day. 3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take 1.5 tablets on [**2159-8-28**] (tomorrow) and [**2159-8-29**] (Wednesday), then resume 1 tablet per day. 6. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 7. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day. 8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia for 7 days. Disp:*7 Tablet(s)* Refills:*0* 9. Triamcinolone Acetonide 0.1 % Ointment Topical Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Primary Diagnosis: CHF exacerbation Congestive hepatopathy Paroxysmal atrial fibrillation with rapid ventricular rate Secondary Diagnosis: Hypothyroidism Orthostatic hypotension Discharge Condition: good, respiratory status back to baseline Discharge Instructions: You were admitted to the hospital because you developed acute shortness of breath and weakness. Upon admission we discovered that your heart was in an abnormal rhythm called atrial fibrillation with rapid ventricular response. This means that your heart was not able to pump blood appropriately because of this and because of your congestive heart failure. This allowed fluid to fill your lungs and made you feel short of breath. You were initially admitted to the ICU were it was discovered that this had not only affected your heart and lungs but also your liver. You were treated with a [**Hospital 4085**] called lasix which helped you cleared this fluid from your lungs. Your condition improved with just one dose of this [**Hospital 4085**]. You were subsequently transfered to the medical floor. We continued your lasix and your condition improved even more. As a result of this treatment your liver also recovered and it is now recovering. We made the following changes to your medications: 1. STOP TAKING simvastatin until directed to resume use by your doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this time. 2. STOP TAKING clonazepam until directed to resume use by your doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this time. 3. STOP TAKING lorazepam until directed to resume use by your doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this time. 4. STOP TAKING zolpidem until directed to resume use by your doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this time. 5. STOP TAKING midodrine until directed to resume use by your doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this time. 6. INCREASE DOSE of Lasix (furosemide) to 60 mg (1.5 tablets) by mouth daily for 2 days (tomorrow and Wednesday). Then resume your usual dose of 40 mg by mouth daily starting on Thursday. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500 mL of fluid per day If you at any point experience chest pain, shortness of breath, weakness, nausea, vomiting, abnormal heart beats, increased leg swelling, defibrillator firing, fevers, chills or any other symptom that concerns you please return to the hospital or contact your PCP or your [**Name9 (PRE) 31931**] for further evaluation. Please keep the follow-up appointments as outlined below. Followup Instructions: Please keep the following appointments: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 250**] Date/Time: [**2159-9-5**] at 2:10 pm Provider: [**Doctor Last Name 31929**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time: [**2159-9-21**] at 2:50 pm Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time: [**2159-9-27**] 9:30 am Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time: [**2159-9-27**] 10:20 am Completed by:[**2159-8-27**]",23,2159-08-24 01:18:00,2159-08-27 17:33:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,CONGESTIVE HEART FAILURE," patient was admitted on [**2159-8-24**] for acute onset dyspnea. patient is a 61 yom with h.o. of severe systolic and diastolic function s/p aicd, cad s/p 5v cabg, hypothyroidism, a. fib p/w acute onset dyspnea, elevated lactate, transaminitis and fluid overloaded on exam. ##. elevated lactate: pt noted to have an elevated lactate of 13.7 on admission. unclear as to the exact etiology of the lactate level. initial workup included osmolar gap (1), serum tox (negative), co-oximetry (negative), and cyanide (pending). level was followed an rapidly trended down to 3.4 with fluids and diuresis. infection was considered however in the setting of a mild leukocytosis and lack of fever and unconvincing history, this seemed less likely. patient was pan cultured and a cxr was performed demonstrating substantial fluid overload. it was later felt that the lactate resulted from hypoperfusion stemming from prolonged svt with abberancy. lactate level was 1.7 on the day of discharge. ##. dyspnea/chf exacerbation: pt presented to ed with complaint of sob of sudden onset with no chest pain. on physical examination pt noted to have jvp, elevated elevated bnp and cxr which suggest fluid overload. chf exacerbation was immediately suspected, flash pulmonary edema during episode of af with rvr. cardiac enzymes were cylced and were negative and dyspnea quickly resolved with diuresis. he responded well to iv lasix (negative > 3 liters on [**2159-8-26**]), and given the concern for further excess fluid, he was instructed to take 60 mg po daily for two days after returning home instead of his usual 40 mg. ##. transaminitis/hyperbilirubinemia: pt noted to have elevated ast, alt, tb on admission in the ed. in the ed he received a ruq ultrasound which showed cholelithiasis with gb wall edema, per radiology was not cholecystitis, as well as moderate ascites. pt does have cholelithiasis although no mention is made of any cbd or prominence. pt also fluid overloaded on examination, transaminitis was thought to have resulted from congestive hepatopathy with possible component of shock liver in setting of hypoperfusion. hepatitis serologies were drawn and statin was held. liver enzymes trended down over the course of the admission. therefore, medications with caution in hepatic failure were held at discharge (including lorazepam, clonazepam, simvastatin, midodrine, and zolpidem). ##. anion gap acidosis: pts noted to have metabolic acidosis with an ag of 26. likely due to lactic acidosis given his lactate of 13.7. the gap resolved completely as lactate trended down. ##. a. fib with rvr: pt noted to go into a. fib with rvr in the ed. although he received 10 of iv lopressor, no response noted. pt has history of a. fib, not anticoagulated due to a prior gi bleed whilst on coumadin. coumadin was held and sotalol was continued. ep was consulted and pacer was interrogated demonstrating no ventricular arrhythmias and multiple episodes of svt with aberrancy. they recommended starting amiodarone; however, patient had allergic reaction to this [**date range 4085**] in past. at discharge, patient was in a paced rhythm at 72 bpm. ##. hypothyroidism: patient was continued on synthroid ##. systolic/diastolic dysfunction: pt received an echo in [**11/2158**] which was notable for an ef of 20% as well as grade iii/iv lv diastolic dysfunction. patient was continued on digoxin. ##. depression: patient continued on home regimen of citalopram and bupropion. ##. insomnia: patient was taking lorazepam and zolpidem qhs at home. as these medications should be used with caution in hepatic impairment, they were held during this admission. the patient received a single dose of trazodone 25 mg po. he was discharged with a prescription for 14 days of trazodone 25 mg to assist with insomnia until his lfts can be re-evaluated and a decision made about a long-term sleeping aid. *** follow up care *** mr. [**known lastname 31930**] will return home with visiting nurse services to attend to his wound care as well as to monitor his vitals (low blood pressure 90s/60s during this admission, but asymptomatic) and fluid status (assess for volume overload). mr. [**known lastname 31930**] will see a health provider [**last name (namepattern4) **] 1 week, and should have his lfts, electrolytes and cbc assessed at that time given the abnormalities noted prior to discharge to confirm that these values continue to stabilize. if lfts have returned to [**location 213**], consider restarting prior home medications which were held in the setting of transaminitis (statin, zolpidem, clonazepam, lorazepam, midodrine). he should also have bp checked (orthostatics performed, given his history) and volume status assessed - he may require increase in baseline lasix. ","PRIMARY: [Acute on chronic combined systolic and diastolic heart failure] SECONDARY: [Acidosis; Other primary cardiomyopathies; Congestive heart failure, unspecified; Hepatitis, unspecified; Atrial fibrillation; Atherosclerosis of native arteries of the extremities with ulceration; Orthostatic hypotension; Ulcer of other part of foot; Unspecified acquired hypothyroidism; Impotence of organic origin; Other and unspecified hyperlipidemia; Aortocoronary bypass status; Dysthymic disorder; Automatic implantable cardiac defibrillator in situ]","patient was admitted on [**2159-8-24**] for acute onset dyspnea. elevated lactate: pt noted to have an elevated lactate of 13.7 on admission. dyspnea/chf exacerbation: pt presented to ed with complaint of sob of sudden onset with no chest pain. chf exacerbation was immediately suspected, flash pulmonary edema during episode of af with rvr. liver enzymes trended down over the course of the admission. likely due to lactic acidosis given his lactate of 13.7. they recommended starting amiodarone; however, patient had allergic reaction to this [**date range 4085**] in past. insomnia: patient was taking lorazepam and zolpidem qhs at home. known lastname 31930**] will see a health provider [**last name (namepattern4) **] 1 week, and should have his lfts, electrolytes and cbc assessed at that time given the abnormalities noted prior to discharge to confirm that these values continue to stabilize.",pt noted to have elevated lactate of 13.7 on admission. lactate resulted from hypoperfusion stemming from prolonged svt with abberancy. pt responded well to iv lasix and given the concern for further excess fluid. 2338,114726.0,9337,2159-10-29,9335,147143.0,2159-08-27,Discharge summary,"Admission Date: [**2159-8-24**] Discharge Date: [**2159-8-27**] Date of Birth: [**2097-9-24**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2181**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 61 y.o. Male with h.o. CAD s/p 5v CABG, CHF s/p AICD, systolic and diastolic dysfunction, hypothyroidism, A. fib p/w dyspnea. Pt states that yesterday evening he noted sudden onset of shortness of breath. He denies any fevers, chills, nausea, vomiting, chest pain, melena, hemetemesis, hematochezia, diarrhea, constipation. In the [**Name (NI) **] pt's initial VS were noted to be T96.2, HR 68, BP 118/84, RR 24, Sat 96%. His initial EKG was concerning for possible V tach however on further review it was noted to be A. fib with aberrancy, pt was given 5mg IV Lopressor which resulted in decrease of HR from 130s to the low 100s, SBP down to the mid 90s. Pt underwent CXR which showed fluid overload and he was thus given Furosemide 40mg x 1. He was also given Vancomycin 1gm IV x 1 due to concern for possible PNA. His labs were notable for lactate of 13.7, mild leukocytosis of 12.3. ALT/AST were noted to be 133/243, Alk Phos 257 with a TB of 5.1. His glc was noted to be 42 with an anion gap acidosis. His INR was noted to be 3.4, Digoxin level 0.3, BNP 6682. He received a RUQ U/S which showed edematous gallbladder wall but no cholecystitis, pt also had cholelithiasis. He also had a right IJ placed and underwent a CT abdomen/pelvis without contrast to eval for source of high lactate. CT scna was negative for bowel wall thickening, pneumotosis but did showed ground glass opacities in the lung. Prior to the CT scan he was given Levofloxacin and Zosyn given his acutely ill appearance and elevated lactate. Past Medical History: CAD s/p CABG Anterior MI [**2144**] h/o massive UGIB in [**2154**] [**1-1**] gastritis [**1-1**] NSAIDs and coumadin(intubated, c/b MRSA VAP, had tracheostomy) CHF (EF 25% by last echo) with BiV pacer and ICD placement L hip arthritis Hyperlipidimia Hypothyroidism h/o Afib in past (not currently on coumadin) Social History: Married > 25 years. Has three adult children. Lives with his wife. Used to work in computers but on disability for health reasons. Denies tobacco, occasional etoh. No illicits. Family History: FH: Father died of MI at age 52 Physical Exam: At Admission: General: Chronically sick appearing Male, appears jaundices lying down in NARD. HEENT: Left Sclera icteric, EOMI, PERRL Neck: JVP noted at mandible Lungs: Crackles noted over right hemithorax and left base. CV: Distant S1, S2, irregularly irregular, no murmurs, rubs, gallops Abdomen: Soft, obese, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, no murphys Ext: Lower extremities cool to touch, sensation intact, movement intact. Healing wound noted on LLE. Pertinent Results: [**2159-8-24**] 12:10AM PT-33.9* PTT-35.9* INR(PT)-3.4* [**2159-8-24**] 12:10AM PLT COUNT-234 [**2159-8-24**] 12:10AM NEUTS-68.8 LYMPHS-24.3 MONOS-6.2 EOS-0.2 BASOS-0.5 [**2159-8-24**] 12:10AM WBC-12.3* RBC-4.98# HGB-12.2* HCT-42.1 MCV-84# MCH-24.4*# MCHC-28.9*# RDW-18.3* [**2159-8-24**] 12:10AM DIGOXIN-0.3* [**2159-8-24**] 12:10AM CALCIUM-8.8 [**2159-8-24**] 12:10AM CK-MB-6 proBNP-6682* [**2159-8-24**] 12:10AM cTropnT-0.05* [**2159-8-24**] 12:10AM LIPASE-25 [**2159-8-24**] 12:10AM ALT(SGPT)-133* AST(SGOT)-243* CK(CPK)-116 ALK PHOS-257* TOT BILI-5.1* DIR BILI-2.0* INDIR BIL-3.1 [**2159-8-24**] 12:10AM GLUCOSE-42* UREA N-22* CREAT-1.5* SODIUM-137 POTASSIUM-4.7 CHLORIDE-94* TOTAL CO2-17* ANION GAP-31* [**2159-8-24**] 12:19AM K+-4.2 [**2159-8-24**] 01:10AM URINE HYALINE-0-2 [**2159-8-24**] 01:10AM URINE RBC-0-2 WBC-[**2-1**] BACTERIA-MOD YEAST-NONE EPI-0-2 [**2159-8-24**] 01:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-12* PH-6.5 LEUK-NEG [**2159-8-24**] 01:10AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2159-8-24**] 01:36AM LACTATE-13.7* [**2159-8-24**] 05:42AM PT-43.7* PTT-42.5* INR(PT)-4.7* [**2159-8-24**] 05:44AM PLT COUNT-182 [**2159-8-24**] 05:44AM WBC-11.5* RBC-4.54* HGB-10.8* HCT-38.0* MCV-84 MCH-23.7* MCHC-28.3* RDW-18.6* [**2159-8-24**] 05:44AM ALBUMIN-3.5 CALCIUM-8.1* PHOSPHATE-4.4# MAGNESIUM-2.0 [**2159-8-24**] 05:44AM CK-MB-NotDone cTropnT-0.05* [**2159-8-24**] 05:44AM ALT(SGPT)-284* AST(SGOT)-770* LD(LDH)-1290* CK(CPK)-90 ALK PHOS-219* TOT BILI-5.2* [**2159-8-24**] 05:44AM GLUCOSE-90 UREA N-24* CREAT-1.4* SODIUM-134 POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-17* ANION GAP-27* [**2159-8-24**] 05:53AM O2 SAT-73 [**2159-8-24**] 05:53AM LACTATE-11.2* [**2159-8-24**] 07:18AM TSH-2.8 [**2159-8-24**] 07:18AM OSMOLAL-291 [**2159-8-24**] 07:23AM O2 SAT-96 CARBOXYHB-2 [**2159-8-24**] 07:23AM LACTATE-9.0* [**2159-8-24**] 07:23AM TYPE-ART PO2-106* PCO2-33* PH-7.39 TOTAL CO2-21 BASE XS--3 COMMENTS-ADD ON CAR [**2159-8-24**] 08:33AM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL SCHISTOCY-OCCASIONAL BURR-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2159-8-24**] 09:23AM URINE RBC-[**5-9**]* WBC-[**5-9**]* BACTERIA-MOD YEAST-NONE EPI-0-2 [**2159-8-24**] 09:23AM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-8* PH-5.0 LEUK-NEG [**2159-8-24**] 09:23AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.023 [**2159-8-24**] 12:49PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2159-8-24**] 12:49PM ALT(SGPT)-589* AST(SGOT)-[**2160**]* LD(LDH)-2362* ALK PHOS-185* TOT BILI-3.8* [**2159-8-24**] 12:49PM GLUCOSE-99 UREA N-27* CREAT-1.3* SODIUM-135 POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16 [**2159-8-24**] 12:59PM HGB-10.7* calcHCT-32 O2 SAT-59 [**2159-8-24**] 12:59PM LACTATE-4.8* [**2159-8-24**] 12:59PM TYPE-[**Last Name (un) **] PO2-37* PCO2-41 PH-7.37 TOTAL CO2-25 BASE XS--1 [**2159-8-24**] 01:33PM O2 SAT-63 [**2159-8-24**] 07:31PM PLT COUNT-138* [**2159-8-24**] 07:31PM WBC-10.0 RBC-4.22* HGB-10.4* HCT-34.4* MCV-82 MCH-24.7* MCHC-30.2* RDW-19.7* [**2159-8-24**] 07:31PM CALCIUM-8.0* PHOSPHATE-2.6*# MAGNESIUM-1.9 [**2159-8-24**] 07:31PM ALT(SGPT)-711* AST(SGOT)-2094* LD(LDH)-1775* ALK PHOS-201* TOT BILI-3.4* [**2159-8-24**] 07:31PM GLUCOSE-75 UREA N-28* CREAT-1.4* SODIUM-135 POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-28 ANION GAP-15 [**2159-8-24**] 08:36PM LACTATE-3.4* Brief Hospital Course: Patient was admitted on [**2159-8-24**] for acute onset dyspnea. Patient is a 61 yom with h.o. of severe systolic and diastolic function s/p AICD, CAD s/p 5v CABG, hypothyroidism, A. fib p/w acute onset dyspnea, elevated lactate, transaminitis and fluid overloaded on exam. ##. Elevated Lactate: Pt noted to have an elevated lactate of 13.7 on admission. Unclear as to the exact etiology of the Lactate level. Initial workup included osmolar gap (1), serum tox (negative), co-oximetry (negative), and cyanide (pending). Level was followed an rapidly trended down to 3.4 with fluids and diuresis. Infection was considered however in the setting of a mild leukocytosis and lack of fever and unconvincing history, this seemed less likely. Patient was pan cultured and a CXR was performed demonstrating substantial fluid overload. It was later felt that the lactate resulted from hypoperfusion stemming from prolonged SVT with abberancy. Lactate level was 1.7 on the day of discharge. ##. Dyspnea/CHF exacerbation: Pt presented to ED with complaint of SOB of sudden onset with no chest pain. On physical examination pt noted to have JVP, elevated elevated BNP and CXR which suggest fluid overload. CHF exacerbation was immediately suspected, flash pulmonary edema during episode of AF with RVR. Cardiac enzymes were cylced and were negative and dyspnea quickly resolved with diuresis. He responded well to IV lasix (negative > 3 liters on [**2159-8-26**]), and given the concern for further excess fluid, he was instructed to take 60 mg PO daily for two days after returning home instead of his usual 40 mg. ##. Transaminitis/hyperbilirubinemia: Pt noted to have elevated AST, ALT, TB on admission in the ED. In the ED he received a RUQ ultrasound which showed cholelithiasis with GB wall edema, per Radiology was not cholecystitis, as well as moderate ascites. Pt does have cholelithiasis although no mention is made of any CBD or prominence. Pt also fluid overloaded on examination, transaminitis was thought to have resulted from congestive hepatopathy with possible component of shock liver in setting of hypoperfusion. Hepatitis serologies were drawn and statin was held. Liver enzymes trended down over the course of the admission. Therefore, medications with caution in hepatic failure were held at discharge (including lorazepam, clonazepam, simvastatin, midodrine, and zolpidem). ##. Anion Gap Acidosis: Pt's noted to have metabolic acidosis with an AG of 26. Likely due to lactic acidosis given his lactate of 13.7. The gap resolved completely as lactate trended down. ##. A. fib with RVR: Pt noted to go into A. fib with RVR in the ED. Although he received 10 of IV Lopressor, no response noted. Pt has history of A. fib, not anticoagulated due to a prior GI bleed whilst on Coumadin. Coumadin was held and sotalol was continued. EP was consulted and pacer was interrogated demonstrating no ventricular arrhythmias and multiple episodes of SVT with aberrancy. They recommended starting amiodarone; however, patient had allergic reaction to this [**Date Range 4085**] in past. At discharge, patient was in a paced rhythm at 72 bpm. ##. Hypothyroidism: patient was continued on synthroid ##. Systolic/diastolic dysfunction: Pt received an Echo in [**11/2158**] which was notable for an EF of 20% as well as Grade III/IV LV diastolic dysfunction. Patient was continued on digoxin. ##. Depression: Patient continued on home regimen of Citalopram and Bupropion. ##. Insomnia: Patient was taking lorazepam and zolpidem QHS at home. As these medications should be used with caution in hepatic impairment, they were held during this admission. The patient received a single dose of trazodone 25 mg PO. He was discharged with a prescription for 14 days of trazodone 25 mg to assist with insomnia until his LFTs can be re-evaluated and a decision made about a long-term sleeping aid. *** FOLLOW UP CARE *** Mr. [**Known lastname 31930**] will return home with visiting nurse services to attend to his wound care as well as to monitor his vitals (low blood pressure 90s/60s during this admission, but asymptomatic) and fluid status (assess for volume overload). Mr. [**Known lastname 31930**] will see a health provider [**Last Name (NamePattern4) **] 1 week, and should have his LFTs, electrolytes and CBC assessed at that time given the abnormalities noted prior to discharge to confirm that these values continue to stabilize. If LFTs have returned to [**Location 213**], consider restarting prior home medications which were held in the setting of transaminitis (statin, zolpidem, clonazepam, lorazepam, midodrine). He should also have BP checked (orthostatics performed, given his history) and volume status assessed - he may require increase in baseline lasix. Medications on Admission: Bupropion 100 mg po bid Citalopram 10 mg daily Clonazepam 0.5 mg po bid Digoxin 125 mcg, 1 tab/2 tabs alterating Lasix 40 mg daily Levothyroxine 50 mcg daily Lorazepam 4 mg qhs Midodrine 1 mg po tid Simvastatin 40 mg daily Sotalol 120 mg po bid Spironolactone 12.5 mg daily Triamcinolone 0.1% ointment Zolpidem 10 mg qhs Discharge Medications: 1. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Digoxin 125 mcg Tablet Sig: 1-2 Tablets PO Alternate 1 or 2 tabs every other day. 3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take 1.5 tablets on [**2159-8-28**] (tomorrow) and [**2159-8-29**] (Wednesday), then resume 1 tablet per day. 6. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 7. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day. 8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia for 7 days. Disp:*7 Tablet(s)* Refills:*0* 9. Triamcinolone Acetonide 0.1 % Ointment Topical Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Primary Diagnosis: CHF exacerbation Congestive hepatopathy Paroxysmal atrial fibrillation with rapid ventricular rate Secondary Diagnosis: Hypothyroidism Orthostatic hypotension Discharge Condition: good, respiratory status back to baseline Discharge Instructions: You were admitted to the hospital because you developed acute shortness of breath and weakness. Upon admission we discovered that your heart was in an abnormal rhythm called atrial fibrillation with rapid ventricular response. This means that your heart was not able to pump blood appropriately because of this and because of your congestive heart failure. This allowed fluid to fill your lungs and made you feel short of breath. You were initially admitted to the ICU were it was discovered that this had not only affected your heart and lungs but also your liver. You were treated with a [**Hospital 4085**] called lasix which helped you cleared this fluid from your lungs. Your condition improved with just one dose of this [**Hospital 4085**]. You were subsequently transfered to the medical floor. We continued your lasix and your condition improved even more. As a result of this treatment your liver also recovered and it is now recovering. We made the following changes to your medications: 1. STOP TAKING simvastatin until directed to resume use by your doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this time. 2. STOP TAKING clonazepam until directed to resume use by your doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this time. 3. STOP TAKING lorazepam until directed to resume use by your doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this time. 4. STOP TAKING zolpidem until directed to resume use by your doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this time. 5. STOP TAKING midodrine until directed to resume use by your doctor. [**First Name (Titles) **] [**Last Name (Titles) 4085**] may cause liver damage if taken at this time. 6. INCREASE DOSE of Lasix (furosemide) to 60 mg (1.5 tablets) by mouth daily for 2 days (tomorrow and Wednesday). Then resume your usual dose of 40 mg by mouth daily starting on Thursday. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500 mL of fluid per day If you at any point experience chest pain, shortness of breath, weakness, nausea, vomiting, abnormal heart beats, increased leg swelling, defibrillator firing, fevers, chills or any other symptom that concerns you please return to the hospital or contact your PCP or your [**Name9 (PRE) 31931**] for further evaluation. Please keep the follow-up appointments as outlined below. Followup Instructions: Please keep the following appointments: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 250**] Date/Time: [**2159-9-5**] at 2:10 pm Provider: [**Doctor Last Name 31929**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time: [**2159-9-21**] at 2:50 pm Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time: [**2159-9-27**] 9:30 am Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time: [**2159-9-27**] 10:20 am Completed by:[**2159-8-27**]",63,2159-08-24 01:18:00,2159-08-27 17:33:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,CONGESTIVE HEART FAILURE," patient was admitted on [**2159-8-24**] for acute onset dyspnea. patient is a 61 yom with h.o. of severe systolic and diastolic function s/p aicd, cad s/p 5v cabg, hypothyroidism, a. fib p/w acute onset dyspnea, elevated lactate, transaminitis and fluid overloaded on exam. ##. elevated lactate: pt noted to have an elevated lactate of 13.7 on admission. unclear as to the exact etiology of the lactate level. initial workup included osmolar gap (1), serum tox (negative), co-oximetry (negative), and cyanide (pending). level was followed an rapidly trended down to 3.4 with fluids and diuresis. infection was considered however in the setting of a mild leukocytosis and lack of fever and unconvincing history, this seemed less likely. patient was pan cultured and a cxr was performed demonstrating substantial fluid overload. it was later felt that the lactate resulted from hypoperfusion stemming from prolonged svt with abberancy. lactate level was 1.7 on the day of discharge. ##. dyspnea/chf exacerbation: pt presented to ed with complaint of sob of sudden onset with no chest pain. on physical examination pt noted to have jvp, elevated elevated bnp and cxr which suggest fluid overload. chf exacerbation was immediately suspected, flash pulmonary edema during episode of af with rvr. cardiac enzymes were cylced and were negative and dyspnea quickly resolved with diuresis. he responded well to iv lasix (negative > 3 liters on [**2159-8-26**]), and given the concern for further excess fluid, he was instructed to take 60 mg po daily for two days after returning home instead of his usual 40 mg. ##. transaminitis/hyperbilirubinemia: pt noted to have elevated ast, alt, tb on admission in the ed. in the ed he received a ruq ultrasound which showed cholelithiasis with gb wall edema, per radiology was not cholecystitis, as well as moderate ascites. pt does have cholelithiasis although no mention is made of any cbd or prominence. pt also fluid overloaded on examination, transaminitis was thought to have resulted from congestive hepatopathy with possible component of shock liver in setting of hypoperfusion. hepatitis serologies were drawn and statin was held. liver enzymes trended down over the course of the admission. therefore, medications with caution in hepatic failure were held at discharge (including lorazepam, clonazepam, simvastatin, midodrine, and zolpidem). ##. anion gap acidosis: pts noted to have metabolic acidosis with an ag of 26. likely due to lactic acidosis given his lactate of 13.7. the gap resolved completely as lactate trended down. ##. a. fib with rvr: pt noted to go into a. fib with rvr in the ed. although he received 10 of iv lopressor, no response noted. pt has history of a. fib, not anticoagulated due to a prior gi bleed whilst on coumadin. coumadin was held and sotalol was continued. ep was consulted and pacer was interrogated demonstrating no ventricular arrhythmias and multiple episodes of svt with aberrancy. they recommended starting amiodarone; however, patient had allergic reaction to this [**date range 4085**] in past. at discharge, patient was in a paced rhythm at 72 bpm. ##. hypothyroidism: patient was continued on synthroid ##. systolic/diastolic dysfunction: pt received an echo in [**11/2158**] which was notable for an ef of 20% as well as grade iii/iv lv diastolic dysfunction. patient was continued on digoxin. ##. depression: patient continued on home regimen of citalopram and bupropion. ##. insomnia: patient was taking lorazepam and zolpidem qhs at home. as these medications should be used with caution in hepatic impairment, they were held during this admission. the patient received a single dose of trazodone 25 mg po. he was discharged with a prescription for 14 days of trazodone 25 mg to assist with insomnia until his lfts can be re-evaluated and a decision made about a long-term sleeping aid. *** follow up care *** mr. [**known lastname 31930**] will return home with visiting nurse services to attend to his wound care as well as to monitor his vitals (low blood pressure 90s/60s during this admission, but asymptomatic) and fluid status (assess for volume overload). mr. [**known lastname 31930**] will see a health provider [**last name (namepattern4) **] 1 week, and should have his lfts, electrolytes and cbc assessed at that time given the abnormalities noted prior to discharge to confirm that these values continue to stabilize. if lfts have returned to [**location 213**], consider restarting prior home medications which were held in the setting of transaminitis (statin, zolpidem, clonazepam, lorazepam, midodrine). he should also have bp checked (orthostatics performed, given his history) and volume status assessed - he may require increase in baseline lasix. ","PRIMARY: [Acute on chronic combined systolic and diastolic heart failure] SECONDARY: [Acidosis; Other primary cardiomyopathies; Congestive heart failure, unspecified; Hepatitis, unspecified; Atrial fibrillation; Atherosclerosis of native arteries of the extremities with ulceration; Orthostatic hypotension; Ulcer of other part of foot; Unspecified acquired hypothyroidism; Impotence of organic origin; Other and unspecified hyperlipidemia; Aortocoronary bypass status; Dysthymic disorder; Automatic implantable cardiac defibrillator in situ]","patient was admitted on [**2159-8-24**] for acute onset dyspnea. elevated lactate: pt noted to have an elevated lactate of 13.7 on admission. dyspnea/chf exacerbation: pt presented to ed with complaint of sob of sudden onset with no chest pain. chf exacerbation was immediately suspected, flash pulmonary edema during episode of af with rvr. liver enzymes trended down over the course of the admission. likely due to lactic acidosis given his lactate of 13.7. they recommended starting amiodarone; however, patient had allergic reaction to this [**date range 4085**] in past. insomnia: patient was taking lorazepam and zolpidem qhs at home. known lastname 31930**] will see a health provider [**last name (namepattern4) **] 1 week, and should have his lfts, electrolytes and cbc assessed at that time given the abnormalities noted prior to discharge to confirm that these values continue to stabilize.",pt noted to have elevated lactate of 13.7 on admission. lactate resulted from hypoperfusion stemming from prolonged svt with abberancy. pt responded well to iv lasix and given the concern for further excess fluid. 2338,114726.0,9337,2159-10-29,9336,184485.0,2159-09-19,Discharge summary,"Admission Date: [**2159-9-14**] Discharge Date: [**2159-9-19**] Date of Birth: [**2097-9-24**] Sex: M Service: MEDICINE Allergies: Penicillins / Amiodarone Attending:[**First Name3 (LF) 458**] Chief Complaint: ICD firing Major Surgical or Invasive Procedure: external DC/CV intubation History of Present Illness: Mr. [**Known lastname 31930**] is a 61 year old male with a history of coronary artery disease s/p MI and CABG, chronic systolic heart failure, recurrent VT s/p ICD placement and atrial fibrillation who presents from home with recurrent ICD firing. Patient reports being in his usual state of health until 3 PM on the day prior to admission. He stopped taking his sotalol approximately 2 weeks prior to admission for unclear reasons. He did not discuss this with his cardiologist Dr. [**Last Name (STitle) **]. Over the past few weeks since discontinuing this [**Last Name (STitle) 4085**] he has noted decreased exercise tolerance and worsening dyspnea on exertion. He typically can walk half a block but now can only walk around his home. He has not been experiencing any fevers or chills. He has not had any episodes of chest pain. He denies worsening orthopnea or PND but does endorse worsening nocturia. He denies worsening lower extremity edema. At 3 PM on the day prior to admission his ICD fired. He has had firings before and he denies any precipitating events. His ICD has since fired 8 times in 12 hours. He has never had repeated firings before. He decided to come to the emergency room. . In the ED, initial vitals were T: 97.8 BP: 150/98 HR: 73 RR: 18 O2: 99% on RA. EKG shows atrial fibrillation with rapid response in the 140s with intermittent demand pacing, intraventricular conduction delay left bundle branch block pattern, no gross ischemic changes, no change from prior dated [**2159-8-24**]. Two episodes of vtach in the ED without firing. EP recommended rate control of his RVR and some lasix. He received diltiazem 10 mg IV x 1 and lasix 80 mg IV x 1. . On review of systems he denies fevers, chills, cough, congestion, nausea, vomiting, abdominal pain, diarrhea, constipation, dysuria, hematuria, leg pain. He denies chest pain, orthopnea, PND. He endorses worsening dyspnea on exertion and nocturia. He has significant lower extremity edema on exam but denies worsening. Past Medical History: Coronary Artery Disease s/p 5 vessel CABG in [**2144**] Anterior MI [**2144**] Large UGIB in [**2154**] thought to be secondary to a combination of gastritis, nsaids, and coumadin (required intubation and tracheostomy secondary to MRSA ventilator associated pneumonia) Chronic systolic heart failure (EF 20% by last echocardiogram) History of VT s/p BiV pacer and ICD placement in [**2144**] now s/p multiple device changes most recently in [**2157**]. Left hip arthritis Hyperlipidimia Hypothyroidism Atrial Fibrillation (not on anticoagulation secondary to GI bleeding) Osteomyelolitis on L foot 1. CARDIAC RISK FACTORS: Dyslipidemia 2. CARDIAC HISTORY: -CABG: Five vessel CABG in [**2144**] -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: [**Company 1543**] Concerto biventricular ICD placed in [**2158-3-30**]. He has three leads. The RV lead is a [**Company 1543**] 6943 implanted [**2150-9-18**]. The atrial lead is a Guidant 4464 also implanted in [**2150-8-30**]. His LV lead is a [**Company 1543**] 4193 implanted in [**2153-7-30**] and the ICD device was implanted in [**2158-3-30**]. Physical Exam: PHYSICAL EXAMINATION: VS: T: 96.7 HR: 100 BP: 93/72 RR: 18 O2: 97% on RA GENERAL: AOriented x3. Mood, affect appropriate. HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: +JVD CARDIAC: irregularly irregular rhythm, tachy. No m/r/g. LUNGS: Resp were unlabored, no accessory muscle use. bilateral crackles half way up lung fields. ICD pocket w/o erythema, warmth or any sign of infection ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. erythema on L anterior leg, no drainage or tenderness. healing ulcer on L foot. Pertinent Results: EKG: Afib RVR in the 140s with intermittent demand pacing, left bundle branch block, no gross ischemic changes, no change from prior dated [**2159-8-24**]. CXR [**2159-9-14**]: A right pectoral pacemaker power pack is redemonstrated, with unchanged position of right atrial pacer and right ventricular defibrillator leads on the single AP view. Also old abandoned AICD and epicardial leads are unchanged, projecting over the right and left heart, respectively. The patient is status post CABG. Other lines projecting over the patient are probably external to the patient. Right internal jugular central venous catheter has been removed. Moderate-to-severe cardiomegaly is relatively unchanged. There is again increase in perihilar and bibasilar opacities, probably representing pulmonary edema, although underlying infection cannot be excluded. The upper lungs are relatively clear. Appearance is not dissimilar to that seen on [**2159-8-24**]. The right lateral sulcus is excluded, but there may be tiny bilateral pleural effusions. No pneumothorax is seen. [**2159-9-14**] WBC 11.2 Hb 10.8 Hct 36.6 Plts 300 [**2159-9-14**] N 66.0 L 27.6 M 5.0 E 0.9 B 0.6 [**2159-9-14**] PT 22.6 PTT 26.7 INR 2.1 [**2159-9-14**] Gluc 105 BUN 19 Cr 1.0 Na 134 K 3.3 Cl 94 HCO3 26 [**2159-9-14**] CK 98 TnT 0.05 [**2159-9-14**] proBNP 8744 [**2159-9-14**] Ca 8.8 Mg 2.0 [**2159-9-14**] Digoxin 0.2 [**2159-9-14**] UA neg Brief Hospital Course: 61 year old male with a h/o CAD s/p MI and CABG in [**2144**], chronic systolic heart failure (EF 20%), recurrent VT s/p ICD placement and atrial fibrillation admitted now for recurrent ICD firing after not taking home Sotalol for 2 weeks. . # Afib/VT: Pt has Afib, h/o VT, with several episodes of VT the night PTA s/p shocks. On admission, pt was in Afib, with occasional pacing, hemodynamically stable and rec'd Dilt for rate control in the ED. On the morning of the 17th, he became hemodynamically unstable with afib and RVR, and a code blue was called during which the patient was intubated, shocked, and administered a dose of amiodarone. On arrival to the CCU, the patient's vital signs were 93, 101/52, 19, 88% on vent. He was intubated, sedated, in sinus and intermittently paced and hemodynamically stable. His labs returned with a K of 6.2 and glucose of 48. Calcium gluconate, glucose, insulin, albuterol and sodium bicarbonate were administered. Fentanyl and midazolam were started for sedation. He was also continued on IV amiodarone drip to maintain sinus rhythm, despite history of hypothyroidism with amiodarone. He was stable after self-extubation and was seen by EP who re-adjusted pacer settings. He was started on amiodarone with good success and transferred back to the floor on [**9-17**]. Pt remained in sinus rhythm with intermittent pacing. Heparin gtt for anticoagulation was eventually dc'd, and since pt has an elev INR at baseline, it was decided not to start Coumadin as it would be difficult to monitor. Pt was continued on Amiodarone 400mg daily to maintain sinus rhythm as per EP recs. Home Sotalol has been dc'd. On telemetry, pt continued to have frequent PVCs, NSVT. Also, pt was started on Digoxin at cautious dose of 0.125mg every other day since pt also on Amiodarone. . # Acute systolic heart failure: pt is volume overloaded per exam, elev BNP and CXR, likely [**1-1**] to poor diet control and med non compliance (dig level low). He improved with aggressive diuresis with IV lasix, later switched to home Lasix dose. His home simvastatin, midodrine, and spironolactone were continued. Digoxin was temporarily held for renal failure but restarted at a more cautious dose prior to discharge. The reason why the pt was no on an ACE-I was not clear. Starting ACE-I during admission was considered but decided to defer it to his outpatient cardiologist. . # Hypothyroidism: [**1-1**] to Amiodarone toxicity, currently asymptomatic. His home levothyroxine was continued. Will have to recheck TSH since Amiodarone has been strated again, also PFTs and LFTs. . # LLE Erythema and L heel ulcer: chronic, stable. No changes indicating acute infection were seen. Pt was provided with wound care. . # Insomnia: stable, home Ativan PRN and Ambien were continued. . # Depression: stable however likely contributing to his medical non-compliance. Started on buproprion and Citalopram. SW was following pt as well. . # Anemia: stable, at baseline, required no transfusions. Pt could benefit from anemia work-up as outpatient. . # Elev INR: unclear etiology (perhaps [**1-1**] to hepatic congestion from heart failure). Pt is off anticoagulation bc of h/o GIB. Liver enzymes showed obstructive picture with nl ALT, AST however elev Alk Phos and T bili of 3.1, however pt w/o abd pain. Recent RUQ u/s negative, just an echogenic liver consistent with fatty infiltration. # Pt was on a low Na cardiac diet, lytes were replted PRN. Pt was on SC Heparin for DVT ppx. Pt was full code. Medications on Admission: MEDICATIONS: Sotalol 120 mg [**Hospital1 **] Digoxin 125 mcg daily, 250mcg on alternative days Ativan 2 mg QHS Ambien 10 mg QHS Levothyroxine 50 mcg daily Midodrine 5 mg TID Simvastatin 40 mg daily Lasix 40mg daily Spiranolactone 25mg daily Bupoprion 50mg [**Hospital1 **] Discharge Medications: 1. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Bupropion HCl 100 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*15 Tablet(s)* Refills:*2* 7. Simvastatin 10 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 8. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 10. Ativan 2 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 11. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: ventricular tachycardia requiring external DC/CV acute on chronic systolic heart failure Discharge Condition: good Discharge Instructions: You were admitted to [**Hospital1 18**] because your ICD had fired multiple times. It was noted that you were having frequent episodes of irregular heart rate, likely due to the fact that you were not taking one of your medications recently. During of one these episodes, you became unresponsive, requiring shocking the heart, placing a breathing tube to help your lungs breath and a brief stay in the ICU. You subsequently recovered nicely from this event and you were placed on optimal heart medications to help your heart stay as regular as possible. Please make the following changes to your medications: 1. Start Amiodarone 400 mg DAILY 2. Start Digoxin 125 mcg EVERY OTHER DAY 3. Stop Digoxin 125 mcg and 250 mcg on alternative days 4. Start Citalopram 10 mg PO DAILY 5. Stop Sotalol 6. Start Buproprion 100mg twice a day Please seek immediate medical attention if you experience frequent ICD firing, dizziness, fainting, palpatations, chest pain, increased shortness of breath, high fevers or any other concerning symptoms. Also, given your heart failure, please weigh yourself every morning and call your PCP if weight goes up more than 3 lbs. Adhere to 2 gm sodium diet and fluid restriction of 1500 cc per day. Followup Instructions: Please keep the following follow-up appointments: [**2159-9-27**] 10:20a [**Doctor Last Name **]-CC7 SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] CC7 CARDIOLOGY (SB) [**2159-9-27**] 09:30a DEVICE CLINIC (SB) SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] DEVICE CLINIC (SB) [**2159-9-21**] 01:45p [**Last Name (LF) **],[**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) 31932**] [**Hospital6 29**], [**Location (un) **] [**Hospital 191**] MEDICAL UNIT Completed by:[**2159-9-22**]",40,2159-09-14 13:15:00,2159-09-19 18:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,AICD FIRING," 61 year old male with a h/o cad s/p mi and cabg in [**2144**], chronic systolic heart failure (ef 20%), recurrent vt s/p icd placement and atrial fibrillation admitted now for recurrent icd firing after not taking home sotalol for 2 weeks. . # afib/vt: pt has afib, h/o vt, with several episodes of vt the night pta s/p shocks. on admission, pt was in afib, with occasional pacing, hemodynamically stable and recd dilt for rate control in the ed. on the morning of the 17th, he became hemodynamically unstable with afib and rvr, and a code blue was called during which the patient was intubated, shocked, and administered a dose of amiodarone. on arrival to the ccu, the patients vital signs were 93, 101/52, 19, 88% on vent. he was intubated, sedated, in sinus and intermittently paced and hemodynamically stable. his labs returned with a k of 6.2 and glucose of 48. calcium gluconate, glucose, insulin, albuterol and sodium bicarbonate were administered. fentanyl and midazolam were started for sedation. he was also continued on iv amiodarone drip to maintain sinus rhythm, despite history of hypothyroidism with amiodarone. he was stable after self-extubation and was seen by ep who re-adjusted pacer settings. he was started on amiodarone with good success and transferred back to the floor on [**9-17**]. pt remained in sinus rhythm with intermittent pacing. heparin gtt for anticoagulation was eventually dcd, and since pt has an elev inr at baseline, it was decided not to start coumadin as it would be difficult to monitor. pt was continued on amiodarone 400mg daily to maintain sinus rhythm as per ep recs. home sotalol has been dcd. on telemetry, pt continued to have frequent pvcs, nsvt. also, pt was started on digoxin at cautious dose of 0.125mg every other day since pt also on amiodarone. . # acute systolic heart failure: pt is volume overloaded per exam, elev bnp and cxr, likely [**1-1**] to poor diet control and med non compliance (dig level low). he improved with aggressive diuresis with iv lasix, later switched to home lasix dose. his home simvastatin, midodrine, and spironolactone were continued. digoxin was temporarily held for renal failure but restarted at a more cautious dose prior to discharge. the reason why the pt was no on an ace-i was not clear. starting ace-i during admission was considered but decided to defer it to his outpatient cardiologist. . # hypothyroidism: [**1-1**] to amiodarone toxicity, currently asymptomatic. his home levothyroxine was continued. will have to recheck tsh since amiodarone has been strated again, also pfts and lfts. . # lle erythema and l heel ulcer: chronic, stable. no changes indicating acute infection were seen. pt was provided with wound care. . # insomnia: stable, home ativan prn and ambien were continued. . # depression: stable however likely contributing to his medical non-compliance. started on buproprion and citalopram. sw was following pt as well. . # anemia: stable, at baseline, required no transfusions. pt could benefit from anemia work-up as outpatient. . # elev inr: unclear etiology (perhaps [**1-1**] to hepatic congestion from heart failure). pt is off anticoagulation bc of h/o gib. liver enzymes showed obstructive picture with nl alt, ast however elev alk phos and t bili of 3.1, however pt w/o abd pain. recent ruq u/s negative, just an echogenic liver consistent with fatty infiltration. # pt was on a low na cardiac diet, lytes were replted prn. pt was on sc heparin for dvt ppx. pt was full code. ","PRIMARY: [Acute on chronic systolic heart failure] SECONDARY: [Acute kidney failure, unspecified; Paroxysmal ventricular tachycardia; Ulcer of heel and midfoot; Hyperosmolality and/or hypernatremia; Acquired coagulation factor deficiency; Other pulmonary insufficiency, not elsewhere classified; Chronic passive congestion of liver; Hyperpotassemia; Fitting and adjustment of other cardiac device; Personal history of noncompliance with medical treatment, presenting hazards to health; Congestive heart failure, unspecified; Old myocardial infarction; Atrial fibrillation; Other left bundle branch block; Other and unspecified hyperlipidemia; Unspecified acquired hypothyroidism; Depressive disorder, not elsewhere classified; Insomnia, unspecified; Anemia, unspecified; Aortocoronary bypass status]","61 year old male with a h/o cad s/p mi and cabg in [**2144**], chronic systolic heart failure (ef 20%), recurrent vt s/p icd placement and atrial fibrillation admitted now for recurrent icd firing after not taking home sotalol for 2 weeks. heparin gtt for anticoagulation was eventually dcd, and since pt has an elev inr at baseline, it was decided not to start coumadin as it would be difficult to monitor. pt was continued on amiodarone 400mg daily to maintain sinus rhythm as per ep recs. on telemetry, pt continued to have frequent pvcs, nsvt. # lle erythema and l heel ulcer: chronic, stable. # insomnia: stable, home ativan prn and ambien were continued. pt could benefit from anemia work-up as outpatient.","61 year old male with afib, h/o vt, with several episodes of vt the night s/p shocks. on admission, pt was intubated, sedated, in sinus and hemodynamically stable. he was continued on amiodarone 400mg daily to maintain sinus rhythm." 5060,119255.0,24311,2182-12-13,24310,193317.0,2182-10-11,Discharge summary,"Admission Date: [**2182-10-10**] Discharge Date: [**2182-10-11**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 338**] Chief Complaint: alcoholic intoxication and heroin abuse Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 24927**] is a 38 yo M with PMH of polysubstance abuse who presents with acute alcoholic intoxication and heroin abuse. He was found around [**Location (un) **] station and brought to [**Hospital1 18**]. On arrival to [**Hospital1 18**], he reported also snorting heroin. In the ED, VS: T 99 BP 98/73 HR 102 RR17 99%RA. He was initially alert and awake, then became somnolent with RR of 6 and O2 sat of 70%. He received naloxone with immediate awakening. RR normalized and O2sat was normal. After several hours in [**Name (NI) **], pt became increasingly agitated and received multiple doses of valium for elevated CIWA scale, receiving total of 50mg PO. Pt has frequent visits to [**Hospital1 18**]. Was recently admitted to MICU Green on [**2182-10-5**]. At that time, seen by psychiatry who left recommendation regarding administration of benzos as patient frequently is administered high doses of benzodiazepines for drug seeking behavior. Past Medical History: Per Discharge Summary ([**2182-6-18**]) Poly Substance Abuse: Benzo/Opiates/IVDU 2. Ethanol Abuse: hx of DTs and withdrawal seizures, intubated in the past. 3. Hepatitis C 4. Hepatitis B 5. Compartment Syndrom RLE, [**2171**] 6. OCD and Anxiety 7. Depression with hx of suicidal ideations 8. Sever Peripheral Neuropathy Social History: From previous DC summary. States he does not speak to any family members, never married, no children. Homeless, states he does not like shelters because he gets ""nervous around all the people."" Family History: Father with depression, OCD and alcoholism. Mother died of DM complications Physical Exam: VS: T 96 HR 86 BP 128/79 02sat 97% RR 12 GEN: Disheveled, appears older than stated age HEENT: EOMI, PERRL NECK: Supple CHEST: CTABL CV: RRR, S1S2, no m/r/g ABD:Soft, NT, ND EXT: No c/c/e Skin: Pruritic papular rash on trunk, groin, ankles bilaterally NEURO: speech slurred, unsteady gait, CN ii-xii intact; able to answer questions appropriately . Pertinent Results: [**2182-10-10**] 03:10PM GLUCOSE-83 UREA N-12 CREAT-0.8 SODIUM-143 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16 [**2182-10-10**] 03:10PM estGFR-Using this [**2182-10-10**] 03:10PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.8 [**2182-10-10**] 03:10PM ASA-NEG ETHANOL-244* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2182-10-10**] 03:10PM WBC-5.1# RBC-4.36* HGB-12.5* HCT-37.7* MCV-87 MCH-28.6 MCHC-33.0 RDW-16.5* [**2182-10-10**] 03:10PM NEUTS-33.2* BANDS-0 LYMPHS-58.8* MONOS-5.5 EOS-1.6 BASOS-0.9 [**2182-10-10**] 03:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2182-10-10**] 03:10PM PLT COUNT-239 Brief Hospital Course: A/P: 38 yo M with PMH of ETOH abuse/withdrawal and multiple hospitalizations presented with acute intoxication and heroin use requiring naloxone in ED. . ETOH intoxication: ETOH level 244. Speech somewhat slurred on exam. Pt admits to drinking rum and Listerine. Received Valium 50mg total in ED for CIWA >10. Had 5mg x 3 of Valium in the MICU. Given thiamine, folate, MVI. Social work was contact[**Name (NI) **] and paperwork for a section 35 was started. Pt left AMA before paperwork could be completed (will take several days). Will need to continue paperwork if pt returns in near future. Scabies: Pt was treated with permethrin cream and Ivermectin x 1. Pt left AMA before further care was done for pt. Medications on Admission: Per Discharge Summary ([**2182-6-18**]), Unknown Compliance 1. Folic Acid 1mg Daily 2. Thiamine 100mg Daily 3. MVT One tab Daily 4. Ferrous Sulfate 325mg One Tab Daily 5. Oxcarbazepine 300mg one tablet [**Hospital1 **] 6. Gabapentin 200mg PO Q8H 7. Prozac 40mg Once Daily Discharge Medications: left AMA Discharge Disposition: Home Discharge Diagnosis: left AMA Discharge Condition: left AMA Discharge Instructions: left AMA Followup Instructions: left AMA Completed by:[**2182-10-11**]",63,2182-10-10 18:16:00,2182-10-11 13:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH WITHDRAWAL," a/p: 38 yo m with pmh of etoh abuse/withdrawal and multiple hospitalizations presented with acute intoxication and heroin use requiring naloxone in ed. . etoh intoxication: etoh level 244. speech somewhat slurred on exam. pt admits to drinking rum and listerine. received valium 50mg total in ed for ciwa >10. had 5mg x 3 of valium in the micu. given thiamine, folate, mvi. social work was contact[**name (ni) **] and paperwork for a section 35 was started. pt left ama before paperwork could be completed (will take several days). will need to continue paperwork if pt returns in near future. scabies: pt was treated with permethrin cream and ivermectin x 1. pt left ama before further care was done for pt. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Opioid abuse, unspecified; Chronic hepatitis C without mention of hepatic coma; Obsessive-compulsive disorders; Anxiety state, unspecified; Cerebral degeneration, unspecified; Lack of housing; Scabies; Alcoholic polyneuropathy]","a/p: 38 yo m with pmh of etoh abuse/withdrawal and multiple hospitalizations presented with acute intoxication and heroin use requiring naloxone in ed. pt left ama before paperwork could be completed (will take several days).",pt admitted to drinking rum and listerine. received valium 50mg total in ed for ciwa >10. left ama before further care was done for pt. 5060,193317.0,24310,2182-10-11,24309,143525.0,2182-10-08,Discharge summary,"Admission Date: [**2182-10-7**] Discharge Date: [**2182-10-8**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 338**] Chief Complaint: EtOH Intoxication Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 38 yo male with a PMH significant for Etoh and Poly substance abuse, Hep B, and Hep C. Pt was found down on the street stating that he wanted to be run over by a car. Pt recently was admitted to the MICU with EtOH intoxication yesterday, pt left AMA. In ED patient vitals were BP 93/58 - 156/89, HR 70-80s, T 98, 100% on 2L. Initially given 5mg haldol for agitation/combative behavior, later given 10mg Valium PO. No access attained. Complained of some tail bone pain which was worked up with plain film of coccyx. ED was prepared for DC however pt reported difficulty walking. Patient appears intoxicated and is not willing to answer questions. Pt does not some abdomen, back, and extremity pain globally. Past Medical History: Per Discharge Summary ([**2182-6-18**]) Poly Substance Abuse: Benzo/Opiates/IVDU 2. Ethanol Abuse: hx of DTs and withdrawal seizures, intubated in the past. 3. Hepatitis C 4. Hepatitis B 5. Compartment Syndrom RLE, [**2171**] 6. OCD and Anxiety 7. Depression with hx of suicidal ideations 8. Sever Peripheral Neuropathy Social History: From previous DC summary. States he does not speak to any family members, never married, no children. Homeless, states he does not like shelters because he gets ""nervous around all the people."" Family History: Father with depression, OCD and alcoholism. Mother died of DM complications Physical Exam: T BP 121 HR 76 RR 20 O2sat 100% on RA General - Resting comfortably in bed, no acute distress, Appears intoxicated and is not interested in answering questions. HEENT - Sclera anicteric, Lips dry Neck - Supple, JVP not elevated, no LAD Pulm - CTA bilaterally; no wheezes, rales, or rhonchi CV - RRR, normal S1/S2; no murmurs, rubs, or gallops Abdomen - Soft, Mild tenderness on palpation of abdomen Ext - Warm, well perfused, radial and DP pulses 2+; no clubbing, cyanosis or edema. Pain with palpation of lower extremity. Neuro - Pt is not willing to participate with exam. Still appears somewhat intoxicate, however mental status is improving. Able to move all extremities. PERRL. EOMI. Pertinent Results: Radiograph Coccyx: Normal bony mineralization and alignment. No evidence of fracture. Apparent mild sclerosis overlying the right S1, S2 region is not appreciated on the more tilted views and is likely artifactual. No evidence of fracture. Views of the L5-S1 region do show some evidence of degenerative osteophyte formation of the anterosuperior aspect of L5, probably some posterior osteophytes of the L5-S1 disc interspace. Brief Hospital Course: Pt is a 38 year old male with significant hx of EtOH/Polysubstance abuse, who presented today with EtOH intoxication and developed respiratory distress, felt to be self induced airway obstruction. . # Airway obstruction: Required a Code Blue, and at first there was concern about a allergic response, later thought to be psychogenic. It resolved without intubation. Sats remained normal. . #.EtOH Intoxication/Withdrawal: Received multiple doses of ativan and valium. No objective signs of withdrawal by time of his transfer to the MICU. Was also given MV and thiamine and folate. . #. Scabies: Found to have extensive infection. Was treated with 5% permethrin cream x 1, but will need repeat out pt treatment in one week. . #.Hep B/Hep C: Hep B infection cleared based on most recent serologies. AST>ALT on recent liver function tests, most likely was secondary to EtOH abuse. . #. Code status: DNR/DNI confirmed 2 days prior with psych . Pt leave AMA on the morning of [**2182-10-8**]. Medications on Admission: Per Discharge Summary ([**2182-6-18**]), Unknown Compliance 1. Folic Acid 1mg Daily 2. Thiamine 100mg Daily 3. MVT One tab Daily 4. Ferrous Sulfate 325mg One Tab Daily 5. Oxcarbazepine 300mg one tablet [**Hospital1 **] 6. Gabapentin 200mg PO Q8H 7. Prozac 40mg Once Daily Discharge Medications: left AMA Discharge Disposition: Home Discharge Diagnosis: Left AMA Discharge Condition: Left AMA Discharge Instructions: Left AMA Followup Instructions: Left AMA Completed by:[**2182-10-9**]",3,2182-10-07 02:09:00,2182-10-08 09:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH INTOXICATION," pt is a 38 year old male with significant hx of etoh/polysubstance abuse, who presented today with etoh intoxication and developed respiratory distress, felt to be self induced airway obstruction. . # airway obstruction: required a code blue, and at first there was concern about a allergic response, later thought to be psychogenic. it resolved without intubation. sats remained normal. . #.etoh intoxication/withdrawal: received multiple doses of ativan and valium. no objective signs of withdrawal by time of his transfer to the micu. was also given mv and thiamine and folate. . #. scabies: found to have extensive infection. was treated with 5% permethrin cream x 1, but will need repeat out pt treatment in one week. . #.hep b/hep c: hep b infection cleared based on most recent serologies. ast>alt on recent liver function tests, most likely was secondary to etoh abuse. . #. code status: dnr/dni confirmed 2 days prior with psych . pt leave ama on the morning of [**2182-10-8**]. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Suicidal ideation; Scabies; Other respiratory abnormalities; Obsessive-compulsive personality disorder; Chronic hepatitis C without mention of hepatic coma; Alcoholic polyneuropathy; Lack of housing; Dysthymic disorder]","pt is a 38 year old male with significant hx of etoh/polysubstance abuse, who presented today with etoh intoxication and developed respiratory distress, felt to be self induced airway obstruction. # airway obstruction: required a code blue, and at first there was concern about a allergic response, later thought to be psychogenic. #.hep b/hep c: hep b infection cleared based on most recent serologies.","pt is a 38 year old male with significant hx of etoh/polysubstance abuse. presented today with etoh intoxication and developed respiratory distress. received multiple doses of ativan and valium, no objective signs of withdrawal." 5060,193317.0,24310,2182-10-11,24308,156497.0,2182-06-18,Discharge summary,"Admission Date: [**2182-6-13**] Discharge Date: [**2182-6-18**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 4365**] Chief Complaint: EtOH intoxication, hypertension. Major Surgical or Invasive Procedure: None History of Present Illness: Please see admission note for full details. Briefly, 37yoM w/ h/o severe alcoholism with multiple admissions for withdrawal, HBV, HCV, who was found passed out on [**6-14**] after drinking more vodka that his usual amount. He also reported a recent h/o fighting with a friend, resulting in R hand and substernal chest pain. He was admitted to the MICU after being found to be in acute withdrawal with HTN (SBP to 200s) and HR>100. MICU Course: Mr. [**Known lastname 24927**] was started on folate, thiamine, MTV, and valium prn for CIWA >10. He was found to have hypernatremia and was treated with gentle IV hydration and drinking to thirst. His musculoskeletal pain was managed with Percocet. Psychiatry was consulted on day of admission to assess patient's capacity to leave AMA. He initially agreed to voluntarily stay in the hospital and completing a Section 35 on [**6-17**], as he did not meet criteria for Section 12 for a psychiatric admission. He was reported to manipulate nurses on floor asking for higher/more frequent doses of Diazepam, with subjective complaints not necessarily correlating to changes in vital signs. Patient was reportedly [**Doctor Last Name **] high for tremor, anxiety, and reported hallucinations with consistent stable vital signs. Psychiatry recommended starting a standing Valium taper with CIWA for objective signs of withdrawal only. On arrival to the floor, the patient reported ""pain everywhere"", and when elicited, focused on chest pain. He also reported having ""withdrawal"", experiencing hot/cold flashes, skin crawling, anxiety, and tremors. He wanted more pain medicine (Percocet), and said that he would leave if he did not get adequate pain medicine. Past Medical History: 1. polysubstance abuse: ETOH, listerine, heroin, IVDU, benzodiazepines 2. ethanol abuse, hx DTs and withdrawal seizures, intubated in past 3. hepatitis C 4. hepatitis B 4. compartment syndrome RLE, [**2171**] 5. OCD and anxiety 6. depression with hx suicidal ideations and attempts 8. chronic bilateral hand swelling 9. severe peripheral neuropathy Social History: He reports drinking [**2-8**] gallon vodka and listerine daily. History of heroin, IVDU, benzodiazepine abuse, alcohol withdrawal seizures and delerium tremens. States he does not speak to any family members, never married, no children. He is currently homeless and states he does not like shelters because he gets ""nervous around all the people"". Family History: Father with depression and alcoholism. Mother died of DM complications. He reports his father had depression, alcoholism and questionable OCD. Physical Exam: VITALS: T: 97.7 BP 97/63 HR 68 RR 18 SpO2 97/RA GENERAL: lying comfortably in bed, wearing cap, sheets pulled tight over body, no obvious tremors PSYCH: Combative Pt refused all other components of PE Pertinent Results: Labs at Admission: [**2182-6-13**] 06:50PM BLOOD WBC-4.4 RBC-4.61 Hgb-12.9* Hct-39.6* MCV-86 MCH-27.9 MCHC-32.5 RDW-16.0* Plt Ct-158 [**2182-6-13**] 06:50PM BLOOD Neuts-35.6* Lymphs-56.9* Monos-2.0 Eos-4.7* Baso-0.8 [**2182-6-13**] 06:50PM BLOOD Glucose-80 UreaN-8 Creat-0.8 Na-147* K-4.2 Cl-109* HCO3-23 AnGap-19 [**2182-6-14**] 07:09PM BLOOD ALT-55* AST-90* AlkPhos-98 TotBili-0.9 [**2182-6-13**] 06:50PM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9 [**2182-6-13**] 06:50PM BLOOD ASA-NEG Ethanol-368* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG Imaging Studies: Right hand plain film ([**6-14**]): Abnormal curvilinear fragment identified just distal to the first interphalangeal joint (volar aspect) as above. Please correlate clinically, particularly on the volar aspect. This is difficult to confirm given the lack of non- localizing symptoms. CXR ([**6-14**]): Since [**2182-4-5**], lungs remain clear. The cardiomediastinal silhouette and hilar contours are unchanged, including minimal prominence of the ascending aorta, could be related to systemic hypertension. There is no pleural effusion. Brief Hospital Course: Mr. [**Known lastname 24927**] is a 37M with a PMH s/f severe alcoholism with several ICU admissions for management alchohol withdrawl in the past, HCV, and HBV, admitted to the [**Hospital Unit Name 153**] for alcohol withdrawal. # Alcohol withdrawal: The patient was maintained on a CIWA scale which required active intervention until the evening of [**6-16**]. He was also continued on Folate, Thiamine and multivitamin. As of the time of leaving the ICU, the patient had agreed to enter Detox, but Psych/Social work had also started the Section 35 process. The patient was called out to the floor after being stable on decreasing doses of valium. He was started on a standing valium taper when arriving on the floor. At time of discharge, he had no signs of objective withdrawal. He was discharged in the company of police to court for section 35 with the collaboration of psych/social work. # Hand pain: Questionable finger fracture on x-ray from recent fighting. The patient was evaluated by hand and found to not need operative intervention or splinting. Pain was controlled with percocet while inpatient. # Hypernatremia: Attributed to dehydration from EtOH abuse. The patient self corrected with PO intake and IV hydration. # Peripheral neuropathy: Attributed in the past to EtOH abuse. Recent folate and B12 within normal limits. No hx of diabetes. Pain was controlled with analgesics. Medications on Admission: (not taking any, but supposed to be on the following) Prozac (pt thinks 40 mg daily) Klonopin 1 mg TID Trileptal (dose uncertain) Remeron (dose uncertain) Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*60 Capsule(s)* Refills:*0* 7. Prozac 40 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses Alcohol withdrawal Right hand pain, no fracture Secondary Diagnoses Anemia Peripheral Neuropathy Hepatitis B Hepatitis C Discharge Condition: Patient afebrile with stable vital signs, discharged with plans for alcohol detoxification program under section 35 Discharge Instructions: You have been admitted to the hospital for alcohol withdrawal. You were discharged under section 35 with plans for detoxification program. Please take all your medications as prescribed. The following changes were made to your medication regimen. 1. Your klonopin was discontinued 2. Your remeron was discontinued 3. You were started on neurontin for pain 4. You were started on iron for your anemia 5. You were also started on thiamine, folate and multivitamins for your nutritional health Please keep all your follow up appointments as scheduled. Please seek medical attention or return to the emergency room if you experience any fevers > 101 degrees, difficulty breathing, chest pain, seizures, or any other concern symptoms. Followup Instructions: Please make an appointment to see your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. He can be reached at [**Telephone/Fax (1) 61608**]. Completed by:[**2182-6-18**]",115,2182-06-14 20:51:00,2182-06-18 11:05:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ETOH INTOXICATION," mr. [**known lastname 24927**] is a 37m with a pmh s/f severe alcoholism with several icu admissions for management alchohol withdrawl in the past, hcv, and hbv, admitted to the [**hospital unit name 153**] for alcohol withdrawal. # alcohol withdrawal: the patient was maintained on a ciwa scale which required active intervention until the evening of [**6-16**]. he was also continued on folate, thiamine and multivitamin. as of the time of leaving the icu, the patient had agreed to enter detox, but psych/social work had also started the section 35 process. the patient was called out to the floor after being stable on decreasing doses of valium. he was started on a standing valium taper when arriving on the floor. at time of discharge, he had no signs of objective withdrawal. he was discharged in the company of police to court for section 35 with the collaboration of psych/social work. # hand pain: questionable finger fracture on x-ray from recent fighting. the patient was evaluated by hand and found to not need operative intervention or splinting. pain was controlled with percocet while inpatient. # hypernatremia: attributed to dehydration from etoh abuse. the patient self corrected with po intake and iv hydration. # peripheral neuropathy: attributed in the past to etoh abuse. recent folate and b12 within normal limits. no hx of diabetes. pain was controlled with analgesics. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Hyperosmolality and/or hypernatremia; Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Unspecified essential hypertension; Anemia, unspecified; Pain in limb; Unarmed fight or brawl; Dysthymic disorder; Obsessive-compulsive disorders; Alcoholic polyneuropathy]","known lastname 24927**] is a 37m with a pmh s/f severe alcoholism with several icu admissions for management alchohol withdrawl in the past, hcv, and hbv, admitted to the [**hospital unit name 153**] for alcohol withdrawal. he was discharged in the company of police to court for section 35 with the collaboration of psych/social work. the patient self corrected with po intake and iv hydration.",a 37m man with a pmh s/f severe alcoholism was admitted to a hospital for alcohol withdrawal. he was kept on a ciwa scale which required active intervention until the evening of [**6-16**]. he was discharged in the company of police to court for section 35. 5060,156497.0,24308,2182-06-18,24307,174823.0,2182-04-07,Discharge summary,"Admission Date: [**2182-4-4**] Discharge Date: [**2182-4-7**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 8263**] Chief Complaint: Alcohol intoxication Altered mental status Major Surgical or Invasive Procedure: Intubation [**2182-4-4**] Extubation [**2182-4-5**] History of Present Illness: Initial history and physical is as per ICU team. .Mr. [**Known lastname 24927**] is a 37M with a history of severe alcoholism with regular admissions to [**Hospital1 18**] for management of withdrawl, complicated by DT's in the past, HBV, and HCV. Today at 2PM he was found unresponsive by EMS at the T station, and brought to the emergency department. . In the ED vitals were T=98.6, BP=111-134/79-96, HR=78-112, RR=[**12-21**], O2sat=97%RA, FSBS 173. He was initially alert and communicative, however, upon falling asleep, he became hypoxic to 54% RA with an absent gag reflex, and was then intubated. Sedated on a propofol drip, given 2mg Ativan given at 1442, 5mg haldol, 2mg of narcan, and 1LNS. Right femoral CVL placed. Labs were notable for an ETOH level of 280, and a leukocytosis to 12,000. Otherwise tox screen was notable only for benzodiazepines (patient was discharged on [**3-31**] for alcohol intoxication, managed with BZDs). A head CT CT Cspine and CXR were negative. Past Medical History: 1. polysubstance abuse: ETOH, listerine, heroin, IVDU, benzodiazepines 2. hepatitis C 3. hepatitis B 4. compartment syndrome RLE, [**2171**] 5. OCD and anxiety 6. depression with hx suicidal ideations and attempts 7. ethanol abuse, hx DTs and withdrawal seizures, intubated in past 8. chronic bilateral hand swelling 9. Severe peripheral neuropathy Social History: The patient has previously reported he is homeless and lives in front of [**Location (un) 7073**] train station. He drinks regularly, often a liter of listerine and a fifth of vodka and additional beer every day. He has a history of IV heroin and smoking cocaine but has insisted he quit both of those activities >10 years ago. He also smoked cigarettes in the past but claims he stopped in [**2167**]. Family History: Father with depression and alcoholism. Mother died of DM complications. Physical Exam: Admission PE: Vitals: T: 96.6, HR 86, BP: 104/76 HR:75 GEN: Sedated intubated HEENT: Pupils pinpoint, equal and reactive bilaterally NECK: No JVD, lymphadenopathy, trachea midline CV: RRR, no M/R/G; 2+ radial, DP, and PT pulses bilaterally PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: Upon weaning propofol, opens eyes to voice, sits up, moves all four extremities to command, babinskis downgoing, no clonus. SKIN: Lacerations at the left brow and cheek. Pertinent Results: Admission labs: [**2182-4-4**] 01:57PM BLOOD WBC-11.3*# RBC-4.55* Hgb-12.9* Hct-39.3* MCV-86 MCH-28.3 MCHC-32.8 RDW-17.3* Plt Ct-426# [**2182-4-4**] 01:57PM BLOOD Neuts-35.7* Bands-0 Lymphs-56.8* Monos-3.2 Eos-3.5 Baso-0.9 [**2182-4-4**] 01:57PM BLOOD Plt Ct-426# [**2182-4-5**] 04:21AM BLOOD PT-13.0 PTT-28.5 INR(PT)-1.1 [**2182-4-4**] 01:57PM BLOOD Glucose-129* UreaN-11 Creat-1.0 Na-142 K-4.9 Cl-101 HCO3-32 AnGap-14 [**2182-4-4**] 01:57PM BLOOD ALT-132* AST-110* AlkPhos-87 TotBili-0.2 [**2182-4-4**] 01:57PM BLOOD Lipase-61* [**2182-4-4**] 01:57PM BLOOD Calcium-9.1 Phos-4.4# Mg-2.2 [**2182-4-4**] 01:57PM BLOOD ASA-NEG Ethanol-280* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2182-4-4**] 06:55PM BLOOD Type-ART pO2-545* pCO2-44 pH-7.40 calTCO2-28 Base XS-2 Intubat-INTUBATED [**2182-4-4**] 06:55PM BLOOD Lactate-1.7 [**2182-4-4**] CT head: 1. No intracranial hemorrhage or edema. 2. Unchanged depressed left nasal bone fracture. [**2182-4-5**] CT C spine: IMPRESSION: No acute fracture. NG tube appears to be looped within the pharynx. . CXR: FINDINGS: In comparison with the study of [**4-4**], there is little overall change. Specifically, no evidence of acute pneumonia. Monitoring and support devices remain in place. Brief Hospital Course: Mr. [**Known lastname 24927**] is a 37M with a PMH s/f severe alcoholism with multiple ICU admissions for management of airway protection/withdrawl in the past, HCV, and HBV, found unresponsive in the setting of alcohol intoxication, intubated for airway protection and hypoxia prior to recieving benzos in ED, with incidentally diagnosed leukocytosis on routine labs. . #. Altered mental status: DDX includes ETOH intoxication with level of 280, other toxic ingestion, intracranial bleed from his fall, seizure from ETOH withdrawl vs. trauma. Head CT negative for a bleed, CT Cspine was negative, and no clear toxic-metabolic abnormalities on initial labs. His mental status improved. . #. Hypoxia: In the setting of alcohol intoxication, likely secondary to an aspiration event. CXR was negative for pneumonia. Pt was extubated in the ICU. His O2 sasts remained stable after that. . #. ETOH intoxication: Patient has a history of withdrawl seizures. Also has severe anxiety at baseline, and is difficult to monitor with a CIWA scale, as his subjective symptoms have been unreliable. We used vital signs (hyperthermia, HTN, Tachycardia)to monitor ETOH withdrawl, and wrote for diazepam as needed. He was given MVI, thiamine, and folic acid. The patient was often very agitated and anxious and demanded valium despite not showing any vital sign evidence of withdrawal. SW was consulted but the patient eloped before he could be seen. As previously documented in previous OMR notes, this patient should be section 35ed for his safety if he continues to come to the hospital intoxicated. . # HCV/HBV: previous hx transaminitis, at baseline . # FEN: Diet was advanced to Regular s/p extubation. . # PPX: heparin SC . # Access: hx of difficulty with pIV and pt combative, femoral CVL placed in ED upon arrival. Removed before discharge. . # Code: Full code . # Dispo: On [**2182-4-7**], the [**Name8 (MD) 228**] RN went to check on him and he was found to have eloped from the hospital. . This discharge summary is signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as Dr. [**Name (STitle) 61607**] is no longer working at [**Hospital1 18**]. Medications on Admission: None Discharge Medications: Pt eloped Discharge Disposition: Home Discharge Diagnosis: ETOH intoxication Discharge Condition: Fair. Discharge Instructions: Pt eloped Followup Instructions: Pt eloped ",72,2182-04-04 15:32:00,2182-04-07 12:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH WITHDRAWAL;UNRESPONSIVE," mr. [**known lastname 24927**] is a 37m with a pmh s/f severe alcoholism with multiple icu admissions for management of airway protection/withdrawl in the past, hcv, and hbv, found unresponsive in the setting of alcohol intoxication, intubated for airway protection and hypoxia prior to recieving benzos in ed, with incidentally diagnosed leukocytosis on routine labs. . #. altered mental status: ddx includes etoh intoxication with level of 280, other toxic ingestion, intracranial bleed from his fall, seizure from etoh withdrawl vs. trauma. head ct negative for a bleed, ct cspine was negative, and no clear toxic-metabolic abnormalities on initial labs. his mental status improved. . #. hypoxia: in the setting of alcohol intoxication, likely secondary to an aspiration event. cxr was negative for pneumonia. pt was extubated in the icu. his o2 sasts remained stable after that. . #. etoh intoxication: patient has a history of withdrawl seizures. also has severe anxiety at baseline, and is difficult to monitor with a ciwa scale, as his subjective symptoms have been unreliable. we used vital signs (hyperthermia, htn, tachycardia)to monitor etoh withdrawl, and wrote for diazepam as needed. he was given mvi, thiamine, and folic acid. the patient was often very agitated and anxious and demanded valium despite not showing any vital sign evidence of withdrawal. sw was consulted but the patient eloped before he could be seen. as previously documented in previous omr notes, this patient should be section 35ed for his safety if he continues to come to the hospital intoxicated. . # hcv/hbv: previous hx transaminitis, at baseline . # fen: diet was advanced to regular s/p extubation. . # ppx: heparin sc . # access: hx of difficulty with piv and pt combative, femoral cvl placed in ed upon arrival. removed before discharge. . # code: full code . # dispo: on [**2182-4-7**], the [**name8 (md) 228**] rn went to check on him and he was found to have eloped from the hospital. . this discharge summary is signed by [**first name4 (namepattern1) **] [**last name (namepattern1) **] as dr. [**name (stitle) 61607**] is no longer working at [**hospital1 18**]. ","PRIMARY: [Acute respiratory failure] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Acute pancreatitis; Alcohol withdrawal; Chronic hepatitis C without mention of hepatic coma; Depressive disorder, not elsewhere classified; Cocaine abuse, unspecified]","known lastname 24927**] is a 37m with a pmh s/f severe alcoholism with multiple icu admissions for management of airway protection/withdrawl in the past, hcv, and hbv, found unresponsive in the setting of alcohol intoxication, intubated for airway protection and hypoxia prior to recieving benzos in ed, with incidentally diagnosed leukocytosis on routine labs. altered mental status: ddx includes etoh intoxication with level of 280, other toxic ingestion, intracranial bleed from his fall, seizure from etoh withdrawl vs. trauma. he was given mvi, thiamine, and folic acid. # access: hx of difficulty with piv and pt combative, femoral cvl placed in ed upon arrival.","mr. [**known lastname 24927**] is a 37m with a pmh s/f severe alcoholism with multiple icu admissions for management of airway protection/withdrawl in the past, hcv, and hbv. ddx includes etoh intoxication with level of 280, other toxic ingestion, intracranial bleed from his fall, seizure from etoh withdrawl vs. trauma " 5060,156497.0,24308,2182-06-18,24306,170299.0,2182-04-01,Discharge summary,"Admission Date: [**2182-3-30**] Discharge Date: [**2182-4-1**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2745**] Chief Complaint: alcohol intoxication Major Surgical or Invasive Procedure: none History of Present Illness: This is a 37 y.o. maln with history of alcoholism and HBV and HCV presenting with presumed intoxication and c/o chest pain complicated by development of profound agitation in the ED requiring multiple sedating meds and restraints. The patient was brought in by EMS complaining of chest pain and appearing intoxicated. Initial vital signs were 98.1, 113/79, 100, 18, 100% on RA. He received 10 mg IV valium and intermittently complained of abdominal, foot, and chest pain. He appeared comfortable slept in the ED initially, though he was put in 4 pt restraints for reasons that are somewhat unclear. Eventually, a few hours after his admission, he became quite agitated screaming for lorazepam and hydromorphone. He receieved another 10 mg diazepam to treat DT's but remained agitated and continued to yell and struggle against restraints for the next two hours. Went on to receive an additonal 20 mg diazepam then 10 mg ziprasidone and finally 5 mg haloperidol. After this last intervention the patient was once again somnolent and had a right sided femoral CVL placed. . On arrival to the floor the patient is sedated and unresponsive. Of note, he has history of multiple previous admissions to [**Hospital1 18**] to EtOH withdrawal and with various drug seeking behaviors. Past Medical History: Polysubstance abuse with alcohol, heroin, IVDU, benzo Hep C Hep B OCD and anxiety Depression seizures from alcohol withdrawal compartment syndrome of RLE in [**2171**] chronic bilateral hand swelling Social History: Homeless. Active alchohol and heroin abuse. Drinks 1 bottle of listerine and vodka daily and reports daily blackouts. Last episode of sobriety was in [**2171**] for 9 months. He reports that he has difficulty with detox because he has OCD and a fear of people which makes shelters difficult for him. He is a non-smoker Family History: father with depression and alcoholism. Mother had diabetes. Physical Exam: Vitals: T: 97.1, HR 86, BP: 117/68 HR: 132 RR: 10 O2Sat: 98% RA GEN: Slightly disheveled middle aged male asleep in bed HEENT: PERRL, sclera anicteric, mucous membranes appear dry, poor dentition NECK: No JVD, lymphadenopathy, trachea midline CV: RRR, no M/R/G; 2+ radial, DP, and PT pulses bilaterally PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: Sedated, responds to painful stimuli, unable to converse or answer questions. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2182-3-31**] CXR: Lungs are clear. Heart size normal. No pleural abnormality or evidence of central adenopathy. Lateral aspect of the right lower chest is excluded from the study. [**2182-3-31**] 04:15AM BLOOD WBC-4.0 RBC-3.59* Hgb-9.9* Hct-30.4* MCV-85 MCH-27.6 MCHC-32.6 RDW-17.1* Plt Ct-223 [**2182-3-30**] 10:30PM BLOOD WBC-3.4* RBC-3.67* Hgb-10.5* Hct-30.4* MCV-83 MCH-28.4 MCHC-34.4 RDW-16.3* Plt Ct-249 [**2182-3-30**] 10:30PM BLOOD Neuts-49.3* Lymphs-36.1 Monos-6.2 Eos-8.1* Baso-0.4 [**2182-3-31**] 11:02AM BLOOD PT-13.0 PTT-27.3 INR(PT)-1.1 [**2182-3-31**] 04:15AM BLOOD Glucose-96 UreaN-9 Creat-0.8 Na-140 K-3.7 Cl-104 HCO3-32 AnGap-8 [**2182-3-30**] 10:30PM BLOOD Glucose-85 UreaN-9 Creat-0.8 Na-144 K-3.1* Cl-106 HCO3-25 AnGap-16 [**2182-3-31**] 04:15AM BLOOD ALT-165* AST-151* LD(LDH)-243 AlkPhos-68 Amylase-68 TotBili-0.3 [**2182-3-30**] 10:30PM BLOOD CK(CPK)-500* [**2182-3-30**] 10:30PM BLOOD cTropnT-<0.01 [**2182-3-31**] 04:15AM BLOOD Phos-4.1 Mg-1.7 Iron-13* [**2182-3-31**] 04:15AM BLOOD calTIBC-338 Ferritn-53 TRF-260 [**2182-3-30**] 10:30PM BLOOD ASA-NEG Ethanol-111* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG Brief Hospital Course: 37yoM hx alcoholism, multiple admits for detox and hx of DTs/withdrawal szs, presenting with intoxication and agitation, admitted to MICU for ethanol withdrawal and monitoring. . # ETOH intoxication/AMS: 37 y.o male with history of polysubstance abues and multiple previous admits for detox/drug seeking behavior. He presented intoxicated and became very agitated in the ED requiring multiple sedating medications. The patient was given a total of 40mg of valium in the ED. In the ICU, he was given an additionl 5mg valium for anxiety. He was also given thiamine, folate, and a multivitamin. Social work was also contact[**Name (NI) **]. The patient was transferred to the medicine floor and on the am of [**4-1**] definitely appeared to be in clinical ETOH withdrawal (despite his well-documented history of faking ETOH withdrawal symptoms for benzos). The patient was aggressivley treated with 200 mg of valium in 9 hours and then determined to no longer have any clinical evidence of ETOH withdrawal (involuntary tremors). However, the patient became very agitated and anxious. The patient was again evaluated by the medicine attending and clearly deemed to not be in ETOH withdrawal anymore. His agitation and anxiety was now behavioral. The patient's femoral line was removed with plan to monitor overnight and d/c in am after shower with taxi voucher. The patient shortly thereafter eloped from the hospital. I would highly advocate that when the patient returns to [**Hospital1 18**] that he be section 25'd. Medications on Admission: . Discharge Medications: None, patient eloped Discharge Disposition: Home Discharge Diagnosis: ETOH withdrawal Patient eloped Discharge Condition: Pt eloped Discharge Instructions: Patient eloped Followup Instructions: Patient eloped. Would recommend section 25 when he eventually returns intoxicated to ED ",78,2182-03-30 22:36:00,2182-04-01 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ALCOHOL WITHDRAWAL," 37yom hx alcoholism, multiple admits for detox and hx of dts/withdrawal szs, presenting with intoxication and agitation, admitted to micu for ethanol withdrawal and monitoring. . # etoh intoxication/ams: 37 y.o male with history of polysubstance abues and multiple previous admits for detox/drug seeking behavior. he presented intoxicated and became very agitated in the ed requiring multiple sedating medications. the patient was given a total of 40mg of valium in the ed. in the icu, he was given an additionl 5mg valium for anxiety. he was also given thiamine, folate, and a multivitamin. social work was also contact[**name (ni) **]. the patient was transferred to the medicine floor and on the am of [**4-1**] definitely appeared to be in clinical etoh withdrawal (despite his well-documented history of faking etoh withdrawal symptoms for benzos). the patient was aggressivley treated with 200 mg of valium in 9 hours and then determined to no longer have any clinical evidence of etoh withdrawal (involuntary tremors). however, the patient became very agitated and anxious. the patient was again evaluated by the medicine attending and clearly deemed to not be in etoh withdrawal anymore. his agitation and anxiety was now behavioral. the patients femoral line was removed with plan to monitor overnight and d/c in am after shower with taxi voucher. the patient shortly thereafter eloped from the hospital. i would highly advocate that when the patient returns to [**hospital1 18**] that he be section 25d. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Anemia, unspecified; Lack of housing; Dysthymic disorder; Obsessive-compulsive disorders]","37yom hx alcoholism, multiple admits for detox and hx of dts/withdrawal szs, presenting with intoxication and agitation, admitted to micu for ethanol withdrawal and monitoring. the patient was aggressivley treated with 200 mg of valium in 9 hours and then determined to no longer have any clinical evidence of etoh withdrawal (involuntary tremors). however, the patient became very agitated and anxious.","37yom hx alcoholism, multiple admits for detox and hx of dts/withdrawal szs. he presented intoxicated and became very agitated in the ed. he was given a total of 40mg of valium in the ed and an additionl 5mg valium for anxiety." 5060,156497.0,24308,2182-06-18,24305,196749.0,2182-01-14,Discharge summary,"Admission Date: [**2182-1-4**] Discharge Date: [**2182-1-14**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 358**] Chief Complaint: Monitoring and treatment of EtOH withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: This is a 37 year-old male with a history of alcoholism with many admissions for intoxication, Hep B+C, polysubstance abuse, and depression, who presents with intoxication. Pt reports that he drank 1 liter of listerine today as well as a fifth of vodka and then blackout. He was brought to the ED intoxicated but has no recollection of how he got to the hospital. He complains of pain at his left knee, but does not recall injuring it, and also complains of chronic abdominal tenderness (but only when someone presses on it). Denies nausea or vomiting. . In the ED, initial vitals were T 98.7, BP 123/87, HR 110, RR 16, 99% on RA. His BAL was 456. Serum tox was also positive for benzos. Urine tox was negative. The plan was initially to observe the patient overnight in the ED until he became sober. However, around 7:30pm, the attending found the patient tremulous, with HR in the 120-130s and complaining of withdrawal symptoms. He was also having visual hallucinations of mice running over his legs. Exam was only notable for some blood on his pants over his left knee and a bump on his L forehead. Neuro exam was non-focal. He remainted tachycardic with HR as high as 140s. He received a total of 15mg PO valium, 15mg IV valium, and 1mg IV ativan. Banana bag was started but PIV was not functioning well. Admitted to the ICU for further monitoring. . On arrival to the [**Hospital Unit Name 153**], the patient is very anxious. He is no longer experiencing visual hallucinations but reports that he is delirious and does not know what is going on. He is adamant that he is going to stop drinking this time and wants to go to a detox facility-- apparently his best friend died one week ago from drinking listerine. . ROS: He has been having frontal headaches for the past month since being hit by an SUV one month ago. Has also had R-sided chest pain at the site of impact from this MVC for the past month. Has broken his nose several times and has difficulty breathing from that. He also notes seeing spots in the periphery of his vision recently. He complains of gait instability when sober (less so when intoxicated) and also peripheral neuropathy in his arms and legs. The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, focal weakness, rash or skin changes. Past Medical History: polysubstance abuse with alcohol, heroin, IVDU, benzo Hep C Hep B OCD and anxiety Depression seizures from alcohol withdrawal compartment syndrome of RLE in [**2171**] chronic bilateral hand swelling Social History: Homeless. Denies IVDU recently. Denies tobacco recently. Does have a history of both. Family History: father with depression and alcoholism. Mother had diabetes. Physical Exam: Vitals: T: 98.7 BP: 138/106 HR: 132 RR: 17 O2Sat: 97% RA GEN: Disheveled male, tremulous, anxious HEENT: EOMI, PERRL, sclera anicteric, no nystagmus, no epistaxis or rhinorrhea, MMM, OP Clear, poor dentition NECK: No JVD, lymphadenopathy, trachea midline COR: tachy, regular, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, diffusely tender to palpation, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords MUSCULOSKELETAL: L knee swollen with 2 small healing lacerations and echymossis over the patella, decreased range of motion (to 90 degrees), tender to palpation over the patella and medial joint line NEURO: A+O x 2 (person, year). CN II ?????? XII grossly intact. Strength 5/5 in upper and lower extremities. Decreased sensation grossly over lower extremities. Normal finger-to-nose. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: 143 104 12 83 AGap=14 4.2 29 0.7 ALT: 60 AP: 101 Tbili: 0.3 Alb: 4.6 AST: 95 LDH: Dbili: TProt: 7.9 [**Doctor First Name **]: Lip: 134 Serum EtOH 456 Serum Benzo Pos Serum ASA, Acetmnphn, Barb, Tricyc Negative Comments: Positive Tricyclic Results Represent Potentially Toxic Levels;Therapeutic Tricyclic Levels Will Typically Have Negative Results Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative 86 5.8 12.3 313 36.3 N:40.2 L:53.0 M:3.8 E:1.6 Bas:1.4 . FINDINGS: Lungs are clear without evidence lung nodules or consolidations. No pleural effusion. Cardiomediastinal silhouette is unremarkable. Bone structures are grossly normal. IMPRESSION: Normal examination without evidence of active or inactive tuberculosis. PPD positive with >20mm reaction Brief Hospital Course: 37 year-old male with a history of alcoholism with multiple admissions for detox and history of DTs/withdrawal seizures who presents with intoxication followed by withdrawal. He received 30 mg Valium in the emergency room and was placed on a q1h CIWA in the ICU. This was transitioned to a standing valium order per his protocol on arrival to the floor. Social work was consulted. MVI/thiamine/folate were given. He was monitored on telemetry. . His lipase and transaminases were elevated during his admission, consistent with his chronic hepatitis C, in addition to alcoholic hepatitis. He had abdominal pain which was the same as on prior admissions and was likely related to alcoholic pancreatitis or gastritis, but was resolved on discharge. This improved and he was tolerating pos. . He noted knee pain as well, and an x-ray was performed which did not show a fracture. . He was started on Klonopin for anxiety, similar to previous outpatient dosing. He had a PPD placed, which was positive at >20 mm, and a CXR was performed which was negative. Unfortunately, on the day of anticipated discharge to [**Hospital1 **] for inpatient alcohol rehabilitation, he left the floor unwitnessed and did not return (AMA, although he left without risk/benefit). Medications on Admission: none chronically on klonopin, but it is frequently stolen on the street. Discharge Medications: none, AMA Discharge Disposition: Home Discharge Diagnosis: alcohol withdrawal/dependence anxiety Discharge Condition: ambulating, no longer in withdrawal Discharge Instructions: AMA Followup Instructions: AMA ",155,2182-01-04 17:40:00,2182-01-14 10:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH WITHDRAWAL," 37 year-old male with a history of alcoholism with multiple admissions for detox and history of dts/withdrawal seizures who presents with intoxication followed by withdrawal. he received 30 mg valium in the emergency room and was placed on a q1h ciwa in the icu. this was transitioned to a standing valium order per his protocol on arrival to the floor. social work was consulted. mvi/thiamine/folate were given. he was monitored on telemetry. . his lipase and transaminases were elevated during his admission, consistent with his chronic hepatitis c, in addition to alcoholic hepatitis. he had abdominal pain which was the same as on prior admissions and was likely related to alcoholic pancreatitis or gastritis, but was resolved on discharge. this improved and he was tolerating pos. . he noted knee pain as well, and an x-ray was performed which did not show a fracture. . he was started on klonopin for anxiety, similar to previous outpatient dosing. he had a ppd placed, which was positive at >20 mm, and a cxr was performed which was negative. unfortunately, on the day of anticipated discharge to [**hospital1 **] for inpatient alcohol rehabilitation, he left the floor unwitnessed and did not return (ama, although he left without risk/benefit). ","PRIMARY: [Alcohol withdrawal delirium] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic pancreatitis; Chronic hepatitis C without mention of hepatic coma; Acute alcoholic hepatitis; Acute alcoholic intoxication in alcoholism, continuous; Pain in joint, lower leg; Lack of housing; Anxiety state, unspecified; Other, mixed, or unspecified drug abuse, unspecified; ]","37 year-old male with a history of alcoholism with multiple admissions for detox and history of dts/withdrawal seizures who presents with intoxication followed by withdrawal. unfortunately, on the day of anticipated discharge to [**hospital1 **] for inpatient alcohol rehabilitation, he left the floor unwitnessed and did not return (ama, although he left without risk/benefit).",37 year-old male with a history of alcoholism with multiple admissions for detox and history of dts/withdrawal seizures who presents with intoxication followed by withdrawal. received 30 mg valium in the emergency room and was placed on a q1h ciwa in the icu. this was transitioned to a standing valium order per his protocol on arrival to the floor. his lipase and transaminases were elevated during his admission 5060,148207.0,24313,2183-02-03,24309,143525.0,2182-10-08,Discharge summary,"Admission Date: [**2182-10-7**] Discharge Date: [**2182-10-8**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 338**] Chief Complaint: EtOH Intoxication Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 38 yo male with a PMH significant for Etoh and Poly substance abuse, Hep B, and Hep C. Pt was found down on the street stating that he wanted to be run over by a car. Pt recently was admitted to the MICU with EtOH intoxication yesterday, pt left AMA. In ED patient vitals were BP 93/58 - 156/89, HR 70-80s, T 98, 100% on 2L. Initially given 5mg haldol for agitation/combative behavior, later given 10mg Valium PO. No access attained. Complained of some tail bone pain which was worked up with plain film of coccyx. ED was prepared for DC however pt reported difficulty walking. Patient appears intoxicated and is not willing to answer questions. Pt does not some abdomen, back, and extremity pain globally. Past Medical History: Per Discharge Summary ([**2182-6-18**]) Poly Substance Abuse: Benzo/Opiates/IVDU 2. Ethanol Abuse: hx of DTs and withdrawal seizures, intubated in the past. 3. Hepatitis C 4. Hepatitis B 5. Compartment Syndrom RLE, [**2171**] 6. OCD and Anxiety 7. Depression with hx of suicidal ideations 8. Sever Peripheral Neuropathy Social History: From previous DC summary. States he does not speak to any family members, never married, no children. Homeless, states he does not like shelters because he gets ""nervous around all the people."" Family History: Father with depression, OCD and alcoholism. Mother died of DM complications Physical Exam: T BP 121 HR 76 RR 20 O2sat 100% on RA General - Resting comfortably in bed, no acute distress, Appears intoxicated and is not interested in answering questions. HEENT - Sclera anicteric, Lips dry Neck - Supple, JVP not elevated, no LAD Pulm - CTA bilaterally; no wheezes, rales, or rhonchi CV - RRR, normal S1/S2; no murmurs, rubs, or gallops Abdomen - Soft, Mild tenderness on palpation of abdomen Ext - Warm, well perfused, radial and DP pulses 2+; no clubbing, cyanosis or edema. Pain with palpation of lower extremity. Neuro - Pt is not willing to participate with exam. Still appears somewhat intoxicate, however mental status is improving. Able to move all extremities. PERRL. EOMI. Pertinent Results: Radiograph Coccyx: Normal bony mineralization and alignment. No evidence of fracture. Apparent mild sclerosis overlying the right S1, S2 region is not appreciated on the more tilted views and is likely artifactual. No evidence of fracture. Views of the L5-S1 region do show some evidence of degenerative osteophyte formation of the anterosuperior aspect of L5, probably some posterior osteophytes of the L5-S1 disc interspace. Brief Hospital Course: Pt is a 38 year old male with significant hx of EtOH/Polysubstance abuse, who presented today with EtOH intoxication and developed respiratory distress, felt to be self induced airway obstruction. . # Airway obstruction: Required a Code Blue, and at first there was concern about a allergic response, later thought to be psychogenic. It resolved without intubation. Sats remained normal. . #.EtOH Intoxication/Withdrawal: Received multiple doses of ativan and valium. No objective signs of withdrawal by time of his transfer to the MICU. Was also given MV and thiamine and folate. . #. Scabies: Found to have extensive infection. Was treated with 5% permethrin cream x 1, but will need repeat out pt treatment in one week. . #.Hep B/Hep C: Hep B infection cleared based on most recent serologies. AST>ALT on recent liver function tests, most likely was secondary to EtOH abuse. . #. Code status: DNR/DNI confirmed 2 days prior with psych . Pt leave AMA on the morning of [**2182-10-8**]. Medications on Admission: Per Discharge Summary ([**2182-6-18**]), Unknown Compliance 1. Folic Acid 1mg Daily 2. Thiamine 100mg Daily 3. MVT One tab Daily 4. Ferrous Sulfate 325mg One Tab Daily 5. Oxcarbazepine 300mg one tablet [**Hospital1 **] 6. Gabapentin 200mg PO Q8H 7. Prozac 40mg Once Daily Discharge Medications: left AMA Discharge Disposition: Home Discharge Diagnosis: Left AMA Discharge Condition: Left AMA Discharge Instructions: Left AMA Followup Instructions: Left AMA Completed by:[**2182-10-9**]",118,2182-10-07 02:09:00,2182-10-08 09:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH INTOXICATION," pt is a 38 year old male with significant hx of etoh/polysubstance abuse, who presented today with etoh intoxication and developed respiratory distress, felt to be self induced airway obstruction. . # airway obstruction: required a code blue, and at first there was concern about a allergic response, later thought to be psychogenic. it resolved without intubation. sats remained normal. . #.etoh intoxication/withdrawal: received multiple doses of ativan and valium. no objective signs of withdrawal by time of his transfer to the micu. was also given mv and thiamine and folate. . #. scabies: found to have extensive infection. was treated with 5% permethrin cream x 1, but will need repeat out pt treatment in one week. . #.hep b/hep c: hep b infection cleared based on most recent serologies. ast>alt on recent liver function tests, most likely was secondary to etoh abuse. . #. code status: dnr/dni confirmed 2 days prior with psych . pt leave ama on the morning of [**2182-10-8**]. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Suicidal ideation; Scabies; Other respiratory abnormalities; Obsessive-compulsive personality disorder; Chronic hepatitis C without mention of hepatic coma; Alcoholic polyneuropathy; Lack of housing; Dysthymic disorder]","pt is a 38 year old male with significant hx of etoh/polysubstance abuse, who presented today with etoh intoxication and developed respiratory distress, felt to be self induced airway obstruction. # airway obstruction: required a code blue, and at first there was concern about a allergic response, later thought to be psychogenic. #.hep b/hep c: hep b infection cleared based on most recent serologies.","pt is a 38 year old male with significant hx of etoh/polysubstance abuse. presented today with etoh intoxication and developed respiratory distress. received multiple doses of ativan and valium, no objective signs of withdrawal." 5060,174823.0,24307,2182-04-07,24302,184857.0,2181-11-20,Discharge summary,"Admission Date: [**2181-11-18**] Discharge Date: [**2181-11-20**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2297**] Chief Complaint: ETOH Withdrawal Major Surgical or Invasive Procedure: PICC placement ([**2181-11-19**]) History of Present Illness: 37 year old homeless man with h/o polysubstance abuse and frequent ICU admissions and ED evals returns with alcohol intoxication and withdrawal. Presented to ED s/p unwitnessed fall while intoxicated. Came in c/o L elbow and R hand pain. Also with left supraorbital laceration that was repaired in the ED. He reports currently drinking 1 bottle of Vodka and large bottle of mouthwash daily. He has a hx of withdrawal seizures as well as Section 35/Section 12 for ETOH abuse. . In the ED, initial VS: T96.6 HR 80 BP 108/73 RR16 100RA. He was monitored overnight, but noted to be progressively more tremulous and tachycardic. Also reported hallucinations. Initially was threatening to leave AMA, but agreed to stay for further treatment. Team unable to get PIVs so femoral line placed for access. He received 50mg PO valium and 2mg of Ativan IM since [**85**]:40 AM. . He was most recently admitted for EtOh withdrawal on [**11-9**] but left AMA. He returned to the ED on [**11-13**] for intoxication and was noted to have elevated amylase, lipase concerning for acute pancreatitis. Again, pt signed out AMA. . On arrival to [**Hospital Unit Name 153**], patient was tremulous, complaining of pain all over and felt like his ""skin was crawling."" Also reported chronic abdominal pain over the last several months that he attributed to excessive intake of listerine. Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Homeless, lives on streets. Denies IVDU for >10yrs. Denies cigs for>10 yrs. Denies SI or HI. He has a history of polysubstance abuse: EtOH, heroin, IVDU, benzo, h/o alcohol withdrawal seizures and DT's, h/o section 35. h/o incarceration for ETOH, estranged from family, never married, no children, homeless. Last worked 17 years ago as a grocery shelf stocker. Family History: Father with depression and alcoholism. Mother died of DM complications. Physical Exam: VS: Afebrile, BP 146/60, HR 114 RR 16 98%RA GEN: Anxious, cooperative. Neuro: AAO to person, place, time, situation. - CN ii-xii intact - motor [**6-11**] bilat upper/lower - tremulous bilateral upper ext - [**Last Name (un) 36**] to light touch intact - toes downgoing bilaterally - gait: not assessed as patient unsteady HEENT: 1.5cm laceration with sutures and associated ecchymosis and swelling of L eyebrow. Dry MM, jvp flat; Poor dentition CV: Tachycardic, reg, no murmurs RESP: CTABL, no w/r/r ABD: Soft/non distended; mild tenderness throughout, hypoactive BS Ext: R femoral line C/D/I; no edema. good pulses SKIN: No rashes Pertinent Results: [**2181-11-20**] 05:35AM BLOOD WBC-5.1 RBC-4.03* Hgb-11.9* Hct-35.1* MCV-87 MCH-29.6 MCHC-34.1 RDW-14.8 Plt Ct-190 [**2181-11-19**] 03:41AM BLOOD WBC-4.3 RBC-3.85* Hgb-11.6* Hct-33.3* MCV-87 MCH-30.2 MCHC-34.8 RDW-15.5 Plt Ct-195 [**2181-11-18**] 02:31PM BLOOD WBC-6.1 RBC-4.43* Hgb-13.2* Hct-37.8* MCV-85 MCH-29.9 MCHC-35.0 RDW-16.0* Plt Ct-272# [**2181-11-18**] 02:31PM BLOOD Neuts-32.6* Lymphs-57.1* Monos-6.0 Eos-3.2 Baso-1.2 [**2181-11-20**] 05:35AM BLOOD PT-12.0 PTT-33.4 INR(PT)-1.0 [**2181-11-20**] 05:35AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-136 K-3.8 Cl-104 HCO3-24 AnGap-12 [**2181-11-20**] 05:35AM BLOOD ALT-44* AST-72* LD(LDH)-286* [**2181-11-20**] 05:35AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9 [**2181-11-18**] 02:31PM BLOOD ASA-NEG Ethanol-137* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG Brief Hospital Course: 36M with EtOH dependence and frequent admissions for EtOH intoxication presents s/p fall with EtOH withdrawal. 1. Alcohol withdrawal: No hypertension or tachycardia this morning. Slightly agitated and with slight upper extremity tremor. Has history of hx of DTs and w/d seizures. Patient was treated with CIWA scale per prior admissions. On hospital day 3, patient signed out AMA. 2. Fall: Patient with unwitnessed fall. Radiographs negative for fracture. 3. Abdominal pain: [**Month (only) 116**] be secondary to alcoholic hepatitis though minimal elevation of LFTs. 4. Alcoholic liver disease: AST/ALT improving. No stigmata of liver disease by physical exam. [**Doctor First Name **]/lipase normal. Also has history of hepatitis B/C. 5. Anemia: Normocytic anemia, at baseline. 6. PPx: Patient treated with heparin SQ for dvt prophylaxis. 7. Access: Patient with femoral CVL placed in ED. PICC placed during admission, which was removed when patient signed out AMA. 8. Dispo: Patient signed out AMA. Medications on Admission: None Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: EtOH withdrawal Discharge Condition: Patient leaving against medical advice. Discharge Instructions: You were admitted for alcohol withdrawal and received benzodiazepines to manage your withdrawal. We recommended transfer to the regular medical floor from the ICU for continued management of your withdrawal symptoms, but you have decided to leave against our medical advice. Followup Instructions: Please follow up with your primary care doctor within the next few days. You should also seek care for substance abuse. Completed by:[**2181-11-20**]",138,2181-11-18 06:42:00,2181-11-20 12:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ALTERED MENTAL STATUS," 36m with etoh dependence and frequent admissions for etoh intoxication presents s/p fall with etoh withdrawal. 1. alcohol withdrawal: no hypertension or tachycardia this morning. slightly agitated and with slight upper extremity tremor. has history of hx of dts and w/d seizures. patient was treated with ciwa scale per prior admissions. on hospital day 3, patient signed out ama. 2. fall: patient with unwitnessed fall. radiographs negative for fracture. 3. abdominal pain: [**month (only) 116**] be secondary to alcoholic hepatitis though minimal elevation of lfts. 4. alcoholic liver disease: ast/alt improving. no stigmata of liver disease by physical exam. [**doctor first name **]/lipase normal. also has history of hepatitis b/c. 5. anemia: normocytic anemia, at baseline. 6. ppx: patient treated with heparin sq for dvt prophylaxis. 7. access: patient with femoral cvl placed in ed. picc placed during admission, which was removed when patient signed out ama. 8. dispo: patient signed out ama. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Open wound of forehead, without mention of complication; Unspecified fall; Chronic hepatitis C without mention of hepatic coma; Lack of housing; Anemia, unspecified; Acute alcoholic hepatitis; Alcoholic gastritis, without mention of hemorrhage; Hypovolemia]","36m with etoh dependence and frequent admissions for etoh intoxication presents s/p fall with etoh withdrawal. alcohol withdrawal: no hypertension or tachycardia this morning. ppx: patient treated with heparin sq for dvt prophylaxis.",36m with etoh dependence and frequent admissions for etoh intoxication present s/p fall with etoh withdrawal. no hypertension or tachycardia this morning. slightly agitated and with slight upper extremity tremor. 5060,174823.0,24307,2182-04-07,24303,197750.0,2181-12-11,Discharge summary,"Admission Date: [**2181-12-7**] Discharge Date: [**2181-12-11**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 8487**] Chief Complaint: ETOH Withdrawal, Chest, Abdominal, Arm and Hand Pain Major Surgical or Invasive Procedure: None History of Present Illness: 37yoM with hx of polysubstance abuse, frequent ICU admissions and ED evals returns with alcohol intoxication and withdrawal. Pt reports currently using ETOH, and presenting for pain from a reported trauma approx 4 days ago at which time the patient reports being hit by a SUV. He states he signed out AMA from the [**Hospital1 3278**] ICU after this accident. Pt with a hx of withdrawal seizures as well as Section 35/Section 12 for ETOH abuse. The patient reports being acutely intoxicated currently, and most recently, drinking Listerine this am. Today the patient was found lying next to [**Company 2486**] where EMS was called and we has brought to the ED. Since leaving [**Hospital1 3278**] he has spent the past few days at [**Location (un) 7073**] Station, drinking Vodka during the day and Listerine at night ""to prevent seizures"". He believes his last seizure occurred three weeks ago. He notes pain all over his body - esp in his hands, chest, abdomen and legs. . In the ED, initial VS 98.3 120/88 116 16 100%2L: In the E.D. he received Morphine 6mg, Valium 50mg, Gabapentin 600mg, Toradol 30mg, 1 banana bag and 2 additional L of NS. He was monitored, but noted to be progressively more tremulous, tachycardic and reporting visual hallucinations. . Of note the pt has had recent admissions for EtOh withdrawal on [**11-9**] but left AMA. He returned to the ED on [**11-13**] for intoxication and was noted to have elevated amylase, lipase concerning for acute pancreatitis. Again, pt signed out AMA. The pt was admitted on [**11-18**], again for acute EtOH withdrwal, and signed out AMA on [**11-20**]. . On arrival to [**Hospital Unit Name 153**]: Pt tremulous, anxious, tachy to 110s, with some visual hallucinations, however not hypertensive or febrile. Pt denies fever, + chills, headache. Admits to chronic abdominal pain of [**8-14**] months duration. Pt also admits to chest pain of one weeks duration since being hit by a car. Pt also noted recent episodes of epistaxis, although none within the past few days. . Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C (Diagnosed around [**2163**], Never treated) Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Homeless, lives on streets. Denies IVDU for >10yrs. Denies cigs for>10 yrs. Denies SI or HI. He has a history of polysubstance abuse: EtOH, heroin, IVDU, benzo, h/o alcohol withdrawal seizures and DT's, h/o section 35. h/o incarceration for ETOH, estranged from family, never married, no children, homeless. Last worked 17 years ago as a grocery shelf stocker. Family History: Father with depression and alcoholism. Mother died of DM complications. Physical Exam: VS: 98.7 113/77 89 98 3LNC GEN: Anxious, cooperative. Alert to date, name but not to location HEENT: PERRLA Dry MM, jvp flat; Poor dentition CV: Tachycardic, reg, no murmurs RESP: CTABL, no w/r/r ABD: Soft/non-distended; mild tenderness throughout, hypoactive BS Ext: 1+ Bilateral upper extremity edema. good pulses SKIN: No rashes Neuro: AOx2, (not location), CN II-XII intact, Motor [**6-11**] bilat, Tremulous bilateral upper ext Pertinent Results: Admission labs [**2181-12-7**] 05:35PM BLOOD WBC-3.5* RBC-3.97* Hgb-11.8* Hct-34.7* MCV-87 MCH-29.7 MCHC-34.0 RDW-15.4 Plt Ct-308# [**2181-12-7**] 05:35PM BLOOD Neuts-33.4* Bands-0 Lymphs-57.1* Monos-5.0 Eos-3.2 Baso-1.3 [**2181-12-7**] 05:35PM BLOOD PT-13.3 PTT-29.8 INR(PT)-1.1 [**2181-12-7**] 05:35PM BLOOD Glucose-198* UreaN-7 Creat-0.8 Na-143 K-3.8 Cl-102 HCO3-25 AnGap-20 [**2181-12-7**] 05:35PM BLOOD ALT-52* AST-101* CK(CPK)-359* AlkPhos-83 [**2181-12-7**] 05:35PM BLOOD Lipase-135* [**2181-12-7**] 05:35PM BLOOD Albumin-4.3 [**2181-12-9**] 04:24AM BLOOD TSH-3.1 [**2181-12-7**] 05:35PM BLOOD ASA-NEG Ethanol-396* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2181-12-7**]: CXR IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: Mr. [**Known lastname 24927**] is a 37M with ETOH dependence and frequent admissions for EtOH intoxication who presents with EtOH withdrawal and global pain. . # EtoH Withdrawal:On admission, the pt was A0x2. Throughout his ICU stay, he had signs of withdrawal with, tachycardia, and tremors of upper extremity bilateral. CIWAs 16-29. However, it is also notable that he knows how to manipulate the CIWA and would frequently do so in order to get increasing amounts of benzodiazepines. On [**12-11**], his CIWA was discontinued and he was told he would be transferred to the floor at which point he signout AMA. While here, he was given thiamine, MVI, folate and PRN electrolytes. . # Abdominal and Chest pain: DDx includes recent trauma (although nothing apparent on exam), acute EtOh hepatitis, pancreatitis, though minimal elevation of LFTs. Less likely cardiac given reproducible nature, and unchanged EKG. No fever or leukocytosis at this time. Lipase slightly increased from [**11-18**] (135 from 56). No evidence of ascites on recent Abd U/S. Troponins were trended. He was given oxycodone 5-10mg Q 4hrs PRN. . # Alcoholic liver disease: AST/ALT elevated in 2:1 ratio, this is his baseline. No stigmata of liver disease by physical exam. Lipase 135 normal. INR 1.1. No scopes in [**Hospital1 **] records. LFTs and coags were monitored. . # Anemia - Iron deficiency anemia baseline per [**11-9**] labs with Ferritin of 11. Hct drop from 34 to 28 in setting of 3L IVF upon admission. No active signs of bleeding, likely diluational. Hct was monitored, pt was given po iron, folate and thiamine. Medications on Admission: None Discharge Medications: Pt was not given medications nor discharge instructions as he left AMA on the morning of [**2181-12-11**]. Discharge Disposition: Home Discharge Diagnosis: . Discharge Condition: . Discharge Instructions: . Followup Instructions: . Completed by:[**2182-1-10**]",117,2181-12-08 19:58:00,2181-12-11 12:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH INTOXICATION," mr. [**known lastname 24927**] is a 37m with etoh dependence and frequent admissions for etoh intoxication who presents with etoh withdrawal and global pain. . # etoh withdrawal:on admission, the pt was a0x2. throughout his icu stay, he had signs of withdrawal with, tachycardia, and tremors of upper extremity bilateral. ciwas 16-29. however, it is also notable that he knows how to manipulate the ciwa and would frequently do so in order to get increasing amounts of benzodiazepines. on [**12-11**], his ciwa was discontinued and he was told he would be transferred to the floor at which point he signout ama. while here, he was given thiamine, mvi, folate and prn electrolytes. . # abdominal and chest pain: ddx includes recent trauma (although nothing apparent on exam), acute etoh hepatitis, pancreatitis, though minimal elevation of lfts. less likely cardiac given reproducible nature, and unchanged ekg. no fever or leukocytosis at this time. lipase slightly increased from [**11-18**] (135 from 56). no evidence of ascites on recent abd u/s. troponins were trended. he was given oxycodone 5-10mg q 4hrs prn. . # alcoholic liver disease: ast/alt elevated in 2:1 ratio, this is his baseline. no stigmata of liver disease by physical exam. lipase 135 normal. inr 1.1. no scopes in [**hospital1 **] records. lfts and coags were monitored. . # anemia - iron deficiency anemia baseline per [**11-9**] labs with ferritin of 11. hct drop from 34 to 28 in setting of 3l ivf upon admission. no active signs of bleeding, likely diluational. hct was monitored, pt was given po iron, folate and thiamine. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Iron deficiency anemia, unspecified; Depressive disorder, not elsewhere classified; Lack of housing]","known lastname 24927**] is a 37m with etoh dependence and frequent admissions for etoh intoxication who presents with etoh withdrawal and global pain. lipase slightly increased from [**11-18**] (135 from 56). # alcoholic liver disease: ast/alt elevated in 2:1 ratio, this is his baseline. hct drop from 34 to 28 in setting of 3l ivf upon admission.",mr. [**known lastname 24927**] is a 37m with etoh dependence and frequent admissions for etoh intoxication. he presents with etoh withdrawal and global pain. he was given oxycodone 5-10mg q 4hrs prn. 5060,174823.0,24307,2182-04-07,24304,135773.0,2181-12-14,Discharge summary,"Admission Date: [**2181-12-12**] Discharge Date: [**2181-12-14**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2297**] Chief Complaint: abdominal pain, alcohol withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 37 yo M with PMH of alcohol abuse with many admissions for intoxication, hepatitis B and C who was brought in by the police after being found intoxicated. He originally did not complain of any pain or other problems. Of note, he was left AMA [**2181-12-11**] from the [**Hospital Unit Name 153**] after admission for intoxication and concern for pancreatitis given elevated amlyase and lipase. . In the ED, his initial vital signs were T 100.3, BP 106/45, HR 108, RR 18, O2sat 98% RA. He was found on exam to be very tender to palpation of his abdomen with rebound and guarding. He was pan-scanned given these findings. He was given 2L NS. He was placed in a C collar for spine protection. He was given levofloxacin 750mg IV x1 prior to imaging because he complained of cough and had the low grade temp. He was given 5mg IV haldol and written for 5mg PO valium but it is unclear if he received this or not. . Currently, he is not answering very many questions. Obviously intoxicated and sleeping. Denies pain. Could not tell me how much alcohol he had today or what he drank. He usually admits to vodka and listerine as his drinks of choice. . Past Medical History: polysubstance abuse with alcohol, heroin, IVDU, benzo Hep C Hep B OCD and anxiety Depression seizures from alcohol withdrawal compartment syndrome of RLE in [**2171**] chronic bilateral hand swelling Social History: Homeless. Denies IVDU recently. Denies tobacco recently. Does have a history of both. Family History: father with depression and alcoholism. Mother had diabetes. Physical Exam: BP 105/67 HR 82 RR13 95% RA Gen: somnolent man, disheaveled, NAD HEENT: pupils 2-3mm, PERRLA, anicteric sclera, facial laceration above R eyebrow, MM dry with lip cracking. Neck with JVD or LAD. CV: RRR, no murmurs, rubs, gallops Pulm: Clear to auscultation bilaterally Abd: normoactive BS, soft, nondistended, tender to deep palpation throughout. + guarding, tender with percussion. + ecchymosis in RLQ Ext: no edema, no rashes, 2+ pulses peripherally Neuro: PERRLA. Responds to occasional questions, not following commands. No tremors, no clonus. Opens eyes to verbal stimulus. 2+ patellar reflexes. Pertinent Results: [**2181-12-12**] 08:30PM BLOOD WBC-3.7* RBC-3.34* Hgb-10.0* Hct-29.2* MCV-88 MCH-30.0 MCHC-34.3 RDW-15.8* Plt Ct-316 [**2181-12-12**] 08:30PM BLOOD Neuts-45.0* Lymphs-47.7* Monos-3.9 Eos-2.2 Baso-1.1 [**2181-12-12**] 08:30PM BLOOD Glucose-76 UreaN-11 Creat-1.0 Na-143 K-4.1 Cl-106 HCO3-29 AnGap-12 [**2181-12-12**] 08:30PM BLOOD ALT-39 AST-82* AlkPhos-69 Amylase-159* TotBili-0.2 [**2181-12-12**] 08:30PM BLOOD Lipase-80* [**2181-12-12**] 08:30PM BLOOD cTropnT-<0.01 [**2181-12-12**] 08:30PM BLOOD ASA-NEG Ethanol-304* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2181-12-12**] 08:41PM BLOOD Lactate-1.2 . [**2181-12-12**] CT Head: 1. No acute intracranial hemorrhage. 2. Cerebellar atrophy. . [**2181-12-12**] CT C-Spine: No acute fracture or malalignment of the cervical spine. Mild degenerative changes. . [**2181-12-12**] X-ray L elbow: No acute fracture or dislocation. Old healed left humeral shaft fracture partially visualized. . [**2181-12-12**] CXR: No acute cardiopulmonary process. . [**2181-12-12**] Abd/Pelvis CT: No CT evidence of pancreatitis or acute intra-abdominal or pelvic findings. Brief Hospital Course: Mr. [**Known lastname 24927**] was admitted with alcohol intoxication and abdominal pain. He had elevated amylase and lipase concerning for pancreatitis. A CT of his abdomen was negative for any abdominal pathology. Initially he was somnolent but on the day after admission he became more arousable. He received approximately 200mg of PO Valium over a 24 hour period for alcohol withdrawal. He continued to complain of abdominal pain but his abdomen was benign and CT did not show any pathology. He was not given narcotics due to concerns for interactions with benzodiazepines and alcohol. His LFTs were mildly elevated consistent with alcoholic disease. He was given multivitamins, thiamine and folate. His electrolytes were monitored; however blood draws were difficult due to poor access. Social work and addiction services were consulted. He was referred the [**Hospital1 **] Stabilization Program who was in the process of accepting him possibly friday [**12-14**] or monday [**12-17**]. An attempt was made to transfer him to the floor and when he was told this, he held his breath and O2 sats dropped to the 70s and he was tachycardic. . On [**2181-12-14**] he left the hospital against medical advice. He was informed of the risks of alcohol withdrawal, hallucinations, seizures, delerium, and death. Medications on Admission: none Discharge Medications: pt left AMA Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Alcohol Withdrawal Discharge Condition: fair Discharge Instructions: Pt left AMA prior to receiving instructions. Followup Instructions: Pt left AMA prior to receiving instructions. ",114,2181-12-12 22:29:00,2181-12-14 12:48:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,PANCREATITIS," mr. [**known lastname 24927**] was admitted with alcohol intoxication and abdominal pain. he had elevated amylase and lipase concerning for pancreatitis. a ct of his abdomen was negative for any abdominal pathology. initially he was somnolent but on the day after admission he became more arousable. he received approximately 200mg of po valium over a 24 hour period for alcohol withdrawal. he continued to complain of abdominal pain but his abdomen was benign and ct did not show any pathology. he was not given narcotics due to concerns for interactions with benzodiazepines and alcohol. his lfts were mildly elevated consistent with alcoholic disease. he was given multivitamins, thiamine and folate. his electrolytes were monitored; however blood draws were difficult due to poor access. social work and addiction services were consulted. he was referred the [**hospital1 **] stabilization program who was in the process of accepting him possibly friday [**12-14**] or monday [**12-17**]. an attempt was made to transfer him to the floor and when he was told this, he held his breath and o2 sats dropped to the 70s and he was tachycardic. . on [**2181-12-14**] he left the hospital against medical advice. he was informed of the risks of alcohol withdrawal, hallucinations, seizures, delerium, and death. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Iron deficiency anemia, unspecified; Alcoholic liver damage, unspecified; Lack of housing]","known lastname 24927**] was admitted with alcohol intoxication and abdominal pain. a ct of his abdomen was negative for any abdominal pathology. an attempt was made to transfer him to the floor and when he was told this, he held his breath and o2 sats dropped to the 70s and he was tachycardic.",mr. [**known lastname 24927**] was admitted with alcohol intoxication and abdominal pain. he received approximately 200mg of po valium over a 24 hour period for alcohol withdrawal. he continued to complain of abdominal pain but his abdomen was benign. 5060,174823.0,24307,2182-04-07,24305,196749.0,2182-01-14,Discharge summary,"Admission Date: [**2182-1-4**] Discharge Date: [**2182-1-14**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 358**] Chief Complaint: Monitoring and treatment of EtOH withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: This is a 37 year-old male with a history of alcoholism with many admissions for intoxication, Hep B+C, polysubstance abuse, and depression, who presents with intoxication. Pt reports that he drank 1 liter of listerine today as well as a fifth of vodka and then blackout. He was brought to the ED intoxicated but has no recollection of how he got to the hospital. He complains of pain at his left knee, but does not recall injuring it, and also complains of chronic abdominal tenderness (but only when someone presses on it). Denies nausea or vomiting. . In the ED, initial vitals were T 98.7, BP 123/87, HR 110, RR 16, 99% on RA. His BAL was 456. Serum tox was also positive for benzos. Urine tox was negative. The plan was initially to observe the patient overnight in the ED until he became sober. However, around 7:30pm, the attending found the patient tremulous, with HR in the 120-130s and complaining of withdrawal symptoms. He was also having visual hallucinations of mice running over his legs. Exam was only notable for some blood on his pants over his left knee and a bump on his L forehead. Neuro exam was non-focal. He remainted tachycardic with HR as high as 140s. He received a total of 15mg PO valium, 15mg IV valium, and 1mg IV ativan. Banana bag was started but PIV was not functioning well. Admitted to the ICU for further monitoring. . On arrival to the [**Hospital Unit Name 153**], the patient is very anxious. He is no longer experiencing visual hallucinations but reports that he is delirious and does not know what is going on. He is adamant that he is going to stop drinking this time and wants to go to a detox facility-- apparently his best friend died one week ago from drinking listerine. . ROS: He has been having frontal headaches for the past month since being hit by an SUV one month ago. Has also had R-sided chest pain at the site of impact from this MVC for the past month. Has broken his nose several times and has difficulty breathing from that. He also notes seeing spots in the periphery of his vision recently. He complains of gait instability when sober (less so when intoxicated) and also peripheral neuropathy in his arms and legs. The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, focal weakness, rash or skin changes. Past Medical History: polysubstance abuse with alcohol, heroin, IVDU, benzo Hep C Hep B OCD and anxiety Depression seizures from alcohol withdrawal compartment syndrome of RLE in [**2171**] chronic bilateral hand swelling Social History: Homeless. Denies IVDU recently. Denies tobacco recently. Does have a history of both. Family History: father with depression and alcoholism. Mother had diabetes. Physical Exam: Vitals: T: 98.7 BP: 138/106 HR: 132 RR: 17 O2Sat: 97% RA GEN: Disheveled male, tremulous, anxious HEENT: EOMI, PERRL, sclera anicteric, no nystagmus, no epistaxis or rhinorrhea, MMM, OP Clear, poor dentition NECK: No JVD, lymphadenopathy, trachea midline COR: tachy, regular, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, diffusely tender to palpation, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords MUSCULOSKELETAL: L knee swollen with 2 small healing lacerations and echymossis over the patella, decreased range of motion (to 90 degrees), tender to palpation over the patella and medial joint line NEURO: A+O x 2 (person, year). CN II ?????? XII grossly intact. Strength 5/5 in upper and lower extremities. Decreased sensation grossly over lower extremities. Normal finger-to-nose. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: 143 104 12 83 AGap=14 4.2 29 0.7 ALT: 60 AP: 101 Tbili: 0.3 Alb: 4.6 AST: 95 LDH: Dbili: TProt: 7.9 [**Doctor First Name **]: Lip: 134 Serum EtOH 456 Serum Benzo Pos Serum ASA, Acetmnphn, Barb, Tricyc Negative Comments: Positive Tricyclic Results Represent Potentially Toxic Levels;Therapeutic Tricyclic Levels Will Typically Have Negative Results Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative 86 5.8 12.3 313 36.3 N:40.2 L:53.0 M:3.8 E:1.6 Bas:1.4 . FINDINGS: Lungs are clear without evidence lung nodules or consolidations. No pleural effusion. Cardiomediastinal silhouette is unremarkable. Bone structures are grossly normal. IMPRESSION: Normal examination without evidence of active or inactive tuberculosis. PPD positive with >20mm reaction Brief Hospital Course: 37 year-old male with a history of alcoholism with multiple admissions for detox and history of DTs/withdrawal seizures who presents with intoxication followed by withdrawal. He received 30 mg Valium in the emergency room and was placed on a q1h CIWA in the ICU. This was transitioned to a standing valium order per his protocol on arrival to the floor. Social work was consulted. MVI/thiamine/folate were given. He was monitored on telemetry. . His lipase and transaminases were elevated during his admission, consistent with his chronic hepatitis C, in addition to alcoholic hepatitis. He had abdominal pain which was the same as on prior admissions and was likely related to alcoholic pancreatitis or gastritis, but was resolved on discharge. This improved and he was tolerating pos. . He noted knee pain as well, and an x-ray was performed which did not show a fracture. . He was started on Klonopin for anxiety, similar to previous outpatient dosing. He had a PPD placed, which was positive at >20 mm, and a CXR was performed which was negative. Unfortunately, on the day of anticipated discharge to [**Hospital1 **] for inpatient alcohol rehabilitation, he left the floor unwitnessed and did not return (AMA, although he left without risk/benefit). Medications on Admission: none chronically on klonopin, but it is frequently stolen on the street. Discharge Medications: none, AMA Discharge Disposition: Home Discharge Diagnosis: alcohol withdrawal/dependence anxiety Discharge Condition: ambulating, no longer in withdrawal Discharge Instructions: AMA Followup Instructions: AMA ",83,2182-01-04 17:40:00,2182-01-14 10:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH WITHDRAWAL," 37 year-old male with a history of alcoholism with multiple admissions for detox and history of dts/withdrawal seizures who presents with intoxication followed by withdrawal. he received 30 mg valium in the emergency room and was placed on a q1h ciwa in the icu. this was transitioned to a standing valium order per his protocol on arrival to the floor. social work was consulted. mvi/thiamine/folate were given. he was monitored on telemetry. . his lipase and transaminases were elevated during his admission, consistent with his chronic hepatitis c, in addition to alcoholic hepatitis. he had abdominal pain which was the same as on prior admissions and was likely related to alcoholic pancreatitis or gastritis, but was resolved on discharge. this improved and he was tolerating pos. . he noted knee pain as well, and an x-ray was performed which did not show a fracture. . he was started on klonopin for anxiety, similar to previous outpatient dosing. he had a ppd placed, which was positive at >20 mm, and a cxr was performed which was negative. unfortunately, on the day of anticipated discharge to [**hospital1 **] for inpatient alcohol rehabilitation, he left the floor unwitnessed and did not return (ama, although he left without risk/benefit). ","PRIMARY: [Alcohol withdrawal delirium] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic pancreatitis; Chronic hepatitis C without mention of hepatic coma; Acute alcoholic hepatitis; Acute alcoholic intoxication in alcoholism, continuous; Pain in joint, lower leg; Lack of housing; Anxiety state, unspecified; Other, mixed, or unspecified drug abuse, unspecified; ]","37 year-old male with a history of alcoholism with multiple admissions for detox and history of dts/withdrawal seizures who presents with intoxication followed by withdrawal. unfortunately, on the day of anticipated discharge to [**hospital1 **] for inpatient alcohol rehabilitation, he left the floor unwitnessed and did not return (ama, although he left without risk/benefit).",37 year-old male with a history of alcoholism with multiple admissions for detox and history of dts/withdrawal seizures who presents with intoxication followed by withdrawal. received 30 mg valium in the emergency room and was placed on a q1h ciwa in the icu. this was transitioned to a standing valium order per his protocol on arrival to the floor. his lipase and transaminases were elevated during his admission 5060,174823.0,24307,2182-04-07,24306,170299.0,2182-04-01,Discharge summary,"Admission Date: [**2182-3-30**] Discharge Date: [**2182-4-1**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2745**] Chief Complaint: alcohol intoxication Major Surgical or Invasive Procedure: none History of Present Illness: This is a 37 y.o. maln with history of alcoholism and HBV and HCV presenting with presumed intoxication and c/o chest pain complicated by development of profound agitation in the ED requiring multiple sedating meds and restraints. The patient was brought in by EMS complaining of chest pain and appearing intoxicated. Initial vital signs were 98.1, 113/79, 100, 18, 100% on RA. He received 10 mg IV valium and intermittently complained of abdominal, foot, and chest pain. He appeared comfortable slept in the ED initially, though he was put in 4 pt restraints for reasons that are somewhat unclear. Eventually, a few hours after his admission, he became quite agitated screaming for lorazepam and hydromorphone. He receieved another 10 mg diazepam to treat DT's but remained agitated and continued to yell and struggle against restraints for the next two hours. Went on to receive an additonal 20 mg diazepam then 10 mg ziprasidone and finally 5 mg haloperidol. After this last intervention the patient was once again somnolent and had a right sided femoral CVL placed. . On arrival to the floor the patient is sedated and unresponsive. Of note, he has history of multiple previous admissions to [**Hospital1 18**] to EtOH withdrawal and with various drug seeking behaviors. Past Medical History: Polysubstance abuse with alcohol, heroin, IVDU, benzo Hep C Hep B OCD and anxiety Depression seizures from alcohol withdrawal compartment syndrome of RLE in [**2171**] chronic bilateral hand swelling Social History: Homeless. Active alchohol and heroin abuse. Drinks 1 bottle of listerine and vodka daily and reports daily blackouts. Last episode of sobriety was in [**2171**] for 9 months. He reports that he has difficulty with detox because he has OCD and a fear of people which makes shelters difficult for him. He is a non-smoker Family History: father with depression and alcoholism. Mother had diabetes. Physical Exam: Vitals: T: 97.1, HR 86, BP: 117/68 HR: 132 RR: 10 O2Sat: 98% RA GEN: Slightly disheveled middle aged male asleep in bed HEENT: PERRL, sclera anicteric, mucous membranes appear dry, poor dentition NECK: No JVD, lymphadenopathy, trachea midline CV: RRR, no M/R/G; 2+ radial, DP, and PT pulses bilaterally PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: Sedated, responds to painful stimuli, unable to converse or answer questions. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2182-3-31**] CXR: Lungs are clear. Heart size normal. No pleural abnormality or evidence of central adenopathy. Lateral aspect of the right lower chest is excluded from the study. [**2182-3-31**] 04:15AM BLOOD WBC-4.0 RBC-3.59* Hgb-9.9* Hct-30.4* MCV-85 MCH-27.6 MCHC-32.6 RDW-17.1* Plt Ct-223 [**2182-3-30**] 10:30PM BLOOD WBC-3.4* RBC-3.67* Hgb-10.5* Hct-30.4* MCV-83 MCH-28.4 MCHC-34.4 RDW-16.3* Plt Ct-249 [**2182-3-30**] 10:30PM BLOOD Neuts-49.3* Lymphs-36.1 Monos-6.2 Eos-8.1* Baso-0.4 [**2182-3-31**] 11:02AM BLOOD PT-13.0 PTT-27.3 INR(PT)-1.1 [**2182-3-31**] 04:15AM BLOOD Glucose-96 UreaN-9 Creat-0.8 Na-140 K-3.7 Cl-104 HCO3-32 AnGap-8 [**2182-3-30**] 10:30PM BLOOD Glucose-85 UreaN-9 Creat-0.8 Na-144 K-3.1* Cl-106 HCO3-25 AnGap-16 [**2182-3-31**] 04:15AM BLOOD ALT-165* AST-151* LD(LDH)-243 AlkPhos-68 Amylase-68 TotBili-0.3 [**2182-3-30**] 10:30PM BLOOD CK(CPK)-500* [**2182-3-30**] 10:30PM BLOOD cTropnT-<0.01 [**2182-3-31**] 04:15AM BLOOD Phos-4.1 Mg-1.7 Iron-13* [**2182-3-31**] 04:15AM BLOOD calTIBC-338 Ferritn-53 TRF-260 [**2182-3-30**] 10:30PM BLOOD ASA-NEG Ethanol-111* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG Brief Hospital Course: 37yoM hx alcoholism, multiple admits for detox and hx of DTs/withdrawal szs, presenting with intoxication and agitation, admitted to MICU for ethanol withdrawal and monitoring. . # ETOH intoxication/AMS: 37 y.o male with history of polysubstance abues and multiple previous admits for detox/drug seeking behavior. He presented intoxicated and became very agitated in the ED requiring multiple sedating medications. The patient was given a total of 40mg of valium in the ED. In the ICU, he was given an additionl 5mg valium for anxiety. He was also given thiamine, folate, and a multivitamin. Social work was also contact[**Name (NI) **]. The patient was transferred to the medicine floor and on the am of [**4-1**] definitely appeared to be in clinical ETOH withdrawal (despite his well-documented history of faking ETOH withdrawal symptoms for benzos). The patient was aggressivley treated with 200 mg of valium in 9 hours and then determined to no longer have any clinical evidence of ETOH withdrawal (involuntary tremors). However, the patient became very agitated and anxious. The patient was again evaluated by the medicine attending and clearly deemed to not be in ETOH withdrawal anymore. His agitation and anxiety was now behavioral. The patient's femoral line was removed with plan to monitor overnight and d/c in am after shower with taxi voucher. The patient shortly thereafter eloped from the hospital. I would highly advocate that when the patient returns to [**Hospital1 18**] that he be section 25'd. Medications on Admission: . Discharge Medications: None, patient eloped Discharge Disposition: Home Discharge Diagnosis: ETOH withdrawal Patient eloped Discharge Condition: Pt eloped Discharge Instructions: Patient eloped Followup Instructions: Patient eloped. Would recommend section 25 when he eventually returns intoxicated to ED ",6,2182-03-30 22:36:00,2182-04-01 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ALCOHOL WITHDRAWAL," 37yom hx alcoholism, multiple admits for detox and hx of dts/withdrawal szs, presenting with intoxication and agitation, admitted to micu for ethanol withdrawal and monitoring. . # etoh intoxication/ams: 37 y.o male with history of polysubstance abues and multiple previous admits for detox/drug seeking behavior. he presented intoxicated and became very agitated in the ed requiring multiple sedating medications. the patient was given a total of 40mg of valium in the ed. in the icu, he was given an additionl 5mg valium for anxiety. he was also given thiamine, folate, and a multivitamin. social work was also contact[**name (ni) **]. the patient was transferred to the medicine floor and on the am of [**4-1**] definitely appeared to be in clinical etoh withdrawal (despite his well-documented history of faking etoh withdrawal symptoms for benzos). the patient was aggressivley treated with 200 mg of valium in 9 hours and then determined to no longer have any clinical evidence of etoh withdrawal (involuntary tremors). however, the patient became very agitated and anxious. the patient was again evaluated by the medicine attending and clearly deemed to not be in etoh withdrawal anymore. his agitation and anxiety was now behavioral. the patients femoral line was removed with plan to monitor overnight and d/c in am after shower with taxi voucher. the patient shortly thereafter eloped from the hospital. i would highly advocate that when the patient returns to [**hospital1 18**] that he be section 25d. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Anemia, unspecified; Lack of housing; Dysthymic disorder; Obsessive-compulsive disorders]","37yom hx alcoholism, multiple admits for detox and hx of dts/withdrawal szs, presenting with intoxication and agitation, admitted to micu for ethanol withdrawal and monitoring. the patient was aggressivley treated with 200 mg of valium in 9 hours and then determined to no longer have any clinical evidence of etoh withdrawal (involuntary tremors). however, the patient became very agitated and anxious.","37yom hx alcoholism, multiple admits for detox and hx of dts/withdrawal szs. he presented intoxicated and became very agitated in the ed. he was given a total of 40mg of valium in the ed and an additionl 5mg valium for anxiety." 5060,174823.0,24307,2182-04-07,24301,153063.0,2181-10-24,Discharge summary,"Admission Date: [**2181-10-23**] Discharge Date: [**2181-10-24**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 5893**] Chief Complaint: CC:[**CC Contact Info 61604**] Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 37YO man with long hx of alcohol abuse, with frequent ED visits/hospitalizations for same was brought to the ED today after being found by EMS sleeping on street. He reports drinking [**2-8**] pints of vodka daily. He eats very little. He also drinks listerine each night. He reports frequent falls (recent scalp lac w/ staples; abrasion over face). His ETOH level was 434 at 10:00 AM. He was given Ativan 2 mg at 6:30 in the ED for CIWA =13; then given Ativan 2 mg at 6:30pm for CIWA = 23. He was admitted to the floor for EtOH withdrawal. . On arrival to the floor, the patient was given Valium 10 mg PO and 10 mg IV over 40 minutes without improvement in his CIWA. He is transferred to the ICU for further management. . Of note, previous admission in [**Month (only) 205**] for ETOH withdrawal pt required 20mg PO valium q15min, then left AMA. . Pt not cooperative for further ROS. . Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Currently reports drinking ""at least"" a lint of vodka each morning and listerine each evening. He has a history of polysubstance abuse: EtOH, heroin, IVDU, benzo, h/o alcohol withdrawal seizures and DT's, h/o section 35. h/o incarceration for possession, estranged from family, never married, no children, homeless Family History: Possible OCD in his father. Physical Exam: Vitals: 99.3, 110/64, 115, 18, 99% RA GEN: diaphoretic, sitting in bed, anxious HEENT:hematoma on R occipital area where staples removed last week. scabb on bridge of nose and R temple. PERRLA 5mm->2mm, EOMI, throat non-erythematous, poor dentition, MMM Lungs: clear CV: tachy, rrr Abd: + bs soft, limited exam, no focal tenderness ext: + tremor, no c/c/e Pertinent Results: Labs: . 143 /103 / 11 /140 Ca: 8.8 Mg: 2.1 P: 3.3 -------------- 3.9 /31 / 0.8 . 4.7 / 13.0 / 315 N:35.4 L:50.6 M:4.4 E:7.8 Bas:1.8 ------- 39.6 . Serum EtOH 434, Serum Benzo Pos, Serum ASA, Acetmnphn, Barb, Tricyc Negative Urine Benzos Pos Urine Barbs, Opiates, Cocaine, Amphet, Mthdne Negative . Imaging: None Brief Hospital Course: In summary, Mr. [**Known lastname 24927**] is a 37 yo male with history of ETOH abuse presents with acute ETOH intoxication. . ETOH abuse. Patient has a long history of alcohol abuse, with innumerable ED visits and hospitalizations for same. Patient was initially on diazepam CIWA scale. Within twelve hours of admission, patient was requesting to leave AMA. He was evaluated by psychiatry who felt he had competence to leave AMA. He was not a candidate for section 35. Risks of leaving hospital against medical advice was discussed with the patient, but he decided to leave. Medications on Admission: None Discharge Medications: None. Patient left AMA. Discharge Disposition: Home Facility: AMA Discharge Diagnosis: Alcohol abuse. Discharge Condition: AMA Discharge Instructions: AMA Followup Instructions: AMA ",165,2181-10-23 18:54:00,2181-10-24 15:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH WITHDRAWAL," in summary, mr. [**known lastname 24927**] is a 37 yo male with history of etoh abuse presents with acute etoh intoxication. . etoh abuse. patient has a long history of alcohol abuse, with innumerable ed visits and hospitalizations for same. patient was initially on diazepam ciwa scale. within twelve hours of admission, patient was requesting to leave ama. he was evaluated by psychiatry who felt he had competence to leave ama. he was not a candidate for section 35. risks of leaving hospital against medical advice was discussed with the patient, but he decided to leave. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Alcoholic polyneuropathy; Lack of housing]","known lastname 24927**] is a 37 yo male with history of etoh abuse presents with acute etoh intoxication. patient was initially on diazepam ciwa scale.","mr. [**known lastname 24927**] is a 37 yo male with history of etoh abuse. patient has a long history of alcohol abuse, with innumerable ed visits and hospitalizations for same. within twelve hours of admission, patient was requesting to leave ama. he was evaluated by psychiatry who felt he had competence to leave." 5060,143525.0,24309,2182-10-08,24308,156497.0,2182-06-18,Discharge summary,"Admission Date: [**2182-6-13**] Discharge Date: [**2182-6-18**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 4365**] Chief Complaint: EtOH intoxication, hypertension. Major Surgical or Invasive Procedure: None History of Present Illness: Please see admission note for full details. Briefly, 37yoM w/ h/o severe alcoholism with multiple admissions for withdrawal, HBV, HCV, who was found passed out on [**6-14**] after drinking more vodka that his usual amount. He also reported a recent h/o fighting with a friend, resulting in R hand and substernal chest pain. He was admitted to the MICU after being found to be in acute withdrawal with HTN (SBP to 200s) and HR>100. MICU Course: Mr. [**Known lastname 24927**] was started on folate, thiamine, MTV, and valium prn for CIWA >10. He was found to have hypernatremia and was treated with gentle IV hydration and drinking to thirst. His musculoskeletal pain was managed with Percocet. Psychiatry was consulted on day of admission to assess patient's capacity to leave AMA. He initially agreed to voluntarily stay in the hospital and completing a Section 35 on [**6-17**], as he did not meet criteria for Section 12 for a psychiatric admission. He was reported to manipulate nurses on floor asking for higher/more frequent doses of Diazepam, with subjective complaints not necessarily correlating to changes in vital signs. Patient was reportedly [**Doctor Last Name **] high for tremor, anxiety, and reported hallucinations with consistent stable vital signs. Psychiatry recommended starting a standing Valium taper with CIWA for objective signs of withdrawal only. On arrival to the floor, the patient reported ""pain everywhere"", and when elicited, focused on chest pain. He also reported having ""withdrawal"", experiencing hot/cold flashes, skin crawling, anxiety, and tremors. He wanted more pain medicine (Percocet), and said that he would leave if he did not get adequate pain medicine. Past Medical History: 1. polysubstance abuse: ETOH, listerine, heroin, IVDU, benzodiazepines 2. ethanol abuse, hx DTs and withdrawal seizures, intubated in past 3. hepatitis C 4. hepatitis B 4. compartment syndrome RLE, [**2171**] 5. OCD and anxiety 6. depression with hx suicidal ideations and attempts 8. chronic bilateral hand swelling 9. severe peripheral neuropathy Social History: He reports drinking [**2-8**] gallon vodka and listerine daily. History of heroin, IVDU, benzodiazepine abuse, alcohol withdrawal seizures and delerium tremens. States he does not speak to any family members, never married, no children. He is currently homeless and states he does not like shelters because he gets ""nervous around all the people"". Family History: Father with depression and alcoholism. Mother died of DM complications. He reports his father had depression, alcoholism and questionable OCD. Physical Exam: VITALS: T: 97.7 BP 97/63 HR 68 RR 18 SpO2 97/RA GENERAL: lying comfortably in bed, wearing cap, sheets pulled tight over body, no obvious tremors PSYCH: Combative Pt refused all other components of PE Pertinent Results: Labs at Admission: [**2182-6-13**] 06:50PM BLOOD WBC-4.4 RBC-4.61 Hgb-12.9* Hct-39.6* MCV-86 MCH-27.9 MCHC-32.5 RDW-16.0* Plt Ct-158 [**2182-6-13**] 06:50PM BLOOD Neuts-35.6* Lymphs-56.9* Monos-2.0 Eos-4.7* Baso-0.8 [**2182-6-13**] 06:50PM BLOOD Glucose-80 UreaN-8 Creat-0.8 Na-147* K-4.2 Cl-109* HCO3-23 AnGap-19 [**2182-6-14**] 07:09PM BLOOD ALT-55* AST-90* AlkPhos-98 TotBili-0.9 [**2182-6-13**] 06:50PM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9 [**2182-6-13**] 06:50PM BLOOD ASA-NEG Ethanol-368* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG Imaging Studies: Right hand plain film ([**6-14**]): Abnormal curvilinear fragment identified just distal to the first interphalangeal joint (volar aspect) as above. Please correlate clinically, particularly on the volar aspect. This is difficult to confirm given the lack of non- localizing symptoms. CXR ([**6-14**]): Since [**2182-4-5**], lungs remain clear. The cardiomediastinal silhouette and hilar contours are unchanged, including minimal prominence of the ascending aorta, could be related to systemic hypertension. There is no pleural effusion. Brief Hospital Course: Mr. [**Known lastname 24927**] is a 37M with a PMH s/f severe alcoholism with several ICU admissions for management alchohol withdrawl in the past, HCV, and HBV, admitted to the [**Hospital Unit Name 153**] for alcohol withdrawal. # Alcohol withdrawal: The patient was maintained on a CIWA scale which required active intervention until the evening of [**6-16**]. He was also continued on Folate, Thiamine and multivitamin. As of the time of leaving the ICU, the patient had agreed to enter Detox, but Psych/Social work had also started the Section 35 process. The patient was called out to the floor after being stable on decreasing doses of valium. He was started on a standing valium taper when arriving on the floor. At time of discharge, he had no signs of objective withdrawal. He was discharged in the company of police to court for section 35 with the collaboration of psych/social work. # Hand pain: Questionable finger fracture on x-ray from recent fighting. The patient was evaluated by hand and found to not need operative intervention or splinting. Pain was controlled with percocet while inpatient. # Hypernatremia: Attributed to dehydration from EtOH abuse. The patient self corrected with PO intake and IV hydration. # Peripheral neuropathy: Attributed in the past to EtOH abuse. Recent folate and B12 within normal limits. No hx of diabetes. Pain was controlled with analgesics. Medications on Admission: (not taking any, but supposed to be on the following) Prozac (pt thinks 40 mg daily) Klonopin 1 mg TID Trileptal (dose uncertain) Remeron (dose uncertain) Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*60 Capsule(s)* Refills:*0* 7. Prozac 40 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses Alcohol withdrawal Right hand pain, no fracture Secondary Diagnoses Anemia Peripheral Neuropathy Hepatitis B Hepatitis C Discharge Condition: Patient afebrile with stable vital signs, discharged with plans for alcohol detoxification program under section 35 Discharge Instructions: You have been admitted to the hospital for alcohol withdrawal. You were discharged under section 35 with plans for detoxification program. Please take all your medications as prescribed. The following changes were made to your medication regimen. 1. Your klonopin was discontinued 2. Your remeron was discontinued 3. You were started on neurontin for pain 4. You were started on iron for your anemia 5. You were also started on thiamine, folate and multivitamins for your nutritional health Please keep all your follow up appointments as scheduled. Please seek medical attention or return to the emergency room if you experience any fevers > 101 degrees, difficulty breathing, chest pain, seizures, or any other concern symptoms. Followup Instructions: Please make an appointment to see your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. He can be reached at [**Telephone/Fax (1) 61608**]. Completed by:[**2182-6-18**]",112,2182-06-14 20:51:00,2182-06-18 11:05:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ETOH INTOXICATION," mr. [**known lastname 24927**] is a 37m with a pmh s/f severe alcoholism with several icu admissions for management alchohol withdrawl in the past, hcv, and hbv, admitted to the [**hospital unit name 153**] for alcohol withdrawal. # alcohol withdrawal: the patient was maintained on a ciwa scale which required active intervention until the evening of [**6-16**]. he was also continued on folate, thiamine and multivitamin. as of the time of leaving the icu, the patient had agreed to enter detox, but psych/social work had also started the section 35 process. the patient was called out to the floor after being stable on decreasing doses of valium. he was started on a standing valium taper when arriving on the floor. at time of discharge, he had no signs of objective withdrawal. he was discharged in the company of police to court for section 35 with the collaboration of psych/social work. # hand pain: questionable finger fracture on x-ray from recent fighting. the patient was evaluated by hand and found to not need operative intervention or splinting. pain was controlled with percocet while inpatient. # hypernatremia: attributed to dehydration from etoh abuse. the patient self corrected with po intake and iv hydration. # peripheral neuropathy: attributed in the past to etoh abuse. recent folate and b12 within normal limits. no hx of diabetes. pain was controlled with analgesics. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Hyperosmolality and/or hypernatremia; Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Unspecified essential hypertension; Anemia, unspecified; Pain in limb; Unarmed fight or brawl; Dysthymic disorder; Obsessive-compulsive disorders; Alcoholic polyneuropathy]","known lastname 24927**] is a 37m with a pmh s/f severe alcoholism with several icu admissions for management alchohol withdrawl in the past, hcv, and hbv, admitted to the [**hospital unit name 153**] for alcohol withdrawal. he was discharged in the company of police to court for section 35 with the collaboration of psych/social work. the patient self corrected with po intake and iv hydration.",a 37m man with a pmh s/f severe alcoholism was admitted to a hospital for alcohol withdrawal. he was kept on a ciwa scale which required active intervention until the evening of [**6-16**]. he was discharged in the company of police to court for section 35. 5060,148207.0,24313,2183-02-03,24311,119255.0,2182-12-13,Discharge summary,"Admission Date: [**2182-12-10**] Discharge Date: [**2182-12-13**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 1936**] Chief Complaint: EtOH withdrawal, R hand swelling/erythema Major Surgical or Invasive Procedure: [**12-11**]-R femoral central line History of Present Illness: 37 year-old homeless gentleman with a history of severe alcoholism with multiple admission to [**Hospital1 18**] for management of withdrawl, most recently d/c'ed [**2182-11-12**], also with hx of DTs, seizure, HBV, HCV, who presented to [**Hospital1 18**] BIBEMS for intoxication. The pt unfortunately does not recall any of the events surrounding how he came to the ED. Pt also states his hands and feet are numb. however he does remember drinking three pints of vodka with a friend two days ago, which is more alcohol that he usually drinks (typically one bottle of Listerine and one pint of vodka daily). He denies doing this for any specific reason; he simply wanted to forget about some of his problems. [**Name (NI) **] denies any SI or HI. The pt does report recently engaging in a ""mock fighting"" event with on of his friends. During this fight he delivered several full-force blows with his right hand, and he has subsequently developed right hand pain with swelling of the third, fourth and fifth digits. Additionally, the pt was hit in the chest full-force roughly twenty times, and now endorses a constant substernal ache. In the ED, triage VS: 95.3 160 113/86 16 100%RA. Exam revealed agitated male with swollen hands. EKG showed sinus tachycardia. EtOH level 375. He was given 10mg po diazepam followed by IV diazapam 10mg x 3. A TLC was placed for access. CXR was negative. Hand Xray negative. He was then admitted to the [**Hospital Unit Name 153**] for further care. Most recent VS: afebrile 100 117/64 18 98%. As above. No fevers or chills. The pt denies any change in vision or difficulty swallowing. No nausea or vomiting. No cough, SOB or wheeze. No abdominal pain. No dysuria or abnormal bowel movements. Past Medical History: 1. Poly Substance Abuse: Benzo/Opiates/IVDU 2. Ethanol Abuse: hx of DTs and withdrawal seizures, intubated in the past. 3. Hepatitis C 4. Hepatitis B 5. Compartment Syndrom RLE, [**2171**] 6. OCD and Anxiety 7. Depression with hx of suicidal ideations 8. Sever Peripheral Neuropathy Social History: From Mass originally. Not in contact with any family members, never married, no children. Homeless, lives at [**Location (un) 7073**] T station. Panhandles for money; has SSI and rep-payee, [**Doctor First Name **] at Community Action in Cities in [**Location (un) **] and she in turns sends him a check for $125/week to [**Location (un) 33316**] House. Currently drinks one fifth of listerine and [**2-8**] fifths rum daily. Substance use hx: Long and severe hx of alcohol with self-reported withdrawal seizures and DTs; states that when he can't use alcohol he will use other ""medications"" including BZPs and narcotics. Multiple detoxes, multiple Section 35s. Also history of opiates and IVDU. Family History: Father with depression, OCD and alcoholism. physically abused as child Mother died of DM complications. Physical Exam: Gen: Chronically ill appearing adult male, no acute distress. HEENT: PERRL, EOMI. Dry MM. Conjunctiva well pigmented. Neck: Supple, without adenopathy or JVD. No tenderness with palpation. Chest: Tender to palpation across anterior chest wall. CTAB anterior and posterior. Cor: Normal S1, S2. RRR, but mildly tachycardic with minimal exertion. No murmurs appreciated. Abdomen: Soft, non-tender and non-distended. +BS, no HSM. Extremity: Pain, moderate swelling and erythema over 3rd, 4th and 5th digits of right hand. Otherwise warm, without edema. 2+ DP pulses bilat. Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all extremities. Diminished peripheral sensation. Positive intention tremor; gain assessment deferred Pertinent Results: [**2182-12-10**] 10:02PM GLUCOSE-161* UREA N-17 CREAT-0.8 SODIUM-141 POTASSIUM-3.4 CHLORIDE-103 TOTAL CO2-20* ANION GAP-21* [**2182-12-10**] 10:02PM OSMOLAL-339* [**2182-12-10**] 10:02PM ETHANOL-206* [**2182-12-10**] 03:12PM GLUCOSE-143* UREA N-19 CREAT-1.0 SODIUM-143 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-22 ANION GAP-24* [**2182-12-10**] 03:12PM ALT(SGPT)-114* AST(SGOT)-156* CK(CPK)-441* ALK PHOS-87 TOT BILI-0.4 CXR [**2182-12-10**]: In comparison with study of [**10-5**], the heart remains within normal limits and there is no evidence of vascular congestion, pleural effusion, or acute pneumonia. HAND XRAY [**2182-12-10**]: There is equivocal soft tissue swelling in relationship to the PIP joint of the fifth finger and I cannot entirely exclude a subtle intra-articular fracture of the distal portion of this proximal phalanx. Localizing history, which is not available to me, would be helpful in this regard. Exam otherwise normal with no overt fracture or joint space narrowing. Other than the equivocal fifth finger findings there is no change from similar exam [**2182-6-13**]. Brief Hospital Course: Mr. [**Known lastname 24927**] is a 37 year-old gentleman w/ a PMH s/f severe alcoholism with several ICU admissions for management alchohol withdrawl in the past, HCV, and HBV, admitted to the [**Hospital Unit Name 153**] for alcohol withdrawal. . #. Alcohol withdrawal: He was treated in the [**Hospital Unit Name 153**] for alcohol withdrawal. He received 40 mg of valium (10 mg po x 4) thus receiving a total of 70 mg of valium over the course of 19 hours. It was noted that if the patient was left alone his VS were stable. With that objective evidence his valium was slowly decreased to to 5 mg po q 6hours for 24 hours and then d/c'ed. On [**2182-12-11**] he was also noted to have apneic episodes where he would desat to the 80s and then his sats would improve with stimulation. His last dose of valium was at 1200pm on [**2182-12-12**]. He was then sent to the floor at 2100. He no longer showed any signs of alcohol withdrawal for at least 24 hrs prior to discharge. CIWA scale was discontinued. Given his numerous admissions for substance abuse, the psychiatry team was consulted and given his poor insight among other considerations, deteriorating health in particular, felt that that he did not have capacity to decide to leave AMA and a Section 35 was completed. . # Hand pain: Questionable finger fracture on x-ray, although this location does not correspond particularly well to pt's symptoms. Treated with NSAIDs. . #. Peripheral neuropathy: Attributed in the past to EtOH abuse. Recent folate and B12 within normal limits. No hx of diabetes. Will control pain with analgesics for now; consider more definitive therapy when acute issues resolved. Repleted B12, folate, replete vitamins Medications on Admission: (not taking any, but supposed to be on the following) Prozac (pt thinks 40 mg daily) Trileptal (dose uncertain) Remeron (dose uncertain) Pt says he is on Klonopin but confirms with psych staff that he is not and should not be on this med Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 3. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Multivitamin 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 Q24H (every 24 hours). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Discharge Diagnosis: Alcohol withdrawal Substance abuse Hand pain Discharge Condition: stable, no further alcohol withdrawal Discharge Instructions: You were admitted to the hospital for alcohol withdrawal and were treated for this. You have not had any objective symptoms of withdrawal for 24 hrs and not required medications prior to discharge. You were to be treated at an inpatient facility for substance abuse. If you have symptoms of chest pain, shortness of breath, seizures, hallucinations or if your condition worsens in any way seek immediate medical attention. Please take all medications as prescribed. Followup Instructions: Follow-up with a primary care doctor at [**Telephone/Fax (1) 12802**] at [**Hospital1 3278**]/[**Hospital1 336**] or per the recommendation of your inpatient facility ",52,2182-12-10 16:45:00,2182-12-13 13:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,DISCH-TRAN TO PSYCH HOSP,ETOH WITHDRAWAL," mr. [**known lastname 24927**] is a 37 year-old gentleman w/ a pmh s/f severe alcoholism with several icu admissions for management alchohol withdrawl in the past, hcv, and hbv, admitted to the [**hospital unit name 153**] for alcohol withdrawal. . #. alcohol withdrawal: he was treated in the [**hospital unit name 153**] for alcohol withdrawal. he received 40 mg of valium (10 mg po x 4) thus receiving a total of 70 mg of valium over the course of 19 hours. it was noted that if the patient was left alone his vs were stable. with that objective evidence his valium was slowly decreased to to 5 mg po q 6hours for 24 hours and then d/ced. on [**2182-12-11**] he was also noted to have apneic episodes where he would desat to the 80s and then his sats would improve with stimulation. his last dose of valium was at 1200pm on [**2182-12-12**]. he was then sent to the floor at 2100. he no longer showed any signs of alcohol withdrawal for at least 24 hrs prior to discharge. ciwa scale was discontinued. given his numerous admissions for substance abuse, the psychiatry team was consulted and given his poor insight among other considerations, deteriorating health in particular, felt that that he did not have capacity to decide to leave ama and a section 35 was completed. . # hand pain: questionable finger fracture on x-ray, although this location does not correspond particularly well to pts symptoms. treated with nsaids. . #. peripheral neuropathy: attributed in the past to etoh abuse. recent folate and b12 within normal limits. no hx of diabetes. will control pain with analgesics for now; consider more definitive therapy when acute issues resolved. repleted b12, folate, replete vitamins ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Acidosis; Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; ; Hypovolemia; Closed fracture of middle or proximal phalanx or phalanges of hand; Unarmed fight or brawl; Sedative, hypnotic or anxiolytic dependence, continuous; Alcoholic polyneuropathy; Chronic hepatitis C without mention of hepatic coma; Dysthymic disorder; Lack of housing; Obsessive-compulsive disorders]","known lastname 24927**] is a 37 year-old gentleman w/ a pmh s/f severe alcoholism with several icu admissions for management alchohol withdrawl in the past, hcv, and hbv, admitted to the [**hospital unit name 153**] for alcohol withdrawal. alcohol withdrawal: he was treated in the [**hospital unit name 153**] for alcohol withdrawal. given his numerous admissions for substance abuse, the psychiatry team was consulted and given his poor insight among other considerations, deteriorating health in particular, felt that that he did not have capacity to decide to leave ama and a section 35 was completed.",a 37 year-old gentleman w/ a pmh s/f severe alcoholism was admitted to the [**hospital unit name 153**] for alcohol withdrawal. he received 40 mg of valium (10 mg po x 4) thus receiving a total of 70 mg of valium over the course of 19 hours. he was noted to have apneic episodes where he would desat to the 80s and then his sats would improve with stimulation. 5060,148207.0,24313,2183-02-03,24310,193317.0,2182-10-11,Discharge summary,"Admission Date: [**2182-10-10**] Discharge Date: [**2182-10-11**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 338**] Chief Complaint: alcoholic intoxication and heroin abuse Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 24927**] is a 38 yo M with PMH of polysubstance abuse who presents with acute alcoholic intoxication and heroin abuse. He was found around [**Location (un) **] station and brought to [**Hospital1 18**]. On arrival to [**Hospital1 18**], he reported also snorting heroin. In the ED, VS: T 99 BP 98/73 HR 102 RR17 99%RA. He was initially alert and awake, then became somnolent with RR of 6 and O2 sat of 70%. He received naloxone with immediate awakening. RR normalized and O2sat was normal. After several hours in [**Name (NI) **], pt became increasingly agitated and received multiple doses of valium for elevated CIWA scale, receiving total of 50mg PO. Pt has frequent visits to [**Hospital1 18**]. Was recently admitted to MICU Green on [**2182-10-5**]. At that time, seen by psychiatry who left recommendation regarding administration of benzos as patient frequently is administered high doses of benzodiazepines for drug seeking behavior. Past Medical History: Per Discharge Summary ([**2182-6-18**]) Poly Substance Abuse: Benzo/Opiates/IVDU 2. Ethanol Abuse: hx of DTs and withdrawal seizures, intubated in the past. 3. Hepatitis C 4. Hepatitis B 5. Compartment Syndrom RLE, [**2171**] 6. OCD and Anxiety 7. Depression with hx of suicidal ideations 8. Sever Peripheral Neuropathy Social History: From previous DC summary. States he does not speak to any family members, never married, no children. Homeless, states he does not like shelters because he gets ""nervous around all the people."" Family History: Father with depression, OCD and alcoholism. Mother died of DM complications Physical Exam: VS: T 96 HR 86 BP 128/79 02sat 97% RR 12 GEN: Disheveled, appears older than stated age HEENT: EOMI, PERRL NECK: Supple CHEST: CTABL CV: RRR, S1S2, no m/r/g ABD:Soft, NT, ND EXT: No c/c/e Skin: Pruritic papular rash on trunk, groin, ankles bilaterally NEURO: speech slurred, unsteady gait, CN ii-xii intact; able to answer questions appropriately . Pertinent Results: [**2182-10-10**] 03:10PM GLUCOSE-83 UREA N-12 CREAT-0.8 SODIUM-143 POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-16 [**2182-10-10**] 03:10PM estGFR-Using this [**2182-10-10**] 03:10PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.8 [**2182-10-10**] 03:10PM ASA-NEG ETHANOL-244* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2182-10-10**] 03:10PM WBC-5.1# RBC-4.36* HGB-12.5* HCT-37.7* MCV-87 MCH-28.6 MCHC-33.0 RDW-16.5* [**2182-10-10**] 03:10PM NEUTS-33.2* BANDS-0 LYMPHS-58.8* MONOS-5.5 EOS-1.6 BASOS-0.9 [**2182-10-10**] 03:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2182-10-10**] 03:10PM PLT COUNT-239 Brief Hospital Course: A/P: 38 yo M with PMH of ETOH abuse/withdrawal and multiple hospitalizations presented with acute intoxication and heroin use requiring naloxone in ED. . ETOH intoxication: ETOH level 244. Speech somewhat slurred on exam. Pt admits to drinking rum and Listerine. Received Valium 50mg total in ED for CIWA >10. Had 5mg x 3 of Valium in the MICU. Given thiamine, folate, MVI. Social work was contact[**Name (NI) **] and paperwork for a section 35 was started. Pt left AMA before paperwork could be completed (will take several days). Will need to continue paperwork if pt returns in near future. Scabies: Pt was treated with permethrin cream and Ivermectin x 1. Pt left AMA before further care was done for pt. Medications on Admission: Per Discharge Summary ([**2182-6-18**]), Unknown Compliance 1. Folic Acid 1mg Daily 2. Thiamine 100mg Daily 3. MVT One tab Daily 4. Ferrous Sulfate 325mg One Tab Daily 5. Oxcarbazepine 300mg one tablet [**Hospital1 **] 6. Gabapentin 200mg PO Q8H 7. Prozac 40mg Once Daily Discharge Medications: left AMA Discharge Disposition: Home Discharge Diagnosis: left AMA Discharge Condition: left AMA Discharge Instructions: left AMA Followup Instructions: left AMA Completed by:[**2182-10-11**]",115,2182-10-10 18:16:00,2182-10-11 13:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH WITHDRAWAL," a/p: 38 yo m with pmh of etoh abuse/withdrawal and multiple hospitalizations presented with acute intoxication and heroin use requiring naloxone in ed. . etoh intoxication: etoh level 244. speech somewhat slurred on exam. pt admits to drinking rum and listerine. received valium 50mg total in ed for ciwa >10. had 5mg x 3 of valium in the micu. given thiamine, folate, mvi. social work was contact[**name (ni) **] and paperwork for a section 35 was started. pt left ama before paperwork could be completed (will take several days). will need to continue paperwork if pt returns in near future. scabies: pt was treated with permethrin cream and ivermectin x 1. pt left ama before further care was done for pt. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Opioid abuse, unspecified; Chronic hepatitis C without mention of hepatic coma; Obsessive-compulsive disorders; Anxiety state, unspecified; Cerebral degeneration, unspecified; Lack of housing; Scabies; Alcoholic polyneuropathy]","a/p: 38 yo m with pmh of etoh abuse/withdrawal and multiple hospitalizations presented with acute intoxication and heroin use requiring naloxone in ed. pt left ama before paperwork could be completed (will take several days).",pt admitted to drinking rum and listerine. received valium 50mg total in ed for ciwa >10. left ama before further care was done for pt. 5060,119255.0,24311,2182-12-13,24309,143525.0,2182-10-08,Discharge summary,"Admission Date: [**2182-10-7**] Discharge Date: [**2182-10-8**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 338**] Chief Complaint: EtOH Intoxication Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 38 yo male with a PMH significant for Etoh and Poly substance abuse, Hep B, and Hep C. Pt was found down on the street stating that he wanted to be run over by a car. Pt recently was admitted to the MICU with EtOH intoxication yesterday, pt left AMA. In ED patient vitals were BP 93/58 - 156/89, HR 70-80s, T 98, 100% on 2L. Initially given 5mg haldol for agitation/combative behavior, later given 10mg Valium PO. No access attained. Complained of some tail bone pain which was worked up with plain film of coccyx. ED was prepared for DC however pt reported difficulty walking. Patient appears intoxicated and is not willing to answer questions. Pt does not some abdomen, back, and extremity pain globally. Past Medical History: Per Discharge Summary ([**2182-6-18**]) Poly Substance Abuse: Benzo/Opiates/IVDU 2. Ethanol Abuse: hx of DTs and withdrawal seizures, intubated in the past. 3. Hepatitis C 4. Hepatitis B 5. Compartment Syndrom RLE, [**2171**] 6. OCD and Anxiety 7. Depression with hx of suicidal ideations 8. Sever Peripheral Neuropathy Social History: From previous DC summary. States he does not speak to any family members, never married, no children. Homeless, states he does not like shelters because he gets ""nervous around all the people."" Family History: Father with depression, OCD and alcoholism. Mother died of DM complications Physical Exam: T BP 121 HR 76 RR 20 O2sat 100% on RA General - Resting comfortably in bed, no acute distress, Appears intoxicated and is not interested in answering questions. HEENT - Sclera anicteric, Lips dry Neck - Supple, JVP not elevated, no LAD Pulm - CTA bilaterally; no wheezes, rales, or rhonchi CV - RRR, normal S1/S2; no murmurs, rubs, or gallops Abdomen - Soft, Mild tenderness on palpation of abdomen Ext - Warm, well perfused, radial and DP pulses 2+; no clubbing, cyanosis or edema. Pain with palpation of lower extremity. Neuro - Pt is not willing to participate with exam. Still appears somewhat intoxicate, however mental status is improving. Able to move all extremities. PERRL. EOMI. Pertinent Results: Radiograph Coccyx: Normal bony mineralization and alignment. No evidence of fracture. Apparent mild sclerosis overlying the right S1, S2 region is not appreciated on the more tilted views and is likely artifactual. No evidence of fracture. Views of the L5-S1 region do show some evidence of degenerative osteophyte formation of the anterosuperior aspect of L5, probably some posterior osteophytes of the L5-S1 disc interspace. Brief Hospital Course: Pt is a 38 year old male with significant hx of EtOH/Polysubstance abuse, who presented today with EtOH intoxication and developed respiratory distress, felt to be self induced airway obstruction. . # Airway obstruction: Required a Code Blue, and at first there was concern about a allergic response, later thought to be psychogenic. It resolved without intubation. Sats remained normal. . #.EtOH Intoxication/Withdrawal: Received multiple doses of ativan and valium. No objective signs of withdrawal by time of his transfer to the MICU. Was also given MV and thiamine and folate. . #. Scabies: Found to have extensive infection. Was treated with 5% permethrin cream x 1, but will need repeat out pt treatment in one week. . #.Hep B/Hep C: Hep B infection cleared based on most recent serologies. AST>ALT on recent liver function tests, most likely was secondary to EtOH abuse. . #. Code status: DNR/DNI confirmed 2 days prior with psych . Pt leave AMA on the morning of [**2182-10-8**]. Medications on Admission: Per Discharge Summary ([**2182-6-18**]), Unknown Compliance 1. Folic Acid 1mg Daily 2. Thiamine 100mg Daily 3. MVT One tab Daily 4. Ferrous Sulfate 325mg One Tab Daily 5. Oxcarbazepine 300mg one tablet [**Hospital1 **] 6. Gabapentin 200mg PO Q8H 7. Prozac 40mg Once Daily Discharge Medications: left AMA Discharge Disposition: Home Discharge Diagnosis: Left AMA Discharge Condition: Left AMA Discharge Instructions: Left AMA Followup Instructions: Left AMA Completed by:[**2182-10-9**]",66,2182-10-07 02:09:00,2182-10-08 09:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH INTOXICATION," pt is a 38 year old male with significant hx of etoh/polysubstance abuse, who presented today with etoh intoxication and developed respiratory distress, felt to be self induced airway obstruction. . # airway obstruction: required a code blue, and at first there was concern about a allergic response, later thought to be psychogenic. it resolved without intubation. sats remained normal. . #.etoh intoxication/withdrawal: received multiple doses of ativan and valium. no objective signs of withdrawal by time of his transfer to the micu. was also given mv and thiamine and folate. . #. scabies: found to have extensive infection. was treated with 5% permethrin cream x 1, but will need repeat out pt treatment in one week. . #.hep b/hep c: hep b infection cleared based on most recent serologies. ast>alt on recent liver function tests, most likely was secondary to etoh abuse. . #. code status: dnr/dni confirmed 2 days prior with psych . pt leave ama on the morning of [**2182-10-8**]. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Suicidal ideation; Scabies; Other respiratory abnormalities; Obsessive-compulsive personality disorder; Chronic hepatitis C without mention of hepatic coma; Alcoholic polyneuropathy; Lack of housing; Dysthymic disorder]","pt is a 38 year old male with significant hx of etoh/polysubstance abuse, who presented today with etoh intoxication and developed respiratory distress, felt to be self induced airway obstruction. # airway obstruction: required a code blue, and at first there was concern about a allergic response, later thought to be psychogenic. #.hep b/hep c: hep b infection cleared based on most recent serologies.","pt is a 38 year old male with significant hx of etoh/polysubstance abuse. presented today with etoh intoxication and developed respiratory distress. received multiple doses of ativan and valium, no objective signs of withdrawal." 5060,119255.0,24311,2182-12-13,24308,156497.0,2182-06-18,Discharge summary,"Admission Date: [**2182-6-13**] Discharge Date: [**2182-6-18**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 4365**] Chief Complaint: EtOH intoxication, hypertension. Major Surgical or Invasive Procedure: None History of Present Illness: Please see admission note for full details. Briefly, 37yoM w/ h/o severe alcoholism with multiple admissions for withdrawal, HBV, HCV, who was found passed out on [**6-14**] after drinking more vodka that his usual amount. He also reported a recent h/o fighting with a friend, resulting in R hand and substernal chest pain. He was admitted to the MICU after being found to be in acute withdrawal with HTN (SBP to 200s) and HR>100. MICU Course: Mr. [**Known lastname 24927**] was started on folate, thiamine, MTV, and valium prn for CIWA >10. He was found to have hypernatremia and was treated with gentle IV hydration and drinking to thirst. His musculoskeletal pain was managed with Percocet. Psychiatry was consulted on day of admission to assess patient's capacity to leave AMA. He initially agreed to voluntarily stay in the hospital and completing a Section 35 on [**6-17**], as he did not meet criteria for Section 12 for a psychiatric admission. He was reported to manipulate nurses on floor asking for higher/more frequent doses of Diazepam, with subjective complaints not necessarily correlating to changes in vital signs. Patient was reportedly [**Doctor Last Name **] high for tremor, anxiety, and reported hallucinations with consistent stable vital signs. Psychiatry recommended starting a standing Valium taper with CIWA for objective signs of withdrawal only. On arrival to the floor, the patient reported ""pain everywhere"", and when elicited, focused on chest pain. He also reported having ""withdrawal"", experiencing hot/cold flashes, skin crawling, anxiety, and tremors. He wanted more pain medicine (Percocet), and said that he would leave if he did not get adequate pain medicine. Past Medical History: 1. polysubstance abuse: ETOH, listerine, heroin, IVDU, benzodiazepines 2. ethanol abuse, hx DTs and withdrawal seizures, intubated in past 3. hepatitis C 4. hepatitis B 4. compartment syndrome RLE, [**2171**] 5. OCD and anxiety 6. depression with hx suicidal ideations and attempts 8. chronic bilateral hand swelling 9. severe peripheral neuropathy Social History: He reports drinking [**2-8**] gallon vodka and listerine daily. History of heroin, IVDU, benzodiazepine abuse, alcohol withdrawal seizures and delerium tremens. States he does not speak to any family members, never married, no children. He is currently homeless and states he does not like shelters because he gets ""nervous around all the people"". Family History: Father with depression and alcoholism. Mother died of DM complications. He reports his father had depression, alcoholism and questionable OCD. Physical Exam: VITALS: T: 97.7 BP 97/63 HR 68 RR 18 SpO2 97/RA GENERAL: lying comfortably in bed, wearing cap, sheets pulled tight over body, no obvious tremors PSYCH: Combative Pt refused all other components of PE Pertinent Results: Labs at Admission: [**2182-6-13**] 06:50PM BLOOD WBC-4.4 RBC-4.61 Hgb-12.9* Hct-39.6* MCV-86 MCH-27.9 MCHC-32.5 RDW-16.0* Plt Ct-158 [**2182-6-13**] 06:50PM BLOOD Neuts-35.6* Lymphs-56.9* Monos-2.0 Eos-4.7* Baso-0.8 [**2182-6-13**] 06:50PM BLOOD Glucose-80 UreaN-8 Creat-0.8 Na-147* K-4.2 Cl-109* HCO3-23 AnGap-19 [**2182-6-14**] 07:09PM BLOOD ALT-55* AST-90* AlkPhos-98 TotBili-0.9 [**2182-6-13**] 06:50PM BLOOD Calcium-8.6 Phos-4.0 Mg-1.9 [**2182-6-13**] 06:50PM BLOOD ASA-NEG Ethanol-368* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG Imaging Studies: Right hand plain film ([**6-14**]): Abnormal curvilinear fragment identified just distal to the first interphalangeal joint (volar aspect) as above. Please correlate clinically, particularly on the volar aspect. This is difficult to confirm given the lack of non- localizing symptoms. CXR ([**6-14**]): Since [**2182-4-5**], lungs remain clear. The cardiomediastinal silhouette and hilar contours are unchanged, including minimal prominence of the ascending aorta, could be related to systemic hypertension. There is no pleural effusion. Brief Hospital Course: Mr. [**Known lastname 24927**] is a 37M with a PMH s/f severe alcoholism with several ICU admissions for management alchohol withdrawl in the past, HCV, and HBV, admitted to the [**Hospital Unit Name 153**] for alcohol withdrawal. # Alcohol withdrawal: The patient was maintained on a CIWA scale which required active intervention until the evening of [**6-16**]. He was also continued on Folate, Thiamine and multivitamin. As of the time of leaving the ICU, the patient had agreed to enter Detox, but Psych/Social work had also started the Section 35 process. The patient was called out to the floor after being stable on decreasing doses of valium. He was started on a standing valium taper when arriving on the floor. At time of discharge, he had no signs of objective withdrawal. He was discharged in the company of police to court for section 35 with the collaboration of psych/social work. # Hand pain: Questionable finger fracture on x-ray from recent fighting. The patient was evaluated by hand and found to not need operative intervention or splinting. Pain was controlled with percocet while inpatient. # Hypernatremia: Attributed to dehydration from EtOH abuse. The patient self corrected with PO intake and IV hydration. # Peripheral neuropathy: Attributed in the past to EtOH abuse. Recent folate and B12 within normal limits. No hx of diabetes. Pain was controlled with analgesics. Medications on Admission: (not taking any, but supposed to be on the following) Prozac (pt thinks 40 mg daily) Klonopin 1 mg TID Trileptal (dose uncertain) Remeron (dose uncertain) Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). Disp:*60 Capsule(s)* Refills:*0* 7. Prozac 40 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses Alcohol withdrawal Right hand pain, no fracture Secondary Diagnoses Anemia Peripheral Neuropathy Hepatitis B Hepatitis C Discharge Condition: Patient afebrile with stable vital signs, discharged with plans for alcohol detoxification program under section 35 Discharge Instructions: You have been admitted to the hospital for alcohol withdrawal. You were discharged under section 35 with plans for detoxification program. Please take all your medications as prescribed. The following changes were made to your medication regimen. 1. Your klonopin was discontinued 2. Your remeron was discontinued 3. You were started on neurontin for pain 4. You were started on iron for your anemia 5. You were also started on thiamine, folate and multivitamins for your nutritional health Please keep all your follow up appointments as scheduled. Please seek medical attention or return to the emergency room if you experience any fevers > 101 degrees, difficulty breathing, chest pain, seizures, or any other concern symptoms. Followup Instructions: Please make an appointment to see your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **]. He can be reached at [**Telephone/Fax (1) 61608**]. Completed by:[**2182-6-18**]",178,2182-06-14 20:51:00,2182-06-18 11:05:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ETOH INTOXICATION," mr. [**known lastname 24927**] is a 37m with a pmh s/f severe alcoholism with several icu admissions for management alchohol withdrawl in the past, hcv, and hbv, admitted to the [**hospital unit name 153**] for alcohol withdrawal. # alcohol withdrawal: the patient was maintained on a ciwa scale which required active intervention until the evening of [**6-16**]. he was also continued on folate, thiamine and multivitamin. as of the time of leaving the icu, the patient had agreed to enter detox, but psych/social work had also started the section 35 process. the patient was called out to the floor after being stable on decreasing doses of valium. he was started on a standing valium taper when arriving on the floor. at time of discharge, he had no signs of objective withdrawal. he was discharged in the company of police to court for section 35 with the collaboration of psych/social work. # hand pain: questionable finger fracture on x-ray from recent fighting. the patient was evaluated by hand and found to not need operative intervention or splinting. pain was controlled with percocet while inpatient. # hypernatremia: attributed to dehydration from etoh abuse. the patient self corrected with po intake and iv hydration. # peripheral neuropathy: attributed in the past to etoh abuse. recent folate and b12 within normal limits. no hx of diabetes. pain was controlled with analgesics. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Hyperosmolality and/or hypernatremia; Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Unspecified essential hypertension; Anemia, unspecified; Pain in limb; Unarmed fight or brawl; Dysthymic disorder; Obsessive-compulsive disorders; Alcoholic polyneuropathy]","known lastname 24927**] is a 37m with a pmh s/f severe alcoholism with several icu admissions for management alchohol withdrawl in the past, hcv, and hbv, admitted to the [**hospital unit name 153**] for alcohol withdrawal. he was discharged in the company of police to court for section 35 with the collaboration of psych/social work. the patient self corrected with po intake and iv hydration.",a 37m man with a pmh s/f severe alcoholism was admitted to a hospital for alcohol withdrawal. he was kept on a ciwa scale which required active intervention until the evening of [**6-16**]. he was discharged in the company of police to court for section 35. 5060,135773.0,24304,2181-12-14,24300,194191.0,2181-08-21,Discharge summary,"Admission Date: [**2181-8-20**] Discharge Date: [**2181-8-21**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2485**] Chief Complaint: etoh w/d Major Surgical or Invasive Procedure: none History of Present Illness: 36 year old homeless man with h/o polysubstance abuse and frequent ICU admissions returns with alcohol intoxication. He reports that he has been drinking daily since being released from prison on [**7-10**]. He drinks enough vodka or listerine so that he blacks out daily. He believes he was brought in by EMS or a local after he was found intoxicated. Per ED reports, he was BIBA after being found down. He was most recently admitted for EtOh withdrawal from [**2-24**] - [**3-5**] and left AMA after his valium dose was tapered. He returned on [**7-4**] with a fall but was discharged from the ED after a negative head CT. . ED: VS on arrival 98.5 114 128/62 16 97% RA. Tox was negative for cocaine, amphetamines. Serum tox was positive for etoh 448 and benzos. Had anion gap of 18 but VBG of 7.49/33/58 and lactate of 3.1. We was given 60-70 IV valium for withdrawal sx of agitation, hypertension, and tachycardia. Also received 3L IVF. . Currently, the patient reports having chest pain x1wk. he thinks he was punched in the chest and has since had intermittently dull/sharp nonradiating substernal chest pain. Now it is [**9-16**] and sharp. It is not exertional nor assoc with SOB or diaphoresis/n/v. Worse w palpation. Also reports falling and hitting right forehead 10d ago. Has had no fevers or residual HA since that time. . ROS otherwise pos for URI-like sx. no diarrhea. Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures - once sent under section 35 to prison due to concern that he was a severe threat to himself with his drinking. required intubation in the past. - has been seen recently by psychiatry in the past to evaluate for possible section 35. Social History: Drinks regularly, prefers listerine and vodka. Has been drinking heavily since release from prison on [**8-9**]. Homeless, lives on streets. Denies IVDU for >10yrs. Denies cigs for>10 yrs. Denies SI or HI Family History: Father with depression and alcoholism. Mother died of DM complications. Physical Exam: VS: 99.8 110 96% RA RR12 133/111 gen: agitated but redirectable. Neuro: aao to person, place, time, situation. - cn ii-xii intact - motor [**6-11**] bilat upper/lower - slightly tremulous upper ex - [**Last Name (un) 36**] to light touch - gait wide based and unsteady - f-n intact bilat - h-s impaired bilat heent: old scar on right forehead. mm dry, jvp flat cards: tachy, reg, no murmurs resp: ctab abd: BS+ NT ND soft, no rebound, no stigmata of liver dz Ext: no edema. good pulses Pertinent Results: EKG: Sinus tachy, nl axis, nl intervals, no acute st-t changes. . Labs: VBG: 7.49/33/58 Lactate 3.1 . 142 102 10 ----------------< 87 4.1 22 0.9 Ca: 9.4 Mg: 2.0 P: 2.9 Serum EtOH 448 Serum Benzo Pos Serum ASA, Acetmnphn, Barb, Tricyc Negative . WBC: 9.5 HCT: 35.7 - at baseline PLT: 208 N:64.2 L:30.8 M:3.5 E:1.1 Bas:0.5 Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative . Repeat chemistry: 140 108 8 -------------< 73 3.3 20 0.7 Ca: 8.0 Mg: 1.6 P: 1.9 repeat lactate 3.1 Brief Hospital Course: 36M with ETOH dependence and frequent admissions for EtOH intoxication presents with EtOH withdrawal. ICU-east course by problem: . # Alcohol withdrawal: presented with signs of withdrawal with agitation, hypertension, tachycardia, and slight tremor of upper ex bilat. Has gait unsteadiness which is likely [**3-10**] acute intox but appears to be chronic based on records. - given that he has hx of DTs and w/d seizures, we treated aggressively with valium in ICU. He received either 60-70 IV valium in the ED. On arrival to the ICU, he was written for valium 20mg PO q15m prn CIWA>10 and he received it almost as frequently as written. He became less agitated after approx 80-100mg (in addition to the IV given in the ED) and then the CIWA scale was spread out to 20mg PO prn q1h. He tolerated this transition well. - He received multivit, folate, thiamine in IVF then PO - social work was consulted the morning after admission when patient was demanding to leave. He felt he had enough valium and actually refused another dose. We explained to him that we preferred that he stay for full evaluation and treatment of etoh w/d and his electrolyte abnormalities. He expressed understanding of our concerns and was able to verbalize the risks and benefits of leaving against our advice. He signed out AMA with plans to seek outpatient treatment. . # Psych: No SI. We had plans to contact psychiatry morning after admission particularly given his high valium need. However, he expressed interest in leaving and we felt he had capacity to make this decision. Social wk was involved but psychiatry was not consulted. . # chest pain: EKG without ischemic changes. CP was reproducible on palpation. Suspected MSK pain. He received one dose of morphine for cp. We then treated with toradol, motrin, and tylenol. We would recommend avoiding narcotics in the future if at all possible and if clinically indicated. His pain improved when his agitation improved. . # elevated lactate: ddx included dehydration, infection, liver disease, hypovolemia, poor sample. Lactic acidosis not likely given the alkalosis seen on VBG. Consider dehydration vs poor quality sample. Infection less likely given no fever or hypotension or any localizing signs of infection. Repeat lactate remained 3.1. Etiology unclear and workup hindered by patient leaving AMA. . # Anion gap: AG 18 in the ED with a normal HCO3 and alkalosis on VBG. ASA negative as were other toxins. Difficult to interpret but wonder if slightly increased AG is from the elevated lactate. Repeat chemistries showed normal anion gap. . #Anemia - normocytic anemia, Hct at baseline . # PPx: Heparin sc tid, PPI given etoh abuse, bowel reg . # FEN: Regular diet, replete lytes prn, banana bag then IVF . # Access: PIV x1 . # Code: FULL . # Communication: Patient . # Dispo: Patient left AMA. Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: ETOH Intoxication/Withdrawal Discharge Condition: fair Discharge Instructions: You were admitted to the hospital because you were found intoxicated by EMS. You were admitted to the ICU and treated with Valium for withdrawal. You were advised to stay in the hospital for continued care and treatment of withdrawal however you decided against medical advice that you no longer wished to receive care. You spoke with the social worker before you left the hospital and were advised to return to [**Street Address(1) 5904**] Inn to speak with your outreach worker there. You signed out against medical advise. Followup Instructions: Please speak with the Outreach worker [**Street Address(1) 29735**] Inn. Please return to the hospital should you have any concerning symptoms including difficulty breathing, falls or injuries requiring medical attention, concerning withdrawal symptoms. ",115,2181-08-20 20:26:00,2181-08-21 11:10:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ALCOHOL WITHDRAWAL," 36m with etoh dependence and frequent admissions for etoh intoxication presents with etoh withdrawal. icu-east course by problem: . # alcohol withdrawal: presented with signs of withdrawal with agitation, hypertension, tachycardia, and slight tremor of upper ex bilat. has gait unsteadiness which is likely [**3-10**] acute intox but appears to be chronic based on records. - given that he has hx of dts and w/d seizures, we treated aggressively with valium in icu. he received either 60-70 iv valium in the ed. on arrival to the icu, he was written for valium 20mg po q15m prn ciwa>10 and he received it almost as frequently as written. he became less agitated after approx 80-100mg (in addition to the iv given in the ed) and then the ciwa scale was spread out to 20mg po prn q1h. he tolerated this transition well. - he received multivit, folate, thiamine in ivf then po - social work was consulted the morning after admission when patient was demanding to leave. he felt he had enough valium and actually refused another dose. we explained to him that we preferred that he stay for full evaluation and treatment of etoh w/d and his electrolyte abnormalities. he expressed understanding of our concerns and was able to verbalize the risks and benefits of leaving against our advice. he signed out ama with plans to seek outpatient treatment. . # psych: no si. we had plans to contact psychiatry morning after admission particularly given his high valium need. however, he expressed interest in leaving and we felt he had capacity to make this decision. social wk was involved but psychiatry was not consulted. . # chest pain: ekg without ischemic changes. cp was reproducible on palpation. suspected msk pain. he received one dose of morphine for cp. we then treated with toradol, motrin, and tylenol. we would recommend avoiding narcotics in the future if at all possible and if clinically indicated. his pain improved when his agitation improved. . # elevated lactate: ddx included dehydration, infection, liver disease, hypovolemia, poor sample. lactic acidosis not likely given the alkalosis seen on vbg. consider dehydration vs poor quality sample. infection less likely given no fever or hypotension or any localizing signs of infection. repeat lactate remained 3.1. etiology unclear and workup hindered by patient leaving ama. . # anion gap: ag 18 in the ed with a normal hco3 and alkalosis on vbg. asa negative as were other toxins. difficult to interpret but wonder if slightly increased ag is from the elevated lactate. repeat chemistries showed normal anion gap. . #anemia - normocytic anemia, hct at baseline . # ppx: heparin sc tid, ppi given etoh abuse, bowel reg . # fen: regular diet, replete lytes prn, banana bag then ivf . # access: piv x1 . # code: full . # communication: patient . # dispo: patient left ama. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Alkalosis; Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Acidosis; Chronic hepatitis C without mention of hepatic coma; Cocaine abuse, unspecified; Lack of housing; Anemia, unspecified; Other chest pain]","36m with etoh dependence and frequent admissions for etoh intoxication presents with etoh withdrawal. - he received multivit, folate, thiamine in ivf then po - social work was consulted the morning after admission when patient was demanding to leave. he signed out ama with plans to seek outpatient treatment. social wk was involved but psychiatry was not consulted. # anion gap: ag 18 in the ed with a normal hco3 and alkalosis on vbg. #anemia - normocytic anemia, hct at baseline .","36m with etoh dependence and frequent admissions for etoh intoxication presents with etoh withdrawal. presented with signs of withdrawal with agitation, hypertension, tachycardia, and slight tremor of upper ex bilat. social work was consulted the morning after admission when patient was demanding to leave." 5060,135773.0,24304,2181-12-14,24301,153063.0,2181-10-24,Discharge summary,"Admission Date: [**2181-10-23**] Discharge Date: [**2181-10-24**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 5893**] Chief Complaint: CC:[**CC Contact Info 61604**] Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 37YO man with long hx of alcohol abuse, with frequent ED visits/hospitalizations for same was brought to the ED today after being found by EMS sleeping on street. He reports drinking [**2-8**] pints of vodka daily. He eats very little. He also drinks listerine each night. He reports frequent falls (recent scalp lac w/ staples; abrasion over face). His ETOH level was 434 at 10:00 AM. He was given Ativan 2 mg at 6:30 in the ED for CIWA =13; then given Ativan 2 mg at 6:30pm for CIWA = 23. He was admitted to the floor for EtOH withdrawal. . On arrival to the floor, the patient was given Valium 10 mg PO and 10 mg IV over 40 minutes without improvement in his CIWA. He is transferred to the ICU for further management. . Of note, previous admission in [**Month (only) 205**] for ETOH withdrawal pt required 20mg PO valium q15min, then left AMA. . Pt not cooperative for further ROS. . Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Currently reports drinking ""at least"" a lint of vodka each morning and listerine each evening. He has a history of polysubstance abuse: EtOH, heroin, IVDU, benzo, h/o alcohol withdrawal seizures and DT's, h/o section 35. h/o incarceration for possession, estranged from family, never married, no children, homeless Family History: Possible OCD in his father. Physical Exam: Vitals: 99.3, 110/64, 115, 18, 99% RA GEN: diaphoretic, sitting in bed, anxious HEENT:hematoma on R occipital area where staples removed last week. scabb on bridge of nose and R temple. PERRLA 5mm->2mm, EOMI, throat non-erythematous, poor dentition, MMM Lungs: clear CV: tachy, rrr Abd: + bs soft, limited exam, no focal tenderness ext: + tremor, no c/c/e Pertinent Results: Labs: . 143 /103 / 11 /140 Ca: 8.8 Mg: 2.1 P: 3.3 -------------- 3.9 /31 / 0.8 . 4.7 / 13.0 / 315 N:35.4 L:50.6 M:4.4 E:7.8 Bas:1.8 ------- 39.6 . Serum EtOH 434, Serum Benzo Pos, Serum ASA, Acetmnphn, Barb, Tricyc Negative Urine Benzos Pos Urine Barbs, Opiates, Cocaine, Amphet, Mthdne Negative . Imaging: None Brief Hospital Course: In summary, Mr. [**Known lastname 24927**] is a 37 yo male with history of ETOH abuse presents with acute ETOH intoxication. . ETOH abuse. Patient has a long history of alcohol abuse, with innumerable ED visits and hospitalizations for same. Patient was initially on diazepam CIWA scale. Within twelve hours of admission, patient was requesting to leave AMA. He was evaluated by psychiatry who felt he had competence to leave AMA. He was not a candidate for section 35. Risks of leaving hospital against medical advice was discussed with the patient, but he decided to leave. Medications on Admission: None Discharge Medications: None. Patient left AMA. Discharge Disposition: Home Facility: AMA Discharge Diagnosis: Alcohol abuse. Discharge Condition: AMA Discharge Instructions: AMA Followup Instructions: AMA ",51,2181-10-23 18:54:00,2181-10-24 15:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH WITHDRAWAL," in summary, mr. [**known lastname 24927**] is a 37 yo male with history of etoh abuse presents with acute etoh intoxication. . etoh abuse. patient has a long history of alcohol abuse, with innumerable ed visits and hospitalizations for same. patient was initially on diazepam ciwa scale. within twelve hours of admission, patient was requesting to leave ama. he was evaluated by psychiatry who felt he had competence to leave ama. he was not a candidate for section 35. risks of leaving hospital against medical advice was discussed with the patient, but he decided to leave. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Alcoholic polyneuropathy; Lack of housing]","known lastname 24927**] is a 37 yo male with history of etoh abuse presents with acute etoh intoxication. patient was initially on diazepam ciwa scale.","mr. [**known lastname 24927**] is a 37 yo male with history of etoh abuse. patient has a long history of alcohol abuse, with innumerable ed visits and hospitalizations for same. within twelve hours of admission, patient was requesting to leave ama. he was evaluated by psychiatry who felt he had competence to leave." 5060,135773.0,24304,2181-12-14,24302,184857.0,2181-11-20,Discharge summary,"Admission Date: [**2181-11-18**] Discharge Date: [**2181-11-20**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2297**] Chief Complaint: ETOH Withdrawal Major Surgical or Invasive Procedure: PICC placement ([**2181-11-19**]) History of Present Illness: 37 year old homeless man with h/o polysubstance abuse and frequent ICU admissions and ED evals returns with alcohol intoxication and withdrawal. Presented to ED s/p unwitnessed fall while intoxicated. Came in c/o L elbow and R hand pain. Also with left supraorbital laceration that was repaired in the ED. He reports currently drinking 1 bottle of Vodka and large bottle of mouthwash daily. He has a hx of withdrawal seizures as well as Section 35/Section 12 for ETOH abuse. . In the ED, initial VS: T96.6 HR 80 BP 108/73 RR16 100RA. He was monitored overnight, but noted to be progressively more tremulous and tachycardic. Also reported hallucinations. Initially was threatening to leave AMA, but agreed to stay for further treatment. Team unable to get PIVs so femoral line placed for access. He received 50mg PO valium and 2mg of Ativan IM since [**85**]:40 AM. . He was most recently admitted for EtOh withdrawal on [**11-9**] but left AMA. He returned to the ED on [**11-13**] for intoxication and was noted to have elevated amylase, lipase concerning for acute pancreatitis. Again, pt signed out AMA. . On arrival to [**Hospital Unit Name 153**], patient was tremulous, complaining of pain all over and felt like his ""skin was crawling."" Also reported chronic abdominal pain over the last several months that he attributed to excessive intake of listerine. Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Homeless, lives on streets. Denies IVDU for >10yrs. Denies cigs for>10 yrs. Denies SI or HI. He has a history of polysubstance abuse: EtOH, heroin, IVDU, benzo, h/o alcohol withdrawal seizures and DT's, h/o section 35. h/o incarceration for ETOH, estranged from family, never married, no children, homeless. Last worked 17 years ago as a grocery shelf stocker. Family History: Father with depression and alcoholism. Mother died of DM complications. Physical Exam: VS: Afebrile, BP 146/60, HR 114 RR 16 98%RA GEN: Anxious, cooperative. Neuro: AAO to person, place, time, situation. - CN ii-xii intact - motor [**6-11**] bilat upper/lower - tremulous bilateral upper ext - [**Last Name (un) 36**] to light touch intact - toes downgoing bilaterally - gait: not assessed as patient unsteady HEENT: 1.5cm laceration with sutures and associated ecchymosis and swelling of L eyebrow. Dry MM, jvp flat; Poor dentition CV: Tachycardic, reg, no murmurs RESP: CTABL, no w/r/r ABD: Soft/non distended; mild tenderness throughout, hypoactive BS Ext: R femoral line C/D/I; no edema. good pulses SKIN: No rashes Pertinent Results: [**2181-11-20**] 05:35AM BLOOD WBC-5.1 RBC-4.03* Hgb-11.9* Hct-35.1* MCV-87 MCH-29.6 MCHC-34.1 RDW-14.8 Plt Ct-190 [**2181-11-19**] 03:41AM BLOOD WBC-4.3 RBC-3.85* Hgb-11.6* Hct-33.3* MCV-87 MCH-30.2 MCHC-34.8 RDW-15.5 Plt Ct-195 [**2181-11-18**] 02:31PM BLOOD WBC-6.1 RBC-4.43* Hgb-13.2* Hct-37.8* MCV-85 MCH-29.9 MCHC-35.0 RDW-16.0* Plt Ct-272# [**2181-11-18**] 02:31PM BLOOD Neuts-32.6* Lymphs-57.1* Monos-6.0 Eos-3.2 Baso-1.2 [**2181-11-20**] 05:35AM BLOOD PT-12.0 PTT-33.4 INR(PT)-1.0 [**2181-11-20**] 05:35AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-136 K-3.8 Cl-104 HCO3-24 AnGap-12 [**2181-11-20**] 05:35AM BLOOD ALT-44* AST-72* LD(LDH)-286* [**2181-11-20**] 05:35AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9 [**2181-11-18**] 02:31PM BLOOD ASA-NEG Ethanol-137* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG Brief Hospital Course: 36M with EtOH dependence and frequent admissions for EtOH intoxication presents s/p fall with EtOH withdrawal. 1. Alcohol withdrawal: No hypertension or tachycardia this morning. Slightly agitated and with slight upper extremity tremor. Has history of hx of DTs and w/d seizures. Patient was treated with CIWA scale per prior admissions. On hospital day 3, patient signed out AMA. 2. Fall: Patient with unwitnessed fall. Radiographs negative for fracture. 3. Abdominal pain: [**Month (only) 116**] be secondary to alcoholic hepatitis though minimal elevation of LFTs. 4. Alcoholic liver disease: AST/ALT improving. No stigmata of liver disease by physical exam. [**Doctor First Name **]/lipase normal. Also has history of hepatitis B/C. 5. Anemia: Normocytic anemia, at baseline. 6. PPx: Patient treated with heparin SQ for dvt prophylaxis. 7. Access: Patient with femoral CVL placed in ED. PICC placed during admission, which was removed when patient signed out AMA. 8. Dispo: Patient signed out AMA. Medications on Admission: None Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: EtOH withdrawal Discharge Condition: Patient leaving against medical advice. Discharge Instructions: You were admitted for alcohol withdrawal and received benzodiazepines to manage your withdrawal. We recommended transfer to the regular medical floor from the ICU for continued management of your withdrawal symptoms, but you have decided to leave against our medical advice. Followup Instructions: Please follow up with your primary care doctor within the next few days. You should also seek care for substance abuse. Completed by:[**2181-11-20**]",24,2181-11-18 06:42:00,2181-11-20 12:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ALTERED MENTAL STATUS," 36m with etoh dependence and frequent admissions for etoh intoxication presents s/p fall with etoh withdrawal. 1. alcohol withdrawal: no hypertension or tachycardia this morning. slightly agitated and with slight upper extremity tremor. has history of hx of dts and w/d seizures. patient was treated with ciwa scale per prior admissions. on hospital day 3, patient signed out ama. 2. fall: patient with unwitnessed fall. radiographs negative for fracture. 3. abdominal pain: [**month (only) 116**] be secondary to alcoholic hepatitis though minimal elevation of lfts. 4. alcoholic liver disease: ast/alt improving. no stigmata of liver disease by physical exam. [**doctor first name **]/lipase normal. also has history of hepatitis b/c. 5. anemia: normocytic anemia, at baseline. 6. ppx: patient treated with heparin sq for dvt prophylaxis. 7. access: patient with femoral cvl placed in ed. picc placed during admission, which was removed when patient signed out ama. 8. dispo: patient signed out ama. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Open wound of forehead, without mention of complication; Unspecified fall; Chronic hepatitis C without mention of hepatic coma; Lack of housing; Anemia, unspecified; Acute alcoholic hepatitis; Alcoholic gastritis, without mention of hemorrhage; Hypovolemia]","36m with etoh dependence and frequent admissions for etoh intoxication presents s/p fall with etoh withdrawal. alcohol withdrawal: no hypertension or tachycardia this morning. ppx: patient treated with heparin sq for dvt prophylaxis.",36m with etoh dependence and frequent admissions for etoh intoxication present s/p fall with etoh withdrawal. no hypertension or tachycardia this morning. slightly agitated and with slight upper extremity tremor. 5060,135773.0,24304,2181-12-14,24303,197750.0,2181-12-11,Discharge summary,"Admission Date: [**2181-12-7**] Discharge Date: [**2181-12-11**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 8487**] Chief Complaint: ETOH Withdrawal, Chest, Abdominal, Arm and Hand Pain Major Surgical or Invasive Procedure: None History of Present Illness: 37yoM with hx of polysubstance abuse, frequent ICU admissions and ED evals returns with alcohol intoxication and withdrawal. Pt reports currently using ETOH, and presenting for pain from a reported trauma approx 4 days ago at which time the patient reports being hit by a SUV. He states he signed out AMA from the [**Hospital1 3278**] ICU after this accident. Pt with a hx of withdrawal seizures as well as Section 35/Section 12 for ETOH abuse. The patient reports being acutely intoxicated currently, and most recently, drinking Listerine this am. Today the patient was found lying next to [**Company 2486**] where EMS was called and we has brought to the ED. Since leaving [**Hospital1 3278**] he has spent the past few days at [**Location (un) 7073**] Station, drinking Vodka during the day and Listerine at night ""to prevent seizures"". He believes his last seizure occurred three weeks ago. He notes pain all over his body - esp in his hands, chest, abdomen and legs. . In the ED, initial VS 98.3 120/88 116 16 100%2L: In the E.D. he received Morphine 6mg, Valium 50mg, Gabapentin 600mg, Toradol 30mg, 1 banana bag and 2 additional L of NS. He was monitored, but noted to be progressively more tremulous, tachycardic and reporting visual hallucinations. . Of note the pt has had recent admissions for EtOh withdrawal on [**11-9**] but left AMA. He returned to the ED on [**11-13**] for intoxication and was noted to have elevated amylase, lipase concerning for acute pancreatitis. Again, pt signed out AMA. The pt was admitted on [**11-18**], again for acute EtOH withdrwal, and signed out AMA on [**11-20**]. . On arrival to [**Hospital Unit Name 153**]: Pt tremulous, anxious, tachy to 110s, with some visual hallucinations, however not hypertensive or febrile. Pt denies fever, + chills, headache. Admits to chronic abdominal pain of [**8-14**] months duration. Pt also admits to chest pain of one weeks duration since being hit by a car. Pt also noted recent episodes of epistaxis, although none within the past few days. . Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C (Diagnosed around [**2163**], Never treated) Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Homeless, lives on streets. Denies IVDU for >10yrs. Denies cigs for>10 yrs. Denies SI or HI. He has a history of polysubstance abuse: EtOH, heroin, IVDU, benzo, h/o alcohol withdrawal seizures and DT's, h/o section 35. h/o incarceration for ETOH, estranged from family, never married, no children, homeless. Last worked 17 years ago as a grocery shelf stocker. Family History: Father with depression and alcoholism. Mother died of DM complications. Physical Exam: VS: 98.7 113/77 89 98 3LNC GEN: Anxious, cooperative. Alert to date, name but not to location HEENT: PERRLA Dry MM, jvp flat; Poor dentition CV: Tachycardic, reg, no murmurs RESP: CTABL, no w/r/r ABD: Soft/non-distended; mild tenderness throughout, hypoactive BS Ext: 1+ Bilateral upper extremity edema. good pulses SKIN: No rashes Neuro: AOx2, (not location), CN II-XII intact, Motor [**6-11**] bilat, Tremulous bilateral upper ext Pertinent Results: Admission labs [**2181-12-7**] 05:35PM BLOOD WBC-3.5* RBC-3.97* Hgb-11.8* Hct-34.7* MCV-87 MCH-29.7 MCHC-34.0 RDW-15.4 Plt Ct-308# [**2181-12-7**] 05:35PM BLOOD Neuts-33.4* Bands-0 Lymphs-57.1* Monos-5.0 Eos-3.2 Baso-1.3 [**2181-12-7**] 05:35PM BLOOD PT-13.3 PTT-29.8 INR(PT)-1.1 [**2181-12-7**] 05:35PM BLOOD Glucose-198* UreaN-7 Creat-0.8 Na-143 K-3.8 Cl-102 HCO3-25 AnGap-20 [**2181-12-7**] 05:35PM BLOOD ALT-52* AST-101* CK(CPK)-359* AlkPhos-83 [**2181-12-7**] 05:35PM BLOOD Lipase-135* [**2181-12-7**] 05:35PM BLOOD Albumin-4.3 [**2181-12-9**] 04:24AM BLOOD TSH-3.1 [**2181-12-7**] 05:35PM BLOOD ASA-NEG Ethanol-396* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2181-12-7**]: CXR IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: Mr. [**Known lastname 24927**] is a 37M with ETOH dependence and frequent admissions for EtOH intoxication who presents with EtOH withdrawal and global pain. . # EtoH Withdrawal:On admission, the pt was A0x2. Throughout his ICU stay, he had signs of withdrawal with, tachycardia, and tremors of upper extremity bilateral. CIWAs 16-29. However, it is also notable that he knows how to manipulate the CIWA and would frequently do so in order to get increasing amounts of benzodiazepines. On [**12-11**], his CIWA was discontinued and he was told he would be transferred to the floor at which point he signout AMA. While here, he was given thiamine, MVI, folate and PRN electrolytes. . # Abdominal and Chest pain: DDx includes recent trauma (although nothing apparent on exam), acute EtOh hepatitis, pancreatitis, though minimal elevation of LFTs. Less likely cardiac given reproducible nature, and unchanged EKG. No fever or leukocytosis at this time. Lipase slightly increased from [**11-18**] (135 from 56). No evidence of ascites on recent Abd U/S. Troponins were trended. He was given oxycodone 5-10mg Q 4hrs PRN. . # Alcoholic liver disease: AST/ALT elevated in 2:1 ratio, this is his baseline. No stigmata of liver disease by physical exam. Lipase 135 normal. INR 1.1. No scopes in [**Hospital1 **] records. LFTs and coags were monitored. . # Anemia - Iron deficiency anemia baseline per [**11-9**] labs with Ferritin of 11. Hct drop from 34 to 28 in setting of 3L IVF upon admission. No active signs of bleeding, likely diluational. Hct was monitored, pt was given po iron, folate and thiamine. Medications on Admission: None Discharge Medications: Pt was not given medications nor discharge instructions as he left AMA on the morning of [**2181-12-11**]. Discharge Disposition: Home Discharge Diagnosis: . Discharge Condition: . Discharge Instructions: . Followup Instructions: . Completed by:[**2182-1-10**]",3,2181-12-08 19:58:00,2181-12-11 12:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH INTOXICATION," mr. [**known lastname 24927**] is a 37m with etoh dependence and frequent admissions for etoh intoxication who presents with etoh withdrawal and global pain. . # etoh withdrawal:on admission, the pt was a0x2. throughout his icu stay, he had signs of withdrawal with, tachycardia, and tremors of upper extremity bilateral. ciwas 16-29. however, it is also notable that he knows how to manipulate the ciwa and would frequently do so in order to get increasing amounts of benzodiazepines. on [**12-11**], his ciwa was discontinued and he was told he would be transferred to the floor at which point he signout ama. while here, he was given thiamine, mvi, folate and prn electrolytes. . # abdominal and chest pain: ddx includes recent trauma (although nothing apparent on exam), acute etoh hepatitis, pancreatitis, though minimal elevation of lfts. less likely cardiac given reproducible nature, and unchanged ekg. no fever or leukocytosis at this time. lipase slightly increased from [**11-18**] (135 from 56). no evidence of ascites on recent abd u/s. troponins were trended. he was given oxycodone 5-10mg q 4hrs prn. . # alcoholic liver disease: ast/alt elevated in 2:1 ratio, this is his baseline. no stigmata of liver disease by physical exam. lipase 135 normal. inr 1.1. no scopes in [**hospital1 **] records. lfts and coags were monitored. . # anemia - iron deficiency anemia baseline per [**11-9**] labs with ferritin of 11. hct drop from 34 to 28 in setting of 3l ivf upon admission. no active signs of bleeding, likely diluational. hct was monitored, pt was given po iron, folate and thiamine. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Iron deficiency anemia, unspecified; Depressive disorder, not elsewhere classified; Lack of housing]","known lastname 24927**] is a 37m with etoh dependence and frequent admissions for etoh intoxication who presents with etoh withdrawal and global pain. lipase slightly increased from [**11-18**] (135 from 56). # alcoholic liver disease: ast/alt elevated in 2:1 ratio, this is his baseline. hct drop from 34 to 28 in setting of 3l ivf upon admission.",mr. [**known lastname 24927**] is a 37m with etoh dependence and frequent admissions for etoh intoxication. he presents with etoh withdrawal and global pain. he was given oxycodone 5-10mg q 4hrs prn. 5060,184857.0,24302,2181-11-20,24300,194191.0,2181-08-21,Discharge summary,"Admission Date: [**2181-8-20**] Discharge Date: [**2181-8-21**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2485**] Chief Complaint: etoh w/d Major Surgical or Invasive Procedure: none History of Present Illness: 36 year old homeless man with h/o polysubstance abuse and frequent ICU admissions returns with alcohol intoxication. He reports that he has been drinking daily since being released from prison on [**7-10**]. He drinks enough vodka or listerine so that he blacks out daily. He believes he was brought in by EMS or a local after he was found intoxicated. Per ED reports, he was BIBA after being found down. He was most recently admitted for EtOh withdrawal from [**2-24**] - [**3-5**] and left AMA after his valium dose was tapered. He returned on [**7-4**] with a fall but was discharged from the ED after a negative head CT. . ED: VS on arrival 98.5 114 128/62 16 97% RA. Tox was negative for cocaine, amphetamines. Serum tox was positive for etoh 448 and benzos. Had anion gap of 18 but VBG of 7.49/33/58 and lactate of 3.1. We was given 60-70 IV valium for withdrawal sx of agitation, hypertension, and tachycardia. Also received 3L IVF. . Currently, the patient reports having chest pain x1wk. he thinks he was punched in the chest and has since had intermittently dull/sharp nonradiating substernal chest pain. Now it is [**9-16**] and sharp. It is not exertional nor assoc with SOB or diaphoresis/n/v. Worse w palpation. Also reports falling and hitting right forehead 10d ago. Has had no fevers or residual HA since that time. . ROS otherwise pos for URI-like sx. no diarrhea. Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures - once sent under section 35 to prison due to concern that he was a severe threat to himself with his drinking. required intubation in the past. - has been seen recently by psychiatry in the past to evaluate for possible section 35. Social History: Drinks regularly, prefers listerine and vodka. Has been drinking heavily since release from prison on [**8-9**]. Homeless, lives on streets. Denies IVDU for >10yrs. Denies cigs for>10 yrs. Denies SI or HI Family History: Father with depression and alcoholism. Mother died of DM complications. Physical Exam: VS: 99.8 110 96% RA RR12 133/111 gen: agitated but redirectable. Neuro: aao to person, place, time, situation. - cn ii-xii intact - motor [**6-11**] bilat upper/lower - slightly tremulous upper ex - [**Last Name (un) 36**] to light touch - gait wide based and unsteady - f-n intact bilat - h-s impaired bilat heent: old scar on right forehead. mm dry, jvp flat cards: tachy, reg, no murmurs resp: ctab abd: BS+ NT ND soft, no rebound, no stigmata of liver dz Ext: no edema. good pulses Pertinent Results: EKG: Sinus tachy, nl axis, nl intervals, no acute st-t changes. . Labs: VBG: 7.49/33/58 Lactate 3.1 . 142 102 10 ----------------< 87 4.1 22 0.9 Ca: 9.4 Mg: 2.0 P: 2.9 Serum EtOH 448 Serum Benzo Pos Serum ASA, Acetmnphn, Barb, Tricyc Negative . WBC: 9.5 HCT: 35.7 - at baseline PLT: 208 N:64.2 L:30.8 M:3.5 E:1.1 Bas:0.5 Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative . Repeat chemistry: 140 108 8 -------------< 73 3.3 20 0.7 Ca: 8.0 Mg: 1.6 P: 1.9 repeat lactate 3.1 Brief Hospital Course: 36M with ETOH dependence and frequent admissions for EtOH intoxication presents with EtOH withdrawal. ICU-east course by problem: . # Alcohol withdrawal: presented with signs of withdrawal with agitation, hypertension, tachycardia, and slight tremor of upper ex bilat. Has gait unsteadiness which is likely [**3-10**] acute intox but appears to be chronic based on records. - given that he has hx of DTs and w/d seizures, we treated aggressively with valium in ICU. He received either 60-70 IV valium in the ED. On arrival to the ICU, he was written for valium 20mg PO q15m prn CIWA>10 and he received it almost as frequently as written. He became less agitated after approx 80-100mg (in addition to the IV given in the ED) and then the CIWA scale was spread out to 20mg PO prn q1h. He tolerated this transition well. - He received multivit, folate, thiamine in IVF then PO - social work was consulted the morning after admission when patient was demanding to leave. He felt he had enough valium and actually refused another dose. We explained to him that we preferred that he stay for full evaluation and treatment of etoh w/d and his electrolyte abnormalities. He expressed understanding of our concerns and was able to verbalize the risks and benefits of leaving against our advice. He signed out AMA with plans to seek outpatient treatment. . # Psych: No SI. We had plans to contact psychiatry morning after admission particularly given his high valium need. However, he expressed interest in leaving and we felt he had capacity to make this decision. Social wk was involved but psychiatry was not consulted. . # chest pain: EKG without ischemic changes. CP was reproducible on palpation. Suspected MSK pain. He received one dose of morphine for cp. We then treated with toradol, motrin, and tylenol. We would recommend avoiding narcotics in the future if at all possible and if clinically indicated. His pain improved when his agitation improved. . # elevated lactate: ddx included dehydration, infection, liver disease, hypovolemia, poor sample. Lactic acidosis not likely given the alkalosis seen on VBG. Consider dehydration vs poor quality sample. Infection less likely given no fever or hypotension or any localizing signs of infection. Repeat lactate remained 3.1. Etiology unclear and workup hindered by patient leaving AMA. . # Anion gap: AG 18 in the ED with a normal HCO3 and alkalosis on VBG. ASA negative as were other toxins. Difficult to interpret but wonder if slightly increased AG is from the elevated lactate. Repeat chemistries showed normal anion gap. . #Anemia - normocytic anemia, Hct at baseline . # PPx: Heparin sc tid, PPI given etoh abuse, bowel reg . # FEN: Regular diet, replete lytes prn, banana bag then IVF . # Access: PIV x1 . # Code: FULL . # Communication: Patient . # Dispo: Patient left AMA. Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: ETOH Intoxication/Withdrawal Discharge Condition: fair Discharge Instructions: You were admitted to the hospital because you were found intoxicated by EMS. You were admitted to the ICU and treated with Valium for withdrawal. You were advised to stay in the hospital for continued care and treatment of withdrawal however you decided against medical advice that you no longer wished to receive care. You spoke with the social worker before you left the hospital and were advised to return to [**Street Address(1) 5904**] Inn to speak with your outreach worker there. You signed out against medical advise. Followup Instructions: Please speak with the Outreach worker [**Street Address(1) 29735**] Inn. Please return to the hospital should you have any concerning symptoms including difficulty breathing, falls or injuries requiring medical attention, concerning withdrawal symptoms. ",91,2181-08-20 20:26:00,2181-08-21 11:10:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ALCOHOL WITHDRAWAL," 36m with etoh dependence and frequent admissions for etoh intoxication presents with etoh withdrawal. icu-east course by problem: . # alcohol withdrawal: presented with signs of withdrawal with agitation, hypertension, tachycardia, and slight tremor of upper ex bilat. has gait unsteadiness which is likely [**3-10**] acute intox but appears to be chronic based on records. - given that he has hx of dts and w/d seizures, we treated aggressively with valium in icu. he received either 60-70 iv valium in the ed. on arrival to the icu, he was written for valium 20mg po q15m prn ciwa>10 and he received it almost as frequently as written. he became less agitated after approx 80-100mg (in addition to the iv given in the ed) and then the ciwa scale was spread out to 20mg po prn q1h. he tolerated this transition well. - he received multivit, folate, thiamine in ivf then po - social work was consulted the morning after admission when patient was demanding to leave. he felt he had enough valium and actually refused another dose. we explained to him that we preferred that he stay for full evaluation and treatment of etoh w/d and his electrolyte abnormalities. he expressed understanding of our concerns and was able to verbalize the risks and benefits of leaving against our advice. he signed out ama with plans to seek outpatient treatment. . # psych: no si. we had plans to contact psychiatry morning after admission particularly given his high valium need. however, he expressed interest in leaving and we felt he had capacity to make this decision. social wk was involved but psychiatry was not consulted. . # chest pain: ekg without ischemic changes. cp was reproducible on palpation. suspected msk pain. he received one dose of morphine for cp. we then treated with toradol, motrin, and tylenol. we would recommend avoiding narcotics in the future if at all possible and if clinically indicated. his pain improved when his agitation improved. . # elevated lactate: ddx included dehydration, infection, liver disease, hypovolemia, poor sample. lactic acidosis not likely given the alkalosis seen on vbg. consider dehydration vs poor quality sample. infection less likely given no fever or hypotension or any localizing signs of infection. repeat lactate remained 3.1. etiology unclear and workup hindered by patient leaving ama. . # anion gap: ag 18 in the ed with a normal hco3 and alkalosis on vbg. asa negative as were other toxins. difficult to interpret but wonder if slightly increased ag is from the elevated lactate. repeat chemistries showed normal anion gap. . #anemia - normocytic anemia, hct at baseline . # ppx: heparin sc tid, ppi given etoh abuse, bowel reg . # fen: regular diet, replete lytes prn, banana bag then ivf . # access: piv x1 . # code: full . # communication: patient . # dispo: patient left ama. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Alkalosis; Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Acidosis; Chronic hepatitis C without mention of hepatic coma; Cocaine abuse, unspecified; Lack of housing; Anemia, unspecified; Other chest pain]","36m with etoh dependence and frequent admissions for etoh intoxication presents with etoh withdrawal. - he received multivit, folate, thiamine in ivf then po - social work was consulted the morning after admission when patient was demanding to leave. he signed out ama with plans to seek outpatient treatment. social wk was involved but psychiatry was not consulted. # anion gap: ag 18 in the ed with a normal hco3 and alkalosis on vbg. #anemia - normocytic anemia, hct at baseline .","36m with etoh dependence and frequent admissions for etoh intoxication presents with etoh withdrawal. presented with signs of withdrawal with agitation, hypertension, tachycardia, and slight tremor of upper ex bilat. social work was consulted the morning after admission when patient was demanding to leave." 5060,184857.0,24302,2181-11-20,24301,153063.0,2181-10-24,Discharge summary,"Admission Date: [**2181-10-23**] Discharge Date: [**2181-10-24**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 5893**] Chief Complaint: CC:[**CC Contact Info 61604**] Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 37YO man with long hx of alcohol abuse, with frequent ED visits/hospitalizations for same was brought to the ED today after being found by EMS sleeping on street. He reports drinking [**2-8**] pints of vodka daily. He eats very little. He also drinks listerine each night. He reports frequent falls (recent scalp lac w/ staples; abrasion over face). His ETOH level was 434 at 10:00 AM. He was given Ativan 2 mg at 6:30 in the ED for CIWA =13; then given Ativan 2 mg at 6:30pm for CIWA = 23. He was admitted to the floor for EtOH withdrawal. . On arrival to the floor, the patient was given Valium 10 mg PO and 10 mg IV over 40 minutes without improvement in his CIWA. He is transferred to the ICU for further management. . Of note, previous admission in [**Month (only) 205**] for ETOH withdrawal pt required 20mg PO valium q15min, then left AMA. . Pt not cooperative for further ROS. . Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Currently reports drinking ""at least"" a lint of vodka each morning and listerine each evening. He has a history of polysubstance abuse: EtOH, heroin, IVDU, benzo, h/o alcohol withdrawal seizures and DT's, h/o section 35. h/o incarceration for possession, estranged from family, never married, no children, homeless Family History: Possible OCD in his father. Physical Exam: Vitals: 99.3, 110/64, 115, 18, 99% RA GEN: diaphoretic, sitting in bed, anxious HEENT:hematoma on R occipital area where staples removed last week. scabb on bridge of nose and R temple. PERRLA 5mm->2mm, EOMI, throat non-erythematous, poor dentition, MMM Lungs: clear CV: tachy, rrr Abd: + bs soft, limited exam, no focal tenderness ext: + tremor, no c/c/e Pertinent Results: Labs: . 143 /103 / 11 /140 Ca: 8.8 Mg: 2.1 P: 3.3 -------------- 3.9 /31 / 0.8 . 4.7 / 13.0 / 315 N:35.4 L:50.6 M:4.4 E:7.8 Bas:1.8 ------- 39.6 . Serum EtOH 434, Serum Benzo Pos, Serum ASA, Acetmnphn, Barb, Tricyc Negative Urine Benzos Pos Urine Barbs, Opiates, Cocaine, Amphet, Mthdne Negative . Imaging: None Brief Hospital Course: In summary, Mr. [**Known lastname 24927**] is a 37 yo male with history of ETOH abuse presents with acute ETOH intoxication. . ETOH abuse. Patient has a long history of alcohol abuse, with innumerable ED visits and hospitalizations for same. Patient was initially on diazepam CIWA scale. Within twelve hours of admission, patient was requesting to leave AMA. He was evaluated by psychiatry who felt he had competence to leave AMA. He was not a candidate for section 35. Risks of leaving hospital against medical advice was discussed with the patient, but he decided to leave. Medications on Admission: None Discharge Medications: None. Patient left AMA. Discharge Disposition: Home Facility: AMA Discharge Diagnosis: Alcohol abuse. Discharge Condition: AMA Discharge Instructions: AMA Followup Instructions: AMA ",27,2181-10-23 18:54:00,2181-10-24 15:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH WITHDRAWAL," in summary, mr. [**known lastname 24927**] is a 37 yo male with history of etoh abuse presents with acute etoh intoxication. . etoh abuse. patient has a long history of alcohol abuse, with innumerable ed visits and hospitalizations for same. patient was initially on diazepam ciwa scale. within twelve hours of admission, patient was requesting to leave ama. he was evaluated by psychiatry who felt he had competence to leave ama. he was not a candidate for section 35. risks of leaving hospital against medical advice was discussed with the patient, but he decided to leave. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Alcoholic polyneuropathy; Lack of housing]","known lastname 24927**] is a 37 yo male with history of etoh abuse presents with acute etoh intoxication. patient was initially on diazepam ciwa scale.","mr. [**known lastname 24927**] is a 37 yo male with history of etoh abuse. patient has a long history of alcohol abuse, with innumerable ed visits and hospitalizations for same. within twelve hours of admission, patient was requesting to leave ama. he was evaluated by psychiatry who felt he had competence to leave." 5060,170299.0,24306,2182-04-01,24301,153063.0,2181-10-24,Discharge summary,"Admission Date: [**2181-10-23**] Discharge Date: [**2181-10-24**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 5893**] Chief Complaint: CC:[**CC Contact Info 61604**] Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 37YO man with long hx of alcohol abuse, with frequent ED visits/hospitalizations for same was brought to the ED today after being found by EMS sleeping on street. He reports drinking [**2-8**] pints of vodka daily. He eats very little. He also drinks listerine each night. He reports frequent falls (recent scalp lac w/ staples; abrasion over face). His ETOH level was 434 at 10:00 AM. He was given Ativan 2 mg at 6:30 in the ED for CIWA =13; then given Ativan 2 mg at 6:30pm for CIWA = 23. He was admitted to the floor for EtOH withdrawal. . On arrival to the floor, the patient was given Valium 10 mg PO and 10 mg IV over 40 minutes without improvement in his CIWA. He is transferred to the ICU for further management. . Of note, previous admission in [**Month (only) 205**] for ETOH withdrawal pt required 20mg PO valium q15min, then left AMA. . Pt not cooperative for further ROS. . Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Currently reports drinking ""at least"" a lint of vodka each morning and listerine each evening. He has a history of polysubstance abuse: EtOH, heroin, IVDU, benzo, h/o alcohol withdrawal seizures and DT's, h/o section 35. h/o incarceration for possession, estranged from family, never married, no children, homeless Family History: Possible OCD in his father. Physical Exam: Vitals: 99.3, 110/64, 115, 18, 99% RA GEN: diaphoretic, sitting in bed, anxious HEENT:hematoma on R occipital area where staples removed last week. scabb on bridge of nose and R temple. PERRLA 5mm->2mm, EOMI, throat non-erythematous, poor dentition, MMM Lungs: clear CV: tachy, rrr Abd: + bs soft, limited exam, no focal tenderness ext: + tremor, no c/c/e Pertinent Results: Labs: . 143 /103 / 11 /140 Ca: 8.8 Mg: 2.1 P: 3.3 -------------- 3.9 /31 / 0.8 . 4.7 / 13.0 / 315 N:35.4 L:50.6 M:4.4 E:7.8 Bas:1.8 ------- 39.6 . Serum EtOH 434, Serum Benzo Pos, Serum ASA, Acetmnphn, Barb, Tricyc Negative Urine Benzos Pos Urine Barbs, Opiates, Cocaine, Amphet, Mthdne Negative . Imaging: None Brief Hospital Course: In summary, Mr. [**Known lastname 24927**] is a 37 yo male with history of ETOH abuse presents with acute ETOH intoxication. . ETOH abuse. Patient has a long history of alcohol abuse, with innumerable ED visits and hospitalizations for same. Patient was initially on diazepam CIWA scale. Within twelve hours of admission, patient was requesting to leave AMA. He was evaluated by psychiatry who felt he had competence to leave AMA. He was not a candidate for section 35. Risks of leaving hospital against medical advice was discussed with the patient, but he decided to leave. Medications on Admission: None Discharge Medications: None. Patient left AMA. Discharge Disposition: Home Facility: AMA Discharge Diagnosis: Alcohol abuse. Discharge Condition: AMA Discharge Instructions: AMA Followup Instructions: AMA ",159,2181-10-23 18:54:00,2181-10-24 15:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH WITHDRAWAL," in summary, mr. [**known lastname 24927**] is a 37 yo male with history of etoh abuse presents with acute etoh intoxication. . etoh abuse. patient has a long history of alcohol abuse, with innumerable ed visits and hospitalizations for same. patient was initially on diazepam ciwa scale. within twelve hours of admission, patient was requesting to leave ama. he was evaluated by psychiatry who felt he had competence to leave ama. he was not a candidate for section 35. risks of leaving hospital against medical advice was discussed with the patient, but he decided to leave. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Alcoholic polyneuropathy; Lack of housing]","known lastname 24927**] is a 37 yo male with history of etoh abuse presents with acute etoh intoxication. patient was initially on diazepam ciwa scale.","mr. [**known lastname 24927**] is a 37 yo male with history of etoh abuse. patient has a long history of alcohol abuse, with innumerable ed visits and hospitalizations for same. within twelve hours of admission, patient was requesting to leave ama. he was evaluated by psychiatry who felt he had competence to leave." 5060,170299.0,24306,2182-04-01,24302,184857.0,2181-11-20,Discharge summary,"Admission Date: [**2181-11-18**] Discharge Date: [**2181-11-20**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2297**] Chief Complaint: ETOH Withdrawal Major Surgical or Invasive Procedure: PICC placement ([**2181-11-19**]) History of Present Illness: 37 year old homeless man with h/o polysubstance abuse and frequent ICU admissions and ED evals returns with alcohol intoxication and withdrawal. Presented to ED s/p unwitnessed fall while intoxicated. Came in c/o L elbow and R hand pain. Also with left supraorbital laceration that was repaired in the ED. He reports currently drinking 1 bottle of Vodka and large bottle of mouthwash daily. He has a hx of withdrawal seizures as well as Section 35/Section 12 for ETOH abuse. . In the ED, initial VS: T96.6 HR 80 BP 108/73 RR16 100RA. He was monitored overnight, but noted to be progressively more tremulous and tachycardic. Also reported hallucinations. Initially was threatening to leave AMA, but agreed to stay for further treatment. Team unable to get PIVs so femoral line placed for access. He received 50mg PO valium and 2mg of Ativan IM since [**85**]:40 AM. . He was most recently admitted for EtOh withdrawal on [**11-9**] but left AMA. He returned to the ED on [**11-13**] for intoxication and was noted to have elevated amylase, lipase concerning for acute pancreatitis. Again, pt signed out AMA. . On arrival to [**Hospital Unit Name 153**], patient was tremulous, complaining of pain all over and felt like his ""skin was crawling."" Also reported chronic abdominal pain over the last several months that he attributed to excessive intake of listerine. Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Homeless, lives on streets. Denies IVDU for >10yrs. Denies cigs for>10 yrs. Denies SI or HI. He has a history of polysubstance abuse: EtOH, heroin, IVDU, benzo, h/o alcohol withdrawal seizures and DT's, h/o section 35. h/o incarceration for ETOH, estranged from family, never married, no children, homeless. Last worked 17 years ago as a grocery shelf stocker. Family History: Father with depression and alcoholism. Mother died of DM complications. Physical Exam: VS: Afebrile, BP 146/60, HR 114 RR 16 98%RA GEN: Anxious, cooperative. Neuro: AAO to person, place, time, situation. - CN ii-xii intact - motor [**6-11**] bilat upper/lower - tremulous bilateral upper ext - [**Last Name (un) 36**] to light touch intact - toes downgoing bilaterally - gait: not assessed as patient unsteady HEENT: 1.5cm laceration with sutures and associated ecchymosis and swelling of L eyebrow. Dry MM, jvp flat; Poor dentition CV: Tachycardic, reg, no murmurs RESP: CTABL, no w/r/r ABD: Soft/non distended; mild tenderness throughout, hypoactive BS Ext: R femoral line C/D/I; no edema. good pulses SKIN: No rashes Pertinent Results: [**2181-11-20**] 05:35AM BLOOD WBC-5.1 RBC-4.03* Hgb-11.9* Hct-35.1* MCV-87 MCH-29.6 MCHC-34.1 RDW-14.8 Plt Ct-190 [**2181-11-19**] 03:41AM BLOOD WBC-4.3 RBC-3.85* Hgb-11.6* Hct-33.3* MCV-87 MCH-30.2 MCHC-34.8 RDW-15.5 Plt Ct-195 [**2181-11-18**] 02:31PM BLOOD WBC-6.1 RBC-4.43* Hgb-13.2* Hct-37.8* MCV-85 MCH-29.9 MCHC-35.0 RDW-16.0* Plt Ct-272# [**2181-11-18**] 02:31PM BLOOD Neuts-32.6* Lymphs-57.1* Monos-6.0 Eos-3.2 Baso-1.2 [**2181-11-20**] 05:35AM BLOOD PT-12.0 PTT-33.4 INR(PT)-1.0 [**2181-11-20**] 05:35AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-136 K-3.8 Cl-104 HCO3-24 AnGap-12 [**2181-11-20**] 05:35AM BLOOD ALT-44* AST-72* LD(LDH)-286* [**2181-11-20**] 05:35AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9 [**2181-11-18**] 02:31PM BLOOD ASA-NEG Ethanol-137* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG Brief Hospital Course: 36M with EtOH dependence and frequent admissions for EtOH intoxication presents s/p fall with EtOH withdrawal. 1. Alcohol withdrawal: No hypertension or tachycardia this morning. Slightly agitated and with slight upper extremity tremor. Has history of hx of DTs and w/d seizures. Patient was treated with CIWA scale per prior admissions. On hospital day 3, patient signed out AMA. 2. Fall: Patient with unwitnessed fall. Radiographs negative for fracture. 3. Abdominal pain: [**Month (only) 116**] be secondary to alcoholic hepatitis though minimal elevation of LFTs. 4. Alcoholic liver disease: AST/ALT improving. No stigmata of liver disease by physical exam. [**Doctor First Name **]/lipase normal. Also has history of hepatitis B/C. 5. Anemia: Normocytic anemia, at baseline. 6. PPx: Patient treated with heparin SQ for dvt prophylaxis. 7. Access: Patient with femoral CVL placed in ED. PICC placed during admission, which was removed when patient signed out AMA. 8. Dispo: Patient signed out AMA. Medications on Admission: None Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: EtOH withdrawal Discharge Condition: Patient leaving against medical advice. Discharge Instructions: You were admitted for alcohol withdrawal and received benzodiazepines to manage your withdrawal. We recommended transfer to the regular medical floor from the ICU for continued management of your withdrawal symptoms, but you have decided to leave against our medical advice. Followup Instructions: Please follow up with your primary care doctor within the next few days. You should also seek care for substance abuse. Completed by:[**2181-11-20**]",132,2181-11-18 06:42:00,2181-11-20 12:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ALTERED MENTAL STATUS," 36m with etoh dependence and frequent admissions for etoh intoxication presents s/p fall with etoh withdrawal. 1. alcohol withdrawal: no hypertension or tachycardia this morning. slightly agitated and with slight upper extremity tremor. has history of hx of dts and w/d seizures. patient was treated with ciwa scale per prior admissions. on hospital day 3, patient signed out ama. 2. fall: patient with unwitnessed fall. radiographs negative for fracture. 3. abdominal pain: [**month (only) 116**] be secondary to alcoholic hepatitis though minimal elevation of lfts. 4. alcoholic liver disease: ast/alt improving. no stigmata of liver disease by physical exam. [**doctor first name **]/lipase normal. also has history of hepatitis b/c. 5. anemia: normocytic anemia, at baseline. 6. ppx: patient treated with heparin sq for dvt prophylaxis. 7. access: patient with femoral cvl placed in ed. picc placed during admission, which was removed when patient signed out ama. 8. dispo: patient signed out ama. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Open wound of forehead, without mention of complication; Unspecified fall; Chronic hepatitis C without mention of hepatic coma; Lack of housing; Anemia, unspecified; Acute alcoholic hepatitis; Alcoholic gastritis, without mention of hemorrhage; Hypovolemia]","36m with etoh dependence and frequent admissions for etoh intoxication presents s/p fall with etoh withdrawal. alcohol withdrawal: no hypertension or tachycardia this morning. ppx: patient treated with heparin sq for dvt prophylaxis.",36m with etoh dependence and frequent admissions for etoh intoxication present s/p fall with etoh withdrawal. no hypertension or tachycardia this morning. slightly agitated and with slight upper extremity tremor. 5060,170299.0,24306,2182-04-01,24303,197750.0,2181-12-11,Discharge summary,"Admission Date: [**2181-12-7**] Discharge Date: [**2181-12-11**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 8487**] Chief Complaint: ETOH Withdrawal, Chest, Abdominal, Arm and Hand Pain Major Surgical or Invasive Procedure: None History of Present Illness: 37yoM with hx of polysubstance abuse, frequent ICU admissions and ED evals returns with alcohol intoxication and withdrawal. Pt reports currently using ETOH, and presenting for pain from a reported trauma approx 4 days ago at which time the patient reports being hit by a SUV. He states he signed out AMA from the [**Hospital1 3278**] ICU after this accident. Pt with a hx of withdrawal seizures as well as Section 35/Section 12 for ETOH abuse. The patient reports being acutely intoxicated currently, and most recently, drinking Listerine this am. Today the patient was found lying next to [**Company 2486**] where EMS was called and we has brought to the ED. Since leaving [**Hospital1 3278**] he has spent the past few days at [**Location (un) 7073**] Station, drinking Vodka during the day and Listerine at night ""to prevent seizures"". He believes his last seizure occurred three weeks ago. He notes pain all over his body - esp in his hands, chest, abdomen and legs. . In the ED, initial VS 98.3 120/88 116 16 100%2L: In the E.D. he received Morphine 6mg, Valium 50mg, Gabapentin 600mg, Toradol 30mg, 1 banana bag and 2 additional L of NS. He was monitored, but noted to be progressively more tremulous, tachycardic and reporting visual hallucinations. . Of note the pt has had recent admissions for EtOh withdrawal on [**11-9**] but left AMA. He returned to the ED on [**11-13**] for intoxication and was noted to have elevated amylase, lipase concerning for acute pancreatitis. Again, pt signed out AMA. The pt was admitted on [**11-18**], again for acute EtOH withdrwal, and signed out AMA on [**11-20**]. . On arrival to [**Hospital Unit Name 153**]: Pt tremulous, anxious, tachy to 110s, with some visual hallucinations, however not hypertensive or febrile. Pt denies fever, + chills, headache. Admits to chronic abdominal pain of [**8-14**] months duration. Pt also admits to chest pain of one weeks duration since being hit by a car. Pt also noted recent episodes of epistaxis, although none within the past few days. . Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C (Diagnosed around [**2163**], Never treated) Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Homeless, lives on streets. Denies IVDU for >10yrs. Denies cigs for>10 yrs. Denies SI or HI. He has a history of polysubstance abuse: EtOH, heroin, IVDU, benzo, h/o alcohol withdrawal seizures and DT's, h/o section 35. h/o incarceration for ETOH, estranged from family, never married, no children, homeless. Last worked 17 years ago as a grocery shelf stocker. Family History: Father with depression and alcoholism. Mother died of DM complications. Physical Exam: VS: 98.7 113/77 89 98 3LNC GEN: Anxious, cooperative. Alert to date, name but not to location HEENT: PERRLA Dry MM, jvp flat; Poor dentition CV: Tachycardic, reg, no murmurs RESP: CTABL, no w/r/r ABD: Soft/non-distended; mild tenderness throughout, hypoactive BS Ext: 1+ Bilateral upper extremity edema. good pulses SKIN: No rashes Neuro: AOx2, (not location), CN II-XII intact, Motor [**6-11**] bilat, Tremulous bilateral upper ext Pertinent Results: Admission labs [**2181-12-7**] 05:35PM BLOOD WBC-3.5* RBC-3.97* Hgb-11.8* Hct-34.7* MCV-87 MCH-29.7 MCHC-34.0 RDW-15.4 Plt Ct-308# [**2181-12-7**] 05:35PM BLOOD Neuts-33.4* Bands-0 Lymphs-57.1* Monos-5.0 Eos-3.2 Baso-1.3 [**2181-12-7**] 05:35PM BLOOD PT-13.3 PTT-29.8 INR(PT)-1.1 [**2181-12-7**] 05:35PM BLOOD Glucose-198* UreaN-7 Creat-0.8 Na-143 K-3.8 Cl-102 HCO3-25 AnGap-20 [**2181-12-7**] 05:35PM BLOOD ALT-52* AST-101* CK(CPK)-359* AlkPhos-83 [**2181-12-7**] 05:35PM BLOOD Lipase-135* [**2181-12-7**] 05:35PM BLOOD Albumin-4.3 [**2181-12-9**] 04:24AM BLOOD TSH-3.1 [**2181-12-7**] 05:35PM BLOOD ASA-NEG Ethanol-396* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2181-12-7**]: CXR IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: Mr. [**Known lastname 24927**] is a 37M with ETOH dependence and frequent admissions for EtOH intoxication who presents with EtOH withdrawal and global pain. . # EtoH Withdrawal:On admission, the pt was A0x2. Throughout his ICU stay, he had signs of withdrawal with, tachycardia, and tremors of upper extremity bilateral. CIWAs 16-29. However, it is also notable that he knows how to manipulate the CIWA and would frequently do so in order to get increasing amounts of benzodiazepines. On [**12-11**], his CIWA was discontinued and he was told he would be transferred to the floor at which point he signout AMA. While here, he was given thiamine, MVI, folate and PRN electrolytes. . # Abdominal and Chest pain: DDx includes recent trauma (although nothing apparent on exam), acute EtOh hepatitis, pancreatitis, though minimal elevation of LFTs. Less likely cardiac given reproducible nature, and unchanged EKG. No fever or leukocytosis at this time. Lipase slightly increased from [**11-18**] (135 from 56). No evidence of ascites on recent Abd U/S. Troponins were trended. He was given oxycodone 5-10mg Q 4hrs PRN. . # Alcoholic liver disease: AST/ALT elevated in 2:1 ratio, this is his baseline. No stigmata of liver disease by physical exam. Lipase 135 normal. INR 1.1. No scopes in [**Hospital1 **] records. LFTs and coags were monitored. . # Anemia - Iron deficiency anemia baseline per [**11-9**] labs with Ferritin of 11. Hct drop from 34 to 28 in setting of 3L IVF upon admission. No active signs of bleeding, likely diluational. Hct was monitored, pt was given po iron, folate and thiamine. Medications on Admission: None Discharge Medications: Pt was not given medications nor discharge instructions as he left AMA on the morning of [**2181-12-11**]. Discharge Disposition: Home Discharge Diagnosis: . Discharge Condition: . Discharge Instructions: . Followup Instructions: . Completed by:[**2182-1-10**]",111,2181-12-08 19:58:00,2181-12-11 12:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH INTOXICATION," mr. [**known lastname 24927**] is a 37m with etoh dependence and frequent admissions for etoh intoxication who presents with etoh withdrawal and global pain. . # etoh withdrawal:on admission, the pt was a0x2. throughout his icu stay, he had signs of withdrawal with, tachycardia, and tremors of upper extremity bilateral. ciwas 16-29. however, it is also notable that he knows how to manipulate the ciwa and would frequently do so in order to get increasing amounts of benzodiazepines. on [**12-11**], his ciwa was discontinued and he was told he would be transferred to the floor at which point he signout ama. while here, he was given thiamine, mvi, folate and prn electrolytes. . # abdominal and chest pain: ddx includes recent trauma (although nothing apparent on exam), acute etoh hepatitis, pancreatitis, though minimal elevation of lfts. less likely cardiac given reproducible nature, and unchanged ekg. no fever or leukocytosis at this time. lipase slightly increased from [**11-18**] (135 from 56). no evidence of ascites on recent abd u/s. troponins were trended. he was given oxycodone 5-10mg q 4hrs prn. . # alcoholic liver disease: ast/alt elevated in 2:1 ratio, this is his baseline. no stigmata of liver disease by physical exam. lipase 135 normal. inr 1.1. no scopes in [**hospital1 **] records. lfts and coags were monitored. . # anemia - iron deficiency anemia baseline per [**11-9**] labs with ferritin of 11. hct drop from 34 to 28 in setting of 3l ivf upon admission. no active signs of bleeding, likely diluational. hct was monitored, pt was given po iron, folate and thiamine. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Iron deficiency anemia, unspecified; Depressive disorder, not elsewhere classified; Lack of housing]","known lastname 24927**] is a 37m with etoh dependence and frequent admissions for etoh intoxication who presents with etoh withdrawal and global pain. lipase slightly increased from [**11-18**] (135 from 56). # alcoholic liver disease: ast/alt elevated in 2:1 ratio, this is his baseline. hct drop from 34 to 28 in setting of 3l ivf upon admission.",mr. [**known lastname 24927**] is a 37m with etoh dependence and frequent admissions for etoh intoxication. he presents with etoh withdrawal and global pain. he was given oxycodone 5-10mg q 4hrs prn. 5060,170299.0,24306,2182-04-01,24304,135773.0,2181-12-14,Discharge summary,"Admission Date: [**2181-12-12**] Discharge Date: [**2181-12-14**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2297**] Chief Complaint: abdominal pain, alcohol withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 37 yo M with PMH of alcohol abuse with many admissions for intoxication, hepatitis B and C who was brought in by the police after being found intoxicated. He originally did not complain of any pain or other problems. Of note, he was left AMA [**2181-12-11**] from the [**Hospital Unit Name 153**] after admission for intoxication and concern for pancreatitis given elevated amlyase and lipase. . In the ED, his initial vital signs were T 100.3, BP 106/45, HR 108, RR 18, O2sat 98% RA. He was found on exam to be very tender to palpation of his abdomen with rebound and guarding. He was pan-scanned given these findings. He was given 2L NS. He was placed in a C collar for spine protection. He was given levofloxacin 750mg IV x1 prior to imaging because he complained of cough and had the low grade temp. He was given 5mg IV haldol and written for 5mg PO valium but it is unclear if he received this or not. . Currently, he is not answering very many questions. Obviously intoxicated and sleeping. Denies pain. Could not tell me how much alcohol he had today or what he drank. He usually admits to vodka and listerine as his drinks of choice. . Past Medical History: polysubstance abuse with alcohol, heroin, IVDU, benzo Hep C Hep B OCD and anxiety Depression seizures from alcohol withdrawal compartment syndrome of RLE in [**2171**] chronic bilateral hand swelling Social History: Homeless. Denies IVDU recently. Denies tobacco recently. Does have a history of both. Family History: father with depression and alcoholism. Mother had diabetes. Physical Exam: BP 105/67 HR 82 RR13 95% RA Gen: somnolent man, disheaveled, NAD HEENT: pupils 2-3mm, PERRLA, anicteric sclera, facial laceration above R eyebrow, MM dry with lip cracking. Neck with JVD or LAD. CV: RRR, no murmurs, rubs, gallops Pulm: Clear to auscultation bilaterally Abd: normoactive BS, soft, nondistended, tender to deep palpation throughout. + guarding, tender with percussion. + ecchymosis in RLQ Ext: no edema, no rashes, 2+ pulses peripherally Neuro: PERRLA. Responds to occasional questions, not following commands. No tremors, no clonus. Opens eyes to verbal stimulus. 2+ patellar reflexes. Pertinent Results: [**2181-12-12**] 08:30PM BLOOD WBC-3.7* RBC-3.34* Hgb-10.0* Hct-29.2* MCV-88 MCH-30.0 MCHC-34.3 RDW-15.8* Plt Ct-316 [**2181-12-12**] 08:30PM BLOOD Neuts-45.0* Lymphs-47.7* Monos-3.9 Eos-2.2 Baso-1.1 [**2181-12-12**] 08:30PM BLOOD Glucose-76 UreaN-11 Creat-1.0 Na-143 K-4.1 Cl-106 HCO3-29 AnGap-12 [**2181-12-12**] 08:30PM BLOOD ALT-39 AST-82* AlkPhos-69 Amylase-159* TotBili-0.2 [**2181-12-12**] 08:30PM BLOOD Lipase-80* [**2181-12-12**] 08:30PM BLOOD cTropnT-<0.01 [**2181-12-12**] 08:30PM BLOOD ASA-NEG Ethanol-304* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2181-12-12**] 08:41PM BLOOD Lactate-1.2 . [**2181-12-12**] CT Head: 1. No acute intracranial hemorrhage. 2. Cerebellar atrophy. . [**2181-12-12**] CT C-Spine: No acute fracture or malalignment of the cervical spine. Mild degenerative changes. . [**2181-12-12**] X-ray L elbow: No acute fracture or dislocation. Old healed left humeral shaft fracture partially visualized. . [**2181-12-12**] CXR: No acute cardiopulmonary process. . [**2181-12-12**] Abd/Pelvis CT: No CT evidence of pancreatitis or acute intra-abdominal or pelvic findings. Brief Hospital Course: Mr. [**Known lastname 24927**] was admitted with alcohol intoxication and abdominal pain. He had elevated amylase and lipase concerning for pancreatitis. A CT of his abdomen was negative for any abdominal pathology. Initially he was somnolent but on the day after admission he became more arousable. He received approximately 200mg of PO Valium over a 24 hour period for alcohol withdrawal. He continued to complain of abdominal pain but his abdomen was benign and CT did not show any pathology. He was not given narcotics due to concerns for interactions with benzodiazepines and alcohol. His LFTs were mildly elevated consistent with alcoholic disease. He was given multivitamins, thiamine and folate. His electrolytes were monitored; however blood draws were difficult due to poor access. Social work and addiction services were consulted. He was referred the [**Hospital1 **] Stabilization Program who was in the process of accepting him possibly friday [**12-14**] or monday [**12-17**]. An attempt was made to transfer him to the floor and when he was told this, he held his breath and O2 sats dropped to the 70s and he was tachycardic. . On [**2181-12-14**] he left the hospital against medical advice. He was informed of the risks of alcohol withdrawal, hallucinations, seizures, delerium, and death. Medications on Admission: none Discharge Medications: pt left AMA Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Alcohol Withdrawal Discharge Condition: fair Discharge Instructions: Pt left AMA prior to receiving instructions. Followup Instructions: Pt left AMA prior to receiving instructions. ",108,2181-12-12 22:29:00,2181-12-14 12:48:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,PANCREATITIS," mr. [**known lastname 24927**] was admitted with alcohol intoxication and abdominal pain. he had elevated amylase and lipase concerning for pancreatitis. a ct of his abdomen was negative for any abdominal pathology. initially he was somnolent but on the day after admission he became more arousable. he received approximately 200mg of po valium over a 24 hour period for alcohol withdrawal. he continued to complain of abdominal pain but his abdomen was benign and ct did not show any pathology. he was not given narcotics due to concerns for interactions with benzodiazepines and alcohol. his lfts were mildly elevated consistent with alcoholic disease. he was given multivitamins, thiamine and folate. his electrolytes were monitored; however blood draws were difficult due to poor access. social work and addiction services were consulted. he was referred the [**hospital1 **] stabilization program who was in the process of accepting him possibly friday [**12-14**] or monday [**12-17**]. an attempt was made to transfer him to the floor and when he was told this, he held his breath and o2 sats dropped to the 70s and he was tachycardic. . on [**2181-12-14**] he left the hospital against medical advice. he was informed of the risks of alcohol withdrawal, hallucinations, seizures, delerium, and death. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Iron deficiency anemia, unspecified; Alcoholic liver damage, unspecified; Lack of housing]","known lastname 24927**] was admitted with alcohol intoxication and abdominal pain. a ct of his abdomen was negative for any abdominal pathology. an attempt was made to transfer him to the floor and when he was told this, he held his breath and o2 sats dropped to the 70s and he was tachycardic.",mr. [**known lastname 24927**] was admitted with alcohol intoxication and abdominal pain. he received approximately 200mg of po valium over a 24 hour period for alcohol withdrawal. he continued to complain of abdominal pain but his abdomen was benign. 5060,170299.0,24306,2182-04-01,24305,196749.0,2182-01-14,Discharge summary,"Admission Date: [**2182-1-4**] Discharge Date: [**2182-1-14**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 358**] Chief Complaint: Monitoring and treatment of EtOH withdrawal Major Surgical or Invasive Procedure: None History of Present Illness: This is a 37 year-old male with a history of alcoholism with many admissions for intoxication, Hep B+C, polysubstance abuse, and depression, who presents with intoxication. Pt reports that he drank 1 liter of listerine today as well as a fifth of vodka and then blackout. He was brought to the ED intoxicated but has no recollection of how he got to the hospital. He complains of pain at his left knee, but does not recall injuring it, and also complains of chronic abdominal tenderness (but only when someone presses on it). Denies nausea or vomiting. . In the ED, initial vitals were T 98.7, BP 123/87, HR 110, RR 16, 99% on RA. His BAL was 456. Serum tox was also positive for benzos. Urine tox was negative. The plan was initially to observe the patient overnight in the ED until he became sober. However, around 7:30pm, the attending found the patient tremulous, with HR in the 120-130s and complaining of withdrawal symptoms. He was also having visual hallucinations of mice running over his legs. Exam was only notable for some blood on his pants over his left knee and a bump on his L forehead. Neuro exam was non-focal. He remainted tachycardic with HR as high as 140s. He received a total of 15mg PO valium, 15mg IV valium, and 1mg IV ativan. Banana bag was started but PIV was not functioning well. Admitted to the ICU for further monitoring. . On arrival to the [**Hospital Unit Name 153**], the patient is very anxious. He is no longer experiencing visual hallucinations but reports that he is delirious and does not know what is going on. He is adamant that he is going to stop drinking this time and wants to go to a detox facility-- apparently his best friend died one week ago from drinking listerine. . ROS: He has been having frontal headaches for the past month since being hit by an SUV one month ago. Has also had R-sided chest pain at the site of impact from this MVC for the past month. Has broken his nose several times and has difficulty breathing from that. He also notes seeing spots in the periphery of his vision recently. He complains of gait instability when sober (less so when intoxicated) and also peripheral neuropathy in his arms and legs. The patient denies any fevers, chills, weight change, nausea, vomiting, abdominal pain, diarrhea, constipation, melena, hematochezia, shortness of breath, orthopnea, PND, lower extremity edema, cough, urinary frequency, urgency, dysuria, lightheadedness, focal weakness, rash or skin changes. Past Medical History: polysubstance abuse with alcohol, heroin, IVDU, benzo Hep C Hep B OCD and anxiety Depression seizures from alcohol withdrawal compartment syndrome of RLE in [**2171**] chronic bilateral hand swelling Social History: Homeless. Denies IVDU recently. Denies tobacco recently. Does have a history of both. Family History: father with depression and alcoholism. Mother had diabetes. Physical Exam: Vitals: T: 98.7 BP: 138/106 HR: 132 RR: 17 O2Sat: 97% RA GEN: Disheveled male, tremulous, anxious HEENT: EOMI, PERRL, sclera anicteric, no nystagmus, no epistaxis or rhinorrhea, MMM, OP Clear, poor dentition NECK: No JVD, lymphadenopathy, trachea midline COR: tachy, regular, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, diffusely tender to palpation, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords MUSCULOSKELETAL: L knee swollen with 2 small healing lacerations and echymossis over the patella, decreased range of motion (to 90 degrees), tender to palpation over the patella and medial joint line NEURO: A+O x 2 (person, year). CN II ?????? XII grossly intact. Strength 5/5 in upper and lower extremities. Decreased sensation grossly over lower extremities. Normal finger-to-nose. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: 143 104 12 83 AGap=14 4.2 29 0.7 ALT: 60 AP: 101 Tbili: 0.3 Alb: 4.6 AST: 95 LDH: Dbili: TProt: 7.9 [**Doctor First Name **]: Lip: 134 Serum EtOH 456 Serum Benzo Pos Serum ASA, Acetmnphn, Barb, Tricyc Negative Comments: Positive Tricyclic Results Represent Potentially Toxic Levels;Therapeutic Tricyclic Levels Will Typically Have Negative Results Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative 86 5.8 12.3 313 36.3 N:40.2 L:53.0 M:3.8 E:1.6 Bas:1.4 . FINDINGS: Lungs are clear without evidence lung nodules or consolidations. No pleural effusion. Cardiomediastinal silhouette is unremarkable. Bone structures are grossly normal. IMPRESSION: Normal examination without evidence of active or inactive tuberculosis. PPD positive with >20mm reaction Brief Hospital Course: 37 year-old male with a history of alcoholism with multiple admissions for detox and history of DTs/withdrawal seizures who presents with intoxication followed by withdrawal. He received 30 mg Valium in the emergency room and was placed on a q1h CIWA in the ICU. This was transitioned to a standing valium order per his protocol on arrival to the floor. Social work was consulted. MVI/thiamine/folate were given. He was monitored on telemetry. . His lipase and transaminases were elevated during his admission, consistent with his chronic hepatitis C, in addition to alcoholic hepatitis. He had abdominal pain which was the same as on prior admissions and was likely related to alcoholic pancreatitis or gastritis, but was resolved on discharge. This improved and he was tolerating pos. . He noted knee pain as well, and an x-ray was performed which did not show a fracture. . He was started on Klonopin for anxiety, similar to previous outpatient dosing. He had a PPD placed, which was positive at >20 mm, and a CXR was performed which was negative. Unfortunately, on the day of anticipated discharge to [**Hospital1 **] for inpatient alcohol rehabilitation, he left the floor unwitnessed and did not return (AMA, although he left without risk/benefit). Medications on Admission: none chronically on klonopin, but it is frequently stolen on the street. Discharge Medications: none, AMA Discharge Disposition: Home Discharge Diagnosis: alcohol withdrawal/dependence anxiety Discharge Condition: ambulating, no longer in withdrawal Discharge Instructions: AMA Followup Instructions: AMA ",77,2182-01-04 17:40:00,2182-01-14 10:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH WITHDRAWAL," 37 year-old male with a history of alcoholism with multiple admissions for detox and history of dts/withdrawal seizures who presents with intoxication followed by withdrawal. he received 30 mg valium in the emergency room and was placed on a q1h ciwa in the icu. this was transitioned to a standing valium order per his protocol on arrival to the floor. social work was consulted. mvi/thiamine/folate were given. he was monitored on telemetry. . his lipase and transaminases were elevated during his admission, consistent with his chronic hepatitis c, in addition to alcoholic hepatitis. he had abdominal pain which was the same as on prior admissions and was likely related to alcoholic pancreatitis or gastritis, but was resolved on discharge. this improved and he was tolerating pos. . he noted knee pain as well, and an x-ray was performed which did not show a fracture. . he was started on klonopin for anxiety, similar to previous outpatient dosing. he had a ppd placed, which was positive at >20 mm, and a cxr was performed which was negative. unfortunately, on the day of anticipated discharge to [**hospital1 **] for inpatient alcohol rehabilitation, he left the floor unwitnessed and did not return (ama, although he left without risk/benefit). ","PRIMARY: [Alcohol withdrawal delirium] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic pancreatitis; Chronic hepatitis C without mention of hepatic coma; Acute alcoholic hepatitis; Acute alcoholic intoxication in alcoholism, continuous; Pain in joint, lower leg; Lack of housing; Anxiety state, unspecified; Other, mixed, or unspecified drug abuse, unspecified; ]","37 year-old male with a history of alcoholism with multiple admissions for detox and history of dts/withdrawal seizures who presents with intoxication followed by withdrawal. unfortunately, on the day of anticipated discharge to [**hospital1 **] for inpatient alcohol rehabilitation, he left the floor unwitnessed and did not return (ama, although he left without risk/benefit).",37 year-old male with a history of alcoholism with multiple admissions for detox and history of dts/withdrawal seizures who presents with intoxication followed by withdrawal. received 30 mg valium in the emergency room and was placed on a q1h ciwa in the icu. this was transitioned to a standing valium order per his protocol on arrival to the floor. his lipase and transaminases were elevated during his admission 5060,196749.0,24305,2182-01-14,24300,194191.0,2181-08-21,Discharge summary,"Admission Date: [**2181-8-20**] Discharge Date: [**2181-8-21**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2485**] Chief Complaint: etoh w/d Major Surgical or Invasive Procedure: none History of Present Illness: 36 year old homeless man with h/o polysubstance abuse and frequent ICU admissions returns with alcohol intoxication. He reports that he has been drinking daily since being released from prison on [**7-10**]. He drinks enough vodka or listerine so that he blacks out daily. He believes he was brought in by EMS or a local after he was found intoxicated. Per ED reports, he was BIBA after being found down. He was most recently admitted for EtOh withdrawal from [**2-24**] - [**3-5**] and left AMA after his valium dose was tapered. He returned on [**7-4**] with a fall but was discharged from the ED after a negative head CT. . ED: VS on arrival 98.5 114 128/62 16 97% RA. Tox was negative for cocaine, amphetamines. Serum tox was positive for etoh 448 and benzos. Had anion gap of 18 but VBG of 7.49/33/58 and lactate of 3.1. We was given 60-70 IV valium for withdrawal sx of agitation, hypertension, and tachycardia. Also received 3L IVF. . Currently, the patient reports having chest pain x1wk. he thinks he was punched in the chest and has since had intermittently dull/sharp nonradiating substernal chest pain. Now it is [**9-16**] and sharp. It is not exertional nor assoc with SOB or diaphoresis/n/v. Worse w palpation. Also reports falling and hitting right forehead 10d ago. Has had no fevers or residual HA since that time. . ROS otherwise pos for URI-like sx. no diarrhea. Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures - once sent under section 35 to prison due to concern that he was a severe threat to himself with his drinking. required intubation in the past. - has been seen recently by psychiatry in the past to evaluate for possible section 35. Social History: Drinks regularly, prefers listerine and vodka. Has been drinking heavily since release from prison on [**8-9**]. Homeless, lives on streets. Denies IVDU for >10yrs. Denies cigs for>10 yrs. Denies SI or HI Family History: Father with depression and alcoholism. Mother died of DM complications. Physical Exam: VS: 99.8 110 96% RA RR12 133/111 gen: agitated but redirectable. Neuro: aao to person, place, time, situation. - cn ii-xii intact - motor [**6-11**] bilat upper/lower - slightly tremulous upper ex - [**Last Name (un) 36**] to light touch - gait wide based and unsteady - f-n intact bilat - h-s impaired bilat heent: old scar on right forehead. mm dry, jvp flat cards: tachy, reg, no murmurs resp: ctab abd: BS+ NT ND soft, no rebound, no stigmata of liver dz Ext: no edema. good pulses Pertinent Results: EKG: Sinus tachy, nl axis, nl intervals, no acute st-t changes. . Labs: VBG: 7.49/33/58 Lactate 3.1 . 142 102 10 ----------------< 87 4.1 22 0.9 Ca: 9.4 Mg: 2.0 P: 2.9 Serum EtOH 448 Serum Benzo Pos Serum ASA, Acetmnphn, Barb, Tricyc Negative . WBC: 9.5 HCT: 35.7 - at baseline PLT: 208 N:64.2 L:30.8 M:3.5 E:1.1 Bas:0.5 Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative . Repeat chemistry: 140 108 8 -------------< 73 3.3 20 0.7 Ca: 8.0 Mg: 1.6 P: 1.9 repeat lactate 3.1 Brief Hospital Course: 36M with ETOH dependence and frequent admissions for EtOH intoxication presents with EtOH withdrawal. ICU-east course by problem: . # Alcohol withdrawal: presented with signs of withdrawal with agitation, hypertension, tachycardia, and slight tremor of upper ex bilat. Has gait unsteadiness which is likely [**3-10**] acute intox but appears to be chronic based on records. - given that he has hx of DTs and w/d seizures, we treated aggressively with valium in ICU. He received either 60-70 IV valium in the ED. On arrival to the ICU, he was written for valium 20mg PO q15m prn CIWA>10 and he received it almost as frequently as written. He became less agitated after approx 80-100mg (in addition to the IV given in the ED) and then the CIWA scale was spread out to 20mg PO prn q1h. He tolerated this transition well. - He received multivit, folate, thiamine in IVF then PO - social work was consulted the morning after admission when patient was demanding to leave. He felt he had enough valium and actually refused another dose. We explained to him that we preferred that he stay for full evaluation and treatment of etoh w/d and his electrolyte abnormalities. He expressed understanding of our concerns and was able to verbalize the risks and benefits of leaving against our advice. He signed out AMA with plans to seek outpatient treatment. . # Psych: No SI. We had plans to contact psychiatry morning after admission particularly given his high valium need. However, he expressed interest in leaving and we felt he had capacity to make this decision. Social wk was involved but psychiatry was not consulted. . # chest pain: EKG without ischemic changes. CP was reproducible on palpation. Suspected MSK pain. He received one dose of morphine for cp. We then treated with toradol, motrin, and tylenol. We would recommend avoiding narcotics in the future if at all possible and if clinically indicated. His pain improved when his agitation improved. . # elevated lactate: ddx included dehydration, infection, liver disease, hypovolemia, poor sample. Lactic acidosis not likely given the alkalosis seen on VBG. Consider dehydration vs poor quality sample. Infection less likely given no fever or hypotension or any localizing signs of infection. Repeat lactate remained 3.1. Etiology unclear and workup hindered by patient leaving AMA. . # Anion gap: AG 18 in the ED with a normal HCO3 and alkalosis on VBG. ASA negative as were other toxins. Difficult to interpret but wonder if slightly increased AG is from the elevated lactate. Repeat chemistries showed normal anion gap. . #Anemia - normocytic anemia, Hct at baseline . # PPx: Heparin sc tid, PPI given etoh abuse, bowel reg . # FEN: Regular diet, replete lytes prn, banana bag then IVF . # Access: PIV x1 . # Code: FULL . # Communication: Patient . # Dispo: Patient left AMA. Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: ETOH Intoxication/Withdrawal Discharge Condition: fair Discharge Instructions: You were admitted to the hospital because you were found intoxicated by EMS. You were admitted to the ICU and treated with Valium for withdrawal. You were advised to stay in the hospital for continued care and treatment of withdrawal however you decided against medical advice that you no longer wished to receive care. You spoke with the social worker before you left the hospital and were advised to return to [**Street Address(1) 5904**] Inn to speak with your outreach worker there. You signed out against medical advise. Followup Instructions: Please speak with the Outreach worker [**Street Address(1) 29735**] Inn. Please return to the hospital should you have any concerning symptoms including difficulty breathing, falls or injuries requiring medical attention, concerning withdrawal symptoms. ",146,2181-08-20 20:26:00,2181-08-21 11:10:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ALCOHOL WITHDRAWAL," 36m with etoh dependence and frequent admissions for etoh intoxication presents with etoh withdrawal. icu-east course by problem: . # alcohol withdrawal: presented with signs of withdrawal with agitation, hypertension, tachycardia, and slight tremor of upper ex bilat. has gait unsteadiness which is likely [**3-10**] acute intox but appears to be chronic based on records. - given that he has hx of dts and w/d seizures, we treated aggressively with valium in icu. he received either 60-70 iv valium in the ed. on arrival to the icu, he was written for valium 20mg po q15m prn ciwa>10 and he received it almost as frequently as written. he became less agitated after approx 80-100mg (in addition to the iv given in the ed) and then the ciwa scale was spread out to 20mg po prn q1h. he tolerated this transition well. - he received multivit, folate, thiamine in ivf then po - social work was consulted the morning after admission when patient was demanding to leave. he felt he had enough valium and actually refused another dose. we explained to him that we preferred that he stay for full evaluation and treatment of etoh w/d and his electrolyte abnormalities. he expressed understanding of our concerns and was able to verbalize the risks and benefits of leaving against our advice. he signed out ama with plans to seek outpatient treatment. . # psych: no si. we had plans to contact psychiatry morning after admission particularly given his high valium need. however, he expressed interest in leaving and we felt he had capacity to make this decision. social wk was involved but psychiatry was not consulted. . # chest pain: ekg without ischemic changes. cp was reproducible on palpation. suspected msk pain. he received one dose of morphine for cp. we then treated with toradol, motrin, and tylenol. we would recommend avoiding narcotics in the future if at all possible and if clinically indicated. his pain improved when his agitation improved. . # elevated lactate: ddx included dehydration, infection, liver disease, hypovolemia, poor sample. lactic acidosis not likely given the alkalosis seen on vbg. consider dehydration vs poor quality sample. infection less likely given no fever or hypotension or any localizing signs of infection. repeat lactate remained 3.1. etiology unclear and workup hindered by patient leaving ama. . # anion gap: ag 18 in the ed with a normal hco3 and alkalosis on vbg. asa negative as were other toxins. difficult to interpret but wonder if slightly increased ag is from the elevated lactate. repeat chemistries showed normal anion gap. . #anemia - normocytic anemia, hct at baseline . # ppx: heparin sc tid, ppi given etoh abuse, bowel reg . # fen: regular diet, replete lytes prn, banana bag then ivf . # access: piv x1 . # code: full . # communication: patient . # dispo: patient left ama. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Alkalosis; Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Acidosis; Chronic hepatitis C without mention of hepatic coma; Cocaine abuse, unspecified; Lack of housing; Anemia, unspecified; Other chest pain]","36m with etoh dependence and frequent admissions for etoh intoxication presents with etoh withdrawal. - he received multivit, folate, thiamine in ivf then po - social work was consulted the morning after admission when patient was demanding to leave. he signed out ama with plans to seek outpatient treatment. social wk was involved but psychiatry was not consulted. # anion gap: ag 18 in the ed with a normal hco3 and alkalosis on vbg. #anemia - normocytic anemia, hct at baseline .","36m with etoh dependence and frequent admissions for etoh intoxication presents with etoh withdrawal. presented with signs of withdrawal with agitation, hypertension, tachycardia, and slight tremor of upper ex bilat. social work was consulted the morning after admission when patient was demanding to leave." 5060,196749.0,24305,2182-01-14,24301,153063.0,2181-10-24,Discharge summary,"Admission Date: [**2181-10-23**] Discharge Date: [**2181-10-24**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 5893**] Chief Complaint: CC:[**CC Contact Info 61604**] Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 37YO man with long hx of alcohol abuse, with frequent ED visits/hospitalizations for same was brought to the ED today after being found by EMS sleeping on street. He reports drinking [**2-8**] pints of vodka daily. He eats very little. He also drinks listerine each night. He reports frequent falls (recent scalp lac w/ staples; abrasion over face). His ETOH level was 434 at 10:00 AM. He was given Ativan 2 mg at 6:30 in the ED for CIWA =13; then given Ativan 2 mg at 6:30pm for CIWA = 23. He was admitted to the floor for EtOH withdrawal. . On arrival to the floor, the patient was given Valium 10 mg PO and 10 mg IV over 40 minutes without improvement in his CIWA. He is transferred to the ICU for further management. . Of note, previous admission in [**Month (only) 205**] for ETOH withdrawal pt required 20mg PO valium q15min, then left AMA. . Pt not cooperative for further ROS. . Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Currently reports drinking ""at least"" a lint of vodka each morning and listerine each evening. He has a history of polysubstance abuse: EtOH, heroin, IVDU, benzo, h/o alcohol withdrawal seizures and DT's, h/o section 35. h/o incarceration for possession, estranged from family, never married, no children, homeless Family History: Possible OCD in his father. Physical Exam: Vitals: 99.3, 110/64, 115, 18, 99% RA GEN: diaphoretic, sitting in bed, anxious HEENT:hematoma on R occipital area where staples removed last week. scabb on bridge of nose and R temple. PERRLA 5mm->2mm, EOMI, throat non-erythematous, poor dentition, MMM Lungs: clear CV: tachy, rrr Abd: + bs soft, limited exam, no focal tenderness ext: + tremor, no c/c/e Pertinent Results: Labs: . 143 /103 / 11 /140 Ca: 8.8 Mg: 2.1 P: 3.3 -------------- 3.9 /31 / 0.8 . 4.7 / 13.0 / 315 N:35.4 L:50.6 M:4.4 E:7.8 Bas:1.8 ------- 39.6 . Serum EtOH 434, Serum Benzo Pos, Serum ASA, Acetmnphn, Barb, Tricyc Negative Urine Benzos Pos Urine Barbs, Opiates, Cocaine, Amphet, Mthdne Negative . Imaging: None Brief Hospital Course: In summary, Mr. [**Known lastname 24927**] is a 37 yo male with history of ETOH abuse presents with acute ETOH intoxication. . ETOH abuse. Patient has a long history of alcohol abuse, with innumerable ED visits and hospitalizations for same. Patient was initially on diazepam CIWA scale. Within twelve hours of admission, patient was requesting to leave AMA. He was evaluated by psychiatry who felt he had competence to leave AMA. He was not a candidate for section 35. Risks of leaving hospital against medical advice was discussed with the patient, but he decided to leave. Medications on Admission: None Discharge Medications: None. Patient left AMA. Discharge Disposition: Home Facility: AMA Discharge Diagnosis: Alcohol abuse. Discharge Condition: AMA Discharge Instructions: AMA Followup Instructions: AMA ",82,2181-10-23 18:54:00,2181-10-24 15:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH WITHDRAWAL," in summary, mr. [**known lastname 24927**] is a 37 yo male with history of etoh abuse presents with acute etoh intoxication. . etoh abuse. patient has a long history of alcohol abuse, with innumerable ed visits and hospitalizations for same. patient was initially on diazepam ciwa scale. within twelve hours of admission, patient was requesting to leave ama. he was evaluated by psychiatry who felt he had competence to leave ama. he was not a candidate for section 35. risks of leaving hospital against medical advice was discussed with the patient, but he decided to leave. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Alcoholic polyneuropathy; Lack of housing]","known lastname 24927**] is a 37 yo male with history of etoh abuse presents with acute etoh intoxication. patient was initially on diazepam ciwa scale.","mr. [**known lastname 24927**] is a 37 yo male with history of etoh abuse. patient has a long history of alcohol abuse, with innumerable ed visits and hospitalizations for same. within twelve hours of admission, patient was requesting to leave ama. he was evaluated by psychiatry who felt he had competence to leave." 5060,196749.0,24305,2182-01-14,24302,184857.0,2181-11-20,Discharge summary,"Admission Date: [**2181-11-18**] Discharge Date: [**2181-11-20**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2297**] Chief Complaint: ETOH Withdrawal Major Surgical or Invasive Procedure: PICC placement ([**2181-11-19**]) History of Present Illness: 37 year old homeless man with h/o polysubstance abuse and frequent ICU admissions and ED evals returns with alcohol intoxication and withdrawal. Presented to ED s/p unwitnessed fall while intoxicated. Came in c/o L elbow and R hand pain. Also with left supraorbital laceration that was repaired in the ED. He reports currently drinking 1 bottle of Vodka and large bottle of mouthwash daily. He has a hx of withdrawal seizures as well as Section 35/Section 12 for ETOH abuse. . In the ED, initial VS: T96.6 HR 80 BP 108/73 RR16 100RA. He was monitored overnight, but noted to be progressively more tremulous and tachycardic. Also reported hallucinations. Initially was threatening to leave AMA, but agreed to stay for further treatment. Team unable to get PIVs so femoral line placed for access. He received 50mg PO valium and 2mg of Ativan IM since [**85**]:40 AM. . He was most recently admitted for EtOh withdrawal on [**11-9**] but left AMA. He returned to the ED on [**11-13**] for intoxication and was noted to have elevated amylase, lipase concerning for acute pancreatitis. Again, pt signed out AMA. . On arrival to [**Hospital Unit Name 153**], patient was tremulous, complaining of pain all over and felt like his ""skin was crawling."" Also reported chronic abdominal pain over the last several months that he attributed to excessive intake of listerine. Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Homeless, lives on streets. Denies IVDU for >10yrs. Denies cigs for>10 yrs. Denies SI or HI. He has a history of polysubstance abuse: EtOH, heroin, IVDU, benzo, h/o alcohol withdrawal seizures and DT's, h/o section 35. h/o incarceration for ETOH, estranged from family, never married, no children, homeless. Last worked 17 years ago as a grocery shelf stocker. Family History: Father with depression and alcoholism. Mother died of DM complications. Physical Exam: VS: Afebrile, BP 146/60, HR 114 RR 16 98%RA GEN: Anxious, cooperative. Neuro: AAO to person, place, time, situation. - CN ii-xii intact - motor [**6-11**] bilat upper/lower - tremulous bilateral upper ext - [**Last Name (un) 36**] to light touch intact - toes downgoing bilaterally - gait: not assessed as patient unsteady HEENT: 1.5cm laceration with sutures and associated ecchymosis and swelling of L eyebrow. Dry MM, jvp flat; Poor dentition CV: Tachycardic, reg, no murmurs RESP: CTABL, no w/r/r ABD: Soft/non distended; mild tenderness throughout, hypoactive BS Ext: R femoral line C/D/I; no edema. good pulses SKIN: No rashes Pertinent Results: [**2181-11-20**] 05:35AM BLOOD WBC-5.1 RBC-4.03* Hgb-11.9* Hct-35.1* MCV-87 MCH-29.6 MCHC-34.1 RDW-14.8 Plt Ct-190 [**2181-11-19**] 03:41AM BLOOD WBC-4.3 RBC-3.85* Hgb-11.6* Hct-33.3* MCV-87 MCH-30.2 MCHC-34.8 RDW-15.5 Plt Ct-195 [**2181-11-18**] 02:31PM BLOOD WBC-6.1 RBC-4.43* Hgb-13.2* Hct-37.8* MCV-85 MCH-29.9 MCHC-35.0 RDW-16.0* Plt Ct-272# [**2181-11-18**] 02:31PM BLOOD Neuts-32.6* Lymphs-57.1* Monos-6.0 Eos-3.2 Baso-1.2 [**2181-11-20**] 05:35AM BLOOD PT-12.0 PTT-33.4 INR(PT)-1.0 [**2181-11-20**] 05:35AM BLOOD Glucose-93 UreaN-8 Creat-0.6 Na-136 K-3.8 Cl-104 HCO3-24 AnGap-12 [**2181-11-20**] 05:35AM BLOOD ALT-44* AST-72* LD(LDH)-286* [**2181-11-20**] 05:35AM BLOOD Calcium-8.4 Phos-3.4 Mg-1.9 [**2181-11-18**] 02:31PM BLOOD ASA-NEG Ethanol-137* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG Brief Hospital Course: 36M with EtOH dependence and frequent admissions for EtOH intoxication presents s/p fall with EtOH withdrawal. 1. Alcohol withdrawal: No hypertension or tachycardia this morning. Slightly agitated and with slight upper extremity tremor. Has history of hx of DTs and w/d seizures. Patient was treated with CIWA scale per prior admissions. On hospital day 3, patient signed out AMA. 2. Fall: Patient with unwitnessed fall. Radiographs negative for fracture. 3. Abdominal pain: [**Month (only) 116**] be secondary to alcoholic hepatitis though minimal elevation of LFTs. 4. Alcoholic liver disease: AST/ALT improving. No stigmata of liver disease by physical exam. [**Doctor First Name **]/lipase normal. Also has history of hepatitis B/C. 5. Anemia: Normocytic anemia, at baseline. 6. PPx: Patient treated with heparin SQ for dvt prophylaxis. 7. Access: Patient with femoral CVL placed in ED. PICC placed during admission, which was removed when patient signed out AMA. 8. Dispo: Patient signed out AMA. Medications on Admission: None Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: EtOH withdrawal Discharge Condition: Patient leaving against medical advice. Discharge Instructions: You were admitted for alcohol withdrawal and received benzodiazepines to manage your withdrawal. We recommended transfer to the regular medical floor from the ICU for continued management of your withdrawal symptoms, but you have decided to leave against our medical advice. Followup Instructions: Please follow up with your primary care doctor within the next few days. You should also seek care for substance abuse. Completed by:[**2181-11-20**]",55,2181-11-18 06:42:00,2181-11-20 12:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ALTERED MENTAL STATUS," 36m with etoh dependence and frequent admissions for etoh intoxication presents s/p fall with etoh withdrawal. 1. alcohol withdrawal: no hypertension or tachycardia this morning. slightly agitated and with slight upper extremity tremor. has history of hx of dts and w/d seizures. patient was treated with ciwa scale per prior admissions. on hospital day 3, patient signed out ama. 2. fall: patient with unwitnessed fall. radiographs negative for fracture. 3. abdominal pain: [**month (only) 116**] be secondary to alcoholic hepatitis though minimal elevation of lfts. 4. alcoholic liver disease: ast/alt improving. no stigmata of liver disease by physical exam. [**doctor first name **]/lipase normal. also has history of hepatitis b/c. 5. anemia: normocytic anemia, at baseline. 6. ppx: patient treated with heparin sq for dvt prophylaxis. 7. access: patient with femoral cvl placed in ed. picc placed during admission, which was removed when patient signed out ama. 8. dispo: patient signed out ama. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Open wound of forehead, without mention of complication; Unspecified fall; Chronic hepatitis C without mention of hepatic coma; Lack of housing; Anemia, unspecified; Acute alcoholic hepatitis; Alcoholic gastritis, without mention of hemorrhage; Hypovolemia]","36m with etoh dependence and frequent admissions for etoh intoxication presents s/p fall with etoh withdrawal. alcohol withdrawal: no hypertension or tachycardia this morning. ppx: patient treated with heparin sq for dvt prophylaxis.",36m with etoh dependence and frequent admissions for etoh intoxication present s/p fall with etoh withdrawal. no hypertension or tachycardia this morning. slightly agitated and with slight upper extremity tremor. 5060,196749.0,24305,2182-01-14,24303,197750.0,2181-12-11,Discharge summary,"Admission Date: [**2181-12-7**] Discharge Date: [**2181-12-11**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 8487**] Chief Complaint: ETOH Withdrawal, Chest, Abdominal, Arm and Hand Pain Major Surgical or Invasive Procedure: None History of Present Illness: 37yoM with hx of polysubstance abuse, frequent ICU admissions and ED evals returns with alcohol intoxication and withdrawal. Pt reports currently using ETOH, and presenting for pain from a reported trauma approx 4 days ago at which time the patient reports being hit by a SUV. He states he signed out AMA from the [**Hospital1 3278**] ICU after this accident. Pt with a hx of withdrawal seizures as well as Section 35/Section 12 for ETOH abuse. The patient reports being acutely intoxicated currently, and most recently, drinking Listerine this am. Today the patient was found lying next to [**Company 2486**] where EMS was called and we has brought to the ED. Since leaving [**Hospital1 3278**] he has spent the past few days at [**Location (un) 7073**] Station, drinking Vodka during the day and Listerine at night ""to prevent seizures"". He believes his last seizure occurred three weeks ago. He notes pain all over his body - esp in his hands, chest, abdomen and legs. . In the ED, initial VS 98.3 120/88 116 16 100%2L: In the E.D. he received Morphine 6mg, Valium 50mg, Gabapentin 600mg, Toradol 30mg, 1 banana bag and 2 additional L of NS. He was monitored, but noted to be progressively more tremulous, tachycardic and reporting visual hallucinations. . Of note the pt has had recent admissions for EtOh withdrawal on [**11-9**] but left AMA. He returned to the ED on [**11-13**] for intoxication and was noted to have elevated amylase, lipase concerning for acute pancreatitis. Again, pt signed out AMA. The pt was admitted on [**11-18**], again for acute EtOH withdrwal, and signed out AMA on [**11-20**]. . On arrival to [**Hospital Unit Name 153**]: Pt tremulous, anxious, tachy to 110s, with some visual hallucinations, however not hypertensive or febrile. Pt denies fever, + chills, headache. Admits to chronic abdominal pain of [**8-14**] months duration. Pt also admits to chest pain of one weeks duration since being hit by a car. Pt also noted recent episodes of epistaxis, although none within the past few days. . Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C (Diagnosed around [**2163**], Never treated) Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Homeless, lives on streets. Denies IVDU for >10yrs. Denies cigs for>10 yrs. Denies SI or HI. He has a history of polysubstance abuse: EtOH, heroin, IVDU, benzo, h/o alcohol withdrawal seizures and DT's, h/o section 35. h/o incarceration for ETOH, estranged from family, never married, no children, homeless. Last worked 17 years ago as a grocery shelf stocker. Family History: Father with depression and alcoholism. Mother died of DM complications. Physical Exam: VS: 98.7 113/77 89 98 3LNC GEN: Anxious, cooperative. Alert to date, name but not to location HEENT: PERRLA Dry MM, jvp flat; Poor dentition CV: Tachycardic, reg, no murmurs RESP: CTABL, no w/r/r ABD: Soft/non-distended; mild tenderness throughout, hypoactive BS Ext: 1+ Bilateral upper extremity edema. good pulses SKIN: No rashes Neuro: AOx2, (not location), CN II-XII intact, Motor [**6-11**] bilat, Tremulous bilateral upper ext Pertinent Results: Admission labs [**2181-12-7**] 05:35PM BLOOD WBC-3.5* RBC-3.97* Hgb-11.8* Hct-34.7* MCV-87 MCH-29.7 MCHC-34.0 RDW-15.4 Plt Ct-308# [**2181-12-7**] 05:35PM BLOOD Neuts-33.4* Bands-0 Lymphs-57.1* Monos-5.0 Eos-3.2 Baso-1.3 [**2181-12-7**] 05:35PM BLOOD PT-13.3 PTT-29.8 INR(PT)-1.1 [**2181-12-7**] 05:35PM BLOOD Glucose-198* UreaN-7 Creat-0.8 Na-143 K-3.8 Cl-102 HCO3-25 AnGap-20 [**2181-12-7**] 05:35PM BLOOD ALT-52* AST-101* CK(CPK)-359* AlkPhos-83 [**2181-12-7**] 05:35PM BLOOD Lipase-135* [**2181-12-7**] 05:35PM BLOOD Albumin-4.3 [**2181-12-9**] 04:24AM BLOOD TSH-3.1 [**2181-12-7**] 05:35PM BLOOD ASA-NEG Ethanol-396* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2181-12-7**]: CXR IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: Mr. [**Known lastname 24927**] is a 37M with ETOH dependence and frequent admissions for EtOH intoxication who presents with EtOH withdrawal and global pain. . # EtoH Withdrawal:On admission, the pt was A0x2. Throughout his ICU stay, he had signs of withdrawal with, tachycardia, and tremors of upper extremity bilateral. CIWAs 16-29. However, it is also notable that he knows how to manipulate the CIWA and would frequently do so in order to get increasing amounts of benzodiazepines. On [**12-11**], his CIWA was discontinued and he was told he would be transferred to the floor at which point he signout AMA. While here, he was given thiamine, MVI, folate and PRN electrolytes. . # Abdominal and Chest pain: DDx includes recent trauma (although nothing apparent on exam), acute EtOh hepatitis, pancreatitis, though minimal elevation of LFTs. Less likely cardiac given reproducible nature, and unchanged EKG. No fever or leukocytosis at this time. Lipase slightly increased from [**11-18**] (135 from 56). No evidence of ascites on recent Abd U/S. Troponins were trended. He was given oxycodone 5-10mg Q 4hrs PRN. . # Alcoholic liver disease: AST/ALT elevated in 2:1 ratio, this is his baseline. No stigmata of liver disease by physical exam. Lipase 135 normal. INR 1.1. No scopes in [**Hospital1 **] records. LFTs and coags were monitored. . # Anemia - Iron deficiency anemia baseline per [**11-9**] labs with Ferritin of 11. Hct drop from 34 to 28 in setting of 3L IVF upon admission. No active signs of bleeding, likely diluational. Hct was monitored, pt was given po iron, folate and thiamine. Medications on Admission: None Discharge Medications: Pt was not given medications nor discharge instructions as he left AMA on the morning of [**2181-12-11**]. Discharge Disposition: Home Discharge Diagnosis: . Discharge Condition: . Discharge Instructions: . Followup Instructions: . Completed by:[**2182-1-10**]",34,2181-12-08 19:58:00,2181-12-11 12:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH INTOXICATION," mr. [**known lastname 24927**] is a 37m with etoh dependence and frequent admissions for etoh intoxication who presents with etoh withdrawal and global pain. . # etoh withdrawal:on admission, the pt was a0x2. throughout his icu stay, he had signs of withdrawal with, tachycardia, and tremors of upper extremity bilateral. ciwas 16-29. however, it is also notable that he knows how to manipulate the ciwa and would frequently do so in order to get increasing amounts of benzodiazepines. on [**12-11**], his ciwa was discontinued and he was told he would be transferred to the floor at which point he signout ama. while here, he was given thiamine, mvi, folate and prn electrolytes. . # abdominal and chest pain: ddx includes recent trauma (although nothing apparent on exam), acute etoh hepatitis, pancreatitis, though minimal elevation of lfts. less likely cardiac given reproducible nature, and unchanged ekg. no fever or leukocytosis at this time. lipase slightly increased from [**11-18**] (135 from 56). no evidence of ascites on recent abd u/s. troponins were trended. he was given oxycodone 5-10mg q 4hrs prn. . # alcoholic liver disease: ast/alt elevated in 2:1 ratio, this is his baseline. no stigmata of liver disease by physical exam. lipase 135 normal. inr 1.1. no scopes in [**hospital1 **] records. lfts and coags were monitored. . # anemia - iron deficiency anemia baseline per [**11-9**] labs with ferritin of 11. hct drop from 34 to 28 in setting of 3l ivf upon admission. no active signs of bleeding, likely diluational. hct was monitored, pt was given po iron, folate and thiamine. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Iron deficiency anemia, unspecified; Depressive disorder, not elsewhere classified; Lack of housing]","known lastname 24927**] is a 37m with etoh dependence and frequent admissions for etoh intoxication who presents with etoh withdrawal and global pain. lipase slightly increased from [**11-18**] (135 from 56). # alcoholic liver disease: ast/alt elevated in 2:1 ratio, this is his baseline. hct drop from 34 to 28 in setting of 3l ivf upon admission.",mr. [**known lastname 24927**] is a 37m with etoh dependence and frequent admissions for etoh intoxication. he presents with etoh withdrawal and global pain. he was given oxycodone 5-10mg q 4hrs prn. 5060,196749.0,24305,2182-01-14,24304,135773.0,2181-12-14,Discharge summary,"Admission Date: [**2181-12-12**] Discharge Date: [**2181-12-14**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2297**] Chief Complaint: abdominal pain, alcohol withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: HPI: 37 yo M with PMH of alcohol abuse with many admissions for intoxication, hepatitis B and C who was brought in by the police after being found intoxicated. He originally did not complain of any pain or other problems. Of note, he was left AMA [**2181-12-11**] from the [**Hospital Unit Name 153**] after admission for intoxication and concern for pancreatitis given elevated amlyase and lipase. . In the ED, his initial vital signs were T 100.3, BP 106/45, HR 108, RR 18, O2sat 98% RA. He was found on exam to be very tender to palpation of his abdomen with rebound and guarding. He was pan-scanned given these findings. He was given 2L NS. He was placed in a C collar for spine protection. He was given levofloxacin 750mg IV x1 prior to imaging because he complained of cough and had the low grade temp. He was given 5mg IV haldol and written for 5mg PO valium but it is unclear if he received this or not. . Currently, he is not answering very many questions. Obviously intoxicated and sleeping. Denies pain. Could not tell me how much alcohol he had today or what he drank. He usually admits to vodka and listerine as his drinks of choice. . Past Medical History: polysubstance abuse with alcohol, heroin, IVDU, benzo Hep C Hep B OCD and anxiety Depression seizures from alcohol withdrawal compartment syndrome of RLE in [**2171**] chronic bilateral hand swelling Social History: Homeless. Denies IVDU recently. Denies tobacco recently. Does have a history of both. Family History: father with depression and alcoholism. Mother had diabetes. Physical Exam: BP 105/67 HR 82 RR13 95% RA Gen: somnolent man, disheaveled, NAD HEENT: pupils 2-3mm, PERRLA, anicteric sclera, facial laceration above R eyebrow, MM dry with lip cracking. Neck with JVD or LAD. CV: RRR, no murmurs, rubs, gallops Pulm: Clear to auscultation bilaterally Abd: normoactive BS, soft, nondistended, tender to deep palpation throughout. + guarding, tender with percussion. + ecchymosis in RLQ Ext: no edema, no rashes, 2+ pulses peripherally Neuro: PERRLA. Responds to occasional questions, not following commands. No tremors, no clonus. Opens eyes to verbal stimulus. 2+ patellar reflexes. Pertinent Results: [**2181-12-12**] 08:30PM BLOOD WBC-3.7* RBC-3.34* Hgb-10.0* Hct-29.2* MCV-88 MCH-30.0 MCHC-34.3 RDW-15.8* Plt Ct-316 [**2181-12-12**] 08:30PM BLOOD Neuts-45.0* Lymphs-47.7* Monos-3.9 Eos-2.2 Baso-1.1 [**2181-12-12**] 08:30PM BLOOD Glucose-76 UreaN-11 Creat-1.0 Na-143 K-4.1 Cl-106 HCO3-29 AnGap-12 [**2181-12-12**] 08:30PM BLOOD ALT-39 AST-82* AlkPhos-69 Amylase-159* TotBili-0.2 [**2181-12-12**] 08:30PM BLOOD Lipase-80* [**2181-12-12**] 08:30PM BLOOD cTropnT-<0.01 [**2181-12-12**] 08:30PM BLOOD ASA-NEG Ethanol-304* Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2181-12-12**] 08:41PM BLOOD Lactate-1.2 . [**2181-12-12**] CT Head: 1. No acute intracranial hemorrhage. 2. Cerebellar atrophy. . [**2181-12-12**] CT C-Spine: No acute fracture or malalignment of the cervical spine. Mild degenerative changes. . [**2181-12-12**] X-ray L elbow: No acute fracture or dislocation. Old healed left humeral shaft fracture partially visualized. . [**2181-12-12**] CXR: No acute cardiopulmonary process. . [**2181-12-12**] Abd/Pelvis CT: No CT evidence of pancreatitis or acute intra-abdominal or pelvic findings. Brief Hospital Course: Mr. [**Known lastname 24927**] was admitted with alcohol intoxication and abdominal pain. He had elevated amylase and lipase concerning for pancreatitis. A CT of his abdomen was negative for any abdominal pathology. Initially he was somnolent but on the day after admission he became more arousable. He received approximately 200mg of PO Valium over a 24 hour period for alcohol withdrawal. He continued to complain of abdominal pain but his abdomen was benign and CT did not show any pathology. He was not given narcotics due to concerns for interactions with benzodiazepines and alcohol. His LFTs were mildly elevated consistent with alcoholic disease. He was given multivitamins, thiamine and folate. His electrolytes were monitored; however blood draws were difficult due to poor access. Social work and addiction services were consulted. He was referred the [**Hospital1 **] Stabilization Program who was in the process of accepting him possibly friday [**12-14**] or monday [**12-17**]. An attempt was made to transfer him to the floor and when he was told this, he held his breath and O2 sats dropped to the 70s and he was tachycardic. . On [**2181-12-14**] he left the hospital against medical advice. He was informed of the risks of alcohol withdrawal, hallucinations, seizures, delerium, and death. Medications on Admission: none Discharge Medications: pt left AMA Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Alcohol Withdrawal Discharge Condition: fair Discharge Instructions: Pt left AMA prior to receiving instructions. Followup Instructions: Pt left AMA prior to receiving instructions. ",31,2181-12-12 22:29:00,2181-12-14 12:48:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,PANCREATITIS," mr. [**known lastname 24927**] was admitted with alcohol intoxication and abdominal pain. he had elevated amylase and lipase concerning for pancreatitis. a ct of his abdomen was negative for any abdominal pathology. initially he was somnolent but on the day after admission he became more arousable. he received approximately 200mg of po valium over a 24 hour period for alcohol withdrawal. he continued to complain of abdominal pain but his abdomen was benign and ct did not show any pathology. he was not given narcotics due to concerns for interactions with benzodiazepines and alcohol. his lfts were mildly elevated consistent with alcoholic disease. he was given multivitamins, thiamine and folate. his electrolytes were monitored; however blood draws were difficult due to poor access. social work and addiction services were consulted. he was referred the [**hospital1 **] stabilization program who was in the process of accepting him possibly friday [**12-14**] or monday [**12-17**]. an attempt was made to transfer him to the floor and when he was told this, he held his breath and o2 sats dropped to the 70s and he was tachycardic. . on [**2181-12-14**] he left the hospital against medical advice. he was informed of the risks of alcohol withdrawal, hallucinations, seizures, delerium, and death. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Chronic hepatitis C without mention of hepatic coma; Iron deficiency anemia, unspecified; Alcoholic liver damage, unspecified; Lack of housing]","known lastname 24927**] was admitted with alcohol intoxication and abdominal pain. a ct of his abdomen was negative for any abdominal pathology. an attempt was made to transfer him to the floor and when he was told this, he held his breath and o2 sats dropped to the 70s and he was tachycardic.",mr. [**known lastname 24927**] was admitted with alcohol intoxication and abdominal pain. he received approximately 200mg of po valium over a 24 hour period for alcohol withdrawal. he continued to complain of abdominal pain but his abdomen was benign. 5060,153063.0,24301,2181-10-24,24300,194191.0,2181-08-21,Discharge summary,"Admission Date: [**2181-8-20**] Discharge Date: [**2181-8-21**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2485**] Chief Complaint: etoh w/d Major Surgical or Invasive Procedure: none History of Present Illness: 36 year old homeless man with h/o polysubstance abuse and frequent ICU admissions returns with alcohol intoxication. He reports that he has been drinking daily since being released from prison on [**7-10**]. He drinks enough vodka or listerine so that he blacks out daily. He believes he was brought in by EMS or a local after he was found intoxicated. Per ED reports, he was BIBA after being found down. He was most recently admitted for EtOh withdrawal from [**2-24**] - [**3-5**] and left AMA after his valium dose was tapered. He returned on [**7-4**] with a fall but was discharged from the ED after a negative head CT. . ED: VS on arrival 98.5 114 128/62 16 97% RA. Tox was negative for cocaine, amphetamines. Serum tox was positive for etoh 448 and benzos. Had anion gap of 18 but VBG of 7.49/33/58 and lactate of 3.1. We was given 60-70 IV valium for withdrawal sx of agitation, hypertension, and tachycardia. Also received 3L IVF. . Currently, the patient reports having chest pain x1wk. he thinks he was punched in the chest and has since had intermittently dull/sharp nonradiating substernal chest pain. Now it is [**9-16**] and sharp. It is not exertional nor assoc with SOB or diaphoresis/n/v. Worse w palpation. Also reports falling and hitting right forehead 10d ago. Has had no fevers or residual HA since that time. . ROS otherwise pos for URI-like sx. no diarrhea. Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures - once sent under section 35 to prison due to concern that he was a severe threat to himself with his drinking. required intubation in the past. - has been seen recently by psychiatry in the past to evaluate for possible section 35. Social History: Drinks regularly, prefers listerine and vodka. Has been drinking heavily since release from prison on [**8-9**]. Homeless, lives on streets. Denies IVDU for >10yrs. Denies cigs for>10 yrs. Denies SI or HI Family History: Father with depression and alcoholism. Mother died of DM complications. Physical Exam: VS: 99.8 110 96% RA RR12 133/111 gen: agitated but redirectable. Neuro: aao to person, place, time, situation. - cn ii-xii intact - motor [**6-11**] bilat upper/lower - slightly tremulous upper ex - [**Last Name (un) 36**] to light touch - gait wide based and unsteady - f-n intact bilat - h-s impaired bilat heent: old scar on right forehead. mm dry, jvp flat cards: tachy, reg, no murmurs resp: ctab abd: BS+ NT ND soft, no rebound, no stigmata of liver dz Ext: no edema. good pulses Pertinent Results: EKG: Sinus tachy, nl axis, nl intervals, no acute st-t changes. . Labs: VBG: 7.49/33/58 Lactate 3.1 . 142 102 10 ----------------< 87 4.1 22 0.9 Ca: 9.4 Mg: 2.0 P: 2.9 Serum EtOH 448 Serum Benzo Pos Serum ASA, Acetmnphn, Barb, Tricyc Negative . WBC: 9.5 HCT: 35.7 - at baseline PLT: 208 N:64.2 L:30.8 M:3.5 E:1.1 Bas:0.5 Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative . Repeat chemistry: 140 108 8 -------------< 73 3.3 20 0.7 Ca: 8.0 Mg: 1.6 P: 1.9 repeat lactate 3.1 Brief Hospital Course: 36M with ETOH dependence and frequent admissions for EtOH intoxication presents with EtOH withdrawal. ICU-east course by problem: . # Alcohol withdrawal: presented with signs of withdrawal with agitation, hypertension, tachycardia, and slight tremor of upper ex bilat. Has gait unsteadiness which is likely [**3-10**] acute intox but appears to be chronic based on records. - given that he has hx of DTs and w/d seizures, we treated aggressively with valium in ICU. He received either 60-70 IV valium in the ED. On arrival to the ICU, he was written for valium 20mg PO q15m prn CIWA>10 and he received it almost as frequently as written. He became less agitated after approx 80-100mg (in addition to the IV given in the ED) and then the CIWA scale was spread out to 20mg PO prn q1h. He tolerated this transition well. - He received multivit, folate, thiamine in IVF then PO - social work was consulted the morning after admission when patient was demanding to leave. He felt he had enough valium and actually refused another dose. We explained to him that we preferred that he stay for full evaluation and treatment of etoh w/d and his electrolyte abnormalities. He expressed understanding of our concerns and was able to verbalize the risks and benefits of leaving against our advice. He signed out AMA with plans to seek outpatient treatment. . # Psych: No SI. We had plans to contact psychiatry morning after admission particularly given his high valium need. However, he expressed interest in leaving and we felt he had capacity to make this decision. Social wk was involved but psychiatry was not consulted. . # chest pain: EKG without ischemic changes. CP was reproducible on palpation. Suspected MSK pain. He received one dose of morphine for cp. We then treated with toradol, motrin, and tylenol. We would recommend avoiding narcotics in the future if at all possible and if clinically indicated. His pain improved when his agitation improved. . # elevated lactate: ddx included dehydration, infection, liver disease, hypovolemia, poor sample. Lactic acidosis not likely given the alkalosis seen on VBG. Consider dehydration vs poor quality sample. Infection less likely given no fever or hypotension or any localizing signs of infection. Repeat lactate remained 3.1. Etiology unclear and workup hindered by patient leaving AMA. . # Anion gap: AG 18 in the ED with a normal HCO3 and alkalosis on VBG. ASA negative as were other toxins. Difficult to interpret but wonder if slightly increased AG is from the elevated lactate. Repeat chemistries showed normal anion gap. . #Anemia - normocytic anemia, Hct at baseline . # PPx: Heparin sc tid, PPI given etoh abuse, bowel reg . # FEN: Regular diet, replete lytes prn, banana bag then IVF . # Access: PIV x1 . # Code: FULL . # Communication: Patient . # Dispo: Patient left AMA. Medications on Admission: none Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: ETOH Intoxication/Withdrawal Discharge Condition: fair Discharge Instructions: You were admitted to the hospital because you were found intoxicated by EMS. You were admitted to the ICU and treated with Valium for withdrawal. You were advised to stay in the hospital for continued care and treatment of withdrawal however you decided against medical advice that you no longer wished to receive care. You spoke with the social worker before you left the hospital and were advised to return to [**Street Address(1) 5904**] Inn to speak with your outreach worker there. You signed out against medical advise. Followup Instructions: Please speak with the Outreach worker [**Street Address(1) 29735**] Inn. Please return to the hospital should you have any concerning symptoms including difficulty breathing, falls or injuries requiring medical attention, concerning withdrawal symptoms. ",64,2181-08-20 20:26:00,2181-08-21 11:10:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ALCOHOL WITHDRAWAL," 36m with etoh dependence and frequent admissions for etoh intoxication presents with etoh withdrawal. icu-east course by problem: . # alcohol withdrawal: presented with signs of withdrawal with agitation, hypertension, tachycardia, and slight tremor of upper ex bilat. has gait unsteadiness which is likely [**3-10**] acute intox but appears to be chronic based on records. - given that he has hx of dts and w/d seizures, we treated aggressively with valium in icu. he received either 60-70 iv valium in the ed. on arrival to the icu, he was written for valium 20mg po q15m prn ciwa>10 and he received it almost as frequently as written. he became less agitated after approx 80-100mg (in addition to the iv given in the ed) and then the ciwa scale was spread out to 20mg po prn q1h. he tolerated this transition well. - he received multivit, folate, thiamine in ivf then po - social work was consulted the morning after admission when patient was demanding to leave. he felt he had enough valium and actually refused another dose. we explained to him that we preferred that he stay for full evaluation and treatment of etoh w/d and his electrolyte abnormalities. he expressed understanding of our concerns and was able to verbalize the risks and benefits of leaving against our advice. he signed out ama with plans to seek outpatient treatment. . # psych: no si. we had plans to contact psychiatry morning after admission particularly given his high valium need. however, he expressed interest in leaving and we felt he had capacity to make this decision. social wk was involved but psychiatry was not consulted. . # chest pain: ekg without ischemic changes. cp was reproducible on palpation. suspected msk pain. he received one dose of morphine for cp. we then treated with toradol, motrin, and tylenol. we would recommend avoiding narcotics in the future if at all possible and if clinically indicated. his pain improved when his agitation improved. . # elevated lactate: ddx included dehydration, infection, liver disease, hypovolemia, poor sample. lactic acidosis not likely given the alkalosis seen on vbg. consider dehydration vs poor quality sample. infection less likely given no fever or hypotension or any localizing signs of infection. repeat lactate remained 3.1. etiology unclear and workup hindered by patient leaving ama. . # anion gap: ag 18 in the ed with a normal hco3 and alkalosis on vbg. asa negative as were other toxins. difficult to interpret but wonder if slightly increased ag is from the elevated lactate. repeat chemistries showed normal anion gap. . #anemia - normocytic anemia, hct at baseline . # ppx: heparin sc tid, ppi given etoh abuse, bowel reg . # fen: regular diet, replete lytes prn, banana bag then ivf . # access: piv x1 . # code: full . # communication: patient . # dispo: patient left ama. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Alkalosis; Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Acidosis; Chronic hepatitis C without mention of hepatic coma; Cocaine abuse, unspecified; Lack of housing; Anemia, unspecified; Other chest pain]","36m with etoh dependence and frequent admissions for etoh intoxication presents with etoh withdrawal. - he received multivit, folate, thiamine in ivf then po - social work was consulted the morning after admission when patient was demanding to leave. he signed out ama with plans to seek outpatient treatment. social wk was involved but psychiatry was not consulted. # anion gap: ag 18 in the ed with a normal hco3 and alkalosis on vbg. #anemia - normocytic anemia, hct at baseline .","36m with etoh dependence and frequent admissions for etoh intoxication presents with etoh withdrawal. presented with signs of withdrawal with agitation, hypertension, tachycardia, and slight tremor of upper ex bilat. social work was consulted the morning after admission when patient was demanding to leave." 5060,194191.0,24300,2181-08-21,24299,117340.0,2181-03-05,Discharge summary,"Admission Date: [**2181-2-24**] Discharge Date: [**2181-3-5**] Date of Birth: [**2144-9-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 358**] Chief Complaint: ETOH intoxication Major Surgical or Invasive Procedure: none History of Present Illness: 36 year old homeless man with h/o polysubstance abuse and frequent ICU admissions returns with alcohol intoxication. He reports that he drank a large bottle of listerine and a fifth of Vodka and then blacked out. He denies falling. Does report getting in a recent fight several days ago, he was punched in the chest and has had episodic chest pain/soreness since. He also fell down and cut his face at some point after the fight. On ROS he reports chest pain/tenderness, headache, burning pain in his hands and feet that has been worsening for at least 7 months, unsteady gait which he feels is worse when sober. He denies hematemasis, hematochezia, melena. He was most recently admitted for EtOh withdrawal from [**Date range (1) 61602**] and left AMA after his valium dose was tapered. He planned to go to Anchor House detox program in [**Location (un) 3320**], MA. He re-presented to the ED on [**2-8**] and once sober, he was unwilling to undergo detox; he was discharged. ED: VS on arrival T 98.9 HR 104 BP134/80 RR 16 96%RA. He was negative for cocaine; positive for benzos and ETOH at 251. He required 40 mg IV Valium, 1 mg PO lorazepam, and 5 mg PO valium for tremulousness and tachycardia. He was given total of 3L IVF. An RIJ was placed for poor PIV access. CXR confirmed its placement. Cardiac enzymes were sent. He received a banana bag Past Medical History: Polysubstance abuse: ETOH, heroin, IVDU, benzodiazepines Hepatitis C Hepatitis B Compartment syndrome RLE, [**2171**] OCD and anxiety Depression with hx suicidal ideations and attempts Alcohol abuse, hx DTs and withdrawal seizures Social History: Drinks regularly, 1 bottle of listerine per day. Uses heroin and benzodiazepines occasionally. Homeless, living in the [**Location (un) **] area. no IVDU since [**2167**]. no cigarrettes in >10 years. Family History: Father with depression and alcoholism. Mother died of DM complications Physical Exam: Vitals: afebrile, VSS Gen: NAD HEENT: PERRL, anicteric, MMM. Neck: supple Chest: clear CV: regular Abd: benign Ext: no edema Skin: No rash Neuro: nonfocal Psych: anxious . Pertinent Results: admission Labs: ------------- [**2181-2-24**] 09:45PM WBC-4.0# RBC-4.03* HGB-12.0* HCT-35.5* MCV-88 MCH-29.9 MCHC-33.9 RDW-16.0* [**2181-2-24**] 09:45PM NEUTS-33.9* LYMPHS-53.3* MONOS-6.3 EOS-5.5* BASOS-1.0 [**2181-2-24**] 09:45PM PLT COUNT-222 [**2181-2-24**] 09:45PM OSMOLAL-370* [**2181-2-24**] 09:45PM ETHANOL-252* [**2181-2-24**] 09:45PM CALCIUM-8.6 PHOSPHATE-1.7* MAGNESIUM-1.4* [**2181-2-24**] 09:45PM GLUCOSE-273* UREA N-11 CREAT-0.9 SODIUM-141 POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-26 ANION GAP-18 [**2181-2-24**] CXR- There is a right CVL seen with the tip positioned in the SVC and no PTX. The lungs are clear [**2181-2-25**] Head CT- IMPRESSION: No acute intracranial hemorrhage. Nearly completely opacified partially visualized left maxillary sinus, as before. Discharge: [**2181-2-28**] 04:13AM BLOOD WBC-7.5 RBC-4.20* Hgb-12.3* Hct-38.4* MCV-92 MCH-29.4 MCHC-32.1 RDW-15.1 Plt Ct-200 [**2181-2-28**] 04:13AM BLOOD Glucose-86 UreaN-9 Creat-0.8 Na-140 K-3.8 Cl-106 HCO3-30 AnGap-8 [**2181-2-26**] 04:18AM BLOOD ALT-44* AST-69* LD(LDH)-172 AlkPhos-104 TotBili-0.5 [**2181-2-28**] 04:13AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.0 Brief Hospital Course: 36M with ETOH dependence and frequent admissions for EtOH intoxication presented with EtOH intoxication/withdrawl. ETOH level 252 on admission. Initially admitted to the ICU for IV valium. Required 120mg valium total over first 24 hours. Patient tapered to PO valium and called out the general medical floor on [**2181-2-28**]. Psychiatry consulted and recommended slow valium taper and referral to [**Doctor Last Name **] house. Also recommended that patient could follow-up at [**Location (un) 61603**] house (BHCHP day shelter) if he complies to showing up to medical clinic after discharge. Mr. [**Known lastname 24927**] was informed he may be considered for Section 35 if he returns to the hospital for alcohol intoxication/withdrawal in the future, as he is considered a risk to his own safety. [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) 11009**] House did not have beds to offer, and as an alternative discharge plan was being arranged, Mr. [**Known lastname 24927**] left AMA. Medications on Admission: He has not taken any prescriptions medications for about 6 months. Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: alcohol withdrawal and dependence Discharge Condition: stable, but patient left AMA Discharge Instructions: Pt left AMA. Followup Instructions: Patient left AMA ",169,2181-02-24 19:23:00,2181-03-05 15:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,ETOH WITHDRAWAL," 36m with etoh dependence and frequent admissions for etoh intoxication presented with etoh intoxication/withdrawl. etoh level 252 on admission. initially admitted to the icu for iv valium. required 120mg valium total over first 24 hours. patient tapered to po valium and called out the general medical floor on [**2181-2-28**]. psychiatry consulted and recommended slow valium taper and referral to [**doctor last name **] house. also recommended that patient could follow-up at [**location (un) 61603**] house (bhchp day shelter) if he complies to showing up to medical clinic after discharge. mr. [**known lastname 24927**] was informed he may be considered for section 35 if he returns to the hospital for alcohol intoxication/withdrawal in the future, as he is considered a risk to his own safety. [**first name8 (namepattern2) 2048**] [**last name (namepattern1) 11009**] house did not have beds to offer, and as an alternative discharge plan was being arranged, mr. [**known lastname 24927**] left ama. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta; Dehydration; Alcoholic polyneuropathy; Opioid abuse, unspecified; Sedative, hypnotic or anxiolytic abuse, unspecified; Chronic hepatitis C without mention of hepatic coma; Lack of housing]","36m with etoh dependence and frequent admissions for etoh intoxication presented with etoh intoxication/withdrawl. also recommended that patient could follow-up at [**location (un) 61603**] house (bhchp day shelter) if he complies to showing up to medical clinic after discharge.",36m with etoh dependence and frequent admissions for etoh intoxication. initially admitted to the icu for iv valium and required 120mg valium total. psychiatry consulted and recommended slow valium taper and referral. 6901,198044.0,16225,2133-09-03,16224,193108.0,2133-03-23,Discharge summary,"Admission Date: [**2133-3-14**] Discharge Date: [**2133-3-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 134**] Chief Complaint: Weakness. Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] y year old man w/ pmh sinus node dysfunction s/p pacemaker placement, afib, HTN, called 911 earlier today after slipping off of his chair and falling to the ground. The patient was unable to get up, and lay on the ground for several hours before he was able to reach a phone. The patient reports fatigue and weakness over the past several days. He lives by himself and cares for himself, depending primarily on meals for wheels for nutrition. The patient [**Age over 90 **] chest pain, shortness of breath, fever, chills, brbpr, melena, dysuria. . In the ED, vitals were HR 124, BP 95/65. 97% RA. EKG showed afib w/aberrancy vs. Vtach. CK was 1589, Trop was .05 (baseline). INR was 12.9. Creatinine was 1.7, up from baseline 0.8. UA was positive for UTI. Pt received 150 amiodarone. Also ceftriaxone, 2.5 SC vitamin K and 1 unit FFP. Past Medical History: HTN GERD Sinus node dysfunction --> DDD pacer Atrial fibrillation s/p cardioversion ORIF right leg Cholecystectomy Cataract removal TURP Aortic stenosis s/p AVR (St. [**Male First Name (un) 923**] porcine valve, [**10-8**]) Carpal tunnel syndrome s/p release Allergic rhinitis Social History: Mr. [**Known lastname 46286**] is a retired window cleaner. He quit smoking 20 years ago and reports having smoked 1.5 packs per day for sixty years. He estimates drinking about 3 alcoholic drinks per month. He lives alone. Family History: Mr. [**Known lastname 46286**] [**Last Name (Titles) **] any contributory family history. Physical Exam: VS: T 99.6, BP 105/70 , HR 120-130 , RR 18 , O2 96 % on RA Gen: Elderly male Caucasian. Tired appearing but Oriented x3 and pleasant. Head: NCAT. Eyes: Sclera anicteric. PERRL, EOMI. Conjunctiva pale. Mouth furrowed, red tongue, no ulcerations seen. Neck: Supple with JVP of 8 cm. CV: Irregularly irregular, normal S1, S2. No S4, no S3. Chest: Resp were unlabored, no accessory muscle use. Scattered crackles, wheeze, rhonchi. Abd: Obese, soft, NTND. No abdominial bruits. Ext: [**12-3**]+ edema bilaterally. No femoral bruits. Skin: 3x3 erythematous shallow ulcer on lateral RLE. Red rash throughout perineal area. Pulses: DP pulses 2+ bilaterally Pertinent Results: [**2133-3-13**] 09:25PM BLOOD WBC-13.2* RBC-4.82 Hgb-14.1 Hct-42.4 MCV-88 MCH-29.3 MCHC-33.4 RDW-14.7 Plt Ct-219 [**2133-3-19**] 06:20AM BLOOD WBC-9.1 RBC-4.27* Hgb-12.4* Hct-37.3* MCV-87 MCH-29.0 MCHC-33.2 RDW-14.5 Plt Ct-161 [**2133-3-13**] 09:25PM BLOOD PT-97.9* PTT-46.1* INR(PT)-12.9* [**2133-3-19**] 06:20AM BLOOD PT-19.6* PTT-35.5* INR(PT)-1.8* [**2133-3-13**] 09:25PM BLOOD Glucose-86 UreaN-79* Creat-1.7* Na-141 K-5.5* Cl-105 HCO3-21* AnGap-21* [**2133-3-19**] 05:59PM BLOOD Glucose-96 UreaN-17 Creat-0.8 Na-136 K-4.1 Cl-101 HCO3-28 AnGap-11 [**2133-3-13**] 09:25PM BLOOD ALT-181* AST-142* CK(CPK)-1589* AlkPhos-162* TotBili-2.0* [**2133-3-17**] 03:44AM BLOOD ALT-93* AST-42* LD(LDH)-422* AlkPhos-127* TotBili-0.7 [**2133-3-13**] 09:25PM BLOOD CK-MB-32* MB Indx-2.0 [**2133-3-13**] 09:25PM BLOOD cTropnT-0.05* [**2133-3-15**] 05:02AM BLOOD CK-MB-8 cTropnT-0.05* [**2133-3-14**] 05:03AM BLOOD CK-MB-22* MB Indx-2.2 [**2133-3-13**] 09:25PM BLOOD Calcium-9.5 Phos-4.7*# Mg-3.0* [**2133-3-19**] 05:59PM BLOOD Calcium-7.6* Phos-2.0* Mg-1.9 [**2133-3-13**] 09:25PM BLOOD TSH-5.0* [**2133-3-13**] 09:25PM BLOOD Free T4-1.1 [**2133-3-18**] 04:34AM BLOOD Digoxin-1.5 [**2133-3-14**] 05:02AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010 [**2133-3-14**] 05:02AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2133-3-14**] 05:02AM URINE RBC-21-50* WBC->50 Bacteri-MOD Yeast-NONE Epi-[**2-4**] RenalEp-0-2 [**2133-3-13**] 09:40PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2133-3-13**] 09:40PM URINE Blood-LG Nitrite-POS Protein-TR Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2133-3-13**] 09:40PM URINE RBC-[**10-22**]* WBC-21-50* Bacteri-MOD Yeast-NONE Epi-0-2 [**2133-3-14**] 09:10AM URINE Hours-RANDOM Creat-64 Na-12 [**2133-3-14**] 05:02AM URINE Hours-RANDOM Creat-32 Na-83 [**2133-3-14**] 09:10AM URINE Osmolal-632 . CT HEAD W/O CONTRAST [**2133-3-14**] 12:10 AM CT HEAD W/O CONTRAST Reason: please assess for bleed [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] yo M presents with weakness. found to be in afib. anticoagulated INR 12 REASON FOR THIS EXAMINATION: please assess for bleed CONTRAINDICATIONS for IV CONTRAST: creat INDICATION: [**Age over 90 **]-year-old male with weakness and AFib with an INR of 12. COMPARISON: [**2133-3-2**]. TECHNIQUE: Non-contrast head CT. FINDINGS: There is no hemorrhage, edema, mass effect, hydrocephalus, or evidence of acute vascular territorial infarct. The ventricular and sulcal prominence remains unchanged. Hypodensities in the external capsule bilaterally are stable and suggestive of lacunar infarct. The osseous structures demonstrate no fractures. There is mucosal thickening within multiple ethmoid air cells, the frontal air cells, as well as maxillary sinuses with an 8-mm retention cyst in the left maxillary sinus. The middle ear cavities and mastoid air cells are clear. The soft tissues are unremarkable. IMPRESSION: No hemorrhage or mass effect. . CHEST (PORTABLE AP) [**2133-3-13**] 9:28 PM CHEST (PORTABLE AP) Reason: chf, pna [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old man with tachy, wide compl, rales REASON FOR THIS EXAMINATION: chf, pna CHEST RADIOGRAPH PERFORMED ON [**2133-3-13**] Compared with prior study from [**2132-1-20**]. CLINICAL HISTORY: [**Age over 90 **]-year-old man with tachycardia, rales, evaluate for CHF or pneumonia. FINDINGS: Portable upright chest radiograph is obtained. Midline sternotomy wires are again noted as is the dual-lead right chest pacemaker with lead tips in the proximal location of the right atrium and right ventricle. The patient is slightly rotated to the left, which somewhat limits evaluation. The cardiomediastinal silhouette is stable with mild cardiac enlargement again noted. There is a layering left pleural effusion noted. Bibasilar atelectatic changes are noted as well. There is no overt CHF. No definite pneumothorax is seen, although the patient's chin overlies the left lung apex, somewhat limiting evaluation. The visualized osseous structures appear stable and intact. IMPRESSION: 1. Stable cardiomegaly with left pleural effusion and bibasilar atelectasis. . Atrial fibrillation with rapid ventricular response and intraventricular conduction defect with secondary ST-T wave abnormalities. Compared to the previous tracing of [**2131-12-28**] atrial fibrillation is new. TRACING #1 Intervals Axes Rate PR QRS QT/QTc P QRS T 118 0 160 354/455 0 -56 122 . The left atrium is moderately dilated. The right atrium is markedly dilated. The estimated right atrial pressure is 10-20mmHg. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis (LVEF = 25-30 %). Right ventricular chamber size is normal. with mild global free wall hypokinesis. The ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis has normal transvalvular gradients. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. There is a minimally increased gradient consistent with trivial mitral stenosis. Trivial mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Moderate [2+] tricuspid regurgitation is seen. There is mild estimated pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2132-1-17**], biventricular function is worse and the trans-aortic gradient has decreased, possibly due to decreased cardiac output. . CHEST (PORTABLE AP) [**2133-3-19**] 7:44 AM CHEST (PORTABLE AP) Reason: interval change of effusion and pulm edema? [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old man with new CHF, vol overload. REASON FOR THIS EXAMINATION: interval change of effusion and pulm edema? PORTABLE CHEST COMPARISON: [**2133-3-17**]. INDICATION: CHF. Congestive heart failure has [**Year (4 digits) 27836**] with increasing vascular engorgement, perihilar edema, and enlarging pleural effusions. Left pleural effusion is now moderate-to-large in size, and the right effusion is small-to-moderate. Brief Hospital Course: [**Age over 90 **] y.o. male w/ pmh afib on coumadin, HTN, AS s/p porcine valve replacement, dementia, found down at home, presenting with UTI, ARF, rhabdomyolysis, and atrial fibrillation w/ aberancy. . #)Chronic systolic CHF: Patient presented with CHF exacerbation, being total body fluid overloaded while being intravascularly fluid depleted. His rhythm was atrial fibrillation with heart rates of 120-130's. He was treated initially with fluids, as his JVP was flat and he had negligible PO intake over the preceeding three days. He was also started on amiodarone in an attempt to cardiovert his rhythm. Echo showed LVEF 25-30% with severe global LV hypokinesis. By hospital Day #2, he began to develop crackles on lung exam and he was begun on a lasix drip in an attempt to diurese his excess fluid. His amiodaorne was discontinued as it was unsuccessful in cardioverting him to sinus rhythm. The patient was then begun on digoxin. He was on a lasix drip for three days and diuresed a total of 8L. The patient maintained adequate blood pressure throughout diuresis. The patient also had a pacer set at a rate of 80. EP was asked to interrogate the pacer and lower his rate to 70, in an effort to improve his symptoms of congestive heart failure. Interrogation revealed that he spends the majority of his time in atrial fibrillation. He is currently diuresing without diuretics. Please monitor ins and outs. When he begins to get even or positive/euvolemic (currently 2L negative without diuretics), please start 20mg PO lasix and titrate for euvolemia. He will need a follow-up ECHO in the next 6-8 weeks. . #)Atrial Fibrillation: Patient presented in atrial fibrillation with rates up to 120-130's. His INR was also at 12.1. He was administered fluids. He was initially begun on amiodarone, but was discontinued after two days because it was unsuccessful in cardioverting his rhythm. he was also administered ffp and vitamin k to reverse his INR. Echo showed dilated left atrium with a globally hypokinetic left ventricle with LVEF 25-30%. Given his left atrial dilation, he was not considered a good condidate for electrical cardioversion. He was next begun on digoxin. After fluid administration and initiation of digoxin, the patient's heart rate gradually slowed to 80-100. After three days, he was restarted on coumadin to maintain a therapeutic INR. His INR climbed to 2.9 on 5mg coumadin on the day of discharge, so he should be given 4mg qday starting on the evening of [**2133-3-23**]. Please check INR [**2133-3-28**]. Please give results to staff physician and fax to PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**First Name3 (LF) **] A, Fax: [**Telephone/Fax (1) 6443**] Phone: [**Telephone/Fax (1) 1144**]. Titrate coumadin to INR goal [**1-4**]. . #)Nutritional Status: patient is dependent on meals on wheels for his nutrition. He reported not eating for several days prior to admission. He was initially treated with thiamine, folate, glucose, vitamin C, zinc supplements, along with a multivitamin. He also received daily meals. After eating, his phosphate decreased to 1.5. This was thought to be a manifestation of refeeding syndrome and he was given phosphate supplements TID. chem 10 on [**2133-3-28**]. Please give results to staff physician and fax to PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**First Name3 (LF) **] A, Fax: [**Telephone/Fax (1) 6443**] Phone: [**Telephone/Fax (1) 1144**]. Titrate neutra phos to replete phosphate, can discontinue when refeeding syndrome is improved. . #) Acute renal failure: Baseline cr 0.8. On admission Cr 1.7, trended back to 0.9 atfer fluid administration. His ARF was thought secondary to hypovolemia. . #) UTI: positive UA upon admission. he also presented with a leukocytosis. He was begun on ceftriaxone for a UTI, and was treated for 7 days. . #) Valvular disease, s/p AVR with [**First Name8 (NamePattern2) **] [**Male First Name (un) 1525**] porcine valve. Patient's INR was initially reversed with ffp and vitamin K. His coumadin was then restarted to maintain a therapeutic INR. . #) Elevated LFTs: AST and ALT elevation may be explained by mild shock liver in setting of hypotension, no good explanation for alk phos and elevated t bili. His liver enzymes an bilirubin trended down to normal with stabilizing his hemodynamic status. . #) Lower Extremity Wounds: the patient had several ulcers on his lower extremities. he was evaluated by wound care and treated with daily dresing changes. . #) Code: FULL Medications on Admission: Nystatin - 100,000 unit/gram Powder - apply to rash twice a day Warfarin [Coumadin] - 5 mg Tablet - one Tablet(s) by mouth as directed Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 9. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet Sig: One (1) Powder in Packet PO TID WITH MEALS (). 10. labwork INR and chem 10 on [**2133-3-28**]. Titrate coumadin to INR goal [**1-4**]. Titrate neutra phos to replete phosphate, can discontinue when refeeding syndrome is improved. Please give results to staff physician and fax to PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**First Name3 (LF) **] A, Fax: [**Telephone/Fax (1) 6443**] Phone: [**Telephone/Fax (1) 1144**] 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 12. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: - acute on chronic systolic congestive heart failure - atrial fibrillation - UTI - hypophosphatemia . Secondary: HTN GERD Sinus node dysfunction --> DDD pacer ORIF right leg Cholecystectomy Cataract removal TURP Aortic stenosis s/p AVR (St. [**Male First Name (un) 923**] porcine valve, [**10-8**]) Carpal tunnel syndrome s/p release Allergic rhinitis Dementia Discharge Condition: good, stable Discharge Instructions: Mr. [**Known lastname 46286**] was seen at [**Hospital1 18**] for heart failure and atrial fibrillation. He was significantly fluid overloaded and he was diuresed during his stay. His afib was control with digoxin after amiodarone failed. He also had his pace maker changed to pace at 70 bpm and his warfarin titrated for goal INR [**1-4**]. He was also given a course of ceftriaxone for UTI. His potassium, phosphate and calcium was being repleted for likely refeeding syndrome. . He should be followed for: - INR, titrate coumadin to goal INR [**1-4**] - cardiopulmonary monitoring, specifically heart rate and blood pressure - weight gain - PT/OT - monitor phosphate, titrate or discontinue phosphate supplement accordingly . INR and chem 10 on [**2133-3-28**]. Titrate coumadin to INR goal [**1-4**]. Titrate neutra phos to replete phosphate, can discontinue when refeeding syndrome is improved. Please give results to staff physician and fax to PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**First Name3 (LF) **] A, Fax: [**Telephone/Fax (1) 6443**] Phone: [**Telephone/Fax (1) 1144**] . Please monitor ins and outs. When he begins to get even or positive/euvolemic (currently 2L negative without diuretics), please start 20mg PO lasix and titrate for euvolemia. . His primary care provider should be called or he should return to the emergency department if he experiences shortness of breath, chest pain, lightheadedness, palpitations, fever greater than 101.5 degrees F, or any other concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2133-4-30**] 3:30 . Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**] Date/Time:[**2133-4-30**] 4:00. - Please call Dr. [**Last Name (STitle) 1911**] for closer follow-up in the next 2-3 weeks. . Please follow-up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in the next 1-2 weeks. His number is [**Telephone/Fax (1) 1144**]. Please call for an appointment. ",164,2133-03-14 00:58:00,2133-03-23 15:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,REHAB/DISTINCT PART HOSP,HYPOTENSION," [**age over 90 **] y.o. male w/ pmh afib on coumadin, htn, as s/p porcine valve replacement, dementia, found down at home, presenting with uti, arf, rhabdomyolysis, and atrial fibrillation w/ aberancy. . #)chronic systolic chf: patient presented with chf exacerbation, being total body fluid overloaded while being intravascularly fluid depleted. his rhythm was atrial fibrillation with heart rates of 120-130s. he was treated initially with fluids, as his jvp was flat and he had negligible po intake over the preceeding three days. he was also started on amiodarone in an attempt to cardiovert his rhythm. echo showed lvef 25-30% with severe global lv hypokinesis. by hospital day #2, he began to develop crackles on lung exam and he was begun on a lasix drip in an attempt to diurese his excess fluid. his amiodaorne was discontinued as it was unsuccessful in cardioverting him to sinus rhythm. the patient was then begun on digoxin. he was on a lasix drip for three days and diuresed a total of 8l. the patient maintained adequate blood pressure throughout diuresis. the patient also had a pacer set at a rate of 80. ep was asked to interrogate the pacer and lower his rate to 70, in an effort to improve his symptoms of congestive heart failure. interrogation revealed that he spends the majority of his time in atrial fibrillation. he is currently diuresing without diuretics. please monitor ins and outs. when he begins to get even or positive/euvolemic (currently 2l negative without diuretics), please start 20mg po lasix and titrate for euvolemia. he will need a follow-up echo in the next 6-8 weeks. . #)atrial fibrillation: patient presented in atrial fibrillation with rates up to 120-130s. his inr was also at 12.1. he was administered fluids. he was initially begun on amiodarone, but was discontinued after two days because it was unsuccessful in cardioverting his rhythm. he was also administered ffp and vitamin k to reverse his inr. echo showed dilated left atrium with a globally hypokinetic left ventricle with lvef 25-30%. given his left atrial dilation, he was not considered a good condidate for electrical cardioversion. he was next begun on digoxin. after fluid administration and initiation of digoxin, the patients heart rate gradually slowed to 80-100. after three days, he was restarted on coumadin to maintain a therapeutic inr. his inr climbed to 2.9 on 5mg coumadin on the day of discharge, so he should be given 4mg qday starting on the evening of [**2133-3-23**]. please check inr [**2133-3-28**]. please give results to staff physician and fax to pcp, [**last name (namepattern4) **]. [**last name (stitle) **], [**first name3 (lf) **] a, fax: [**telephone/fax (1) 6443**] phone: [**telephone/fax (1) 1144**]. titrate coumadin to inr goal [**1-4**]. . #)nutritional status: patient is dependent on meals on wheels for his nutrition. he reported not eating for several days prior to admission. he was initially treated with thiamine, folate, glucose, vitamin c, zinc supplements, along with a multivitamin. he also received daily meals. after eating, his phosphate decreased to 1.5. this was thought to be a manifestation of refeeding syndrome and he was given phosphate supplements tid. chem 10 on [**2133-3-28**]. please give results to staff physician and fax to pcp, [**last name (namepattern4) **]. [**last name (stitle) **], [**first name3 (lf) **] a, fax: [**telephone/fax (1) 6443**] phone: [**telephone/fax (1) 1144**]. titrate neutra phos to replete phosphate, can discontinue when refeeding syndrome is improved. . #) acute renal failure: baseline cr 0.8. on admission cr 1.7, trended back to 0.9 atfer fluid administration. his arf was thought secondary to hypovolemia. . #) uti: positive ua upon admission. he also presented with a leukocytosis. he was begun on ceftriaxone for a uti, and was treated for 7 days. . #) valvular disease, s/p avr with [**first name8 (namepattern2) **] [**male first name (un) 1525**] porcine valve. patients inr was initially reversed with ffp and vitamin k. his coumadin was then restarted to maintain a therapeutic inr. . #) elevated lfts: ast and alt elevation may be explained by mild shock liver in setting of hypotension, no good explanation for alk phos and elevated t bili. his liver enzymes an bilirubin trended down to normal with stabilizing his hemodynamic status. . #) lower extremity wounds: the patient had several ulcers on his lower extremities. he was evaluated by wound care and treated with daily dresing changes. . #) code: full ","PRIMARY: [Congestive heart failure, unspecified] SECONDARY: [Acute kidney failure, unspecified; Urinary tract infection, site not specified; Rhabdomyolysis; Ulcer of calf; Acute on chronic systolic heart failure; Disorders of phosphorus metabolism; Atrial fibrillation; Unspecified essential hypertension; Esophageal reflux; Cardiac pacemaker in situ; Heart valve replaced by transplant]","male w/ pmh afib on coumadin, htn, as s/p porcine valve replacement, dementia, found down at home, presenting with uti, arf, rhabdomyolysis, and atrial fibrillation w/ aberancy. he was treated initially with fluids, as his jvp was flat and he had negligible po intake over the preceeding three days. echo showed lvef 25-30% with severe global lv hypokinesis. by hospital day #2, he began to develop crackles on lung exam and he was begun on a lasix drip in an attempt to diurese his excess fluid. the patient maintained adequate blood pressure throughout diuresis. he will need a follow-up echo in the next 6-8 weeks. given his left atrial dilation, he was not considered a good condidate for electrical cardioversion. please give results to staff physician and fax to pcp, [**last name (namepattern4) **]. [** he was evaluated by wound care and treated with daily dresing changes.","a male with uti, arf, rhabdomyolysis, and atrial fibrillation found down at home. he was treated with fluids, as his jvp was flat and he was intravascularly fluid depleted. he was started on amiodarone in an attempt to cardiovert his rhythm." 7095,167836.0,8296,2200-03-26,8295,100931.0,2200-03-08,Discharge summary,"Admission Date: [**2200-3-7**] Discharge Date: [**2200-3-8**] Date of Birth: [**2123-7-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Doctor First Name 1402**] Chief Complaint: hypotension Major Surgical or Invasive Procedure: pacemaker placement History of Present Illness: 76 year old male with DM, ESRD on HD via LUE AV fistula placed [**12/2196**] s/p multiple stenoses and angioplasties with angioplasty [**2200-1-16**] who is undergoing IV antibiotic therapy cefazolin at HD for MSSA bacteremia of unclear duration and source. He was at HD today for his regular visit and was noted to have hypotension. His pulse was then checked and found to be low, and his dialysis was cut short by 2 hours and he was transferred to [**Hospital1 18**] ER for further evaluation. . Upon presentation, pt denied complaints, but was noted to be in complete heart block with a wide complex escape rhythm (RBBB pattern) at 40 bpm. Known to have second degree AV block on EKG prior. BP was 110/68 and RR 18 with sats 94%. Pacer pads were placed. Carotid sinus massage and exercise were performed with no prominent effect on AV nodal conduction. He was noted to have WCB that was likely in the His bundle. As a pacemaker was recommended, ID was consulted due to recent infection/bacteremia. A TEE was performed and did not reveal any vegetations. He was afebrile with negative Blood cx's since [**2-22**], maintained on Abx at dialysis. Went for PPM placement today and was complicated by very difficult to access anatomy. In holding area post procedure pt delirius and confused, needed a team of ten people to keep control of him. Glucose was 17 on one measurement. Repeat was 200. He started the procedure with a glucose of 100. He had been NPO all day awaiting the procedure.He remained confused even after and was admitted to CCU for 1:1 monitoring. Past Medical History: -Diabetes mellitus 2 -chronic kidney disease stage 4 on HD MWF -Ulcerative colitis: no flares x 25 years -Right adrenal adenoma. -Gout. -History of prostate cancer, status post prostatectomy. -Remote history of nephrolithiasis. -Hypertension -Peripheral vascular disease s/p left [**Doctor Last Name **]-dp bypass -carotid stenosis -infrarenal abdominal aortic aneurysm -deep venous thrombosis in [**2195**] -iron deficiency anemia -recent episode of aphasia which resolved - ? TIA Social History: Quit smoking at age 73. Retired as a chemical mixer from a leather tannery. No alcohol or illicit drug use. Lives at home with his wife and family. Family History: Brother had liver cancer. Father and mother had cerebrovascular accidents. Paternal grandfather rectal cancer. Physical Exam: PE: T: 98.8 HR: 95 BP: 106/65 RR: 23 100% RA. Neuro: PERRLA, A0X3 CVS: [**12-18**] HSM heard best at apex R chest: dressing over pacemaker C/D/I Lungs: CTA-B abd: +bs, soft, nt, nd Ext: wwp,trace edema pulses dopplerable Pertinent Results: [**2200-3-7**] 11:28PM GLUCOSE-163* UREA N-25* CREAT-5.1*# SODIUM-145 POTASSIUM-4.9 CHLORIDE-97 TOTAL CO2-38* ANION GAP-15 [**2200-3-7**] 11:28PM ALT(SGPT)-0 AST(SGOT)-24 ALK PHOS-112 TOT BILI-0.7 [**2200-3-7**] 11:28PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-2.1 [**2200-3-7**] 11:28PM WBC-11.9* RBC-2.84* HGB-7.8* HCT-27.3* MCV-96 MCH-27.6 MCHC-28.7* RDW-25.9* [**2200-3-7**] 11:28PM PLT COUNT-151 [**2200-3-7**] 11:28PM PT-14.0* PTT-28.3 INR(PT)-1.2* [**2200-3-7**] 11:50AM GLUCOSE-94 K+-4.0 . Echo [**2200-3-7**] No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Right atrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect is seen by 2D or color Doppler. with mild global free wall hypokinesis. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild to moderate ([**12-14**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is at least mild pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No valvular vegetations or peri-valvular abcesses seen. Mild to moderate mitral regurgitation. Mildly depressed left ventricular and moderately depressed right ventricular systolic function. Complex plaque in descending aorta and aortic arch. Mild pulmonary hypertension. . CXR [**2200-3-8**] - IMPRESSION: Evidence for mild vascular congestion and very small pleural effusions. Cardiomegaly. A transvenous pacemaker in place. Brief Hospital Course: 76 yo M w/ PMHx of HTN, DM, and ESRD on HD who was known to have second degree AV block on prior EKG noted on admission to have deteriorated to complete heart block. Altered Mental Status: His course post PM placement was complicated by delirium, in the setting of hypoglycemia to 17. He received an amp of d50 with improvement of his GFS to the 200s. He was delirious initially on the floor and per discussions with his spouse he is confused at baseline. In addition to the hypoglycemia, he may have been particularly sensitive to sedating medications, and there may be some metabolic component given his ESRD although his electrolytes were not markedly abnormal. His GFS were checked every 4 hours, he received repeated reorientation, and benzodiazepines were avoided. His sensorium continued to improve. Complete heart block s/p Pacemaker: He had a [**Company **] DDD pacemaker placed set at 60-120. He was appropriately V paced on telemetry and subsequent EKG. He received a CXR the day following his procedure showing that the leads were appropriately positioned. EP interoggation post procedure showed the pacemaker was working appropriately. He was instricted to wear a slight to immobilize his right arm for several weeks post procedure. A plan was made for him to follow up with the device clinic within one week of discharge. He needs a new cardiologist and the phone number for the cardiology clinic was given to him to set up an appointment. ESRD on HD: He has ESRD on hemodialysis MWF. Due to his episode of hypotension, his Friday hemodialysis session was terminated prematurely, and he only received half of his dialysis. He was discussed with our renal team and was not found to be grossly volume overloaded nor were the electrolytes particularly abnormal. Dialysis was deferred to his next scheduled session on Monday. MSSA bacteremia: undergoing IV antibiotic therapy cefazolin at HD for MSSA bacteremia of unclear duration and source. At this point he is 13 days into his course. He should complete the course of cefazolin decided by his nephrologists at dialysis. HTN: He was normotensive this hospitalization. His antihypertensive regimen with metoprolol and lisinopril was continued. Carotid stenosis /Infrarenal AAA/PVD: He was continued on asa, simvastatin, lisinopril. Medications on Admission: 1. Albuterol Sulfate 2 puffs QID PRN 2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TIDAC 3. Clopidogrel 75 mg PO q day 4. Fluticasone-Salmeterol 100-50 mcg/Dose [**Hospital1 **] 5. Lasix 40 mg PO BID 6. Glipizide 2.5 mg ER PO BID 7. Lisinopril 40 mg PO Q day 8. Metoprolol Tartrate 100 mg Tablet PO Q day 9. Ranitidine HCl 150 mg PO Q day 10. Silver Sulfadiazine 1 % Cream Sig: Q day 11. Simvastatin 10 mg Tablet PO Q HS 12. Aspirin 325 mg PO Q day 13. Folic Acid 1 mg PO Q day 14. B Complex-Vitamin C-Folic Acid 1 mg Capsule PO Q day 15. Cefazolin at HD Discharge Medications: 1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 2. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY (Daily) as needed for apply to foot wounds. 12. Cefazolin 10 gram Recon Soln Sig: Two (2) grams IV Injection HD PROTOCOL (HD Protochol). 13. Glipizide 2.5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2* 14. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 15. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary. Complete heart Block S/P pacemaker placement Secondary End Stage Renal Disease Diabetes Discharge Condition: Alert and oriented to person, place and time. Mildly confused. Discharge Instructions: You were admitted to the hospital because you had dropped your blood pressure during dialysis. You were found to have complete heart block on EKG, a condition where the [**Doctor Last Name 1754**] of your heart do not communicate electrically. For this reason, you had to have a pacemaker placed. You were disoriented after the procedure because your blood sugar was low however this has been corrected. Some of the sedating medications may take some time to wear off, so you may be a little confused intitially. Please see your doctor if you still feel confused after a couple of days. The following changes were made to your medications: - DECREASE glipizide to 2.5mg ONCE a day. It is very important that you do not engage in any stretching or lifting using your right arm. Please keep the pacemaker area dry for 1 week. Please limit movement of your right arm and wear the arm sling for six weeks. Followup Instructions: Provider: [**Name10 (NameIs) **] Clinic. Please follow up within one week of discharge. The number to call to make your appointment is [**Telephone/Fax (1) 62**]. You need a new cardiologist. Please call [**Hospital1 18**] cardiology at ([**Telephone/Fax (1) 2037**] to set up an appointment Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1142**] Date/Time:[**2200-3-19**] 3:00 Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2200-3-20**] 10:30 Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2200-4-17**] 8:30 ",18,2200-03-07 16:24:00,2200-03-08 14:40:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,COMPLETE HEART BLOCK," 76 yo m w/ pmhx of htn, dm, and esrd on hd who was known to have second degree av block on prior ekg noted on admission to have deteriorated to complete heart block. altered mental status: his course post pm placement was complicated by delirium, in the setting of hypoglycemia to 17. he received an amp of d50 with improvement of his gfs to the 200s. he was delirious initially on the floor and per discussions with his spouse he is confused at baseline. in addition to the hypoglycemia, he may have been particularly sensitive to sedating medications, and there may be some metabolic component given his esrd although his electrolytes were not markedly abnormal. his gfs were checked every 4 hours, he received repeated reorientation, and benzodiazepines were avoided. his sensorium continued to improve. complete heart block s/p pacemaker: he had a [**company **] ddd pacemaker placed set at 60-120. he was appropriately v paced on telemetry and subsequent ekg. he received a cxr the day following his procedure showing that the leads were appropriately positioned. ep interoggation post procedure showed the pacemaker was working appropriately. he was instricted to wear a slight to immobilize his right arm for several weeks post procedure. a plan was made for him to follow up with the device clinic within one week of discharge. he needs a new cardiologist and the phone number for the cardiology clinic was given to him to set up an appointment. esrd on hd: he has esrd on hemodialysis mwf. due to his episode of hypotension, his friday hemodialysis session was terminated prematurely, and he only received half of his dialysis. he was discussed with our renal team and was not found to be grossly volume overloaded nor were the electrolytes particularly abnormal. dialysis was deferred to his next scheduled session on monday. mssa bacteremia: undergoing iv antibiotic therapy cefazolin at hd for mssa bacteremia of unclear duration and source. at this point he is 13 days into his course. he should complete the course of cefazolin decided by his nephrologists at dialysis. htn: he was normotensive this hospitalization. his antihypertensive regimen with metoprolol and lisinopril was continued. carotid stenosis /infrarenal aaa/pvd: he was continued on asa, simvastatin, lisinopril. ","PRIMARY: [Atrioventricular block, complete] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease; Bacteremia; Renal dialysis status; Peripheral vascular disease, unspecified; Gout, unspecified; Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site; Personal history of malignant neoplasm of prostate; Other alteration of consciousness; Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled; Polyneuropathy in diabetes]","76 yo m w/ pmhx of htn, dm, and esrd on hd who was known to have second degree av block on prior ekg noted on admission to have deteriorated to complete heart block. altered mental status: his course post pm placement was complicated by delirium, in the setting of hypoglycemia to 17. he was delirious initially on the floor and per discussions with his spouse he is confused at baseline. a plan was made for him to follow up with the device clinic within one week of discharge. dialysis was deferred to his next scheduled session on monday.","76 yo m w/ pmhx of htn, dm, and esrd on hd who was known to have second degree av block on prior ekg noted on admission to have deteriorated to complete heart block. he received an amp of d50 with improvement of his gfs to the 200s. his electrolytes were not markedly abnormal." 8559,105407.0,16314,2153-08-26,16313,145304.0,2153-05-08,Discharge summary,"Admission Date: [**2153-4-24**] Discharge Date: [**2153-5-8**] Date of Birth: [**2090-1-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3276**] Chief Complaint: abdominal pain, constipation Major Surgical or Invasive Procedure: Right IJ central line placement PICC placement Transfusion of [**First Name3 (LF) **] products History of Present Illness: 63-yo M with history of AS s/p AVR, PAF, [**Hospital **] transferred from OSH with Hct drop, esophageal mass. He initially presented to his PCP with constipation [**Name Initial (PRE) **] 3 weeks, with mild abd distention and diffuse abd pain. Poor PO intake due to fear of abd pain. Lost a few pounds x past few weeks. No n/v. About 1 week PTA, he had abd and chest CT that showed retroperitoneal and retro-mediastinal LAD. Was seen by GI, who found him to have positive guaiac on exam and referred to [**Hospital3 **] ED, where repeat abd CT again showed LAD with ?colonic obstruction, which prompted a barium enema study that was negative for bowel obstruction. Since the enema, he has had dark-colored diarrhea. He also reports malaise x past few weeks. . He was admitted to [**Hospital3 **]. Labs were notable for WBC 25, Hct 22 (42 one week prior), plts 122. INR 3.0, Cr 1. For his Hct drop, he received 4 units of pRBCs alogn with 2 units of FFP. Hct increased to 26. He underwent an EGD which revealed a lower esophageal mass which was oozing [**Hospital3 **]. Bx and brushings were taken. Per GI, the patient was also having some hemoptysis, raising suspicion for tracheoesophageal fistula. He was hemodynamically stable, mentating well without any hematemesis, hemoptysis, or rectal bleeding. He was transferred to [**Hospital1 18**] for further management. On arrival, he was stable, alert, awake. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting. No dysuria. Denied arthralgias or myalgias. Past Medical History: AS s/p AVR (Booing valve) PAF not on warfarin hemachromatosis with regular phlebotomies; normal liver bx a few months ago Social History: Works as a dye maker. No smoking. Social drinking. Family History: Mother had gastric ca and died of emphysema Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur best heard at RUSB Abdomen: soft, non-tender, moderately distended, slightly tense, bowel sounds present, no rebound tenderness or guarding Rectal: guaiac positive Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs [**2153-4-24**] 07:50PM [**Year/Month/Day 3143**] WBC-24.0*# RBC-3.22* Hgb-9.9* Hct-28.0* MCV-87# MCH-30.8 MCHC-35.5* RDW-17.4* Plt Ct-110*# [**2153-4-24**] 07:50PM [**Year/Month/Day 3143**] Neuts-57 Bands-14* Lymphs-8* Monos-2 Eos-2 Baso-1 Atyps-0 Metas-8* Myelos-8* NRBC-7* [**2153-4-24**] 07:50PM [**Year/Month/Day 3143**] PT-17.7* PTT-34.9 INR(PT)-1.6* [**2153-4-24**] 07:50PM [**Year/Month/Day 3143**] Fibrino-75* [**2153-4-24**] 08:20PM [**Year/Month/Day 3143**] FDP-320-640* [**2153-4-25**] 09:39AM [**Month/Day/Year 3143**] Ret Aut-4.3* [**2153-4-24**] 07:50PM [**Year/Month/Day 3143**] Glucose-141* UreaN-43* Creat-0.8 Na-139 K-4.6 Cl-103 HCO3-25 AnGap-16 [**2153-4-24**] 07:50PM [**Year/Month/Day 3143**] ALT-31 AST-78* LD(LDH)-1665* AlkPhos-193* TotBili-1.5 [**2153-4-24**] 07:50PM [**Year/Month/Day 3143**] Calcium-8.8 Phos-4.1# Mg-2.8* UricAcd-7.4* Interim/Discharge Labs [**2153-5-4**] 02:29PM [**Month/Day/Year 3143**] CEA-5432* [**2153-4-25**] 12:32AM [**Month/Day/Year 3143**] Lactate-1.7 [**2153-5-2**] 03:15AM [**Month/Day/Year 3143**] Albumin-2.0* Calcium-7.7* Phos-2.7 Mg-2.0 [**2153-5-6**] 12:00AM [**Month/Day/Year 3143**] Albumin-2.5* Calcium-7.7* Phos-3.6 Mg-2.1 [**2153-5-6**] 12:00AM [**Month/Day/Year 3143**] ALT-44* AST-33 LD(LDH)-621* AlkPhos-148* TotBili-0.7 [**2153-4-29**] 06:32AM [**Month/Day/Year 3143**] Glucose-192* UreaN-47* Creat-0.8 Na-147* K-4.0 Cl-115* HCO3-25 AnGap-11 [**2153-5-7**] 11:50PM [**Month/Day/Year 3143**] Glucose-115* UreaN-12 Creat-0.6 Na-138 K-3.9 Cl-105 HCO3-26 AnGap-11 [**2153-4-26**] 05:15AM [**Month/Day/Year 3143**] FDP-[**Telephone/Fax (1) 14007**]* [**2153-5-2**] 07:31PM [**Month/Day/Year 3143**] Fibrino-367 [**2153-5-7**] 01:00AM [**Month/Day/Year 3143**] Fibrino-326 [**2153-4-26**] 02:45PM [**Month/Day/Year 3143**] Plt Smr-VERY LOW Plt Ct-53* LPlt-2+ [**2153-4-26**] 05:47PM [**Month/Day/Year 3143**] PT-16.6* PTT-36.5* INR(PT)-1.5* [**2153-4-30**] 07:51PM [**Month/Day/Year 3143**] PT-15.3* PTT-29.1 INR(PT)-1.4* [**2153-5-7**] 01:00AM [**Month/Day/Year 3143**] PT-13.9* PTT-21.5* INR(PT)-1.2* [**2153-5-7**] 11:50PM [**Month/Day/Year 3143**] Plt Ct-120* [**2153-5-6**] 12:00AM [**Month/Day/Year 3143**] Neuts-72* Bands-4 Lymphs-9* Monos-6 Eos-1 Baso-1 Atyps-0 Metas-7* Myelos-0 [**2153-4-26**] 05:47PM [**Month/Day/Year 3143**] WBC-18.8* RBC-3.02* Hgb-9.1* Hct-25.2* MCV-83 MCH-30.0 MCHC-36.1* RDW-18.0* Plt Ct-56* [**2153-4-29**] 02:44AM [**Month/Day/Year 3143**] WBC-9.8 RBC-3.49* Hgb-10.5* Hct-30.4*# MCV-87 MCH-30.0 MCHC-34.4 RDW-18.3* Plt Ct-83* [**2153-4-30**] 05:08AM [**Month/Day/Year 3143**] WBC-6.3 RBC-2.85* Hgb-8.6* Hct-25.0* MCV-88 MCH-30.3 MCHC-34.5 RDW-17.6* Plt Ct-58* [**2153-5-2**] 07:31PM [**Month/Day/Year 3143**] WBC-4.4 RBC-3.13* Hgb-9.1* Hct-26.5* MCV-85 MCH-29.1 MCHC-34.4 RDW-16.2* Plt Ct-68* [**2153-5-7**] 11:50PM [**Month/Day/Year 3143**] WBC-3.3* RBC-3.16* Hgb-9.8* Hct-29.0* MCV-92 MCH-31.0 MCHC-33.8 RDW-19.2* Plt Ct-120* Micro Data [**Month/Day/Year **] cx no growth IMAGING [**2153-4-25**] CXRIMPRESSION: AP chest compared to [**2147-2-4**]: Diaphragm is elevated, lowering the lung volumes. Examination is marked as an upright view, this may not be the case. Nevertheless, no free subdiaphragmatic gas is demonstrated. Colon and stomach are distended with gas. Lungs are grossly clear aside from mild left basal atelectasis. Moderate cardiomegaly is longstanding. No pneumothorax or pleural effusion.\ [**2153-4-25**] KUB IMPRESSION: No definite evidence of obstruction. No evidence of free air on limited supine view. [**4-28**] Abdomen: Contrast material is again present throughout the colon. There is distention of the transverse colon measuring about 10 cm, compared to 8.4 cm previously. Contrast is seen distally within the rectosigmoid region and in the descending colon, both of which appear nondistended. Mildly prominent air- filled loops of small bowel are also present. [**2153-5-5**] Abdomen: Portable AP radiograph of the abdomen was compared to [**2153-4-29**]. On the current study, no evidence of large bowel dilatation has been demonstrated, but note is made that the upper abdomen was not included in the field of view. The currently imaged pattern of the bowel gas distribution is nonspecific and does not demonstrate any apparent abnormality. Brief Hospital Course: 63 year old gentleman with newly diagnosed esophageal adenocarcinoma and upper GI bleed. 1) GI Bleed/[**Year (4 digits) **] loss anemia: Patient developed GI bleed and [**Year (4 digits) **] loss anemia due to bleeding from esophageal mass which was complicated by thrombocytopenia and DIC as below. The patient was admitted to the ICU from [**Hospital3 4107**] with a hematocrit in the 20s requiring 23 unit [**Hospital3 **] transfusions while in the ICU. Surgery, GI & Radiation/Oncology were consulted and the patient underwent XRT which alleviated his bleeding. He did not require tranfusions of [**Hospital3 **] for ~36 hours and was called out to the Oncology floor. On the floor, he was transfused 2 unit PRBCs intitially [**5-4**] then did not require any further transfusions. His platelets also remained stable and DIC resolved. He was started on PPI [**Hospital1 **] and continued on this at discharge. 2) DIC: The patient presented with an INR of 3, fibrinogen near 100 and platelets in the 50s. The etiology of his DIC was felt to be due to underlying tumor burden. He was transfused multiple units of platelets, FFP and cryoprecipitate. As his bleeding subsided with XRT, his DIC resolved as well. 3) Esophageal Adenocarcinoma: The patient was diagnosed with stage IV adenocarcinoma. Oncology was consulted and they initiated 5FU/Oxalyplatin therapy in conjunction with XRT. He will have an outpatient PET which was scheduled prior to discharge and will follow up with Dr. [**Last Name (STitle) 3274**]. 4) Afib: Pt had episodes of afib with RVR in the [**Hospital Unit Name 153**] responding to diltizem but remained rate controlled on the floor in the 80s. He was continued on his previous metoprolol dosing at discharge. 5) Foot ulcerations: Pt developed maceration and erythema of his feet bilaterally with lower extremity edema. Podiatry was unable to see him prior to discharge in house but an appointment was made with his outpatient podiatrist the following day after discharge. 6) Low grade fever: Pt had a low grade fever 2 days prior to discharge but had no signs or symptoms of infection other than possibly feet as above. He was afebrile 24 hours prior to discharge off antibiotics and cx were negative and f/u arranged with podiatry as above. Medications on Admission: metoprolol 25 mg PO bid atorvastatin 40 mg qhs acetaminophen flexeril prn Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 tube* Refills:*2* 4. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)) as needed for nausea. Disp:*100 Tablet(s)* Refills:*0* 5. Outpatient Lab Work Please check CBC on Thursday [**2153-5-10**] and fax to Dr. [**Last Name (STitle) 3274**] at [**Telephone/Fax (1) 22294**] 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: Primary Diagnosis Esophageal Adenocarcinoma Acute [**Hospital3 **] loss anemia secondary to Esophageal cancer Disseminated intravascular coagulation Secondary Diagnosis: Paroxysmal atrial fibrillation Discharge Condition: Hemodynamically stable, HR 80s and regular,stable [**Hospital3 **] counts, last transfused [**2153-5-4**], afebrile with low grade fever 100.8 on [**2153-5-7**] Discharge Instructions: You were admitted to the the hospital with bleeding and problems with [**Name2 (NI) **] clotting likely related to cancer in your esophagus. You received [**Name2 (NI) **] and platelet transfusions in the intensive care unit. You were then transferred to the regular oncology floor and you did well with no further bleeding. You were seen by physical therapy who recommended you have more physical therapy at home. We made the following changes to your medications We added Bacitracin We added Pantoprazole 40mg PO BID We added reglan as needed for nausea Please return to the ER or call your primary oncologist if you develop chest pain, palpitations, shortness of breath, abdominal pain, nausea, vomiting, [**Name2 (NI) **] in the stool or dark stools, or any other concerning symptoms. Followup Instructions: Dr. [**Name (STitle) 3548**] [**Doctor Last Name 776**], [**2153-6-6**], 11 AM, [**Hospital Ward Name 332**] Basement (Radiation Oncology) Please follow up with Drs. [**Last Name (STitle) 3274**] and [**Name5 (PTitle) 1852**] [**0-0-**]. You have an appointment on Tuesday [**5-15**] at 2pm, on [**Hospital Ward Name 23**] [**Location (un) 8939**]. Please follow up with the Podiatrist, Dr. [**Last Name (STitle) **] (who works with Dr. [**Last Name (STitle) **] tomorrow [**2153-5-9**] at noon. Call [**0-0-**] if you have any questions. You also have a PET scan scheduled for Friday [**5-11**]. You were given information regarding this over the telephone [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**] ",110,2153-04-24 18:26:00,2153-05-08 16:40:00,EMERGENCY,TRANSFER FROM HOSP/EXTRAM,HOME HEALTH CARE,GASTROINTESTINAL BLEED," 63 year old gentleman with newly diagnosed esophageal adenocarcinoma and upper gi bleed. 1) gi bleed/[**year (4 digits) **] loss anemia: patient developed gi bleed and [**year (4 digits) **] loss anemia due to bleeding from esophageal mass which was complicated by thrombocytopenia and dic as below. the patient was admitted to the icu from [**hospital3 4107**] with a hematocrit in the 20s requiring 23 unit [**hospital3 **] transfusions while in the icu. surgery, gi & radiation/oncology were consulted and the patient underwent xrt which alleviated his bleeding. he did not require tranfusions of [**hospital3 **] for ~36 hours and was called out to the oncology floor. on the floor, he was transfused 2 unit prbcs intitially [**5-4**] then did not require any further transfusions. his platelets also remained stable and dic resolved. he was started on ppi [**hospital1 **] and continued on this at discharge. 2) dic: the patient presented with an inr of 3, fibrinogen near 100 and platelets in the 50s. the etiology of his dic was felt to be due to underlying tumor burden. he was transfused multiple units of platelets, ffp and cryoprecipitate. as his bleeding subsided with xrt, his dic resolved as well. 3) esophageal adenocarcinoma: the patient was diagnosed with stage iv adenocarcinoma. oncology was consulted and they initiated 5fu/oxalyplatin therapy in conjunction with xrt. he will have an outpatient pet which was scheduled prior to discharge and will follow up with dr. [**last name (stitle) 3274**]. 4) afib: pt had episodes of afib with rvr in the [**hospital unit name 153**] responding to diltizem but remained rate controlled on the floor in the 80s. he was continued on his previous metoprolol dosing at discharge. 5) foot ulcerations: pt developed maceration and erythema of his feet bilaterally with lower extremity edema. podiatry was unable to see him prior to discharge in house but an appointment was made with his outpatient podiatrist the following day after discharge. 6) low grade fever: pt had a low grade fever 2 days prior to discharge but had no signs or symptoms of infection other than possibly feet as above. he was afebrile 24 hours prior to discharge off antibiotics and cx were negative and f/u arranged with podiatry as above. ","PRIMARY: [Malignant neoplasm of other specified part of esophagus] SECONDARY: [Defibrination syndrome; Acute posthemorrhagic anemia; Hematemesis; Hyperosmolality and/or hypernatremia; Thrombocytopenia, unspecified; Ulcer of other part of foot; Atrial fibrillation; Fever, unspecified; Leukocytopenia, unspecified; Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use; Heart valve replaced by other means]","63 year old gentleman with newly diagnosed esophageal adenocarcinoma and upper gi bleed. he was transfused multiple units of platelets, ffp and cryoprecipitate. as his bleeding subsided with xrt, his dic resolved as well. 4) afib: pt had episodes of afib with rvr in the [**hospital unit name 153**] responding to diltizem but remained rate controlled on the floor in the 80s. he was continued on his previous metoprolol dosing at discharge.",63 year old gentleman with newly diagnosed esophageal adenocarcinoma. he developed gi bleed and loss anemia due to bleeding from esophageal mass. patient underwent xrt which alleviated his bleeding. 10774,142104.0,8553,2140-10-30,8551,146298.0,2140-09-12,Discharge summary,"Admission Date: [**2140-9-7**] Discharge Date: [**2140-9-12**] Date of Birth: [**2068-2-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30062**] Chief Complaint: melana, chest pain Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: 72 year old male with CAD s/p CABG, atrial fib on coumadin, s/p VT/VF arrest with BiV pacer; CHF with EF 15% admitted to the MICU ([**9-7**]) after presenting with CP, SOB, abdominal pain, melena, INR of 3, and Hct drop from 40 to 37. He was admitted to the MICU where he was given FFP and 1u PRBCs and ruled out for ACS. He was seen by GI, Surgery, and Cardiology. GI c/s resulted in plan for EGD. Surgery c/s resulted in INR reversal and serial exams and hcts. Cardiology felt the patient's CP was not [**2-13**] a cardiac etiology. He was ruled out for MI regardless. His Hct was 31 at its lowest but remained stable and, as he was stable overall, he was felt appropriate for transfer to the floor for further work up of his melena. . Of note, last [**Month (only) 547**], the patient had a similar presentation and EGD, c-scope, and capsule endoscopy demonstrated gastritis, Barrett's, diverticulosis and grade 1 hemorrhoids were found, without any active bleeding. At time of transfer, the patient endorsed mild abdominal pain and diaphoresis. He denied chest pain. He had not had a BM in 2 days. Past Medical History: --CAD status post CABG with simultaneous aortic aneurysm repair in [**2133**], history of stenting of the left circumflex artery [**2135**] --s/p VT/VF arrest, s/p ICD placement in [**2135**] --Ischemic cardiomyopathy with an ED of 20%, s/p BiV pacer [**10-18**] --Chest wall cellulitis over pacer site [**3-19**] vs. ICD pacer pocket infection --PAF --CKD with baseline Cr. 1.6-2 --Hyperlipidemia --Asthma --Anxiety --Alzheimer's dementia --Hypothyroidism --GI bleed of unknown etiology [**2138**]. EGD revealed esophagitis, Barrett's esophagus, and duodenitis. No ulcers. --Diverticulosis --GERD --S/P Cholecystectomy Social History: Patient originally from [**Country 4754**] and moved to the United States in [**2089**]. Worked as an off-set printer in [**Location (un) 686**], where he continues to live with his wife. Father of five children. Retired 6 years ago, and since his recent heart problems, says he rarely leaves the house. Most of his time is spent in front of the television with his wife handling their affairs at home. No history of smoking, past or present. Patient was a heavy drinker until 20 years ago, when he stopped completely after attending AA and encountering marital difficulties. No history of illicit drug use. Family History: Non-contributory. Physical Exam: Afebrile, 115/69, 75, 18, 99%2L General Appearance: Pleasant, obese male, mildly diaphoretic lying in bed in no acute distress. Eyes / Conjunctiva: PERRL, EOMI, no icterus Head, Ears, Nose, Throat: NCAT, MMMI, JVD 10cm Cardiovascular: paced, [**3-17**] looud blowing systolic murmur loudest at LUSB with radiation along the left sternal border throughout, large, prolonged and displaced PMI Respiratory / Chest: CTA b/l Abdominal: Soft, mild guarding, +BS, subumbilical tenderness with mild tenderness in bl lower quadrents, no guarding Extremities: pneumoboots in place, dps 1+ bl Neurologic: Attentive, Follows simple commands, a and o times 3, movement and sensation intact in all extremities Pertinent Results: [**2140-9-7**] 03:20PM PT-29.2* PTT-31.4 INR(PT)-3.0* [**2140-9-7**] 03:20PM PLT COUNT-168 [**2140-9-7**] 03:20PM NEUTS-75.5* LYMPHS-13.8* MONOS-7.0 EOS-3.4 BASOS-0.4 [**2140-9-7**] 03:20PM WBC-8.6 RBC-4.30* HGB-12.4* HCT-37.0* MCV-86 MCH-28.8 MCHC-33.5 RDW-14.6 [**2140-9-7**] 03:20PM DIGOXIN-0.9 [**2140-9-7**] 03:20PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-2.3 [**2140-9-7**] 03:20PM CK-MB-4 [**2140-9-7**] 03:20PM cTropnT-0.01 [**2140-9-7**] 03:20PM LIPASE-44 [**2140-9-7**] 03:20PM ALT(SGPT)-20 AST(SGOT)-28 CK(CPK)-112 ALK PHOS-89 TOT BILI-0.2 [**2140-9-7**] 03:20PM estGFR-Using this [**2140-9-7**] 03:20PM GLUCOSE-72 UREA N-23* CREAT-1.7* SODIUM-138 POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-32 ANION GAP-10 [**2140-9-7**] 03:32PM K+-4.6 [**2140-9-7**] 03:32PM COMMENTS-GREEN TOP [**2140-9-7**] 06:02PM HCT-35.6* [**2140-9-7**] 06:12PM LACTATE-0.9 [**2140-9-7**] 11:30PM HCT-31.1* [**2140-9-7**] 11:30PM URINE HOURS-RANDOM UREA N-377 CREAT-52 SODIUM-50 [**2140-9-7**] 11:30PM DIGOXIN-0.8* [**2140-9-7**] 11:30PM MAGNESIUM-2.0 [**2140-9-7**] 11:30PM CK-MB-4 cTropnT-0.01 [**2140-9-7**] 11:30PM CK(CPK)-110 [**2140-9-7**] 11:30PM GLUCOSE-89 UREA N-20 CREAT-1.6* SODIUM-141 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-30 ANION GAP-11 EKG - [**9-7**]: Ventricular paced rhythm Atrial mechanism uncertain - may be paced ot possible ectopic atrial rhythm Since previous tracing of [**2140-4-19**], ventricular ectopy absent and P wave morphology appears changed CXR - [**9-7**]: SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The cardiomediastinal contour is unchanged, with moderate cardiomegaly. There is no pleural effusion or evidence of focal consolidation. The dual-lead pacing device is unchanged in appearance. Osseous structures are unremarkable. IMPRESSION: No significant change since [**2140-4-12**]. No evidence of pneumonia or congestive heart failure. KUB - [**9-9**]: FINDINGS: There is non-specific bowel gas in the abdomen. There are no distended loops of bowel, or concerning air-fluid levels. There is air in the rectum. There is a large amount of feces in the descending colon, suggesting constipation. Of note, there is a right hip hemiarthroplasty hardware, without apparent hardware complication. There is a mild lumbar levoscoliosis. There are surgical clips at the right upper quadrant, from prior cholecystectomy. There are wires projected on to the heart, likely pacer wires. IMPRESSION: No evidence of bowel obstruction. Likely constipation. EGD - [**9-9**]: Barrett's Exophagitis, Gastritis, Duodenitis Brief Hospital Course: 72 year old male with CAD s/p CABG, atrial fib on coumadin, s/p VT/VF arrest now with BiV pacer; CHF with EF 15% who presented with what appears to be non-cardiac chest pain, abdominal pain and melena. . # Melena/Abdominal pain: HCT decreased to 31 from BL of 33 on arrival to MICU. INR was reversed. Serial hematocrits were checked and remained stable despite the patient remaining guiac positive. Aspirin and Coumadin were held until after EGD at which time they were restarted. IV PPI was given until EGD. Patient was converted to PO PPI [**Hospital1 **] and instructed to continue as such for six weeks. GI follow up [**Hospital1 1988**]. Patient had similar episode in [**4-19**] and had an extensive GI workup which was negative. . # Chest Pain: Pain resolved by the time the patient arrived to the floor. Cardiology felt the pain was unlikely to be cardiac in nature as cardiac enzymes were negative on arrival to the ED after 5 hours of constant chest pain. Pain could be esophageal as patient has history of Esophagitis and Barretts esophagus. Last possibility is aortic chest pain as patient has history of thoracic aortic aneurysm repair, small concern for dissection although unlikely as patient remained stable throughout his hopitalization and his CP resolved. . # CAD: Patient is s/p CABG. Chest pain unlikely to be cardiac. MI ruled out. ASA, BB and statin were initially held in setting of possible GIB but were restarted prior to discharge. . # CHF: Patient with history of ischemic CMP with EF 15%. Home Lasix, Aldactone, and Toprol were intially held but reintroduced prior to discharge. Home digoxin was continued. . # PAF: Patient s/p BiV pacer placement on Coumadin. INR was reversed intially but coumadin was restarted prior to discharge. Digoxin was continued. . # VF/VT arrest: Patient is s/p BiV pacer/ICD placement. Home Sotalol, Mexiletine were continued. . # Asthma: Albuterol MDI at home. Albuterol Nebs were given PRN. . # Hypothyroidism: Home levoxyl was continued. . # CKD: Patient with Cr of 1.7 on admission with Baseline Cr 1.5-2. Remained stable. . # Alzheimer??????s: Held home Donepezil, Celexa initially. Restarted prior to discharge. Medications on Admission: Sotalol 80mg [**Hospital1 **] Lipitor 20mg daily Donepezil 5mg daily Quetiapine 25mg, 3tabs qAM, 1tab noon, 3tabs qHS Celexa 60mg daily Protonix 40mg daily ASA 81mg daily Clonazepam 0.5mg TID PRN Lisinopril 5mg daily Digoxin 125mcg, [**1-13**] tab daily K-Dur daily Spironolactone 25mg daily Levothyroxin3e 112mcg daily Trazodone 25mg qHS Mexiletine 150mg TID Albuterol MDI 2puf q6hPRN Fluticasone 110mcg 2puff [**Hospital1 **] Toprol SL 50mg daily Lasix 40mg TID Coumadin Discharge Medications: 1. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Digoxin 125 mcg Tablet Sig: [**1-13**] Tablet PO DAILY (Daily). 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): Take twice per day for a total of 6 weeks. Can then resume once per day. Disp:*45 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 8. Warfarin 1 mg Tablet Sig: 2-3 Tablets PO once a day: 2 to 3 tablets by mouth once per day or as directed. 9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Celexa 40 mg Tablet Sig: 1.5 Tablets PO once a day. 12. Donepezil 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 16. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 17. Miralax 100 % Powder Sig: One (1) packet PO once a day. 18. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 19. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO qam. 20. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO qnoon. 21. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO at bedtime. 22. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day. 23. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 24. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 25. Promethazine 12.5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Upper GastroIntestinal Bleed Barrett's Esophagitis Gastritis Duodenitis Discharge Condition: Fair Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2L You were admitted to the hospital because you had blood in your stool along with a decrease in your blood count/hematocrit concerning for ongoing bleeding. Because you also had chest pain upon presentation, you were also admitted to rule out the possibility that you were experiencing a heart attack. You had an EGD performed which showed irritation and inflammation of your esophagus, stomach, and duodenum. This irritation could be the cause of your bloody stool and decrease in blood count. You were given blood replacement products along with high doses of protonix and your blood count remained stable. You should continue to take you protonix twice per day for the next 6 weeks. You have follow up with the GI doctors [**Name5 (PTitle) 1988**]. You should call your doctor and/or return to the emergency room if you have dark tarry stools or bright red blood in your stool, Chest Pain, Shortness of Breath, or any other corncerning symptoms. Followup Instructions: [**9-14**] at 9:30am DEVICE CLINIC (Phone:[**Telephone/Fax (1) 59**]) [**9-14**] at 10:00am [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP (Phone:[**Telephone/Fax (1) 62**]) [**9-30**] at 11:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD (Phone:[**Telephone/Fax (1) 463**]) ",48,2140-09-07 21:07:00,2140-09-12 17:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,CHEST PAIN," 72 year old male with cad s/p cabg, atrial fib on coumadin, s/p vt/vf arrest now with biv pacer; chf with ef 15% who presented with what appears to be non-cardiac chest pain, abdominal pain and melena. . # melena/abdominal pain: hct decreased to 31 from bl of 33 on arrival to micu. inr was reversed. serial hematocrits were checked and remained stable despite the patient remaining guiac positive. aspirin and coumadin were held until after egd at which time they were restarted. iv ppi was given until egd. patient was converted to po ppi [**hospital1 **] and instructed to continue as such for six weeks. gi follow up [**hospital1 1988**]. patient had similar episode in [**4-19**] and had an extensive gi workup which was negative. . # chest pain: pain resolved by the time the patient arrived to the floor. cardiology felt the pain was unlikely to be cardiac in nature as cardiac enzymes were negative on arrival to the ed after 5 hours of constant chest pain. pain could be esophageal as patient has history of esophagitis and barretts esophagus. last possibility is aortic chest pain as patient has history of thoracic aortic aneurysm repair, small concern for dissection although unlikely as patient remained stable throughout his hopitalization and his cp resolved. . # cad: patient is s/p cabg. chest pain unlikely to be cardiac. mi ruled out. asa, bb and statin were initially held in setting of possible gib but were restarted prior to discharge. . # chf: patient with history of ischemic cmp with ef 15%. home lasix, aldactone, and toprol were intially held but reintroduced prior to discharge. home digoxin was continued. . # paf: patient s/p biv pacer placement on coumadin. inr was reversed intially but coumadin was restarted prior to discharge. digoxin was continued. . # vf/vt arrest: patient is s/p biv pacer/icd placement. home sotalol, mexiletine were continued. . # asthma: albuterol mdi at home. albuterol nebs were given prn. . # hypothyroidism: home levoxyl was continued. . # ckd: patient with cr of 1.7 on admission with baseline cr 1.5-2. remained stable. . # alzheimer??????s: held home donepezil, celexa initially. restarted prior to discharge. ","PRIMARY: [Hemorrhage of gastrointestinal tract, unspecified] SECONDARY: [Paroxysmal ventricular tachycardia; Chronic systolic heart failure; Congestive heart failure, unspecified; Other chest pain; Esophageal reflux; Unspecified acquired hypothyroidism; Aortocoronary bypass status; Duodenitis, without mention of hemorrhage; Alzheimer's disease; Dementia in conditions classified elsewhere without behavioral disturbance; Asthma, unspecified type, unspecified; Other and unspecified hyperlipidemia; Chronic kidney disease, unspecified; Barrett's esophagus; Unspecified gastritis and gastroduodenitis, without mention of hemorrhage; Long-term (current) use of anticoagulants; Other specified forms of chronic ischemic heart disease; Automatic implantable cardiac defibrillator in situ; Atrial fibrillation]","72 year old male with cad s/p cabg, atrial fib on coumadin, s/p vt/vf arrest now with biv pacer; chf with ef 15% who presented with what appears to be non-cardiac chest pain, abdominal pain and melena. last possibility is aortic chest pain as patient has history of thoracic aortic aneurysm repair, small concern for dissection although unlikely as patient remained stable throughout his hopitalization and his cp resolved. inr was reversed intially but coumadin was restarted prior to discharge. # vf/vt arrest: patient is s/p biv pacer/icd placement.","72 year old male with cad s/p cabg, atrial fib on coumadin, s/p vt/vf arrest now with biv pacer; chf with ef 15% who presented with what appears to be non-cardiac chest pain, abdominal pain and melena. aspirin and coumadin were held until after egd at which time they were restarted. iv ppi was given until egd" 10774,142104.0,8553,2140-10-30,8552,130230.0,2140-10-18,Discharge summary,"Admission Date: [**2140-10-11**] Discharge Date: [**2140-10-18**] Date of Birth: [**2068-2-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Black stools, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis. H/O GIB w most recent admission on [**2140-9-12**]. Now with black stools since MN accompanied by mid-sternal CP with radiation to left arm. Took all BP meds this AM (per pt, usual BP in the 90s range). Also c/o lightheadedness and SOB. . In the ED, VS: T 98 BP 105/76 HR 75 RR 21 97%2L. Guaiac pos black stool. Patient received morphine for CP with mild improvement in pain. EKG was v-paced with no obvious ST/TW changes. NG lavage was negative x 2. He received 2U FFP and 5 mg PO vitamin K for INR reversal and 1L IVFs. Seen by Cards in ED, recommennd echo in AM, . On arrival to the MICU, pt states his discomfort has imporved,d own from [**8-21**] to [**4-21**], described as dull ache in chest, non-radiating, constant since 11 PM last night, as well as discomfort in the lower abdomen (identical to past abd pain in setting of past GIB x 2). + nausea. Past Medical History: --CAD status post CABG with simultaneous aortic aneurysm repair in [**2133**], history of stenting of the left circumflex artery [**2135**] --s/p VT/VF arrest, s/p ICD placement in [**2135**] --Ischemic cardiomyopathy with an ED of 20%, s/p BiV pacer [**10-18**] --Chest wall cellulitis over pacer site [**3-19**] vs. ICD pacer pocket infection --PAF --CKD with baseline Cr. 1.6-2 --Hyperlipidemia --Asthma --Anxiety --Alzheimer's dementia --Hypothyroidism --GI bleed of unknown etiology [**2138**]. EGD revealed esophagitis, Barrett's esophagus, and duodenitis. No ulcers. --Diverticulosis --GERD --S/P Cholecystectomy Social History: Patient originally from [**Country 4754**] and moved to the United States in [**2089**]. Worked as an off-set printer in [**Location (un) 686**], where he continues to live with his wife. Father of five children. Retired 6 years ago, and since his recent heart problems, says he rarely leaves the house. Most of his time is spent in front of the television with his wife handling their affairs at home. No history of smoking, past or present. Patient was a heavy drinker until 20 years ago, when he stopped completely after attending AA and encountering marital difficulties. No history of illicit drug use. Family History: Non-contributory. Physical Exam: VS: afebrile Heart rate: 75 paced Normotensive and satting well on room air GEN: Elderly male, NAD, lying in bed HEENT: PERRL, anicteric NECK: Supple, no JVD CHEST: CTAB CV: s1s2 + SEM, + heave with lateral displacement of the PMI ABD: +BS, soft, ND, mild TTP lower quadrants bilaterally, no rebound or guarding BACK: No CVAT Rectak: Trace guaiac positive black stool EXT: WD/WP, no pedal edema NEURO: A&O x 3, MAE, speech fluent, nonfocal Pertinent Results: CBC: [**2140-10-11**] 12:45PM BLOOD WBC-9.9 RBC-4.59* Hgb-13.3* Hct-39.8* MCV-87 MCH-29.1 MCHC-33.5 RDW-14.2 Plt Ct-149* [**2140-10-13**] 06:38AM BLOOD WBC-7.8 RBC-4.02* Hgb-11.7* Hct-34.7* MCV-87 MCH-29.0 MCHC-33.6 RDW-14.0 Plt Ct-121* [**2140-10-18**] 05:27AM BLOOD WBC-6.6 RBC-4.06* Hgb-11.9* Hct-35.1* MCV-87 MCH-29.2 MCHC-33.8 RDW-14.9 Plt Ct-152 Coags: [**2140-10-11**] 12:45PM BLOOD PT-24.7* PTT-29.8 INR(PT)-2.4* [**2140-10-14**] 04:45AM BLOOD PT-18.4* PTT-29.4 INR(PT)-1.7* [**2140-10-17**] 04:55AM BLOOD PT-15.2* PTT-31.5 INR(PT)-1.3* Chemistry: [**2140-10-11**] 12:45PM BLOOD Glucose-102 UreaN-31* Creat-2.0* Na-140 K-3.9 Cl-100 HCO3-30 AnGap-14 [**2140-10-13**] 06:38AM BLOOD Glucose-68* UreaN-26* Creat-1.5* Na-142 K-4.1 Cl-103 HCO3-27 AnGap-16 [**2140-10-18**] 05:27AM BLOOD Glucose-85 UreaN-22* Creat-1.7* Na-141 K-3.9 Cl-102 HCO3-30 AnGap-13 [**2140-10-11**] 12:45PM BLOOD Calcium-9.5 Phos-2.7 Mg-2.2 [**2140-10-14**] 04:45AM BLOOD Calcium-8.6 Phos-1.8* Mg-2.1 [**2140-10-17**] 04:55AM BLOOD Calcium-9.3 Phos-3.1 Mg-1.8 Cardiac Enzymes: [**2140-10-11**] 12:45PM BLOOD CK(CPK)-97 [**2140-10-12**] 03:22AM BLOOD CK(CPK)-90 [**2140-10-12**] 10:26PM BLOOD CK(CPK)-102 LFTs: [**2140-10-11**] 07:15PM BLOOD ALT-24 AST-38 CK(CPK)-92 AlkPhos-86 Amylase-72 TotBili-0.3 Lipase: [**2140-10-11**] 07:15PM BLOOD Lipase-35 Cardiac Enzymes: [**2140-10-11**] 12:45PM BLOOD cTropnT-0.01 [**2140-10-12**] 03:22AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2140-10-12**] 10:26PM BLOOD CK-MB-4 cTropnT-0.01 Digoxin: [**2140-10-11**] 12:45PM BLOOD Digoxin-0.4* ECG: Sinus rhythm with demand ventricular pacing Ventricular premature complexes Since previous tracing of the same date, QRS width shorter, assess LV pacing CXR: FINDINGS: The pacer/defibrillator leads are again seen terminating in the right ventricle and coronary sinus. There are median sternotomy wires. An additional disconnected pacer wire is seen within the left chest wall, as on prior. There is no evidence of pneumonia. There is cardiomegaly, without CHF. There is no pneumothorax or pleural effusion. Degenerative changes are seen at the right humeral head. The bones are otherwise unremarkable. IMPRESSION: No acute intrathoracic process. Cardiomegaly without CHF. ECHO: The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe regional left ventricular systolic dysfunction with akinesis of all inferior and inferolateral segments and of the basal lateral segments. The other segments are severely hypokinetic. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe focal and global LV systolic dysfunction. Moderate to severe aortic stenosis. Moderate mitral regurgitation. Abdominal XR: FOUR VIEWS OF THE ABDOMEN: There are moderately dilated loops of small bowel, and multiple air-fluid levels are demonstrated on the left lateral decubitus. There is no evidence of free air. Cholecystectomy clips in the right upper quadrant and the right hip arthroplasty are again identified. There is air within the rectum. The left hip demonstrates moderate degenerative change. Midline sternotomy wires and a pacing device are identified. IMPRESSION: Moderately dilated loops of small bowel and air-fluid levels are consistent with ileus or early/partial small-bowel obstruction. Brief Hospital Course: The patient was admitted to the MICU for monitoring and serial Hcts. His BP reamined in the 90-110 systolic range. A Hct drop from 39 to 32 was noted, which then stabilized. GI saw the patient, no plan for emergent scope. Cardiology saw the pt and recommended an echocardiogram. Cardiac enzymes were cycled; the first two sets were negative, the third troponin was 0.02 (has been similar in the past), in the setting of constant chest pain x 24 hours. Diuretics and anti-hypertensives were held. . A/P: 72 yo M with MMP including CAD, CHF, CRI admit with GIB, abdominal pain, and chest pain, now callout from MICU. . # GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI showed erosions in stomach and duodenum c/w NSAID gastropathy, had a normal [**Last Name (un) **] in [**Month (only) 547**]. Hct stable and has not required transfusion. No evidence of active bleed. LFTs normal on admit. Mesenteric ischemia was considered as patient stabalized this was not pursed. He had some persistent nausea which improved with reglan. He was discharged in omeprazole. . # Chest pain: with extensive CAD and CHF history. Echo done this admit as above. He was ruled out for an MI. . # Systolic heart failure: Focal akinesia as above. He was satting well on room air and did not have clinical evidence of heart failure . # Afib: Medications were continued, coumadin was stopped. . # Chronic renal insufficiency: Baseline cr 1.6-2. Currently at baseline. . # Hyperlipidemia: - continue statin . # Hypothyroidism: - continue levothyroxine . # Asthma: - continue home meds . CODE: Full (confirmed with patient) . Communication: Pt, wife [**Doctor First Name **] [**Telephone/Fax (1) 30058**]) Medications on Admission: Sotalol 80mg [**Hospital1 **] Lipitor 20mg daily Donepezil 5mg daily Quetiapine 25mg, 3tabs qAM, 1tab noon, 3tabs qHS Celexa 60mg daily Protonix 40mg daily ASA 81mg daily Clonazepam 0.5mg TID PRN Lisinopril 5mg daily Digoxin 125mcg, [**1-13**] tab daily K-Dur daily Spironolactone 25mg daily Levothyroxin3e 112mcg daily Trazodone 25mg qHS Mexiletine 150mg TID Albuterol MDI 2puf q6hPRN Fluticasone 110mcg 2puff [**Hospital1 **] Toprol SL 50mg daily Lasix 40mg TID Coumadin Discharge Medications: 1. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day. 5. Quetiapine 25 mg Tablet Sig: as directed Tablet PO three times a day: take 2 tabs every morning, 1 tab at noontime, and 3 tabs at bedtime. 6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 9. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 11. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 14. NitroQuick 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain: as previously directed, take up to 3 tabs five minutes apart. 15. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 17. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 18. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 19. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 20. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for nausea. Disp:*45 Tablet(s)* Refills:*2* 21. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 22. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Gastrointestinal bleeding . Congestive heart failure, systolic dysfunction, chronic Coronary artery disease Atrial fibrillation Chronic kidney disease Alzheimer's dementia Discharge Condition: Stable Discharge Instructions: You were admitted with bleeding, likely from your stomach. We think that this was in part related to taking coumadin and after much discussion, we have stopped this medication. You blood counts have been stable. . Please return to the hospital or call your doctor if you have worsening abdominal pain, pain after eating, blood in your vomit or stools, dark colored stools, chest pain, shortness of breath, or any new symptoms that you are concerned about. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. . Since you were admitted we have made the following medication changes: * Please stop taking COUMADIN. * Your lasix dose was increased to 80 mg daily. Followup Instructions: Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 26894**], to schedule a followup appointment within 2 weeks. . You also have the following upcoming appointments at [**Hospital1 18**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21795**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2140-11-4**] 1:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2140-11-25**] 8:40 DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2140-12-19**] 1:00 ",12,2140-10-11 14:34:00,2140-10-18 15:38:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,CHEST PAIN;TELEMETRY;GI BLEED," the patient was admitted to the micu for monitoring and serial hcts. his bp reamined in the 90-110 systolic range. a hct drop from 39 to 32 was noted, which then stabilized. gi saw the patient, no plan for emergent scope. cardiology saw the pt and recommended an echocardiogram. cardiac enzymes were cycled; the first two sets were negative, the third troponin was 0.02 (has been similar in the past), in the setting of constant chest pain x 24 hours. diuretics and anti-hypertensives were held. . a/p: 72 yo m with mmp including cad, chf, cri admit with gib, abdominal pain, and chest pain, now callout from micu. . # gi bleed/abd pain: hx gi bleeding in the past, recent egd by gi showed erosions in stomach and duodenum c/w nsaid gastropathy, had a normal [**last name (un) **] in [**month (only) 547**]. hct stable and has not required transfusion. no evidence of active bleed. lfts normal on admit. mesenteric ischemia was considered as patient stabalized this was not pursed. he had some persistent nausea which improved with reglan. he was discharged in omeprazole. . # chest pain: with extensive cad and chf history. echo done this admit as above. he was ruled out for an mi. . # systolic heart failure: focal akinesia as above. he was satting well on room air and did not have clinical evidence of heart failure . # afib: medications were continued, coumadin was stopped. . # chronic renal insufficiency: baseline cr 1.6-2. currently at baseline. . # hyperlipidemia: - continue statin . # hypothyroidism: - continue levothyroxine . # asthma: - continue home meds . code: full (confirmed with patient) . communication: pt, wife [**doctor first name **] [**telephone/fax (1) 30058**]) ","PRIMARY: [Hemorrhage of gastrointestinal tract, unspecified] SECONDARY: [Acute on chronic systolic heart failure; Atrial fibrillation; Other and unspecified angina pectoris; Hypovolemia; Aortic valve disorders; Asthma, unspecified type, unspecified; Chronic kidney disease, unspecified; Aortocoronary bypass status; Long-term (current) use of anticoagulants; Automatic implantable cardiac defibrillator in situ; Alzheimer's disease; Dementia in conditions classified elsewhere without behavioral disturbance; Congestive heart failure, unspecified; Unspecified analgesic and antipyretic causing adverse effects in therapeutic use; Anticoagulants causing adverse effects in therapeutic use; Other specified forms of chronic ischemic heart disease; Other and unspecified hyperlipidemia; Barrett's esophagus; Diverticulosis of colon (without mention of hemorrhage); Unspecified acquired hypothyroidism]","the patient was admitted to the micu for monitoring and serial hcts. cardiac enzymes were cycled; the first two sets were negative, the third troponin was 0.02 (has been similar in the past), in the setting of constant chest pain x 24 hours. # systolic heart failure: focal akinesia as above. # afib: medications were continued, coumadin was stopped.","the patient was admitted to the micu for monitoring and serial hcts. his bp was reamined in the 90-110 systolic range, which then stabilized. cardiac enzymes were cycled; the first two sets were negative. the third troponin was 0.02 (has been similar in the past) diuretics and anti-hypertensives were held." 10774,197363.0,8555,2141-04-05,8554,173586.0,2141-03-30,Discharge summary,"Admission Date: [**2141-3-8**] Discharge Date: [**2141-3-30**] Date of Birth: [**2068-2-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Chest pain and abdominal pain Major Surgical or Invasive Procedure: none History of Present Illness: This is a 73 year old male with past medical history significant for CAD s/p CABG and PCI to LCx, aortic stenosis, VT/VF arrest s/p ICD, CHF (EF 20%) s/p BiV pacer, afib on coumadin, CRI and diverticulosis who presents with 1 hour of chest pain similar to anginal equivalent that radiated to abd and back. Assocated with nausea. Took ntg tab w/o relief. No pleuritic chest pain. The abd pain is LLQ predominant w/o radiation. He states that he has had black stools on both of the last 2 days associated with changed smell of the stools. He has had no bloody stool. The abd pain usually is better after eating. There have been no new foods and no sick contacts. . Of note the patient was recently in the [**Hospital1 18**] for abdominal pain in [**1-20**]. At which time his labs were unremarkable. A CT abd showed no acute pathology to explain his pain. He received IV fluids and slowly advanced his diet to normal prior to discharge. . In ED, initial vitals were 97.8 120/70 100 14 100%RA. Stools brown and OB negative. ECG was V-paced at 85bpm, cardiac enzymes were negative. Patient given aspirin, nitro tabs, morphine. . On floor, patient was with decreasing chest pain but still with nausea. The abdominal pain is also improved. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, he denies recent fevers, chills or rigors. he denies exertional buttock or calf pain. his weight has been stable at 222-223pounds. His baseline function is 1 flight of stairs. All of the other review of systems were negative. . Cardiac review of systems is notable for paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: CAD status post CABG with simultaneous aortic aneurysm repair in [**2133**], history of stenting of the left circumflex artery [**2135**] s/p VT/VF arrest, s/p ICD placement in [**2135**] iCMP (EF 20%) s/p BiV pacer [**10-18**] Chest wall cellulitis over pacer site [**3-19**] vs. ICD pacer pocket infection AFib (not anti-coagulated due to recurrent GI bleeds) CKD Stage III b/l Cr. ~1.6 Hyperlipidemia Asthma Anxiety Alzheimer's dementia Hypothyroidism Diverticulosis GERD s/p cholecystectomy . CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension Social History: married, lives with wife. [**Name (NI) **] originally from [**Country 4754**]. No history of smoking. Patient was a heavy drinker until 20 years ago. No history of illicit drugs Family History: No family history of early MI, otherwise non-contributory. Physical Exam: On admission- VS: 98.5 100/71 82 16 99%2L wt. 222 lbs GENERAL: WDWN obese male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. CARDIAC: PMI laterally displaced. RR, normal S1, S2. [**2-17**] systolic murmur at RUSB c/w AS. No r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, minimal tender to LLSB. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. guiaiac negative brown stool. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Neuro: -MS alert and oriented x3. coherent response to interview -CN II-XII intact -Motor moving all 4 extremities symmetrically. -[**Last Name (un) **] light touch intact to face/hands/feet Pertinent Results: ======== Labs ======== [**2141-3-30**] 11:51AM BLOOD Hct-27.8* [**2141-3-30**] 11:51AM BLOOD PT-22.2* PTT-91.8* INR(PT)-2.1* [**2141-3-30**] 04:09AM BLOOD WBC-9.2 RBC-2.92* Hgb-8.4* Hct-26.2* MCV-90 MCH-28.8 MCHC-32.1 RDW-15.5 Plt Ct-255 [**2141-3-30**] 04:09AM BLOOD Glucose-193* UreaN-31* Creat-2.0* Na-132* K-4.5 Cl-97 HCO3-27 AnGap-13 [**2141-3-11**] 06:37AM BLOOD WBC-6.5 RBC-4.10* Hgb-11.9* Hct-35.6* MCV-87 MCH-29.1 MCHC-33.5 RDW-14.6 Plt Ct-144* [**2141-3-10**] 05:15AM BLOOD WBC-7.4 RBC-4.16* Hgb-12.2* Hct-35.8* MCV-86 MCH-29.2 MCHC-34.0 RDW-14.7 Plt Ct-136* [**2141-3-9**] 05:15AM BLOOD WBC-8.7 RBC-4.14* Hgb-12.3* Hct-35.7* MCV-86 MCH-29.7 MCHC-34.5 RDW-14.5 Plt Ct-145* [**2141-3-8**] 06:45PM BLOOD WBC-9.2 RBC-4.44* Hgb-13.0* Hct-38.5* MCV-87 MCH-29.2 MCHC-33.7 RDW-14.5 Plt Ct-193 [**2141-3-11**] 06:37AM BLOOD Glucose-86 UreaN-17 Creat-1.6* Na-140 K-4.0 Cl-103 HCO3-27 AnGap-14 [**2141-3-10**] 05:15AM BLOOD Glucose-72 UreaN-20 Creat-1.5* Na-138 K-3.8 Cl-103 HCO3-27 AnGap-12 [**2141-3-9**] 05:15AM BLOOD Glucose-86 UreaN-25* Creat-1.6* Na-140 K-4.4 Cl-102 HCO3-29 AnGap-13 [**2141-3-8**] 06:45PM BLOOD Glucose-95 UreaN-26* Creat-1.7* Na-138 K-4.3 Cl-100 HCO3-31 AnGap-11 [**2141-3-10**] 05:15AM BLOOD ALT-42* AST-47* AlkPhos-132* Amylase-112* [**2141-3-9**] 05:15AM BLOOD LD(LDH)-276* CK(CPK)-86 Amylase-208* [**2141-3-8**] 06:45PM BLOOD ALT-20 AST-30 CK(CPK)-96 AlkPhos-92 Amylase-137* TotBili-0.3 [**2141-3-11**] 06:37AM BLOOD Lipase-33 [**2141-3-10**] 05:15AM BLOOD Lipase-46 [**2141-3-9**] 04:05PM BLOOD Lipase-58 [**2141-3-9**] 05:15AM BLOOD Lipase-164* [**2141-3-8**] 06:45PM BLOOD Lipase-124* [**2141-3-9**] 05:15AM BLOOD CK-MB-NotDone cTropnT-0.01 [**2141-3-8**] 06:45PM BLOOD cTropnT-<0.01 [**2141-3-8**] 06:45PM BLOOD Digoxin-0.7* . ========= Radiology ========= CXR [**3-8**] FINDINGS: PA and lateral views of the chest are obtained. Three-lead pacer device is unchanged with lead tips positioned in the expected location. Midline sternotomy wires are unchanged. Cardiomegaly is stable. There is no CHF or evidence of pneumonia. No pleural effusion or pneumothorax is seen. Osseous structures are intact. IMPRESSION: No significant change with persistent cardiomegaly and no evidence of CHF or pneumonia. . RUQ U/S [**3-9**] RIGHT UPPER QUADRANT ULTRASOUND: The liver appears unremarkable in echotexture and architecture, without focal liver lesion seen. Flow in the main portal vein is in normal hepatopetal direction. No intra- or extra- hepatic biliary ductal dilatation is noted, with the common duct measuring 5 mm. Again the gallbladder is absent, consistent with prior cholecystectomy. Visualization of the pancreatic tail is slightly limited due to overlying bowel gas however the visualized pancreas appears unremarkable and unchanged. No pancreatic ductal dilatation is noted. No ascites is seen. The spleen is enlarged, measuring 13.8 cm. IMPRESSION: 1. Patient is status post cholecystectomy. No intra- or extra-hepatic biliary ductal dilatation is noted. No choledocholithiasis seen. 2. Incidentally noted splenomegaly. . =========== Cardiology =========== TTE [**3-9**] Conclusions The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is severely dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size is normal. with borderline normal free wall function. with focal hypokinesis of the apical free wall. The aortic root is mildly dilated at the sinus level. There are focal calcifications in the aortic arch. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. The main pulmonary artery is dilated. The branch pulmonary arteries are dilated. Compared with the findings of the prior study (images reviewed) of [**2140-10-12**], no major change is evident. . Myocardial perfusion study [**3-11**] IMPRESSION: 1) Severe left ventricular enlargment 2) Probably some viability within an inferior wall defect. TTE [**2141-3-14**] The left ventricular cavity is dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets are mildly thickened. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-13**]+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Focused views. Severe left ventricular sysolic dysfunction. Mild to moderate mitral regurgitation. Compared with the prior study (images reviewed) of [**2141-3-9**], this is a limited/emergent/focused study and direct comparison cannot be made. Cardiac Cath [**2141-3-20**] COMMENTS: 1. Coronary angiography of this right dominant system demonstrated no angiographically apparent flow-limiting coronary artery disease. 2. Non-selective arteriography of the LIMA-LAD showed no apparent flow-limiting disease. 3. Limited resting hemodynamics revealed a central aortic pressure of 134/92 mmHg. FINAL DIAGNOSIS: 1. No angiographically apparent flow-limiting coronary artery disease. 2. Patent LIMA-LAD. [**2141-3-26**] LEFT UPPER EXTREMITY VENOUS ULTRASOUND: [**Doctor Last Name **]-scale and color and pulsed wave Doppler examination was performed over the right subclavian vein as well as the left internal jugular, subclavian, axillary, brachial, basilic, and cephalic veins. Note is made of nearly occlusive thrombosis of the left cephalic, basilic, brachial, and axillary veins. Flow is demonstrated in the left and right subclavian veins. More proximally, note is made of likely pacemaker wire entering the left subclavian vein. The internal jugular vein demonstrates normal compressibility and flow. IMPRESSION: Left upper extremity DVT extending from the superficial cephalic and basilic veins into the brachial and axillary deep veins. CXRs: [**2141-3-28**] PORTABLE SEMI-UPRIGHT RADIOGRAPH OF THE CHEST: The distal tip of right PICC projects in the mid SVC. There has been interval removal of the endotracheal tube and NG tube. The remainder of the study including the position of the AICD leads and the cardiopulmonary status appear unchanged. IMPRESSION: Standard position of the right PICC with no complication. Pertinent Micro data [**2141-3-22**] 2:00 pm URINE Source: Catheter. **FINAL REPORT [**2141-3-24**]** URINE CULTURE (Final [**2141-3-24**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S GRAM STAIN (Final [**2141-3-21**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2141-3-24**]): MODERATE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S C diff negative Blood cx ngtd Brief Hospital Course: # VT: Initially on home meds of mexilitine and sotalol. On the floor, had an episode VT on telemetry and lost pulses. He [**Month/Day/Year 1834**] CPR, receiving a total of 4 shocks, 4mg of epinephrine, amiodarone 150mg x 2, Lidocaine 100mg x 1, magnesium 2mg, bicarb 1 amp, and calcium. Pacer interrogation showed his VT was below the rate of detection. He was manually paced out of VT several times but with return to VT each time. Finally, lidocaine and amiodarone gtts were started and the patient was successfully converted back to a paced rhythm. His mexilitine and sotalol were held. He was intubated during the code, but rapidly extubated afterward. From [**3-15**] to [**3-21**], he had repeated episodes of VT, receiving multiple ICD shocks each time, with conversion to a paced rhythm. The first of these episodes was associated with hypotension, but subsequent episodes showed good BP. He was given ativan for sedation due to the multiple shocks, and was reintubated [**3-19**] for airway protection from sedation. Over the course of these several episodes, he received multiple amiodarone and lidocaine boluses, and was variably on and off drips of these medications. On [**3-21**], he had an EP study and had 1 circuit ablated and an epicardial circuit interrupted. He was transitioned to a final regimen of oral mexilitene alone. After the study, he was kept sedated and initially required phenylephrine and vasopressin. He had multiple VT episodes on [**3-22**], but successfully paced out without shocks. He was weaned off pressors and extubated, and subsequently started on metoprolol, which was uptitrated to 25mg TID. His only further VT was on [**3-28**], and he was successsfully paced out. EP recommends that he continue on telemetry monitoring for 48 hours after discharge. # Chest pain: Has a history of CAD, although cardiac cath done during admission was clean and biomarkers on admission for chest pain in the ER were negative. After CPR, patient had significant reproducible chest wall tenderness that was due to the direct trauma of chest compressions. This pain was not felt to be ischemia. He was treated initially with IV morphine and hydromorphone, but received better pain control after transitioning to oral MS contin. He is also on [**Month/Year (2) 1988**] tylenol and a lidocaine patch. # Anxiety: Patient has known anxiety, and this was significantly worsened in the setting of recurrent VT and receiving many ICD shocks. Psychiatry was consulted and advised seroquel PRN in addition to his standing doses. He was also continued on citalopram and low dose clonazepam. Despite this, he continued to have significant anxiety; he would have episodes of lightheadedness and palpitations, despite normal vital signs and no telemetry changes. Also, he at times thought his ICD had fired, but review of telemetry showed this was not the case. He also becomes diaphoretic, but per patient and wife, this is long-standing and his baseline. # Abdominal pain: Presented with nausea, vomiting, abdominal pain and elevated lipase, otherwise normal LFTs. No cholethiasis on abdominal u/s. He was ruled out for acute cardiac event. He was treated with bowel rest and his diet was slowly advanced as tolerated. # DVT: LUE had swelling and ultrasound was positive. He was started on a heparin drip and bridged to warfarin before discharge. Continued on PPI and sucralfate given history of GI bleeds and ASA was lowered from 325mg to 81mg daily. He will need a follow up ultrasound in [**3-15**] mos. # Pump: LVEF 20% on TTE [**10-19**]. Also has known AS, although during admission patient was refusing AVR and valvuloplasty. He became hypervolemic around [**3-18**], requiring a lasix gtt. His volume status improved and he was transitioned to his home dose of lasix 40mg PO daily. His digoxin was stopped due to arrhythmogenic concerns. Beta blocker continued as above. Spironolactone was increased from 12.5 to 25mg daily. # CKD: Baseline Cr around 1.6. Prior to discharge, his creatinine trended up to 2.0 in the setting of increased ACE-I and restarting furosemide. Per discussion with his outpatient cardiologist, this is acceptable for now and can be followed after discharge, with med changes made as needed. # MRSA Pneumonia: Pt developed MRSA pneumonia with sputum growing MRSA. He was treated with Vancomycin 8 day course which he completed on [**2141-3-29**] # UTI: Pt had E coli UTI. He was initially on pip-tazo for empiric pneumonia coverage, but changed to ceftriaxone once sensitivities returned. He completed a 7 day course of antibiotics. # CODE: Code status had been changed to 1 externmal shock if neccessary but no compressions. This was reversed on [**2141-3-28**] when patient expressed desire to be full code. Medications on Admission: Sotalol 80 mg [**Hospital1 **] Levothyroxine 112 mcg daily Citalopram 60 mg daily Quetiapine 50 mg QAM Quetiapine 25 mg daily at noon Quetiapine 75 mg QHS Sucralfate 1 gram QID Mexiletine 150 mg Q8H Pantoprazole 40 mg Q12 Atorvastatin 20 mg daily Fluticasone-Salmeterol 250-50 mc 2 puffs [**Hospital1 **] Donepezil 5 mg QHS Metoprolol Succinate 50 mg QHS Furosemide 40 mg daily Spironolactone 12.5 mg daily Nitroglycerin 0.3 mg PRN (as needed) as needed for chest pain. Clonazepam 0.5 mg TID (3 times a day) as needed for anxiety. Trazodone 50 mg qhs:prn insomnia Metoclopramide 25 mg q8 prn Digoxin 0.0625 mcg daily Albuterol 90 mcg prn Aspirin 81 mg daily K-Dur 20 mEq daily . Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Furosemide 40 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. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): at noon. 10. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 11. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 12. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: Hold for loose stools. 15. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed. 17. Quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed for anxiety. 18. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 20. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 21. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO four times a day. 22. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 23. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold SBP< 90. 24. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 25. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 26. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 27. FerrouSul 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 28. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 29. Morphine 15 mg Tablet Sustained Release Sig: [**1-13**] Tablet Sustained Releases PO every eight (8) hours as needed for chest pain. 30. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO once a day. 31. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: check INR on [**2141-4-1**]. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Primary: Pancreatitis, Ventricular Tachycardia, Hypotension, Pneumonia Secondary: Aortic stenosis, Coronary artery disease Discharge Condition: stable, tolerating oral intake Discharge Instructions: You presented to the hospital with chest pain and abdominal pain. There was some initial concern that you were having a heart attack, but this was ruled out by basic lab work. Your chest pain resolved in the emergency room and you were chest pain free on the cardiology floor. It was recommended that you consider valvuloplasy and angioplasty for your tight aortic valve in your heart and your blocked blood vessels in your heart, but you refused this intervention. Your abdominal pain was felt to be due to inflammation in the pancreas. An ultrasound of your abdomen did not reveal any stones as the cause of this inflammation. Your pancreas improved with gently hydration. While you were in the hospital, you also developed worsening of your abnormal heart rhythm, requiring many shocks by your ICD. You were kept sedated and with a breathing tube since the shocks were so uncomfortable. You [**Location (un) 1834**] a procedure to help improve your heart rhythm, and this helped your heart rhythm considerably. You also developed pneumonia while you were in the hospital, and we are treating you with antibiotics. We have made several medication changes as listed below. . We made the following changes to your medications: - sotalol - we discontinued this medication - trazodone - we discontinued this medication - spironolactone - we increased this medication from 12.5mg once a day to 25mg daily. - reglan - we have decreased this medication from 25mg three times a day as you need it to 10mg three times a day as you need it. - magnesium repletion as given at home. -your Toprol was changed to short acting metoprolol -your fluticasone was changed to Advair. -we started tylenol around the clock, a lidoderm patch and long acting morphine to treat your chest pain caused by rib fractures. -Warfarin to treat the clot in your left arm . Please seek immediate medical attention if you experience worsening shortness of breath, abdominal pain, dizziness, bloody bowel movements, black tarry bowel movements or any other change from your baseline health status. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day of 6 pounds in 3 days Adhere to 2 gm sodium diet Fluid Restriction: Followup Instructions: Gastroenterology: Please follow up with Dr. [**Last Name (STitle) 3708**] on [**4-7**] at 12:30pm. [**Hospital Ward Name 452**] 1, [**Location (un) **], [**Hospital Ward Name 516**] entrance, [**Hospital1 18**]. If you need to change this appointment please call [**Telephone/Fax (1) 463**]. . Cardiology: Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] Phone: ([**Telephone/Fax (1) 2037**]. Date/Time: [**Telephone/Fax (1) 766**] [**4-3**] at 1:00 pm. [**Hospital Ward Name 23**] Building, [**Location (un) 436**] [**Hospital Ward Name 516**], [**Hospital1 18**] . Primary care: Pleaes call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment after you leave the rehabilitation facility to discuss this hospital stay Completed by:[**2141-3-30**]",6,2141-03-08 23:26:00,2141-03-30 13:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,LONG TERM CARE HOSPITAL,CHEST PAIN," # vt: initially on home meds of mexilitine and sotalol. on the floor, had an episode vt on telemetry and lost pulses. he [**month/day/year 1834**] cpr, receiving a total of 4 shocks, 4mg of epinephrine, amiodarone 150mg x 2, lidocaine 100mg x 1, magnesium 2mg, bicarb 1 amp, and calcium. pacer interrogation showed his vt was below the rate of detection. he was manually paced out of vt several times but with return to vt each time. finally, lidocaine and amiodarone gtts were started and the patient was successfully converted back to a paced rhythm. his mexilitine and sotalol were held. he was intubated during the code, but rapidly extubated afterward. from [**3-15**] to [**3-21**], he had repeated episodes of vt, receiving multiple icd shocks each time, with conversion to a paced rhythm. the first of these episodes was associated with hypotension, but subsequent episodes showed good bp. he was given ativan for sedation due to the multiple shocks, and was reintubated [**3-19**] for airway protection from sedation. over the course of these several episodes, he received multiple amiodarone and lidocaine boluses, and was variably on and off drips of these medications. on [**3-21**], he had an ep study and had 1 circuit ablated and an epicardial circuit interrupted. he was transitioned to a final regimen of oral mexilitene alone. after the study, he was kept sedated and initially required phenylephrine and vasopressin. he had multiple vt episodes on [**3-22**], but successfully paced out without shocks. he was weaned off pressors and extubated, and subsequently started on metoprolol, which was uptitrated to 25mg tid. his only further vt was on [**3-28**], and he was successsfully paced out. ep recommends that he continue on telemetry monitoring for 48 hours after discharge. # chest pain: has a history of cad, although cardiac cath done during admission was clean and biomarkers on admission for chest pain in the er were negative. after cpr, patient had significant reproducible chest wall tenderness that was due to the direct trauma of chest compressions. this pain was not felt to be ischemia. he was treated initially with iv morphine and hydromorphone, but received better pain control after transitioning to oral ms contin. he is also on [**month/year (2) 1988**] tylenol and a lidocaine patch. # anxiety: patient has known anxiety, and this was significantly worsened in the setting of recurrent vt and receiving many icd shocks. psychiatry was consulted and advised seroquel prn in addition to his standing doses. he was also continued on citalopram and low dose clonazepam. despite this, he continued to have significant anxiety; he would have episodes of lightheadedness and palpitations, despite normal vital signs and no telemetry changes. also, he at times thought his icd had fired, but review of telemetry showed this was not the case. he also becomes diaphoretic, but per patient and wife, this is long-standing and his baseline. # abdominal pain: presented with nausea, vomiting, abdominal pain and elevated lipase, otherwise normal lfts. no cholethiasis on abdominal u/s. he was ruled out for acute cardiac event. he was treated with bowel rest and his diet was slowly advanced as tolerated. # dvt: lue had swelling and ultrasound was positive. he was started on a heparin drip and bridged to warfarin before discharge. continued on ppi and sucralfate given history of gi bleeds and asa was lowered from 325mg to 81mg daily. he will need a follow up ultrasound in [**3-15**] mos. # pump: lvef 20% on tte [**10-19**]. also has known as, although during admission patient was refusing avr and valvuloplasty. he became hypervolemic around [**3-18**], requiring a lasix gtt. his volume status improved and he was transitioned to his home dose of lasix 40mg po daily. his digoxin was stopped due to arrhythmogenic concerns. beta blocker continued as above. spironolactone was increased from 12.5 to 25mg daily. # ckd: baseline cr around 1.6. prior to discharge, his creatinine trended up to 2.0 in the setting of increased ace-i and restarting furosemide. per discussion with his outpatient cardiologist, this is acceptable for now and can be followed after discharge, with med changes made as needed. # mrsa pneumonia: pt developed mrsa pneumonia with sputum growing mrsa. he was treated with vancomycin 8 day course which he completed on [**2141-3-29**] # uti: pt had e coli uti. he was initially on pip-tazo for empiric pneumonia coverage, but changed to ceftriaxone once sensitivities returned. he completed a 7 day course of antibiotics. # code: code status had been changed to 1 externmal shock if neccessary but no compressions. this was reversed on [**2141-3-28**] when patient expressed desire to be full code. ","PRIMARY: [Acute pancreatitis] SECONDARY: [Cardiac arrest; Paroxysmal ventricular tachycardia; Chronic systolic heart failure; Methicillin resistant pneumonia due to Staphylococcus aureus; Urinary tract infection, site not specified; ; Acute kidney failure with lesion of tubular necrosis; Ventricular fibrillation; Congestive heart failure, unspecified; Aortic valve disorders; Other specified forms of chronic ischemic heart disease; Atrial fibrillation; Long-term (current) use of anticoagulants; Asthma, unspecified type, unspecified; Other and unspecified hyperlipidemia; Chronic kidney disease, Stage III (moderate); Aortocoronary bypass status; Alzheimer's disease; Dementia in conditions classified elsewhere without behavioral disturbance; Unspecified acquired hypothyroidism; Diverticulosis of colon (without mention of hemorrhage); ; Fitting and adjustment of automatic implantable cardiac defibrillator]","# vt: initially on home meds of mexilitine and sotalol. he was intubated during the code, but rapidly extubated afterward. he was given ativan for sedation due to the multiple shocks, and was reintubated [**3-19**] for airway protection from sedation. he was transitioned to a final regimen of oral mexilitene alone. after the study, he was kept sedated and initially required phenylephrine and vasopressin. # dvt: lue had swelling and ultrasound was positive. also has known as, although during admission patient was refusing avr and valvuloplasty. his volume status improved and he was transitioned to his home dose of lasix 40mg po daily. his digoxin was stopped due to arrhythmogenic concerns. per discussion with his outpatient cardiologist, this is acceptable for now and can be followed after discharge, with med changes made as needed.","# vt patient on the floor, receiving a total of 4 shocks, 4mg of epinephrine. he was manually paced out of vt several times but with return to vt each time. he was weaned off pressors and extubated, and subsequently started on metoprolol." 10774,197363.0,8555,2141-04-05,8553,142104.0,2140-10-30,Discharge summary,"Admission Date: [**2140-10-23**] Discharge Date: [**2140-10-30**] Date of Birth: [**2068-2-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: melena Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy [**2140-10-26**] Esophagogastroduodenoscopy [**2140-10-27**] History of Present Illness: 72 yo M with PMH of CAD s/p CABG and PCI to LCx, AS, VT/VF arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis admitted with abdominal pain and melena for two days. Reported hypotension by VNA to 96/P. The patient has a history of recurrent GIB with most recent admission on [**2140-10-11**] to [**10-18**]. During last hospital stay the patient was admitted to the MICU for monitoring and serial Hcts. A Hct drop from 39 to 32 was noted, which then stabilized. GI saw the patient and deferred scope. His coumadin was discontinued at this time due to recurrent bleeding. He was also admitted on [**9-12**] with melena and abd pain. EGD showed Barrett's esophagitis, gastritis, and duodenitis. He has a history of polyp removal in the cecum and one in the ascending colon in [**4-19**], histology was adenomatous. He also had a capsule study at that time, that did not show additional source of bleed in the small bowel. In ED, Vitals T 98.2, HR 78, BP 111/61, RR 18, 100% 2L NC. NG lavage showed scant blood initially which cleared with lavage. HCT stable. He was given morphine 4mg X3. No ASA given. Bolused with 40mg IV pantoprazole X1. On arrival to MICU, pt is in no acute distress. Reports [**5-17**] black, tarry stools last pm with associated dizziness. Pt has also had ongoing abdominal and back pain since discharge last week. His pain is constant and non-radiating located in his chest, abdomen and back. Past Medical History: CAD status post CABG with simultaneous aortic aneurysm repair in [**2133**], history of stenting of the left circumflex artery [**2135**] s/p VT/VF arrest, s/p ICD placement in [**2135**] iCMP (EF 20%) s/p BiV pacer [**10-18**] Chest wall cellulitis over pacer site [**3-19**] vs. ICD pacer pocket infection AFib CKD Stage III b/l Cr. ~1.6 Hyperlipidemia Asthma Anxiety Alzheimer's dementia Hypothyroidism Diverticulosis GERD s/p CCY Social History: Patient originally from [**Country 4754**] and moved to the United States in [**2089**]. Father of five children. No history of smoking. Patient was a heavy drinker until 20 years ago, when he stopped completely after attending AA and encountering marital difficulties. No history of illicit drug use. Family History: Non-contributory Physical Exam: DISCHARGE PHYSICAL EXAM V/S: 99.1, 97.6, 120/70-102/62, 80s, 16, 94% RA GEN - Obese gentleman appears comfortable, NAD HEENT- sclera anicteric, OP clear with MMM NECK: supple without JVD, delayed carotid upstroke no bruit CV: reg rate nl S1 no S2 III/VI SEM at LUSB PULM: CTAB no w/r/r ABD: soft NTND normoactive BS no organomegaly EXT- warm, dry diminished distal pulses no c/c/e NEURO: A&Ox3 Pertinent Results: [**2140-10-30**] 08:20AM BLOOD WBC-7.0 RBC-3.95* Hgb-11.7* Hct-34.5* MCV-87 MCH-29.5 MCHC-33.8 RDW-14.2 Plt Ct-198 [**2140-10-29**] 08:10AM BLOOD WBC-5.6 RBC-3.82* Hgb-11.2* Hct-33.2* MCV-87 MCH-29.4 MCHC-33.7 RDW-14.7 Plt Ct-186 [**2140-10-28**] 07:35AM BLOOD WBC-5.8 RBC-3.60* Hgb-10.5* Hct-31.5* MCV-88 MCH-29.1 MCHC-33.2 RDW-14.2 Plt Ct-167 [**2140-10-27**] 07:00AM BLOOD WBC-6.5 RBC-3.66* Hgb-10.7* Hct-32.0* MCV-87 MCH-29.1 MCHC-33.4 RDW-14.3 Plt Ct-160 [**2140-10-26**] 06:10AM BLOOD WBC-12.4* RBC-4.01* Hgb-12.0* Hct-34.6* MCV-86 MCH-29.9 MCHC-34.6 RDW-14.5 Plt Ct-164 [**2140-10-25**] 06:00AM BLOOD WBC-9.0 RBC-4.04* Hgb-11.5* Hct-35.4* MCV-88 MCH-28.5 MCHC-32.6 RDW-14.5 Plt Ct-176 [**2140-10-24**] 07:52PM BLOOD Hct-34.6* [**2140-10-24**] 04:57PM BLOOD Hct-33.4* [**2140-10-24**] 06:55AM BLOOD WBC-7.9 RBC-4.09* Hgb-12.1* Hct-35.6* MCV-87 MCH-29.5 MCHC-33.9 RDW-14.9 Plt Ct-181 [**2140-10-24**] 01:05AM BLOOD Hct-34.5* [**2140-10-23**] 06:45PM BLOOD WBC-10.1 RBC-4.03* Hgb-11.8* Hct-35.0* MCV-87 MCH-29.2 MCHC-33.6 RDW-14.4 Plt Ct-175 [**2140-10-23**] 12:58PM BLOOD WBC-7.7 RBC-4.21* Hgb-12.1* Hct-36.1* MCV-86 MCH-28.8 MCHC-33.6 RDW-15.0 Plt Ct-169 [**2140-10-28**] 07:35AM BLOOD ALT-18 AST-20 AlkPhos-86 TotBili-0.2 [**2140-10-24**] 08:19AM BLOOD CK(CPK)-103 [**2140-10-24**] 01:05AM BLOOD CK(CPK)-124 [**2140-10-23**] 12:58PM BLOOD CK(CPK)-189* [**2140-10-24**] 08:19AM BLOOD CK-MB-3 cTropnT-0.01 [**2140-10-23**] 12:58PM BLOOD cTropnT-0.01 [**2140-10-24**] 08:14PM BLOOD Lactate-0.9 . [**2140-10-26**] 12:52 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2140-10-27**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2140-10-27**]): REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 30063**] @ 3:55A [**2140-10-27**]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. . [**2140-10-25**] CT OF THE ABDOMEN WITH IV CONTRAST: Within the visualized lung bases, there is atelectasis within the left lung base. There is no pleural effusion. Visualized heart and pericardium reveal no pericardial effusion. The liver, spleen, pancreas, and adrenal glands are unremarkable. Multiple rounded hypodensities in bilateral kidneys are stable, likely reflecting renal cysts. Patient is status post cholecystectomy. The stomach and small bowel are unremarkable. There is diverticulosis of the colon, without evidence of diverticulitis. There is no evidence of acute inflammation, or secondary signs to suggest mesenteric ischemia. Evaluation of the intra-abdominal vasculature reveals moderate diffuse atherosclerotic calcification involving the abdominal aorta, not significantly changed from prior study. There is mild atherosclerosis at the origin of the celiac axis. Otherwise, celiac axis, superior mesenteric artery, and inferior mesenteric artery and their branches appear patent and unremarkable. There is no free air, free fluid, or pathologic adenopathy. CT OF THE PELVIS WITH IV CONTRAST: Urinary bladder, rectum, and prostate are unremarkable. There is no pelvic lymphadenopathy or free fluid. OSSEOUS STRUCTURES: Patient status post total right hip replacement. No suspicious lytic or sclerotic lesions identified. IMPRESSION: No acute intra-abdominal process identified. The celiac axis, SMA, and [**Female First Name (un) 899**] appear patent without thrombosis or occlusion. No secondary signs to suggest mesenteric ischemia identified. . [**2140-10-26**] L-SPINE (AP & LAT) FINDINGS: There is a levocurvature of the mid lumbar spine. Multilevel anterior osteophytes are noted. The disc spaces appear largely preserved aside from the scoliosis. Extensive vascular calcifications are noted. There is a right hip total arthroplasty, partially visualized. IMPRESSION: Multilevel degenerative changes as detailed. . [**2140-10-26**] Gastric mucosal biopsies A. Body: Focal active gastritis; [**Doctor Last Name 6311**] stain shows no definite helicobacter-like organisms with satisfactory control. B. Antrum: No diagnostic abnormalities recognized. Brief Hospital Course: #Acute gastritis - The patient was admitted to the ICU overnight for observation given reported hypotension prior to admission. Blood pressure was readily fluid-responsive and the patient remained hemodynamically stable. Melena resolved after admission and hematocrit remained stable, obviating the need for blood transfusion. He was treated with PPI gtt in the ICU which was changed to PPI [**Hospital1 **] on the floor. The patient [**Hospital1 1834**] EGD showing erosive gastritis and Barrett's esophagus but no active bleeding. Continued to hold coumadin. Aspirin was restarted in the setting of [**Hospital1 **] PPI and carafate therapy which will be continued after discharge at the recommendation of the consulting GI team. He will follow up in [**Hospital **] clinic, in part to schedule surveillance endoscopy for the monitoring of Barrett's. . #Candidal esophagitis - EGD also revealed candidal esophagitis which had been present on endoscopy 6 months prior and perhaps inadequately treated with a 10-day course of fluconazole. HIV Ab test was negative at that time. A 3-week course of oral fluconazole was started with LFT's to be rechecked 1 week after discharge. He was counseled regarding the proper use of his corticosteroid inhalers including rinsing thoroughly after use. . #C. difficile colitis - The patient was started on a 2 week course of flagyl. He was placed on contact precautions. [**Name2 (NI) **] was counseled not to drink alcohol while taking metronidazole. . #Abdominal/back pain - This pain reportedly had been present for several years but had subacutely worsened over the past [**6-23**] months. Paraspinal muscle tenderness on examination was suggestive of musculoskeletal pathology. CTA abd/pelvis showed sigmoid diverticulosis but no evidence of mesenteric ischemia or AAA. Lumbar plain film showed only chronic degenerative changes but no compression deformity or lytic lesion. Stable hematocrit made a RP bleed unlikely. Urinalysis, LFT's, calcium, and SPEP/UPEP were normal. Pain was well-controlled with tylenol. . #Chronic systolic CHF - The patient appeared euvolemic without signs or symptoms of acute CHF. ACEi had been discontinued prior to admission due to hypotension. He will continue on beta-blocker, digoxin, and diuretic therapy after discharge. . #Atrial fibrillation - Coumadin was held due to recurrent UGIB, as above. Aspirin was continued. He was encouraged to follow up with his cardiologist as soon as possible. . #Chronic kidney disease stage III - Creatinine remained at baseline. Medications were dosed accordingly. . #Hyperlipidemia - Continued statin. . #Hypothyroidism - Continued levothyroxine. . #Asthma - Continued home regimen with counseling regarding proper use of steroid inhalers, as above. . #Nutrition - Heart-healthy diet. . #Propylaxis - Pneumoboots, PPI Medications on Admission: Sotalol 80 mg PO BID Atorvastatin 20 mg PO DAILY Donepezil 5 mg PO HS Citalopram 40 mg 1.5 Tab PO DAILY Quetiapine 25 mg Tab PO TID Clonazepam 0.5 mg Tablet 1 Tablet PO TID PRN anxiety Digoxin 62.5 mcg PO DAILY K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal 1 Tab PO daily Levothyroxine 112 mcg Tablet 1 Tablet PO DAILY Trazodone 50 mg Tablet 1 PO HS Mexiletine 150 mg Capsule 1 Capsule PO Q8H Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] NitroQuick 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain Magnesium Oxide 400 mg Tablet 1 Tablet PO daily Pantoprazole 40 mg Tablet 1 tab Q 12 Aspirin 81 mg Tablet PO DAILY Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID/PRN nausea Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr po daily Furosemide 80 mg Tablet PO daily Discharge Medications: 1. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 11 days: Through Wednesday, [**11-9**]. Disp:*11 Tablet(s)* Refills:*0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 11 days: Through Wednesday, [**11-9**]. Disp:*33 Tablet(s)* Refills:*0* 3. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day. 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO NOON (At Noon). 9. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 10. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*0* 11. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 13. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) INH Inhalation [**Hospital1 **] (2 times a day). 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 16. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for nausea. 17. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 18. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 20. Donepezil 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 21. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime. 22. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 23. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day. 24. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 25. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 26. GlycoLax 17 gram (100 %) Powder in Packet Sig: One (1) packet PO once a day. 27. Nitrostat 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual three times a day as needed for chest pain: Take up to 3 tablets 5 minutes apart as needed for chest pain and seek immediate medical attention. 28. Outpatient Lab Work Please check chemistries and liver function tests on [**Hospital1 766**], [**11-7**] and fax the results to the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26894**] at [**Telephone/Fax (1) 16236**]. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary 1) Acute blood loss anemia 2) Acute gastritis 3) Candidal esophagitis 4) Clostridium difficile colitis Secondary 1) Coronary artery disease 2) Chronic systolic heart failure 3) Atrial fibrillation 4) Chronic kidney disease stage III 5) Hypothyroidism Discharge Condition: asymptomatic with stable vital signs. Discharge Instructions: You were admitted to the hospital with dark stools, likely from erosions and inflammation in the lining of the stomach seen on upper endoscopy. Your coumadin (warfarin) was discontinued due to recurrent bleeding. Continue taking aspirin daily as prescribed. Take protonix 2 times daily and a new medication carafate (sucralfate) 4 times daily to help heal and protect the stomach lining. Upper endoscopy also showed a fungal infection in the esophagus which was partially treated with an antifungal medication. Please continue taking Fluconazole through Tuesday, [**11-15**]. Please have blood drawn for chemistries and liver function tests on [**Month (only) 766**], [**11-7**] and ensure that the results are faxed to Dr. [**Last Name (STitle) 26895**] office at [**Telephone/Fax (1) 16236**]. You were diagnosed with a bacterial infection in the large intestine which was partially treated with an antibiotic medication. Please continue Flagyl (metronidazole) as prescribed through Wednesday, [**11-9**]. Do not drink alcohol while taking this medication due to the risks of side effects from this combination. You no longer need to use the fluticasone inhaler if you are also using advair. Please be sure to rinse out your mouth and throat after using this medication to help prevent infection. Please continue taking your other medications as prescribed. Please adhere to a diet with less than 2 grams of sodium daily. Please weight yourself daily and call your physician if your weight increases by greater than 3 lbs. Please call the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26894**] at [**Telephone/Fax (1) 3329**] to arrange a follow up appointment in 1 week. Please call the office of Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] at [**Telephone/Fax (1) 62**] to arrange a follow up appointment in [**1-13**] weeks. Please follow up with Dr. [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) 1407**] on Friday, [**11-4**] at 1:00. The office phone number is [**Telephone/Fax (1) 463**]. Please call your physician or return to the Emergency Department if you experience fever, chills, sweats, dizziness, lightheadedness, difficulty or pain with swallowing, chest pain, palpitations, shortness of breath, cough, abdominal pain, vomiting, diarrhea, bloody or black stools, or leg swelling or pain. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21795**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2140-11-4**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2140-11-25**] 8:40 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2140-12-19**] 1:00 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2140-10-30**]",157,2140-10-23 15:20:00,2140-10-30 14:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,CHEST PAIN;TELEMETRY;MELENA," #acute gastritis - the patient was admitted to the icu overnight for observation given reported hypotension prior to admission. blood pressure was readily fluid-responsive and the patient remained hemodynamically stable. melena resolved after admission and hematocrit remained stable, obviating the need for blood transfusion. he was treated with ppi gtt in the icu which was changed to ppi [**hospital1 **] on the floor. the patient [**hospital1 1834**] egd showing erosive gastritis and barretts esophagus but no active bleeding. continued to hold coumadin. aspirin was restarted in the setting of [**hospital1 **] ppi and carafate therapy which will be continued after discharge at the recommendation of the consulting gi team. he will follow up in [**hospital **] clinic, in part to schedule surveillance endoscopy for the monitoring of barretts. . #candidal esophagitis - egd also revealed candidal esophagitis which had been present on endoscopy 6 months prior and perhaps inadequately treated with a 10-day course of fluconazole. hiv ab test was negative at that time. a 3-week course of oral fluconazole was started with lfts to be rechecked 1 week after discharge. he was counseled regarding the proper use of his corticosteroid inhalers including rinsing thoroughly after use. . #c. difficile colitis - the patient was started on a 2 week course of flagyl. he was placed on contact precautions. [**name2 (ni) **] was counseled not to drink alcohol while taking metronidazole. . #abdominal/back pain - this pain reportedly had been present for several years but had subacutely worsened over the past [**6-23**] months. paraspinal muscle tenderness on examination was suggestive of musculoskeletal pathology. cta abd/pelvis showed sigmoid diverticulosis but no evidence of mesenteric ischemia or aaa. lumbar plain film showed only chronic degenerative changes but no compression deformity or lytic lesion. stable hematocrit made a rp bleed unlikely. urinalysis, lfts, calcium, and spep/upep were normal. pain was well-controlled with tylenol. . #chronic systolic chf - the patient appeared euvolemic without signs or symptoms of acute chf. acei had been discontinued prior to admission due to hypotension. he will continue on beta-blocker, digoxin, and diuretic therapy after discharge. . #atrial fibrillation - coumadin was held due to recurrent ugib, as above. aspirin was continued. he was encouraged to follow up with his cardiologist as soon as possible. . #chronic kidney disease stage iii - creatinine remained at baseline. medications were dosed accordingly. . #hyperlipidemia - continued statin. . #hypothyroidism - continued levothyroxine. . #asthma - continued home regimen with counseling regarding proper use of steroid inhalers, as above. . #nutrition - heart-healthy diet. . #propylaxis - pneumoboots, ppi ","PRIMARY: [Other specified gastritis, with hemorrhage] SECONDARY: [Intestinal infection due to Clostridium difficile; Candidal esophagitis; Chronic systolic heart failure; Acute posthemorrhagic anemia; Congestive heart failure, unspecified; Atrial fibrillation; Long-term (current) use of anticoagulants; Alzheimer's disease; Dementia in conditions classified elsewhere without behavioral disturbance; Other and unspecified hyperlipidemia; Aortocoronary bypass status; Esophageal reflux; Unspecified acquired hypothyroidism; Chronic kidney disease, Stage III (moderate); Other specified forms of chronic ischemic heart disease; Asthma, unspecified type, unspecified; Automatic implantable cardiac defibrillator in situ; Aortic valve disorders; Barrett's esophagus; Diverticulosis of colon (without mention of hemorrhage); Unspecified analgesic and antipyretic causing adverse effects in therapeutic use]","#acute gastritis - the patient was admitted to the icu overnight for observation given reported hypotension prior to admission. #candidal esophagitis - egd also revealed candidal esophagitis which had been present on endoscopy 6 months prior and perhaps inadequately treated with a 10-day course of fluconazole. a 3-week course of oral fluconazole was started with lfts to be rechecked 1 week after discharge. name2 (ni) **] was counseled not to drink alcohol while taking metronidazole. he was encouraged to follow up with his cardiologist as soon as possible. #chronic kidney disease stage iii - creatinine remained at baseline.",egd showed erosive gastritis and barretts esophagus but no active bleeding. aspirin was restarted in the setting of [**hospital1 **] ppi and carafate therapy which will be continued after discharge at the recommendation of the consulting gi team. egd also revealed candidal esophagitis which had been present on endoscopy 6 months prior and perhaps inadequately treated. 10774,197363.0,8555,2141-04-05,8552,130230.0,2140-10-18,Discharge summary,"Admission Date: [**2140-10-11**] Discharge Date: [**2140-10-18**] Date of Birth: [**2068-2-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Black stools, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis. H/O GIB w most recent admission on [**2140-9-12**]. Now with black stools since MN accompanied by mid-sternal CP with radiation to left arm. Took all BP meds this AM (per pt, usual BP in the 90s range). Also c/o lightheadedness and SOB. . In the ED, VS: T 98 BP 105/76 HR 75 RR 21 97%2L. Guaiac pos black stool. Patient received morphine for CP with mild improvement in pain. EKG was v-paced with no obvious ST/TW changes. NG lavage was negative x 2. He received 2U FFP and 5 mg PO vitamin K for INR reversal and 1L IVFs. Seen by Cards in ED, recommennd echo in AM, . On arrival to the MICU, pt states his discomfort has imporved,d own from [**8-21**] to [**4-21**], described as dull ache in chest, non-radiating, constant since 11 PM last night, as well as discomfort in the lower abdomen (identical to past abd pain in setting of past GIB x 2). + nausea. Past Medical History: --CAD status post CABG with simultaneous aortic aneurysm repair in [**2133**], history of stenting of the left circumflex artery [**2135**] --s/p VT/VF arrest, s/p ICD placement in [**2135**] --Ischemic cardiomyopathy with an ED of 20%, s/p BiV pacer [**10-18**] --Chest wall cellulitis over pacer site [**3-19**] vs. ICD pacer pocket infection --PAF --CKD with baseline Cr. 1.6-2 --Hyperlipidemia --Asthma --Anxiety --Alzheimer's dementia --Hypothyroidism --GI bleed of unknown etiology [**2138**]. EGD revealed esophagitis, Barrett's esophagus, and duodenitis. No ulcers. --Diverticulosis --GERD --S/P Cholecystectomy Social History: Patient originally from [**Country 4754**] and moved to the United States in [**2089**]. Worked as an off-set printer in [**Location (un) 686**], where he continues to live with his wife. Father of five children. Retired 6 years ago, and since his recent heart problems, says he rarely leaves the house. Most of his time is spent in front of the television with his wife handling their affairs at home. No history of smoking, past or present. Patient was a heavy drinker until 20 years ago, when he stopped completely after attending AA and encountering marital difficulties. No history of illicit drug use. Family History: Non-contributory. Physical Exam: VS: afebrile Heart rate: 75 paced Normotensive and satting well on room air GEN: Elderly male, NAD, lying in bed HEENT: PERRL, anicteric NECK: Supple, no JVD CHEST: CTAB CV: s1s2 + SEM, + heave with lateral displacement of the PMI ABD: +BS, soft, ND, mild TTP lower quadrants bilaterally, no rebound or guarding BACK: No CVAT Rectak: Trace guaiac positive black stool EXT: WD/WP, no pedal edema NEURO: A&O x 3, MAE, speech fluent, nonfocal Pertinent Results: CBC: [**2140-10-11**] 12:45PM BLOOD WBC-9.9 RBC-4.59* Hgb-13.3* Hct-39.8* MCV-87 MCH-29.1 MCHC-33.5 RDW-14.2 Plt Ct-149* [**2140-10-13**] 06:38AM BLOOD WBC-7.8 RBC-4.02* Hgb-11.7* Hct-34.7* MCV-87 MCH-29.0 MCHC-33.6 RDW-14.0 Plt Ct-121* [**2140-10-18**] 05:27AM BLOOD WBC-6.6 RBC-4.06* Hgb-11.9* Hct-35.1* MCV-87 MCH-29.2 MCHC-33.8 RDW-14.9 Plt Ct-152 Coags: [**2140-10-11**] 12:45PM BLOOD PT-24.7* PTT-29.8 INR(PT)-2.4* [**2140-10-14**] 04:45AM BLOOD PT-18.4* PTT-29.4 INR(PT)-1.7* [**2140-10-17**] 04:55AM BLOOD PT-15.2* PTT-31.5 INR(PT)-1.3* Chemistry: [**2140-10-11**] 12:45PM BLOOD Glucose-102 UreaN-31* Creat-2.0* Na-140 K-3.9 Cl-100 HCO3-30 AnGap-14 [**2140-10-13**] 06:38AM BLOOD Glucose-68* UreaN-26* Creat-1.5* Na-142 K-4.1 Cl-103 HCO3-27 AnGap-16 [**2140-10-18**] 05:27AM BLOOD Glucose-85 UreaN-22* Creat-1.7* Na-141 K-3.9 Cl-102 HCO3-30 AnGap-13 [**2140-10-11**] 12:45PM BLOOD Calcium-9.5 Phos-2.7 Mg-2.2 [**2140-10-14**] 04:45AM BLOOD Calcium-8.6 Phos-1.8* Mg-2.1 [**2140-10-17**] 04:55AM BLOOD Calcium-9.3 Phos-3.1 Mg-1.8 Cardiac Enzymes: [**2140-10-11**] 12:45PM BLOOD CK(CPK)-97 [**2140-10-12**] 03:22AM BLOOD CK(CPK)-90 [**2140-10-12**] 10:26PM BLOOD CK(CPK)-102 LFTs: [**2140-10-11**] 07:15PM BLOOD ALT-24 AST-38 CK(CPK)-92 AlkPhos-86 Amylase-72 TotBili-0.3 Lipase: [**2140-10-11**] 07:15PM BLOOD Lipase-35 Cardiac Enzymes: [**2140-10-11**] 12:45PM BLOOD cTropnT-0.01 [**2140-10-12**] 03:22AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2140-10-12**] 10:26PM BLOOD CK-MB-4 cTropnT-0.01 Digoxin: [**2140-10-11**] 12:45PM BLOOD Digoxin-0.4* ECG: Sinus rhythm with demand ventricular pacing Ventricular premature complexes Since previous tracing of the same date, QRS width shorter, assess LV pacing CXR: FINDINGS: The pacer/defibrillator leads are again seen terminating in the right ventricle and coronary sinus. There are median sternotomy wires. An additional disconnected pacer wire is seen within the left chest wall, as on prior. There is no evidence of pneumonia. There is cardiomegaly, without CHF. There is no pneumothorax or pleural effusion. Degenerative changes are seen at the right humeral head. The bones are otherwise unremarkable. IMPRESSION: No acute intrathoracic process. Cardiomegaly without CHF. ECHO: The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe regional left ventricular systolic dysfunction with akinesis of all inferior and inferolateral segments and of the basal lateral segments. The other segments are severely hypokinetic. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe focal and global LV systolic dysfunction. Moderate to severe aortic stenosis. Moderate mitral regurgitation. Abdominal XR: FOUR VIEWS OF THE ABDOMEN: There are moderately dilated loops of small bowel, and multiple air-fluid levels are demonstrated on the left lateral decubitus. There is no evidence of free air. Cholecystectomy clips in the right upper quadrant and the right hip arthroplasty are again identified. There is air within the rectum. The left hip demonstrates moderate degenerative change. Midline sternotomy wires and a pacing device are identified. IMPRESSION: Moderately dilated loops of small bowel and air-fluid levels are consistent with ileus or early/partial small-bowel obstruction. Brief Hospital Course: The patient was admitted to the MICU for monitoring and serial Hcts. His BP reamined in the 90-110 systolic range. A Hct drop from 39 to 32 was noted, which then stabilized. GI saw the patient, no plan for emergent scope. Cardiology saw the pt and recommended an echocardiogram. Cardiac enzymes were cycled; the first two sets were negative, the third troponin was 0.02 (has been similar in the past), in the setting of constant chest pain x 24 hours. Diuretics and anti-hypertensives were held. . A/P: 72 yo M with MMP including CAD, CHF, CRI admit with GIB, abdominal pain, and chest pain, now callout from MICU. . # GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI showed erosions in stomach and duodenum c/w NSAID gastropathy, had a normal [**Last Name (un) **] in [**Month (only) 547**]. Hct stable and has not required transfusion. No evidence of active bleed. LFTs normal on admit. Mesenteric ischemia was considered as patient stabalized this was not pursed. He had some persistent nausea which improved with reglan. He was discharged in omeprazole. . # Chest pain: with extensive CAD and CHF history. Echo done this admit as above. He was ruled out for an MI. . # Systolic heart failure: Focal akinesia as above. He was satting well on room air and did not have clinical evidence of heart failure . # Afib: Medications were continued, coumadin was stopped. . # Chronic renal insufficiency: Baseline cr 1.6-2. Currently at baseline. . # Hyperlipidemia: - continue statin . # Hypothyroidism: - continue levothyroxine . # Asthma: - continue home meds . CODE: Full (confirmed with patient) . Communication: Pt, wife [**Doctor First Name **] [**Telephone/Fax (1) 30058**]) Medications on Admission: Sotalol 80mg [**Hospital1 **] Lipitor 20mg daily Donepezil 5mg daily Quetiapine 25mg, 3tabs qAM, 1tab noon, 3tabs qHS Celexa 60mg daily Protonix 40mg daily ASA 81mg daily Clonazepam 0.5mg TID PRN Lisinopril 5mg daily Digoxin 125mcg, [**1-13**] tab daily K-Dur daily Spironolactone 25mg daily Levothyroxin3e 112mcg daily Trazodone 25mg qHS Mexiletine 150mg TID Albuterol MDI 2puf q6hPRN Fluticasone 110mcg 2puff [**Hospital1 **] Toprol SL 50mg daily Lasix 40mg TID Coumadin Discharge Medications: 1. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day. 5. Quetiapine 25 mg Tablet Sig: as directed Tablet PO three times a day: take 2 tabs every morning, 1 tab at noontime, and 3 tabs at bedtime. 6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 9. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 11. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 14. NitroQuick 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain: as previously directed, take up to 3 tabs five minutes apart. 15. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 17. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 18. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 19. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 20. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for nausea. Disp:*45 Tablet(s)* Refills:*2* 21. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 22. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Gastrointestinal bleeding . Congestive heart failure, systolic dysfunction, chronic Coronary artery disease Atrial fibrillation Chronic kidney disease Alzheimer's dementia Discharge Condition: Stable Discharge Instructions: You were admitted with bleeding, likely from your stomach. We think that this was in part related to taking coumadin and after much discussion, we have stopped this medication. You blood counts have been stable. . Please return to the hospital or call your doctor if you have worsening abdominal pain, pain after eating, blood in your vomit or stools, dark colored stools, chest pain, shortness of breath, or any new symptoms that you are concerned about. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. . Since you were admitted we have made the following medication changes: * Please stop taking COUMADIN. * Your lasix dose was increased to 80 mg daily. Followup Instructions: Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 26894**], to schedule a followup appointment within 2 weeks. . You also have the following upcoming appointments at [**Hospital1 18**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21795**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2140-11-4**] 1:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2140-11-25**] 8:40 DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2140-12-19**] 1:00 ",169,2140-10-11 14:34:00,2140-10-18 15:38:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,CHEST PAIN;TELEMETRY;GI BLEED," the patient was admitted to the micu for monitoring and serial hcts. his bp reamined in the 90-110 systolic range. a hct drop from 39 to 32 was noted, which then stabilized. gi saw the patient, no plan for emergent scope. cardiology saw the pt and recommended an echocardiogram. cardiac enzymes were cycled; the first two sets were negative, the third troponin was 0.02 (has been similar in the past), in the setting of constant chest pain x 24 hours. diuretics and anti-hypertensives were held. . a/p: 72 yo m with mmp including cad, chf, cri admit with gib, abdominal pain, and chest pain, now callout from micu. . # gi bleed/abd pain: hx gi bleeding in the past, recent egd by gi showed erosions in stomach and duodenum c/w nsaid gastropathy, had a normal [**last name (un) **] in [**month (only) 547**]. hct stable and has not required transfusion. no evidence of active bleed. lfts normal on admit. mesenteric ischemia was considered as patient stabalized this was not pursed. he had some persistent nausea which improved with reglan. he was discharged in omeprazole. . # chest pain: with extensive cad and chf history. echo done this admit as above. he was ruled out for an mi. . # systolic heart failure: focal akinesia as above. he was satting well on room air and did not have clinical evidence of heart failure . # afib: medications were continued, coumadin was stopped. . # chronic renal insufficiency: baseline cr 1.6-2. currently at baseline. . # hyperlipidemia: - continue statin . # hypothyroidism: - continue levothyroxine . # asthma: - continue home meds . code: full (confirmed with patient) . communication: pt, wife [**doctor first name **] [**telephone/fax (1) 30058**]) ","PRIMARY: [Hemorrhage of gastrointestinal tract, unspecified] SECONDARY: [Acute on chronic systolic heart failure; Atrial fibrillation; Other and unspecified angina pectoris; Hypovolemia; Aortic valve disorders; Asthma, unspecified type, unspecified; Chronic kidney disease, unspecified; Aortocoronary bypass status; Long-term (current) use of anticoagulants; Automatic implantable cardiac defibrillator in situ; Alzheimer's disease; Dementia in conditions classified elsewhere without behavioral disturbance; Congestive heart failure, unspecified; Unspecified analgesic and antipyretic causing adverse effects in therapeutic use; Anticoagulants causing adverse effects in therapeutic use; Other specified forms of chronic ischemic heart disease; Other and unspecified hyperlipidemia; Barrett's esophagus; Diverticulosis of colon (without mention of hemorrhage); Unspecified acquired hypothyroidism]","the patient was admitted to the micu for monitoring and serial hcts. cardiac enzymes were cycled; the first two sets were negative, the third troponin was 0.02 (has been similar in the past), in the setting of constant chest pain x 24 hours. # systolic heart failure: focal akinesia as above. # afib: medications were continued, coumadin was stopped.","the patient was admitted to the micu for monitoring and serial hcts. his bp was reamined in the 90-110 systolic range, which then stabilized. cardiac enzymes were cycled; the first two sets were negative. the third troponin was 0.02 (has been similar in the past) diuretics and anti-hypertensives were held." 10774,173586.0,8554,2141-03-30,8552,130230.0,2140-10-18,Discharge summary,"Admission Date: [**2140-10-11**] Discharge Date: [**2140-10-18**] Date of Birth: [**2068-2-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Black stools, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 72 yo M with PMH of CAD s/p CABG and PCI to L circ, AS, VT/VF arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis. H/O GIB w most recent admission on [**2140-9-12**]. Now with black stools since MN accompanied by mid-sternal CP with radiation to left arm. Took all BP meds this AM (per pt, usual BP in the 90s range). Also c/o lightheadedness and SOB. . In the ED, VS: T 98 BP 105/76 HR 75 RR 21 97%2L. Guaiac pos black stool. Patient received morphine for CP with mild improvement in pain. EKG was v-paced with no obvious ST/TW changes. NG lavage was negative x 2. He received 2U FFP and 5 mg PO vitamin K for INR reversal and 1L IVFs. Seen by Cards in ED, recommennd echo in AM, . On arrival to the MICU, pt states his discomfort has imporved,d own from [**8-21**] to [**4-21**], described as dull ache in chest, non-radiating, constant since 11 PM last night, as well as discomfort in the lower abdomen (identical to past abd pain in setting of past GIB x 2). + nausea. Past Medical History: --CAD status post CABG with simultaneous aortic aneurysm repair in [**2133**], history of stenting of the left circumflex artery [**2135**] --s/p VT/VF arrest, s/p ICD placement in [**2135**] --Ischemic cardiomyopathy with an ED of 20%, s/p BiV pacer [**10-18**] --Chest wall cellulitis over pacer site [**3-19**] vs. ICD pacer pocket infection --PAF --CKD with baseline Cr. 1.6-2 --Hyperlipidemia --Asthma --Anxiety --Alzheimer's dementia --Hypothyroidism --GI bleed of unknown etiology [**2138**]. EGD revealed esophagitis, Barrett's esophagus, and duodenitis. No ulcers. --Diverticulosis --GERD --S/P Cholecystectomy Social History: Patient originally from [**Country 4754**] and moved to the United States in [**2089**]. Worked as an off-set printer in [**Location (un) 686**], where he continues to live with his wife. Father of five children. Retired 6 years ago, and since his recent heart problems, says he rarely leaves the house. Most of his time is spent in front of the television with his wife handling their affairs at home. No history of smoking, past or present. Patient was a heavy drinker until 20 years ago, when he stopped completely after attending AA and encountering marital difficulties. No history of illicit drug use. Family History: Non-contributory. Physical Exam: VS: afebrile Heart rate: 75 paced Normotensive and satting well on room air GEN: Elderly male, NAD, lying in bed HEENT: PERRL, anicteric NECK: Supple, no JVD CHEST: CTAB CV: s1s2 + SEM, + heave with lateral displacement of the PMI ABD: +BS, soft, ND, mild TTP lower quadrants bilaterally, no rebound or guarding BACK: No CVAT Rectak: Trace guaiac positive black stool EXT: WD/WP, no pedal edema NEURO: A&O x 3, MAE, speech fluent, nonfocal Pertinent Results: CBC: [**2140-10-11**] 12:45PM BLOOD WBC-9.9 RBC-4.59* Hgb-13.3* Hct-39.8* MCV-87 MCH-29.1 MCHC-33.5 RDW-14.2 Plt Ct-149* [**2140-10-13**] 06:38AM BLOOD WBC-7.8 RBC-4.02* Hgb-11.7* Hct-34.7* MCV-87 MCH-29.0 MCHC-33.6 RDW-14.0 Plt Ct-121* [**2140-10-18**] 05:27AM BLOOD WBC-6.6 RBC-4.06* Hgb-11.9* Hct-35.1* MCV-87 MCH-29.2 MCHC-33.8 RDW-14.9 Plt Ct-152 Coags: [**2140-10-11**] 12:45PM BLOOD PT-24.7* PTT-29.8 INR(PT)-2.4* [**2140-10-14**] 04:45AM BLOOD PT-18.4* PTT-29.4 INR(PT)-1.7* [**2140-10-17**] 04:55AM BLOOD PT-15.2* PTT-31.5 INR(PT)-1.3* Chemistry: [**2140-10-11**] 12:45PM BLOOD Glucose-102 UreaN-31* Creat-2.0* Na-140 K-3.9 Cl-100 HCO3-30 AnGap-14 [**2140-10-13**] 06:38AM BLOOD Glucose-68* UreaN-26* Creat-1.5* Na-142 K-4.1 Cl-103 HCO3-27 AnGap-16 [**2140-10-18**] 05:27AM BLOOD Glucose-85 UreaN-22* Creat-1.7* Na-141 K-3.9 Cl-102 HCO3-30 AnGap-13 [**2140-10-11**] 12:45PM BLOOD Calcium-9.5 Phos-2.7 Mg-2.2 [**2140-10-14**] 04:45AM BLOOD Calcium-8.6 Phos-1.8* Mg-2.1 [**2140-10-17**] 04:55AM BLOOD Calcium-9.3 Phos-3.1 Mg-1.8 Cardiac Enzymes: [**2140-10-11**] 12:45PM BLOOD CK(CPK)-97 [**2140-10-12**] 03:22AM BLOOD CK(CPK)-90 [**2140-10-12**] 10:26PM BLOOD CK(CPK)-102 LFTs: [**2140-10-11**] 07:15PM BLOOD ALT-24 AST-38 CK(CPK)-92 AlkPhos-86 Amylase-72 TotBili-0.3 Lipase: [**2140-10-11**] 07:15PM BLOOD Lipase-35 Cardiac Enzymes: [**2140-10-11**] 12:45PM BLOOD cTropnT-0.01 [**2140-10-12**] 03:22AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2140-10-12**] 10:26PM BLOOD CK-MB-4 cTropnT-0.01 Digoxin: [**2140-10-11**] 12:45PM BLOOD Digoxin-0.4* ECG: Sinus rhythm with demand ventricular pacing Ventricular premature complexes Since previous tracing of the same date, QRS width shorter, assess LV pacing CXR: FINDINGS: The pacer/defibrillator leads are again seen terminating in the right ventricle and coronary sinus. There are median sternotomy wires. An additional disconnected pacer wire is seen within the left chest wall, as on prior. There is no evidence of pneumonia. There is cardiomegaly, without CHF. There is no pneumothorax or pleural effusion. Degenerative changes are seen at the right humeral head. The bones are otherwise unremarkable. IMPRESSION: No acute intrathoracic process. Cardiomegaly without CHF. ECHO: The left atrium is dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe regional left ventricular systolic dysfunction with akinesis of all inferior and inferolateral segments and of the basal lateral segments. The other segments are severely hypokinetic. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets are severely thickened/deformed. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe focal and global LV systolic dysfunction. Moderate to severe aortic stenosis. Moderate mitral regurgitation. Abdominal XR: FOUR VIEWS OF THE ABDOMEN: There are moderately dilated loops of small bowel, and multiple air-fluid levels are demonstrated on the left lateral decubitus. There is no evidence of free air. Cholecystectomy clips in the right upper quadrant and the right hip arthroplasty are again identified. There is air within the rectum. The left hip demonstrates moderate degenerative change. Midline sternotomy wires and a pacing device are identified. IMPRESSION: Moderately dilated loops of small bowel and air-fluid levels are consistent with ileus or early/partial small-bowel obstruction. Brief Hospital Course: The patient was admitted to the MICU for monitoring and serial Hcts. His BP reamined in the 90-110 systolic range. A Hct drop from 39 to 32 was noted, which then stabilized. GI saw the patient, no plan for emergent scope. Cardiology saw the pt and recommended an echocardiogram. Cardiac enzymes were cycled; the first two sets were negative, the third troponin was 0.02 (has been similar in the past), in the setting of constant chest pain x 24 hours. Diuretics and anti-hypertensives were held. . A/P: 72 yo M with MMP including CAD, CHF, CRI admit with GIB, abdominal pain, and chest pain, now callout from MICU. . # GI bleed/Abd pain: Hx GI bleeding in the past, recent EGD by GI showed erosions in stomach and duodenum c/w NSAID gastropathy, had a normal [**Last Name (un) **] in [**Month (only) 547**]. Hct stable and has not required transfusion. No evidence of active bleed. LFTs normal on admit. Mesenteric ischemia was considered as patient stabalized this was not pursed. He had some persistent nausea which improved with reglan. He was discharged in omeprazole. . # Chest pain: with extensive CAD and CHF history. Echo done this admit as above. He was ruled out for an MI. . # Systolic heart failure: Focal akinesia as above. He was satting well on room air and did not have clinical evidence of heart failure . # Afib: Medications were continued, coumadin was stopped. . # Chronic renal insufficiency: Baseline cr 1.6-2. Currently at baseline. . # Hyperlipidemia: - continue statin . # Hypothyroidism: - continue levothyroxine . # Asthma: - continue home meds . CODE: Full (confirmed with patient) . Communication: Pt, wife [**Doctor First Name **] [**Telephone/Fax (1) 30058**]) Medications on Admission: Sotalol 80mg [**Hospital1 **] Lipitor 20mg daily Donepezil 5mg daily Quetiapine 25mg, 3tabs qAM, 1tab noon, 3tabs qHS Celexa 60mg daily Protonix 40mg daily ASA 81mg daily Clonazepam 0.5mg TID PRN Lisinopril 5mg daily Digoxin 125mcg, [**1-13**] tab daily K-Dur daily Spironolactone 25mg daily Levothyroxin3e 112mcg daily Trazodone 25mg qHS Mexiletine 150mg TID Albuterol MDI 2puf q6hPRN Fluticasone 110mcg 2puff [**Hospital1 **] Toprol SL 50mg daily Lasix 40mg TID Coumadin Discharge Medications: 1. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day. 5. Quetiapine 25 mg Tablet Sig: as directed Tablet PO three times a day: take 2 tabs every morning, 1 tab at noontime, and 3 tabs at bedtime. 6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 9. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 11. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 14. NitroQuick 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain: as previously directed, take up to 3 tabs five minutes apart. 15. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 17. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 18. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 19. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 20. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for nausea. Disp:*45 Tablet(s)* Refills:*2* 21. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 22. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Gastrointestinal bleeding . Congestive heart failure, systolic dysfunction, chronic Coronary artery disease Atrial fibrillation Chronic kidney disease Alzheimer's dementia Discharge Condition: Stable Discharge Instructions: You were admitted with bleeding, likely from your stomach. We think that this was in part related to taking coumadin and after much discussion, we have stopped this medication. You blood counts have been stable. . Please return to the hospital or call your doctor if you have worsening abdominal pain, pain after eating, blood in your vomit or stools, dark colored stools, chest pain, shortness of breath, or any new symptoms that you are concerned about. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. . Since you were admitted we have made the following medication changes: * Please stop taking COUMADIN. * Your lasix dose was increased to 80 mg daily. Followup Instructions: Please call your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 26894**], to schedule a followup appointment within 2 weeks. . You also have the following upcoming appointments at [**Hospital1 18**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21795**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2140-11-4**] 1:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2140-11-25**] 8:40 DEVICE CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2140-12-19**] 1:00 ",163,2140-10-11 14:34:00,2140-10-18 15:38:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,CHEST PAIN;TELEMETRY;GI BLEED," the patient was admitted to the micu for monitoring and serial hcts. his bp reamined in the 90-110 systolic range. a hct drop from 39 to 32 was noted, which then stabilized. gi saw the patient, no plan for emergent scope. cardiology saw the pt and recommended an echocardiogram. cardiac enzymes were cycled; the first two sets were negative, the third troponin was 0.02 (has been similar in the past), in the setting of constant chest pain x 24 hours. diuretics and anti-hypertensives were held. . a/p: 72 yo m with mmp including cad, chf, cri admit with gib, abdominal pain, and chest pain, now callout from micu. . # gi bleed/abd pain: hx gi bleeding in the past, recent egd by gi showed erosions in stomach and duodenum c/w nsaid gastropathy, had a normal [**last name (un) **] in [**month (only) 547**]. hct stable and has not required transfusion. no evidence of active bleed. lfts normal on admit. mesenteric ischemia was considered as patient stabalized this was not pursed. he had some persistent nausea which improved with reglan. he was discharged in omeprazole. . # chest pain: with extensive cad and chf history. echo done this admit as above. he was ruled out for an mi. . # systolic heart failure: focal akinesia as above. he was satting well on room air and did not have clinical evidence of heart failure . # afib: medications were continued, coumadin was stopped. . # chronic renal insufficiency: baseline cr 1.6-2. currently at baseline. . # hyperlipidemia: - continue statin . # hypothyroidism: - continue levothyroxine . # asthma: - continue home meds . code: full (confirmed with patient) . communication: pt, wife [**doctor first name **] [**telephone/fax (1) 30058**]) ","PRIMARY: [Hemorrhage of gastrointestinal tract, unspecified] SECONDARY: [Acute on chronic systolic heart failure; Atrial fibrillation; Other and unspecified angina pectoris; Hypovolemia; Aortic valve disorders; Asthma, unspecified type, unspecified; Chronic kidney disease, unspecified; Aortocoronary bypass status; Long-term (current) use of anticoagulants; Automatic implantable cardiac defibrillator in situ; Alzheimer's disease; Dementia in conditions classified elsewhere without behavioral disturbance; Congestive heart failure, unspecified; Unspecified analgesic and antipyretic causing adverse effects in therapeutic use; Anticoagulants causing adverse effects in therapeutic use; Other specified forms of chronic ischemic heart disease; Other and unspecified hyperlipidemia; Barrett's esophagus; Diverticulosis of colon (without mention of hemorrhage); Unspecified acquired hypothyroidism]","the patient was admitted to the micu for monitoring and serial hcts. cardiac enzymes were cycled; the first two sets were negative, the third troponin was 0.02 (has been similar in the past), in the setting of constant chest pain x 24 hours. # systolic heart failure: focal akinesia as above. # afib: medications were continued, coumadin was stopped.","the patient was admitted to the micu for monitoring and serial hcts. his bp was reamined in the 90-110 systolic range, which then stabilized. cardiac enzymes were cycled; the first two sets were negative. the third troponin was 0.02 (has been similar in the past) diuretics and anti-hypertensives were held." 10774,173586.0,8554,2141-03-30,8553,142104.0,2140-10-30,Discharge summary,"Admission Date: [**2140-10-23**] Discharge Date: [**2140-10-30**] Date of Birth: [**2068-2-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 905**] Chief Complaint: melena Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy [**2140-10-26**] Esophagogastroduodenoscopy [**2140-10-27**] History of Present Illness: 72 yo M with PMH of CAD s/p CABG and PCI to LCx, AS, VT/VF arrest with BiV pacer, CHF (EF 20%), afib on coumadin, CRI (BL Cr 1.6-2), and diverticulosis admitted with abdominal pain and melena for two days. Reported hypotension by VNA to 96/P. The patient has a history of recurrent GIB with most recent admission on [**2140-10-11**] to [**10-18**]. During last hospital stay the patient was admitted to the MICU for monitoring and serial Hcts. A Hct drop from 39 to 32 was noted, which then stabilized. GI saw the patient and deferred scope. His coumadin was discontinued at this time due to recurrent bleeding. He was also admitted on [**9-12**] with melena and abd pain. EGD showed Barrett's esophagitis, gastritis, and duodenitis. He has a history of polyp removal in the cecum and one in the ascending colon in [**4-19**], histology was adenomatous. He also had a capsule study at that time, that did not show additional source of bleed in the small bowel. In ED, Vitals T 98.2, HR 78, BP 111/61, RR 18, 100% 2L NC. NG lavage showed scant blood initially which cleared with lavage. HCT stable. He was given morphine 4mg X3. No ASA given. Bolused with 40mg IV pantoprazole X1. On arrival to MICU, pt is in no acute distress. Reports [**5-17**] black, tarry stools last pm with associated dizziness. Pt has also had ongoing abdominal and back pain since discharge last week. His pain is constant and non-radiating located in his chest, abdomen and back. Past Medical History: CAD status post CABG with simultaneous aortic aneurysm repair in [**2133**], history of stenting of the left circumflex artery [**2135**] s/p VT/VF arrest, s/p ICD placement in [**2135**] iCMP (EF 20%) s/p BiV pacer [**10-18**] Chest wall cellulitis over pacer site [**3-19**] vs. ICD pacer pocket infection AFib CKD Stage III b/l Cr. ~1.6 Hyperlipidemia Asthma Anxiety Alzheimer's dementia Hypothyroidism Diverticulosis GERD s/p CCY Social History: Patient originally from [**Country 4754**] and moved to the United States in [**2089**]. Father of five children. No history of smoking. Patient was a heavy drinker until 20 years ago, when he stopped completely after attending AA and encountering marital difficulties. No history of illicit drug use. Family History: Non-contributory Physical Exam: DISCHARGE PHYSICAL EXAM V/S: 99.1, 97.6, 120/70-102/62, 80s, 16, 94% RA GEN - Obese gentleman appears comfortable, NAD HEENT- sclera anicteric, OP clear with MMM NECK: supple without JVD, delayed carotid upstroke no bruit CV: reg rate nl S1 no S2 III/VI SEM at LUSB PULM: CTAB no w/r/r ABD: soft NTND normoactive BS no organomegaly EXT- warm, dry diminished distal pulses no c/c/e NEURO: A&Ox3 Pertinent Results: [**2140-10-30**] 08:20AM BLOOD WBC-7.0 RBC-3.95* Hgb-11.7* Hct-34.5* MCV-87 MCH-29.5 MCHC-33.8 RDW-14.2 Plt Ct-198 [**2140-10-29**] 08:10AM BLOOD WBC-5.6 RBC-3.82* Hgb-11.2* Hct-33.2* MCV-87 MCH-29.4 MCHC-33.7 RDW-14.7 Plt Ct-186 [**2140-10-28**] 07:35AM BLOOD WBC-5.8 RBC-3.60* Hgb-10.5* Hct-31.5* MCV-88 MCH-29.1 MCHC-33.2 RDW-14.2 Plt Ct-167 [**2140-10-27**] 07:00AM BLOOD WBC-6.5 RBC-3.66* Hgb-10.7* Hct-32.0* MCV-87 MCH-29.1 MCHC-33.4 RDW-14.3 Plt Ct-160 [**2140-10-26**] 06:10AM BLOOD WBC-12.4* RBC-4.01* Hgb-12.0* Hct-34.6* MCV-86 MCH-29.9 MCHC-34.6 RDW-14.5 Plt Ct-164 [**2140-10-25**] 06:00AM BLOOD WBC-9.0 RBC-4.04* Hgb-11.5* Hct-35.4* MCV-88 MCH-28.5 MCHC-32.6 RDW-14.5 Plt Ct-176 [**2140-10-24**] 07:52PM BLOOD Hct-34.6* [**2140-10-24**] 04:57PM BLOOD Hct-33.4* [**2140-10-24**] 06:55AM BLOOD WBC-7.9 RBC-4.09* Hgb-12.1* Hct-35.6* MCV-87 MCH-29.5 MCHC-33.9 RDW-14.9 Plt Ct-181 [**2140-10-24**] 01:05AM BLOOD Hct-34.5* [**2140-10-23**] 06:45PM BLOOD WBC-10.1 RBC-4.03* Hgb-11.8* Hct-35.0* MCV-87 MCH-29.2 MCHC-33.6 RDW-14.4 Plt Ct-175 [**2140-10-23**] 12:58PM BLOOD WBC-7.7 RBC-4.21* Hgb-12.1* Hct-36.1* MCV-86 MCH-28.8 MCHC-33.6 RDW-15.0 Plt Ct-169 [**2140-10-28**] 07:35AM BLOOD ALT-18 AST-20 AlkPhos-86 TotBili-0.2 [**2140-10-24**] 08:19AM BLOOD CK(CPK)-103 [**2140-10-24**] 01:05AM BLOOD CK(CPK)-124 [**2140-10-23**] 12:58PM BLOOD CK(CPK)-189* [**2140-10-24**] 08:19AM BLOOD CK-MB-3 cTropnT-0.01 [**2140-10-23**] 12:58PM BLOOD cTropnT-0.01 [**2140-10-24**] 08:14PM BLOOD Lactate-0.9 . [**2140-10-26**] 12:52 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2140-10-27**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2140-10-27**]): REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 30063**] @ 3:55A [**2140-10-27**]. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. . [**2140-10-25**] CT OF THE ABDOMEN WITH IV CONTRAST: Within the visualized lung bases, there is atelectasis within the left lung base. There is no pleural effusion. Visualized heart and pericardium reveal no pericardial effusion. The liver, spleen, pancreas, and adrenal glands are unremarkable. Multiple rounded hypodensities in bilateral kidneys are stable, likely reflecting renal cysts. Patient is status post cholecystectomy. The stomach and small bowel are unremarkable. There is diverticulosis of the colon, without evidence of diverticulitis. There is no evidence of acute inflammation, or secondary signs to suggest mesenteric ischemia. Evaluation of the intra-abdominal vasculature reveals moderate diffuse atherosclerotic calcification involving the abdominal aorta, not significantly changed from prior study. There is mild atherosclerosis at the origin of the celiac axis. Otherwise, celiac axis, superior mesenteric artery, and inferior mesenteric artery and their branches appear patent and unremarkable. There is no free air, free fluid, or pathologic adenopathy. CT OF THE PELVIS WITH IV CONTRAST: Urinary bladder, rectum, and prostate are unremarkable. There is no pelvic lymphadenopathy or free fluid. OSSEOUS STRUCTURES: Patient status post total right hip replacement. No suspicious lytic or sclerotic lesions identified. IMPRESSION: No acute intra-abdominal process identified. The celiac axis, SMA, and [**Female First Name (un) 899**] appear patent without thrombosis or occlusion. No secondary signs to suggest mesenteric ischemia identified. . [**2140-10-26**] L-SPINE (AP & LAT) FINDINGS: There is a levocurvature of the mid lumbar spine. Multilevel anterior osteophytes are noted. The disc spaces appear largely preserved aside from the scoliosis. Extensive vascular calcifications are noted. There is a right hip total arthroplasty, partially visualized. IMPRESSION: Multilevel degenerative changes as detailed. . [**2140-10-26**] Gastric mucosal biopsies A. Body: Focal active gastritis; [**Doctor Last Name 6311**] stain shows no definite helicobacter-like organisms with satisfactory control. B. Antrum: No diagnostic abnormalities recognized. Brief Hospital Course: #Acute gastritis - The patient was admitted to the ICU overnight for observation given reported hypotension prior to admission. Blood pressure was readily fluid-responsive and the patient remained hemodynamically stable. Melena resolved after admission and hematocrit remained stable, obviating the need for blood transfusion. He was treated with PPI gtt in the ICU which was changed to PPI [**Hospital1 **] on the floor. The patient [**Hospital1 1834**] EGD showing erosive gastritis and Barrett's esophagus but no active bleeding. Continued to hold coumadin. Aspirin was restarted in the setting of [**Hospital1 **] PPI and carafate therapy which will be continued after discharge at the recommendation of the consulting GI team. He will follow up in [**Hospital **] clinic, in part to schedule surveillance endoscopy for the monitoring of Barrett's. . #Candidal esophagitis - EGD also revealed candidal esophagitis which had been present on endoscopy 6 months prior and perhaps inadequately treated with a 10-day course of fluconazole. HIV Ab test was negative at that time. A 3-week course of oral fluconazole was started with LFT's to be rechecked 1 week after discharge. He was counseled regarding the proper use of his corticosteroid inhalers including rinsing thoroughly after use. . #C. difficile colitis - The patient was started on a 2 week course of flagyl. He was placed on contact precautions. [**Name2 (NI) **] was counseled not to drink alcohol while taking metronidazole. . #Abdominal/back pain - This pain reportedly had been present for several years but had subacutely worsened over the past [**6-23**] months. Paraspinal muscle tenderness on examination was suggestive of musculoskeletal pathology. CTA abd/pelvis showed sigmoid diverticulosis but no evidence of mesenteric ischemia or AAA. Lumbar plain film showed only chronic degenerative changes but no compression deformity or lytic lesion. Stable hematocrit made a RP bleed unlikely. Urinalysis, LFT's, calcium, and SPEP/UPEP were normal. Pain was well-controlled with tylenol. . #Chronic systolic CHF - The patient appeared euvolemic without signs or symptoms of acute CHF. ACEi had been discontinued prior to admission due to hypotension. He will continue on beta-blocker, digoxin, and diuretic therapy after discharge. . #Atrial fibrillation - Coumadin was held due to recurrent UGIB, as above. Aspirin was continued. He was encouraged to follow up with his cardiologist as soon as possible. . #Chronic kidney disease stage III - Creatinine remained at baseline. Medications were dosed accordingly. . #Hyperlipidemia - Continued statin. . #Hypothyroidism - Continued levothyroxine. . #Asthma - Continued home regimen with counseling regarding proper use of steroid inhalers, as above. . #Nutrition - Heart-healthy diet. . #Propylaxis - Pneumoboots, PPI Medications on Admission: Sotalol 80 mg PO BID Atorvastatin 20 mg PO DAILY Donepezil 5 mg PO HS Citalopram 40 mg 1.5 Tab PO DAILY Quetiapine 25 mg Tab PO TID Clonazepam 0.5 mg Tablet 1 Tablet PO TID PRN anxiety Digoxin 62.5 mcg PO DAILY K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal 1 Tab PO daily Levothyroxine 112 mcg Tablet 1 Tablet PO DAILY Trazodone 50 mg Tablet 1 PO HS Mexiletine 150 mg Capsule 1 Capsule PO Q8H Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] NitroQuick 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual as needed as needed for chest pain Magnesium Oxide 400 mg Tablet 1 Tablet PO daily Pantoprazole 40 mg Tablet 1 tab Q 12 Aspirin 81 mg Tablet PO DAILY Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID/PRN nausea Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr po daily Furosemide 80 mg Tablet PO daily Discharge Medications: 1. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 11 days: Through Wednesday, [**11-9**]. Disp:*11 Tablet(s)* Refills:*0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 11 days: Through Wednesday, [**11-9**]. Disp:*33 Tablet(s)* Refills:*0* 3. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Citalopram 40 mg Tablet Sig: 1.5 Tablets PO once a day. 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO NOON (At Noon). 9. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 10. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*0* 11. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 13. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) INH Inhalation [**Hospital1 **] (2 times a day). 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 16. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours) as needed for nausea. 17. Klonopin 0.5 mg Tablet Sig: One (1) Tablet PO three times a day as needed for anxiety. 18. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 20. Donepezil 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 21. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime. 22. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 23. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day. 24. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 25. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 26. GlycoLax 17 gram (100 %) Powder in Packet Sig: One (1) packet PO once a day. 27. Nitrostat 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual three times a day as needed for chest pain: Take up to 3 tablets 5 minutes apart as needed for chest pain and seek immediate medical attention. 28. Outpatient Lab Work Please check chemistries and liver function tests on [**Hospital1 766**], [**11-7**] and fax the results to the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26894**] at [**Telephone/Fax (1) 16236**]. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary 1) Acute blood loss anemia 2) Acute gastritis 3) Candidal esophagitis 4) Clostridium difficile colitis Secondary 1) Coronary artery disease 2) Chronic systolic heart failure 3) Atrial fibrillation 4) Chronic kidney disease stage III 5) Hypothyroidism Discharge Condition: asymptomatic with stable vital signs. Discharge Instructions: You were admitted to the hospital with dark stools, likely from erosions and inflammation in the lining of the stomach seen on upper endoscopy. Your coumadin (warfarin) was discontinued due to recurrent bleeding. Continue taking aspirin daily as prescribed. Take protonix 2 times daily and a new medication carafate (sucralfate) 4 times daily to help heal and protect the stomach lining. Upper endoscopy also showed a fungal infection in the esophagus which was partially treated with an antifungal medication. Please continue taking Fluconazole through Tuesday, [**11-15**]. Please have blood drawn for chemistries and liver function tests on [**Month (only) 766**], [**11-7**] and ensure that the results are faxed to Dr. [**Last Name (STitle) 26895**] office at [**Telephone/Fax (1) 16236**]. You were diagnosed with a bacterial infection in the large intestine which was partially treated with an antibiotic medication. Please continue Flagyl (metronidazole) as prescribed through Wednesday, [**11-9**]. Do not drink alcohol while taking this medication due to the risks of side effects from this combination. You no longer need to use the fluticasone inhaler if you are also using advair. Please be sure to rinse out your mouth and throat after using this medication to help prevent infection. Please continue taking your other medications as prescribed. Please adhere to a diet with less than 2 grams of sodium daily. Please weight yourself daily and call your physician if your weight increases by greater than 3 lbs. Please call the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26894**] at [**Telephone/Fax (1) 3329**] to arrange a follow up appointment in 1 week. Please call the office of Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] at [**Telephone/Fax (1) 62**] to arrange a follow up appointment in [**1-13**] weeks. Please follow up with Dr. [**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) 1407**] on Friday, [**11-4**] at 1:00. The office phone number is [**Telephone/Fax (1) 463**]. Please call your physician or return to the Emergency Department if you experience fever, chills, sweats, dizziness, lightheadedness, difficulty or pain with swallowing, chest pain, palpitations, shortness of breath, cough, abdominal pain, vomiting, diarrhea, bloody or black stools, or leg swelling or pain. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 21795**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2140-11-4**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2140-11-25**] 8:40 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2140-12-19**] 1:00 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2140-10-30**]",151,2140-10-23 15:20:00,2140-10-30 14:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,CHEST PAIN;TELEMETRY;MELENA," #acute gastritis - the patient was admitted to the icu overnight for observation given reported hypotension prior to admission. blood pressure was readily fluid-responsive and the patient remained hemodynamically stable. melena resolved after admission and hematocrit remained stable, obviating the need for blood transfusion. he was treated with ppi gtt in the icu which was changed to ppi [**hospital1 **] on the floor. the patient [**hospital1 1834**] egd showing erosive gastritis and barretts esophagus but no active bleeding. continued to hold coumadin. aspirin was restarted in the setting of [**hospital1 **] ppi and carafate therapy which will be continued after discharge at the recommendation of the consulting gi team. he will follow up in [**hospital **] clinic, in part to schedule surveillance endoscopy for the monitoring of barretts. . #candidal esophagitis - egd also revealed candidal esophagitis which had been present on endoscopy 6 months prior and perhaps inadequately treated with a 10-day course of fluconazole. hiv ab test was negative at that time. a 3-week course of oral fluconazole was started with lfts to be rechecked 1 week after discharge. he was counseled regarding the proper use of his corticosteroid inhalers including rinsing thoroughly after use. . #c. difficile colitis - the patient was started on a 2 week course of flagyl. he was placed on contact precautions. [**name2 (ni) **] was counseled not to drink alcohol while taking metronidazole. . #abdominal/back pain - this pain reportedly had been present for several years but had subacutely worsened over the past [**6-23**] months. paraspinal muscle tenderness on examination was suggestive of musculoskeletal pathology. cta abd/pelvis showed sigmoid diverticulosis but no evidence of mesenteric ischemia or aaa. lumbar plain film showed only chronic degenerative changes but no compression deformity or lytic lesion. stable hematocrit made a rp bleed unlikely. urinalysis, lfts, calcium, and spep/upep were normal. pain was well-controlled with tylenol. . #chronic systolic chf - the patient appeared euvolemic without signs or symptoms of acute chf. acei had been discontinued prior to admission due to hypotension. he will continue on beta-blocker, digoxin, and diuretic therapy after discharge. . #atrial fibrillation - coumadin was held due to recurrent ugib, as above. aspirin was continued. he was encouraged to follow up with his cardiologist as soon as possible. . #chronic kidney disease stage iii - creatinine remained at baseline. medications were dosed accordingly. . #hyperlipidemia - continued statin. . #hypothyroidism - continued levothyroxine. . #asthma - continued home regimen with counseling regarding proper use of steroid inhalers, as above. . #nutrition - heart-healthy diet. . #propylaxis - pneumoboots, ppi ","PRIMARY: [Other specified gastritis, with hemorrhage] SECONDARY: [Intestinal infection due to Clostridium difficile; Candidal esophagitis; Chronic systolic heart failure; Acute posthemorrhagic anemia; Congestive heart failure, unspecified; Atrial fibrillation; Long-term (current) use of anticoagulants; Alzheimer's disease; Dementia in conditions classified elsewhere without behavioral disturbance; Other and unspecified hyperlipidemia; Aortocoronary bypass status; Esophageal reflux; Unspecified acquired hypothyroidism; Chronic kidney disease, Stage III (moderate); Other specified forms of chronic ischemic heart disease; Asthma, unspecified type, unspecified; Automatic implantable cardiac defibrillator in situ; Aortic valve disorders; Barrett's esophagus; Diverticulosis of colon (without mention of hemorrhage); Unspecified analgesic and antipyretic causing adverse effects in therapeutic use]","#acute gastritis - the patient was admitted to the icu overnight for observation given reported hypotension prior to admission. #candidal esophagitis - egd also revealed candidal esophagitis which had been present on endoscopy 6 months prior and perhaps inadequately treated with a 10-day course of fluconazole. a 3-week course of oral fluconazole was started with lfts to be rechecked 1 week after discharge. name2 (ni) **] was counseled not to drink alcohol while taking metronidazole. he was encouraged to follow up with his cardiologist as soon as possible. #chronic kidney disease stage iii - creatinine remained at baseline.",egd showed erosive gastritis and barretts esophagus but no active bleeding. aspirin was restarted in the setting of [**hospital1 **] ppi and carafate therapy which will be continued after discharge at the recommendation of the consulting gi team. egd also revealed candidal esophagitis which had been present on endoscopy 6 months prior and perhaps inadequately treated. 10774,130230.0,8552,2140-10-18,8551,146298.0,2140-09-12,Discharge summary,"Admission Date: [**2140-9-7**] Discharge Date: [**2140-9-12**] Date of Birth: [**2068-2-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30062**] Chief Complaint: melana, chest pain Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy History of Present Illness: 72 year old male with CAD s/p CABG, atrial fib on coumadin, s/p VT/VF arrest with BiV pacer; CHF with EF 15% admitted to the MICU ([**9-7**]) after presenting with CP, SOB, abdominal pain, melena, INR of 3, and Hct drop from 40 to 37. He was admitted to the MICU where he was given FFP and 1u PRBCs and ruled out for ACS. He was seen by GI, Surgery, and Cardiology. GI c/s resulted in plan for EGD. Surgery c/s resulted in INR reversal and serial exams and hcts. Cardiology felt the patient's CP was not [**2-13**] a cardiac etiology. He was ruled out for MI regardless. His Hct was 31 at its lowest but remained stable and, as he was stable overall, he was felt appropriate for transfer to the floor for further work up of his melena. . Of note, last [**Month (only) 547**], the patient had a similar presentation and EGD, c-scope, and capsule endoscopy demonstrated gastritis, Barrett's, diverticulosis and grade 1 hemorrhoids were found, without any active bleeding. At time of transfer, the patient endorsed mild abdominal pain and diaphoresis. He denied chest pain. He had not had a BM in 2 days. Past Medical History: --CAD status post CABG with simultaneous aortic aneurysm repair in [**2133**], history of stenting of the left circumflex artery [**2135**] --s/p VT/VF arrest, s/p ICD placement in [**2135**] --Ischemic cardiomyopathy with an ED of 20%, s/p BiV pacer [**10-18**] --Chest wall cellulitis over pacer site [**3-19**] vs. ICD pacer pocket infection --PAF --CKD with baseline Cr. 1.6-2 --Hyperlipidemia --Asthma --Anxiety --Alzheimer's dementia --Hypothyroidism --GI bleed of unknown etiology [**2138**]. EGD revealed esophagitis, Barrett's esophagus, and duodenitis. No ulcers. --Diverticulosis --GERD --S/P Cholecystectomy Social History: Patient originally from [**Country 4754**] and moved to the United States in [**2089**]. Worked as an off-set printer in [**Location (un) 686**], where he continues to live with his wife. Father of five children. Retired 6 years ago, and since his recent heart problems, says he rarely leaves the house. Most of his time is spent in front of the television with his wife handling their affairs at home. No history of smoking, past or present. Patient was a heavy drinker until 20 years ago, when he stopped completely after attending AA and encountering marital difficulties. No history of illicit drug use. Family History: Non-contributory. Physical Exam: Afebrile, 115/69, 75, 18, 99%2L General Appearance: Pleasant, obese male, mildly diaphoretic lying in bed in no acute distress. Eyes / Conjunctiva: PERRL, EOMI, no icterus Head, Ears, Nose, Throat: NCAT, MMMI, JVD 10cm Cardiovascular: paced, [**3-17**] looud blowing systolic murmur loudest at LUSB with radiation along the left sternal border throughout, large, prolonged and displaced PMI Respiratory / Chest: CTA b/l Abdominal: Soft, mild guarding, +BS, subumbilical tenderness with mild tenderness in bl lower quadrents, no guarding Extremities: pneumoboots in place, dps 1+ bl Neurologic: Attentive, Follows simple commands, a and o times 3, movement and sensation intact in all extremities Pertinent Results: [**2140-9-7**] 03:20PM PT-29.2* PTT-31.4 INR(PT)-3.0* [**2140-9-7**] 03:20PM PLT COUNT-168 [**2140-9-7**] 03:20PM NEUTS-75.5* LYMPHS-13.8* MONOS-7.0 EOS-3.4 BASOS-0.4 [**2140-9-7**] 03:20PM WBC-8.6 RBC-4.30* HGB-12.4* HCT-37.0* MCV-86 MCH-28.8 MCHC-33.5 RDW-14.6 [**2140-9-7**] 03:20PM DIGOXIN-0.9 [**2140-9-7**] 03:20PM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-2.3 [**2140-9-7**] 03:20PM CK-MB-4 [**2140-9-7**] 03:20PM cTropnT-0.01 [**2140-9-7**] 03:20PM LIPASE-44 [**2140-9-7**] 03:20PM ALT(SGPT)-20 AST(SGOT)-28 CK(CPK)-112 ALK PHOS-89 TOT BILI-0.2 [**2140-9-7**] 03:20PM estGFR-Using this [**2140-9-7**] 03:20PM GLUCOSE-72 UREA N-23* CREAT-1.7* SODIUM-138 POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-32 ANION GAP-10 [**2140-9-7**] 03:32PM K+-4.6 [**2140-9-7**] 03:32PM COMMENTS-GREEN TOP [**2140-9-7**] 06:02PM HCT-35.6* [**2140-9-7**] 06:12PM LACTATE-0.9 [**2140-9-7**] 11:30PM HCT-31.1* [**2140-9-7**] 11:30PM URINE HOURS-RANDOM UREA N-377 CREAT-52 SODIUM-50 [**2140-9-7**] 11:30PM DIGOXIN-0.8* [**2140-9-7**] 11:30PM MAGNESIUM-2.0 [**2140-9-7**] 11:30PM CK-MB-4 cTropnT-0.01 [**2140-9-7**] 11:30PM CK(CPK)-110 [**2140-9-7**] 11:30PM GLUCOSE-89 UREA N-20 CREAT-1.6* SODIUM-141 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-30 ANION GAP-11 EKG - [**9-7**]: Ventricular paced rhythm Atrial mechanism uncertain - may be paced ot possible ectopic atrial rhythm Since previous tracing of [**2140-4-19**], ventricular ectopy absent and P wave morphology appears changed CXR - [**9-7**]: SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The cardiomediastinal contour is unchanged, with moderate cardiomegaly. There is no pleural effusion or evidence of focal consolidation. The dual-lead pacing device is unchanged in appearance. Osseous structures are unremarkable. IMPRESSION: No significant change since [**2140-4-12**]. No evidence of pneumonia or congestive heart failure. KUB - [**9-9**]: FINDINGS: There is non-specific bowel gas in the abdomen. There are no distended loops of bowel, or concerning air-fluid levels. There is air in the rectum. There is a large amount of feces in the descending colon, suggesting constipation. Of note, there is a right hip hemiarthroplasty hardware, without apparent hardware complication. There is a mild lumbar levoscoliosis. There are surgical clips at the right upper quadrant, from prior cholecystectomy. There are wires projected on to the heart, likely pacer wires. IMPRESSION: No evidence of bowel obstruction. Likely constipation. EGD - [**9-9**]: Barrett's Exophagitis, Gastritis, Duodenitis Brief Hospital Course: 72 year old male with CAD s/p CABG, atrial fib on coumadin, s/p VT/VF arrest now with BiV pacer; CHF with EF 15% who presented with what appears to be non-cardiac chest pain, abdominal pain and melena. . # Melena/Abdominal pain: HCT decreased to 31 from BL of 33 on arrival to MICU. INR was reversed. Serial hematocrits were checked and remained stable despite the patient remaining guiac positive. Aspirin and Coumadin were held until after EGD at which time they were restarted. IV PPI was given until EGD. Patient was converted to PO PPI [**Hospital1 **] and instructed to continue as such for six weeks. GI follow up [**Hospital1 1988**]. Patient had similar episode in [**4-19**] and had an extensive GI workup which was negative. . # Chest Pain: Pain resolved by the time the patient arrived to the floor. Cardiology felt the pain was unlikely to be cardiac in nature as cardiac enzymes were negative on arrival to the ED after 5 hours of constant chest pain. Pain could be esophageal as patient has history of Esophagitis and Barretts esophagus. Last possibility is aortic chest pain as patient has history of thoracic aortic aneurysm repair, small concern for dissection although unlikely as patient remained stable throughout his hopitalization and his CP resolved. . # CAD: Patient is s/p CABG. Chest pain unlikely to be cardiac. MI ruled out. ASA, BB and statin were initially held in setting of possible GIB but were restarted prior to discharge. . # CHF: Patient with history of ischemic CMP with EF 15%. Home Lasix, Aldactone, and Toprol were intially held but reintroduced prior to discharge. Home digoxin was continued. . # PAF: Patient s/p BiV pacer placement on Coumadin. INR was reversed intially but coumadin was restarted prior to discharge. Digoxin was continued. . # VF/VT arrest: Patient is s/p BiV pacer/ICD placement. Home Sotalol, Mexiletine were continued. . # Asthma: Albuterol MDI at home. Albuterol Nebs were given PRN. . # Hypothyroidism: Home levoxyl was continued. . # CKD: Patient with Cr of 1.7 on admission with Baseline Cr 1.5-2. Remained stable. . # Alzheimer??????s: Held home Donepezil, Celexa initially. Restarted prior to discharge. Medications on Admission: Sotalol 80mg [**Hospital1 **] Lipitor 20mg daily Donepezil 5mg daily Quetiapine 25mg, 3tabs qAM, 1tab noon, 3tabs qHS Celexa 60mg daily Protonix 40mg daily ASA 81mg daily Clonazepam 0.5mg TID PRN Lisinopril 5mg daily Digoxin 125mcg, [**1-13**] tab daily K-Dur daily Spironolactone 25mg daily Levothyroxin3e 112mcg daily Trazodone 25mg qHS Mexiletine 150mg TID Albuterol MDI 2puf q6hPRN Fluticasone 110mcg 2puff [**Hospital1 **] Toprol SL 50mg daily Lasix 40mg TID Coumadin Discharge Medications: 1. Sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 3. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Digoxin 125 mcg Tablet Sig: [**1-13**] Tablet PO DAILY (Daily). 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): Take twice per day for a total of 6 weeks. Can then resume once per day. Disp:*45 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 8. Warfarin 1 mg Tablet Sig: 2-3 Tablets PO once a day: 2 to 3 tablets by mouth once per day or as directed. 9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 11. Celexa 40 mg Tablet Sig: 1.5 Tablets PO once a day. 12. Donepezil 5 mg Tablet Sig: One (1) Tablet PO at bedtime. 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation twice a day. 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 15. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 16. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 17. Miralax 100 % Powder Sig: One (1) packet PO once a day. 18. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 19. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO qam. 20. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO qnoon. 21. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO at bedtime. 22. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO once a day. 23. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 24. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 25. Promethazine 12.5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for nausea. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Upper GastroIntestinal Bleed Barrett's Esophagitis Gastritis Duodenitis Discharge Condition: Fair Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 2L You were admitted to the hospital because you had blood in your stool along with a decrease in your blood count/hematocrit concerning for ongoing bleeding. Because you also had chest pain upon presentation, you were also admitted to rule out the possibility that you were experiencing a heart attack. You had an EGD performed which showed irritation and inflammation of your esophagus, stomach, and duodenum. This irritation could be the cause of your bloody stool and decrease in blood count. You were given blood replacement products along with high doses of protonix and your blood count remained stable. You should continue to take you protonix twice per day for the next 6 weeks. You have follow up with the GI doctors [**Name5 (PTitle) 1988**]. You should call your doctor and/or return to the emergency room if you have dark tarry stools or bright red blood in your stool, Chest Pain, Shortness of Breath, or any other corncerning symptoms. Followup Instructions: [**9-14**] at 9:30am DEVICE CLINIC (Phone:[**Telephone/Fax (1) 59**]) [**9-14**] at 10:00am [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP (Phone:[**Telephone/Fax (1) 62**]) [**9-30**] at 11:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD (Phone:[**Telephone/Fax (1) 463**]) ",36,2140-09-07 21:07:00,2140-09-12 17:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,CHEST PAIN," 72 year old male with cad s/p cabg, atrial fib on coumadin, s/p vt/vf arrest now with biv pacer; chf with ef 15% who presented with what appears to be non-cardiac chest pain, abdominal pain and melena. . # melena/abdominal pain: hct decreased to 31 from bl of 33 on arrival to micu. inr was reversed. serial hematocrits were checked and remained stable despite the patient remaining guiac positive. aspirin and coumadin were held until after egd at which time they were restarted. iv ppi was given until egd. patient was converted to po ppi [**hospital1 **] and instructed to continue as such for six weeks. gi follow up [**hospital1 1988**]. patient had similar episode in [**4-19**] and had an extensive gi workup which was negative. . # chest pain: pain resolved by the time the patient arrived to the floor. cardiology felt the pain was unlikely to be cardiac in nature as cardiac enzymes were negative on arrival to the ed after 5 hours of constant chest pain. pain could be esophageal as patient has history of esophagitis and barretts esophagus. last possibility is aortic chest pain as patient has history of thoracic aortic aneurysm repair, small concern for dissection although unlikely as patient remained stable throughout his hopitalization and his cp resolved. . # cad: patient is s/p cabg. chest pain unlikely to be cardiac. mi ruled out. asa, bb and statin were initially held in setting of possible gib but were restarted prior to discharge. . # chf: patient with history of ischemic cmp with ef 15%. home lasix, aldactone, and toprol were intially held but reintroduced prior to discharge. home digoxin was continued. . # paf: patient s/p biv pacer placement on coumadin. inr was reversed intially but coumadin was restarted prior to discharge. digoxin was continued. . # vf/vt arrest: patient is s/p biv pacer/icd placement. home sotalol, mexiletine were continued. . # asthma: albuterol mdi at home. albuterol nebs were given prn. . # hypothyroidism: home levoxyl was continued. . # ckd: patient with cr of 1.7 on admission with baseline cr 1.5-2. remained stable. . # alzheimer??????s: held home donepezil, celexa initially. restarted prior to discharge. ","PRIMARY: [Hemorrhage of gastrointestinal tract, unspecified] SECONDARY: [Paroxysmal ventricular tachycardia; Chronic systolic heart failure; Congestive heart failure, unspecified; Other chest pain; Esophageal reflux; Unspecified acquired hypothyroidism; Aortocoronary bypass status; Duodenitis, without mention of hemorrhage; Alzheimer's disease; Dementia in conditions classified elsewhere without behavioral disturbance; Asthma, unspecified type, unspecified; Other and unspecified hyperlipidemia; Chronic kidney disease, unspecified; Barrett's esophagus; Unspecified gastritis and gastroduodenitis, without mention of hemorrhage; Long-term (current) use of anticoagulants; Other specified forms of chronic ischemic heart disease; Automatic implantable cardiac defibrillator in situ; Atrial fibrillation]","72 year old male with cad s/p cabg, atrial fib on coumadin, s/p vt/vf arrest now with biv pacer; chf with ef 15% who presented with what appears to be non-cardiac chest pain, abdominal pain and melena. last possibility is aortic chest pain as patient has history of thoracic aortic aneurysm repair, small concern for dissection although unlikely as patient remained stable throughout his hopitalization and his cp resolved. inr was reversed intially but coumadin was restarted prior to discharge. # vf/vt arrest: patient is s/p biv pacer/icd placement.","72 year old male with cad s/p cabg, atrial fib on coumadin, s/p vt/vf arrest now with biv pacer; chf with ef 15% who presented with what appears to be non-cardiac chest pain, abdominal pain and melena. aspirin and coumadin were held until after egd at which time they were restarted. iv ppi was given until egd" 11638,122879.0,15382,2179-12-03,15380,133678.0,2179-09-22,Discharge summary,"Admission Date: [**2179-9-16**] Discharge Date: [**2179-9-22**] Date of Birth: [**2108-5-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1515**] Chief Complaint: Hypovolemia Major Surgical or Invasive Procedure: none History of Present Illness: 71 year old F with PMH significant for advanced ischemic cardiomyopathy EF 15%, atrial fibrillation with ICD and CKD who presented to [**Hospital **] hospital [**2179-9-14**] for generalized weakness. Patient reports gaining fluid (notably abdomen and lower extremity) since early [**Month (only) 462**] and consequently toresmide was increased and metolazone started. Per OMR notes patient's creatinine increased to 4.7, had 15 pound weight loss (177 from dry weight 190lb), lower blood pressures and was consequently referred to [**Hospital **] Hospital. Due to weight loss all diuretics were on hold since [**2179-9-7**]. Patient reports 1 month history of increasing fatigue, weakness and shortness of breath. Denies increase in orthopnea, PND. Denies syncope, pre-syncope or dizziness. Denies chest pain. Denies fever, chills, cough or increase in urination. . Patient's presenting vitals to [**Hospital **] Hospital were temperature 97.1, HR 70, RR 20, blood pressure 78/56. Labs notable for creatinine of 4.7, Hematocrit 26.1, CBC 2.5, plt 60,000, INR 2.6. She was given 3 units pRBC and 2.5+ L of fluid. Cardiology was consulted. Patient did not require pressor support. Heme was consulted for pancytopenia felt to be secondary to hypersplenism (demonstrated on ultrasound, new since 5/[**2177**]). Patient was transferred to [**Hospital1 18**] CCU for further care. . On review of systems, she denies any prior history of stroke, TIA, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative Past Medical History: 1. ischemic cardiomyopathy (EF 10-25%) s/p BiV ICD 2. Coronary artery disease status post PTCA and stenting of the LAD in [**2164**]. 3. h/o PE secondary to DVT s/p IVC filter 4. Atrial fibrillation status post cardioversion and biventricular pacemaker implantation. 5. HTN 6. Obesity 7. PVD 8. small VSD 9. hypothyroidism PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Dyslipidemia 2. CARDIAC HISTORY: -Ischemic cardiomyopathy EF %15-20 s/p biv ICD -CAD s/p post PTCA and stenting of the LAD in [**2164**]. -CABG: None -PACING/ICD: atrial fibrillation on anticoagulation and ICD biventricular pacemaker 3. OTHER PAST MEDICAL HISTORY: chronic kidney disease bilateral DVT s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] filter pulmonary embolism osteoarthritis hyperkalemia Social History: Pt lives alone. She is not married. She reports a 20 pack year history, however she quit 30 yrs ago. Denies EtOH or illicit drug use. Family History: Mother had MI at age 50. Father in good health. Maternal uncle died of MI in his 50's. Physical Exam: Gen: alert, talkative, NAD HEENT: supple, no LAd, Pos JVD at 12 cm CV: RRR, 2/6 systolic murmur at apex RESP: CTAB, no crackles or wheezes ABD: distended, soft, pos fluid wave, umbilical hernia, EXTR: 1+ edema bilat. right > L NEURO: alert, oriented, Extremeties: Groin Pulses: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Skin: intact Access: PIV Tubes: Foley d/c'ed. Pertinent Results: [**2179-9-22**] 06:50AM BLOOD WBC-3.8* RBC-3.30* Hgb-10.8* Hct-31.7* MCV-96 MCH-32.7* MCHC-34.0 RDW-17.1* Plt Ct-95* [**2179-9-16**] 10:40PM BLOOD Neuts-86.4* Lymphs-8.9* Monos-3.3 Eos-1.0 Baso-0.4 [**2179-9-22**] 06:50AM BLOOD Plt Ct-95* [**2179-9-22**] 06:50AM BLOOD Glucose-91 UreaN-83* Creat-2.3* Na-135 K-4.5 Cl-99 HCO3-27 AnGap-14 . CXR [**9-17**]: AP chest compared to [**2175-9-20**]: Severe cardiomegaly has progressed. Lungs are clear. Pulmonary and mediastinal vasculature are unremarkable and there is no pleural effusion. Transvenous right atrial and left ventricular pacer leads and right ventricular pacer defibrillator lead are unchanged in their respective positions. No pneumothorax. . Right Leg Ultrasound: [**2179-9-17**] Grayscale color and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, popliteal, and tibial veins were performed. There is normal flow, compression and augmentation seen in all of the vessels. IMPRESSION: No evidence of deep vein thrombosis in the right leg. . Abdominal Ultrasound: [**2179-9-17**] IMPRESSION: 1. Mild splenomegaly. 2. No thrombus identified within the IVC. 3. Large amount of ascites. Brief Hospital Course: 70 year old female with severe biventricular failure with profoundly reduced left ventricular ejection fraction of 15%, moderate mitral regurgitation and tricuspid regurgitation with moderate pulmonary hypertension presented to outside hospital for fatigue and hypotension. Transferred to [**Hospital1 18**] for further treatment of her renal failure and heart failure. . # PUMP: Patient with known ischemic cardiomyopathy EF 15%. New splenomegaly concerning for worsening of EF. On admission, pt was 7 lbs below her dry weight (190) and with poor renal function therefore there was some concern for over-diuresis. Gentle IVF was given and pt was allow to re-equilibrate. She appeared to be perfusing well and did not require ionotropic support. Her renal function improved over the course of her stay, as did her edema with PO intake and holding her diuretics. She was continued on her home cardiac meds including lisinopril (decreased to 2.5/day), carvedilol and ASA. She will be discharged on 20 mg toresemide daily for diuresis. Her Fluid status will need to be monitored very closely as she is quite fragile. Daily weights will need to be monitored and as her wieght increases, she will need to have more diuretics added on. Please contact [**Name (NI) **] [**Last Name (NamePattern1) **] NP, her heart failure NP for further management at [**Telephone/Fax (1) 62**]. . # RHYTHM: Mrs [**Known lastname **] is AV paced with right bundle branch block with underlying A Fib. She was treated with coumadin, amiodarone and carvedilol. Her coumadin was decreased on discharge for elevated INR, and she will follow up for repeat INR and warfarin adjustment. She was seen by EP for evaluation of her pacer settings, however adjustments were deferred to the outpatient setting as changes need to be done under echo, therefore she has an appointment scheduled this month for adjustment of pacer settings. . # CORONARIES: One vessel coronary artery disease with patent prior LAD stent. Last cath [**2171**]. No chest pain during this admission. ASA, carvedilol and statin were continued. . # Acute on chronic renal failure: Her baseline creatinine is 1.3-2, during this visit creatinine peaked at 3.2 and was thought to be pre-renal in the setting of over-diuresis. Her renal function improved with diuretics and encouraging PO intake. . # Pancytopenia: Heme consulted at OSH - felt to be secondary to splenomegaly secondary to CHF. Platelets were stable during this admission. Would recommend following as an outpatient with hematology. . # Asymmetric lower extremity swelling: Right > Left. LENI OSH negative. Patient reports no recent instrumentation. This was felt to be a chronic issue related to positioning as it is no worse than baseline and the patient tends to lie primarily on her right side. . # Hypothyroid: Her levothyroxine was continued at outpatient doses. . # LE muscle spasm Not a [**Last Name **] problem, pt states started about mid [**Month (only) **]. Interfering with activity, not able to walk now and is assist of two to chair. Unclear how much hospitalization and deconditioning are contributing. No improvement with hydration. Electolytes WNL. Pt was started on Ca and will follow-up as an outpatient. Dr. [**Last Name (STitle) **], a neurologist from [**Location (un) **] has been contact[**Name (NI) **] to see the pt as soon as possible, her sister, will help with setting this appt up in a timely manner. Medications on Admission: - omeprazole 20 mg po qd - simvastatin 20mg po qd - amiodarone 200 mg qd - carvedilol 25 mg po [**12-18**] tab in am and 1 tab pm - Levoxyl 112 mg po qd - recently stopped coumadin, allopurinol, colchecine, lisinopril, Metolazone 2.5mg twice a week, torsemide 40 mg [**Hospital1 **], digoxin Discharge Medications: 1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Pt's home dose is 4mg daily. Please check INR on [**9-24**]. 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): this will need to be uptitrated as weight increases over dry weight. . 13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 14. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 1439**] Discharge Diagnosis: Acute on Chronic systolic Congestive Heart Failure Atrial fibrillation Acute on chronic Kidney Disease Pancytopenia Hx of Bilateral DVT s/p filter Discharge Condition: stable weight= 85.4kg. This is pt's dry weight. BP= 80's-90's/50's. This is pts baseline HR= 70's. O2 sat on RA= 97% Discharge Instructions: You had too much fluid taken off and your kidneys did not function well. We stopped all of your diuretics and gave you some intravenous fluid. Your kidney function is now better and we will restart the Torsemide at a very low dose. You will need to be followed closely over the next few weeks because you will need to have more of your medicines restarted. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] is the CHF NP who follows you on a regular basis. She can be reached with any questions at [**Telephone/Fax (1) 62**]. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Follow a low sodium (2000mg) diet Do not drink more than 6 cups of fluid per day or about 1.5 liters. We have set up an outpatient appt to see a neurologist about your muscle spasms. . Medication changes: 1. Decrease your Torsemide to 20 mg daily 2. Decrease your Lisinopril to 2.5 mg daily 3. Decrease Warfarin to 2mg daily until your INR is < 3.0, then increase to 4mg daily. 4. Do not take Colchicine or Allopurinol unless your gout comes back (you were not taking this at home) 5. START taking Calcium and Vitamin D to prevent osteoporosis. Followup Instructions: Primary Care: [**Last Name (LF) 44661**],[**First Name3 (LF) 25**] M. Phone: [**Telephone/Fax (1) 44659**] Date/time: Please call for an appt after you get out of rehabilitation. Cardiology: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2179-9-29**] 10:30 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2179-10-6**] 10:00 . Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2179-10-6**] 10:30 Neurology: Dr. [**Last Name (STitle) **] Phone: [**Telephone/Fax (1) 44662**] Date/Time: Office will call with an appt. Completed by:[**2179-9-22**]",72,2179-09-16 21:42:00,2179-09-22 14:10:00,EMERGENCY,TRANSFER FROM HOSP/EXTRAM,SNF,CONGESTIVE HEART FAILURE," 70 year old female with severe biventricular failure with profoundly reduced left ventricular ejection fraction of 15%, moderate mitral regurgitation and tricuspid regurgitation with moderate pulmonary hypertension presented to outside hospital for fatigue and hypotension. transferred to [**hospital1 18**] for further treatment of her renal failure and heart failure. . # pump: patient with known ischemic cardiomyopathy ef 15%. new splenomegaly concerning for worsening of ef. on admission, pt was 7 lbs below her dry weight (190) and with poor renal function therefore there was some concern for over-diuresis. gentle ivf was given and pt was allow to re-equilibrate. she appeared to be perfusing well and did not require ionotropic support. her renal function improved over the course of her stay, as did her edema with po intake and holding her diuretics. she was continued on her home cardiac meds including lisinopril (decreased to 2.5/day), carvedilol and asa. she will be discharged on 20 mg toresemide daily for diuresis. her fluid status will need to be monitored very closely as she is quite fragile. daily weights will need to be monitored and as her wieght increases, she will need to have more diuretics added on. please contact [**name (ni) **] [**last name (namepattern1) **] np, her heart failure np for further management at [**telephone/fax (1) 62**]. . # rhythm: mrs [**known lastname **] is av paced with right bundle branch block with underlying a fib. she was treated with coumadin, amiodarone and carvedilol. her coumadin was decreased on discharge for elevated inr, and she will follow up for repeat inr and warfarin adjustment. she was seen by ep for evaluation of her pacer settings, however adjustments were deferred to the outpatient setting as changes need to be done under echo, therefore she has an appointment scheduled this month for adjustment of pacer settings. . # coronaries: one vessel coronary artery disease with patent prior lad stent. last cath [**2171**]. no chest pain during this admission. asa, carvedilol and statin were continued. . # acute on chronic renal failure: her baseline creatinine is 1.3-2, during this visit creatinine peaked at 3.2 and was thought to be pre-renal in the setting of over-diuresis. her renal function improved with diuretics and encouraging po intake. . # pancytopenia: heme consulted at osh - felt to be secondary to splenomegaly secondary to chf. platelets were stable during this admission. would recommend following as an outpatient with hematology. . # asymmetric lower extremity swelling: right > left. leni osh negative. patient reports no recent instrumentation. this was felt to be a chronic issue related to positioning as it is no worse than baseline and the patient tends to lie primarily on her right side. . # hypothyroid: her levothyroxine was continued at outpatient doses. . # le muscle spasm not a [**last name **] problem, pt states started about mid [**month (only) **]. interfering with activity, not able to walk now and is assist of two to chair. unclear how much hospitalization and deconditioning are contributing. no improvement with hydration. electolytes wnl. pt was started on ca and will follow-up as an outpatient. dr. [**last name (stitle) **], a neurologist from [**location (un) **] has been contact[**name (ni) **] to see the pt as soon as possible, her sister, will help with setting this appt up in a timely manner. ","PRIMARY: [Acute on chronic systolic heart failure] SECONDARY: [Acute kidney failure, unspecified; ; Ventricular septal defect; Congestive heart failure, unspecified; Other specified forms of chronic ischemic heart disease; Atrial fibrillation; Right bundle branch block; Mitral valve disorders; Other chronic pulmonary heart diseases; Diseases of tricuspid valve; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified; Chronic kidney disease, unspecified; Coronary atherosclerosis of native coronary artery; Splenomegaly; Unspecified acquired hypothyroidism; Peripheral vascular disease, unspecified; Obesity, unspecified; Osteoarthrosis, unspecified whether generalized or localized, site unspecified; Spasm of muscle; Swelling of limb; Automatic implantable cardiac defibrillator in situ; Personal history of venous thrombosis and embolism; Percutaneous transluminal coronary angioplasty status; Long-term (current) use of anticoagulants]","70 year old female with severe biventricular failure with profoundly reduced left ventricular ejection fraction of 15%, moderate mitral regurgitation and tricuspid regurgitation with moderate pulmonary hypertension presented to outside hospital for fatigue and hypotension. on admission, pt was 7 lbs below her dry weight (190) and with poor renal function therefore there was some concern for over-diuresis. daily weights will need to be monitored and as her wieght increases, she will need to have more diuretics added on. # rhythm: mrs [**known lastname **] is av paced with right bundle branch block with underlying a fib. her renal function improved with diuretics and encouraging po intake. patient reports no recent instrumentation. unclear how much hospitalization and deconditioning are contributing.",70 year old female with severe biventricular failure. profoundly reduced left ventricular ejection fraction of 15%. moderate mitral regurgitation and tricuspid regurgitation with moderate pulmonary hypertension. transferred to hospital for further treatment of her renal failure and heart failure. 11638,155878.0,15383,2180-01-21,15381,136238.0,2179-11-06,Discharge summary,"Admission Date: [**2179-10-26**] Discharge Date: [**2179-11-6**] Date of Birth: [**2108-5-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Increasing Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 71-year-old woman with advanced end-stage ischemic cardiomyopathy with severe left ventricular contractile function with LVEF of 10%, atrial fibrillation, [**Hospital1 **]-V ICD, CKD, with past history of DVT, PE on Coumadin who presents with increasing dyspnea. The patient was recently discharged from [**Hospital1 18**] CCU on [**9-22**] for CHF exacerbation and was discharged to rehab facility. Since that time, patient was hospitalized at [**Location (un) **] two weeks ago for pneumonia. The patient reports that over the past week, the patient has had increasing dyspnea with exertion. At baseline, patient is unable to perform ADLs without the assistance of physical therapy. Over the past week, there has been a noticible worsening in her physical limitations. The patient recently saw Dr. [**First Name (STitle) 437**] as an outpatient and had her dose of Torsemide increased from 20mg to 40mg and Carvedilol was discontinued and switched to Metoprolol tartrate 12.5mg [**Hospital1 **]. Patient was taken to [**Hospital **] hospital for initial evaluation and was given another dose of torsemide 40mg x 1 and then transferred to [**Hospital1 18**] as her cardiac care is here. Patient's initial VS in the ED were 98.3 76 105/70 16 96 on 4LNC. Pt was initially dyspneic, RR in 20s, wheezes bilaterally. Ascities worse than in past few weeks. 2+ pedal edema. Cardiac review of systems is notable for presence of chest pain at rehab, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema. No palpitations, syncope or presyncope. Past Medical History: . ischemic cardiomyopathy (EF 10-25%) s/p BiV ICD 2. Coronary artery disease status post PTCA and stenting of the LAD in [**2164**]. 3. h/o PE secondary to DVT s/p IVC filter 4. Atrial fibrillation status post cardioversion and biventricular pacemaker implantation. 5. HTN 6. Obesity 7. PVD 8. small VSD 9. hypothyroidism PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Dyslipidemia 2. CARDIAC HISTORY: -Ischemic cardiomyopathy EF %15-20 s/p biv ICD -CAD s/p post PTCA and stenting of the LAD in [**2164**]. -CABG: None -PACING/ICD: atrial fibrillation on anticoagulation and ICD biventricular pacemaker 3. OTHER PAST MEDICAL HISTORY: chronic kidney disease bilateral DVT s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] filter pulmonary embolism osteoarthritis hyperkalemia Social History: Pt lives alone but currently resides at [**Hospital 599**] rehab. She is not married. She reports a 20 pack year history, however she quit 30 yrs ago. Denies EtOH or illicit drug use. Family History: Mother had MI at age 50. Father in good health. Maternal uncle died of MI in his 50's. Physical Exam: VS: 99.5, 95/60, 80, 22, 94% 3L NC GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 15 cm. CARDIAC: PMI inferolaterally displaced, RR, normal S1, S2. Holosystolic murmur at apex. LUNGS: Bilateral rales to mid-lung fields. ABDOMEN: Soft, distended. + Fluid wave. Mild Hepatomegaly. Unable to palpate spleen. EXTREMITIES: +2 BLE edema. RLE > LLE. Warm SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Pertinent Results: Admission Labs: [**2179-10-26**] 12:30AM WBC-6.2# RBC-3.60* HGB-11.3* HCT-34.7* MCV-96 MCH-31.3 MCHC-32.5 RDW-18.6* [**2179-10-26**] 12:30AM PLT SMR-NORMAL PLT COUNT-182# [**2179-10-26**] 12:30AM PT-28.4* PTT-36.3* INR(PT)-2.8* [**2179-10-26**] 12:30AM CK-MB-NotDone proBNP-[**Numeric Identifier 44663**]* [**2179-10-26**] 12:30AM cTropnT-0.04* [**2179-10-26**] 12:30AM ALT(SGPT)-51* AST(SGOT)-56* CK(CPK)-62 ALK PHOS-194* TOT BILI-1.7* [**2179-10-26**] 12:30AM GLUCOSE-112* UREA N-48* CREAT-1.6* SODIUM-136 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-27 ANION GAP-17 . EKG: [**2179-10-26**] 0003: V Paced at 69, w/ RAD, bifascicular block. . TTE [**10-26**]: The left atrium is moderately dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with anterior, septal and apical akinesis, as well as akinesis of the distal inferior wall (proximal LAD distribution). There is mild hypokinesis of the remaining segments (LVEF = 15-20%). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**12-18**]+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . IMPRESSION: Dilated left ventricle with severe regional systolic dysfunction, c/w an extensive prior LAD infarction. Dilated right ventricle with severe systolic dysfunction. Mild to moderate mitral regurgitation. Severe tricuspid regurgitation. At least mild pulmonary hypertension. . Compared with the prior study (images reviewed) of [**2177-5-26**], severity of tricuspid regurgitation has increased. The other findings are similar. . RLE US [**10-26**]: No right lower extremity DVT. ABD DOPPLER [**10-26**]: 1. Distended hepatic veins and ascites, the constellation of findings can be seen in the setting of congestive heart failure. Otherwise, normal Doppler examination of the liver. . 2. No evidence of biliary pathology. . MYOCARDIAL VIABILITY STUDY [**10-27**]: Within limitation of current study, fixed defects in distal anterior and apical walls are consistent with scarring. Improvement of inferior wall defect with correction is suggestive of myocardial viability. . LHC/RHC [**11-2**]: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed one vessel coronary artery disease. The LMCA had no angiographically apparent disease. The LAD had mild instent restenosis of the prior stent. The LCx had no angiographically apparent disease. The RCA was occluded and similar to prior. 2. Resting hemodynamics on milrinone therapy revealed moderately elevated right and left sided filling pressures with an RVEDP of 15 mmHg and PCWP of 20 mmHg. There was moderate pulmonary hypertension with a PASP of 42/20 mmHg. There was normal systemic blood pressure with central pressure of 108/63 mmHg. There was a low-normal cardiac index of 2.1 L/min/m2. There was no transaortic valve gradient on careful pullback from LV to aorta. 3. Peripheral angiography revealed patent renal arteries bilaterally. . FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Moderate biventricular diastolic dysfunction. 3. Moderate pulmonary hypertension. 4. Normal systemic pressure. 5. Low-normal cardiac index. 6. Patent renal arteries. . KUB [**11-2**]: 1. There is no ileus or small bowel obstruction. 2. Tubular radiopaque left paraspinal structure of unknown etiology warrants repeat AP and lateral radiograph. . Brief Hospital Course: 71-year-old woman with advanced end-stage ischemic cardiomyopathy with severe left ventricular contractile function with LVEF of 10%-15%, atrial fibrillation, [**Hospital1 **]-V ICD, low cardiac output state, chronic kidney disease with past history of DVT, PE on Coumadin. #. NYHA Class 4 Systolic congestive Heart Failure, EF 15%. with severe volume overloaded on examination on admission. She had a low output state with known low EF and dilated ischemic cardiomyopathy. It was felt that she would likely need inotropic support and she was sent to the CCU for diuresis with milrinone gtt + lasix gtt + metolazone. The patient had significant diuresis on this regimen. It was felt that if there was viable myocardium currently hibernating [**1-18**] low perfusion state, intervention may improve cardiac function. A myocardial viability study was performed and demonstrated inferior wall myocardial viability. LHC/RHC were performed but no intervenable targets were appreciated; additionally, the patient was thought to be a poor candidate for CABG/TR [**1-18**] poor targets for grafts. It was therefore felt that the patient could only be maximized on medical therapy. Diuresis was changed to PO on [**11-5**] to her precious dose of Torsemide and metolazone was added daily to regimen. Weight on discharge________. Would follow lytes every other day until stable and weekly thereafter. # C-diff colitis - Positive C. difficile toxin assay. Patient was started on PO metronidazole and cholesyramine with clinical improvement as gauged by frequency of diarrhea, fever, and WBC count. Peak WBC 11.4. Flagyl to be continued x 7 more days. Once 2 week flagyl course is finished, can consider restarting immodium for symptomatic relief. # UTI - Patient was found to have UTI [**1-18**] Klebsiella pneumoniae, pansensitive except for intermediate sensitivity to nitrofurantoin. She was started on ciprofloxacin for 7 day course, finished on [**11-4**]. #. Rhythm: She has a BiV ICD in place and was V-paced on ECG. She was monitored on telemetry. No events. #. Coronaries: Patient with mid-LAD BMS '[**64**]. Trop 0.04, CK-MB negative that was likely related to CHF exacerbation. She was continued on a statin and aspirin. #. URI: She had been diagnosed with a URI prior to admission and had been started on Zithromax. This was held in the hospital and sputum cultures were sent, found to be negative. Pt is currently asymptomatic. #. Asicites: She had significant ascities on exam and she was s/p 6L tap two weeks ago. It was felt her ascites was likely related to right-sided heart failure and would be difficult to resolve with diuretics. She was restarted on her home regimen of torsemide plus Metolazone as noted above. #. LFT abnormalities: She had a mild transaminities with an AP 190, TBili 1.7. It appeared to be obstructive pattern, likely related to congestive hepatopathy. Resolved prior to discharge. #. H/o DVT/PE: She was anticoagulated with Coumadin and has a [**Location (un) 260**] filter in place. She had a RLE U/S that showed no DVT. Her INR today is _______. INR should be followed every other day until stable and weekly thereafter. # Hypothyroidism: Continued Levothyroxine. # CODE: She was full code during this hospitalization. It is thought that she is end stage in regard to her CHF with medical treatment her only option at this time. Palliative care was not persued during this hospital stay but may be introduced by Dr. [**First Name (STitle) 437**]/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**MD Number(3) 44664**] continues to have frequent hospitalizations. Medications on Admission: Allopurinol 100mg daily Amiodarone 200mg daily Levothyroxine 125mcg daily ASA 81mg daily Zocor 20mg daily Zithromax 250mg daily (until [**10-26**]) for URI Torsemide 40mg po BID Metoprolol Succinate 12.5mg po BID Digoxin 0.0625 mcg daily Prilosec 20mg daily Zinc 220mg po daily Vit C 500mg po daily Coumadin 2.5mg daily Biscacodyl 10mg suppository daily prn for constipation Milk of Mag 30ml po daily prn for constipation Melatonin 1mg po qhs prn for insomnia MVI Immodium 2mg po 4x daily prn for loose stool Discharge Medications: 1. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO at bedtime. 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO twice a day. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for cough/sob. 11. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough: Hold for sedation or RR < 10. 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 14 days: last day [**11-20**]. 13. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) PO BID (2 times a day): Do not give at the same time as Levothyroxine, metolazone and Digoxin. . 14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: check INR every other day. 15. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 16. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 17. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-18**] Sprays Nasal QID (4 times a day) as needed for dry nose. 18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Care Center - [**Location (un) 1439**] Discharge Diagnosis: Acute on chronic systolic heart failure Clostridium difficile colitis Klebsiella Urinary Tract Infection. Discharge Condition: Dry weight 100 kg. Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were seen at [**Hospital1 18**] with heart failure. You were admitted to the cardiac care unit for diuresis with Milrinone and lasix. We are discharging you home on the same heart failure regimen as you were admitted with and adding metolazone 2.5mg po daily in the am. You were found to have clostridium difficile colitis and were started on flagyl. You were also found to have a urinary tract infection and were treated with a seven day course of ciprofloxacin. Weigh yourself every morning, call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Cardiology: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2179-11-22**] 10:00 ",76,2179-10-26 00:33:00,2179-11-06 17:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,SNF,CONGESTIVE HEART FAILURE," 71-year-old woman with advanced end-stage ischemic cardiomyopathy with severe left ventricular contractile function with lvef of 10%-15%, atrial fibrillation, [**hospital1 **]-v icd, low cardiac output state, chronic kidney disease with past history of dvt, pe on coumadin. #. nyha class 4 systolic congestive heart failure, ef 15%. with severe volume overloaded on examination on admission. she had a low output state with known low ef and dilated ischemic cardiomyopathy. it was felt that she would likely need inotropic support and she was sent to the ccu for diuresis with milrinone gtt + lasix gtt + metolazone. the patient had significant diuresis on this regimen. it was felt that if there was viable myocardium currently hibernating [**1-18**] low perfusion state, intervention may improve cardiac function. a myocardial viability study was performed and demonstrated inferior wall myocardial viability. lhc/rhc were performed but no intervenable targets were appreciated; additionally, the patient was thought to be a poor candidate for cabg/tr [**1-18**] poor targets for grafts. it was therefore felt that the patient could only be maximized on medical therapy. diuresis was changed to po on [**11-5**] to her precious dose of torsemide and metolazone was added daily to regimen. weight on discharge________. would follow lytes every other day until stable and weekly thereafter. # c-diff colitis - positive c. difficile toxin assay. patient was started on po metronidazole and cholesyramine with clinical improvement as gauged by frequency of diarrhea, fever, and wbc count. peak wbc 11.4. flagyl to be continued x 7 more days. once 2 week flagyl course is finished, can consider restarting immodium for symptomatic relief. # uti - patient was found to have uti [**1-18**] klebsiella pneumoniae, pansensitive except for intermediate sensitivity to nitrofurantoin. she was started on ciprofloxacin for 7 day course, finished on [**11-4**]. #. rhythm: she has a biv icd in place and was v-paced on ecg. she was monitored on telemetry. no events. #. coronaries: patient with mid-lad bms [**64**]. trop 0.04, ck-mb negative that was likely related to chf exacerbation. she was continued on a statin and aspirin. #. uri: she had been diagnosed with a uri prior to admission and had been started on zithromax. this was held in the hospital and sputum cultures were sent, found to be negative. pt is currently asymptomatic. #. asicites: she had significant ascities on exam and she was s/p 6l tap two weeks ago. it was felt her ascites was likely related to right-sided heart failure and would be difficult to resolve with diuretics. she was restarted on her home regimen of torsemide plus metolazone as noted above. #. lft abnormalities: she had a mild transaminities with an ap 190, tbili 1.7. it appeared to be obstructive pattern, likely related to congestive hepatopathy. resolved prior to discharge. #. h/o dvt/pe: she was anticoagulated with coumadin and has a [**location (un) 260**] filter in place. she had a rle u/s that showed no dvt. her inr today is _______. inr should be followed every other day until stable and weekly thereafter. # hypothyroidism: continued levothyroxine. # code: she was full code during this hospitalization. it is thought that she is end stage in regard to her chf with medical treatment her only option at this time. palliative care was not persued during this hospital stay but may be introduced by dr. [**first name (stitle) 437**]/[**first name8 (namepattern2) **] [**last name (namepattern1) **] [**md number(3) 44664**] continues to have frequent hospitalizations. ","PRIMARY: [Acute on chronic systolic heart failure] SECONDARY: [Acute kidney failure, unspecified; Intestinal infection due to Clostridium difficile; Urinary tract infection, site not specified; Other ascites; Congestive heart failure, unspecified; Other specified forms of chronic ischemic heart disease; Coronary atherosclerosis of native coronary artery; Other chronic pulmonary heart diseases; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified; Chronic kidney disease, unspecified; Unspecified acquired hypothyroidism; Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site; Pressure ulcer, buttock; Pressure ulcer, stage II; Peripheral vascular disease, unspecified; Personal history of venous thrombosis and embolism; Automatic implantable cardiac defibrillator in situ]","71-year-old woman with advanced end-stage ischemic cardiomyopathy with severe left ventricular contractile function with lvef of 10%-15%, atrial fibrillation, [**hospital1 **]-v icd, low cardiac output state, chronic kidney disease with past history of dvt, pe on coumadin. with severe volume overloaded on examination on admission. a myocardial viability study was performed and demonstrated inferior wall myocardial viability. # uti - patient was found to have uti [**1-18**] klebsiella pneumoniae, pansensitive except for intermediate sensitivity to nitrofurantoin. asicites: she had significant ascities on exam and she was s/p 6l tap two weeks ago. # code: she was full code during this hospitalization. palliative care was not persued during this hospital stay but may be introduced by dr.",71-year-old woman with advanced end-stage ischemic cardiomyopathy. she had a low output state with known low ef and dilated ischemic cardiomyopathy. she was sent to the ccu for diuresis with milrinone gtt + lasix gtt + metolazone. 11638,155878.0,15383,2180-01-21,15382,122879.0,2179-12-03,Discharge summary,"Admission Date: [**2179-11-21**] Discharge Date: [**2179-12-3**] Date of Birth: [**2108-5-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: shoulder pain Major Surgical or Invasive Procedure: 1. Irrigation and debridement left shoulder via anterolateral deltopectoral miniarthrotomy with cultures. 2. Aspiration left hip joint under fluoroscopy. 3. Irrigation and debridement 3rd metacarpophalangeal joint, superficial abscess. 4. Endotracheal Intubation History of Present Illness: 71 yo F w/ CAD, ischemic CMY (EF 10%) s/p [**Hospital1 **]-V ICD, atrial fibrillation, CKD, with past history of DVT and PE on Coumadin who was recently discharged from the CCU ([**11-6**]) for CHF exacerbation c/b C.diff infection, who is now being transferred from [**Hospital **] hospital for ?Septic shoulder joint and hypoxia, requiring intubation. Patient is intubated and sedated so history obtained from HCP (niece) and transfer records. She presented to [**Location (un) **] on [**11-18**] with left shoulder pain. Orthopedics was consulted and joint aspiration was done which showed +hemarthrosis. Joint culture now growing staph aureus. She was given oxacillin initially and then per discharge note, received Vancomycin althouth transfer medication list does not have Vancomycin listed as being given. Today, the patient developed hypoxia and required increasing O2 requirement and was placed on a NRB with O2 sat in 90-92% range per HCP. O2 sat then declined to 70% on NRB and patient was then electively intubated prior to transfer. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: BM stent to the LAD in [**2164**], Occluded RCA/no intervention -PACING/ICD: Ischemic cardiomyopathy (EF 10-25%) s/p BiV ICD and atrial fibrillation 3. H/o PE secondary to DVT s/p IVC filter on Coumadin 4. PVD 5. Small VSD 6. Hypothyroidism 7. CKD 8. Osteoarthritis Social History: -Tobacco history: 20 pack year history, however she quit 30 yrs ago -ETOH: Denies -Illicit drugs: Denies Pt lives alone but currently resides at [**Hospital 599**] rehab. She is not married. Family History: Mother had MI at age 50, maternal uncle died of MI in his 50's. No family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: Temp BP 99/58 HR 70 RR 14 on AC TV 450, PEEP 5, 100% FiO2 GENERAL: Elderly female, intuabed, sedated HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Supple with JVP to angle of jaw CARDIAC: normal S1, S2. II/VI SEM, RRR LUNGS: CTAB, no wheezes, crackles or ronchi ABDOMEN: Soft, NT, +ascites, +fluid wave EXTREMITIES: No c/c/e, dopplerable pedal pulses, Right shoulder with +effusion no erythema, right MCP joint with +blanching erythema and edema, +TTP SKIN: +dry skin Pertinent Results: ADMISSION LABS [**2179-11-21**]: [**2179-11-21**] 03:48AM WBC-10.9# Hgb-12.3 Hct-39.3 Plt Ct-207 [**2179-11-21**] 03:48AM PT-80.1* PTT-48.4* INR(PT)-9.6* [**2179-11-21**] 03:48AM Glucose-141* UreaN-70* Creat-2.7* Na-129* K-5.5* Cl-93* HCO3-22 AnGap-20 [**2179-11-21**] 03:48AM ALT-9 AST-17 LD(LDH)-213 CK(CPK)-15* AlkPhos-130* TotBili-1.7* [**2179-11-21**] 03:48AM CK-MB-NotDone cTropnT-0.07* [**2179-11-21**] 03:48AM Albumin-3.5 Calcium-8.9 Phos-4.6*# Mg-2.4 [**2179-11-21**] 03:48AM ESR-30* [**2179-11-21**] 03:48AM CRP-291.3* [**2179-11-21**] 03:48AM Vanco-10.1 [**2179-11-21**] 03:48AM Digoxin-3.8* [**2179-11-21**] 04:13AM Type-ART pO2-81* pCO2-46* pH-7.32* calTCO2-25 Base XS--2 [**2179-11-21**] 04:13AM Lactate-1.4 URINE: [**2179-11-21**] 05:45AM Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007 [**2179-11-21**] 05:45AM Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2179-11-21**] 05:45AM RBC-[**2-18**]* WBC-[**5-26**]* Bacteri-RARE Yeast-NONE Epi-0-2 RenalEp-[**2-18**] [**2179-11-21**] 05:45AM Hours-RANDOM UreaN-190 Creat-20 Na-69 JOINT FLUID: [**2179-11-21**] 10:19AM WBC-[**Numeric Identifier **]* RBC-[**Numeric Identifier 44665**]* Polys-84* Lymphs-3 Monos-5 Macro-8 [**2179-11-21**] 10:19AM Crystal-FEW Shape-RHOMBOID Locatio-INTRAC Birefri-POS Comment-c/w calcium phosphate deposits [**2179-11-25**] 08:30AM WBC-[**Numeric Identifier 42138**]* RBC-[**Numeric Identifier 44666**]* Polys-91* Lymphs-1 Monos-8 OTHER PERTINENT LABS: [**2179-11-21**] 03:48AM INR(PT)-9.6* [**2179-11-21**] 10:24AM INR(PT)-11.2* [**2179-11-21**] 08:04PM INR(PT)-3.3* [**2179-11-22**] 04:04AM INR(PT)-3.4* [**2179-11-23**] 02:30AM INR(PT)-2.7* [**2179-11-24**] 06:29AM INR(PT)-2.8* [**2179-11-24**] 03:32PM INR(PT)-2.8* [**2179-11-25**] 03:28AM INR(PT)-2.7* [**2179-11-25**] 11:27AM INR(PT)-2.0* [**2179-11-26**] 05:25AM INR(PT)-2.4* [**2179-11-27**] 03:10AM INR(PT)-2.5* [**2179-11-28**] 03:56AM INR(PT)-2.2* [**2179-11-29**] 02:56AM INR(PT)-2.0* [**2179-11-29**] 10:56AM INR(PT)-2.0* [**2179-11-30**] 05:44AM INR(PT)-1.8* MICRO: [**Date range (1) 44667**] BCx: MRSA [**2179-11-21**] MRSA Screen: positive [**2179-11-21**] Joint fluid (shoulder): MRSA [**2179-11-21**] UCx: negative [**2179-11-21**] Sputum Cx: respiratory flora [**2179-11-23**] Catheter tip: negative [**2179-11-25**] Joint fluid (L hip): MRSA [**2179-11-25**] R 3rd MCP: MRSA [**2179-11-25**] Shoulder: MRSA [**Date range (1) 44668**] BCx: NGTD IMAGING: [**2179-11-21**] CXR: There is opacification in the right upper zone. This could represent volume loss in the right upper lobe or possible supervening consolidation. [**2179-11-21**] Repeat CXR: In comparison with the earlier study of this date, there has been substantial clearing of the right upper lung opacification. This suggests expectoration of a mucous plug with relief of volume loss. [**2179-11-21**] Shoulder XR: No previous films are available for comparison. There is sclerosis, with narrowing and some irregularity involving the glenohumeral joint. This may merely reflect degenerative changes, though the possibility of an indolent infection cannot be excluded. MRI might be helpful for further evaluation. [**2179-11-21**] Hand XR: The third MCP joint is quite well maintained without convincing erosions. Degenerative change is seen involving the first CMC as well as the second DIP joint. Some narrowing is also seen involving several other DIP and PIP joints. [**2179-11-22**] CXR: No significant change from prior exam, allowing for significant leftward rotation of the patient [**2179-11-23**] ECHO: The left atrial appendage emptying velocity is depressed (<0.2m/s). A probable thrombus is seen in the left atrial appendage. No mass or thrombus is seen in the right atrium or right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is severely depressed. The right ventricular cavity is dilated with moderate global free wall hypokinesis. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal, though restricted motion of the posterior leaflet is seen. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. [Due to acoustic shadowing, the severity of tricuspid regurgitation may be significantly UNDERestimated.] No vegetation/mass is seen on the pulmonic valve. There is a trivial/physiologic pericardial effusion. IMPRESSION: No valvular vegetation or wire-associated vegetation. Probable left atrial appendage thrombus with spontaneous echo contrast also identified within the body of the left atrial appendage. Mild mitral regurgitation, at least moderate tricuspid regurgitation. Severe biventricular systolic dysfunction. [**2179-11-29**] ECHO: The left atrium is elongated. The right atrium is markedly dilated. The interatrial septum is aneurysmal. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated with severe global hypokinesis. The basal inferolateral wall contracts best (LVEF = 20 %). The estimated cardiac index is borderline low (2.0-2.5L/min/m2). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**12-18**]+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is a very small circumferential pericardial effusion without echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2179-10-26**], estimated pulmonary artery systolic pressure is now higher DISCHARGE LABS: Brief Hospital Course: 71 yo F w/ CAD, ischemic CMY (EF 10%) s/p [**Hospital1 **]-V ICD, atrial fibrillation, CKD, with past history of DVT and PE on Coumadin who was recently discharged from the CCU ([**11-6**]) for CHF exacerbation complicated by C.diff infection who was transferred from an outside hospital with a septic shoulder joint and acute respiratory failure requiring intubation. 1. Respiratory Failure: Patient has history of CHF with EF 10% which is the likely cause of her respiratory failure. She was diuresed agressivly with lasix drip, weaned from vent. She was also maintained on dopamine to maintain high cardiac output, eventually weaned off and restarted on digoxin. Her respiratory status continued to improve with diuresis. At time of discharge she was saturating well on room air. Of note, the patient changed her code status to DNR/DNI following extubation although she briefly reversed this status to be taken to the operating room (see below). However, on day of discharge, she reversed herself and decided she did want CPR, intubation and pressors for short term therapy only. She stated she would not want to be intubated long term. 2. Septic Joint: Patient with + staph aureus in left shoulder and later, blood cultures from the outside hospital also grew MRSA. Presented with low BP, requiring pressor support likely a combination of sepsis and cardiogenic shock (see below). Per report, patient also had +hemearthrosis of left shoulder in the setting of supratherapeutic INR. Patient's picc line was felt to be the likely source of infection and this line was discontinued at the time of admission. Initially, it was unclear if Staph aureus in culture at OSH was a contaminant, given that physical exam was not entirely consistent with a spetic joint. Vancomycin was continued and ortho reaspirated the left shoulder on day of admission; fluid analysis confirmed bacterial infection. On [**11-25**], the patient was taken to the operating room for washout of shoulder and right 3rd MCP joint, both of which contained pus. Left hip was also aspirated, which eventually grew MRSA also. Patient was continued on Vancomycin with routine trough levels monitored. Blood cultures were followed daily and remained positive until [**2179-11-25**]. Echo on [**11-23**] showed no evidence of endocarditis although an intraatrial thrombus was visualized which may be infected. The patient will need prolonged therapy with vancomycin. She will follow up with in the infectious disease clinic. 3. CORONARIES: Patient with history of extensive CAD with right dominant system, mild instent re-stenois of the LAD BM stent and occluded RCA. Throughout hospitalization, patient had no subjective or objective symptoms of ischemia, and serial cardiac enzymes were stable. Initially, b-blocker was held secondary to severe hypotension requiring pressor support although aspirin continued. By time of discharge, patient was also tolerating low dose b-blocker and ACEI. 4. PUMP: Patient with history of ischemic cardiomyopathy, EF 10%, s/p BiV ICD ([**Company 1543**] Concerto C154DWK) on [**12-24**]. Presented with symptoms of acute on chronic congestive heart failure with symptoms of both volume overload (high RV pressure, pulmonary edema, ascites, peripheral edema) and poor cardiac output (acute on chronic kidney failure, hypotension). With initial hypotension, a CVL was inserted with attempt to float a swan-ganz catheter to better assess fluid status. Unfortunately, due to technical difficulties, PA catheter was not able to be placed and the patient was treated with dopamine to improve cardiac output. Once blood pressure had stabilized and systemic infection improved, patient was started on lasix drip for aggressive diuresis. Prior to discharge, patient was restarted on her home medication regimen of torsemide, lisinopril and metoprolol. Of note, patient was also restarted on digoxin after discontinuation of dopamine. These levels will need to be monitored carefully given patient's fluctuating creatinine clearance. 5. RHYTHM: Patient with h/o atrial fibrillation, s/p BiV ICD ([**Company 1543**] Concerto C154DWK) [**12-24**], on coumadin and amiodarone as antiarrhythmic. Presented with supratherapeutic INR and hemarthosis of left shoulder. Coagulopathy was reversed with FFP prior to shoulder and MCP washout. Found to have intra-atrial thrombus on TEE during hospitalization. Needs to be maintained on heparin gtt following surgical procedure until coumadin reached theraputic goal of INR [**1-19**]. Heparin can be held while vancomycin is infusing. 6. Acute on CRF: Patient w/ baseline Cr 1.3-1.8, 2.4 on presentation, likely related to poor forward flow from CHF. Medications were renal dosed and renal function followed carefully throughout hospital course. Kidney function improved to baseline by time of discharge. 7. H/o DVT/PE: Patient has h/o DVT/PE currently on coumadin and has [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 260**] filter in place. As noted above, patient presented with supratherapeutic INR which was reversed prior to surgical intervention. For the duration of the hospital stay, the patient was maintained on heparin gtt, which should be continued until coumadin reachs therapeutic levels again, 2.0-3.0. 8. Hypothyroidism: stable, continue Levothyroxine. 9. Access: The patient had a new single lumen PICC line placed in her right arm on [**2179-11-30**] by interventional radiology. The PICC line would not pass beyond the mid-clavicular area due to a stenosis in the subclavian vein. It was cut to this length and is slightly longer than a traditional midline. A PICC cannot be placed in the other arm because of her pacemaker. The patient should get her vancomycin infusion over an hour. Her vancomycin should be diluted into 250ml to decrease the chance of fibrosis or irration to this artery. Please monitor the patient's arm for swelling or pain because she is at an increased risk of clot, however, she is on anticoagulation. 10. CODE STATUS: Full code on [**2179-12-3**] Medications on Admission: Allopurinol 100mg daily Amiodarone 200mg daily Aspirin 81mg daily Vit C 500mg daily Cholestyramine 4gm [**Hospital1 **] Digoxin 0.0625mg daily Levothyroxine 0.125mg daily Metolazone 2.5mg daily Metoprolol Tartrate 12.5mg [**Hospital1 **] MVI Omeprazole 20mg daily Simvastatin 20mg qHS Torsemide 40mg daily Zinc Sulfate 220mg daily Warfarin Oxacillin 1gm q6h Propofol bolus for intubation, changed to Fentanyl/Versed Dilaudid 0.4mg q4h PRN pain Vicodin 1-2 tabs q4h PRN pain Discharge Medications: 1. Outpatient Lab Work Please get weekly CBC with differential, BUN/ Creatinine and vancomycin trough. Start date: [**2179-12-8**] Fax results to [**Hospital **] clinic: [**Telephone/Fax (1) 1419**] 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 9. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours): Please d/c once pain well controlled. 10. Tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 11. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): HOLD SBP < 85. 13. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 14. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 16. Torsemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY (Every Other Day). 18. Vancomycin 500 mg IV Q 24H 19. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 20. Heparin (Porcine)-0.45% NaCl 25,000 unit/250 mL Parenteral Solution Sig: sliding scale units Intravenous continuous. 21. Heparin Lock 10 unit/mL Solution Sig: Two (2) ml Intravenous after NS flush. 22. Saline Flush 0.9 % Syringe Sig: Ten (10) cc Injection before and after vancomycin dose. 23. Outpatient Lab Work Please get chem-7 every 3 days to follow K, Na and renal status. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary Diagnosis: Septic Joint acute on chronic congestive heart failure intra-atrial thrombus Secondary Diagnosis: atrial fibrillation Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted to the hospital with left shoulder pain. You were found to have an infection in your shoulder that had spread to your blood, left hip and right hand. In the operating room, the orthopedic doctors [**Name5 (PTitle) 44669**] out your infected joints which should help cure your infection. You were also started on vancomycin, an antibiotic that you will need to continue after you leave the hospital. You should follow up with the infectious disease specialists who will determine how long you need to continue the vancomycin. . You also had difficulty breathing when you first came to the hospital, requiring a breathing tube. Your trouble breathing was likely caused by an exacerbation of your heart failure which caused fluid to accumulate on your lungs. We treated you with medications to help remove this excess fluid and the breathing tube was able to be removed. Medication changes: 1. Start Vancomycin to treat the joint and blood infections. 2. Decrease the Torsemide to 20 mg twice daily 3. Decrease the Digoxin to every other day . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Please follow up in infectious disease clinic with Dr. [**First Name (STitle) **] on [**2179-12-24**] at 9:30. Phone:[**Telephone/Fax (1) 457**] [**Hospital Unit Name **] [**Location (un) 448**], [**Doctor First Name **], [**Location (un) 86**]. . Cardiology: Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] Phone [**Telephone/Fax (1) 62**] Date/Time: Monday [**12-13**] at 9:00am. [**Hospital Ward Name 23**] clinical center, [**Location (un) 436**], [**Hospital Ward Name 516**] [**Hospital1 18**]. . Ortho: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP. Date/Time: [**12-21**] at 11:00am. [**Hospital Ward Name 23**] Clinical Center, [**Location (un) **], [**Location (un) **], [**Hospital Ward Name 516**], [**Hospital1 18**]. ",49,2179-11-21 01:05:00,2179-12-03 16:20:00,EMERGENCY,EMERGENCY ROOM ADMIT,SNF,BIVENTRICULAR HEART FAILURE," 71 yo f w/ cad, ischemic cmy (ef 10%) s/p [**hospital1 **]-v icd, atrial fibrillation, ckd, with past history of dvt and pe on coumadin who was recently discharged from the ccu ([**11-6**]) for chf exacerbation complicated by c.diff infection who was transferred from an outside hospital with a septic shoulder joint and acute respiratory failure requiring intubation. 1. respiratory failure: patient has history of chf with ef 10% which is the likely cause of her respiratory failure. she was diuresed agressivly with lasix drip, weaned from vent. she was also maintained on dopamine to maintain high cardiac output, eventually weaned off and restarted on digoxin. her respiratory status continued to improve with diuresis. at time of discharge she was saturating well on room air. of note, the patient changed her code status to dnr/dni following extubation although she briefly reversed this status to be taken to the operating room (see below). however, on day of discharge, she reversed herself and decided she did want cpr, intubation and pressors for short term therapy only. she stated she would not want to be intubated long term. 2. septic joint: patient with + staph aureus in left shoulder and later, blood cultures from the outside hospital also grew mrsa. presented with low bp, requiring pressor support likely a combination of sepsis and cardiogenic shock (see below). per report, patient also had +hemearthrosis of left shoulder in the setting of supratherapeutic inr. patients picc line was felt to be the likely source of infection and this line was discontinued at the time of admission. initially, it was unclear if staph aureus in culture at osh was a contaminant, given that physical exam was not entirely consistent with a spetic joint. vancomycin was continued and ortho reaspirated the left shoulder on day of admission; fluid analysis confirmed bacterial infection. on [**11-25**], the patient was taken to the operating room for washout of shoulder and right 3rd mcp joint, both of which contained pus. left hip was also aspirated, which eventually grew mrsa also. patient was continued on vancomycin with routine trough levels monitored. blood cultures were followed daily and remained positive until [**2179-11-25**]. echo on [**11-23**] showed no evidence of endocarditis although an intraatrial thrombus was visualized which may be infected. the patient will need prolonged therapy with vancomycin. she will follow up with in the infectious disease clinic. 3. coronaries: patient with history of extensive cad with right dominant system, mild instent re-stenois of the lad bm stent and occluded rca. throughout hospitalization, patient had no subjective or objective symptoms of ischemia, and serial cardiac enzymes were stable. initially, b-blocker was held secondary to severe hypotension requiring pressor support although aspirin continued. by time of discharge, patient was also tolerating low dose b-blocker and acei. 4. pump: patient with history of ischemic cardiomyopathy, ef 10%, s/p biv icd ([**company 1543**] concerto c154dwk) on [**12-24**]. presented with symptoms of acute on chronic congestive heart failure with symptoms of both volume overload (high rv pressure, pulmonary edema, ascites, peripheral edema) and poor cardiac output (acute on chronic kidney failure, hypotension). with initial hypotension, a cvl was inserted with attempt to float a swan-ganz catheter to better assess fluid status. unfortunately, due to technical difficulties, pa catheter was not able to be placed and the patient was treated with dopamine to improve cardiac output. once blood pressure had stabilized and systemic infection improved, patient was started on lasix drip for aggressive diuresis. prior to discharge, patient was restarted on her home medication regimen of torsemide, lisinopril and metoprolol. of note, patient was also restarted on digoxin after discontinuation of dopamine. these levels will need to be monitored carefully given patients fluctuating creatinine clearance. 5. rhythm: patient with h/o atrial fibrillation, s/p biv icd ([**company 1543**] concerto c154dwk) [**12-24**], on coumadin and amiodarone as antiarrhythmic. presented with supratherapeutic inr and hemarthosis of left shoulder. coagulopathy was reversed with ffp prior to shoulder and mcp washout. found to have intra-atrial thrombus on tee during hospitalization. needs to be maintained on heparin gtt following surgical procedure until coumadin reached theraputic goal of inr [**1-19**]. heparin can be held while vancomycin is infusing. 6. acute on crf: patient w/ baseline cr 1.3-1.8, 2.4 on presentation, likely related to poor forward flow from chf. medications were renal dosed and renal function followed carefully throughout hospital course. kidney function improved to baseline by time of discharge. 7. h/o dvt/pe: patient has h/o dvt/pe currently on coumadin and has [**initials (namepattern4) **] [**last name (namepattern4) 260**] filter in place. as noted above, patient presented with supratherapeutic inr which was reversed prior to surgical intervention. for the duration of the hospital stay, the patient was maintained on heparin gtt, which should be continued until coumadin reachs therapeutic levels again, 2.0-3.0. 8. hypothyroidism: stable, continue levothyroxine. 9. access: the patient had a new single lumen picc line placed in her right arm on [**2179-11-30**] by interventional radiology. the picc line would not pass beyond the mid-clavicular area due to a stenosis in the subclavian vein. it was cut to this length and is slightly longer than a traditional midline. a picc cannot be placed in the other arm because of her pacemaker. the patient should get her vancomycin infusion over an hour. her vancomycin should be diluted into 250ml to decrease the chance of fibrosis or irration to this artery. please monitor the patients arm for swelling or pain because she is at an increased risk of clot, however, she is on anticoagulation. 10. code status: full code on [**2179-12-3**] ","PRIMARY: [Methicillin resistant Staphylococcus aureus septicemia] SECONDARY: [Acute respiratory failure; Acute kidney failure, unspecified; Septic shock; Acute on chronic systolic heart failure; Pyogenic arthritis, shoulder region; Hemarthrosis, shoulder region; Ventricular septal defect; Severe sepsis; Atrial fibrillation; Other ill-defined heart diseases; Other specified forms of chronic ischemic heart disease; Chronic kidney disease, unspecified; Coronary atherosclerosis of native coronary artery; Chronic total occlusion of coronary artery; Unspecified acquired hypothyroidism; Congestive heart failure, unspecified; Percutaneous transluminal coronary angioplasty status; Automatic implantable cardiac defibrillator in situ; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism]","71 yo f w/ cad, ischemic cmy (ef 10%) s/p [**hospital1 **]-v icd, atrial fibrillation, ckd, with past history of dvt and pe on coumadin who was recently discharged from the ccu ([**11-6**]) for chf exacerbation complicated by c.diff infection who was transferred from an outside hospital with a septic shoulder joint and acute respiratory failure requiring intubation. respiratory failure: patient has history of chf with ef 10% which is the likely cause of her respiratory failure. septic joint: patient with + staph aureus in left shoulder and later, blood cultures from the outside hospital also grew mrsa. initially, it was unclear if staph aureus in culture at osh was a contaminant, given that physical exam was not entirely consistent with a spetic joint. blood cultures were followed daily and remained positive until [**2179-11-25**]. the patient will need prolonged therapy with vancomycin. prior to discharge, patient was restarted on her home medication regimen of torsemide, lisinopril and metoprolol. of note, patient was also restarted on digoxin after discontinuation of dopamine. rhythm: patient with h/o atrial fibrillation, s/p biv icd ([**company 1543**] concerto c154dwk) [**12-24**], on coumadin and amiodarone as antiarrhythmic. presented with supratherapeutic inr and hemarthosis of left shoulder. medications were renal dosed and renal function followed carefully throughout hospital course.","71-year-old has history of chf with ef 10% which is likely cause of her respiratory failure. she was transferred from an outside hospital with a septic shoulder joint and acute respiratory failure requiring intubation. she reversed herself and decided she did want cpr, intubation and pressors for short term therapy only." 11638,122879.0,15382,2179-12-03,15381,136238.0,2179-11-06,Discharge summary,"Admission Date: [**2179-10-26**] Discharge Date: [**2179-11-6**] Date of Birth: [**2108-5-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Increasing Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 71-year-old woman with advanced end-stage ischemic cardiomyopathy with severe left ventricular contractile function with LVEF of 10%, atrial fibrillation, [**Hospital1 **]-V ICD, CKD, with past history of DVT, PE on Coumadin who presents with increasing dyspnea. The patient was recently discharged from [**Hospital1 18**] CCU on [**9-22**] for CHF exacerbation and was discharged to rehab facility. Since that time, patient was hospitalized at [**Location (un) **] two weeks ago for pneumonia. The patient reports that over the past week, the patient has had increasing dyspnea with exertion. At baseline, patient is unable to perform ADLs without the assistance of physical therapy. Over the past week, there has been a noticible worsening in her physical limitations. The patient recently saw Dr. [**First Name (STitle) 437**] as an outpatient and had her dose of Torsemide increased from 20mg to 40mg and Carvedilol was discontinued and switched to Metoprolol tartrate 12.5mg [**Hospital1 **]. Patient was taken to [**Hospital **] hospital for initial evaluation and was given another dose of torsemide 40mg x 1 and then transferred to [**Hospital1 18**] as her cardiac care is here. Patient's initial VS in the ED were 98.3 76 105/70 16 96 on 4LNC. Pt was initially dyspneic, RR in 20s, wheezes bilaterally. Ascities worse than in past few weeks. 2+ pedal edema. Cardiac review of systems is notable for presence of chest pain at rehab, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema. No palpitations, syncope or presyncope. Past Medical History: . ischemic cardiomyopathy (EF 10-25%) s/p BiV ICD 2. Coronary artery disease status post PTCA and stenting of the LAD in [**2164**]. 3. h/o PE secondary to DVT s/p IVC filter 4. Atrial fibrillation status post cardioversion and biventricular pacemaker implantation. 5. HTN 6. Obesity 7. PVD 8. small VSD 9. hypothyroidism PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Dyslipidemia 2. CARDIAC HISTORY: -Ischemic cardiomyopathy EF %15-20 s/p biv ICD -CAD s/p post PTCA and stenting of the LAD in [**2164**]. -CABG: None -PACING/ICD: atrial fibrillation on anticoagulation and ICD biventricular pacemaker 3. OTHER PAST MEDICAL HISTORY: chronic kidney disease bilateral DVT s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] filter pulmonary embolism osteoarthritis hyperkalemia Social History: Pt lives alone but currently resides at [**Hospital 599**] rehab. She is not married. She reports a 20 pack year history, however she quit 30 yrs ago. Denies EtOH or illicit drug use. Family History: Mother had MI at age 50. Father in good health. Maternal uncle died of MI in his 50's. Physical Exam: VS: 99.5, 95/60, 80, 22, 94% 3L NC GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 15 cm. CARDIAC: PMI inferolaterally displaced, RR, normal S1, S2. Holosystolic murmur at apex. LUNGS: Bilateral rales to mid-lung fields. ABDOMEN: Soft, distended. + Fluid wave. Mild Hepatomegaly. Unable to palpate spleen. EXTREMITIES: +2 BLE edema. RLE > LLE. Warm SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Pertinent Results: Admission Labs: [**2179-10-26**] 12:30AM WBC-6.2# RBC-3.60* HGB-11.3* HCT-34.7* MCV-96 MCH-31.3 MCHC-32.5 RDW-18.6* [**2179-10-26**] 12:30AM PLT SMR-NORMAL PLT COUNT-182# [**2179-10-26**] 12:30AM PT-28.4* PTT-36.3* INR(PT)-2.8* [**2179-10-26**] 12:30AM CK-MB-NotDone proBNP-[**Numeric Identifier 44663**]* [**2179-10-26**] 12:30AM cTropnT-0.04* [**2179-10-26**] 12:30AM ALT(SGPT)-51* AST(SGOT)-56* CK(CPK)-62 ALK PHOS-194* TOT BILI-1.7* [**2179-10-26**] 12:30AM GLUCOSE-112* UREA N-48* CREAT-1.6* SODIUM-136 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-27 ANION GAP-17 . EKG: [**2179-10-26**] 0003: V Paced at 69, w/ RAD, bifascicular block. . TTE [**10-26**]: The left atrium is moderately dilated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with anterior, septal and apical akinesis, as well as akinesis of the distal inferior wall (proximal LAD distribution). There is mild hypokinesis of the remaining segments (LVEF = 15-20%). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is moderately dilated with severe global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**12-18**]+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. . IMPRESSION: Dilated left ventricle with severe regional systolic dysfunction, c/w an extensive prior LAD infarction. Dilated right ventricle with severe systolic dysfunction. Mild to moderate mitral regurgitation. Severe tricuspid regurgitation. At least mild pulmonary hypertension. . Compared with the prior study (images reviewed) of [**2177-5-26**], severity of tricuspid regurgitation has increased. The other findings are similar. . RLE US [**10-26**]: No right lower extremity DVT. ABD DOPPLER [**10-26**]: 1. Distended hepatic veins and ascites, the constellation of findings can be seen in the setting of congestive heart failure. Otherwise, normal Doppler examination of the liver. . 2. No evidence of biliary pathology. . MYOCARDIAL VIABILITY STUDY [**10-27**]: Within limitation of current study, fixed defects in distal anterior and apical walls are consistent with scarring. Improvement of inferior wall defect with correction is suggestive of myocardial viability. . LHC/RHC [**11-2**]: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed one vessel coronary artery disease. The LMCA had no angiographically apparent disease. The LAD had mild instent restenosis of the prior stent. The LCx had no angiographically apparent disease. The RCA was occluded and similar to prior. 2. Resting hemodynamics on milrinone therapy revealed moderately elevated right and left sided filling pressures with an RVEDP of 15 mmHg and PCWP of 20 mmHg. There was moderate pulmonary hypertension with a PASP of 42/20 mmHg. There was normal systemic blood pressure with central pressure of 108/63 mmHg. There was a low-normal cardiac index of 2.1 L/min/m2. There was no transaortic valve gradient on careful pullback from LV to aorta. 3. Peripheral angiography revealed patent renal arteries bilaterally. . FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Moderate biventricular diastolic dysfunction. 3. Moderate pulmonary hypertension. 4. Normal systemic pressure. 5. Low-normal cardiac index. 6. Patent renal arteries. . KUB [**11-2**]: 1. There is no ileus or small bowel obstruction. 2. Tubular radiopaque left paraspinal structure of unknown etiology warrants repeat AP and lateral radiograph. . Brief Hospital Course: 71-year-old woman with advanced end-stage ischemic cardiomyopathy with severe left ventricular contractile function with LVEF of 10%-15%, atrial fibrillation, [**Hospital1 **]-V ICD, low cardiac output state, chronic kidney disease with past history of DVT, PE on Coumadin. #. NYHA Class 4 Systolic congestive Heart Failure, EF 15%. with severe volume overloaded on examination on admission. She had a low output state with known low EF and dilated ischemic cardiomyopathy. It was felt that she would likely need inotropic support and she was sent to the CCU for diuresis with milrinone gtt + lasix gtt + metolazone. The patient had significant diuresis on this regimen. It was felt that if there was viable myocardium currently hibernating [**1-18**] low perfusion state, intervention may improve cardiac function. A myocardial viability study was performed and demonstrated inferior wall myocardial viability. LHC/RHC were performed but no intervenable targets were appreciated; additionally, the patient was thought to be a poor candidate for CABG/TR [**1-18**] poor targets for grafts. It was therefore felt that the patient could only be maximized on medical therapy. Diuresis was changed to PO on [**11-5**] to her precious dose of Torsemide and metolazone was added daily to regimen. Weight on discharge________. Would follow lytes every other day until stable and weekly thereafter. # C-diff colitis - Positive C. difficile toxin assay. Patient was started on PO metronidazole and cholesyramine with clinical improvement as gauged by frequency of diarrhea, fever, and WBC count. Peak WBC 11.4. Flagyl to be continued x 7 more days. Once 2 week flagyl course is finished, can consider restarting immodium for symptomatic relief. # UTI - Patient was found to have UTI [**1-18**] Klebsiella pneumoniae, pansensitive except for intermediate sensitivity to nitrofurantoin. She was started on ciprofloxacin for 7 day course, finished on [**11-4**]. #. Rhythm: She has a BiV ICD in place and was V-paced on ECG. She was monitored on telemetry. No events. #. Coronaries: Patient with mid-LAD BMS '[**64**]. Trop 0.04, CK-MB negative that was likely related to CHF exacerbation. She was continued on a statin and aspirin. #. URI: She had been diagnosed with a URI prior to admission and had been started on Zithromax. This was held in the hospital and sputum cultures were sent, found to be negative. Pt is currently asymptomatic. #. Asicites: She had significant ascities on exam and she was s/p 6L tap two weeks ago. It was felt her ascites was likely related to right-sided heart failure and would be difficult to resolve with diuretics. She was restarted on her home regimen of torsemide plus Metolazone as noted above. #. LFT abnormalities: She had a mild transaminities with an AP 190, TBili 1.7. It appeared to be obstructive pattern, likely related to congestive hepatopathy. Resolved prior to discharge. #. H/o DVT/PE: She was anticoagulated with Coumadin and has a [**Location (un) 260**] filter in place. She had a RLE U/S that showed no DVT. Her INR today is _______. INR should be followed every other day until stable and weekly thereafter. # Hypothyroidism: Continued Levothyroxine. # CODE: She was full code during this hospitalization. It is thought that she is end stage in regard to her CHF with medical treatment her only option at this time. Palliative care was not persued during this hospital stay but may be introduced by Dr. [**First Name (STitle) 437**]/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**MD Number(3) 44664**] continues to have frequent hospitalizations. Medications on Admission: Allopurinol 100mg daily Amiodarone 200mg daily Levothyroxine 125mcg daily ASA 81mg daily Zocor 20mg daily Zithromax 250mg daily (until [**10-26**]) for URI Torsemide 40mg po BID Metoprolol Succinate 12.5mg po BID Digoxin 0.0625 mcg daily Prilosec 20mg daily Zinc 220mg po daily Vit C 500mg po daily Coumadin 2.5mg daily Biscacodyl 10mg suppository daily prn for constipation Milk of Mag 30ml po daily prn for constipation Melatonin 1mg po qhs prn for insomnia MVI Immodium 2mg po 4x daily prn for loose stool Discharge Medications: 1. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO at bedtime. 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO twice a day. 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for cough/sob. 11. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough: Hold for sedation or RR < 10. 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 14 days: last day [**11-20**]. 13. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) PO BID (2 times a day): Do not give at the same time as Levothyroxine, metolazone and Digoxin. . 14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: check INR every other day. 15. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 16. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 17. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-18**] Sprays Nasal QID (4 times a day) as needed for dry nose. 18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] Senior Care Center - [**Location (un) 1439**] Discharge Diagnosis: Acute on chronic systolic heart failure Clostridium difficile colitis Klebsiella Urinary Tract Infection. Discharge Condition: Dry weight 100 kg. Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were seen at [**Hospital1 18**] with heart failure. You were admitted to the cardiac care unit for diuresis with Milrinone and lasix. We are discharging you home on the same heart failure regimen as you were admitted with and adding metolazone 2.5mg po daily in the am. You were found to have clostridium difficile colitis and were started on flagyl. You were also found to have a urinary tract infection and were treated with a seven day course of ciprofloxacin. Weigh yourself every morning, call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP if weight goes up more than 3 lbs in 1 day or 6 pounds in 3 days. Followup Instructions: Cardiology: Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2179-11-22**] 10:00 ",27,2179-10-26 00:33:00,2179-11-06 17:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,SNF,CONGESTIVE HEART FAILURE," 71-year-old woman with advanced end-stage ischemic cardiomyopathy with severe left ventricular contractile function with lvef of 10%-15%, atrial fibrillation, [**hospital1 **]-v icd, low cardiac output state, chronic kidney disease with past history of dvt, pe on coumadin. #. nyha class 4 systolic congestive heart failure, ef 15%. with severe volume overloaded on examination on admission. she had a low output state with known low ef and dilated ischemic cardiomyopathy. it was felt that she would likely need inotropic support and she was sent to the ccu for diuresis with milrinone gtt + lasix gtt + metolazone. the patient had significant diuresis on this regimen. it was felt that if there was viable myocardium currently hibernating [**1-18**] low perfusion state, intervention may improve cardiac function. a myocardial viability study was performed and demonstrated inferior wall myocardial viability. lhc/rhc were performed but no intervenable targets were appreciated; additionally, the patient was thought to be a poor candidate for cabg/tr [**1-18**] poor targets for grafts. it was therefore felt that the patient could only be maximized on medical therapy. diuresis was changed to po on [**11-5**] to her precious dose of torsemide and metolazone was added daily to regimen. weight on discharge________. would follow lytes every other day until stable and weekly thereafter. # c-diff colitis - positive c. difficile toxin assay. patient was started on po metronidazole and cholesyramine with clinical improvement as gauged by frequency of diarrhea, fever, and wbc count. peak wbc 11.4. flagyl to be continued x 7 more days. once 2 week flagyl course is finished, can consider restarting immodium for symptomatic relief. # uti - patient was found to have uti [**1-18**] klebsiella pneumoniae, pansensitive except for intermediate sensitivity to nitrofurantoin. she was started on ciprofloxacin for 7 day course, finished on [**11-4**]. #. rhythm: she has a biv icd in place and was v-paced on ecg. she was monitored on telemetry. no events. #. coronaries: patient with mid-lad bms [**64**]. trop 0.04, ck-mb negative that was likely related to chf exacerbation. she was continued on a statin and aspirin. #. uri: she had been diagnosed with a uri prior to admission and had been started on zithromax. this was held in the hospital and sputum cultures were sent, found to be negative. pt is currently asymptomatic. #. asicites: she had significant ascities on exam and she was s/p 6l tap two weeks ago. it was felt her ascites was likely related to right-sided heart failure and would be difficult to resolve with diuretics. she was restarted on her home regimen of torsemide plus metolazone as noted above. #. lft abnormalities: she had a mild transaminities with an ap 190, tbili 1.7. it appeared to be obstructive pattern, likely related to congestive hepatopathy. resolved prior to discharge. #. h/o dvt/pe: she was anticoagulated with coumadin and has a [**location (un) 260**] filter in place. she had a rle u/s that showed no dvt. her inr today is _______. inr should be followed every other day until stable and weekly thereafter. # hypothyroidism: continued levothyroxine. # code: she was full code during this hospitalization. it is thought that she is end stage in regard to her chf with medical treatment her only option at this time. palliative care was not persued during this hospital stay but may be introduced by dr. [**first name (stitle) 437**]/[**first name8 (namepattern2) **] [**last name (namepattern1) **] [**md number(3) 44664**] continues to have frequent hospitalizations. ","PRIMARY: [Acute on chronic systolic heart failure] SECONDARY: [Acute kidney failure, unspecified; Intestinal infection due to Clostridium difficile; Urinary tract infection, site not specified; Other ascites; Congestive heart failure, unspecified; Other specified forms of chronic ischemic heart disease; Coronary atherosclerosis of native coronary artery; Other chronic pulmonary heart diseases; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified; Chronic kidney disease, unspecified; Unspecified acquired hypothyroidism; Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site; Pressure ulcer, buttock; Pressure ulcer, stage II; Peripheral vascular disease, unspecified; Personal history of venous thrombosis and embolism; Automatic implantable cardiac defibrillator in situ]","71-year-old woman with advanced end-stage ischemic cardiomyopathy with severe left ventricular contractile function with lvef of 10%-15%, atrial fibrillation, [**hospital1 **]-v icd, low cardiac output state, chronic kidney disease with past history of dvt, pe on coumadin. with severe volume overloaded on examination on admission. a myocardial viability study was performed and demonstrated inferior wall myocardial viability. # uti - patient was found to have uti [**1-18**] klebsiella pneumoniae, pansensitive except for intermediate sensitivity to nitrofurantoin. asicites: she had significant ascities on exam and she was s/p 6l tap two weeks ago. # code: she was full code during this hospitalization. palliative care was not persued during this hospital stay but may be introduced by dr.",71-year-old woman with advanced end-stage ischemic cardiomyopathy. she had a low output state with known low ef and dilated ischemic cardiomyopathy. she was sent to the ccu for diuresis with milrinone gtt + lasix gtt + metolazone. 11638,155878.0,15383,2180-01-21,15380,133678.0,2179-09-22,Discharge summary,"Admission Date: [**2179-9-16**] Discharge Date: [**2179-9-22**] Date of Birth: [**2108-5-29**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1515**] Chief Complaint: Hypovolemia Major Surgical or Invasive Procedure: none History of Present Illness: 71 year old F with PMH significant for advanced ischemic cardiomyopathy EF 15%, atrial fibrillation with ICD and CKD who presented to [**Hospital **] hospital [**2179-9-14**] for generalized weakness. Patient reports gaining fluid (notably abdomen and lower extremity) since early [**Month (only) 462**] and consequently toresmide was increased and metolazone started. Per OMR notes patient's creatinine increased to 4.7, had 15 pound weight loss (177 from dry weight 190lb), lower blood pressures and was consequently referred to [**Hospital **] Hospital. Due to weight loss all diuretics were on hold since [**2179-9-7**]. Patient reports 1 month history of increasing fatigue, weakness and shortness of breath. Denies increase in orthopnea, PND. Denies syncope, pre-syncope or dizziness. Denies chest pain. Denies fever, chills, cough or increase in urination. . Patient's presenting vitals to [**Hospital **] Hospital were temperature 97.1, HR 70, RR 20, blood pressure 78/56. Labs notable for creatinine of 4.7, Hematocrit 26.1, CBC 2.5, plt 60,000, INR 2.6. She was given 3 units pRBC and 2.5+ L of fluid. Cardiology was consulted. Patient did not require pressor support. Heme was consulted for pancytopenia felt to be secondary to hypersplenism (demonstrated on ultrasound, new since 5/[**2177**]). Patient was transferred to [**Hospital1 18**] CCU for further care. . On review of systems, she denies any prior history of stroke, TIA, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative Past Medical History: 1. ischemic cardiomyopathy (EF 10-25%) s/p BiV ICD 2. Coronary artery disease status post PTCA and stenting of the LAD in [**2164**]. 3. h/o PE secondary to DVT s/p IVC filter 4. Atrial fibrillation status post cardioversion and biventricular pacemaker implantation. 5. HTN 6. Obesity 7. PVD 8. small VSD 9. hypothyroidism PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Dyslipidemia 2. CARDIAC HISTORY: -Ischemic cardiomyopathy EF %15-20 s/p biv ICD -CAD s/p post PTCA and stenting of the LAD in [**2164**]. -CABG: None -PACING/ICD: atrial fibrillation on anticoagulation and ICD biventricular pacemaker 3. OTHER PAST MEDICAL HISTORY: chronic kidney disease bilateral DVT s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] filter pulmonary embolism osteoarthritis hyperkalemia Social History: Pt lives alone. She is not married. She reports a 20 pack year history, however she quit 30 yrs ago. Denies EtOH or illicit drug use. Family History: Mother had MI at age 50. Father in good health. Maternal uncle died of MI in his 50's. Physical Exam: Gen: alert, talkative, NAD HEENT: supple, no LAd, Pos JVD at 12 cm CV: RRR, 2/6 systolic murmur at apex RESP: CTAB, no crackles or wheezes ABD: distended, soft, pos fluid wave, umbilical hernia, EXTR: 1+ edema bilat. right > L NEURO: alert, oriented, Extremeties: Groin Pulses: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+ Skin: intact Access: PIV Tubes: Foley d/c'ed. Pertinent Results: [**2179-9-22**] 06:50AM BLOOD WBC-3.8* RBC-3.30* Hgb-10.8* Hct-31.7* MCV-96 MCH-32.7* MCHC-34.0 RDW-17.1* Plt Ct-95* [**2179-9-16**] 10:40PM BLOOD Neuts-86.4* Lymphs-8.9* Monos-3.3 Eos-1.0 Baso-0.4 [**2179-9-22**] 06:50AM BLOOD Plt Ct-95* [**2179-9-22**] 06:50AM BLOOD Glucose-91 UreaN-83* Creat-2.3* Na-135 K-4.5 Cl-99 HCO3-27 AnGap-14 . CXR [**9-17**]: AP chest compared to [**2175-9-20**]: Severe cardiomegaly has progressed. Lungs are clear. Pulmonary and mediastinal vasculature are unremarkable and there is no pleural effusion. Transvenous right atrial and left ventricular pacer leads and right ventricular pacer defibrillator lead are unchanged in their respective positions. No pneumothorax. . Right Leg Ultrasound: [**2179-9-17**] Grayscale color and Doppler son[**Name (NI) 1417**] of the right common femoral, superficial femoral, popliteal, and tibial veins were performed. There is normal flow, compression and augmentation seen in all of the vessels. IMPRESSION: No evidence of deep vein thrombosis in the right leg. . Abdominal Ultrasound: [**2179-9-17**] IMPRESSION: 1. Mild splenomegaly. 2. No thrombus identified within the IVC. 3. Large amount of ascites. Brief Hospital Course: 70 year old female with severe biventricular failure with profoundly reduced left ventricular ejection fraction of 15%, moderate mitral regurgitation and tricuspid regurgitation with moderate pulmonary hypertension presented to outside hospital for fatigue and hypotension. Transferred to [**Hospital1 18**] for further treatment of her renal failure and heart failure. . # PUMP: Patient with known ischemic cardiomyopathy EF 15%. New splenomegaly concerning for worsening of EF. On admission, pt was 7 lbs below her dry weight (190) and with poor renal function therefore there was some concern for over-diuresis. Gentle IVF was given and pt was allow to re-equilibrate. She appeared to be perfusing well and did not require ionotropic support. Her renal function improved over the course of her stay, as did her edema with PO intake and holding her diuretics. She was continued on her home cardiac meds including lisinopril (decreased to 2.5/day), carvedilol and ASA. She will be discharged on 20 mg toresemide daily for diuresis. Her Fluid status will need to be monitored very closely as she is quite fragile. Daily weights will need to be monitored and as her wieght increases, she will need to have more diuretics added on. Please contact [**Name (NI) **] [**Last Name (NamePattern1) **] NP, her heart failure NP for further management at [**Telephone/Fax (1) 62**]. . # RHYTHM: Mrs [**Known lastname **] is AV paced with right bundle branch block with underlying A Fib. She was treated with coumadin, amiodarone and carvedilol. Her coumadin was decreased on discharge for elevated INR, and she will follow up for repeat INR and warfarin adjustment. She was seen by EP for evaluation of her pacer settings, however adjustments were deferred to the outpatient setting as changes need to be done under echo, therefore she has an appointment scheduled this month for adjustment of pacer settings. . # CORONARIES: One vessel coronary artery disease with patent prior LAD stent. Last cath [**2171**]. No chest pain during this admission. ASA, carvedilol and statin were continued. . # Acute on chronic renal failure: Her baseline creatinine is 1.3-2, during this visit creatinine peaked at 3.2 and was thought to be pre-renal in the setting of over-diuresis. Her renal function improved with diuretics and encouraging PO intake. . # Pancytopenia: Heme consulted at OSH - felt to be secondary to splenomegaly secondary to CHF. Platelets were stable during this admission. Would recommend following as an outpatient with hematology. . # Asymmetric lower extremity swelling: Right > Left. LENI OSH negative. Patient reports no recent instrumentation. This was felt to be a chronic issue related to positioning as it is no worse than baseline and the patient tends to lie primarily on her right side. . # Hypothyroid: Her levothyroxine was continued at outpatient doses. . # LE muscle spasm Not a [**Last Name **] problem, pt states started about mid [**Month (only) **]. Interfering with activity, not able to walk now and is assist of two to chair. Unclear how much hospitalization and deconditioning are contributing. No improvement with hydration. Electolytes WNL. Pt was started on Ca and will follow-up as an outpatient. Dr. [**Last Name (STitle) **], a neurologist from [**Location (un) **] has been contact[**Name (NI) **] to see the pt as soon as possible, her sister, will help with setting this appt up in a timely manner. Medications on Admission: - omeprazole 20 mg po qd - simvastatin 20mg po qd - amiodarone 200 mg qd - carvedilol 25 mg po [**12-18**] tab in am and 1 tab pm - Levoxyl 112 mg po qd - recently stopped coumadin, allopurinol, colchecine, lisinopril, Metolazone 2.5mg twice a week, torsemide 40 mg [**Hospital1 **], digoxin Discharge Medications: 1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Pt's home dose is 4mg daily. Please check INR on [**9-24**]. 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): this will need to be uptitrated as weight increases over dry weight. . 13. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 14. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 1439**] Discharge Diagnosis: Acute on Chronic systolic Congestive Heart Failure Atrial fibrillation Acute on chronic Kidney Disease Pancytopenia Hx of Bilateral DVT s/p filter Discharge Condition: stable weight= 85.4kg. This is pt's dry weight. BP= 80's-90's/50's. This is pts baseline HR= 70's. O2 sat on RA= 97% Discharge Instructions: You had too much fluid taken off and your kidneys did not function well. We stopped all of your diuretics and gave you some intravenous fluid. Your kidney function is now better and we will restart the Torsemide at a very low dose. You will need to be followed closely over the next few weeks because you will need to have more of your medicines restarted. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] is the CHF NP who follows you on a regular basis. She can be reached with any questions at [**Telephone/Fax (1) 62**]. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Follow a low sodium (2000mg) diet Do not drink more than 6 cups of fluid per day or about 1.5 liters. We have set up an outpatient appt to see a neurologist about your muscle spasms. . Medication changes: 1. Decrease your Torsemide to 20 mg daily 2. Decrease your Lisinopril to 2.5 mg daily 3. Decrease Warfarin to 2mg daily until your INR is < 3.0, then increase to 4mg daily. 4. Do not take Colchicine or Allopurinol unless your gout comes back (you were not taking this at home) 5. START taking Calcium and Vitamin D to prevent osteoporosis. Followup Instructions: Primary Care: [**Last Name (LF) 44661**],[**First Name3 (LF) 25**] M. Phone: [**Telephone/Fax (1) 44659**] Date/time: Please call for an appt after you get out of rehabilitation. Cardiology: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2179-9-29**] 10:30 Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2179-10-6**] 10:00 . Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2179-10-6**] 10:30 Neurology: Dr. [**Last Name (STitle) **] Phone: [**Telephone/Fax (1) 44662**] Date/Time: Office will call with an appt. Completed by:[**2179-9-22**]",121,2179-09-16 21:42:00,2179-09-22 14:10:00,EMERGENCY,TRANSFER FROM HOSP/EXTRAM,SNF,CONGESTIVE HEART FAILURE," 70 year old female with severe biventricular failure with profoundly reduced left ventricular ejection fraction of 15%, moderate mitral regurgitation and tricuspid regurgitation with moderate pulmonary hypertension presented to outside hospital for fatigue and hypotension. transferred to [**hospital1 18**] for further treatment of her renal failure and heart failure. . # pump: patient with known ischemic cardiomyopathy ef 15%. new splenomegaly concerning for worsening of ef. on admission, pt was 7 lbs below her dry weight (190) and with poor renal function therefore there was some concern for over-diuresis. gentle ivf was given and pt was allow to re-equilibrate. she appeared to be perfusing well and did not require ionotropic support. her renal function improved over the course of her stay, as did her edema with po intake and holding her diuretics. she was continued on her home cardiac meds including lisinopril (decreased to 2.5/day), carvedilol and asa. she will be discharged on 20 mg toresemide daily for diuresis. her fluid status will need to be monitored very closely as she is quite fragile. daily weights will need to be monitored and as her wieght increases, she will need to have more diuretics added on. please contact [**name (ni) **] [**last name (namepattern1) **] np, her heart failure np for further management at [**telephone/fax (1) 62**]. . # rhythm: mrs [**known lastname **] is av paced with right bundle branch block with underlying a fib. she was treated with coumadin, amiodarone and carvedilol. her coumadin was decreased on discharge for elevated inr, and she will follow up for repeat inr and warfarin adjustment. she was seen by ep for evaluation of her pacer settings, however adjustments were deferred to the outpatient setting as changes need to be done under echo, therefore she has an appointment scheduled this month for adjustment of pacer settings. . # coronaries: one vessel coronary artery disease with patent prior lad stent. last cath [**2171**]. no chest pain during this admission. asa, carvedilol and statin were continued. . # acute on chronic renal failure: her baseline creatinine is 1.3-2, during this visit creatinine peaked at 3.2 and was thought to be pre-renal in the setting of over-diuresis. her renal function improved with diuretics and encouraging po intake. . # pancytopenia: heme consulted at osh - felt to be secondary to splenomegaly secondary to chf. platelets were stable during this admission. would recommend following as an outpatient with hematology. . # asymmetric lower extremity swelling: right > left. leni osh negative. patient reports no recent instrumentation. this was felt to be a chronic issue related to positioning as it is no worse than baseline and the patient tends to lie primarily on her right side. . # hypothyroid: her levothyroxine was continued at outpatient doses. . # le muscle spasm not a [**last name **] problem, pt states started about mid [**month (only) **]. interfering with activity, not able to walk now and is assist of two to chair. unclear how much hospitalization and deconditioning are contributing. no improvement with hydration. electolytes wnl. pt was started on ca and will follow-up as an outpatient. dr. [**last name (stitle) **], a neurologist from [**location (un) **] has been contact[**name (ni) **] to see the pt as soon as possible, her sister, will help with setting this appt up in a timely manner. ","PRIMARY: [Acute on chronic systolic heart failure] SECONDARY: [Acute kidney failure, unspecified; ; Ventricular septal defect; Congestive heart failure, unspecified; Other specified forms of chronic ischemic heart disease; Atrial fibrillation; Right bundle branch block; Mitral valve disorders; Other chronic pulmonary heart diseases; Diseases of tricuspid valve; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified; Chronic kidney disease, unspecified; Coronary atherosclerosis of native coronary artery; Splenomegaly; Unspecified acquired hypothyroidism; Peripheral vascular disease, unspecified; Obesity, unspecified; Osteoarthrosis, unspecified whether generalized or localized, site unspecified; Spasm of muscle; Swelling of limb; Automatic implantable cardiac defibrillator in situ; Personal history of venous thrombosis and embolism; Percutaneous transluminal coronary angioplasty status; Long-term (current) use of anticoagulants]","70 year old female with severe biventricular failure with profoundly reduced left ventricular ejection fraction of 15%, moderate mitral regurgitation and tricuspid regurgitation with moderate pulmonary hypertension presented to outside hospital for fatigue and hypotension. on admission, pt was 7 lbs below her dry weight (190) and with poor renal function therefore there was some concern for over-diuresis. daily weights will need to be monitored and as her wieght increases, she will need to have more diuretics added on. # rhythm: mrs [**known lastname **] is av paced with right bundle branch block with underlying a fib. her renal function improved with diuretics and encouraging po intake. patient reports no recent instrumentation. unclear how much hospitalization and deconditioning are contributing.",70 year old female with severe biventricular failure. profoundly reduced left ventricular ejection fraction of 15%. moderate mitral regurgitation and tricuspid regurgitation with moderate pulmonary hypertension. transferred to hospital for further treatment of her renal failure and heart failure. 11860,158547.0,22991,2203-06-07,22990,162521.0,2203-05-21,Discharge summary,"Admission Date: [**2203-5-14**] Discharge Date: [**2203-5-21**] Date of Birth: [**2134-9-28**] Sex: F Service: MEDICINE Allergies: Dapsone / Cyclosporine / Cefepime / Aztreonam / Azithromycin / Vancomycin Attending:[**First Name3 (LF) 3913**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: Cardiac Catheterization Placement of tunneled right internal jugular central venous line History of Present Illness: 68yo woman with h/o NHL s/p SCT in [**2199**] who presented to the ED with acute onset shortness of breath. She describes waking up at 5am on the day of admission because of severe pain from post-herpetic neuralgia in her left face. She then began feeling very short of breath and wheezy for the next 20 minutes. No associated chest pain. No fevers or chills. No nausea or vomiting. She has otherwise been feeling well. She denies any similar symptoms in the past. She has not had any orthopnea or prior episodes of PND. No pleuritic chest pain, no dyspnea on exertion, no LE edema or weight gain. She has been able to mow the lawn and go up a flight of stairs without any difficulty. No recent travel. She does not have a personal or family history of blood clots nor does she have a history of miscarriages. She had tacos last night for dinner. No nausea or vomiting. In the ED, initial VS were: 97.5 192/101 128 24 86% RA. Her oxygen improved to 100% on NRB. She appeared to have increased work of breathing and she had b/l rales on exam; guaiac was negative. BNP was elevated at [**Numeric Identifier 59336**]. The team was concerned about the possibility of PE, but they did not obtain CTA chest because of her advanced kidney disease. The ED team felt that PE was high enough on their differential that they opted to treat with a heparin gtt. They obtained a CT head, which showed some lacunes that were new as compared to [**2199**]. Neurology was consulted to advise whether anticoagulation would be safe. After discussing with oncology, heparin gtt was started. Although the team was concerned about the possibility of heart failure, she was given SL nitroglycerin and ASA but not started on lasix or BP medications. She did receive clindamycin and levofloxacin for concern of a possible RLL infiltrate. She was also given prednisone 60mg x 1 because of the possibility that she might be adrenally insufficient on chronic steroids. Upon arrival to the ICU, she reported feeling comfortable. Her pain was mild and she was not having any difficulty breathing. Past Medical History: - Large Cell Lymphoma: Diagnosed [**2197**], s/p allogeneic SCT in [**6-13**]. Has had multiple regimens of chemotherapy c/b GVHD - Chronic Graft vs Host Disease, mild (cutaneous, liver) - CKD Stage V: Unclear if secondary to chemotherapy, cyclosporin, or GVHD. Had LUE AV fistula placed but found to have occluded left brachiocephalic vessel on fistalugram - Hyponatremia felt to be due to increased fluid intake - s/p Thyroidectomy for thyroid mass, pathology was benign - Herpes zoster c/b post-herpetic neuralgia s/p nerve block Social History: Quit smoking 36 yrs ago. Very occ EtOH use. Married with two daughters. Formerly worked in human resources at a department store. Family History: No fam history of blood clots Her mom deceased age 87 of cerebral hemorrhage. Father deceased age 48 of malignant hypertension. Aunt deceased from breast cancer. Brother [**Name (NI) 59335**] massive MI at the age of 66. Additional brother with hypertension and emphysema Physical Exam: 97.6 129/69 111 18 94% 2L Very pleasant woman in no distress. PERRL, EOMI. Left lid ptosis. CN II-XII intact. OP clear, MMM. Neck supple, no thyroid enlargement, no adenopathy. S1, S2, regular tachycardia, +rub. Lung with good air movement and crackles [**12-12**] of way up b/l. Abd soft and not tender, no palpable mass, no hepatomegaly. Very mild asterixis R>L. Strength 5/5 in UE and LE b/l. No LE edema. DP +2 b/l. Dark discoloration of skin over arms and back. LUE AV fistula with palpable thrill. Pertinent Results: LABORATORY RESULTS ==================== On Admission: WBC-7.2 RBC-3.53* Hgb-11.5* Hct-34.9* MCV-99* RDW-18.0* Plt Ct-226 -- Neuts-74.1* Bands-0 Lymphs-14.2* Monos-8.4 Eos-2.7 Baso-0.7 PT-12.1 PTT-26.2 INR(PT)-1.0 Glucose-114* UreaN-75* Creat-5.2* Na-127* K-4.7 Cl-96 HCO3-12* Calcium-7.8* Phos-6.1*# Mg-2.5 TSH-1.5 On Discharge: WBC-5.8 RBC-3.15* Hgb-9.8* Hct-30.9* MCV-98 RDW-16.8* Plt Ct-169 PT-13.0 PTT-66.9* INR(PT)-1.1 Glucose-84 UreaN-44* Creat-3.9* Na-144 K-4.1 Cl-105 HCO3-29 [**2203-5-20**] 06:42AM BLOOD ALT-13 AST-16 LD(LDH)-184 AlkPhos-63 TotBili-0.2 Calcium-9.1 Phos-2.7 Mg-2.1 MICROBIOLOGY ============= Blood Cultures [**2203-5-14**]: One out of two bottles STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON REQUEST.. Aerobic Bottle Gram Stain (Final [**2203-5-16**]): GRAM POSITIVE COCCI IN CLUSTERS. Blood Cultures*2 [**2203-5-16**]: No growth Rapid Respiratory Viral Screen [**2203-5-15**]: **FINAL REPORT [**2203-5-17**]** Respiratory Viral Culture (Final [**2203-5-17**]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [**Telephone/Fax (1) 6182**] within 1 week if additional testing is needed. Rapid Respiratory Viral Antigen Test (Final [**2203-5-15**]): Respiratory viral antigens not detected. SPECIMEN SCREENED FOR: ADENO,PARAINFLUENZA 1,2,3 INFLUENZA A,B AND RSV. HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HCV Ab-NEGATIVE OTHER STUDIES ============== ECG [**2203-5-14**]: Sinus tachycardia with atrial premature beats. Poor R wave progression in leads V1-V3. Cannot rule out old anteroseptal myocardial infarction. Diffuse non-specific ST-T wave abnormalities. Compared to the previous tracing of [**2203-2-15**] there has been interval loss of R wave in leads V2-V3. Chest Radiograph [**2203-5-14**]: CONCLUSION: Added density at the right costophrenic angle is suggestive of an infiltrate. Blunting of the right costophrenic angle is suggestive of a small basal effusion. CT Head W/O Contrast [**2203-5-14**]: CONCLUSION: Periventricular ischemia and scattered lacunar infarcts. No intracranial hemorrhage. CT Chest W/O Contrast [**2203-5-14**]: CONCLUSION: 1. Bibasal effusions along with increased interstitial markings and confluent ground-glass opacities predominantly in the upper lobes. The differential considerations are fluid overload, or CHF. Please correlate clinically. 2. Scattered tiny calcific densities in the left breast may represent fibroadenomas. Mammography is recommended on a non-emergent basis. 3. No mediastinal masses. Transthoracic Echocardiogram [**2203-5-17**]: Conclusions The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is borderline dilated. Overall left ventricular systolic function is probably mildly depressed (LVEF=~40-45%? %) with basal inferior hypokinesis and possible septal hypokinesis (views are technically suboptimal for assessment of regional wall motion). Diastolic function could not be adquately assessed. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. --Compared with the prior study (images reviewed) of [**2203-1-6**], the left ventricle is now more dilated, left ventricular systolic function is more depressed with new regional wall motion abnormality, the mitral valve chordae appear tethered, mitral regurgitation is now much more prominent. Cardiac Catheterization [**2203-5-18**]: COMMENTS: 1. Selective coronary angiography of this right dominant system revealed single vessel disease. The LMCA was free of critical stenoses. The LAD had a bifurcation lesion with a 50% stenosis in the mid-LAD and 70% stenosis in the D1 branch. The LCx and RCA were widely patent. 2. Resting hemodynamics revealed mildly elevated right heart filling pressures with a mean RA of 11mmHg and severely elevated left heart filling pressures with a mean PCWP of 28mmHg. The cardiac index was preserved at 3.7 l/min/m2. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Severe diastolic ventricular dysfunction. Brief Hospital Course: Ms [**Known lastname 59332**] is a 68yo woman with h/o non-Hodgkin's lymphoma s/p SCT in [**2199**] and stage V CKD who presented with acute dyspnea in the setting of pain, hypertension, and volume overload. # Dyspnea and Hypoxia: She most likely developed flash pulmonary edema from sudden hypertension from the pain in the setting of chronic renal disease. This was supported by CXR and CT chest. She was given Lasix for diuresis. To cover PE (she has had persistent tachycardia), she was started on heparin gtt. This was discontinued as the likelihood of PE was very low given hypoxia and tachycardia resolved with diuresis. She had no evidence of infection or pneumonia. She takes her pentamidine faithfully, so was unlikely to be PCP. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was done during her admission to evaluate for suspected diastolic dysfunction, however showed new inferior basal wall motion abnormality and new moderate to severe mitral regurgitation, see below. # Systolic CHF: New diagnosis, on this admission. [**Last Name (NamePattern4) **] showed EF 40-45%, but likely overestimated given significant new MR. Likely secondary to ischemic event, either from plaque rupture given family history, hyperlipidemia, or vasospasm. The patient had a cardiac catheterization which did not show evidence of occlusive disease. She was started on metoprolol, atorvastatin, and aspirin during her hospital stay. # Sinus Tachycardia: Most likely this was secondary to pain and dyspnea, unlikely to be PE. She was empirically started on a heparin gtt, but stopped when she was no longer hypoxic. TSH was WNL. # CKD stage V: On admission, the patient had mild signs of uremia on exam and labs but denies frank symptoms apart from volume overload. Unfortunately, occlusion of left brachiocephalic makes left AV fistula unusable. Renal was consulted during her hospitalization and did not think she required acute hemodialysis. Transplant surgery was consulted to discuss the possibility of placing another fistula on the right. However, given the new development of CHF, this surgery was placed on hold, and a temporary HD line was placed. Hemodialysis was electively initiated during her hospitalization. She had Hep C and Hep B antibiodies sent. A PPD was placed . All hepatitis serologies were negative and there was no induration to PPD. The patient was discharged to outpatient dialysis. # Graft vs Host Disease: Pt was continued on home prednisone after discussing with oncology. She is also on monthly pentamidine given long term steroids. # Post-herpetic neuralgia: Pt was continued on home pregabalin and nortriptyline for pain control. She will follow up in pain clinic. # Small vessel ischemic disease on Head CT: Neuro was consulted and recommended aspirin, which was started. # h/o thyroidectomy: TSH was WNL. Pt was continued on home dose of levothyroxine. . # Hyponatremia: Chronic, will monitor . # Code: DNR/DNI (confirmed with patient) Medications on Admission: Prednisone 2.5mg daily (for GVHD) Levothyroxine 125mcg daily Nortriptyline 10mg QHS Pregabalin 25mg [**Hospital1 **] Calcium and vitamin D Centrum silver Pentamidine 300mg every month Albuterol inhaler (almost never uses) Discharge Medications: 1. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 4. Pregabalin 25 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Cholecalciferol (Vitamin D3) 400 unit Capsule Sig: One (1) Capsule PO twice a day. 6. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q4H (every 4 hours) as needed for sob, wheezing. 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*2* 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 * Refills:*2* 11. Multivitamin Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Systolic and Diastolic Heart Failure Stage V Chronic Kidney Disease Post Herpetic Neuralgia Secondary Diagnoses: History of allogeneic stem cell transplant for non-Hodgkin's Lymphoma Chronic graft versus host disease Hypothyroidism Discharge Condition: Good, stable on room air, tolerating PO's, euvolemic Discharge Instructions: You were admitted to [**Hospital1 18**] for evaluation of shortness of breath. You were found to have new heart failure and volume overload from your chronic kidney failure. You had a cardiac catheterization which showed evidence of coronary artery disease, but did not explain your heart failure and valve symptoms. You were also stared on hemodialysis while you were inpatient. Medication Changes: START Metoprolol 12.5mg twice a day START Aspirin 81mg daily START Atorvastatin 10mg daily START NEPHROCAPS We discontinued your Calcium Acetate (Phoslo) and Sodium bicarb. Please do not take this medications any more unless asked to do so by your Nephrologist. . Your PPD was negative. . It is important that you see your docotrs for further follow up, as we have arranged for you (see below). . If you experience worsening shortness of breath, chest pain, fevers, chills or any other concerning symptoms please seek medical attention. Followup Instructions: Please set up an appointment to see your PCP Dr [**Last Name (STitle) 29827**] to follow up on your hospitalization. Please keep your previously scheduled appointments: [**2203-5-24**] 01:30p [**Last Name (LF) **],[**First Name3 (LF) 3750**] C. SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] HEMATOLOGY/ONCOLOGY ([**Telephone/Fax (1) 3241**]) [**2203-5-24**] 01:30p [**Last Name (LF) **],[**First Name3 (LF) **] E. SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] HEMATOLOGY/ONCOLOGY ([**Telephone/Fax (1) 3241**]) [**2203-5-27**] 11:10a [**Doctor Last Name **] ONE [**Location (un) **] PLACE ([**Location (un) **], MA), [**Location (un) **] PAIN MANAGEMENT CENTER ([**Telephone/Fax (1) 1652**] [**2203-5-31**] 11:20a [**Doctor Last Name **] [**Hospital6 29**], [**Location (un) **] CC7 CARDIOLOGY (SB) ",17,2203-05-14 22:59:00,2203-05-21 15:46:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,PNEUMONIA," ms [**known lastname 59332**] is a 68yo woman with h/o non-hodgkins lymphoma s/p sct in [**2199**] and stage v ckd who presented with acute dyspnea in the setting of pain, hypertension, and volume overload. # dyspnea and hypoxia: she most likely developed flash pulmonary edema from sudden hypertension from the pain in the setting of chronic renal disease. this was supported by cxr and ct chest. she was given lasix for diuresis. to cover pe (she has had persistent tachycardia), she was started on heparin gtt. this was discontinued as the likelihood of pe was very low given hypoxia and tachycardia resolved with diuresis. she had no evidence of infection or pneumonia. she takes her pentamidine faithfully, so was unlikely to be pcp. [**initials (namepattern4) **] [**last name (namepattern4) **] was done during her admission to evaluate for suspected diastolic dysfunction, however showed new inferior basal wall motion abnormality and new moderate to severe mitral regurgitation, see below. # systolic chf: new diagnosis, on this admission. [**last name (namepattern4) **] showed ef 40-45%, but likely overestimated given significant new mr. likely secondary to ischemic event, either from plaque rupture given family history, hyperlipidemia, or vasospasm. the patient had a cardiac catheterization which did not show evidence of occlusive disease. she was started on metoprolol, atorvastatin, and aspirin during her hospital stay. # sinus tachycardia: most likely this was secondary to pain and dyspnea, unlikely to be pe. she was empirically started on a heparin gtt, but stopped when she was no longer hypoxic. tsh was wnl. # ckd stage v: on admission, the patient had mild signs of uremia on exam and labs but denies frank symptoms apart from volume overload. unfortunately, occlusion of left brachiocephalic makes left av fistula unusable. renal was consulted during her hospitalization and did not think she required acute hemodialysis. transplant surgery was consulted to discuss the possibility of placing another fistula on the right. however, given the new development of chf, this surgery was placed on hold, and a temporary hd line was placed. hemodialysis was electively initiated during her hospitalization. she had hep c and hep b antibiodies sent. a ppd was placed . all hepatitis serologies were negative and there was no induration to ppd. the patient was discharged to outpatient dialysis. # graft vs host disease: pt was continued on home prednisone after discussing with oncology. she is also on monthly pentamidine given long term steroids. # post-herpetic neuralgia: pt was continued on home pregabalin and nortriptyline for pain control. she will follow up in pain clinic. # small vessel ischemic disease on head ct: neuro was consulted and recommended aspirin, which was started. # h/o thyroidectomy: tsh was wnl. pt was continued on home dose of levothyroxine. . # hyponatremia: chronic, will monitor . # code: dnr/dni (confirmed with patient) ","PRIMARY: [Hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage V or end stage renal disease] SECONDARY: [Acute combined systolic and diastolic heart failure; Chronic kidney disease, Stage V; Herpes zoster with other nervous system complications; Complications of transplanted bone marrow; Chronic graft-versus-host disease; Compression of vein; Hyposmolality and/or hyponatremia; Other specified cardiac dysrhythmias; Hyperpotassemia; Personal history of other lymphatic and hematopoietic neoplasms; Coronary atherosclerosis of native coronary artery; Congestive heart failure, unspecified; Other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation; Unspecified acquired hypothyroidism; Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use; Polyneuropathy due to drugs; Hyperpigmentation of eyelid]","ms [**known lastname 59332**] is a 68yo woman with h/o non-hodgkins lymphoma s/p sct in [**2199**] and stage v ckd who presented with acute dyspnea in the setting of pain, hypertension, and volume overload. # dyspnea and hypoxia: she most likely developed flash pulmonary edema from sudden hypertension from the pain in the setting of chronic renal disease. she takes her pentamidine faithfully, so was unlikely to be pcp. [**initials (namepattern4) **] [**last name (namepattern4) **] was done during her admission to evaluate for suspected diastolic dysfunction, however showed new inferior basal wall motion abnormality and new moderate to severe mitral regurgitation, see below. likely secondary to ischemic event, either from plaque rupture given family history, hyperlipidemia, or vasospasm. pt was continued on home dose of levothyroxine.","ms [**known last name 59332**] is a 68yo woman with h/o non-hodgkins lymphoma s/p sct. she presented with acute dyspnea in the setting of pain, hypertension, and volume overload. she was empirically started on a heparin gtt, but stopped when she was no longer hypoxic." 13305,106092.0,14242,2180-01-06,14241,122062.0,2179-11-27,Discharge summary,"Admission Date: [**2179-11-21**] Discharge Date: [**2179-11-27**] Date of Birth: [**2123-3-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: Confusion, agitation Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [**Known lastname 42326**] is a 56 y.o. M with alcoholic cirrhosis complicated by UGIB [**3-13**] esophageal varices s/p TIPS and TIPS redo in [**Month (only) 216**] [**2179**], admitted for increasing confusion and agitation over the last 3 days. The patient's relative called the GI fellow today and reported that he has not been taking his lactulose, not giving himself insulin, and has possibly been drinking alcohol. He refused to come be evaluated in the ED, but GI fellow recommended that the relative have an ambulance bring him to the ED. . In the ED, initial vs were: T 98.6, P 116, BP 154/93, R 16, O2 sat 100% RA. He was noted to be encephalopathic, agitated and would not answer questions. Per ED physical exam, pt jaundiced with soft, nondistended, nontender abdomen. Guaiac negative. He spiked a temperature to 103.1 and blood cultures were sent. 3g unasyn IV was given for empiric coverage of SBP. CT head negative, CXR negative. Abd US showed no ascites. Received 1.5L NS. Repleted K with 40 IV. In 2 point restraints for agitation, was swinging at staff in the ED. Was given versed 1mg IV as well. . On the floor, pt is agitated and will not cooperate with interview or exam. . Review of sytems: unable to obtain . Past Medical History: 1. Alcoholic cirrhosis - hx of esophageal variceal bleed and hepatic encephalopathy. He has had 2 TIPS procedures with stent placement in [**2166**] and again in [**2176**]. Underwent TIPS revision in [**8-17**] and [**9-17**]. 2. Chronic pancreatitis complicated by a parapancreatic cyst that was infected with enteroccocus and coagulase negative staph. On vancomycin from [**Date range (2) 42329**], then linezolid [**Date range (1) 42330**]. 3. Type 2 DM on insulin 4. Anemia of chronic disease 5. Thrombocytopenia 6. Depression 7. Umbilical Hernia 8. History of delerium tremens Social History: He lives alone. He is currently unemployed.Has three children. He has a history of heavy alcohol use but none since [**7-17**] (per OMR). Smokes 1.5 PPD. No IVDU, no other illicits. Family History: father - cirrhosis Physical Exam: Vitals: T: 97.5, BP: 143/100, P: 109, R: 20, O2: 100% 3L, FS 243 General: Alert, muttering profanities (repeatedly saying ""get the F*** out of my house""), smells of urine, not answering questions, moving all extremities, no acute distress Skin: jaundiced, no rash or bruising noted HEENT: Scleral icterus, dry MM, would not open mouth Neck: supple, JVP not elevated, no LAD Lungs: would not cooperate with exam however lungs sound clear to auscultation anteriorly CV: Tachycardic, regular, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission labs: [**2179-11-21**] 03:12PM BLOOD WBC-6.6 RBC-3.59* Hgb-13.4* Hct-36.4* MCV-101* MCH-37.3*# MCHC-36.9*# RDW-16.3* Plt Ct-54* [**2179-11-21**] 03:12PM BLOOD Neuts-80.0* Lymphs-9.8* Monos-3.9 Eos-5.4* Baso-0.9 [**2179-11-21**] 03:12PM BLOOD PT-17.4* PTT-35.4* INR(PT)-1.6* [**2179-11-21**] 03:12PM BLOOD Glucose-253* UreaN-9 Creat-0.7 Na-137 K-2.7* Cl-103 HCO3-21* AnGap-16 [**2179-11-21**] 03:12PM BLOOD ALT-61* AST-116* LD(LDH)-317* CK(CPK)-94 AlkPhos-432* TotBili-15.3* DirBili-8.3* IndBili-7.0 [**2179-11-21**] 03:12PM BLOOD Lipase-12 [**2179-11-21**] 03:12PM BLOOD cTropnT-<0.01 [**2179-11-21**] 03:12PM BLOOD Calcium-8.6 Phos-1.2* Mg-1.4* [**2179-11-21**] 03:00PM BLOOD Ammonia-206* [**2179-11-21**] 03:12PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2179-11-21**] 03:19PM BLOOD Lactate-2.5* . [**2179-11-21**] CT head without contrast: 1. No evidence of acute intracranial pathology. 2. Stable old right temporal lacunar type infarct. . [**2179-11-23**] Liver, gallbladder US: 1. Patent posterior TIPS with wall-to-wall flow. Velocities in the proximal and mid TIPS have decreased compared to prior. Apparent interval increase in velocity in the posterior TIPS may be secondary to turbulence. 2. Right and left portal vein not interrogated due to limited patient cooperation. 3. Cirrhotic liver with small gallstone as described. . [**2179-11-26**] CXR: Right basilar alveolar opacity and right pleural effusion increased, still small, suggesting pneumonia in the clinical context. The left lung is clear except to note basilar atelectasis. Minimal left pleural effusion is unchanged. The cardiomediastinal silhouette and hilar contours are otherwise normal. . Discharge labs: . [**2179-11-27**] 05:15AM BLOOD WBC-4.9 RBC-2.79* Hgb-10.5* Hct-30.5* MCV-110* MCH-37.7* MCHC-34.5 RDW-17.3* Plt Ct-72* [**2179-11-26**] 05:40AM BLOOD PT-18.5* PTT-37.6* INR(PT)-1.7* [**2179-11-27**] 05:15AM BLOOD TotBili-8.8* [**2179-11-26**] 05:40AM BLOOD ALT-46* AST-92* LD(LDH)-333* AlkPhos-287* TotBili-10.0* [**2179-11-27**] 05:15AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.6 Brief Hospital Course: Pt is a 56 yo M with h/o EtOH cirrhosis s/p TIPS with multiple revisions here with confusion/ agitation. . 1. Confusion: Likely [**3-13**] Hepatic Encephalopathy as pt's relative reports he is non-compliant with lactulose at home. The relative also reports pt has been drinking ETOH at home although tox screens in ED were negative. He was admitted and started on lactulose however [**3-13**] agitation and non-compliance he had to be given lactulose via enema. On the afternoon of [**11-22**], he became briefly unresponsive on the floor. He continued to protect his airway during this episode and woke up as ABG was being drawn however he was transferred to the MICU for closer monitoring. On the morning of [**11-23**] he was transferred back to the floor with an NGT in place through which he was recieving lactulose. With this, he slowly began to clear over the next several days and his lactulose was gradually tapered to 30 ml QID at the time of discharge. Pt has a h/o DT with persistently elevated CIWA during the first 4 days of this admission. Thus, withdrawl was also likely contributing to some confusion as could benzos used to treat withdrwal. Pt's TIPS was initially unable to be fully assessed [**3-13**] pt's inability to comply with exam. However, US on [**11-23**] showed the posterior TIPS to be patent. Finally, infection could have been a contributer to the pt's confusion. He had a temp to 103 reportedly in ED and was put on Ceftriaxone for presumptive SBP. However, SBP seemed unlikely as pt had never c/o abd pain, spiked another fever, and had limited ascites. Fever in ED could have been [**3-13**] agitation, EtOH withdrawl and/or acute alcoholic hepatitis. Thus, Cefriaxone was discontinued on [**11-23**]. However, fever recurred on [**11-25**] and [**11-26**]. Blood and urine cultures were ordered and negative. There was thought to be too little ascitic fluid to tap. CXR showed likely aspiration PNA and the pt was put on Ceftriaxone and Azithromycin. This was changed to PO Levofloxacin for a planned 4 more days of antibiotic treatment at discharge. Of note, on [**2179-11-27**] the pt was sufficiently cleared to insist that he be discharged and state that he would not stay in the hospital for further treatment. He was discharged home on Levofloxacin, Lactulose and Rifaximin. . 2. EtOH Cirrhosis s/p TIPS: MELD on admission 22. LFT's all incr at admission stabilized by discharge with T bili down to 8.8 on [**11-27**]. Lasix and spironolactone were held [**3-13**] hypernatremia early in the admission. Spironolactone was restarted prior to discharge but lasix was not as pt was still having tenuous BP. He should follow up with his PCP to restart this. Continued home MVI, thiamine, folic acid, nadolol and omeprazole. . 3. DM type [**Name (NI) **] Pt non-compliant with Insulin per relative's report at home. He was kept on a HISS and lantus regimen here and discharged on Lantus at the increased dose of 38 units daily which he required here. . 4. h/o depression- Initially help amitryptyline while pt sedated but this was restarted prior to discharge. . 5. Thrombocytopenia- likely [**3-13**] liver pathology, recent EtOH use. No signs of bleeding, stable at discharge. Medications on Admission: Medications: (per ED paperwork, pt not cooperative) Amitryptypline 10 mg po qhs Neurontin 100mg (dosing not specified) Lactulose 30 ml po TID Rifaximin 600 mg po BID Furosemide 40 mg po daily Folic acid 1 mg po daily MVI 1 tablet po daily Spironolactone 150 mg po daily Omeprazole EC 20 mg daily Lantus 34 units SQ qhs Humalog Sliding Scale Insulin QIDACHS Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:*4 Tablet(s)* Refills:*0* 4. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). Disp:*3600 ML(s)* Refills:*2* 6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 7. Spironolactone 50 mg Tablet Sig: Three (3) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 8. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Insulin Glargine 100 unit/mL Solution Sig: 38U Subcutaneous at bedtime. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: 1. Hepatic Encephalopathy 2. Alcohol Withdrawal 3. Alcoholic Cirrhosis 4. Pneumonia Secondary Diagnosis: 1. Diabetes Mellitus, Type 2, uncontrolled 2. Depression 3. Thrombocytopenia Secondary Diagnosis: Discharge Condition: Stable. Discharge Instructions: You were admitted with confusion. This was likely due to both encephalopathy as well as alcohol withdrawal. You were monitored closely. You were restartd on lactulose to help with your confusion. You were given medications to help prevent alcohol withdrawal. You MUST stop drinking alcohol. Please continue to take your medications as prescribed. The following changes have been made: Please take the antibiotic, Levofloxacin 750mg daily, for pneumonia for 5 days. Please keep all your medical appointments. If you have any of the following symptoms, please call your doctor or go to the nearest ER: fever > 101, chest pain, abdominal pain, shortness of breath, bright red blood per rectum, black or red stools, vomiting red blood, confusion, or any other concerning symptoms. Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42325**]. Please call [**Telephone/Fax (1) 31553**] to reschedule. Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-12-22**] 8:40 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2180-1-7**] 9:15 Completed by:[**2179-12-1**]",40,2179-11-21 20:59:00,2179-11-27 14:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ENCEPHALOPATHY," pt is a 56 yo m with h/o etoh cirrhosis s/p tips with multiple revisions here with confusion/ agitation. . 1. confusion: likely [**3-13**] hepatic encephalopathy as pts relative reports he is non-compliant with lactulose at home. the relative also reports pt has been drinking etoh at home although tox screens in ed were negative. he was admitted and started on lactulose however [**3-13**] agitation and non-compliance he had to be given lactulose via enema. on the afternoon of [**11-22**], he became briefly unresponsive on the floor. he continued to protect his airway during this episode and woke up as abg was being drawn however he was transferred to the micu for closer monitoring. on the morning of [**11-23**] he was transferred back to the floor with an ngt in place through which he was recieving lactulose. with this, he slowly began to clear over the next several days and his lactulose was gradually tapered to 30 ml qid at the time of discharge. pt has a h/o dt with persistently elevated ciwa during the first 4 days of this admission. thus, withdrawl was also likely contributing to some confusion as could benzos used to treat withdrwal. pts tips was initially unable to be fully assessed [**3-13**] pts inability to comply with exam. however, us on [**11-23**] showed the posterior tips to be patent. finally, infection could have been a contributer to the pts confusion. he had a temp to 103 reportedly in ed and was put on ceftriaxone for presumptive sbp. however, sbp seemed unlikely as pt had never c/o abd pain, spiked another fever, and had limited ascites. fever in ed could have been [**3-13**] agitation, etoh withdrawl and/or acute alcoholic hepatitis. thus, cefriaxone was discontinued on [**11-23**]. however, fever recurred on [**11-25**] and [**11-26**]. blood and urine cultures were ordered and negative. there was thought to be too little ascitic fluid to tap. cxr showed likely aspiration pna and the pt was put on ceftriaxone and azithromycin. this was changed to po levofloxacin for a planned 4 more days of antibiotic treatment at discharge. of note, on [**2179-11-27**] the pt was sufficiently cleared to insist that he be discharged and state that he would not stay in the hospital for further treatment. he was discharged home on levofloxacin, lactulose and rifaximin. . 2. etoh cirrhosis s/p tips: meld on admission 22. lfts all incr at admission stabilized by discharge with t bili down to 8.8 on [**11-27**]. lasix and spironolactone were held [**3-13**] hypernatremia early in the admission. spironolactone was restarted prior to discharge but lasix was not as pt was still having tenuous bp. he should follow up with his pcp to restart this. continued home mvi, thiamine, folic acid, nadolol and omeprazole. . 3. dm type [**name (ni) **] pt non-compliant with insulin per relatives report at home. he was kept on a hiss and lantus regimen here and discharged on lantus at the increased dose of 38 units daily which he required here. . 4. h/o depression- initially help amitryptyline while pt sedated but this was restarted prior to discharge. . 5. thrombocytopenia- likely [**3-13**] liver pathology, recent etoh use. no signs of bleeding, stable at discharge. ","PRIMARY: [Hepatic encephalopathy] SECONDARY: [Pneumonia, organism unspecified; Alcohol withdrawal; Alcoholic cirrhosis of liver; Portal hypertension; Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled; Depressive disorder, not elsewhere classified; Thrombocytopenia, unspecified; Hypopotassemia; Anemia of other chronic disease; Tobacco use disorder]","pt is a 56 yo m with h/o etoh cirrhosis s/p tips with multiple revisions here with confusion/ agitation. on the afternoon of [**11-22**], he became briefly unresponsive on the floor. on the morning of [**11-23**] he was transferred back to the floor with an ngt in place through which he was recieving lactulose. thus, withdrawl was also likely contributing to some confusion as could benzos used to treat withdrwal. he was discharged home on levofloxacin, lactulose and rifaximin. lasix and spironolactone were held [**3-13**] hypernatremia early in the admission. thrombocytopenia- likely [**3-13**] liver pathology, recent etoh use.","pt is a 56 yo m with h/o etoh cirrhosis s/p tips with multiple revisions here with confusion/ agitation. he was admitted and started on lactulose however [**3-13**] agitation and non-compliance he had to be given lactulose via enema. on the afternoon of [**11-22**], he became briefly unresponsive on the floor." 13305,122062.0,14241,2179-11-27,14240,181328.0,2179-08-31,Discharge summary,"Admission Date: [**2179-8-27**] Discharge Date: [**2179-8-31**] Date of Birth: [**2123-3-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 330**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: TIPS evaluation and Redo History of Present Illness: 56M with EtOH cirrhosis s/p TIPS x2 (last [**2176**]), DM2, who is admitted to the MICU for hematemesis x1. The patient states that this AM, he started on cymbalta for his peripheral neuropathy, and 1 hour after taking the medication, he felt nauseous and vomited. He vomited a few times, that were mostly bilious, but at 11 AM, he vomited bright red blood. He states that it was a small cup worth, mostly just streaked with blood, but concerned enough to bring him to the ED. He denies chest pain, SOB, lightheadedness, dizziness, abdominal pain, melena, BRBPR. Of note, he was admitted [**6-17**] for hematemesis as well. . In the ED, vitals were 98.7, 129/73, 82, 18, 97% RA. He was found to be guaiac negative. He had hypokalemia which was repleted, and he had an abdominal US with dopplers to evaluate his TIPS. He was given pantoprazole 40 mg IV x 1 and zofran x 1. He was then transferred to the MICU for further evaluation. Past Medical History: 1. Alcoholic cirrhosis - hx of esophageal variceal bleed and hepatic encephalopathy. He has had 2 TIPS procedures with stent placement in [**2166**] and again in [**2176**]. 2. Chronic pancreatitis complicated by a parapancreatic cyst that was infected with enteroccocus and coagulase negative. On vancomycin from [**Date range (2) 42329**] then linezolid [**Date range (1) 42330**]. 3. Type 2 DM on insulin 4. Anemia of chronic disease 5. Thrombocytopenia 6. Depression 7. Umbilical Hernia 8. History of delerium tremens Social History: He lives alone. He is currently unemployed.Has three children. He has a history of heavy alcohol use but none since [**4-14**]. Smokes 1.5 PPD. No IVDU, no other illicits. Family History: father - cirrhosis Physical Exam: VS: 97.7 129/101 76 13 98% 2L GEN: WD male, NAD, pleasant HEENT: + scleral icterus; PERRL CV: RRR- distant LUNGS: few bibasilar rhonci. otherwise clear ADBOMEN: soft, slightly distended, no tenderness. + dullness to percussion. hepatic edge not palpable. guaiac negative per ED notes EXT: trace pedal edema NEURO: A/O x 3; no asterxis Pertinent Results: [**2179-8-27**] 02:40PM PT-17.3* PTT-32.4 INR(PT)-1.6* PLT COUNT-107* WBC-7.7 RBC-3.49* HGB-11.5* HCT-34.4* MCV-99* MCH-33.1* MCHC-33.5 RDW-16.5* ALBUMIN-3.2* LIPASE-28 ALT(SGPT)-25 AST(SGOT)-43* ALK PHOS-225* TOT BILI-4.8* GLUCOSE-378* UREA N-10 CREAT-0.9 SODIUM-132* POTASSIUM-2.8* CHLORIDE-95* TOTAL CO2-25 ANION GAP-15 [**2179-8-27**] 07:39PM HCT-31.3* CHEST (PA & LAT) Study Date of [**2179-8-27**] 3:49 PM FINDINGS: There are bibasal effusions with consolidation in the right lower lobe. The heart and mediastinum appear unremarkable. There is a TIPS catheter in the right upper quadrant. The focal opacity in the right lower lobe may represent an early pneumonia or aspiration. DUPLEX DOPP ABD/PEL Study Date of [**2179-8-27**] 4:26 PM Doppler son[**Name (NI) **] for TIPS evaluation demonstrate two TIPS, one of them is completely occluded, the second one has appropriate wall-to-wall flow with velocities ranging from 94-155 cm/sec, considerably higher than prior study, suggesting in stent stenosis. REVISN HEPATIC SHUNT TIPS Study Date of [**2179-8-30**] 2:41 IMPRESSION: 1. Pre-angioplasty portal venogram demonstrating focal stenosis of the distal (hepatic vein end) aspect of the TIPS shunt. 2. Angioplasty with 10 x 40 mm balloon with improved flow on post-angioplasty portal venogram. 3. Drop in portosystemic gradient from 19 mmHg to 9 mmHg. Brief Hospital Course: 56 yo M with Ethanol Induced Cirrhosis, Upper GI bleed s/p TIPS who was admitted for hematemesis. # Hematemesis: The patient was admitted to the ICU. On initial presentation in the ED, vitals were 98.7, 129/73, 82, 18, 97% RA. He was found to be guaiac negative. He had hypokalemia which was repleted, and he had an abdominal US with Dopplers to evaluate his TIPS which was initially reported to be patent. He was given pantoprazole 40 mg IV x 1 and Zofran x 1. He was then transferred to the MICU for further evaluation. In the MICU, he was started on an octreotide gtt. Serial hematocrits were monitored and were stable not requiring any transfusions. He had no further episodes of vomiting and was tolerating clears without difficulty. His octreotide gtt was discontinued and he was transferred to the Hepatorenal service. # Ethanol Induced Cirrhosis: The patient had a history of TIPs and these were evaluated on admission. Although initially reported as patent, repeat review showed evidence of stenosis and the patient underwent a successful TIPs revision. At the time of discharge, the patient was doing well, tolerating a regular diet and was without pain. He was discharged with follow-up in the [**Hospital **] clinic. # Pneumonia: A chest x-ray in the ED was concerning for a RLL infiltrate suspicious for a pneumonia or aspiration. The patient was started on Levaquin. He received a 5 day course of antibiotics. The patient was afebrile and without evidence of pneumonia at discharge. # Diabetic Neuropathy: The patient's initial presentation appeared to be related to cymbalta which the patient was prescribed for treatment diabetic neuropathy of his feet. The patient was started on Amitriptyline as an alternative medication. The patient responded well to this therapy and was given instructions to follow-up with his primary care physician regarding maintenance of this medication. Medications on Admission: 1. Folic Acid 1 mg daily 2. Furosemide 40 mg daily 3. Insulin Glargine 34 mg hs 4. Lispro SS 5. Lactulose 30mL 3-4x/day 6. Pantoprazole 40 mg PO daily 7. Pregabalin 100 mg PO BID 8. Rifaximin 400 mg PO tid 9. Aldactone 100 mg PO daily 10. Multivitamin daily 11. Sucralfate 1 gram PO QID Discharge Medications: 1. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 3. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO twice a day. 4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. Aldactone 100 mg Tablet Sig: 1.5 Tablets PO once a day. 8. Lantus 100 unit/mL Solution Sig: One (1) 34 Subcutaneous at bedtime. 9. Insulin Lispro 100 unit/mL Solution Sig: One (1) units Subcutaneous PRN. 10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Hematemesis EtOH Induced Cirrhosis Diabetic Neuropathy Community Acquired Pneumonia Seconday Diagnoses: Diabetes Discharge Condition: Hemodynamically stable, afebrile and without pain. Discharge Instructions: You were admitted for concern for nausea, vomiting and gastrointestinal bleeding. You did not have any bleeding while in the hospital. Your nausea improved and appeared to be realated to taking Cymbalta. Given your history of espohageal bleeding, an ultrasound of your liver was performed which showed your TIPS was occluded. This was corrected with a TIPS revision procedure. You are have follow-up with the liver center on [**9-14**]. Please attend this appointment as scheduled. In addition, you will need re-evaluation of your TIPS with an outpatient ultrasound. This was scheduled for the same day as your Liver center appointment ([**9-14**]). This is scheduled for 10:30AM. You cannot eat or drink after midnight the evening prior to this study. On your admission, you appeared to have a pneumonia. You have completed a 7 day course of antibiotics. You do not appear to have any ongoing symptoms but you should follow-up with your primary care physician. You have been reporting foot pain which had been treated with lyrica and cymbalta. Because these medications did not work for you, we have started you on a new medication (Amitryptiline) which seems to have helped. You are being discharged with a prescription for this medication. Please take as directed and follow-up with your primary care provider. Because of the side effects you experiencec with Cymbalata, you should not take this medication. Please continue to take all other previously prescribed medications as directed. You should call your physician or seek medical attendion if you experience nausea, vomiting, vomiting blood, dark tarry stools, abdominal pain, diarrhea, shortness of breath, chest pain, cough or any other concerning symptom. Followup Instructions: TIPS Ultrasound [**2179-9-14**] [**Hospital Ward Name 23**] Building 10:30 am Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2179-9-14**] 8:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2179-9-14**] 8:30 Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-9-13**] 9:15 Completed by:[**2179-9-2**]",88,2179-08-27 16:10:00,2179-08-31 19:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,UPPER GI BLEED," 56 yo m with ethanol induced cirrhosis, upper gi bleed s/p tips who was admitted for hematemesis. # hematemesis: the patient was admitted to the icu. on initial presentation in the ed, vitals were 98.7, 129/73, 82, 18, 97% ra. he was found to be guaiac negative. he had hypokalemia which was repleted, and he had an abdominal us with dopplers to evaluate his tips which was initially reported to be patent. he was given pantoprazole 40 mg iv x 1 and zofran x 1. he was then transferred to the micu for further evaluation. in the micu, he was started on an octreotide gtt. serial hematocrits were monitored and were stable not requiring any transfusions. he had no further episodes of vomiting and was tolerating clears without difficulty. his octreotide gtt was discontinued and he was transferred to the hepatorenal service. # ethanol induced cirrhosis: the patient had a history of tips and these were evaluated on admission. although initially reported as patent, repeat review showed evidence of stenosis and the patient underwent a successful tips revision. at the time of discharge, the patient was doing well, tolerating a regular diet and was without pain. he was discharged with follow-up in the [**hospital **] clinic. # pneumonia: a chest x-ray in the ed was concerning for a rll infiltrate suspicious for a pneumonia or aspiration. the patient was started on levaquin. he received a 5 day course of antibiotics. the patient was afebrile and without evidence of pneumonia at discharge. # diabetic neuropathy: the patients initial presentation appeared to be related to cymbalta which the patient was prescribed for treatment diabetic neuropathy of his feet. the patient was started on amitriptyline as an alternative medication. the patient responded well to this therapy and was given instructions to follow-up with his primary care physician regarding maintenance of this medication. ","PRIMARY: [Hematemesis] SECONDARY: [Pneumonia, organism unspecified; Other complications due to other vascular device, implant, and graft; Chronic pancreatitis; Portal hypertension; Alcoholic cirrhosis of liver; Other and unspecified alcohol dependence, unspecified; Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled; Polyneuropathy in diabetes; Hypopotassemia; Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure; Anemia of other chronic disease; Thrombocytopenia, unspecified; Depressive disorder, not elsewhere classified; Umbilical hernia without mention of obstruction or gangrene; Long-term (current) use of insulin; Awaiting organ transplant status; Hypotension, unspecified; Hypoxemia; Esophageal varices in diseases classified elsewhere, without mention of bleeding]","56 yo m with ethanol induced cirrhosis, upper gi bleed s/p tips who was admitted for hematemesis. he had no further episodes of vomiting and was tolerating clears without difficulty. # ethanol induced cirrhosis: the patient had a history of tips and these were evaluated on admission. he was discharged with follow-up in the [**hospital **] clinic.","56 yo m with ethanol induced cirrhosis, upper gi bleed s/p tips who was admitted for hematemesis. on initial presentation in the ed, vitals were 98.7, 129/73, 82, 18, 97% ra. he was found to be guaiac negative. he was given pantoprazole 40 mg iv x 1 and zofran x 1." 13305,122062.0,14241,2179-11-27,14239,126212.0,2179-07-07,Discharge summary,"Admission Date: [**2179-7-5**] Discharge Date: [**2179-7-7**] Date of Birth: [**2123-3-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 943**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: Esophagoduodenoscopy History of Present Illness: 56M with EtOH cirrhosis s/p TIPS who was admitted for hematemesis to MICU for 24 hours and then to the floor. Pt presented with hematemesis on [**7-5**]. Pt was hemodynamically stable with hct of 36.4 from 39.5 (checked on [**6-29**]) and was admitted to MICU. Liver was notified and performed an EGD in am which showed 3 cords of grade I - II varices and esophageal erosions without evidence of bleeding . They recommended high dose PPI and carafate. Pt had no further episodes of hematemasis and was started on diet. Pt's subsequently had a decrease in hct to 29.9 at 4 pm and then 29.8 at 8 pm and 27 at 1 am on [**7-6**]. Pt also underwent liver u/s with dopplers which showed that the TIPS remained patent. . Pt currently denies dizziness, cp, sob, abd pain, nausea, vomiting. Current vs in micu before transfer were 98.6, 93 110/61 17 98% RA. Past Medical History: 1. Alcoholic cirrhosis - hx of esophageal variceal bleed and hepatic encephalopathy. He has had 2 TIPS procedures with stent placement in [**2166**] and again in [**2176**]. 2. Chronic pancreatitis complicated by a parapancreatic cyst that was infected with enteroccocus and coagulase negative. On vancomycin from [**Date range (2) 42329**] then linezolid [**Date range (1) 42330**]. 3. Type 2 DM on insulin 4. Anemia of chronic disease 5. Thrombocytopenia 6. Depression 7. Umbilical Hernia 8. History of delerium tremens Social History: He lives alone. He is currently unemployed.Has three children. He has a history of heavy alcohol use but none since [**4-14**]. Smokes 1.5 PPD. No IVDU, no other illicits. Family History: father - cirrhosis Physical Exam: PE: T 98.6 HR 93 BP 110/61 RR 17 O2 sat 98% RA Gen: awake, alert, NAD HEENT: NCAT, scleral icterus, PERRL, EOMI, OP clear, MMM CV: RRR, no m/r/g Pulm: diffuse wheezing Abd: soft, NT, ND Ext: no c/c/e no asterixis Pertinent Results: Liver US: FINDINGS: [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 493**] images were obtained, liver is markedly coarsened and echogenic, consistent with known history of cirrhosis. There is a failed TIPS stent in the right lobe of the liver without internal flow. Adjacent to it, there is an active TIPS with wall-to- wall flow and velocities in the proximal, mid and distal TIPS measured at 22, 30, and 66 cm/sec respectively, compared to 42, 74, and 90 cm/sec previously. Hepatopetal flow is noted in the main portal vein, with velocity of approximately 23 cm/sec, compared to 29 cm/sec previously. Again noted is a cholelithiasis, without evidence of acute cholecystitis. There is no perihepatic ascites. There is no intra- or extra-hepatic biliary ductal dilatation. Common duct measures 4 mm. IMPRESSION: Patent TIPS with wall-to-wall flow; internal velocities are slightly lower than on the prior study. . [**2179-7-7**] 05:55AM BLOOD WBC-8.0 RBC-2.58* Hgb-9.7* Hct-27.9* MCV-108* MCH-37.5* MCHC-34.7 RDW-14.5 Plt Ct-80* [**2179-7-6**] 01:16AM BLOOD WBC-6.9 RBC-2.48*# Hgb-9.4* Hct-27.3* MCV-110* MCH-38.0* MCHC-34.5 RDW-14.9 Plt Ct-76* [**2179-7-5**] 06:22AM BLOOD WBC-8.3 RBC-3.32* Hgb-12.2* Hct-36.4* MCV-110* MCH-36.6* MCHC-33.4 RDW-14.7 Plt Ct-109* [**2179-7-5**] 06:22AM BLOOD PT-15.5* PTT-33.8 INR(PT)-1.4* [**2179-7-7**] 05:55AM BLOOD PT-15.5* PTT-30.7 INR(PT)-1.4* [**2179-7-5**] 06:22AM BLOOD Glucose-430* UreaN-13 Creat-1.0 Na-127* K-3.7 Cl-90* HCO3-22 AnGap-19 [**2179-7-6**] 01:16AM BLOOD Glucose-346* UreaN-12 Creat-0.9 Na-129* K-3.9 Cl-97 HCO3-25 AnGap-11 [**2179-7-6**] 05:15AM BLOOD Glucose-394* UreaN-11 Creat-0.9 Na-128* K-4.1 Cl-96 HCO3-24 AnGap-12 [**2179-7-7**] 05:55AM BLOOD Glucose-237* UreaN-10 Creat-0.7 Na-130* K-3.2* Cl-96 HCO3-25 AnGap-12 [**2179-7-6**] 05:15AM BLOOD ALT-44* AST-82* LD(LDH)-275* AlkPhos-265* TotBili-6.4* [**2179-7-7**] 05:55AM BLOOD Calcium-8.5 Phos-1.8* Mg-1.7 Brief Hospital Course: A/P: 56M with EtOH cirrhosis s/p TIPS presents for hematemesis . #. Hematemesis: s/p EGD showing nonbleeding esophageal varices and esophageal erosions/esophagitis. There was no clear ulcer visualized. It was felt his bleeding were due to GE junction erosions and microtears. No overt M-W tears were visualized. His hematocrit did drop initially which may have been dilutional but there after remained stable. Patient should continue on PPI and sucrafate. He will follow up in liver clinic. . #. DM2: - patient was continued on his home dose of lantus with a sliding scale. . #. Cirrhosis: TIPS patent on ultrasound. His aldactone, lasix were restarted on [**7-6**] with stable renal function. Patient was continued on rifaxamin, lactulose. He was continued CTX for SBP ppx for 3 days but due to true variceal bleeding his antibiotics were discontinued. Patient should continue on mvi, folic acid. . #. Full code Medications on Admission: Meds: at home folic acid 1 mg per day, Furosemide 40 mg per day, glargine insulin 36 units at night SSI lactulose 30 cc three to four times per day, Protonix one tablet per day (40 mg), Lyrica 100 mg twice a day, rifaximin 200 mg two tablets three times a day, Aldactone 150 mg per day multivitamin one tablet daily. . Meds on transfer to [**Hospital1 18**]: Aluminum-magnesium hydrox-simethicone 15-30cc po qid/prn Ceftriaxone 1gm iv q24h folic acid 1mg po qday gabapentin 600mg po q8h insulin SS lactulose 30mg po tid lyrica 100mg po bid morphin sulfate 1mg iv q4h/prn pantoprazole 40mg po q24 prochlorperazine 10mg po/iv q6h/prn rifaximin 200mg po tid sucralfate 1mg po qid Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Insulin Glargine 100 unit/mL Cartridge Sig: Thirty Four (34) units Subcutaneous at bedtime. 4. Insulin Lispro 100 unit/mL Cartridge Sig: per sliding scale Subcutaneous four times a day: inject subcutaenously four times a day according to sliding scale. 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three to four times a day. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. Pregabalin 25 mg Capsule Sig: Four (4) Capsule PO BID (2 times a day). 8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Aldactone 50 mg Tablet Sig: Two (2) Tablet PO once a day. 10. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Hematemesis Secondary: Alcoholic cirrhosis Chronic pancreatitis Type 2 DM Anemia of chronic disease Thrombocytopenia Depression Discharge Condition: Vitals stable. Hematocrit stable. No bleeding. Discharge Instructions: You were admitted after vomiting up a small amount of blood. You had an EGD which showed that you have esophageal varices and ulceration of your esophagus, but no active bleeding. You should continue to take all medications as prescribed. If you develop further bleeding, chest pain, shortness of breath, or other concerning symptoms, you should return to the emergency room. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-8-4**] 10:00 Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-7-8**] 8:30 Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-9-15**] 8:00 Completed by:[**2179-7-9**]",143,2179-07-05 06:39:00,2179-07-07 16:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,UPPER GI BLEED," a/p: 56m with etoh cirrhosis s/p tips presents for hematemesis . #. hematemesis: s/p egd showing nonbleeding esophageal varices and esophageal erosions/esophagitis. there was no clear ulcer visualized. it was felt his bleeding were due to ge junction erosions and microtears. no overt m-w tears were visualized. his hematocrit did drop initially which may have been dilutional but there after remained stable. patient should continue on ppi and sucrafate. he will follow up in liver clinic. . #. dm2: - patient was continued on his home dose of lantus with a sliding scale. . #. cirrhosis: tips patent on ultrasound. his aldactone, lasix were restarted on [**7-6**] with stable renal function. patient was continued on rifaxamin, lactulose. he was continued ctx for sbp ppx for 3 days but due to true variceal bleeding his antibiotics were discontinued. patient should continue on mvi, folic acid. . #. full code ","PRIMARY: [Hematemesis] SECONDARY: [Chronic pancreatitis; Alcoholic cirrhosis of liver; Thrombocytopenia, unspecified; Anemia, unspecified; Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled]","a/p: 56m with etoh cirrhosis s/p tips presents for hematemesis . patient should continue on mvi, folic acid.",56m with etoh cirrhosis s/p tips presents for hematemesis. bleeding was due to erosions and microtears. patient should continue on ppi and sucrafate. 13305,106092.0,14242,2180-01-06,14240,181328.0,2179-08-31,Discharge summary,"Admission Date: [**2179-8-27**] Discharge Date: [**2179-8-31**] Date of Birth: [**2123-3-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 330**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: TIPS evaluation and Redo History of Present Illness: 56M with EtOH cirrhosis s/p TIPS x2 (last [**2176**]), DM2, who is admitted to the MICU for hematemesis x1. The patient states that this AM, he started on cymbalta for his peripheral neuropathy, and 1 hour after taking the medication, he felt nauseous and vomited. He vomited a few times, that were mostly bilious, but at 11 AM, he vomited bright red blood. He states that it was a small cup worth, mostly just streaked with blood, but concerned enough to bring him to the ED. He denies chest pain, SOB, lightheadedness, dizziness, abdominal pain, melena, BRBPR. Of note, he was admitted [**6-17**] for hematemesis as well. . In the ED, vitals were 98.7, 129/73, 82, 18, 97% RA. He was found to be guaiac negative. He had hypokalemia which was repleted, and he had an abdominal US with dopplers to evaluate his TIPS. He was given pantoprazole 40 mg IV x 1 and zofran x 1. He was then transferred to the MICU for further evaluation. Past Medical History: 1. Alcoholic cirrhosis - hx of esophageal variceal bleed and hepatic encephalopathy. He has had 2 TIPS procedures with stent placement in [**2166**] and again in [**2176**]. 2. Chronic pancreatitis complicated by a parapancreatic cyst that was infected with enteroccocus and coagulase negative. On vancomycin from [**Date range (2) 42329**] then linezolid [**Date range (1) 42330**]. 3. Type 2 DM on insulin 4. Anemia of chronic disease 5. Thrombocytopenia 6. Depression 7. Umbilical Hernia 8. History of delerium tremens Social History: He lives alone. He is currently unemployed.Has three children. He has a history of heavy alcohol use but none since [**4-14**]. Smokes 1.5 PPD. No IVDU, no other illicits. Family History: father - cirrhosis Physical Exam: VS: 97.7 129/101 76 13 98% 2L GEN: WD male, NAD, pleasant HEENT: + scleral icterus; PERRL CV: RRR- distant LUNGS: few bibasilar rhonci. otherwise clear ADBOMEN: soft, slightly distended, no tenderness. + dullness to percussion. hepatic edge not palpable. guaiac negative per ED notes EXT: trace pedal edema NEURO: A/O x 3; no asterxis Pertinent Results: [**2179-8-27**] 02:40PM PT-17.3* PTT-32.4 INR(PT)-1.6* PLT COUNT-107* WBC-7.7 RBC-3.49* HGB-11.5* HCT-34.4* MCV-99* MCH-33.1* MCHC-33.5 RDW-16.5* ALBUMIN-3.2* LIPASE-28 ALT(SGPT)-25 AST(SGOT)-43* ALK PHOS-225* TOT BILI-4.8* GLUCOSE-378* UREA N-10 CREAT-0.9 SODIUM-132* POTASSIUM-2.8* CHLORIDE-95* TOTAL CO2-25 ANION GAP-15 [**2179-8-27**] 07:39PM HCT-31.3* CHEST (PA & LAT) Study Date of [**2179-8-27**] 3:49 PM FINDINGS: There are bibasal effusions with consolidation in the right lower lobe. The heart and mediastinum appear unremarkable. There is a TIPS catheter in the right upper quadrant. The focal opacity in the right lower lobe may represent an early pneumonia or aspiration. DUPLEX DOPP ABD/PEL Study Date of [**2179-8-27**] 4:26 PM Doppler son[**Name (NI) **] for TIPS evaluation demonstrate two TIPS, one of them is completely occluded, the second one has appropriate wall-to-wall flow with velocities ranging from 94-155 cm/sec, considerably higher than prior study, suggesting in stent stenosis. REVISN HEPATIC SHUNT TIPS Study Date of [**2179-8-30**] 2:41 IMPRESSION: 1. Pre-angioplasty portal venogram demonstrating focal stenosis of the distal (hepatic vein end) aspect of the TIPS shunt. 2. Angioplasty with 10 x 40 mm balloon with improved flow on post-angioplasty portal venogram. 3. Drop in portosystemic gradient from 19 mmHg to 9 mmHg. Brief Hospital Course: 56 yo M with Ethanol Induced Cirrhosis, Upper GI bleed s/p TIPS who was admitted for hematemesis. # Hematemesis: The patient was admitted to the ICU. On initial presentation in the ED, vitals were 98.7, 129/73, 82, 18, 97% RA. He was found to be guaiac negative. He had hypokalemia which was repleted, and he had an abdominal US with Dopplers to evaluate his TIPS which was initially reported to be patent. He was given pantoprazole 40 mg IV x 1 and Zofran x 1. He was then transferred to the MICU for further evaluation. In the MICU, he was started on an octreotide gtt. Serial hematocrits were monitored and were stable not requiring any transfusions. He had no further episodes of vomiting and was tolerating clears without difficulty. His octreotide gtt was discontinued and he was transferred to the Hepatorenal service. # Ethanol Induced Cirrhosis: The patient had a history of TIPs and these were evaluated on admission. Although initially reported as patent, repeat review showed evidence of stenosis and the patient underwent a successful TIPs revision. At the time of discharge, the patient was doing well, tolerating a regular diet and was without pain. He was discharged with follow-up in the [**Hospital **] clinic. # Pneumonia: A chest x-ray in the ED was concerning for a RLL infiltrate suspicious for a pneumonia or aspiration. The patient was started on Levaquin. He received a 5 day course of antibiotics. The patient was afebrile and without evidence of pneumonia at discharge. # Diabetic Neuropathy: The patient's initial presentation appeared to be related to cymbalta which the patient was prescribed for treatment diabetic neuropathy of his feet. The patient was started on Amitriptyline as an alternative medication. The patient responded well to this therapy and was given instructions to follow-up with his primary care physician regarding maintenance of this medication. Medications on Admission: 1. Folic Acid 1 mg daily 2. Furosemide 40 mg daily 3. Insulin Glargine 34 mg hs 4. Lispro SS 5. Lactulose 30mL 3-4x/day 6. Pantoprazole 40 mg PO daily 7. Pregabalin 100 mg PO BID 8. Rifaximin 400 mg PO tid 9. Aldactone 100 mg PO daily 10. Multivitamin daily 11. Sucralfate 1 gram PO QID Discharge Medications: 1. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 3. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO twice a day. 4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. Aldactone 100 mg Tablet Sig: 1.5 Tablets PO once a day. 8. Lantus 100 unit/mL Solution Sig: One (1) 34 Subcutaneous at bedtime. 9. Insulin Lispro 100 unit/mL Solution Sig: One (1) units Subcutaneous PRN. 10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Hematemesis EtOH Induced Cirrhosis Diabetic Neuropathy Community Acquired Pneumonia Seconday Diagnoses: Diabetes Discharge Condition: Hemodynamically stable, afebrile and without pain. Discharge Instructions: You were admitted for concern for nausea, vomiting and gastrointestinal bleeding. You did not have any bleeding while in the hospital. Your nausea improved and appeared to be realated to taking Cymbalta. Given your history of espohageal bleeding, an ultrasound of your liver was performed which showed your TIPS was occluded. This was corrected with a TIPS revision procedure. You are have follow-up with the liver center on [**9-14**]. Please attend this appointment as scheduled. In addition, you will need re-evaluation of your TIPS with an outpatient ultrasound. This was scheduled for the same day as your Liver center appointment ([**9-14**]). This is scheduled for 10:30AM. You cannot eat or drink after midnight the evening prior to this study. On your admission, you appeared to have a pneumonia. You have completed a 7 day course of antibiotics. You do not appear to have any ongoing symptoms but you should follow-up with your primary care physician. You have been reporting foot pain which had been treated with lyrica and cymbalta. Because these medications did not work for you, we have started you on a new medication (Amitryptiline) which seems to have helped. You are being discharged with a prescription for this medication. Please take as directed and follow-up with your primary care provider. Because of the side effects you experiencec with Cymbalata, you should not take this medication. Please continue to take all other previously prescribed medications as directed. You should call your physician or seek medical attendion if you experience nausea, vomiting, vomiting blood, dark tarry stools, abdominal pain, diarrhea, shortness of breath, chest pain, cough or any other concerning symptom. Followup Instructions: TIPS Ultrasound [**2179-9-14**] [**Hospital Ward Name 23**] Building 10:30 am Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2179-9-14**] 8:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2179-9-14**] 8:30 Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] CENTER - NON BILLING Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2179-9-13**] 9:15 Completed by:[**2179-9-2**]",128,2179-08-27 16:10:00,2179-08-31 19:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,UPPER GI BLEED," 56 yo m with ethanol induced cirrhosis, upper gi bleed s/p tips who was admitted for hematemesis. # hematemesis: the patient was admitted to the icu. on initial presentation in the ed, vitals were 98.7, 129/73, 82, 18, 97% ra. he was found to be guaiac negative. he had hypokalemia which was repleted, and he had an abdominal us with dopplers to evaluate his tips which was initially reported to be patent. he was given pantoprazole 40 mg iv x 1 and zofran x 1. he was then transferred to the micu for further evaluation. in the micu, he was started on an octreotide gtt. serial hematocrits were monitored and were stable not requiring any transfusions. he had no further episodes of vomiting and was tolerating clears without difficulty. his octreotide gtt was discontinued and he was transferred to the hepatorenal service. # ethanol induced cirrhosis: the patient had a history of tips and these were evaluated on admission. although initially reported as patent, repeat review showed evidence of stenosis and the patient underwent a successful tips revision. at the time of discharge, the patient was doing well, tolerating a regular diet and was without pain. he was discharged with follow-up in the [**hospital **] clinic. # pneumonia: a chest x-ray in the ed was concerning for a rll infiltrate suspicious for a pneumonia or aspiration. the patient was started on levaquin. he received a 5 day course of antibiotics. the patient was afebrile and without evidence of pneumonia at discharge. # diabetic neuropathy: the patients initial presentation appeared to be related to cymbalta which the patient was prescribed for treatment diabetic neuropathy of his feet. the patient was started on amitriptyline as an alternative medication. the patient responded well to this therapy and was given instructions to follow-up with his primary care physician regarding maintenance of this medication. ","PRIMARY: [Hematemesis] SECONDARY: [Pneumonia, organism unspecified; Other complications due to other vascular device, implant, and graft; Chronic pancreatitis; Portal hypertension; Alcoholic cirrhosis of liver; Other and unspecified alcohol dependence, unspecified; Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled; Polyneuropathy in diabetes; Hypopotassemia; Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure; Anemia of other chronic disease; Thrombocytopenia, unspecified; Depressive disorder, not elsewhere classified; Umbilical hernia without mention of obstruction or gangrene; Long-term (current) use of insulin; Awaiting organ transplant status; Hypotension, unspecified; Hypoxemia; Esophageal varices in diseases classified elsewhere, without mention of bleeding]","56 yo m with ethanol induced cirrhosis, upper gi bleed s/p tips who was admitted for hematemesis. he had no further episodes of vomiting and was tolerating clears without difficulty. # ethanol induced cirrhosis: the patient had a history of tips and these were evaluated on admission. he was discharged with follow-up in the [**hospital **] clinic.","56 yo m with ethanol induced cirrhosis, upper gi bleed s/p tips who was admitted for hematemesis. on initial presentation in the ed, vitals were 98.7, 129/73, 82, 18, 97% ra. he was found to be guaiac negative. he was given pantoprazole 40 mg iv x 1 and zofran x 1." 15853,111874.0,23002,2174-12-02,23001,199461.0,2174-11-25,Discharge summary,"Admission Date: [**2174-11-21**] Discharge Date: [**2174-11-25**] Date of Birth: [**2098-2-28**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6346**] Chief Complaint: Abdominal pain, Nausea/Vomiting Major Surgical or Invasive Procedure: None. History of Present Illness: 76 year-old gentleman with known ventral hernia presents with vomiting and abdominal pain. The abdominal pain began suddenly at 6PM to the left of midline where the patient has known about a hernia for ""years."". The pain was persistent and rated [**9-5**]. The EMTs came to pick the patient up and witnessed him vomit approximately 500 cc of dark emesis. Upon arrival to [**Hospital1 18**], the patient is still in pain, but pain is relieved with morphine. He is still nauseated. He denies fevers/chills. Last BM was yesterday and he is not passing flatus. Past Medical History: 1. He had a ventral hernia repair in [**2174**] that has subsequently recurred his hernia. 2. sub-pubic lipoma 3. ? back surgery in the past 4. Severe Aortic Stenosis Social History: He is a veteran of the Korean war. He worked for [**Location (un) **] township until the age of 30 when he retired due to back pain. He lives alone. He drinks 1 case of beer per week and [**1-28**] quarts of wine per week. He has a 60 pack-year smoking history, but he quit 20 years ago. Family History: His family history is only significant for hypertension. Physical Exam: On Admission VS: T 97.2, HR 89, BP 158/70, RR 20, 94%RA GEN: NAD, A&O x 3 LUNGS: Clear B/L CV: Irregularly irregular, nl S1 and S2 ABD: Soft, slightly TTP to left of midline where there is a prominent hernia, hernia is reducible when patient relaxes but reexpands immediately after, ND, no guarding, no rebound, no palpable groin hernias RECTAL: Guaiac neg EXT: 1+ edema of LE B/L At Discharge 96.6 120 110/80 20 96% RA Gen: A&Ox3, talkative and pleasant Lungs: decreased b/s at bases b/l CV: irreg irreg, tachycardic, [**5-2**] blowing systolic murmur at left sternal border Abd: soft, non-tender, easily reducable ventral hernia. Inguinal hernia firm, unchanged from admission Ext: no edema Pertinent Results: [**2174-11-20**] 10:45PM BLOOD WBC-5.7 RBC-4.44* Hgb-14.9 Hct-44.4 MCV-100* MCH-33.5* MCHC-33.6 RDW-14.4 Plt Ct-113* [**2174-11-21**] 09:05AM BLOOD WBC-2.3*# RBC-3.87* Hgb-13.5* Hct-38.9* MCV-100* MCH-34.8* MCHC-34.7 RDW-13.7 Plt Ct-91* [**2174-11-23**] 12:45PM BLOOD WBC-4.9 RBC-3.82* Hgb-12.7* Hct-38.1* MCV-100* MCH-33.4* MCHC-33.4 RDW-14.2 Plt Ct-111* [**2174-11-24**] 02:19AM BLOOD WBC-5.2 RBC-3.74* Hgb-13.0* Hct-37.5* MCV-100* MCH-34.7* MCHC-34.6 RDW-13.6 Plt Ct-96* [**2174-11-20**] 10:45PM BLOOD PT-13.8* PTT-25.7 INR(PT)-1.2* [**2174-11-20**] 10:45PM BLOOD Glucose-151* UreaN-25* Creat-1.9* Na-139 K-5.6* Cl-99 HCO3-26 AnGap-20 [**2174-11-21**] 09:05AM BLOOD Glucose-129* UreaN-25* Creat-1.8* Na-139 K-4.6 Cl-101 HCO3-27 AnGap-16 [**2174-11-23**] 12:45PM BLOOD Glucose-138* UreaN-24* Creat-1.5* Na-139 K-4.3 Cl-107 HCO3-24 AnGap-12 [**2174-11-24**] 02:19AM BLOOD Glucose-118* UreaN-28* Creat-1.4* Na-141 K-4.1 Cl-108 HCO3-22 AnGap-15 [**2174-11-21**] 12:50PM BLOOD CK(CPK)-99 [**2174-11-23**] 12:10PM BLOOD CK(CPK)-288* [**2174-11-24**] 02:19AM BLOOD CK(CPK)-245* [**2174-11-21**] 12:50PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2174-11-23**] 12:10PM BLOOD CK-MB-7 cTropnT-0.02* [**2174-11-24**] 02:19AM BLOOD CK-MB-9 [**2174-11-23**] 05:26PM BLOOD Type-ART pO2-64* pCO2-35 pH-7.43 calTCO2-24 Base XS-0 [**2174-11-24**] 02:34AM BLOOD Type-ART pO2-62* pCO2-32* pH-7.45 calTCO2-23 Base XS-0 [**2174-11-20**] 10:54PM BLOOD Lactate-3.6* [**2174-11-24**] 02:34AM BLOOD Lactate-1.3 Brief Hospital Course: Patient was admitted to the general surgery service from the emergency room on [**11-21**] with symptoms of a small bowel obstruction secondary to a large ventral hernia. He was decompressed with an NG tube and given IV fluids for resuscitation. His large ventral hernia was tender but able to be manualy decompressed. On hospital day 2 the patient stated he was feeling better and self-d/c'd his NG tube, he refused to have another placed. He agreed to be seen by cardiology and plastic surgery for pre-operative consultation regarding his large ventral hernia, but after learning that a possible component separation would be necessary and that his cardiovascular status was significantly compromised, was adamently uninterested in any surgical intervention. Cardiology performed a TTE that revealed severe aortic valve stenosis with a valvular area of 0.6cm, and stated he would be a very high risk operative candidate, recommending a valvuloplasty prior to any elective surgery. The patient understood his condition and given that he was feeling better was adament about not undergoing further testing or intervention. He was evaluated by psychiatry and deemed competent to make such decisions on his own. On hospital day 3 he was transferred to the ICU for respiratory distress, desaturation and tachypnea. He was placed on a face mask in the ICU but was clear about his wishes to be DNR/DNI, however he did not officially sign the DNR/DNI form. His wishes were corroborated with his only out of hospital contact, [**Name (NI) 9485**] [**Name (NI) 59352**], a family friend. After rate control for his afib, he was tranferred back to the floor on hospital day 4, tolerating a regular diet and sating in the mid 90s on RA. The palliative care team, social work and case management were all [**Name (NI) 653**] regarding dispo planning for this gentleman, and a tentative plan for home hospice in the form of VNA was made. He was insistent on discharge on HD3 but agreed to stay overnight for on more day to sort out his support at home. Several friends were [**Name (NI) 653**] who agreed to check in on the patient, he refused VNA or home hospice. At the time of discharge on HD 5 he was tolerating a regular diet, his vital signs were normal and the patient, nursing and medical staff agreed on a plan for him to return home with regular visits from his several friends listed above. Medications on Admission: doxazosin, lisinopril, simvastatin Discharge Medications: 1. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: One tablet by mouth Monday-Saturday. Two tablets by mouth on Sundays. Discharge Disposition: Home Discharge Diagnosis: Severe Aortic Stenosis. Ventral hernia. Resolved small bowel obstruction. Discharge Condition: Stable. Tolerating regular diet. Not currently obstructed. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Adhere to 2 gm sodium diet. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Followup Instructions: Please call Dr [**First Name (STitle) 2819**] office to schedule an appointment [**Telephone/Fax (1) 2998**] if you would like to follow-up with him for elective surgery. ",7,2174-11-21 03:19:00,2174-11-25 18:40:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,BOWEL OBSTRUCTION," patient was admitted to the general surgery service from the emergency room on [**11-21**] with symptoms of a small bowel obstruction secondary to a large ventral hernia. he was decompressed with an ng tube and given iv fluids for resuscitation. his large ventral hernia was tender but able to be manualy decompressed. on hospital day 2 the patient stated he was feeling better and self-d/cd his ng tube, he refused to have another placed. he agreed to be seen by cardiology and plastic surgery for pre-operative consultation regarding his large ventral hernia, but after learning that a possible component separation would be necessary and that his cardiovascular status was significantly compromised, was adamently uninterested in any surgical intervention. cardiology performed a tte that revealed severe aortic valve stenosis with a valvular area of 0.6cm, and stated he would be a very high risk operative candidate, recommending a valvuloplasty prior to any elective surgery. the patient understood his condition and given that he was feeling better was adament about not undergoing further testing or intervention. he was evaluated by psychiatry and deemed competent to make such decisions on his own. on hospital day 3 he was transferred to the icu for respiratory distress, desaturation and tachypnea. he was placed on a face mask in the icu but was clear about his wishes to be dnr/dni, however he did not officially sign the dnr/dni form. his wishes were corroborated with his only out of hospital contact, [**name (ni) 9485**] [**name (ni) 59352**], a family friend. after rate control for his afib, he was tranferred back to the floor on hospital day 4, tolerating a regular diet and sating in the mid 90s on ra. the palliative care team, social work and case management were all [**name (ni) 653**] regarding dispo planning for this gentleman, and a tentative plan for home hospice in the form of vna was made. he was insistent on discharge on hd3 but agreed to stay overnight for on more day to sort out his support at home. several friends were [**name (ni) 653**] who agreed to check in on the patient, he refused vna or home hospice. at the time of discharge on hd 5 he was tolerating a regular diet, his vital signs were normal and the patient, nursing and medical staff agreed on a plan for him to return home with regular visits from his several friends listed above. ","PRIMARY: [Ventral, unspecified, hernia with obstruction] SECONDARY: [Aortic valve disorders; Atrial fibrillation; Unspecified psychosis; Chronic kidney disease, unspecified; Other and unspecified hyperlipidemia; Lumbago; Other chronic pain; Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS); Personal history of venous thrombosis and embolism]","patient was admitted to the general surgery service from the emergency room on [**11-21**] with symptoms of a small bowel obstruction secondary to a large ventral hernia. on hospital day 2 the patient stated he was feeling better and self-d/cd his ng tube, he refused to have another placed. cardiology performed a tte that revealed severe aortic valve stenosis with a valvular area of 0.6cm, and stated he would be a very high risk operative candidate, recommending a valvuloplasty prior to any elective surgery. he was evaluated by psychiatry and deemed competent to make such decisions on his own.","a patient was admitted to the general surgery service with symptoms of a small bowel obstruction secondary to a large ventral hernia. on hospital day 2 the patient stated he was feeling better and self-d/cd his ng tube, he refused to have another placed. he was evaluated by psychiatry and deemed competent to make such decisions on his own." 18082,181163.0,11814,2156-03-29,11813,164053.0,2155-11-29,Discharge summary,"Admission Date: [**2155-10-29**] Discharge Date: [**2155-11-29**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Erythromycin Base / Lactose Intolerance Attending:[**First Name3 (LF) 348**] Chief Complaint: Left foot ulcer/cellulitis Major Surgical or Invasive Procedure: Picc line History of Present Illness: Mrs. [**Known lastname 31102**] is a [**Age over 90 **] yo with MMM who was admitted on [**2155-10-29**] with a left foot ulcer. She was treated w/ PO abx as outpt without much improvement and, thus, was admitted for IV abx and eval for possible osteo. MR foot on [**11-1**] without clear evidence of osteo, though it could not be ruled out. ESR & CRP elevated in past (not checked on this admission). Superficial cx + for MRSA. Podiatry & vascular consulted. Non-invasives performed, revealing severe PVD of left foot. Angio/possible surgical tx was being discussed when pt fell while in hospital. Unfortunately, on [**2155-11-4**], pt found ""slumped in bathroom"", apparently after trying to ambulate on her own. No reported LOC/loss of bowel or bladder conintence. Fall thought to be mechanical. Head CT showed acute left frontal subdural hematoma, without evidence of shift of midline structures, as well as left frontal subgaleal hematoma. Neurosurgery saw pt, no intervention recommended. Anti-coagulants/anti-platelet agents held. Platelets transfused (?). Repeat head CT on [**11-5**] showed expansion from 4mm to 8mm. Neurosurg still felt no intervention necessary given risk. Repeat scan on [**11-6**] & [**11-7**] showed stable SDH. On [**11-7**] PM, following repeat CT head, pt reportedly had decreased MS, desaturation to 88% on RA, and fevers to 101.9. Triggered for desaturation to 88% on RA. O2 sats improved to 92-93% on 2-3L NC. She was described as rousable to sternal rub. Pt given ethacrynic acid to diurese. Morning of [**11-8**], pt received her metoprolol, then had BP 70s/30s. Was noted to be unrousable to painful stimuli. Peripheral dopamine was started and the MICU team was contact[**Name (NI) **] for transfer Pt arrived in MICU on dopamine. She received bolus of ~1L and pressure improved to 110s to 120s systolic. Dopamine was stopped. A-line was place. She was eventually transferred back out to the medicine floor. She was started on levofloxacin/flagyl for presumed aspiration PNA and screened for rehab. She was discharged to rehab the morning of [**2155-11-29**]. Past Medical History: 1) Diabetes mellitus (Hgb A1C 5.8% in [**2-8**]) 2) Frequent UTI 3) Gastroesophageal reflux disease 4) S/p CVA w/residual mild R hemiparesis 5) Osteoporosis 6) Mild cognitive impairment 7) Depression/Anxiety 8) Osteoarthritis 9) Hypothyroidism (last TSH 2.8 in [**11-7**]) 10) Chronic diarrhea 11) COPD, on night O2 at home (FEV1 0.88 (73% pred), FVC 1.2, elevated EV1/VC ratio in [**1-6**]), no prior intubations, was placed on steroid taper at last admission in [**3-11**]. 12)Diastolic CHF 13)Coronary Artery Disease with cath [**1-8**], no intervention 14)s/p admission for fall at home discharged on [**2155-8-29**] Social History: Smoked 2ppd until [**2131**]. [**2-4**] glass of wine 3-4x/week. Worked as a secretary. Independent with ADLs, not IADL. Has 24 hour caretaker. [**Name (NI) **] (daughter) is the Healthcare proxy. Family History: Non-contributory Physical Exam: Vitals: T 95.6 HR 74 BP 89/38 R 20 97% 3LNC Gen: pale, elderly cachectic female lying in bed, does not respond to voice, but does withdraw to painful stimuli HEENT: NCAT, sclerae anicteric/noninjected, EOMI, PERRL, OP clear, uvula midline, dry MM Neck: JVP ~5 cm, no LAD CV: distant heart sounds, nl S1/S2, [**2-8**] diastolic and systolic non radiating murmur noted Lungs: decreased breath sounds at the bases, otherwise CTA, no wheezes Ab: soft, NTND, NABS, no HSM by percussion, no rebound or guarding Extrem: no c/c/e Skin: warm, lef foot, inner surface of big toe w/ mild erythema surround scabbed area, no fluctance or drainage Neuro: not speaking, does not allow her eyes to be opened, will move all extremities when stimulated by pain Pertinent Results: [**2155-10-29**] Foot MR - Edema involving the lateral aspect of the first metatarsal head and to a lesser extent the base of the first toe proximal phalanx. The appearance is nonspecific. Considerations include changes related to altered mechanics and trauma. Osteomyelitis is not excluded. [**2155-11-4**] CT Head - Study limited by motion artifact. New acute left frontal subdural hematoma seen, without evidence of shift of midline structures. Left frontal subgaleal hematoma. [**2155-11-9**] MR [**Name13 (STitle) 430**] - 1. Left subdural hematoma. 2. No evidence of acute infarct. 3. Marked cerebral atrophy. 4. Multiple nonspecific FLAIR hyperintense foci in the periventricular and deep white matter likely represent chronic microvascular ischemic changes. [**2155-11-24**] CT Head - Appropriate evolution of the left frontal subdural hematoma without evidence of new hemorrhage. [**2155-11-25**] LENI - No deep vein thrombosis seen in either leg. Brief Hospital Course: [**Age over 90 **] F with with COPD on home 02, h/o CVA, DM II, diastolic CHF, MRSA +, admitted with foot ulcer, hospitalization complicated by fall w/ SDH, fevers, & worsening mental status. # SDH: [**Hospital **] hospital course was complicated by SDH which was sustained s/p fall. Initial CT showed 4mm hematoma, next CT on [**11-5**] showed expansion to 8mm, repeats on [**11-6**] & [**11-7**] have been stable. Neurosurgery recommended supportive care only. Held anti-coagulation/anti-platelet agents. Repeated CTs showed no changes. EEG no signs of seizure ativity. Keppra given for seizure prophlaxis but stoped as it was thought to be contributing to MS changes. Repeat CT scans stable and examined by neurosurgery. Patient was restarted on ASA per NSG recs. She was seen by neurosurgery prior to discharge and had plans to see them in clinic in [**2-4**] weeks. At that time the patient will need a repeat head CT. # Altered mental status: per family pt has been ""unresponsive""/ minimally responsive for two days, since her fall. At baseline, pt is interactive & talkative, though demented. Has been minimally responsive voice & painful stimili for ~24hr. [**2155-11-8**] AM not responding to painful stimuli. Suspect that some of MS change is due to effect of SDH, though there is no shift/mass effect. Could be some infectious component, though no clear source apart from her L foot ulcer, which appears to be improving. No metabolic abnormalities to explain change. Could be related to hypothyroidism. Treated for potential infections. Pt became more alert without any intervention. At the time of discharge, the patient was answering questions with yes or no answers and following basic commands. # Hypotension: Patient had episode of hypotension while in the hospital. She was transfered to the ICU briefly where she recieved fluids and was briefly on dopamine. Thought to be related to hypovolemia / antihypertension medications. She was rehydrated in the MICU and her blood pressures improved. She was slowly restarted on her home BP meds as her BP tolerated. #Pneumonia: Patient was noted to have episodes of tachypnea and tachycardia. Cxray revealed a infiltrate. Suspicion for aspiration pneumonia and patient was started on flagyl and levoquin on [**2155-11-27**]. She will need to complete a 10 day course (last day should be [**2155-12-6**]). #Foot ulcer: MRI w/o definitive evidence of osteo. She will be treated with a 6 week total course of Vancomycin for the infection. Wound swab postive for MRSA. Course to end on [**2155-12-10**]. Dosing based on levels (goal vanco trough >15; currently on q 36hr dosing). # COPD: on home O2, 2L, w/ baseline 02 sats 90-95% per family. She was continued on Nebs and O2 as needed while hospitalized. # CAD: Patient was ruled out during hypotensive episode. Cardiac enzymes remained negative and her EKGS were without evidence of acute events. She was continued on ASA but plavix was held per neurosurgery recs. # Anemia: Has anemia of chronic disease at baseline--confirmed by iron studies this admission. Hct has slowly dropped from ~37 on admission to 24 and stabilized at 27. Causes likely include possible slow GIB, repeated phlebotomy, and acute illness. No gross hemorrhage, apart from SDH, which is stable. Hemolysis labs negative. She was noted to be guiac positive during this admission which will need futher workup as an outpatient. She did not require any tranfusions. # Diastolic CHF: EF 50-55%. JVP ~5. Appears euvolemic on exam. Patient's metoprolol was held after her transfer to the ICU. She was continued on her lisinopril without signs of volume overload. Her metoprolol was restarted on the day of discharge. # Hyponatremia - patient was noted to be mildly hyponatermic at times during admission. Sodium responded to gentle IV hydration with normal saline. # Hypothyroid: She was continued on her home levothyroxine. # DM2: At home patient controlled with diet and glipizide. She was covered with sliding scale while in house. Sugars were well controlled. Because her sugars were well controlled her glipizide was not restarted at the time of discharge. # FEN: Patient was started on tube feeds. She failed multiple speech and swallow evaluations. After discussion with patient's family, a G/J tube was placed. Medications on Admission: Ipratropium Bromide Neb 1 NEB IH Q8H Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **] Aspirin 81 mg PO daily Fluoxetine HCl 20 mg PO daily Glipizide 2.5 mg PO daily Metoprolol 12.5 mg PO BID Levothyroxine Sodium 50 mcg PO daily Lisinopril 2.5 mg PO daily Lorazepam 0.5 mg PO daily Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 7. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 10 days: Please continue until [**12-7**]. 10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 10 days: Please continue until [**12-7**]. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every eight (8) hours as needed. 12. PICC Care PICC care per protocol 13. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gm Intravenous Q36H (every 36 hours): Please continue until [**12-10**]. Please check troughs - goal 15-20. 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a day: please hold for SBP<90 or HR<55. 15. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: 1. Traumatic left parietal SDH. 2. Delirium. 3. LLE 1st MTP cellulitis/ulcer. 4. Cachexia Secondary: 1. Diabetes Mellitus Type II. 2. Anemia of Chronic Disease. 3. Diastolic Heart Failure. 4. Moderate RCA and D1 coronary artery disease. 5. Hypertension. 6. Gastroesophageal reflux disease 7. S/P Pontine CVA w/residual mild right hemiparesis 8. Osteoporosis 9. Dementia. 10. Depression/Anxiety 11. Osteoarthritis 12. Hypothyroidism 13. COPD on Home 02 14. Chronic diarrhea. 15. MRSA Discharge Condition: Stable, maintaining oxygen saturation, mental status improved Discharge Instructions: You were seen in the hospital for treatment of cellulitis. During the hospitalization you had a subdural hemorrhage. Neurosurgery followed you while in the hospital and no surgery was indicated. You will follow up with Dr. [**First Name (STitle) **] from neurosurgery in two weeks and have a repeat CT scan. You were also treated for aspiration pneumonia. Please finish your course of antibiotics. Please keep the appointments listed below Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. The following changes have been made to your home medications. 1. Your lisinopril was increased from 2.5mg to 5mg daily 2. We have been holding your glipizide while you were in the hospital. Your sugars have been well controlled. 3. We also have been holding your ativan. 4. You have 2 new antibiotics that need to be continued to another 7 days after you are discharged. These antibiotics are called levofloxacin and flagyl. 5. You are on vancomycin for a total of 6 weeks for a foot ulcer. If you have any change in mental status, new neurological symptoms, shortness of breath, or other concerning symptoms, please call your PCP or go to the emergency room. Followup Instructions: Please call Dr. [**Last Name (STitle) **] office and make an appointment to see him on or about [**12-8**]. She will also need a repeat CT scan on that same day. His office number is [**Telephone/Fax (1) 1669**]. They can also help schedule the CT Scan. ",121,2155-10-29 13:03:00,2155-11-29 13:34:00,EMERGENCY,EMERGENCY ROOM ADMIT,SNF,CELLULITIS," [**age over 90 **] f with with copd on home 02, h/o cva, dm ii, diastolic chf, mrsa +, admitted with foot ulcer, hospitalization complicated by fall w/ sdh, fevers, & worsening mental status. # sdh: [**hospital **] hospital course was complicated by sdh which was sustained s/p fall. initial ct showed 4mm hematoma, next ct on [**11-5**] showed expansion to 8mm, repeats on [**11-6**] & [**11-7**] have been stable. neurosurgery recommended supportive care only. held anti-coagulation/anti-platelet agents. repeated cts showed no changes. eeg no signs of seizure ativity. keppra given for seizure prophlaxis but stoped as it was thought to be contributing to ms changes. repeat ct scans stable and examined by neurosurgery. patient was restarted on asa per nsg recs. she was seen by neurosurgery prior to discharge and had plans to see them in clinic in [**2-4**] weeks. at that time the patient will need a repeat head ct. # altered mental status: per family pt has been ""unresponsive""/ minimally responsive for two days, since her fall. at baseline, pt is interactive & talkative, though demented. has been minimally responsive voice & painful stimili for ~24hr. [**2155-11-8**] am not responding to painful stimuli. suspect that some of ms change is due to effect of sdh, though there is no shift/mass effect. could be some infectious component, though no clear source apart from her l foot ulcer, which appears to be improving. no metabolic abnormalities to explain change. could be related to hypothyroidism. treated for potential infections. pt became more alert without any intervention. at the time of discharge, the patient was answering questions with yes or no answers and following basic commands. # hypotension: patient had episode of hypotension while in the hospital. she was transfered to the icu briefly where she recieved fluids and was briefly on dopamine. thought to be related to hypovolemia / antihypertension medications. she was rehydrated in the micu and her blood pressures improved. she was slowly restarted on her home bp meds as her bp tolerated. #pneumonia: patient was noted to have episodes of tachypnea and tachycardia. cxray revealed a infiltrate. suspicion for aspiration pneumonia and patient was started on flagyl and levoquin on [**2155-11-27**]. she will need to complete a 10 day course (last day should be [**2155-12-6**]). #foot ulcer: mri w/o definitive evidence of osteo. she will be treated with a 6 week total course of vancomycin for the infection. wound swab postive for mrsa. course to end on [**2155-12-10**]. dosing based on levels (goal vanco trough >15; currently on q 36hr dosing). # copd: on home o2, 2l, w/ baseline 02 sats 90-95% per family. she was continued on nebs and o2 as needed while hospitalized. # cad: patient was ruled out during hypotensive episode. cardiac enzymes remained negative and her ekgs were without evidence of acute events. she was continued on asa but plavix was held per neurosurgery recs. # anemia: has anemia of chronic disease at baseline--confirmed by iron studies this admission. hct has slowly dropped from ~37 on admission to 24 and stabilized at 27. causes likely include possible slow gib, repeated phlebotomy, and acute illness. no gross hemorrhage, apart from sdh, which is stable. hemolysis labs negative. she was noted to be guiac positive during this admission which will need futher workup as an outpatient. she did not require any tranfusions. # diastolic chf: ef 50-55%. jvp ~5. appears euvolemic on exam. patients metoprolol was held after her transfer to the icu. she was continued on her lisinopril without signs of volume overload. her metoprolol was restarted on the day of discharge. # hyponatremia - patient was noted to be mildly hyponatermic at times during admission. sodium responded to gentle iv hydration with normal saline. # hypothyroid: she was continued on her home levothyroxine. # dm2: at home patient controlled with diet and glipizide. she was covered with sliding scale while in house. sugars were well controlled. because her sugars were well controlled her glipizide was not restarted at the time of discharge. # fen: patient was started on tube feeds. she failed multiple speech and swallow evaluations. after discussion with patients family, a g/j tube was placed. ","PRIMARY: [Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled] SECONDARY: [Other and unspecified cerebral laceration and contusion, without mention of open intracranial wound, with no loss of consciousness; Cellulitis and abscess of foot, except toes; Unspecified osteomyelitis, ankle and foot; Pneumonitis due to inhalation of food or vomitus; Chronic diastolic heart failure; Atherosclerosis of native arteries of the extremities with ulceration; Anemia of other chronic disease; Congestive heart failure, unspecified; Ulcer of other part of foot; Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled; Other bone involvement in diseases classified elsewhere; Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site; Infection with microorganisms resistant to penicillins; Unspecified fall; Accidents occurring in residential institution; Esophageal reflux; Osteoporosis, unspecified; Dysthymic disorder; Coronary atherosclerosis of native coronary artery; Chronic airway obstruction, not elsewhere classified; Diarrhea; Epistaxis; Other iatrogenic hypotension; Other antihypertensive agents causing adverse effects in therapeutic use]","[**age over 90 **] f with with copd on home 02, h/o cva, dm ii, diastolic chf, mrsa +, admitted with foot ulcer, hospitalization complicated by fall w/ sdh, fevers, & worsening mental status. [**2155-11-8**] am not responding to painful stimuli. # hypotension: patient had episode of hypotension while in the hospital. she was transfered to the icu briefly where she recieved fluids and was briefly on dopamine. thought to be related to hypovolemia / antihypertension medications. she will need to complete a 10 day course (last day should be [**2155-12-6**]). #foot ulcer: mri w/o definitive evidence of osteo. she was continued on nebs and o2 as needed while hospitalized. no gross hemorrhage, apart from sdh, which is stable. her metoprolol was restarted on the day of discharge. sodium responded to gentle iv hydration with normal saline.","pt has been ""unresponsive""/ minimally responsive for two days, since her fall. pt is interactive & talkative, though demented. no metabolic abnormalities to explain change." 19827,199336.0,15704,2106-06-11,15703,166475.0,2106-05-20,Discharge summary,"Admission Date: [**2106-5-13**] Discharge Date: [**2106-5-20**] Date of Birth: [**2038-4-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2234**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: Central Veinous line placement PICC placement History of Present Illness: This is a 68M t4 level paraplejia, CAD, CHF EF , severe sacral debub, multiple UTIs, PE with IVC filter who is sent from rehab with Hypotension. Of note, recently discharged from [**Hospital1 18**] after and admission for code stroke [**4-21**]--[**4-27**] which at the end, it was thought to be a seizure episode. Prior to that, admitted [**2106-4-6**]- [**2106-4-15**] for fever and hypotension treated for UTI and wound infection with Vanc/Zosyn compleatted on [**4-21**]. . Sent to the ED, after he was noted hypotensive today into the 60's.Per referal, he was noted with BO into the 60's that did not repond to fluid boluses. Per report, his baseline BP 80-90's. He had also been currently treated with antibiotics for a UTI. He completely his Vancomycin/Zosyn treatment course for enterococi UTI and decub/ulcer swab infection on [**4-21**]. . In the ED, VS: He was hypotensive into the 60's, good mental status. A IJ line was placed and levophed was started. Levophed was also started. ID was curvesided and agreed with Vanc/Zosyn for empiric coverage . ROS: Denied fever, chills, SOB, cough, chest pain, abdominal pain, blood in stools, weight gain or weight loss Social History: He moved here from [**Country 3594**] (after living in many different countries) in the [**2068**]. He is retired from a job in the maritime industry. Divorced 24 years ago. Three children. Quit smoking [**2076**]. Quit drinking [**2080**]. No history of illicit drug use or abuse. Family History: No stroke, aneurysm, no seizure, no AAA. Pertinent Results: Admit labs: [**2106-5-13**] 01:25PM BLOOD WBC-9.4# RBC-3.52* Hgb-8.7* Hct-28.1* MCV-80* MCH-24.8* MCHC-31.1 RDW-17.0* [**2106-5-13**] 01:25PM BLOOD PT-26.6* PTT-38.4* INR(PT)-2.7* [**2106-5-13**] 01:25PM BLOOD Glucose-101 UreaN-15 Creat-1.1 Na-139 K-4.7 Cl-104 HCO3-24 AnGap-16 [**2106-5-13**] 01:25PM BLOOD ALT-5 AST-10 LD(LDH)-124 CK(CPK)-50 AlkPhos-89 TotBili-0.2 [**2106-5-13**] 01:25PM BLOOD Albumin-2.8* Calcium-8.6 Phos-2.3* Mg-1.6 [**2106-5-14**] 04:00AM BLOOD Cortsol-14.0 ================================================= Discharge labs: [**2106-5-19**] 03:19AM BLOOD WBC-6.3 RBC-3.17* Hgb-7.7* Hct-25.5* MCV-81* MCH-24.2* MCHC-30.1* RDW-17.6* Plt Ct-146* [**2106-5-19**] 03:19AM BLOOD Plt Ct-146* [**2106-5-19**] 03:19AM BLOOD PT-29.5* PTT-37.4* INR(PT)-3.0* [**2106-5-19**] 03:19AM BLOOD Glucose-79 UreaN-5* Creat-0.5 Na-140 K-3.9 Cl-109* HCO3-24 AnGap-11 [**2106-5-18**] 05:50AM BLOOD ALT-6 AST-9 AlkPhos-78 Amylase-46 TotBili-0.2 [**2106-5-19**] 03:19AM BLOOD Mg-1.7 Cholesterol: [**2106-5-17**] 05:40AM BLOOD Triglyc-79 HDL-18 CHOL/HD-3.1 LDLcalc-21 [**2106-5-17**] 05:40AM BLOOD Cholest-55 ========================================================== ECG:Sinus rhythm. Prior inferior myocardial infarction. Diffuse non-specific ST-T wave changes. Compared to the previous tracing of [**2106-4-22**] there is diffuse ST segment and T wave flattening. Otherwise, no diagnostic interim change. ========================================================== CHEST (PORTABLE AP); -77 BY DIFFERENT PHYSICIAN Reason: infiltrate? pneumothorax? [**Hospital 93**] MEDICAL CONDITION: 68 year old man with urosepsis, s/p hypoxia and coughing, increased o2 requirement REASON FOR THIS EXAMINATION: infiltrate? pneumothorax? AP CHEST 8:45 P.M. [**5-13**] HISTORY: Hypoxia and coughing. Possible pneumothorax. IMPRESSION: AP chest compared to [**4-21**] through [**5-13**]: Lungs are clear. Heart size normal. No pneumothorax or pleural effusion. The patient has had median sternotomy. Tip of the right jugular line projects over the upper SVC. No pneumothorax. ============================================================== MR [**Name13 (STitle) 6452**] W & W/O CONTRAST [**2106-5-17**] 8:23 AM MR [**Name13 (STitle) 6452**] W & W/O CONTRAST Reason: Please evalaute L-spine/coccyx--patient with multiple sacral Contrast: MAGNEVIST [**Hospital 93**] MEDICAL CONDITION: 68 year old man with T4 paraplegia, multiple sacral decub include probe to bone- admit with sepsis-unclear source REASON FOR THIS EXAMINATION: Please evalaute L-spine/coccyx--patient with multiple sacral decubitus ulcers, sepsis unclear source--?osteomyelitis CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: T4 paraplegia with multiple sacral decubitus ulcers probing to bone. Admitted with sepsis of unclear source. Please evaluate for osteomyelitis. TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained through the lumbar spine without and with intravenous contrast. COMPARISON: MR lumbar spine images of [**2105-2-20**]. MR LUMBAR SPINE WITHOUT AND WITH CONTRAST: Sagittal images were obtained through the lumbosacral spine; however, axial images go through S1-S2. There is no evidence of lumbar spine fracture or malalignment. At L2-L3 and L3-L4, there is no evidence of significant canal stenosis or neural foraminal narrowing. At L4-L5, there are degenerative endplate changes consistent with type 2 [**Last Name (un) 13425**] changes. There is mild loss of disc height with mild-to-moderate left and moderate right neural foraminal narrowing without significant canal stenosis. At L5-S1, there are type 2 [**Last Name (un) 13425**] degenerative changes of the endplates with mild loss of the vertebral body and disc space height. A mild central disc bulge is again noted along with mild bilateral facet hypertrophy causing moderate left and mild-to-moderate right neural foraminal narrowing. There has been no change in the signal intensity within the lumbosacral spine since the prior exam. There is no abnormal enhancement. There is no evidence of osteomyelitis. There is marked atrophy of the conus of the spinal cord as well as the paraspinal musculature consistent with the patient's history of paraplegia. IMPRESSION: 1. No evidence of osteomyelitis within the lumbar spine and visualized portion of the sacrum. 2. Multilevel degenerative changes as described above without high-grade spinal canal stenosis. 3. Atrophy of the conus of the spinal cord and paraspinal muscles consistent with paraplegia ============================================================= Brief Hospital Course: 68M T4 paraplegia, CAD, systolic CHF, sacral decubitus ulcers, multiple UTIs, PE with IVC filter on anticoagulation admitted with hypotension. . # Hypotension/Septicemia: Pt (chronic nursing home pt) was considered to have multiple possible sources of infection including lines, urosepsis, and decubitus ulcers. Pt was started on vancomycin for MRSA, meropenem for pseudomonas, ciprofloxacin for double GNR coverage, and metronidazole for anaerobic coverage. Of note, had been on levoquin and flagyl for unclear reasons at [**Hospital 100**] Rehab for sometime before admission to [**Hospital1 18**]. Aggressive fluid rescucitation and pressors in ICU. Pt was taken off pressors two days after admission, and remained afebrile throughout. PICC line removed, foley catheter changed. Blood, urine, and midline cultures remained no growth throughout but were of little value given antibiotic therapy preceding cultures. Plastic surgery evaluated sacral decubs and did not feel they were likely source of sepsis. MRI of sacral decubs without evidence of sepsis. C. diff considered, no samples sent in ICU and then on floor, no stool for sample. Influenza negative. Appropriate adrenal response on [**Last Name (un) 104**] stim testing. Patient to receive two week course of vancomycin/meropenem given septicemia without source. He should receive flagyl for one week after completion of these given high risk for c. diff and possible c. diff as cause of septicemia. Needs safety labs including CBC, chem-10, lft's [**5-24**]. 7more days vanc/meropenm and 14 days flagyl. ********Please note, after this course, patient should have serial blood cultures, urine cultures and evaluation/wound culture by plastic surgery as he has had multiple admissions for septicemia of unclear etiology. He should not be treated empirically with antibiotics unless these cultures are performed or unless he is critically ill, precluding the ability to obtain these cultures. It is strongly suspected that his decubitus ulcers may be leading to these episodes, but almost chronic institution of antibiotics without culture data precludes definitive treatment. Furthermore, patient has baseline low blood pressure from chronic systolic heart failure and possible autonomic dysregulation. On discharge, BP 80's to 100's on low dose lisinopril and carvedilol . # Decubitus ulcer: Pt was noted to have extensive decubitus ulcers, and plastics as well as wound care were consulted. Wound care recs were followed; plastics did not feel further imaging or tissue sampling was warranted. MRI was obtained and did not demonstrate osteomyelitis. . Chronic Systolic Heart Failure: EF 25%. With aggressive fluids/pressors, no pulmonary edema. Low dose lisinopril and carvedilol re-started by [**5-18**]. BP's generally 80's to 100's. . Coronary Artery Disease: No specific ischemic changes on ECG. Maintained on aspirin. Beta blocker and ace inhibitor added by discharge. Statin discontinued as cholesterol very low (total of 55). . # PE s/p IVC filter: Pt's warfarin was initially held given INR 3.5; anticoagulation dosing was per INR with goal between 2 and 3. On day of d/c, [**5-20**] INR of 2.9, plan 1mg coumadin today. Should have INR check on [**5-21**] and then week of [**5-23**]. . # Depression: Continued citalopram . # h/o seizures: Continued Keppra . # h/o cholelitiasis/abdominal pain/GERD: Patient with intermittent complaints of RUQ and epigastric abdominal pain, also left sided chest.. PPI changed to [**Hospital1 **], tums and maalox added. LFT's within normal limits on serial measurements. RUQ U/S showed large stone in gallbladder which has been seen previously, no evidence choleycystitis Continued ursodiol throughout. If ongoing pain, patietn should be evaluated by surgery once he has completed his antibioitic course for consideration of choleycystectomy . Medications on Admission: Ipratropium q8h Levetiracetam 500 [**Hospital1 **] levofloxacine 250 daily [**2106-5-5**] [**2106-5-19**] Megace 400 mg once daily Metronidazol 500 mg TID [**2106-5-5**] / [**2106-5-19**] -- apparently after debridment. Omeprazole 20 mg daily Ondansetron 4 mg q8h Oxycodone 5 mg TID potassium 20 meq Senna 1 tab ursodiol 300 mg [**Hospital1 **] warfarin [**5-12**] 0.5 mg INR [**2106-5-12**] 2.3 albuterol 2 puff q6h aspirin 81 daily Baclofen 10 mg TID Bisacodyl 10 mg once daily Calcium carbonate 650 TID Carvedilol 3.125 [**Hospital1 **] Citalopram 30 mg qd fluticasone/salmeterol Advair 250/50 Gabapentin 300 [**Hospital1 **] Insulin sliding scale PRN Tylenol 650 q4h MAALOx Prochlorperazine 25 mg q12 rectall Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 4. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 18. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once for 1 doses: on [**5-20**]. 19. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: must have INR check on [**5-21**] and [**5-23**] Goal INR is [**3-14**]. 20. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Recon Soln Intravenous Q6H (every 6 hours) for 7 days. 21. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 7 days. 22. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 14 days. 23. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed for gas. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: 1. Septicemia, NOS 2. Chronic Systolic Heart Failure 3. Coronary Artery Disease 4. Pulmonary Embolism 5. Paraplegia 6. Sacral Decubitus Ulcer 7. GERD 8. choledocholithiasis without obstruction 9. Anemia 10. Seizure history Discharge Condition: Afebrile, stable, tolerating PO intake, systolic bp 80-100 Discharge Instructions: Adhere to 2 gm sodium diet Fluid Restriction:2 liters . All medications as prescribed. We have made a number of changes. Please note patient to receive coumadin 1mg on [**2106-5-20**] for INR of 2.9 and then to resume coumadin therapy on [**2106-5-20**]. Should have INR checked on [**2106-5-21**] to guide further therapy (had been getting 2mg daily but now on multiple antibiotics). Goal INR is between 2 and 3. Usual dose will likely need to be altered given concurrent vancomycin/meropenem/flagyl therapy. Patient's systolic blood pressure generally between 80 and 100. Patient should receive lisinopril and carvedilol unless bp drops below eighty given his heart failure. Once patient completes antibiotic course, should have blood cultures sent and be seen by plastic surgery. He has had a number of admissions for sepsis of unclear etiology. He should not be treated with empiric antibiotics before having blood, urine and wound cultures sent unless he is critically ill. Patient should have INR checked on [**5-21**] and then during week of [**5-23**] to guide coumadin therapy. Patient should have full set of safety labs checked [**5-24**] including CBC, Chem-10, alt, ast, total bilirubin. Patient has ongoing right upper quadrant/right sided chest pain. It has been extesnively worked up. he does have gallstones but no evidence of choleycystitis. If this is ongoing, he should be evaluated by a surgeon once he has finished his antibiotic course. Follow up as below. Followup Instructions: Patient should follow up with primary care doctor within two weeks of discharge from [**Hospital **] Rehab. You will be followed by doctors there in the meantime. You should follow up with plastic surgery here at [**Hospital3 **] after completing your antibiotic course. You also have the previously scheduled appointments: Neurology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7598**], MD Phone:[**Telephone/Fax (1) 5434**] Date/Time:[**2106-7-16**] 9:30 Cardiology: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) 3947**]. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2106-11-3**] 9:40 Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2106-11-3**] 11:00 ",22,2106-05-13 16:51:00,2106-05-20 17:40:00,EMERGENCY,EMERGENCY ROOM ADMIT,LONG TERM CARE HOSPITAL,HYPOTENSION," 68m t4 paraplegia, cad, systolic chf, sacral decubitus ulcers, multiple utis, pe with ivc filter on anticoagulation admitted with hypotension. . # hypotension/septicemia: pt (chronic nursing home pt) was considered to have multiple possible sources of infection including lines, urosepsis, and decubitus ulcers. pt was started on vancomycin for mrsa, meropenem for pseudomonas, ciprofloxacin for double gnr coverage, and metronidazole for anaerobic coverage. of note, had been on levoquin and flagyl for unclear reasons at [**hospital 100**] rehab for sometime before admission to [**hospital1 18**]. aggressive fluid rescucitation and pressors in icu. pt was taken off pressors two days after admission, and remained afebrile throughout. picc line removed, foley catheter changed. blood, urine, and midline cultures remained no growth throughout but were of little value given antibiotic therapy preceding cultures. plastic surgery evaluated sacral decubs and did not feel they were likely source of sepsis. mri of sacral decubs without evidence of sepsis. c. diff considered, no samples sent in icu and then on floor, no stool for sample. influenza negative. appropriate adrenal response on [**last name (un) 104**] stim testing. patient to receive two week course of vancomycin/meropenem given septicemia without source. he should receive flagyl for one week after completion of these given high risk for c. diff and possible c. diff as cause of septicemia. needs safety labs including cbc, chem-10, lfts [**5-24**]. 7more days vanc/meropenm and 14 days flagyl. ********please note, after this course, patient should have serial blood cultures, urine cultures and evaluation/wound culture by plastic surgery as he has had multiple admissions for septicemia of unclear etiology. he should not be treated empirically with antibiotics unless these cultures are performed or unless he is critically ill, precluding the ability to obtain these cultures. it is strongly suspected that his decubitus ulcers may be leading to these episodes, but almost chronic institution of antibiotics without culture data precludes definitive treatment. furthermore, patient has baseline low blood pressure from chronic systolic heart failure and possible autonomic dysregulation. on discharge, bp 80s to 100s on low dose lisinopril and carvedilol . # decubitus ulcer: pt was noted to have extensive decubitus ulcers, and plastics as well as wound care were consulted. wound care recs were followed; plastics did not feel further imaging or tissue sampling was warranted. mri was obtained and did not demonstrate osteomyelitis. . chronic systolic heart failure: ef 25%. with aggressive fluids/pressors, no pulmonary edema. low dose lisinopril and carvedilol re-started by [**5-18**]. bps generally 80s to 100s. . coronary artery disease: no specific ischemic changes on ecg. maintained on aspirin. beta blocker and ace inhibitor added by discharge. statin discontinued as cholesterol very low (total of 55). . # pe s/p ivc filter: pts warfarin was initially held given inr 3.5; anticoagulation dosing was per inr with goal between 2 and 3. on day of d/c, [**5-20**] inr of 2.9, plan 1mg coumadin today. should have inr check on [**5-21**] and then week of [**5-23**]. . # depression: continued citalopram . # h/o seizures: continued keppra . # h/o cholelitiasis/abdominal pain/gerd: patient with intermittent complaints of ruq and epigastric abdominal pain, also left sided chest.. ppi changed to [**hospital1 **], tums and maalox added. lfts within normal limits on serial measurements. ruq u/s showed large stone in gallbladder which has been seen previously, no evidence choleycystitis continued ursodiol throughout. if ongoing pain, patietn should be evaluated by surgery once he has completed his antibioitic course for consideration of choleycystectomy . ","PRIMARY: [Unspecified septicemia] SECONDARY: [Septic shock; Acute systolic heart failure; Paraplegia; Pressure ulcer, buttock; Pressure ulcer, lower back; Pressure ulcer, hip; Severe sepsis; Chronic airway obstruction, not elsewhere classified; Congestive heart failure, unspecified; Esophageal reflux; Personal history of venous thrombosis and embolism]","68m t4 paraplegia, cad, systolic chf, sacral decubitus ulcers, multiple utis, pe with ivc filter on anticoagulation admitted with hypotension. pt was started on vancomycin for mrsa, meropenem for pseudomonas, ciprofloxacin for double gnr coverage, and metronidazole for anaerobic coverage. 7more days vanc/meropenm and 14 days flagyl. ********please note, after this course, patient should have serial blood cultures, urine cultures and evaluation/wound culture by plastic surgery as he has had multiple admissions for septicemia of unclear etiology. on discharge, bp 80s to 100s on low dose lisinopril and carvedilol . with aggressive fluids/pressors, no pulmonary edema. low dose lisinopril and carvedilol re-started by [**5-18**]. if ongoing pain, patietn should be evaluated by surgery once he has completed his antibioitic course for consideration of choleycystectomy .","pt was started on vancomycin for mrsa, meropenem for pseudomonas, ciprofloxacin for double gnr coverage, and metronidazole for anaerobic coverage. pt was taken off pressors two days after admission and remained afebrile throughout. plastic surgery evaluated sacral decubs and did not feel they were likely source of sepsis." 19827,199336.0,15704,2106-06-11,15702,178197.0,2106-04-15,Discharge summary,"Admission Date: [**2106-4-6**] Discharge Date: [**2106-4-15**] Date of Birth: [**2038-4-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: Fever, hypotension Major Surgical or Invasive Procedure: Bedside debridement of ulcerations by plastic surgery team History of Present Illness: 68M with h/o t4 paraplegia x 2yrs, felt [**3-13**] ""inflammatory spinal disease"", with a chronic indwelling foley, sacral decubitus ulcers, presents to [**Hospital1 18**] from rehab after RN noted 1d of fever (tmax 101.8). [**Name8 (MD) **] RN caring for pt at rehab, pt noted some mild abdominal discomfort (chronic), but otherwise denied any recent symptoms of cough, n/v, constipation, rash. Pt has been having chronic diarrhea (x3/day, x2-3/night) for past 1yr, etiology unclear. [**Name2 (NI) 227**] persistent fevers x24hrs, pt was brought to [**Hospital1 18**] ED. [**Name8 (MD) **] RN BP prior to leaving rehab was 100/72. . Per pt, he notes chronic abdominal pain, ""always there"", diffuse, sharp, sometimes awakening him from sleep, no relation to food or BMs. somewhat worse over the preceding 4 months, but actually improving over the past few days. At present, he states his pain has completely resolved. ROS otherwise significant for +orthopnea, pt also notes nonproductive cough x 3 weeks, no flu sx (body aches, congestion, sore throat). Pt denies flut shot or pneumovax. +sick contacts (lives in [**Hospital 100**] Rehab). . Upon arrival in ED VS=100.4 100 87/51 12 95%RA. UA was c/w UTI, pt was started on vanco and zosyn, UCx and BCx sent. sacral ulcers felt to be stage 4, no evidence of superinfection. BP initially responded to 3L IVF (99/53), however after 3rd litre, BP down to 85/40, pt therefore received RIJ TLC, and possibly an additional 1L IVF bolus, afterwhich BP improved to 115/70. Pt was asymptomatic, mentating throughout without specific complaints. . Pt also noted moderate abdominal tenderness. CT ABD done which showed no acute processes. CXR unremarkable, EKG unremarkable (old Q in III, ?mild ST changes V1). . Pt admitted to ICU for further monitoring given hypotension. . Past Medical History: 1. Inflammatory disease of the spinal cord of uncertain etiology. MRA [**10-16**] negative for vascular malformation. Initial CSF analysis showed elevated protein (82) without oligoclonal bands. NMO blood titer negative, RPR negative, Lyme serology negative, [**Doctor First Name **] negative, Ro and La negative, ACE level normal, neuromyelitis IgG negative, ESR 70, CRP 66.8. Ultimately treated with broad spectrum antibiotics, corticosteroids (two weeks of Solu-Medrol followed by a prednisone taper), and 5 days of mannitol without improvement. He is followed by neurology for a dense paraplegia (T4) with neuropathic pain, restrictive shoulder arthropathy, and a neurogenic bladder requiring a chronic indwelling foley. 2. Chronic sacral decubitus ulcer, previously treated with a VAC dressing 3. Multiple UTI (including Pseudomonas) 4. Pulmonary embolus [**11-15**] s/p IVC filter placement 5. Asthma 6. Two-vessel coronary artery disease s/p CABG 4-5 years ago 7. Systolic CHF (EF 25-30% on [**2-15**] TTE) 8. Repaired liver laceration 9. Chronic back pain 10. Vitiligo 11. Feeding tube 12. Depression 13. MRSA from sacral swab and sputum 14. Prior transient episodes of leg paralysis 15. Right frontal lobe brain lesion biopsied [**11-15**] and c/w gliosis; resolved on repeat imaging 16. Abnormal visual evoked potentials Social History: He moved here from [**Country 3594**] (after living in many different countries) in the [**2068**]. He is retired from a job in the maritime industry. Divorced 24 years ago. Three children. Quit smoking [**2076**]. Quit drinking [**2080**]. No history of illicit drug use or abuse. Family History: No stroke, aneurysm, no seizure, no AAA. Physical Exam: VS: 96.6 85 105/66 15 100%2L Gen: Well appearing male in NAD lying in bed. HEENT: JVD <6-8cm, MMM, lips slightly pale. Chest: CTA bilaterally, no w/r/r. CV: RRR, physiologic splitting S2, no r/g. 3/6 SEM @ LSB. Abd: Soft, nontender to deep palpation in all four quadrants, distended, tympanic (?gas), negative murphys sign, well-healed midline g-tube scar. Extremities: Warm, well perfused, no C/C. [**2-10**]+ edema bilaterally to knees. Skin: Vitiligo on hands. Large round 6x4 cm diameter pressure decubitus ulcer on sacrum and 4x3cm decub ulcer on left ischial tuberosity. Appears clean with granulation tissue in center, no s/sx of infection. no purulent drainage. Neuro: CN grossly intact. A&O x 3, pleasantly conversant. Pertinent Results: [**2106-4-5**] 11:50PM BLOOD WBC-9.08 RBC-4.37* Hgb-11.2* Hct-34.9* MCV-80* MCH-25.6* MCHC-32.0 RDW-15.1 [**2106-4-8**] 04:47AM BLOOD WBC-6.7 RBC-3.49* Hgb-8.9* Hct-28.5* MCV-82 MCH-25.6* MCHC-31.4 RDW-14.9 [**2106-4-5**] 11:50PM BLOOD Glucose-125* UreaN-11 Creat-0.5 Na-137 K-4.0 Cl-101 HCO3-27 AnGap-13 [**2106-4-8**] 04:47AM BLOOD Glucose-109* UreaN-5* Creat-0.4* Na-139 K-3.7 Cl-110* HCO3-23 AnGap-10 [**2106-4-6**] 10:27PM BLOOD CK-MB-5 cTropnT-0.08* [**2106-4-6**] 08:11AM BLOOD cTropnT-0.08* [**2106-4-5**] 11:50PM BLOOD CK-MB-NotDone cTropnT-0.09* [**2106-4-8**] 04:47AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0 [**2106-4-6**] 12:05PM BLOOD Cortsol-15.3 [**2106-4-6**] 12:05PM BLOOD CRP-122.0* [**2106-4-6**] 01:45PM BLOOD Lactate-1.4 [**2106-4-6**] 12:00PM BLOOD Lactate-0.7 [**2106-4-6**] 12:02AM BLOOD Lactate-1.7 CT ABD/Pelv [**2106-4-6**]: 1. Severe sacral and right ischial tuberosity decubitus ulcers. 2. No acute intra-abdominal inflammatory process. 3. Cholelithiasis. CXR [**4-6**] Bedside frontal chest radiograph is compared to [**2106-1-2**] and demonstrate clear lungs, normal pulmonary vasculature, and no evidence for pleural effusions. The heart and mediastinal contours, remarkable for tortuous aorta, are stable. This patient is status post median sternotomy. IMPRESSION: No acute cardiopulmonary process. EKGs: NSR, essentially unchanged from prior tracings WBC scan; IMPRESSION: 1. Unchanged appearance of residual sacrum with adjacent posterior focal radiotracer uptake, again apparently within adjacent soft tissues. However, given the proximity of the uptake, bony involvement with infection cannot be excluded. 2. Similar sclerotic appearance of right lower ischium and adjacent soft tissue thickening. Although the CT appearance suggests chronic osteomyelitis, immediately adjacent radiotracer activity has resolved and the bony abnormality appears unchanged. 3. New cellulitis along the right lower buttock, at the interface with the thigh and inferior to the prior site of infection. 4. More extensive radiotracer uptake in the left lower buttock, with fat stranding on CT suggesting cellulitis. Although the soft tissue abnormality extends to the ischial tuberosity, there is no CT evidence of bone destruction or abnormal bony radiotracer uptake in this area. [**2106-4-6**] 6:38 pm SWAB Source: left ischial tuberosity. **FINAL REPORT [**2106-4-10**]** GRAM STAIN (Final [**2106-4-6**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2106-4-10**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). Susceptibility will be performed on P. aeruginosa and S. aureus if sparse growth or greater. STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([**8-/2404**]) immediately if sensitivity to clindamycin is required on this patient's isolate. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2106-4-10**]): NO ANAEROBES ISOLATED. [**2106-4-6**] 6:38 pm SWAB Source: sacral decubitus ulcer. **FINAL REPORT [**2106-4-10**]** GRAM STAIN (Final [**2106-4-6**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2106-4-10**]): ESCHERICHIA COLI. RARE GROWTH. PSEUDOMONAS AERUGINOSA. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | PSEUDOMONAS AERUGINOSA | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S 4 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- <=4 S 8 S PIPERACILLIN/TAZO----- <=4 S 8 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Final [**2106-4-10**]): NO ANAEROBES ISOLATED. Brief Hospital Course: A/P: 67M h/o T4 paraplegia, recurrent UTIs [**3-13**] indwelling foley, multiple stage 4 decubs was admitted to ICU initially with fever to 101.8, transient hypotension that resolved with 3-4L IVF but continued on sepsis protocol. . # FEVER - Felt due to UTI and or osteomyelitis. Cx. all neg, but swab suggested colonization with mrsa; also seen on swab, pseudomonas and enterococcus. Emperically treated with vancomycin and zosyn given this information and prior culture data that was reviewed here. Tagged wbc scan as above. Plastic surgery consult evaluated wounds and felt that pt. did not have evidence of osteomyelitis. Plan two weeks of abx for empiric treatment for complicated UTI. Foley replaced. Follow up with [**Month/Day (2) **] arranged for evaluation for suprapubic catheter. Follow up with plastic surgery also arranged. . # HYPOTENSION - resolved with IVF and treatment of infection as above. # H/O PE - s/p IVC filter, INR elevated, so warfarin held, then given 5 po vitamin K given sustained inr over 4.0. INR came down to 1.8 with this, so warfarin resumed. Otherwise, home medication regimen continued in hospital for other chronic medical issues as outlined in pmhx. and in medication list below. Medications on Admission: vitamin c 500mg po qdaily aspirin 81mg po qdaily baclofen 5mg po tid calcium carbonate 650mg po bid citalopram 40mg po qdaily pepcid 20mg po qdaily advair 250/50 IH [**Hospital1 **] gabapentin 400mg po bid simethicone 80mg po tid simvastatin 40mg po qdaily tramadol 25mg po tid ursodiol 300mg po qdaily warfarin 3mg po qdaily prostat 30ml oral [**Hospital1 **] (liquid protein supplement) . Discharge Medications: 1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 7 days. gram 2. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 7 days. 3. Sodium Hypochlorite 0.25 % Solution Sig: One (1) Appl Miscellaneous ASDIR (AS DIRECTED) for 1 days: apply to ischial wounds only, for one day ([**4-16**]) in [**Hospital1 **] wet to dry dsg changes. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation [**Hospital1 **] (2 times a day). 9. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed. 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 13. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QDAILY (). 14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 17. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 19. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**2-10**] Tablet, Rapid Dissolves PO Q8H (every 8 hours) as needed. 20. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: UTI with sepsis Chronic sacral and ischial decubitus ulcerations Chronic, systolic, heart failure Hx. PE with SVC filter, on warfarin Discharge Condition: Stable Discharge Instructions: Return to the [**Hospital1 18**] Emergency Department for: Fever Hypotension Followup Instructions: Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2106-4-23**] 1:30 For evaluation for suprapubic catheter placment: Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2106-4-28**] 9:30 ",57,2106-04-06 07:05:00,2106-04-15 18:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LONG TERM CARE HOSPITAL,FEVER," a/p: 67m h/o t4 paraplegia, recurrent utis [**3-13**] indwelling foley, multiple stage 4 decubs was admitted to icu initially with fever to 101.8, transient hypotension that resolved with 3-4l ivf but continued on sepsis protocol. . # fever - felt due to uti and or osteomyelitis. cx. all neg, but swab suggested colonization with mrsa; also seen on swab, pseudomonas and enterococcus. emperically treated with vancomycin and zosyn given this information and prior culture data that was reviewed here. tagged wbc scan as above. plastic surgery consult evaluated wounds and felt that pt. did not have evidence of osteomyelitis. plan two weeks of abx for empiric treatment for complicated uti. foley replaced. follow up with [**month/day (2) **] arranged for evaluation for suprapubic catheter. follow up with plastic surgery also arranged. . # hypotension - resolved with ivf and treatment of infection as above. # h/o pe - s/p ivc filter, inr elevated, so warfarin held, then given 5 po vitamin k given sustained inr over 4.0. inr came down to 1.8 with this, so warfarin resumed. otherwise, home medication regimen continued in hospital for other chronic medical issues as outlined in pmhx. and in medication list below. ","PRIMARY: [Infection and inflammatory reaction due to indwelling urinary catheter] SECONDARY: [Unspecified septicemia; Sepsis; Paraplegia; Pressure ulcer, lower back; Pressure ulcer, hip; Chronic systolic heart failure; Urinary tract infection, site not specified; Aortocoronary bypass status; Congestive heart failure, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","a/p: 67m h/o t4 paraplegia, recurrent utis [**3-13**] indwelling foley, multiple stage 4 decubs was admitted to icu initially with fever to 101.8, transient hypotension that resolved with 3-4l ivf but continued on sepsis protocol. all neg, but swab suggested colonization with mrsa; also seen on swab, pseudomonas and enterococcus. follow up with [**month/day (2) **] arranged for evaluation for suprapubic catheter.","67m h/o t4 paraplegia, recurrent utis was admitted to icu initially with fever to 101.8, transient hypotension that resolved with 3-4l ivf but continued on sepsis protocol. emperically treated with vancomycin and zosyn given this information and prior culture data that was reviewed here." 19827,166475.0,15703,2106-05-20,15702,178197.0,2106-04-15,Discharge summary,"Admission Date: [**2106-4-6**] Discharge Date: [**2106-4-15**] Date of Birth: [**2038-4-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1990**] Chief Complaint: Fever, hypotension Major Surgical or Invasive Procedure: Bedside debridement of ulcerations by plastic surgery team History of Present Illness: 68M with h/o t4 paraplegia x 2yrs, felt [**3-13**] ""inflammatory spinal disease"", with a chronic indwelling foley, sacral decubitus ulcers, presents to [**Hospital1 18**] from rehab after RN noted 1d of fever (tmax 101.8). [**Name8 (MD) **] RN caring for pt at rehab, pt noted some mild abdominal discomfort (chronic), but otherwise denied any recent symptoms of cough, n/v, constipation, rash. Pt has been having chronic diarrhea (x3/day, x2-3/night) for past 1yr, etiology unclear. [**Name2 (NI) 227**] persistent fevers x24hrs, pt was brought to [**Hospital1 18**] ED. [**Name8 (MD) **] RN BP prior to leaving rehab was 100/72. . Per pt, he notes chronic abdominal pain, ""always there"", diffuse, sharp, sometimes awakening him from sleep, no relation to food or BMs. somewhat worse over the preceding 4 months, but actually improving over the past few days. At present, he states his pain has completely resolved. ROS otherwise significant for +orthopnea, pt also notes nonproductive cough x 3 weeks, no flu sx (body aches, congestion, sore throat). Pt denies flut shot or pneumovax. +sick contacts (lives in [**Hospital 100**] Rehab). . Upon arrival in ED VS=100.4 100 87/51 12 95%RA. UA was c/w UTI, pt was started on vanco and zosyn, UCx and BCx sent. sacral ulcers felt to be stage 4, no evidence of superinfection. BP initially responded to 3L IVF (99/53), however after 3rd litre, BP down to 85/40, pt therefore received RIJ TLC, and possibly an additional 1L IVF bolus, afterwhich BP improved to 115/70. Pt was asymptomatic, mentating throughout without specific complaints. . Pt also noted moderate abdominal tenderness. CT ABD done which showed no acute processes. CXR unremarkable, EKG unremarkable (old Q in III, ?mild ST changes V1). . Pt admitted to ICU for further monitoring given hypotension. . Past Medical History: 1. Inflammatory disease of the spinal cord of uncertain etiology. MRA [**10-16**] negative for vascular malformation. Initial CSF analysis showed elevated protein (82) without oligoclonal bands. NMO blood titer negative, RPR negative, Lyme serology negative, [**Doctor First Name **] negative, Ro and La negative, ACE level normal, neuromyelitis IgG negative, ESR 70, CRP 66.8. Ultimately treated with broad spectrum antibiotics, corticosteroids (two weeks of Solu-Medrol followed by a prednisone taper), and 5 days of mannitol without improvement. He is followed by neurology for a dense paraplegia (T4) with neuropathic pain, restrictive shoulder arthropathy, and a neurogenic bladder requiring a chronic indwelling foley. 2. Chronic sacral decubitus ulcer, previously treated with a VAC dressing 3. Multiple UTI (including Pseudomonas) 4. Pulmonary embolus [**11-15**] s/p IVC filter placement 5. Asthma 6. Two-vessel coronary artery disease s/p CABG 4-5 years ago 7. Systolic CHF (EF 25-30% on [**2-15**] TTE) 8. Repaired liver laceration 9. Chronic back pain 10. Vitiligo 11. Feeding tube 12. Depression 13. MRSA from sacral swab and sputum 14. Prior transient episodes of leg paralysis 15. Right frontal lobe brain lesion biopsied [**11-15**] and c/w gliosis; resolved on repeat imaging 16. Abnormal visual evoked potentials Social History: He moved here from [**Country 3594**] (after living in many different countries) in the [**2068**]. He is retired from a job in the maritime industry. Divorced 24 years ago. Three children. Quit smoking [**2076**]. Quit drinking [**2080**]. No history of illicit drug use or abuse. Family History: No stroke, aneurysm, no seizure, no AAA. Physical Exam: VS: 96.6 85 105/66 15 100%2L Gen: Well appearing male in NAD lying in bed. HEENT: JVD <6-8cm, MMM, lips slightly pale. Chest: CTA bilaterally, no w/r/r. CV: RRR, physiologic splitting S2, no r/g. 3/6 SEM @ LSB. Abd: Soft, nontender to deep palpation in all four quadrants, distended, tympanic (?gas), negative murphys sign, well-healed midline g-tube scar. Extremities: Warm, well perfused, no C/C. [**2-10**]+ edema bilaterally to knees. Skin: Vitiligo on hands. Large round 6x4 cm diameter pressure decubitus ulcer on sacrum and 4x3cm decub ulcer on left ischial tuberosity. Appears clean with granulation tissue in center, no s/sx of infection. no purulent drainage. Neuro: CN grossly intact. A&O x 3, pleasantly conversant. Pertinent Results: [**2106-4-5**] 11:50PM BLOOD WBC-9.08 RBC-4.37* Hgb-11.2* Hct-34.9* MCV-80* MCH-25.6* MCHC-32.0 RDW-15.1 [**2106-4-8**] 04:47AM BLOOD WBC-6.7 RBC-3.49* Hgb-8.9* Hct-28.5* MCV-82 MCH-25.6* MCHC-31.4 RDW-14.9 [**2106-4-5**] 11:50PM BLOOD Glucose-125* UreaN-11 Creat-0.5 Na-137 K-4.0 Cl-101 HCO3-27 AnGap-13 [**2106-4-8**] 04:47AM BLOOD Glucose-109* UreaN-5* Creat-0.4* Na-139 K-3.7 Cl-110* HCO3-23 AnGap-10 [**2106-4-6**] 10:27PM BLOOD CK-MB-5 cTropnT-0.08* [**2106-4-6**] 08:11AM BLOOD cTropnT-0.08* [**2106-4-5**] 11:50PM BLOOD CK-MB-NotDone cTropnT-0.09* [**2106-4-8**] 04:47AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.0 [**2106-4-6**] 12:05PM BLOOD Cortsol-15.3 [**2106-4-6**] 12:05PM BLOOD CRP-122.0* [**2106-4-6**] 01:45PM BLOOD Lactate-1.4 [**2106-4-6**] 12:00PM BLOOD Lactate-0.7 [**2106-4-6**] 12:02AM BLOOD Lactate-1.7 CT ABD/Pelv [**2106-4-6**]: 1. Severe sacral and right ischial tuberosity decubitus ulcers. 2. No acute intra-abdominal inflammatory process. 3. Cholelithiasis. CXR [**4-6**] Bedside frontal chest radiograph is compared to [**2106-1-2**] and demonstrate clear lungs, normal pulmonary vasculature, and no evidence for pleural effusions. The heart and mediastinal contours, remarkable for tortuous aorta, are stable. This patient is status post median sternotomy. IMPRESSION: No acute cardiopulmonary process. EKGs: NSR, essentially unchanged from prior tracings WBC scan; IMPRESSION: 1. Unchanged appearance of residual sacrum with adjacent posterior focal radiotracer uptake, again apparently within adjacent soft tissues. However, given the proximity of the uptake, bony involvement with infection cannot be excluded. 2. Similar sclerotic appearance of right lower ischium and adjacent soft tissue thickening. Although the CT appearance suggests chronic osteomyelitis, immediately adjacent radiotracer activity has resolved and the bony abnormality appears unchanged. 3. New cellulitis along the right lower buttock, at the interface with the thigh and inferior to the prior site of infection. 4. More extensive radiotracer uptake in the left lower buttock, with fat stranding on CT suggesting cellulitis. Although the soft tissue abnormality extends to the ischial tuberosity, there is no CT evidence of bone destruction or abnormal bony radiotracer uptake in this area. [**2106-4-6**] 6:38 pm SWAB Source: left ischial tuberosity. **FINAL REPORT [**2106-4-10**]** GRAM STAIN (Final [**2106-4-6**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2106-4-10**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). Susceptibility will be performed on P. aeruginosa and S. aureus if sparse growth or greater. STAPH AUREUS COAG +. SPARSE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. Please contact the Microbiology Laboratory ([**8-/2404**]) immediately if sensitivity to clindamycin is required on this patient's isolate. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2106-4-10**]): NO ANAEROBES ISOLATED. [**2106-4-6**] 6:38 pm SWAB Source: sacral decubitus ulcer. **FINAL REPORT [**2106-4-10**]** GRAM STAIN (Final [**2106-4-6**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2106-4-10**]): ESCHERICHIA COLI. RARE GROWTH. PSEUDOMONAS AERUGINOSA. RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | PSEUDOMONAS AERUGINOSA | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S 4 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- <=4 S 8 S PIPERACILLIN/TAZO----- <=4 S 8 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S ANAEROBIC CULTURE (Final [**2106-4-10**]): NO ANAEROBES ISOLATED. Brief Hospital Course: A/P: 67M h/o T4 paraplegia, recurrent UTIs [**3-13**] indwelling foley, multiple stage 4 decubs was admitted to ICU initially with fever to 101.8, transient hypotension that resolved with 3-4L IVF but continued on sepsis protocol. . # FEVER - Felt due to UTI and or osteomyelitis. Cx. all neg, but swab suggested colonization with mrsa; also seen on swab, pseudomonas and enterococcus. Emperically treated with vancomycin and zosyn given this information and prior culture data that was reviewed here. Tagged wbc scan as above. Plastic surgery consult evaluated wounds and felt that pt. did not have evidence of osteomyelitis. Plan two weeks of abx for empiric treatment for complicated UTI. Foley replaced. Follow up with [**Month/Day (2) **] arranged for evaluation for suprapubic catheter. Follow up with plastic surgery also arranged. . # HYPOTENSION - resolved with IVF and treatment of infection as above. # H/O PE - s/p IVC filter, INR elevated, so warfarin held, then given 5 po vitamin K given sustained inr over 4.0. INR came down to 1.8 with this, so warfarin resumed. Otherwise, home medication regimen continued in hospital for other chronic medical issues as outlined in pmhx. and in medication list below. Medications on Admission: vitamin c 500mg po qdaily aspirin 81mg po qdaily baclofen 5mg po tid calcium carbonate 650mg po bid citalopram 40mg po qdaily pepcid 20mg po qdaily advair 250/50 IH [**Hospital1 **] gabapentin 400mg po bid simethicone 80mg po tid simvastatin 40mg po qdaily tramadol 25mg po tid ursodiol 300mg po qdaily warfarin 3mg po qdaily prostat 30ml oral [**Hospital1 **] (liquid protein supplement) . Discharge Medications: 1. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 7 days. gram 2. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours) for 7 days. 3. Sodium Hypochlorite 0.25 % Solution Sig: One (1) Appl Miscellaneous ASDIR (AS DIRECTED) for 1 days: apply to ischial wounds only, for one day ([**4-16**]) in [**Hospital1 **] wet to dry dsg changes. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation [**Hospital1 **] (2 times a day). 9. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed. 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 13. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO QDAILY (). 14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 16. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 17. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 19. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**2-10**] Tablet, Rapid Dissolves PO Q8H (every 8 hours) as needed. 20. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: UTI with sepsis Chronic sacral and ischial decubitus ulcerations Chronic, systolic, heart failure Hx. PE with SVC filter, on warfarin Discharge Condition: Stable Discharge Instructions: Return to the [**Hospital1 18**] Emergency Department for: Fever Hypotension Followup Instructions: Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2106-4-23**] 1:30 For evaluation for suprapubic catheter placment: Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2106-4-28**] 9:30 ",35,2106-04-06 07:05:00,2106-04-15 18:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LONG TERM CARE HOSPITAL,FEVER," a/p: 67m h/o t4 paraplegia, recurrent utis [**3-13**] indwelling foley, multiple stage 4 decubs was admitted to icu initially with fever to 101.8, transient hypotension that resolved with 3-4l ivf but continued on sepsis protocol. . # fever - felt due to uti and or osteomyelitis. cx. all neg, but swab suggested colonization with mrsa; also seen on swab, pseudomonas and enterococcus. emperically treated with vancomycin and zosyn given this information and prior culture data that was reviewed here. tagged wbc scan as above. plastic surgery consult evaluated wounds and felt that pt. did not have evidence of osteomyelitis. plan two weeks of abx for empiric treatment for complicated uti. foley replaced. follow up with [**month/day (2) **] arranged for evaluation for suprapubic catheter. follow up with plastic surgery also arranged. . # hypotension - resolved with ivf and treatment of infection as above. # h/o pe - s/p ivc filter, inr elevated, so warfarin held, then given 5 po vitamin k given sustained inr over 4.0. inr came down to 1.8 with this, so warfarin resumed. otherwise, home medication regimen continued in hospital for other chronic medical issues as outlined in pmhx. and in medication list below. ","PRIMARY: [Infection and inflammatory reaction due to indwelling urinary catheter] SECONDARY: [Unspecified septicemia; Sepsis; Paraplegia; Pressure ulcer, lower back; Pressure ulcer, hip; Chronic systolic heart failure; Urinary tract infection, site not specified; Aortocoronary bypass status; Congestive heart failure, unspecified; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants]","a/p: 67m h/o t4 paraplegia, recurrent utis [**3-13**] indwelling foley, multiple stage 4 decubs was admitted to icu initially with fever to 101.8, transient hypotension that resolved with 3-4l ivf but continued on sepsis protocol. all neg, but swab suggested colonization with mrsa; also seen on swab, pseudomonas and enterococcus. follow up with [**month/day (2) **] arranged for evaluation for suprapubic catheter.","67m h/o t4 paraplegia, recurrent utis was admitted to icu initially with fever to 101.8, transient hypotension that resolved with 3-4l ivf but continued on sepsis protocol. emperically treated with vancomycin and zosyn given this information and prior culture data that was reviewed here." 21202,155154.0,30385,2146-02-24,30384,106349.0,2145-09-12,Discharge summary,"Admission Date: [**2145-9-7**] Discharge Date: [**2145-9-12**] Date of Birth: [**2090-7-16**] Sex: M Service: MEDICINE Allergies: Cefepime / Cipro Attending:[**First Name3 (LF) 3913**] Chief Complaint: Hypotension, cough Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 47367**] is a 55 yo male s/p allogeneic stem cell transplant for AML [**6-/2143**] with chronic GVHD on long-term steroids, DM, hx of PE on coumadin. . He presents to his [**Hospital 3242**] clinic with fatigue for several days, and anorexia, with about 12-16 hours of worsening shortness of breath. . Endorses increased cough with yellow sputum production and chills, but no fever. This morning, he reported an acute episode of dyspnea that did not rapidly improved, and occured with little amounts of activity and somewhat improved with rest. No PND/orthopnea. No hemoptysis. . He has had no new rashes, and has not had documented fevers. He has no diarrhea, but has been nauseated without vomiting. He reports mild epigastric pain. He has a mild headache made somewhat worse with light, but he feels that this is very consistent with flares of GVH and not different (has occured he estimates about 8 times). . In clinic SBP 70's, and he was given saline with improvement, but then the BP decreased down to the 80's. Labs from clinic showed that Cr increased to 2.9 (baseline 1.1). WBC increased somewhat. He was transferred to the ED for further evaluation. . In the ED, initial vs were: 4 97.6 72 105/73 18 99% He was given total of 3L of saline, and recent vital signs were 98.8 129/85 80 16 96% on 2L at time of transfer. A bedside ""shock"" ultrasound US in ED showed no cardiac effusion, no evidence of gross RV overload. EKG was not significantly changed. Her INR was 3.0. Of note, he was also complaining of left sided shoulder/neck pain associated with shortness of breath and diaphoresis. . For interventions, he received 1 gm vanc and 1gm aztreonam, 40 mg medrol, and 2 L IVF in clinic, and another liter in the ED. Past Medical History: - AML-M7: s/p matched unrelated allogenic transplant on [**2143-6-24**] - Chronic extensive GVHD of skin and liver, liver biopsy [**4-23**] consistent with GVHD, managed with cyclosporine, steroids, periodic CellCept, and has received 1 cycle of Rituxan. - Type 2 DM - Hyperlipidemia - H/o AVN bilateral hips - HTN - H/o nephrolithiasis, lithotripsy and previous nephrostomy tube and emergent surgery to repair ureteral damage - h/o left interpolar renal lesion, followed with MRs - h/o BCC s/p excision - h/o SCC left cheek, s/p Mohs' [**5-/2144**] - h/o multiple back surgeries: Lumbar L5-S1 surgery x 3, and cervical spine fusion (bone graft, no hardware) - h/o anterior cervical diskectomy and instrument arthrodesis at C5-C6 and C6-C7 for degenerative cervical spondylitic disease with spinal cord compression and foraminal stenosis at C5-C6 and C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**] - Chronic numbness, neuropathic pain in left upper extremity. - Multilevel compression fractures T11, T12, L1 and mild compression L3 and L4. - h/o pulmonary embolism [**11/2144**] on anticoagulated from [**11/2144**]-present - h/o RSV [**11/2144**] requiring ICU admission - h/o OSA, planned BIPAP, followed by Dr. [**Last Name (STitle) 4507**] Social History: Lives with his wife, and one of children, worked as a [**Company 22957**] technician until [**Month (only) 547**] when he took early retirement and he is no longer working. Tob: previously smoked 1ppd for many years but quit 2.5 years ago EtOH: h/o social use; none recently Family History: Mother died suddenly in her 70s. Father died of unknown cancer with tumors visible across body. One sister has thyroid cancer. One brother has diabetes and kidney stones. One sister has [**Name (NI) 5895**]. Physical Exam: Tmax: 36.7 ??????C (98.1 ??????F) Tcurrent: 36.7 ??????C (98.1 ??????F) HR: 85 (85 - 85) bpm BP: 101/66(75) {101/66(75) - 101/66(75)} mmHg RR: 11 (11 - 11) insp/min SpO2: 97% Heart rhythm: SR (Sinus Rhythm) . General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: mild RUQ->mid epigastrium tenderness GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . No calf or thigh tenderness. Skin: depigmentation on hands, redness of neck, but no notable skin changes otherwise. No rashes. Pertinent Results: [**9-9**] CT chest without contrast IMPRESSION: 1. Mostly resolved parenchymal opacities, leaving several parenchymal bands which are felt most likely to represent residua of a prior infectious or inflammatory process. 2. Subacute to chronic rib fractures, including along the right posterior seventh rib, where there is faint but suspicious sclerosis extending further laterally than would usually be expected in the setting of an uncomplicated rib fracture. In the setting of prior treated hematological malignancy, the finding of vague sclerosis raises concern for a bone marrow abnormality such as myelofibrosis or potentially a form of disease recurrence. Mostly, however, the bones appear within normal limits. . [**9-9**] PFT's SPIROMETRY Pre drug Post drug Actual Pred %Pred Actual %Pred %chg FVC 3.86 5.05 76 3.83 76 -1 FEV1 2.83 3.60 79 2.69 75 -5 FEV1/FVC 73 71 103 70 98 -4 . [**9-8**] RUQ US IMPRESSION: 1. Polyp at neck of gallbladder (1.2cm), which was also seen on prior ultrasound scan [**2145-2-9**]. This has not changed significantly since prior ultrasound scan, but followup imaging is advised. . [**9-8**] Echo The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. . Micro: [**9-8**] CMV VL negative [**9-8**] sputum: oropharyngeal flora [**9-8**] urine cx negative [**9-8**] viral screen and cx negative [**9-7**] blood cx negative . ON ADMISSION: [**2145-9-7**] 01:05PM BLOOD WBC-11.1* RBC-4.39* Hgb-16.0 Hct-49.0 MCV-112* MCH-36.5* MCHC-32.7 RDW-14.9 Plt Ct-264 [**2145-9-7**] 01:05PM BLOOD Neuts-85.1* Lymphs-7.0* Monos-5.2 Eos-2.5 Baso-0.3 [**2145-9-7**] 01:05PM BLOOD PT-30.5* INR(PT)-3.0* [**2145-9-7**] 01:05PM BLOOD UreaN-28* Creat-2.9*# Na-140 K-4.4 Cl-101 HCO3-29 AnGap-14 [**2145-9-7**] 01:05PM BLOOD ALT-24 AST-20 LD(LDH)-201 CK(CPK)-37* AlkPhos-155* TotBili-0.3 [**2145-9-7**] 01:05PM BLOOD cTropnT-0.05* [**2145-9-7**] 01:05PM BLOOD Albumin-4.2 Calcium-9.3 Phos-2.6* Mg-2.4 [**2145-9-7**] 08:13PM BLOOD Lactate-1.9 . ON DISCHARGE: [**2145-9-12**] 05:40AM BLOOD WBC-7.2 RBC-3.45* Hgb-12.5* Hct-38.3* MCV-111* MCH-36.2* MCHC-32.7 RDW-15.0 Plt Ct-211 [**2145-9-12**] 05:40AM BLOOD Neuts-68.8 Lymphs-17.2* Monos-7.9 Eos-5.7* Baso-0.4 [**2145-9-12**] 05:40AM BLOOD Plt Ct-211 [**2145-9-12**] 05:40AM BLOOD Glucose-80 UreaN-18 Creat-0.9 Na-143 K-3.7 Cl-104 HCO3-30 AnGap-13 [**2145-9-12**] 05:40AM BLOOD ALT-25 AST-18 LD(LDH)-181 AlkPhos-112 TotBili-0.2 [**2145-9-12**] 05:40AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.1 UricAcd-4.6 Brief Hospital Course: 55 y/o male with ?viral syndrome vs. other atypical infection with hypotension that is suspected to be hypovolemia or adrenal insufficiency, with acute renal failure. . # Lethargy: concern for viral syndrome, including activation of CMV, or a respiratory virus. He has been known EBV+ in the past. This could also be related to sensation of dyspnea that he has been having, and warranted further cardiovascular and pulmonary work-up in parallel with the infectious work-up. In the ICU, continued broad spectrum antibiotics of vancomycin and aztreonam (given allergy). Infectious workup largely negative including CMV VL, respiratory panel, EBV VL, fungal markers, blood cultures, urine cultures, CT chest. Pt's lethargy improved with IVFs, antibiotics, and stress dose steroids. Did not ever need pressors. . # Dyspnea/Cough: Concern for infectious process. Regarding VTE, his risk should be reduced with therapeutic INR, though the concern for coumadin failure merits consideration, though would be unlikely and he has no other signs and symptoms of DVT. PFTs completed [**9-9**], with official report pending at time of this summary. CT chest showing resolving parenchymal processes, resolving infectious/inflammatory process. Continued broad spectrum antibiotics initially. When no infiltrate noted on CXR, decreased ABX to 5 days of azithromycin for treatment of bronchitis. . # Hypotension: A bedside ""shock"" ultrasound US in ED showed no cardiac effusion, no evidence of gross RV overload. EKG unchanged. Patient's hypotension was fluid/stress dose steroids responsive. Initially given stress dose steroids with plans to resume home dose. Also given IVF repletion. BPs normalized. Likely etiology was slight adrenal insufficiency in setting of viral syndrome despite negative infectious workup. Patient discharged with prednisone 7.5 mg daily. . # Acute Renal Failure: Likely pre-renal azotemia. Improved with IVFs. Cr 0.9 on discharge. . # Mild epigastric/RUQ tenderness: No laboratory e/o hepatitis. RUQ US showing polyp at neck of gallbladder (1.2cm), which was also seen on prior ultrasound scan [**2145-2-9**]. No other findings to explain epigastric pain. This pain has resolved on discharge. . # Pulmonary Embolism [**11-23**]: continued coumadin with INR goal [**1-19**]. # Diabetes: Continued NPH 12 units [**Hospital1 **], with close sugar monitoring and diabetic diet. Medications on Admission: ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth three times a day BUDESONIDE [ENTOCORT EC] - (Dose adjustment - no new Rx) - 3 mg Capsule, Sust. Release 24 hr - 1 (One) Capsule(s) by mouth twice a day FOLIC ACID - (Dose adjustment - no new Rx) - 1 mg Tablet - 1 (One) Tablet(s) by mouth once a day HYDROMORPHONE - 2 mg Tablet - [**12-18**] Tablet(s) by mouth every [**3-22**] hours as needed for pain INSULIN LISPRO [HUMALOG] - SS LISINOPRIL - (Dose adjustment - no new Rx) - 5 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL TARTRATE - 25 mg Tablet - 1 (One) Tablet(s) by mouth twice a day OXYCODONE - 20 mg Tablet Sustained Release 12 hr - 3 (Three) Tablet(s) by mouth every morning (60 mg), 1 tablet every 2pm (20 mg) and 3 tablets every evening (60 mg) PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once day PREDNISONE - 2.5 mg Tablet - 2 (Two) Tablet(s) by mouth once a day RISEDRONATE [ACTONEL] - 35 mg Tablet q Saturday TESTOSTERONE [ANDROGEL] - 50 mg/5 gram (1 %) Gel in Packet - Apply to upper torso once daily WARFARIN [COUMADIN] - (Dose adjustment - no new Rx) - 2.5 mg Tablet - 2 (Two) Tablet(s) by mouth once a day or as directed CHOLECALCIFEROL (VITAMIN D3) [DELTA D3] - (Dose adjustment - no new Rx) - 400 unit Tablet - 1 Tablet(s) by mouth DAILY (Daily) INSULIN NPH HUMAN RECOMB - (Prescribed by Other Provider) - 100 unit/mL Suspension - 12 units twice a day Please take first dose in the morning and the second dose at bedtime Discharge Medications: 1. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 5. OxyContin 60 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day: QAM and QPM. 6. OxyContin 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO once a day: at 1400 every day. 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 8. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO twice a day. 9. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): For total 7.5 mg daily. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week: On Saturdays. 13. AndroGel 1 %(50 mg/5 gram) Gel in Packet Sig: One (1) packet Transdermal once a day: Apply to upper torso once daily as directed. 14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) units Subcutaneous twice a day. 15. Insulin Lispro 100 unit/mL Solution Sig: Varied units Subcutaneous four times a day: As per home sliding scale. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Hypotension/adrenal insufficiency Bronchitis Acute renal failure . Secondary diagnosis: AML s/p MUD allogeneic SCT [**6-/2143**] Chronic GVHD of skin/liver h/o PE Diabetes mellitus Discharge Condition: Stable, afebrile, BP 113/76, RR 16, sats 96% on RA, INR 1.8. Discharge Instructions: You were admitted with fatigue, shortness of breath, cough, low blood pressure and acute renal failure. We were concerned for early sepsis and you were in the ICU initially. You received broad spectrum antibiotics and stress dose steroids, but a full workup (including viral swabs, cultures, ECHO, and CT chest) were unrevealing. CT chest showed resolving infiltrates and your symptoms improved so the antibiotics were switched to azithromycin for presumed bronchitis. Your prednisone was increased due to presumed mild adrenal insufficiency. . The following medication changes were made: 1) Prednisone increased to 7.5mg daily 2) Azithromycin (antibiotic) started, to be completed as outpatient 3) Your lisinopril (blood pressure medication) and metoprolol were discontinued. Do NOT resume these medications until speaking to Dr. [**Last Name (STitle) **]. . You need to have your INR checked on Tuesday, [**2145-9-14**]. You also need to follow up with Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 3236**] within the next week. Please call their office tomorrow to make this appointment. . of the following symptoms: fever, chills, shortness of breath, difficulty breathing, abdominal pain, cough, flu symptoms, or any other worrisome symptoms. Followup Instructions: You need to have your INR checked on Tuesday, [**2145-9-14**]. . Please call Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) 3235**] [**Last Name (NamePattern1) 72254**] office to make an appointment to be seen later this week. They can be reached at [**Telephone/Fax (1) 3241**]. Completed by:[**2145-9-17**]",165,2145-09-07 20:37:00,2145-09-12 16:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,SEPSIS," 55 y/o male with ?viral syndrome vs. other atypical infection with hypotension that is suspected to be hypovolemia or adrenal insufficiency, with acute renal failure. . # lethargy: concern for viral syndrome, including activation of cmv, or a respiratory virus. he has been known ebv+ in the past. this could also be related to sensation of dyspnea that he has been having, and warranted further cardiovascular and pulmonary work-up in parallel with the infectious work-up. in the icu, continued broad spectrum antibiotics of vancomycin and aztreonam (given allergy). infectious workup largely negative including cmv vl, respiratory panel, ebv vl, fungal markers, blood cultures, urine cultures, ct chest. pts lethargy improved with ivfs, antibiotics, and stress dose steroids. did not ever need pressors. . # dyspnea/cough: concern for infectious process. regarding vte, his risk should be reduced with therapeutic inr, though the concern for coumadin failure merits consideration, though would be unlikely and he has no other signs and symptoms of dvt. pfts completed [**9-9**], with official report pending at time of this summary. ct chest showing resolving parenchymal processes, resolving infectious/inflammatory process. continued broad spectrum antibiotics initially. when no infiltrate noted on cxr, decreased abx to 5 days of azithromycin for treatment of bronchitis. . # hypotension: a bedside ""shock"" ultrasound us in ed showed no cardiac effusion, no evidence of gross rv overload. ekg unchanged. patients hypotension was fluid/stress dose steroids responsive. initially given stress dose steroids with plans to resume home dose. also given ivf repletion. bps normalized. likely etiology was slight adrenal insufficiency in setting of viral syndrome despite negative infectious workup. patient discharged with prednisone 7.5 mg daily. . # acute renal failure: likely pre-renal azotemia. improved with ivfs. cr 0.9 on discharge. . # mild epigastric/ruq tenderness: no laboratory e/o hepatitis. ruq us showing polyp at neck of gallbladder (1.2cm), which was also seen on prior ultrasound scan [**2145-2-9**]. no other findings to explain epigastric pain. this pain has resolved on discharge. . # pulmonary embolism [**11-23**]: continued coumadin with inr goal [**1-19**]. # diabetes: continued nph 12 units [**hospital1 **], with close sugar monitoring and diabetic diet. ","PRIMARY: [Unspecified septicemia] SECONDARY: [Acute kidney failure, unspecified; Glucocorticoid deficiency; Acute myeloid leukemia, in remission; Complications of transplanted bone marrow; Chronic graft-versus-host disease; Severe sepsis; Adrenal cortical steroids causing adverse effects in therapeutic use; Acute bronchitis; Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation; Personal history of venous thrombosis and embolism; Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled; Long-term (current) use of steroids]","viral syndrome vs. other atypical infection with hypotension that is suspected to be hypovolemia or adrenal insufficiency, with acute renal failure. # dyspnea/cough: concern for infectious process. # hypotension: a bedside ""shock"" ultrasound us in ed showed no cardiac effusion, no evidence of gross rv overload. initially given stress dose steroids with plans to resume home dose. # pulmonary embolism [**11-23**]: continued coumadin with inr goal [**1-19**].","pts lethargy improved with ivfs, antibiotics, and stress dose steroids. pts lethargy improved with ivfs, antibiotics, and stress dose steroids." 23161,115895.0,17796,2138-08-03,17795,168634.0,2138-07-27,Discharge summary,"Admission Date: [**2138-7-18**] Discharge Date: [**2138-7-27**] Date of Birth: [**2055-3-1**] Sex: M Service: MEDICINE Allergies: Phenylephrine Attending:[**First Name3 (LF) 1711**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: none History of Present Illness: 83 yo Russian speaking male with a history of CAD and a recent NSTEMI reportedly complicated by cardiogenic shock (hospitalized at [**Hospital3 **] and discharged to rehab yesterday) presents from rehab after experiencing CP and subsequent hypotension following NTG adminstration. At [**Hospital3 **] apparently underwent cath which demonstrated anatomy not ammendable to stenting. At rehab today, experienced chest pain and was given ASA and NTG. He subsequently became hypotensive with SBPs reportedly in the 80s. Per wife for many years pt had chest discomfort lasting about 5-10 minutes about once a month at home that usually resolves with NTG. however for the past 5-6 days he has had it everyday and at times more than once a day at rest. this morning he was in bed when chest pain began. after he took ntg he began to feel unwell and bp was noted to be in the 80s. he apparently also has been having blood streak in the stool and urine since admitted at [**Hospital3 **] but was evaluated there. she also states he has exertional dyspnea on going up the stairs but denies syncope. pt apparent has not had any fever, chill, rigor. he however does have a cough with minimal sputum production. . In the [**Hospital1 18**] ED, the pt's initial vitals were stable. He denied any further chest pain. A chest x-ray was concering for possible pneumonia and the patient was treated with antibiotics. However he's afebrile and has a normal wcc. He was also evaluated in the ED by cardiology who advised against emperic anticoagulation. The pt is now admitted to the CCU for close monitoring. His most recent vitals prior to transfer were: HR 60, RR 23, 110/47, 97% 4L . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: 3. OTHER PAST MEDICAL HISTORY: . MR AS, severe CHF, systolic and diastolic dysfunction, Recurrent MI with cardiogenic shock [**2133-8-7**]. Multiple PCI procedures PAD with IC Right foot plantar ulcer CRI. Bronchiectasis/emphysema/recurrent bronchitis Diabetic neuropathy, possible early diabetic nephropathy Chronic recurrent left ear infection Social History: Lives at home with wife. -Tobacco history: Denies. -ETOH: Rare social EtOH. -Illicit drugs: Family History: Noncontributory Physical Exam: Temp 37.3, hr 70/min, bp 107/70, rr 16/min, sats 96% on ra GENERAL: appears in no apparent distress. Mood, affect appropriate. [**Month/Day/Year 4459**]: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, jvp mildly elevated in a 30% angle CARDIAC: rrr, nl s1, faint s2, [**5-12**] ejection systolic murmur in right second intercostal space with radiation to neck. LUNGS: reduce air entry bilaterally with expiratory wheeze. ABDOMEN: soft, non tender, nl bs EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: 1+ dp and pt pulses Pertinent Results: ADMISSION LABS: CBC: [**2138-7-18**] 01:39PM BLOOD WBC-5.0 RBC-3.18*# Hgb-9.6*# Hct-28.9*# MCV-91 MCH-30.1 MCHC-33.1 RDW-16.2* Plt Ct-340# [**2138-7-18**] 01:39PM BLOOD Neuts-78.4* Lymphs-14.4* Monos-4.0 Eos-2.7 Baso-0.5 [**2138-7-27**] BLOOD WBC-8.7 Hgb-8.1*# Hct-24.6*# Plt Ct-191# COAGS: [**2138-7-18**] 01:39PM BLOOD PT-13.8* PTT-24.3 INR(PT)-1.2* CHEMISTRIES: [**2138-7-18**] 01:39PM BLOOD Glucose-289* UreaN-32* Creat-1.6* Na-135 K-4.9 Cl-98 HCO3-28 AnGap-14 [**2138-7-27**] BLOOD Glucose-83* UreaN-35* Creat-1.6* Na-139 K-4.0 Cl-103 HCO3-26 LFTS: [**2138-7-19**] 06:00AM BLOOD ALT-27 AST-22 LD(LDH)-213 CK(CPK)-61 AlkPhos-85 TotBili-0.6 CEs: [**2138-7-18**] 01:39PM BLOOD cTropnT-0.05* [**2138-7-18**] 01:39PM BLOOD CK-MB-NotDone [**2138-7-18**] 07:08PM BLOOD CK-MB-NotDone cTropnT-0.05* [**2138-7-19**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.06* [**2138-7-22**] 05:15AM BLOOD CK-MB-NotDone cTropnT-0.04* [**2138-7-18**] 01:39PM BLOOD CK(CPK)-71 [**2138-7-18**] 07:08PM BLOOD CK(CPK)-64 [**2138-7-18**] 07:08PM BLOOD Calcium-8.2* Phos-2.8 Mg-2.1 IRON STUDIES: [**2138-7-19**] 06:00AM BLOOD calTIBC-247* VitB12-918* Folate-11.9 Ferritn-240 TRF-190* URINE STUDIES: [**2138-7-22**] 06:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 [**2138-7-22**] 06:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG = = = = = = = = ================================================================ MICRO: [**2138-7-25**] Urine Cx: URINE CULTURE (Final [**2138-7-27**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**7-25**], [**7-26**] Blood Cx: Pending = = = = = = = = ================================================================ [**7-18**] TTE The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. LV systolic function appears depressed (ejection fraction 30 percent) secondary to akinesis of the posterior wall and anterior septum, and hypokinesis of the rest of the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2138-2-21**], the left ventricular ejection fraction is further reduced. CXR [**7-19**] The current study demonstrates left basilar opacity which is new since [**2138-4-17**], and although appears to be smaller than on [**2138-7-18**], is consistent with a new left lower lobe infiltrate that might be worrisome for infectious process. No short interval change in the cardiomediastinal silhouette is demonstrated. There is no evidence of failure, pleural effusion, or pneumothorax. CXR [**7-25**] FINDINGS: In comparison with study of [**7-19**], there is increased opacification at the right base medially with silhouetting of the heart border. Although some of this may merely represent atelectasis, the appearance is worrisome for developing middle lobe pneumonia. Unfortunately, the lateral view is somewhat limited and does not adequately show this region. No evidence of vascular congestion. Video Swallow: Gross aspiration of nectar thick liquids which the patient was sensate. Brief Hospital Course: 83 year old man with complex medical issues including Diasolic and systolic CHF, severe AS, CKD, COPD and DM-2, PVD and chronic ulcers presents from nursing facility after taking NTG for his chest pain that resulted in hypotension that subsequently resolved spontanously. Pt also has new AF at [**Hospital3 5097**], started on amiodarone, persistant hematuria and anemia. . # CAD: Patient with recent NSTEMI reportedly complicated by cardiogenic shock (hospitalized at [**Hospital3 **] and discharged to rehab one day prior to admission). He reportly had CP at rehab and was given SLN with subsequent hypotension. At [**Hospital3 **] the patient underwent cath that demonstrated clean LM, LAD total occulsion, LCx 50%, RCA 60%, LAD collaterals being filled by RCA and anatomy was not ammendable to stenting. On arrival he was chest pain free. The patient was medically managed with high dose statin, BB and ASA. His cath films were reviewed by both cardiac surgery and interventional cardiology. The plan is to continue medical mangement given his lesions are not amenable to either PCI or CABG. He had 2 episodes of chest pain during his hospital course associated with no ECG changes or cardiac enzyme elevation. The pain was relieved with IV morphine. . #. Severe Aortic Stenosis: ECHO revealed a valve area of 0.8-1.0cm2 with a mean gradient of 23. He was evaluated by Cardiac Surgery who as noted above did not recommend CABG/AVR. Notably, the patient's severe AS makes treating his chest pain difficult since he is pre-load dependent and medications such as sub-lingial nitroglycerin can result in hypotension. Thus, this medication should be avoided. # Atrial Fibrillation: His AF was noted during his admission to [**Hospital3 5097**] in mid [**Month (only) 116**]. He was started on an amiodorone gtt at OSH and discharged to rehab on 200mg [**Hospital1 **]. His dose was further reduced to 200 mg daily during this hospitalization. He was also continued on metoprolol. # Chronic Systolic Congestive Heart Failure: The patient underwent ECHO that showed and EF of 30%. There was no evidence of overload clinically. He was continued on lasix, spironolactone, lisinopril and metoprolol. # Urinary Tract Infection: Patient found to have asymptomatic UTI. Gram neg rods in urine. He was started on cipro on [**7-26**], but cx grew E. Coli resistant to cipro. He was changed to Bactrim DS 1tab [**Hospital1 **] on [**7-27**] and should complete a total 7 day course. # Left lower lob infiltrate: This was felt to be secondary to aspiration pneumonitis since the patient was shown to aspirate during speech and swallow evaluation. Given he remained afebrile without leukocytosis he was not treated with ABX for this condition. Patient was started on a diet of pureed solids and honey thickened liquids to prevent further aspiration events. # Aspiration: Patient underwent video swallow that demonstrated aspiration. Speech and swallow had the following recs: 1. PO diet: pureed solids, honey thick liquids 2. PO meds: crushed in puree 3. Q4 oral care 4. 1:1 assist with meals to maintain aspiration precautions They also recommend f/u by swallow therapy in rehab setting and will require videoswallow study in [**2-7**] weeks to consider diet upgrade. # Iron deficiency Anemia: The patient's Hct in [**3-17**] 40, but on admission Hct was 28 and has remained stable. Notably, he has had multiple guiac positive stool and plan is for him to undergo outpatient EGD and colonoscopy on [**2138-7-28**]. However, the patient and family would like to postpone the GI workup until after rehab. They were given the phone number for [**Hospital **] clinic to reschedule if they would like to. The patient was continued on PPI and Iron. #) Hematuria: On admission the patient had hematuria that had started during his prior admission to [**Hospital3 **]. On [**7-20**] he was seen by urology and removed a large amount of old clot from his foley. There was no active bleeding. His foley was changed to a larger diameter foley. A repeat UA [**7-22**] was negative for blood. Patient should follow up as an outpatient with Dr. [**Last Name (STitle) 27027**]. The Urology contact number is [**Telephone/Fax (1) 164**]. #) Acute on Chronic Kidney Disease: The patient's creatinine was 1.6 on admission and has remained stable. He is at his baseline. #) DM: The patient's insulin was increased to his home dose of 50U lantus with improved glucose control. His home glyburide and precose were held during his admission and was covered with an ISS. Medications on Admission: simvastatsin 80mg daily aspirin 325 mg daily Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q12H amiodarone 200mg [**Hospital1 **] allopurinol 150mg daily lasix 40mg daily lisinopril 5mg daily metoprolol 50mg [**Hospital1 **] spironolactone 12.5mg daily lantus 40units daily and sliding scale Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 5. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Outpatient Speech/Swallowing Therapy Please reassess swallowing on [**2138-7-30**] thanks 14. Lantus 100 unit/mL Solution Sig: Fifty (50) U Subcutaneous at bedtime. 15. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day: please follow attached sliding scale. 16. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 17. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas. 18. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO BID (2 times a day) as needed for constipation. 19. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 20. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days: day1: [**7-27**]. Discharge Disposition: Extended Care Facility: [**Hospital **] rehab Discharge Diagnosis: Primary: -Coronary Artery Disease -Aortic Stenosis -Hematuria -Acute on chronic Renal Failure -Urinary Tract Infection Secondary: Chronic systolic heart failure Diabetes Mellitus Type 2 Discharge Condition: stable Discharge Instructions: You had chest pain and was transferred from [**Hospital3 580**] for evaluation. You were evaluated by cardiac surgery for a possible bypass and aortic valve replacement. At this time, it is not recommended that you get this surgery. We do not think your chest pain is related to your heart. Please take tylenol if you develop the pain. You will need to see Dr. [**First Name (STitle) 572**] for evaluation of blood in your stools and a urologist for blood in your urine. A colonoscopy and endoscopy was scheduled for [**7-28**] to evaluate bleeding and pain. However, you requested to postpone the procedure for a few weeks while you are at rehab. Please call GI: ([**Telephone/Fax (1) 2233**] to reschedule. You were seen by a speech therapist who felt that you were aspirating food into your lungs. You were started on a honey thick liquids and pureed food diet. Intravenous fluids were started to prevent dehydration. You will need to be re evaluated in about a week to determine if you are still aspirating. You also had a UTI and was started on bactrim DS 1 tab twice a day which you should continue for 7 days. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet Followup Instructions: Cardiology: [**First Name8 (NamePattern2) 1026**] [**Doctor Last Name 1016**] Phone: [**Telephone/Fax (1) 62**] Date/Time: [**8-28**] at 1:20pm. Urology: Dr. [**Last Name (STitle) 770**] Phone: [**Telephone/Fax (1) 164**] Please make f/u as outpt to evaluate hematuria. [**9-22**] at 1:10pm. [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 470**]. Gastroenterology: Colonoscopy and EGD: Monday [**7-28**] at 11:30am. [**Hospital Ward Name 1950**] 3 on [**Hospital Ward Name 516**]. Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 452**] will do procedure. However, you requested to have it postponed for a few weeks while you recover at rehab. Please call GI: ([**Telephone/Fax (1) 2233**] to reschedule your appointment. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2138-7-31**] 3:00 Podiatry: Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2138-8-20**] 1:30 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2138-8-21**] 10:10 Completed by:[**2138-7-27**]",7,2138-07-18 16:20:00,2138-07-27 14:20:00,EMERGENCY,EMERGENCY ROOM ADMIT,LONG TERM CARE HOSPITAL,CHEST PAIN," 83 year old man with complex medical issues including diasolic and systolic chf, severe as, ckd, copd and dm-2, pvd and chronic ulcers presents from nursing facility after taking ntg for his chest pain that resulted in hypotension that subsequently resolved spontanously. pt also has new af at [**hospital3 5097**], started on amiodarone, persistant hematuria and anemia. . # cad: patient with recent nstemi reportedly complicated by cardiogenic shock (hospitalized at [**hospital3 **] and discharged to rehab one day prior to admission). he reportly had cp at rehab and was given sln with subsequent hypotension. at [**hospital3 **] the patient underwent cath that demonstrated clean lm, lad total occulsion, lcx 50%, rca 60%, lad collaterals being filled by rca and anatomy was not ammendable to stenting. on arrival he was chest pain free. the patient was medically managed with high dose statin, bb and asa. his cath films were reviewed by both cardiac surgery and interventional cardiology. the plan is to continue medical mangement given his lesions are not amenable to either pci or cabg. he had 2 episodes of chest pain during his hospital course associated with no ecg changes or cardiac enzyme elevation. the pain was relieved with iv morphine. . #. severe aortic stenosis: echo revealed a valve area of 0.8-1.0cm2 with a mean gradient of 23. he was evaluated by cardiac surgery who as noted above did not recommend cabg/avr. notably, the patients severe as makes treating his chest pain difficult since he is pre-load dependent and medications such as sub-lingial nitroglycerin can result in hypotension. thus, this medication should be avoided. # atrial fibrillation: his af was noted during his admission to [**hospital3 5097**] in mid [**month (only) 116**]. he was started on an amiodorone gtt at osh and discharged to rehab on 200mg [**hospital1 **]. his dose was further reduced to 200 mg daily during this hospitalization. he was also continued on metoprolol. # chronic systolic congestive heart failure: the patient underwent echo that showed and ef of 30%. there was no evidence of overload clinically. he was continued on lasix, spironolactone, lisinopril and metoprolol. # urinary tract infection: patient found to have asymptomatic uti. gram neg rods in urine. he was started on cipro on [**7-26**], but cx grew e. coli resistant to cipro. he was changed to bactrim ds 1tab [**hospital1 **] on [**7-27**] and should complete a total 7 day course. # left lower lob infiltrate: this was felt to be secondary to aspiration pneumonitis since the patient was shown to aspirate during speech and swallow evaluation. given he remained afebrile without leukocytosis he was not treated with abx for this condition. patient was started on a diet of pureed solids and honey thickened liquids to prevent further aspiration events. # aspiration: patient underwent video swallow that demonstrated aspiration. speech and swallow had the following recs: 1. po diet: pureed solids, honey thick liquids 2. po meds: crushed in puree 3. q4 oral care 4. 1:1 assist with meals to maintain aspiration precautions they also recommend f/u by swallow therapy in rehab setting and will require videoswallow study in [**2-7**] weeks to consider diet upgrade. # iron deficiency anemia: the patients hct in [**3-17**] 40, but on admission hct was 28 and has remained stable. notably, he has had multiple guiac positive stool and plan is for him to undergo outpatient egd and colonoscopy on [**2138-7-28**]. however, the patient and family would like to postpone the gi workup until after rehab. they were given the phone number for [**hospital **] clinic to reschedule if they would like to. the patient was continued on ppi and iron. #) hematuria: on admission the patient had hematuria that had started during his prior admission to [**hospital3 **]. on [**7-20**] he was seen by urology and removed a large amount of old clot from his foley. there was no active bleeding. his foley was changed to a larger diameter foley. a repeat ua [**7-22**] was negative for blood. patient should follow up as an outpatient with dr. [**last name (stitle) 27027**]. the urology contact number is [**telephone/fax (1) 164**]. #) acute on chronic kidney disease: the patients creatinine was 1.6 on admission and has remained stable. he is at his baseline. #) dm: the patients insulin was increased to his home dose of 50u lantus with improved glucose control. his home glyburide and precose were held during his admission and was covered with an iss. ","PRIMARY: [Subendocardial infarction, subsequent episode of care] SECONDARY: [Acute kidney failure, unspecified; Pneumonitis due to inhalation of food or vomitus; Urinary tract infection, site not specified; Chronic combined systolic and diastolic heart failure; Injury to bladder and urethra, without mention of open wound into cavity; Acute posthemorrhagic anemia; Blood in stool; Coronary atherosclerosis of native coronary artery; Intermediate coronary syndrome; Congestive heart failure, unspecified; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified; Chronic kidney disease, unspecified; Bronchiectasis without acute exacerbation; Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled; Polyneuropathy in diabetes; Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled; Atherosclerosis of native arteries of the extremities with ulceration; Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled; Peripheral angiopathy in diseases classified elsewhere; Mitral valve insufficiency and aortic valve stenosis; ; Hematuria, unspecified; Iron deficiency anemia, unspecified; Chronic total occlusion of coronary artery; Other constipation; Atrial fibrillation; Unspecified accident; Long-term (current) use of insulin]","83 year old man with complex medical issues including diasolic and systolic chf, severe as, ckd, copd and dm-2, pvd and chronic ulcers presents from nursing facility after taking ntg for his chest pain that resulted in hypotension that subsequently resolved spontanously. at [**hospital3 **] the patient underwent cath that demonstrated clean lm, lad total occulsion, lcx 50%, rca 60%, lad collaterals being filled by rca and anatomy was not ammendable to stenting. he was started on an amiodorone gtt at osh and discharged to rehab on 200mg [**hospital1 **]. his dose was further reduced to 200 mg daily during this hospitalization. # chronic systolic congestive heart failure: the patient underwent echo that showed and ef of 30%. he was started on cipro on [**7-26**], but cx grew e. coli resistant to cipro. 1:1 assist with meals to maintain aspiration precautions they also recommend f/u by swallow therapy in rehab setting and will require videoswallow study in [**2-7**] weeks to consider diet upgrade. the patient was continued on ppi and iron. #) hematuria: on admission the patient had hematuria that had started during his prior admission to [**hospital3 **].","83 year old man presents from nursing facility with complex medical issues including diasolic and systolic chf, severe as, ckd, copd and dm-2, pvd and chronic ulcers. pt also has new af at [**hospital3 5097**], started on amiodarone, persistant hematuria and anemia." 23657,164590.0,13516,2143-04-08,13515,134743.0,2142-10-25,Discharge summary,"Admission Date: [**2142-10-22**] Discharge Date: [**2142-10-25**] Date of Birth: [**2112-11-14**] Sex: M Service: MEDICINE Allergies: Penicillins / Watermelon / Almond Oil Attending:[**First Name3 (LF) 2297**] Chief Complaint: Nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 29M h/o Type I Diabetes, c/b gastroparesis, erosive gastritis with h/o upper GI bleed. Presents with n/v, malaise after an EtOH binge. . Pt states that he was in his USOH until Saturday. He had 4 beers and 3 rum & Coke. Afterwards, has had nausea & vomiting. . He also has since been non-compliant with his insulin, missing several doses of insulin over the past few days. Last evening, did not take any NPH or regular insulin. . ROS otherwise significant for a cough over the past several days, minimally productive of scant greenish sputum. Otherwise, denies f/c/s. No dysuria. No CP, SOB, abd pain. . In ED, fingerstick blood sugar 422 and BP 235/104. AG 19, ketones in urine, but no evidence of UTI. Started on IV insulin gtt, received 3L NS. Labetalol 5mg IV x 2 with SBP down to 170s systolic. Past Medical History: 1. Type I diabetes mellitus, uncontrolled. Last HbA1c 10.8 [**2142-5-3**]. Followed by Dr. [**Last Name (STitle) 9835**] at [**Last Name (un) **]. Complicated by gastroparesis, nephropathy. 2. Erosive gastritis per EGD [**2137**]. Noncompliant with GI follow up for EGD after [**2141**] hospitalization/elopement. Noncompliant with PPI. 3. Hypertension, uncontrolled 4. Chronic renal insufficiency, baseline 1.5 5. Gastroesophageal reflux disease 6. Depression Social History: Works at [**Company 2475**] in office services. Lives with girlfriend in [**Location (un) 686**]. Smokes approx 5 cigarettes/week. Usually rare EtOH, except this past weekend. Denies illicit drug use. Family History: Mr. [**Known lastname 21822**] has 4 brothers and 5 sisters, all with no known Hx of diabetes or significant medical problems. His [**Name2 (NI) **] are alive and well. He reports that his grandfather had Diabetes, but he isn??????t sure what type. Physical Exam: Temp 99.7 BP 149/87 HR 88 RR 20 O2 sat 99% GEN: pt [**Name (NI) **]3, NAD, well nourished HEENT: PERRLA CV: RRR Resp: CTAB no wheezes or crackles Ab: +BS, soft, NT, ND EXT: no edema, bruising, or cyanosis Pertinent Results: [**2142-10-22**] 08:59AM GLUCOSE-336* UREA N-51* CREAT-2.9* SODIUM-137 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-21* ANION GAP-24* [**2142-10-25**] 03:39AM BLOOD Glucose-59* UreaN-29* Creat-2.3* Na-140 K-3.6 Cl-106 HCO3-24 AnGap-14 Brief Hospital Course: 29 M with DM1, DKA, hypertensive urgency likely secondary to noncompliance. . DKA - likely [**2-9**] noncompliance. - No evidence of infection as precipitant. CXR neg, UA with 0-2 wbc, low grade fevers initially which have cleared, no increased WBC - CE x2 are nl - gave fluids and insulin drip - AG closed by HD 2 however pt continued to have some nausea - HD 3 pt began taking PO, and was transitioned to [**1-9**] of his home humalog dose - HD 4 pt, had good PO intake, without nausea or vomiting . # Hypertensive Urgency - also likely [**2-9**] noncompliance, as pt missed his am's dose of BP medications before admission. - initially difficult to manage with IV metoprolol and hydralazine - Came under control to SBP of 150-170 range with 75 mg tid of metoprolol and 10 mg of norvasc. - will discharge on daily metoprolol and norvasc to increase compliance - pt likely to have baseline high blood pressures given history of non-compliance - Did not restart ACE-I due to worsening of renal function . # ARF - currently 2.3 down from Cr 2.9, with baseline ~2, likely prerenal [**2-9**] DKA - Gave IV hydration to assist with pre-renal causes, but Cr did not return completely to baseline. - Should follow up worsening renal function at [**Hospital **] clinic on f/u apt as outpatient. . # FEN - Pt not tolerating PO's currently initially, but did increase with time, IV fluid, and reglan. - emesis initially treated with IV zofran and phenergan. - pt transitioned to IV reglan and then PO reglan with good results - has reported history of gastroparesis and has been on reglan before - will give pt outpatient perscription for reglan to assist with gastroparesis - pt eating full meal at discharge - continued home PPI . # Proph - PPI - pneumoboots and ambulation - bowel regimen Medications on Admission: NPH 40 u [**Hospital1 **] lisinopril 5 mg po Discharge Medications: 1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 2. Amlodipine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*2* 4. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2* 5. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: Twenty (20) units Subcutaneous at bedtime. Disp:*600 units* Refills:*2* 6. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen [**Last Name (STitle) **]: Twenty (20) units Subcutaneous At breakfast. Disp:*600 units* Refills:*2* 7. Regular insulin sliding scale Please see attached regular insulin sliding scale. Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: # Diabetic ketoacidosis secondary to diabetes mellitus type 1 # Gastroparesis secondary to diabetes mellitus type 1 # Diabetes mellitus type 1 # Hypertensive urgency . Secondary diagnosis: # Chronic renal insufficiency secondary to diabetes mellitus type 1 # Diabetic neuropathy # Gastroesophageal reflux disease # Erosive gastritis # Depression Discharge Condition: Stable, tolerating PO intake. Discharge Instructions: You were admitted to the intensive care unit because you were hypoglycemic (had very low blood sugar) because of your type 1 diabetes. We started you on an insulin trip. In addition, you were nauseous and vomiting, probably related to gastroparesis (slow intestinal movements) related to your type 1 diabetes, and we gave you medications to help your intestines move. Finally, we found that you had very high blood pressures, and we gave you medications to lower your blood pressure. . We have started you on some new medications: . # For your nausea and vomiting: Metoclopramide 10 mg. Take one tablet before meals and at bedtime every day. . # For your high blood pressure: 1. Toprol XL 200mg daily: Take 200 mg daily in the mornings. 2. Amlodipine 10mg daily: Take 10mg daily in the mornings. . # For your insulin: We have written a prescription for an insulin pen for you to inject your NPH insulin. You should inject 20 units NPH at every breakfast, and another 20 units NPH at every bedtime. We have DECREASED your insulin dosage ONLY BECAUSE YOU ARE NOT EATING A FULL DIET YET. Once you start eating a full diet, you should return to using your 40 units NPH at every breakfast, and another 40 units NPH at every bedtime. . We have ***STOPPED*** your lisinopril 5mg daily because of your kidney function. Please follow up with the kidney doctor mentioned below to determine whether you should restart it. . Otherwise, we have not changed your medications. . We have made several appointments for you. Please keep these appointments. . If you experience nausea, vomiting, headache, changes in vision, chest pain, fever, shortness of breath, or any other symptoms you are concerned about, go immediately to the emergency room and call your primary care doctor. Followup Instructions: Because of your health, we strongly encourage you to follow up with the doctors [**Name5 (PTitle) 7928**]. We have made the following appointments for you: . [**Hospital 2793**] clinic (for your kidney): Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**], tel. [**Telephone/Fax (1) 60**], Wednesday, [**10-31**], at 8 am, Medical Specialties [**Hospital Ward Name 23**] [**Location (un) **] . [**Hospital **] clinic (for your diabetes): Dr. [**First Name (STitle) **] [**Name (STitle) 9835**], tel. [**Telephone/Fax (1) 2384**], Wednesday, [**10-31**], at 1pm, [**Last Name (un) **] Diabetes Center, [**Location (un) **]. Please check in at front desk. . Primary care (for your overall health): Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], tel. [**Telephone/Fax (1) 250**], Wednesday, [**11-7**], at 1:30 pm, [**Location (un) 3387**], Central 6, [**Hospital Ward Name 23**] Building. . Please call if there are any conflicts with your schedule. ",165,2142-10-22 11:09:00,2142-10-25 14:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,DIABETIC KETOACIDOSIS," 29 m with dm1, dka, hypertensive urgency likely secondary to noncompliance. . dka - likely [**2-9**] noncompliance. - no evidence of infection as precipitant. cxr neg, ua with 0-2 wbc, low grade fevers initially which have cleared, no increased wbc - ce x2 are nl - gave fluids and insulin drip - ag closed by hd 2 however pt continued to have some nausea - hd 3 pt began taking po, and was transitioned to [**1-9**] of his home humalog dose - hd 4 pt, had good po intake, without nausea or vomiting . # hypertensive urgency - also likely [**2-9**] noncompliance, as pt missed his ams dose of bp medications before admission. - initially difficult to manage with iv metoprolol and hydralazine - came under control to sbp of 150-170 range with 75 mg tid of metoprolol and 10 mg of norvasc. - will discharge on daily metoprolol and norvasc to increase compliance - pt likely to have baseline high blood pressures given history of non-compliance - did not restart ace-i due to worsening of renal function . # arf - currently 2.3 down from cr 2.9, with baseline ~2, likely prerenal [**2-9**] dka - gave iv hydration to assist with pre-renal causes, but cr did not return completely to baseline. - should follow up worsening renal function at [**hospital **] clinic on f/u apt as outpatient. . # fen - pt not tolerating pos currently initially, but did increase with time, iv fluid, and reglan. - emesis initially treated with iv zofran and phenergan. - pt transitioned to iv reglan and then po reglan with good results - has reported history of gastroparesis and has been on reglan before - will give pt outpatient perscription for reglan to assist with gastroparesis - pt eating full meal at discharge - continued home ppi . # proph - ppi - pneumoboots and ambulation - bowel regimen ","PRIMARY: [Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage I through stage IV, or unspecified] SECONDARY: [Diabetes with ketoacidosis, type I [juvenile type], uncontrolled; Acute kidney failure, unspecified; Chronic kidney disease, unspecified; Gastroparesis; Personal history of noncompliance with medical treatment, presenting hazards to health; Polyneuropathy in diabetes; Other specified gastritis, without mention of hemorrhage; Esophageal reflux; Depressive disorder, not elsewhere classified; Alcohol abuse, unspecified; Diabetes with neurological manifestations, type I [juvenile type], uncontrolled; Diabetes with renal manifestations, type I [juvenile type], uncontrolled]","29 m with dm1, dka, hypertensive urgency likely secondary to noncompliance. # hypertensive urgency - also likely [**2-9**] noncompliance, as pt missed his ams dose of bp medications before admission. - should follow up worsening renal function at [**hospital **] clinic on f/u apt as outpatient.","29 m with dm1, dka, hypertensive urgency likely secondary to noncompliance. cxr neg, ua with 0-2 wbc, low grade fevers initially which have cleared. pt transitioned to iv reglan and then po reglan with good results." 23657,176997.0,13519,2145-04-18,13518,169263.0,2145-03-24,Discharge summary,"Admission Date: [**2145-3-21**] Discharge Date: [**2145-3-24**] Date of Birth: [**2112-11-14**] Sex: M Service: MEDICINE Allergies: Penicillins / Watermelon / Almond Oil Attending:[**First Name3 (LF) 783**] Chief Complaint: Shortness of breath, nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 32 y/o M with hx of DM I, HTN, ESRD on HD (last HD yesterday with uneventful full run). Today had sudden onset SOB when he woke up. Felt positional and was improved with sitting up and worsened with lying down. Also then had symptoms with diarrhea and vomiting a few hours after waking up. They were non-bilious, non-bloody emesis and diarrhea. His SOB continued and he felt as if he had a tight feeling in his chest. Also felt some tightness substernally. No fevers, chills. Did have some sweats recently, but had otherwise been feeling well and healthy since his last discharge for n/v and gastroparesis. . In the ED, initial vitals were T 100.4, 203/116, 114 NSR, 40, 85% RA. Overall, mildly uncomfortable and working to breath, rales bilaterally. Had soft, distended, non-tender abdomen. Refused guiac exam. He received vanco, zosyn, and levo for potential pna. Also received an ASA. Started on nitro gtt for hypertension. Renal aware of patient and that he received contrast for his CTA. . On transfer from the ED, his vitals were 181/107, 124, 25, 97% NRB (was 90 on 6L). He was mildly uncomfortable. He is complaining of shortness of breath and a headache. His nausea is mostly improved. He otherwise is comfortable on 6L NC. . In the MICU, he had CTA which was negative for PE and consistent with pulmonary edema so antibiotics were discontinued. He received a one time dose of lasix 20 IV with good UOP and BP improved on home regimen as he was weaned off nitro drip and down to 2L O2 by NC. At time of transfer, he reports SOB much improved and denies any current CP. Past Medical History: - HTN - DM I since age 19, seen at [**Last Name (un) **]. Complicated by nephropathy, gastroparesis, and possibly retinopathy. - CKD: thought to be related to HTN and longstanding diabetes. Now on hemodialysis T/Th/Sat. Does make urine. Has been listed on kidney/pancreas transplant wait list since 4/[**2144**]. - Anemia: Thought to be combination of iron deficiency and CKD, now on epo with dialysis - Depression - s/p appendectomy [**7-/2144**] Social History: States that he previously drank heavily (30-40 drinks/week) but has not used alcohol since [**2144-11-14**]. +h/o tobacco use, quit in [**2142**], relapsed, quit last year and denies tobacco currently. Denies other drugs. Neg PPD [**2145-2-26**]. Lives with girlfriend. Family History: No FH of pancreatitis. Diabetes and heart trouble in grandfather. Physical Exam: General Appearance: Well nourished Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), no rubs Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Clear : , Crackles : few at bilateral bases) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: Trace, Left lower extremity edema: Absent Skin: Not assessed Neurologic: Attentive, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed Pertinent Results: [**2145-3-21**] 07:00PM BLOOD WBC-8.1 RBC-3.05* Hgb-8.4* Hct-27.1* MCV-89 MCH-27.5 MCHC-31.0 RDW-15.3 Plt Ct-275 [**2145-3-22**] 04:02AM BLOOD WBC-9.3 RBC-2.64* Hgb-7.4* Hct-23.7* MCV-90 MCH-28.1 MCHC-31.3 RDW-15.4 Plt Ct-282 [**2145-3-23**] 07:20AM BLOOD WBC-10.4 RBC-2.74* Hgb-8.1* Hct-24.7* MCV-90 MCH-29.3 MCHC-32.6 RDW-15.8* Plt Ct-312 [**2145-3-24**] 06:03AM BLOOD WBC-5.1# RBC-2.65* Hgb-7.9* Hct-24.1* MCV-91 MCH-29.8 MCHC-32.8 RDW-15.6* Plt Ct-252 [**2145-3-21**] 07:00PM BLOOD Neuts-86.7* Lymphs-9.3* Monos-3.7 Eos-0.3 Baso-0.1 [**2145-3-22**] 04:02AM BLOOD PT-11.8 PTT-26.0 INR(PT)-1.0 [**2145-3-21**] 07:00PM BLOOD Glucose-214* UreaN-23* Creat-6.4*# Na-137 K-5.5* Cl-99 HCO3-30 AnGap-14 [**2145-3-22**] 04:02AM BLOOD Glucose-91 UreaN-27* Creat-7.3* Na-138 K-4.6 Cl-101 HCO3-30 AnGap-12 [**2145-3-23**] 07:20AM BLOOD Glucose-127* UreaN-36* Creat-9.3*# Na-135 K-6.1* Cl-97 HCO3-26 AnGap-18 [**2145-3-24**] 06:03AM BLOOD Glucose-177* UreaN-26* Creat-7.0*# Na-134 K-4.9 Cl-95* HCO3-31 AnGap-13 [**2145-3-21**] 07:00PM BLOOD ALT-77* AST-71* AlkPhos-93 TotBili-0.3 [**2145-3-22**] 04:02AM BLOOD ALT-57* AST-39 CK(CPK)-261 AlkPhos-80 TotBili-0.3 [**2145-3-23**] 07:20AM BLOOD ALT-44* AST-25 AlkPhos-90 TotBili-0.4 [**2145-3-24**] 06:03AM BLOOD ALT-33 AST-21 AlkPhos-78 TotBili-0.2 [**2145-3-21**] 07:00PM BLOOD Lipase-177* [**2145-3-21**] 07:00PM BLOOD proBNP-[**Numeric Identifier 40887**]* [**2145-3-21**] 07:00PM BLOOD cTropnT-0.10* [**2145-3-22**] 04:02AM BLOOD CK-MB-2 cTropnT-0.12* [**2145-3-22**] 12:10PM BLOOD CK-MB-2 cTropnT-0.12* [**2145-3-22**] 04:02AM BLOOD Calcium-8.6 Phos-2.2*# Mg-1.6 [**2145-3-23**] 07:20AM BLOOD Calcium-8.6 Phos-2.5* Mg-1.7 [**2145-3-24**] 06:03AM BLOOD Calcium-8.3* Phos-4.5# Mg-1.6 [**2145-3-21**] 7:00 pm BLOOD CULTURE LINE EJ: Pending at discharge. URINE CULTURE (Final [**2145-3-23**]): NO GROWTH. Legionella Urinary Antigen (Final [**2145-3-22**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. -- Radiology Report CHEST (PORTABLE AP) Study Date of [**2145-3-21**] Final Report EXAM: Chest frontal, single AP upright portable view. Large areas of airspace opacity involving the right mid-to-lower lung, likely involving the right middle and lower lobes and possibly the right upper lobe. There is suggestion of small bilateral pleural effusions. The cardiac silhouette remains enlarged. IMPRESSION: 1. Right lung airspace opacity concerning for infectious process vs edema. Recommend clinical correlation and followup to resolution. Small bilateral pleural effusions. 2. Persistent moderate cardiomegaly. --- Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2145-3-21**] Final Report CHEST CT WITH IV CONTRAST: The thoracic aorta is normal in course and caliber, without dissection. The pulmonary arteries opacify normally, without evidence of pulmonary embolism. The main pulmonary artery is enlarged, measuring 3.6 cm in diameter. Mediastinal and hilar lymph nodes do not meet size criteria for pathologic enlargement. There are extensive nodular opacities involving all lobes of the lungs, mid lung and basal predominant. More confluent areas of airspace consolidation are present centrally and dependently. There is interlobular septal thickening, left greater than right. The airways are patent bilaterally to the subsegmental level. There is a small right pleural effusion and a moderate pericardial effusion. The heart is enlarged. Enlarged prevascular and pretracheal mediastinal lymph nodes are likely reactive. Anterior mediastinal soft tissue density is likely residual thymus. Imaging of the upper abdomen is unremarkable. There are no concerning osseous lesions. IMPRESSION: 1. No pulmonary embolism. No aortic dissection. 2. Extensive nodular opacities throughout all lobes concerning for infection. Confluent areas of airspace opacity may reflect pulmonary edema or infection. Septal thickening consistent with interstitial pulmonary edema. Mediastinal lymphadenopathy, may be reactive. 3. Moderate pericardial effusion. 4. Small right pleural effusion. 5. Enlarged main pulmonary artery suggestive of pulmonary arterial hypertension. --- Portable TTE (Complete) Done [**2145-3-22**] at 9:30:00 AM FINAL Findings This study was compared to the prior study of [**2144-2-14**]. Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Mild LA enlargement. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Low normal LVEF. Estimated cardiac index is normal (>=2.5L/min/m2). No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Mildly dilated aortic sinus. Mildly dilated ascending aorta. No 2D or Doppler evidence of distal arch coarctation. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: Small to moderate pericardial effusion. Effusion circumferential. No echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Conclusions The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is low normal. Quantitative biplane LVEF is 52%. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is a small to moderate sized circumferential pericardial effusion without echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. IMPRESSION: Mild symmetric left ventricular hypertrophy with low normal systolic function. Moderate pulmonary artery systolic hypertension. Small-moderate circumferential pericardial effusion. Compared with the prior study (images reviewed) of [**2144-2-14**], left ventricular systolic function is less vigorous and pulmonary artery systolic hypertension is now identified. CLINICAL IMPLICATIONS: Based on [**2142**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. --- Radiology Report CHEST (PORTABLE AP) Study Date of [**2145-3-22**] Final Report PORTABLE CHEST FINDINGS: Previously identified asymmetrically distributed opacities in the right lung have rapidly improved with only minimal residual opacities, predominantly in the right retrocardiac region. However, opacity in the left retrocardiac area has slightly worsened. Small pleural effusions are again demonstrated. Cardiac silhouette remains enlarged and there is persistent increase in pulmonary vascularity. IMPRESSION: 1. Rapid improvement in right-sided alveolar opacities, which may have been due to asymmetrical pulmonary edema or aspiration considering the rapid improvement. Worsening opacities at left base could reflect evolving infection in the appropriate clinical setting. 2. Enlarged cardiac silhouette with known pericardial effusion. 3. Small bilateral pleural effusions. -- Radiology Report CHEST (PA & LAT) Study Date of [**2145-3-23**] Final Report IMPRESSION: PA and lateral chest compared to [**3-22**]: Severe cardiomegaly is stable. Small left pleural effusion is new or newly apparent. Pulmonary vascular congestion is mild though the upper lobe vessels are clearly dilated and there is no pulmonary edema. -- Brief Hospital Course: 32yom w T1DM, ESRD on hemodialysis, HTN presented with sudden onset dyspnea, likely due to flash pulmonary edema in setting of severe hypertension. # Shortness of breath: Presented w sudden onset dyspnea. Most likely due to flash pulmonary edema given severe HTN on presentation, elevated BNP, CXR and CTA showing pulmonary edema which rapidly resolved with blood pressure control. Echo showed new findings of mild LV systolic dysfunction (EF 52%), moderate pulmonary artery HTN, and small-moderate circumferential pericardial effusion (previously seen on CT abd [**2145-3-6**]). Troponins cycled every 8 hours were 0.10, 0.12, 0.12, consistent with demand ischemia in setting of renal failure without concern for an acute ischemic event. EKG on admission was unchanged from prior. CTA was negative for PE. Initially, CXR had infiltrate concerning for PNA, so pt was started on antibiotics for hospital acquired PNA. However, these were discontinued after rapid improvement of CXR with diuresis. In the MICU, pt was treated with a nitro drip, lasix (with good urine output), and supplmental O2 via nasal cannula. On transfer to the floor, lungs were wheezy and pt sated 91%-95% on 2-4L NC. After hemodialysis, lungs were clear, and pt sated 95-100% on room air. Although patient had low grade temperatures (99.0), he did not develop localizing symptoms or leukocytosis concerning for health care acquired pneumonia. Given good urine output despite being on hemodialysis, patient was started on 80mg daily of Lasix PO by Renal upon discharge. . # Hypertension: SBP in 200s on arrival in setting of medication noncompliance secondary to PO intolerance. Placed on nitro drip until tolerating POs, at which point home antihypertensives (hydralazine, lisinopril, metoprolol) were restarted. SBP ranged 120s-170s on floor with some improvement after dialysis as well. . # End stage renal failure: Renal followed patient, and he was able to remain on his regular T/Th/Sat dialysis schedule while in house. . # Nausea/Vomiting: Etiology for nausea and vomiting unclear, although likely from gastroparesis as noted in previous admissions. Was given zofran and reglan PRN with good control of symptoms. . # Pulmonary Hypertension: Increased PASP new since last TTE and slightly decreased LVEF compared with 2/09 as well as BNP [**Numeric Identifier 14123**] all suggest left heart failure as etiology of pulmonary hypertension. Patient should consider further work-up as outpatient (rheum, LFTs, HIV, right heart cath...) . # Pericardial Effusion: likely secondary to renal failure. Unchanged based on findings on CT scan. Pulsus < 10 without signs of tamponade. . # Anemia: On transfer to MICU, Hct was 27, which was above baseline of 23. Thought to be secondary to volume contraction in the setting of nause and vomiting. With improvement of nausea/vomiting his hematocrit trended back to his baseline of 23. No clinical evidence of bleeding during his stay. . # Transaminitis: On admission, mildly elevated AST and ALT in 70s. Alk phos was normal. Unclear etiology, but perhaps secondary to hepatic congestion in setting of flash pulmonary edema. Had normal ultrasound last admission. Liver function tests were trended and came down with improvement in his clinical status. . # Type I Diabetes: Complicated by nephropathy, neuropathy and gastroparesis. Remained on insulin sliding scale and home lantus dose. Blood sugar ranged from 161-204. No anion gap on routine labs to suggest ketoacidosis. Medications on Admission: # Hydralazine 25 mg tabs, 1-2 tabs TID # Amlodipine 10 mg daily # Calcium Acetate 667 mg TID # Vitamin D 5,000 units daily # Calcitriol 0.25 mcg daily # Metoclopramide 5 mg TID PRN # Lisinopril 20 mg daily # Metoprolol Succinate 200 mg Tablet Sustained Release daily # EMLA 2.5-2.5 % Cream [**Hospital1 **] # Humalog Sliding Scale # Glargine 15 u qHS Discharge Medications: 1. Hydralazine 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 2. Lisinopril 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Calcium Acetate 667 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Metoclopramide 10 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3 times a day): Do not take when you have loose stools, diarrhea. 5. Vitamin D 5,000 unit Tablet [**Hospital1 **]: One (1) Tablet PO once a day for 2 weeks. 6. Ergocalciferol (Vitamin D2) 50,000 unit Capsule [**Hospital1 **]: One (1) Capsule PO once a week: Mondays. 7. Calcitriol 0.25 mcg Capsule [**Hospital1 **]: One (1) Capsule PO once a day. 8. Amlodipine 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr [**Hospital1 **]: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 10. Lasix 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Fifteen (15) units Subcutaneous with breakfast. 12. Humalog 100 unit/mL Solution [**Hospital1 **]: per sliding scale Subcutaneous four times a day. Discharge Disposition: Home Discharge Diagnosis: Primary: Flash pulmonary edema with hypertensive urgency Secondary: ESRD on hemodialysis, type 1 diabetes mellitus, gastroparesis, anemia Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: -You were admitted with acute shortness of breath, nausea and vomiting. You likely had an episode of ""flash pulmonary edema,"" or rapid fluid buildup in the lungs, due to high blood pressures (perhaps from high sodium/salt meal). Your blood pressure was aggressively controlled; fluid in your lungs was removed by hemodialysis and a water pill (Lasix) with improvement in your breathing. . -It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> Start Lasix 80mg daily . -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. Followup Instructions: Please make an appointment to see your primary care doctor within 2 weeks. You can reach Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 40888**] office at [**Telephone/Fax (1) 250**]. . Department: [**Hospital3 249**] When: WEDNESDAY [**2145-3-24**] at 12:00 PM With: [**First Name8 (NamePattern2) 971**] [**Last Name (NamePattern1) **], LICSW [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: TRANSPLANT When: MONDAY [**2145-4-12**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: FRIDAY [**2145-4-16**] at 3:00 PM With: [**Year (4 digits) **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] ",25,2145-03-21 21:13:00,2145-03-24 11:14:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,SHORTNESS OF BREATH," 32yom w t1dm, esrd on hemodialysis, htn presented with sudden onset dyspnea, likely due to flash pulmonary edema in setting of severe hypertension. # shortness of breath: presented w sudden onset dyspnea. most likely due to flash pulmonary edema given severe htn on presentation, elevated bnp, cxr and cta showing pulmonary edema which rapidly resolved with blood pressure control. echo showed new findings of mild lv systolic dysfunction (ef 52%), moderate pulmonary artery htn, and small-moderate circumferential pericardial effusion (previously seen on ct abd [**2145-3-6**]). troponins cycled every 8 hours were 0.10, 0.12, 0.12, consistent with demand ischemia in setting of renal failure without concern for an acute ischemic event. ekg on admission was unchanged from prior. cta was negative for pe. initially, cxr had infiltrate concerning for pna, so pt was started on antibiotics for hospital acquired pna. however, these were discontinued after rapid improvement of cxr with diuresis. in the micu, pt was treated with a nitro drip, lasix (with good urine output), and supplmental o2 via nasal cannula. on transfer to the floor, lungs were wheezy and pt sated 91%-95% on 2-4l nc. after hemodialysis, lungs were clear, and pt sated 95-100% on room air. although patient had low grade temperatures (99.0), he did not develop localizing symptoms or leukocytosis concerning for health care acquired pneumonia. given good urine output despite being on hemodialysis, patient was started on 80mg daily of lasix po by renal upon discharge. . # hypertension: sbp in 200s on arrival in setting of medication noncompliance secondary to po intolerance. placed on nitro drip until tolerating pos, at which point home antihypertensives (hydralazine, lisinopril, metoprolol) were restarted. sbp ranged 120s-170s on floor with some improvement after dialysis as well. . # end stage renal failure: renal followed patient, and he was able to remain on his regular t/th/sat dialysis schedule while in house. . # nausea/vomiting: etiology for nausea and vomiting unclear, although likely from gastroparesis as noted in previous admissions. was given zofran and reglan prn with good control of symptoms. . # pulmonary hypertension: increased pasp new since last tte and slightly decreased lvef compared with 2/09 as well as bnp [**numeric identifier 14123**] all suggest left heart failure as etiology of pulmonary hypertension. patient should consider further work-up as outpatient (rheum, lfts, hiv, right heart cath...) . # pericardial effusion: likely secondary to renal failure. unchanged based on findings on ct scan. pulsus < 10 without signs of tamponade. . # anemia: on transfer to micu, hct was 27, which was above baseline of 23. thought to be secondary to volume contraction in the setting of nause and vomiting. with improvement of nausea/vomiting his hematocrit trended back to his baseline of 23. no clinical evidence of bleeding during his stay. . # transaminitis: on admission, mildly elevated ast and alt in 70s. alk phos was normal. unclear etiology, but perhaps secondary to hepatic congestion in setting of flash pulmonary edema. had normal ultrasound last admission. liver function tests were trended and came down with improvement in his clinical status. . # type i diabetes: complicated by nephropathy, neuropathy and gastroparesis. remained on insulin sliding scale and home lantus dose. blood sugar ranged from 161-204. no anion gap on routine labs to suggest ketoacidosis. ","PRIMARY: [Acute diastolic heart failure] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Unspecified disease of pericardium; Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled; Other chronic pulmonary heart diseases; Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled; Congestive heart failure, unspecified; Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled; Hyperpotassemia; Renal dialysis status; Background diabetic retinopathy; Gastroparesis; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Long-term (current) use of insulin; Anemia in chronic kidney disease; Iron deficiency anemia, unspecified; Depressive disorder, not elsewhere classified; Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH]; Other postprocedural status]","32yom w t1dm, esrd on hemodialysis, htn presented with sudden onset dyspnea, likely due to flash pulmonary edema in setting of severe hypertension. in the micu, pt was treated with a nitro drip, lasix (with good urine output), and supplmental o2 via nasal cannula. # end stage renal failure: renal followed patient, and he was able to remain on his regular t/th/sat dialysis schedule while in house. # anemia: on transfer to micu, hct was 27, which was above baseline of 23. no clinical evidence of bleeding during his stay. # transaminitis: on admission, mildly elevated ast and alt in 70s. liver function tests were trended and came down with improvement in his clinical status.",32yom esrd presented with sudden onset dyspnea. likely due to flash pulmonary edema in setting of severe hypertension. echo showed new findings of mild lv systolic dysfunction (ef 52%) 23657,176997.0,13519,2145-04-18,13517,125544.0,2145-02-27,Discharge summary,"Admission Date: [**2145-2-18**] Discharge Date: [**2145-2-27**] Date of Birth: [**2112-11-14**] Sex: M Service: MEDICINE Allergies: Penicillins / Watermelon / Almond Oil Attending:[**First Name3 (LF) 9454**] Chief Complaint: Nausea/vomiting, diarrhea --> DKA Major Surgical or Invasive Procedure: PICC line placement Initiation of hemodialysis History of Present Illness: Mr. [**Known lastname 21822**] is a 32 year-old man with a history of HTN, type 1 diabetes with gastroparesis, CKD stage V and recently s/p AV fistula [**2145-1-22**] in anticipation of HD, and anemia who presents with profuse watery vomiting and watery diarrhea for last 2 days. No blood or mucus. No fevers but did have night sweats and chills. He also has crampy abdominal pain improved with bowel movements. He has only been able to keep down sips. He denies any lightheadedness. He does still make urine and has not noted any change in UOP, dysuria, or hematuria. He denies any sick contacts but did just return to work yesterday after recovering from placement of a RUE graft on [**1-26**]. He denies any recent travel or antibiotics use. He states his BS have been in 100s and he has been taking his lantus 15 in AM, but states this is what his DKA has felt like in the past. Past Medical History: - HTN - DM I since age 19, seen at [**Last Name (un) **]. Complicated by nephropathy, gastroparesis, proteinuria and possibly retinopathy. -CKD: thought to be related to HTN and longstanding DMII. Underwent RUE fistula placement on [**1-26**] for planned HD initiation. Being considered for liver-pancreas transplant - Anemia: Thought to be combination of iron deficiency and CKD, still taking iron - Depression - S/p appendectomy [**7-/2144**] Social History: Lives with his girlfriend. [**Name (NI) 1403**] in a clerical setting. Quit smoking 2 days ago, 5 pk year history. Occasional ETOH. No illicit drugs. Family History: Diabetes and heart trouble in grandfather Physical Exam: Physical Exam (on Admission) Vitals: T 99.2, HR 100, BP 171/90, RR 12, O2sat 97RA. General: Uncomfortable appearing young man, recently vomited small amount of nonbloody nonbilous emesis HEENT: NCAT, MMM, oropharynx clear Neck: Supple, LAD Pulm: CTA B CV: Tachycardic but regular, promienent P2, no m/r/g Abd: BS hyperactive but not high-pitched, diffuse tenderness without guarding or rebound, nondistended Extrem: No LE edema, DP pulses 2+ Neuro: AAOx 3, grossly nonfocal, no asterixis Derm: No rash Pertinent Results: On admission to MICU: pH 7.27 pCO2 24 pO2 233 HCO3 12 BaseXS -13 140 107 100 AGap=26 -------------<305 5.1 12 15.2 Ca: 8.3 Mg: 2.0 P: 8.0 ALT: 62 AP: 77 Tbili: 0.1 AST: 33 [**Doctor First Name **]: 93 Lip: 59 Osms:346 Serum Acetmnphn Negative MCV 88 wbc 8.2 plts 272 hct 20.0 N:87.2 L:8.7 M:3.1 E:0.8 Bas:0.1 Lactate: 0.8 EKG: NSR at 97 bpm, nl axis and intervals, no ST-T wave changes Chem ([**2-27**]): 140/4.1 101/29 31/8.7 < 70 Ca=8.0 Mg=1.8 P=4.1 CBC ([**2-27**]): 6.4 > 22.1 < 233 Blood culture [**2-24**] and [**2-27**]: Final read negative Brief Hospital Course: In the ER on [**2-18**], his vitals were: T 100.1, P 98, BP 164/90, RR 16, O2 sat 100%. He had abdominal pain, and he was guiac negative. His initial creatinine was 15.3, his glucose was 162, and he had a metabolic acidosis with an anion gap of 24 (up from his baseline of 19, due to his chronic kidney disease). He was given 2L IVF for hydration, and his anion gap closed to 20. He was given morphine 4 mg IV x 2 and zofran 4 mg IV x 2, and admitted to medicine. On transfer to the floor his vitals were: T 99.2, HR 100, BP 171/90, RR 12, O2sat 97% on room air. . On the medicine floor he had worsening nausea, vomiting and abdominal pain, his glucose rose to 305, his gap increased to 21 and his pH was 7.27. He received another 2 liters of normal saline, but become tachypneic. His tachypnea resolved with diuresis (Lasix 20 mg IV). On [**2-19**] the patient was transferred to the MICU for an insulin drip and management of DKA. He received 2 liters of D5W in normal saline, then 1 liter of D5W with 3 amps of bicarb, then 1 liter of D5W with K+. For his hematocrit of 20 he received 1 unit of pRBCs. His gap was back down to 21 by 23:00 that evening. On [**2-20**] the patient had his first session of hemodialysis. He declined his renal diet all day, then at midnight had [**State 19827**] Fried Chicken brought in from outside. In the early AM of [**2-21**] he developed nausea, vomiting, a glucose of 436 and DKA. He had an EKG that showed no ischemia, and morphine for pain. For systolic blood pressures from 190-210 he received IV doses of his home PO antihypertensives (Hydralazine and Metoprolol). The patient was refusing his calcium capsules because they were too big to swallow, and tried to order a pizza in instead of hospital food. By [**2-24**] he had been transitioned from insulin drip to insulin boluses. On [**2-25**] he had his 4th session of dialysis. He wanted to leave that evening AMA (felt he had lost his freedom), but was convinced to stay. On [**2-26**] he again wanted to leave AMA but was again convinced to stay one more day for a 5th dialysis session and to arrange optimal outpatient followup. He was transferred out of the ICU to the medicine floor. Overnight on [**3-31**], he [**Date Range 28316**] a fever to 100.9. Blood cultures were sent and he underwent his 5th dialysis session. Following his HD session, he was seen by the medical team and advised to stay in the hospital for one more day to assess for an infection, given his overnight fever and recent initiation of hemodialysis. He was advised to stay to ensure he remained afebrile for 24 hours. Mr. [**Known lastname 21822**] refused this advise and decided to sign out AGAINST MEDICAL ADVICE, despite repeated discussions with him regarding our decision and desire to monitor him for another day. By problem: Anion gap metabolic acidosis/hyperglycemia/DKA. Increased above baseline on presentation probably due to uremia in setting of dehydration. It slightly improved s/p 2L IVF near baseline gap of 19. But after brief stay on the regular medicine floor, his blood sugar elevated into the 200-300s and anion gap increased; acetone found in serum and ketones seen in urinalysis, concerning for DKA. Lactate was normal. In the MICU, patient was started on an insulin gtt and started on intravenous fluids. In total, patient received 2L D51/2NS, then D5W with 3 amps bicarb in 1L, then D5W with potassium. He had a PICC placed for regular (every 4 hour) electrolyte checks. Patient's anion gap decreased to baseline ~17, given patient's underlying end-stage renal disease/uremia. Insulin gtt was discontinued and [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs, patient was started on a fixed Lantus and Humalog sliding scale. Of note, on [**2-20**], patient refused hospital diet and had his girlfriend bring him [**State 19827**] Fried Chicken; his blood sugars and anion gap increased. Patient required resumption of insulin gtt briefly; he was resumed on insulin sliding scale and fixed dose, with Nutrition Consult and Social Work following for coping/management of his long-standing, complicated Type 1 Diabetes Mellitus. N/V/D, abdominal pain. Given low grade fever and acute onset, most c/w viral gastroenteritis although possible that this was exacerbated by uremia. Also, patient has a hx of gastroparesis. Abdominal exam nonfocal but with tenderness initially that resolved. Did have an episode of resumed, increased abdominal pain after consumption of KFC, likely due to brief opening of anion gap and underlying gastroparesis. Lipase was normal. Mild elevation of LFTs gradually resolved. Pt did not appear fluid overloaded on exam. Patient's diarrhea resolved while in MICU and as per above, developed appetite and was able to tolerate PO medications/diet. Clostridium difficile toxin was sent and negative Acute on chronic renal failure. Pt was already in end stage renal disease (stage 4) on admission. AV fisulta had been recently placed for initiation of hemodialysis. In the setting of profuse nausea, vomiting and diarrhea, there was also likely a prerenal component to the bump in creatinine. Patient received 2L intravenous fluids in the ED and then approximately 4L to manage his DKA. Patient did become hypertensive likely in this setting. Patient was continued on calcitriol, calcium acetate, and nephrotoxic medications were avoided. Renal followed the patient during this admission and initiated hemodialysis with good effect on his creatinine and volume status. Anemia. Initially on arrival to the MICU, hematocrit was 20, mildly below baseline of 25 and felt due to the combination of iron deficiency and CKD. Patient did not have emesis or blood in his stools. Patient was transfused one unit of pRBC with good effect. He was continued on iron supplements and may benefit from Epogen with hemodialysis in the future. HTN. Poorly controlled, likely in the setting of initial acute discomfort and later due to volume overload in the setting of his ESRD and intravenous fluids for DKA. Patient was ultimately transitioned to a regimen of Metoprolol 100mg twice daily, Amlodipine 10mg daily and Hydralazine 50mg three times daily. Fever. Mr. [**Known lastname 21822**] [**Last Name (Titles) 28316**] a fever to 100.9 on the night of [**3-31**]. As discussed above, in the setting of recent initiation of hemodialysis and pending blood cultures, the patient was advised to remain in the hospital to be sure he was afebrile for 24 hours, without signs or symptoms of infection, and that his blood cultures remained negative. Mr. [**Known lastname 21822**] refused, and signed out AGAINST MEDICAL ADVICE. Medications on Admission: Calcium Acetate 667 mg 2 tabs tid w/ meals Amlodipine 10mg daily Metoprolol succinate 100mg daily Ferrous sulfate 1 tab daily Calcitriol 0.25mcg daily Hydralazine 25mg tid Humalog SS Lantus 15 units qAM . Allergies: Penicillins, Watermelon, Almond Oil Discharge Medications: 1. Calcium Acetate 667 mg Capsule [**Known lastname **]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*180 Capsule(s)* Refills:*2* 2. Amlodipine 5 mg Tablet [**Known lastname **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Hydralazine 25 mg Tablet [**Known lastname **]: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 50 mg Tablet [**Known lastname **]: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. Insulin regimen Please follow printout of insulin dosing (Humalog) 6. Insulin Glargine 100 unit/mL Solution [**Known lastname **]: Fifteen (15) units Subcutaneous at bedtime. Disp:*1 month supply* Refills:*2* 7. Calcitriol 0.25 mcg Capsule [**Known lastname **]: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Viral Gastroenteritis Diabetic Ketoacidosis Diabetes Mellitus type 1 CKD stage V, requiring initiation of hemodialysis Discharge Condition: The patient is leaving AGAINST MEDICAL ADVICE given his recent fevers, pending blood cultures, and recent initiation of hemodialysis. Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: *LEAVING AGAINST MEDICAL ADVICE* You were admitted to the hospital for nausea and vomiting. While in the hospital, your sugars were elevated and you were found to have Diabetic Ketoacidosis (DKA). You were treated with an insulin drip and your DKA initially resolved. However, you were not compliant with your diabetic diet and after eating fried chicken you redeveloped signs of DKA requiring a second insulin drip. You developed further episodes of DKA during your hospitalization and each required insulin drip in the intensive care unit. Additionally, during this hospitalization you were initiated on hemodialysis which you will require three times a week. You [**Known lastname 28316**] a fever on [**2-24**] and again on [**2-27**], and blood cultures were taken to evaluate for any signs of blood infection. These must be followed by your primary care doctor or your outpatient nephrologist. Given your recent initiation of hemodialysis and lengthy hospital course, we advise you to remain in the hospital while we await the results of these cultures. As you have decided to leave, it will be AGAINST MEDICAL ADVICE as we strongly believe that you should continue to be evaluated for signs and potential sources of infection given your recent fevers. We want to ensure that you did not have an active infection and do not have fevers over the next 24 hours. We made the following changes to your home medications: Hydralazine 50 mg TID (you were taking 25 mg TID prior) Metoprolol Tartrate 100 [**Hospital1 **] (you were on a long acting metoprolol once daily prior) Please also follow the attached printout of sliding scale insulin dosing based on your blood sugars. Followup Instructions: Appointment #1 MD: [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] ([**Company 191**] Post [**Hospital **] Clinic) Specialty: Internal Medicine Date/ Time: Monday, [**3-1**], 8:15am Location: [**Location (un) **], [**Hospital Ward Name 23**] Building, [**Location (un) **] Central Suite Phone number: [**Telephone/Fax (1) 250**] . Appointment #2 MD: [**First Name8 (NamePattern2) 7208**] [**Last Name (NamePattern1) 978**] Specialty: Endocrinology Date/ Time: Tuesday, [**3-2**], 9 am Location: [**Hospital **] Clinic Phone number: [**Telephone/Fax (1) 2490**] Apt # 3: Social Work: [**3-24**] at 12PM with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10927**], LICSW in [**Company 191**] Please call [**Telephone/Fax (1) 250**] to cancel or change if needed ",50,2145-02-18 20:45:00,2145-02-27 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,DEHYDRATION," in the er on [**2-18**], his vitals were: t 100.1, p 98, bp 164/90, rr 16, o2 sat 100%. he had abdominal pain, and he was guiac negative. his initial creatinine was 15.3, his glucose was 162, and he had a metabolic acidosis with an anion gap of 24 (up from his baseline of 19, due to his chronic kidney disease). he was given 2l ivf for hydration, and his anion gap closed to 20. he was given morphine 4 mg iv x 2 and zofran 4 mg iv x 2, and admitted to medicine. on transfer to the floor his vitals were: t 99.2, hr 100, bp 171/90, rr 12, o2sat 97% on room air. . on the medicine floor he had worsening nausea, vomiting and abdominal pain, his glucose rose to 305, his gap increased to 21 and his ph was 7.27. he received another 2 liters of normal saline, but become tachypneic. his tachypnea resolved with diuresis (lasix 20 mg iv). on [**2-19**] the patient was transferred to the micu for an insulin drip and management of dka. he received 2 liters of d5w in normal saline, then 1 liter of d5w with 3 amps of bicarb, then 1 liter of d5w with k+. for his hematocrit of 20 he received 1 unit of prbcs. his gap was back down to 21 by 23:00 that evening. on [**2-20**] the patient had his first session of hemodialysis. he declined his renal diet all day, then at midnight had [**state 19827**] fried chicken brought in from outside. in the early am of [**2-21**] he developed nausea, vomiting, a glucose of 436 and dka. he had an ekg that showed no ischemia, and morphine for pain. for systolic blood pressures from 190-210 he received iv doses of his home po antihypertensives (hydralazine and metoprolol). the patient was refusing his calcium capsules because they were too big to swallow, and tried to order a pizza in instead of hospital food. by [**2-24**] he had been transitioned from insulin drip to insulin boluses. on [**2-25**] he had his 4th session of dialysis. he wanted to leave that evening ama (felt he had lost his freedom), but was convinced to stay. on [**2-26**] he again wanted to leave ama but was again convinced to stay one more day for a 5th dialysis session and to arrange optimal outpatient followup. he was transferred out of the icu to the medicine floor. overnight on [**3-31**], he [**date range 28316**] a fever to 100.9. blood cultures were sent and he underwent his 5th dialysis session. following his hd session, he was seen by the medical team and advised to stay in the hospital for one more day to assess for an infection, given his overnight fever and recent initiation of hemodialysis. he was advised to stay to ensure he remained afebrile for 24 hours. mr. [**known lastname 21822**] refused this advise and decided to sign out against medical advice, despite repeated discussions with him regarding our decision and desire to monitor him for another day. by problem: anion gap metabolic acidosis/hyperglycemia/dka. increased above baseline on presentation probably due to uremia in setting of dehydration. it slightly improved s/p 2l ivf near baseline gap of 19. but after brief stay on the regular medicine floor, his blood sugar elevated into the 200-300s and anion gap increased; acetone found in serum and ketones seen in urinalysis, concerning for dka. lactate was normal. in the micu, patient was started on an insulin gtt and started on intravenous fluids. in total, patient received 2l d51/2ns, then d5w with 3 amps bicarb in 1l, then d5w with potassium. he had a picc placed for regular (every 4 hour) electrolyte checks. patients anion gap decreased to baseline ~17, given patients underlying end-stage renal disease/uremia. insulin gtt was discontinued and [**first name8 (namepattern2) **] [**last name (un) **] recs, patient was started on a fixed lantus and humalog sliding scale. of note, on [**2-20**], patient refused hospital diet and had his girlfriend bring him [**state 19827**] fried chicken; his blood sugars and anion gap increased. patient required resumption of insulin gtt briefly; he was resumed on insulin sliding scale and fixed dose, with nutrition consult and social work following for coping/management of his long-standing, complicated type 1 diabetes mellitus. n/v/d, abdominal pain. given low grade fever and acute onset, most c/w viral gastroenteritis although possible that this was exacerbated by uremia. also, patient has a hx of gastroparesis. abdominal exam nonfocal but with tenderness initially that resolved. did have an episode of resumed, increased abdominal pain after consumption of kfc, likely due to brief opening of anion gap and underlying gastroparesis. lipase was normal. mild elevation of lfts gradually resolved. pt did not appear fluid overloaded on exam. patients diarrhea resolved while in micu and as per above, developed appetite and was able to tolerate po medications/diet. clostridium difficile toxin was sent and negative acute on chronic renal failure. pt was already in end stage renal disease (stage 4) on admission. av fisulta had been recently placed for initiation of hemodialysis. in the setting of profuse nausea, vomiting and diarrhea, there was also likely a prerenal component to the bump in creatinine. patient received 2l intravenous fluids in the ed and then approximately 4l to manage his dka. patient did become hypertensive likely in this setting. patient was continued on calcitriol, calcium acetate, and nephrotoxic medications were avoided. renal followed the patient during this admission and initiated hemodialysis with good effect on his creatinine and volume status. anemia. initially on arrival to the micu, hematocrit was 20, mildly below baseline of 25 and felt due to the combination of iron deficiency and ckd. patient did not have emesis or blood in his stools. patient was transfused one unit of prbc with good effect. he was continued on iron supplements and may benefit from epogen with hemodialysis in the future. htn. poorly controlled, likely in the setting of initial acute discomfort and later due to volume overload in the setting of his esrd and intravenous fluids for dka. patient was ultimately transitioned to a regimen of metoprolol 100mg twice daily, amlodipine 10mg daily and hydralazine 50mg three times daily. fever. mr. [**known lastname 21822**] [**last name (titles) 28316**] a fever to 100.9 on the night of [**3-31**]. as discussed above, in the setting of recent initiation of hemodialysis and pending blood cultures, the patient was advised to remain in the hospital to be sure he was afebrile for 24 hours, without signs or symptoms of infection, and that his blood cultures remained negative. mr. [**known lastname 21822**] refused, and signed out against medical advice. ","PRIMARY: [Diabetes with ketoacidosis, type I [juvenile type], uncontrolled] SECONDARY: [Acute kidney failure, unspecified; End stage renal disease; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease; Secondary hyperparathyroidism (of renal origin); Intestinal infection due to other organism, not elsewhere classified; Diabetes with renal manifestations, type I [juvenile type], uncontrolled; Diabetes with neurological manifestations, type I [juvenile type], uncontrolled; Gastroparesis; Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled; Background diabetic retinopathy; Dehydration; Anemia in chronic kidney disease; Iron deficiency anemia, unspecified; Depressive disorder, not elsewhere classified; Long-term (current) use of insulin]","in the er on [**2-18**], his vitals were: t 100.1, p 98, bp 164/90, rr 16, o2 sat 100%. his tachypnea resolved with diuresis (lasix 20 mg iv). his gap was back down to 21 by 23:00 that evening. in the early am of [**2-21**] he developed nausea, vomiting, a glucose of 436 and dka. for systolic blood pressures from 190-210 he received iv doses of his home po antihypertensives (hydralazine and metoprolol). by [**2-24**] he had been transitioned from insulin drip to insulin boluses. he was transferred out of the icu to the medicine floor. but after brief stay on the regular medicine floor, his blood sugar elevated into the 200-300s and anion gap increased; acetone found in serum and ketones seen in urinalysis, concerning for dka. mild elevation of lfts gradually resolved. patients diarrhea resolved while in micu and as per above, developed appetite and was able to tolerate po medications/diet. patient did not have emesis or blood in his stools. he was continued on iron supplements and may benefit from epogen with hemodialysis in the future. patient was ultimately transitioned to a regimen of metoprolol 100mg twice daily, amlodipine 10mg daily and hydralazine 50mg three times daily.","on transfer to the floor his vitals were t 99.2, hr 100, bp 171/90, rr 12, o2sat 97% on room air. on the medicine floor he had worsening nausea, vomiting and abdominal pain. his glucose rose to 305, his gap increased to 21 and his ph was 7.27. he declined his renal diet all day, then at midnight had fried chicken brought in from outside." 23657,169263.0,13518,2145-03-24,13517,125544.0,2145-02-27,Discharge summary,"Admission Date: [**2145-2-18**] Discharge Date: [**2145-2-27**] Date of Birth: [**2112-11-14**] Sex: M Service: MEDICINE Allergies: Penicillins / Watermelon / Almond Oil Attending:[**First Name3 (LF) 9454**] Chief Complaint: Nausea/vomiting, diarrhea --> DKA Major Surgical or Invasive Procedure: PICC line placement Initiation of hemodialysis History of Present Illness: Mr. [**Known lastname 21822**] is a 32 year-old man with a history of HTN, type 1 diabetes with gastroparesis, CKD stage V and recently s/p AV fistula [**2145-1-22**] in anticipation of HD, and anemia who presents with profuse watery vomiting and watery diarrhea for last 2 days. No blood or mucus. No fevers but did have night sweats and chills. He also has crampy abdominal pain improved with bowel movements. He has only been able to keep down sips. He denies any lightheadedness. He does still make urine and has not noted any change in UOP, dysuria, or hematuria. He denies any sick contacts but did just return to work yesterday after recovering from placement of a RUE graft on [**1-26**]. He denies any recent travel or antibiotics use. He states his BS have been in 100s and he has been taking his lantus 15 in AM, but states this is what his DKA has felt like in the past. Past Medical History: - HTN - DM I since age 19, seen at [**Last Name (un) **]. Complicated by nephropathy, gastroparesis, proteinuria and possibly retinopathy. -CKD: thought to be related to HTN and longstanding DMII. Underwent RUE fistula placement on [**1-26**] for planned HD initiation. Being considered for liver-pancreas transplant - Anemia: Thought to be combination of iron deficiency and CKD, still taking iron - Depression - S/p appendectomy [**7-/2144**] Social History: Lives with his girlfriend. [**Name (NI) 1403**] in a clerical setting. Quit smoking 2 days ago, 5 pk year history. Occasional ETOH. No illicit drugs. Family History: Diabetes and heart trouble in grandfather Physical Exam: Physical Exam (on Admission) Vitals: T 99.2, HR 100, BP 171/90, RR 12, O2sat 97RA. General: Uncomfortable appearing young man, recently vomited small amount of nonbloody nonbilous emesis HEENT: NCAT, MMM, oropharynx clear Neck: Supple, LAD Pulm: CTA B CV: Tachycardic but regular, promienent P2, no m/r/g Abd: BS hyperactive but not high-pitched, diffuse tenderness without guarding or rebound, nondistended Extrem: No LE edema, DP pulses 2+ Neuro: AAOx 3, grossly nonfocal, no asterixis Derm: No rash Pertinent Results: On admission to MICU: pH 7.27 pCO2 24 pO2 233 HCO3 12 BaseXS -13 140 107 100 AGap=26 -------------<305 5.1 12 15.2 Ca: 8.3 Mg: 2.0 P: 8.0 ALT: 62 AP: 77 Tbili: 0.1 AST: 33 [**Doctor First Name **]: 93 Lip: 59 Osms:346 Serum Acetmnphn Negative MCV 88 wbc 8.2 plts 272 hct 20.0 N:87.2 L:8.7 M:3.1 E:0.8 Bas:0.1 Lactate: 0.8 EKG: NSR at 97 bpm, nl axis and intervals, no ST-T wave changes Chem ([**2-27**]): 140/4.1 101/29 31/8.7 < 70 Ca=8.0 Mg=1.8 P=4.1 CBC ([**2-27**]): 6.4 > 22.1 < 233 Blood culture [**2-24**] and [**2-27**]: Final read negative Brief Hospital Course: In the ER on [**2-18**], his vitals were: T 100.1, P 98, BP 164/90, RR 16, O2 sat 100%. He had abdominal pain, and he was guiac negative. His initial creatinine was 15.3, his glucose was 162, and he had a metabolic acidosis with an anion gap of 24 (up from his baseline of 19, due to his chronic kidney disease). He was given 2L IVF for hydration, and his anion gap closed to 20. He was given morphine 4 mg IV x 2 and zofran 4 mg IV x 2, and admitted to medicine. On transfer to the floor his vitals were: T 99.2, HR 100, BP 171/90, RR 12, O2sat 97% on room air. . On the medicine floor he had worsening nausea, vomiting and abdominal pain, his glucose rose to 305, his gap increased to 21 and his pH was 7.27. He received another 2 liters of normal saline, but become tachypneic. His tachypnea resolved with diuresis (Lasix 20 mg IV). On [**2-19**] the patient was transferred to the MICU for an insulin drip and management of DKA. He received 2 liters of D5W in normal saline, then 1 liter of D5W with 3 amps of bicarb, then 1 liter of D5W with K+. For his hematocrit of 20 he received 1 unit of pRBCs. His gap was back down to 21 by 23:00 that evening. On [**2-20**] the patient had his first session of hemodialysis. He declined his renal diet all day, then at midnight had [**State 19827**] Fried Chicken brought in from outside. In the early AM of [**2-21**] he developed nausea, vomiting, a glucose of 436 and DKA. He had an EKG that showed no ischemia, and morphine for pain. For systolic blood pressures from 190-210 he received IV doses of his home PO antihypertensives (Hydralazine and Metoprolol). The patient was refusing his calcium capsules because they were too big to swallow, and tried to order a pizza in instead of hospital food. By [**2-24**] he had been transitioned from insulin drip to insulin boluses. On [**2-25**] he had his 4th session of dialysis. He wanted to leave that evening AMA (felt he had lost his freedom), but was convinced to stay. On [**2-26**] he again wanted to leave AMA but was again convinced to stay one more day for a 5th dialysis session and to arrange optimal outpatient followup. He was transferred out of the ICU to the medicine floor. Overnight on [**3-31**], he [**Date Range 28316**] a fever to 100.9. Blood cultures were sent and he underwent his 5th dialysis session. Following his HD session, he was seen by the medical team and advised to stay in the hospital for one more day to assess for an infection, given his overnight fever and recent initiation of hemodialysis. He was advised to stay to ensure he remained afebrile for 24 hours. Mr. [**Known lastname 21822**] refused this advise and decided to sign out AGAINST MEDICAL ADVICE, despite repeated discussions with him regarding our decision and desire to monitor him for another day. By problem: Anion gap metabolic acidosis/hyperglycemia/DKA. Increased above baseline on presentation probably due to uremia in setting of dehydration. It slightly improved s/p 2L IVF near baseline gap of 19. But after brief stay on the regular medicine floor, his blood sugar elevated into the 200-300s and anion gap increased; acetone found in serum and ketones seen in urinalysis, concerning for DKA. Lactate was normal. In the MICU, patient was started on an insulin gtt and started on intravenous fluids. In total, patient received 2L D51/2NS, then D5W with 3 amps bicarb in 1L, then D5W with potassium. He had a PICC placed for regular (every 4 hour) electrolyte checks. Patient's anion gap decreased to baseline ~17, given patient's underlying end-stage renal disease/uremia. Insulin gtt was discontinued and [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs, patient was started on a fixed Lantus and Humalog sliding scale. Of note, on [**2-20**], patient refused hospital diet and had his girlfriend bring him [**State 19827**] Fried Chicken; his blood sugars and anion gap increased. Patient required resumption of insulin gtt briefly; he was resumed on insulin sliding scale and fixed dose, with Nutrition Consult and Social Work following for coping/management of his long-standing, complicated Type 1 Diabetes Mellitus. N/V/D, abdominal pain. Given low grade fever and acute onset, most c/w viral gastroenteritis although possible that this was exacerbated by uremia. Also, patient has a hx of gastroparesis. Abdominal exam nonfocal but with tenderness initially that resolved. Did have an episode of resumed, increased abdominal pain after consumption of KFC, likely due to brief opening of anion gap and underlying gastroparesis. Lipase was normal. Mild elevation of LFTs gradually resolved. Pt did not appear fluid overloaded on exam. Patient's diarrhea resolved while in MICU and as per above, developed appetite and was able to tolerate PO medications/diet. Clostridium difficile toxin was sent and negative Acute on chronic renal failure. Pt was already in end stage renal disease (stage 4) on admission. AV fisulta had been recently placed for initiation of hemodialysis. In the setting of profuse nausea, vomiting and diarrhea, there was also likely a prerenal component to the bump in creatinine. Patient received 2L intravenous fluids in the ED and then approximately 4L to manage his DKA. Patient did become hypertensive likely in this setting. Patient was continued on calcitriol, calcium acetate, and nephrotoxic medications were avoided. Renal followed the patient during this admission and initiated hemodialysis with good effect on his creatinine and volume status. Anemia. Initially on arrival to the MICU, hematocrit was 20, mildly below baseline of 25 and felt due to the combination of iron deficiency and CKD. Patient did not have emesis or blood in his stools. Patient was transfused one unit of pRBC with good effect. He was continued on iron supplements and may benefit from Epogen with hemodialysis in the future. HTN. Poorly controlled, likely in the setting of initial acute discomfort and later due to volume overload in the setting of his ESRD and intravenous fluids for DKA. Patient was ultimately transitioned to a regimen of Metoprolol 100mg twice daily, Amlodipine 10mg daily and Hydralazine 50mg three times daily. Fever. Mr. [**Known lastname 21822**] [**Last Name (Titles) 28316**] a fever to 100.9 on the night of [**3-31**]. As discussed above, in the setting of recent initiation of hemodialysis and pending blood cultures, the patient was advised to remain in the hospital to be sure he was afebrile for 24 hours, without signs or symptoms of infection, and that his blood cultures remained negative. Mr. [**Known lastname 21822**] refused, and signed out AGAINST MEDICAL ADVICE. Medications on Admission: Calcium Acetate 667 mg 2 tabs tid w/ meals Amlodipine 10mg daily Metoprolol succinate 100mg daily Ferrous sulfate 1 tab daily Calcitriol 0.25mcg daily Hydralazine 25mg tid Humalog SS Lantus 15 units qAM . Allergies: Penicillins, Watermelon, Almond Oil Discharge Medications: 1. Calcium Acetate 667 mg Capsule [**Known lastname **]: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*180 Capsule(s)* Refills:*2* 2. Amlodipine 5 mg Tablet [**Known lastname **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Hydralazine 25 mg Tablet [**Known lastname **]: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 50 mg Tablet [**Known lastname **]: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. Insulin regimen Please follow printout of insulin dosing (Humalog) 6. Insulin Glargine 100 unit/mL Solution [**Known lastname **]: Fifteen (15) units Subcutaneous at bedtime. Disp:*1 month supply* Refills:*2* 7. Calcitriol 0.25 mcg Capsule [**Known lastname **]: One (1) Capsule PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Viral Gastroenteritis Diabetic Ketoacidosis Diabetes Mellitus type 1 CKD stage V, requiring initiation of hemodialysis Discharge Condition: The patient is leaving AGAINST MEDICAL ADVICE given his recent fevers, pending blood cultures, and recent initiation of hemodialysis. Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: *LEAVING AGAINST MEDICAL ADVICE* You were admitted to the hospital for nausea and vomiting. While in the hospital, your sugars were elevated and you were found to have Diabetic Ketoacidosis (DKA). You were treated with an insulin drip and your DKA initially resolved. However, you were not compliant with your diabetic diet and after eating fried chicken you redeveloped signs of DKA requiring a second insulin drip. You developed further episodes of DKA during your hospitalization and each required insulin drip in the intensive care unit. Additionally, during this hospitalization you were initiated on hemodialysis which you will require three times a week. You [**Known lastname 28316**] a fever on [**2-24**] and again on [**2-27**], and blood cultures were taken to evaluate for any signs of blood infection. These must be followed by your primary care doctor or your outpatient nephrologist. Given your recent initiation of hemodialysis and lengthy hospital course, we advise you to remain in the hospital while we await the results of these cultures. As you have decided to leave, it will be AGAINST MEDICAL ADVICE as we strongly believe that you should continue to be evaluated for signs and potential sources of infection given your recent fevers. We want to ensure that you did not have an active infection and do not have fevers over the next 24 hours. We made the following changes to your home medications: Hydralazine 50 mg TID (you were taking 25 mg TID prior) Metoprolol Tartrate 100 [**Hospital1 **] (you were on a long acting metoprolol once daily prior) Please also follow the attached printout of sliding scale insulin dosing based on your blood sugars. Followup Instructions: Appointment #1 MD: [**First Name4 (NamePattern1) 2184**] [**Last Name (NamePattern1) 2185**] ([**Company 191**] Post [**Hospital **] Clinic) Specialty: Internal Medicine Date/ Time: Monday, [**3-1**], 8:15am Location: [**Location (un) **], [**Hospital Ward Name 23**] Building, [**Location (un) **] Central Suite Phone number: [**Telephone/Fax (1) 250**] . Appointment #2 MD: [**First Name8 (NamePattern2) 7208**] [**Last Name (NamePattern1) 978**] Specialty: Endocrinology Date/ Time: Tuesday, [**3-2**], 9 am Location: [**Hospital **] Clinic Phone number: [**Telephone/Fax (1) 2490**] Apt # 3: Social Work: [**3-24**] at 12PM with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10927**], LICSW in [**Company 191**] Please call [**Telephone/Fax (1) 250**] to cancel or change if needed ",25,2145-02-18 20:45:00,2145-02-27 18:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,LEFT AGAINST MEDICAL ADVI,DEHYDRATION," in the er on [**2-18**], his vitals were: t 100.1, p 98, bp 164/90, rr 16, o2 sat 100%. he had abdominal pain, and he was guiac negative. his initial creatinine was 15.3, his glucose was 162, and he had a metabolic acidosis with an anion gap of 24 (up from his baseline of 19, due to his chronic kidney disease). he was given 2l ivf for hydration, and his anion gap closed to 20. he was given morphine 4 mg iv x 2 and zofran 4 mg iv x 2, and admitted to medicine. on transfer to the floor his vitals were: t 99.2, hr 100, bp 171/90, rr 12, o2sat 97% on room air. . on the medicine floor he had worsening nausea, vomiting and abdominal pain, his glucose rose to 305, his gap increased to 21 and his ph was 7.27. he received another 2 liters of normal saline, but become tachypneic. his tachypnea resolved with diuresis (lasix 20 mg iv). on [**2-19**] the patient was transferred to the micu for an insulin drip and management of dka. he received 2 liters of d5w in normal saline, then 1 liter of d5w with 3 amps of bicarb, then 1 liter of d5w with k+. for his hematocrit of 20 he received 1 unit of prbcs. his gap was back down to 21 by 23:00 that evening. on [**2-20**] the patient had his first session of hemodialysis. he declined his renal diet all day, then at midnight had [**state 19827**] fried chicken brought in from outside. in the early am of [**2-21**] he developed nausea, vomiting, a glucose of 436 and dka. he had an ekg that showed no ischemia, and morphine for pain. for systolic blood pressures from 190-210 he received iv doses of his home po antihypertensives (hydralazine and metoprolol). the patient was refusing his calcium capsules because they were too big to swallow, and tried to order a pizza in instead of hospital food. by [**2-24**] he had been transitioned from insulin drip to insulin boluses. on [**2-25**] he had his 4th session of dialysis. he wanted to leave that evening ama (felt he had lost his freedom), but was convinced to stay. on [**2-26**] he again wanted to leave ama but was again convinced to stay one more day for a 5th dialysis session and to arrange optimal outpatient followup. he was transferred out of the icu to the medicine floor. overnight on [**3-31**], he [**date range 28316**] a fever to 100.9. blood cultures were sent and he underwent his 5th dialysis session. following his hd session, he was seen by the medical team and advised to stay in the hospital for one more day to assess for an infection, given his overnight fever and recent initiation of hemodialysis. he was advised to stay to ensure he remained afebrile for 24 hours. mr. [**known lastname 21822**] refused this advise and decided to sign out against medical advice, despite repeated discussions with him regarding our decision and desire to monitor him for another day. by problem: anion gap metabolic acidosis/hyperglycemia/dka. increased above baseline on presentation probably due to uremia in setting of dehydration. it slightly improved s/p 2l ivf near baseline gap of 19. but after brief stay on the regular medicine floor, his blood sugar elevated into the 200-300s and anion gap increased; acetone found in serum and ketones seen in urinalysis, concerning for dka. lactate was normal. in the micu, patient was started on an insulin gtt and started on intravenous fluids. in total, patient received 2l d51/2ns, then d5w with 3 amps bicarb in 1l, then d5w with potassium. he had a picc placed for regular (every 4 hour) electrolyte checks. patients anion gap decreased to baseline ~17, given patients underlying end-stage renal disease/uremia. insulin gtt was discontinued and [**first name8 (namepattern2) **] [**last name (un) **] recs, patient was started on a fixed lantus and humalog sliding scale. of note, on [**2-20**], patient refused hospital diet and had his girlfriend bring him [**state 19827**] fried chicken; his blood sugars and anion gap increased. patient required resumption of insulin gtt briefly; he was resumed on insulin sliding scale and fixed dose, with nutrition consult and social work following for coping/management of his long-standing, complicated type 1 diabetes mellitus. n/v/d, abdominal pain. given low grade fever and acute onset, most c/w viral gastroenteritis although possible that this was exacerbated by uremia. also, patient has a hx of gastroparesis. abdominal exam nonfocal but with tenderness initially that resolved. did have an episode of resumed, increased abdominal pain after consumption of kfc, likely due to brief opening of anion gap and underlying gastroparesis. lipase was normal. mild elevation of lfts gradually resolved. pt did not appear fluid overloaded on exam. patients diarrhea resolved while in micu and as per above, developed appetite and was able to tolerate po medications/diet. clostridium difficile toxin was sent and negative acute on chronic renal failure. pt was already in end stage renal disease (stage 4) on admission. av fisulta had been recently placed for initiation of hemodialysis. in the setting of profuse nausea, vomiting and diarrhea, there was also likely a prerenal component to the bump in creatinine. patient received 2l intravenous fluids in the ed and then approximately 4l to manage his dka. patient did become hypertensive likely in this setting. patient was continued on calcitriol, calcium acetate, and nephrotoxic medications were avoided. renal followed the patient during this admission and initiated hemodialysis with good effect on his creatinine and volume status. anemia. initially on arrival to the micu, hematocrit was 20, mildly below baseline of 25 and felt due to the combination of iron deficiency and ckd. patient did not have emesis or blood in his stools. patient was transfused one unit of prbc with good effect. he was continued on iron supplements and may benefit from epogen with hemodialysis in the future. htn. poorly controlled, likely in the setting of initial acute discomfort and later due to volume overload in the setting of his esrd and intravenous fluids for dka. patient was ultimately transitioned to a regimen of metoprolol 100mg twice daily, amlodipine 10mg daily and hydralazine 50mg three times daily. fever. mr. [**known lastname 21822**] [**last name (titles) 28316**] a fever to 100.9 on the night of [**3-31**]. as discussed above, in the setting of recent initiation of hemodialysis and pending blood cultures, the patient was advised to remain in the hospital to be sure he was afebrile for 24 hours, without signs or symptoms of infection, and that his blood cultures remained negative. mr. [**known lastname 21822**] refused, and signed out against medical advice. ","PRIMARY: [Diabetes with ketoacidosis, type I [juvenile type], uncontrolled] SECONDARY: [Acute kidney failure, unspecified; End stage renal disease; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease; Secondary hyperparathyroidism (of renal origin); Intestinal infection due to other organism, not elsewhere classified; Diabetes with renal manifestations, type I [juvenile type], uncontrolled; Diabetes with neurological manifestations, type I [juvenile type], uncontrolled; Gastroparesis; Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled; Background diabetic retinopathy; Dehydration; Anemia in chronic kidney disease; Iron deficiency anemia, unspecified; Depressive disorder, not elsewhere classified; Long-term (current) use of insulin]","in the er on [**2-18**], his vitals were: t 100.1, p 98, bp 164/90, rr 16, o2 sat 100%. his tachypnea resolved with diuresis (lasix 20 mg iv). his gap was back down to 21 by 23:00 that evening. in the early am of [**2-21**] he developed nausea, vomiting, a glucose of 436 and dka. for systolic blood pressures from 190-210 he received iv doses of his home po antihypertensives (hydralazine and metoprolol). by [**2-24**] he had been transitioned from insulin drip to insulin boluses. he was transferred out of the icu to the medicine floor. but after brief stay on the regular medicine floor, his blood sugar elevated into the 200-300s and anion gap increased; acetone found in serum and ketones seen in urinalysis, concerning for dka. mild elevation of lfts gradually resolved. patients diarrhea resolved while in micu and as per above, developed appetite and was able to tolerate po medications/diet. patient did not have emesis or blood in his stools. he was continued on iron supplements and may benefit from epogen with hemodialysis in the future. patient was ultimately transitioned to a regimen of metoprolol 100mg twice daily, amlodipine 10mg daily and hydralazine 50mg three times daily.","on transfer to the floor his vitals were t 99.2, hr 100, bp 171/90, rr 12, o2sat 97% on room air. on the medicine floor he had worsening nausea, vomiting and abdominal pain. his glucose rose to 305, his gap increased to 21 and his ph was 7.27. he declined his renal diet all day, then at midnight had fried chicken brought in from outside." 25256,144551.0,12435,2162-04-02,12434,170994.0,2162-03-16,Discharge summary,"Admission Date: [**2162-2-4**] Discharge Date: [**2162-3-16**] Date of Birth: [**2123-3-28**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2485**] Chief Complaint: Chief Complaint: Low oxygen saturation at clinic Reason for MICU admission: hypercarbic respiratory failure Major Surgical or Invasive Procedure: Intubation/mechanical ventilation Arterial line placement s/p tracheostomy placement [**2162-3-8**] History of Present Illness: 38M with NHL s/p alloSCT [**2155**] and DLI [**2156**], in remission but with chronic GVHD including bronchiolitis obliterans and severe restrictive lung disease, initially admitted to [**Year (4 digits) 3242**] service on [**2-4**] with shortness of breath, now transferred to MICU for hypercarbic respiratory failure. . He was at routine clinic visit on [**2-4**] and noted shortness of breath and sats 93% RA. He had had recent outpatient treatment for pneumonia starting [**1-21**], briefly interrupted due to elevated bilirubin. Has been on very low dose IL-2 subcutaneously at home, last received prior to admission. . During his hospital course, he was treated with cefepime and levofloxacin (now day 14). Pulmonary was consulted and recommended chest PT and hypertonic saline. He remained on RA for the most part, maintaining sats in 90-97% range. Afebrile with exception of T100.5 on [**2-9**] and 100.3 this morning. IL-2 was stopped at admission and tacrolimus was trialed for enhanced immunosuppresion, but was stopped today due to development of tremor in the past few days. On rounds this AM he noted fatigue without new respiratory symptoms. Got chest PT, lasix 20 mg, vancomycin, and nebs. During the course of the morning he looked more fatigued then started working harder to breathe. CXR was grossly unchanged. He was started on 1-2L O2. Somnolence then developed and he needed to be lifted from chair to bed. ABG done and pending at the time of transfer. He was working hard to breathe but not responding to verbal stimuli. He was rapidly transported to the [**Hospital Unit Name 153**] and intubated. Immediately prior to intubation he was apneic and required bag ventilation. . Review of Systems: (+) Unable to obtain; see admission note. Notables include significant weight loss for which GI was consulted, and development of bilateral LE edema (as well as some in UEs). Past Medical History: Past Oncologic History: - [**4-/2154**] p/w fevers, night sweats, and weight loss in the setting of a left inguinal lymph node. - CT scan: 15x14x10cm mass in the LUQ. - Bx grade II/III follicular lymphoma. - Treated with six cycles of CHOP/Rituxan with good response, but showed evidence for relapse in [**12/2154**] and was treated with MINE chemotherapy for two cycles. - [**3-/2155**]: Underwent stem cell mobilization with Cytoxan followed by autologous stem cell transplant in - [**7-/2155**]: Noted for disease recurrence. He was initially treated with a course of Rituxan without response followed by Zevalin with - [**3-/2156**]: Noted progression of his disease. He was treated with one cycle of [**Hospital1 **] followed by one cycle of ESHAP. - [**2156-7-29**]: Nonmyeloablative allogeneic stem cell transplant with a [**5-30**] HLA-matched unrelated donor with Campath conditioning - Six-month follow-up CT noted for disease progression. - [**1-/2157**]: Received donor lymphocyte infusion in , complicated by acute liver/GI GVHD grade IV, for which [**Known firstname **] required a prolonged hospitalization in the summer of [**2156**]. - Multiple GI bleeds requiring ICU admissions and multiple transfusions and embolization of his bleeding. - Noted to have CNS lesions felt consistent with PTLD and this was treated with a course of Rituxan. No evidence for recurrence of the PTLD. - Acute liver GVHD, on CellCept, prednisone, and photophoresis. - [**2157-12-28**] Photophoresis was d/c'd due to episodes of bacteremia and eventual removal of his apheresis catheter. - [**2158-6-13**] restarted photopheresis on a weekly basis on , but then discontinued this again on [**2158-9-7**] as this was felt not to be making any impact on his liver function tests. - undergone phlebotomy due to iron overload with corresponding drop in his ferritin. He has continued with transient rises in his transaminases and bilirubin and has remained on varying doses of CellCept and prednisone which has been slowly tapered over the time. - [**2160-1-10**] CellCept discontinued. - [**2159-1-19**] admission due to increasing right hip pain. MRI revealed edema and infiltrating process in the psoas muscle bilaterally. After extensive workup, this was felt related to an infection and required several admissions with completion of antibiotics in 03/[**2158**]. - [**7-/2160**]: Last scans showed no evidence for lymphom and he has remained in remission. - [**2160-10-20**]: URI and treatment with course of Levaquin. - [**2160-11-13**] completed a 4 week course of Rituxan to treat his GVHD. -In [**5-/2161**], noted to have tiny echogenic nodule on abdominal [**Year (4 digits) 950**]. MRI of the liver also showed this nodule but was not as concerning on review and he is due to have a repeat MRI imaging in early [**Month (only) **]. -- GI varices and attempts at banding have been unsuccessful due to difficulty with passing the necessary instruments. He has been on a low dose beta blocker as well as simvastatin, which was started on [**2161-7-7**] to help with medical management of his varices. -On [**2161-8-3**], worsening cough and was noted to have a small new pneumothorax in the left apical area. This has essentially resolved over time - Issues with weight loss (followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]); multiple tests done with no etiology found; question malabsorption related to GVHD - Has on and off respiratory infections and has been treated with antibiotics with possible pneumonia. Question underlying exacerbations of pulmonary GVHD in setting of his URIs. - Currently receives IVIG every month. . Other Past Medical History: 1. Non-Hodgkin's lymphoma s/p allo SCT 2. Grade 4 Acute GVHD of GI/liver following DLI with GI bleed, chronic transaminitis, portal HTN with esophageal varices (not able to band) 3. History of intracranial lesions felt consistent with PTLD. 4. Extensinve chronic GVHD of lung, liver, skin, mucous membranes. 5. Grade II esophageal varices, intollerant to beta blockade. 6. HSV in nasal washing [**11/2159**](completed course of Valtrex) 7. Hypothyroidism 8. hx of Psoas muscle infection . Social History: Smoke: never EtOH: none currently; occassional use prior to NHL dx Drugs: never Born in [**Country **] and moved to the U.S. for college ([**Hospital1 **]). Married in [**2160-8-25**] and lives in [**Location **]. No children. Stays at home and writes (currently writing a book on being diagnosed with cancer at young age). Family History: Without history of lymphoma or other cancers in the family No FHx of DM or HTN Mother: Alive, Thyroid disease Father: [**Name (NI) 38646**] cardiac cath with angioplasty of 2 vessels, asthma 2 older brothers: alive and well Physical Exam: VS: 96.6 129 110/77 21 100% AC FiO2 100%, VT: 350, RR: 24, PEEP 5 GEN: intubated, sedated, cachectic. HEENT: PERRL 4->3, oropharynx clear. Neck: Thin, JVD to 3 cm ASA. CV: tachy, regular, S1 S2, no mrg apprciated. PULM: Poor air entry bilaterally, no wheezes/rhonchi/crackles appreciated. ABD: audible bowel sounds, tense abdomen though appears nontender. LIMBS: 2+ pitting edema bilaterally, warm. NEURO: sedated, moving all extremities prior to intubation. Post intubation with some posturing and tremors of RUE in particular, ?tacro effect. SKIN: diffuse scattered GVHD associated rash. Pertinent Results: CBC [**2162-2-20**] 03:55AM BLOOD WBC-6.7 RBC-2.94* Hgb-9.0* Hct-27.5* MCV-93 MCH-30.6 MCHC-32.7 RDW-16.3* Plt Ct-95* [**2162-2-19**] 04:14AM BLOOD WBC-8.9 RBC-3.21* Hgb-9.5* Hct-30.4* MCV-95 MCH-29.7 MCHC-31.3 RDW-16.4* Plt Ct-100* [**2162-2-18**] 04:29AM BLOOD WBC-9.8 RBC-3.32* Hgb-9.9* Hct-31.8* MCV-96 MCH-29.7 MCHC-31.0 RDW-16.4* Plt Ct-130* [**2162-2-17**] 01:08PM BLOOD WBC-11.0 RBC-3.63* Hgb-10.7* Hct-35.6* MCV-98 MCH-29.5 MCHC-30.1* RDW-15.8* Plt Ct-135* CHEMISTRY [**2162-2-20**] 03:55AM BLOOD Glucose-131* UreaN-19 Creat-0.3* Na-138 K-4.2 Cl-100 HCO3-32 AnGap-10 [**2162-2-19**] 04:14AM BLOOD Glucose-88 UreaN-20 Creat-0.3* Na-137 K-4.2 Cl-102 HCO3-30 AnGap-9 [**2162-2-18**] 04:29AM BLOOD Glucose-83 UreaN-21* Creat-0.4* Na-138 K-4.3 Cl-101 HCO3-30 AnGap-11 [**2162-2-17**] 01:08PM BLOOD Glucose-168* UreaN-27* Creat-0.4* Na-141 K-4.4 Cl-97 HCO3-37* AnGap-11 [**2162-2-19**] 04:14AM BLOOD ALT-51* AST-67* AlkPhos-249* TotBili-1.5 [**2162-2-17**] 01:08PM BLOOD ALT-76* AST-72* LD(LDH)-332* CK(CPK)-31* AlkPhos-297* TotBili-1.2 [**2162-2-17**] 12:29AM BLOOD ALT-80* AST-78* LD(LDH)-278* AlkPhos-287* TotBili-1.0 [**2162-2-16**] 12:00AM BLOOD ALT-86* AST-109* LD(LDH)-317* AlkPhos-338* TotBili-1.2 DirBili-0.8* IndBili-0.4 [**2162-2-20**] 03:55AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.7 MICRO [**2162-3-4**] 1:08 pm BRONCHOALVEOLAR LAVAGE RIGHT LOWER LOBE. GRAM STAIN (Final [**2162-3-4**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2162-3-8**]): KLEBSIELLA PNEUMONIAE. ~1000/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- =>128 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R REPORTS CXR PA/LAT [**2162-2-4**]: Increased consolidation at the base of the left lung is accompanied by new small left pleural effusion, could be pneumonia. Right lung generally clear aside from mild peribronchial infiltration in the right upper lobe. Heart size normal. No evidence of central adenopathy. ECHO [**2162-2-18**] IMPRESSION: Vigorous biventircular systolic function. No clinically-significant valvular disease seen. Normal estimated intracardiac filling pressures. ABDOMINAL U/S [**2162-2-19**]: FINDINGS: Since prior examination, there has been interval development of a moderate-to-severe amount of intra-abdominal ascites. The largest pocket of ascites is noted within the right lower quadrant measuring up to 13.6 cm in anterior-posterior dimensions, approximately 1 cm from the skin surface. IMPRESSION: Moderate-to-severe intra-abdominal ascites with largest pocket in right lower quadrant . CXR [**2162-3-8**]: Left lower lobe remains entirely consolidated. Small left pleural effusion is larger. Right infrahilar consolidation is stable. Tip of the new tracheostomy tube is just a few millimeters above the carina, probably not optimal. Feeding tube ends in the stomach. No right pleural effusion. Heart size normal. Right PIC line ends in the upper right atrium. Findings were discussed by telephone with the patient's nurse at the time of dictation. . Discharge Labs: [**2162-3-10**] 05:19AM BLOOD WBC-5.5 RBC-2.84* Hgb-8.2* Hct-27.2* MCV-96 MCH-28.9 MCHC-30.1* RDW-16.3* Plt Ct-166 [**2162-3-6**] 03:15AM BLOOD Neuts-77* Bands-2 Lymphs-15* Monos-4 Eos-1 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2162-3-10**] 05:19AM BLOOD Glucose-66* UreaN-13 Creat-0.2* Na-142 K-3.6 Cl-108 HCO3-24 AnGap-14 [**2162-3-8**] 03:47AM BLOOD ALT-40 AST-41* LD(LDH)-225 AlkPhos-259* TotBili-0.9 [**2162-3-10**] 05:19AM BLOOD Calcium-6.6* Phos-1.5* Mg-1.5* [**2162-2-25**] 03:20AM BLOOD calTIBC-316 VitB12-1776* Folate-GREATER TH Ferritn-230 TRF-243 [**2162-3-3**] 12:06AM BLOOD TSH-0.71 [**2162-2-17**] 08:50AM BLOOD tacroFK-9.1 [**2162-3-8**] 08:51PM BLOOD Type-ART pO2-177* pCO2-65* pH-7.33* calTCO2-36* Base XS-6 [**2162-3-4**] 04:27AM BLOOD Lactate-1.0 Brief Hospital Course: 38M with NHL s/p alloBMT complicated by multi-organ GVHD and BO with severe baseline lung disease and CO2 retention, presenting with dyspnea and cough, now transfered to [**Hospital Unit Name 153**] for hypercarbic respiratory failure. . # Hypercarbic respiratory failure. The etiology of his respiratory failure was thought to be most likely [**1-26**] 3 factors: 1) worsening pulmonary GVHD 2) cirrhosis also likely [**1-26**] GVHD and may benefit from a therapeutic para to help his breathing 3) low negative inspiratory force (NIF) values, suggestive of weak muscles of respiration, possibly secondary to ICU or steroid myopathy. Infection thought to be less likely given negative BAL. CTA negative for PE. Therefore, although vanc, levo, and cefepime were continued, pt was started on methylprednisolone 50mg IV Q12H. CT head for somnolence negative. After discussion with his oncologist and the primary medical team, CT surgery was consulted for tracheostomy and GI was consulted about placing a PEG tube. Patient was tried several times on PSV and a vent weaning trial in the days leading up to the scheduled operation and the patient was noted to tolerate progressively lower pressure support. PEG and trach placement was tentatively scheduled for [**2162-2-26**] but the patient's condition improved and he was extubated on the morning of [**2162-2-26**]. He intermittently required NIPPV for respiratory fatigue but in general his ABGs were reassuring enough for him to remain on oxygen supplementation alone. On [**2-28**], the patient appeared to be in respiratory fatigue which continued and worsened with increasing tachycardia in the setting of pt spiking fevers. As a result, he was reintubated on [**2162-3-3**]. A bronchoscopy was performed which revealed GNRs in the sputum. He was kept on broad spectrum antibiotic coverage and was switched to Meropenem when BAL cultures showed Klebsiella pneumoniae sensitive to this antibiotic. On [**3-8**], a trach was placed at the bedside without difficulty. He was able to tolerate breathing without ventilatory support for 1.5 hours by [**2162-3-14**], but otherwise was on pressure support, with a PSV of 12 and PEEP of 5. He completed an 8 day course of meropenem on [**2162-3-15**]. . #Fever. The patient was noted to have increasing leukocytosis and low grade temps on [**2162-3-2**]. [**Date Range 3242**] was consulted and recommended that we check CT sinus, CT chest, and start empiric antibiotic treatment with vanc/cefepime/voriconazole. The results of the CT sinus and CT chest were consistent with marked interval worsening of right lower lobe pneumonia.. Culture data from BAL was consistent with meropenem-sensitive klebsiella pneumonia. The patient was started on this antibiotic with resolution of his fevers. Just prior to discharge, the patient thought he may have aspirated some contents of his NG tube which had been dislodged overnight. A new Dobhoff was placed by IR on [**3-10**]. He did have a low grade fever to 100.5F on [**3-10**]. As a result, he was started on Vancomycin, per [**Month/Year (2) 3242**] recommendations. C. difficile toxin was negative x 2, and vancomycin was stopped on [**2162-3-12**], with no further fevers. . #Diarrhea/loose stools. Mr. [**Known lastname 38598**] reported frequent loose stools on [**3-11**]. He was started empirically on po vanco, per [**Month/Year (2) 3242**] recomendations, and stopped once C. Diff toxin was negative. . # Hypotension. Normotensive prior to intubation but had some prolonged low BPs most likely secondary to positive pressure effects and sedation. CTA negative for PE. TTE also wnl. Neosynephrine quickly weaned off. Normotensive since extubation. . # Tremor. Occurring on [**Month/Year (2) 3242**] floor prior to events, though ?med effect from tacro. Low suspicion for seizure activity given chronicity and with normal mental status prior. Resolved during ICU stay. . # Edema. New this admission, though to be [**1-26**] IVFs. Past echocardiograms have all been within normal limits. A TTE on this admission was similarly normal, but his symptoms did self-resolve. [**Month (only) 116**] have been related to cirrhosis although albumin only 3.6. . # Non-Hodgkin's lymphoma s/p allo [**Month (only) 3242**]: Most recent PET scan with no evidence of recurrent disease and he remains in remission. . # GVHD. Respiratory plan as above, prednisone and MMF per above, PPx with bactrim DS and Acyclovir. On [**2162-3-13**], patient was treated with one dose of rituxan. . # Elevated LFTs. At baseline from GVHD. . # Hypothyroidism. No active issues. Levothyroxine 125 mcg daily M-Saturday was continued. . # Gastric varices. Asymptomatic. No e/o GI bleed. Metoprolol restarted at 12.5 mg PO BID. . # Nutrition: Patient was advanced to a regular diet with supplemental Ensure on [**2162-2-26**] after extubation. A Dobhoff was placed by IR on [**3-10**] as patient was unable to keep up with adequate po intake for caloric needs. He will require tube feeds based on nutrition recommendations until he is able to maintain adequate po intake. . CODE STATUS: FULL CODE (confirmed) Medications on Admission: ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs(s) inhaled q 4-6h as needed for chest tightness/SOB/exposure to cold air ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for Nebulization - 1 neb inhaled four times daily as needed for shortness of breath AZITHROMYCIN - (On Hold from [**2162-1-28**] to unknown for on levaquin) - 250 mg Tablet - 1 (One) Tablet(s) by mouth three times a week Start after Zpak completed BUDESONIDE-FORMOTEROL [SYMBICORT] - 160 mcg-4.5 mcg/Actuation HFA Aerosol Inhaler - 2 puffs inhaled twice daily ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - 50,000 unit Capsule - 1 (One) Capsule(s) by mouth once a week ERYTHROMYCIN - (Prescribed by Other Provider) - 5 mg/gram Ointment - [**12-28**] inch to both eyes at bedtime. FAMCICLOVIR - 250 mg Tablet - 2 (Two) Tablet(s) by mouth twice a day IPRATROPIUM BROMIDE - 0.2 mg/mL (0.02 %) Solution - 1 vial nebulized three times daily as needed for cough and shortness of breath ISOSORBIDE DINITRATE - 5 mg Tablet - one to 1(one) Tablet(s) by mouth daily LEVOFLOXACIN [LEVAQUIN] - (Prescribed by Other Provider) - 250 mg Tablet - 2 Tablet(s) by mouth once a day for 14 days started on [**2162-1-21**] LEVOTHYROXINE [LEVOXYL] - 125 mcg Tablet - 1 (One) Tablet(s) by mouth once a day Monday - Saturday. - No Substitution LIPASE-PROTEASE-AMYLASE [CREON] - (Prescribed by Other Provider) - 60,000 unit-[**Unit Number **],000 unit-[**Unit Number **],000 unit Capsule, Delayed Release(E.C.) - 3 Capsule(s) by mouth three times a day Take with meals LOFEMAX - (Prescribed by Other Provider) - - 1 drop to right eye daily LORAZEPAM - 0.5 mg Tablet - 1 to 2 Tablet(s) by mouth at bedtime as needed for insomnia METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1 (One) Tablet(s) by mouth once a day MYCOPHENOLATE MOFETIL - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 250 mg Capsule - 1 (One) Capsule(s) by mouth twice a day NYSTATIN - 100,000 unit/mL Suspension - 5 (Five) ml(s) by mouth four times a day PREDNISONE - (Prescribed by Other Provider) - 10 mg Tablet - 2 (Two) Tablet(s) by mouth once a day SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth daily SULFAMETHOXAZOLE-TRIMETHOPRIM - 800 mg-160 mg Tablet - 1 (One) Tablet(s) by mouth three times a week (Monday, Wednesday, Friday) MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (Prescribed by Other Provider) - 500 mcg-250 mcg Tablet, Chewable - 1 (One) Tablet(s) by mouth once a day Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Non hodgkins lymphoma Hypoxic respiratory failure Klebsiella Pneumonia Bronchiolitis Obliterans GVHD Discharge Condition: stable, s/p tracheostomy, afebrile, on PSV. Followup Instructions: Patient should have close monitoring and follow-up with [**Hospital1 3242**] while at rehab, and should see his oncologist within 1 week of discharge from rehabilitation facility. ",17,2162-02-04 17:24:00,2162-03-16 11:30:00,EMERGENCY,CLINIC REFERRAL/PREMATURE,LONG TERM CARE HOSPITAL,LYMPHOMA," 38m with nhl s/p allobmt complicated by multi-organ gvhd and bo with severe baseline lung disease and co2 retention, presenting with dyspnea and cough, now transfered to [**hospital unit name 153**] for hypercarbic respiratory failure. . # hypercarbic respiratory failure. the etiology of his respiratory failure was thought to be most likely [**1-26**] 3 factors: 1) worsening pulmonary gvhd 2) cirrhosis also likely [**1-26**] gvhd and may benefit from a therapeutic para to help his breathing 3) low negative inspiratory force (nif) values, suggestive of weak muscles of respiration, possibly secondary to icu or steroid myopathy. infection thought to be less likely given negative bal. cta negative for pe. therefore, although vanc, levo, and cefepime were continued, pt was started on methylprednisolone 50mg iv q12h. ct head for somnolence negative. after discussion with his oncologist and the primary medical team, ct surgery was consulted for tracheostomy and gi was consulted about placing a peg tube. patient was tried several times on psv and a vent weaning trial in the days leading up to the scheduled operation and the patient was noted to tolerate progressively lower pressure support. peg and trach placement was tentatively scheduled for [**2162-2-26**] but the patients condition improved and he was extubated on the morning of [**2162-2-26**]. he intermittently required nippv for respiratory fatigue but in general his abgs were reassuring enough for him to remain on oxygen supplementation alone. on [**2-28**], the patient appeared to be in respiratory fatigue which continued and worsened with increasing tachycardia in the setting of pt spiking fevers. as a result, he was reintubated on [**2162-3-3**]. a bronchoscopy was performed which revealed gnrs in the sputum. he was kept on broad spectrum antibiotic coverage and was switched to meropenem when bal cultures showed klebsiella pneumoniae sensitive to this antibiotic. on [**3-8**], a trach was placed at the bedside without difficulty. he was able to tolerate breathing without ventilatory support for 1.5 hours by [**2162-3-14**], but otherwise was on pressure support, with a psv of 12 and peep of 5. he completed an 8 day course of meropenem on [**2162-3-15**]. . #fever. the patient was noted to have increasing leukocytosis and low grade temps on [**2162-3-2**]. [**date range 3242**] was consulted and recommended that we check ct sinus, ct chest, and start empiric antibiotic treatment with vanc/cefepime/voriconazole. the results of the ct sinus and ct chest were consistent with marked interval worsening of right lower lobe pneumonia.. culture data from bal was consistent with meropenem-sensitive klebsiella pneumonia. the patient was started on this antibiotic with resolution of his fevers. just prior to discharge, the patient thought he may have aspirated some contents of his ng tube which had been dislodged overnight. a new dobhoff was placed by ir on [**3-10**]. he did have a low grade fever to 100.5f on [**3-10**]. as a result, he was started on vancomycin, per [**month/year (2) 3242**] recommendations. c. difficile toxin was negative x 2, and vancomycin was stopped on [**2162-3-12**], with no further fevers. . #diarrhea/loose stools. mr. [**known lastname 38598**] reported frequent loose stools on [**3-11**]. he was started empirically on po vanco, per [**month/year (2) 3242**] recomendations, and stopped once c. diff toxin was negative. . # hypotension. normotensive prior to intubation but had some prolonged low bps most likely secondary to positive pressure effects and sedation. cta negative for pe. tte also wnl. neosynephrine quickly weaned off. normotensive since extubation. . # tremor. occurring on [**month/year (2) 3242**] floor prior to events, though ?med effect from tacro. low suspicion for seizure activity given chronicity and with normal mental status prior. resolved during icu stay. . # edema. new this admission, though to be [**1-26**] ivfs. past echocardiograms have all been within normal limits. a tte on this admission was similarly normal, but his symptoms did self-resolve. [**month (only) 116**] have been related to cirrhosis although albumin only 3.6. . # non-hodgkins lymphoma s/p allo [**month (only) 3242**]: most recent pet scan with no evidence of recurrent disease and he remains in remission. . # gvhd. respiratory plan as above, prednisone and mmf per above, ppx with bactrim ds and acyclovir. on [**2162-3-13**], patient was treated with one dose of rituxan. . # elevated lfts. at baseline from gvhd. . # hypothyroidism. no active issues. levothyroxine 125 mcg daily m-saturday was continued. . # gastric varices. asymptomatic. no e/o gi bleed. metoprolol restarted at 12.5 mg po bid. . # nutrition: patient was advanced to a regular diet with supplemental ensure on [**2162-2-26**] after extubation. a dobhoff was placed by ir on [**3-10**] as patient was unable to keep up with adequate po intake for caloric needs. he will require tube feeds based on nutrition recommendations until he is able to maintain adequate po intake. . code status: full code (confirmed) ","PRIMARY: [Acute and chronic respiratory failure] SECONDARY: [Pneumonia, organism unspecified; Pneumonia due to Klebsiella pneumoniae; Pneumonitis due to inhalation of food or vomitus; Dependence on respirator, status; Complications of transplanted bone marrow; Chronic graft-versus-host disease; Nodular lymphoma, unspecified site, extranodal and solid organ sites; Portal hypertension; Esophageal varices in diseases classified elsewhere, without mention of bleeding; Other specified alveolar and parietoalveolar pneumonopathies; Unspecified intestinal malabsorption; Paroxysmal supraventricular tachycardia; Unspecified pleural effusion; Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation; Accidents occurring in other specified places; Varices of other sites; Unspecified acquired hypothyroidism; Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified; Adrenal cortical steroids causing adverse effects in therapeutic use; Hypoxemia; Nonspecific low blood pressure reading; Iron deficiency anemia, unspecified; Cirrhosis of liver without mention of alcohol]","38m with nhl s/p allobmt complicated by multi-organ gvhd and bo with severe baseline lung disease and co2 retention, presenting with dyspnea and cough, now transfered to [**hospital unit name 153**] for hypercarbic respiratory failure. after discussion with his oncologist and the primary medical team, ct surgery was consulted for tracheostomy and gi was consulted about placing a peg tube. he was kept on broad spectrum antibiotic coverage and was switched to meropenem when bal cultures showed klebsiella pneumoniae sensitive to this antibiotic. the patient was noted to have increasing leukocytosis and low grade temps on [**2162-3-2**]. [** normotensive prior to intubation but had some prolonged low bps most likely secondary to positive pressure effects and sedation. occurring on [**month/year (2) 3242**] floor prior to events, though ? new this admission, though to be [**1-26**] ivfs. # non-hodgkins lymphoma s/p allo [**month (only) 3242**]: most recent pet scan with no evidence of recurrent disease and he remains in remission.","38m with nhl s/p allobmt complicated by multi-organ gvhd and bo. presenting with dyspnea and cough, now transferred to [**hospital unit name 153**] for hypercarbic respiratory failure." 25696,188176.0,11473,2170-11-12,11472,192616.0,2170-05-21,Discharge summary,"Admission Date: [**2170-5-5**] Discharge Date: [**2170-5-21**] Date of Birth: [**2118-2-1**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:[**First Name3 (LF) 6565**] Chief Complaint: right lower extremity swelling Major Surgical or Invasive Procedure: none History of Present Illness: 52 year old man with a PMH of metatstatic prostate cancer, PE, DVT on lovenox, hx of IVC filter in [**2168-4-9**] presents with increased leg swelling. Patient reports right leg pain that acutely started on the day prior to admission. He likens the sensation to feeling as though something were crawling up his leg and pain was reproduced with standing. These symptoms are similar to symptoms he's experienced with previous DVTs. He denies any injury to his leg and also denies prolonged travel or immobility. He also noticed shortness of breath without chest pain. Given these symptoms, he presented to the [**Hospital1 18**] ED for further evaluation. . In the [**Hospital1 18**] ED, vitals were as follows T - 98.8, HR - 117, BP - 128/80, RR - 12, O2 - 99%RA. CXR was unremarkable. LENIs showed non-occlusive DVT on the right. CTA chest was ordered, but was pending at the time of admission. Given concern for DVT/PE, IV Heparin was started, though because of the GIB, patient was admitted to the ICU for concern of GIB in the setting of anticoagulation Past Medical History: PAST MEDICAL HISTORY: 1. Metastatic prostate cancer to bone refractory to hormone therapy 2. Bilateral LE DVTs complicated by bilateral PE [**4-/2168**], treated with enoxoparin then warfarin, and status post IVC filter placement 04/[**2168**]. Last with DVT on [**2169-1-7**], now on enoxoparin 120 mg daily. 3. Psoriasis 4. Hypercholesterolemia 5. Seasonal allergies 6. Obstructive sleep apnea on CPAP . PAST ONCOLOGIC HISTORY (per prior discharge summary): Metastatic prostate cancer to bone refractory to hormone therapy s/p cycle 1 of Carboplatin and Taxotere [**2168-12-15**]. Dx in [**2163**] as [**Doctor Last Name **] 8 s/p surgical prostatectomy with XRT to T9 spinal metastasis in [**11-12**] followed by hormonal therapy, Taxotere (2 cycles), ketoconazole, hydrocortisone, mitoxantrone, and DES. He was recently noted to have a rise in his PSA to the 400 range, and a L-spine MRI on [**11-15**] showed multiple spine metastatic foci (no prior MRI L-spine for comparison, bone scan in [**6-/2168**] without clear spine metastases). He received his first cycle of Carboplatin and Taxotere on [**2168-12-15**]. Social History: He lives at home with his wife and his 12 year-old son. [**Name (NI) **] does not smoke. He denies tobacco, alcohol or illicit drug use. He formerly worked as heavy machine operator at [**Location (un) 86**] Water and Sewage. Family History: No family history of thrombophilic disorders. Physical Exam: PHYSICAL EXAM: Vitals: T - 99.5, BP - 131/79, HR - 119, RR - 16, O2 - 99% 3 L NC Gen: Awake, alert, NAD HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous CV: Distant heart sounds, [**2-10**] body habitus, but otherwise, no m/r/g Pulm: Small inspiratory crackles at the bases bilaterally Abd: Soft, NT, ND + BS Rectal: Guaiac negative Ext: No c/c/e; RLE markedly bigger than LLE with mild erythema and keratoses on shins Pertinent Results: CTA (prelim read): IMPRESSION: 1. No evidence of pulmonary embolism. 2. Innumerable diffuse osseous metastatic sclerotic lesions. 3. Stable T9 compression fracture. 4. Fatty liver. LENIS: IMPRESSION: Partially occlusive thrombus within the mid right superficial femoral vein consistent with chronic recanalized DVT. CXR: FINDINGS: Single bedside AP examination labeled ""upright"" with excessive lordotic positioning, as compared with studies dated [**2170-4-11**] and [**2169-2-21**]; the overall appearance has not much changed. The lung volumes remain low with bibasilar vascular crowding, but no focal airspace process. Allowing for these factors, the heart is top normal in size with only equivocal upper zone pulmonary vascular redistribution, but no overt CHF or pleural effusion. Brief Hospital Course: 52-year-old man with metastatic prostate cancer, not on active chemo with recurrent DVTs/PEs despite anticoagulation, also with recent GIB, presented with LE swelling, found to have RLE DVT. . # DVT: The patient presented with worse clot burden. He was on enoxaparin at home. Anti-Xa activity not checked on admission. He underwent an IVC venogram and mechanical thrombolysis with local TPA on [**2170-5-7**]. Heparin was then discontinued, and he was started on enoxaparin 120 mg [**Hospital1 **] on [**2170-5-8**]. (The patient had been on enoxaparin 80 mg [**Hospital1 **] before this admission.) His anti-Xa activity was therapeutic. He was sent home with enoxaparin 120 mg SC bid. . # Chronic pain: the patient experienced significant pain from bone metastases during this admission, requiring hydromorphone PCA. Palliative care was consulted on pain management. His pain gradually improved and he was discharged with methadone 20 mg PO qid and hydromorphone 12-24 mg PO q2h prn as well as gabapentin. . # Intermittent delirium: most likely from high-dose pain meds. His delirium resolved as his pain medications were weaned down. . # Fever: The patient spiked a fever of 101.1 on [**2170-5-15**]. He was empirically started on vancomycin because of concerning for a PICC line infection. However, when his blood cultures came back negative, and he defervesced promtly, the vancomycin was discontinued after 3 days. . # Metastatic prostate cancer: with bone mets. Spine CT showed extensive spine mets. Not able to tolerated spine MRI. PSA > 900 from the 126 in [**Month (only) 547**]. After a discussion with his outpatient oncologist, he was discharged with a plan for possible samarium as outpatient. . # UTI: pan-sensitive Klebsiella. He was initially started on ceftriaxone, which was switched to TMP/SMX when sensitivities were available. He finished a 7 days of TMP/SMX. . # Anemia: During his last admission, AVM seen on EGD was cauterized on [**2170-4-24**] during last admission. During this admission he received 2 units of pRBCs in MICU, and his hematocrit was stable after that. He was continued on PPI and sucralfate. . # Psoriasis: continued on outpatient creams. . # Obstructive Sleep Apnea: continued on CPAP. . # Communication: [**First Name8 (NamePattern2) **] [**Known lastname **](wife/HCP)-([**Telephone/Fax (1) 36628**] (h)/([**Telephone/Fax (1) 36629**] (c) . # Code: FULL Medications on Admission: 1. Lorazepam 1 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. Senna 8.6 mg PO BID 4. Pantoprazole 40 mg PO BID 5. Sucralfate 1 gram PO QID 6. Lidocaine 5 % TD 7. Bisacodyl 10 mg PO QD 8. Nortriptyline 50 mg PO QD 9. Celecoxib 200 mg PO BID 10. Gabapentin 300 mg PO TID 11. Tylenol PRN 12. Enoxaparin 80 mg SC BID 13. OxyContin 80 mg PO TID 14. Hydromorphone 4-8 mg PO Q3-4 hours Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Enoxaparin 120 mg/0.8 mL Syringe Sig: One [**Age over 90 **]y (120) mg Subcutaneous Q12H (every 12 hours). Disp:*qs 1 month's supply* Refills:*2* 7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for constipation. Disp:*120 Tablet(s)* Refills:*0* 9. Clobetasol 0.05 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 10. Hydromorphone 4 mg Tablet Sig: Three (3) Tablet PO Q2H (every 2 hours) as needed for pain. Disp:*qs 1 month's supply* Refills:*0* 11. Methadone 10 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:*240 Tablet(s)* Refills:*2* 12. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 13. Dulcolax 10 mg Suppository Sig: Ten (10) mg Rectal once a day as needed for constipation. Disp:*qs 1 month's supply* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: deep venous thrombosis Secondary diagnoses: metastatic prostate cancer, obstructive sleep apnea, psoriasis Discharge Condition: stable Discharge Instructions: You presented to the [**Hospital1 18**] with leg pain and were found to have a blood clot in your leg. You underwent a procedure to break up the clot and received blood thinner. Please continue to take all your medications, especially the enoxaparin (Lovenox), as instructed. Please follow up with your physicians. If you develop worsening pain, difficulty breathing, fevers, chills, chest pain, or any other concerning symptom, please go to the nearest Emergency Room immediately. Followup Instructions: * Oncology: Dr. [**Last Name (STitle) **], please call ([**Telephone/Fax (1) 31457**] to make a follow-up appointment within 2 weeks. * Primary care: Dr. [**Last Name (STitle) **], please call [**Telephone/Fax (1) 7477**] to maek a follow-up appointment within 2 weeks. [**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**] ",175,2170-05-05 22:00:00,2170-05-21 12:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,"DVT, ANEMIA"," 52-year-old man with metastatic prostate cancer, not on active chemo with recurrent dvts/pes despite anticoagulation, also with recent gib, presented with le swelling, found to have rle dvt. . # dvt: the patient presented with worse clot burden. he was on enoxaparin at home. anti-xa activity not checked on admission. he underwent an ivc venogram and mechanical thrombolysis with local tpa on [**2170-5-7**]. heparin was then discontinued, and he was started on enoxaparin 120 mg [**hospital1 **] on [**2170-5-8**]. (the patient had been on enoxaparin 80 mg [**hospital1 **] before this admission.) his anti-xa activity was therapeutic. he was sent home with enoxaparin 120 mg sc bid. . # chronic pain: the patient experienced significant pain from bone metastases during this admission, requiring hydromorphone pca. palliative care was consulted on pain management. his pain gradually improved and he was discharged with methadone 20 mg po qid and hydromorphone 12-24 mg po q2h prn as well as gabapentin. . # intermittent delirium: most likely from high-dose pain meds. his delirium resolved as his pain medications were weaned down. . # fever: the patient spiked a fever of 101.1 on [**2170-5-15**]. he was empirically started on vancomycin because of concerning for a picc line infection. however, when his blood cultures came back negative, and he defervesced promtly, the vancomycin was discontinued after 3 days. . # metastatic prostate cancer: with bone mets. spine ct showed extensive spine mets. not able to tolerated spine mri. psa > 900 from the 126 in [**month (only) 547**]. after a discussion with his outpatient oncologist, he was discharged with a plan for possible samarium as outpatient. . # uti: pan-sensitive klebsiella. he was initially started on ceftriaxone, which was switched to tmp/smx when sensitivities were available. he finished a 7 days of tmp/smx. . # anemia: during his last admission, avm seen on egd was cauterized on [**2170-4-24**] during last admission. during this admission he received 2 units of prbcs in micu, and his hematocrit was stable after that. he was continued on ppi and sucralfate. . # psoriasis: continued on outpatient creams. . # obstructive sleep apnea: continued on cpap. . # communication: [**first name8 (namepattern2) **] [**known lastname **](wife/hcp)-([**telephone/fax (1) 36628**] (h)/([**telephone/fax (1) 36629**] (c) . # code: full ","PRIMARY: [Acute venous embolism and thrombosis of deep vessels of proximal lower extremity] SECONDARY: [Secondary malignant neoplasm of bone and bone marrow; Urinary tract infection, site not specified; Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site; Delirium due to conditions classified elsewhere; Anemia, unspecified; Neoplasm related pain (acute) (chronic); Pure hypercholesterolemia; Obstructive sleep apnea (adult)(pediatric); Other psoriasis; Personal history of malignant neoplasm of prostate]","52-year-old man with metastatic prostate cancer, not on active chemo with recurrent dvts/pes despite anticoagulation, also with recent gib, presented with le swelling, found to have rle dvt. # dvt: the patient presented with worse clot burden. # metastatic prostate cancer: with bone mets. after a discussion with his outpatient oncologist, he was discharged with a plan for possible samarium as outpatient. # anemia: during his last admission, avm seen on egd was cauterized on [**2170-4-24**] during last admission.","52-year-old man with metastatic prostate cancer, not on active chemo with recurrent dvts/pes despite anticoagulation, also with recent gib, found to have rle dvt. he underwent an ivc venogram and mechanical thrombolysis with local tpa on [**2170-5-7**]. he was started on enoxaparin 120 mg [**hospital1 **] on [**2170-" 26212,159674.0,22772,2190-01-22,22771,117561.0,2189-08-24,Discharge summary,"Admission Date: [**2189-8-20**] Discharge Date: [**2189-8-24**] Date of Birth: [**2133-11-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Perirectal abscess/ pain x 7 days. Major Surgical or Invasive Procedure: I and D of abscess History of Present Illness: 55 year old cantonese speaking male , PMH of ESRD on tri weekly dialysis, DM, HTN, who presents with perirectal pain and perirectal mass x 7 days. Past Medical History: -- HTN: difficult to control, multiple agents used -- DM: with retinopathy, nephropathy -- ESRD due to IgA nephropathy/DM -- diabetic retinopathy- Blindness -- R subclavian Thrombus [**2187**] - stopped anticoagulation in [**2187**] -- Anemia of chronic disease -- Hyperlipidemia -- CAD - not an intervetional or CABG candidate. Cardiac catheterization from [**2188-2-4**] showed 3VD with a 30% left main, a diffusely diseased LAD with 80% mid stenosis, 90% diagonal, 60% second diagonal, and 90% OM1. None suitable for PCI or CABG. EF 60-70% TTE [**2188-10-14**] Social History: Cantonese/Mandarin speaking, limited English, immigrated to the US 10 yrs ago, currently lives with wife and 3 children, has been blind for approx 3 years, has not worked recently; No history of tobacco use, alcohol, or illicit drug use. Wife injects insulin. Family History: No family history of DM, CAD, Stroke, HTN, or Renal Disease Physical Exam: per surgery team VS Gen: Drowsy, hard to keep awake ( per wife is baseline state ). Chest: Left dialysis catheter in Left subclavian vein. CVS: RRR II/Vi Harsh systolic murmur at LSB and L 5th intercostal space midclavicualr. No carotid bruits. Pulm: CTAB no w/r/r Abd: Soft NT/ ND + BS Ext: No C/E bl . per icu team a day later: VS: T 96.2; HR 68; BP 205/68; RR 22; SpO2 100% 3L NC GEN: NAD, dyskinesia of mouth (lip smacking, tongue thrusting) HEENT: mmm, poor dentition, small lesion on L side tongue, no LAD, neck supple, no masses, blind, L eye: cloudy bloody cornea no discernible pupil, R eye: small fixed pupil, injected conjunctiva CV: RRR, no M/R/G LUNGS: CTA B, 100% 3L NC, episodes of panting ABD: decreased bs, soft, ntnd EXT: warm, dry, 2+ pedal and radial pulses, no edema or cyanosis Perirectal area: packing is saturated with blood, edema surrounding I/D site, very tender Pertinent Results: 138 96 19 -------------< 79 3.4 29 6.0 Ca: 8.6 Mg: 1.6 P: 2.4 D . WBC: 11.4 HCT: 36.2 PLT: 198 . PT: 14.3 PTT: 33.9 INR: 1.2 . CXR: FINDINGS: In comparison with the study of [**5-11**], there is again enlargement of the cardiac silhouette, although less prominent than on the previous study. There is again engorgement of the pulmonary vessels consistent with substantial elevation of pulmonary venous pressure. The costophrenic angles have cleared, consistent with decreased pleural effusion Brief Hospital Course: Mr. [**Known lastname 724**] is a 55 year old man with a PMH significant for ESRD on MWF HD, CAD, DM, anemia, poorly controlled HTN, and anemia transferred from the surgical service for monitoring s/p perirectal I/D. 1. Perirectal Abscess: The patient was admitted for a perirectal abscess status post I/D on [**8-19**]. Mr. [**Known lastname 724**] was initially treated with ciprofloxacin and flagyl. After wound culture speciated out as MRSA, vancomycin was added to the patient's antibiotic therapy. Per Dr. [**Last Name (STitle) **] of surgery, antibiotic therapy will need to be continued for 14 days (stop on [**9-5**]). The patient was treated with oxycodone PRN for pain control, which he did not require in the 48 hours prior to discharge. A follow-up appointment was scheduled for the patient with Dr. [**Last Name (STitle) **] in outpatient clinic in 2 weeks. 2. HTN: After the patient's I/D procedure, he became hypertensive with SBP >200 and was transferred to the [**Hospital Ward Name 332**] ICU for closer monitoring. His home medications were continued and he was also placed on a nitroglycerin drip which was continued until his hemodialysis on [**8-21**], at which point he became hypotensive and the nitroglycerin was discontinued. Upon transfer to the medicine floor, his blood pressure remained stable. At discharge, patient was continued on his home regimen of labetolol, minoxidil, clonidine, imdur, and amlodipine. 3. CAD: Patient's ASA and plavix was held for the I/D procedure. At discharge, patient was resumed on all home medications including ASA, plavix, losartan, labetolol, lisinopril. 4. DM 2: Patient continued on 70/30 and RISS Q6H during his hospital course. 5. Hyperlipidemia: Patient continued on home statin therapy. 6. ESRD: Patient on MWF hemodialysis, which was continued during his hospital course. Last HD was on day of discharge ([**Month/Year (2) 766**]). Nephrocaps continued during hospital course. The patient will need vancomycin dosed per HD protocol. 7. Anemia of chronic disease: On discharge, patient's HCT stable and at baseline. Medications on Admission: Allergies: NKDA Home meds (per OMR): Atorvastatin 40mg po daily Aspirin 325mg po daily Clonidine patch Epogen (2xper wk) Hydralazine 50mg po daily Insulin (NPH 10 units [**Hospital1 **]) Lisinopril 40mg daily Losartan 100mg daily Metoprolol tartrate 150mg po bid Minoxidil 2.5mb po bid Amlodipine 10mg daily Nephrocaps Calcium 500mg po tid Plavix 75mg po daily Protonix 40mg po daily Reglan 5mg q8h IV Fluticasone 2 puffs IH [**Hospital1 **] Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY (Daily) as needed for constipation. 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day. 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 7. Minoxidil 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Isosorbide Dinitrate 10 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 10. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO Before every meal. 11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. Fluticasone 50 mcg/Actuation Disk with Device Sig: Two (2) puffs Inhalation twice a day. 14. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day) as needed. 15. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge Sig: 8 units in the morning and 6 units at night . Subcutaneous daily. 16. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. 17. Metronidazole 250 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 12 days: Stop on [**9-5**]. Disp:*36 Tablet(s)* Refills:*0* 18. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 12 days: STOP ON [**9-5**]. Disp:*12 Tablet(s)* Refills:*0* 19. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gram Intravenous HD PROTOCOL (HD Protochol) for 12 days: STOP ON [**9-5**]. gram 20. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge Sig: 8 units in the AM and 6 units in the PM Subcutaneous twice a day. 21. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 22. Outpatient Lab Work Vancomycin trough to be drawn on Friday ([**8-28**]) prior to hemodialysis. Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: Primary 1. Perirectal abscess 2. Hypertension Secondary Diabetes ESRD qMWF due to IgA nephropathy/DM Diabetic retinopathy R subclavian Thrombus [**2187**] - stopped anticoagulation in [**2187**] Anemia of chronic disease Hyperlipidemia CAD Discharge Condition: Patient was discharged in stable condition. Discharge Instructions: 1. You were admitted for a perirectal abscess, which was surgically drained. You will need to take antibiotics for a total of 14 days (STOP ON [**9-5**]). Your antibiotic regimen is: Vancomycin 1000mg per HD protocol Flagyl 250mg po TID (to be given after hemodialysis) Ciprofloxacin 500 mg by mouth every 24 hours (to be given after hemodialysis) 2. You will need to have a blood test (vancomycin trough) drawn on Friday (8/285) prior to hemodialysis. 3. You should resume all of your home medications as prior to admission. It is important that you take all of your medications as prescribed. 4. You have a follow-up appointment with the surgeon as listed below. It is very important that you make all of your doctors [**Name5 (PTitle) 4314**]. 5. If you develop a fever, chest pain, shortness of breath, or other concerning symptoms, you should contact your PCP or go to the local Emergency Department immediately. Followup Instructions: You are scheduled for a follow-up appointment with Dr. [**Last Name (STitle) **] of surgery on [**2189-9-3**] at 4pm at [**Street Address(2) 1126**] in [**Location (un) **], MA. Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-4**] weeks. You can [**Month/Day (2) **] an appointment by calling ([**Telephone/Fax (1) 58911**]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 12902**], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2189-11-19**] 10:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2190-4-6**] 11:20 Completed by:[**2189-8-24**]",151,2189-08-20 10:06:00,2189-08-24 16:30:00,EMERGENCY,CLINIC REFERRAL/PREMATURE,HOME HEALTH CARE,PERI RECTAL ABSCESS," mr. [**known lastname 724**] is a 55 year old man with a pmh significant for esrd on mwf hd, cad, dm, anemia, poorly controlled htn, and anemia transferred from the surgical service for monitoring s/p perirectal i/d. 1. perirectal abscess: the patient was admitted for a perirectal abscess status post i/d on [**8-19**]. mr. [**known lastname 724**] was initially treated with ciprofloxacin and flagyl. after wound culture speciated out as mrsa, vancomycin was added to the patients antibiotic therapy. per dr. [**last name (stitle) **] of surgery, antibiotic therapy will need to be continued for 14 days (stop on [**9-5**]). the patient was treated with oxycodone prn for pain control, which he did not require in the 48 hours prior to discharge. a follow-up appointment was scheduled for the patient with dr. [**last name (stitle) **] in outpatient clinic in 2 weeks. 2. htn: after the patients i/d procedure, he became hypertensive with sbp >200 and was transferred to the [**hospital ward name 332**] icu for closer monitoring. his home medications were continued and he was also placed on a nitroglycerin drip which was continued until his hemodialysis on [**8-21**], at which point he became hypotensive and the nitroglycerin was discontinued. upon transfer to the medicine floor, his blood pressure remained stable. at discharge, patient was continued on his home regimen of labetolol, minoxidil, clonidine, imdur, and amlodipine. 3. cad: patients asa and plavix was held for the i/d procedure. at discharge, patient was resumed on all home medications including asa, plavix, losartan, labetolol, lisinopril. 4. dm 2: patient continued on 70/30 and riss q6h during his hospital course. 5. hyperlipidemia: patient continued on home statin therapy. 6. esrd: patient on mwf hemodialysis, which was continued during his hospital course. last hd was on day of discharge ([**month/year (2) 766**]). nephrocaps continued during hospital course. the patient will need vancomycin dosed per hd protocol. 7. anemia of chronic disease: on discharge, patients hct stable and at baseline. ","PRIMARY: [Abscess of anal and rectal regions] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease; Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled; Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled; Background diabetic retinopathy; Anemia in chronic kidney disease]","known lastname 724**] is a 55 year old man with a pmh significant for esrd on mwf hd, cad, dm, anemia, poorly controlled htn, and anemia transferred from the surgical service for monitoring s/p perirectal i/d. 1. a follow-up appointment was scheduled for the patient with dr. [** his home medications were continued and he was also placed on a nitroglycerin drip which was continued until his hemodialysis on [**8-21**], at which point he became hypotensive and the nitroglycerin was discontinued. esrd: patient on mwf hemodialysis, which was continued during his hospital course. the patient will need vancomycin dosed per hd protocol.","mr. [**known lastname 724**] is a 55 year old man with a pmh significant for esrd on mwf hd, cad, dm, anemia, poorly controlled htn, and anemia." 26901,179730.0,24113,2185-10-17,24112,160675.0,2185-07-04,Discharge summary,"Admission Date: [**2185-7-1**] Discharge Date: [**2185-7-4**] Date of Birth: [**2160-11-6**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 1257**] Chief Complaint: DKA Major Surgical or Invasive Procedure: Femoral line placement History of Present Illness: Mr [**Known lastname 61289**] is a 24M with poorly-controlled DM who presents with DKA. He was well until approx 4d ago when he developed a nonproductive cough, along with chills and sweats and some nasal congestion but no fevers. The evening prior to admission he developed periumbilical abdominal discomfort accompanied by nausea and non-bloody vomiting. Has chronic constipation with BMs usually 1x week, had 4 BMs the day prior to presentation. His PO intake was poor. He last took his insulin approximately 24h prior to presentation. Has been making urine, but no dysuria, hematuria, no NSAID use. Reports low back pain similar to prior. Denies metalic taste, pruritis, dyspnea. . In the emergency department, vitals were 98.3 104 154/82 16 100% on RA. On exam, writhing in abdominal pain. He was given zofran, ativan, insulin (10 units x2 sq) currently on 7units/hr drip. CXR showed a LLL pna and he was given levofloxacin. Had a femoral line placed for access, 22 wrist PIV. Given 4L of normal saline. Renal was not contact[**Name (NI) **]. HR low 100's BP 160's RR 22. Past Medical History: - Diabetes mellitus, type I. Diagnosed in [**2162**]. Poorly controlled with past DKA. Complicated with retinopathy, nephropathy - Hypertension, poorly controlled - Chronic kidney disease - Chronic constipation Social History: Lives with aunt in [**Location (un) 686**]. Smokes 2 packs per week since age 16. Denies recent alcohol use. Denies illicit drug use, now or in the past. Family History: Father, grandmother with diabetes mellitus. No relatives currently on dialysis. Physical Exam: Vitals 97.2 94 138/87 12 95% on RA General Lying in bed appearing comfortable HEENT Sclera anicteric, MMM Neck Supple no JVD Pulm Lungs clear bilaterally, no rales or wheezing CV Regular S1 S2 no m/r/g Abd Soft nontender +bowel sounds Extrem Warm no edema palpable pulses Neuro Sleepy but arousable, responds to commands, answering appropriately, moving all extremities without focal deficits Derm No rash Lines/tubes/drains Brief Hospital Course: 24 year old man with poorly controlled DM and HTN with ESRD not yet on HD presents with DKA in setting of insulin noncompliance and an underlying viral pneumonia versus viral URI. He was admitted to the ICU and started on an insulin drip. The anion gap closed and he was transitioned to glargine in the morning (22 units) and maintained on a sliding scale. He was followed by the [**Last Name (un) 387**] consult team while hospitalized and will see them as an outpatient this week. He had abnormal chest film along with cough and chills. He was started on empiric levofloxacin, however, his flu swab came back positive for influenza A and the antibiotics were discontinued. The influenza was not H1N1 by state lab testing. He was afebrile for 24 hours prior to discharge. We found normocytic anemia likely from CKD. Iron studies were sent and were pending at the time of discharge. They will be followed up by the [**Hospital **] clinic and he will likely be started on epoetin as an outpatient. He was discharged on empiric iron. Medications on Admission: metoprolol 50mg [**Hospital1 **] amlodipine 10mg daily simvastatin 20mg daily hydralazine 50mg tid aranesp 40mcg qweek insulin galrgine 20 units qhs insulin humalog sliding scale miralax senna Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Hydralazine 25 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 6. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22) units Subcutaneous once a day. 7. Insulin Lispro 100 unit/mL Solution Sig: AS DIR Subcutaneous four times a day: As needed per sliding scale. 8. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Diabetic Keto-acidosis Influenza A Chronic Kidney Disease Anemia of Chronic Disease Discharge Condition: Afebrile, hemodynamically stable. Discharge Instructions: You were admitted to the hospital with the flu. Because you were sick your diabetes was not in good control and you needed insulin through an IV for a couple of days. You have been able to eat and take your insulin now and should continue doing this when you are discharged. Medication changes: CHANGE: Glargine to 22units at breakfast time START: Reglan 5mg by mouth with meals and at bedtime START: Iron 325mg by mouth twice daily Please come back to the hospital or call your doctor if you have fevers, chills, abdominal pain, nausea, vomiting, inability to take your insulin, inability to eat, chest pain, back pain, rash, or any other concerning symptoms. Followup Instructions: Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 14166**] ([**Telephone/Fax (1) 14167**]) in the next 1-2 weeks. Please follow up with Dr.[**Name (NI) 33126**] nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]-[**Doctor Last Name **] ([**Telephone/Fax (1) 3637**]) on [**2185-7-7**] at 1:00pm. Completed by:[**2185-7-4**]",105,2185-07-01 15:16:00,2185-07-04 17:41:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,PNEUMONIA;DIABETIC KETOACIDOSIS," 24 year old man with poorly controlled dm and htn with esrd not yet on hd presents with dka in setting of insulin noncompliance and an underlying viral pneumonia versus viral uri. he was admitted to the icu and started on an insulin drip. the anion gap closed and he was transitioned to glargine in the morning (22 units) and maintained on a sliding scale. he was followed by the [**last name (un) 387**] consult team while hospitalized and will see them as an outpatient this week. he had abnormal chest film along with cough and chills. he was started on empiric levofloxacin, however, his flu swab came back positive for influenza a and the antibiotics were discontinued. the influenza was not h1n1 by state lab testing. he was afebrile for 24 hours prior to discharge. we found normocytic anemia likely from ckd. iron studies were sent and were pending at the time of discharge. they will be followed up by the [**hospital **] clinic and he will likely be started on epoetin as an outpatient. he was discharged on empiric iron. ","PRIMARY: [Diabetes with ketoacidosis, type I [juvenile type], uncontrolled] SECONDARY: [Influenza with pneumonia; Chronic kidney disease, Stage IV (severe); Acute kidney failure, unspecified; Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled; Background diabetic retinopathy; Diabetes with renal manifestations, type I [juvenile type], uncontrolled; Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere; Constipation, unspecified; Anemia in chronic kidney disease; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified; Gastroparesis; Personal history of noncompliance with medical treatment, presenting hazards to health]","24 year old man with poorly controlled dm and htn with esrd not yet on hd presents with dka in setting of insulin noncompliance and an underlying viral pneumonia versus viral uri. he was admitted to the icu and started on an insulin drip. the anion gap closed and he was transitioned to glargine in the morning (22 units) and maintained on a sliding scale.",24 year old man with poorly controlled dm and htn with esrd not yet on hd. he was admitted to the icu and started on an insulin drip. his flu swab came back positive for influenza a and antibiotics were discontinued. 27790,162585.0,18577,2113-08-18,18576,127130.0,2113-07-21,Discharge summary,"Admission Date: [**2113-7-12**] Discharge Date: [**2113-7-21**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1854**] Chief Complaint: The patient's chief complaint is of increasing ataxia while at rehab facility. Major Surgical or Invasive Procedure: 1. [**2114-7-14**] Left Craniotomy for Subdural Hematoma History of Present Illness: Patient is a 85M with a PMH significant for atrial fibrillation presently treated with a pacemaker and aspirin therapy. He reports having been on Coumadin at one point in time, but not for a while now. He returns to the ED this afternoon with chief complaint of increasing ataxia while at rehab facility. He was transferred back to [**Hospital1 18**] for re-evaluation for ? recurrance of SDH. Past Medical History: PMHx: 1. Atrial Fibrillation requiring the use of a pacemaker 2. Prostate CA presently undergoing work-up for cryotherapy. 3. s/p Bilateral cataract surgery Social History: Social Hx: resides at home alone in [**Location (un) 51029**] Family History: Family Hx: non-contributory. Physical Exam: O: T: 98.1 BP:157/63 HR:59 RR:16 O2Sats: 98% RA Gen: WD/WN, comfortable, NAD. HEENT:normocephalic, atraumatic Pupils: surgically irregular, minimally reactive EOMs: intact Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-20**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils are surgically asymmetric and minimally reactive to light, 3mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-24**] throughout. Slight right pronator drift. Right sided dysmetria. Sensation: Intact to light touch, propioception. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Coordination: normal on finger-nose-finger Pertinent Results: Speech & Swallow Evaluation: RECOMMENDATIONS: 1. PO diet: regular solids, nectar thick liquids. 2. PO meds whole with nectar thick liquids. 3. 1:1 supervision with meals to maintain aspiration precautions and assist with feeding. Encourage pt to alternate bites with sips to clear. 4. Please reconsult if there are concerns for aspiration on this diet and a videoswallow study can be performed. 5. Repeat swallow evaluation early next week here or at rehab. Pre-operative HCT: IMPRESSION: Increased size of left cerebral convexity subdural hemorrhage, with new hyperdensity suggestive of rebleeding. 8-mm rightward subfalcine herniation. Post-operative HCT: IMPRESSION: S/p left frontal craniotomy with interval decrease in the size of the subdural collection. Partial improvement in associated mass effect. Labs: [**2113-7-21**] 06:44AM BLOOD WBC-7.8 RBC-3.05* Hgb-9.6* Hct-28.1* MCV-92 MCH-31.6 MCHC-34.3 RDW-13.1 Plt Ct-269 [**2113-7-21**] 06:44AM BLOOD Glucose-107* UreaN-17 Creat-0.5 Na-137 K-3.9 Cl-106 HCO3-24 AnGap-11 [**2113-7-21**] 06:44AM BLOOD Calcium-8.1* Phos-2.5* Mg-2.2 Brief Hospital Course: The patient on [**7-14**] was brought to the OR for a craniotomy for a large left SDH. His pressure was kept below 140 and after the procedure his stayed overnight in PACU and on [**7-15**] his was transferred to stepdown. He began treatment for a UTI with levaquin. A speech and swallow evaluation on [**7-17**], and dietary adjustments were made accordingly. Due to the nature of his urine culture, he was MRSA screened and finalized as negative on [**2113-7-21**]. His neurlogical examination has been stable since his operative intervention, and determined to be appropriate for rehabilitation. Medications on Admission: 1. ASA 81mg daily 2. Folic Acid 400mcg daily 3. Calcium 500mg daily 4. Casodex 50mg daily 5. Actonel 35mg weekly 6. Tagamet 300mg daily 7. Metamucil daily 8. Dilantin 100mg TID Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Bicalutamide 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 12. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day). 13. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 14. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Left Subdural Hematoma Urinary tract infection Post-surgical urinary retention Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures have been removed. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in 10 days for removal of your sutures. This may also be done at the rehab facility. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **]/[**Doctor Last Name **], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[**2113-7-21**]",28,2113-07-12 17:36:00,2113-07-21 13:20:00,EMERGENCY,EMERGENCY ROOM ADMIT,REHAB/DISTINCT PART HOSP,ACUTE SUBDURAL HEMATOMA," the patient on [**7-14**] was brought to the or for a craniotomy for a large left sdh. his pressure was kept below 140 and after the procedure his stayed overnight in pacu and on [**7-15**] his was transferred to stepdown. he began treatment for a uti with levaquin. a speech and swallow evaluation on [**7-17**], and dietary adjustments were made accordingly. due to the nature of his urine culture, he was mrsa screened and finalized as negative on [**2113-7-21**]. his neurlogical examination has been stable since his operative intervention, and determined to be appropriate for rehabilitation. ","PRIMARY: [Subdural hemorrhage] SECONDARY: [Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness; Urinary tract infection, site not specified; Compression of brain; Atrial fibrillation; Cardiac pacemaker in situ; Malignant neoplasm of prostate]","the patient on [**7-14**] was brought to the or for a craniotomy for a large left sdh. his pressure was kept below 140 and after the procedure his stayed overnight in pacu and on [**7-15**] his was transferred to stepdown.","the patient was brought to the or for a craniotomy for a large left sdh. due to the nature of his urine culture, he was mrsa screened. his neurlogical examination has been stable since his operative intervention." 27960,179767.0,15207,2196-01-28,15205,119407.0,2195-09-04,Discharge summary,"Admission Date: [**2195-9-3**] Discharge Date: [**2195-9-4**] Date of Birth: [**2171-11-13**] Sex: F Service: MEDICINE Allergies: Vicodin / Augmentin / Diflucan Attending:[**First Name3 (LF) 3556**] Chief Complaint: angioedema vs anaphylaxis Major Surgical or Invasive Procedure: None. History of Present Illness: History of Present Illness: 23F PMH idiopathic chronic urticaria and angioedema, asthma followed by allergy presenting with tongue swelling and dysphagia starting at 7:45 am soon after awakening. Denies shortness of breath, wheezing, dizziness, urticaria, flushing, pruritus. The patient is not taking any new medications and denies new exposures or insect bites prior to this episode. The patient does admit to smoking one cigarette the night prior to admission. The patient took benadryl, ranitidine, loratidine and a shot of her Epi-Pen prior to presenting to the ED. In the ED, the patient's vital signs were T 98.1, P 64, BP 133/61, RR 20, O2sat 100%RA. The patient was evaluated by ENT with laryngoscope showing oropharyngeal swelling but no swelling of the vocal cords. The patient was given a dose of methylprednisolone 125 mg IV. The patient feels symptomatic improvement in tongue swelling and dysphagia on admission. . Of note, the patient has had chronic urticaria and angioedema since Cesearean section performed [**2195-6-7**] for failure to progress after 30 hour labor; done under epidural. The patient has seubsequently been seen in the ED multiple times for facial and tongue swelling. The patient was given prednisone 60 mg x 5 days [**2195-8-11**] for isolated upper lip swelling. . Review of systems: As above. Negative for fevers, chills, chest pain, abdominal pain, nausea, vomiting, diarrhea, melena, BRBPR, dysuria, hematuria. The patient has not had a menstrual cycle since giving birth as above. Past Medical History: 1. Asthma 2. Seasonal allergies 3. Status post cholecystectomy ([**4-30**]) 4. Status post medical abortion of 16 week gestation in [**8-2**]. 5. Status post motor vehicle accident in 8th grade. She was recommended to wear an LSO brace for stability, however, she refused. She has not had porblems with back pain though. Social History: She lives at home with her father, twin sister, and two-month old child. She works as an administrator at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] International. Rare social tobacco use. She denies alcohol and IV drug use. Family History: Mother - age 53, seizures, DM Father - age 55, DM, HTN 2 brothers - asthma 2 sisters - 1 identical twin w/ asthma; 1 murmur, arrhythmias Physical Exam: Vitals: AF P:91 BP:129/74 RR:12 O2sat:100%RA General: Well appearing female in no acute distress, speaking full sentences without stridor. HEENT: Pupils equal and reactive, extraoccular movements intact, tongue edematous, OP edematous but no signs of airway compromise, no edema of lips or ocular membranes, moist mucous membranes. Neck: Supple without lymphadenopathy or edema. Cardiac: Regular rate and rhythm without murmurs, rubs, or gallops. Pulmonary: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Abdomen: Normoactive bowel sounds, soft, obese, no rebound or guarding, well-healed Cesarean scar. Extremities: Warm and well perfused without cyanosis or edema. Neurological: Cranial nerves II through XII intact. Gait narrow-based and steady. Pertinent Results: [**2195-9-3**] 10:25AM GLUCOSE-98 UREA N-12 CREAT-0.7 SODIUM-140 POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-25 ANION GAP-12 [**2195-9-3**] 10:25AM MAGNESIUM-2.2 IRON-15* [**2195-9-3**] 10:25AM calTIBC-464 FERRITIN-5.1* TRF-357 [**2195-9-3**] 10:25AM WBC-8.0 RBC-4.03* HGB-9.4* HCT-29.7* MCV-74* MCH-23.3* MCHC-31.6 RDW-17.2* [**2195-9-3**] 10:25AM NEUTS-80.1* LYMPHS-17.3* MONOS-1.2* EOS-1.1 BASOS-0.3 [**2195-9-3**] 10:25AM PLT COUNT-390 [**2195-9-3**] 09:40AM GLUCOSE-102 UREA N-13 CREAT-0.8 SODIUM-138 POTASSIUM-4.8 CHLORIDE-106 TOTAL CO2-22 ANION GAP-15 [**2195-9-3**] 09:40AM estGFR-Using this CHEST (PORTABLE AP) Reason: Evaluate for pathology. [**Hospital 93**] MEDICAL CONDITION: 23 year old woman with chronic urticaria, angioedema p/w OP swelling. REASON FOR THIS EXAMINATION: Evaluate for pathology. CHEST AP PORTABLE SINGLE VIEW. INDICATION: Chronic urticaria, angioedema. Evaluate for possible pulmonary pathology. FINDINGS: AP single view of the chest has been obtained with patient in sitting upright position and analysis is performed in comparison with a preceding PA and lateral chest examination of [**2195-8-19**]. No significant interval change has occurred in the previously as normal identified chest examination. Heart size is within normal limits considering AP technique. Noteworthy is considerable adiposity in the form of prominent soft tissue surrounding the thorax. IMPRESSION: No new chest abnormality on portable AP single view chest examination in comparison with normal previous study of [**10-19**]. Brief Hospital Course: Pt was treated for an acute episode of angioedema with a question of anaphylaxis. The patient has a history of presumed idiopathic chronic urticaria and angioedema and has no no known precipitants to this episode. The patient is followed by Dr. [**Last Name (STitle) **] from allergy. The patient's vital signs were stable and examination was siginificant for tongue swelling but no signs of airway compromise. The patient took benadryl, ranitidine, famotidine and a shot of her Epi-Pen prior to presenting to the ED. The patient was given a dose of methylprednisolone 125 mg IV was continued on benadryl, ranitidine, loratidine. Pt was monitored overnight in the ICU and no further episodes of airway compromise or angioedema. We contact[**Name (NI) **] her outpatient allergist who felt this patient most likely had acute angioedema. Aftrer 24 hours in the ICU, the patient was discharged home in stable condition. Medications on Admission: Doxepin 25 mg QHS Loratidine 10 mg QD Ranitidine 300 mg QD Benadryl 50 mg [**Hospital1 **] Epi-Pen 0.3 mg/0.3 mL Syringe PRN Discharge Medications: 1. Doxepin 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 2. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 5. EpiPen 0.3 mg/0.3 mL Syringe Sig: One (1) Intramuscular once a day as needed for allergy symptoms. Disp:*2 syringe* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Angioedema versus anaphylaxis. 2. Idiopathic chronic urticaria and angioedema. 3. Chronic iron-deficiency anemia. . Secondary: 1. Seasonal allergies. 2. Asthma, in remission; one hospitalization but never intubated. 3. Gastroesophageal reflux disease. 4. Status post cholecystectomy 5/[**2190**]. 5. Status post medical abortion of 16 week gestation in 8/[**2192**]. 6. Status post motor vehicle accident in 8th grade. Discharge Condition: Afebrile, vital signs stable. No signs of airway compromise. Discharge Instructions: You were admitted with another episode of angioedema and tongue swelling. It is very important that you take your medications and keep an Epi-Pen at home. Please follow-up with your allergist as below. . Please follow-up with your primary care physician regarding your [**Name9 (PRE) 44267**] anemia, likely due to blood loss from menstrual cycles. . Please contact a physician if you experience fevers, chills, tongue swelling or other angioedema, shortness of breath, or any other concerning symptoms. . Please take your medications as prescribed. There were no changes to your medications. . Please keep your follow-up appointments as below. Followup Instructions: Previously scheduled appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 30764**], MD Phone:[**Telephone/Fax (1) 1723**] Date/Time:[**2195-9-23**] 2:45 . Please call your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at [**Telephone/Fax (1) 250**] to schedule an appointment within two weeks. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**] ",146,2195-09-03 09:53:00,2195-09-04 09:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ALLERGIC REACTION," pt was treated for an acute episode of angioedema with a question of anaphylaxis. the patient has a history of presumed idiopathic chronic urticaria and angioedema and has no no known precipitants to this episode. the patient is followed by dr. [**last name (stitle) **] from allergy. the patients vital signs were stable and examination was siginificant for tongue swelling but no signs of airway compromise. the patient took benadryl, ranitidine, famotidine and a shot of her epi-pen prior to presenting to the ed. the patient was given a dose of methylprednisolone 125 mg iv was continued on benadryl, ranitidine, loratidine. pt was monitored overnight in the icu and no further episodes of airway compromise or angioedema. we contact[**name (ni) **] her outpatient allergist who felt this patient most likely had acute angioedema. aftrer 24 hours in the icu, the patient was discharged home in stable condition. ","PRIMARY: [Angioneurotic edema, not elsewhere classified] SECONDARY: [Iron deficiency anemia, unspecified; Asthma, unspecified type, unspecified; Esophageal reflux; Unspecified accident]","pt was treated for an acute episode of angioedema with a question of anaphylaxis. aftrer 24 hours in the icu, the patient was discharged home in stable condition.",pt was treated for an acute episode of angioedema with a question of anaphylaxis. the patient has a history of presumed idiopathic chronic urticaria and angioedema. the patient was discharged home in stable condition after 24 hours in the icu. 27960,179767.0,15207,2196-01-28,15206,191411.0,2195-11-26,Discharge summary,"Admission Date: [**2195-11-21**] Discharge Date: [**2195-11-26**] Date of Birth: [**2171-11-13**] Sex: F Service: MEDICINE Allergies: Vicodin / Augmentin / Diflucan / Amoxicillin Attending:[**First Name3 (LF) 3561**] Chief Complaint: Tongue Swelling Major Surgical or Invasive Procedure: Endotracheal intubation History of Present Illness: 24 y.o. female with history of idiopathic urticaria and angioedema with multiple hospitalizations for tongue swelling who presented to the ED this morning with tongue swelling. Patient reportedly woke up from sleep short of breath at which time she noticed her tongue swelling. It is unclear if there was any direct precipitant. EMS was notified and she was given Epinephrine in the field x 1 with no effect. Once in the ER, she was noted to have severe left-sided tongue swelling and received an additional dose of Epinephrine as well as Famotidine, Benadryl and Solu-medrol with no improvement in symptoms after 10 minutes. She was then electively intubated to protect her airway and admitted to the MICU for further management. . With regards to the patient's tongue swelling, she began experiencing symptoms of frequent hives and tongue swelling after a cesarian section in [**Month (only) **] of this year. She has no clear triggers though the patient's father has noticed that the episodes seem to coincide with periods of high emotional stress. She has been followed in allergy/immunology and is felt to have idiopathic urticaria and angioedema and uses an Epinephrine pen, approximately once every week for these symptoms. She additionally has been on Prednisone tapers subsequent to her multiple hospitalizations, which of note have not resulted in an intubation until now. Other pertinent work-up for this condition includes an investigation into atopy and the patient has no history of frequent infections, immune disorders, eczema, contact allergies, reactions to foods, meds, latex, insect stings. She has an identical twin sister who has not had any such reactions nor has anyone in her immediate family. C4 levels checked in the past have been WNL, with respect to a work-up for C1 esterase deficiency. Past Medical History: 1. Chronic urticaria and angioedemea since C-section done on [**6-4**] for failure to progress after 30 hour labor 2. Asthma 3. Seasonal allergies 4. Status post cholecystectomy ([**4-30**]) Social History: Lives with father and siblings and has a 5 month old son. [**Name (NI) 6961**] are separated and there appears to be some tension between mother and children as mother has a psychiatric illness. Per father he and patient have also recently had a tumultuous relationship and are currently not on speaking terms. Reportedly infrequent alcohol or tobacco use and no IV drugs. Family History: Father with seasonal allergies. Otherwise, no history of related urticaria, angioedema. Physical Exam: Vitals: T-96.0 , BP-115/46, HR-81, RR-14, O2-100% AC 550/14/.[**5-2**] General: Sedated, intubated, NAD HEENT: NC/AT; PERRLA, EOMI; Tongue notably swollen, mostly on left CV: S1, S2 nl, no m/r/g appreciated Lungs: CTAB Abd: Soft, NT, ND, + BS Ext: No c/c/c Neuro: Grossly intact, but pt. is sedated. She appropriately withdraws from pain and can open eyes on request Skin: No urticaria or other rashes Pertinent Results: CXR ([**10-21**]): Endotracheal tube in satisfactory position 5 cm above the carina. No acute cardiopulmonary process. [**2195-11-21**] 11:25AM BLOOD WBC-10.6 RBC-4.34 Hgb-10.5* Hct-32.9* MCV-76* MCH-24.3* MCHC-32.0 RDW-17.1* Plt Ct-523* [**2195-11-23**] 04:24AM BLOOD WBC-6.7 RBC-2.62*# Hgb-6.2*# Hct-23.9*# MCV-91# MCH-23.7* MCHC-26.0*# RDW-17.5* Plt Ct-317 [**2195-11-23**] 06:08AM BLOOD WBC-11.4*# RBC-4.24# Hgb-10.4*# Hct-32.7*# MCV-77*# MCH-24.4* MCHC-31.8# RDW-18.3* Plt Ct-566*# [**2195-11-24**] 03:32AM BLOOD WBC-16.9* RBC-3.85* Hgb-9.4* Hct-29.2* MCV-76* MCH-24.5* MCHC-32.3 RDW-17.8* Plt Ct-426 [**2195-11-26**] 03:24AM BLOOD WBC-12.5* RBC-3.80* Hgb-9.5* Hct-29.1* MCV-77* MCH-24.9* MCHC-32.4 RDW-17.7* Plt Ct-367 [**2195-11-21**] 11:25AM BLOOD Glucose-135* UreaN-15 Creat-0.7 Na-144 K-3.1* Cl-107 HCO3-24 AnGap-16 [**2195-11-22**] 03:56AM BLOOD Glucose-172* UreaN-13 Creat-0.7 Na-137 K-5.4* Cl-106 HCO3-21* AnGap-15 [**2195-11-25**] 03:56AM BLOOD Glucose-117* UreaN-23* Creat-0.6 Na-146* K-3.8 Cl-110* HCO3-31 AnGap-9 [**2195-11-22**] 10:58AM BLOOD FSH-11 LH-15 Prolact-23 [**2195-11-22**] 10:58AM BLOOD Estradl-20 [**2195-11-22**] 10:58AM BLOOD C4-38 [**2195-11-21**] 06:23PM BLOOD Type-ART pO2-191* pCO2-44 pH-7.38 calTCO2-27 Base XS-0 [**2195-11-22**] 01:39AM BLOOD Type-ART pO2-94 pCO2-44 pH-7.40 calTCO2-28 Base XS-1 [**2195-11-23**] 06:58PM BLOOD C1 ESTERASE INHIBITOR, FUNCTIONAL ASSAY-PND [**2195-11-22**] 10:50AM BLOOD ANTI-FCER1 ANTIBODY-PND Brief Hospital Course: A/P: 24 y.o. female with history of idiopathic urticaria and angioedema who presents with tongue swelling, unresponsive to H2 blocker, steroids, epinephrine and benadryl, electively intubated to protect airway and admitted to the MICU for further management. . Respiratory: Elective intubation to protect airway in the setting of angioedema. No underlying lung disease besides asthma and currently not wheezy. Would expect that patient can be easily extubated once tongue obstruction has been resolved. Extubated on [**11-24**] after 2 days with cuff leak. . Angioedema: Etiology is unclear. [**Name2 (NI) **] does not have a significant amount of atopy in personal history and has been worked up, at least partially for C1 esterase deficiency with C4. Patient initially treated with Solumedrol and then converted to prednisone. Also treated with ranitidine and fexofenadine as well as benadryl. Following extubation, benadryl discontinued. Steroid taper started. Patient discharged on a 10 day steroid taper and will follow up with allergy as an outpatient. She was also continued on her ranitidine and fexofenatine transitioned to loratadine as an outpatient. . Asthma: No active issues. She was continued on albuterol prn. . Anemia: Patient has iron deficiency anemia by labs done in [**Month (only) **]. She had a mild hematocrit drop during hospitalization but had no evidence of bleeding. She can be followed up with her PCP as an outpatient. . Depression: On Doxepin as an outpatient. Home dose restarted prior to discharge. . FEN: Following extubation tolerated regular diet without issue. . PPx: continued on heparin sc and H2 blocker . Code: FULL . Communication: must communicate both w father and mother. they do not see patient at same time. ** Father, Rev. [**Known lastname 44268**] - ([**Telephone/Fax (1) 44269**] (c), ([**Telephone/Fax (1) 44270**] (h), ([**Telephone/Fax (1) 44271**] (cell phone of Rev. [**Known lastname 44272**] son, [**Doctor First Name 71**] ** Mom [**Telephone/Fax (1) 44273**] Medications on Admission: Doxepin 75 mg QHS Loratidine 10 mg QD Ranitidine 300 mg QD Epi-Pen 0.3 mg/0.3 mL Syringe PRN Ativan 0.5mg QHS Discharge Medications: 1. Doxepin 75 mg Capsule Sig: One (1) Capsule PO at bedtime. 2. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day. 3. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. EpiPen 0.3 mg/0.3 mL Syringe Sig: One (1) injection Intramuscular prn as needed for anaphylaxis. Disp:*4 syringes* Refills:*0* 5. Prednisone 10 mg Tablet Sig: as directed Tablet PO as directed for 4 days: Take 5 tablets [**11-27**], take 4 tablets [**11-28**], take 3 tablets [**11-29**], take 2 tablets [**11-30**], then switch to 5 mg tablets as directed. Disp:*14 Tablet(s)* Refills:*0* 6. Prednisone 5 mg Tablet Sig: as directed Tablet PO as directed for 3 days: Take 3 tablets on [**12-1**], then take 2 tablets on [**12-2**], then take 1.5 tablets on [**12-3**], then discontinue. Disp:*7 Tablet(s)* Refills:*0* 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. idiopathic angioedema Secondary: 1. asthma 2. chronic urticaria Discharge Condition: Ambulatory. Stable vital signs at baseline. No respiratory distress. Discharge Instructions: Please continue to take all medications as prescribed. It is important that you not miss any of your medications to prevent further episodes of angioedema. Please complete your steroid taper as outlined below. Please follow up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] as below. Please call your doctor or return to the hospital if you experience any recurrent lip swelling, tongue swelling, other facial swelling, fevers, chills, or any other concerns. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] at [**Location (un) 8170**] on [**2195-12-24**] at 4pm. Phone: [**Telephone/Fax (1) 44274**] Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2195-12-7**] at 7 pm. Phone: [**Telephone/Fax (1) 1247**] Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital **] on [**2195-3-24**] at 4pm. Phone: [**Telephone/Fax (1) 1247**] ",63,2195-11-21 11:00:00,2195-11-26 16:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ALLERGIC REACTION," a/p: 24 y.o. female with history of idiopathic urticaria and angioedema who presents with tongue swelling, unresponsive to h2 blocker, steroids, epinephrine and benadryl, electively intubated to protect airway and admitted to the micu for further management. . respiratory: elective intubation to protect airway in the setting of angioedema. no underlying lung disease besides asthma and currently not wheezy. would expect that patient can be easily extubated once tongue obstruction has been resolved. extubated on [**11-24**] after 2 days with cuff leak. . angioedema: etiology is unclear. [**name2 (ni) **] does not have a significant amount of atopy in personal history and has been worked up, at least partially for c1 esterase deficiency with c4. patient initially treated with solumedrol and then converted to prednisone. also treated with ranitidine and fexofenadine as well as benadryl. following extubation, benadryl discontinued. steroid taper started. patient discharged on a 10 day steroid taper and will follow up with allergy as an outpatient. she was also continued on her ranitidine and fexofenatine transitioned to loratadine as an outpatient. . asthma: no active issues. she was continued on albuterol prn. . anemia: patient has iron deficiency anemia by labs done in [**month (only) **]. she had a mild hematocrit drop during hospitalization but had no evidence of bleeding. she can be followed up with her pcp as an outpatient. . depression: on doxepin as an outpatient. home dose restarted prior to discharge. . fen: following extubation tolerated regular diet without issue. . ppx: continued on heparin sc and h2 blocker . code: full . communication: must communicate both w father and mother. they do not see patient at same time. ** father, rev. [**known lastname 44268**] - ([**telephone/fax (1) 44269**] (c), ([**telephone/fax (1) 44270**] (h), ([**telephone/fax (1) 44271**] (cell phone of rev. [**known lastname 44272**] son, [**doctor first name 71**] ** mom [**telephone/fax (1) 44273**] ","PRIMARY: [Angioneurotic edema, not elsewhere classified] SECONDARY: [Acute respiratory failure; Asthma, unspecified type, unspecified; Iron deficiency anemia, unspecified; Hypopotassemia; Essential thrombocythemia; Unspecified accident]","female with history of idiopathic urticaria and angioedema who presents with tongue swelling, unresponsive to h2 blocker, steroids, epinephrine and benadryl, electively intubated to protect airway and admitted to the micu for further management. extubated on [**11-24**] after 2 days with cuff leak. name2 (ni) **] does not have a significant amount of atopy in personal history and has been worked up, at least partially for c1 esterase deficiency with c4. known lastname 44268**] - ([**telephone/fax (1) 44269**] (c), ([**telephone/fax (1) 44270**] (h), ([**telephone/fax (1) 44271**] (cell phone of rev. [**","female with history of idiopathic urticaria and angioedema. unresponsive to h2 blocker, steroids, epinephrine and benadryl. extubated on [**11-24**] after 2 days with cuff leak." 28043,127710.0,14227,2176-08-07,14223,149969.0,2176-06-12,Discharge summary,"Admission Date: [**2176-6-3**] Discharge Date: [**2176-6-12**] Service: MEDICINE Allergies: Amoxicillin / Penicillins / Coumadin / Oxycodone / Megestrol Acetate / Remeron / Ritalin Attending:[**First Name3 (LF) 5129**] Chief Complaint: 87 yo man with history of prostate cancer s/p XRT, dementia, prior bladder rupture, who was treated in the [**Hospital1 18**] MICU for a new bladder rupture and urosepsis, transfered to SIRS 2 primarily for management of resolving urosepsis, peritonitis, post-surgical pain, and delirium. Major Surgical or Invasive Procedure: Anterior bladder perforation closure, placement of suprapubic catheter and peritoneal drain History of Present Illness: 87 yo man with history of prostate CA in [**2156**] s/p XRT, prior bladder rupture, indwelling foley, multiple UTIs, and recently dx dementia who presented to ED from NH with weeks of lower abdominal pain and groin pain. Bright red hematuria was seen at his nursing home. His foley was changed 1 week prior to admission with sm amount of blood that cleared at the time. He was unable to give other ROS. His family reported that the pt had been having abd pain and hematuria all week since foley change, and he was brought to the ED because he was having fevers, nausea/vomiting and worsening pain. Prior to this past week, he had been at his best recent baseline (w/a h/o one year of new onset dementia), totally recovered from prior stroke, working with PT, alert and oriented although. After he presentated to ED he had n/v and one episode of abd pain. He triggered for tachycardia with HR 130s while vomiting. His abdomen was soft on exam. He had gross hematuria noted and urology was consulted. In line with their recs a CT with IV contrast was ordered which showed the foley catheter balloon dilated in urethra, urology came and replaced the foley. The pt started to become hypotensive, with a lowest BP to 65/30, and he received approximately 2-3L liters IVF with minimal response. He had a RIJ line placed, and he was started on norepinephrine. His labs were notable for lactate 2.4, WBC 7.7 with 15% bands. His UA was positive with gram negative rods. He was thus started on cefepime/gent/vanc. The pt then had CT cystogram after foley replacement prior to transfer to [**Hospital Unit Name 153**], notable for bladder rupture, this was believed to have occured sometime in the past week either immediately or some time after foley replacement. Urology saw the patient again, at which point his abdomen was noted to be diffusely tender but not hard. His BP was noted to be 100-120s while he was being weaned off norepinephrine. After the pt was appropriately stabilized, he was taken on [**2176-6-4**] to the OR for repair of his bladder rupture and placement of a suprapubic catheter. Post-op the pt was hemodynamically stable and c/o abdominal pain. As the pt recovered from his sepsis w/ IV abx and IV NS his serial CXRs showed worsening pulmonary edema, which improved with diuresis with IV lasix. His SBP values also went up to the 200s, at which point his home HTN regimen was restarted. He also became delirious soon after surgery, likely due to resolving urosepsis, pain, and pain medications. He was transfered to the medical team for management of his resolving urosepsis, post-op pain management, and delirium. Past Medical History: - DM II, on insulin - Prostate CA s/p XRT. Diagnosed in [**2156**]. - Chronic urinary incontinence, s/p TURP [**10-6**]. - History of UTI's, including prior MRSA and pseudomonas growth. (Has chronic indwelling foley, changed Q6 weeks, on ppx with cephalexin per Dr. [**Last Name (STitle) 770**] - S/p bladder rupture and repair [**2-8**] - A Fib, not anticoagulated due to bleeding history. - Hyperthyroidism. - Depression. - Hypertension. - PVD. - H/o CVA [**2172**] - Severe chronic axonal neuropathy, radiculopathy and plexopathy (due to XRT) per Dr. [**Last Name (STitle) **], with right foot drop for many years. Bed ridden. - L3 compression fracture. - Cataract s/p bilateral laser surgery, also with ""macular edema"" s/p dexamethasone injxn. - Hard of hearing - L thyroid nodule, benign. Social History: [**Location (un) 1036**] resident. Smoked 2ppd tobacco x 24 years. Quit in [**2137**]. Denies EtOH. Former WWII vet. Former Fire Fighter. Wife is HCP. Daughter is RN, Son is engineer. Family History: No illnesses, strokes, DM or early heart attacks run in the family. Physical Exam: Vitals: T:96.5 BP:132/68 P:103 (AF) R: 30 SaO2: 94% RA CVP 8 General: Awake, responds to command, marked speech latency, minimal response to questions. Appears frail, uncomfortable and fatigued. HEENT: Pale sclera. MM dry. Neck: Supple, no LAD. R CVL IJ in place. Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales Cardiac: Tachycardic, irregular, 2/6 systolic murmur Abdomen: BS present. Abd soft. Diffusely tender w/tap tenderness throughout but w/o rebound or guarding. Extremities: Mild dependent edema in UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**], cool toes with evidence of PVD/dry gangrene of right 2nd/3rd toes. Upper extremitites well perfused. Foley in place, draining clear urine. Skin: No ulcers noted. Scattered excoriated lesions on right lower quadrant/groin area. Neurologic:Awake, responds to commands, can give coherent answers. Oriented to person and hospital, not to specific hospital, or year, marked speech latency. EOMI. Slight right facial droop and UE contracture, resolves with effort. Moving all extremities, grip strength equal. Pertinent Results: Labs Admission labs [**2176-6-3**] 03:46PM BLOOD WBC-7.4 RBC-3.92* Hgb-11.6*# Hct-34.9*# MCV-89 MCH-29.5 MCHC-33.1 RDW-16.1* Plt Ct-302 [**2176-6-3**] 03:46PM BLOOD PT-13.7* PTT-25.1 INR(PT)-1.2* [**2176-6-3**] 03:46PM BLOOD Glucose-124* UreaN-28* Creat-0.9 Na-139 K-4.9 Cl-107 HCO3-21* AnGap-16 [**2176-6-3**] 03:46PM BLOOD Albumin-3.3* [**2176-6-4**] 01:31AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.5* [**2176-6-4**] 05:39AM BLOOD Type-ART pO2-70* pCO2-30* pH-7.37 calTCO2-18* Base XS--6 [**2176-6-3**] 03:47PM BLOOD Glucose-120* Lactate-2.4* Na-141 K-4.6 Cl-105 calHCO3-22 Discharge labs: [**2176-6-12**] 06:04AM BLOOD WBC-11.2* RBC-3.34* Hgb-10.2* Hct-30.6* MCV-92 MCH-30.5 MCHC-33.2 RDW-16.2* Plt Ct-331 [**2176-6-12**] 06:04AM BLOOD Glucose-133* UreaN-26* Creat-1.2 Na-139 K-4.2 Cl-108 HCO3-24 AnGap-11 [**2176-6-12**] 06:04AM BLOOD Calcium-7.3* Phos-2.3* Mg-2.2 [**2176-6-12**] 06:04AM BLOOD Genta-5.8 Microbiology: [**2176-6-6**] 10:25 am URINE. URINE CULTURE (Final [**2176-6-7**]): NO GROWTH. [**2176-6-4**] 12:00 pm PERITONEAL FLUID **FINAL REPORT [**2176-6-11**]** GRAM STAIN (Final [**2176-6-4**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. REPORTED BY PHONE TO [**Last Name (LF) **], [**First Name3 (LF) **] @ 1822 ON [**2176-6-4**]. FLUID CULTURE (Final [**2176-6-11**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. PSEUDOMONAS AERUGINOSA. RARE GROWTH. DR. [**First Name (STitle) **] #[**Numeric Identifier 42293**] REQUESTED SENSITIVITIES [**2176-6-9**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM------------- 0.5 S PIPERACILLIN---------- 8 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2176-6-8**]): NO ANAEROBES ISOLATED. [**2176-6-3**] 3:46 pm BLOOD CULTURE FINAL REPORT [**2176-6-9**]** Blood Culture, Routine (Final [**2176-6-9**]):NO GROWTH. [**2176-6-3**] 3:46 pm URINE from CATHETER FINAL REPORT [**2176-6-5**]** URINE CULTURE (Final [**2176-6-5**]): Culture workup discontinued. Further incubation showed contamination with mixed fecal flora. Clinical significance of isolate(s) uncertain. Interpret with caution. GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. . Imaging Studies: CT abdomen/pelvis w/ contrast ([**6-3**]) 1. Pyelonephritis of the left kidney. No abscess. 2. The Foley catheter balloon is inflated in the penile urethra. Small amount of gas within the bladder and the left distal ureter are most likely related to the catheterization. 3. Small amount of free fluid is noted within the pelvis. CT abdomen/pelvis w/ contrast ([**6-9**]) IMPRESSIONS: 1. Small, 3.6 x 1.2 x 4 cm fluid collection at the posterior-superior aspect of the bladder dome, with an enhancing rim, concerning for abscess. The right pelvic catheter does not terminate within this collection. 2. Trace residual free fluid in the mesentery of the pelvis. Interval resolution of free contrast material in the pelvis. CXR ([**6-7**]) The NG tube tip is in the stomach. The right internal jugular line tip is at mid SVC. There is interval improvement up to almost complete resolution of pulmonary edema. The left retrocardiac opacity is still present, most likely consistent with left lower lobe atelectasis. Pleural effusion, bilateral, is small, left more than right. Brief Hospital Course: 87 yo man with history of prostate cancer s/p XRT, prior bladder rupture, and dementia who was treated in the [**Hospital1 18**] MICU for a second bladder rupture, bladder rupture repair and suprapubic catheter placement, UTI, sepsis, and peritonitis who was transfered to the Medicine service for management of his post-surgical pain, resolving peritonitis, delirium, and heart rate control. . # Bladder rupture, urosepsis, peritonitis . The pt had a history of bladder rupture s/p repair in [**1-/2175**] and presented to this admission with evidence of new rupture on CT in setting of vague abdominal pain, nausea, vomiting and evolving shock. He likely has friable bladder tissue in setting of XRT for prostate CA and prior rupture. At admission it was unclear how long the rupture had been present, but may have been related temporally to recent foley catheter change one week prior. He had a history of MRSA, proteus, klebsiella and pseudomonas UTIs, and thus was started on broad spectrum antibiotics (vancomycin, cefepime, and gentamicin) at admission. . He was bolused with IV fluids overnight in the MICU and went to the OR on the first hospital day. In the OR, a perforation in the anterior bladder wall was closed. A suprapubic catheter was placed in a posterior bladder wall perforation, and a JP drain was placed in the peritoneum. Cultures were taken from the peritoneal fluid and urine that grew out Pseudomonas sensitive to cefepime and gent, resistent to cipro. After the surgery, the output from the JP drain continued to decrease. Chemical analysis was consistent with serum, rather than urine, and on the basis of this it was felt that the bladder perforations were successfully sealed. Post-operatively, he was treated with IV morphine and acetaminophen for pain control. He was transfused 2 units PRBCs for hematocrit 27, with appropriate bump. The pt did go on to c/o some post-surgical pain. He continued to drain clear urine from both the urethral and suprapubic catheters. He had a CT scan on [**6-9**] to assess for a fluid collection or abscess in the pelvic cavity, which showed a small fluid collection that requires follow up CT. Thus he was cleared for the removal of his JP drain. His surgical incision remained clean, dry, and intact. He had two negative urine cx. The cx of his peritoneal fluid sample taken on [**2176-6-4**] showed no growth except for rare Pseudomonas Aeruginosa growth that were shown on [**2176-6-12**] to be sensitive to Cefepim and Vancomycin. He was continued on his regimen of IV Cefepim, Vancomycin, and Gentamycin for 10 days to ensure adequate tx of his UTI and peritonitis, but was switched to solely Cefepim coverage on [**2176-6-12**] when the culture sensitivities returns. He had a PICC line placed on [**2176-6-12**] for the completion of his 14 day course of Cefepime. He did have mild urine leakage around his suprapubic catheter, but this only lasted 3 days and Urology was not concerned given that his catheters both continued to drain clear urine. He is scheduled for a F/U pelvic CT scan to reasscess the region concerning for a possible abscess, and he is also scheduled for a F/U visit with his urologist Dr. [**Last Name (STitle) 770**] for in 2 weeks. . # Delirium W/R/T the pt's mental status, after his surgery, he became increasingly agitated and disoriented. The delirium was felt to be secondary to pain, recent surgery, infection, and narcotics in the setting of baseline dementia. The pt. had been receiving IV Dilaudid for pain. Overall the narcotics were used sparingly and his infection was treated with [**Last Name (STitle) 17577**] broad spectrum abx. Zyprexa was used in small doses for acute agitation with adequate sedation. He was placed in soft restraints to protect against the pt pulling out his NGT or either of his catheters or drains. [**2176-6-7**] was the last time that the pt received Zyprexa for agitation/delirium, and he became alert and oriented to person, hospital name, and month/year since [**6-9**] and has been at his baseline since then (he has some known dementia). He is alert and oriented x3 on D/C. . # Anemia W/R/T the pt's anemia as above, he received 2 units PRBCs post-operatively for hematocrit of 27. His blood count then stabilized and he did not require further transfusions. His hemolytic work-up was negative. He stabilized in the low 30s throughout his stay and has been stable. . # Atrial fibrillation The pt has a h/o atrial fibrillation controlled only by Metoprolol and has not been anticoagulated due to his h/o hemorrhage on coumadin. While in the hospital he had multiple episodes of atrial fibrillation with RVR to 130-160s, typically related to pain and stress. His metoprolol had been held due to hypotension at admission, but was restarted to manage his RVR when his blood pressure tolerated. He continued to have such episodes of afib with RVR throughout his stay, and thus his Metoprolol dose was increased to 50 mg Q 8H up from 25 mg [**Hospital1 **], which his BP tolerated. With this increase in the metoprolol maintained an average HR in the 70s and stopped having episodes of RVR. He will need outpt F/U to assess any need to adjust this regimen. . # Diabetes mellitus II: The pt was placed on a humalog sliding scale with 15U NPH in the AM, however was taken off of the NPH due to hypoglycemia in the MICU. on the floor, the pt developed hyperglycemia to the 200's and was consistently over 180, at which point 4 [**Location **] was added and his sliding scale was increased to maintain better glycemic control. He subsequently had lower blood glucose levels overall, but still has some levels in the 200s and now that he is not infected and will be having decreasing levels of pain and stress, his insulin regimen will likely need to be adjusted at the rehab facility with [**Location 17577**] finger sticks and his primary care should f/u on this as well. . # Volume status/Blood pressure The pt has a h/o hypertension controlled on amlodipine and metoprolol, but he was hypotensive at admission, at whcih point he was hydrated aggressively with IV normal saline overnight and post-operatively. As he recovered from hypotension and sepsis, his blood pressure came up. Serial CXRs showed worsening pulmonary edema and he was diuresed with boluses of IV Lasix, which completely cleared his pulmonary edema. His outpatient antihypertensives (except for Lisinopril) were restarted as tolerated after he had recovered from peritonitis and urosepsis. Lisinopril should be restarted as an outpatient as tolerated by his blood pressure with the new adjustment to the metoprolol levels. . # Nutrition: W/R/T the pt's nutrition, given the pt's delirium, an NGT was placed for tube feeds which were given continuously. He had a speech and swallow consult with a swallow study and was noted to be silently aspirating and was thus deemed unable to take POs until he has rehab and a further evaluation. NGtube and PEG were both considered, and it was decided to plan for discharge with the NG tube with plans for speech and [**Hospital 42294**] with a goal of reachieving ability to take POs. For now he has a feed rate of 40ml/hr but his goal is 60ml/hr. The rate was slowed given recent NGT residuals, but he is on Metoclopramide and and has recently begun a bowel regimen to ensure that there is no backup causing these residuals. Instrucitons are to hold for residuals over 150ml. . # Scrotal Edema and candidal infection The pt also experienced extreme scrotal edema for being given about 14 liters of IV fluid for his urospesis/hypotension. His scrotum was elevated to decrease the edema, and has decreased but is still an issue. He also developed a erythematous rash around his scrotum and groin area which was treated with 2% Miconazole powder. There is no warmth in this area or any appearance of cellulitis. The plan is to continue to manage with miconazole powder. . # Depression: The pt has a h/o depression and had been on 10mg Lexapro per night prior to admission. His home dose of Lexapro was held during this admission given his delirium with the plan to restart it as an outpatient. . The pt was known to be a full code status. . Signed: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42295**] (Sub-Intern) pager number [**Serial Number 11736**] [**Last Name (LF) **], [**First Name3 (LF) 1439**] (Resident) [**Numeric Identifier 16045**] [**Last Name (LF) **], [**First Name3 (LF) 518**] (Attending) Medications on Admission: Cephalexin daily UTI ppx NPH 15 units QAM RISS Heparin SC TID Azo cranberry 450mg daily Bisoprolol 5mg daily Norvasc 5mg daily Aspirin 81mg daily Florastor 250mg [**Hospital1 **] Tylenol 500mg TID MVI [**Hospital1 **] Lisinopril 5mg daily Simvastatin 10mg QHS Prilosec 20mg daily Lexapro 20mg daily MOM PRN constipation Bisacodyl PRN constipation Fleet's enema PRN constipation Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for Pain/fever for 3 weeks. 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 Appl* Refills:*2* 4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for bladder pain. Disp:*1 Tablet(s)* Refills:*0* 5. Ondansetron 4 mg IV Q8H:PRN nausea, vomiting 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. Disp:*1 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). Disp:*1 Tablet(s)* Refills:*2* 8. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). Disp:*1 50 mg/5 ml* Refills:*2* 9. Insulin Glargine 100 unit/mL Solution Sig: Four (4) UNits Subcutaneous at bedtime. 10. Cefepime 2 gram Recon Soln Sig: Two (2) g Intravenous twice a day for 5 days. 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection TID (3 times a day). 12. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Your primary Diagnoses Include: Bladder rupture Peritonitis Urinary tract infection sepsis Secondary Diagnoses Delirium Diabetes mellitus Atrial fibrillation with episodes of rapid ventricular rate Discharge Condition: Stable. Afebrile. At his baseline mental status. Pain adequately controlled on standing Tylenol. Discharge Instructions: You were admitted to the hospital for treatment of bladder rupture and infection. You underwent surgery to repair the leak in the bladder. Afterwards, you were treated with intravenous antibiotics for infection in the space around the bladder. There have been changes to your medications as follows: 1. Metoprolol increased to 50 mg Q 8H. This level may need to be decreased in the future as recommended at followup with your primary care doctor given you heart rate in the future. Scheduled appointments: Please return to the [**Hospital1 18**] [**Hospital Ward Name 23**] Clinical center on [**2176-6-17**] for your scheduled follow-up CT scan of the pelvis. Plan for returning to the [**Hospital1 18**] for a followup appointment with your Urologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] on Monday [**2176-6-17**] at 3 PM. The location of this appointment will be at the [**Hospital1 18**] [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Building [**Location (un) **] Surgical Specialities. Please call the phone number: ([**Telephone/Fax (1) 7707**] with quesitons about this appointment. Please call your doctor or return to the emergency room for fever > 101 deg F, worsening abdominal or bladder pain, or other new symptoms concerning to you. Followup Instructions: Newly-scheduled follow-ups: - F/U CT 1 week after discharge to re-assess for abscess. CT scheduled for [**2176-6-17**] at 8:15 AM at [**Location (un) **], [**Hospital Ward Name 5074**] [**Location (un) 470**]. - F/U urology appointment: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 5727**] Date/Time: [**2176-6-17**] 3:00PM. ",56,2176-06-03 20:13:00,2176-06-12 17:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,SNF,SEPSIS," 87 yo man with history of prostate cancer s/p xrt, prior bladder rupture, and dementia who was treated in the [**hospital1 18**] micu for a second bladder rupture, bladder rupture repair and suprapubic catheter placement, uti, sepsis, and peritonitis who was transfered to the medicine service for management of his post-surgical pain, resolving peritonitis, delirium, and heart rate control. . # bladder rupture, urosepsis, peritonitis . the pt had a history of bladder rupture s/p repair in [**1-/2175**] and presented to this admission with evidence of new rupture on ct in setting of vague abdominal pain, nausea, vomiting and evolving shock. he likely has friable bladder tissue in setting of xrt for prostate ca and prior rupture. at admission it was unclear how long the rupture had been present, but may have been related temporally to recent foley catheter change one week prior. he had a history of mrsa, proteus, klebsiella and pseudomonas utis, and thus was started on broad spectrum antibiotics (vancomycin, cefepime, and gentamicin) at admission. . he was bolused with iv fluids overnight in the micu and went to the or on the first hospital day. in the or, a perforation in the anterior bladder wall was closed. a suprapubic catheter was placed in a posterior bladder wall perforation, and a jp drain was placed in the peritoneum. cultures were taken from the peritoneal fluid and urine that grew out pseudomonas sensitive to cefepime and gent, resistent to cipro. after the surgery, the output from the jp drain continued to decrease. chemical analysis was consistent with serum, rather than urine, and on the basis of this it was felt that the bladder perforations were successfully sealed. post-operatively, he was treated with iv morphine and acetaminophen for pain control. he was transfused 2 units prbcs for hematocrit 27, with appropriate bump. the pt did go on to c/o some post-surgical pain. he continued to drain clear urine from both the urethral and suprapubic catheters. he had a ct scan on [**6-9**] to assess for a fluid collection or abscess in the pelvic cavity, which showed a small fluid collection that requires follow up ct. thus he was cleared for the removal of his jp drain. his surgical incision remained clean, dry, and intact. he had two negative urine cx. the cx of his peritoneal fluid sample taken on [**2176-6-4**] showed no growth except for rare pseudomonas aeruginosa growth that were shown on [**2176-6-12**] to be sensitive to cefepim and vancomycin. he was continued on his regimen of iv cefepim, vancomycin, and gentamycin for 10 days to ensure adequate tx of his uti and peritonitis, but was switched to solely cefepim coverage on [**2176-6-12**] when the culture sensitivities returns. he had a picc line placed on [**2176-6-12**] for the completion of his 14 day course of cefepime. he did have mild urine leakage around his suprapubic catheter, but this only lasted 3 days and urology was not concerned given that his catheters both continued to drain clear urine. he is scheduled for a f/u pelvic ct scan to reasscess the region concerning for a possible abscess, and he is also scheduled for a f/u visit with his urologist dr. [**last name (stitle) 770**] for in 2 weeks. . # delirium w/r/t the pts mental status, after his surgery, he became increasingly agitated and disoriented. the delirium was felt to be secondary to pain, recent surgery, infection, and narcotics in the setting of baseline dementia. the pt. had been receiving iv dilaudid for pain. overall the narcotics were used sparingly and his infection was treated with [**last name (stitle) 17577**] broad spectrum abx. zyprexa was used in small doses for acute agitation with adequate sedation. he was placed in soft restraints to protect against the pt pulling out his ngt or either of his catheters or drains. [**2176-6-7**] was the last time that the pt received zyprexa for agitation/delirium, and he became alert and oriented to person, hospital name, and month/year since [**6-9**] and has been at his baseline since then (he has some known dementia). he is alert and oriented x3 on d/c. . # anemia w/r/t the pts anemia as above, he received 2 units prbcs post-operatively for hematocrit of 27. his blood count then stabilized and he did not require further transfusions. his hemolytic work-up was negative. he stabilized in the low 30s throughout his stay and has been stable. . # atrial fibrillation the pt has a h/o atrial fibrillation controlled only by metoprolol and has not been anticoagulated due to his h/o hemorrhage on coumadin. while in the hospital he had multiple episodes of atrial fibrillation with rvr to 130-160s, typically related to pain and stress. his metoprolol had been held due to hypotension at admission, but was restarted to manage his rvr when his blood pressure tolerated. he continued to have such episodes of afib with rvr throughout his stay, and thus his metoprolol dose was increased to 50 mg q 8h up from 25 mg [**hospital1 **], which his bp tolerated. with this increase in the metoprolol maintained an average hr in the 70s and stopped having episodes of rvr. he will need outpt f/u to assess any need to adjust this regimen. . # diabetes mellitus ii: the pt was placed on a humalog sliding scale with 15u nph in the am, however was taken off of the nph due to hypoglycemia in the micu. on the floor, the pt developed hyperglycemia to the 200s and was consistently over 180, at which point 4 [**location **] was added and his sliding scale was increased to maintain better glycemic control. he subsequently had lower blood glucose levels overall, but still has some levels in the 200s and now that he is not infected and will be having decreasing levels of pain and stress, his insulin regimen will likely need to be adjusted at the rehab facility with [**location 17577**] finger sticks and his primary care should f/u on this as well. . # volume status/blood pressure the pt has a h/o hypertension controlled on amlodipine and metoprolol, but he was hypotensive at admission, at whcih point he was hydrated aggressively with iv normal saline overnight and post-operatively. as he recovered from hypotension and sepsis, his blood pressure came up. serial cxrs showed worsening pulmonary edema and he was diuresed with boluses of iv lasix, which completely cleared his pulmonary edema. his outpatient antihypertensives (except for lisinopril) were restarted as tolerated after he had recovered from peritonitis and urosepsis. lisinopril should be restarted as an outpatient as tolerated by his blood pressure with the new adjustment to the metoprolol levels. . # nutrition: w/r/t the pts nutrition, given the pts delirium, an ngt was placed for tube feeds which were given continuously. he had a speech and swallow consult with a swallow study and was noted to be silently aspirating and was thus deemed unable to take pos until he has rehab and a further evaluation. ngtube and peg were both considered, and it was decided to plan for discharge with the ng tube with plans for speech and [**hospital 42294**] with a goal of reachieving ability to take pos. for now he has a feed rate of 40ml/hr but his goal is 60ml/hr. the rate was slowed given recent ngt residuals, but he is on metoclopramide and and has recently begun a bowel regimen to ensure that there is no backup causing these residuals. instrucitons are to hold for residuals over 150ml. . # scrotal edema and candidal infection the pt also experienced extreme scrotal edema for being given about 14 liters of iv fluid for his urospesis/hypotension. his scrotum was elevated to decrease the edema, and has decreased but is still an issue. he also developed a erythematous rash around his scrotum and groin area which was treated with 2% miconazole powder. there is no warmth in this area or any appearance of cellulitis. the plan is to continue to manage with miconazole powder. . # depression: the pt has a h/o depression and had been on 10mg lexapro per night prior to admission. his home dose of lexapro was held during this admission given his delirium with the plan to restart it as an outpatient. . the pt was known to be a full code status. . signed: [**first name8 (namepattern2) **] [**last name (namepattern1) 42295**] (sub-intern) pager number [**serial number 11736**] [**last name (lf) **], [**first name3 (lf) 1439**] (resident) [**numeric identifier 16045**] [**last name (lf) **], [**first name3 (lf) 518**] (attending) ","PRIMARY: [Septicemia due to pseudomonas] SECONDARY: [Septic shock; Accidental puncture or laceration during a procedure, not elsewhere classified; Other suppurative peritonitis; Urinary tract infection, site not specified; Pulmonary congestion and hypostasis; Acute posthemorrhagic anemia; Rupture of bladder, nontraumatic; Severe sepsis; Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled; Atrial fibrillation; Personal history of malignant neoplasm of prostate; Long-term (current) use of insulin; Gross hematuria; Unspecified essential hypertension; Depressive disorder, not elsewhere classified; Mononeuritis of lower limb, unspecified; Late effect of radiation; ; Other specified antibiotics causing adverse effects in therapeutic use; Pressure ulcer, lower back; Pressure ulcer, heel; Pressure ulcer, stage II; Pressure ulcer, stage I; Candidiasis of skin and nails; Edema of male genital organs]","87 yo man with history of prostate cancer s/p xrt, prior bladder rupture, and dementia who was treated in the [**hospital1 18**] micu for a second bladder rupture, bladder rupture repair and suprapubic catheter placement, uti, sepsis, and peritonitis who was transfered to the medicine service for management of his post-surgical pain, resolving peritonitis, delirium, and heart rate control. # bladder rupture, urosepsis, peritonitis . he was bolused with iv fluids overnight in the micu and went to the or on the first hospital day. after the surgery, the output from the jp drain continued to decrease. his surgical incision remained clean, dry, and intact. he was continued on his regimen of iv cefepim, vancomycin, and gentamycin for 10 days to ensure adequate tx of his uti and peritonitis, but was switched to solely cefepim coverage on [**2176-6-12**] when the culture sensitivities returns. he had a picc line placed on [**2176-6-12**] for the completion of his 14 day course of cefepime. last name (stitle) 770**] for in 2 weeks. 2176-6-7**] was the last time that the pt received zyprexa for agitation/delirium, and he became alert and oriented to person, hospital name, and month/year since [**6-9**] and has been at his baseline since then (he has some known dementia). while in the hospital he had multiple episodes of atrial fibrillation with rvr to 130-160s, typically related to pain and stress. as he recovered from hypotension and sepsis, his blood pressure came up. for now he has a feed rate of 40ml/hr but his goal is 60ml/hr. instrucitons are to hold for residuals over 150ml.","87 yo man with history of prostate cancer s/p xrt, prior bladder rupture, and dementia. treated in the micu for a second bladder rupture, bladder rupture repair and suprapubic catheter placement, uti, sepsis, and peritonitis. post-operatively, he was treated with iv morphine and acetaminophen for pain control." 28043,127710.0,14227,2176-08-07,14224,135417.0,2176-07-04,Discharge summary,"Admission Date: [**2176-6-17**] Discharge Date: [**2176-7-4**] Service: MEDICINE Allergies: Amoxicillin / Penicillins / Coumadin / Oxycodone / Megestrol Acetate / Remeron / Ritalin Attending:[**First Name3 (LF) 689**] Chief Complaint: Altered mental status. Major Surgical or Invasive Procedure: Endotracheal intubation. PICC line placement. Dobhoff (nasogastric) tube placement. PEG tube placement History of Present Illness: Mr. [**Known lastname 42290**] is an 87 year-old man with atrial fibrillation, diabetes mellitus II, prostate cancer s/p XRT, cerebrovascular accident, dementia, and bladder rupture most recently on [**6-3**], s/p repair and complicated by peritonitis, delirium who presents from rehab with altered mental status. Regarding his prior hospitalization, he presented to [**Hospital1 18**] on [**6-3**] after the onset of abdominal pain and hematuria. His foley was replaced with no improvement in his symptoms, subsequently undergoing CT scan with findings consistent with ruptured bladder. He had also become hypotensive at that point requiring pressors and transfer to the MICU. He underwent repair of an anterior bladder rupture on [**6-4**] with placement of a foley, SP catheter, and JP drain. Peritoneal culture grew rare Pseudomonas, and his antibiotics were initially Vanco, Cefepime, Gent x10 days, narrowed to Cefepime. A follow up CT scan demonstrated a small fluid collection, though it was unclear if it was indeed an abscess. He was discharged to rehab with a PICC, foley, SP catheter, completion of 14-day course of Cefepime, and follow up CT scan and urology follow-up. Per report, the patient was found today at [**Hospital **] rehab with altered mental status. Per report, he was more lethargic and confused during the course of the day. Patient is usually verbal, though was found to be non-verbal prior to transfer, lying supine and moaning. FSBG 187. The son visited him last Thursday and was reportedly at his baseline, conversing, lucid, awake and alert. However, yesterday he was less conversant, calling his wife's name, but responding to commands. He was also noted to be tremulous all over. There was no obvious indication of new symptoms such as new pain, respiratory symptoms, new numbness/weakness or other neurological symptoms. In the ED, vitals were 99.6, 74, 130/85, 25, 95% on RA. He was agitated without meningismus, and was intubated for airway protection (100% AC 550x12, 100%). Admission labs revealed a white count of 23 and Cr of 2.3. LP done in ER, needle trauma at end of tap. He was given vancomycin, ceftriaxone, and zosyn (started), which was changed to cefepime given his PCN allergy. Given 2L fluid, and was transiently hypotensive to 90s, which responded to 130s systolic after 250cc bolus. Past Medical History: -DM II, on insulin -prostate CA s/p XRT [**2156**] -chronic urinary incontinence, s/p TURP [**10-6**] -history of UTIs, including prior MRSA, klebsiella, proteus, pseuduomonas -s/p bladder rupture and repair x2, [**2-8**], [**6-8**] -atrial fibrillation, not anticoagulated due to h/o bleeding -hyperthyroidism -depression -hypertension -moderate aortic stenosis on TTE [**5-/2176**] -peripheral vascular disease -h/o CVA [**2172**] -severe chronic axonal neuropathy, radiculopathy and plexopathy (due to XRT) per Dr. [**Last Name (STitle) **], with right foot drop for many years -L3 compression fracture -cataract s/p bilateral laser surgery, also with ""macular edema"" s/p dexamethasone injection -hard of hearing -left thyroid nodule, benign Social History: Smoked 2 ppd tobacco x24 years. Quit in [**2137**]. Denies EtOH. Former WWII vet. Former Fire Fighter. Wife is HCP. Daughter is RN, son is engineer. Family History: No illnesses, strokes, DM or early heart attacks run in the family. Physical Exam: Vitals: Tm 98.4, Tc 97.8, HR 58 (58-78), BP 143/82, RR 17, sat 100%RA General: minimally interactive; squeezes hands on command but will not close eyes on command; winces when pressure is applied to suprapubic region Lungs: clear anteriorly Chest: RRR, normal S1/S2 Abdomen: moderate suprapubic tenderess, normal bowel sounds; suprapubic catheter, folety catheter, and rectal tube are in place Extremites: hands with trace pitting edema, diffuse ecchymoses, legs are non-edematous Pertinent Results: Labs at Admission: [**2176-6-17**] 03:22AM BLOOD WBC-22.6*# RBC-3.76* Hgb-11.3* Hct-35.8* MCV-95 MCH-30.0 MCHC-31.4 RDW-16.3* Plt Ct-522*# [**2176-6-17**] 03:22AM BLOOD Neuts-88.5* Lymphs-6.3* Monos-3.4 Eos-1.4 Baso-0.4 [**2176-6-17**] 03:22AM BLOOD PT-15.5* PTT-29.5 INR(PT)-1.4* [**2176-6-17**] 03:22AM BLOOD Glucose-184* UreaN-53* Creat-2.3*# Na-135 K-4.7 Cl-102 HCO3-24 AnGap-14 [**2176-6-18**] 04:17AM BLOOD ALT-9 AST-14 LD(LDH)-247 TotBili-0.2 [**2176-6-17**] 03:22AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.5* Mg-2.1 [**2176-6-18**] 04:17AM BLOOD calTIBC-164* Hapto-184 Ferritn-251 TRF-126* [**2176-6-19**] 03:49AM BLOOD VitB12-1024* Folate-14.6 Micro Studies: [**2176-6-29**] URINE URINE CULTURE- negative [**2176-6-28**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- negative [**2176-6-20**] BLOOD CULTURE Blood Culture, Routine- negative [**2176-6-19**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE- yeast [**2176-6-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST- negative [**2176-6-19**] BLOOD CULTURE Blood Culture, Routine- negative [**2176-6-19**] URINE URINE CULTURE- negative [**2176-6-18**] URINE Legionella Urinary Antigen - negative [**2176-6-17**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {YEAST, STAPH AUREUS COAG +}; LEGIONELLA CULTURE- negative GRAM STAIN (Final [**2176-6-17**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): YEAST(S). _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S [**2176-6-17**] CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE- negative [**2176-6-17**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE- negative [**2176-6-17**] BLOOD CULTURE Blood Culture, Routine- negative [**2176-6-17**] BLOOD CULTURE Blood Culture, Routine- negative [**2176-6-17**] URINE URINE CULTURE- negative Cerebrospinal Fluid: [**2176-6-17**] 05:30AM CEREBROSPINAL FLUID (CSF) WBC-19 RBC-8450* Polys-78 Lymphs-14 Monos-5 Eos-3 [**2176-6-17**] 05:30AM CEREBROSPINAL FLUID (CSF) WBC-11 RBC-1650* Polys-78 Lymphs-15 Monos-7 [**2176-6-17**] 05:30AM CEREBROSPINAL FLUID (CSF) TotProt-59* Glucose-101 [**2176-6-17**] 11:19AM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS PCR-negative for HSV 1 and HSV 2 Imaging Studies: CT Abdomen and Pelvis ([**6-17**]): 1. Anasarca. New small left greater than right pleural effusions. Tiny pericardial effusion. 2. Right basilar airspace opacity concerning for aspiration. 3. Superpubic and Foley catheter remain within the decompressed bladder. [**Doctor Last Name 406**] drain is removed. The fluid in the previously seen rim-enhancing pelvic fluid collection has essentially resolved, with now 2.4 x 1.7 x 1.8 cm soft tissue seen remaining where fluid collection was. No definite new fluid collection seen. EEG ([**6-17**]): IMPRESSION: This is an abnormal portable EEG recording due to the independent left and right parasagittal discharges and the focal slowing in the parasagittal area. The background was slow alternating with periods of relative suppression, as well as multifocal slowing. For about 15 minutes, there were bifrontally predominant triphasic waves that evolved into more rhythmic pattern reaching a maximum of 1.5-2 Hz. The first and second abnormalities suggest cortical irritability as well as subcortical dysfunction in the parasagittal areas. The third abnormality suggests multifocal a moderate to severe encephalopathy. The fourth abnormality may be seen in encephalopathies but also raises concern for electrographic seizure activity, although no clear change was seen in the patient's behavior on video. Thus, continuous EEG recording may be of further diagnostic value in this patient to evaluate for subclinical seizures. Of note is the irregular cardiac rhythm suggestive of atrial fibrilllation. TTE ([**6-19**]): The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the prior study (images reviewed) of [**2172-12-17**], the degree of AS is now moderate. MRI Head ([**6-24**]): IMPRESSION: No evidence for acute ischemia. Slight progression of periventricular hyperintensity which could reflect progression of small vessel ischemia. Less likely, this could represent transependymal CSF flow from NPH. Foci of hypersignal in the right frontal and parietal lobe which were not present on the prior MRI may represent interval ischemia which is chronic. . . DISCHARGE LABS: . Na: 147 Cl: 118 Cr: 1.7 Hct: 23.8 Ca: 8.0 Brief Hospital Course: In summary an 87 year-old man with history of atrial fibrillation, diabetes mellitus II, dementia, history of prostate cancer s/p XRT c/b bladder rupture x2 with recent surgical repair, MDR UTIs, who presents from rehab with altered mental status. # Altered mental status: etiology is not clear. He was intubated in the emergency room for airway protection (extubated later on [**6-24**]). He had a leukocytosis of 23 with neutrophilic predominance at admission. CSF was traumatic but we could not exclude bacterial meningitis. Other considerations included delirium in setting of infection (meningitis, aspiration pneumonia, or urinary tract infection), acute renal failure, and seizures. He was treated empirically for meningitis with ceftriaxone, vancomycin, and Bactrim. Neurology was consulted. EEG showed possible non-convulsive status epilepticus while in the intensive care unit. Therefore he was started on Dilantin. MRI showed no evidence of acute vascular event. Despite the above treatments, his mental status did not return to pre-admission baseline. After transfer to the floors, he had completed a 14-day course of antibiotics and remained therapeutic on Dilantin. The patient's mental status has gradually improved, and Neurology recommended continuing Dilantin and follow up with Neurology upon discharge. # Seizures: MRI was without mass or evidence of stroke. Non-convulsive status epilepticus was felt to be precipitated by meningitis. He was loaded on phenytoin and levels were followed until therapeutic. # Acute renal failure: His creatinine was up to 2.3 during this admission from previous baseline 0.5-1.0. This was thought secondary to gentamicin toxicity during prior admission or possibly precipitated by infection/sepsis. His creatinine came down with treatment of infection, but has not reached previous baseline. He is still producing good amount of urine and creatinine has been stable at 1.7. # Anemia: his baseline hematocrit from early [**2176**] is 30. There were no signs of active bleeding on exam. The anemia was felt to be due to phlebotomy effect and inflammation and chronic disease. We maintained an active type and screen. Blood transfusion was not necessary. # S/p Bladder repair: He has had two bladder ruptures in the last two years. He now has a chronic foley and suprapubic catheter. At last admission the bladder perforation appeared to be healing well with clear drainage. During this admission there was a small fluid collection in the peritoneum, which was a non-specific finding. His foley and supra-pubic catheters continued to drain clear urine, and abdominal exam was benign. # Diabetes mellitus II: bood sugars were stable. We continued his home insulin sliding scale and held his Lantus initially. We restarted this medication on [**7-2**], and his sugars remained within good contol. # Atrial fibrillation: he is not on anticoagulation due to history of bleeding. In the intensive care unit he had episodes of atrial fibrillation with RVR. He was intially treated with metoprolol, then was loaded on amiodorone with good rate control. After transfer to the floors, there was concern of high-degree atrioventricular block. Electrophysiology service was consulted and recommended that amiodorone be discontinued. He was kept on metoprolol at a dose of 25 mg twice daily and he was started on ASA 81 mg daily prior to admission. # Hypertension: We continued metoprolol and held amlodipine. Blood pressure control was good on this regimen. Medications on Admission: Amlodipine 5 mg PO DAILY (Daily). Acetaminophen 500 mg (2) Tablet PO Q 8H (Every 8 Hours) as needed Miconazole Nitrate 2 % Powder (1) Appl Topical [**Hospital1 **] Ondansetron 4 mg IV Q8H:PRN nausea, vomiting Senna 8.6 mg (1) Tablet PO DAILY (Daily) as needed for constipation Metoprolol Tartrate 50 mg PO Q8H Docusate Sodium 50 mg/5 mL Liquid (1) PO DAILY Insulin Glargine 6 Units Subcutaneous at bedtime Cefepime 2 gram [**Hospital1 **] through [**6-16**] Lovenox 40mg SC Daily Metoclopramide 5 mg PO every six 6 hours Discharge Medications: 1. Phenytoin 125 mg/5 mL Suspension Sig: One (1) PO TID (3 times a day). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 7. Insulin Glargine 100 unit/mL Cartridge Sig: Six (6) Units Subcutaneous at bedtime. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 10. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 11. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: PRIMARY DIAGNOSES Meningitis Atrial fibrillation with rapid ventricular response Non-convulsive status epilepticus Acute renal failure . SECONDARY DIAGNOSES History of bladder rupture Moderate aortic stenosis Diabetes type II Discharge Condition: Vital signs stable. Afebrile. Discharge Instructions: You were admitted to the hospital for evaluation of altered mental status. We believe that you had an infection, although we were not able to isolate the source. We treated you with a fourteen-day course of antibiotics, which you completed while in the hospital. In addition, we noticed that you were having seizures and started you on a medicine to help prevent seizures in the future. We also placed a G-tube in your stomach in order to improve your nutrition. . While you were here, we made the following changes to your medications: 1. We started you on Dilantin for seizures 2. We discontinued your Amlodipine and decreased your Metoprolol to 25 mg PO twice daily 3. We discontinued your Ondansetron 4. We started you on Aspirin 81 mg daily 5. We increased your senna to twice daily instead of once daily 6. We discontinued your Lovenox injections and started you on Heparing injections three times daily Please take all medications as prescribed. Please keep all previously scheduled appointments Please return to the ED or your healthcare facility if you experience shortness of breath, chest pain, fevers, chills, increasing confusion, seizures, or any other concerning symptoms. Followup Instructions: Please follow-up with your primary provider one week after being discharged from [**Hospital 100**] Rehab. Their phone number is [**Telephone/Fax (1) 3070**]. PROVIDER: [**Name10 (NameIs) **] [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**] (Nephrology). Date and time: [**8-9**] at 11am. Location: [**Hospital Ward Name 23**] Clinical Center [**Location (un) 436**]. Phone number: [**Telephone/Fax (1) 60**] PROVIDER: [**Name10 (NameIs) **], [**Name11 (NameIs) 1112**] MD (Neurology). Date/Time: [**2176-10-2**] at 1 PM. Location: [**Hospital Ward Name 23**] Building [**Location (un) **]. Completed by:[**2176-7-4**]",34,2176-06-17 06:36:00,2176-07-04 14:01:00,EMERGENCY,EMERGENCY ROOM ADMIT,LONG TERM CARE HOSPITAL,ALTERED MENTAL STATUS," in summary an 87 year-old man with history of atrial fibrillation, diabetes mellitus ii, dementia, history of prostate cancer s/p xrt c/b bladder rupture x2 with recent surgical repair, mdr utis, who presents from rehab with altered mental status. # altered mental status: etiology is not clear. he was intubated in the emergency room for airway protection (extubated later on [**6-24**]). he had a leukocytosis of 23 with neutrophilic predominance at admission. csf was traumatic but we could not exclude bacterial meningitis. other considerations included delirium in setting of infection (meningitis, aspiration pneumonia, or urinary tract infection), acute renal failure, and seizures. he was treated empirically for meningitis with ceftriaxone, vancomycin, and bactrim. neurology was consulted. eeg showed possible non-convulsive status epilepticus while in the intensive care unit. therefore he was started on dilantin. mri showed no evidence of acute vascular event. despite the above treatments, his mental status did not return to pre-admission baseline. after transfer to the floors, he had completed a 14-day course of antibiotics and remained therapeutic on dilantin. the patients mental status has gradually improved, and neurology recommended continuing dilantin and follow up with neurology upon discharge. # seizures: mri was without mass or evidence of stroke. non-convulsive status epilepticus was felt to be precipitated by meningitis. he was loaded on phenytoin and levels were followed until therapeutic. # acute renal failure: his creatinine was up to 2.3 during this admission from previous baseline 0.5-1.0. this was thought secondary to gentamicin toxicity during prior admission or possibly precipitated by infection/sepsis. his creatinine came down with treatment of infection, but has not reached previous baseline. he is still producing good amount of urine and creatinine has been stable at 1.7. # anemia: his baseline hematocrit from early [**2176**] is 30. there were no signs of active bleeding on exam. the anemia was felt to be due to phlebotomy effect and inflammation and chronic disease. we maintained an active type and screen. blood transfusion was not necessary. # s/p bladder repair: he has had two bladder ruptures in the last two years. he now has a chronic foley and suprapubic catheter. at last admission the bladder perforation appeared to be healing well with clear drainage. during this admission there was a small fluid collection in the peritoneum, which was a non-specific finding. his foley and supra-pubic catheters continued to drain clear urine, and abdominal exam was benign. # diabetes mellitus ii: bood sugars were stable. we continued his home insulin sliding scale and held his lantus initially. we restarted this medication on [**7-2**], and his sugars remained within good contol. # atrial fibrillation: he is not on anticoagulation due to history of bleeding. in the intensive care unit he had episodes of atrial fibrillation with rvr. he was intially treated with metoprolol, then was loaded on amiodorone with good rate control. after transfer to the floors, there was concern of high-degree atrioventricular block. electrophysiology service was consulted and recommended that amiodorone be discontinued. he was kept on metoprolol at a dose of 25 mg twice daily and he was started on asa 81 mg daily prior to admission. # hypertension: we continued metoprolol and held amlodipine. blood pressure control was good on this regimen. ","PRIMARY: [Meningitis, unspecified] SECONDARY: [Grand mal status; Acute kidney failure, unspecified; Acute respiratory failure; Acidosis; Other complications due to other internal prosthetic device, implant, and graft; ; Atrial fibrillation; ; Other urinary incontinence; Hypotension, unspecified; Peripheral vascular disease, unspecified; Benign essential hypertension; Anemia of other chronic disease; Hyperpotassemia; Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled; Pressure ulcer, lower back; Pressure ulcer, unspecified stage; Brachial plexus lesions; Neuralgia, neuritis, and radiculitis, unspecified; Other acquired deformities of ankle and foot; Aortic valve disorders; Other persistent mental disorders due to conditions classified elsewhere; Other postprocedural status; Personal history of malignant neoplasm of prostate; Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits; Personal history of Methicillin resistant Staphylococcus aureus; Long-term (current) use of insulin; Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure; Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure]","in summary an 87 year-old man with history of atrial fibrillation, diabetes mellitus ii, dementia, history of prostate cancer s/p xrt c/b bladder rupture x2 with recent surgical repair, mdr utis, who presents from rehab with altered mental status. he had a leukocytosis of 23 with neutrophilic predominance at admission. eeg showed possible non-convulsive status epilepticus while in the intensive care unit. he was loaded on phenytoin and levels were followed until therapeutic. # acute renal failure: his creatinine was up to 2.3 during this admission from previous baseline 0.5-1.0. this was thought secondary to gentamicin toxicity during prior admission or possibly precipitated by infection/sepsis. # diabetes mellitus ii: bood sugars were stable. blood pressure control was good on this regimen.","mdr utis presented from rehab with altered mental status. he had a leukocytosis of 23 with neutrophilic predominance at admission. he was treated empirically for meningitis with ceftriaxone, vancomycin, and bactrim." 28043,135417.0,14224,2176-07-04,14223,149969.0,2176-06-12,Discharge summary,"Admission Date: [**2176-6-3**] Discharge Date: [**2176-6-12**] Service: MEDICINE Allergies: Amoxicillin / Penicillins / Coumadin / Oxycodone / Megestrol Acetate / Remeron / Ritalin Attending:[**First Name3 (LF) 5129**] Chief Complaint: 87 yo man with history of prostate cancer s/p XRT, dementia, prior bladder rupture, who was treated in the [**Hospital1 18**] MICU for a new bladder rupture and urosepsis, transfered to SIRS 2 primarily for management of resolving urosepsis, peritonitis, post-surgical pain, and delirium. Major Surgical or Invasive Procedure: Anterior bladder perforation closure, placement of suprapubic catheter and peritoneal drain History of Present Illness: 87 yo man with history of prostate CA in [**2156**] s/p XRT, prior bladder rupture, indwelling foley, multiple UTIs, and recently dx dementia who presented to ED from NH with weeks of lower abdominal pain and groin pain. Bright red hematuria was seen at his nursing home. His foley was changed 1 week prior to admission with sm amount of blood that cleared at the time. He was unable to give other ROS. His family reported that the pt had been having abd pain and hematuria all week since foley change, and he was brought to the ED because he was having fevers, nausea/vomiting and worsening pain. Prior to this past week, he had been at his best recent baseline (w/a h/o one year of new onset dementia), totally recovered from prior stroke, working with PT, alert and oriented although. After he presentated to ED he had n/v and one episode of abd pain. He triggered for tachycardia with HR 130s while vomiting. His abdomen was soft on exam. He had gross hematuria noted and urology was consulted. In line with their recs a CT with IV contrast was ordered which showed the foley catheter balloon dilated in urethra, urology came and replaced the foley. The pt started to become hypotensive, with a lowest BP to 65/30, and he received approximately 2-3L liters IVF with minimal response. He had a RIJ line placed, and he was started on norepinephrine. His labs were notable for lactate 2.4, WBC 7.7 with 15% bands. His UA was positive with gram negative rods. He was thus started on cefepime/gent/vanc. The pt then had CT cystogram after foley replacement prior to transfer to [**Hospital Unit Name 153**], notable for bladder rupture, this was believed to have occured sometime in the past week either immediately or some time after foley replacement. Urology saw the patient again, at which point his abdomen was noted to be diffusely tender but not hard. His BP was noted to be 100-120s while he was being weaned off norepinephrine. After the pt was appropriately stabilized, he was taken on [**2176-6-4**] to the OR for repair of his bladder rupture and placement of a suprapubic catheter. Post-op the pt was hemodynamically stable and c/o abdominal pain. As the pt recovered from his sepsis w/ IV abx and IV NS his serial CXRs showed worsening pulmonary edema, which improved with diuresis with IV lasix. His SBP values also went up to the 200s, at which point his home HTN regimen was restarted. He also became delirious soon after surgery, likely due to resolving urosepsis, pain, and pain medications. He was transfered to the medical team for management of his resolving urosepsis, post-op pain management, and delirium. Past Medical History: - DM II, on insulin - Prostate CA s/p XRT. Diagnosed in [**2156**]. - Chronic urinary incontinence, s/p TURP [**10-6**]. - History of UTI's, including prior MRSA and pseudomonas growth. (Has chronic indwelling foley, changed Q6 weeks, on ppx with cephalexin per Dr. [**Last Name (STitle) 770**] - S/p bladder rupture and repair [**2-8**] - A Fib, not anticoagulated due to bleeding history. - Hyperthyroidism. - Depression. - Hypertension. - PVD. - H/o CVA [**2172**] - Severe chronic axonal neuropathy, radiculopathy and plexopathy (due to XRT) per Dr. [**Last Name (STitle) **], with right foot drop for many years. Bed ridden. - L3 compression fracture. - Cataract s/p bilateral laser surgery, also with ""macular edema"" s/p dexamethasone injxn. - Hard of hearing - L thyroid nodule, benign. Social History: [**Location (un) 1036**] resident. Smoked 2ppd tobacco x 24 years. Quit in [**2137**]. Denies EtOH. Former WWII vet. Former Fire Fighter. Wife is HCP. Daughter is RN, Son is engineer. Family History: No illnesses, strokes, DM or early heart attacks run in the family. Physical Exam: Vitals: T:96.5 BP:132/68 P:103 (AF) R: 30 SaO2: 94% RA CVP 8 General: Awake, responds to command, marked speech latency, minimal response to questions. Appears frail, uncomfortable and fatigued. HEENT: Pale sclera. MM dry. Neck: Supple, no LAD. R CVL IJ in place. Pulmonary: Lungs CTA bilaterally, no wheezes, ronchi or rales Cardiac: Tachycardic, irregular, 2/6 systolic murmur Abdomen: BS present. Abd soft. Diffusely tender w/tap tenderness throughout but w/o rebound or guarding. Extremities: Mild dependent edema in UEs and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**], cool toes with evidence of PVD/dry gangrene of right 2nd/3rd toes. Upper extremitites well perfused. Foley in place, draining clear urine. Skin: No ulcers noted. Scattered excoriated lesions on right lower quadrant/groin area. Neurologic:Awake, responds to commands, can give coherent answers. Oriented to person and hospital, not to specific hospital, or year, marked speech latency. EOMI. Slight right facial droop and UE contracture, resolves with effort. Moving all extremities, grip strength equal. Pertinent Results: Labs Admission labs [**2176-6-3**] 03:46PM BLOOD WBC-7.4 RBC-3.92* Hgb-11.6*# Hct-34.9*# MCV-89 MCH-29.5 MCHC-33.1 RDW-16.1* Plt Ct-302 [**2176-6-3**] 03:46PM BLOOD PT-13.7* PTT-25.1 INR(PT)-1.2* [**2176-6-3**] 03:46PM BLOOD Glucose-124* UreaN-28* Creat-0.9 Na-139 K-4.9 Cl-107 HCO3-21* AnGap-16 [**2176-6-3**] 03:46PM BLOOD Albumin-3.3* [**2176-6-4**] 01:31AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.5* [**2176-6-4**] 05:39AM BLOOD Type-ART pO2-70* pCO2-30* pH-7.37 calTCO2-18* Base XS--6 [**2176-6-3**] 03:47PM BLOOD Glucose-120* Lactate-2.4* Na-141 K-4.6 Cl-105 calHCO3-22 Discharge labs: [**2176-6-12**] 06:04AM BLOOD WBC-11.2* RBC-3.34* Hgb-10.2* Hct-30.6* MCV-92 MCH-30.5 MCHC-33.2 RDW-16.2* Plt Ct-331 [**2176-6-12**] 06:04AM BLOOD Glucose-133* UreaN-26* Creat-1.2 Na-139 K-4.2 Cl-108 HCO3-24 AnGap-11 [**2176-6-12**] 06:04AM BLOOD Calcium-7.3* Phos-2.3* Mg-2.2 [**2176-6-12**] 06:04AM BLOOD Genta-5.8 Microbiology: [**2176-6-6**] 10:25 am URINE. URINE CULTURE (Final [**2176-6-7**]): NO GROWTH. [**2176-6-4**] 12:00 pm PERITONEAL FLUID **FINAL REPORT [**2176-6-11**]** GRAM STAIN (Final [**2176-6-4**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. REPORTED BY PHONE TO [**Last Name (LF) **], [**First Name3 (LF) **] @ 1822 ON [**2176-6-4**]. FLUID CULTURE (Final [**2176-6-11**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. PSEUDOMONAS AERUGINOSA. RARE GROWTH. DR. [**First Name (STitle) **] #[**Numeric Identifier 42293**] REQUESTED SENSITIVITIES [**2176-6-9**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM------------- 0.5 S PIPERACILLIN---------- 8 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2176-6-8**]): NO ANAEROBES ISOLATED. [**2176-6-3**] 3:46 pm BLOOD CULTURE FINAL REPORT [**2176-6-9**]** Blood Culture, Routine (Final [**2176-6-9**]):NO GROWTH. [**2176-6-3**] 3:46 pm URINE from CATHETER FINAL REPORT [**2176-6-5**]** URINE CULTURE (Final [**2176-6-5**]): Culture workup discontinued. Further incubation showed contamination with mixed fecal flora. Clinical significance of isolate(s) uncertain. Interpret with caution. GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. . Imaging Studies: CT abdomen/pelvis w/ contrast ([**6-3**]) 1. Pyelonephritis of the left kidney. No abscess. 2. The Foley catheter balloon is inflated in the penile urethra. Small amount of gas within the bladder and the left distal ureter are most likely related to the catheterization. 3. Small amount of free fluid is noted within the pelvis. CT abdomen/pelvis w/ contrast ([**6-9**]) IMPRESSIONS: 1. Small, 3.6 x 1.2 x 4 cm fluid collection at the posterior-superior aspect of the bladder dome, with an enhancing rim, concerning for abscess. The right pelvic catheter does not terminate within this collection. 2. Trace residual free fluid in the mesentery of the pelvis. Interval resolution of free contrast material in the pelvis. CXR ([**6-7**]) The NG tube tip is in the stomach. The right internal jugular line tip is at mid SVC. There is interval improvement up to almost complete resolution of pulmonary edema. The left retrocardiac opacity is still present, most likely consistent with left lower lobe atelectasis. Pleural effusion, bilateral, is small, left more than right. Brief Hospital Course: 87 yo man with history of prostate cancer s/p XRT, prior bladder rupture, and dementia who was treated in the [**Hospital1 18**] MICU for a second bladder rupture, bladder rupture repair and suprapubic catheter placement, UTI, sepsis, and peritonitis who was transfered to the Medicine service for management of his post-surgical pain, resolving peritonitis, delirium, and heart rate control. . # Bladder rupture, urosepsis, peritonitis . The pt had a history of bladder rupture s/p repair in [**1-/2175**] and presented to this admission with evidence of new rupture on CT in setting of vague abdominal pain, nausea, vomiting and evolving shock. He likely has friable bladder tissue in setting of XRT for prostate CA and prior rupture. At admission it was unclear how long the rupture had been present, but may have been related temporally to recent foley catheter change one week prior. He had a history of MRSA, proteus, klebsiella and pseudomonas UTIs, and thus was started on broad spectrum antibiotics (vancomycin, cefepime, and gentamicin) at admission. . He was bolused with IV fluids overnight in the MICU and went to the OR on the first hospital day. In the OR, a perforation in the anterior bladder wall was closed. A suprapubic catheter was placed in a posterior bladder wall perforation, and a JP drain was placed in the peritoneum. Cultures were taken from the peritoneal fluid and urine that grew out Pseudomonas sensitive to cefepime and gent, resistent to cipro. After the surgery, the output from the JP drain continued to decrease. Chemical analysis was consistent with serum, rather than urine, and on the basis of this it was felt that the bladder perforations were successfully sealed. Post-operatively, he was treated with IV morphine and acetaminophen for pain control. He was transfused 2 units PRBCs for hematocrit 27, with appropriate bump. The pt did go on to c/o some post-surgical pain. He continued to drain clear urine from both the urethral and suprapubic catheters. He had a CT scan on [**6-9**] to assess for a fluid collection or abscess in the pelvic cavity, which showed a small fluid collection that requires follow up CT. Thus he was cleared for the removal of his JP drain. His surgical incision remained clean, dry, and intact. He had two negative urine cx. The cx of his peritoneal fluid sample taken on [**2176-6-4**] showed no growth except for rare Pseudomonas Aeruginosa growth that were shown on [**2176-6-12**] to be sensitive to Cefepim and Vancomycin. He was continued on his regimen of IV Cefepim, Vancomycin, and Gentamycin for 10 days to ensure adequate tx of his UTI and peritonitis, but was switched to solely Cefepim coverage on [**2176-6-12**] when the culture sensitivities returns. He had a PICC line placed on [**2176-6-12**] for the completion of his 14 day course of Cefepime. He did have mild urine leakage around his suprapubic catheter, but this only lasted 3 days and Urology was not concerned given that his catheters both continued to drain clear urine. He is scheduled for a F/U pelvic CT scan to reasscess the region concerning for a possible abscess, and he is also scheduled for a F/U visit with his urologist Dr. [**Last Name (STitle) 770**] for in 2 weeks. . # Delirium W/R/T the pt's mental status, after his surgery, he became increasingly agitated and disoriented. The delirium was felt to be secondary to pain, recent surgery, infection, and narcotics in the setting of baseline dementia. The pt. had been receiving IV Dilaudid for pain. Overall the narcotics were used sparingly and his infection was treated with [**Last Name (STitle) 17577**] broad spectrum abx. Zyprexa was used in small doses for acute agitation with adequate sedation. He was placed in soft restraints to protect against the pt pulling out his NGT or either of his catheters or drains. [**2176-6-7**] was the last time that the pt received Zyprexa for agitation/delirium, and he became alert and oriented to person, hospital name, and month/year since [**6-9**] and has been at his baseline since then (he has some known dementia). He is alert and oriented x3 on D/C. . # Anemia W/R/T the pt's anemia as above, he received 2 units PRBCs post-operatively for hematocrit of 27. His blood count then stabilized and he did not require further transfusions. His hemolytic work-up was negative. He stabilized in the low 30s throughout his stay and has been stable. . # Atrial fibrillation The pt has a h/o atrial fibrillation controlled only by Metoprolol and has not been anticoagulated due to his h/o hemorrhage on coumadin. While in the hospital he had multiple episodes of atrial fibrillation with RVR to 130-160s, typically related to pain and stress. His metoprolol had been held due to hypotension at admission, but was restarted to manage his RVR when his blood pressure tolerated. He continued to have such episodes of afib with RVR throughout his stay, and thus his Metoprolol dose was increased to 50 mg Q 8H up from 25 mg [**Hospital1 **], which his BP tolerated. With this increase in the metoprolol maintained an average HR in the 70s and stopped having episodes of RVR. He will need outpt F/U to assess any need to adjust this regimen. . # Diabetes mellitus II: The pt was placed on a humalog sliding scale with 15U NPH in the AM, however was taken off of the NPH due to hypoglycemia in the MICU. on the floor, the pt developed hyperglycemia to the 200's and was consistently over 180, at which point 4 [**Location **] was added and his sliding scale was increased to maintain better glycemic control. He subsequently had lower blood glucose levels overall, but still has some levels in the 200s and now that he is not infected and will be having decreasing levels of pain and stress, his insulin regimen will likely need to be adjusted at the rehab facility with [**Location 17577**] finger sticks and his primary care should f/u on this as well. . # Volume status/Blood pressure The pt has a h/o hypertension controlled on amlodipine and metoprolol, but he was hypotensive at admission, at whcih point he was hydrated aggressively with IV normal saline overnight and post-operatively. As he recovered from hypotension and sepsis, his blood pressure came up. Serial CXRs showed worsening pulmonary edema and he was diuresed with boluses of IV Lasix, which completely cleared his pulmonary edema. His outpatient antihypertensives (except for Lisinopril) were restarted as tolerated after he had recovered from peritonitis and urosepsis. Lisinopril should be restarted as an outpatient as tolerated by his blood pressure with the new adjustment to the metoprolol levels. . # Nutrition: W/R/T the pt's nutrition, given the pt's delirium, an NGT was placed for tube feeds which were given continuously. He had a speech and swallow consult with a swallow study and was noted to be silently aspirating and was thus deemed unable to take POs until he has rehab and a further evaluation. NGtube and PEG were both considered, and it was decided to plan for discharge with the NG tube with plans for speech and [**Hospital 42294**] with a goal of reachieving ability to take POs. For now he has a feed rate of 40ml/hr but his goal is 60ml/hr. The rate was slowed given recent NGT residuals, but he is on Metoclopramide and and has recently begun a bowel regimen to ensure that there is no backup causing these residuals. Instrucitons are to hold for residuals over 150ml. . # Scrotal Edema and candidal infection The pt also experienced extreme scrotal edema for being given about 14 liters of IV fluid for his urospesis/hypotension. His scrotum was elevated to decrease the edema, and has decreased but is still an issue. He also developed a erythematous rash around his scrotum and groin area which was treated with 2% Miconazole powder. There is no warmth in this area or any appearance of cellulitis. The plan is to continue to manage with miconazole powder. . # Depression: The pt has a h/o depression and had been on 10mg Lexapro per night prior to admission. His home dose of Lexapro was held during this admission given his delirium with the plan to restart it as an outpatient. . The pt was known to be a full code status. . Signed: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 42295**] (Sub-Intern) pager number [**Serial Number 11736**] [**Last Name (LF) **], [**First Name3 (LF) 1439**] (Resident) [**Numeric Identifier 16045**] [**Last Name (LF) **], [**First Name3 (LF) 518**] (Attending) Medications on Admission: Cephalexin daily UTI ppx NPH 15 units QAM RISS Heparin SC TID Azo cranberry 450mg daily Bisoprolol 5mg daily Norvasc 5mg daily Aspirin 81mg daily Florastor 250mg [**Hospital1 **] Tylenol 500mg TID MVI [**Hospital1 **] Lisinopril 5mg daily Simvastatin 10mg QHS Prilosec 20mg daily Lexapro 20mg daily MOM PRN constipation Bisacodyl PRN constipation Fleet's enema PRN constipation Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours) as needed for Pain/fever for 3 weeks. 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*1 Appl* Refills:*2* 4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for bladder pain. Disp:*1 Tablet(s)* Refills:*0* 5. Ondansetron 4 mg IV Q8H:PRN nausea, vomiting 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. Disp:*1 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8 Hours). Disp:*1 Tablet(s)* Refills:*2* 8. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). Disp:*1 50 mg/5 ml* Refills:*2* 9. Insulin Glargine 100 unit/mL Solution Sig: Four (4) UNits Subcutaneous at bedtime. 10. Cefepime 2 gram Recon Soln Sig: Two (2) g Intravenous twice a day for 5 days. 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Units Injection TID (3 times a day). 12. Metoclopramide 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Your primary Diagnoses Include: Bladder rupture Peritonitis Urinary tract infection sepsis Secondary Diagnoses Delirium Diabetes mellitus Atrial fibrillation with episodes of rapid ventricular rate Discharge Condition: Stable. Afebrile. At his baseline mental status. Pain adequately controlled on standing Tylenol. Discharge Instructions: You were admitted to the hospital for treatment of bladder rupture and infection. You underwent surgery to repair the leak in the bladder. Afterwards, you were treated with intravenous antibiotics for infection in the space around the bladder. There have been changes to your medications as follows: 1. Metoprolol increased to 50 mg Q 8H. This level may need to be decreased in the future as recommended at followup with your primary care doctor given you heart rate in the future. Scheduled appointments: Please return to the [**Hospital1 18**] [**Hospital Ward Name 23**] Clinical center on [**2176-6-17**] for your scheduled follow-up CT scan of the pelvis. Plan for returning to the [**Hospital1 18**] for a followup appointment with your Urologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 770**] on Monday [**2176-6-17**] at 3 PM. The location of this appointment will be at the [**Hospital1 18**] [**Hospital Ward Name 5074**] [**Hospital Ward Name 23**] Building [**Location (un) **] Surgical Specialities. Please call the phone number: ([**Telephone/Fax (1) 7707**] with quesitons about this appointment. Please call your doctor or return to the emergency room for fever > 101 deg F, worsening abdominal or bladder pain, or other new symptoms concerning to you. Followup Instructions: Newly-scheduled follow-ups: - F/U CT 1 week after discharge to re-assess for abscess. CT scheduled for [**2176-6-17**] at 8:15 AM at [**Location (un) **], [**Hospital Ward Name 5074**] [**Location (un) 470**]. - F/U urology appointment: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 5727**] Date/Time: [**2176-6-17**] 3:00PM. ",22,2176-06-03 20:13:00,2176-06-12 17:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,SNF,SEPSIS," 87 yo man with history of prostate cancer s/p xrt, prior bladder rupture, and dementia who was treated in the [**hospital1 18**] micu for a second bladder rupture, bladder rupture repair and suprapubic catheter placement, uti, sepsis, and peritonitis who was transfered to the medicine service for management of his post-surgical pain, resolving peritonitis, delirium, and heart rate control. . # bladder rupture, urosepsis, peritonitis . the pt had a history of bladder rupture s/p repair in [**1-/2175**] and presented to this admission with evidence of new rupture on ct in setting of vague abdominal pain, nausea, vomiting and evolving shock. he likely has friable bladder tissue in setting of xrt for prostate ca and prior rupture. at admission it was unclear how long the rupture had been present, but may have been related temporally to recent foley catheter change one week prior. he had a history of mrsa, proteus, klebsiella and pseudomonas utis, and thus was started on broad spectrum antibiotics (vancomycin, cefepime, and gentamicin) at admission. . he was bolused with iv fluids overnight in the micu and went to the or on the first hospital day. in the or, a perforation in the anterior bladder wall was closed. a suprapubic catheter was placed in a posterior bladder wall perforation, and a jp drain was placed in the peritoneum. cultures were taken from the peritoneal fluid and urine that grew out pseudomonas sensitive to cefepime and gent, resistent to cipro. after the surgery, the output from the jp drain continued to decrease. chemical analysis was consistent with serum, rather than urine, and on the basis of this it was felt that the bladder perforations were successfully sealed. post-operatively, he was treated with iv morphine and acetaminophen for pain control. he was transfused 2 units prbcs for hematocrit 27, with appropriate bump. the pt did go on to c/o some post-surgical pain. he continued to drain clear urine from both the urethral and suprapubic catheters. he had a ct scan on [**6-9**] to assess for a fluid collection or abscess in the pelvic cavity, which showed a small fluid collection that requires follow up ct. thus he was cleared for the removal of his jp drain. his surgical incision remained clean, dry, and intact. he had two negative urine cx. the cx of his peritoneal fluid sample taken on [**2176-6-4**] showed no growth except for rare pseudomonas aeruginosa growth that were shown on [**2176-6-12**] to be sensitive to cefepim and vancomycin. he was continued on his regimen of iv cefepim, vancomycin, and gentamycin for 10 days to ensure adequate tx of his uti and peritonitis, but was switched to solely cefepim coverage on [**2176-6-12**] when the culture sensitivities returns. he had a picc line placed on [**2176-6-12**] for the completion of his 14 day course of cefepime. he did have mild urine leakage around his suprapubic catheter, but this only lasted 3 days and urology was not concerned given that his catheters both continued to drain clear urine. he is scheduled for a f/u pelvic ct scan to reasscess the region concerning for a possible abscess, and he is also scheduled for a f/u visit with his urologist dr. [**last name (stitle) 770**] for in 2 weeks. . # delirium w/r/t the pts mental status, after his surgery, he became increasingly agitated and disoriented. the delirium was felt to be secondary to pain, recent surgery, infection, and narcotics in the setting of baseline dementia. the pt. had been receiving iv dilaudid for pain. overall the narcotics were used sparingly and his infection was treated with [**last name (stitle) 17577**] broad spectrum abx. zyprexa was used in small doses for acute agitation with adequate sedation. he was placed in soft restraints to protect against the pt pulling out his ngt or either of his catheters or drains. [**2176-6-7**] was the last time that the pt received zyprexa for agitation/delirium, and he became alert and oriented to person, hospital name, and month/year since [**6-9**] and has been at his baseline since then (he has some known dementia). he is alert and oriented x3 on d/c. . # anemia w/r/t the pts anemia as above, he received 2 units prbcs post-operatively for hematocrit of 27. his blood count then stabilized and he did not require further transfusions. his hemolytic work-up was negative. he stabilized in the low 30s throughout his stay and has been stable. . # atrial fibrillation the pt has a h/o atrial fibrillation controlled only by metoprolol and has not been anticoagulated due to his h/o hemorrhage on coumadin. while in the hospital he had multiple episodes of atrial fibrillation with rvr to 130-160s, typically related to pain and stress. his metoprolol had been held due to hypotension at admission, but was restarted to manage his rvr when his blood pressure tolerated. he continued to have such episodes of afib with rvr throughout his stay, and thus his metoprolol dose was increased to 50 mg q 8h up from 25 mg [**hospital1 **], which his bp tolerated. with this increase in the metoprolol maintained an average hr in the 70s and stopped having episodes of rvr. he will need outpt f/u to assess any need to adjust this regimen. . # diabetes mellitus ii: the pt was placed on a humalog sliding scale with 15u nph in the am, however was taken off of the nph due to hypoglycemia in the micu. on the floor, the pt developed hyperglycemia to the 200s and was consistently over 180, at which point 4 [**location **] was added and his sliding scale was increased to maintain better glycemic control. he subsequently had lower blood glucose levels overall, but still has some levels in the 200s and now that he is not infected and will be having decreasing levels of pain and stress, his insulin regimen will likely need to be adjusted at the rehab facility with [**location 17577**] finger sticks and his primary care should f/u on this as well. . # volume status/blood pressure the pt has a h/o hypertension controlled on amlodipine and metoprolol, but he was hypotensive at admission, at whcih point he was hydrated aggressively with iv normal saline overnight and post-operatively. as he recovered from hypotension and sepsis, his blood pressure came up. serial cxrs showed worsening pulmonary edema and he was diuresed with boluses of iv lasix, which completely cleared his pulmonary edema. his outpatient antihypertensives (except for lisinopril) were restarted as tolerated after he had recovered from peritonitis and urosepsis. lisinopril should be restarted as an outpatient as tolerated by his blood pressure with the new adjustment to the metoprolol levels. . # nutrition: w/r/t the pts nutrition, given the pts delirium, an ngt was placed for tube feeds which were given continuously. he had a speech and swallow consult with a swallow study and was noted to be silently aspirating and was thus deemed unable to take pos until he has rehab and a further evaluation. ngtube and peg were both considered, and it was decided to plan for discharge with the ng tube with plans for speech and [**hospital 42294**] with a goal of reachieving ability to take pos. for now he has a feed rate of 40ml/hr but his goal is 60ml/hr. the rate was slowed given recent ngt residuals, but he is on metoclopramide and and has recently begun a bowel regimen to ensure that there is no backup causing these residuals. instrucitons are to hold for residuals over 150ml. . # scrotal edema and candidal infection the pt also experienced extreme scrotal edema for being given about 14 liters of iv fluid for his urospesis/hypotension. his scrotum was elevated to decrease the edema, and has decreased but is still an issue. he also developed a erythematous rash around his scrotum and groin area which was treated with 2% miconazole powder. there is no warmth in this area or any appearance of cellulitis. the plan is to continue to manage with miconazole powder. . # depression: the pt has a h/o depression and had been on 10mg lexapro per night prior to admission. his home dose of lexapro was held during this admission given his delirium with the plan to restart it as an outpatient. . the pt was known to be a full code status. . signed: [**first name8 (namepattern2) **] [**last name (namepattern1) 42295**] (sub-intern) pager number [**serial number 11736**] [**last name (lf) **], [**first name3 (lf) 1439**] (resident) [**numeric identifier 16045**] [**last name (lf) **], [**first name3 (lf) 518**] (attending) ","PRIMARY: [Septicemia due to pseudomonas] SECONDARY: [Septic shock; Accidental puncture or laceration during a procedure, not elsewhere classified; Other suppurative peritonitis; Urinary tract infection, site not specified; Pulmonary congestion and hypostasis; Acute posthemorrhagic anemia; Rupture of bladder, nontraumatic; Severe sepsis; Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled; Atrial fibrillation; Personal history of malignant neoplasm of prostate; Long-term (current) use of insulin; Gross hematuria; Unspecified essential hypertension; Depressive disorder, not elsewhere classified; Mononeuritis of lower limb, unspecified; Late effect of radiation; ; Other specified antibiotics causing adverse effects in therapeutic use; Pressure ulcer, lower back; Pressure ulcer, heel; Pressure ulcer, stage II; Pressure ulcer, stage I; Candidiasis of skin and nails; Edema of male genital organs]","87 yo man with history of prostate cancer s/p xrt, prior bladder rupture, and dementia who was treated in the [**hospital1 18**] micu for a second bladder rupture, bladder rupture repair and suprapubic catheter placement, uti, sepsis, and peritonitis who was transfered to the medicine service for management of his post-surgical pain, resolving peritonitis, delirium, and heart rate control. # bladder rupture, urosepsis, peritonitis . he was bolused with iv fluids overnight in the micu and went to the or on the first hospital day. after the surgery, the output from the jp drain continued to decrease. his surgical incision remained clean, dry, and intact. he was continued on his regimen of iv cefepim, vancomycin, and gentamycin for 10 days to ensure adequate tx of his uti and peritonitis, but was switched to solely cefepim coverage on [**2176-6-12**] when the culture sensitivities returns. he had a picc line placed on [**2176-6-12**] for the completion of his 14 day course of cefepime. last name (stitle) 770**] for in 2 weeks. 2176-6-7**] was the last time that the pt received zyprexa for agitation/delirium, and he became alert and oriented to person, hospital name, and month/year since [**6-9**] and has been at his baseline since then (he has some known dementia). while in the hospital he had multiple episodes of atrial fibrillation with rvr to 130-160s, typically related to pain and stress. as he recovered from hypotension and sepsis, his blood pressure came up. for now he has a feed rate of 40ml/hr but his goal is 60ml/hr. instrucitons are to hold for residuals over 150ml.","87 yo man with history of prostate cancer s/p xrt, prior bladder rupture, and dementia. treated in the micu for a second bladder rupture, bladder rupture repair and suprapubic catheter placement, uti, sepsis, and peritonitis. post-operatively, he was treated with iv morphine and acetaminophen for pain control." 28223,121068.0,12930,2190-09-12,12929,187916.0,2190-05-30,Discharge summary,"Admission Date: [**2190-5-20**] Discharge Date: [**2190-5-30**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: gangrenous toe Major Surgical or Invasive Procedure: Lower extremity angiogram with balloon angioplasty and placement of stent History of Present Illness: Mr. [**Known lastname 39714**] is an 89yo gentleman with dementia, PVD, diastolic CHF, and AFib on coumadin admitted for work-up of gangrenous toe and mental status changes. Of note, he had been taking increased doses of percocet for the painful foot, and he had been increasingly withdrawn in the setting of his son's death on [**5-6**]. Shortly after admission to the floor, he was noted to be unresponsive except to sternal rub; ABG was 7.07/120/225. A Code Blue was called, and the patient was intubated for hypercarbic respiratory failure. In the MICU, he was found to be febrile; cultures were significant for a positive UA, and he was started on cipro. He self-extubated himself during a spontaneous breathing trial and did well without need for reintubation. Per his family, his mental status at baseline is that he responds to questions but is not oriented. Past Medical History: Chronic Diastolic CHF (EF 45%) PVD s/p R SFA stent [**2-/2190**], s/p PTA peroneal, s/p R tarsometatarsal amputation Tachy-brady syndrome s/p PPM Atrial fibriallation on coumadin CAD CRI (baseline Cr 1.5-2.0) h/o locally advanced prostate cancer Anemia of chronic disease (colonoscopy and EGD unremarkable) h/o lung nodules (recent CT scan with unchanged nodules on chest CT - likely silicosis vs malignancy) ?? h/o miner's lung Gout dementia CVA Allergies: NKDA PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5456**] Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Social History: Worked as a coal miner. Has 24/7 care at home for daily activities; 15 children. Not ambulating since his recent amputation of toes on right foot. Needs help with daily activities (eating, dressing). Family History: Non-contributory. Physical Exam: VS- 100.0 158/52 54 20 100% RA Gen- Awake, pleasant, responds slowly to some questions, not at all to others, oriented to self but not to place or time. Heent- MMM, anicteric, missing teeth Neck- Supple, no LAD, healing IV wound L neck, JVP not elevated. Heart- S1, S2, RRR, I/VI systolic murmur. Chest- Moving air well, no crackles. Abd- soft, NT, ND, pos BS, no palpable masses Ext- [**Last Name (un) **] bed pallor, no clubbing, no edema. Right toes have been amputated; Left big toe is gangrenous, but no frank pus or warmth. No LE edema. Neuro- UE somewhat rigid with superimposed tremor. Head slumped to the side. Pertinent Results: [**2190-5-20**] 01:15PM BLOOD WBC-8.6 RBC-3.51* Hgb-9.5* Hct-31.2* MCV-89 MCH-27.0 MCHC-30.3* RDW-17.5* Plt Ct-431 [**2190-5-23**] 03:15AM BLOOD WBC-13.8*# RBC-3.49* Hgb-9.7* Hct-31.0* MCV-89 MCH-27.6 MCHC-31.1 RDW-17.6* Plt Ct-196 [**2190-5-30**] 05:00AM BLOOD WBC-5.9 RBC-3.20* Hgb-8.7* Hct-27.5* MCV-86 MCH-27.2 MCHC-31.6 RDW-18.0* Plt Ct-381 [**2190-5-20**] 01:15PM BLOOD PT-19.3* PTT-34.1 INR(PT)-1.8* [**2190-5-30**] 05:00AM BLOOD PT-14.6* PTT-33.4 INR(PT)-1.3* [**2190-5-20**] 01:15PM BLOOD Glucose-155* UreaN-43* Creat-2.5* Na-147* K-5.6* Cl-105 HCO3-29 AnGap-19 [**2190-5-30**] 05:00AM BLOOD Glucose-81 UreaN-16 Creat-1.5* Na-145 K-4.0 Cl-106 HCO3-27 AnGap-16 [**2190-5-20**] 01:15PM BLOOD ALT-63* AST-90* AlkPhos-99 TotBili-0.2 [**2190-5-22**] 05:20AM BLOOD ALT-120* AST-121* LD(LDH)-404* AlkPhos-68 TotBili-0.2 [**2190-5-28**] 07:25AM BLOOD ALT-29 AST-22 [**2190-5-20**] 01:15PM BLOOD Lipase-24 [**2190-5-20**] 05:18PM BLOOD CK-MB-6 cTropnT-0.16* [**2190-5-21**] 03:23AM BLOOD CK-MB-NotDone cTropnT-0.17* [**2190-5-20**] 01:15PM BLOOD Albumin-3.6 Calcium-8.7 Phos-5.6*# Mg-2.6 [**2190-5-30**] 05:00AM BLOOD Calcium-8.2* Phos-3.2 Mg-1.8 [**2190-5-21**] 06:09PM BLOOD VitB12-GREATER TH Folate-GREATER TH [**2190-5-24**] 05:50AM BLOOD %HbA1c-5.5 [**2190-5-25**] 08:05AM BLOOD Triglyc-60 HDL-36 CHOL/HD-2.8 LDLcalc-51 [**2190-5-21**] 06:09PM BLOOD TSH-2.9 [**2190-5-20**] 01:15PM BLOOD ASA-NEG* Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2190-5-21**] 01:28AM BLOOD Type-ART Temp-36.7 pO2-240* pCO2-106* pH-7.11* calTCO2-36* Base XS-0 Intubat-NOT INTUBA [**2190-5-21**] 02:09AM BLOOD Type-ART pO2-225* pCO2-120* pH-7.07* calTCO2-37* Base XS-0 [**2190-5-23**] 06:06AM BLOOD Type-ART pO2-180* pCO2-48* pH-7.37 calTCO2-29 Base XS-2 [**2190-5-20**] 01:10PM BLOOD Lactate-2.2* [**2190-5-23**] 06:06AM BLOOD Lactate-1.0 [**2190-5-21**] 02:09AM BLOOD freeCa-1.20 Urine Cx [**5-22**] Citrobacter freundii sensitive to cipro Blood Cx [**5-20**], [**5-22**] negative Resp Cx: no significant growth ECG: Paced, no acute changes Studies~ Left foot plain film [**2190-5-20**]: Transverse fracture of the mid diaphysis of the second proximal phalanx. CXR [**2190-5-20**]: Bilateral parenchymal opacities, for which CT of the chest is recommended for further evaluation and to exclude malignancy. CT Head [**2190-5-21**]: There is no evidence of acute intracranial hemorrhage or mass effect. Unchanged low-attenuation areas in the subcortical white matter and focal low attenuations likely consistent with small vessel disease and lacunar ischemic changes. Persistent and unchanged right frontal subcortical area of low density, likely consistent with sequela of an old ischemic event. If there is no clinical contraindication, MRI of the head with diffusion-weighted sequences may provide better characterization of these findings. RUQ Ultrasound [**5-21**]: 1. Cholelithiasis with no signs of cholecystitis. 2. Trace of ascites. 3. Atrophic kidneys. Renal US [**5-24**]: 1. Bilateral atrophic kidneys without evidence of hydronephrosis or renal calculi. 2. Right upper pole simple cyst measuring up to 1.2 cm. CXR [**5-25**]: 1. Interval worsening of the mild pulmonary edema. Unchanged bilateral multifocal pneumonia. 2. Increasing moderate right pleural effusion. LE Angiogram [**5-27**]: 1. Access was obtained in a treograde fashion in teh right common femoral artery. AN omniflush catheter was advanced to the level of L2/L3 and a dstal abdominal aortogram was prefromed. The abdominal aorta had moderate diffuse disease. The renal arteries were poorly seen. The RCIA, IIA and EIA were patent. The RCFA was patent and teh RLE was not imaged beyond that point. The LCIA, EIA and IIA were patent as was the L CFA. The LSFA had a 70% stenosis. The ominiflush catheter was then advanced over the [**Doctor Last Name 534**] over an angled gluide wire and selective angiography of the LLE was preformed. The popliteal artery was patent with mild diffuse disease. There was a high grade stenosis of the TPT and the AT and the PT were 100% occluded. There were diffuse high grade stenoses of the peroneal artery. The left DP and foot filled via collaterals from the PA artery. 2. Successful PTA of the L PA with a 3.0 balloon. Final angiography revealed a 20% residual stenosis and no dissection. (See PTA comments) 3. Successful stenting of the LSFA with a 6.0 x 60 mm protege stent which was post dilate dto 6.0 with a admiral balloon. Final angiography revealed no residual stenosis in the stent, no dissection and normal flow. (See PTA comments) FINAL DIAGNOSIS: 1. Peripheral vascular disease. 2. Stenting of the LSFA. 3. Successful PTA of the L PA Brief Hospital Course: 89yo gentleman with dementia, HTN, PVD, CAD, AFib (s/p PPM for tachy-brady syndrome), and CKD who admitted with gangrenous toe, found to have mental status changes upon arrival to the floor. # Mental status change/Hypercarbic respiratory failure Shortly after admission to the hospital floor, the patient was noted to be obtunded. An ABG showed significant hypercarbia to 120 and a code blue was called. The patient was intubated and transferred to the MICU for further care. Within 48 hours of intubation, the patient self-extubated during a spontaneous breathing trial and did well on his own; he did not require re-intubation. The precipitating event for his hypercarbic respiratory failure was unclear. A CT of his head did not show any acute event. It was noted that he had been taking increasing doses of percocet just prior to his presentation, and there was concern that he might have had narcotic induced hypoventilation. Through the rest of his course, his mental status was oriented to person only. He responded to most simple questions. His family felt that he was at his baseline. # Fevers: The patient was febrile on [**5-22**], shortly after presentation to the MICU. His cultures were significant for Citrobacter freundi in his urine. He was started on ciprofloxacin for his UTI on [**5-22**] x a 2 week course to be completed [**6-4**]. His blood cultures were negative. Although subsequent CXRs were read as possible pneumonia, his fevers resolved with treatment of his UTI and he did not have clinical manifestations of pneumonia. Upon review of his prior chest films and CT chest, he has a long history of nodules and pulmonary opacities due to silicosis. # Acute Renal Failure on Chronic Renal Insufficiency/ Acute on chronic diastolic heart failure: Patient's baseline creatinine ranges 1.5-2.0. At the time of admission, his Cr was 2.5. His diuretics were held and he was given several liters of fluid in the MICU and transfused one unit of pRBCs. Renal ultrasound showed no evidence of obstruction. His creatinine improved to 1.4 prior to his cath and was 1.5 on the day of discharge. Although he initially appeared dehydrated on admission, Mr. [**Known lastname 39714**] developed lower extremity edema and crackles on his exam in the setting of receiving IV fluids for ARF and prior to his catheterization. He was kept in the hospital after the angiogram for diuresis. He was given IV lasix and then transitioned to PO lasix. His home lasix dose was increased from 40mg daily to 80mg daily to continue diuresis for his lower extremity edema. **His blood will be drawn [**6-2**] and a BUN/Cr should be sent to his primary care doctor so that his dose of lasix can be adjusted as appropriate. He will likely need to be put back on 40mg lasix daily once his lower extremity has improved.** # Gangrenous left big toe/Peripheral vascular disease: After the patient's renal function returned to baseline, he was brought to the cath lab and underwent LE angiography with balloon angioplasty and a stent to his LSFA. He was continued on aspirin and plavix was started. There was no evidence of infection in his lower extremities. He had recently completed 2 weeks of keflex prior to his admission. Wound care was provided per wound care nursing recommendations. The patient should follow-up with Dr. [**Last Name (STitle) **]. # Hypertension: Mr. [**Known lastname 39714**] developed hypertensive urgency during his hospital stay. The trigger for his elevated BPs was not clear, though his systolic blood pressure was noted to be elevated 150s-170s even before he became acutely hypertensive to 200 and was transferred to the CCU. His pressures were acutely controlled with hydralazine. His metoprolol was increased and he was started on norvasc. At the time of discharge, his blood pressures were greatly improved on this regimen with systolic pressures in the 130s to 150s. His blood pressure regimen should continue to be adjusted as needed as an outpatient. # Transaminitis: Patient was noted to have a transaminitis upon admission. He had a RUQ ultrasound that showed gallstones but no evidence of cholecystitis. His transaminitis resolved with IV fluids and his ALT/AST were normal at the time of discharge. # Anemia: Patient's Hct was stable at 28-31. He received 1 unit of packed red cells in the setting of ARF while he was in the MICU with an appropriate increase in his Hct. His iron supplementation was continued. # Coronary artery disease: There was no evidence of active coronary disease. His ASA, atorvastatin, and metoprolol were continued. # History of Atrial fibrillation: Patient is s/p PPM for tachybrady syndrome. He was V-paced on telemetry. His coumadin was initially held in anticipation of angiography. At the time of discharge, his coumadin was restarted. His INR will be drawn on Wednesday to allow his coumadin to be adjusted as needed since he is being sent home on ciprofloxacin, which interacts with coumadin. # Dementia/Delirium: After his extubation, the patient was felt to be at his baseline as discussed above. His valproate, which he takes at home for behavioral control, was continued. His wife was advised to avoid narcotics because of the concern that the percocet had been responsible for his hypoventilation. # Neurotic excoriations on neck: Dermatology was consulted for ulcerated lesions on the patient's neck and head. They felt that he had neurotic excoriations and that the lesions would heal if he would stop picking at them. He was given mitts to wear and the sores should be covered with vaseline and then gauze to help prevent him from scratching them. # Gout: continued allopurinol # Nutrition: Soft/dysphagia diet with nectar thickened liquid per speech and swallow # Code: full (confirmed with wife) # Dispo: He was discharged to home, where he has 24 hour care as well as a hospital bed and VNA. # Communication: Wife [**Name (NI) 382**] [**Name (NI) **] [**Telephone/Fax (1) 39715**]. # Note that the following medication changes were made: - increased metoprolol to 150mg daily - increased lasix to 80mg daily*** Please note that this dose will probably need to be decreased down to 40mg daily in the next week. - started norvasc (amlodipine) 5mg daily - started plavix (clopidogrel) 75mg daily - started ciprofloxacin 500mg twice a day for 5 more days to treat urine infection (last day to take is [**6-4**]) - stop taking percocet or oxycodone as these medications may have been responsible for making your breathing dangerously slow. Medications on Admission: ASA 81mg PO daily Iron 65mg daily Allopurinol 100mg PO daily Colchicine .6mg PO daily Divalproex 250mg PO bid Tolterodine LA 4mg daily Montelukast 10mg PO daily Metoprolol XL 50mg daily Atorvastatin 10mg PO daily Docustate 100mg PO bid Warfarin 2.5mg PO qhs Lasix 40mg daily oxycodone 1tab q4-6hours prn megace 1 teaspoon daily MVI Keflex course [**2190-5-11**] Discharge Medications: 1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Valproate Sodium 250 mg/5 mL Syrup Sig: Two [**Age over 90 1230**]y (250) mg PO Q12H (every 12 hours). 5. Multivitamins Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 6. Iron 27 mg (Elemental) Tablet Sig: Two (2) Tablet PO once a day. 7. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: adjust dose as directed by your primary doctor. 9. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 10. Megestrol 400 mg/10 mL Suspension Sig: One (1) teaspoon PO DAILY (Daily). 11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*0* 12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 13. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 14. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days: Last day to take is [**6-4**]. Disp:*10 Tablet(s)* Refills:*0* 15. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO ONCE (Once): **you will probably need to decrease your dose to 40mg sometime in the next week as directed by your physician**. Disp:*60 Tablet(s)* Refills:*0* 16. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. 17. Tolterodine 4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary Diagnosis: Peripheral vascular disease Secondary Diagnoses: Dry gangrene, Hypercarbic respiratory failure, Mental status change, Hypertension, Atrial fibrillation Discharge Condition: Afebrile, vital signs stable, mental status at baseline (oriented to person but not place or time) Discharge Instructions: You were admitted with dry gangrene of your big toe. There is no sign of infection. The gangrene is there because of poor blood flow to the foot. You had an angiogram and a stentwas placed to help the blood flow to your foot. 1. Please take all medications as prescribed. Note that the following medication changes were made: - increased metoprolol to 150mg daily - increased lasix to 80mg daily*** Please note that this dose will probably need to be decreased down to 40mg daily in the next week. - started norvasc (amlodipine) 5mg daily - started plavix (clopidogrel) 75mg daily - started ciprofloxacin 500mg twice a day for 5 more days to treat urine infection (last day to take is [**6-4**]) - stop taking percocet or oxycodone as these medications may have been responsible for making your breathing dangerously slow. 2. Please attend all follow-up appointments. 3. Please call your doctor or return to the hospital if you develop chest pain, palpitations, fevers, any change in the wounds on your feet (including redness or pus), or any other concerning symptom. ***You need to call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 34604**] office on the afternoon of Wednesday, [**6-2**] to follow up on your bloodwork. Dr. [**Last Name (STitle) 5456**] may adjust your dose of coumadin (also called warfarin) or your dose of lasix depending on the results of your bloodwork.*** Followup Instructions: 1. Please call your primary doctor and set up an appointment for the next 2-3 weeks: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5456**] [**Telephone/Fax (1) 5457**]. 2. Please call Dr. [**Last Name (STitle) **] for an appointment in the next 4 weeks: [**Telephone/Fax (1) 7960**]. 3. Please keep your previously scheduled appointments: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2190-6-18**] 10:15 Completed by:[**2190-5-30**]",105,2190-05-20 15:55:00,2190-05-30 19:17:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ALTERED MENTAL STATUS," 89yo gentleman with dementia, htn, pvd, cad, afib (s/p ppm for tachy-brady syndrome), and ckd who admitted with gangrenous toe, found to have mental status changes upon arrival to the floor. # mental status change/hypercarbic respiratory failure shortly after admission to the hospital floor, the patient was noted to be obtunded. an abg showed significant hypercarbia to 120 and a code blue was called. the patient was intubated and transferred to the micu for further care. within 48 hours of intubation, the patient self-extubated during a spontaneous breathing trial and did well on his own; he did not require re-intubation. the precipitating event for his hypercarbic respiratory failure was unclear. a ct of his head did not show any acute event. it was noted that he had been taking increasing doses of percocet just prior to his presentation, and there was concern that he might have had narcotic induced hypoventilation. through the rest of his course, his mental status was oriented to person only. he responded to most simple questions. his family felt that he was at his baseline. # fevers: the patient was febrile on [**5-22**], shortly after presentation to the micu. his cultures were significant for citrobacter freundi in his urine. he was started on ciprofloxacin for his uti on [**5-22**] x a 2 week course to be completed [**6-4**]. his blood cultures were negative. although subsequent cxrs were read as possible pneumonia, his fevers resolved with treatment of his uti and he did not have clinical manifestations of pneumonia. upon review of his prior chest films and ct chest, he has a long history of nodules and pulmonary opacities due to silicosis. # acute renal failure on chronic renal insufficiency/ acute on chronic diastolic heart failure: patients baseline creatinine ranges 1.5-2.0. at the time of admission, his cr was 2.5. his diuretics were held and he was given several liters of fluid in the micu and transfused one unit of prbcs. renal ultrasound showed no evidence of obstruction. his creatinine improved to 1.4 prior to his cath and was 1.5 on the day of discharge. although he initially appeared dehydrated on admission, mr. [**known lastname 39714**] developed lower extremity edema and crackles on his exam in the setting of receiving iv fluids for arf and prior to his catheterization. he was kept in the hospital after the angiogram for diuresis. he was given iv lasix and then transitioned to po lasix. his home lasix dose was increased from 40mg daily to 80mg daily to continue diuresis for his lower extremity edema. **his blood will be drawn [**6-2**] and a bun/cr should be sent to his primary care doctor so that his dose of lasix can be adjusted as appropriate. he will likely need to be put back on 40mg lasix daily once his lower extremity has improved.** # gangrenous left big toe/peripheral vascular disease: after the patients renal function returned to baseline, he was brought to the cath lab and underwent le angiography with balloon angioplasty and a stent to his lsfa. he was continued on aspirin and plavix was started. there was no evidence of infection in his lower extremities. he had recently completed 2 weeks of keflex prior to his admission. wound care was provided per wound care nursing recommendations. the patient should follow-up with dr. [**last name (stitle) **]. # hypertension: mr. [**known lastname 39714**] developed hypertensive urgency during his hospital stay. the trigger for his elevated bps was not clear, though his systolic blood pressure was noted to be elevated 150s-170s even before he became acutely hypertensive to 200 and was transferred to the ccu. his pressures were acutely controlled with hydralazine. his metoprolol was increased and he was started on norvasc. at the time of discharge, his blood pressures were greatly improved on this regimen with systolic pressures in the 130s to 150s. his blood pressure regimen should continue to be adjusted as needed as an outpatient. # transaminitis: patient was noted to have a transaminitis upon admission. he had a ruq ultrasound that showed gallstones but no evidence of cholecystitis. his transaminitis resolved with iv fluids and his alt/ast were normal at the time of discharge. # anemia: patients hct was stable at 28-31. he received 1 unit of packed red cells in the setting of arf while he was in the micu with an appropriate increase in his hct. his iron supplementation was continued. # coronary artery disease: there was no evidence of active coronary disease. his asa, atorvastatin, and metoprolol were continued. # history of atrial fibrillation: patient is s/p ppm for tachybrady syndrome. he was v-paced on telemetry. his coumadin was initially held in anticipation of angiography. at the time of discharge, his coumadin was restarted. his inr will be drawn on wednesday to allow his coumadin to be adjusted as needed since he is being sent home on ciprofloxacin, which interacts with coumadin. # dementia/delirium: after his extubation, the patient was felt to be at his baseline as discussed above. his valproate, which he takes at home for behavioral control, was continued. his wife was advised to avoid narcotics because of the concern that the percocet had been responsible for his hypoventilation. # neurotic excoriations on neck: dermatology was consulted for ulcerated lesions on the patients neck and head. they felt that he had neurotic excoriations and that the lesions would heal if he would stop picking at them. he was given mitts to wear and the sores should be covered with vaseline and then gauze to help prevent him from scratching them. # gout: continued allopurinol # nutrition: soft/dysphagia diet with nectar thickened liquid per speech and swallow # code: full (confirmed with wife) # dispo: he was discharged to home, where he has 24 hour care as well as a hospital bed and vna. # communication: wife [**name (ni) 382**] [**name (ni) **] [**telephone/fax (1) 39715**]. # ","PRIMARY: [Atherosclerosis of native arteries of the extremities with gangrene] SECONDARY: [Acute respiratory failure; Urinary tract infection, site not specified; Chronic diastolic heart failure; Acute kidney failure, unspecified; Malignant essential hypertension; Drug-induced delirium; Hyperosmolality and/or hypernatremia; Congestive heart failure, unspecified; Chronic kidney disease, unspecified; Other specified analgesics and antipyretics causing adverse effects in therapeutic use; Other nonspecific abnormal serum enzyme levels; Pure hypercholesterolemia; Gout, unspecified; Anemia of other chronic disease; Atrial fibrillation; Cardiac pacemaker in situ; Pneumoconiosis due to other silica or silicates; Other amputation stump complication]","89yo gentleman with dementia, htn, pvd, cad, afib (s/p ppm for tachy-brady syndrome), and ckd who admitted with gangrenous toe, found to have mental status changes upon arrival to the floor. # acute renal failure on chronic renal insufficiency/ acute on chronic diastolic heart failure: patients baseline creatinine ranges 1.5-2.0. he was kept in the hospital after the angiogram for diuresis. he will likely need to be put back on 40mg lasix daily once his lower extremity has improved.** the patient should follow-up with dr. [** the trigger for his elevated bps was not clear, though his systolic blood pressure was noted to be elevated 150s-170s even before he became acutely hypertensive to 200 and was transferred to the ccu. his metoprolol was increased and he was started on norvasc. his blood pressure regimen should continue to be adjusted as needed as an outpatient. he had a ruq ultrasound that showed gallstones but no evidence of cholecystitis. his asa, atorvastatin, and metoprolol were continued. his coumadin was initially held in anticipation of angiography. # dementia/delirium: after his extubation, the patient was felt to be at his baseline as discussed above.","89yo gentleman with dementia, htn, pvd, cad, afib, and ckd admitted with gangrenous toe. he was found to have mental status changes upon arrival to the floor. within 48 hours of intubation, the patient self-extubated during a spontaneous breathing trial." 28259,111485.0,12626,2188-10-02,12610,113482.0,2188-09-08,Discharge summary,"Admission Date: [**2188-8-21**] Discharge Date: [**2188-9-8**] Date of Birth: [**2111-12-1**] Sex: M Service: MEDICINE Allergies: Phenytoin / Decadron Attending:[**First Name3 (LF) 7223**] Chief Complaint: Meningioma Major Surgical or Invasive Procedure: [**2188-8-20**]: Left Craniotomy for Meningioma with reconstruction [**2188-8-31**]: G-tube placement History of Present Illness: 76-year-old male with history of recurrent meningioma s/p bifrontal craniotomy with cranioplasty and bone flap [**2188-8-21**], transferred from TICU for further management of post-operative atrial fibrillation. Patient has baseline sinus bradycardia and underwent ablation after presentation with tachyarrythmia on [**2188-7-16**]. Patient unable to give history. Past Medical History: 1. Atypical Reccurent Right Frontal Meningioma: Symptoms began in [**2180-6-22**] per [**First Name8 (NamePattern2) 38984**] [**Last Name (NamePattern1) **] ""when he became forgetful and sluggish. Initially he was treated for depression. A head MRI showed a large dura-based mass in the right frontal brain. A resection was done by [**Name6 (MD) 1528**] Cares, MD [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital1 38994**]. Pathology was atypical meningioma. He did well until [**10-22**] when the mass recurred. He had a second resection on [**2182-1-9**] by Dr. [**Last Name (STitle) 38985**]. This was followed with involved-field cranial irradiation by [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 38986**], MD [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital1 **] from [**Month (only) **] to [**2182-3-22**] to 5760 cGy. A follow up MRI on [**2183-6-26**] showed a 0.5-mm dural based nodular enhancement and he was referred here for SRS. Surveillance MRI on [**2184-12-8**] revealed growth of the meningioma in the superior margin of the surgical cavity invading the skull. He underwent craniectomy on [**2185-1-26**] by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **] [**Last Name (Titles) 38987**]. There had been invasion into the inner and outer tables of the skull. A piece of Duagen dural substitute was placed over the dural defect and then Methyl Methacrylate cranioplasty was placed over the skull defect. Pathology revealed atypical meningioma."" Underwent cyberknife therapy in [**2-27**]. He has been maintained on temodar (chemo) 25mg/m2. 2. Atrial fibrillation: Known to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and followed by Dr. [**Last Name (STitle) 16958**]. 3. GERD 4. OA of knee 5. Hypothyroid Social History: Married with two children. Used to smoke a pack a day but quit in [**2151**]. Used to drink beer but stopped when he was put on Coumadin. Mother died at 80 from stroke. Father died at 60's, unclear cause. Bother died 60 from lung cancer. Family History: Non-contributory Physical Exam: Gen: elderly male in NAD. Oriented x 1. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. CV: Regular rate, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: Resp were unlabored, no accessory muscle use. Poor air flow bases bilateral. No wheezes or crackles. Abd: Soft, NTND. PEG tube inplace. No HSM or tenderness. Ext: No c/c/e. Skin: No stasis dermatitis, ulcers, scars. Pertinent Results: [**2188-8-22**] Echocardiogram: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Overall left ventricular systolic function is normal (LVEF 60%). The right ventricular cavity is dilated with depressed free wall contractility. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. There is an anterior space which most likely represents a fat pad. There are no echocardiographic signs of tamponade. . Compared with the findings of the prior study (images reviewed) of [**2188-7-15**], the findings are similar. . Head CT [**2188-8-31**]: Multifocal intraparenchymal hemorrhage centered within the right frontal lobe with surrounding edema is relatively unchanged when compared to prior exam. A small amount of extra-axial hemorrhage along the right frontal craniotomy is stable in appearance as well. Areas of pneumocephalus near the right frontal craniotomy mesh is persistent. There is no shift of normally midline structures. The ventricle configuration is unchanged. Hypodensity in the periventricular and subcortical white matter reflects chronic microvascular and vascular ischemic changes. Secretions in the right frontal sinus is unchanged. . MRI [**2188-8-22**]: Status post interval resection of right frontal scalp mass and the contiguous extra-axial enhancing lesions. There is stable enhancing heterogeneous tissue in the inferior right frontal lobe. There are findings suggestive of ischemia in the right frontal lobe which is new compared to the prior study of [**2188-8-21**]. There is a new mesh cranioplasty in the right frontal region. . Labs on Admission: [**2188-8-21**] 11:30AM BLOOD WBC-2.5* RBC-3.39* Hgb-11.0* Hct-29.7* MCV-87 MCH-32.5* MCHC-37.1* RDW-14.1 Plt Ct-202 [**2188-8-21**] 08:20AM BLOOD PT-23.0* PTT-33.7 INR(PT)-2.2* [**2188-8-21**] 05:45PM BLOOD Glucose-196* UreaN-15 Creat-1.2 Na-142 K-3.9 Cl-105 HCO3-26 AnGap-15 [**2188-8-21**] 05:45PM BLOOD Calcium-10.0 Phos-3.3 Mg-2.5 . Labs on Discharge: Brief Hospital Course: Patient was electively admitted on [**8-21**] for a planned surgical resection and esthetic reconstruction of his left cranium for recurrent meningioma. On admission, his coagulation studies were elevated, requiring the use of FFP infusion and vitamin K infusion to correct prior to surgery. This was done uneventfully, and surgery proceded. Intraoperatively, he had several episodes of atrial fibrillation with rapid ventricular response, which was refractory to cardioversion. He also underwent an intraoperative TEE for further interrogation of this process. Post-operatively, he was admitted to the ICU for this reason, and cardiology consulted for control of his atrial fibrillation he was started on an Amiodarone drip and Diltiazem drips which eventually converted him. He remained abulic, followed commands inconsistently and answered in one word answers. . # Atrial Fibrillation: On [**8-27**] he was transferred to the step down unit. On [**8-27**]: Back into afib on Esmolol. On [**8-29**]: amio 200 [**Hospital1 **], LFTs wnl; back in afib. Lopressor 37.5mg PO BID. On [**2188-8-29**], patient was transferred from trauma SICU to medicine cardiology service. On arrival, he was in atrial fibrillation with RVR. Per cardiology recs, he was given acebutolol 200mg via the NG tube. Overnight, patient pulled out his NG tube. Given that he had failed swallow studies twice in the previous week, he was not able to take any medications by mouth. Plan was to give patient IV beta-blockers as needed until a PEG tube was placed. On the morning of [**2188-8-30**], patient was given metoprolol IV 5mg x1 for atrial flutter with heart rate in 130s. Patient converted back to sinus rhythm. On [**2188-9-1**] patient re-entered A Fib with RVR. Patient was started on Acebutolol, Amiodarone 100mg qd and digoxin 0.125mg. Metoprolol was not started as patient become bradycardiac last time he converted. However, patient did not convert with Acebutolol titrated up to 400mg [**Hospital1 **] consequently we started Metoprolol. Patient converted on [**2188-9-6**] when titrated to Metoprolol 100mg [**Hospital1 **]. No significant pauses or brady on conversion. Patient recently had ablation in [**6-29**]. Pacemaker placement not an ideal option as patient will require multiple MRI for meningioma resection follow-up. - Discharge on the following medications for rate control: Metroprolol 75mg po BID, Amiodarone 100mg po qd, Digoxin 0.125mcg po every other day. - Started Aspirin 81 mg, Neurosurgery stated this was ok. **** Per neurosurgery, need to wait 1 month before anticoagulation can be started due to recent craniotomy. Patient is a candidate for anti-coagulation, was in A Fib with AVR during hospitliazation. In 1 month need to discuss with Neurosurgery and Cardiology re-starting anti-coagulation **** . # s/p frontal craniotomy: Of note, on [**2188-8-30**] plastic surgery noted fluid build up at the incision site on frontal region. Fluid was cultured and final report was no growth. Patient received vancomycin for a 5 day course given that infection to that area could be devastating. Kept head of bed elevated. Continued Keppra for seizure prophylaxis. Patient has follow-up appointments with Neurosurgery and Plastic surgery (will be removing sutures). . # FEN: Patient has failed swallow study twice. Patient pulled out NG tube night of [**2188-8-29**]. G tube placed [**2188-8-31**]. On tube feeds with banana flakes secondary to bowel incontinence. - Diet order per nutrition in page 1 - discontinue banana flakes if patient becomes constipated - peg site needs to changed daily with dry dressing . # Hypothyroidism: Repeat TSH 1.3, however free T4 remained elevated at 1.9. Decreased Levothyroxine from 50mcg to 37.5 mcg. - Recheck TSH and free T4 in 1 month . # Hematuria: Urine culture negative. Repeat Ua no RBC. Hematuria most likely secondary to trauma from patient pulling at foley. Condom cath did not work, patient currently incontinent. Discharge on foley. When patient becomes more oriented can d/c foley - recheck Ua for hematuria in [**1-23**] months . # DM: Morning NPH units increased to 14 from 12 as blood sugars slightly elevated.Can adjust sliding scale at rehab as appropriate. . #. Hypertension: Well-controlled throughout admission. Continued lisinopril 10mg PO daily, for rate control patient on Metoprolol 75 mg [**Hospital1 **] with hold parameters. . # Code Status: Full, confirmed with wife Medications on Admission: 1. Amiodorone (200 mg daily) 2. Coumadin [Warfarin] (stopped [**2188-8-17**]) 3. Levoxyl (50mcg daily) 4. Lisinopril [Prinivil, Zestril] (10 mg daily) 5. Metoprolol succinate [Toprol XL] (25 mg daily) 6. Neurontin (Gabapentin)(400 mg [**Hospital1 **]) 7. Sanctura 20 mg [**Hospital1 **]) 8. Pepcid (Famotidine)(20 mg daily) Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis: Meningioma Atrial fibrillation with RVR . Secondary Diagnosis: Hypothyroidism Diabetes GERD Discharge Condition: Vitals stable, sinus rythm. Discharge Instructions: You were admitted on [**2188-8-21**] for removal of a meningioma. During the hospital course you were transferred to the cardiology service for further management of a fast heart rhythm. You eventually converted to sinus rythym. . We have made changes to your medications please take them as directed. . Please attend your follow-up appointments as listed: 1) You have an appointment with Plastic Surgery Clinic on [**2188-9-12**] 01:30p [**Hospital6 29**], [**Location (un) **]. They will be removing your sutures. 2) You have an appointment with Radiology on [**2188-10-7**] 08:30a XCT [**Apartment Address(1) 9394**] [**Hospital Ward Name **] CC CLINICAL CENTER, [**Location (un) **] RADIOLOGY to have a CT head. Immediately following you have an appointment with Neurosurgery on [**2188-10-7**] 9:30 am with Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. LM [**Hospital Unit Name **], [**Location (un) **] NEUROSURGERY WEST. You will not need an MRI of the brain, as this was done during your hospital stay. If you have any questions there number is [**Telephone/Fax (1) 1669**]. 3) Follow-up with your Cardiologist, Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] on [**10-16**] at 10:20am. His office is at [**Hospital6 29**], [**Location (un) **] CC7 CARDIOLOGY 4) Follow with primary care doctor Mr. [**Name13 (STitle) **] in [**2-25**] weeks. Have [**Hospital **] rehab call [**Telephone/Fax (1) 38995**] to make an appointment. . Call your primary care doctor or go to the ER if you experience rapid heart rate, feeling dizzy, pass out, chest pain, shortness of breath or any other symptoms. . The following discharge Instructions have been provided by Neurosurgery regarding your surgery: ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Advil, and Ibuprofen etc. - If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered. - Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING - New onset of tremors or seizures. - Any confusion or change in mental status. - Any numbness, tingling, weakness in your extremities. - Pain or headache that is continually increasing, or not relieved by pain medication. - Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. - Fever greater than or equal to 101?????? F. Followup Instructions: 1) You have an appointment with Plastic Surgery Clinic on [**8-23**] 1:30pm at [**Hospital Ward Name 23**] Building [**Location (un) 470**]. They will be removing your sutures. . 2) You have an appointment with Radiology on [**2188-10-7**] 08:30a XCT [**Apartment Address(1) 9394**] [**Hospital Ward Name **] CC CLINICAL CENTER, [**Location (un) **] RADIOLOGY to have a CT head. Immediately following you have an appointment with Neurosurgery on [**2188-10-7**] 9:30 am with Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. LM [**Hospital Unit Name **], [**Location (un) **] NEUROSURGERY WEST. You will not need an MRI of the brain, as this was done during your hospital stay. If you have any questions there number is [**Telephone/Fax (1) 1669**]. . 3) Follow-up with your Cardiologist, Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] on [**10-16**] at 10:20am. His office is at [**Hospital6 29**], [**Location (un) **] CC7 CARDIOLOGY . 4) Follow with primary care doctor Mr. [**Name13 (STitle) **] in [**2-25**] weeks. Have rehab call [**Telephone/Fax (1) 38995**] to make an appointment. Completed by:[**2188-9-8**]",24,2188-08-21 12:30:00,2188-09-08 15:30:00,ELECTIVE,PHYS REFERRAL/NORMAL DELI,REHAB/DISTINCT PART HOSP,MENINGIOMA/SDA," patient was electively admitted on [**8-21**] for a planned surgical resection and esthetic reconstruction of his left cranium for recurrent meningioma. on admission, his coagulation studies were elevated, requiring the use of ffp infusion and vitamin k infusion to correct prior to surgery. this was done uneventfully, and surgery proceded. intraoperatively, he had several episodes of atrial fibrillation with rapid ventricular response, which was refractory to cardioversion. he also underwent an intraoperative tee for further interrogation of this process. post-operatively, he was admitted to the icu for this reason, and cardiology consulted for control of his atrial fibrillation he was started on an amiodarone drip and diltiazem drips which eventually converted him. he remained abulic, followed commands inconsistently and answered in one word answers. . # atrial fibrillation: on [**8-27**] he was transferred to the step down unit. on [**8-27**]: back into afib on esmolol. on [**8-29**]: amio 200 [**hospital1 **], lfts wnl; back in afib. lopressor 37.5mg po bid. on [**2188-8-29**], patient was transferred from trauma sicu to medicine cardiology service. on arrival, he was in atrial fibrillation with rvr. per cardiology recs, he was given acebutolol 200mg via the ng tube. overnight, patient pulled out his ng tube. given that he had failed swallow studies twice in the previous week, he was not able to take any medications by mouth. plan was to give patient iv beta-blockers as needed until a peg tube was placed. on the morning of [**2188-8-30**], patient was given metoprolol iv 5mg x1 for atrial flutter with heart rate in 130s. patient converted back to sinus rhythm. on [**2188-9-1**] patient re-entered a fib with rvr. patient was started on acebutolol, amiodarone 100mg qd and digoxin 0.125mg. metoprolol was not started as patient become bradycardiac last time he converted. however, patient did not convert with acebutolol titrated up to 400mg [**hospital1 **] consequently we started metoprolol. patient converted on [**2188-9-6**] when titrated to metoprolol 100mg [**hospital1 **]. no significant pauses or brady on conversion. patient recently had ablation in [**6-29**]. pacemaker placement not an ideal option as patient will require multiple mri for meningioma resection follow-up. - ","PRIMARY: [Benign neoplasm of cerebral meninges] SECONDARY: [Cerebral edema; Atrial flutter; Hemorrhage complicating a procedure; Unspecified protein-calorie malnutrition; Injury to bladder and urethra, without mention of open wound into cavity; Hyperosmolality and/or hypernatremia; Atrial fibrillation; Sinoatrial node dysfunction; Congestive heart failure, unspecified; ; Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled; Unspecified essential hypertension; Unspecified acquired hypothyroidism; Esophageal reflux; Osteoarthrosis, localized, not specified whether primary or secondary, lower leg; Long-term (current) use of anticoagulants; Unspecified accident; Personal history of irradiation, presenting hazards to health; Personal history of tobacco use; Anemia, unspecified; Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation]","patient was electively admitted on [**8-21**] for a planned surgical resection and esthetic reconstruction of his left cranium for recurrent meningioma. this was done uneventfully, and surgery proceded. on [**8-27**]: back into afib on esmolol. on [**2188-8-29**], patient was transferred from trauma sicu to medicine cardiology service. on the morning of [**2188-8-30**], patient was given metoprolol iv 5mg x1 for atrial flutter with heart rate in 130s.","patient had several episodes of atrial fibrillation with rapid ventricular response. he was started on an amiodarone drip and diltiazem drips which eventually converted him. on [**2188-8-30**], patient was given metoprolol iv 5mg x1 for atrial flutter." 28933,118513.0,21653,2170-08-07,21652,190604.0,2170-04-20,Discharge summary,"Admission Date: [**2170-4-7**] Discharge Date: [**2170-4-20**] Date of Birth: [**2136-7-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3913**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None. History of Present Illness: 33 year old male with h/o large B-cell lymphoma status post allogenic stem cell transplant in [**2166**], complicated by severe graft versus host disease of the skin and oral mucousa requiring TPN, recent PE on Lovenox and recent admission for shortness of breath and [**Female First Name (un) **] fungemia. He presented to [**Hospital 3242**] clinic today with shortness of breath, malaise and fever. Also c/o dull chest ache across entire chest without any pain or palpitations. Denies pluiritic cp. +nonproductive cough. Fever to 102 AM of admisison. +nausea and emesis X 1, one day PTA. . Initial vitals T 103, BP 114/88 HR 160 and 91%RA. He was given 6 mg adenosine with brief slowing of HR to 120s and ?Flutter waves. He was given 2L IVF and underwent CTA to eval for PE. He also received his outpt dose of 50mg metoprolol. On return to the floor from CT, HR 135, SBP 75. The pt was transferred to the MICU for further mgmt. Past Medical History: (No changes since last admission) # Large B cell lymphoma, s/p sibling-matched allogenic SCT in [**6-/2167**] - c/b severe GVHD of skin, GI/mouth - had been receiving photopheresis -> stopped, now on rituxan - TPN dependent (via PICC) # Migraines # h/o vaso-vagal syncope with blood draws # h/o bacteremia - coagulase neg Staph [**10-5**] and [**1-15**] - Step Viridans [**1-15**] - tx w/ 6wks of vancomycin; pheresis catheter was removed - vancomycin started [**1-19**] - TEE deferred given severe GI GVHD # Steroid myopathy # Moraxella sinusitis - + sputum [**12/2090**], s/p 10d levaquin # Cardiomyopathy - TTE [**4-5**] EF 45-50% - Likely multifactorial: chemotherapy, radiation, GVHD, tachycardia # Fungemia with [**Female First Name (un) **] [**Female First Name (un) 29361**], in process of treatment with caspofungin . ONCOLOGIC HISTORY: The patient was diagnosed with diffuse large B-cell lymphoma in [**9-/2165**] and treated with eight cycles of R-CHOP and 25 doses of XRT, finished in 6/[**2165**]. In [**6-/2166**], relapsed with disease found in periaortic lymph nodes and in the spleen. He received one cycle of ICE chemotherapy on [**2166-8-11**], underwent autologous stem cell transplant and was discharged [**2166-11-11**]. Follow up PET scan on [**2167-1-30**] demonstrated recurrent persistent uptake in the spleen, mesentery, and with new liver and pulmonary lesions. Liver biopsy demonstrated diffuse large B-cell lymphoma and he was treated with three weekly doses of Rituxan but continued to progress. He was treated with salvage therapy with one cycle of MINE chemotherapy as an inpatient starting [**2167-4-23**] and CT scan demonstrated response in the lung and liver with stable disease in the spleen. The patient was admitted for a second cycle of MINE chemotherapy on [**2167-6-4**]. He received a nonmyeloablative sibling-matched allogeneic SCT in 8/[**2166**]. He has had severe chronic GVHD of the skin and oropharyngeal mucosa; he is currently undergoing Rituxan weekly x4 for GVHD, last completed at end of [**Month (only) 958**]. Social History: No changes since last admission: He lives with his wife and 6 year old son. [**Name (NI) **] works as a sales manager for [**Company 56968**], although he has been out of work recently due to his recent hospitalizations. He does not smoke and has not had any alcohol intake since prior to transplant. Family History: No changes since last admission: His paternal grandmother had breast cancer and a paternal uncle had cancer of an unknown etiology. His father had diabetes and died of a myocardial infarction. Physical Exam: Vitals: T 103.1 P 165 R 25 127/70 100% on 2L General: Chronically ill appearing male, appearing older than stated age. Dry, flaking skin over sclap. Appears in moderate distress but speaking in full sentences. HEENT: NC/AT. Dry flaking skin, alopecia. Oropharynx clear without any evidence of thrush, moist mucous membranes, no exudates or lesions. Neck: Leathery skin, no apparent LAD. Lungs: CTAB, no w/r/r, good air movement. Cardiac: Tachycardic, regular, S1, S2, no m/g/r. Abdomen: Soft, non-tender, non-distended, +BS, difficult to assess for HSM due to thickened skin. Skin: Scleroderma-like changes, thickened skin. Areas of hypo and hyperpigmentation over face, back, arms, abdomen. On left side, PICC dressing is in place. PICC site c/d/i without erythema/tenderness/induration. Neuro: A&Ox3, CNs sym and intact. Pertinent Results: [**2170-4-6**] 11:50AM WBC-12.6* RBC-3.94* HGB-11.4* HCT-36.7* MCV-93 MCH-28.8 MCHC-31.0 RDW-25.4* [**2170-4-6**] 11:50AM PLT SMR-HIGH PLT COUNT-462* [**2170-4-6**] 11:50AM NEUTS-86.3* BANDS-0 LYMPHS-9.3* MONOS-3.9 EOS-0.4 BASOS-0.1 [**2170-4-6**] 11:50AM GRAN CT-[**Numeric Identifier 56969**]* [**2170-4-6**] 11:50AM GLUCOSE-121* UREA N-19 CREAT-0.5 SODIUM-134 POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-30 ANION GAP-15 . CTA Chest ([**2170-4-7**]) 1. New right lower lobe consolidation consistent with acute pneumonia. 2. Multiple nodular opacities in the right and left upper lobes are grossly unchanged. Stable small left pleural effusion. . CT Chest ([**2170-4-14**]) 1. Marked interval increase in the large left pleural effusion with associated compressive left lower lobe atelectasis. An embedded focus of consolidation with a parapneumonic effusion cannot be excluded. 2. Small focus of tree-in-[**Male First Name (un) 239**] opacity at superolateral right middle lobe (2:24) may reflect evolving infection/inflammation. 3. Interval improvement in the right lower lobe atelectasis with better parenchymal aeration of the right lung. Multiple bilateral pulmonary nodules are unchanged since [**2170-4-7**]. . Echo ([**2170-4-17**]) The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis (LVEF = 45-50 %). Overall left ventricular systolic function is mildly depressed. Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild global left ventricular systolic dysfunction with normal estimated left ventricular filling pressure. Tachycardia. Compared with the prior study (images reviewed) of [**2170-3-15**], the heart rate is faster. The other findings are similar. Brief Hospital Course: Patient presented to outpatient clinic with hypotension and tachycardia. Attempted stabilization on floor, but then admitted to the ICU for management. . #Pneumosepsis: Patient admitted to the ICU for management. Impression on admission was for sepsis. Patient was aggressively volume resuscitated with improvement in his BP and HR. Started on cefepime and caspofungin on arrival. Central venous access was attempted w/o success. Left IJ repeatedly coiled and turned upwards into R-IJ on CXR. Line was d/c'd and decision was made to use PICC line in interim period. Blood cultures grew strep pneumo pan sensitive and patient was narrowed to nafcillin but then later changed to ceftriaxone given its improved activity against strep infections. CT of the chest confirmed lobar infiltrate in RLL w/o evidence of significant effusion. Patient became mildly hypoxic following rehydration requiring at peak time 4L NC. Subsequently respiratory status improved to 2L at time of call out from ICU, but still desating with exertion. CXR demonstrated minimal pleural effusion on right at site of infiltrate and moderate L-pleural effusion thought to be related to fluids. A repeat chest CT was obtained which confirmed the presence of a large left effusion; the pulmonary service was consulted and a thoracentesis was performed though only a few cc's of fluid were able to be aspirated. Fluid analysis demonstrated an exudate that had no micro growth at the time of discharge. The pt developed a small PTX as a result of the thoracentesis however he was asymptomatic with this and it improved with supportive care. At the time of discharge, the pt was completing his two week course of ceftriaxone. . #GVHD: The pt's GVHD is severe. He was continued on his home regimen which includes prednisone, tacrolimus, CellCept and Gleevec. His tacrolimus dosing was uptitrated based on his serum levels. Prophylaxis with Bactrim, acyclovir, and posaconazole was continued. . #Hypertension: The pt's metoprolol was held on arrival to ICU. It was restarted at 1/2 home dose prior to call out from the MICU and eventually titrated up to above his admission dose to better treat his tacycardia. . #Tachycardia: The pt's baseline HR is known to be in 100-120's. This has been attributed in the past to chemotherapy, radiation, or GVHD. On this admission, the pt's metoprolol was titrated up for better HR control with excellent effect. . #H/O PE: The pt has a history of PE in the past. A CTA at time of admission was negative for additional PE. His home Lovenox was continued. Medications on Admission: 1. Acyclovir 200 mg/5 mL Suspension [**Year (4 digits) **]: Ten (10) mL PO every eight (8) hours. 2. Cyclobenzaprine 10 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO BID (2 times a day) as needed. 3. Imatinib 400 mg Tablet [**Year (4 digits) **]: One (1) Tablet PO DAILY (Daily). 4. Enoxaparin 60 mg/0.6 mL Syringe [**Year (4 digits) **]: Sixty (60) mg Subcutaneous Q12H (every 12 hours). 5. Fluticasone 110 mcg/Actuation Aerosol [**Year (4 digits) **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day. 7. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every six (6) hours as needed for nausea, anxiety. 8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a day). 9. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution [**Last Name (STitle) **]: Seven [**Age over 90 1230**]y (750) mg PO BID (2 times a day). 10. Posaconazole 200 mg/5 mL Suspension [**Age over 90 **]: Two Hundred (200) mg PO three times a day. 11. Tacrolimus 0.5 mg Capsule [**Age over 90 **]: One (1) Capsule PO QAM (once a day (in the morning)). 12. Prednisone 5 mg/mL Concentrate [**Age over 90 **]: Fifteen (15) mg PO twice a day. 13. Artificial Saliva 0.15-0.15 % Solution [**Age over 90 **]: Thirty (30) ML Mucous membrane QID (4 times a day) as needed. 14. Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension [**Age over 90 **]: Ten (10) ML PO DAILY (Daily). 15. Sarna Anti-Itch 0.5-0.5 % Lotion Topical 16. Insulin Regular Human 100 unit/mL Solution [**Age over 90 **]: sliding scale Injection ASDIR (AS DIRECTED). 17. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback [**Age over 90 **]: One (1) gram Intravenous Q24H (every 24 hours): Day 1 = [**2170-4-14**]. Please continue through [**2170-4-28**]. 18. Artificial Tears Ophthalmic Discharge Medications: 1. Acyclovir 200 mg/5 mL Suspension [**Month/Day/Year **]: Ten (10) mL PO every eight (8) hours. 2. Cyclobenzaprine 10 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID (2 times a day) as needed. 3. Imatinib 400 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO DAILY (Daily). 4. Enoxaparin 60 mg/0.6 mL Syringe [**Month/Day/Year **]: Sixty (60) mg Subcutaneous Q12H (every 12 hours). 5. Fluticasone 110 mcg/Actuation Aerosol [**Month/Day/Year **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day. 7. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO every six (6) hours as needed for nausea, anxiety. 8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO TID (3 times a day). 9. Mycophenolate Mofetil 200 mg/mL Suspension for Reconstitution [**Last Name (STitle) **]: Seven [**Age over 90 1230**]y (750) mg PO BID (2 times a day). 10. Posaconazole 200 mg/5 mL Suspension [**Age over 90 **]: Two Hundred (200) mg PO three times a day. 11. Tacrolimus 1 mg Capsule [**Age over 90 **]: One (1) Capsule PO QAM (once a day (in the morning)). 12. Prednisone 5 mg/mL Concentrate [**Age over 90 **]: Fifteen (15) mg PO twice a day. 13. Artificial Saliva 0.15-0.15 % Solution [**Age over 90 **]: Thirty (30) ML Mucous membrane QID (4 times a day) as needed. 14. Trimethoprim-Sulfamethoxazole 40-200 mg/5 mL Suspension [**Age over 90 **]: Ten (10) ML PO DAILY (Daily). 15. Sarna Anti-Itch 0.5-0.5 % Lotion Topical 16. Insulin Regular Human 100 unit/mL Solution [**Age over 90 **]: sliding scale Injection ASDIR (AS DIRECTED). 17. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback [**Age over 90 **]: One (1) gram Intravenous Q24H (every 24 hours): Day 1 = [**2170-4-14**]. Please continue through [**2170-4-28**]. 18. Artificial Tears Ophthalmic Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: pneumosepsis large B cell lymphoma GVHD cardiomyopathy tachycardia Discharge Condition: Overall improved. Vitals stable, afebrile. Discharge Instructions: You were admitted with pneumonia and low blood pressure. We have treated you and you have improved. You are now being discharged to rehab for further care. . Please contact Dr. [**Last Name (STitle) 410**], the on-call hematology/oncology fellow, or go to the emergency if you experience any fevers above 100.0, chills, significant nausea or vomiting, inability to keep down food or drink, difficulty breathing, cough, chest pain, or other concerning symptoms. Followup Instructions: You have a follow-up appointment scheduled with Dr. [**Last Name (STitle) 410**] on [**Last Name (LF) 2974**], [**4-27**] at 9:00AM. Please call ([**Telephone/Fax (1) 14703**] if you need to change this. . You have a follow-up appointment scheduled with Drs. [**First Name (STitle) **] and [**Name5 (PTitle) **] from the [**Hospital1 18**] Pulmonary Division on [**5-21**] at 2:40PM. Please call [**Telephone/Fax (1) 612**] if you need to change this. ",109,2170-04-07 12:33:00,2170-04-20 12:43:00,EMERGENCY,CLINIC REFERRAL/PREMATURE,REHAB/DISTINCT PART HOSP,FEVER/SHORTNESS OF BREATH," patient presented to outpatient clinic with hypotension and tachycardia. attempted stabilization on floor, but then admitted to the icu for management. . #pneumosepsis: patient admitted to the icu for management. impression on admission was for sepsis. patient was aggressively volume resuscitated with improvement in his bp and hr. started on cefepime and caspofungin on arrival. central venous access was attempted w/o success. left ij repeatedly coiled and turned upwards into r-ij on cxr. line was d/cd and decision was made to use picc line in interim period. blood cultures grew strep pneumo pan sensitive and patient was narrowed to nafcillin but then later changed to ceftriaxone given its improved activity against strep infections. ct of the chest confirmed lobar infiltrate in rll w/o evidence of significant effusion. patient became mildly hypoxic following rehydration requiring at peak time 4l nc. subsequently respiratory status improved to 2l at time of call out from icu, but still desating with exertion. cxr demonstrated minimal pleural effusion on right at site of infiltrate and moderate l-pleural effusion thought to be related to fluids. a repeat chest ct was obtained which confirmed the presence of a large left effusion; the pulmonary service was consulted and a thoracentesis was performed though only a few ccs of fluid were able to be aspirated. fluid analysis demonstrated an exudate that had no micro growth at the time of discharge. the pt developed a small ptx as a result of the thoracentesis however he was asymptomatic with this and it improved with supportive care. at the time of discharge, the pt was completing his two week course of ceftriaxone. . #gvhd: the pts gvhd is severe. he was continued on his home regimen which includes prednisone, tacrolimus, cellcept and gleevec. his tacrolimus dosing was uptitrated based on his serum levels. prophylaxis with bactrim, acyclovir, and posaconazole was continued. . #hypertension: the pts metoprolol was held on arrival to icu. it was restarted at 1/2 home dose prior to call out from the micu and eventually titrated up to above his admission dose to better treat his tacycardia. . #tachycardia: the pts baseline hr is known to be in 100-120s. this has been attributed in the past to chemotherapy, radiation, or gvhd. on this admission, the pts metoprolol was titrated up for better hr control with excellent effect. . #h/o pe: the pt has a history of pe in the past. a cta at time of admission was negative for additional pe. his home lovenox was continued. ","PRIMARY: [Pneumococcal septicemia [Streptococcus pneumoniae septicemia]] SECONDARY: [Pneumococcal pneumonia [Streptococcus pneumoniae pneumonia]; Septic shock; Unspecified pleural effusion; Iatrogenic pneumothorax; Complications of transplanted bone marrow; Other primary cardiomyopathies; Hyposmolality and/or hyponatremia; Severe sepsis; Unspecified essential hypertension]","patient presented to outpatient clinic with hypotension and tachycardia. attempted stabilization on floor, but then admitted to the icu for management. patient was aggressively volume resuscitated with improvement in his bp and hr. the pt developed a small ptx as a result of the thoracentesis however he was asymptomatic with this and it improved with supportive care. prophylaxis with bactrim, acyclovir, and posaconazole was continued. #hypertension: the pts metoprolol was held on arrival to icu.","patient presented to outpatient clinic with hypotension and tachycardia. attempted stabilization on floor, but then admitted to the icu for management. impression on admission was for sepsis. patient was aggressively volume resuscitated with improvement in his bp and hr." 28999,128539.0,16343,2179-03-03,16341,118414.0,2178-11-10,Discharge summary,"Admission Date: [**2178-11-2**] Discharge Date: [**2178-11-10**] Date of Birth: [**2116-7-30**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1854**] Chief Complaint: CC:[**CC Contact Info 46547**] Major Surgical or Invasive Procedure: VP shunt placement History of Present Illness: HPI: Pt unreliable historian secondary to confusion. 62yo male with known hx of clear cell renal cancer with brain metastases. [**Name (NI) 1094**] wife reports 5day hx of increased confusion, unstable wide shuffled gait, blurred vision not improved with new glasses. Past Medical History: PMHx: -clear cell renal cancer/brain metastases -[**2173-12-4**] right radical nephrectomy and wedge resection of the right lower lung. -Tarceva/Avastin trial [**7-/2175**] till [**2177-5-7**] when started Avastin alone. -Increasing lung nodules [**2177-12-10**] and screening for IL-2 revealed brain met. -Received one cycle of IL-2. He is s/p: 1. Cyberknife SRS [**Date range (1) 46548**] to 2750 cGy brainstem 2. Cyberknife SRS [**2178-5-5**] to 1800 cGy left cerebellar met 3. WBXRT [**Date range (1) 46549**]/07 to 3600 cGy 4. Sutent started [**2178-7-7**] Social History: Social Hx: lives with his wife Family History: nc Physical Exam: PHYSICAL EXAM: T: 97.3 BP: 106/60 HR:63 R: 16 O2Sats: 97% RA Gen: WD/WN, comfortable, NAD. HEENT: Radiation induced alopecia. Pupils: [**2-6**], sluggish rxn EOMs: intact with FFOV Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. nl S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, flat affect able to follow commands. Orientation: Oriented to person, place, not time. Language: Speech slow, deliberate. Slow to process, able to repeat. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3-2mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements. Strength full power [**4-11**] throughout. No pronator drift Sensation: Intact to light touch Toes downgoing bilaterally Coordination: decreased finger to nose coordination on Rt, rapid alternating movements, heel to shin on discharge his orientation, speech, fluency of speech and gait have improved. Pertinent Results: CT: Interval increase in size of the metastatic lesion involving the right tectum which now measures 17 x 18 mm with a hyperdense appearance concerning for hemorrhage. There is interval increase in associated midbrain edema as well as mass effect on the aquaduct of sylvius. There is resultant hydrocephalus, new, with increase in periventricular hypoattenuation compatible with transependymal flow of CSF in the setting of hydrocephalus. There is a stable appearance of the small lesion in the eriventricular white matter adjacent to the right occipital [**Doctor Last Name 534**]. The lesion previously noted in the left CP angle is poorly assessed. There is no evidence of major vascular territorial infarction. There is no extra-axial hemorrhage. Surrounding soft tissue and osseous structures appear unremarkable. Nodular mucosal thickening noted in the maxillary sinuses bilaterally. Right mastoid air cell opacification is noted. [**2178-11-2**] 01:15PM WBC-4.8 RBC-3.31* HGB-12.4* HCT-38.5* MCV-116*# MCH-37.3* MCHC-32.2 RDW-15.3 [**2178-11-2**] 01:15PM GLUCOSE-92 UREA N-27* CREAT-1.6* SODIUM-141 POTASSIUM-5.8* CHLORIDE-108 TOTAL CO2-19* ANION GAP-20 Brief Hospital Course: The patient is a 62 year-old male who presented with tactile tumor and renal cell carcinoma and hydrocephalus. On [**2178-11-4**] he underwent a VP shunt successfully, and he was taken back to the recovery room, extubated and was noted to be neurologically improved from his preoperative condition. Post-op CT stable. On [**2178-11-5**] in am he was lethargic, stat head CT was repeated, which was stable. Prior to CT blood glucose was checked, which was decreased, and he received D50 [**12-9**] an ampule with elevated blood glucose when rechecked in 30 min. The rest of his hospitalization was uneventful. he advanced in his diet and activity. He was seen by PT and OT and deemed a candidate for rehab. he is voiding freely and moving his bowels. We contact[**Name (NI) **] Dr. [**Last Name (STitle) **] about his sutent and megace in the peri-operative phase. He stated it was best to start him on wednesday (one week post op). His follow up appts are detailed in the discharge instructions. Medications on Admission: Medications prior to admission: Atenolol 50 mg PM, Lisinopril 20 mg PM, Zocor 20 mg PM, Provigil 400 mg AM, Zyprexa 2.5 mg PRN, Pepcid 10 mg PRN, Megestrol 2 tsp (400 mg) when on Sutent, Sutent 25 mg (2 weeks on/1 week off). Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Modafinil 100 mg Tablet Sig: Four (4) Tablet PO daily (). 9. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 10. Megestrol 40 mg/mL Suspension Sig: One (1) PO DAILY (Daily). 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed: PLEASE DO NOT EXCEED MORE THAN 4000 MG OF TYLENOL OVER 24 HOUR PERIOD. 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): PLEASE FOLLOW SLIDING SCALE. 15. Dexamethasone 1 mg Tablet Sig: Three (3) Tablet PO tid () for 3 doses. 16. Dexamethasone 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 3 doses. 17. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO tid () for 3 doses. 18. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO bid () for 2 doses. 19. Dexamethasone 1 mg Tablet Sig: One (1) Tablet PO qd () for 1 doses. Discharge Disposition: Extended Care Facility: [**Hospital **] Medical Center - [**Hospital1 3597**] Discharge Diagnosis: OBSTRUCTIVE HYDROCEPHALUS Discharge Condition: NEUROLOGICALLY STABLE Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have your incision checked daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: PLEASE HAVE YOUR SUTURES REMOVED ON [**2178-11-18**] BY A REHAB HEALTH CARE PROVIDER PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN FOUR WEEKS. YOU WILL NEED AN [**Last Name (STitle) 4338**] OF THE BRAIN WITH and WITHOUT GADOLIDIUM Provider: [**Name10 (NameIs) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2178-12-14**] 3:00 Provider: [**Name10 (NameIs) 4338**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2178-12-14**] 12:20 F/U with Dr. [**Last Name (STitle) **] in [**1-10**] weeks, please call [**Telephone/Fax (1) 38171**] Completed by:[**2178-11-10**]",113,2178-11-02 17:33:00,2178-11-10 17:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,REHAB/DISTINCT PART HOSP,ALTERED MENTAL STATUS," the patient is a 62 year-old male who presented with tactile tumor and renal cell carcinoma and hydrocephalus. on [**2178-11-4**] he underwent a vp shunt successfully, and he was taken back to the recovery room, extubated and was noted to be neurologically improved from his preoperative condition. post-op ct stable. on [**2178-11-5**] in am he was lethargic, stat head ct was repeated, which was stable. prior to ct blood glucose was checked, which was decreased, and he received d50 [**12-9**] an ampule with elevated blood glucose when rechecked in 30 min. the rest of his hospitalization was uneventful. he advanced in his diet and activity. he was seen by pt and ot and deemed a candidate for rehab. he is voiding freely and moving his bowels. we contact[**name (ni) **] dr. [**last name (stitle) **] about his sutent and megace in the peri-operative phase. he stated it was best to start him on wednesday (one week post op). his follow up appts are detailed in the discharge instructions. ","PRIMARY: [Obstructive hydrocephalus] SECONDARY: [Secondary malignant neoplasm of brain and spinal cord; Other specified visual disturbances; Unspecified sleep apnea; Personal history of malignant neoplasm of renal pelvis; Personal history of irradiation, presenting hazards to health]","the patient is a 62 year-old male who presented with tactile tumor and renal cell carcinoma and hydrocephalus. last name (stitle) **] about his sutent and megace in the peri-operative phase.",a 62 year-old male presented with tactile tumor and renal cell carcinoma and hydrocephalus. he underwent a vp shunt successfully and was taken back to the recovery room. he was noted to be neurologically improved from his preoperative condition. 29035,152710.0,17989,2154-02-11,17959,124081.0,2153-10-03,Discharge summary,"Admission Date: [**2153-10-1**] [**Month/Day/Year **] Date: [**2153-10-3**] Date of Birth: [**2089-12-13**] Sex: F Service: SURGERY Allergies: Erythromycin Base / Indomethacin / Actonel / Reglan Attending:[**First Name3 (LF) 695**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: [**2153-10-2**]: Thoracentesis History of Present Illness: 63F 2 months s/p combined kidney and liver [**Month/Day/Year **] and splenectomy ([**2153-7-22**]) for end-stage liver disease secondary to nonalcoholic steatohepatitis and end-stage renal disease. She is currently at a [**Hospital1 1501**] for rehab and wound care. Also c/o chronic abdominal pain. Recent admission for UTI - on meropenum. Also with an open wound being packed W-Dry. Now c/o SOB and low grade fever (100.4). No CP. Says he Q. Minimal pain at kidney incision. Past Medical History: - NASH cirrhosis: Liver bx [**2152-9-6**] = Stage IV cirrhosis, Grade 2 inflammation, complicated by portal HTN - Esophageal varicies (grade I and II, s/p banding), s/p TIPS [**8-15**] - History of encephalopathy - History of ascites - Anemia - Thrombocytopenia - ESRD on HD due to diabetes and contrast-induced nephropathy - Type 2 diabetes with retinopathy, nephropathy, and neuropathy - History of C. difficile infection - History of seizures - Small left frontal meningioma - Hypertension - GERD - OSA - Leg cramps/? RLS - DJD of neck - History of dermoid cyst - Right adrenal mass -[**2153-9-22**] klebsiella uti . Past Surgical History: (per OMR) - Status post cholecystectomy followed by tubal ligation - Status post left oopherectomy - Status post appendectomy . Past Psychiatric History: (per OMR) Depression first experienced in high school. First hospitalization in [**2131**] (after husband's death). History of cutting and burning self. History of overdose. One course of ECT in past that was helpful. . Social History: Widowed, lived in [**Hospital3 **] although most recently has been at [**Hospital1 2670**] SNIF. Has 4 children, several in MA. Smoking: None; EtOH: Never; Illicits: None Family History: Mom: CAD, stroke Dad: HTN, DM Physical Exam: 100.4 86 120/62 18 84% RA in triage AAOx3 NAD no icterus or jaundice RRR decreased BS on R side, left clear Liver scar well healed, lower abd wound with wet to dry - granulating well tender R side of abd wound to mild palpation No diffuse guarding or rebound mild edema, extrem warm Pertinent Results: On Admisssion: [**2153-10-1**] WBC-3.3* RBC-3.10* Hgb-9.7* Hct-30.4* MCV-98 MCH-31.3 MCHC-31.8 RDW-18.3* Plt Ct-456* PT-12.3 PTT-28.3 INR(PT)-1.0 Glucose-82 UreaN-17 Creat-0.7 Na-139 K-4.7 Cl-103 HCO3-27 AnGap-14 ALT-21 AST-23 CK(CPK)-24* AlkPhos-109 TotBili-0.3 At [**Month/Day/Year **] [**2153-10-3**] WBC-3.0* RBC-2.86* Hgb-9.1* Hct-28.3* MCV-99* MCH-31.7 MCHC-32.1 RDW-18.3* Plt Ct-417 Glucose-127* UreaN-21* Creat-0.9 Na-143 K-4.4 Cl-106 HCO3-27 AnGap-14 ALT-18 AST-14 AlkPhos-102 TotBili-0.2 Calcium-8.6 Phos-4.7* Mg-1.8 Brief Hospital Course: 63 y/o female s/p liver/kidney [**Month/Day/Year **] who returns with ongoing issues of vague abdominal pain and also some dyspnea. She has had a recent admission for a UTI being treated with Meropenum through [**10-6**]. She presented with low grade fever and dyspnea and was de-satting into the high 80's. A non-rebreather was placed, this type of face mask causes great anxiety for this patient. A chest x-ray shows Right pleural effusion with basilar atelectasis, cannot exclude pneumonia and an ABG confirmed respiratory acidosis. On [**10-2**] she underwent a thoracentesis and [**2144**] cc clear straw colored drainage was removed by the interventional pulmonology team. Her O2 requirement immediately dropped and her respiratory rate improved and she felt subjectively better. In addition she received IV lasix with good resulting urine output. The patient was transferred to the regular surgical floor and continued to feel subjectively better with decreasing O2 requirements, and by post procedure day one she was on room air with no evidence of desats and routinely 94% on room air. The patient also had c/o right calf pain, and the right lower extremity is larger than the left. Non-invasive studies reveal no evidence of DVT. Foley was discontinued and the patient c/o urinary discomfort. She will be treated with pyridium as the UA is negative and she continues on the meropenum. Chest xray on [**10-3**] shows improvement. The left side is more clear, the right side shows small to moderate pleural effusion. The vasculature is engorged but does not show pulmonary edema. She continues to atelectasis on the right. Physical exam reveals no crackles but there is diminished breath sounds about midway up lung field. The interventional pulmonary team was contact[**Name (NI) **] for further recommendations and she is to be treated symptomatically PRN. The lasix dose was increased while she was hospitalized. Medications on Admission: Furosemide 20' Amlodipine 5' Prednisone 5' citalopram 60' Levetiracetam 500"" MMF 250"" Nystatin 5"""" Omeprazole 20' Trimethoprim-Sulfamethoxazole 80-400' Valganciclovir 450' Senna 1"" Docusate Sodium 100"" Lidocaine 5 %(700 mg/patch) Tacrolimus 3"" Meropenem 500"""" Trazodone 50' Insulin NPH 30' [**Name (NI) **] Medications: 1. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty (30) units Subcutaneous once a day. 2. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous four times a day. 3. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ml PO four times a day. 12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: 6 tablets maximum daily. 15. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 17. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a day. 19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety. 20. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. 21. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 4 days: Through [**2153-10-6**]. 22. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: per protocol ML Intravenous PRN (as needed) as needed for line flush. [**Month/Day/Year **] Disposition: Extended Care Facility: [**Hospital 2670**] Rehab [**Hospital **] Diagnosis: Pleural effusion; s/p thoracentesis [**Hospital **] Condition: Stable/ Good. No O2 requirement [**Hospital **] Instructions: Please call the [**Hospital **] clinic at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, diarrhea, chest pain, increased shortness of breath, increased abdominal pain or other concerning symptoms Continue labwork evry Monday and Thursday and fax to [**Telephone/Fax (1) 697**] to include CBC, Chem 10, LFTs, UA, trough Prograf The [**Telephone/Fax (1) **] clinic will work with the facility for medication management. Please do not change any immunosuppressives with checking with [**Telephone/Fax (1) **] clinic No heavy lifting Patient may shower, replace dressing. Complete Meropenum course on [**2153-10-6**] Followup Instructions: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2153-10-26**] 11:00 [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**] Date/Time:[**2153-10-29**] 8:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2153-10-3**]",131,2153-10-01 18:57:00,2153-10-03 14:20:00,EMERGENCY,EMERGENCY ROOM ADMIT,SNF,"FEVER,ORIGIN UNKNOWN"," 63 y/o female s/p liver/kidney [**month/day/year **] who returns with ongoing issues of vague abdominal pain and also some dyspnea. she has had a recent admission for a uti being treated with meropenum through [**10-6**]. she presented with low grade fever and dyspnea and was de-satting into the high 80s. a non-rebreather was placed, this type of face mask causes great anxiety for this patient. a chest x-ray shows right pleural effusion with basilar atelectasis, cannot exclude pneumonia and an abg confirmed respiratory acidosis. on [**10-2**] she underwent a thoracentesis and [**2144**] cc clear straw colored drainage was removed by the interventional pulmonology team. her o2 requirement immediately dropped and her respiratory rate improved and she felt subjectively better. in addition she received iv lasix with good resulting urine output. the patient was transferred to the regular surgical floor and continued to feel subjectively better with decreasing o2 requirements, and by post procedure day one she was on room air with no evidence of desats and routinely 94% on room air. the patient also had c/o right calf pain, and the right lower extremity is larger than the left. non-invasive studies reveal no evidence of dvt. foley was discontinued and the patient c/o urinary discomfort. she will be treated with pyridium as the ua is negative and she continues on the meropenum. chest xray on [**10-3**] shows improvement. the left side is more clear, the right side shows small to moderate pleural effusion. the vasculature is engorged but does not show pulmonary edema. she continues to atelectasis on the right. physical exam reveals no crackles but there is diminished breath sounds about midway up lung field. the interventional pulmonary team was contact[**name (ni) **] for further recommendations and she is to be treated symptomatically prn. the lasix dose was increased while she was hospitalized. ","PRIMARY: [Unspecified pleural effusion] SECONDARY: [Acidosis; Urinary tract infection, site not specified; Kidney replaced by transplant; Liver replaced by transplant; Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled; Background diabetic retinopathy; Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled; Polyneuropathy in diabetes; Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled; Epilepsy, unspecified, without mention of intractable epilepsy; Unspecified essential hypertension; Esophageal reflux; Obstructive sleep apnea (adult)(pediatric)]","63 y/o female s/p liver/kidney [**month/day/year **] who returns with ongoing issues of vague abdominal pain and also some dyspnea. on [**10-2**] she underwent a thoracentesis and [**2144**] cc clear straw colored drainage was removed by the interventional pulmonology team. the patient was transferred to the regular surgical floor and continued to feel subjectively better with decreasing o2 requirements, and by post procedure day one she was on room air with no evidence of desats and routinely 94% on room air. she continues to atelectasis on the right.",63 y/o female s/p liver/kidney returns with ongoing issues of vague abdominal pain and dyspnea. she presented with low grade fever and dyspnea and was de-satting into the high 80s. she received iv lasix with good resulting urine output. 29035,152710.0,17989,2154-02-11,17958,108831.0,2153-08-21,Discharge summary,"Admission Date: [**2153-7-9**] [**Month/Day/Year **] Date: [**2153-8-21**] Date of Birth: [**2089-12-13**] Sex: F Service: SURGERY Allergies: Erythromycin Base / Indomethacin / Actonel / Reglan Attending:[**First Name3 (LF) 695**] Chief Complaint: GI bleeding. Major Surgical or Invasive Procedure: [**2153-7-22**]: liver and kidney [**Month/Day/Year **] History of Present Illness: The patient is a 63 year old female iwth a history of NASH cirrhosis awaiting [**Month/Day/Year **], complicated by portal vein hypertension, grade 2 esophogeal varices s/p TIPS, encephalopathy, recurrent pleural effusions, ESRD on HD awaiting [**Month/Day/Year **] was was transfered from [**Hospital1 **] Care with GIB unresponsive to multiple transfusions. The patient was recently hospitalized at [**Hospital1 18**] from [**Date range (1) 19159**] for altered mental status believed secondary to hepatic encephalopathy. During the admission the patient had a large melanotic stool, and an EGD showed which showed portal hypertensive gastropathy vs. GAVE syndrome without varices. On day of [**Date range (1) **], the patient had a hct of 26.9. While at [**Hospital1 **], patient describes having melena for a couple of days, without BRBPR. She reportedly received 4units of PRBC over the weekend, without improvement of HCT. When checked at [**Hospital1 **], hct was less than 21, and she was transfered to [**Hospital1 18**] for further evaluation. Of note, the patient has questioning of clotting of her AV graft, with an inability to dialyze on the day of presentation. . On presenation ot [**Hospital1 18**], initial vitas were 98.5, BP 102/39, HR 56, 94% on RA. Her vitals remained stable, and hct was 23.3. She was transfused with 1 unit of PRBC, cipro for SBP ppx, IV protonix, started on an octreotide gtt, and given 1 L of NS. She was noted to have a melanotic, guaic positive stool. She was admitted to the MICU for further manegment. . Past Medical History: - NASH cirrhosis: Liver bx [**2152-9-6**] = Stage IV cirrhosis, Grade 2 inflammation, complicated by portal HTN - Esophageal varicies (grade I and II, s/p banding), s/p TIPS [**8-15**] - History of encephalopathy - History of ascites - Anemia - Thrombocytopenia - ESRD on HD due to diabetes and contrast-induced nephropathy - Type 2 diabetes with retinopathy, nephropathy, and neuropathy - History of C. difficile infection - History of seizures - Small left frontal meningioma - Hypertension - GERD - OSA - Leg cramps/? RLS - DJD of neck - History of dermoid cyst - Right adrenal mass . Past Surgical History: (per OMR) - Status post cholecystectomy followed by tubal ligation - Status post left oopherectomy - Status post appendectomy . Past Psychiatric History: (per OMR) Depression first experienced in high school. First hospitalization in [**2131**] (after husband's death). History of cutting and burning self. History of overdose. One course of ECT in past that was helpful. . Social History: Widowed, lived in [**Hospital3 **] although most recently has been at rehab. Has 4 children, several in MA. Smoking: None; EtOH: Never; Illicits: None Family History: Family History: Mom: CAD, stroke Dad: HTN, DM Physical Exam: On presentation to the MICU: VS: T 97.9 BP 104/40 HR 83 RR 20 97% 2L GENERAL: NAD, lethargic but opens eyes to voice and follows commands HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. dryMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 3/6 SEM best heard at RUSB, no rubs or [**Last Name (un) 549**]. JVP=7cm. LUNGS: decreased BS at right base but poor effort, no wheezing or rhonchi ABDOMEN: +BS, Soft, NT, obese, distended, negative fluid wave but Dullness to percussion throughout all 4 quadrants, No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Lethargice CN 2-12 grossly intact. Preserved sensation throughout grossly. Moves all 4 extremities(unable to interact for strength exam) but b/l arms contracted. Increased tone with all extremities. [**2-9**]+ reflexes, equal BL. Unable to assess coordination. Gait assessment deferred. +asterixis PSYCH: unable to assess . Pertinent Results: On Admission: [**2153-7-9**] WBC-3.3* RBC-2.54* HGB-8.0* HCT-23.3* MCV-92 MCH-31.4 MCHC-34.3 RDW-18.3* NEUTS-67.5 LYMPHS-26.4 MONOS-5.4 EOS-0.3 BASOS-0.4 PLT COUNT-65* PT-16.4* PTT-32.4 INR(PT)-1.5* GLUCOSE-150* UREA N-55* CREAT-5.4*# SODIUM-134 POTASSIUM-4.5 CHLORIDE-101 TOTAL CO2-24 ANION GAP-14 LIPASE-40 ALT(SGPT)-11 AST(SGOT)-17 ALK PHOS-98 TOT BILI-1.0 . Hct Trend: [**2153-7-10**] 02:12AM BLOOD Hct-23.0* [**2153-7-10**] 09:04AM BLOOD Hct-20.9* [**2153-7-10**] 12:42PM BLOOD Hct-23.4* [**2153-7-10**] 05:22PM BLOOD Hct-22.7* [**2153-7-11**] 12:27AM BLOOD Hct-26.8* [**2153-7-11**] 05:52AM BLOOD Hct-25.8* . At [**Month/Day/Year **]: [**2153-8-20**] WBC-12.1* RBC-3.30* Hgb-10.0* Hct-31.2* MCV-94 MCH-30.2 MCHC-32.0 RDW-16.2* Plt Ct-893* Glucose-96 UreaN-19 Creat-0.6 Na-139 K-5.1 Cl-105 HCO3-26 AnGap-13 ALT-20 AST-10 AlkPhos-116 TotBili-0.3 Albumin-2.9* Calcium-8.3* Phos-3.5 Mg-1.5* tacroFK-6.9 Brief Hospital Course: 63 y/o female with NASH cirrhosis, c/b portal hypertension, grade [**2-9**] esophageal varices s/p TIPS, encephalopathy, recurrent pleural effusions requiring weekly thoracentesis, and ESRD on HD who was admitted with GI Bleed. . # UGIB: Has h/o NASH cirrhosis c/b varicies s/p banding and EGD 2 weeks prior with severe portal hypertensive gastropathy vs. GAVE syndrome. Presented with melenotic stools and hematocrit drop unresponsive to transfusion. EGD showed clotted blood and known varices/gastropathy with no active bleeding. ? oozing from gastropathy. Hct stablelized after 2 units pRBCs and was called out of the ICU to the medicine floor. PPI was continued. . Dyspnea: Likely related to reaccumulating pleural effusion. Required 2 thoracentesis procedures on the medicine service prior to [**Month/Day (2) **]. Fluid was exudative by lights criteria and cultures were negative. Likely related to underlying liver disease. She received one tap for 1 liter post op and has otherwise been stable. . # Fever: Patient was intermittently febrile while on the medicine service prior to [**Month/Day (2) **]. Culture data and c diff toxin were unrevealing. She was placed on Vanco and Zosyn empirically from [**7-15**] to [**7-21**] until [**Month/Year (2) **] for presumed HAP, but no adequate sputum could be obtained. She had one episode of fever post [**Month/Year (2) **] that was related to a Klebsiella UTI which was treated with Zosyn x 5 days, she remained afebrile through the rest of hospitalizations. . # ESRD: Prior to [**Month/Year (2) **], was on TTS HD schedule. Received liver/kidney [**Month/Year (2) **].Because she was highly sensitized, she received plasmapheresis and thymoglobulin. The creatinine was down to 0.6 by time of [**Month/Year (2) **]. . # NASH Cirrhosis: On the medicine service, patient was continued on lactulose, rifaximin, midodrine, ursodiol, nadolol and bactrim DS for SBP prophylaxis prior to [**Month/Year (2) **]. She received a combined liver and kidney [**Month/Year (2) **] on [**7-21**] (extending into [**7-22**]) She was taken to the OR with Drs [**Last Name (STitle) **] and [**Name5 (PTitle) 816**]. The liver surgery consisted of Orthotopic deceased donor liver [**Name5 (PTitle) **], piggyback, portal vein to portal vein anastomosis, common hepatic artery donor to proper hepatic artery recipient, common bile duct to common bile duct anastomosis with no T-tube. Splenectomy was also done to assist with increased PRA for the kidney. Post operatively her liver enzymes returned to [**Location 213**] very soon after surgery and remained stable throughtout the hospitalization. She received routine immunosuppression to include Cellcept and Prograf as well as the induction Thymo and solumedrol with plasmapheresis for the highly sensitzed kidney. She also received IVIg x 3 doses. . Nutrition: Patient will continue on tube feeds. Her appetite has improved over the course of the hospitalization but is still requiring some supplementation via [**Location 40056**]. . # DM2: Continue glargine and SSI. . # History of seizure: Leviticetam is continued post op. . # Depression/Anxiety: Continue on citalopram (dose increased to 40 mg daily on [**8-19**]) and ativan PRN . Medications on Admission: Albuterol Sulfate (0.083 % nebs inhaled q(4) hours prn Allopurinol 100 mg Tablet PO QOD Nephrocaps daily Citalopram 60 mg Tablet by mouth daily Gabapentin 300 mg Capsule PO QOD Hydroxyzine HCl 25 mg Tablet PO q8hr prn pruritis Novolog SS Lantus 18 units at bedtime Ipratropium Bromide (0.02 %) q(6) prn Lactulose 45 CCs by mouth qid Lamotrigine 100 mg Tablet by mouth at bedtime Keppra 1,000 mg Tablet by mouth once a day after HD on HD days Lorazepam 1 mg Tablet by mouth q (8) prn anxiety Midodrine 5 mg by mouth QTUTHSA (TU,TH,SA) Nadolol 20 mg Tablet by mouth once a day Pantoprazole 40 mg Tablet, Delayed Release (E.C.) by mouth every q12 Rifaximin 400 mg Tablet PO TID Renagel 800 mg Tablet by mouth TID Bactrim DS 800 mg-160 mg Tablet by mouth daily Ursodiol 600 mg Capsule PO BID OTC: Calcium Carbonate-Vitamin D3 [Caltrate-600 Plus Vitamin D3] 600 mg-400 unit Tablet 2 Tablet(s) by mouth once a day Multivitamin 1 Tablet(s) by mouth once a day (OTC) . [**Month/Year (2) **] Medications: 1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for diarrhea. 4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for peri area. 8. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for diarrhea. 10. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Follow [**Month/Year (2) **] clinic taper. 11. Insulin Glargine 100 unit/mL Solution Sig: Thirty Two (32) units Subcutaneous at bedtime. 12. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale Injection four times a day. 13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 14. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO twice a day. 15. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 16. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for agitation/anxiety. [**Month/Year (2) **] Disposition: Extended Care Facility: [**Hospital1 **] [**Hospital1 **] Diagnosis: NASH cirrhosis ESRD s/p combined liver/kidney [**Hospital1 **] [**Hospital1 **] Condition: Stable/Good [**Hospital1 **] Instructions: Please call the [**Hospital1 **] clinic at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, diarrhea, inability to take or keep down food, fluids or medications. Labs to be drawn every Monday and Thursday to include CBC, Chem 10, AST, ALT, t bili, Alk Phos, trough Prograf level and U/A Continue cycled tube feeds via [**Name (NI) 40056**] PT Abdominal wound normal saline moist to dry dressing daily Sacral dressing q 72 hours and PRN Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2153-8-29**] 3:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2153-9-5**] 11:00 [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2153-9-14**] 11:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2153-8-21**]",174,2153-07-09 22:39:00,2153-08-21 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,LONG TERM CARE HOSPITAL,UPPER GI BLEED," 63 y/o female with nash cirrhosis, c/b portal hypertension, grade [**2-9**] esophageal varices s/p tips, encephalopathy, recurrent pleural effusions requiring weekly thoracentesis, and esrd on hd who was admitted with gi bleed. . # ugib: has h/o nash cirrhosis c/b varicies s/p banding and egd 2 weeks prior with severe portal hypertensive gastropathy vs. gave syndrome. presented with melenotic stools and hematocrit drop unresponsive to transfusion. egd showed clotted blood and known varices/gastropathy with no active bleeding. ? oozing from gastropathy. hct stablelized after 2 units prbcs and was called out of the icu to the medicine floor. ppi was continued. . dyspnea: likely related to reaccumulating pleural effusion. required 2 thoracentesis procedures on the medicine service prior to [**month/day (2) **]. fluid was exudative by lights criteria and cultures were negative. likely related to underlying liver disease. she received one tap for 1 liter post op and has otherwise been stable. . # fever: patient was intermittently febrile while on the medicine service prior to [**month/day (2) **]. culture data and c diff toxin were unrevealing. she was placed on vanco and zosyn empirically from [**7-15**] to [**7-21**] until [**month/year (2) **] for presumed hap, but no adequate sputum could be obtained. she had one episode of fever post [**month/year (2) **] that was related to a klebsiella uti which was treated with zosyn x 5 days, she remained afebrile through the rest of hospitalizations. . # esrd: prior to [**month/year (2) **], was on tts hd schedule. received liver/kidney [**month/year (2) **].because she was highly sensitized, she received plasmapheresis and thymoglobulin. the creatinine was down to 0.6 by time of [**month/year (2) **]. . # nash cirrhosis: on the medicine service, patient was continued on lactulose, rifaximin, midodrine, ursodiol, nadolol and bactrim ds for sbp prophylaxis prior to [**month/year (2) **]. she received a combined liver and kidney [**month/year (2) **] on [**7-21**] (extending into [**7-22**]) she was taken to the or with drs [**last name (stitle) **] and [**name5 (ptitle) 816**]. the liver surgery consisted of orthotopic deceased donor liver [**name5 (ptitle) **], piggyback, portal vein to portal vein anastomosis, common hepatic artery donor to proper hepatic artery recipient, common bile duct to common bile duct anastomosis with no t-tube. splenectomy was also done to assist with increased pra for the kidney. post operatively her liver enzymes returned to [**location 213**] very soon after surgery and remained stable throughtout the hospitalization. she received routine immunosuppression to include cellcept and prograf as well as the induction thymo and solumedrol with plasmapheresis for the highly sensitzed kidney. she also received ivig x 3 doses. . nutrition: patient will continue on tube feeds. her appetite has improved over the course of the hospitalization but is still requiring some supplementation via [**location 40056**]. . # dm2: continue glargine and ssi. . # history of seizure: leviticetam is continued post op. . # depression/anxiety: continue on citalopram (dose increased to 40 mg daily on [**8-19**]) and ativan prn . ","PRIMARY: [Other specified disorders of stomach and duodenum] SECONDARY: [End stage renal disease; Hemorrhage of gastrointestinal tract, unspecified; Portal hypertension; Esophageal varices in diseases classified elsewhere, without mention of bleeding; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease; Other ascites; Unspecified pleural effusion; Pneumonia, organism unspecified; Urinary tract infection, site not specified; Other complications due to renal dialysis device, implant, and graft; Paroxysmal ventricular tachycardia; Hepatic encephalopathy; ; Cardiac arrest; Cirrhosis of liver without mention of alcohol; Other chronic nonalcoholic liver disease; Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled; Polyneuropathy in diabetes; Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled; Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled; Background diabetic retinopathy; Anemia in chronic kidney disease; Epilepsy, unspecified, without mention of intractable epilepsy; Esophageal reflux; Obstructive sleep apnea (adult)(pediatric); Dysthymic disorder; Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site; 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]","63 y/o female with nash cirrhosis, c/b portal hypertension, grade [**2-9**] esophageal varices s/p tips, encephalopathy, recurrent pleural effusions requiring weekly thoracentesis, and esrd on hd who was admitted with gi bleed. egd showed clotted blood and known varices/gastropathy with no active bleeding. ? # fever: patient was intermittently febrile while on the medicine service prior to [**month/day (2) **]. received liver/kidney [**month/year (2) **].because she was highly sensitized, she received plasmapheresis and thymoglobulin. # nash cirrhosis: on the medicine service, patient was continued on lactulose, rifaximin, midodrine, ursodiol, nadolol and bactrim ds for sbp prophylaxis prior to [**month/year (2) **]. splenectomy was also done to assist with increased pra for the kidney.","63 y/o female with nash cirrhosis, c/b portal hypertension, grade [**2-9**] esophageal varicies s/p tips, encephalopathy, recurrent pleural effusions requiring weekly thoracentesis, and esrd on hd who was admitted with gi bleed. presented with melenotic stools and hematocrit drop unresponsive to transfusion " 29035,108831.0,17958,2153-08-21,17957,115770.0,2153-05-16,Discharge summary,"Admission Date: [**2153-5-14**] [**Year/Month/Day **] Date: [**2153-5-16**] Date of Birth: [**2089-12-13**] Sex: F Service: MEDICINE Allergies: Erythromycin Base / Indomethacin / Actonel / Reglan Attending:[**First Name3 (LF) 3561**] Chief Complaint: Hypoxia and hypotension s/p thoracentesis Major Surgical or Invasive Procedure: None History of Present Illness: 63 F with NASH cirrhosis, recurrent pleural effusions, DM, ESRD on TTS schedule who was sent to the ER after 2 liter thoracentesis done by radiology. Her oxygen saturation dropped to the high 80s and she was transiently hypotensive to 80s systolic. She denied lightheadedness, dizziness, chest pain, nausea, diaphoresis, her only complaint was of pleurisy on inspiration. In the ER her blood pressure was stable in the 90s systolic (b/l 90-100s), CXR with no PTX, 99% 4L/NC. Clinically without complaints, asking for food. Guiaic negative. No other complaints. No fluids given. Admitted to MICU for close observation of hemodynamics. . Review of systems is otherwise negative other than HPI. In the ICU she had no complaints other than pleurisy. Past Medical History: NASH cirrhosis: Liver bx [**2152-9-6**] = Stage IV cirrhosis, Grade 2 inflammation, complicated by portal HTN --Esophageal varicies (grade I and II, s/p banding), s/p TIPS in [**9-15**] --History of encephalopathy --History of ascites - Anemia - Thrombocytopenia - ESRD on HD due to diabetes and contrast-induced nephropathy - Type 2 diabetes with retinopathy, nephropathy, and neuropathy - History of C. difficile infection - History of seizures - Small left frontal meningioma - Hypertension - GERD - OSA - Leg cramps/? RLS - DJD of neck - History of dermoid cyst - Right adrenal mass . Past Surgical History: - Status post cholecystectomy followed by tubal ligation - Status post left oopherectomy - Status post appendectomy . Past Psychiatric History: Depression first experienced in high school. First hospitalization in [**2131**] (after husband's death). History of cutting and burning self. History of overdose. One course of ECT in past that was helpful. Social History: Social History: Widowed, lived in [**Hospital3 **] although most recently has been at rehab. Has 4 children, several in MA. Smoking: None EtOH: Never Illicits: None Family History: Family History: Mom: CAD, stroke Dad: HTN, DM Physical Exam: Tmax: 36.7 ??????C (98 ??????F) Tcurrent: 36.7 ??????C (98 ??????F) HR: 58 (56 - 62) bpm BP: 98/34(49) {76/34(47) - 100/47(59)} mmHg RR: 15 (11 - 15) insp/min SpO2: 97% General Appearance: No acute distress Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Lymphatic: Cervical WNL, Supraclavicular WNL Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Expansion: Symmetric), (Percussion: Dullness : RLL), (Breath Sounds: Diminished: RLL) Abdominal: Soft, Non-tender, Bowel sounds present, Distended, ascites present Extremities: Right: 1+, Left: 1+ Skin: Not assessed Neurologic: Attentive, Follows simple commands, Responds to: Not assessed, Oriented (to): x3, Movement: Not assessed, Tone: Not assessed Pertinent Results: COMPARISON: [**2153-4-29**]. FINDINGS: There is no pneumothorax. There is small residual pleural effusion on the right. Left lung is clear. There is no left effusion. Heart and mediastinal contours are stable. Right-sided tunneled catheter is again noted, and the tip is situated within the right atrium. A tip is noted, and projects over the expected location within the liver. Osseous structures are stable. IMPRESSION: No pneumothorax. ------------ [**5-15**] CHEST PORTABLE AP REASON FOR EXAM: 63-year-old woman with re-expansion pulmonary edema, assess change. Since yesterday, right middle lobe and right lower lobe alveolar opacity decreased. Bilateral pleural effusions are unchanged, still small, more marked on the right. Right hemodialysis catheter still ends in the right atrium. Clips in the upper abdomen are unchanged. There is no other change. Brief Hospital Course: 63 F with cirrhosis, ESRD s/p thoracentesis who presents with hypoxia and hypotension in setting likely re-expansion pulmonary edema . #. Hypoxia- patient currently 99% on 2L and comfortable. Suspect she had some desaturation in setting of re- expansion edema which has stabilized. No evidence of pneumothorax on multiple CXR, there is re-accumulation of fluid in the right lung. She was monitored for 48 hours in the ICU and had stable blood pressure and oxygen saturation on 2 liters of oxygen. She was discharged to rehab facility. She should have future thoracentesis by interventional pulmonary in order to follow trans pulmonary pressures to avoid re-expansion pulmonary edema. . # Hypotension- patient back to baseline, suspect transient hypotension in setting volume shifts after thoracentesis. Baseline systolic pressure 90s. . # ESRD- [**3-12**] diabetes, continue phos binder, was dialyzed on [**5-15**] with 3 liters removed. - call renal in AM, due for HD - continued midodrine with HD . # Cirrhosis- on transplant list - Encephalopathy- continued lactulose and rifaximin - SBP- h/o prior SBP, continued Bactrim DS ppx - ascites- off diuretics, intermittent PC as indicated, none this hospitalization - varices- nadolol - anemia- cont PPI . # Diabetes- continued lantus and humalog SS . # Seizures- continued lamictal . # Depression- continued celexa CODE STATUS: confimred FULL CODE Medications on Admission: Acetaminophen prn Lactulose 30cc qid Lamotrigine 100 mg qhs Pantoprazole 40 mg daily Allopurinol 100 mg qod Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q8H prn Lorazepam 0.5 mg q8h prn Gabapentin 300 mg daily Sevelamer HCl 800mg po tid Cholecalciferol 800 units daily Rifaximin 200 mg po tid Albuterol prn Ipratropium prn B-Complex with Vitamin C po daily Insulin Glargine 20 units QHS Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY Keppra 1,000 mg Tablet Sig: One (1) Tablet PO once a day Docusate Sodium 100 mg PO BID Bactrim DS 1 tab daily Midodrine 5 mg Tablet Sig: One (1) Tablet PO QTUTHSA Zolpidem 5 mg Tablet Sig: 0.5 Tablet PO HS Insulin Lispro Subcutaneous [**Month/Day (4) **] Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). 2. Lamotrigine 100 mg Tablet Sig: One (1) 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. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Ursodiol 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). 10. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed. 12. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 17. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 18. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20) Subcutaneous at bedtime. 19. Insulin Lispro 100 unit/mL Cartridge Sig: as directed Subcutaneous four times a day: per sliding scale. 20. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 22. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 23. Midodrine 5 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (TU,TH,SA). 24. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. [**Month/Day (4) **] Disposition: Extended Care Facility: [**Last Name (LF) 2670**] , [**First Name3 (LF) 5871**] [**First Name3 (LF) **] Diagnosis: Re-expansion pulmonary edema [**First Name3 (LF) **] Condition: Stable [**First Name3 (LF) **] Instructions: You were in the ICU for monitoring after fluid removal of your lung. Your vitals were stable. Follow up with the liver doctors [**First Name (Titles) **] [**Last Name (Titles) **]. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2153-6-22**] 11:30 ",97,2153-05-14 22:41:00,2153-05-16 14:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,SNF,HYPOXIA," 63 f with cirrhosis, esrd s/p thoracentesis who presents with hypoxia and hypotension in setting likely re-expansion pulmonary edema . #. hypoxia- patient currently 99% on 2l and comfortable. suspect she had some desaturation in setting of re- expansion edema which has stabilized. no evidence of pneumothorax on multiple cxr, there is re-accumulation of fluid in the right lung. she was monitored for 48 hours in the icu and had stable blood pressure and oxygen saturation on 2 liters of oxygen. she was discharged to rehab facility. she should have future thoracentesis by interventional pulmonary in order to follow trans pulmonary pressures to avoid re-expansion pulmonary edema. . # hypotension- patient back to baseline, suspect transient hypotension in setting volume shifts after thoracentesis. baseline systolic pressure 90s. . # esrd- [**3-12**] diabetes, continue phos binder, was dialyzed on [**5-15**] with 3 liters removed. - call renal in am, due for hd - continued midodrine with hd . # cirrhosis- on transplant list - encephalopathy- continued lactulose and rifaximin - sbp- h/o prior sbp, continued bactrim ds ppx - ascites- off diuretics, intermittent pc as indicated, none this hospitalization - varices- nadolol - anemia- cont ppi . # diabetes- continued lantus and humalog ss . # seizures- continued lamictal . # depression- continued celexa code status: confimred full code ","PRIMARY: [Acute edema of lung, unspecified] SECONDARY: [Unspecified pleural effusion; Portal hypertension; End stage renal disease; Esophageal varices in diseases classified elsewhere, without mention of bleeding; Acute respiratory failure; Cirrhosis of liver without mention of alcohol; Other chronic nonalcoholic liver disease; Other iatrogenic hypotension; Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation; Obstructive sleep apnea (adult)(pediatric); Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled; Polyneuropathy in diabetes; Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled; Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled; Background diabetic retinopathy; Esophageal reflux; Anemia in chronic kidney disease]","63 f with cirrhosis, esrd s/p thoracentesis who presents with hypoxia and hypotension in setting likely re-expansion pulmonary edema . # hypotension- patient back to baseline, suspect transient hypotension in setting volume shifts after thoracentesis. # cirrhosis- on transplant list - encephalopathy- continued lactulose and rifaximin - sbp- h/o prior sbp, continued bactrim ds ppx - ascites- off diuretics, intermittent pc as indicated, none this hospitalization - varices- nadolol - anemia- cont ppi .","cirrhosis, esrd s/p thoracentesis who presents with hypoxia and hypotension in setting likely re-expansion pulmonary edema. she should have future thoracentesis by interventional pulmonary in order to follow trans pulmonary pressures to avoid re-expansion pulmonary edema." 29495,182822.0,23427,2126-01-30,23403,152287.0,2125-11-13,Discharge summary,"Admission Date: [**2125-11-6**] Discharge Date: [**2125-11-13**] Date of Birth: [**2062-4-14**] Sex: F Service: UROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 824**] Chief Complaint: 1.4cm right renal calculus Major Surgical or Invasive Procedure: s/p right ureteroscopy, laser lithotripsy History of Present Illness: 63F who underwent a renal ultrasound in [**Country 651**] for back pain approximately five years ago that showed some kind of kidney stone and maybe hydronephrosis, per the patient; the history is unclear. Since that time, she denies any further symptoms and currently is not in pain. She also denies any nausea or vomiting, difficulty with her urination or fevers and chills. She did undergo a CT scan of abdomen and pelvis on [**8-31**] with and without contrast, which showed a 14 mm right upper pole nonobstructing calculus with moderate right upper pole cortical thinning. Past Medical History: Her past medical history is notable for hypertension and a pacemaker that was placed for apparently bradycardia, per the patient. She has been seen by Dr. [**Last Name (STitle) **] in Cardiology for chest pain that was not concerning. Social History: She reports no history of tobacco use and rare alcohol. The patient is not currently working. Family History: Her family history is notable for heart disease, but no kidney stones. Physical Exam: AVSS, BP 105/75 NAD, NCAT EOM full, PERRL Neck supple, no LAD Chest with bibasilar crackles, no wheezes RRR, no MRG Abdomen soft, minimally distended, NT, NABS LE WWP, trace peripheral edema Pertinent Results: CHEST (PORTABLE AP) [**2125-11-8**] 2:59 AM CHEST (PORTABLE AP) Reason: 300 [**Hospital 93**] MEDICAL CONDITION: 63 year old woman with septic shock, flash edema REASON FOR THIS EXAMINATION: Effusion, PNA CLINICAL INDICATION: 63-year-old woman with septic shock and flash edema, evaluate for effusion or pneumonia. COMPARISON: [**2125-11-7**]. SEMI-UPRIGHT CHEST X-RAY: Compared with [**2125-11-7**] there is stable congestive heart failure with large pleural effusions right greater than left. Pacemaker device and right kidney stent are stable. A right There is a slight increase in pulmonary edema. IMPRESSION: Slightly increased moderately severe pulmonary edema right greater than left. Stable bilateral pleural effusions right greater than left. Coexistant pneumonia cannot be excluded. ******************** PORTABLE ABDOMEN [**2125-11-7**] 8:08 AM PORTABLE ABDOMEN Reason: eval for sbo [**Hospital 93**] MEDICAL CONDITION: 63 year old woman with SOB/pulmonary edema and abdominal discomfort REASON FOR THIS EXAMINATION: eval for sbo STUDY: Portable abdomen. INDICATION: A 63-year-old female with shortness of breath/pulmonary edema presenting with abdominal discomfort. Status post small-bowel obstruction. COMPARISONS: CT dated [**2125-8-31**]. FINDINGS: A right ureteral stent is identified. A pigtail loop can be visualized projecting over the stated area of the bladder. The upper pigtail loop appears slightly unfolded, but is probably within the renal pelvis. On these two supine views, there are no distended loops of small bowel. The bowel gas pattern is overall nonspecific. The soft tissues and osseous structures are grossly unremarkable. IMPRESSION: No evidence of obstruction. ******************** ECHO: [**2125-11-7**] The left atrium is elongated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Transmitral Doppler and tissue velocity imaging are consistent with normal LV diastolic function. There is no ventricular septal defect. The right ventricular cavity is mildly dilated. Right ventricular systolic function is normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. ******************** AEROBIC BOTTLE (Final [**2125-11-12**]): THIS IS A CORRECTED REPORT [**2125-11-12**] 11:30AM. REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**2125-11-12**] 11:35AM. NO GROWTH. PREVIOUSLY REPORTED AS GRAM NEGATIVE DIPLOCOCCI [**2125-11-12**] 11:30AM. ANAEROBIC BOTTLE (Final [**2125-11-10**]): REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 60045**] 4I 21:15 [**2125-11-7**]. ESCHERICHIA COLI. FINAL SENSITIVITIES. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- =>64 R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: Here for semi-elective ureteroscopy and laser lithotripsy for >1cm renal pelvis stone. She was feeling well, in her usual state of health and took her antihypertensive medications this morning. Her Pre-op Vs were T 99.1, P 71, BP 149/80, RR 20, 100% on RA. The procedure begatn at 15:35 and ended at 17:08, and required GETA (with propofol for sedation) and was uncomplicated. Post-operatively she was hypertensive with BP 190/100 which responded to 5mg Iv labetalol; however her BP trended down by 7pm to the low 100's with HR a-paced at 70. At 2100 she was febrile to 101.8 and had severe nausea and vomiting for which she was given 200mcg fentanyl, 2mg midazolam, 1mg haldol for nausea, 125mg demerol for shakes, 3.25mg promethazine, and 4mg zofran along with 240mg gentamycin and 1g vancomycin for presumed urosepsis. Her BP then trended down to the 80's-90's where it remained despite 3.5L IVF in the post-operative setting. Her oxygen saturation was also noted to be in the low 90's on 2L N/C, briefly requiring 6L nasal canula and then back to 2-3L n/c. ID: Placed empirically on vanc and gent, then changed to vanc and cefepime on POD1. By the end of POD1, blood cx grew out GNR in the anaerobic bottle, resistant to ceftriaxone, cipro, levo. Since sensitivities to cefepime were unknown, but this organism was known to be sensitive to gentamycin, on POD2, the pt was again placed on gent. After 3 doses, abx were again changed to from gent to meropenem on POD3. In addition the pt remained on vancomycin. Flagyl was added due to concern for C.diff on POD2 after an episode of diarrhea. POD4, vanc and flagyl were discontinued and the pt was maintained on meropenem until discharge, after cultures grew E.coli with extended resistance, but susceptibility to [**Last Name (un) 2830**] and ertapenem. The day of discharge POD7, the pt received one dose of ertapenem in house; it was arranged for her to receive daily dosing as an outpatient. Follow up after antibiotics with urology was arranged. CV: Baseline BP unknown, but in [**Name (NI) 13042**], pt was initally hypertensive as above and then hypotensive after sedation and BB. The night of admission the pt received 10L IVF to sustain her pressures. POD1-2 BPs primarily ranged in 80-90s systolic without fluid boluses or pressors. Urine output remained high and pt was mentating fine. By POD3, the SBP rose to 110s. Pressors were not used. On POD2, pt also went into afib with RVR, 10mg iv lopressor was used in conjunction with PO lopressor to control the rate. The pt spontaneously reverted back to NSR on POD2 later in the day. On POD4, the pt again had an episode of Afib, rate controlled with PO lopressor, which again spontaneously converted to NSR. After this date she maintained sinus rhythm until discharge. Medicine was consulted and they recommended no acute treatment during this hospitalization and follow up with her PCP for management of this rhythm. Pulm: Pt went into flash pulmonary edema the evening of admission after receiving aggressive IVF resuscitation. Her O2 requirement increased from 2LNC to 15L/min per non-rebreather. By the following morning, after being diuresed with IV lasix, the pt was on 4L via nasal cannula and sating 95-100%. By POD4, the pt was saturating well on room air, and she remained off supplemental oxygen for the remainder of the hospitalization. GI: On POD1, the pt complained of moderate lower abdominal pain. She was distended on exam. KUB demonstrated a non-obstructive gas pattern with gas in the sigmoid colon. By POD2, the pt was passing flatus and her distention had reduced. Medications on Admission: metoprolol 12.5 [**Hospital1 **] isosorbide dinitrate [**Hospital1 **] aspirin Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for temp>101, pain. 4. Ertapenem 1 gram Recon Soln Sig: One (1) gram Intravenous once a day for 9 days. Disp:*9 grams* Refills:*0* 5. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*3 inhalers* Refills:*1* 6. Saline Flush 0.9 % Syringe Sig: [**5-3**] ml Injection SASH, prn. Disp:*180 ml* Refills:*2* 7. Heparin Flush 100 unit/mL Kit Sig: [**2-26**] ml Intravenous SASH, prn. Disp:*90 ml* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: s/p right ureteroscopy, laser lithotripsy, urosepsis Discharge Condition: good Discharge Instructions: You may shower and bathe normally. Do not drive or drink alcohol if taking narcotic pain medication. Resume all of your home medications, but please avoid aspirin/advil for one week. Call your Urologist's office ([**Telephone/Fax (1) 164**]) to schedule a follow-up appointment in [**1-27**] weeks, or if you have any questions. If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Followup Instructions: Call [**Telephone/Fax (1) 164**] to arrange follow up after you have completed your antibiotics in [**1-27**] weeks. ",78,2125-11-06 17:26:00,2125-11-13 13:13:00,EMERGENCY,CLINIC REFERRAL/PREMATURE,HOME HEALTH CARE,KIDNEY STONES," here for semi-elective ureteroscopy and laser lithotripsy for >1cm renal pelvis stone. she was feeling well, in her usual state of health and took her antihypertensive medications this morning. her pre-op vs were t 99.1, p 71, bp 149/80, rr 20, 100% on ra. the procedure begatn at 15:35 and ended at 17:08, and required geta (with propofol for sedation) and was uncomplicated. post-operatively she was hypertensive with bp 190/100 which responded to 5mg iv labetalol; however her bp trended down by 7pm to the low 100s with hr a-paced at 70. at 2100 she was febrile to 101.8 and had severe nausea and vomiting for which she was given 200mcg fentanyl, 2mg midazolam, 1mg haldol for nausea, 125mg demerol for shakes, 3.25mg promethazine, and 4mg zofran along with 240mg gentamycin and 1g vancomycin for presumed urosepsis. her bp then trended down to the 80s-90s where it remained despite 3.5l ivf in the post-operative setting. her oxygen saturation was also noted to be in the low 90s on 2l n/c, briefly requiring 6l nasal canula and then back to 2-3l n/c. id: placed empirically on vanc and gent, then changed to vanc and cefepime on pod1. by the end of pod1, blood cx grew out gnr in the anaerobic bottle, resistant to ceftriaxone, cipro, levo. since sensitivities to cefepime were unknown, but this organism was known to be sensitive to gentamycin, on pod2, the pt was again placed on gent. after 3 doses, abx were again changed to from gent to meropenem on pod3. in addition the pt remained on vancomycin. flagyl was added due to concern for c.diff on pod2 after an episode of diarrhea. pod4, vanc and flagyl were discontinued and the pt was maintained on meropenem until discharge, after cultures grew e.coli with extended resistance, but susceptibility to [**last name (un) 2830**] and ertapenem. the day of discharge pod7, the pt received one dose of ertapenem in house; it was arranged for her to receive daily dosing as an outpatient. follow up after antibiotics with urology was arranged. cv: baseline bp unknown, but in [**name (ni) 13042**], pt was initally hypertensive as above and then hypotensive after sedation and bb. the night of admission the pt received 10l ivf to sustain her pressures. pod1-2 bps primarily ranged in 80-90s systolic without fluid boluses or pressors. urine output remained high and pt was mentating fine. by pod3, the sbp rose to 110s. pressors were not used. on pod2, pt also went into afib with rvr, 10mg iv lopressor was used in conjunction with po lopressor to control the rate. the pt spontaneously reverted back to nsr on pod2 later in the day. on pod4, the pt again had an episode of afib, rate controlled with po lopressor, which again spontaneously converted to nsr. after this date she maintained sinus rhythm until discharge. medicine was consulted and they recommended no acute treatment during this hospitalization and follow up with her pcp for management of this rhythm. pulm: pt went into flash pulmonary edema the evening of admission after receiving aggressive ivf resuscitation. her o2 requirement increased from 2lnc to 15l/min per non-rebreather. by the following morning, after being diuresed with iv lasix, the pt was on 4l via nasal cannula and sating 95-100%. by pod4, the pt was saturating well on room air, and she remained off supplemental oxygen for the remainder of the hospitalization. gi: on pod1, the pt complained of moderate lower abdominal pain. she was distended on exam. kub demonstrated a non-obstructive gas pattern with gas in the sigmoid colon. by pod2, the pt was passing flatus and her distention had reduced. ","PRIMARY: [Other postoperative infection] SECONDARY: [Septicemia due to escherichia coli [E. coli]; Severe sepsis; Septic shock; Defibrination syndrome; Cardiac complications, not elsewhere classified; Atrial fibrillation; ; Cardiac pacemaker in situ; Unspecified essential hypertension; Calculus of kidney]","here for semi-elective ureteroscopy and laser lithotripsy for >1cm renal pelvis stone. by the end of pod1, blood cx grew out gnr in the anaerobic bottle, resistant to ceftriaxone, cipro, levo. pod4, vanc and flagyl were discontinued and the pt was maintained on meropenem until discharge, after cultures grew e.coli with extended resistance, but susceptibility to [**last name (un) 2830**] and ertapenem. the day of discharge pod7, the pt received one dose of ertapenem in house; it was arranged for her to receive daily dosing as an outpatient. follow up after antibiotics with urology was arranged. by the following morning, after being diuresed with iv lasix, the pt was on 4l via nasal cannula and sating 95-100%. gi: on pod1, the pt complained of moderate lower abdominal pain.","pre-op vs were t 99.1, p 71, bp 149/80, rr 20, 100% on ra. post-operatively she was hypertensive with bp 190/100 which responded to 5mg iv labetalol. at 2100 she was febrile to 101.8 and had severe nausea and vomiting." 30341,121351.0,30890,2145-07-31,30889,174592.0,2145-06-18,Discharge summary,"Admission Date: [**2145-5-28**] Discharge Date: [**2145-6-18**] Date of Birth: [**2084-3-2**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 5552**] Chief Complaint: Dehydration. Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 61 year old man with metastatic esophageal cancer to liver and lung presents from clinic with dehydration and severe mucositis. He is s/p initiation of cycle 1 of ECX (epirubicin, cisplatin, and xeloda) on [**5-20**]. Since his treatment, he has been feeling fatigued and developed a sore throat and mouth sores. He has been able to eat and drink although drinking sometimes makes him nauseated. He was prescribed magic mouthwash and did not noticed much improvement. Patietn also states that he feels confused sometims and with a slow mind. He had dairrhea in the morning with normal color, but watery stool. He denies any sick contacts or exposure to people in nursing homes, children or other infectious agents. . He had planned on coming into the outpatient treatment area for IVFs, but because he has been feeling so unwell, he presented in clinic today for evaluation. . In clinic, he was found to be orthostatic and appeared dehydrated on exam. He was noted to have oral thrush. He was given 2L NS, zofran 8 mg IV and nystatin 5 cc as well as diflucan 200 mg. he was seen by Dr. [**Last Name (STitle) **]. He is now being admitted for rehydration and treatment of his mucositis and thrush. Past Medical History: PAST ONCOLOGIC HISTORY: ====================== He initially presented in [**11/2142**] due to dysphagia and weight loss. At that time, he had a barium swallow, which showed a pinpoint narrowing of his distal esophagus. He had endoscopy and underwent dilatation of this stricture. He did not have much improvement with the dilatation and in [**Month (only) 116**] of this year underwent a second dilatation once again with no improvement. He had motility tests, which were most consistent with achalasia. In [**Month (only) **], he underwent a Botox injection to the narrowing in order to help to release it. He had a CT scan after this which showed a 1.5 cm gastrohepatic lymph node. On [**2143-8-28**] he underwent an upper endoscopy on which they saw distal esophageal narrowing. They also performed multiple biopsies of the area of narrowing. Of note, they saw some ulceration in the GE junction and a thick abnormal fold concerning for esophageal or gastric cardia cancer. The biopsy showed moderate to poorly differentiated adenocarcinoma. After this he underwent endoscopic ultrasound, however, they were unable to pass the ultrasound probe beyond the stricture. He has had a port, g-tube, and esophageal stent placed. He started treatment with 5-FU and Cisplatin on [**2143-10-10**] with concurrent radiation therapy. Radiation was completed on [**2143-11-26**]. He was admitted from [**2143-11-26**] to the [**2143-12-3**] with febrile neutropenia and dehydration. He underwent an esophagectomy on [**2144-1-20**]. Pathology from this showed a metastatic adenocarcinoma with 4/6 perigastric lymph nodes positive, and a separate foci of tumor in the adjacent adipose tissue. He completed treatment in [**2144-1-4**]. He had liver lesions noted on a CT scan [**2145-1-16**]. He had these biopsied on [**2145-1-27**] and the pathology came back as consistent with metastasis from esophageal cancer. . PAST MEDICAL HISTORY: ==================== - Esophageal cancer- moderate to poorly differentiated adenocarcinoma; Rec'd 5-FU/cisplatin with concurrent XRT in [**10-11**], now s/p minimally invasive esophagectomy [**1-10**]. - h/o atrial fibrillation - h/o S. viridans bacteremia - Sinusitis, status post surgery - Hypertension - Vocal cord paralysis Social History: He originally moved from [**Country 6171**] 17 years ago. Married, 2 children. Teaches French and Spanish. He used to smoke a pack a day, but quit 15 years ago. He used to drink a couple of glasses of wine with dinner each night, but not since diagnosis. Family History: He has a father with pancreatic cancer who died at the age of 70. Physical Exam: Vitals - T: 98.1 BP: 104/74 HR: 67 RR: 16 02 sat: 100% on RA . GENERAL: NAD, very pelasant gentleman, hoarse, very french accent SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no mrg LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, strenght [**6-8**] in upper and lower extremities, DTRs [**6-8**], [**Name2 (NI) 73082**] 27 Pertinent Results: On Admission: [**2145-5-28**] 10:00AM WBC-2.9*# RBC-4.84 HGB-15.0 HCT-43.9 MCV-91 MCH-30.9 MCHC-34.1 RDW-13.8 [**2145-5-28**] 10:00AM PLT SMR-VERY LOW PLT COUNT-35*# [**2145-5-28**] 10:00AM GRAN CT-2240 [**2145-5-28**] 10:00AM ALT(SGPT)-100* AST(SGOT)-51* ALK PHOS-75 TOT BILI-1.4 DIR BILI-0.3 INDIR BIL-1.1 [**2145-5-28**] 10:00AM ALBUMIN-3.5 PHOSPHATE-3.5 MAGNESIUM-2.2 [**2145-5-28**] 10:00AM UREA N-36* CREAT-1.0 SODIUM-138 POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13 [**2145-5-28**] 10:00AM GRAN CT-2240 Pertinent Interim/Discharge Labs [**2145-6-18**] 12:23AM BLOOD WBC-12.3* RBC-3.46* Hgb-10.7* Hct-30.5* MCV-88 MCH-31.0 MCHC-35.2* RDW-18.6* Plt Ct-228 [**2145-6-14**] 12:00AM BLOOD WBC-19.3* RBC-3.03* Hgb-9.4* Hct-28.2* MCV-93 MCH-30.9 MCHC-33.2 RDW-17.9* Plt Ct-98* [**2145-6-13**] 12:00AM BLOOD PT-15.5* INR(PT)-1.4* [**2145-6-8**] 09:36AM BLOOD PT-28.0* PTT-31.1 INR(PT)-2.8* [**2145-6-6**] 12:00AM BLOOD Gran Ct-253* [**2145-6-7**] 12:00AM BLOOD Gran Ct-704* [**2145-6-9**] 12:00AM BLOOD Gran Ct-7521 [**2145-6-18**] 12:23AM BLOOD Glucose-91 UreaN-19 Creat-0.5 Na-134 K-4.4 Cl-103 HCO3-24 AnGap-11 [**2145-6-15**] 12:00AM BLOOD ALT-27 AST-32 LD(LDH)-292* AlkPhos-160* TotBili-2.1* [**2145-6-18**] 12:23AM BLOOD Calcium-7.0* Phos-3.5 Mg-1.9 [**2145-6-15**] 12:00AM BLOOD Albumin-2.0* Calcium-6.9* Phos-3.1 Mg-1.9 CT abdomen/pelvis [**5-30**]: 1. No evidence of diverticulitis, abscess, or any acute pathology to explain LLQ pain. 2. New wedge-shaped hypodensities within the spleen, likely infarcts given relatively rapid appearance from the prior study. 3. Although incompletely assessed due to collapsed bowel, apparent wall thickening of the ascending colon which may represent bowel wall edema. No secondary signs of inflammation (ie no fat stranding). CXR [**6-3**]: As compared to the previous radiograph, there is increasing opacity at the left lung base, combined with a newly appeared blunting of the left costophrenic sinus, presumably due to effusion. The size of the cardiac silhouette is unchanged. Unchanged normal right lung, unchanged Port-A-Cath system. CT chest [**6-4**]: 1. New diffuse transverse colon wall thickening and surrounding inflammatory change consistent with colitis, only partially visualized. Further evaluation with dedicated CT enterography of the abdomen and pelvis may be obtained for further evaluation. 2. New, small left, and trace right, pleural effusions. 3. New tree-in-[**Male First Name (un) 239**] opacities in the right lower lobe with mild improvement in right upper lobe tree-in-[**Male First Name (un) 239**] opacities. These findings may be due to aspiration. TTE [**6-8**]: No vegetations seen (suboptimal-quality study). Mild mitral regurgitation. Normal global and regional biventricular systolic function. RUE U/S [**6-8**]: DVT involving the right distal brachial vein, as well as the cephalic vein. CXR [**6-9**]: Compared to [**6-3**], there is more opacification in the left lower lobe, which could be worsening atelectasis or pneumonia particularly due to recent aspiration. There has also been increase in diameter of the cardiac silhouette and the azygos vein which may indicate volume overload but there is no pulmonary edema. MICRO [**6-1**] blood cx: Strep Pneumoniae Brief Hospital Course: 1. Pneumococcal infection: While the patient was neutropenic, he was febrile once. Cultures were sent and he was started on empiric cefepime. Imaging suggested a LLL pneumonia, and blood cultures grew GPC, for which vancomycin was added. The GPC were speciated as S. pneumoniae. TTE showed no vegetations. No further blood cultures were positive, and his antibiotics were eventually narrowed to ceftriaxone alone for a 14 day course, starting at the resolution of neutropenia. For easier dosing at home, he was changed to Cefpodoxine to finish course after discharge. 2. Mucositis: Unable to tolerate PO and was resuscitated with IVF. He was started on oral lidocaine and gelclairm as well as oral fluconazole and nystatin for [**Female First Name (un) 564**]. He was later taken off the fluconazole as it elevated his transaminases and changed to micafungin. However, this was also stopped as it elevated his bilirubin. IV morphine was used for pain control and he briefly required a PCA pump. Once his neutropenia resolved, his mucositis began to improve. However, the resultant increase in secretions caused respiratory distress and hypoxia, requiring ICU transfer for frequent deep suctioning and nebulizers. This resolved rapidly and he returned to the floor. Mucositis subsequently improved. 3. Acute renal failure: Despite normal creatinine at 1.0, this essentially doubled from low baseline of 0.4-0.7 and BUN/creatinine 36. Likely in the setting of poor PO. He was agressively hydrated with IVF and creatinine improved. 4. Neutropenia: Secondary to chemotherapy. His ANC continued to trend down during admission until he became severely neutropenic. He was started on filgrastim and eventually his ANC completely recovered. 5. Thrombocytopenia: Also secondary to chemotherapy. Early in the admission, he had some hematochezia, so was transfused plts to keep his count over 30,000. 6. Right UE DVT: Found on U/S in the setting of arm swelling. He was started on enoxaparin. 7. Colitis: Early on, paient complained of LLQ pain, associated with hematochezia and then dark stools. He required 2 units RBCs for this, but endoscopy could not be done due to his neutropenia and thrombocytopenia. Stool studies were negative. CT abdomen showed some bowel edema, but no diverticulitis. A CT chest done a few days later noted some transverse colitis, although he was asymptomatic. Metronidazole was empirically started and continued for 5 days. Later on, in the setting of starting enoxaparin for DVT, he had dark guaiac positive stools. GI was consulted and felt bleeding was related to mucositis vs colitis/inflammation in setting of anticoagulation and did not feel there was indication for scope as an inpatient. His hematocrit was stable prior to discharge. 8. Esophageal cancer: On admission, he was day 9 status post chemotherapy. He received no further treatments as an inpatient, and he will follow up with his oncologist as an outpatient. 9. Nutrition: Due to poor POs, PPN was started as there was not enough access for TPN in the patient's chest port due to antibiotics and IV fluids. Once his antibiotics were weaned, TPN was initiated via his port. He also had an elevated INR that was likely nutritional, and improved with vitamin K. Medications on Admission: Emend 125mg day 1, 80mg days [**3-9**] Xeloda 2g [**Hospital1 **] (days [**2-17**]) Dexamethasone 4mg (days [**3-10**]) Magic mouthwash tid prn Lorazepam 0.5-1mg q4-6h prn Megestrol 100mg/10ml susp daily Metoclopramide 5mg tid Metoprolol 100mg [**Hospital1 **] Ondansetron 8mg q8h prn (? GI upset) Gelclair tid Oxycodone 5-10mg q4-6h prn Prochlorperazine 10mg q6-8h prn Ranitidine 150mg [**Hospital1 **] Sucralfate 1g tid Zolpidem 10mg hs prn Discharge Medications: 1. Flushes Saline flush 10cc SASH and prn heparin flush 10U/ml 5cc SASH and prn Heparin 100U/ml 5cc deaccess port 2. Lidocaine HCl 2 % Solution Sig: Fifteen (15) ML Mucous membrane TID (3 times a day) as needed. Disp:*1 bottle* Refills:*0* 3. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for anxiety or nausea. 4. Megestrol 400 mg/10 mL Suspension Sig: 100mg/10ml suspension PO once a day. 5. Reglan 5 mg Tablet Sig: One (1) Tablet PO three times a day. 6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. 8. Oral Wound Care Products Gel in Packet Sig: One (1) ML Mucous membrane TID (3 times a day) as needed. 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. 10. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea or vomit. 11. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO three times a day. 12. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 13. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous Q12H (every 12 hours). Disp:*60 syringe* Refills:*0* 14. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 3 days. Disp:*12 Tablet(s)* Refills:*0* 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 16. Outpatient Lab Work Please do weekly lab work and fax to [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 18971**] [**Telephone/Fax (1) 55043**] to monito while on TPN. Check CBC, BUN, Cr, electrolytes, albumin, LFTs. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Primary: Chemotherapy induced diarrhea and mucositis Pneumococcal bacteremia Pneumonia Deep venous thrombosis Secondary: Esophageal cancer Hypertension Discharge Condition: hemodynamically stable, afebrile, shortnes of breath and cough improved Discharge Instructions: You were admitted to [**Hospital1 18**] with dehydration, diarrhea, and inflammation of the mucous membranes (mucositis). We gave you IV fluids and started TPN, a form of nutrition given through the veins. We also treated you with antibiotics for a bloodstream infection and a pneumonia. We also started enoxaparin (Lovenox), a blood thinner, due to a blood clot found in your arm veins. Once your white blood cells recovered from your chemotherapy, your mucositis continued to improve. We changed your ranitidine to pantopraxole. Please take all medications as prescribed and go to all follow up appointments. If you experience fevers, chills, vomiting, diarrhea, abdominal pain, worsening mouth/throat pain, bloody stools, or any other concerning symptoms, please seek medical attention or come to the ER immediately. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **]. Call [**Telephone/Fax (1) 6568**] for an appointment in [**2-5**] weeks. ",43,2145-05-28 14:38:00,2145-06-18 13:00:00,EMERGENCY,CLINIC REFERRAL/PREMATURE,HOME HEALTH CARE,DEHYDRATION," 1. pneumococcal infection: while the patient was neutropenic, he was febrile once. cultures were sent and he was started on empiric cefepime. imaging suggested a lll pneumonia, and blood cultures grew gpc, for which vancomycin was added. the gpc were speciated as s. pneumoniae. tte showed no vegetations. no further blood cultures were positive, and his antibiotics were eventually narrowed to ceftriaxone alone for a 14 day course, starting at the resolution of neutropenia. for easier dosing at home, he was changed to cefpodoxine to finish course after discharge. 2. mucositis: unable to tolerate po and was resuscitated with ivf. he was started on oral lidocaine and gelclairm as well as oral fluconazole and nystatin for [**female first name (un) 564**]. he was later taken off the fluconazole as it elevated his transaminases and changed to micafungin. however, this was also stopped as it elevated his bilirubin. iv morphine was used for pain control and he briefly required a pca pump. once his neutropenia resolved, his mucositis began to improve. however, the resultant increase in secretions caused respiratory distress and hypoxia, requiring icu transfer for frequent deep suctioning and nebulizers. this resolved rapidly and he returned to the floor. mucositis subsequently improved. 3. acute renal failure: despite normal creatinine at 1.0, this essentially doubled from low baseline of 0.4-0.7 and bun/creatinine 36. likely in the setting of poor po. he was agressively hydrated with ivf and creatinine improved. 4. neutropenia: secondary to chemotherapy. his anc continued to trend down during admission until he became severely neutropenic. he was started on filgrastim and eventually his anc completely recovered. 5. thrombocytopenia: also secondary to chemotherapy. early in the admission, he had some hematochezia, so was transfused plts to keep his count over 30,000. 6. right ue dvt: found on u/s in the setting of arm swelling. he was started on enoxaparin. 7. colitis: early on, paient complained of llq pain, associated with hematochezia and then dark stools. he required 2 units rbcs for this, but endoscopy could not be done due to his neutropenia and thrombocytopenia. stool studies were negative. ct abdomen showed some bowel edema, but no diverticulitis. a ct chest done a few days later noted some transverse colitis, although he was asymptomatic. metronidazole was empirically started and continued for 5 days. later on, in the setting of starting enoxaparin for dvt, he had dark guaiac positive stools. gi was consulted and felt bleeding was related to mucositis vs colitis/inflammation in setting of anticoagulation and did not feel there was indication for scope as an inpatient. his hematocrit was stable prior to discharge. 8. esophageal cancer: on admission, he was day 9 status post chemotherapy. he received no further treatments as an inpatient, and he will follow up with his oncologist as an outpatient. 9. nutrition: due to poor pos, ppn was started as there was not enough access for tpn in the patients chest port due to antibiotics and iv fluids. once his antibiotics were weaned, tpn was initiated via his port. he also had an elevated inr that was likely nutritional, and improved with vitamin k. ","PRIMARY: [Drug induced neutropenia] SECONDARY: [Pneumonia, organism unspecified; Malignant neoplasm of liver, secondary; Secondary malignant neoplasm of lung; Candidiasis of mouth; Acute kidney failure, unspecified; ; Malignant neoplasm of other specified part of esophagus; Bacteremia; Dehydration; Anemia, unspecified; ; Atrial fibrillation; Other stomatitis and mucositis (ulcerative); Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use; Abnormal coagulation profile; Diarrhea; Pneumococcus infection in conditions classified elsewhere and of unspecified site; Unilateral paralysis of vocal cords or larynx, partial; Unspecified essential hypertension; Other and unspecified noninfectious gastroenteritis and colitis]","pneumococcal infection: while the patient was neutropenic, he was febrile once. cultures were sent and he was started on empiric cefepime. this resolved rapidly and he returned to the floor. his anc continued to trend down during admission until he became severely neutropenic. a ct chest done a few days later noted some transverse colitis, although he was asymptomatic. esophageal cancer: on admission, he was day 9 status post chemotherapy. nutrition: due to poor pos, ppn was started as there was not enough access for tpn in the patients chest port due to antibiotics and iv fluids.",mucositis: unable to tolerate po and was resuscitated with ivf. acute renal failure: essentially doubled from low baseline of 0.4-0.7. thrombocytopenia: secondary to chemotherapy. 30659,123675.0,13337,2146-03-26,13336,110439.0,2145-12-24,Discharge summary,"Admission Date: [**2145-12-20**] Discharge Date: [**2145-12-24**] Date of Birth: [**2087-12-9**] Sex: F Service: MEDICINE Allergies: Zanaflex Attending:[**First Name3 (LF) 10293**] Chief Complaint: Chief complaint: Hypotension post-TIPS revision, after transfer from OSH ([**Hospital3 17162**]) with shortness of breath, refractory ascites Major Surgical or Invasive Procedure: TIPS revision, paracentesis x 2 History of Present Illness: History of Present Illness Ms. [**Known lastname **] is a 58 yo woman with a history of HCV cirrhosis s/p TIPS [**3-5**] who presents with increased abdominal distension. . She previously had refractory ascites in early [**2145**], and underwent placement of TIPS for this reason. She was then doing well and was without significant ascites on aldactone. Lasix was added [**11-4**] for some edema. Subsequently her ascites continued to worsen. She was getting therapeutic paracentesis with removal of [**7-4**] L each time every two weeks. US [**11-18**] showed increased velocity in the TIPS. . She was recently admitted to [**Hospital3 **] [**Date range (1) 40579**] with increasing SOB, received 60 mg lasix underwent removal of 10 L of ascitic fluid, with resolution of SOB. Creatinine at that time on admission was 1.8. She had an ultrasound with Doppler [**12-12**] showing increased flow in the TIPS. . She was doing well until [**12-18**] when she presented for routine labs and was found to have renal failure beyond her baseline (creatinine 2.0 elevated from recent b/l 1.5) and hyperkalemia to 5.4 with peaked T waves. She received kayexalate, insulin, bicarb, D50 and was admitted. Diuretics were held. Because of concern for TIPS occlusion, she was transferred to [**Hospital1 18**] for possible revision. . On acceptance to the medicine team, she complains of epigastric pain, worse with lying and accompanied by a sour taste. She denies fevers, chills, change in bowel movements or blood in BM (baseline 4 BM/day on lactulose). Also no chest pain or shortness of breath. No urinary symptoms. . Upon admission to [**Hospital1 18**], plan was to proceed with TIPS revision. The day of admission to the MICU, she underwent TIPS revision and had a 6L paracentesis. Intraoperatively you way hypotensive to SBP 70s, treated with 1L 5% albumin and neo gtt without complication. [**Name (NI) **], pt again became hypotensive to the 70s, asymmptomatic and resolve with 50g 25% albumin and 500cc NS. In total in [**Name (NI) 13042**], pt received 1400cc NS, 800cc Bicarb/D5W and 200cc of 25% albumin. EBL 147ml. . Upon transfer to MICU, patient confirms story as above. States she's had some mild abdominal pain. . Past Medical History: PAST MEDICAL HISTORY: # ESLD secondary to HCV cirrhosis - Hep C dxed [**2126**], unknown exposure: no hx transfusion, IVDU, tatoo placed after hep C diagnosis - genotype IA, treated with multiple courses of interferon unsuccessfully - bx [**2140**] stage 3-4 fibrosis - hx encephalopathy, - grade 3 varices banded [**3-5**]. No history of variceal bleeding. + history of hemorrhoidal bleeding. - hx refractory ascites, s/p TIPS [**2145-3-19**], revised [**8-3**] after presenting with recurrent ascites - on transplant list # Renal insufficiency, baseline creatinine 1.5 per OSH records but previously has bumped to >2 # Diastolic CHF # Asthma # Depression # Anxiety # GERD # IDDM # Seizure disorder # Hypertension # OSA # Refractory nausea - controlled with reglan - ? gastroparesis # s/p CCY # h/o Asthma - stable # Pancytopenia - related to ESLD . Social History: From [**Male First Name (un) **] and visited recently. ? past h/o IVDU. Denies tobacco, EtOH, or current recreational drug use. Family History: Family History: no family history of liver disease Physical Exam: Admission PE: T 96.1 89, 100/58, 23, 99/RA Gen: no apparent distress, appears well HEENT/NECK: could not visualize JVP, supple, oropharynx clear, sclera anicteric Cor: regular, 2/6 systolic murmur heard best at the left upper sternal border Pulm: lungs clear bilaterally except fine bibasilar crackles posteriorly Abd: Distended, soft, nontender. + shifting dullness. No rebound, no guarding. Ext: trace pitting edema bilaterally, warm Neuro: A&O x 3, appropriate, coherent historian, no asterixis. Pertinent Results: EKG [**12-20**]: Normal sinus rhythm at 87 bpm. Normal axis, normal intervals. No evidence of ischemia. . Admission Labs: [**2145-12-21**] 03:40AM BLOOD WBC-4.3 RBC-2.91* Hgb-10.3* Hct-28.5* MCV-98 MCH-35.6* MCHC-36.2* RDW-14.1 Plt Ct-88* [**2145-12-21**] 03:40AM BLOOD Neuts-72.3* Lymphs-15.6* Monos-8.4 Eos-3.2 Baso-0.6 [**2145-12-21**] 03:40AM BLOOD PT-14.6* PTT-32.8 INR(PT)-1.3* [**2145-12-21**] 03:40AM BLOOD Plt Ct-88* [**2145-12-21**] 03:40AM BLOOD Glucose-173* UreaN-35* Creat-1.7* Na-126* K-4.2 Cl-95* HCO3-25 AnGap-10 [**2145-12-21**] 03:40AM BLOOD ALT-24 AST-39 LD(LDH)-246 AlkPhos-393* TotBili-4.9* [**2145-12-21**] 03:40AM BLOOD Albumin-2.2* Calcium-7.5* Phos-3.8 Mg-2.1 . Labs prior to discharge: [**2145-12-24**] 06:15AM BLOOD WBC-2.7* RBC-2.43* Hgb-9.1* Hct-23.8* MCV-98 MCH-37.3* MCHC-38.0* RDW-14.5 Plt Ct-66* [**2145-12-24**] 06:15AM BLOOD Glucose-125* UreaN-35* Creat-1.5* Na-129* K-4.1 Cl-97 HCO3-25 AnGap-11 [**2145-12-24**] 06:15AM BLOOD ALT-17 AST-33 AlkPhos-229* TotBili-5.4* . Micro: [**2145-12-21**] URINE CULTURE (Final [**2145-12-22**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . Radographic studies: . LIVER OR GALLBLADDER US [**12-21**] (to evaluate TIPs) IMPRESSION: 1. Patent TIPS with velocities of 100 to 180 cm/s. 2. There is a lack of wall-to-wall flow in the mid to distal TIPS, suggestive of neo-intimal hyperplasia. 3. Interval increase in the amount of ascites since the prior exam. 4. Splenomegaly. Brief Hospital Course: A 57 yo woman with HCV cirrhosis s/p TIPS is transferred from OSH with refractory ascites for consideration of TIPS revision. . # Ascites: The patient had large ascites on exam but was not uncomfortable. Last therapeutic tap had been [**12-13**]. Ultrasound showed lack of wall-to-wall flow in the mid to distal TIPS, suggestive of neo-intimal hyperplasia. Given the history of apparent improvement in ascites after placement and subsequently after revision of TIPS, she underwent TIPS revision with 10 mm balloon and improved flow. Follow-up US two days later showed patent tips. Paracentesis of 6 L was done at the time of revision, and an additional 11.25 liters were taken off two days later, with albumin replacement each time. Diuretics were held for elevated creatinine. PPI was continued for reflux symptoms likely secondary to ascites. . # Hypotension: Intraoperatively while under general anesthesia, patient was hypotensive with SBP 70s. This continued in the [**Month/Year (2) 13042**] post-operatively. Initial hypotension likely related to anesthesia and fluid shift from large volume paracentesis. She was transferred briefly to the MICU, where blood pressure returned to baseline SBP 90s with IVF and albumin. . # Acute renal failure: Creatinine at OSH was increased from baseline 1.5 to 2.0. On admission, creatinine was 1.7. Diuretics were held. Urinary sodium was <10, consistent with prerenal vs HRS. She was given albumin at the time of paracentesis, and creatinine trended down to 1.5 prior to discharge. She was discharged off all diuretics with plans for lab tests in 3 days to monitor kidney function given that she had large volume paracentesis on the day of discharge. . # UTI: She had had a recent E Coli treated with Bactrim at an outside hospital. UA and cultures here were negative. . # Hyponatremia: Sodium was near baseline. She was asymptomatic. . # DM: Lantus was continued at home dose; she was given regular insulin as needed. . # Pancytopenia: Hematocrit and platelets were at baseline. . # Depression/Anxiety. Mirtazapine and trazadone were continued. . # Seizure disorder: Carbamazepine was continued. . Medications on Admission: - Potassium 20mEq PO daily - Spironolactone 200mg PO daily - Lactulose 30ml PO QID, titrated to [**2-28**] BM daily - Rifaximin 400 mg PO TID - Metoclopramide 10mg QACHS - Lasix 40mg daily - Clotrimazole - Levaquin 250mg daily (for E. coli UTI, subseq R to levoflox) - Protonix 40mg daily - Mirtazapine 15mg PO HS - Lantus 26 units SubQ - Carbamazepine 200 mg QAM, 400 mg QPM - Ibuprofen PRN pain - Folic acid 1mg daily - Dulcolax 1 tablet PO Q12H Discharge Medications: 1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). 2. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day) as needed for nausea. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Lantus 26 units qhs 7. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 8. Carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO QPM (once a day (in the evening)). 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day) as needed. 11. Outpatient Lab Work Please do chemistry panel including creatinine, CBC, and LFTs. Please fax results to: [**Telephone/Fax (1) 697**] ATTN: Dr. [**Last Name (STitle) 497**]. Discharge Disposition: Home Discharge Diagnosis: primary: cirrhosis secondary: renal insufficiency, diastolic congestive heart failure, type 2 diabetes Discharge Condition: stable Discharge Instructions: You were admitted to the hospital because you needed to have your TIPS revised. You had the TIPS revised and fluid taken out of your abdomen. The following medications were changed in the hospital: spironolactone, lasix, levaquin, and potassium were stopped . Please have your labs checked next Monday, [**12-27**] with the attached prescription. . Please call your doctor or return to the hospital if you have chest pain or shortnes of breath, increasing abdominal girth, fevers and chills, or other symptoms that are concerning to you. Followup Instructions: Please have your labs checked on Monday, [**12-27**] with the attached prescription. . You will need to have follow-up TIPS surveillance in [**7-4**] weeks. Dr. [**Last Name (STitle) 497**] can arrange this. . You have an appointment for an ultrasound and then at the [**Hospital 20871**] clinic: ULTRASOUND Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-1-12**] 1:45 TRANSPLANT [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2146-1-12**] 3:20 Completed by:[**2145-12-25**]",92,2145-12-20 23:09:00,2145-12-24 18:40:00,EMERGENCY,TRANSFER FROM HOSP/EXTRAM,HOME,REFRACTORY ASCITES," a 57 yo woman with hcv cirrhosis s/p tips is transferred from osh with refractory ascites for consideration of tips revision. . # ascites: the patient had large ascites on exam but was not uncomfortable. last therapeutic tap had been [**12-13**]. ultrasound showed lack of wall-to-wall flow in the mid to distal tips, suggestive of neo-intimal hyperplasia. given the history of apparent improvement in ascites after placement and subsequently after revision of tips, she underwent tips revision with 10 mm balloon and improved flow. follow-up us two days later showed patent tips. paracentesis of 6 l was done at the time of revision, and an additional 11.25 liters were taken off two days later, with albumin replacement each time. diuretics were held for elevated creatinine. ppi was continued for reflux symptoms likely secondary to ascites. . # hypotension: intraoperatively while under general anesthesia, patient was hypotensive with sbp 70s. this continued in the [**month/year (2) 13042**] post-operatively. initial hypotension likely related to anesthesia and fluid shift from large volume paracentesis. she was transferred briefly to the micu, where blood pressure returned to baseline sbp 90s with ivf and albumin. . # acute renal failure: creatinine at osh was increased from baseline 1.5 to 2.0. on admission, creatinine was 1.7. diuretics were held. urinary sodium was <10, consistent with prerenal vs hrs. she was given albumin at the time of paracentesis, and creatinine trended down to 1.5 prior to discharge. she was discharged off all diuretics with plans for lab tests in 3 days to monitor kidney function given that she had large volume paracentesis on the day of discharge. . # uti: she had had a recent e coli treated with bactrim at an outside hospital. ua and cultures here were negative. . # hyponatremia: sodium was near baseline. she was asymptomatic. . # dm: lantus was continued at home dose; she was given regular insulin as needed. . # pancytopenia: hematocrit and platelets were at baseline. . # depression/anxiety. mirtazapine and trazadone were continued. . # seizure disorder: carbamazepine was continued. . ","PRIMARY: [Other complications due to other vascular device, implant, and graft] SECONDARY: [Acute kidney failure, unspecified; Other ascites; Diastolic heart failure, unspecified; ; Urinary tract infection, site not specified; Hyposmolality and/or hyponatremia; Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation; Other iatrogenic hypotension; Cirrhosis of liver without mention of alcohol; Congestive heart failure, unspecified; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified; Chronic kidney disease, unspecified; Chronic hepatitis C without mention of hepatic coma; Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled; Hyperpotassemia; Asthma, unspecified type, unspecified; Dysthymic disorder; Esophageal reflux; Obstructive sleep apnea (adult)(pediatric); Epilepsy, unspecified, without mention of intractable epilepsy; ; Long-term (current) use of insulin]","a 57 yo woman with hcv cirrhosis s/p tips is transferred from osh with refractory ascites for consideration of tips revision. given the history of apparent improvement in ascites after placement and subsequently after revision of tips, she underwent tips revision with 10 mm balloon and improved flow. diuretics were held for elevated creatinine. urinary sodium was <10, consistent with prerenal vs hrs. # pancytopenia: hematocrit and platelets were at baseline.","a 57 yo woman with hcv cirrhosis s/p tips is transferred from osh with refractory ascites for consideration of tips revision. ultrasound showed lack of wall-to-wall flow in the mid to distal tips, suggestive of neo-intimal hyperplasia. she underwent tips revision with 10 mm balloon and improved flow. follow-up us two days later showed patent tips." 31692,116133.0,19351,2186-07-02,19350,174449.0,2186-04-13,Discharge summary,"Admission Date: [**2186-3-10**] Discharge Date: [**2186-4-13**] Date of Birth: [**2130-11-30**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1666**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 55 yo man w/ h/o end-stage sarcoid dx on home O2 (3L NC) no longer on xplant list, on home O2, who p/w SOB, f/c x 5 days. Pt was in his USOH until 5 days ago when noted increased SOB, dry cough. Called PCPs office on [**3-8**], who directed him to go to ED, but pt waited as is having financial problems at home and wanted to wait to work out some things before coming to ED. Pt had self-titrated up O2 to 4L. Also states felt like he had a fever o/n, but did not take temp. Today pt was seen at home by OT who noted that he had decreased O2 sats to 85-90% on 4L O2. OT called PCPs office who instructed them to call ambulance. Pt initially presented to [**Hospital3 **] where initial vitals noted to be T 98.8, HR 81, BP 132/68, RR 18, O2 91% 4L NC. Labs notable for slightly elevated WBC at 10.4. CXR there demonstrated ?new infiltrate, although difficult to assess given underlying lung dx. Pt was given rocephin 1gm x 1, azithro 500mg x 1, and transferred to [**Hospital1 18**]. In ED initial vitals T 97.4, HR 104, BP 115/82, RR 20, O2 91% 4L NC. Pt admitted for further management. Currently pt c/o continued SOB, cough, no other complaints at this time. Past Medical History: 1. Hepatitis C, diagnosed as part of the lung transplant workup at the [**Hospital1 756**]. He is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in GI. He is hepatitis B core surface antibody positive and surface antigen negative. In addition, he has hepatitis C antibody plus type 2b with a viral load in [**8-/2185**], of 5.5 million. He had grade 2 fibrosis on [**2184-4-28**]. He is not thought to be a candidate currently for interferon treatment given his sarcoidosis. He has transaminitis. 2. Sarcoidosis. He is followed by Dr. [**Last Name (STitle) 2168**]. The patient has been obtaining PFTs from Dr. [**Last Name (STitle) **], and he is currently on azathioprine and prednisone with prophylaxis Bactrim. 3. Sleep apnea. 4. Erectile dysfunction. 5. Emotional lability and anxiety. 6. Status post mandible fracture [**8-20**]. 7. Status post multiple rib and clavicle fractures over the past year secondary to fall. 8. Spinal stenosis: diagnosed on MRI and is followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**], [**First Name3 (LF) **] orthopedic physician at the [**Hospital1 18**]. The diagnosis was established as part of a workup for progressive lower leg weakness, which led to multiple falls and currently an inability to ambulate. 9. Shingles in [**12/2184**] on the right side of the face with residual neuropathic pain. Social History: Lives in an apartment in [**Location (un) 1459**] with his 27 yo daughter who is s/p traumatic brain injury in a motor vehicle accident. Has another daughter from whom he is estranged. Recently divorced from his wife of 33 years who he says did ""not want to take care of him."" Patient is a former food salesman, selling restaurant supplies to pizzerias. Has been unemployed for about a year, no longer on unemployment. Recently obtained some disability benefits. Reports a 10 pack year smoking history, but quit 20 years ago. Reports no history of ethanol use or IV drug use. Pt had previous admission in which he was on high doses of methadone and benzodiazepenes that were verified by PCP to be prescribed by an outpatient physician to treat his pain from spinal stenosis; pt believed to withdraw from both on previous admissions. Family History: Non contributory of pulmonary disease. Physical Exam: Admission Vitals - T 97.9, HR 97, BP 121/70, RR 25, O2 86% --> 94% 4L NC Gen - awake, alert, eating [**Location (un) 6002**], tachypnic slightly, speaking in full sentences CVS - RRR no noted m/r/g Lungs - mild decreased BS diffusely but overall fairly good air movement w/ no noted crackles, + mild wheezing Abd - soft, NT/ND Ext - trace LE edema b/l . Discharge Vitals - T 97.9, HR 97, BP 126/86, RR 18, O2 98%6L with facemask mist supplementation Gen - awake, alert, comfortable, speaking in full sentences CVS - RRR no noted m/r/g Lungs - mild decreased BS diffusely but overall fairly good air movement w/ no noted crackles, + mild expiratory wheezes at bases, no increased work of breathing Abd - soft, NT/ND Ext - trace LE edema b/l, + mild right forearm edema Pertinent Results: CXR [**2186-3-11**]:Extensive pulmonary fibrosis and architectural distortion, presumably due to the provided history of sarcoid although basilar predominance is atypical. No findings to suggest an acute superimposed pneumonia, but subtle infection could be easily obscured by the chronic lung disease. . CXR [**2186-4-6**]: Today's study demonstrates fracture displacement of the right seventh rib laterally, other lower fractures were demonstrated along the lateral chest wall on the 9:27 a.m. film. Severe pulmonary fibrosis and marked emphysema are longstanding. There is no evidence of acute pulmonary changes though subtle findings would be missed. No appreciable pleural effusion is seen. Heart size is normal. No pneumothorax. . CT Chest [**2186-3-14**] 1. No evidence of pneumonia or other acute cardiopulmonary process. 2. Chronic severe pulmonary fibrosis, could be end- stage sarcoidosis. Chronic pulmonary hypertension. 3. Previous right upper lobe infection resolved. 4. Possible small right upper lobe mycetoma. 5. New left lower lobe 3.5 mm lung nodule warrants [**5-25**] month CT followup. . CT abd: 1. Bilateral rectus sheath hematomas as described above. Small amount of blood in the fat-containing right inguinal hernia. 2. No evidence of retroperitoneal hematoma. 3. Changes in the lung bases, incompletely evaluated, are consistent with the patient's history of sarcoid. 4. Healing bilateral rib fractures. 5. Abdominal aortic ectasia as above up to 2.8 cm. 6. Nonobstructing left nephrolithiasis. . CT Chest [**2186-4-6**]: 1. Small PE of segmental/subsegmental right upper lobe branch. This was communicated by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 24949**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3766**] by telephone in the AM on [**2186-4-10**]. 2. New minimally displaced fracture of the lateral right ninth rib. Multiple additional bilateral healing rib fractures. 3. Healing left distal clavicle fracture. 3. Resolution of right upper lobe pneumonia. 4. Chronic severe pulmonary fibrosis in the setting of sarcoidosis. . LE U/S:No evidence of DVT in either extremity. . CBC [**2186-3-11**] 05:15AM BLOOD WBC-9.2 RBC-3.74* Hgb-13.2* Hct-39.3* MCV-105* MCH-35.4* MCHC-33.6 RDW-15.3 Plt Ct-259 [**2186-3-13**] 04:40AM BLOOD WBC-10.6 RBC-3.70* Hgb-13.0* Hct-39.3* MCV-106* MCH-35.3* MCHC-33.2 RDW-15.9* Plt Ct-294 [**2186-3-14**] 04:40AM BLOOD WBC-12.0* RBC-3.53* Hgb-12.4* Hct-36.9* MCV-105* MCH-35.1* MCHC-33.6 RDW-15.4 Plt Ct-269 [**2186-3-19**] 05:11AM BLOOD WBC-10.1 RBC-3.72* Hgb-13.1* Hct-39.9* MCV-107* MCH-35.1* MCHC-32.7 RDW-16.1* Plt Ct-232 [**2186-3-21**] 04:40AM BLOOD WBC-11.3* RBC-3.71* Hgb-13.1* Hct-39.9* MCV-108* MCH-35.4* MCHC-32.9 RDW-16.2* Plt Ct-298 [**2186-3-23**] 07:30AM BLOOD WBC-11.0 RBC-3.56* Hgb-12.4* Hct-38.6* MCV-108* MCH-34.9* MCHC-32.3 RDW-16.2* Plt Ct-297 [**2186-3-25**] 06:22AM BLOOD WBC-10.8 RBC-3.40* Hgb-12.0* Hct-36.4* MCV-107* MCH-35.4* MCHC-33.1 RDW-16.3* Plt Ct-282 [**2186-3-28**] 03:58PM BLOOD Hct-32.0* [**2186-3-31**] 07:55AM BLOOD WBC-10.6 RBC-2.86* Hgb-10.0* Hct-31.1* MCV-109* MCH-35.1* MCHC-32.2 RDW-16.9* Plt Ct-361 [**2186-4-2**] 06:03AM BLOOD WBC-11.1* RBC-2.91* Hgb-10.3* Hct-32.3* MCV-111* MCH-35.2* MCHC-31.8 RDW-17.1* Plt Ct-320 [**2186-4-5**] 05:54AM BLOOD WBC-15.2* RBC-3.26* Hgb-11.6* Hct-36.2* MCV-111* MCH-35.5* MCHC-32.0 RDW-16.5* Plt Ct-367 [**2186-4-9**] 05:42AM BLOOD WBC-9.6 RBC-3.10* Hgb-11.1* Hct-33.9* MCV-109* MCH-35.8* MCHC-32.8 RDW-16.2* Plt Ct-259 [**2186-4-10**] 04:08AM BLOOD WBC-8.6 RBC-3.18* Hgb-11.2* Hct-34.7* MCV-109* MCH-35.1* MCHC-32.1 RDW-16.3* Plt Ct-277 [**2186-4-11**] 05:35AM BLOOD WBC-7.7 RBC-3.18* Hgb-11.2* Hct-34.7* MCV-109* MCH-35.3* MCHC-32.4 RDW-16.3* Plt Ct-290 . Chem 7 [**2186-3-11**] 05:15AM BLOOD Glucose-243* UreaN-16 Creat-0.5 Na-138 K-4.9 Cl-101 HCO3-28 AnGap-14 [**2186-3-13**] 04:40AM BLOOD Glucose-222* UreaN-20 Creat-0.5 Na-141 K-3.9 Cl-105 HCO3-27 AnGap-13 [**2186-3-15**] 05:31AM BLOOD Glucose-125* UreaN-18 Creat-0.5 Na-143 K-3.9 Cl-104 HCO3-29 AnGap-14 [**2186-3-19**] 05:11AM BLOOD Glucose-154* UreaN-27* Creat-0.5 Na-144 K-4.3 Cl-105 HCO3-30 AnGap-13 [**2186-3-23**] 07:30AM BLOOD Glucose-103 UreaN-23* Creat-0.6 Na-140 K-4.3 Cl-100 HCO3-32 AnGap-12 [**2186-3-26**] 05:39AM BLOOD Glucose-142* UreaN-29* Creat-0.6 Na-143 K-4.6 Cl-105 HCO3-25 AnGap-18 [**2186-3-28**] 06:42AM BLOOD Glucose-128* UreaN-23* Creat-0.4* Na-143 K-4.2 Cl-105 HCO3-34* AnGap-8 [**2186-3-30**] 05:05AM BLOOD Glucose-120* UreaN-22* Creat-0.5 Na-140 K-4.6 Cl-101 HCO3-32 AnGap-12 [**2186-4-1**] 06:06AM BLOOD Glucose-98 UreaN-17 Creat-0.5 Na-142 K-4.2 Cl-104 HCO3-36* AnGap-6* [**2186-4-3**] 05:17AM BLOOD Glucose-186* UreaN-25* Creat-0.5 Na-143 K-4.2 Cl-104 HCO3-35* AnGap-8 [**2186-4-9**] 05:42AM BLOOD Glucose-139* UreaN-24* Creat-0.6 Na-144 K-3.9 Cl-102 HCO3-36* AnGap-10 [**2186-4-10**] 04:08AM BLOOD Glucose-139* UreaN-20 Creat-0.5 Na-145 K-3.8 Cl-106 HCO3-35* AnGap-8 [**2186-4-11**] 05:35AM BLOOD Glucose-111* UreaN-20 Creat-0.5 Na-147* K-3.9 Cl-106 HCO3-36* AnGap-9 . MISC [**2186-3-11**] 05:15AM BLOOD ALT-131* AST-140* LD(LDH)-342* [**2186-3-19**] 05:11AM BLOOD ALT-96* AST-113* AlkPhos-104 TotBili-0.5 [**2186-4-8**] 03:52AM BLOOD CK-MB-NotDone cTropnT-0.08* [**2186-4-8**] 11:50AM BLOOD CK-MB-NotDone cTropnT-0.15* [**2186-4-8**] 05:55PM BLOOD Type-ART pO2-79* pCO2-54* pH-7.44 calTCO2-38* Base XS-10 [**2186-4-8**] 05:55PM BLOOD O2 Sat-93 Brief Hospital Course: #SHORTNESS OF BREATH / VIRAL BRONCHITIS / SARCOIDOSIS / ANXIETY Mr. [**Known lastname 52653**] was admitted with worsening SOB and lower oxygen saturations. This was not felt to be a flare of sarcoidosis but more likely a viral infection on top of severe underlying lung disease caused by sarcoid. A pulmonary consultation was obtained. Prednisone was increased to 60mg PO daily in addition to his azathioprine 150mg once daily. His oxygen flow was increased to four liters, and later to 5-6 liters. He briefly went to the MICU on [**2186-4-7**] for worsening tachypnea; he remained on his baseline 6L NC with shovel mask mist support. After returning to the floor and again becoming tachypneic, he underwent CTA which showed as small subsegmental PE. LENI's were negative for DVT. As the patient had had recent bleeding with rectus sheath hematomas, anticoagulation was not started.His outpt pulmonologist was made aware and agreed with holding off on anticoagulation. At discharge, he was restarted on lower dose sc heparin 5000 [**Hospital1 **] (down from TID). He will be followed closely as an outpt with Dr. [**Last Name (STitle) **]. At discharge he was 97% on 6L NC and shovel mask mist support, slightly tachypnic. Per Dr.[**Last Name (STitle) 18309**], transtracheal oxygen catheter has been discussed to improve oxygen delivery. He was evaluated by throracic surgery during his inpt stay but a decision was defered as the surgeon was out of town. The cardiothoracic surgery clinic will call the patient with an appointment to follow up in clinic for evaluation. . #PSEUDOMONAS PNEUMONIA He stabilized after initial presentation but intermittently became tachypneic from his viral bronchitis, but later developed much more productive cough with phlegm. Sputum culture was obtained which was notable for multidrug-resistant pseudomonas. CT scan showed interval developement of new RUL consolidation. He was treated with meropenem for 14 days. Subsequent CT showed interval resolution. . #SEVERE ANXIETY He has severe anxiety related to advanced illness and is quite fearful of death, and this exacerbated respiratory symptoms. A palliative care consultation was obtained and the patient wsa tried on sublingual morphine with an increase in his anxiolytic medications. He personally was not yet ready for hospice. In terms of psychopharmacology, the patient was started on risperidone 1mg PO BID, and his duloxetine was increased to 90mg PO daily. SL Morphine aided in comfort. . #RIB FRACTURES / OSTEOPOROSIS: THe patient had several old rib fractures, but also developed a new acute rib fracture during this admission. This is due to chronic steroid use and coughing. A vitamin D level was normal in [**11-19**]. A repeat Vit D level is pending. This value should be followed up on and Vit D supplements started if low. The patient may also need bisphosphonates although the long-term benefits are doubtful given his poor prognosis. . #RECTUS SHEALTH HEMATOMA The patient developed a moderate sized rectus shealth hematoma during this admission with 8 point hematocrit drop. This was felt to be in part to coughing while on subcutaneous heparin injections. Heparin sc was discontinued. His HCT stabilized without intervention. Heparin at a lower dose of 5000 [**Hospital1 **] was restarted. If the patient has any sign of bleeding or worsening abd bruising, discontinue heparin and please use pneumoboots. . #FALL The patient fell on [**2186-4-6**] while toileting. He did not hit his head and had no LOC. New rib fracture and rectus sheath hematoma were not attributed to this fall. . #SPINAL STENOSIS The patient was continued on long and short acting morphine for pain control. His MS contin was increased to 45/15/45 mg three times per day respectively. He had sublingual morphine and percocet on PRN basis. . #PAIN MEDICATION ISSUES The patient was seen by nursing to be saving pain medication for his daughter. [**Name (NI) **] was directly observed taking all medications subsequently. There were no subsequent concerns regarding pain medication. . # MENTAL STATUS The patient is typically fully oriented, though he had frequent periods where he was unsure of surroundings. He typically became quite paranoid at night and felt that most night nurses were playing tricks on him. He was started on risperidone 1mg PO BID with PRN haldol for agitation. Medications on Admission: Albuterol PRN , Azathioprine 150mg daily Klonipin 0.5mg TID PRN Cymbalta 60mg daily Advair 500/50 INH [**Hospital1 **] Remeron 15mg qhs Morphine SR 30mg TID Omeprazole 20mg daily Percocet q6hr PRN Prednisone 40mg daily Simvastatin 20mg daily Spiriva 18mcg INH daily Trazadone 50mg qhs PRN ASA 325mg daily colace senna thiamine 100mg daily tylenol PRN Discharge Medications: 1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 2. Azathioprine 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 13. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO QMWF (). 14. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 15. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 16. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 18. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO q 1:00pm as needed. 20. Morphine 15 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO QAM (once a day (in the morning)). 21. Morphine 15 mg Tablet Sustained Release Sig: Three (3) Tablet Sustained Release PO QPM (once a day (in the evening)). 22. Morphine Concentrate 20 mg/mL Solution Sig: 0.5-0.75 mL PO Q3H (every 3 hours) as needed. 23. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q3H PRN (). 24. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 25. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 26. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 27. Haloperidol 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 28. Insulin 12 units NPH qAM, 6 units NPH qPM Regular Insulin Sliding scale coverage (see attached scale) 29. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 30. Sodium Chloride 0.65 % Aerosol, Spray Sig: Two (2) Spray Nasal QID (4 times a day) as needed. 31. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Primary: - Acute exacerbation of COPD - Hospital acquired pneumonia - Rectus sheath hematoma - End stage pulmonary sarcoid Secondary: - Chronic immunosuppression - Obstructive sleep apnea - Left III nerve palsy - Anxiety; depression; paranoia - Traumatic mandibular, rib, clavicle fractures - Spinal stenosis; frequent falls - Chronic pain - Zoster - Hepatitis C Discharge Condition: Stable. On 6L NC. afebrile. Discharge Instructions: You were admitted with shortness of breath and thought to have a viral bronchitis on top of your sarcoidosis. You had a new pneumonia and were treated with IV antibiotics: 14 day course of meropenem completed. You were continued on a higher dose of predisone as well as your current dose of azathioprine. . You had a large abdominal (rectus sheath) hematoma that will improve over time. . Your medications were changed. Your prednisone was increased as above. Your pain medications have changed; please review your NEW medication list and adjust your home meds as needed. . If you develop worsening shortness of breath, low oxygen saturations on your current level of home oxygen, fevers or chills, please return to the hospital. Followup Instructions: New left lower lobe 3.5 mm lung nodule warrants [**5-25**] month CT followup. . Please make an appointment with Dr. [**Last Name (STitle) **], your outpt psychiatrist ([**Telephone/Fax (1) 52654**]) to be seen in [**12-14**] weeks. Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2186-5-1**] 2:00 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2186-5-1**] 1:00 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2186-5-1**] 1:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**] ",80,2186-03-10 21:06:00,2186-04-13 14:34:00,EMERGENCY,EMERGENCY ROOM ADMIT,LONG TERM CARE HOSPITAL,PNEUMONIA," #shortness of breath / viral bronchitis / sarcoidosis / anxiety mr. [**known lastname 52653**] was admitted with worsening sob and lower oxygen saturations. this was not felt to be a flare of sarcoidosis but more likely a viral infection on top of severe underlying lung disease caused by sarcoid. a pulmonary consultation was obtained. prednisone was increased to 60mg po daily in addition to his azathioprine 150mg once daily. his oxygen flow was increased to four liters, and later to 5-6 liters. he briefly went to the micu on [**2186-4-7**] for worsening tachypnea; he remained on his baseline 6l nc with shovel mask mist support. after returning to the floor and again becoming tachypneic, he underwent cta which showed as small subsegmental pe. lenis were negative for dvt. as the patient had had recent bleeding with rectus sheath hematomas, anticoagulation was not started.his outpt pulmonologist was made aware and agreed with holding off on anticoagulation. at discharge, he was restarted on lower dose sc heparin 5000 [**hospital1 **] (down from tid). he will be followed closely as an outpt with dr. [**last name (stitle) **]. at discharge he was 97% on 6l nc and shovel mask mist support, slightly tachypnic. per dr.[**last name (stitle) 18309**], transtracheal oxygen catheter has been discussed to improve oxygen delivery. he was evaluated by throracic surgery during his inpt stay but a decision was defered as the surgeon was out of town. the cardiothoracic surgery clinic will call the patient with an appointment to follow up in clinic for evaluation. . #pseudomonas pneumonia he stabilized after initial presentation but intermittently became tachypneic from his viral bronchitis, but later developed much more productive cough with phlegm. sputum culture was obtained which was notable for multidrug-resistant pseudomonas. ct scan showed interval developement of new rul consolidation. he was treated with meropenem for 14 days. subsequent ct showed interval resolution. . #severe anxiety he has severe anxiety related to advanced illness and is quite fearful of death, and this exacerbated respiratory symptoms. a palliative care consultation was obtained and the patient wsa tried on sublingual morphine with an increase in his anxiolytic medications. he personally was not yet ready for hospice. in terms of psychopharmacology, the patient was started on risperidone 1mg po bid, and his duloxetine was increased to 90mg po daily. sl morphine aided in comfort. . #rib fractures / osteoporosis: the patient had several old rib fractures, but also developed a new acute rib fracture during this admission. this is due to chronic steroid use and coughing. a vitamin d level was normal in [**11-19**]. a repeat vit d level is pending. this value should be followed up on and vit d supplements started if low. the patient may also need bisphosphonates although the long-term benefits are doubtful given his poor prognosis. . #rectus shealth hematoma the patient developed a moderate sized rectus shealth hematoma during this admission with 8 point hematocrit drop. this was felt to be in part to coughing while on subcutaneous heparin injections. heparin sc was discontinued. his hct stabilized without intervention. heparin at a lower dose of 5000 [**hospital1 **] was restarted. if the patient has any sign of bleeding or worsening abd bruising, discontinue heparin and please use pneumoboots. . #fall the patient fell on [**2186-4-6**] while toileting. he did not hit his head and had no loc. new rib fracture and rectus sheath hematoma were not attributed to this fall. . #spinal stenosis the patient was continued on long and short acting morphine for pain control. his ms contin was increased to 45/15/45 mg three times per day respectively. he had sublingual morphine and percocet on prn basis. . #pain medication issues the patient was seen by nursing to be saving pain medication for his daughter. [**name (ni) **] was directly observed taking all medications subsequently. there were no subsequent concerns regarding pain medication. . # mental status the patient is typically fully oriented, though he had frequent periods where he was unsure of surroundings. he typically became quite paranoid at night and felt that most night nurses were playing tricks on him. he was started on risperidone 1mg po bid with prn haldol for agitation. ","PRIMARY: [Obstructive chronic bronchitis with acute bronchitis] SECONDARY: [Pneumonia due to Pseudomonas; Acute posthemorrhagic anemia; Pneumonia, organism unspecified; Acidosis; Other pulmonary embolism and infarction; Pathologic fracture of other specified site; Sarcoidosis; Lung involvement in other diseases classified elsewhere; Obstructive sleep apnea (adult)(pediatric); Unspecified viral hepatitis C without hepatic coma; Other dependence on machines, supplemental oxygen; Third or oculomotor nerve palsy, partial; Dysthymic disorder; Spinal stenosis, unspecified region; Constipation, unspecified; Encounter for palliative care; Other disorders of muscle, ligament, and fascia; Other chronic pulmonary heart diseases; Hypoxemia; Other chronic pain; Other abnormal glucose; Adrenal cortical steroids causing adverse effects in therapeutic use; Osteoporosis, unspecified]","#shortness of breath / viral bronchitis / sarcoidosis / anxiety mr. [** as the patient had had recent bleeding with rectus sheath hematomas, anticoagulation was not started.his outpt pulmonologist was made aware and agreed with holding off on anticoagulation. he will be followed closely as an outpt with dr. [** sputum culture was obtained which was notable for multidrug-resistant pseudomonas. heparin at a lower dose of 5000 [**hospital1 **] was restarted. #fall the patient fell on [**2186-4-6**] while toileting. #pain medication issues the patient was seen by nursing to be saving pain medication for his daughter. # mental status the patient is typically fully oriented, though he had frequent periods where he was unsure of surroundings. he was started on risperidone 1mg po bid with prn haldol for agitation.","mr. [**known lastname 52653**] was admitted with worsening sob and lower oxygen saturations. this was not felt to be a flare of sarcoidosis but more likely a viral infection on top of severe underlying lung disease caused by sarcoid. he was 97% on 6l nc and shovel mask mist support, slightly tachypnic." 31969,151726.0,21685,2110-05-14,21684,116681.0,2109-12-27,Discharge summary,"Admission Date: [**2109-12-23**] Discharge Date: [**2109-12-27**] Date of Birth: [**2033-9-7**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4616**] Chief Complaint: Malaise and fever Major Surgical or Invasive Procedure: central line placement History of Present Illness: This is a 76 yo F w/h/o pancreatic cancer s/p whipple and s/p external beam XRT concurrent with xeloda, currently being treated with Gemcitabine weekly w/last chemo [**2109-12-18**]. At home, pt had persistant malaise, light-headedness, and LE myalgias which normally last ~2 days after chemotherapy but this time persisted. She also noted 2 days of fever to max of 101.5, along with rhinorrhea, sore throat, and epistaxis which had been bothering her for ~1 week. She normally checks her BP at home, but for the past few days her automated BP cuff had been saying ""unreadable"" when she tried to measure it. Pt's baseline BP is reportedly in 120s, but in the past after chemo it would dip to the 100s. With chemo, pt reports decreased apetite, and her daughter notes that she has lost 2 lbs in the past week. Also of note, pt has had chronic diarrhea for ~6 months, but after starting Lomotil, Immodium, and Viokase 8 (pancreatic enzyme replacment) her #of BMs has decreased from 4 to 2 per day. On the morning of admission, the fever and light-headedness prompted the pt's family to call her oncology NP, who told them to call EMS. On EMS arrival BP was 100/50. . On ROS Pt denies SOB, chest pain, cough, headache, sinus pressure, neck stiffness, visual changes, nausea, vommiting, worsening diarrhea, melena, hematochezia, dysuria, and hematuria. . In the [**Hospital1 18**] ED SBP was initially in the low 100s, and temp=100.6. 2L IVF where given, and despite the administraton of fluid SBP fell to the 80s. Right IJ placed (MAP 58 CVP 10) and pt was started on norepinephrine gtt and Vanco/Ceftaz were administered. Pt was never tachycardic or hypoxic. Lactate 1.0, HCT 25. Guiac (-) brown stool. CXR was clear, and U/A clear. Past Medical History: -pancreatic cancer diagnosed at [**Hospital6 1597**] [**4-16**], s/p Whipple [**2109-5-10**]. S/p Cyber Knife and external beam XRT concurrent with xeloda. Currently getting Gemcitabine weekly w/last chemo [**2109-12-18**]. -CBD obstruction with stent - s/p PE on coumadin - h/o uterine sarcoma: stage Ib, grade III endometrial carcinoma: s/p TAH-BSO [**9-13**], - Aortic stenosis - Hypertension - Type 2 diabetes - Glaucoma - herpes in L eye Social History: No smoking, No alcohol, no drug use. Lives alone in home in [**Location (un) 583**], but son or daughter stays with her at night. Independent when well. Children have been staying with her because they are concerned about her. Dtr. is HCP. Family History: daughter with endometrial carcinoma, sister with liver cancer, father with lung cancer, no fam h/o blood clots Physical Exam: VS: Temp: 97.3 BP: 102/42 HR:71 RR:16 O2sat 98 RA CVP 11 GEN: pleasant, comfortable, NAD HEENT: R PERRL, L Pupil Surgical, EOMI, anicteric, MMM, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no blowing [**2-13**] creshendo/decreshendo M heard throughout precorium but best at RUSB ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No clonus. RECTAL (in ED): Guiac (-) brown stool Pertinent Results: CBC: [**2109-12-23**] WBC-4.4 RBC-2.66* Hgb-9.2* Hct-24.5* MCV-92 MCH-34.5* MCHC-37.6* RDW-13.5 Plt Ct-93* [**2109-12-23**] WBC-3.9* RBC-1.94*# Hgb-6.6*# Hct-18.7* MCV-97 MCH-34.0* MCHC-35.1* RDW-14.0 Plt Ct-75* [**2109-12-27**] WBC-3.7* RBC-2.63* Hgb-8.7* Hct-24.5* MCV-93 MCH-33.2* MCHC-35.6* RDW-13.9 Plt Ct-88* . COAGS: [**2109-12-23**] PT-36.1* PTT-51.4* INR(PT)-3.8* [**2109-12-27**] PT-18.9* PTT-30.4 INR(PT)-1.7* . CHEM: [**2109-12-23**] Glucose-154* UreaN-37* Creat-1.6* Na-131* K-3.9 Cl-97 HCO3-18* AnGap-20 [**2109-12-27**] Glucose-153* UreaN-14 Creat-0.9 Na-133 K-3.8 Cl-105 HCO3-22 AnGap-10 . ANEMIA LABS: [**2109-12-26**] Iron-36 calTIBC-139* Folate-9.2 Ferritn-GREATER TH TRF-107* . URINE: [**2109-12-23**] Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM RBC-0 WBC-[**5-20**]* Bacteri-MOD Yeast-MOD Epi-[**2-12**] . [**12-23**] BCx: negative [**12-23**] UCx: YEAST. 10,000-100,000 ORGANISMS/ML.. [**12-24**] UCx: YEAST. ~6OOO/ML. [**12-26**] Stool: FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA. . [**2109-12-23**] CXR AP UPRIGHT CHEST: The tip of a new right internal jugular central venous catheter terminates in the distal SVC. The cardiac, mediastinal and hilar contours appear stable. The lungs are clear. The pulmonary vasculature is normal. There is no pleural effusion or pneumothorax. The visualized osseous structures appear unremarkable. IMPRESSION: 1. Standard position of the right IJ central venous catheter, terminating in the distal SVC. 2. No acute cardiopulmonary process. . [**12-23**] EKG Sinus rhythm. Compared to the previous tracing of [**2109-7-3**] R wave progression is improved. Brief Hospital Course: A/P: 76 yo F w/ h/o pancreatic cancer, currently receiving chemotherapy who presented with fever and hypotension requiring pressors: pt initially admitted to ICU for r/o sepsis. Pt with mildly positive UA and no other clear source of infection, . . # Hypotension: on presentation had hypotension that was not responisve to fluids. She was started on levophed in the ED and after 12 hours in ICU levofed was successfully weaned and BP was stable. Hypotension was most likely [**1-11**] decreased PO intake in the setting of chronic diarrhea and outpatient antihypertensive medications. Sepsis was considered since pt continued to have hypotension despite CVP of 12. Before D/C from the ICU BP was stable for 24 hours and pt was afebrile. Pt had initially been started on cipro and flagyl for weakly positive UA and empiric coverage for possible intra-abdominal process. These antibiotics were stopped shortly thereafter due to lack of data c/w infectious etiology (see below). Remained afebrile and BP stable off of antibiotics. On the Onc floor, her BPs were stable off of her antihypertensive regimen. We were able to restart her atenolol but ACE was held on discharge, to be restarted as tolerated as an outpatient. . # Pancreatic Cancer: Chemo side effects likely contributed to diarrhea. Onc plans were held and deferred to outpatient oncology team. . # Diarrhea: Pt was continued on home viokase for pancreatic enzyme replacement. She also takes immodium and lomotil for chronic diarrhea. A Ciff assay was negative. . # Pancytopenia: All cell lines were depressed -- likely pancytopenia [**1-11**] chemotherapy. No signs of bleeding aside from epistaxis in the setting of supratherapeutic INR. Pt was transfused a total of 2 units pRBCs with appropriate HCT response. Also received 1 unit platelets (see below). . # Fever: Fever resolved by the time of call out from the ICU. Pt was afebrile on floor. Culture data did not reveal a clear source. Likely that fever on presentation was due to a viral URI, given history of rhinorrhea and sore throat. Because Cx data was negative cipro and flagyl were discontinued on the day that she was called out from the MICU. Abx not resumed on floor. . # Hx of PE: treated with coumadin at home. INR was supratherapeutic throughout time in the ICU. On the day of call-out she was having epistaxis. Likely that quinolone administration was prolonging the INR. Given FFP before transfer to the floor. Had some persistent bleeding on floor. Was transfused 1 unit of platelets (nadir value was 40 with bleeding), with resolution of epistaxis. Resumed coumadin regimen prior to d/c, but was still not therapeutic prior to discharge. Therefore, given enoxaparin daily injections with plan for outpt INR checks. . # Myalgias: most likley [**1-11**] chemo. Gave tylenol PRN. . # DM: On glyburide at home, which was held and HISS was given. Restarted on discharge. . # Code: Full Medications on Admission: Atenolol 50 mg PO DAILY Enalapril 10 mg PO DAILY Warfarin 2.5 mg TTSS and 3 mg MWF Glyburide 2.5 mg PO BID Ativan 0.5-1 mg QDay PRN Compazine 10 mg TID PRN Lomotil 2.5 mg PO BID Viokase 8 1-2 tabs QIDAC Vit B12 Immodium Discharge Medications: 1. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO 4X/WEEK ([**Doctor First Name **],TU,TH,SA). 2. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO 3X/WEEK (MO,WE,FR). 3. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 6. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO DAILY (Daily) as needed for Anxiety. 7. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet Sig: 1-2 Tablets PO QIDAC (). 8. GlyBURIDE 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO as directed as needed for diarrhea. 10. Enoxaparin 100 mg/mL Syringe Sig: One Hundred (100) mg Subcutaneous once a day: until otherwise instructed by MD. [**Last Name (Titles) **]:*5 syringes* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Primary: Hypotension . Secondary: # pancreatic cancer diagnosed at [**Hospital6 1597**] [**4-16**], s/p Whipple [**2109-5-10**]. S/p Cyber Knife and external beam XRT concurrent with xeloda. Currently getting Gemcitabine weekly w/last chemo [**2109-12-18**]. # CBD obstruction with stent # s/p PE on coumadin # h/o uterine sarcoma: stage Ib, grade III endometrial carcinoma: s/p TAH-BSO [**9-13**], # Aortic stenosis # Hypertension # Type 2 diabetes # Glaucoma # herpes in L eye Discharge Condition: stable, normotensive, ambulating independently Discharge Instructions: You were admitted to the hospital with fevers and low blood pressure. You were briefly in our ICU because you needed medicine to suppport your blood pressure. However, you were quickly able to come off that medicine. We checked for any signs of infection but there were none. . We are restarting one of your blood pressure medicines, atenolol. However, given your recent low blood pressures, you should not take you enalapril until instructed by your PCP or oncologist. . You will be going home with physical therapy and a visiting nurse to check your blood counts as well as the level of couadin in your blood. In the meantime, you will need to take an injection of Lovenox once per day to make sure your blood is thin enough. . Please make sure to take all your medicines as prescribed. Please keep all your followup appointments. If you experience any fevers/chills, lightheadedness, or other symptoms which concern you, please call your doctor or go to the ED. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2110-1-8**] 1:00 Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2110-1-8**] 1:00 Provider: [**Name10 (NameIs) **] FELT, RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2110-1-8**] 2:00 . Please see your PCP: [**Name10 (NameIs) **],[**First Name3 (LF) 251**] R [**Telephone/Fax (1) 57021**], in the next 2 weeks. ",138,2109-12-23 17:22:00,2109-12-27 17:53:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,HYPOTENSION," a/p: 76 yo f w/ h/o pancreatic cancer, currently receiving chemotherapy who presented with fever and hypotension requiring pressors: pt initially admitted to icu for r/o sepsis. pt with mildly positive ua and no other clear source of infection, . . # hypotension: on presentation had hypotension that was not responisve to fluids. she was started on levophed in the ed and after 12 hours in icu levofed was successfully weaned and bp was stable. hypotension was most likely [**1-11**] decreased po intake in the setting of chronic diarrhea and outpatient antihypertensive medications. sepsis was considered since pt continued to have hypotension despite cvp of 12. before d/c from the icu bp was stable for 24 hours and pt was afebrile. pt had initially been started on cipro and flagyl for weakly positive ua and empiric coverage for possible intra-abdominal process. these antibiotics were stopped shortly thereafter due to lack of data c/w infectious etiology (see below). remained afebrile and bp stable off of antibiotics. on the onc floor, her bps were stable off of her antihypertensive regimen. we were able to restart her atenolol but ace was held on discharge, to be restarted as tolerated as an outpatient. . # pancreatic cancer: chemo side effects likely contributed to diarrhea. onc plans were held and deferred to outpatient oncology team. . # diarrhea: pt was continued on home viokase for pancreatic enzyme replacement. she also takes immodium and lomotil for chronic diarrhea. a ciff assay was negative. . # pancytopenia: all cell lines were depressed -- likely pancytopenia [**1-11**] chemotherapy. no signs of bleeding aside from epistaxis in the setting of supratherapeutic inr. pt was transfused a total of 2 units prbcs with appropriate hct response. also received 1 unit platelets (see below). . # fever: fever resolved by the time of call out from the icu. pt was afebrile on floor. culture data did not reveal a clear source. likely that fever on presentation was due to a viral uri, given history of rhinorrhea and sore throat. because cx data was negative cipro and flagyl were discontinued on the day that she was called out from the micu. abx not resumed on floor. . # hx of pe: treated with coumadin at home. inr was supratherapeutic throughout time in the icu. on the day of call-out she was having epistaxis. likely that quinolone administration was prolonging the inr. given ffp before transfer to the floor. had some persistent bleeding on floor. was transfused 1 unit of platelets (nadir value was 40 with bleeding), with resolution of epistaxis. resumed coumadin regimen prior to d/c, but was still not therapeutic prior to discharge. therefore, given enoxaparin daily injections with plan for outpt inr checks. . # myalgias: most likley [**1-11**] chemo. gave tylenol prn. . # dm: on glyburide at home, which was held and hiss was given. restarted on discharge. . # code: full ","PRIMARY: [Acute kidney failure, unspecified] SECONDARY: [Other specified aplastic anemias; Hyposmolality and/or hyponatremia; Acidosis; Hypovolemia; Personal history of venous thrombosis and embolism; Personal history of malignant neoplasm of other gastrointestinal tract; Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use; Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled; Epistaxis; Unspecified essential hypertension; Aortic valve disorders; Long-term (current) use of anticoagulants]","a/p: 76 yo f w/ h/o pancreatic cancer, currently receiving chemotherapy who presented with fever and hypotension requiring pressors: pt initially admitted to icu for r/o sepsis. she was started on levophed in the ed and after 12 hours in icu levofed was successfully weaned and bp was stable. also received 1 unit platelets (see below). because cx data was negative cipro and flagyl were discontinued on the day that she was called out from the micu. # hx of pe: treated with coumadin at home. was transfused 1 unit of platelets (nadir value was 40 with bleeding), with resolution of epistaxis. therefore, given enoxaparin daily injections with plan for outpt inr checks.",pt with mildly positive ua and no other clear source of infection was admitted to icu for r/o sepsis. she was started on levophed in the ed and after 12 hours in icu levofed was successfully weaned and bp was stable. pt was continued on home viokase for pancreatic enzyme replacement and immodium and lomotil for chronic diarrhea. 32247,113222.0,15732,2122-09-29,15731,180961.0,2122-09-17,Discharge summary,"Admission Date: [**2122-9-11**] Discharge Date: [**2122-9-17**] Date of Birth: [**2059-1-8**] Sex: F Service: SURGERY Allergies: Percocet / Motrin / Nsaids / Aspirin / Dilantin Attending:[**First Name3 (LF) 668**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2122-9-13**]: negative exploratory laparotomy History of Present Illness: 62yo F w/ a PMH of ESRD on HD s/p failed kidney transplant, DVT (associated w/ HD cath), and HTN who presents to the ED today with right lower quadrant abdominal pain and hypotension. She was nauseated last night and had vomiting x 1. Nonbloody, nonbilious. Last bowel movement was 2 days ago. Not constipated. No diarrhea. No fever chillls or night sweats. She has had the abdominal pain for weeks. Food makes the pain better. She has not eaten today so the pain has gotten worse over the last couple of days. Past Medical History: 1. Diabetes mellitus.- unclear hx, not on medication, nl [**Name (NI) **] 2. End-stage renal disease secondary to diabetes mellitus s/p failed dual kidney transplant 3. Hemodialysis. 4. Hypertension. 5. Hyperlipidemia. 6. Thrombosis of bilateral IVJ (catheter placement)-- DVT associated with HD catheter RUE on anticoagulation 7. SVC syndrome [**1-13**], s/p thrombectomy, on anticoagulation, hospitalization complicated by obturator hematoma and required intubation, PEG and Trach with VAP, and questionable seizure 8. Currently, in hemodialysis. 9. Osteoarthritis. 10. Arthritis of the left knee at age nine, treated with ACTH resulting in secondary [**Location (un) **]. 11. rheumatic fever as child 12. Afib with RVR Past Surgical History: 1. Kidney transplant in [**2119**]. 2. Left arm AV fistula for dialysis. 3. Removal of remnant of AV fistula, left arm. 4. Catheter placement for hemodialysis. 5. Low back surgery (unspecified) Social History: -lives with her nephew [**Name (NI) **], but does not know his number -Brother is HCP -[**Name (NI) 1139**]: 10pkyr [**Name2 (NI) 1818**], recently quit but states that she has restarted and smoking 5 cigs per day -denies etoh/illicits Family History: Mother and sister with diabetes mellitus. Kidney failure in mother, sister Physical Exam: Vital signs: T 96.0 HR 110 BP 96/46 RR 16 O2sat 95% on RA General: No acute distress Cardiovascular: regular rate and rhythm, systolic murmur Pulmonary: clear to ausculation bilaterally Abdomen: Soft, nondisteded, tender to palpation in the suprapubic area and in the right lower quadrant, no guarding Rectal exam: guiac negative, no gross blood, no hemorrhoids on exam Pertinent Results: On Admission: [**2122-9-10**] WBC-9.2 RBC-4.33 Hgb-14.1 Hct-42.7 MCV-99* MCH-32.5* MCHC-33.0 RDW-15.4 Plt Ct-451* PT-22.3* INR(PT)-2.1* Glucose-199* UreaN-47* Creat-9.7*# Na-139 K-4.0 Cl-92* HCO3-26 AnGap-25* ALT-9 AST-12 AlkPhos-45 TotBili-0.3 Calcium-9.7 Phos-7.0* Mg-2.3 On Discharge [**2122-9-17**] WBC-6.2 RBC-2.94* Hgb-9.5* Hct-29.9* MCV-102* MCH-32.4* MCHC-31.9 RDW-14.5 Plt Ct-317 PT-31.2* PTT-40.3* INR(PT)-3.2* K-3.6 Brief Hospital Course: 63 y/o female s/p failed kidney transplant in past and recent admission for She now returns with abdominal pain. A CT scan of the abdomen demonstrated portal venous air and pneumatosis involving the right colon. She was taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. In summary, upon inspection of the peritoneal cavity there was no free fluid. No fibrinous exudate and no foul smell. There was virtually no adhesions in the abdominal cavity. The terminal ileum was identified. This was run retrograde to the ligament Treitz without evidence of small bowel pathology. There was no significant pathology involving the right colon. No evidence of the pneumatosis or gangrenous changes were identified. The colon was run from the right colon to the distal sigmoid. Multiple diverticula are noted throughout the left-sided colon as well as 1 or 2 small diverticula in the small bowel, but again no evidence of perforation, no gangrenous changes, no pneumatosis was identified. There was no fibrinous exudate. In the PACU following the case she became increasingly somnolent, BP hypertensive, she was reintubated and transferred to the ICU. She was started on IV Levaquin. She was extubated on POD 1 and remained stable thereafter. HD via tunneled line with last HD on [**9-16**] with 2 Liters removed. She was kept on telemetry and had an episode of tachycardia which resolved without additional beta blockade. Every day she became more alert and more able to participate with PT, so she was able to be discharged home with full services for OT/PT, nursing and social work Coumadin restarting [**9-19**] with PT/INR to be drawn and results faxed to [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**] by the VNA. She will then resume monitoring with Dr[**Name (NI) 4849**] at [**Location (un) **] as she was pre-hospitalization. Next HD Saturday [**9-20**]. Stable per renal. Medications on Admission: ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day B COMPLEX-VITAMIN C-FOLIC ACID [RENAL CAPS] - (Prescribed by Other Provider) - 1 mg Capsule - 1 Capsule(s) by mouth once a day CINACALCET [SENSIPAR] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 90 mg Tablet - 1 Tablet(s) by mouth once a day DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] - (Prescribed by Other Provider) - 40 mcg/mL Solution - once per week weekly LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth daily METOPROLOL TARTRATE - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet by mouth daily SERTRALINE [ZOLOFT] - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth hs WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 4 Tablet(s) by mouth once a day Discharge Medications: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr [**Month/Year (2) **]: One (1) Tablet Sustained Release 24 hr PO once a day. 2. Atorvastatin 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day. 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month/Year (2) **]: One (1) Cap PO DAILY (Daily). 4. Cinacalcet 90 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day. 5. Sertraline 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day. 6. Lisinopril 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen-Codeine 300-30 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 8. Warfarin 1 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO once a day: Please restart [**2122-9-18**]. Do NOT dose on [**9-17**]. 9. Levetiracetam 250 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO twice a day: Started with previous admission, scripts given at last discharge. Disp:*90 Tablet(s)* Refills:*2* 10. Levetiracetam 250 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO following HD. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Abdominal pain s/p ex-lap for potential small bowel obstruction, which was negative Discharge Condition: Good Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, diarrhea, increased abdominal pain, inability to take or keep down medications. Monitor incision for redness, drainage or bleeding. Incison may be left open to air. Continue hemodialysis via left tunneled dialysis line. Next HD [**9-19**] at [**Location (un) **] Continue food, fluid and medications per renal recommendations No showering with dialysis catheter Dr[**Name (NI) **] at [**Location (un) **] dialysis will continue to follow PT/INR, dialysis unit aware Followup Instructions: [**Last Name (LF) **],[**First Name3 (LF) **] TRANSPLANT SOCIAL WORK Date/Time:[**2122-9-25**] 1:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time: [**2122-9-25**] 2 PM [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-10-16**] 2:00 [**Month/Day/Year 1220**]. [**Name5 (PTitle) 540**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2122-11-10**] 4:30 Completed by:[**2122-9-17**]",12,2122-09-11 22:13:00,2122-09-17 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,BENIGN PNEUMATOSIS," 63 y/o female s/p failed kidney transplant in past and recent admission for she now returns with abdominal pain. a ct scan of the abdomen demonstrated portal venous air and pneumatosis involving the right colon. she was taken to the or with dr [**first name8 (namepattern2) **] [**last name (namepattern1) **]. in summary, upon inspection of the peritoneal cavity there was no free fluid. no fibrinous exudate and no foul smell. there was virtually no adhesions in the abdominal cavity. the terminal ileum was identified. this was run retrograde to the ligament treitz without evidence of small bowel pathology. there was no significant pathology involving the right colon. no evidence of the pneumatosis or gangrenous changes were identified. the colon was run from the right colon to the distal sigmoid. multiple diverticula are noted throughout the left-sided colon as well as 1 or 2 small diverticula in the small bowel, but again no evidence of perforation, no gangrenous changes, no pneumatosis was identified. there was no fibrinous exudate. in the pacu following the case she became increasingly somnolent, bp hypertensive, she was reintubated and transferred to the icu. she was started on iv levaquin. she was extubated on pod 1 and remained stable thereafter. hd via tunneled line with last hd on [**9-16**] with 2 liters removed. she was kept on telemetry and had an episode of tachycardia which resolved without additional beta blockade. every day she became more alert and more able to participate with pt, so she was able to be discharged home with full services for ot/pt, nursing and social work coumadin restarting [**9-19**] with pt/inr to be drawn and results faxed to [**first name8 (namepattern2) 5969**] [**last name (namepattern1) 5970**] by the vna. she will then resume monitoring with dr[**name (ni) 4849**] at [**location (un) **] as she was pre-hospitalization. next hd saturday [**9-20**]. stable per renal. ","PRIMARY: [Other specified disorders of intestine] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease; ; Acidosis; Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled; Atrial fibrillation; Hypotension, unspecified; ]","63 y/o female s/p failed kidney transplant in past and recent admission for she now returns with abdominal pain. she was taken to the or with dr [**first name8 (namepattern2) **] [**last name (namepattern1) **]. multiple diverticula are noted throughout the left-sided colon as well as 1 or 2 small diverticula in the small bowel, but again no evidence of perforation, no gangrenous changes, no pneumatosis was identified. she was extubated on pod 1 and remained stable thereafter.","63 y/o female s/p failed kidney transplant in past and recent admission. ct scan showed portal venous air and pneumatosis involving the right colon. no evidence of perforation, gangrenous changes, pneumatosis or gangrenous changes." 32247,127308.0,15733,2122-12-31,15732,113222.0,2122-09-29,Discharge summary,"Admission Date: [**2122-9-22**] Discharge Date: [**2122-9-29**] Date of Birth: [**2059-1-8**] Sex: F Service: MEDICINE Allergies: Percocet / Motrin / Nsaids / Aspirin / Dilantin / Ativan Attending:[**First Name3 (LF) 1973**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: Intubation History of Present Illness: 63F with multiple medical problems and multiple admissions for altered mental status presenting with abdominal pain and altered mental status. Ms. [**Known lastname **] [**Last Name (Titles) 1834**] exploratory laparotomy on [**2122-9-11**] and was found to have benign cecal pneumatosis. The patient presents now for progressive confusion and decreased mental acuity. The family is not available to discuss their concerns and the patient complains of unchanged abdominal pain. In the ED her vitals were 98.2 99 123/39 17 99%RA. FSG was 86 on arrival. Exam showed A+O x 1. Labs were c/w ESRD, with AG acidosis, but no hyperkalemia. Neurology was consulted given the AMS, and felt it was due to a toxic-metabolic encephalopathy and not a central insult or seizure. CXR was unrevealing except for LLL atelectasis. No urine able to be obtained but blood cultures were sent. A CT head was negative. A CT abdomen and pelvis was obtained which showed no acute process or abscess, but a small hematoma/stranding in the anterior subcutaneous tissues and likely also left rectus, c/w recent surgery. Her HR did increase to the 140s in the ED, responded to IV labetolol, but pressure dropped. This responded to IVF. She was given 250mg of levetiracetam and admitted to medicine for further workup of AMS and correction of electrolytes. Past Medical History: PMH: 1. Multiple admission with altered MS recently ([**10-13**]) - with recent extensive neurological workup revealing multifocal etiology likely due to HD fluid/electrolyte shifts, ? uremia prior to HD, also component of vascular dementia. Started on [**Month/Year (2) 13401**] [**9-14**]. 2. Diabetes mellitus. 3 End-stage renal disease secondary to diabetes mellitus s/p failed dual extended-criteria donor renal transplant (BK virus nephropathy) 4. Hemodialysis. 5. Hypertension. 6. Hyperlipidemia. 7. Thrombosis of bilateral IVJ (catheter placement)-- DVT associated with HD catheter RUE on anticoagulation (Coumadin) --balloon angioplasty performed [**1-13**]. 8. Osteoarthritis. 9. PER OMR NOTES (?) - Arthritis of the left knee at age nine, treated with ACTH resulting in secondary [**Location (un) **]. She was diagnosed with rheumatic fever. 10. h/o Trach and PEG [**1-13**] (reversed [**2-13**]). 11. h/o L tension pneumothorax [**2-7**] intubation . Past Surgical History: 1. Kidney transplant in [**2119**] b/l in RLQ 2. Left arm AV fistula for dialysis. 3. Removal of remnant of AV fistula, left arm. 4. Catheter placement for hemodialysis. 5. Low back surgery (unspecified) Social History: The patient smokes half a pack of cigarettes a day for the last 20 years. She does not drink alcohol or has ever experienced with recreational drugs, has no tattoos. The patient has had transfusions in [**2119**] and [**2120**]. The patient is a homemaker. The patient has experienced economic problems lately. . Family History: Family History: From prior d/c summary Mother and sister with diabetic mellitus. Kidney failure in mother, sister Physical Exam: On admission to ICU PE: intubated, sedated, NAD VS: T 98.0 BP 157/64--> 80s/40s with propofol HR 96 RR 12, 100% AC 100% 500 x 20 5 General: intubated, sedated HEENT: tongue is swollen and protruding from her mouth, blood visible around ET tube, lips swollen. L pupil briskly reactive to light from 3 mm --> 1 mm; R pupil is sluggish, 3 mm --> 2 mm. anicteric . NECK: no JVD, supple CV: +s1s2 RRR 2/6 systolic murmur, no R/G. +L.sided tunnel cath no erythema, C/D/I, currently accessed/receiveing IVF. PULM: CTA B/L ABD: +bs, midline inscision c/d/i, staples in place, soft, ND. EXT: no C/C/edema 2+pulses b/l NEURO: intubated/sedated. moves all 4. Pertinent Results: Admission labs: [**2122-9-21**] 04:00PM PLT COUNT-415 [**2122-9-21**] 04:00PM NEUTS-67.4 LYMPHS-20.1 MONOS-9.8 EOS-2.6 BASOS-0.1 [**2122-9-21**] 04:00PM WBC-8.3 RBC-2.72* HGB-9.1* HCT-27.7* MCV-102* MCH-33.3* MCHC-32.7 RDW-16.1* [**2122-9-21**] 04:00PM ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG [**2122-9-21**] 04:00PM CALCIUM-9.7 PHOSPHATE-8.0*# MAGNESIUM-2.5 [**2122-9-21**] 04:00PM GLUCOSE-58* UREA N-49* CREAT-13.8*# SODIUM-136 POTASSIUM-6.8* CHLORIDE-99 TOTAL CO2-21* ANION GAP-23* [**2122-9-21**] 04:09PM LACTATE-1.4 K+-4.6 [**2122-9-21**] 05:24PM PT-18.3* PTT-29.2 INR(PT)-1.7* [**2122-9-22**] 06:50AM PLT COUNT-421 [**2122-9-22**] 06:50AM WBC-8.5 RBC-2.83* HGB-9.2* HCT-29.4* MCV-104* MCH-32.7* MCHC-31.4 RDW-15.5 [**9-21**] CT ABD/PELVIS: no acute process, diverticulosis, extensive atherosclerotic changes, left anterior subcutaneous tissue stranding with hematoma-post surgical, extensive collateral circulation, suggestive of an upper extremity thrombus. CT HEAD (noncontrast) [**9-21**]: no acute intracranial process, multiple lacunar infarcts, chronic small vessel ischemic disease (unchanged) EEG: This is an abnormal 24-hour video EEG telemetry in the waking and sleeping states due to the occasional left mid-temporal sharp waves suggestive of a potential focus of epileptogenesis. In addition, there were bursts of generalized delta frequency slowing suggestive of midline subcortical dysfunction. Nonetheless, there were no electrographic seizures and no pushbutton activations noted. [**2122-9-29**] 01:30PM BLOOD WBC-6.4 RBC-3.28* Hgb-10.9* Hct-33.7* MCV-103* MCH-33.3* MCHC-32.4 RDW-16.6* Plt Ct-470* [**2122-9-29**] 01:30PM BLOOD Plt Ct-470* [**2122-9-29**] 01:30PM BLOOD PT-27.6* PTT-131.8* INR(PT)-2.8* [**2122-9-29**] 01:30PM BLOOD Glucose-134* UreaN-36* Creat-9.5*# Na-136 K-3.7 Cl-97 HCO3-26 AnGap-17 [**2122-9-29**] 01:30PM BLOOD Calcium-8.6 Phos-5.8* Mg-2.2 Brief Hospital Course: 1. Altered mental status/seizure/intubation: most likely etiology is multiple missed hemodialysis sessions/uremia. It is possible the Tylenol with codeine she was taking for post operative pain control contributed. The morning following admission she had an episode of decreased responsiveness, clonic jerks, lip smacking and hand automatisms. She was evaluated by neurology and was given Ativan and Depakote for complex partial seizure. Approximately 1 hour after this she became unresponsive and her tongue was swollen. She was intubated for airway protection due to angioedema. Her mental status normalized (thought to be related to post-ictal state and medications), EEG was negative for status epilepticus, head CT and toxicology screens were negative. The patient required daily dialysis from [**Date range (3) 45315**] and her mental status normalized and was stable for several days at discharge. 2. Angioedema/respiratory failure: Her tongue was noted to be swollen prior to the administration of Depakote during suctioning prior to intubation. The angioedema seemed to correlate with the Ativan administration. There is a report of angioedema in the past, attributed to Dilantin--but she received Ativan at that time as well. She was treated for 24 hours with steroids with remarkable improvement. Her lisinopril was also discontinued. Her intubation was for airway protection in the setting of altered mental status and angioedema. She had persistent apneic episodes on the ventilator and never developed a cuff leak. She has presumed tracheal stenosis from prior tracheostomy. She was successfully extubated in the presence of anesthesia on [**2122-9-25**]. It is recommended she have an outpatient sleep study to evaluate for obstructive sleep apnea as well as an outpatient allergy evaluation. 3. Seizures: The patient suffered a partial complex seizure on the morning after admission. The neurology team followed the patient throughout her admission. She was initially loaded with depakote, however, this was then tapered off and her [**Date Range 13401**] dosing was increased to 500 mg twice daily and an additional dose following hemodialysis. She will follow up with Neurology as an outpatient. 4. ESRD on HD: She missed two outpatient HD sessions prior to admission. She was dialyzed daily in the MICU from [**Date range (1) 45316**] then returned to her scheduled of T/T/Saturday. 5. Atrial fibrillation: Rate control with metoprolol. She had a single episode of RVR in the ED prior to admission which responded to labetalol, otherwise, she was effectively rate controlled. Her INR was subtherapeutic at admission, but was therapeutic at discharge. Her INR will need to be followed in rehabilitation and outpatient monitoring set up prior to discharge home. 6. Abdominal Pain: likely post operative, waxed and waned on this admission. At the time of discharge, the pain was controlled by Tylenol. Her staples were removed by the surgical team during this hospitalization. She had increased discharge from her abdominal wound noted on [**2122-9-28**]. The surgery team evaluated and felt the wound was healing well and there was no evidence of a wound infection. They recommended daily dry dressing changes. 7. Benign Hypertension: continued on amlodipine and metoprolol. Lisinopril discontinued in the setting of angioedema and not restarted. The amlodipine was started in its place. Her blood pressure ranged 110-140s/50-70s prior to discharge. 8. Disposition: the patient was discharged to a rehabilitation facility. She will benefit from a home safety evaluation and visiting nurses to evaluate medication understanding/compliance. She requires INR monitoring. As an outpatient, she should have an allergy evaluation for the recurrent angioedema as well as a sleep study to evaluate sleep apnea. Medications on Admission: MEDS: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr [**Date Range **]: One (1) Tablet Sustained Release 24 hr PO once a day. 2. Atorvastatin 20 mg Tablet [**Date Range **]: One (1) Tablet PO once a day. 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Date Range **]: One (1) Cap PO DAILY (Daily). 4. Cinacalcet 90 mg Tablet [**Date Range **]: One (1) Tablet PO once a day. 5. Sertraline 100 mg Tablet [**Date Range **]: One (1) Tablet PO once a day. 6. Lisinopril 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen-Codeine 300-30 mg Tablet [**Date Range **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 8. Warfarin 1 mg Tablet [**Date Range **]: Two (2) Tablet PO once a day: Please restart [**2122-9-18**]. Do NOT dose on [**9-17**]. 9. Levetiracetam 250 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO twice a day: Started with previous admission 10. Levetiracetam 250 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO following HD. Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO TID (3 times a day). 2. Atorvastatin 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month/Year (2) **]: One (1) Cap PO DAILY (Daily). 4. Cinacalcet 30 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO DAILY (Daily). 5. Sertraline 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 6. Warfarin 1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 7. Levetiracetam 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day). 8. Levetiracetam 500 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HD PROTOCOL (HD Protochol). 9. Amlodipine 5 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY (Daily). 10. Acetaminophen 500 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed: not to exceed 4 grams/24 hours. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Primary: Altered mental status Uremia Angioedema Respiratory failure Complex partial seizure Secondary Hypertension End stage renal disease on hemodialysis Atrial fibrillation Seizure Disorder Failed renal transplant X 2 Hyperlipidemia Discharge Condition: At mental status baseline, pain controlled, tolerating diet Discharge Instructions: You were admitted with confusion in the setting of missed hemodialysis sessions. In the hospital, you had a seizure and a reaction to a medication which caused your tongue to swell and necessitated a breathing tube. You had several daily dialysis sessions and your confusion resolved. You had abdominal pain which was controlled with Tylenol. Surgery evaluated your wound and thought you were healing well. You are being discharged to a rehabilitation facility to regain your strength after the long hospitalization. Followup Instructions: Please call your primary provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 45317**] for an appointment within 1 week of rehabilitation discharge. Surgery Follow Up: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-10-16**] 2:00 Neurology Follow Up: Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2122-11-10**] 4:30 Renal Transplant Appointment: Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2123-1-15**] 9:00 Completed by:[**2122-9-29**]",93,2122-09-22 01:46:00,2122-09-29 18:35:00,EMERGENCY,EMERGENCY ROOM ADMIT,SNF,ALTERED MENTAL STATUS," 1. altered mental status/seizure/intubation: most likely etiology is multiple missed hemodialysis sessions/uremia. it is possible the tylenol with codeine she was taking for post operative pain control contributed. the morning following admission she had an episode of decreased responsiveness, clonic jerks, lip smacking and hand automatisms. she was evaluated by neurology and was given ativan and depakote for complex partial seizure. approximately 1 hour after this she became unresponsive and her tongue was swollen. she was intubated for airway protection due to angioedema. her mental status normalized (thought to be related to post-ictal state and medications), eeg was negative for status epilepticus, head ct and toxicology screens were negative. the patient required daily dialysis from [**date range (3) 45315**] and her mental status normalized and was stable for several days at discharge. 2. angioedema/respiratory failure: her tongue was noted to be swollen prior to the administration of depakote during suctioning prior to intubation. the angioedema seemed to correlate with the ativan administration. there is a report of angioedema in the past, attributed to dilantin--but she received ativan at that time as well. she was treated for 24 hours with steroids with remarkable improvement. her lisinopril was also discontinued. her intubation was for airway protection in the setting of altered mental status and angioedema. she had persistent apneic episodes on the ventilator and never developed a cuff leak. she has presumed tracheal stenosis from prior tracheostomy. she was successfully extubated in the presence of anesthesia on [**2122-9-25**]. it is recommended she have an outpatient sleep study to evaluate for obstructive sleep apnea as well as an outpatient allergy evaluation. 3. seizures: the patient suffered a partial complex seizure on the morning after admission. the neurology team followed the patient throughout her admission. she was initially loaded with depakote, however, this was then tapered off and her [**date range 13401**] dosing was increased to 500 mg twice daily and an additional dose following hemodialysis. she will follow up with neurology as an outpatient. 4. esrd on hd: she missed two outpatient hd sessions prior to admission. she was dialyzed daily in the micu from [**date range (1) 45316**] then returned to her scheduled of t/t/saturday. 5. atrial fibrillation: rate control with metoprolol. she had a single episode of rvr in the ed prior to admission which responded to labetalol, otherwise, she was effectively rate controlled. her inr was subtherapeutic at admission, but was therapeutic at discharge. her inr will need to be followed in rehabilitation and outpatient monitoring set up prior to discharge home. 6. abdominal pain: likely post operative, waxed and waned on this admission. at the time of discharge, the pain was controlled by tylenol. her staples were removed by the surgical team during this hospitalization. she had increased discharge from her abdominal wound noted on [**2122-9-28**]. the surgery team evaluated and felt the wound was healing well and there was no evidence of a wound infection. they recommended daily dry dressing changes. 7. benign hypertension: continued on amlodipine and metoprolol. lisinopril discontinued in the setting of angioedema and not restarted. the amlodipine was started in its place. her blood pressure ranged 110-140s/50-70s prior to discharge. 8. disposition: the patient was discharged to a rehabilitation facility. she will benefit from a home safety evaluation and visiting nurses to evaluate medication understanding/compliance. she requires inr monitoring. as an outpatient, she should have an allergy evaluation for the recurrent angioedema as well as a sleep study to evaluate sleep apnea. ","PRIMARY: [Toxic encephalopathy] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease; Acidosis; Kidney replaced by transplant; Other postoperative infection; Angioneurotic edema, not elsewhere classified; Diabetes with renal manifestations, type II or unspecified type, uncontrolled; Other convulsions; Abdominal pain, left lower quadrant; Other chronic pain; Atrial fibrillation; Apnea; Benzodiazepine-based tranquilizers causing adverse effects in therapeutic use; Diabetes with other specified manifestations, type II or unspecified type, uncontrolled; Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation; Other iatrogenic hypotension; Abnormal coagulation profile; Other and unspecified hyperlipidemia; Osteoarthrosis, unspecified whether generalized or localized, site unspecified; ; Personal history of venous thrombosis and embolism; Long-term (current) use of anticoagulants; Tracheostomy status; Gastrostomy status; Other postprocedural status]","altered mental status/seizure/intubation: most likely etiology is multiple missed hemodialysis sessions/uremia. she was evaluated by neurology and was given ativan and depakote for complex partial seizure. angioedema/respiratory failure: her tongue was noted to be swollen prior to the administration of depakote during suctioning prior to intubation. it is recommended she have an outpatient sleep study to evaluate for obstructive sleep apnea as well as an outpatient allergy evaluation. she was dialyzed daily in the micu from [**date range (1) 45316**] then returned to her scheduled of t/t/saturday. atrial fibrillation: rate control with metoprolol. her inr will need to be followed in rehabilitation and outpatient monitoring set up prior to discharge home. her staples were removed by the surgical team during this hospitalization.",most likely etiology is multiple missed hemodialysis sessions/uremia. she was given ativan and depakote for complex partial seizure. she was intubated for airway protection due to angioedema. 32247,127308.0,15733,2122-12-31,15730,105172.0,2122-09-10,Discharge summary,"Admission Date: [**2122-9-3**] Discharge Date: [**2122-9-10**] Date of Birth: [**2059-1-8**] Sex: F Service: MEDICINE Allergies: Percocet / Motrin / Nsaids / Aspirin / Dilantin Attending:[**First Name3 (LF) 30**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None. History of Present Illness: 62yo F w/ a PMH of ESRD on HD s/p failed kidney transplant, DVT (associated w/ HD cath), and HTN who presents to the ED today after being found on her neighbors stoop confused and apparently topless. History is primarily taken from EMS reports as the patient recalls little of the event. Apparently she was feeling her usual self when she went to HD today. She remembers the ride home but she states she got off at the wrong street. The next thing she remembers was being evaluated by EMS. Of note, her FS was apparently 69 in the field but she is not taking insulin currently. No history of incontinence, tongue laceration, injury or LOC. It is not clear how long she was unattended prior to being found. She had a similar presentation in [**1-13**] with question of seizure activity but was eventually thought not to be having seizures. Also reports blood in her urine last night, and abdominal pain. Reports occasionaly missing her medications, but always taking her statin and coumadin. Recent change in coumadin from 5 to 7mg. In the ED her vitals were 97.6, 108, 200/100, 100% RA. FS was in 100s on arrival. She received 5mg IV and 100mg PO of metoprolol which slowed her rate and lowered her BP to more appropriate levels. She did have episodes of sinus tach up into the 130s during EJ placement attempts. However, this resolved prior to transfer. She was evaluated by neurology in the ED who felt that she was primarily encephalopathic without focality but could not rule out a seizure. Past Medical History: 1. Diabetes mellitus.- unclear hx, not on medication, nl [**Name (NI) **] 2. End-stage renal disease secondary to diabetes mellitus s/p failed dual kidney transplant 3. Hemodialysis. 4. Hypertension. 5. Hyperlipidemia. 6. Thrombosis of bilateral IVJ (catheter placement)-- DVT associated with HD catheter RUE on anticoagulation 7. SVC syndrome [**1-13**], s/p thrombectomy, on anticoagulation, hospitalization complicated by obturator hematoma and required intubation, PEG and Trach with VAP, and questionable seizure 8. Currently, in hemodialysis. 9. Osteoarthritis. 10. Arthritis of the left knee at age nine, treated with ACTH resulting in secondary [**Location (un) **]. 11. rheumatic fever as child 12. Afib with RVR Past Surgical History: 1. Kidney transplant in [**2119**]. 2. Left arm AV fistula for dialysis. 3. Removal of remnant of AV fistula, left arm. 4. Catheter placement for hemodialysis. 5. Low back surgery (unspecified) Social History: -lives with her nephew [**Name (NI) **], but does not know his number -Brother is HCP -[**Name (NI) 1139**]: 10pkyr [**Name2 (NI) 1818**], recently quit but states that she has restarted and smoking 5 cigs per day -denies etoh/illicits Family History: Mother and sister with diabetic mellitus. Kidney failure in mother, sister Physical Exam: VS: 96.7, 155/84, 83, 20, 98%RA GEN: Well appearing, NAD HEENT: NCAT, EOMI, PERRL, oropharynx clear and without erythema or exudate NECK: Supple, no LAD, no appreciable JVD CV: RRR, normal S1S2, systolic murmur at lower sternal border, no rubs or gallops, 2+ pulses PULM: CTAB, no w/r/r, good air movement bilaterally ABD: Soft, ND, mild suprapubic tenderness without rebound or guarding, normoactive bowel sounds, no organomegaly, no abdominal bruit appreciated EXT: Warm and well perfused, full and symmetric distal pulses, no pedal edema NEURO: AOx2, trouble with date. Memory [**1-8**] at 2min. Language fluent. Strength 5/5 in all extremities. Sensation intact to light touch diffusely. DTRs 2+ bilaterally in patella and biceps, toes down going. Gait deferred. Seems confused about her history Pertinent Results: [**2122-9-3**] 01:50PM BLOOD WBC-8.7 RBC-3.84*# Hgb-12.5# Hct-37.0 MCV-96 MCH-32.5* MCHC-33.8 RDW-15.5 Plt Ct-254# [**2122-9-10**] 07:59AM BLOOD WBC-9.2 RBC-4.33 Hgb-14.1 Hct-42.7 MCV-99* MCH-32.5* MCHC-33.0 RDW-15.4 Plt Ct-451* [**2122-9-3**] 02:46PM BLOOD PT-17.1* PTT-28.0 INR(PT)-1.6* [**2122-9-10**] 07:59AM BLOOD PT-22.3* INR(PT)-2.1* [**2122-9-3**] 01:50PM BLOOD Glucose-88 UreaN-15 Creat-4.9* Na-140 K-3.9 Cl-97 HCO3-28 AnGap-19 [**2122-9-8**] 07:45AM BLOOD Glucose-88 UreaN-60* Creat-12.2*# Na-139 K-4.0 Cl-97 HCO3-22 AnGap-24 [**2122-9-10**] 07:59AM BLOOD Glucose-199* UreaN-47* Creat-9.7*# Na-139 K-4.0 Cl-92* HCO3-26 AnGap-25* [**2122-9-3**] 01:50PM BLOOD ALT-13 AST-16 AlkPhos-58 TotBili-0.5 [**2122-9-3**] 01:50PM BLOOD Calcium-10.1 Phos-3.8 Mg-1.9 [**2122-9-10**] 07:59AM BLOOD Calcium-9.7 Phos-7.0* Mg-2.3 [**2122-9-7**] 07:30AM BLOOD VitB12-1032* Folate-GREATER TH [**2122-9-7**] 07:30AM BLOOD TSH-1.2 [**2122-9-4**] 05:40AM BLOOD PTH-401* [**2122-9-3**] 01:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2122-9-3**] 07:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.005 [**2122-9-3**] 07:30PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2122-9-3**] 07:30PM URINE RBC-0-2 WBC-[**6-16**]* Bacteri-FEW Yeast-NONE Epi-[**11-26**] [**2122-9-4**] 01:30AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG Urine cx ([**9-3**], [**9-4**], [**9-6**]): mixed flora consistent with contamination Blood cx ([**9-4**]): 2 negative, 1 NGTD Cdiff ([**9-6**]): negative CXR [**2122-9-3**]: IMPRESSION: No evidence of acute cardiopulmonary process Head CT without Contrast [**2122-9-3**]: IMPRESSION: No hemorrhage or acute edema. EEG [**2122-9-4**]: IMPRESSION: This is an abnormal routine EEG due to the slow background, generalized bursts of slow activity, and multifocal slow transients with triphasic features. These findings suggest a widespread encephalopathy afecting both cortical and subcortical structures. Medications, metabolic disturbancies and infections are among the most common causes. There were no lateralized or epileptiform features noted. Abdominal CT with contrast [**2122-9-4**]: IMPRESSION: No evidence of abdominal inflammatory process, or other specific CT finding to explain abdominal pain. Head CT without Contrast [**2122-9-6**]: (prelim) Limited study, despite being repeated, no acute intracranial hemorrhage appreciated. MRI Head without contrast [**2122-9-7**]: CONCLUSION: No definite interval change in the appearance of the brain compared to the prior study. Brief Hospital Course: 1) Altered mental status: Pt with similar presentations in the past. Labs to evaluate for a toxic-metabolic cause were unrevealing. She was initially treated with Cipro for a suspected UTI, but stopped on day 2 as this drug can lower the seizure threshold and urine grew mixed flora. Head imaging with CT and MRI was unrevealing. EEG showed generalized slowing. On the morning of [**9-5**] during her HD treatment, she became very agitated, confused, and then unresponsive. Her arms were clutched to her chest in fists and her eyes were deviated to the left. She was given 1 mg of Ativan and remained disoriented and somnolent, presumably postictal. Of note, she was also dialyzed earlier on the day of admission. Neurology was consulted and felt her presentation was due to fluid and electrolyte shifts with HD and recommended [**Date Range 13401**] for her apparent seizure. Dilantin was avoided due to prior drug related angioedema. She remained confused and agitated, and her somnolence increased. She was vomiting and minimally responsive to sternal rub. She was transferred to the MICU for observation, received IV haldol for agitation, and was called out the next day as she remained stable. She subsequently received HD two more times with no adverse reaction. Her mental status improved and she was A&Ox3 at discharge, although likely with some chronic cognitive deficits. Her sertraline was held during this admission as well as on discharge, and can be addressed as an outpatient. 2) ESRD on HD: She was continued on her Tu/Th/Sat HD schedule. She was continued on nephrocaps and cinacalcet and started on sevelamer. 3) History of DVT/SVC syndrome: Her INR was initially subtherapeutic at 1.6 and she was bridged on a heparin drip. With warfarin 5mg daily, it improved to 1.9. However, her heparin and warfarin were held when her mental status deteriorated. Once CT head showed no bleed, her heparin was continued. When decision was made to not perform LP, her warfarin was restarted and heparin was stopped due to a therapeutic INR of 2.2. Medications on Admission: ATORVASTATIN - 20 mg by mouth once a day B COMPLEX-VITAMIN C-FOLIC ACID 1 Capsule(s) by mouth once a day CINACALCET 90 mg by mouthonce a day DARBEPOETIN ALFA IN POLYSORBAT - 40 mcg/mL Solution - once per week weekly LISINOPRIL - 5 mg by mouth daily METOPROLOL TARTRATE - 100 mg by mouth daily SERTRALINE 100 mg by mouth hs WARFARIN - - 7 mg by mouth once a day Tylenol 3 PRN pain Discharge Medications: 1. Levetiracetam 250 mg Tablet [**Date Range **]: One (1) Tablet PO QHD (each hemodialysis). Disp:*12 Tablet(s)* Refills:*2* 2. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Date Range **]: One (1) Cap PO DAILY (Daily). 4. Atorvastatin 20 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 5. Darbepoetin Alfa In Polysorbat 40 mcg/0.4 mL Pen Injector [**Date Range **]: One (1) Subcutaneous once a week. 6. Lisinopril 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 7. Levetiracetam 250 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Sevelamer HCl 800 mg Tablet [**Date Range **]: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS): Take with meals. Disp:*90 Tablet(s)* Refills:*2* 9. Cinacalcet 90 mg Tablet [**Date Range **]: One (1) Tablet PO once a day. 10. Warfarin 5 mg Tablet [**Date Range **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet [**Date Range **]: One (1) Tablet PO once a day: Take at same time as 5mg pill. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Caregroup Discharge Diagnosis: Primary: Altered mental status, seizure history Secondary: End stage renal disease, status post renal transplant Discharge Condition: Stable. Discharge Instructions: You were admitted to [**Hospital1 18**] with confusion. This occurred after your dialysis. It is possible that you had a seizure during your confusion. It is not clear what caused the confusion, but it has improved greatly, with no problems after your last dialysis. Please take all medications as prescribed and go to all follow up appointments. We are holding your sertraline (Zoloft) for now as this might have contributed to your confusion. We have started you on [**Last Name (LF) **], [**First Name3 (LF) **] antiseizure medication, with assistance from the neurologists. We are also starting sevelamer, a medication to help your electrolytes. Note that you should take your metoprolol twice daily. If you experience any confusion, seizures, weakness, fevers, or any other concerning symptoms, please seek medical attention or come to the ER immediately. Followup Instructions: Primary Care: Dr. [**Last Name (STitle) **], ([**Telephone/Fax (1) 45314**], Wed [**9-16**], 1pm Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-10-16**] 2:00 Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**] & [**Doctor Last Name **], Neurology Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2122-11-10**] 4:30 Completed by:[**2122-9-10**]",112,2122-09-03 20:37:00,2122-09-10 17:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ALTERED MENTAL STATUS," 1) altered mental status: pt with similar presentations in the past. labs to evaluate for a toxic-metabolic cause were unrevealing. she was initially treated with cipro for a suspected uti, but stopped on day 2 as this drug can lower the seizure threshold and urine grew mixed flora. head imaging with ct and mri was unrevealing. eeg showed generalized slowing. on the morning of [**9-5**] during her hd treatment, she became very agitated, confused, and then unresponsive. her arms were clutched to her chest in fists and her eyes were deviated to the left. she was given 1 mg of ativan and remained disoriented and somnolent, presumably postictal. of note, she was also dialyzed earlier on the day of admission. neurology was consulted and felt her presentation was due to fluid and electrolyte shifts with hd and recommended [**date range 13401**] for her apparent seizure. dilantin was avoided due to prior drug related angioedema. she remained confused and agitated, and her somnolence increased. she was vomiting and minimally responsive to sternal rub. she was transferred to the micu for observation, received iv haldol for agitation, and was called out the next day as she remained stable. she subsequently received hd two more times with no adverse reaction. her mental status improved and she was a&ox3 at discharge, although likely with some chronic cognitive deficits. her sertraline was held during this admission as well as on discharge, and can be addressed as an outpatient. 2) esrd on hd: she was continued on her tu/th/sat hd schedule. she was continued on nephrocaps and cinacalcet and started on sevelamer. 3) history of dvt/svc syndrome: her inr was initially subtherapeutic at 1.6 and she was bridged on a heparin drip. with warfarin 5mg daily, it improved to 1.9. however, her heparin and warfarin were held when her mental status deteriorated. once ct head showed no bleed, her heparin was continued. when decision was made to not perform lp, her warfarin was restarted and heparin was stopped due to a therapeutic inr of 2.2. ","PRIMARY: [Altered mental status] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease; Urinary tract infection, site not specified; Complications of transplanted kidney; Other complications due to renal dialysis device, implant, and graft; Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity; Epilepsy, unspecified, without mention of intractable epilepsy; Long-term (current) use of anticoagulants; Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled; Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation; Other and unspecified hyperlipidemia; ; Personal history of noncompliance with medical treatment, presenting hazards to health; Other specified cardiac dysrhythmias; Osteoarthrosis, unspecified whether generalized or localized, site unspecified; ]","1) altered mental status: pt with similar presentations in the past. her arms were clutched to her chest in fists and her eyes were deviated to the left. she remained confused and agitated, and her somnolence increased. she was transferred to the micu for observation, received iv haldol for agitation, and was called out the next day as she remained stable. once ct head showed no bleed, her heparin was continued.","pt was initially treated with cipro for a suspected uti, but stopped on day 2. she was given 1 mg of ativan and remained disoriented and somnolent. her mental status improved and she was a&ox3 at discharge, although likely with some chronic cognitive deficits." 32247,113222.0,15732,2122-09-29,15730,105172.0,2122-09-10,Discharge summary,"Admission Date: [**2122-9-3**] Discharge Date: [**2122-9-10**] Date of Birth: [**2059-1-8**] Sex: F Service: MEDICINE Allergies: Percocet / Motrin / Nsaids / Aspirin / Dilantin Attending:[**First Name3 (LF) 30**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None. History of Present Illness: 62yo F w/ a PMH of ESRD on HD s/p failed kidney transplant, DVT (associated w/ HD cath), and HTN who presents to the ED today after being found on her neighbors stoop confused and apparently topless. History is primarily taken from EMS reports as the patient recalls little of the event. Apparently she was feeling her usual self when she went to HD today. She remembers the ride home but she states she got off at the wrong street. The next thing she remembers was being evaluated by EMS. Of note, her FS was apparently 69 in the field but she is not taking insulin currently. No history of incontinence, tongue laceration, injury or LOC. It is not clear how long she was unattended prior to being found. She had a similar presentation in [**1-13**] with question of seizure activity but was eventually thought not to be having seizures. Also reports blood in her urine last night, and abdominal pain. Reports occasionaly missing her medications, but always taking her statin and coumadin. Recent change in coumadin from 5 to 7mg. In the ED her vitals were 97.6, 108, 200/100, 100% RA. FS was in 100s on arrival. She received 5mg IV and 100mg PO of metoprolol which slowed her rate and lowered her BP to more appropriate levels. She did have episodes of sinus tach up into the 130s during EJ placement attempts. However, this resolved prior to transfer. She was evaluated by neurology in the ED who felt that she was primarily encephalopathic without focality but could not rule out a seizure. Past Medical History: 1. Diabetes mellitus.- unclear hx, not on medication, nl [**Name (NI) **] 2. End-stage renal disease secondary to diabetes mellitus s/p failed dual kidney transplant 3. Hemodialysis. 4. Hypertension. 5. Hyperlipidemia. 6. Thrombosis of bilateral IVJ (catheter placement)-- DVT associated with HD catheter RUE on anticoagulation 7. SVC syndrome [**1-13**], s/p thrombectomy, on anticoagulation, hospitalization complicated by obturator hematoma and required intubation, PEG and Trach with VAP, and questionable seizure 8. Currently, in hemodialysis. 9. Osteoarthritis. 10. Arthritis of the left knee at age nine, treated with ACTH resulting in secondary [**Location (un) **]. 11. rheumatic fever as child 12. Afib with RVR Past Surgical History: 1. Kidney transplant in [**2119**]. 2. Left arm AV fistula for dialysis. 3. Removal of remnant of AV fistula, left arm. 4. Catheter placement for hemodialysis. 5. Low back surgery (unspecified) Social History: -lives with her nephew [**Name (NI) **], but does not know his number -Brother is HCP -[**Name (NI) 1139**]: 10pkyr [**Name2 (NI) 1818**], recently quit but states that she has restarted and smoking 5 cigs per day -denies etoh/illicits Family History: Mother and sister with diabetic mellitus. Kidney failure in mother, sister Physical Exam: VS: 96.7, 155/84, 83, 20, 98%RA GEN: Well appearing, NAD HEENT: NCAT, EOMI, PERRL, oropharynx clear and without erythema or exudate NECK: Supple, no LAD, no appreciable JVD CV: RRR, normal S1S2, systolic murmur at lower sternal border, no rubs or gallops, 2+ pulses PULM: CTAB, no w/r/r, good air movement bilaterally ABD: Soft, ND, mild suprapubic tenderness without rebound or guarding, normoactive bowel sounds, no organomegaly, no abdominal bruit appreciated EXT: Warm and well perfused, full and symmetric distal pulses, no pedal edema NEURO: AOx2, trouble with date. Memory [**1-8**] at 2min. Language fluent. Strength 5/5 in all extremities. Sensation intact to light touch diffusely. DTRs 2+ bilaterally in patella and biceps, toes down going. Gait deferred. Seems confused about her history Pertinent Results: [**2122-9-3**] 01:50PM BLOOD WBC-8.7 RBC-3.84*# Hgb-12.5# Hct-37.0 MCV-96 MCH-32.5* MCHC-33.8 RDW-15.5 Plt Ct-254# [**2122-9-10**] 07:59AM BLOOD WBC-9.2 RBC-4.33 Hgb-14.1 Hct-42.7 MCV-99* MCH-32.5* MCHC-33.0 RDW-15.4 Plt Ct-451* [**2122-9-3**] 02:46PM BLOOD PT-17.1* PTT-28.0 INR(PT)-1.6* [**2122-9-10**] 07:59AM BLOOD PT-22.3* INR(PT)-2.1* [**2122-9-3**] 01:50PM BLOOD Glucose-88 UreaN-15 Creat-4.9* Na-140 K-3.9 Cl-97 HCO3-28 AnGap-19 [**2122-9-8**] 07:45AM BLOOD Glucose-88 UreaN-60* Creat-12.2*# Na-139 K-4.0 Cl-97 HCO3-22 AnGap-24 [**2122-9-10**] 07:59AM BLOOD Glucose-199* UreaN-47* Creat-9.7*# Na-139 K-4.0 Cl-92* HCO3-26 AnGap-25* [**2122-9-3**] 01:50PM BLOOD ALT-13 AST-16 AlkPhos-58 TotBili-0.5 [**2122-9-3**] 01:50PM BLOOD Calcium-10.1 Phos-3.8 Mg-1.9 [**2122-9-10**] 07:59AM BLOOD Calcium-9.7 Phos-7.0* Mg-2.3 [**2122-9-7**] 07:30AM BLOOD VitB12-1032* Folate-GREATER TH [**2122-9-7**] 07:30AM BLOOD TSH-1.2 [**2122-9-4**] 05:40AM BLOOD PTH-401* [**2122-9-3**] 01:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2122-9-3**] 07:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.005 [**2122-9-3**] 07:30PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2122-9-3**] 07:30PM URINE RBC-0-2 WBC-[**6-16**]* Bacteri-FEW Yeast-NONE Epi-[**11-26**] [**2122-9-4**] 01:30AM URINE bnzodzp-NEG barbitr-NEG opiates-POS cocaine-NEG amphetm-NEG mthdone-NEG Urine cx ([**9-3**], [**9-4**], [**9-6**]): mixed flora consistent with contamination Blood cx ([**9-4**]): 2 negative, 1 NGTD Cdiff ([**9-6**]): negative CXR [**2122-9-3**]: IMPRESSION: No evidence of acute cardiopulmonary process Head CT without Contrast [**2122-9-3**]: IMPRESSION: No hemorrhage or acute edema. EEG [**2122-9-4**]: IMPRESSION: This is an abnormal routine EEG due to the slow background, generalized bursts of slow activity, and multifocal slow transients with triphasic features. These findings suggest a widespread encephalopathy afecting both cortical and subcortical structures. Medications, metabolic disturbancies and infections are among the most common causes. There were no lateralized or epileptiform features noted. Abdominal CT with contrast [**2122-9-4**]: IMPRESSION: No evidence of abdominal inflammatory process, or other specific CT finding to explain abdominal pain. Head CT without Contrast [**2122-9-6**]: (prelim) Limited study, despite being repeated, no acute intracranial hemorrhage appreciated. MRI Head without contrast [**2122-9-7**]: CONCLUSION: No definite interval change in the appearance of the brain compared to the prior study. Brief Hospital Course: 1) Altered mental status: Pt with similar presentations in the past. Labs to evaluate for a toxic-metabolic cause were unrevealing. She was initially treated with Cipro for a suspected UTI, but stopped on day 2 as this drug can lower the seizure threshold and urine grew mixed flora. Head imaging with CT and MRI was unrevealing. EEG showed generalized slowing. On the morning of [**9-5**] during her HD treatment, she became very agitated, confused, and then unresponsive. Her arms were clutched to her chest in fists and her eyes were deviated to the left. She was given 1 mg of Ativan and remained disoriented and somnolent, presumably postictal. Of note, she was also dialyzed earlier on the day of admission. Neurology was consulted and felt her presentation was due to fluid and electrolyte shifts with HD and recommended [**Date Range 13401**] for her apparent seizure. Dilantin was avoided due to prior drug related angioedema. She remained confused and agitated, and her somnolence increased. She was vomiting and minimally responsive to sternal rub. She was transferred to the MICU for observation, received IV haldol for agitation, and was called out the next day as she remained stable. She subsequently received HD two more times with no adverse reaction. Her mental status improved and she was A&Ox3 at discharge, although likely with some chronic cognitive deficits. Her sertraline was held during this admission as well as on discharge, and can be addressed as an outpatient. 2) ESRD on HD: She was continued on her Tu/Th/Sat HD schedule. She was continued on nephrocaps and cinacalcet and started on sevelamer. 3) History of DVT/SVC syndrome: Her INR was initially subtherapeutic at 1.6 and she was bridged on a heparin drip. With warfarin 5mg daily, it improved to 1.9. However, her heparin and warfarin were held when her mental status deteriorated. Once CT head showed no bleed, her heparin was continued. When decision was made to not perform LP, her warfarin was restarted and heparin was stopped due to a therapeutic INR of 2.2. Medications on Admission: ATORVASTATIN - 20 mg by mouth once a day B COMPLEX-VITAMIN C-FOLIC ACID 1 Capsule(s) by mouth once a day CINACALCET 90 mg by mouthonce a day DARBEPOETIN ALFA IN POLYSORBAT - 40 mcg/mL Solution - once per week weekly LISINOPRIL - 5 mg by mouth daily METOPROLOL TARTRATE - 100 mg by mouth daily SERTRALINE 100 mg by mouth hs WARFARIN - - 7 mg by mouth once a day Tylenol 3 PRN pain Discharge Medications: 1. Levetiracetam 250 mg Tablet [**Date Range **]: One (1) Tablet PO QHD (each hemodialysis). Disp:*12 Tablet(s)* Refills:*2* 2. Metoprolol Tartrate 50 mg Tablet [**Date Range **]: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Date Range **]: One (1) Cap PO DAILY (Daily). 4. Atorvastatin 20 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 5. Darbepoetin Alfa In Polysorbat 40 mcg/0.4 mL Pen Injector [**Date Range **]: One (1) Subcutaneous once a week. 6. Lisinopril 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 7. Levetiracetam 250 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Sevelamer HCl 800 mg Tablet [**Date Range **]: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS): Take with meals. Disp:*90 Tablet(s)* Refills:*2* 9. Cinacalcet 90 mg Tablet [**Date Range **]: One (1) Tablet PO once a day. 10. Warfarin 5 mg Tablet [**Date Range **]: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. Warfarin 2 mg Tablet [**Date Range **]: One (1) Tablet PO once a day: Take at same time as 5mg pill. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Caregroup Discharge Diagnosis: Primary: Altered mental status, seizure history Secondary: End stage renal disease, status post renal transplant Discharge Condition: Stable. Discharge Instructions: You were admitted to [**Hospital1 18**] with confusion. This occurred after your dialysis. It is possible that you had a seizure during your confusion. It is not clear what caused the confusion, but it has improved greatly, with no problems after your last dialysis. Please take all medications as prescribed and go to all follow up appointments. We are holding your sertraline (Zoloft) for now as this might have contributed to your confusion. We have started you on [**Last Name (LF) **], [**First Name3 (LF) **] antiseizure medication, with assistance from the neurologists. We are also starting sevelamer, a medication to help your electrolytes. Note that you should take your metoprolol twice daily. If you experience any confusion, seizures, weakness, fevers, or any other concerning symptoms, please seek medical attention or come to the ER immediately. Followup Instructions: Primary Care: Dr. [**Last Name (STitle) **], ([**Telephone/Fax (1) 45314**], Wed [**9-16**], 1pm Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-10-16**] 2:00 Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**] & [**Doctor Last Name **], Neurology Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2122-11-10**] 4:30 Completed by:[**2122-9-10**]",19,2122-09-03 20:37:00,2122-09-10 17:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ALTERED MENTAL STATUS," 1) altered mental status: pt with similar presentations in the past. labs to evaluate for a toxic-metabolic cause were unrevealing. she was initially treated with cipro for a suspected uti, but stopped on day 2 as this drug can lower the seizure threshold and urine grew mixed flora. head imaging with ct and mri was unrevealing. eeg showed generalized slowing. on the morning of [**9-5**] during her hd treatment, she became very agitated, confused, and then unresponsive. her arms were clutched to her chest in fists and her eyes were deviated to the left. she was given 1 mg of ativan and remained disoriented and somnolent, presumably postictal. of note, she was also dialyzed earlier on the day of admission. neurology was consulted and felt her presentation was due to fluid and electrolyte shifts with hd and recommended [**date range 13401**] for her apparent seizure. dilantin was avoided due to prior drug related angioedema. she remained confused and agitated, and her somnolence increased. she was vomiting and minimally responsive to sternal rub. she was transferred to the micu for observation, received iv haldol for agitation, and was called out the next day as she remained stable. she subsequently received hd two more times with no adverse reaction. her mental status improved and she was a&ox3 at discharge, although likely with some chronic cognitive deficits. her sertraline was held during this admission as well as on discharge, and can be addressed as an outpatient. 2) esrd on hd: she was continued on her tu/th/sat hd schedule. she was continued on nephrocaps and cinacalcet and started on sevelamer. 3) history of dvt/svc syndrome: her inr was initially subtherapeutic at 1.6 and she was bridged on a heparin drip. with warfarin 5mg daily, it improved to 1.9. however, her heparin and warfarin were held when her mental status deteriorated. once ct head showed no bleed, her heparin was continued. when decision was made to not perform lp, her warfarin was restarted and heparin was stopped due to a therapeutic inr of 2.2. ","PRIMARY: [Altered mental status] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease; Urinary tract infection, site not specified; Complications of transplanted kidney; Other complications due to renal dialysis device, implant, and graft; Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity; Epilepsy, unspecified, without mention of intractable epilepsy; Long-term (current) use of anticoagulants; Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled; Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation; Other and unspecified hyperlipidemia; ; Personal history of noncompliance with medical treatment, presenting hazards to health; Other specified cardiac dysrhythmias; Osteoarthrosis, unspecified whether generalized or localized, site unspecified; ]","1) altered mental status: pt with similar presentations in the past. her arms were clutched to her chest in fists and her eyes were deviated to the left. she remained confused and agitated, and her somnolence increased. she was transferred to the micu for observation, received iv haldol for agitation, and was called out the next day as she remained stable. once ct head showed no bleed, her heparin was continued.","pt was initially treated with cipro for a suspected uti, but stopped on day 2. she was given 1 mg of ativan and remained disoriented and somnolent. her mental status improved and she was a&ox3 at discharge, although likely with some chronic cognitive deficits." 32247,127308.0,15733,2122-12-31,15731,180961.0,2122-09-17,Discharge summary,"Admission Date: [**2122-9-11**] Discharge Date: [**2122-9-17**] Date of Birth: [**2059-1-8**] Sex: F Service: SURGERY Allergies: Percocet / Motrin / Nsaids / Aspirin / Dilantin Attending:[**First Name3 (LF) 668**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2122-9-13**]: negative exploratory laparotomy History of Present Illness: 62yo F w/ a PMH of ESRD on HD s/p failed kidney transplant, DVT (associated w/ HD cath), and HTN who presents to the ED today with right lower quadrant abdominal pain and hypotension. She was nauseated last night and had vomiting x 1. Nonbloody, nonbilious. Last bowel movement was 2 days ago. Not constipated. No diarrhea. No fever chillls or night sweats. She has had the abdominal pain for weeks. Food makes the pain better. She has not eaten today so the pain has gotten worse over the last couple of days. Past Medical History: 1. Diabetes mellitus.- unclear hx, not on medication, nl [**Name (NI) **] 2. End-stage renal disease secondary to diabetes mellitus s/p failed dual kidney transplant 3. Hemodialysis. 4. Hypertension. 5. Hyperlipidemia. 6. Thrombosis of bilateral IVJ (catheter placement)-- DVT associated with HD catheter RUE on anticoagulation 7. SVC syndrome [**1-13**], s/p thrombectomy, on anticoagulation, hospitalization complicated by obturator hematoma and required intubation, PEG and Trach with VAP, and questionable seizure 8. Currently, in hemodialysis. 9. Osteoarthritis. 10. Arthritis of the left knee at age nine, treated with ACTH resulting in secondary [**Location (un) **]. 11. rheumatic fever as child 12. Afib with RVR Past Surgical History: 1. Kidney transplant in [**2119**]. 2. Left arm AV fistula for dialysis. 3. Removal of remnant of AV fistula, left arm. 4. Catheter placement for hemodialysis. 5. Low back surgery (unspecified) Social History: -lives with her nephew [**Name (NI) **], but does not know his number -Brother is HCP -[**Name (NI) 1139**]: 10pkyr [**Name2 (NI) 1818**], recently quit but states that she has restarted and smoking 5 cigs per day -denies etoh/illicits Family History: Mother and sister with diabetes mellitus. Kidney failure in mother, sister Physical Exam: Vital signs: T 96.0 HR 110 BP 96/46 RR 16 O2sat 95% on RA General: No acute distress Cardiovascular: regular rate and rhythm, systolic murmur Pulmonary: clear to ausculation bilaterally Abdomen: Soft, nondisteded, tender to palpation in the suprapubic area and in the right lower quadrant, no guarding Rectal exam: guiac negative, no gross blood, no hemorrhoids on exam Pertinent Results: On Admission: [**2122-9-10**] WBC-9.2 RBC-4.33 Hgb-14.1 Hct-42.7 MCV-99* MCH-32.5* MCHC-33.0 RDW-15.4 Plt Ct-451* PT-22.3* INR(PT)-2.1* Glucose-199* UreaN-47* Creat-9.7*# Na-139 K-4.0 Cl-92* HCO3-26 AnGap-25* ALT-9 AST-12 AlkPhos-45 TotBili-0.3 Calcium-9.7 Phos-7.0* Mg-2.3 On Discharge [**2122-9-17**] WBC-6.2 RBC-2.94* Hgb-9.5* Hct-29.9* MCV-102* MCH-32.4* MCHC-31.9 RDW-14.5 Plt Ct-317 PT-31.2* PTT-40.3* INR(PT)-3.2* K-3.6 Brief Hospital Course: 63 y/o female s/p failed kidney transplant in past and recent admission for She now returns with abdominal pain. A CT scan of the abdomen demonstrated portal venous air and pneumatosis involving the right colon. She was taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. In summary, upon inspection of the peritoneal cavity there was no free fluid. No fibrinous exudate and no foul smell. There was virtually no adhesions in the abdominal cavity. The terminal ileum was identified. This was run retrograde to the ligament Treitz without evidence of small bowel pathology. There was no significant pathology involving the right colon. No evidence of the pneumatosis or gangrenous changes were identified. The colon was run from the right colon to the distal sigmoid. Multiple diverticula are noted throughout the left-sided colon as well as 1 or 2 small diverticula in the small bowel, but again no evidence of perforation, no gangrenous changes, no pneumatosis was identified. There was no fibrinous exudate. In the PACU following the case she became increasingly somnolent, BP hypertensive, she was reintubated and transferred to the ICU. She was started on IV Levaquin. She was extubated on POD 1 and remained stable thereafter. HD via tunneled line with last HD on [**9-16**] with 2 Liters removed. She was kept on telemetry and had an episode of tachycardia which resolved without additional beta blockade. Every day she became more alert and more able to participate with PT, so she was able to be discharged home with full services for OT/PT, nursing and social work Coumadin restarting [**9-19**] with PT/INR to be drawn and results faxed to [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**] by the VNA. She will then resume monitoring with Dr[**Name (NI) 4849**] at [**Location (un) **] as she was pre-hospitalization. Next HD Saturday [**9-20**]. Stable per renal. Medications on Admission: ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day B COMPLEX-VITAMIN C-FOLIC ACID [RENAL CAPS] - (Prescribed by Other Provider) - 1 mg Capsule - 1 Capsule(s) by mouth once a day CINACALCET [SENSIPAR] - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 90 mg Tablet - 1 Tablet(s) by mouth once a day DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] - (Prescribed by Other Provider) - 40 mcg/mL Solution - once per week weekly LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth daily METOPROLOL TARTRATE - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet by mouth daily SERTRALINE [ZOLOFT] - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth hs WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 4 Tablet(s) by mouth once a day Discharge Medications: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr [**Month/Year (2) **]: One (1) Tablet Sustained Release 24 hr PO once a day. 2. Atorvastatin 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day. 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month/Year (2) **]: One (1) Cap PO DAILY (Daily). 4. Cinacalcet 90 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day. 5. Sertraline 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day. 6. Lisinopril 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen-Codeine 300-30 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*20 Tablet(s)* Refills:*0* 8. Warfarin 1 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO once a day: Please restart [**2122-9-18**]. Do NOT dose on [**9-17**]. 9. Levetiracetam 250 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO twice a day: Started with previous admission, scripts given at last discharge. Disp:*90 Tablet(s)* Refills:*2* 10. Levetiracetam 250 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO following HD. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Abdominal pain s/p ex-lap for potential small bowel obstruction, which was negative Discharge Condition: Good Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever > 101, chills, nausea, vomiting, diarrhea, increased abdominal pain, inability to take or keep down medications. Monitor incision for redness, drainage or bleeding. Incison may be left open to air. Continue hemodialysis via left tunneled dialysis line. Next HD [**9-19**] at [**Location (un) **] Continue food, fluid and medications per renal recommendations No showering with dialysis catheter Dr[**Name (NI) **] at [**Location (un) **] dialysis will continue to follow PT/INR, dialysis unit aware Followup Instructions: [**Last Name (LF) **],[**First Name3 (LF) **] TRANSPLANT SOCIAL WORK Date/Time:[**2122-9-25**] 1:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time: [**2122-9-25**] 2 PM [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-10-16**] 2:00 [**Month/Day/Year 1220**]. [**Name5 (PTitle) 540**] & [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2122-11-10**] 4:30 Completed by:[**2122-9-17**]",105,2122-09-11 22:13:00,2122-09-17 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,BENIGN PNEUMATOSIS," 63 y/o female s/p failed kidney transplant in past and recent admission for she now returns with abdominal pain. a ct scan of the abdomen demonstrated portal venous air and pneumatosis involving the right colon. she was taken to the or with dr [**first name8 (namepattern2) **] [**last name (namepattern1) **]. in summary, upon inspection of the peritoneal cavity there was no free fluid. no fibrinous exudate and no foul smell. there was virtually no adhesions in the abdominal cavity. the terminal ileum was identified. this was run retrograde to the ligament treitz without evidence of small bowel pathology. there was no significant pathology involving the right colon. no evidence of the pneumatosis or gangrenous changes were identified. the colon was run from the right colon to the distal sigmoid. multiple diverticula are noted throughout the left-sided colon as well as 1 or 2 small diverticula in the small bowel, but again no evidence of perforation, no gangrenous changes, no pneumatosis was identified. there was no fibrinous exudate. in the pacu following the case she became increasingly somnolent, bp hypertensive, she was reintubated and transferred to the icu. she was started on iv levaquin. she was extubated on pod 1 and remained stable thereafter. hd via tunneled line with last hd on [**9-16**] with 2 liters removed. she was kept on telemetry and had an episode of tachycardia which resolved without additional beta blockade. every day she became more alert and more able to participate with pt, so she was able to be discharged home with full services for ot/pt, nursing and social work coumadin restarting [**9-19**] with pt/inr to be drawn and results faxed to [**first name8 (namepattern2) 5969**] [**last name (namepattern1) 5970**] by the vna. she will then resume monitoring with dr[**name (ni) 4849**] at [**location (un) **] as she was pre-hospitalization. next hd saturday [**9-20**]. stable per renal. ","PRIMARY: [Other specified disorders of intestine] SECONDARY: [End stage renal disease; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease; ; Acidosis; Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled; Atrial fibrillation; Hypotension, unspecified; ]","63 y/o female s/p failed kidney transplant in past and recent admission for she now returns with abdominal pain. she was taken to the or with dr [**first name8 (namepattern2) **] [**last name (namepattern1) **]. multiple diverticula are noted throughout the left-sided colon as well as 1 or 2 small diverticula in the small bowel, but again no evidence of perforation, no gangrenous changes, no pneumatosis was identified. she was extubated on pod 1 and remained stable thereafter.","63 y/o female s/p failed kidney transplant in past and recent admission. ct scan showed portal venous air and pneumatosis involving the right colon. no evidence of perforation, gangrenous changes, pneumatosis or gangrenous changes." 40526,101343.0,18227,2123-06-06,18226,100456.0,2123-05-25,Discharge summary,"Admission Date: [**2123-4-26**] Discharge Date: [**2123-5-25**] Date of Birth: [**2091-8-18**] Sex: F Service: SURGERY Allergies: Codeine / Remicade / Vancomycin Attending:[**First Name3 (LF) 3376**] Chief Complaint: Admit Crohn's flare with abscess to Surgery Major Surgical or Invasive Procedure: [**4-29**] CT-guided placement of drainage catheter into pelvic abscess. Scant thick pus aspirated initially. [**5-4**] The indwelling right pelvic catheter was easily exchanged for a similar cathete [**5-12**] CT-guided placement of two pigtail drainage catheters in two residual intra-abdominal abscess collections. [**5-14**] washout/ex-lap/drain placement History of Present Illness: 31F with h/o Crohn's disease refractory to medical mgmt (remicade, etc) currently on slow steroid taper. Recently admitted [**2-25**] with microperforation. Dr. [**Last Name (STitle) 1120**] planned on ileocecectomy on [**5-5**]. The pt now presents with epigastric pain X 2 weeks in spite of being on cipro, flagyl, prednisone. Flagyl d/c'd 2 weeks ago and put on prilosec by Dr. [**Last Name (STitle) 2161**]. Over past week, pain is worse and in past 24 hrs severe [**6-28**] pain in epigastrum and RLQ. Pt reports sweating but denies fevers. This AM, following taking her PO mediacation the pt reported emesis 10-15 times. She also noted [**8-28**] abdominal pain, mostly RLQ, but also LUQ. Loose stools no melena or BRBPR. Pt reports dry mouth but denies lighheadedness, dizziness, visual changes or other presyncopal symptoms. In ED, 99,4 115/69 120 17 100%RA. While in the ED, Tm 101.4 and tachy to 130s, normotensive. WBC 5.1 with 15% bandemia, diffuse peritonitis and rigid abdomen, diffusely tender. CT abd/pelvis with likely early developing abscess with pockets of free air in pelvis. The pt received 4L of NS, Dilaudid 1mg IV x7, Morphine 4mg IV, Zofran 4gm IX x1 for pain and tylenol 1gm PO. Abx were initially continued with Cipro 400mg IV and Flagyl 500mg IV which was later switched to Vanc 1g IV and Zosyn 4.5mg was given. An NG tube was placed which the pt states relieved some of her abdominal bloating. Upon further review of systems: (+) Per HPI (-) Denies chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Occasional chest pressure, but denies tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. The pt stated it took her 3-4 minutes to initiate urination today in the setting of increased abdominal pain. Denies dysuria. Past Medical History: Crohn's Disease Depression h/o arthritis related to medications Anorexia Nervosa/OCD Past Surgical History s/p Wisdom teeth removal in [**2103**] LEEP procedure in [**2121**] Primary Care Physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5781**] GI: Dr. [**Last Name (STitle) 2161**] Social History: Works at [**Hospital3 328**] in PR department [**11-21**] EtOH drinks, ~3 times per week smoked [**11-20**] ppd X 3-4yrs quit 9 years ago Family History: Cousin with [**Name (NI) 4522**] Disease Father CAD Physical Exam: Vitals: T: 99.9 BP: 117/72 P: 114 R: 24-29 93-96%O2: General: Alert, oriented, NAD when lying still HEENT: Dry MMM, PERRLA, EOMI Neck: supple, JVP 6-7cm, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: firm, diffusely tender, non-distended, hypoactive bowel sounds present. + Guarding. Tenderness to palpation > Rebound. Ext: Warm. 2+ pulses, no clubbing, cyanosis or edema . at discharge: Gen: a and o x 3, nad CV: RRR no m/r/g RESP: LSCTA bilat ABD: Soft, nt, nd, + bs Incision: ota with steri strips Pertinent Results: CT Abdomen (Wet-Read) [**2123-4-26**] 1. Increased size of pelvic collection, Image 2:61, with multiple tiny pockets of extraluminal air. The collection shows early signs of organizing to an abscess. 2. Worsening of bowel wall thickening, consistent with Crohn's flare. CT Abdomen [**2123-4-28**] (wet read) Marked interval increase in intraperitoneal fluid tracking through the mesentery, around the liver, and collecting in the pelvis. Large pre-sacral pelvic collection has increased in size and demonstrates increased rim enhancement, concerning for developing abscess. Hyperemic mesentery and omental inflammatory changes, likely worsened since the prior study. Focal collection previously identified in the mid-pelvis appears largely unchanged. Redemonstration of bowel wall abnormalities c/w Crohn's flare, largely stable. . IMAGING [**3-18**] CT abd: wall thickening/inflammatory fat stranding of TI, cecum, hepatic flexure, 2.4 cm early abscess adj to cecum [**4-26**] CT abd: inc pelvic fluid collection w/ mult tiny pockets of extraluminal air, early signs of organization, worsening bowel wall thickening [**4-28**] CT abd: marked inc intraperitoneal fluid tracking thru mesentery, around liver, [**Last Name (un) **] in pelvis, lg pre-sacral pelvic [**Last Name (un) **] inc in size w/ inc rim enhancement, ? abscess, worsened hyperemic mesentery & omental inflamm changes, focal [**Last Name (un) **] in mid-pelvis largely unchanged, stable bowel wall abnl [**5-9**] CT abd: interval [**Month (only) **] pelvic fluid [**Last Name (un) **], o/w stable [**5-10**] RUE U/S: no dvt [**5-12**] CT: drains in place [**5-13**] CXR: increased L eff, atelectasis, new R eff improved on CXR [**5-16**] . [**2123-5-16**] Blood Cx2 [**2123-5-16**] urine [**2123-5-16**] cxr [**Month (only) **]. lf pleural effusion,consol or pneumo lt base is not excluded [**2123-5-14**] Tissue(OR) PMN, no growth [**2123-5-13**] CXR Increased left effusion/atelectasis and new small right effusion [**2123-5-12**] abcess x2 GRAM POSITIVE COCCI (pairs) (pairs/clusters). PMNs [**2123-5-12**] bld times 4 negative [**2123-5-11**] urine neg [**2123-5-10**] bld x2 negative [**2123-5-10**] urine neg [**2123-5-8**] bld negative [**2123-5-5**] abscess C.albicans, s. viridans AND lactobacillus [**2123-5-4**] abscess C.albicans, S.viridans, lactobacillus [**2123-4-29**] abscess >3 bacterial types Brief Hospital Course: 31F here with long-standing refractory Crohn's presenting with a severe flare and intravascular depletion. . # Abdominal Pain/Surgical Abdomen: Most likely [**12-21**] Crohn's Flare given findings on CT (Multiple Tiny Pockets of Extraluminal Air, Worsening bowel wall thickening consistent with Crohns flare). Other less likely etiologies include perforated ulcer (given chronic steroid use). Evaluated by surgery in ED and upon admission to [**Hospital Unit Name 153**]. Received IV vancomycin/zosyn. Per GI to continue hydrcortisone 100 mg qdaily. NGT placed. Foley in place. Strict NPO, serial abd exam. - NPO - Serial Abdominal Exam -Antibiotics -Hydrocortisone 100mg Daily - Morphine 2-4mg IV PRN Abdominal Pain . # Sinus Tachycardia: In the setting of intravascular depletion, crohns flare, abdominal pain. - IVF resuscitation - Pain Control with Morphine 2-4mg IV PRN - Broad Spectrum ABx . The patient was transferred to [**Hospital Ward Name 1950**] 5 she was made NPO with IVF/Foley/IVMeds/ABX. She was febrile to 102.9 with increased pain. Her pain medication was changed from morphine to dilaudid with good effect. The patient also had a repeat CT scan showing a fluid collection in her abdomen. She was taken to IR to have a drain place. Scant thick pus aspirated and cultured. . A PICC line was placed and the patient was started on TPN with bowel rest. She continued to spike temps to 103.0. Multiple fever workups were done including BCX, UCX and CXR all negative for infection. She had multiple CT scans done indicating abcesses. She was taken to IR for Drain placement, 2 drains placed for a total of 4 drains. . Despite the drain placements the patient continued to spike temps to 104.6 on HD 19 requiring a cooling blanket. She was than pre-op'd and taken to the OR for ex-lap, washout and drain placement. . She returned to the floor. She was maintained as NPO, TPN was continued along with a PCA, IVF, ABX. Infectious disease was also consulted to recommend treatment. POD 1 the patient was afebrile. However she continued to spike daily fevers there on out. ID continued to follow the patient adjust antibiotics as needed. . The patient c/o of severe pain and the pain service was consulted. She was started on a fentynal patch and PO dilaudid with good effect. At discharge the patient no longer needed the fentynal patch, her pain was well controlled with dilaudid. Her TPN was cycled and with the return of bowel function and flatus her diet was advanced from sips to regular. Her TPN was d/c'd once she tolerated regular diet. All of her drains were d/c'd prior to d/c. The patient was encouraged to have ensure with all meals. All D/C paperwork was reviewed with the patient and all questions answered. She will follow up with Dr. [**Last Name (STitle) 1120**] in [**11-20**] weeks. Medications on Admission: Ciprofloxacin 500 mg [**Hospital1 **] Celexa 20mg qday Protonix 40 mg qday Prednisone 25 mg qday Ambien 10 mg qday PRN OCP Folate MVI CITRACAL + Vit D 250 mg-200 unit PO TID Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. Disp:*60 Tablet(s)* Refills:*2* 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain for 2 weeks. Disp:*50 Tablet(s)* Refills:*0* 4. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: Three (3) Capsule, Sust. Release 24 hr PO DAILY (Daily) for 8 weeks. Disp:*168 Capsule, Sust. Release 24 hr(s)* Refills:*0* 8. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Discharge Disposition: Home Discharge Diagnosis: Primary: Crohn's Flare Fevers Dehydration Sinus Tachycardia Fluid collection . Secondary: depression, Crohn's dz Discharge Condition: Stable. Tolerating regular diet. Pain well controlled with oral medications Discharge Instructions: Please call your doctor or return to the ER for any of the following: * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Followup Instructions: 1. Please call Dr.[**Name (NI) 3377**] office, [**Telephone/Fax (1) 160**], to make a follow up appointment in [**11-20**] weeks. . Scheduled Appointments : Provider: [**Name10 (NameIs) **] RM 3 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2123-5-3**] 8:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2123-5-18**] 8:40 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2163**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2123-6-21**] 10:00 NEITHER DICTATED NOR READ BY ME Completed by:[**2123-5-25**]",12,2123-04-26 20:13:00,2123-05-25 14:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,INTRAABDOMINAL ABSCESS," 31f here with long-standing refractory crohns presenting with a severe flare and intravascular depletion. . # abdominal pain/surgical abdomen: most likely [**12-21**] crohns flare given findings on ct (multiple tiny pockets of extraluminal air, worsening bowel wall thickening consistent with crohns flare). other less likely etiologies include perforated ulcer (given chronic steroid use). evaluated by surgery in ed and upon admission to [**hospital unit name 153**]. received iv vancomycin/zosyn. per gi to continue hydrcortisone 100 mg qdaily. ngt placed. foley in place. strict npo, serial abd exam. - npo - serial abdominal exam -antibiotics -hydrocortisone 100mg daily - morphine 2-4mg iv prn abdominal pain . # sinus tachycardia: in the setting of intravascular depletion, crohns flare, abdominal pain. - ivf resuscitation - pain control with morphine 2-4mg iv prn - broad spectrum abx . the patient was transferred to [**hospital ward name 1950**] 5 she was made npo with ivf/foley/ivmeds/abx. she was febrile to 102.9 with increased pain. her pain medication was changed from morphine to dilaudid with good effect. the patient also had a repeat ct scan showing a fluid collection in her abdomen. she was taken to ir to have a drain place. scant thick pus aspirated and cultured. . a picc line was placed and the patient was started on tpn with bowel rest. she continued to spike temps to 103.0. multiple fever workups were done including bcx, ucx and cxr all negative for infection. she had multiple ct scans done indicating abcesses. she was taken to ir for drain placement, 2 drains placed for a total of 4 drains. . despite the drain placements the patient continued to spike temps to 104.6 on hd 19 requiring a cooling blanket. she was than pre-opd and taken to the or for ex-lap, washout and drain placement. . she returned to the floor. she was maintained as npo, tpn was continued along with a pca, ivf, abx. infectious disease was also consulted to recommend treatment. pod 1 the patient was afebrile. however she continued to spike daily fevers there on out. id continued to follow the patient adjust antibiotics as needed. . the patient c/o of severe pain and the pain service was consulted. she was started on a fentynal patch and po dilaudid with good effect. at discharge the patient no longer needed the fentynal patch, her pain was well controlled with dilaudid. her tpn was cycled and with the return of bowel function and flatus her diet was advanced from sips to regular. her tpn was d/cd once she tolerated regular diet. all of her drains were d/cd prior to d/c. the patient was encouraged to have ensure with all meals. all d/c paperwork was reviewed with the patient and all questions answered. she will follow up with dr. [**last name (stitle) 1120**] in [**11-20**] weeks. ","PRIMARY: [Regional enteritis of small intestine with large intestine] SECONDARY: [Peritoneal abscess; Other candidiasis of other specified sites; Peritonitis (acute) generalized; Anorexia nervosa; Pulmonary collapse; Unspecified pleural effusion; Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus; Arthropathy associated with gastrointestinal conditions other than infections; Obsessive-compulsive disorders; Dehydration; Iron deficiency anemia, unspecified; Other acute pain; Other chronic pain; Abdominal pain, right lower quadrant; Abdominal pain, left upper quadrant; Other specified cardiac dysrhythmias; Dysthymic disorder; Personal history of tobacco use; Long-term (current) use of steroids]","31f here with long-standing refractory crohns presenting with a severe flare and intravascular depletion. - ivf resuscitation - pain control with morphine 2-4mg iv prn - broad spectrum abx . her pain medication was changed from morphine to dilaudid with good effect. she was taken to ir for drain placement, 2 drains placed for a total of 4 drains. her tpn was cycled and with the return of bowel function and flatus her diet was advanced from sips to regular. her tpn was d/cd once she tolerated regular diet. last name (stitle) 1120**] in [**11-20**] weeks.",31f with long-standing refractory crohns presenting with a severe flare and intravascular depletion. evaluated by surgery in ed and upon admission to [**hospital unit name 153**]. received iv vancomycin/zosyn. per gi to continue hydrcortisone 100 mg qdaily. 40577,144014.0,18944,2144-12-23,18943,135411.0,2144-12-04,Discharge summary,"Admission Date: [**2144-11-8**] Discharge Date: [**2144-12-4**] Date of Birth: [**2092-8-6**] Sex: M Service: SURGERY Allergies: Zestril Attending:[**First Name3 (LF) 4691**] Chief Complaint: motorcycle trauma with hemodynamic instability Major Surgical or Invasive Procedure: [**11-8**] exploratory laparotomy, washout of BL arms, R groin and repair R knee degloving injury [**11-9**] washout of R groin, removal of lap band port, ORIF R elbow [**11-10**] ORIF L elbow [**11-11**] Trach, open placement of G-tube, removal gastric band History of Present Illness: 52yo M on motorcycle who rearended a car and was then struck from behind at 70mph. Initially brought to [**Hospital 189**] Hospital where noted to have BL UE fractures, hypotensive, and thus intubated and transferred to [**Hospital1 18**] for further eval and mgmt. Past Medical History: motorcycle trauma with BL open Monteggia fractures, R knee degloving injury, hypotension, facial laceration acute on chronic renal failure (previous baseline creatinine 2.0, now 2.7) hypernatremia anemia of chronic renal disease morbid obesity s/p lap gastric band ([**Doctor Last Name **]) [**12-25**], now removed DM2 CAD s/p stenting x2 ([**12-19**] at [**Hospital1 1774**]) HTN hypercholesterolemia CHF OSA Back Pain Psoriatic Arthritis L shoulder pain Social History: Lives with wife, 3 children. On disability, former truck driver. Former smoker, quit [**9-24**] after 80 pack year history. No current ETOH, former heavy drinker. No illicits. Family History: Father - leukemia, [**Name2 (NI) 32071**] heart disease. Mother - [**Name (NI) 2320**]. Sister - [**Name (NI) 2320**]. Physical Exam: 50, 81/40, 18, 100% Intubated. Moving legs BL, withdrawal to pain Face swollen BL breath sounds L->midline abdominal laceration. FAST negative. BL elbow lacerations with open fractures R knee degloving injury. Pertinent Results: [**2144-12-4**] 01:36AM BLOOD WBC-7.4 RBC-2.62* Hgb-7.8* Hct-23.4* MCV-89 MCH-29.8 MCHC-33.4 RDW-13.7 Plt Ct-174 [**2144-12-4**] 01:36AM BLOOD PT-17.6* PTT-34.0 INR(PT)-1.6* [**2144-12-4**] 01:36AM BLOOD Glucose-46* UreaN-90* Creat-2.7* Na-139 K-5.7* Cl-106 HCO3-26 AnGap-13 [**2144-12-4**] 06:06AM BLOOD K-5.4* [**2144-12-4**] 01:36AM BLOOD Calcium-9.1 Phos-5.8* Mg-3.0* [**2144-11-26**] 02:33AM BLOOD calTIBC-160* Ferritn-978* TRF-123* [**2144-11-8**] 08:22PM BLOOD ASA-NEG Ethanol-69* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: 52yo M brought to [**Hospital1 18**] by ambulance as a trauma basic. Evaluation in trauma bay demonstrated persistent hypotension which mildly improved with IVF resuscitation and 3u PRBC transfusion, despite a negative FAST examination. A DPL was attempted and was not confirmatory for the absence of hemoperitoneum. Accordingly, he was brought to the operating room for exploratory laparotomy which did not reveal an intraabdominal injury, as well as washout/debridement of his BL UE injuries by orthopedics; please see each operative report for further details. Post-operatively he was brought to the TSICU, intubated and sedated, and hemodynamically stable. The remainder of his hospital course will be summarized by system: . Neuro: Sedation and analgesia provided by drips during intubation, weaned after tracheotomy. Currently off drips and managed with intermittent ativan and oxycodone. . CV: Pressors were weaned off quickly after initial operation. He was hemodynamically stable throughout the remainder of his hospital stay. On lopressor, norvasc, and imdur for HTN, with intermittent hydralazine. . Resp: The vent settings were progressively weaned, slowed by volume overload from his perioperative resuscitation which was limited due to his acute-on-chronic renal failure. He was extubated on HD 10 but required reintubation that same day. He was trach'd on HD 13 because of failure to wean/extubate. Vent was progressively weaned, currently on CPAP/PS 35%, PS between 5 and 10, and PEEP 5. He tolerates trach collar intermittently. He did have an enterobacter PNA on HD 15, resistant to Zosyn/cephalosporins, which was treated with a 7-day course of Cipro IV and Tobramycin inhaled. . GI: No intraabdominal injuries identified at laparotomy. The port for the gastric band was exposed by the abdominal laceration and removed on HD 2 by Dr. [**Last Name (STitle) **]. The remainder of the gastric band was removed at the time of surgical g-tube placement on HD 13. Tube feeds were begun the following day. Has been on a bowel regimen with regular stools. . GU/Renal: Pt has chronic renal insufficiency, which flared to acute renal failure after attempted diuresis. Initially creatinine 2.1, peaked at 5.1, and settled at 2.7. Renal consulted; presumably ATN. Vascular surgery consulted for possible renal artery stenosis -- considered angiogram with carbon dioxide contrast but deferred as renal function began to improve. Hypernatremia of 155 treated with extensive FW administration, resistant to improvement by both G-tube and IV, now resolved and beginning to reduce the FW administration. One additional attempt at diuresis on HD 25 caused sl increase in creatinine and further attempts have been put on hold. . Heme: Pt was transfused in the trauma bay and OR. He remained anemic with Hct in the low 20's over the next few days despite continued transfusions, presumably from chronic renal failure. Because he was hemodynamically stable, further transfusions were not given. Ultimately he received 19 units of PRBC, 4u of Plts, and 7u of FFP over the course of his hospitalization. . ID: Cellulitis of RUE surgical site treated with Kefzol for ~1 week. Enterobacter PNA on HD 15, resistant to Zosyn/cephalosporins, which was treated with a 7-day course of Cipro IV and Tobramycin inhaled. . Endo: Glycemic control managed by [**Last Name (un) **] consult, initially for hyperglycemia and lately for hypoglycemia. Insulin gtt initially required, now controlled with SQ by sliding scale and long-term doses. . MSK: BL open Monteggia fractures washed out on HD 1, R fixed with ORIF on HD 2, L fixed with ORIF on HD 3. Cellulitis of R treated with Kefzol. R groin laceration washed out on HD 1 by GenSurg, WTD dsg applied, and re-washed out on HD 2 with placement of VAC. Currently receiving WTD to R groin. R knee degloving injury was washed out by ortho on HD 1, wrapped, and stitched eventually removed. Currently scabbed. C-spine and TLS-spine were cleared radiographically. Nasal laceration at L alar was repaired by plastics, with sutures removed prior to discharge. . Proph: Hep SQ TID. GI prophylaxis ceased upon tolerance of TF. Medications on Admission: plavix 75', bASA', lopressor 25'', imdur 30', cozaar 100', lasix 80'', lipitor 80', zetia 10', gemfibrozil 600'', amaryl 2'', novolin 14am/10pm, [**Last Name (un) **], celexa 20', flonase 50'', vit D 50000qwk Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-19**] Drops Ophthalmic PRN (as needed). 4. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q2H (every 2 hours) as needed. 5. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day) as needed. 6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 8. Triamcinolone Acetonide 0.025 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 9. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL mL PO Q6H (every 6 hours) as needed. 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 15. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 17. Oxycodone 5 mg/5 mL Solution Sig: Ten (10) mL PO Q8H (every 8 hours). 18. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 19. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 20. Insulin Glargine 100 unit/mL Solution Sig: 0.25 mL Subcutaneous at bedtime: 25u of Glargine qday at bedtime. 21. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as directed Subcutaneous four times a day: Sliding Scale: 61-120 mg/dL 0 Units 121-140 mg/dL 4 Units 141-160 mg/dL 6 Units 161-180 mg/dL 8 Units 181-200 mg/dL 10 Units 201-220 mg/dL 12 Units 221-240 mg/dL 14 Units 241-260 mg/dL 16 Units 261-280 mg/dL 18 Units 281-300 mg/dL 20 Units 301-320 mg/dL 22 Units 321-340 mg/dL 24 Units 341-360 mg/dL 26 Units 361-380 mg/dL 28 Units 381-400 mg/dL 30 Units > 400 mg/dL 32 Units . 22. Metoclopramide 5 mg/mL Solution Sig: One (1) mL Injection Q6H (every 6 hours). 23. Hydromorphone 2 mg/mL Solution Sig: 0.25-1 mL Injection Q3H (every 3 hours) as needed for pain. 24. Lorazepam 2 mg/mL Syringe Sig: 0.25 mL Injection HS (at bedtime). 25. Lorazepam 2 mg/mL Syringe Sig: 0.25 mL Injection Q8H (every 8 hours) as needed for agitation. 26. Hydralazine 20 mg/mL Solution Sig: 0.5-1 mL Injection Q6H (every 6 hours) as needed for SBP > 160. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: motorcycle trauma with BL open Monteggia fractures, R knee degloving injury, hypotension, facial laceration acute on chronic renal failure (previous baseline creatinine 2.0, now 2.7) hypernatremia anemia of chronic renal disease morbid obesity s/p lap gastric band ([**Doctor Last Name **]) [**12-25**], now removed DM2 CAD s/p stenting x2 ([**12-19**] at [**Hospital1 1774**]) HTN hypercholesterolemia CHF OSA Back Pain Psoriatic Arthritis L shoulder pain Discharge Condition: stable, on vent via trach, tolerating tube feeds via g-tube. Discharge Instructions: [**Name8 (MD) **] MD for: fever or chills; nausea, vomiting, constipation, diarrhea, or abdominal pain; redness, swelling, or drainage from any incision. Wean vent to trach collar as tolerated. Tube feeds via G-tube. Physical therapy for PROM of BL upper extremities. Followup Instructions: Follow-up with Trauma surgery, Dr. [**Last Name (STitle) **], in 2 weeks. Call [**Telephone/Fax (1) 6429**] for an appointment. Follow-up with Orthopedic surgery, Drs. [**Last Name (STitle) 1005**] [**Name5 (PTitle) **] [**Name5 (PTitle) **], in 2 weeks. Call [**Telephone/Fax (1) 1228**] for an appointment. Follow-up with Vascular surgery, Dr. [**Last Name (STitle) **], in 2 weeks. Call [**Telephone/Fax (1) 2625**] for an appointment. Follow-up with Bariatric surgery, Dr. [**Last Name (STitle) **]. Call [**Telephone/Fax (1) 2723**] for an appointment. Follow-up with Nephrology, Dr. [**Last Name (STitle) 4090**], in 2 weeks. Call [**Telephone/Fax (1) 3637**] for an appointment. Follow-up with your outpatient primary care physician [**Last Name (NamePattern4) **] 2 weeks. ",19,2144-11-08 21:58:00,2144-12-04 13:25:00,EMERGENCY,EMERGENCY ROOM ADMIT,REHAB/DISTINCT PART HOSP,MOTOR CYCLE COLLISION," 52yo m brought to [**hospital1 18**] by ambulance as a trauma basic. evaluation in trauma bay demonstrated persistent hypotension which mildly improved with ivf resuscitation and 3u prbc transfusion, despite a negative fast examination. a dpl was attempted and was not confirmatory for the absence of hemoperitoneum. accordingly, he was brought to the operating room for exploratory laparotomy which did not reveal an intraabdominal injury, as well as washout/debridement of his bl ue injuries by orthopedics; please see each operative report for further details. post-operatively he was brought to the tsicu, intubated and sedated, and hemodynamically stable. the remainder of his hospital course will be summarized by system: . neuro: sedation and analgesia provided by drips during intubation, weaned after tracheotomy. currently off drips and managed with intermittent ativan and oxycodone. . cv: pressors were weaned off quickly after initial operation. he was hemodynamically stable throughout the remainder of his hospital stay. on lopressor, norvasc, and imdur for htn, with intermittent hydralazine. . resp: the vent settings were progressively weaned, slowed by volume overload from his perioperative resuscitation which was limited due to his acute-on-chronic renal failure. he was extubated on hd 10 but required reintubation that same day. he was trachd on hd 13 because of failure to wean/extubate. vent was progressively weaned, currently on cpap/ps 35%, ps between 5 and 10, and peep 5. he tolerates trach collar intermittently. he did have an enterobacter pna on hd 15, resistant to zosyn/cephalosporins, which was treated with a 7-day course of cipro iv and tobramycin inhaled. . gi: no intraabdominal injuries identified at laparotomy. the port for the gastric band was exposed by the abdominal laceration and removed on hd 2 by dr. [**last name (stitle) **]. the remainder of the gastric band was removed at the time of surgical g-tube placement on hd 13. tube feeds were begun the following day. has been on a bowel regimen with regular stools. . gu/renal: pt has chronic renal insufficiency, which flared to acute renal failure after attempted diuresis. initially creatinine 2.1, peaked at 5.1, and settled at 2.7. renal consulted; presumably atn. vascular surgery consulted for possible renal artery stenosis -- considered angiogram with carbon dioxide contrast but deferred as renal function began to improve. hypernatremia of 155 treated with extensive fw administration, resistant to improvement by both g-tube and iv, now resolved and beginning to reduce the fw administration. one additional attempt at diuresis on hd 25 caused sl increase in creatinine and further attempts have been put on hold. . heme: pt was transfused in the trauma bay and or. he remained anemic with hct in the low 20s over the next few days despite continued transfusions, presumably from chronic renal failure. because he was hemodynamically stable, further transfusions were not given. ultimately he received 19 units of prbc, 4u of plts, and 7u of ffp over the course of his hospitalization. . id: cellulitis of rue surgical site treated with kefzol for ~1 week. enterobacter pna on hd 15, resistant to zosyn/cephalosporins, which was treated with a 7-day course of cipro iv and tobramycin inhaled. . endo: glycemic control managed by [**last name (un) **] consult, initially for hyperglycemia and lately for hypoglycemia. insulin gtt initially required, now controlled with sq by sliding scale and long-term doses. . msk: bl open monteggia fractures washed out on hd 1, r fixed with orif on hd 2, l fixed with orif on hd 3. cellulitis of r treated with kefzol. r groin laceration washed out on hd 1 by gensurg, wtd dsg applied, and re-washed out on hd 2 with placement of vac. currently receiving wtd to r groin. r knee degloving injury was washed out by ortho on hd 1, wrapped, and stitched eventually removed. currently scabbed. c-spine and tls-spine were cleared radiographically. nasal laceration at l alar was repaired by plastics, with sutures removed prior to discharge. . proph: hep sq tid. gi prophylaxis ceased upon tolerance of tf. ","PRIMARY: [Open fracture of shaft of ulna (alone)] SECONDARY: [; Open wound of knee, leg [except thigh], and ankle, with tendon involvement; Acute posthemorrhagic anemia; Injury to other intra-abdominal organs without mention of open wound into cavity, peritoneum; Traumatic shock; Acute kidney failure with lesion of tubular necrosis; Pneumonia due to other gram-negative bacteria; Mechanical complication due to other implant and internal device, not elsewhere classified; Other postoperative infection; Cellulitis and abscess of upper arm and forearm; Hyperosmolality and/or hypernatremia; Other motor vehicle traffic accident involving collision with motor vehicle injuring motorcyclist; Closed dislocation of wrist, unspecified part; Open Monteggia's fracture; Open wound of abdominal wall, lateral, complicated; Morbid obesity; 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; Bariatric surgery status; Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation; Chronic kidney disease, unspecified; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified; Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation; Open wound of nose, unspecified site, complicated; Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled; Congestive heart failure, unspecified; Obstructive sleep apnea (adult)(pediatric); Psoriatic arthropathy]","52yo m brought to [**hospital1 18**] by ambulance as a trauma basic. a dpl was attempted and was not confirmatory for the absence of hemoperitoneum. accordingly, he was brought to the operating room for exploratory laparotomy which did not reveal an intraabdominal injury, as well as washout/debridement of his bl ue injuries by orthopedics; please see each operative report for further details. neuro: sedation and analgesia provided by drips during intubation, weaned after tracheotomy. he did have an enterobacter pna on hd 15, resistant to zosyn/cephalosporins, which was treated with a 7-day course of cipro iv and tobramycin inhaled. one additional attempt at diuresis on hd 25 caused sl increase in creatinine and further attempts have been put on hold. msk: bl open monteggia fractures washed out on hd 1, r fixed with orif on hd 2, l fixed with orif on hd 3. r knee degloving injury was washed out by ortho on hd 1, wrapped, and stitched eventually removed.","52yo m brought to trauma bay by ambulance as a trauma basic. evaluation demonstrated persistent hypotension which mildly improved with ivf resuscitation and 3u prbc transfusion, despite a negative fast examination. post-operatively he was brought to the tsicu, intubated and sedated, and hemodynamically stable." 43122,168271.0,13574,2101-06-13,13573,180308.0,2101-05-19,Discharge summary,"Admission Date: [**2101-5-12**] Discharge Date: [**2101-5-19**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1**] Chief Complaint: - abdominal pain Major Surgical or Invasive Procedure: - closure/[**Location (un) **] patch for perforated duodenal ulcer History of Present Illness: On admission: The patient is a [**Age over 90 **]-year-old female who began having intermittant generalized abdominal pain about 4 days ago. She had some mild nausea and one episode of small volume emesis, but she attributes this to her vertigo. Today, her pain increased a great deal, and became quite sharp and constant and unbearable to the point that she was crying at home. She was brought to the ED by EMS for evaluation. Her last BM was earlier today and was normal. She denies fever and chills. She does have anorexia, but she says this has been going on for some months. Past Medical History: - hypertension - palpitations - depression - vertigo - COPD/asthma - hearing loss Social History: - rare social alcohol use, denies T/D - lives in [**Location **] in senior housing Family History: - non-contributory Physical Exam: Day of Discharge: Vitals - T:97.9 BP:125/62 HR:83 RR:20 O2sat:98% on 2L NC FS:113-134 Gen: NAD, A&O x 3 CV: irregular, normal rate Resp: CTAB, no respiratory distress Abd: soft, not distended, minimal TTP Incision: C/D/I, no erythema or induration JP site: dressing C/D/I L UE: improved erythema, but still with palpable cord Pertinent Results: [**2101-5-12**] CXR: IMPRESSION: Pneumoperitoneum with bowel perforation better assessed on CT abdomen/pelvis performed within the same hour. Large left diaphragmatic hernia. Right lung base bronchiectasis may be related to chronic aspiration. . [**2101-5-12**] CT ABD/PELVIS: IMPRESSIONS: 1. Findings suggest bowel perforation, likely from the region of the pylorus/first portion of the duodenum where there is circumferential wall thickening and apparent small rent through the anterior wall. This causes large pneumoperitoneum and mild-to-moderate ascites. 2. Large, stomach- and colon-containing left diaphragmatic hernia. 3. Peripheral ground- glass opacities in the right lower lobe concerning for aspiration. 4. Few scattered sigmoid colonic diverticulae, without definite diverticulitis, thus making this less likely cause for bowel perforation. . [**2101-5-12**] WBC-7.2 Hgb-11.4 Hct-33.8 Plt Ct-420 [**2101-5-12**] Neuts-88 Bands-2 Lymphs-2 Monos-5 Eos-2 Baso-1 Atyps-0 Metas-0 Myelos-0 [**2101-5-13**] WBC-15.5 Hgb-10.8 Hct-32.5 Plt Ct-458 [**2101-5-14**] WBC-10.6 Hgb-8.4 Hct-24.9 Plt Ct-374 [**2101-5-15**] WBC-9.2 Hgb-9.1 Hct-27.2 Plt Ct-378 [**2101-5-17**] WBC-8.5 Hgb-9.5 Hct-28.5 Plt Ct-349 . [**2101-5-18**] Glucose-86 UreaN-10 Creat-0.5 Na-133 K-4.2 Cl-98 HCO3-29 [**2101-5-18**] Calcium-7.5 Phos-3.3 Mg-1.9 . [**2101-5-12**] PT-15.2 PTT-28.4 INR(PT)-1.3 [**2101-5-15**] PT-15.3 PTT-30.9 INR(PT)-1.3 [**2101-5-16**] PT-16.0 PTT-30.2 INR(PT)-1.4 [**2101-5-17**] PT-17.2 PTT-30.9 INR(PT)-1.6 Brief Hospital Course: *)Duodenal Ulcer She was taken to the operating room, where a 4mm defect in the pyloroduodenal area was noted. The defect was repaired and reinforced with an omental patch; please see the operative report for full details. Her diet was slowly advanced and on discharge she was tolerating a regular diet, albeit with the same decreased appetite she had had for several months as reported on admission. . *)Tachycardia Her post-operative course was complicated by tachycardia, which was initially thought to be atrial fibrillation. Cardiology was consulted and felt that it may be multi-focal tachycardia. She had been on verapamil as an outpatient, but was started on diltiazem during her hospitalization for acute rate control. This was maintained, as verapamil was noted to be more constipating. On discharge her heartrate was well controlled on diltiazem. . *)Cellulitis On POD#5 erythema was noted at the site of a prior infiltrated IV on her left arm. The area was marked and appeared to grow in size; vancomycin was started with subsequent improvement of the erythema. She was discharged on a course of Bactrim to complete 7 days of antibiotics, per ID curbside recommendations. . *)Disposition Physical therapists worked with her during her hospital course and recommended further therapy after discharge. She was discharged to a rehabilitation facility to continue her post-operative recovery. Her home medications, with the exception of verapamil, were re-started shortly after surgery and were continued during her hospital course. Medications on Admission: - albuterol - estrogen ring - Advair - Atrovent - meclizine - Detrol [**Name Prefix (Prefixes) **] - [**Last Name (Prefixes) 40988**] - Tylenol prn Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID (4 times a day) as needed for low calcium, heartburn. 4. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 5. Codeine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Inhalation twice a day. 7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Inhalation twice a day. 8. Bactrim DS 160-800 mg Tablet Sig: Two (2) Tablet PO twice a day for 4 days. Disp:16 Tablet(s) Refills:0 Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary: Perforated duodenal ulcer Post-op low urine output RUE cellulitis . Secondary: HTN, asthma/COPD, L leg cellulitis, occasional palpitations Discharge Condition: Stable. Tolerating regular diet. Pain well controlled with oral medications. Discharge Instructions: Rehab: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. . Incision Care: -Your staples can be removed at rehab on [**5-25**] and steri strips should be applied. -Steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after applicaiton -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. . Cellulitis (skin infection) of the left arm: - please take your antibiotics as directed - if the infection does not continue to improve, an additional antibiotic may be added (Keflex/cephalexin) - you will need a set of labs while you are taking Bactrim Followup Instructions: 1. Please call Dr.[**Name (NI) 10946**] office to make a follow up appointment in [**12-24**] weeks. . Scheduled Appointments : Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2101-9-26**] 9:20 Completed by:[**2101-5-19**]",25,2101-05-12 05:21:00,2101-05-19 13:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,SNF,PNEUMOPERITONEUM," *)duodenal ulcer she was taken to the operating room, where a 4mm defect in the pyloroduodenal area was noted. the defect was repaired and reinforced with an omental patch; please see the operative report for full details. her diet was slowly advanced and on discharge she was tolerating a regular diet, albeit with the same decreased appetite she had had for several months as reported on admission. . *)tachycardia her post-operative course was complicated by tachycardia, which was initially thought to be atrial fibrillation. cardiology was consulted and felt that it may be multi-focal tachycardia. she had been on verapamil as an outpatient, but was started on diltiazem during her hospitalization for acute rate control. this was maintained, as verapamil was noted to be more constipating. on discharge her heartrate was well controlled on diltiazem. . *)cellulitis on pod#5 erythema was noted at the site of a prior infiltrated iv on her left arm. the area was marked and appeared to grow in size; vancomycin was started with subsequent improvement of the erythema. she was discharged on a course of bactrim to complete 7 days of antibiotics, per id curbside recommendations. . *)disposition physical therapists worked with her during her hospital course and recommended further therapy after discharge. she was discharged to a rehabilitation facility to continue her post-operative recovery. her home medications, with the exception of verapamil, were re-started shortly after surgery and were continued during her hospital course. ","PRIMARY: [Chronic or unspecified duodenal ulcer with perforation, without mention of obstruction] SECONDARY: [Unspecified peritonitis; Cellulitis and abscess of upper arm and forearm; Cardiac complications, not elsewhere classified; Other specified disorders of peritoneum; Unspecified essential hypertension; Depressive disorder, not elsewhere classified; Chronic obstructive asthma, unspecified; Tachycardia, unspecified; 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; Atrial fibrillation]","*)duodenal ulcer she was taken to the operating room, where a 4mm defect in the pyloroduodenal area was noted. *)tachycardia her post-operative course was complicated by tachycardia, which was initially thought to be atrial fibrillation. she was discharged to a rehabilitation facility to continue her post-operative recovery.",a 4mm defect in the pyloroduodenal area was noted. the defect was repaired and reinforced with an omental patch. she was discharged on a course of bactrim to complete 7 days of antibiotics. 43126,132026.0,23429,2124-09-26,23428,124079.0,2124-08-17,Discharge summary,"Admission Date: [**2124-3-1**] Discharge Date: [**2124-8-17**] Date of Birth: [**2067-4-22**] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 3913**] Chief Complaint: CLL with [**Doctor Last Name 6261**] Transformation, admitted for Allo SCT Major Surgical or Invasive Procedure: Hickmann Placement & Removal Central Venous Line Placement and removal x3 PICC Placement and removal x2 Sigmoidoscopy with biopsy Paracentesis History of Present Illness: Mr. [**Known lastname **] is a 56-year-old male with history of CLL with P53 mutation, s/p FCR and PCR, and Campath [**2123-7-9**], with recent new onset ([**2122-12-21**])left cervical lymph node enlargment which upon biopsy revealed large cell ([**Doctor Last Name 6261**]) transformation, s/p [**Hospital1 **] ([**Date range (1) 60068**]), s/p ESHAP ([**Date range (1) 35870**]/09) ([**Date range (1) 60070**]) admitted now for an ablative Cytoxan/Busulfan matched ([**7-27**]) unrelated donor peripheral stem cell transplant. . The patient reports fatigue and anorexia since previous admission with decreased taste sensation. He is otherwise feeling well. On review of systems, he denies any fever, chills, nausea, vomiting, chest pain, SOB, diarrhea, constipation, dysuria, abdominal pain, weakness, numbness, or tingling. He reports anxiety and fear entering transplant, but he has accepted that it is the next step in his therapy and he is ready. Past Medical History: Past Medical History: Hypertension Hypercholesterolemia (diet controlled) S/p tonsillectomy CLL (see below) . Past Oncologic History (Per [**Hospital **] Clinic Note): Pt presented with his disease back in [**10/2119**] with an elevated white count and LDH. He was without any splenomegaly or any cytopenias at that time. He did have some bulky lymphadenopathy. Over the course of six months, his white count began to rise and essentially doubled to approximately 130,000 with a rising in his LDH of up to 1400, and he also was noted to have worsening palpable lymphadenopathy. He then completed four cycles of FCR therapy, which he completed back in 09/[**2119**]. He had an excellent response to therapy and was monitored off treatment for approximately two years. He then presented in [**7-/2122**] with a rising white count, approximately 50% lymphocytes, and a mildly elevated LDH. He also had some mild worsening palpable lymphadenopathy. He then received four cycles of PCR, but did not have much in the way of response and his treatment regimen was switched to R-CVP of which he received two cycles. He did again not have a significant response, though continued to have an excellent performance status, and he was ultimately switched to Campath therapy. He did have resolution of his lymphocytosis, and his white count has come down nicely, but did not have much in the way of response in terms of reducing his bulky lymphadenopathy. He had received chemotherapy initially through 06/[**2122**]. We had decided to observe him off treatment, and ultimately, we had decided to move forward with an allogeneic stem cell transplant; however, back at the end of the summer, his donor had backed out. He also had return of his disease, and we reinitiated Campath regimen. This, however, ultimately was cut short on [**2123-7-7**] due to question of an infection versus PE for which he was ruled out. He has been followed closely by ID and has been treated on Augmentin since that time through therapy. He then was restarted back on Campath and completed six weeks of treatment dose as previously his cycles have been interrupted. He again had normalization of his white count and also no longer had any lymphocytosis. However, he again did not have much in the way of significant response to his lymphadenopathy. He then eventually had developed an enlarging left cervical node which was biopsied and was found to have [**Doctor Last Name **] transformation. He was admitted on [**2124-1-5**] for [**Hospital1 **]. This [**Hospital1 **] was overall well tolerated. He completed his first course of ESHAP on [**2124-2-2**], and tolerated this well. . Four cycles of FCR (Fludarabine, Cytoxan, Rituxan) completed on [**2120-8-15**], four cycles of PCR (Pentostatin, Cytoxan, Rituxan) completed on [**2122-10-1**], two cycles of R-CVP completed on [**2123-3-11**], Campath treatment subcutaneously initiated on [**2123-4-14**] and stopped on [**2123-4-30**], reinitiated on [**2123-6-23**] and stopped on [**2123-7-7**], restarted on [**2123-10-11**] and completed approximately six weeks of therapy which he completed on [**2123-12-3**]. Reinitiated therapy due to [**Doctor Last Name 6261**] transformation with [**Hospital1 **] treatment (Continuous infusion of etoposide, Adriamycin, and Vincristine on days [**11-21**], Oral prednisone on days [**11-22**], and Cytoxan on day 5) in 02/[**2123**]. D/t inadequate disease response from [**Hospital1 **] regimen was switched to ESHAP (Bolus of Etoposide on days [**11-21**], Cisplatin continuous infusion on days [**11-21**], Methylprednisolone IV on days [**11-22**], Cytarabine 2g/m2 IV over 2 hours on day 5 only). Social History: Has been married for 30 years. He works as a software engineer. He does not smoke and drinks occasional alcohol He has one daughter who is 20-years-old. Family History: Notable for father who died of prostate cancer, with question of lung involvement at the end. His mother had a history of MS and one of his brothers is obese. An uncle with pancreatic cancer and an aunt with breast cancer. Physical Exam: ON ADMISSION: VS- 97.1 114/70 80 18 98%@RA Gen: awake, alert, no acute distress, pleasant HEENT: mucous membranes moist, always with a different [**Location (un) 86**] sports hat, today Bruins. Neck: Non-tender, neck supple, no JVD, no thyromegaly CV: S1 & S2 regular without murmur Lungs: Clear to auscultation bilaterally, no wheezes/rales/rhonchi Abd: soft, non-tender or distended, no HSM, BS present Ext: No edema, 2+ DP pulses bilaterally Neuro: AOx3, CN2-12 intact grossly, strength 5/5 diffusely, sensation intact diffusely, coordination intact bilaterally. FTN/HTS intact, negative Romberg's sign. ON DISCHARGE: T: 97.0 BP: 119/92 HR: 86 RR: 18 SP02: 98%RA General: Quite, slow movements, no acute distress HEENT: Moist mucous membranes, no palpable LAD, neck is supple CARDIAC: Regular rate and rhythm; normal S1 and S2 RESP: Clear to auscultation bilaterally; no wheezes, rales, rhonchi ABDOMEN: +BS, non-tender, non-distended EXTREMITY: 1+ edema bilaterally; full range of movement SKIN: Slightly ashen/icteric Pertinent Results: Please note, there are 5 months worth of labs in our system. Please find below the admission labs, and below them, the discharge labs. . ADMISSION LABS: [**2124-3-1**] 09:25AM BLOOD WBC-14.0* RBC-3.19* Hgb-10.0* Hct-28.0* MCV-88 MCH-31.2 MCHC-35.5* RDW-19.3* Plt Ct-117*# [**2124-3-1**] 09:25AM BLOOD Neuts-33* Bands-2 Lymphs-55* Monos-5 Eos-0 Baso-1 Atyps-1* Metas-3* Myelos-0 [**2124-3-1**] 09:25AM BLOOD Hypochr-NORMAL Anisocy-2+ Poiklo-NORMAL Macrocy-1+ Microcy-1+ Polychr-1+ [**2124-3-1**] 09:25AM BLOOD PT-12.0 INR(PT)-1.0 [**2124-3-1**] 09:25AM BLOOD Gran Ct-5320 [**2124-3-1**] 09:25AM BLOOD UreaN-23* Creat-1.1 Na-147* K-4.1 Cl-106 HCO3-28 AnGap-17 [**2124-3-1**] 09:25AM BLOOD ALT-27 AST-33 LD(LDH)-604* AlkPhos-103 TotBili-0.3 DirBili-0.1 IndBili-0.2 [**2124-3-1**] 09:25AM BLOOD Calcium-9.1 Phos-3.2 Mg-1.6 UricAcd-4.5 . DISCHARGE LABS: Na 131, K 3.7, Cl 101, HC03 18 (stable), BUN 24, Cr. 0.5, Glucose 172, WBC 6.7, Hgb 9.0, Hct 26.9, Plt 95, Ca 8.2, Mg 1.9, Phos 2.2. LFTS (trending down) ALT 214, AST 93, LDH 668, Alk Phos 421. Urine culture [**8-14**]: <10,000 organisms. U/A: Bili small, bacteria few (most likely contaminated), protein trace, glucose 300, nitrates negative, leukocytes negative. Other results: . Last CMV VL [**2124-8-14**] Negative. . ID RESULTS: -Cdiff negative x4 since [**6-25**] -[**2124-7-22**] cryptococcal Ag negative -[**2124-7-20**] Peritoneal fluid negative, Gstain and Cx, Fungal, anaerobes, AFB all negative -[**2124-7-14**] CSF negative Gstain, Cx, Crypto, fungal, Ag -[**2124-7-12**] stool Cx all negative --VRE bacteremia, s/p linezolid x 2 weeks - Strep milleri bacteremia, treated, and resolved, TTE [**4-21**] no vegetation. There is a note that HHV6 was positive at the same time as patient developed evanescent rash, which was attributed to HHV6. Repeat serum viral load was negative a week later. -BK viruria >390 million ([**4-24**]) with bladder spasms, but then symptoms resolved. . Last positive Cx's we have on record are: Final [**2124-5-17**]: ENTEROCOCCUS FAECIUM. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 60071**] [**2124-5-11**]. Anaerobic Bottle Gram Stain (Final [**2124-5-14**]): GRAM POSITIVE COCCI IN CHAINS. . Aerobic Bottle Gram Stain (Final [**2124-5-15**]): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. . Culture taken from colon: Time Taken Not Noted Log-In Date/Time: [**2124-5-10**] 6:22 pm TISSUE COLON. NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. TISSUE (Final [**2124-5-13**]): ENTEROCOCCUS SP.. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S PENICILLIN G---------- =>64 R VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final [**2124-5-16**]): BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. BETA LACTAMASE POSITIVE. ACID FAST CULTURE (Final [**2124-7-10**]): NO MYCOBACTERIA ISOLATED. ACID FAST SMEAR (Final [**2124-5-11**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Final [**2124-5-26**]): NO FUNGUS ISOLATED. [**2124-4-15**] 12:05 pm BLOOD CULTURE **FINAL REPORT [**2124-4-18**]** Blood Culture, Routine (Final [**2124-4-18**]): STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. FINAL SENSITIVITIES. CLINDAMYCIN RESISTANT @ > 2MCG/ML. ERYTHROMYCIN RESISTANT @>4MCG/ML. Sensitivity testing performed by Sensititre. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP | CLINDAMYCIN----------- R ERYTHROMYCIN---------- R PENICILLIN G---------- 0.06 S VANCOMYCIN------------ 1 S Anaerobic Bottle Gram Stain (Final [**2124-4-16**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 1035AM [**2124-4-16**]. GRAM POSITIVE COCCI IN CHAINS. The following are significant reports from the last 5 months. However, due to volume of reports, this list is not inclusive. [**2124-7-21**] CXR FINDINGS: In comparison with study of [**7-12**], there is a slightly better inspiration with continued enlargement of the cardiac silhouette and widening of the mediastinum due to extensive mediastinal lipomatosis. Lungs are clear and there is no vascular congestion. CENTRAL CATHETER REMAINS IN PLACE. [**2124-7-19**] Doppler u/s abdomen FINDINGS: Transabdominal ultrasound with Doppler demonstrates patent hepatic veins including the right middle and left hepatic veins. There is appropriate direction of flow. No thrombus is seen. Patient evaluation is limited due to patient's inability to breath-hold. The main portal vein was seen to be patent with appropriate direction of flow on the earlier study. The hepatic artery was not visualized. Moderate ascites throughout the abdomen, unchanged from prior study. IMPRESSION: Limited evaluation. Hepatic veins are patent with appropriate direction of flow with no thrombus seen. [**2124-7-18**] CT abdomen pelvis FINDINGS: The lung bases demonstrate increased atelectasis when compared to prior study of [**2124-5-11**]. In addition, there are bilateral pleural effusions, left greater than right, both slightly increased in size since the prior study. The heart size is normal. The spleen, gallbladder, pancreas, adrenal glands, stomach are within normal limits. Both kidneys demonstrate parapelvic cysts bilaterally. Otherwise, the kidneys both enhance and excrete contrast symmetrically bilaterally. A small hyperdensity is noted within the right lobe of the liver (2:22), unchanged in size and appearance since at least [**2124-3-17**]. Multiple small retroperitoneal and mesenteric lymph nodes are again noted, none meeting CT criteria for pathologic enlargement. There is no free air. There is a moderate amount of ascites, which has increased in amount since the CT of [**5-11**]. In addition, there is a significant amount of soft tissue edema throughout the entire subcutaneous tissues of the abdomen, which has greatly increased also since the prior study. There is persistent mild bowel wall thickening at the ileum that apperas moreso in the terminal ileum, not significantly changed. Fatty change in the wall of the terminal ileum also is stable. In some of the areas of wall thickening there is striated enhancement, but the mucosal enhancement is only mildly increased and this is in collapsed bowel. No distended bowel shows wall thickening with striated enhancement. There are mildly dilated loops of jejunum and proximal ileum without a transition pint. Previously described possible edema of the gastric antrum/pylorus is not apparent on today's study. CT OF THE PELVIS WITH IV CONTRAST: The rectum and prostate are within normal limits. Air within the bladder is likely due to recent placement of a Foley catheter. A large amount of free fluid is noted within the pelvis, increased since the prior study. There is no pelvic or inguinal lymphadenopathy. There is a small left sided fat containing inguinal hernia. BONE WINDOWS: No suspicious osseous lesions are seen. Left eighth rib deformity consistent with old healed fracture, unchanged. IMPRESSION: 1. Increased ascites within the abdomen and pelvis. Bilateral pleural effusions, left greater than right, also slightly increased since the prior study. Anasarca. 2. Persistent mild ileal wall thickening and with fatty deposition in the terminal ileal wall, unchanged. No convinving active ileitis at this time with the findings likely reflecting chronic changes from graft versus host disease. No obstruction, but likely mild small bowel ileus. [**2124-7-15**] MRI head FINDINGS: The diffusion images, which are adequate for interpretation, demonstrate no acute infarct. There is no mass effect or midline shift. The remaining images are limited by motion demonstrate no obvious midline shift or hydrocephalus. There are no obvious areas of enhancement seen on motion limited axial images but evaluation is limited. Subtle areas of high signal on both basal ganglia region on post-gadolinium axial images are artifactual from pulsation artifacts. IMPRESSION: Limited study due to motion. Diffusion images which are adequate for interpretation demonstrate no acute infarct. Other images, which are limited demonstrate no obvious abnormalities, but for better evaluation if clinically indicated, a repeat study can be obtained with sedation. [**2124-7-3**] RUE U/S FINDINGS: RIGHT UPPER EXTREMITY VENOUS ULTRASOUND: The right internal jugular vein is patent. The proximal right subclavian vein at the level of the internal jugular vein is patent. Just distal to the internal jugular vein, the subclavian vein is thrombosed. The vein is distended with echogenic clot and demonstrates absence of flow and compressibility. The axillary vein is now only partially thrombosed, with minimal flow seen around the echogenic clot. There is partial compressibility. The basilic vein is patent. One of the paired brachial veins remains thrombosed with echogenic clot distending the lumen and absence of flow and compressibility. The other brachial vein is patent. The cephalic vein remains completely thrombosed without compressibility or flow. The left subclavian vein is patent. IMPRESSION: 1. Interval improvement in degree of the right upper extremity thrombosis, now with only partial clot in the right axillary vein, and flow in the basilic vein. 2. Persistent thrombosis of the superficial veins of the right upper extremity, with thrombosis of one of the paired brachial veins and the axillary vein. [**2124-6-15**] ECHO Findings LEFT ATRIUM: Mild LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness. Small LV cavity. Overall normal LVEF (>55%). No resting LVOT gradient. No VSD. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No masses or vegetations on aortic valve, but cannot be fully excluded due to suboptimal image quality. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No masses or vegetations on mitral valve, but cannot be fully excluded due to suboptimal image quality. Normal mitral valve supporting structures. No MS. Mild (1+) MR. LV inflow uninterpretable due to tachycardia and/or fusion of spectral Doppler E and A waves TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. Normal tricuspid valve supporting structures. No TS. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. No vegetation/mass on pulmonic valve. Normal main PA. No Doppler evidence for PDA PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Overall left ventricular systolic function is normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Mild (1+) mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2124-5-12**], no major change. IMPRESSION: Suboptimal image quality. No obvious vegetations seen If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. [**2124-7-21**] FLOW CYTOMETRY PERIPHERAL BLOOD FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: HLA-DR, FMC-7, Kappa, and CD antigens 3, 5, 10, 19, 20, 23, 38, 45. RESULTS: Three color gating (CD45 versus light scatter) is used to determine population of interest. B cells are extremely scant in number, however, appear polytypic. T cells comprise 90% of lymphoid gated events. INTERPRETATION Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by a non-Hodgkin B-cell lymphoma are not seen in specimen. Correlation with clinical findings is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts or sample preparation. [**2124-7-20**] FLOW CYTOMETRY ASCITES FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: HLA-DR, FMC-7, Kappa, Lambda, and CD antigens 3, 5, 10, 19, 20, 23, 38, 45. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. B cells are scant in number precluding evaluation of clonality. T cells comprise 90% of lymphoid gated events. INTERPRETATION Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by a non-Hodgkin B-cell lymphoma are not seen in specimen. Correlation with clinical findings is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts or sample preparation. [**2124-6-26**] FLOW CYTOMETRY OF CSF FLUID The following tests (antibodies) were performed: Kappa, Lambda, and CD antigens 19, 45. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. B cells are scant in number precluding evaluation of clonality. T cells comprise 99% of lymphoid gated events. INTERPRETATION Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by lymphoma are not seen in specimen. Correlation with clinical findings is recommended. Flow cytometry immunophenotyping may not detect all lymphomas as due to topography, sampling or artifacts of sample preparation. [**2124-5-29**] SKIN BX DIAGNOSIS: 1. Skin, right forearm, biopsy (A-B): Interface and superficial perivascular dermatitis with marked dyskeratosis, dermal melanophages, and extravasated erythrocytes, see note. Note: The degree of dyskeratosis (some at basal layer), lack of eosinophils, and finding of lymphocyte-keratinocyte satellitosis favor graft versus host disease, if clinically appropriate. The histologic differential diagnosis includes a drug eruption.. This case was discussed with Dr. [**Last Name (STitle) **] on [**2124-5-30**]. 2. Skin, left upper back, biopsy (C): Interface and superficial perivascular dermatitis with marked dyskeratosis, dermal melanophages, and extravasated erythrocytes, see note. Note: The degree of dyskeratosis (some at basal layer), lack of eosinophils, and finding of lymphocyte-keratinocyte satellitosis favor graft versus host disease, if clinically appropriate. The histologic differential diagnosis includes a drug eruption. This case was discussed with Dr. [**Last Name (STitle) **] on [**2124-5-30**]. [**2124-5-18**] GI BX DIAGNOSIS: Terminal ileum, biopsy: Granulation tissue and ulcer bed with crystalline material. See note. Note: No intact intestinal epithelium is seen. The crystalline material is morphologically consistent with sodium polystyrene sulfonate (Kayexalate), which is reported to be associated with gastrointestinal tract ulcers. Reactive atypia is noted within the granulation tissue, however, no definite viral inclusions are identified. An immunohistochemical stain for cytomegalovirus is in process and results will be reported as an addendum. Severe acute graft versus host disease cannot be excluded based on the morphologic findings. The case was reviewed with Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 7108**], who concurs. The findings were discussed with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2124-5-19**]. ADDENDUM: Immunohistochemical stain for CMV is negative. [**2124-3-30**] - SIGMOIDOSCOPY - Impression: Diverticulosis of the sigmoid colon Normal mucosa in the sigmoid colon (biopsy) Otherwise normal sigmoidoscopy to descending colon at 50 cm . [**2124-3-30**] - PATHOLOGY - GI BIOPSIES (2 JARS) DIAGNOSIS: Colonic mucosa biopsies, two: A. Sigmoid: Colonic mucosa, no diagnostic abnormalities recognized. B. Rectum: Colonic mucosa with rare crypt cell apoptosis, see note. Note: These findings are not diagnostic for GVHD. Immunostain for CMV is negative. . [**2124-4-12**] - PATHOLOGY - Skin, abdomen: - Interface dermatitis with dyskeratotic keratinocytes, and mild superficial perivascular lymphocytic infiltrate consistent with graft versus host disease, see note. Note: The histological differential diagnosis includes a reaction to drugs. The current specimen shows lymphocyte-keratinocyte satellitosis and marked apoptic bodies at the interface level, and no eosinophilia is noted. The keratinocytic dyskeratosis is predominantly seen at the basal keratinocytes level, and no dermal edema is seen. Overall, a diagnosis of graft versus host disease (GVHD) is favored, if compatible with the clinical presentation. . MICROBIOLOGY TESTS: [**2124-4-15**] BLOOD CULTURE Blood Culture, Routine-FINAL {STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP}; Anaerobic Bottle Gram Stain-FINAL Anaerobic Bottle Gram Stain-FINAL INPATIENT FINAL SENSITIVITIES. CLINDAMYCIN RESISTANT @ > 2MCG/ML. ERYTHROMYCIN RESISTANT @>4MCG/ML. Sensitivity testing performed by Sensititre. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP | CLINDAMYCIN----------- R ERYTHROMYCIN---------- R PENICILLIN G---------- 0.06 S VANCOMYCIN------------ 1 S Anaerobic Bottle Gram Stain (Final [**2124-4-16**]): [**2124-4-16**] BLOOD CULTURE -FINAL {STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP} [**2124-4-18**] BLOOD CULTURE -FINAL NO GROWTH. Brief Hospital Course: Mr. [**Known lastname **] is a 56-year-old male with history of CLL with large cell transformation who was admitted for a scheduled allogeneic MUD SCT on [**2124-3-10**]. His course was complicated by febrile neutropenia and acute GVHD involving the intestinal tract, liver and skin. He was discharged to [**Hospital1 **] in stable condition with symptomatic improvement. = = = = = = = = = = = = = = = = = = = = = ================================================================ [**Date range (3) 60072**] # Allo BMT - Day 0: [**2124-3-10**] from MUD ([**7-27**], mismatch at one HLA-A allele). The patient underwent a Busulfan/Cytoxan conditioning regimen which did not cause neutropenia and he tolerated it with only mild diarrhea. His initial transplant proceeded without incident. The patient was started on Acyclovir, Fluconazole and Ursodiol per protocol on Day -2. Cyclosporine was started Day -1 and monitored by level. Methotrexate was given per protocol on Days +1, and then again on Day +7 (delayed due to concern of transaminitis - see below), and day +11. He received inhaled pentamidine on a monthly basis ([**3-29**] and [**4-30**]). He was started on atovaquone for PCP prophylaxis on [**4-8**]. Fungal prophylaxis was switched micafungin while the patient had fever & neutropenia. The patient was on voriconazole for a short period of time, but changed back to micafungin due to concern of exacerbating chemotherapy induced liver toxicity. . # Acute GVHD - The patient course was complicated by acute GVHD which started as a blanching rash on [**3-20**]. The patient was treated empirically for GVHD with steroids, which improved his rash, but when the steroids were tapered the patient developed severe watery diarrhea, up to 2L a day at times. The gastroenterology service was consulted and on [**3-30**] the patient had a flexible sigmoidoscopy. Biopsies of the sigmoid and rectum were non-diagnostic but consistent with GVHD. Stool cultures for bacterial and viral pathogens and for C. diff were negative. The steroids were again tapered as the patient's diarrhea improved, however, the patient developed a morbilliform rash and his diarrhea worsened. Dermatology biopsied the rash, and the pathology was consistent with GVHD. His skin rash evolved into desquamation and bullae and his diarrhea symptoms flared when steroids doses were tapered. The patient was treated with high-dose (2mg/kg) methylprednisone, cellcept, cyclosporine and Remicade x 2 ([**4-14**] and [**4-22**]). He also developed liver involvement with GVHD. His TBili was elevated to max of 2.7 on [**4-24**]. After his second dose of remicade, his symptoms improved and a very slow steroid taper was reattempted. Steroid taper was ultimately unsuccessful with patient requiring methylprednisolone 25 mg in am and 20 mg in pm. It was thought that the skin rash may have been worsened by cefepime. The cefepime was switched to meropenem and derm was once again consulted on [**5-31**]. Derm took a biopsy which showed results consistent with GVHD and unlikely for drug reaction. . # Fevers and neutropenia - The patient developed fevers in the setting of neutropenia post transplant on [**3-13**] and was treated with broad spectrum antibiotics and antifungal coverage. Cultures remained negative and no source was identified. C diff was negative on multiple occasions throughout this hospitalization. His counts recovered ([**3-22**]) and antibiotics were discontinued. . # VRE bacteremia - The patient developed bloody diarrhea and underwent colonoscopy for evaluation ([**5-18**]). He was hemodynamically stable at this time. The colonscopy was negative as was an EGD. The following evening the patient developed a fever to 102 and blood cultures grew VRE bacteremia. He was started on linezolid and cefepime. His IJ was removed as was his PICC line for access. The fevers resolved as did the bacteremia. . # Fevers - The patient again became febrile on [**5-31**]. He had no symptoms and his vital signs remained stable. The patient was continued on meropenem, linezolid and flagyl was added to cover potential c. diff. He consistently cultured negative. His PICC was removed with no resolution of the fevers. His IJ was removed on [**6-9**]. Following this his fevers resolved. . # HHV6 infection: The patient spiked a fever [**3-27**] when he was no longer neutropenic and he developed a splotchy and evanescent rash, which disappeared within 24 hours. A serum HHV6 viral load was eventually positive, and HHV6 was felt to be the likely cause of the patient??????s rash. Repeat testing a week later for HHV6 was negative. . # Strept Milleri Bacteremia: On [**4-15**] blood cultures were drawn as the patient appeared unwell and had borderline low blood pressures. The patient was not neutropenic at this time. Blood cultures eventually grew Strep milleri. The patient was treated with vancomycin initially and then switched to ceftazadime and flagyl and then to cefepime per ID recommendations. TTE was negative for endocarditis. The patient was deemed to high risk to undergo TEE so it was determined that he would complete a 4 week course from the first negative blood culture on [**4-18**] (D/C ON [**5-15**]). . # BK virus: In early [**Month (only) **], while the patient was on multiple immunosuppressant medications for GVHD, he developed dysuria, difficulty voiding and hematuria. There was initially concern about urinary retention; however, once the foley was placed the patient only had a small amount drained from the bladder. Urine bacterial cultures were negative, but urine studies were positive for BK virus. He eventually developed BK viremia. The patient suffered from painful bladder spasms as a result of his BK virus. Urology service was consulted to assist with bladder spasm control. His bladder spasms were symptomatically managed with flomax, detrol, pyridium and a morphine PCA. ID was consulted and they recommended treatment with intravesicular cedofivir. In addition, the patient was given IVIG on [**5-6**] to help boost his Ig levels in the setting of such high levels of immunosuppression. Urology recommended an outpatient cystoscopy after discharge for further evaluation of microscopic hematuria. . # Decreased Mental Status - In Mid [**2124-5-17**], patient had waxing/[**Doctor Last Name 688**] mental status: AOx2, missing date, with a mild decrease in his mental status. On [**6-13**] the patient's mental status worsened. He was able to follow simple commands but not complex commands. He was also complaining of some visual halluciantions and made some coherent but nonsensical statements. An MRI was conducted which showed no pathology that would account for the mental status change. Neurology was consulted. It was thought that the most likely cause was metabolic encephalopathy secondary to one of his medications. In the past he has had similar symptoms in response to cyclosporin. At that time he was given a cyclosporin holiday and changed to tacrolimus with a recovery of his mental status to baseline. He is also on steroids and mycophenolate and received etanercept. #) Hypertension: The patient has a history hypertension that is generally exacerbated by steroids. His anti-hypertensive medications required frequent adjustment during this hospitalization. His Diltiazem was changed to Nifedipine due to concern regarding hepatotoxicity. His metoprolol dose was increased. On [**6-11**] nifedipine was stopped due to low blood pressures. . #) Anascarca: The patient's severe GVHD caused an inflammatory state with required aggressive fluid replacement. The patient developed severe anascarca and ascites and had an approximately 40lb weight gain secondary to GVHD. Once his GVHD stabilized, he was diuresed with lasix which at one point caused prerenal acute renal failure with a creatinine peak of 1.7. However, this resolved with fluids. Patient currently has 1+ edema bilaterally in both legs, but no other symptoms of fluid overlaod. . #) Superficial venous clots: On [**4-14**], the patient developed superficial venous clots in his left cephalic and basilic veins near a PICC line site. He did not have any DVT. . #) GERD: The patient was started on a PPI on [**3-28**] due to increased symptoms of ""heartburn"" in the setting of high dose steroids. He was discharged with omeprazole 20mg. . #) Access: The patient had multiple central lines at various times during this hospitalization, which were required as the patient was unable to take POs. He had a Hickmann tunnelled catheter which was removed because it was non-functional. He also had right PICC x2 (the first of which was removed due to a superficial phlebitis), a left IJ, a right subclavian (removed when the patient was bacteremic) and a right IJ. He currently has no central access. = = = = = = = = = = = = = = = = = = = ================================================================ [**Hospital Unit Name 153**] (Intensive Care Unit) course ([**Date range (2) 60073**]) . # Hypothermia / MS changes: Multiple possible etiologies in the immunocompromised pt s/p BMT, concern for sepsis given elevated lactate (although unclear as to what pt's baseline lactate level is given malignancy and adenopathy, was stable at 3.0 on transfer) and resp alkalosis. Pt had recent VRE bacteremia, after central line placement, the midline was removed and sent for culture. MRI shows possible embolic infarcts which raises concern for endocarditis as another possible source of sepsis. TSH was low normal ruling out hypothyroid myxedema. Concern for meningitis or other central process given persistent resp alkalosis. Additional concern for med toxicity given hx of MS changes with cyclosporine. LP was performed and suggestive of possible aseptic meningitis, etiologies include HSV and other viruses (CMV, HHV, number of others sent out) vs malignancy related as 99% lymphs on tap vs drug (chemo/immunosup) toxicity. Ammonia level normal. BMT/heme thought that the CSF lymphs were not likely malignant. ID recommended coverage for empiric HSV with foscarnet (due to better coverage of HSV 6). ID also recommended, f/u galactomannan, B-D-glucan as another survey for invasive fungal infection without need for broader fungal coverage now. We initially placed the patient on Linezolid, cipro, Meropenem, flagyl, Micafungin, foscarnet and Atovaquone (pt not taking since NPO), but then d/c'd cipro once it was felt that pseudomonas was unlikely. The pt reported having some loose stools but C. diff was negative and empiric flagyl treatment was d/c'd. Atovaquone was restarted when pt able to PO clear liquid diet. Otherwise, with this treatment the patient became normothermic with temps >96, with improved mental status, and hemodynamically stable (never with need for intubation/pressors). . # Anemia: HCT 22 from 26, now stable 23. Not likely dilutional (Plts, WBC increased). [**Month (only) 116**] be related to blood draws vs bleeding. 2U pRBC given. Hemolysis/DIC labs negative. Continue to monitor daily labs. . Upon discharge from [**Hospital Unit Name 153**]: [**2124-6-20**]: #GVHD - The patient continued to have copious diarrhea since his discharge from the [**Hospital Unit Name 153**]. The patient was restarted on etanercept on [**6-28**]. This was held for several days when the patient appeared septic on [**7-12**], however, was restarted on [**2124-7-15**] after the patient's condition improved, and then finally d/c'd again the week after. The diarrhea improved significantly on tincture of opium, however this caused the patient to become confused. He was switched to lomotil which has alleviated the diarrhea somewhat. He continues to be on cellcept 1500mg [**Hospital1 **], budesonide 3mg tid, and methylprednisolone. . #MS changes - The patient had multiple episodes of hypothermia to as low as [**Age over 90 **]F, with associated mental status changes. During his most recent episode on [**2124-7-12**], his blood pressure also dropped to 90/60, and he was started on meropenem and daptomycin because of the possibility of sepsis. The patient's blood pressure improved with boluses and antibiotics. MRI head was negative, and LP glucose, protein were normal. However, it was thought that the daptomycin was potentially causing a further elevation in his bilirubin, and this was stopped on [**7-15**]. . #Adenovirus - The patient was found to have >100,000 copies of adenovrius in his blod on [**6-28**]. CSF was sent from [**6-26**] which also showed evidence of adenovirus. However, repeat level on [**7-6**] showed decreasing adenovirus levels and cidofivir was not started. A repeat LP was performed on [**2124-7-14**], HHV-6, CMV, Enterovirus, viral culture, HSV PCR, EBV PCR, [**Male First Name (un) 2326**], Adenovirus pending. Blood adenovirus level also re-sent. . #RUE clot - The patient was found to have a RUE clot [**12-20**] picc line, however his last U/S showed some resolution. He was not on anticoag due to hx of GI bleeds, following clinically. . #GI bleed - Since leaving the unit, the patient has had several GI bleeds, first on [**6-29**] after supratherapeutic PTT, more recently on [**7-11**]. Both episodes were managed conservatively with fluids given that the likely etiology was graft vs. host disease. . #Ascites/edema - The patient was placed on lasix 20bid to improve his overall anasarca and ascites. = = = = = = = = = = = = = = = = = = = = = ================================================================ From [**2124-7-17**] to [**2124-8-17**] (Date of Discharge) 1. GVHD: By the beginning of [**Month (only) **], the pt did not have any GVHD associated rash and he was not having any significant amount of diarrhea, however he did have increases in his LFT's and total bilirubin (as below) that were associated with altered mental status, increased somnolence and decreased responsiveness (see below, AMS). GVHD was in the differential of this liver dysfunction. He continued on immunosuppressive regimen of cellcept, Budesonide, Methylprednisolone and enterecept. Enterecept was eventually discontinued and doses of other immunosuppressive were readjusted in accordance with liver function. He was also started on Rituxan once per week and had received [**1-19**] doses by the time of discharge. By d/c his LFT's were still increased, with a Tbili holding steady in the 6's. The amt of diarrhea changed from day to day but was typically [**12-22**] loose stools per day, occasionally with frank blood, and occasionally with guiac + but not frankly bloody. On discharge, patient was kept on Methylprednisone 25mg AM/20mg PM, Cellcept 750mg every 8 hours and budesonide 3mg TID. He will receive one more dose of Rituxan on [**8-19**]. . 2. Increased Tbili: This was thought to be GVHD vs drug effect. The Tbili steadily increased in late [**Month (only) 216**] until early [**Month (only) **], when it peaked at 9.6 and this was concurrent with his altered mental staus (as below). Acyclovir was d/c'd. Pt was to get an MRI abdomen but was unable to sit still long enough to get it, therefore was sent for CT abdomen with and without contrast [**2124-7-18**], which showed an interval increase in his ascites, increase in his pleural effusions L>R, and chronic ileal wall thickening c/w GVHD. Hepatology was consulted and a paracentesis was performed in early [**Month (only) **] that was essentially non-diagnostic, ascites cultures were negative, and the picture was essentially consistent with portal hypertension. Rifaxamin was started. Liver Bx was recommended but was not performed because by this time the pt was clinically improving, waking up, and AMS was resolving. However, despite the improved mental status, his LFT's and Tbili continued to increase and peaked at 9.6 before they again began to decline again and were steadily in the 6's on d/c. He began to clinically improve, his scleral icterus got better and no liver Bx was ever performed. Rifaxamin was stopped without consequence. Acyclovir was added on and continued at discharge. . 3. Altered Mental Status: The first week of [**Month (only) **], the patient was noted to be very somnolent, confused and saying nonsensical things. Concurrent with this was hypothermia and hypotension. This was thought to be mostly due to hepatic encephalopathy. An LP performed on [**7-14**] was non diagnostic and all viral studies from that procedure were negative. MRI head [**7-14**] was also non diagnostic. Neuro was consulted and recommended a 24hr bedside EEG to evaluate for subclinical seizures, however he eventually began to dramatically turn around though and became more awake, was conversational, able to express himself, was requesting food, and EEG was not felt to be necessary. His mental status steadily cleared up although it was noted that he would have occasional delirium, would be a little restless at night (he had actually pulled out a central venous line one night, another was placed, but he then pulled that one out several days later), saying odd things in the morning before he fully woke up, and sundowning a little at night. At baseline, he is lethargic but appropriate early in the morning, will follow commands, but later in the day after he has fully woken up he is very appropriate, concerned about his care, his health and his plan. . 4. Hypothermia and Hypotension--Seen to be occasionally hypotensive to the 90's, which responded to fluid boluses, and hypothermic to a low of 93.8. Was put on a warmer. The pt's Metoprolol was d/c'd and his bp's began to improve from high 90's/low 100's to the 110's. Temperature began to improve as well. By the time the pt's mental status improved, his blood pressures and hypothermia were no longer an issue. His vital signs remained stable and hypothermia/hypoTN were not an issue for several weeks leading up to discharge. In fact, the pt's blood pressure and heart rate began to increase the week after Metoprolol was d/c'd and was added back in with a decrease in bp and pulse seen. He was d/c'd on Metoprolol 12.5 TID with steady vitals. . 5. GIB--While he was AMS, pt was not having active GI bleed or diarrhea issues, but after he woke up he began having loose BM's with obvious dark red blood. For the next several weeks in [**Month (only) **], the pt would occasionally have dark red stools, which required occasional PRBC transfusion, but never compromised him from a hemodynamic standpoint. He also received occasional platelets --> During [**Month (only) **], the pt required 6U of PRBC's and 5 of platelets. GI was consulted but felt the pt not stable for colonoscopy as the large ammount of ascites fluid would lead to infection. They also felt that he had been scoped within the past several months and no change would be seen since his clinical condition was not much changed. By the time of discharge the pt's Hct was stable, he was having occasional guiac + stools but not felt to be compromised by them. . 6. Adenoviremia: Patient was found to have >100,000 copies of adenovrius in his blood on [**6-28**], also with adenovirus in CSF from [**6-26**]. Repeat level on [**7-6**] showed decreasing adenovirus levels at approx. 3000 and cidofivir was not started. A repeat LP was performed on [**2124-7-14**], HHV-6, CMV, Enterovirus, viral culture, HSV PCR, EBV PCR, [**Male First Name (un) 2326**], Adenovirus were all negative. Blood adenovirus level was present and found to be positive at titer approx. 1900. A repeat measurement later in [**Month (only) **] showed a titer of 696, and no specific therapy was started. . 7. RUE clot: Found to have RUE clot of several months duration but not anti-coagulated due to h/o GIB's. On [**2124-7-24**] pt's R hand and forearm seen to be acutely grossly swollen, L hand normal, however by the afternoon the pt's R arm returned to its normal size without any interventions. It was questioned whether he was sleeping on that arm which led to its swelling. In any event, the patient was unable to be anticoagulated to the GIB's. . 8. Anasarca: The pt was grossly edematous up to his abdomen. After Metoprolol was d/c'd and hypotension resolved, Lasix was increased to 40mg IV bid with appropriate response. He continued to put out urine and as his anasarca steadily decreased his Lasix was tapered. By the point of discharge, his legs were drastically reduced from earlier, with barely any baseline swelling even being noticeable. His Lasix was stopped. . 9. Nutrition: The patient was started on TPN while his mental status was poor and he was not eating, but by the time he began to wake up he was requesting food. TPN was continued for several weeks even after he had woken up, and eventually was totally stopped, as the pt was increasingly taking good PO solids and liquids. He had also pulled out two central lines by this point and did not have access for TPN anyways. So he was given a trial to take PO on his own, which he has done well with by the time of discharge. . 10. BK viruria: The pt was noted to have RBC's in his UA during [**Month (only) **] and thus a BK virus assay was sent, which came back >5 million copies. No specific therapy was initiated. Follow up UA's then showed that the RBC's were zero. Given recent complaints of dysuria, another BK virus was sent and results are pending. . 11. Mood: The pt had appropriately depressed moods at various points and was very desolate that he had been in bed 5 mos, couldn't move his legs, and didn't feel he was making progress. Remeron was tried for several nights (to increase his sleep at night and stimulate his appetite) but was thought to increase restlessness/confusion at night, then was stopped. He was never tried on any other stimulant or antidepressant. His mood would likely get better as his clinical condition, mobility, and overall status improve, and this was repeatedly explained to him. . 12. Disposition: The pt basically needs aggressive rehabilitation at this point, as he has major proximal LE muscle wasting and myopathy likely due to long term steroid use. He has good distal LE strength, but cannot stand or lift his legs very well. If steroids can be tapered, he may be able to regain his strength. We were attempting to use Rituxan in an attempt to wean steroids. He is eating and drinking well and needs to be encouraged to eat and drink. If food and drink is put in front of him he will eat it. Medications on Admission: Acyclovir 400 mg PO Q8H Allopurinol 300 mg Tablet PO DAILY Augmentin 500mg PO TID Atenolol 100 mg PO Daily Fluconazole 200 mg PO Q24H Diltiazem HCl 240 mg PO DAILY Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H Pentamidine 300mg inh qm x 6m (last dose [**2124-2-10**]) Compazine 10mg PO q6-8 PRN nausea Ativan 0.5-1mg PO q4-6 PRN nausea, anxiety, insomnia Discharge Medications: 1. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day). 2. Saliva Substitution Combo No.2 Solution Sig: One (1) ML Mucous membrane QID (4 times a day). 3. Oral Wound Care Products Gel in Packet Sig: One (1) ML Mucous membrane QID (4 times a day) as needed for mouth pain. 4. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 5. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl Topical QID (4 times a day) as needed for GVHD. 6. Atovaquone 750 mg/5 mL Suspension Sig: One (1) PO DAILY (Daily). 7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): Please see attached sliding scale. 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 9. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO QSUN ([**Doctor First Name **]). 11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO ASDIR (AS DIRECTED). 12. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO ASDIR (AS DIRECTED). 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 14. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 15. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 16. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO TID (3 times a day). 17. Mycophenolate Mofetil 500 mg Tablet Sig: 1.5 Tablets PO Q 8H (Every 8 Hours). 18. Potassium & Sodium Phosphates 280-160-250 mg Powder in Packet Sig: One (1) Powder in Packet PO ONCE (Once) for 1 doses. 19. Micafungin 100 mg Recon Soln Sig: One (1) Recon Soln Intravenous DAILY (Daily). 20. Rituximab 10 mg/mL Concentrate Sig: Seven Hundred-Fifteen (715) MG Intravenous Give dose #4 (last dose) on [**2124-8-19**] for 1 doses: Please give 715mg on [**2124-8-19**]. 21. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln Sig: Twenty Five (25) MG Injection QAM : Please give 25mg of methylprednisolone sodium succ every morning. 22. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln Sig: Twenty (20) MG Injection Q PM: Please give 20MG of methylprednisolone sodium succ every night. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary/active diagnoses on discharge: 1. CLL s/p [**Doctor Last Name 6261**] Transformation 2. Allogeneic Stem Cell Transplant [**2124-3-10**] 3. Chronic Graft versus Host disease of the liver, GI system, and skin 4. Chronic GI bleed 5. Chronic Anemia 6. Thrombocytopenia 7. Hypertension 8. BK viruria 9. Adenoviremia 10. Extensive RUE deep venous thromboses Discharge Condition: By the time of discharge, the pt's chronic graft versus host disease was stable, his chronic GI bleed was not hemodynamically compromising, the pt had been working with PT to increase his strength and mobility, was taking good PO foods and liquids, vital signs were stable, and was medically cleared for discharge. Discharge Instructions: You have been admitted to the hospital for an allogeneic stem cell transplant on [**2124-3-10**]. Please see discharge summary for COMPLETE SUMMARY of your hospital course since [**2124-3-1**]. . Please see attached for COMPLETE LIST of your current medications. This was RECONCILED with admission list. . If you experience fever >100, shortness of breath, chest pain, abdominal pain, headache, pain with urination, weight loss, or any other concerning symptom, please call Dr. [**Last Name (STitle) **] or 911 immediately. Followup Instructions: Patient will need complete CBC with differential and complete chemistry (Chem 10) within 24-48 hours of discharge on [**8-18**]. Please fax results to Dr. [**Last Name (STitle) **] at: [**Telephone/Fax (1) 21962**]. . DR. [**Last Name (STitle) **] AND [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: [**2124-8-21**] at 12:30pm. [**Telephone/Fax (1) 3241**] or [**Telephone/Fax (1) 3237**]. . Dr. [**Last Name (STitle) **], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2124-9-18**] 10:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**] Date/Time:[**2124-9-18**] 10:30 . Urology for blood in urine: Wednesday [**9-20**] at 4pm [**Hospital Ward Name 23**] [**Location (un) **]. ",40,2124-03-01 11:10:00,2124-08-17 15:40:00,ELECTIVE,PHYS REFERRAL/NORMAL DELI,LONG TERM CARE HOSPITAL,CHRONIC LYMPHOCYTIC LEUKEMIA\BONE MARROW TRANSPLANT," mr. [**known lastname **] is a 56-year-old male with history of cll with large cell transformation who was admitted for a scheduled allogeneic mud sct on [**2124-3-10**]. his course was complicated by febrile neutropenia and acute gvhd involving the intestinal tract, liver and skin. he was discharged to [**hospital1 **] in stable condition with symptomatic improvement. = = = = = = = = = = = = = = = = = = = = = ================================================================ [**date range (3) 60072**] # allo bmt - day 0: [**2124-3-10**] from mud ([**7-27**], mismatch at one hla-a allele). the patient underwent a busulfan/cytoxan conditioning regimen which did not cause neutropenia and he tolerated it with only mild diarrhea. his initial transplant proceeded without incident. the patient was started on acyclovir, fluconazole and ursodiol per protocol on day -2. cyclosporine was started day -1 and monitored by level. methotrexate was given per protocol on days +1, and then again on day +7 (delayed due to concern of transaminitis - see below), and day +11. he received inhaled pentamidine on a monthly basis ([**3-29**] and [**4-30**]). he was started on atovaquone for pcp prophylaxis on [**4-8**]. fungal prophylaxis was switched micafungin while the patient had fever & neutropenia. the patient was on voriconazole for a short period of time, but changed back to micafungin due to concern of exacerbating chemotherapy induced liver toxicity. . # acute gvhd - the patient course was complicated by acute gvhd which started as a blanching rash on [**3-20**]. the patient was treated empirically for gvhd with steroids, which improved his rash, but when the steroids were tapered the patient developed severe watery diarrhea, up to 2l a day at times. the gastroenterology service was consulted and on [**3-30**] the patient had a flexible sigmoidoscopy. biopsies of the sigmoid and rectum were non-diagnostic but consistent with gvhd. stool cultures for bacterial and viral pathogens and for c. diff were negative. the steroids were again tapered as the patients diarrhea improved, however, the patient developed a morbilliform rash and his diarrhea worsened. dermatology biopsied the rash, and the pathology was consistent with gvhd. his skin rash evolved into desquamation and bullae and his diarrhea symptoms flared when steroids doses were tapered. the patient was treated with high-dose (2mg/kg) methylprednisone, cellcept, cyclosporine and remicade x 2 ([**4-14**] and [**4-22**]). he also developed liver involvement with gvhd. his tbili was elevated to max of 2.7 on [**4-24**]. after his second dose of remicade, his symptoms improved and a very slow steroid taper was reattempted. steroid taper was ultimately unsuccessful with patient requiring methylprednisolone 25 mg in am and 20 mg in pm. it was thought that the skin rash may have been worsened by cefepime. the cefepime was switched to meropenem and derm was once again consulted on [**5-31**]. derm took a biopsy which showed results consistent with gvhd and unlikely for drug reaction. . # fevers and neutropenia - the patient developed fevers in the setting of neutropenia post transplant on [**3-13**] and was treated with broad spectrum antibiotics and antifungal coverage. cultures remained negative and no source was identified. c diff was negative on multiple occasions throughout this hospitalization. his counts recovered ([**3-22**]) and antibiotics were discontinued. . # vre bacteremia - the patient developed bloody diarrhea and underwent colonoscopy for evaluation ([**5-18**]). he was hemodynamically stable at this time. the colonscopy was negative as was an egd. the following evening the patient developed a fever to 102 and blood cultures grew vre bacteremia. he was started on linezolid and cefepime. his ij was removed as was his picc line for access. the fevers resolved as did the bacteremia. . # fevers - the patient again became febrile on [**5-31**]. he had no symptoms and his vital signs remained stable. the patient was continued on meropenem, linezolid and flagyl was added to cover potential c. diff. he consistently cultured negative. his picc was removed with no resolution of the fevers. his ij was removed on [**6-9**]. following this his fevers resolved. . # hhv6 infection: the patient spiked a fever [**3-27**] when he was no longer neutropenic and he developed a splotchy and evanescent rash, which disappeared within 24 hours. a serum hhv6 viral load was eventually positive, and hhv6 was felt to be the likely cause of the patient??????s rash. repeat testing a week later for hhv6 was negative. . # strept milleri bacteremia: on [**4-15**] blood cultures were drawn as the patient appeared unwell and had borderline low blood pressures. the patient was not neutropenic at this time. blood cultures eventually grew strep milleri. the patient was treated with vancomycin initially and then switched to ceftazadime and flagyl and then to cefepime per id recommendations. tte was negative for endocarditis. the patient was deemed to high risk to undergo tee so it was determined that he would complete a 4 week course from the first negative blood culture on [**4-18**] (d/c on [**5-15**]). . # bk virus: in early [**month (only) **], while the patient was on multiple immunosuppressant medications for gvhd, he developed dysuria, difficulty voiding and hematuria. there was initially concern about urinary retention; however, once the foley was placed the patient only had a small amount drained from the bladder. urine bacterial cultures were negative, but urine studies were positive for bk virus. he eventually developed bk viremia. the patient suffered from painful bladder spasms as a result of his bk virus. urology service was consulted to assist with bladder spasm control. his bladder spasms were symptomatically managed with flomax, detrol, pyridium and a morphine pca. id was consulted and they recommended treatment with intravesicular cedofivir. in addition, the patient was given ivig on [**5-6**] to help boost his ig levels in the setting of such high levels of immunosuppression. urology recommended an outpatient cystoscopy after discharge for further evaluation of microscopic hematuria. . # decreased mental status - in mid [**2124-5-17**], patient had waxing/[**doctor last name 688**] mental status: aox2, missing date, with a mild decrease in his mental status. on [**6-13**] the patients mental status worsened. he was able to follow simple commands but not complex commands. he was also complaining of some visual halluciantions and made some coherent but nonsensical statements. an mri was conducted which showed no pathology that would account for the mental status change. neurology was consulted. it was thought that the most likely cause was metabolic encephalopathy secondary to one of his medications. in the past he has had similar symptoms in response to cyclosporin. at that time he was given a cyclosporin holiday and changed to tacrolimus with a recovery of his mental status to baseline. he is also on steroids and mycophenolate and received etanercept. #) hypertension: the patient has a history hypertension that is generally exacerbated by steroids. his anti-hypertensive medications required frequent adjustment during this hospitalization. his diltiazem was changed to nifedipine due to concern regarding hepatotoxicity. his metoprolol dose was increased. on [**6-11**] nifedipine was stopped due to low blood pressures. . #) anascarca: the patients severe gvhd caused an inflammatory state with required aggressive fluid replacement. the patient developed severe anascarca and ascites and had an approximately 40lb weight gain secondary to gvhd. once his gvhd stabilized, he was diuresed with lasix which at one point caused prerenal acute renal failure with a creatinine peak of 1.7. however, this resolved with fluids. patient currently has 1+ edema bilaterally in both legs, but no other symptoms of fluid overlaod. . #) superficial venous clots: on [**4-14**], the patient developed superficial venous clots in his left cephalic and basilic veins near a picc line site. he did not have any dvt. . #) gerd: the patient was started on a ppi on [**3-28**] due to increased symptoms of ""heartburn"" in the setting of high dose steroids. he was discharged with omeprazole 20mg. . #) access: the patient had multiple central lines at various times during this hospitalization, which were required as the patient was unable to take pos. he had a hickmann tunnelled catheter which was removed because it was non-functional. he also had right picc x2 (the first of which was removed due to a superficial phlebitis), a left ij, a right subclavian (removed when the patient was bacteremic) and a right ij. he currently has no central access. = = = = = = = = = = = = = = = = = = = ================================================================ [**hospital unit name 153**] (intensive care unit) course ([**date range (2) 60073**]) . # hypothermia / ms changes: multiple possible etiologies in the immunocompromised pt s/p bmt, concern for sepsis given elevated lactate (although unclear as to what pts baseline lactate level is given malignancy and adenopathy, was stable at 3.0 on transfer) and resp alkalosis. pt had recent vre bacteremia, after central line placement, the midline was removed and sent for culture. mri shows possible embolic infarcts which raises concern for endocarditis as another possible source of sepsis. tsh was low normal ruling out hypothyroid myxedema. concern for meningitis or other central process given persistent resp alkalosis. additional concern for med toxicity given hx of ms changes with cyclosporine. lp was performed and suggestive of possible aseptic meningitis, etiologies include hsv and other viruses (cmv, hhv, number of others sent out) vs malignancy related as 99% lymphs on tap vs drug (chemo/immunosup) toxicity. ammonia level normal. bmt/heme thought that the csf lymphs were not likely malignant. id recommended coverage for empiric hsv with foscarnet (due to better coverage of hsv 6). id also recommended, f/u galactomannan, b-d-glucan as another survey for invasive fungal infection without need for broader fungal coverage now. we initially placed the patient on linezolid, cipro, meropenem, flagyl, micafungin, foscarnet and atovaquone (pt not taking since npo), but then d/cd cipro once it was felt that pseudomonas was unlikely. the pt reported having some loose stools but c. diff was negative and empiric flagyl treatment was d/cd. atovaquone was restarted when pt able to po clear liquid diet. otherwise, with this treatment the patient became normothermic with temps >96, with improved mental status, and hemodynamically stable (never with need for intubation/pressors). . # anemia: hct 22 from 26, now stable 23. not likely dilutional (plts, wbc increased). [**month (only) 116**] be related to blood draws vs bleeding. 2u prbc given. hemolysis/dic labs negative. continue to monitor daily labs. . upon discharge from [**hospital unit name 153**]: [**2124-6-20**]: #gvhd - the patient continued to have copious diarrhea since his discharge from the [**hospital unit name 153**]. the patient was restarted on etanercept on [**6-28**]. this was held for several days when the patient appeared septic on [**7-12**], however, was restarted on [**2124-7-15**] after the patients condition improved, and then finally d/cd again the week after. the diarrhea improved significantly on tincture of opium, however this caused the patient to become confused. he was switched to lomotil which has alleviated the diarrhea somewhat. he continues to be on cellcept 1500mg [**hospital1 **], budesonide 3mg tid, and methylprednisolone. . #ms changes - the patient had multiple episodes of hypothermia to as low as [**age over 90 **]f, with associated mental status changes. during his most recent episode on [**2124-7-12**], his blood pressure also dropped to 90/60, and he was started on meropenem and daptomycin because of the possibility of sepsis. the patients blood pressure improved with boluses and antibiotics. mri head was negative, and lp glucose, protein were normal. however, it was thought that the daptomycin was potentially causing a further elevation in his bilirubin, and this was stopped on [**7-15**]. . #adenovirus - the patient was found to have >100,000 copies of adenovrius in his blod on [**6-28**]. csf was sent from [**6-26**] which also showed evidence of adenovirus. however, repeat level on [**7-6**] showed decreasing adenovirus levels and cidofivir was not started. a repeat lp was performed on [**2124-7-14**], hhv-6, cmv, enterovirus, viral culture, hsv pcr, ebv pcr, [**male first name (un) 2326**], adenovirus pending. blood adenovirus level also re-sent. . #rue clot - the patient was found to have a rue clot [**12-20**] picc line, however his last u/s showed some resolution. he was not on anticoag due to hx of gi bleeds, following clinically. . #gi bleed - since leaving the unit, the patient has had several gi bleeds, first on [**6-29**] after supratherapeutic ptt, more recently on [**7-11**]. both episodes were managed conservatively with fluids given that the likely etiology was graft vs. host disease. . #ascites/edema - the patient was placed on lasix 20bid to improve his overall anasarca and ascites. = = = = = = = = = = = = = = = = = = = = = ================================================================ from [**2124-7-17**] to [**2124-8-17**] (date of discharge) 1. gvhd: by the beginning of [**month (only) **], the pt did not have any gvhd associated rash and he was not having any significant amount of diarrhea, however he did have increases in his lfts and total bilirubin (as below) that were associated with altered mental status, increased somnolence and decreased responsiveness (see below, ams). gvhd was in the differential of this liver dysfunction. he continued on immunosuppressive regimen of cellcept, budesonide, methylprednisolone and enterecept. enterecept was eventually discontinued and doses of other immunosuppressive were readjusted in accordance with liver function. he was also started on rituxan once per week and had received [**1-19**] doses by the time of discharge. by d/c his lfts were still increased, with a tbili holding steady in the 6s. the amt of diarrhea changed from day to day but was typically [**12-22**] loose stools per day, occasionally with frank blood, and occasionally with guiac + but not frankly bloody. on discharge, patient was kept on methylprednisone 25mg am/20mg pm, cellcept 750mg every 8 hours and budesonide 3mg tid. he will receive one more dose of rituxan on [**8-19**]. . 2. increased tbili: this was thought to be gvhd vs drug effect. the tbili steadily increased in late [**month (only) 216**] until early [**month (only) **], when it peaked at 9.6 and this was concurrent with his altered mental staus (as below). acyclovir was d/cd. pt was to get an mri abdomen but was unable to sit still long enough to get it, therefore was sent for ct abdomen with and without contrast [**2124-7-18**], which showed an interval increase in his ascites, increase in his pleural effusions l>r, and chronic ileal wall thickening c/w gvhd. hepatology was consulted and a paracentesis was performed in early [**month (only) **] that was essentially non-diagnostic, ascites cultures were negative, and the picture was essentially consistent with portal hypertension. rifaxamin was started. liver bx was recommended but was not performed because by this time the pt was clinically improving, waking up, and ams was resolving. however, despite the improved mental status, his lfts and tbili continued to increase and peaked at 9.6 before they again began to decline again and were steadily in the 6s on d/c. he began to clinically improve, his scleral icterus got better and no liver bx was ever performed. rifaxamin was stopped without consequence. acyclovir was added on and continued at discharge. . 3. altered mental status: the first week of [**month (only) **], the patient was noted to be very somnolent, confused and saying nonsensical things. concurrent with this was hypothermia and hypotension. this was thought to be mostly due to hepatic encephalopathy. an lp performed on [**7-14**] was non diagnostic and all viral studies from that procedure were negative. mri head [**7-14**] was also non diagnostic. neuro was consulted and recommended a 24hr bedside eeg to evaluate for subclinical seizures, however he eventually began to dramatically turn around though and became more awake, was conversational, able to express himself, was requesting food, and eeg was not felt to be necessary. his mental status steadily cleared up although it was noted that he would have occasional delirium, would be a little restless at night (he had actually pulled out a central venous line one night, another was placed, but he then pulled that one out several days later), saying odd things in the morning before he fully woke up, and sundowning a little at night. at baseline, he is lethargic but appropriate early in the morning, will follow commands, but later in the day after he has fully woken up he is very appropriate, concerned about his care, his health and his plan. . 4. hypothermia and hypotension--seen to be occasionally hypotensive to the 90s, which responded to fluid boluses, and hypothermic to a low of 93.8. was put on a warmer. the pts metoprolol was d/cd and his bps began to improve from high 90s/low 100s to the 110s. temperature began to improve as well. by the time the pts mental status improved, his blood pressures and hypothermia were no longer an issue. his vital signs remained stable and hypothermia/hypotn were not an issue for several weeks leading up to discharge. in fact, the pts blood pressure and heart rate began to increase the week after metoprolol was d/cd and was added back in with a decrease in bp and pulse seen. he was d/cd on metoprolol 12.5 tid with steady vitals. . 5. gib--while he was ams, pt was not having active gi bleed or diarrhea issues, but after he woke up he began having loose bms with obvious dark red blood. for the next several weeks in [**month (only) **], the pt would occasionally have dark red stools, which required occasional prbc transfusion, but never compromised him from a hemodynamic standpoint. he also received occasional platelets --> during [**month (only) **], the pt required 6u of prbcs and 5 of platelets. gi was consulted but felt the pt not stable for colonoscopy as the large ammount of ascites fluid would lead to infection. they also felt that he had been scoped within the past several months and no change would be seen since his clinical condition was not much changed. by the time of discharge the pts hct was stable, he was having occasional guiac + stools but not felt to be compromised by them. . 6. adenoviremia: patient was found to have >100,000 copies of adenovrius in his blood on [**6-28**], also with adenovirus in csf from [**6-26**]. repeat level on [**7-6**] showed decreasing adenovirus levels at approx. 3000 and cidofivir was not started. a repeat lp was performed on [**2124-7-14**], hhv-6, cmv, enterovirus, viral culture, hsv pcr, ebv pcr, [**male first name (un) 2326**], adenovirus were all negative. blood adenovirus level was present and found to be positive at titer approx. 1900. a repeat measurement later in [**month (only) **] showed a titer of 696, and no specific therapy was started. . 7. rue clot: found to have rue clot of several months duration but not anti-coagulated due to h/o gibs. on [**2124-7-24**] pts r hand and forearm seen to be acutely grossly swollen, l hand normal, however by the afternoon the pts r arm returned to its normal size without any interventions. it was questioned whether he was sleeping on that arm which led to its swelling. in any event, the patient was unable to be anticoagulated to the gibs. . 8. anasarca: the pt was grossly edematous up to his abdomen. after metoprolol was d/cd and hypotension resolved, lasix was increased to 40mg iv bid with appropriate response. he continued to put out urine and as his anasarca steadily decreased his lasix was tapered. by the point of discharge, his legs were drastically reduced from earlier, with barely any baseline swelling even being noticeable. his lasix was stopped. . 9. nutrition: the patient was started on tpn while his mental status was poor and he was not eating, but by the time he began to wake up he was requesting food. tpn was continued for several weeks even after he had woken up, and eventually was totally stopped, as the pt was increasingly taking good po solids and liquids. he had also pulled out two central lines by this point and did not have access for tpn anyways. so he was given a trial to take po on his own, which he has done well with by the time of discharge. . 10. bk viruria: the pt was noted to have rbcs in his ua during [**month (only) **] and thus a bk virus assay was sent, which came back >5 million copies. no specific therapy was initiated. follow up uas then showed that the rbcs were zero. given recent complaints of dysuria, another bk virus was sent and results are pending. . 11. mood: the pt had appropriately depressed moods at various points and was very desolate that he had been in bed 5 mos, couldnt move his legs, and didnt feel he was making progress. remeron was tried for several nights (to increase his sleep at night and stimulate his appetite) but was thought to increase restlessness/confusion at night, then was stopped. he was never tried on any other stimulant or antidepressant. his mood would likely get better as his clinical condition, mobility, and overall status improve, and this was repeatedly explained to him. . 12. disposition: the pt basically needs aggressive rehabilitation at this point, as he has major proximal le muscle wasting and myopathy likely due to long term steroid use. he has good distal le strength, but cannot stand or lift his legs very well. if steroids can be tapered, he may be able to regain his strength. we were attempting to use rituxan in an attempt to wean steroids. he is eating and drinking well and needs to be encouraged to eat and drink. if food and drink is put in front of him he will eat it. ","PRIMARY: [Other malignant lymphomas, unspecified site, extranodal and solid organ sites] SECONDARY: [Acute kidney failure, unspecified; Toxic encephalopathy; Other specified septicemias; Sepsis; Hepatic encephalopathy; Chronic lymphoid leukemia, without mention of having achieved remission; Other complications due to other vascular device, implant, and graft; Acute venous embolism and thrombosis of superficial veins of upper extremity; Complications of transplanted bone marrow; Acute graft-versus-host disease; Bacteremia; Unspecified pleural effusion; Other ascites; Urinary tract infection, site not specified; Acute venous embolism and thrombosis of subclavian veins; Alkalosis; Meningitis due to adenovirus; Hemorrhage of gastrointestinal tract, unspecified; Portal hypertension; Hyposmolality and/or hyponatremia; Toxic myopathy; Other disorders of neurohypophysis; Candidiasis of mouth; Other specified erythematous conditions; Diarrhea; Neutropenia, unspecified; Fever presenting with conditions classified elsewhere; Hepatitis, unspecified; Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use; Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus]; Infection with microorganisms without mention of resistance to multiple drugs; Streptococcus infection in conditions classified elsewhere and of unspecified site, other streptococcus; Human herpesvirus 6 infection; Other specified viral infection; Microscopic hematuria; ; Pure hypercholesterolemia; Unspecified essential hypertension]","known lastname **] is a 56-year-old male with history of cll with large cell transformation who was admitted for a scheduled allogeneic mud sct on [**2124-3-10**]. he was discharged to [**hospital1 **] in stable condition with symptomatic improvement. his initial transplant proceeded without incident. biopsies of the sigmoid and rectum were non-diagnostic but consistent with gvhd. steroid taper was ultimately unsuccessful with patient requiring methylprednisolone 25 mg in am and 20 mg in pm. the cefepime was switched to meropenem and derm was once again consulted on [**5-31**]. cultures remained negative and no source was identified. he was started on linezolid and cefepime. his ij was removed as was his picc line for access. the fevers resolved as did the bacteremia. # fevers - the patient again became febrile on [**5-31**]. he had no symptoms and his vital signs remained stable. # hhv6 infection: the patient spiked a fever [**3-27**] when he was no longer neutropenic and he developed a splotchy and evanescent rash, which disappeared within 24 hours. blood cultures eventually grew strep milleri. the patient was treated with vancomycin initially and then switched to ceftazadime and flagyl and then to cefepime per id recommendations. # bk virus: in early [**month (only) **], while the patient was on multiple immunosuppressant medications for gvhd, he developed dysuria, difficulty voiding and hematuria. on [**6-13**] the patients mental status worsened. an mri was conducted which showed no pathology that would account for the mental status change. he is also on steroids and mycophenolate and received etanercept. on [**6-11**] nifedipine was stopped due to low blood pressures. he had a hickmann tunnelled catheter which was removed because it was non-functional. pt had recent vre bacteremia, after central line placement, the midline was removed and sent for culture. mri shows possible embolic infarcts which raises concern for endocarditis as another possible source of sepsis. tsh was low normal ruling out hypothyroid myxedema. not likely dilutional (plts, wbc increased). [** month (only) 116**] be related to blood draws vs bleeding. the diarrhea improved significantly on tincture of opium, however this caused the patient to become confused. he was switched to lomotil which has alleviated the diarrhea somewhat. during his most recent episode on [**2124-7-12**], his blood pressure also dropped to 90/60, and he was started on meropenem and daptomycin because of the possibility of sepsis. the patients blood pressure improved with boluses and antibiotics. = = = = = = = = = = = = = = = = = = = = = ================================================================ from [**2124-7-17**] to [**2124-8-17**] (date of discharge) 1. increased tbili: this was thought to be gvhd vs drug effect. pt was to get an mri abdomen but was unable to sit still long enough to get it, therefore was sent for ct abdomen with and without contrast [**2124-7-18**], which showed an interval increase in his ascites, increase in his pleural effusions l>r, and chronic ileal wall thickening c/w gvhd. acyclovir was added on and continued at discharge. concurrent with this was hypothermia and hypotension. an lp performed on [**7-14**] was non diagnostic and all viral studies from that procedure were negative. it was questioned whether he was sleeping on that arm which led to its swelling. if steroids can be tapered, he may be able to regain his strength.","mr. [**known lastname **] is a 56-year-old male with history of cll with large cell transformation. his course was complicated by febrile neutropenia and acute gvhd involving the intestinal tract, liver and skin. he was discharged to [**hospital1 **] in stable condition with symptomatic improvement." 43147,180640.0,12752,2127-03-27,12751,161625.0,2127-03-09,Discharge summary,"Admission Date: [**2127-3-3**] Discharge Date: [**2127-3-9**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: ICU monitoring, central venous catheter placement, PICC line placement, arterial catheter placement. History of Present Illness: 89f with large pna requiring intbuation. Presented from rehab facility, found to have change in mental status with severe respiratory distress, transferred to [**Hospital1 18**]. In [**Hospital1 18**] ED, t103 rectally, 182/120, rr30, sats 90% on face mask, GCS 3. Pt intubated with use of fentanyl versed, CXR showed R-sided pna ""over entire lung."" Given ceftriaXONE, vancomycin 1g, acetaminophen rectally 650mg for HAP pneumonia. Vital signs on transfer 129/70, hr91, 5peep ac fio2 10%, 100% sats. 2pIVs. Of note, recent hospitalized [**2-10**] at [**Hospital1 18**] for R-ACA infarct. echo unremarkbale, started on asa, statin. Pt had ""pneumonia"" on admit; On Amp-Sulbactam (Unasyn) 3g IV q6 on [**2127-2-11**], Follow-up CXR on [**2-12**] looked worse than her initial IV cipro/flagyl [**2127-2-13**]. Then on [**2-18**] changed to Amp-Clavunalic 500mg q8 and PO cipro/flagyl x5d (finished [**2127-2-24**]). A CXR was obtained on [**2-18**] which showed stable findings. During her hospital stay, she was hypertensive thus treated with lisinopril and metoprolol. Physical exam on discharge from that admission was remarkable for abulia and decreased strength on left. Past Medical History: 1. Hypertension, recently poorly controlled and fluctuating 2. Alzheimer's dementia 3. Pituitary macroadenoma, followed and unchanged per CT scans at [**Hospital3 **] (2.5 cm) 4. Autonomic dysfunction, hyponatremia, secondary to ?SIADH ([**2119**])/free water intake 5. Low TSH 6. Thyroid Goiter 7. Syncopal episodes 8. Anemia of chronic disease Social History: Since the R ACA stroke, pt has been living in a rehab. Fully dependent, as she is hemiplegic on left and alert and oriented to first name only. Per medical records: Tob: denies. EtOH: denies. Drugs: denies Family History: Noncontributory Physical Exam: General: Not responsive to voice. HEENT: Sclera anicteric, MMM Neck: supple, JVP not elevated, no LAD Lungs: scattered rales, rhonchi R>L CV: RRR, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+ anasarca. Pertinent Results: [**2127-3-3**] 07:25PM BLOOD WBC-12.9* RBC-3.35* Hgb-10.1* Hct-31.6* MCV-94 MCH-30.2 MCHC-32.0 RDW-15.1 Plt Ct-429 [**2127-3-8**] 04:50AM BLOOD WBC-16.3* RBC-2.80* Hgb-8.5* Hct-26.1* MCV-93 MCH-30.2 MCHC-32.4 RDW-15.3 Plt Ct-304 [**2127-3-8**] 04:50AM BLOOD PT-14.0* PTT-31.9 INR(PT)-1.2* [**2127-3-3**] 07:25PM BLOOD Glucose-139* UreaN-19 Creat-0.7 Na-138 K-6.1* Cl-111* HCO3-23 AnGap-10 [**2127-3-8**] 04:50AM BLOOD Glucose-121* UreaN-22* Creat-0.8 Na-137 K-3.6 Cl-101 HCO3-26 AnGap-14 [**2127-3-3**] 07:25PM BLOOD ALT-45* AST-119* LD(LDH)-587* CK(CPK)-69 AlkPhos-129* TotBili-0.3 [**2127-3-5**] 03:45AM BLOOD ALT-30 AST-44* LD(LDH)-299* AlkPhos-114 TotBili-0.3 [**2127-3-3**] 07:25PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 3602**]* [**2127-3-3**] 07:25PM BLOOD cTropnT-0.04* [**2127-3-4**] 02:11AM BLOOD CK-MB-5 cTropnT-0.05* [**2127-3-4**] 01:30PM BLOOD CK-MB-NotDone cTropnT-0.07* [**2127-3-3**] 07:25PM BLOOD Albumin-2.0* Calcium-6.1* Phos-2.8 Mg-1.5* [**2127-3-8**] 04:50AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.1 [**2127-3-3**] 07:25PM BLOOD TSH-0.26* [**2127-3-3**] 07:25PM BLOOD Free T4-1.2 [**2127-3-3**] 07:25PM BLOOD Cortsol-38.2* [**2127-3-3**] 08:42PM BLOOD Type-ART Tidal V-500 PEEP-5 FiO2-100 pO2-202* pCO2-30* pH-7.46* calTCO2-22 Base XS-0 AADO2-481 REQ O2-81 Intubat-INTUBATED Vent-CONTROLLED [**2127-3-8**] 08:23AM BLOOD Type-ART Temp-38.3 FiO2-36 O2 Flow-15 pO2-107* pCO2-49* pH-7.46* calTCO2-36* Base XS-9 Intubat-NOT INTUBA [**2127-3-3**] 07:37PM BLOOD Lactate-2.6* [**2127-3-8**] 08:23AM BLOOD Lactate-1.9 [**2127-3-4**] 03:16AM BLOOD freeCa-1.08* [**2127-3-7**] 03:09AM BLOOD freeCa-1.11* . Discharge labs: [**2127-3-9**] 03:28AM BLOOD WBC-18.2* RBC-2.67* Hgb-8.0* Hct-24.6* MCV-92 MCH-29.4 MCHC-31.9 RDW-14.9 Plt Ct-308 [**2127-3-9**] 03:28AM BLOOD Neuts-86.2* Lymphs-7.4* Monos-3.5 Eos-2.7 Baso-0.2 [**2127-3-9**] 03:28AM BLOOD Glucose-126* UreaN-24* Creat-0.9 Na-136 K-3.2* Cl-105 HCO3-26 AnGap-8 [**2127-3-9**] 03:28AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.9 . Microbiology: [**2127-3-3**] BLOOD CULTURE Blood Culture, Routine-FINAL {ENTEROCOCCUS FAECIUM, PRESUMPTIVE CLOSTRIDIUM PERFRINGENS}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-neg [**2127-3-3**] BLOOD CULTURE Blood Culture, Routine-Neg [**2127-3-5**] BLOOD CULTURE Blood Culture, Routine-No growth to date [**2127-3-5**] BLOOD CULTURE Blood Culture, Routine-No growth to date [**2127-3-9**] BLOOD CULTURE Blood Culture, Routine-No growth to date [**2127-3-4**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-neg [**2127-3-6**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-neg [**2127-3-9**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-pending [**2127-3-4**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-yeast, sparse growth [**2127-3-5**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-yeast, sparse growth [**2127-3-3**] URINE URINE CULTURE-FINAL neg [**2127-3-5**] URINE URINE CULTURE-FINAL neg [**2127-3-4**] Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture-neg; Rapid Respiratory Viral Antigen Test-neg [**2127-3-4**] BRONCHOALVEOLAR LAVAGE GRAM STAIN- 4+ PMNs; RESPIRATORY CULTURE-no growth; LEGIONELLA CULTURE- neg; VIRAL CULTURE: R/O CYTOMEGALOVIRUS-no growth to date [**2127-3-4**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2127-3-3**] URINE Legionella Urinary Antigen -FINAL INPATIENT . Radiology . CXR [**2127-3-3**]: IMPRESSION: 1. Interval development of multifocal airspace opacities in the right lung concerning for pneumonia. 2. Persistent small to moderate sized bilateral pleural effusions. 3. Slightly low lying endotracheal tube with tip terminating 2.5 cm superior to the carina. 4. Probable overinflation of the endotracheal cuff balloon. . CT head [**2127-3-5**]: IMPRESSION: 1. Progressive cystic encephalomalacia and volume loss in the distribution of the right anterior cerebral artery, consistent with evolution of prior infarct. 2. Unchanged sellar region mass, with imaging characteristics most suggestive of a pituitary macroadenoma, without hemorrhage. 3. No new acute intracranial process, including no hemorrhage, edema, mass effect, or acule large vascular territorial infarction. . CXR [**2127-3-8**]: Increase in right upper lobe and left upper lobe multifocal opacities, could be aspiration/pneumonia. Bilateral pleural effusion slightly improved. Retrocardiac opacity persists. Increase in interstitial edema. . CT abdomen/pelvis without contrast [**2127-3-8**] 1. No evidence of infectious source to explain bacteremia. 2. Moderate bilateral pleural effusions, with consolidation vs. atelectasis at the left lung base. Brief Hospital Course: 89F with shock and respiratory failure likely from pna. . # Respiratory Failure: Patient was hypoxic with CXR showing multifocal right lobe infiltrate. Patient had recent ACA stroke and failed speach and swallow and not thought to be a good candidate for tube feeds but the family wanted to continue to feed her, putting her at high risk for aspiration. She was intubated on presentation to the hospital and then extubated successfully on [**2127-3-6**]. - Pt was started on Vanco/Zosyn for HAP given recent hospital stay and current living situation in the rehab. Pt received 6 days of Vancomycin, after which it was discontinued. Zosyn was continued and pt should complete a course of 14 days (Day 1=[**3-3**]) - On discharge, pt was satting in high 90s to 100 on FiO2 of 35%. - sputum gram stain showed less than 25 PMNs and culture grew rare yeast. - urine legionella was negative. - Bronchoalveolar lavage sample showed 4+ PMNs, CMV culture negative to date, andrespiratory cultures negative. - [**1-5**] blood culture bottles from admission tested positive for enterococcus. ID service was consulted, who felt that this was likely a contaminant. CT abdomen and pelvis was done, which showed no abscesses or specific source of bacteremia. - Further blood cultures were sent, and were negative to date at the time of discharge. The final results should be followed up by the rehab facility. - C. diff was checked twice, both times negative. Given her high risk for c. diff and loose stools, it was again checked on [**3-9**], and the result is pending. It should be followed up by the rehab facility. . # Shock: Patient had fever, hypoxia, and hypotension on presentation. Most likely this is septic shock secondary to pna. Less likely cardiogenic (CK is flat, EKG without ischemic changes). Could also have component of central adrenal insufficiency given pituitary macroadenoma (eos not elevated or absent). - Early goal directed therapy was implemented - Lactate level was followed which peaked at 3.0 and was 1.9 on [**3-8**]. - MI was ruled out with negative cardiac enzymes - cortisol level was checked (38.3 in AM) . # Neuro/ AMS: h/o right ACA stroke recently. Pt is rarely responsive to voice. Opens eyes to noxious stimuli. There may be a component of delirium in addition to residual deficits from the large stroke recently. - Medication list was reviewed and pared down to minimize risk of drug effects - Continued asa and statin . # Hypertension: Her home antihypertensives included metoprolol and lisinopril. They were held in the beginning of her hospital stay due to hypotension, then restarted slowly when she became hypertensive. Metoprolol and lisinopril can be titrated up in the rehab depending on her BP curve. . # Thyroid: Pt with goiter and low TSH in setting of pit macroadenoma; Free T4 was WNL. . # anemia: at baseline of mid 20s. Hct was followed. She did not require transfusions. . # hypocalcemia (even when corrected for low albumin) on admission: unclear cause, however it resolved spontaneously. Ionized calcium was WNL and stable. . # FEN: IVF PRN, replete electrolytes, TF per NG tube . # Prophylaxis: Subcutaneous heparin # Access: PICC line. A line was discontinued. # Code: Full # Communication: Patient's family (daughter and grandson) Medications on Admission: 1. Aspirin 325 mg qd 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H prn 3. Docusate Sodium 100 [**Hospital1 **] 4. Simvastatin 20mg qd 5. Lisinopril 5 mg qd 6. Metoprolol Tartrate 25 mg tid Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary diagnoses: Aspiration Pneumonia Right ACA CVA Secondary Diagnoses: HTN Pituitary macroadenoma Alzheimer's Dementia Hyponatremia Hypothyroidism Anemia of chronic disease Discharge Condition: Fair, VSS, afebrile, responsive to painful stimuli only. Discharge Instructions: You were treated for your pneumonia. You also have had a stroke. You should not Completed by:[**2127-3-9**]",18,2127-03-03 19:58:00,2127-03-09 14:29:00,EMERGENCY,EMERGENCY ROOM ADMIT,LONG TERM CARE HOSPITAL,PNEUMONIA," 89f with shock and respiratory failure likely from pna. . # respiratory failure: patient was hypoxic with cxr showing multifocal right lobe infiltrate. patient had recent aca stroke and failed speach and swallow and not thought to be a good candidate for tube feeds but the family wanted to continue to feed her, putting her at high risk for aspiration. she was intubated on presentation to the hospital and then extubated successfully on [**2127-3-6**]. - pt was started on vanco/zosyn for hap given recent hospital stay and current living situation in the rehab. pt received 6 days of vancomycin, after which it was discontinued. zosyn was continued and pt should complete a course of 14 days (day 1=[**3-3**]) - on discharge, pt was satting in high 90s to 100 on fio2 of 35%. - sputum gram stain showed less than 25 pmns and culture grew rare yeast. - urine legionella was negative. - bronchoalveolar lavage sample showed 4+ pmns, cmv culture negative to date, andrespiratory cultures negative. - [**1-5**] blood culture bottles from admission tested positive for enterococcus. id service was consulted, who felt that this was likely a contaminant. ct abdomen and pelvis was done, which showed no abscesses or specific source of bacteremia. - further blood cultures were sent, and were negative to date at the time of discharge. the final results should be followed up by the rehab facility. - c. diff was checked twice, both times negative. given her high risk for c. diff and loose stools, it was again checked on [**3-9**], and the result is pending. it should be followed up by the rehab facility. . # shock: patient had fever, hypoxia, and hypotension on presentation. most likely this is septic shock secondary to pna. less likely cardiogenic (ck is flat, ekg without ischemic changes). could also have component of central adrenal insufficiency given pituitary macroadenoma (eos not elevated or absent). - early goal directed therapy was implemented - lactate level was followed which peaked at 3.0 and was 1.9 on [**3-8**]. - mi was ruled out with negative cardiac enzymes - cortisol level was checked (38.3 in am) . # neuro/ ams: h/o right aca stroke recently. pt is rarely responsive to voice. opens eyes to noxious stimuli. there may be a component of delirium in addition to residual deficits from the large stroke recently. - medication list was reviewed and pared down to minimize risk of drug effects - continued asa and statin . # hypertension: her home antihypertensives included metoprolol and lisinopril. they were held in the beginning of her hospital stay due to hypotension, then restarted slowly when she became hypertensive. metoprolol and lisinopril can be titrated up in the rehab depending on her bp curve. . # thyroid: pt with goiter and low tsh in setting of pit macroadenoma; free t4 was wnl. . # anemia: at baseline of mid 20s. hct was followed. she did not require transfusions. . # hypocalcemia (even when corrected for low albumin) on admission: unclear cause, however it resolved spontaneously. ionized calcium was wnl and stable. . # fen: ivf prn, replete electrolytes, tf per ng tube . # prophylaxis: subcutaneous heparin # access: picc line. a line was discontinued. # code: full # communication: patients family (daughter and grandson) ","PRIMARY: [Pneumonitis due to inhalation of food or vomitus] SECONDARY: [Acute respiratory failure; Septic shock; Severe sepsis; Hyposmolality and/or hyponatremia; Alkalosis; Hypocalcemia; Anemia in chronic kidney disease; Unspecified essential hypertension; Alzheimer's disease; Dementia in conditions classified elsewhere without behavioral disturbance; Benign neoplasm of pituitary gland and craniopharyngeal duct; Unspecified acquired hypothyroidism; Other late effects of cerebrovascular disease; Long-term (current) use of aspirin]","89f with shock and respiratory failure likely from pna. patient had recent aca stroke and failed speach and swallow and not thought to be a good candidate for tube feeds but the family wanted to continue to feed her, putting her at high risk for aspiration. - pt was started on vanco/zosyn for hap given recent hospital stay and current living situation in the rehab. - bronchoalveolar lavage sample showed 4+ pmns, cmv culture negative to date, andrespiratory cultures negative. ct abdomen and pelvis was done, which showed no abscesses or specific source of bacteremia. it should be followed up by the rehab facility. # thyroid: pt with goiter and low tsh in setting of pit macroadenoma; free t4 was wnl.","89f with shock and respiratory failure likely from pna. family wanted to continue to feed her, putting her at high risk for aspiration. she was intubated on presentation to the hospital and then extubated successfully." 43529,172162.0,16873,2115-09-26,16872,194815.0,2115-08-23,Discharge summary,"Admission Date: [**2115-8-20**] Discharge Date: [**2115-8-23**] Date of Birth: [**2032-12-31**] Sex: M Service: MEDICINE Allergies: Ace Inhibitors / Norvasc Attending:[**First Name3 (LF) 106**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 82M with CAD, chronic diastolic CHF, AFib on coumadin admitted with dyspnea. Three days ago patient notes that he was not feeling well. He was more fatigued than usual and had shortness of breath with walking. He did not have palpitations, chest pain, fevers, chills, orthopnea, pnd, worse edema than baseline (has had chronic LE edema X 5 years), syncope, or presyncope. At about 3 am on the morning of admission he awoke to turn down the AC because he was chilly. When he sat up he became acutely short of breath. His wife was able to calm him down and when he lay back down he felt better. However, over the course of the next few hours he started to feel more and more short of breath, even when lying down, and by 7am his wife was very concerned. She noticed that when she tried to stand him up to walk to the living room he was very weak and his legs were wobbly. She called 911, and they brought him to the ED. . Upon presentation to the ED initial vitals were: T 98 HR 76 BP 179/68 RR 28 SP02 98%RA. In the ED patient denied CP, fever, chills, cough, weight gain. His O2 sats declined from 98% on RA ->91% on 4L->96% on NRB. CXR showed mild fluid overload and possible PNA. Bedside TTE revealed: LA is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . Compared with the findings of the prior study (images reviewed) of [**2112-4-11**], the findings are similar. . He received the following medications: Aspirin 81mg, CeftriaXONE 1g, Azithromycin 500mg, Nitroglycerin SL 0.4mg SLX3 (for HF not for complaints of CP), and Furosemide 80mg IV X 1. He felt better after the furosemide (he put out 500mL) and his O2 requirement came down to 94% on 4L. He was transferred to the floor. . On the floor patient remained on NC and then on first set of vitals was noted to be hypoxic to the mid-80s on 5L NC. He was placed on a NRB and his O2 sat came up to 100%. He had no complaints of chest pain, palpitations, shortness of breath, abdominal pain, nausea, vomiting, or cough at the time. His EKG was unchanged from prior. A CXR was also unchanged. ABG showed an elevated A-a gradient with PO2 103 on the NRB. He was given another 80mg IV lasix, morphine, and started on nitro paste. Intially he improved with this regimen, however, he would occasionally dip into the high 80s and then recover spontaneously on the NRB and they were unable to wean him off the NRB. He was transferred to the CCU for his continued requirement of the NRB. . On presentation to the ccu the patient was comfortable on a NC. He denied fevers, chills, palpitations, chest pain, nausea, vomiting, diaphoresis, abdominal pain, bloating, worsening edema, weight gain, diarrhea, and dysuria. He endorsed shortness of breath as outlined above although currently less than prior, constipation off and on for several years, and chronic edema of his lower extremities for the last 5 years - treated with lasix. Past Medical History: 1. CARDIAC RISK FACTORS: hypertension, dyslipidemia. 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: s/p PTCA x1 15 years ago records not at the [**Hospital1 18**] -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: GASTRITIS H.pylori + (treated) GOUT SYNCOPE RENAL INSUFFICIENCY (creat ~ 1.6) VENOUS INSUFFICIENCY and lower extremity edema BENIGN PROSTATIC HYPERTROPHY ATRIAL FIBRILLATION diastolic dysfunction with volume overload treated with lasix RETINAL VASCULAR OCCLUSION in [**2115-4-19**] thought [**1-21**] plaque rupture not thrombotic event as therapeutic on coumadin at the time Social History: Originally from Poland. Worked in [**Doctor First Name 533**] labor camp for a few years before emmigrating. Also was in the service in the US. Lives in [**Location **], MA with his wife. [**Name (NI) 1139**] history: Former 15 pack-year smoker, quit 60 years ago. Rare ETOH use. No recent travel. No sick contacts. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory Physical Exam: PE on admission: V/S: Wt 89.4 kg T 99.5->102 ax BP 170/71 HR 70 RR 22 O2sat 94%6L NC GENERAL: WDWN M in NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP to angle of jaw CARDIAC: PMI located in 5th intercostal space, midclavicular line. irregularly irregular with distant heart sounds. No m/r/g. LUNGS: Resp were unlabored, no accessory muscle use. Scattered expiratory wheezes with poor air movement bilaterally and crackles about [**12-22**] of the way up bilaterally. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Umbilical hernia without tenderness. EXTREMITIES: 1+ edema bilaterally to knees. Negative homans sign. NEURO: Alert and oriented X 3. Right pupil larger than left. Left arm slightly weaker than right. PE on discharge: V/S: Tmax 99, Tc 97.5, BP 154/69 (130-157/59-69) HR 65 (55-83) RR 16 O2sat 94%RA GENERAL: elderly white male in NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRLA, Conjunctiva pink, OP clear with no erythema or exudate NECK: Supple with JVP to angle of jaw CARDIAC: PMI located in 5th intercostal space, midclavicular line. irregularly irregular with distant heart sounds. No m/r/g. LUNGS: Resp unlabored, no accessory muscle use. scatttered rales at left base. ABDOMEN: + BS, Soft, NTND. No HSM. Umbilical hernia without tenderness. EXTREMITIES: Trace edema in LE b/l, no cyanosis or clubbing NEURO: Alert and oriented X 3. Right pupil larger than left. Left arm slightly weaker than right. Pertinent Results: On Admission: . [**2115-8-20**] 08:05AM BLOOD WBC-8.7# RBC-3.99* Hgb-10.7* Hct-34.4* MCV-86 MCH-26.8* MCHC-31.1 RDW-16.1* Plt Ct-214 [**2115-8-20**] 08:05AM BLOOD PT-20.1* PTT-32.0 INR(PT)-1.9* [**2115-8-20**] 08:05AM BLOOD Glucose-172* UreaN-45* Creat-1.7* Na-139 K-4.1 Cl-101 HCO3-23 AnGap-19 [**2115-8-20**] 08:05AM BLOOD CK-MB-NotDone proBNP-2736* [**2115-8-20**] 08:05AM BLOOD cTropnT-0.06* [**2115-8-21**] 05:43AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.7 [**2115-8-20**] 03:35PM BLOOD TSH-0.43 [**2115-8-20**] 05:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.006 [**2115-8-20**] 05:00PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2115-8-20**] 05:00PM URINE RBC-[**11-8**]* WBC-0-2 Bacteri-MOD Yeast-NONE Epi-0 . On discharge: [**2115-8-23**] 05:35AM BLOOD WBC-6.6 RBC-3.74* Hgb-9.9* Hct-31.6* MCV-85 MCH-26.6* MCHC-31.5 RDW-16.8* Plt Ct-265 [**2115-8-23**] 05:35AM BLOOD PT-27.5* PTT-41.0* INR(PT)-2.7* [**2115-8-23**] 05:35AM BLOOD Glucose-127* UreaN-60* Creat-1.5* Na-142 K-4.0 Cl-105 HCO3-28 AnGap-13 [**2115-8-23**] 05:35AM BLOOD Calcium-8.9 Phos-3.5 Mg-3.2* . Urine culture [**8-20**] negative Blood cultures 9/1 and [**8-21**] NGTD Legionella urine antigen neg [**8-20**] . TTE [**8-20**]: The left atrium is mildly dilated. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is normal (LVEF>55%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] There may be inferolateral hypokinesis but views are technically suboptimal. Right ventricular chamber size is normal. with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. An eccentric, laterally directed jet of moderate to severe (3+) mitral regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2113-11-23**], mitral regurgitation is now more prominent. There may be inferolateral hypokinesis in the current study but images are technically suboptimal for assessment of regional wall motion. The left ventricular cavity is now more dilated. . Portable CXR [**8-20**]: Bilateral perihilar opacities may represent congestive heart failure versus pneumonia. In the setting of the patient's elevated BNP, findings more likely represent moderate congestive heart failure. . Repeat Portable CXR [**8-20**]: Stable appearance with bilateral perihilar airspace opacities. Mild cardiomegaly. . Portable CXR [**8-21**]: In comparison with the study of [**8-20**], there is little overall change in the bilateral lower lung and left perihilar patchy opacifications, consistent with multifocal pneumonia. . Lower extremity dopplers [**8-21**]: No evidence of deep vein thrombosis in either leg. [**Hospital Ward Name 4675**] cyst seen in the right popliteal fossa. Brief Hospital Course: ASSESSMENT AND PLAN: 82 year old man with history of CAD s/p PCTA 15 years ago, diastolic CHF with history of fluid overload on lasix, atrial fibrillation on coumadin with recent admission for retinal occlusion, admitted with dyspnea on exertion, hypoxia, and fever and transferred to the ICU due to increasing oxygen requirements. . # Hypoxia: Likely this is multifactorial in etiology, from both pulmonary and cardiac sources. He presented with evidence of volume overload on exam, on CXR, and with an elevated BNP. In addition, he had a fever likely infiltrate on CXR thought to be consistent with community acquired pneumonia. PE was also a consideration, but felt to be less likely because he was anticoagulated on coumadin and had other more likely etiologies for his hypoxia ([**Doctor Last Name **] score 4). Consequently, he was treated for community acquired pneumonia with azithromycin and ceftriaxone/cefpodoxime for a total five day course to end on [**2115-8-24**]. In addition, TTE showed new LV dilation likely causing more severe MR [**First Name (Titles) **] [**Last Name (Titles) **] with preserved LVEF (although this is likely over-estimated in MR) consistent with acute exacerbation of his diastolic CHF. He was diuresed with furosemide over the course of his admission, and his noninvasive oxygen requirements declined; he was able to maintain oxygen saturation in the high 90s at room air on discharge. . # Fever: Most likely infectious with either pulmonary or urinary infection being most probable given leukocytosis, positive UA and hypoxia with CXR showing possible infiltrate. Blood and urine cultures NGTD, unable to obtain sputum culture. Treated for both UTI and CAP; initially with ceftriaxone and azithromycin, and transitioned to cefpodoxime with plan for total five day course to end [**2115-8-24**]. . # CORONARIES: Patient with remote history of CAD s/p PTCA at OSH and his tropinins were slightly elevated troponins with a peak of 0.19 on [**2115-8-21**], flat CKs and negative MBs in the setting of CRF. Cardiac enzymes were thought to be most likely elevated from fluid overload and ventricular dilatation, and not cleared secondary to renal failure. The patient denied any anginal symptoms, and serial ECGs were not suggestive of any acute ischemia. He was continued on home dose of statin, and started on aspirin 81 mg PO daily. Per history, he is unable to tolerate beta blockers and ace inhibitors. . # PUMP: Patient has history of diastolic dysfunction and has had episodes of fluid overload treated with oral lasix in the past. TTE on this admission revealed new LV dilation and worsening of his MR with pulmonary artery hypertension, likely related to his acute fluid overload. He was treated with aggressive diuresis, a salt restricted diet and continuation of home blood pressure regimen for afterload reduction with felodipine, hydralazine, clonidine and Imdur. . # RHYTHM: The patient was monitored on telemetry and was found to be intermittently in slow atrial fibrillation, with some ECGs showing sinus bradycardia with prolonged AV conduction and occasional junctional escape beats. The patient is on coumadin for atrial fibrillation at home, and was found to be subtherapeutic on admission. He also had a recent history of retinal artery occlusion while anticoagulated. For that reason, he was maintained on a heparin drip until INR was again therapeutic. In addition, his coumadin was decreased from 5 to 2.5 on [**8-22**], with a plan to return to home dose of 5 mg on [**8-25**] after he has finished his course of antibiotics. . # Hypertension: Patient's BP was 170/70 at recent PCP visit and has been dificult to control according to OMR notes for last several years. He is unable to tolerate ACE inhibitors or beta blockers. During this admission, he was maintained on his home regimen with hydralazine, clonidine, felodipine and Imdur. . # Lower extremity edema: Thought to be related to fluid overload from acute on chronic diastolic CHF. LE dopplers on [**8-21**] were negative for DVT. . # Chronic renal insufficiency: Patient remained at or below his baseline creatinine of 1.7 during the course of the admission. . # Hyperlipidemia: Continued home dose of statin. . # Gout: Continued home dose of allopurinol . # CODE: DNR/DNI confirmed on admission with patient and family Medications on Admission: ALLOPURINOL 300 mg daily CLONIDINE 0.1 mg twice daily FELODIPINE 10 mg daily FUROSEMIDE 80 mg daily HYDRALAZINE 150 mg TID IMDUR 60 mg daily SIMVASTATIN 40 mg daily WARFARIN 5 mg daily Discharge Medications: 1. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hydralazine 50 mg Tablet Sig: Three (3) Tablet PO three times a day. 4. Felodipine 10 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 9. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:*1 Tablet(s)* Refills:*0* 11. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 1 days. Disp:*4 Tablet(s)* Refills:*0* 12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 13. Outpatient Lab Work Please check INR on Sunday [**2115-8-25**] and call results to Dr. [**Name (NI) 47530**] office at [**Telephone/Fax (1) 1144**] 14. Furosemide 40 mg Tablet Sig: Two (2) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Primary Diagnosis: Community Acquired Pneumonia Secondary Diagnosis: Acute on Chronic Diastolic Chronic Congestive Heart Failure Atrial Fibrillation on coumadin Coronary Arteryu Disease Chronic Kidney Disease Discharge Condition: stable Discharge Instructions: You had a pneumonia that caused your oxygen level to be low and you were admitted to the intensive care unit. Your fevers and low oxygen resolved slowly with intravenous antibiotics. You are now on oral antibiotics and will need to take them for one more day. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet, information was given to you about this. . Medication changes: 1. Start 1 baby aspirin daily 2. Continue Azithromycin until [**8-24**] 3. Continue Cefpodoxime until [**8-24**] 4. Take 2.5 mg of coumadin on [**8-24**], then resume 5 mg of coumadin on [**8-25**]. . Please call Dr. [**Last Name (STitle) **] if you have fevers, increasing cough, chest pain, trouble breathing, or any other concerning symptoms. Please check your INR on Sunday [**2115-8-25**]. Followup Instructions: Cardiology: Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2115-9-19**] 3:40 Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2115-10-24**] 2:00 Primary Care: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time: Thursday [**2115-8-29**] at 11:00am. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2115-11-27**] 9:00 ",34,2115-08-20 11:09:00,2115-08-23 14:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,CONGESTIVE HEART FAILURE," assessment and plan: 82 year old man with history of cad s/p pcta 15 years ago, diastolic chf with history of fluid overload on lasix, atrial fibrillation on coumadin with recent admission for retinal occlusion, admitted with dyspnea on exertion, hypoxia, and fever and transferred to the icu due to increasing oxygen requirements. . # hypoxia: likely this is multifactorial in etiology, from both pulmonary and cardiac sources. he presented with evidence of volume overload on exam, on cxr, and with an elevated bnp. in addition, he had a fever likely infiltrate on cxr thought to be consistent with community acquired pneumonia. pe was also a consideration, but felt to be less likely because he was anticoagulated on coumadin and had other more likely etiologies for his hypoxia ([**doctor last name **] score 4). consequently, he was treated for community acquired pneumonia with azithromycin and ceftriaxone/cefpodoxime for a total five day course to end on [**2115-8-24**]. in addition, tte showed new lv dilation likely causing more severe mr [**first name (titles) **] [**last name (titles) **] with preserved lvef (although this is likely over-estimated in mr) consistent with acute exacerbation of his diastolic chf. he was diuresed with furosemide over the course of his admission, and his noninvasive oxygen requirements declined; he was able to maintain oxygen saturation in the high 90s at room air on discharge. . # fever: most likely infectious with either pulmonary or urinary infection being most probable given leukocytosis, positive ua and hypoxia with cxr showing possible infiltrate. blood and urine cultures ngtd, unable to obtain sputum culture. treated for both uti and cap; initially with ceftriaxone and azithromycin, and transitioned to cefpodoxime with plan for total five day course to end [**2115-8-24**]. . # coronaries: patient with remote history of cad s/p ptca at osh and his tropinins were slightly elevated troponins with a peak of 0.19 on [**2115-8-21**], flat cks and negative mbs in the setting of crf. cardiac enzymes were thought to be most likely elevated from fluid overload and ventricular dilatation, and not cleared secondary to renal failure. the patient denied any anginal symptoms, and serial ecgs were not suggestive of any acute ischemia. he was continued on home dose of statin, and started on aspirin 81 mg po daily. per history, he is unable to tolerate beta blockers and ace inhibitors. . # pump: patient has history of diastolic dysfunction and has had episodes of fluid overload treated with oral lasix in the past. tte on this admission revealed new lv dilation and worsening of his mr with pulmonary artery hypertension, likely related to his acute fluid overload. he was treated with aggressive diuresis, a salt restricted diet and continuation of home blood pressure regimen for afterload reduction with felodipine, hydralazine, clonidine and imdur. . # rhythm: the patient was monitored on telemetry and was found to be intermittently in slow atrial fibrillation, with some ecgs showing sinus bradycardia with prolonged av conduction and occasional junctional escape beats. the patient is on coumadin for atrial fibrillation at home, and was found to be subtherapeutic on admission. he also had a recent history of retinal artery occlusion while anticoagulated. for that reason, he was maintained on a heparin drip until inr was again therapeutic. in addition, his coumadin was decreased from 5 to 2.5 on [**8-22**], with a plan to return to home dose of 5 mg on [**8-25**] after he has finished his course of antibiotics. . # hypertension: patients bp was 170/70 at recent pcp visit and has been dificult to control according to omr notes for last several years. he is unable to tolerate ace inhibitors or beta blockers. during this admission, he was maintained on his home regimen with hydralazine, clonidine, felodipine and imdur. . # lower extremity edema: thought to be related to fluid overload from acute on chronic diastolic chf. le dopplers on [**8-21**] were negative for dvt. . # chronic renal insufficiency: patient remained at or below his baseline creatinine of 1.7 during the course of the admission. . # hyperlipidemia: continued home dose of statin. . # gout: continued home dose of allopurinol . # code: dnr/dni confirmed on admission with patient and family ","PRIMARY: [Congestive heart failure, unspecified] SECONDARY: [Pneumonia, organism unspecified; Urinary tract infection, site not specified; Acute on chronic diastolic heart failure; Atrial fibrillation; Gout, unspecified; Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified; Chronic kidney disease, unspecified; Venous (peripheral) insufficiency, unspecified; Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS); Other and unspecified hyperlipidemia; Hematuria, unspecified; Coronary atherosclerosis of native coronary artery; Long-term (current) use of anticoagulants]","assessment and plan: 82 year old man with history of cad s/p pcta 15 years ago, diastolic chf with history of fluid overload on lasix, atrial fibrillation on coumadin with recent admission for retinal occlusion, admitted with dyspnea on exertion, hypoxia, and fever and transferred to the icu due to increasing oxygen requirements. consequently, he was treated for community acquired pneumonia with azithromycin and ceftriaxone/cefpodoxime for a total five day course to end on [**2115-8-24**]. in addition, tte showed new lv dilation likely causing more severe mr [**first name (titles) **] [**last name (titles) **] with preserved lvef (although this is likely over-estimated in mr) consistent with acute exacerbation of his diastolic chf. # pump: patient has history of diastolic dysfunction and has had episodes of fluid overload treated with oral lasix in the past. tte on this admission revealed new lv dilation and worsening of his mr with pulmonary artery hypertension, likely related to his acute fluid overload. he is unable to tolerate ace inhibitors or beta blockers. # hyperlipidemia: continued home dose of statin.","82 year old man with history of cad s/p pcta 15 years ago admitted with dyspnea on exertion, hypoxia, and fever. admitted with evidence of volume overload on exam, on cxr, and with an elevated bnp. he was treated for community acquired pneumonia with azithromycin and ceftriaxone/cefpodoxime." 47733,175486.0,21693,2151-04-24,21692,162330.0,2151-03-28,Discharge summary,"Admission Date: [**2151-3-7**] Discharge Date: [**2151-3-28**] Date of Birth: [**2111-7-13**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: VF arrest Major Surgical or Invasive Procedure: Endotracheal intubation (now extubated) Central venous line placement (now removed) Femoral line placement (now removed) Electrophysiology study with cardiac catheterization History of Present Illness: 39M w/ pmh significant for ebstein's anomaly s/p tricuspid valve reconstruction, right and left sided systolic congestive heart failure, presenting with palpitations which awoke him from sleep. The patient presented to the ED where he appeared pale and was found to be in VT to the 230's. He began to experience chest pain and was given amiodarone 150mg IV X1, followed by amiodarone gtt. He became diaphoretic and was therefore given etomidate and shocked with 200J. His rhythm then became fine V-fib, he became unresponsive and apneic. CPR was initiated, epinephrine given X1, CPR continued, shocked again at 360J, returned to V-Tach @ 240, Intubated, returned to sinus rhyhthm, aspirated vomitus. had right bronchus intubation and ETT was pulled back in ED. Blood pressures dropped to 48/43, started on levophed, pressure increased to 124/77. . On presentation to the CCU, the patient is intubated with mottled skin, on levophed, neosynephrine and vasopressin, with HR 85 and BP 125/77. Past Medical History: 1. Ebstein anomaly, s/p tricuspid valve reconstruction - moderate to severe tricuspid regurgitation - right heart failure, RVEF 25% in [**6-17**] 2. ASD, s/p primary closure [**3-/2136**] 3. Left heart failure with evidence of noncompaction of LV, with LVEF 28% in [**6-17**] 4. Hyperlipidemia 5. Hypertension 6. Obstructive sleep apnea 7. Obesity 8. DVT 9. Superficial phlebitis 10. endocarditis w/ septic emboli to brain prior to Cardiac surgery. Social History: Remote tobacco use, quit 5-6 years ago. Still smokes an occasional cigar. No history of alcohol abuse but has occasional drink. No illicit drugs. Patient works as the [**Hospital1 18**] fax machine repairman. He is married with 1 biologic child, aged 9 months, 2 older children from his wife's prior marriage Family History: There is no family history of premature coronary artery disease or sudden death. Father's family history is unknown, mother is alive in her 60's Physical Exam: Date and time of exam: [**2151-3-7**] General appearance: sedated, intubated, obese Vital signs: per R.N. Height: 72 Inch, 183 cm BP right arm: 95 / 67 mmHg Weight: 100 kg T current: 99.6 Cm HR: 99 bpm RR: 32 insp/minO2 sat: 93 % on Supplemental oxygen: 100% Eyes: (Conjunctiva and lids: WNL) Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums and palette: WNL) Neck: (Jugular veins: Not visible), (Thyroid: WNL) Back / Musculoskeletal: (Chest wall structure: WNL) Respiratory: (Auscultation: diminished on left, rhonchi bilaterally.) Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL), (Auscultation: S1: WNL, S3: Absent, S4: Absent) Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No), (Pulsatile mass: No), (Hepatosplenomegaly: No) Genitourinary: (WNL) Femoral Artery: (Right femoral artery: No bruit), (Left femoral artery: No bruit) Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait and station: WNL), (Muscle strength and tone: WNL), (Dorsalis pedis artery: Right: 1+, Left: 1+), (Posterior tibial artery: Right: 1+, Left: 1+), (Edema: Right: 0, Left: 0) Skin: (mottled abdomen, cyanotic extreemities.) Pertinent Results: admission labs- [**2151-3-7**] 05:30AM BLOOD WBC-9.4 RBC-4.83 Hgb-14.9 Hct-44.4 MCV-92 MCH-30.8 MCHC-33.5 RDW-14.0 Plt Ct-306 [**2151-3-7**] 05:30AM BLOOD Neuts-57.6 Lymphs-35.6 Monos-4.5 Eos-1.9 Baso-0.4 [**2151-3-7**] 05:30AM BLOOD PT-16.7* PTT-30.4 INR(PT)-1.5* [**2151-3-8**] 02:59PM BLOOD Fibrino-546* [**2151-3-8**] 02:59PM BLOOD FDP-80-160* [**2151-3-7**] 05:30AM BLOOD Glucose-185* UreaN-16 Creat-1.0 Na-133 K-6.3* Cl-97 HCO3-26 AnGap-16 [**2151-3-7**] 05:30AM BLOOD CK(CPK)-267* [**2151-3-7**] 02:56PM BLOOD CK(CPK)-262* [**2151-3-7**] 08:29PM BLOOD CK(CPK)-740* [**2151-3-8**] 03:01AM BLOOD ALT-400* AST-448* LD(LDH)-586* AlkPhos-68 TotBili-1.2 [**2151-3-11**] 04:12AM BLOOD Lipase-200* [**2151-3-7**] 05:30AM BLOOD CK-MB-6 [**2151-3-7**] 05:30AM BLOOD cTropnT-<0.01 [**2151-3-7**] 02:56PM BLOOD CK-MB-7 cTropnT-0.36* [**2151-3-7**] 08:29PM BLOOD CK-MB-9 cTropnT-0.30* [**2151-3-7**] 05:30AM BLOOD Calcium-8.6 Phos-4.6* Mg-2.1 [**2151-3-8**] 08:21PM BLOOD Vanco-6.6* [**2151-3-7**] 06:19AM BLOOD Type-ART pO2-71* pCO2-51* pH-7.24* calTCO2-23 Base XS--5 Intubat-INTUBATED [**2151-3-7**] 05:35AM BLOOD Glucose-165* Na-135 K-9.6* Cl-94* calHCO3-25 [**2151-3-7**] 06:19AM BLOOD Hgb-14.6 calcHCT-44 O2 Sat-90 COHgb-2 MetHgb-0.2 [**2151-3-7**] 06:19AM BLOOD freeCa-1.07* Select labs- [**2151-3-12**] 04:36AM BLOOD WBC-18.9*# RBC-4.13* Hgb-12.6* Hct-37.2* MCV-90 MCH-30.5 MCHC-33.8 RDW-14.7 Plt Ct-307 [**2151-3-8**] 02:59PM BLOOD PT-24.6* PTT-39.6* INR(PT)-2.5* [**2151-3-9**] 03:33AM BLOOD Glucose-170* UreaN-48* Creat-3.2* Na-129* K-4.4 Cl-96 HCO3-23 AnGap-14 [**2151-3-9**] 03:33AM BLOOD ALT-1211* AST-1132* CK(CPK)-4046* AlkPhos-53 TotBili-1.8* [**2151-3-10**] 05:00AM BLOOD ALT-1286* AST-864* LD(LDH)-677* AlkPhos-54 TotBili-1.7* [**2151-3-11**] 04:12AM BLOOD Lipase-200* Reports- head CT with and without contrast [**2151-3-7**] IMPRESSION: 1. No acute intracranial pathology. 2. Encephalomalacia of the right occipital pole with associated ex vacuo dilatation of the right lateral ventricular occipital [**Doctor Last Name 534**] suggestive of prior cerebral injury. ================================ Chest CTA [**2151-3-7**] IMPRESSION: 1. Small left pneumothorax, likely related to acute left rib fractures. Other rib deformities are bilateral. 2. Bibasilar and peribronchial opacities, could be due to massive aspiration, associated with atelectasis. 3. Severe cardiomegaly with marked enlargement of right atrium and right ventricle in this patient with known Ebstein malformation and prior sternotomy for tricuspid plasty. 4. Mediastinal lipomatosis. 5. Venous shunt between the right and the middle hepatic veins, could be due to old Budd-Chiari disease. Tiny filling defect in the abnormal connection could be branching vessels or thrombus, likely old. . ================================ [**2151-3-7**] CT chest IMPRESSION: 1. No residual pneumothorax in the upper two-thirds of the chest. One residual air bubble in the mediastinum. No chest tube was installed. 2. No other change since earlier today. ================================ CT chest [**2151-3-13**]- IMPRESSION: 1. No evidence of intra-abdominal fluid collection. 2. Basal pulmonary consolidation with small pleural effusions. 3. Mediastinal lipomatosis. 4. Right adrenal myelolipoma. 5. Evidence of previous right hip AVN. . Echo with bubble study No spontaneous echo contrast or thrombus is seen in the left atrium/left atrial appendage or the right atrium/right atrial appendage. The left and atrial and right appendage emptying velocities are depressed (<0.2m/s). The intra-atrial septum is thickened consistent with prior ASD closure surgery. No residual atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness and cavity size are grossly normal. The apex is heavily trabeculated. Systolic function could not be adequately assessed. Th e systolic function appears depressed. The right ventricular cavity is dilated with marked free wall hypokinesis. There are simple atheroma in the descending thoracic aorta to 45cm from the incisors. The descending aorta is relatively small, but no coarctation or dissection is seen. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The tricuspid annular ring is identified and appears well seated. Mild to moderate tricuspid regurgitation is seen. There is no pericardial effusion. IMPRESSION: No atrial septal defect by 2D or color Doppler. Well seated tricuspid annular ring with mild-moderate tricuspid regurgitation. Severe right ventricular cavity enlargement with depressed biventricular systolic function. . Cardiac MRI:Impression: 1. Normal left ventricular cavity size with globally depressed systolic function. The LVEF was severely decreased at 28%. No MR evidence of prior myocardial scarring/infarction although images technically suboptimal. Prominent non-compacted left ventricular myocardium that meet CMR criteria for non-compaction. 2. Abnormal and apically displaced tricuspid valve consistent with Ebstein's anomaly. A tricuspid annulplasty ring was present. Moderately depressed systolic function of the functional right ventricle with RVEF at 25%. Abnormal septal motion consistent with right ventricular pressure / volume overload. Markedly dilated inferior vena cava and hepatic veins consistent with elevated right atrial pressure. 3. Mild aortic regurgitation. Moderate-to-severe tricuspid regurgitation through tricuspid leaflets of functional right ventricle. Severe tricuspid regurgitation through tricuspid annulus of structural right ventricle. 4. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was normal. 5. Biatrial enlargement. . Chest x-ray [**2151-3-17**] - IMPRESSION: 1. Stable appearance of the mediastinum and cardiac silhouette. 2. Status post extubation. No evidence of atelectasis. . EKG [**2151-3-26**]- Sinus rhythm. The P-R interval is prolonged. Left axis deviation. Right bundle-branch block with left anterior fascicular block. There are Q waves in the inferior leads consistent with prior infarction. There is an abnormal precordial transition consistent with possible prior anterior myocardial infarction. Low voltage in the precordial leads. Compared to the previous tracing the P-R interval is longer. Brief Hospital Course: 39M w/ pmh of ebstein's anomaly, s/p tricuspid valve reconstruction, right and left sided systolic congestive heart failure, presenting with unstable ventricular tachycardia, s/p resuscitation with return to sinus tachycardia, s/p intubation and extubation. . # Ventricular Tachycardia: Likely result of natural history of ebstein anomaly. Patient underwent CPR and intubation with return to normal sinus rhythm. Suppressed ectopy with Amiodarone. Also started metoprolol for rate-control. Amiodarone increased to 200mg TID. Had cardiac MRI with final read as above. Patient then underwent EP study where they were unable to induce ventricular fibrillation so unable to ablate. EP was unable to place an ICD during this admission given recent procedure and significant abnormal heart anatomy. Patient to follow up with Dr. [**Last Name (STitle) **] in [**2-12**] weeks to discuss possible ICD placement in the future. In addition, patient to have monitor set up at home as per Dr. [**Last Name (STitle) **]. . #Respiratory Failure - Now resolved. Initially primarily hypoxemic, with unclear etiology. Differential includes ARDS, PNA/sepsis, shunt, and volume overload. Improvement with nitric oxide suggested some shunt physiology, although intracardiac shunt was not evident on TEE. Respiratory failure improved with diuresis. Decreased Fi02 and PEEP and nitric oxide weaned off with improved compliance. Methemaglobin negative. Multifactorial secondary to CHF, OSA, and restrictive ventilation due to habitus. Required mechanical ventilation from admission (intubated during V Fib arrrest in ED), and extubated on [**2151-3-16**], without difficulty. Since, patient has been satting well on room air using CPAP at night. . #Hypotension (resolved): Initially secondary to VT, in addition probably contribution from sedatives, positive pressure ventilation especially in the setting of marked RV dysfunction. [**Month (only) 116**] also be intravscularly volume depleted, but total body overloaded. Sepsis less likely at this point, given broad spectrum antibiotic coverage, negative culture data, although stil febrile. Patient initially on 3-pressors which were weaned off. In terms of sepsis work-up all culture data negative, although patient was treated empirically for VAP. Initially held all blood pressure medications including beta blocker and ACE inhibitor which were restarted slowly after hypotension had resolved. . # Fevers: Leukocytosis/fever/right lobe infiltrate- Patient felt to have likely aspiration PNA with witnessed emesis during intubation. Cultures were all negative. Femoral line was removed and sent for culture. Given negative culture data, patient was treated for VAP and then there was concern that possible drug fever given persistant fever and no positive culture data. Fevers improved after patient was extubated and did not recur. . # Chronic Systolic Congestive Heart Failure: Has right sided heart failure only, s/p tricuspid reconstruction and ASD repair. Patint on low dose metoprolol and lisinopril as above, cont aspirin 325. Initially held statin in the setting of worsening liver abnormalities but restarted as LFTs improved. Continued patient's outpatient lasix dose of 40 mg Po daily once blood pressures had improved. . # Pain: has left sided chest wall pain [**3-15**] fractured ribs from resuscitation. Patient was treated with Lidocaine patch daily as well as standing Tylenol. Patient was discharged on tylenol PRN. . #Gout: Patient as outpatient on colchicine and allopurinol although patient not taking allopurinol at home. Initially concern that fever may be secondary to gout. Patient was tapped and tap revealed WBC, Joint Fluid 300* #/uL 0 - 150 RBC, Joint Fluid [**Numeric Identifier 1871**]* #/uL 0 - 0 Polys 80* % 0 - 25 Lymphocytes 4 % 0 - 75 Monocytes 0 % 0 - 70 Macrophage 16 % 0 - 70 FEW SIDEROTIC GRANULES PRESENT Joint Crystals, Number NO[**Serial Number **]. Patient states that he is having pain in his right knee which he thinks is from his gout. Given improvement in renal function and patient's request restarted colchicine at outpatient dose. . # Anemia - patient with Cr 31 currently previous baseline 41. Patient has not had anemia labs checked. Added on anemia labs to discharge labs. Patient will require active type and screen prior to additional procedures . FEN: regular cardiac diet, replete lytes PRN . ACCESS: PIV . PROPHYLAXIS: hep sc, colace, senna, PPI daily CODE: Full Colde Medications on Admission: ALBUTEROL - 90 mcg Aerosol - ii puffs ih qid prn ALLOPURINOL - 300 mg Tablet - 2 Tablet(s) by mouth daily ATORVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day COLCHICINE - 0.6 mg Tablet - One Tablet(s) by mouth once a day DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth daily FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - 2 puffs nasally twice a day x two weeks FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth once a day LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE [TOPROL XL] - 25 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth once a day Discharge Medications: 1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation four times a day as needed for shortness of breath or wheezing. Discharge Disposition: Home Discharge Diagnosis: Primary: Ventricular fibrillation arrest . Secondary: Ebstein's anomaly Chronic left heart failure Hyperlipidemia Hypertension Obstructive sleep apnea Gout Discharge Condition: Good, hemodynamically stable, afebrile Discharge Instructions: You were admitted after cardiac arrest. The arrest was most likely caused by underlying rhythm abnormalities related to your Ebstein's Anomaly. You were intubated for airway protection, and finally extubated after your respiratory status improved. You had fevers that resolved after extubation. As you improved significantly, you were transferred to the floor from the ICU. You were evaluated by an electrophysiology study, but no ablatable source could be identified in your heart. You need to follow-up in 2 weeks with Dr. [**Last Name (STitle) **] for further evaluation and possible ICD placement. Please also follow-up as strongly advised below. Dr. [**Last Name (STitle) **] is arranging for you to have an outpatient cardionet or loop recorder at home after discharge. . Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction:1500ml . The following changes were made to your medications: - We are stopping your digoxin as your have not been on it in the hospital -STOP Allopurinol for now, re-discuss with Dr. [**Last Name (STitle) **] [**Name (STitle) **] Lisinopril to 2.5mg PO daily -CHANGE Metoprolol to 25 mg PO BID -START Amiodarone 200mg PO 3 times daily -START Aspirin 325mg PO daily . If you experience any chest pain, shortness of breath, palpitations, weakness, nausea, vomiting, dizziness, lightheadedness, or have any other concerns please [**Name6 (MD) 138**] your MD or return to the ED. Followup Instructions: Please call to set up a follow-up appointment within 2 weeks with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2037**] for further evaluation for ICD and monitoring of your cardiac status. . Please follow-up with the Adult Congenital Heart Clinic within 1 month for further monitoring of your Ebstein's anomaly. . Please call the rheumatology department ([**Telephone/Fax (1) 1668**] for a follow up appointment with Dr. [**Last Name (STitle) **] to discuss when and if to restart allopurinol treatment for gout. . Please follow-up with Sleep Medicine ([**Telephone/Fax (1) 9525**] to schedule a repeat outpatient sleep study. . Please call the [**Hospital **] Clinic ([**Telephone/Fax (1) 7026**] as outpatient to discuss weight loss in the case of further possible heart surgery. We would reccomend you follow up within 1-2 weeks. Completed by:[**2151-3-28**]",27,2151-03-07 06:24:00,2151-03-28 14:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,CARDIAC ARREST," 39m w/ pmh of ebsteins anomaly, s/p tricuspid valve reconstruction, right and left sided systolic congestive heart failure, presenting with unstable ventricular tachycardia, s/p resuscitation with return to sinus tachycardia, s/p intubation and extubation. . # ventricular tachycardia: likely result of natural history of ebstein anomaly. patient underwent cpr and intubation with return to normal sinus rhythm. suppressed ectopy with amiodarone. also started metoprolol for rate-control. amiodarone increased to 200mg tid. had cardiac mri with final read as above. patient then underwent ep study where they were unable to induce ventricular fibrillation so unable to ablate. ep was unable to place an icd during this admission given recent procedure and significant abnormal heart anatomy. patient to follow up with dr. [**last name (stitle) **] in [**2-12**] weeks to discuss possible icd placement in the future. in addition, patient to have monitor set up at home as per dr. [**last name (stitle) **]. . #respiratory failure - now resolved. initially primarily hypoxemic, with unclear etiology. differential includes ards, pna/sepsis, shunt, and volume overload. improvement with nitric oxide suggested some shunt physiology, although intracardiac shunt was not evident on tee. respiratory failure improved with diuresis. decreased fi02 and peep and nitric oxide weaned off with improved compliance. methemaglobin negative. multifactorial secondary to chf, osa, and restrictive ventilation due to habitus. required mechanical ventilation from admission (intubated during v fib arrrest in ed), and extubated on [**2151-3-16**], without difficulty. since, patient has been satting well on room air using cpap at night. . #hypotension (resolved): initially secondary to vt, in addition probably contribution from sedatives, positive pressure ventilation especially in the setting of marked rv dysfunction. [**month (only) 116**] also be intravscularly volume depleted, but total body overloaded. sepsis less likely at this point, given broad spectrum antibiotic coverage, negative culture data, although stil febrile. patient initially on 3-pressors which were weaned off. in terms of sepsis work-up all culture data negative, although patient was treated empirically for vap. initially held all blood pressure medications including beta blocker and ace inhibitor which were restarted slowly after hypotension had resolved. . # fevers: leukocytosis/fever/right lobe infiltrate- patient felt to have likely aspiration pna with witnessed emesis during intubation. cultures were all negative. femoral line was removed and sent for culture. given negative culture data, patient was treated for vap and then there was concern that possible drug fever given persistant fever and no positive culture data. fevers improved after patient was extubated and did not recur. . # chronic systolic congestive heart failure: has right sided heart failure only, s/p tricuspid reconstruction and asd repair. patint on low dose metoprolol and lisinopril as above, cont aspirin 325. initially held statin in the setting of worsening liver abnormalities but restarted as lfts improved. continued patients outpatient lasix dose of 40 mg po daily once blood pressures had improved. . # pain: has left sided chest wall pain [**3-15**] fractured ribs from resuscitation. patient was treated with lidocaine patch daily as well as standing tylenol. patient was discharged on tylenol prn. . #gout: patient as outpatient on colchicine and allopurinol although patient not taking allopurinol at home. initially concern that fever may be secondary to gout. patient was tapped and tap revealed wbc, joint fluid 300* #/ul 0 - 150 rbc, joint fluid [**numeric identifier 1871**]* #/ul 0 - 0 polys 80* % 0 - 25 lymphocytes 4 % 0 - 75 monocytes 0 % 0 - 70 macrophage 16 % 0 - 70 few siderotic granules present joint crystals, number no[**serial number **]. patient states that he is having pain in his right knee which he thinks is from his gout. given improvement in renal function and patients request restarted colchicine at outpatient dose. . # anemia - patient with cr 31 currently previous baseline 41. patient has not had anemia labs checked. added on anemia labs to discharge labs. patient will require active type and screen prior to additional procedures . fen: regular cardiac diet, replete lytes prn . access: piv . prophylaxis: hep sc, colace, senna, ppi daily code: full colde ","PRIMARY: [Paroxysmal ventricular tachycardia] SECONDARY: [Chronic systolic heart failure; Ebstein's anomaly; Acute respiratory failure; Pneumonitis due to inhalation of food or vomitus; Cardiogenic shock; Acute and subacute necrosis of liver; Acute kidney failure with lesion of tubular necrosis; Iatrogenic pneumothorax; Ventilator associated pneumonia; Congestive heart failure, unspecified; Hyposmolality and/or hyponatremia; Alkalosis; Closed fracture of two ribs; Cardiac arrest; Other iatrogenic hypotension; Other specified misadventures during medical care; Other and unspecified hyperlipidemia; Unspecified essential hypertension; Obstructive sleep apnea (adult)(pediatric); Mitral valve disorders; Obesity, unspecified; Anemia, unspecified; Venous (peripheral) insufficiency, unspecified; Gout, unspecified; Personal history of venous thrombosis and embolism; Personal history of thrombophlebitis; Other postprocedural status]","39m w/ pmh of ebsteins anomaly, s/p tricuspid valve reconstruction, right and left sided systolic congestive heart failure, presenting with unstable ventricular tachycardia, s/p resuscitation with return to sinus tachycardia, s/p intubation and extubation. patient underwent cpr and intubation with return to normal sinus rhythm. had cardiac mri with final read as above. last name (stitle) **] in [**2-12**] weeks to discuss possible icd placement in the future. initially primarily hypoxemic, with unclear etiology. improvement with nitric oxide suggested some shunt physiology, although intracardiac shunt was not evident on tee. respiratory failure improved with diuresis. #gout: patient as outpatient on colchicine and allopurinol although patient not taking allopurinol at home. fen: regular cardiac diet, replete lytes prn .","39m w/ pmh of ebsteins anomaly, s/p tricuspid valve reconstruction, right and left sided systolic congestive heart failure. patient underwent cpr and intubation with return to normal sinus rhythm. suppressed ectopy with amiodarone. also started metoprolol for rate-control." 49081,140192.0,14375,2161-11-27,14374,127653.0,2161-11-05,Discharge summary,"Admission Date: [**2161-10-18**] Discharge Date: [**2161-11-5**] Date of Birth: [**2099-7-2**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3276**] Chief Complaint: dyspnea, low grade fever Major Surgical or Invasive Procedure: pleurex catheter drainage EGD History of Present Illness: Mr. [**Known lastname 42603**] is a 62 year old male with a h/o metastatic large cell lung cancer to bone c/b recurrent malignant pleural effusion requiring pleurex catheter placement, HIV (CD4 535) on HAART, htn who presented to the ED with pleuritic CP and dyspnea which has been his long standing issues. He further states that he flt like he was dying and is not cmofortable with going home. In ED vitals were stable with sats 100% on 1.5L o2 and bp of 134/89, temp 99.4. labs are at baseline. CXR revealed moderate to large left sided pleural effusion with pleurex drain and minimal interval changes. His temp subsequently went to 100.5 although he [**Doctor First Name 1638**] any neck stiffness, photophobia, cough, nausea, vomiting, diarrhoea, dysuria or rash. He was cultured and started on vanco and zosyn. He's seen by psych who felt he's not at suicidal risk. He's admitted for further care. Past Medical History: [**7-/2159**]: Diagnosed with non small cell lung cancer by CT guided biopsy [**2159-9-20**]: PET scan with low-attenuation lesion in the left lobe of the thyroid gland measuring 25 x 7 mm in addition to markedly FDG avid left upper lobe mass consistent with known cancer and FDG avid prominent bilateral axillary lymphadenopathy suspicious for metastatic disease, but no pathologically enlarged infraclavicular lymph nodes. He also had retroperitoneal internal and external iliac chain FDG avid lymphadenopathy considered unusual for lung carcinoma. [**2159-10-29**]: FNA of the thyroid, which was negative. [**2159-10-31**]: Left axillary lymph node dissection. With pathology revealing florid reactive follicular hyperplasia consistent with HIV associated lymphadenopathy. Further staging and treatment were deferred until the patient was stabilized on HAART therapy. He was initially seen by infectious disease doctors [**Last Name (NamePattern4) **] [**2160-1-10**] and was started on HAART therapy in 01/[**2160**]. [**3-/2160**]: He was hospitalized for influenza. After the hospitalization, he was lost to follow up until [**Month (only) **]. Other than the visit with his infectious disease on [**2160-5-5**], he then lost to follow up until [**7-13**]. [**2160-7-24**]: CT demonstrated left upper lobe mass minimally increased in size from [**3-/2160**] with a sub 5 mm left upper lobe pulmonary nodule with additional stable bilateral nodules, new left-sided pleural effusion. [**2160-8-6**]: Bronchoscopy, mediastinoscopy, and pleural drainage and talc pleurodesis by Dr. [**Last Name (STitle) **]. Pathology revealed 4R lymph nodes with no malignancy but frozen sections showed metastatic large cell carcinoma and 4L lymph nodes that showed metastatic large cell carcinoma. A level 7 lymph node showed metastatic large cell carcinoma and a parietal pleural biopsy also showed metastatic large cell carcinoma involving the pleura. He was started on carboplatin and gemcitabine on [**2160-8-28**] he has completed 4 cycles. [**2160-12-5**]: MR [**Name13 (STitle) **] with L1 lesion . MEDICAL HISTORY: - Peripheral vestibulopathy - HIV: Diagnosed in the [**2142**], he had been previously cared for by Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 42604**] at [**Hospital6 **]. [**2160-10-30**] -> CD4 425, VL undetectable - Positive PPD-negative AFB [**1-11**]-s/p 6 months Rifampin in [**2148**]. - Hypertension. - History of appendicitis status post appendectomy in [**2126**]. Social History: He is originally of Haitian origin. His wife and children live in [**Country 2045**]. He is an employee in the food service industry here at [**Hospital1 18**]. He reports a prior history of tobacco, having stopped in [**2148**]. He is sexually active only with women. He denies any intravenous drug use. He received transfusions potentially around the time of his appendectomy in [**2126**]. Family History: No premature CAD or cancer. Physical Exam: T: 97.6 BP: 122/89 HR: 100 RR: 20 O2 100% 2LNC Gen: Pleasant, chronically ill appearing male in NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple. JVP low. CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**] LUNGS: Prominent breath sounds. Decreased on L halfway up. ABD: NABS. Soft, NT, ND. No HSM EXT: WWP, NO CCE. Full distal pulses bilaterally. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Moving all extremities. Exam at discharge: O: 126/88 99 99.1 98% RA 1154/1520 Gen: Pleasant, chronically ill appearing male in NAD HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple. JVP low. CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**], mild chest discomfort reproducible over sternum LUNGS: Prominent breath sounds. Decreased on L halfway up. ABD: NABS. Soft, NT, ND. No HSM EXT: WWP, NO CCE. Full distal pulses bilaterally. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Moving all extremities. Pertinent Results: [**2161-10-18**] WBC-10.7 Hgb-9.8* Hct-30.9* Plt Ct-577* [**2161-10-19**] WBC-3.6*# Hgb-8.6* Hct-25.8* Plt Ct-397 [**2161-10-19**] WBC-2.3* Hgb-9.6* Hct-29.3* Plt Ct-379 [**2161-10-20**] WBC-1.5* Hgb-9.0* Hct-27.7* Plt Ct-319 [**2161-10-21**] WBC-2.1* Hgb-9.1* Hct-27.4* Plt Ct-257 [**2161-10-22**] WBC-2.9* Hgb-8.6* Hct-26.6* Plt Ct-220 [**2161-10-23**] WBC-3.8* Hgb-8.9* Hct-27.3* Plt Ct-169 [**2161-10-24**] WBC-3.9* Hgb-8.2* Hct-25.4* Plt Ct-167 [**2161-10-24**] WBC-4.0 Hgb-8.5* Hct-26.9* Plt Ct-153 [**2161-10-25**] WBC-4.5 Hgb-7.4* Hct-21.9* Plt Ct-178 [**2161-10-26**] WBC-5.5 Hgb-7.9* Hct-24.0* Plt Ct-182 [**2161-10-27**] WBC-6.4 Hgb-9.2* Hct-26.7* Plt Ct-172 [**2161-10-28**] WBC-7.0 Hgb-9.8* Hct-28.6* Plt Ct-227 [**2161-10-29**] WBC-8.5 Hgb-9.6* Hct-28.7* Plt Ct-279 [**2161-10-30**] WBC-8.3 Hgb-9.4* Hct-29.7* Plt Ct-359 [**2161-10-31**] WBC-7.8 Hgb-9.8* Hct-29.6* Plt Ct-458* [**2161-11-1**] WBC-7.9 Hgb-9.3* Hct-28.5* Plt Ct-521* [**2161-11-2**] WBC-5.8 Hgb-9.7* Hct-29.3* Plt Ct-595* [**2161-11-4**] WBC-6.8 Hgb-9.3* Hct-29.4* Plt Ct-676* [**2161-11-5**] WBC-7.5 Hgb-9.0* Hct-28.0* Plt Ct-656* [**2161-10-28**] WBC-7.0 Lymph-43* Abs [**Last Name (un) **]-3010 CD3%-78 Abs CD3-2339* CD4%-16 Abs CD4-483 CD8%-61 Abs CD8-1824* CD4/CD8-0.3* [**2161-10-18**] UreaN-11 Creat-1.2 Na-136 K-4.6 Cl-96 HCO3-28 AnGap-17 [**2161-10-19**] UreaN-10 Creat-1.1 Na-139 K-3.8 Cl-102 HCO3-30 AnGap-11 [**2161-10-20**] UreaN-6 Creat-1.2 Na-140 K-3.7 Cl-103 HCO3-30 AnGap-11 [**2161-10-21**] UreaN-11 Creat-1.4* Na-142 K-3.8 Cl-102 HCO3-31 AnGap-13 [**2161-10-22**] UreaN-9 Creat-1.4* Na-141 K-3.7 Cl-100 HCO3-31 AnGap-14 [**2161-10-23**] UreaN-8 Creat-1.6* Na-141 K-4.0 Cl-104 HCO3-30 AnGap-11 [**2161-10-23**] UreaN-8 Creat-1.6* Na-138 K-3.9 Cl-100 HCO3-29 AnGap-13 [**2161-10-24**] UreaN-7 Creat-1.7* Na-139 K-3.6 Cl-101 HCO3-30 AnGap-12 [**2161-10-25**] UreaN-7 Creat-1.7* Na-138 K-4.0 Cl-100 HCO3-30 AnGap-12 [**2161-10-26**] UreaN-10 Creat-2.0* Na-139 K-4.0 Cl-100 HCO3-31 AnGap-12 [**2161-10-27**] UreaN-13 Creat-2.0* Na-140 K-4.2 Cl-103 HCO3-29 AnGap-12 [**2161-10-28**] UreaN-10 Creat-2.0* Na-141 K-4.0 Cl-102 HCO3-30 AnGap-13 [**2161-10-29**] UreaN-11 Creat-2.1* Na-143 K-4.0 Cl-105 HCO3-26 AnGap-16 [**2161-10-30**] UreaN-11 Creat-2.3* Na-143 K-4.2 Cl-105 HCO3-29 AnGap-13 [**2161-10-31**] UreaN-11 Creat-2.3* Na-141 K-4.2 Cl-105 HCO3-28 AnGap-12 [**2161-11-1**] UreaN-12 Creat-2.3* Na-143 K-4.3 Cl-105 HCO3-30 AnGap-12 [**2161-11-2**] UreaN-11 Creat-2.3* Na-145 K-4.3 Cl-105 HCO3-29 AnGap-15 [**2161-11-3**] UreaN-9 Creat-1.9* Na-143 K-4.1 Cl-104 HCO3-29 AnGap-14 [**2161-11-4**] UreaN-8 Creat-2.1* Na-147* K-4.3 Cl-108 HCO3-31 AnGap-12 [**2161-11-5**] UreaN-9 Creat-1.8* Na-145 K-4.2 Cl-105 HCO3-32 AnGap-12 [**2161-10-24**] ALT-97* AST-89* LD(LDH)-505* CK(CPK)-97 AP-288* Amylase-93 TotBili-5.1* [**2161-10-24**] CK(CPK)-102 [**2161-10-25**] ALT-79* AST-66* LD(LDH)-478* CK(CPK)-88 AP-246* Amylase-80 TotBili-4.4* DirBili-0.2 IndBili-4.2 [**2161-10-26**] ALT-64* AST-53* AP-244* TotBili-4.2* [**2161-10-27**] ALT-50* AST-43* LD(LDH)-497* AP-227* Amylase-78 TotBili-4.5* [**2161-10-28**] ALT-41* AST-41* LD(LDH)-514* AP-230* TotBili-4.4* [**2161-10-29**] ALT-37 AST-43* AP-236* TotBili-3.1* [**2161-10-30**] ALT-58* AST-79* LD(LDH)-486* AP-406* TotBili-1.5 [**2161-10-31**] ALT-44* AST-51* LD(LDH)-483* AP-371* TotBili-0.7 [**2161-11-1**] ALT-45* AST-61* LD(LDH)-469* AP-402* TotBili-0.4 [**2161-11-4**] ALT-86* AST-165* LD(LDH)-619* AP-465* TotBili-0.4 [**2161-11-5**] ALT-59* AST-69* LD(LDH)-607* AP-409* TotBili-0.4 [**2161-10-24**] CK-MB-2 cTropnT-<0.01 [**2161-10-24**] CK-MB-2 cTropnT-<0.01 [**2161-10-25**] CK-MB-2 cTropnT-<0.01 [**2161-10-28**] Type-ART pO2-92 pCO2-26* pH-7.66* calTCO2-30 Base XS-9 [**2161-10-28**] Type-ART pO2-26* pCO2-37 pH-7.53* calTCO2-32* Base XS-6 [**2161-10-29**] Type-[**Last Name (un) **] pO2-43* pCO2-47* pH-7.45 calTCO2-34* Base XS-7 [**2161-10-30**] Type-[**Last Name (un) **] pO2-154* pCO2-46* pH-7.45 calTCO2-33* Base XS-7 C [**2161-10-28**] Lactate-1.1 Na-143 K-3.7 Cl-102 [**2161-10-28**] Lactate-2.1* Na-144 K-3.8 Cl-101 [**2161-10-21**] URINE Hours-RANDOM Creat-31 Na-31 K-13 Cl-30 [**2161-10-24**] URINE Hours-RANDOM Creat-31 Na-24 [**2161-10-28**] URINE Hours-RANDOM Creat-30 Na-49 K-16 Cl-39 [**2161-10-30**] URINE Hours-RANDOM UreaN-126 Creat-45 Na-32 Phos-6.8 [**2161-10-28**] URINE Osmolal-160 [**2161-10-30**] URINE Osmolal-153 [**2161-10-20**] PLEURAL WBC-600* RBC-8125* Polys-0 Lymphs-95* Monos-5* [**2161-10-21**] PLEURAL WBC-889* RBC-[**Numeric Identifier 42605**]* Polys-1* Lymphs-89* Monos-6* Eos-1* Meso-2* Macro-1* [**2161-11-5**] PLEURAL WBC-650* RBC-[**Numeric Identifier 42606**]* Polys-7* Lymphs-91* Monos-2* [**2161-10-20**] PLEURAL TotProt-3.9 LD(LDH)-527 [**2161-10-20**] PLEURAL TotProt-3.4 LD(LDH)-447 [**2161-10-21**] PLEURAL TotProt-3.7 Glucose-119 LD(LDH)-430 CXR [**10-18**] IMPRESSION: Moderate to large left pleural effusion with related atelectasis unchanged. Subtle consolidation on the left could be obscured however the right lung remains clear. CXR [**10-20**] 1. No pulmonary embolism. 2. No significant change in moderate left pleural effusion. While small loculations of the effusion are associated, the pleural catheter resides within the largest pleural collection. Nodular thickening and enhancement of the pleura may be secondary to metastatic involvement versus iatrogenic etiologies (i.e. pleurodesis). 3. No significant change in left upper lobe pulmonary mass or innumerable lung metastases. Diffuse interlobular septal thickening may again represent lymphangitic spread of carcinoma. 4. Persistant round atelectasis involving a large portion of the left lower lobe. CXR [**10-28**] FINDINGS: As compared to the previous examination, there is no relevant change. The extent of the pre-existing left-sided pleural effusion is constant. The effusion fills more than 50% of the left hemithorax and distributes through the entirety of the pleural space. The retrocardiac lung areas and the few ventilated left lung areas are clearly atelectatic. There could be mild displacement of the heart over the midline into the right hemithorax, probably exaggerated by a relatively severe thoracic scoliosis. The right lung is free of effusions. However, mild overhydration is seen. No evidence of pneumothorax, no focal parenchymal opacities suggesting pneumonia. CXR [**10-31**] IMPRESSION: Extensive left effusion; however, decreased compared to [**2161-10-28**]. No new consolidations and no PTX. CT head [**10-28**] 1. Known pituitary/sellar mass is again identified, unchanged but incompletely evaluated. 2. No large mass lesion separate from this or area of hemorrhage. Please note that MRI is more sensitive in detection of small lesions and can be considered for assessment of metastatic disease. Renal ultrasound: No evidence of stones or hydronephrosis in either kidney. Simple cyst in the right kidney. Abdominal ultrasound [**11-4**] 1. Normal-appearing liver, with no intrahepatic lesion seen. 2. s/p cholecystectomy. The common duct is not dilated, and there is no intrahepatic biliary dilatation. ECHO: No vegetations EGD: mucosal erythema c/w gastritis pleural fluid at discharge: GRAM STAIN (Final [**2161-11-5**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2161-11-8**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH Brief Hospital Course: 62 year old male with a h/o metastatic large cell lung cancer to bone c/b recurrent malignant pleural effusion requiring pleurex catheter placement, HIV (CD4 535) on HAART, htn who presented with dyspnea, unchanged pleural effusion on cxr and low grade fever. # Coagulase negative staph in pleural fluid, urine: Initially thought to be contaminant but grew in several samples and then in urine. Blood cultures were all negative and an echocardiogram showed no vegetations. The patient was treated with levofloxacin and was afebrile. # Pleural effusion: Drained by IP frequently throughout hospitalization usually followed by improvement in dyspnea. See above for pleural fluid analysis at discharge. The patient will continue to receive thrice weekly pleurex drainage via VNA at home. # [**Last Name (un) **]: Likely contrast induced nephropathy though elevation persisted longer than expected. Peaked at 2.3 and trending down on discharge to 1.8. # Epigastric pain. Persistent nausea/vomiting and epigastric pain. Ruled out for MI. Had EGD which showed gastritis. Path from biopsy pending. Symptoms began to improve before discharge. # Tachypnea/Anxiety. Patient was transferred to MICU overnight for tachypnea and respiratory alkalosis with pH of 7.6. It resolved with ativan and morphine. A central drive for respiratory alkalosis was ruled out by CT. He was started on [**Hospital1 **] Klonipin with good effect. # Lung cancer: Plan per primary oncologist. # HIV. CD4 483. HAART was stopped for [**Last Name (un) **], elevated LFTs. He will follow with HIV doctor as outpatient. # Hypertension: controlled well with amlodpine # Depression/suicidal ideation: iniatlly followed by pscyh for question of suicidal ideation on admission but this appears to have been a misunderstanding. They did recommend Celexa. This was started at 10mg for one day but it was not continued as patient was sent to the MICU on that day. Code- full Medications on Admission: amlodipine 10 mg daily atazanavir 300 mg daily Truvada 200mg/300mg daily ritonivir 100 mg daily alimenta Q3weeks folic acid 1 mg daily ibuprofen 800 mg TID morphine SR 15 mg [**Hospital1 **] oxycodone 5-10 mg Q4H prn ranitidine 150 mg daily colace/senna compazine 10 mg prn lactulose prn albuterol prn Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*30 Tablet(s)* Refills:*2* 8. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a day. 9. Compazine 10 mg Tablet Sig: One (1) Tablet PO once a day as needed for nausea. Disp:*30 Tablet(s)* Refills:*0* 10. Lactulose 10 gram Packet Sig: One (1) PO once a day. Disp:*30 packets* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: metastatic large cell lung cancer HIV/AIDS Secondary Diagnoses: # stage IIIB large cell lung cancer metastatic to bone - started Alimenta [**2161-7-16**] # HIV, CD4 [**6-13**] 535, VL undetectable - diagnosed in [**2142**] - re-initiated HAART on [**2160-2-28**] # chronic malignant pleural effusion s/p talc pleurodesis [**8-12**] with pleurex catheter placed [**1-12**] for recurrent effusion # Hypertension # Positive PPD-negative AFB [**1-11**]-s/p 6 months Rifampin in [**2148**]. # Hepatitis B # s/p cholecystectomy on [**2161-4-1**] # h/o appendicitis status post appendectomy in [**2126**] # Sellar mass seen on MRI most recently on [**2160-8-4**] - a stable appearance of the intra and suprasellar mass - nonfunctioning mass as worked up by endocrinology # Low back pain Discharge Condition: stable and improved Discharge Instructions: You were admitted to the hospital for shortness of breath. Your symptoms improved after some fluid was drained from the catheter in your chest. A CT scan of your chest showed that you did not have any blood clots in your lungs. You developed mild kidney dysfunction during stay that improved with fluids. You also developed abdominal pain during your hospitalization. An endoscopic procedure showed that you had no inflammation in your esophagous, and some mild inflammation in your stomach. Biopsies were taken and we are still awaiting the results. An ultrasound of your abdomen also was normal. You continued to improve and you were discharged on [**2161-11-5**] home with services. The following changes have been made to your medications: please do not take your HIV medications until you meet with Dr. [**Last Name (STitle) 7443**]: atazanavir Truvada ritonivir See below for follow up appointments. Please call your doctor or 911 if you develop worsening shortness of breath, chest pain, fevers or chills, worsening abdominal pain, persistent vomiting or diarrhea, or any other concerning medical symptoms. Followup Instructions: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2161-11-18**] 11:30 please call your primary oncologist, Dr. [**Last Name (STitle) 3274**], at [**Telephone/Fax (1) 15512**], this week to set up a follow up appointment next week [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**] ",22,2161-10-18 18:44:00,2161-11-05 16:45:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,PLEURAL EFFUSION," 62 year old male with a h/o metastatic large cell lung cancer to bone c/b recurrent malignant pleural effusion requiring pleurex catheter placement, hiv (cd4 535) on haart, htn who presented with dyspnea, unchanged pleural effusion on cxr and low grade fever. # coagulase negative staph in pleural fluid, urine: initially thought to be contaminant but grew in several samples and then in urine. blood cultures were all negative and an echocardiogram showed no vegetations. the patient was treated with levofloxacin and was afebrile. # pleural effusion: drained by ip frequently throughout hospitalization usually followed by improvement in dyspnea. see above for pleural fluid analysis at discharge. the patient will continue to receive thrice weekly pleurex drainage via vna at home. # [**last name (un) **]: likely contrast induced nephropathy though elevation persisted longer than expected. peaked at 2.3 and trending down on discharge to 1.8. # epigastric pain. persistent nausea/vomiting and epigastric pain. ruled out for mi. had egd which showed gastritis. path from biopsy pending. symptoms began to improve before discharge. # tachypnea/anxiety. patient was transferred to micu overnight for tachypnea and respiratory alkalosis with ph of 7.6. it resolved with ativan and morphine. a central drive for respiratory alkalosis was ruled out by ct. he was started on [**hospital1 **] klonipin with good effect. # lung cancer: plan per primary oncologist. # hiv. cd4 483. haart was stopped for [**last name (un) **], elevated lfts. he will follow with hiv doctor as outpatient. # hypertension: controlled well with amlodpine # depression/suicidal ideation: iniatlly followed by pscyh for question of suicidal ideation on admission but this appears to have been a misunderstanding. they did recommend celexa. this was started at 10mg for one day but it was not continued as patient was sent to the micu on that day. code- full ","PRIMARY: [Malignant pleural effusion] SECONDARY: [Human immunodeficiency virus [HIV] disease; Pneumonia, organism unspecified; Acute kidney failure with lesion of tubular necrosis; Malignant neoplasm of upper lobe, bronchus or lung; Secondary malignant neoplasm of bone and bone marrow; Alkalosis; Mixed acid-base balance disorder; Hyperosmolality and/or hypernatremia; Other specified gastritis, without mention of hemorrhage; Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus; Vestibular neuronitis; Unspecified essential hypertension; Unspecified gastritis and gastroduodenitis, without mention of hemorrhage; Cyst of kidney, acquired; Lumbago; Unspecified adjustment reaction; Unspecified condition of brain; Esophageal reflux; Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH]; Constipation, unspecified; Other drugs and medicinal substances causing adverse effects in therapeutic use; Depressive disorder, not elsewhere classified]","62 year old male with a h/o metastatic large cell lung cancer to bone c/b recurrent malignant pleural effusion requiring pleurex catheter placement, hiv (cd4 535) on haart, htn who presented with dyspnea, unchanged pleural effusion on cxr and low grade fever. # pleural effusion: drained by ip frequently throughout hospitalization usually followed by improvement in dyspnea. see above for pleural fluid analysis at discharge. # hypertension: controlled well with amlodpine # depression/suicidal ideation: iniatlly followed by pscyh for question of suicidal ideation on admission but this appears to have been a misunderstanding.",# pleural effusion drained by ip frequently throughout hospitalization. likely contrast induced nephropathy though elevation persisted longer than expected. # tachypnea/anxiety. patient was transferred to micu overnight. 51698,190004.0,23245,2142-03-09,23244,137588.0,2142-02-19,Discharge summary,"Admission Date: [**2142-2-13**] Discharge Date: [**2142-2-19**] Date of Birth: [**2072-4-9**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: Headaches, emesis, altered mental status, right hemiparesis Major Surgical or Invasive Procedure: [**2142-2-13**]: Left Craniotomy for subdural Hematoma with Dr. [**First Name (STitle) **] History of Present Illness: This is a 69 year old male who has been on Coumadin for a history of multiple DVTs and a PE. He had complained of a headache for several days and had multiple episodes of vomiting. His son found him confused after family members reported a stuporous ""drunken"" state. He was brought to the OSH. He reportedly wasmoving all extremities and was able to answer some questions. His head CT revealed a large left SDH. He was given 10 mg SC of vitamin K and FFP as well as a dilantin load. He was transferred to [**Hospital1 18**] for a neurosurgical evaluation. Upon arrival to [**Hospital1 18**], he was still moving spontaneously but unable to answer questions per the ER. He was given profiline and a second dose of FFP. Past Medical History: varicose vein stripping DVT L superfical femoral L4-5, L5-S1 stenosis HTN hyperlipidemia PE IVC filter hip replacement Social History: warehouse worker forced to quit 1 [**1-13**] yrs ago due to L hip pain. no tobacco, no ETOH Family History: NC Physical Exam: On admission: T:98.3 BP:147/89 HR:89 RR:17 O2Sats:98% 4L NC Gen: Lethargic, agitated HEENT: Pupils: PERRL EOMs-unable to test Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Obese, Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Lethargic, follows some commands. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: unable to test V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX-XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Moving left side spontaneously. Moving RUE spontaneously but less than left. Briskly withdraws RLE to minimal noxious stimuli. Unable to assess pronator drift. Sensation: Appears intact to light touch bilaterally and patient opens eyes and says ""Ai"" to noxious stimuli. On Discharge: A&Ox3 PERRL 3-2mm bilaterally EOMs: intact Face symmetrical Tongue midline Motor: D B T IP Q H [**Last Name (un) **] AT [**Last Name (un) 938**] R 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 Incision: clean, dry and intact- anterior aspect of wound has an area of white- appears to be dressing that was stuck to incisional glue. Pertinent Results: CT Head [**2142-2-13**]: Left subdural hematoma with a hyperdense focus in the left frontoparietal region consistent with acute hemorrhage. 1.4 cm rightward subfalcine herniation and compression of the left lateral ventricle without ventricular entrapment. Overall, unchanged since outside hospital study performed two hours ago. CT Head [**2142-2-14**]: Newly apparent 5-mm in transverse dimension posteriorly centered right subdural hemorrhage. The patient is status post left craniotomy with interval evacuation of previously noted left subdural hemorrhage. Improvement in mass effect with now 4 mm rightward midline shift decreased from 9 using comparable measurements. Improvement in compression of the left lateral ventricle. LENIS [**2142-2-15**]: 1. Incomplete compressibility of the left mid-to-lower superficial femoral vein which may represent partially occlusive or chronic DVT. 2. No evidence of right lower extremity DVT. CT Head [**2142-2-19**]: Stable CT scan Brief Hospital Course: Mr. [**Known lastname 1794**] was admitted to [**Hospital1 18**] under the CAre of Dr [**First Name (STitle) **]. He was taken to the OR on the evening of [**2142-2-13**] for Left craniotomy for SDH evacuation. He was left intubated and transported to the ICU. He was extubated aorund noon on [**2142-2-14**]. He was MAE with right sided weakness but not following commands. HE became febrile to 101.8 early am on [**2142-2-15**]. Sputum cultures were positive for Gram + cocci in pairs. LENS showed a Left superficial femoral DVT that was either chronic or a new partially occlusive DVT. His PCP [**Last Name (NamePattern4) **].[**Last Name (STitle) 1057**] was contact[**Name (NI) **] at his new office [**Telephone/Fax (1) 14331**]. His office had records dating from [**2139**]. The patient has been on Coumdain since then without a new diagnosis of DVT. Therefore we determined that his origical DVT was prior to [**2139**] and this finding was consistant with new L DVT. Venodynes were removed form the LLE. Hematology was consulted with regards to whether anticoagulation is warranted. In the context of a recent evacuation of the SDH and the small size of the DVT, it was felt that the patient can be initiated on subcutaneous heparin at prophylactic dose since the patient has an IVC filter in place. The joint decision between neurosurgery and hematology was to initiate anti-coagulation approxiamtely 2 weeks after the SDH evacuation. He was seen by the Speach/Swallow service. They recommended a pureed diet. His neruologic status was improved on 2.4 and transfer to the SDU was initiated. On [**2142-2-16**] he was neurologically stable in the SDU. Levofloxacin was started in the setting of low grade fever and sputum with gram + cocci. CT head showed a L PCA infarct. Stroke Neurology was consulted. Work up revealed no evidence of embolic or thrombotic lesions. The patient will f/u with the neurology clinic for work up of hypercoagulability. Also on [**2142-2-16**], his foley was discontiued for a voiding trial. His bowel regimen was increased. PT and OT were consulted. KUB showed a decrease in air in small bowel and repeat head CT was stable. Pt was cleared to go to rehab on [**2142-2-19**] Medications on Admission: Coumadin 6 mg daily Verapamin ER 180 mg daily Simvastatin 20 mg daily Ibuprofen 600 mg PRN - arthritic pain Aspirin 81 mg daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, temp. 2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Verapamil 120 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours). 4. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Insulin Lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours). 9. Hydrocortisone Acetate 1 % Ointment Sig: One (1) Appl Rectal TID (3 times a day) as needed for PRN. 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 11. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for Constipation. 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for Constipation. 13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO TID (3 times a day). 15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 16. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Tablet(s) 18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 19. Ondansetron 4 mg IV Q8H:PRN nausea 20. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Hospital Discharge Diagnosis: Left Subdural Hematoma Left Superficial Femeral Deep Vein Thrombosis Left PCA infarct Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair but do not scrub surgical wound. Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Coumadin may be restarted on [**2142-2-26**] ?????? You have been prescribed an anti-seizure medicine, Keppra, take it as prescribed. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? You need to continue a strict bowel regimen. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. **** SUTURES ARE DISSOLVEABLE**** Please keep dry x 7days post-op. NO COUMADIN UNTIL [**2142-2-26**] Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 9403**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen on [**2142-3-8**] (this is one week post Coumadin). ??????You will need a CT scan of the brain without contrast. ??????You will need to follow up with Dr. [**Last Name (STitle) **] from Stroke Neurology please call ([**Telephone/Fax (1) 7394**] for an appointment. Your TTE was done inpatient prior to discharge. Completed by:[**2142-2-19**]",18,2142-02-13 21:28:00,2142-02-19 17:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,LONG TERM CARE HOSPITAL,SUBDURAL HEMATOMA," mr. [**known lastname 1794**] was admitted to [**hospital1 18**] under the care of dr [**first name (stitle) **]. he was taken to the or on the evening of [**2142-2-13**] for left craniotomy for sdh evacuation. he was left intubated and transported to the icu. he was extubated aorund noon on [**2142-2-14**]. he was mae with right sided weakness but not following commands. he became febrile to 101.8 early am on [**2142-2-15**]. sputum cultures were positive for gram + cocci in pairs. lens showed a left superficial femoral dvt that was either chronic or a new partially occlusive dvt. his pcp [**last name (namepattern4) **].[**last name (stitle) 1057**] was contact[**name (ni) **] at his new office [**telephone/fax (1) 14331**]. his office had records dating from [**2139**]. the patient has been on coumdain since then without a new diagnosis of dvt. therefore we determined that his origical dvt was prior to [**2139**] and this finding was consistant with new l dvt. venodynes were removed form the lle. hematology was consulted with regards to whether anticoagulation is warranted. in the context of a recent evacuation of the sdh and the small size of the dvt, it was felt that the patient can be initiated on subcutaneous heparin at prophylactic dose since the patient has an ivc filter in place. the joint decision between neurosurgery and hematology was to initiate anti-coagulation approxiamtely 2 weeks after the sdh evacuation. he was seen by the speach/swallow service. they recommended a pureed diet. his neruologic status was improved on 2.4 and transfer to the sdu was initiated. on [**2142-2-16**] he was neurologically stable in the sdu. levofloxacin was started in the setting of low grade fever and sputum with gram + cocci. ct head showed a l pca infarct. stroke neurology was consulted. work up revealed no evidence of embolic or thrombotic lesions. the patient will f/u with the neurology clinic for work up of hypercoagulability. also on [**2142-2-16**], his foley was discontiued for a voiding trial. his bowel regimen was increased. pt and ot were consulted. kub showed a decrease in air in small bowel and repeat head ct was stable. pt was cleared to go to rehab on [**2142-2-19**] ","PRIMARY: [Subdural hemorrhage] SECONDARY: [Compression of brain; Cerebral artery occlusion, unspecified with cerebral infarction; Pneumonia, organism unspecified; Hemiplegia, unspecified, affecting unspecified side; Acute venous embolism and thrombosis of deep vessels of proximal lower extremity; Long-term (current) use of anticoagulants; Personal history of venous thrombosis and embolism; Hip joint replacement; Other and unspecified hyperlipidemia; Unspecified essential hypertension; Obesity, unspecified]","known lastname 1794**] was admitted to [**hospital1 18**] under the care of dr [**first name (stitle) **]. he was extubated aorund noon on [**2142-2-14**]. the joint decision between neurosurgery and hematology was to initiate anti-coagulation approxiamtely 2 weeks after the sdh evacuation. the patient will f/u with the neurology clinic for work up of hypercoagulability. kub showed a decrease in air in small bowel and repeat head ct was stable.",sputum cultures showed a left superficial femoral dvt that was either chronic or a new partially occlusive dvt. the patient has been on coumdain since then without a new diagnosis of dvt. hematology was consulted with regards to whether anticoagulation is warranted. 54610,122829.0,19216,2150-07-15,19215,100003.0,2150-04-21,Discharge summary,"Admission Date: [**2150-4-17**] Discharge Date: [**2150-4-21**] Date of Birth: [**2090-5-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 12174**] Chief Complaint: coffee ground emesis Major Surgical or Invasive Procedure: EGD Right IJ CVL History of Present Illness: Mr. [**Known lastname 52368**] is a 59M w HepC cirrhosis c/b grade I/II esophageal varices and portal gastropathy (last EGD [**3-/2150**]), who p/w coffee-ground emesis and melena x2 days. . Pt was in his USOH until about 2-3 days PTA, when he began experiencing intermittent nausea. He had 2-3 episodes of coffee-ground emesis and 1 episode of tarry black stool in the morning of admission. He reports some lightheadedness which is not new, but denies frank hematemesis, BRBPR, abdominal pain, fever, chills, significant increases in his abdominal girth. He denies drinking or medication non-compliance. He also reports taking naproxen for back pain 2-3 times a day in the recent past. . In the ED, his vitals were 97.4, 93/41, 69, 18, 100% on RA. He was given 4L NS IV, protonix 40mg IV, started on an octreotide drip. He had guaiac positive brown stool on rectal exam. He was seen by the liver fellow in the ED who felt this was unlikely a variceal bleed and recommended work up for infection. An NG tube was attempted, however, patient was unable to tolerate it in the ED. Abdominal ultrasound was done which showed a patent portal vein, scant ascites but not enough to tap. BP dropped to 80/34, pt transferred to MICU for hemodynamic monitoring. . In the MICU, pt was given 3 pRBC, Hct bumped from 21.3 to 28. Started on norepinephrine gtt for a few hours, but BP stabilized. On transfer to the floor, remains hemodynamically stable. Feels good, denies tarry or bloody BMs, emesis. Past Medical History: HCV Cirrhosis (tx with interferon x2 with no response) Portal Gastropathy Grade II Esophageal varices HTN Social History: He lives alone. He is drinking alcohol, usually one session per week. He has four to five drinks per session. He was told to completely abstain from alcohol, effective as of today. He smokes about 20 cigarettes per day. Family History: NC Physical Exam: ON ADMISSION: VS: T95.9 HR 71 BP 83/36 RR 11 96% 2L NC Gen: somnolent, oriented x 3, unable to assess for asterixis given somnolence HEENT: PERRLA, EOMI Neck: supple, JVP at angle of jaw (fluid bolus running wide open) CV: RRR s1 s2 no appreciable murmur Lungs: CTAB Abd: distended, non tender, no rebound or guarding, bowel sounds positive Ext: 1+ pitting edema bilaterally Skin: warm, diaphoretic, no rash or lesions noted Pertinent Results: LABS ON ADMISSION: [**2150-4-17**] 01:30PM BLOOD WBC-17.9*# RBC-2.78* Hgb-8.5* Hct-26.0* MCV-94 MCH-30.6 MCHC-32.7 RDW-20.6* Plt Ct-186 [**2150-4-17**] 01:30PM BLOOD Neuts-61.2 Lymphs-28.8 Monos-6.9 Eos-2.2 Baso-0.9 [**2150-4-17**] 02:13PM BLOOD PT-17.7* PTT-34.5 INR(PT)-1.6* [**2150-4-17**] 01:30PM BLOOD Glucose-92 UreaN-51* Creat-1.3* Na-131* K-5.7* Cl-104 HCO3-21* AnGap-12 [**2150-4-17**] 01:30PM BLOOD ALT-126* AST-260* LD(LDH)-426* AlkPhos-157* TotBili-3.3* [**2150-4-17**] 06:41PM BLOOD Calcium-7.5* Phos-3.8 Mg-1.9 . LABS ON DISCHARGE: [**2150-4-21**] 05:00AM BLOOD WBC-10.7 RBC-2.94* Hgb-9.6* Hct-27.0* MCV-92 MCH-32.6* MCHC-35.6* RDW-21.2* Plt Ct-110* [**2150-4-21**] 05:00AM BLOOD PT-17.4* PTT-35.6* INR(PT)-1.6* [**2150-4-21**] 05:00AM BLOOD Glucose-84 UreaN-15 Creat-1.0 Na-132* K-4.4 Cl-99 HCO3-25 AnGap-12 [**2150-4-21**] 05:00AM BLOOD ALT-113* AST-210* AlkPhos-111 TotBili-3.6* [**2150-4-21**] 05:00AM BLOOD Calcium-8.1* Phos-3.8 Mg-1.7 . OTHER LABS: [**2150-4-18**] 06:25AM BLOOD CK-MB-9 cTropnT-<0.01 [**2150-4-17**] 06:41PM BLOOD CK-MB-11* MB Indx-4.9 cTropnT-<0.01 [**2150-4-17**] 01:30PM BLOOD Lipase-85* . URINE: [**2150-4-17**] 11:01PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2150-4-17**] 11:01PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-NEG [**2150-4-17**] 11:01PM URINE RBC-63* WBC-7* Bacteri-NONE Yeast-NONE Epi-<1 . MICROBIOLOGY: Blood, urine cultures - negative H.pylori serum antibody - negative . CARDIOLOGY: . TTE ([**4-18**]): Conclusions The left atrium is dilated. Left ventricular wall thicknesses and cavity size are normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Hyperdynamic LV systolic function. Mild mitral regurgitation. Moderate pulmonary artery systolic hypertension. . EKG ([**4-17**]): Sinus rhythm Prolonged QT interval is nonspecific but clinical correlation is suggested No previous tracing available for comparison Intervals Axes Rate PR QRS QT/QTc P QRS T 70 160 96 462/479 70 55 52 . GI: EGD ([**4-20**]): 1. Varices at the lower third of the esophagus and middle third of the esophagus. 2. Erythema and erosion in the antrum and pylorus compatible with non-steroidal induced gastritis. 3. Bleeding from a pyloric ulcer in the pylorus compatible with non-steroidal induced ulcer (injection, thermal therapy). 4. Normal mucosa in the duodenum. 5. Otherwise normal EGD to third part of the duodenum . RADIOLOGY: . CXR ([**4-17**]): The prominent bulge to the right heart border could be due to pericardial effusion, _____ cyst, and enlarged right atrium. There is no mediastinal vascular engorgement to suggest cardiac tamponade. Pulmonary vasculature is normal. The lungs are clear and there is no pleural effusion. Overall heart size is normal. Right jugular line ends at the junction of the brachiocephalic veins. No pneumothorax or pleural effusion. . ABD U/S ([**4-17**]): IMPRESSION: 1. No son[**Name (NI) 493**] evidence for portal venous thrombosis. Portal vein flow is hepatopetal and wall-to-wall. 2. No significant ascites. A sliver of perihepatic ascites. 3. Persistent coarsened echotexture of the liver consistent with known history of cirrhosis. 4. Splenomegaly Brief Hospital Course: Mr [**Known lastname 52368**] is a 59M w HCV cirrhosis w grade II esophageal varices admitted w coffee-ground emesis and melena concerning for UGIB, s/p MICU stay for hypotension. . # UGIB: Pt did not have any more bleeds while in hospital. EGD revealed erythema and erosion in the antrum and pylorus compatible with non-steroidal induced gastritis. Pt did remember taking increased doses of naproxen for backache. Started on pantoprazole 40mg PO BID for one week with repeat endoscopy scheduled in one week ([**4-30**]). Recommended to take tylenol (max daily dose of 2gm) for pain instead of NSAIDs. Blood pressure meds were held at first, given MICU admission for hypotension, but were restarted on discharge. . # HCV Cirrhosis: appears to be progressing to liver failure, with elevated INR at 1.6, decreased albumin at 2.6, tbili slightly elevated at 3.6, and chronic LE edema. Pt was continued on prophylactic medications. . # FULL CODE Medications on Admission: FUROSEMIDE 20mg daily LISINOPRIL 10 mg daily SPIRONOLACTONE 100 mg daily Discharge Medications: 1. Phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous membrane PRN (as needed). 2. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**6-15**] hours as needed: no more than 6 tablets of regular strength tylenol per day. 8. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 1 weeks. Disp:*qs * Refills:*0* 9. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day for 1 weeks: then take 1 tablet daily. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. Disp:*qs * Refills:*0* 12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Peptic ulcer GI bleed Discharge Condition: asymptomatic Discharge Instructions: You were admitted for bleeding from an ulcer in your stomach. This ulcer is at least partially caused by naproxen. You should stop taking naproxen and take only tylenol for pain. You should not take any NSAIDS for pain including ibuprofen, naproxen, aleve, motrin, aspirin, toradol, or advil. It is okay to take tylenol but do not take more than 4 extra strength tylenol a day (2gram daily maximum). . The following medication changes were made: Do not take naproxen Take pantoprazole 40 mg twice daily for one week. Then take 40 mg daily. . You are scheduled to get a repeat endoscopy next week. Prior to the procedure do not have anything to drink or eat after midnight. . Please return to the ER if you have any chest pain, lightheadeness, fever, chills, bloody or black stools or any other concerning symptoms. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2150-4-30**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7290**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2150-4-30**] 1:30 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2150-5-7**] 11:00 Completed by:[**2150-4-24**]",85,2150-04-17 15:34:00,2150-04-21 17:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,UPPER GI BLEED," mr [**known lastname 52368**] is a 59m w hcv cirrhosis w grade ii esophageal varices admitted w coffee-ground emesis and melena concerning for ugib, s/p micu stay for hypotension. . # ugib: pt did not have any more bleeds while in hospital. egd revealed erythema and erosion in the antrum and pylorus compatible with non-steroidal induced gastritis. pt did remember taking increased doses of naproxen for backache. started on pantoprazole 40mg po bid for one week with repeat endoscopy scheduled in one week ([**4-30**]). recommended to take tylenol (max daily dose of 2gm) for pain instead of nsaids. blood pressure meds were held at first, given micu admission for hypotension, but were restarted on discharge. . # hcv cirrhosis: appears to be progressing to liver failure, with elevated inr at 1.6, decreased albumin at 2.6, tbili slightly elevated at 3.6, and chronic le edema. pt was continued on prophylactic medications. . # full code ","PRIMARY: [Acute gastric ulcer with hemorrhage, without mention of obstruction] SECONDARY: [Acute posthemorrhagic anemia; Chronic hepatitis C without mention of hepatic coma; Cirrhosis of liver without mention of alcohol; Esophageal varices in diseases classified elsewhere, without mention of bleeding; Other specified disorders of stomach and duodenum; Unspecified essential hypertension; Unspecified gastritis and gastroduodenitis, without mention of hemorrhage; Edema]","mr [**known lastname 52368**] is a 59m w hcv cirrhosis w grade ii esophageal varices admitted w coffee-ground emesis and melena concerning for ugib, s/p micu stay for hypotension. pt did remember taking increased doses of naproxen for backache.",mr [**known lastname 52368**] is a 59m w hcv cirrhosis w grade ii esophageal varices admitted w coffee-ground emesis and melena concerning for ugib. egd revealed erythema and erosion in the antrum and pylorus compatible with non-steroidal induced gastritis. started on pantoprazole 40mg po 54610,147673.0,19217,2150-12-28,19216,122829.0,2150-07-15,Discharge summary,"Admission Date: [**2150-7-13**] Discharge Date: [**2150-7-15**] Date of Birth: [**2090-5-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 949**] Chief Complaint: Blood in rectum; Possible confusion Major Surgical or Invasive Procedure: None History of Present Illness: 60 yo M with Hep C cirrhosis, grade II esophageal varices, recent admission for UGIB [**2-9**] NSAID gastritis, referred for admission throught the ED by hepatology clinic. Pt had called in to ask about recent medication changes and was noted by NP to have slurred speech and tangentail thought process. Also relayed hx of new imbalance leading to a fall during which he may have hit his head on [**7-7**]. Per his brother (who lives in [**State **] but speks to him by phone regularly), his speech has been off baseline since his discharge in [**2150-4-8**]. Pt's partner who lives in the area could not be contact[**Name (NI) **] to corroborate. Per last liver clinic note has been off ETOH since [**Month (only) **] (corroborated with pt) and if stays off may be candidate for transplant list in [**2150-9-8**]. . In the ED, initial vs were: T=97.8 P=73 BP R O2 sat. Routine rectal exam revealed bright red blood in rectum and Hct was 30 which down from last measurement on [**7-7**] but not really deviating from recent baseline. Pt did not tolerate NG tube placement. Seen by hepatology and started on IV PPI and octreotide drip. Hemodynamically stable throughout entire ED course. NCHCT done to r/o bleed given hx of head injury was unremarkable. . Neuro was consulted shortly after arrival to floor regarding concern for facial droop and slurrred speech. Per their initial eval, not concerning for acute ischemic infarct. Past Medical History: HCV Cirrhosis (tx with interferon x2 with no response) Portal Gastropathy Grade II Esophageal varices HTN Recent admission [**4-/2150**]: UGIB [**2-9**] non-steroidal induced gastritis Social History: He lives alone. He is drinking alcohol, usually one session per week. He has four to five drinks per session. He was told to completely abstain from alcohol, effective as of today. He smokes about 20 cigarettes per day. Family History: NC Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admit Labs: WBC-13.6* RBC-3.10* Hgb-10.7* Hct-30.8* MCV-100* MCH-34.6* MCHC-34.8 RDW-20.0* Plt Ct-132* Neuts-61 Bands-6* Lymphs-14* Monos-14* Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-2* Promyel-1* Hypochr-NORMAL Anisocy-2+ Poiklo-1+ Macrocy-3+ Microcy-NORMAL Polychr-OCCASIONAL Target-1+ Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] Plt Smr-LOW Plt Ct-132* PT-15.8* PTT-34.2 INR(PT)-1.4* Glucose-126* UreaN-28* Creat-1.1 Na-123* K-4.8 Cl-93* HCO3-24 AnGap-11 Calcium-8.5 Phos-3.4 Mg-1.9 ALT-132* AST-228* CK(CPK)-346* AlkPhos-193* TotBili-7.6* CK-MB-11* MB Indx-3.2 cTropnT-<0.01 Ethanol-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.006 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG Hapto-<20* On discharge: WBC-11.2* RBC-3.23* Hgb-10.8* Hct-32.3* MCV-100* MCH-33.4* MCHC-33.4 RDW-18.8* Plt Ct-136* PT-15.7* PTT-33.1 INR(PT)-1.4* Glucose-116* UreaN-26* Creat-1.1 Na-123* K-5.3* Cl-94* HCO3-22 AnGap-12 ALT-131* AST-239* AlkPhos-137* TotBili-8.9* Studies: CT Head Without Contrast - No acute intracranial process. CXR (PA/Lat) - No evidence of acute cardiopulmonary abnormalities. Hyperinflated lungs. EKG: Sinus rhythm. Normal tracing. Brief Hospital Course: # Concern for GI Bleed - Considering that the patient had stable hematocrits after his admission to the hospital and that blood was only found in his rectum on exam, it was felt that he was not experiencing a significant GI bleed. Nevertheless, he was admitted to the ICU for monitoring overnight. He was kept on an octreotide drip and an IV PPI overnight. His hematocrit remained stable overnight and he did not have any GI bleeding events. The following day, he was transferred to the floor. He is scheduled for an outpatient colonoscopy with Dr. [**Last Name (STitle) **]. # Altered mental status - The patient presented with a history of unstable gait, a possible facial droop, and slurred speech of questionable chronicity. This combination, in conjunction with normal hematocrit, was concerning for ischemic stroke. Neurology was consulted. Neurology felt that the patient's symptoms were possibly metabolic in nature and mentioned that hyponatremia could contribute to falls and a change in mental status. The patient was also started on lactulose secondary to his having possibly mental status changes in the setting of liver disease. Considering his alcohol history, he was also started on thiamine and folate. # Hepatitis C Cirrhosis and Worsening LFTs - The most striking change in the patient's liver function tests was the increase in his total and direct bilirubin. Another worrisome feature was the increase in the patient's AFP. This could be progression of cirrhosis as he failed interferon twice. He is to follow-up with Dr. [**Last Name (STitle) **] as an outpatient to work this up. # Alcohol Abuse - According to the patient and the hepatology clinic notes, the patient has quit using alcohol. On admit, he was started on thiamine and folate. He was also placed on the CIWA protocol as needed, in case he had been drinking. Of note, the patient was negative for alcohol on admission. . # Abnormal Differential - On his admit labs, the patient had an abnormal differential, and he complained of a sore throat prior to admission with thrush seen per patient. He had a repeat differential that was also abnormal. His chest x-ray and urinalysis were negative. He was afebrile throughout hospital course. Medications on Admission: CLOBETASOL 0.05 % Ointment twice a day FLUOCINOLONE 0.025 % Cream FUROSEMIDE 40 mg daily GABAPENTIN 300 mg Capsule; [**1-10**] Capsule(s) by mouth once daily takes prn for sleep or itch LISINOPRIL 10 mg Tablet daily NADOLOL 20 mg Tablet daily PANTOPRAZOLE 40 mg daily SPIRONOLACTONE 100 mg daily ACETAMINOPHEN 500 mg Tablet as needed for 2-3 times daily prn Discharge Medications: 1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime) as needed for SLEEP/ITCH. 3. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO TID (3 times a day). Disp:*1 bottle* Refills:*3* 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO three times a day. Disp:*180 Tablet(s)* Refills:*2* 9. Lasix 20 mg Tablet Sig: [**1-9**] Tablet PO once a day: please hold this medication for now. 10. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: encephalopathy hyponatremia Discharge Condition: stable Discharge Instructions: You were admitted to the hospital for confusion and slurred speech. The neurologists saw you and thought this was not related to your brain. You were found to have some blood in your stool but your blood count did not significantly drop. You will need a colonoscopy to evaluate this as an outpatient. . Your blood work also showed low sodium. You should restrict your fluid intake to one liter (32 oz) daily. Do not eat or drink ice and ice chips. Limit popsicles to [**2-10**] daily. Please hold the lasix and Sprinonolactone until you have labs checked and discuss this with Dr. [**Last Name (STitle) **]. You should go to the lab in the [**Hospital Unit Name **] on [**Doctor First Name **] to have your sodium checked on Monday. . The following medications were changed: - stop lasix and spironolactone temporarily - start taking lactulose to improve confusion - start taking rifaxamin to improve confusion Please keep your appointments as listed below. If you experience lots of bleeding from your rectum, vomiting blood or worsening confusion, go to the ER. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2150-7-28**] 8:45 . Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2150-10-6**] 10:15 Provider: [**Name10 (NameIs) **] [**Apartment Address(1) **] (ST-3) GI ROOMS Date/Time:[**2150-8-5**] 8:30 ",166,2150-07-13 18:56:00,2150-07-15 17:40:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ALTERED MENTAL STATUS," # concern for gi bleed - considering that the patient had stable hematocrits after his admission to the hospital and that blood was only found in his rectum on exam, it was felt that he was not experiencing a significant gi bleed. nevertheless, he was admitted to the icu for monitoring overnight. he was kept on an octreotide drip and an iv ppi overnight. his hematocrit remained stable overnight and he did not have any gi bleeding events. the following day, he was transferred to the floor. he is scheduled for an outpatient colonoscopy with dr. [**last name (stitle) **]. # altered mental status - the patient presented with a history of unstable gait, a possible facial droop, and slurred speech of questionable chronicity. this combination, in conjunction with normal hematocrit, was concerning for ischemic stroke. neurology was consulted. neurology felt that the patients symptoms were possibly metabolic in nature and mentioned that hyponatremia could contribute to falls and a change in mental status. the patient was also started on lactulose secondary to his having possibly mental status changes in the setting of liver disease. considering his alcohol history, he was also started on thiamine and folate. # hepatitis c cirrhosis and worsening lfts - the most striking change in the patients liver function tests was the increase in his total and direct bilirubin. another worrisome feature was the increase in the patients afp. this could be progression of cirrhosis as he failed interferon twice. he is to follow-up with dr. [**last name (stitle) **] as an outpatient to work this up. # alcohol abuse - according to the patient and the hepatology clinic notes, the patient has quit using alcohol. on admit, he was started on thiamine and folate. he was also placed on the ciwa protocol as needed, in case he had been drinking. of note, the patient was negative for alcohol on admission. . # abnormal differential - on his admit labs, the patient had an abnormal differential, and he complained of a sore throat prior to admission with thrush seen per patient. he had a repeat differential that was also abnormal. his chest x-ray and urinalysis were negative. he was afebrile throughout hospital course. ","PRIMARY: [Chronic hepatitis C with hepatic coma] SECONDARY: [Hyposmolality and/or hyponatremia; Hemorrhage of rectum and anus; Portal hypertension; Esophageal varices in diseases classified elsewhere, without mention of bleeding; Alcoholic cirrhosis of liver; Other and unspecified alcohol dependence, unspecified; Anemia, unspecified; Other specified disorders of stomach and duodenum; Unspecified gastritis and gastroduodenitis, without mention of hemorrhage; Unspecified essential hypertension; Tobacco use disorder]","# concern for gi bleed - considering that the patient had stable hematocrits after his admission to the hospital and that blood was only found in his rectum on exam, it was felt that he was not experiencing a significant gi bleed. he is scheduled for an outpatient colonoscopy with dr. [** # altered mental status - the patient presented with a history of unstable gait, a possible facial droop, and slurred speech of questionable chronicity. # hepatitis c cirrhosis and worsening lfts - the most striking change in the patients liver function tests was the increase in his total and direct bilirubin. this could be progression of cirrhosis as he failed interferon twice.","the patient had stable hematocrits after his admission to the hospital and that blood was only found in his rectum on exam. he was kept on an octreotide drip and an iv ppi overnight. his hematocrit remained stable overnight and he did not have any gi bleeding events. the following day, he was transferred to the floor and is scheduled for an outpatient colonoscopy." 61932,165934.0,15105,2159-07-20,15104,126267.0,2159-05-22,Discharge summary,"Admission Date: [**2159-5-7**] Discharge Date: [**2159-5-22**] Date of Birth: [**2093-11-29**] Sex: M Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1835**] Chief Complaint: Right hand clumsiness Major Surgical or Invasive Procedure: [**5-9**]->Left Craniotomy for mass resection [**5-14**]->Right Craniotomy for mass resection History of Present Illness: 65 y/o male who has had right arm weakness/clumsiness characterized by dropping of objects difficulty with position sensation, went to [**Hospital6 **] on [**5-7**] when symptoms became worse. Ct of the head showed an area of hemorrhage in the left temp/ parietal lobe and an MRI revealed two lesions one in the right and one in the left temp. parietal regions. He was then transferred to [**Hospital1 18**] for definitive neurosurgical care Past Medical History: Melanoma lesion on left posterior neck resected two years ago with clear margins. Diverticulosis s/p partial bowel resection Social History: Married, One glass of wine/day, remote smoking history 30 years ago for 20yrs/pk/day Family History: father-leukemia [**Name (NI) 44090**] CA Physical Exam: Exam upon admission: T:98.6 BP: 153 /100 HR: 80 R:18 O2Sats:98% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: L 7mm flicker, R 6 to 4 brisk EOMs: intact Neck: Supple. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-27**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, as above. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. Right hand grip strength 4/5, finger to nose dysmetria and pronator drift. No abnormal movements. Left arm strength full. Sensation: Intact to light touch Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally No clonus Exam on Discharge: The patient is dysarthric. He is oriented x 3. He has a slightly flattened left nasal labial fold. Pupils are PERRL. He has persistant right upper extremity weakness, and left upper extremity weakness that is steroid dose dependent. His distal(LE) strength is full. Sensation is intact. Both wounds are clean, dry and intact; without erythema or drainage. Sutures have been removed. Pertinent Results: Labs on Admission: [**2159-5-7**] 12:20AM BLOOD WBC-10.3 RBC-4.61 Hgb-13.9* Hct-40.4 MCV-88 MCH-30.2 MCHC-34.5 RDW-13.2 Plt Ct-361 [**2159-5-7**] 12:20AM BLOOD Neuts-87.4* Lymphs-9.2* Monos-2.2 Eos-0.8 Baso-0.4 [**2159-5-7**] 12:20AM BLOOD PT-14.1* PTT-27.5 INR(PT)-1.2* [**2159-5-7**] 03:30AM BLOOD Calcium-9.4 Phos-2.4* Mg-2.1 Labs on Discharge: XXXXXXXXXXX Imaging: CT Torso [**2159-5-7**]: CT CHEST: The left thyroid is enlarged and heterogeneous without focal lesion. A 2.9 x 2.1 cm left lower lobe subpleural lung mass (3:42) and a 5 mm right upper lobe nodule (3:40) are noted. Calcified nodule near the right hilum (3:33) likely represents sequela of prior granulomatous disease. There is no mediastinal adenopathy. Several enlarged right axillary lymph nodes measure up to 25 x 22 mm (3:22). Heart size is normal. There is no pericardial effusion. The pulmonary arteries are patent to the segmental level. CT ABDOMEN: The gallbladder, spleen, adrenals, and pancreas are unremarkable. Well-circumscribed hypodense subcentimeter liver lesion in segment III (3:50) likely represents a cyst but is not fully characterized. The liver is otherwise unremarkable without evidence of intra- or extra-hepatic biliary dilatation or focal lesion. Both kidneys demonstrate several subcentimeter well- circumscribed lesions which likely represent cysts but are not fully characterized. There is extensive descending and distal transverse colon diverticulosis without evidence of diverticulitis. The intra-abdominal loops of large and small bowel are otherwise unremarkable without evidence of pneumatosis, free air, or obstruction. There is no mesenteric or retroperitoneal lymphadenopathy. CT PELVIS: The bladder, rectum, and prostate are unremarkable. There is extensive sigmoid diverticulosis without evidence of diverticulitis. Bone windows demonstrate no lesion that is concerning for metastasis or infection. Mild multilevel degenerative changes are noted. IMPRESSION: 1. Left lower lobe lung mass likely represents metastasis, although tissue diagnosis can be obtained if indicated. 2. Right axillary lymphadenopathy likely reflects metastatic recurrence. 3. Heterogeneous left thyroid should be further evaluated on thyroid ultrasound. 4. Extensive diverticulosis without evidence of diverticulitis. Head CT [**5-7**]: FINDINGS: In the right frontotemporal region, there is a 2.5 x 3.3 cm hypodensity with fine hyperdense rim and surrounding vasogenic edema (series 2, image 19). This is essentially identical in size to the lesion defined on the MR (2.6 x 3.3 cm). There is slight effacement of the subjacent body of the right lateral ventricle but no significant shift of the midline structures. At the left frontovertex, there is 2.2 x 3.0 cm hyperdense lesion, with mild surrounding vasogenic edema and overlying subarachnoid hemorrhage, similar in size to the lesion defined on the MR (2.0 x 2.7 cm). At the posterolateral aspect of this process, there is an ovoid isodense focus measuring 1.2 x 0.9 cm (2:24), corresponding to the enhancing peripheral nodule on the MR. [**Name13 (STitle) **] other foci of acute hemorrhage are seen. There is no fracture. There is no osteolytic or- blastic lesion. Mastoid air cells and paranasal sinuses are clear. No subcutaneous nodules are demonstrated. IMPRESSION: Unchanged appearance of right frontotemporal lesion and left frontovertex hemorrhagic lesion, likely metastases (for further details, please refer to the MR [**First Name (Titles) 767**] [**Hospital6 1597**]). MRI Head [**5-11**](post-rsxn): FINDINGS: The patient is status post left parietal craniotomy, in comparison with the prior study, the previously described left frontal lobe mass lesion, has been resected. The T1 sequence without contrast demonstrates a nodular area of hyperintensity signal, likely consistent with blood products and apparently unchanged after the administration of gadolinium contrast. Restricted diffusion is noted adjacent in the posterior margin of the surgical area, blooming artifacts and magnetic susceptibility changes are visualized in the surgical bed. The pattern of vasogenic edema is unchanged. The right frontoparietal deep white matter lesion is unchanged and demonstrates again thick rim enhancement as well as mural enhancement as described in the prior examination. Normal flow void signal is identified in the major vascular structures, the orbits, the paranasal sinuses and mastoid air cells are unremarkable. IMPRESSION: 1. Status post left parietal craniotomy, there is a nodular area of hyperintensity signal in the surgical bed and posterior surgical margin, likely consistent with blood products, however residual mass lesion is a consideration, follow-up is recommended. 2. Similar pattern of vasogenic edema, the right frontoparietal deep white matter lesion is unchanged. Head CT [**5-14**](post-rsxn) FINDINGS: Again noted are left parietal craniotomy changes, with air seen within the surgical bed, similar in appearance to prior study. Residual vasogenic edema within the left frontal and parietal lobes are again noted. Minimal focus of hemorrhage within the surgical bed is also unchanged. In the interim, there has been interval right frontal craniotomy, with post-surgical changes seen, with pneumocephalus, small foci of hemorrhage. There is residual vasogenic edema. Additionally, there is pneumocephalus overlying the right frontal lobe, as well as small subdural collections bilaterally. No new foci of hemorrhage are identified. Ventricles and sulci are normal in caliber and configuration. There is no shift of normally midline structures. Visualized paranasal sinuses are normally aerated. IMPRESSION: 1. Interval right frontal craniotomy, with expected post-surgical changes within the surgical bed, with pneumocephalus, small amount of hemorrhage. 2. Stable post-surgical changes within the left parietal lobe, following surgical resection. Head CT [**5-16**]: NON-CONTRAST HEAD CT: There has been no significant interval change since one day prior. There are bilateral craniotomies with post-surgical changes in the left parietal lobe, including a tiny amount of pneumocephalus, residual postoperative hemorrhage and vasogenic edema. Within the right temporal and parietal resection bed, there is pneumocephalus, hemorrhage and edema. Postoperative hemorrhage is stable measuring 5.7 x 4.1 cm. There is stable minimal shift of midline structures, of approximately 3 mm leftward shift. No new foci of hemorrhage are identified. The visualized paranasal sinuses and mastoid air cells are clear. IMPRESSION: No significant change in the right temporoparietal lobe resection bed hemorrhage and additional postoperative edema and pneumocephalus within the left cerebral hemisphere. Head CT [**5-17**]: FINDINGS: Patient is status post bilateral craniotomies. Within the surgical bed in the right temporal and parietal lobes, there is residual hemorrhage, pneumocephalus, and vasogenic edema. Compared to the prior study, there has been no interval change in size of the residual hemorrhage. Postoperative changes in the left parietal lobe with tiny residual hemorrhage, pneumocephalus, and vasogenic edema are also stable. There is a minimal leftward shift of normally midline structures of approximately 3 mm, unchanged. There are no new foci of hemorrhage. Ventricles and sulci are normal in caliber and configuration without evidence of hydrocephalus. Visualized paranasal sinuses and mastoid air cells are normally aerated. IMPRESSION: 1. No significant interval change from the prior study in the postoperative hemorrhage within the right temporoparietal lobe resection bed. 2. Stable post-surgical changes with the left parietal resection bed. LENIS [**5-15**]: BILATERAL LOWER EXTREMITY ULTRASOUND: Grayscale and color Doppler imaging of the right and left common femoral, superficial femoral and popliteal veins demonstrate normal compressibility, augmentation, waveforms and flow. The peroneal veins are unremarkable. IMPRESSION: No lower extremity DVT. EKG [**5-7**]: Sinus rhythm Modest ST junctional depression is nonspecific and may be within normal limits, but clinical correlation is suggested No previous tracing available for comparison Intervals Axes Rate PR QRS QT/QTc P QRS T 89 156 98 366/416 28 -25 5 Brief Hospital Course: The patient was admitted to the neurosurgery service on [**5-7**]. On [**5-9**] he went to the operating room for a left sided craniotomy to resect the first of two brain lesions. Post-operatively he was monitored in the ICU for 24hrs without incident. He was then transferred to the neurosurgery floor for continued planning for the resection of the right sided lesion. During his hospital stay, neuro oncology and radiation oncology were consulted for this patient. On 4.20, he underwent right sided craniotomy for debulking of said lesion prior to cyberknife therapy could be started. Post operatively, he was again transferred to the ICU for continued monitoring. On POD#1 he was found to have new weakness in the left upper extremity, and to be more lethargic. A head CT was immediately done and there was new bleeding identified in the right sided resection cavity, as well as increased vasogenic edema. He did not worsen neurologically that day, so head CT was again repeated on [**5-16**]. Vasogenic edema was again noted, and lethargy persisted. It was decided to increase the dose of his steroids from 4mg three times daily to 6mg four times daily. The patient was improving neurologically and was transferred to the stepdown unit on [**2159-5-17**]. He was evaluated by neuro-oncology and was scheduled for a Brain [**Hospital 341**] Clinic appointment. PT and OT evaluated the patient and recommended rehab placement. His diet was advanced to regular and he tolerated that well. His steroids were initially decreased to 3mg QID, but had recurrance of left upper extremity weakness. The steroids were again increased to 4mg QID; and to remain at this dose until WBR therapy was initiated and could have this re-evaluated. On [**5-21**],he was transported to the [**Hospital1 18**] [**Hospital Ward Name **] to receive mapping planning for WBR. He tolerated this well, and was returned to the [**Hospital Ward Name **]. He was then discharged to an appropriate rehab facility on [**2159-5-22**] with follow up scheduled in the brain tumor clinic. Medications on Admission: [**Hospital1 **] Benadryl prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 11. Regular Insulin Sliding Scale Regular Insulin Sliding Scale per nursing flow sheet Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Right fronto-temporal, and left frontovertex brain lesions Discharge Condition: Neurologically Stable Discharge Instructions: General Instructions/Information ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may shower and wash your head normally, as your sutures have been removed prior to discharge. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? You have been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? You are being sent home on steroid medication, make sure you are taking a medication to protect your stomach (Prilosec, Protonix, or Pepcid), as these medications can cause stomach irritation. Make sure to take your steroid medication with meals, or a glass of milk. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: increasing redness, increased swelling, increased tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**8-3**] days (from your 2nd surgery) for a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????You have an appointment in the Brain [**Hospital 341**] Clinic with Dr. [**Last Name (STitle) 724**] [**Telephone/Fax (1) 1844**]. It is on [**2159-6-4**] at 2:00 pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of [**Hospital1 18**], on [**Hospital Ward Name 23**] 8. ??????You will not need an MRI of the brain as this was done during your acute hospitalization Completed by:[**2159-5-22**]",59,2159-05-07 01:43:00,2159-05-22 14:55:00,EMERGENCY,EMERGENCY ROOM ADMIT,LONG TERM CARE HOSPITAL,HEAD MASS," the patient was admitted to the neurosurgery service on [**5-7**]. on [**5-9**] he went to the operating room for a left sided craniotomy to resect the first of two brain lesions. post-operatively he was monitored in the icu for 24hrs without incident. he was then transferred to the neurosurgery floor for continued planning for the resection of the right sided lesion. during his hospital stay, neuro oncology and radiation oncology were consulted for this patient. on 4.20, he underwent right sided craniotomy for debulking of said lesion prior to cyberknife therapy could be started. post operatively, he was again transferred to the icu for continued monitoring. on pod#1 he was found to have new weakness in the left upper extremity, and to be more lethargic. a head ct was immediately done and there was new bleeding identified in the right sided resection cavity, as well as increased vasogenic edema. he did not worsen neurologically that day, so head ct was again repeated on [**5-16**]. vasogenic edema was again noted, and lethargy persisted. it was decided to increase the dose of his steroids from 4mg three times daily to 6mg four times daily. the patient was improving neurologically and was transferred to the stepdown unit on [**2159-5-17**]. he was evaluated by neuro-oncology and was scheduled for a brain [**hospital 341**] clinic appointment. pt and ot evaluated the patient and recommended rehab placement. his diet was advanced to regular and he tolerated that well. his steroids were initially decreased to 3mg qid, but had recurrance of left upper extremity weakness. the steroids were again increased to 4mg qid; and to remain at this dose until wbr therapy was initiated and could have this re-evaluated. on [**5-21**],he was transported to the [**hospital1 18**] [**hospital ward name **] to receive mapping planning for wbr. he tolerated this well, and was returned to the [**hospital ward name **]. he was then discharged to an appropriate rehab facility on [**2159-5-22**] with follow up scheduled in the brain tumor clinic. ","PRIMARY: [Secondary malignant neoplasm of brain and spinal cord] SECONDARY: [Intracerebral hemorrhage; Secondary malignant neoplasm of lung; Secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb; Iatrogenic cerebrovascular infarction or hemorrhage; Cerebral edema; Personal history of malignant melanoma of skin; Lack of coordination; Other musculoskeletal symptoms referable to limbs; Dysphagia, unspecified; Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation; Diverticulosis of colon (without mention of hemorrhage); Personal history of tobacco use]","the patient was admitted to the neurosurgery service on [**5-7**]. on [**5-9**] he went to the operating room for a left sided craniotomy to resect the first of two brain lesions. post operatively, he was again transferred to the icu for continued monitoring. the steroids were again increased to 4mg qid; and to remain at this dose until wbr therapy was initiated and could have this re-evaluated. on [**5-21**],he was transported to the [**hospital1 18**] [**hospital ward name **] to receive mapping planning for wbr.",the patient underwent a left sided craniotomy to resect the first of two brain lesions. post operatively he was monitored in the icu for 24hrs without incident. he was evaluated by neuro-oncology and was scheduled for a brain clinic appointment. 65449,169230.0,9518,2193-01-21,9517,187354.0,2192-12-26,Discharge summary,"Admission Date: [**2192-12-23**] Discharge Date: [**2192-12-26**] Date of Birth: [**2168-10-28**] Sex: M Service: MEDICINE Allergies: Cozaar / Spironolactone Attending:[**First Name3 (LF) 4765**] Chief Complaint: SOB/DOE Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 32362**] is a 24 year old man with a history of non-ischemic cardiomypathy (EF 15-20%) and morbid obesity who presents with shortness of breath, lower extremity edema and abdominal distention for the past 2 weeks. He states that on the day of admission ([**2191-12-24**]) he felt short of breath and a chest tightness described as ""pulling"" sensation in the center of his chest, worse with deep inspiration. He reports decreased expercise tolerance and is only able to ambulate [**12-22**] a block (previously could ambulate several blocks). He can climb 1 flight of stairs. He denies dietary indiscretion and states he has been taking all medications as prescribed. He has 3 pillow orthopnea which has worsened in the past few weeks. He denies overt chest pain, PND, diarrhea, constipation, fever, chills, night sweats, nausea, vomiting, dysuria. ROS is positive for chronic cough x 1 year. He was supposed to have an EP study with or without AICD placement on [**11-20**] that was postponed to [**2193-1-2**] for symptoms akin to a cold. (No record in chart) On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. In the ED, initial vitals were 99.6 63 146/95 32 95% RA. He triggered in the ED for tachypnea with a RR of 32 and his HR was 110-120s and sinus during his ED stay. He received 1 SL NTG, ASA 325mg and Lasix 40mg IV x 1, to which he put out 850ml of urine and reported feeling improvement in symptoms Past Medical History: 1. Presumed Idiopathic dilated cardiomyopathy, EF 15-20% (echo [**9-28**]) - diagnosed [**11-27**] when he presented to [**Hospital1 18**] with cough, fever, and increasing SOB. Chest CT showed bilateral lung infiltrates and enlarged mediastinal lymph nodes consistent with multifocal pneumonia, and echocardiography showed moderate to severe global left ventricular hypokinesis (LVEF = 25-30 %), with normal valve function, and no pericardial effusion. Lab work for RSV was positive, while HIV, influenza, EBV, CMV, Lyme and multiple blood cultures were unremarkable. Repeated echo 10 months later confirms severely depressed and dilated LV with LVEF of [**10-4**]%, and LVEDD of 7.8 cm - last hospitalized [**5-29**] for CHF exacerbation, treated with IV lasix - evaluated [**2192-11-1**] by ED (Dr. [**Last Name (STitle) **] for ICD placement, recommended general anesthesia for EPS and ICD placement 2. Childhood asthma 3. Morbid obesity 4. Sleep apnea - on CPAP but has not been using it 5. Moderate, Worsening pulmonary hypertension (46 mmHg [**9-28**]) (20-28 in [**4-28**]) 6. Fatty Liver by CT. Obese and hx of EtOH. INR 1.4-1.7 since [**5-29**]; Bili 1.7; HCV neg; HBV immune. Social History: He is unmarried and lives at home with his parents. He works as a high school wrestling coach and in security. He never smoked. He drank ""a lot"" in college, previously quoting 6 beer/weekend but not elaborting this time; started drinking in [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 32363**] high school. He has a history of cocaine use, ""a great deal"" in sophmore year. Drinks an occasional glass of wine. Family History: Father is 65 year-old and mother is 55 year-old. Both have diabetes. He has 4 healthy older sisters. There is no family history of SCD or cardiomyopathy. Physical Exam: VS: T= 97.3 BP= 136/61 HR=114 RR= 23 O2 sat= 97% 3L GENERAL: Obese African-American man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple without appreciable JVP, although cannot currently assess due to body habitus. Dark Acanthosis nigricans bilaterally CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, crackles at Right base, no wheezes or rhonchi. ABDOMEN: Obese with diffuse anasarca and tense skin. No pain on palpation. Positive bowel sounds. EXTREMITIES: 3+ pitting edema to mid-abodmen. Dry skin of lower extremities with changes of venous stasis. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Skin: dry, cool. Acanthosis as above. Neurologic: Cn 2-12 intact, full strength globally Pertinent Results: ADMISSION LABLS WBC-12.3* RBC-5.33 Hgb-12.7* Hct-38.8* MCV-73* MCH-23.8* MCHC-32.8 RDW-19.1* Plt Ct-284 Glucose-136* UreaN-15 Creat-1.0 Na-136 K-4.2 Cl-102 HCO3-23 AnGap-15 ALT-15 AST-25 CK(CPK)-97 AlkPhos-82 TotBili-1.7* PT-17.3* PTT-27.9 INR(PT)-1.6* CK-MB-2 cTropnT-<0.01 proBNP-2319* CK-MB-NotDone cTropnT-0.01 Digoxin-0.3* [**2192-12-24**] 03:52AM BLOOD Calcium-8.9 Phos-4.7* Mg-1.9 Iron-PND IRON calTIBC-503* Ferritn-47 TRF-387* Iron-36* Liver [**2192-12-23**] PT-17.3* PTT-27.9 INR(PT)-1.6* [**2192-12-25**] PT-16.1* PTT-28.9 INR(PT)-1.4* [**2192-12-23**] ALT-15 AST-25 CK(CPK)-97 AlkPhos-82 TotBili-1.7* [**2192-12-26**] TotBili-1.9* DirBili-1.0* IndBili-0.9 Brief Hospital Course: Mr. [**Known lastname 32362**] is a 24 year old man with a history of non-ischemic cardiomyopathy, NYH Class II CHF, EF 15-20% who presents with DOE/SOB over one month, acutely over one week. He was treated for acute on chronic CHF exacerbation. He was diuresed with IV and then PO lasix, achieving a net negative balance of ~ 7 litres. He was discharged to optimize his fluid status prior to an AICD placement By Problem 1. Acute on Chronic CHF Exacerbation: Underlying etiology for patient's chronic heart failure was presumed to be viral in origin, could also be related to cocaine use in years prior to diagnosis or alcohol abuse. All lab testing negative except for RSV, including HIV, EBV, CMV, Lyme, RPR. Current exacerbation likely due to poor dietary compliance as patient does not weigh himself daily and could easily become overloaded particularly in the context of the Holidays. He denied any medication noncompliance. The patient was aggressively diuresed with iV furosemide and by time of discharge he was 7 litres net negative and sent home on 40 mg of PO furosemide [**Hospital1 **]. 2. Tachycardia: The patient had CHF with rates around 100-130 at presentation. This appears to be a chronic problem per previous notes. This improved somewhat with diuresis and improvement of his respiratory status. Doses of metoprolol were increased over hospitalization without change in heart rate (100-120 on telemetry). The patient should have an AICD for purposes of primary prevention given his low EF. Plans are underway to finish this as an outpatient. He was discharged on 100 mg Toprol XL [**Hospital1 **] 3. Iron Deficiency Anemia: The patient continued to be microcytic with indices suggestive of iron deficiency. He is also hemoglobin AC which could explain some microcytosis. No signs of active bleeding and previous CT [**Last Name (un) **] was negative. He was discharged on iron TID with ascorbic acid for absorption and senna/colace for constipation 4: Hyperbilirubinemia/ Liver Dysfunction: Patient had a slightly elevated INR and bilirubin at presentation with normal transaminases. Both of these parameters were slightly above his previous values though he doe have a known element of non-alcoholic steatohepatitis (defined by ALT/AST and US/CT evidence of fatty infiltration). Given his two presumptive diagnoses (NAFLD/NASH and Congestive Hepatolpathy) he is at increased risk of fibrosis. His negative transaminases and elevated bilirubin (half direct, half indirect) were likely in the setting of hepatic congestion and decreased cardiac output during his heart failure exacerbation. His bilirubin was elevated at the time of discharge, but this would not be expected to fall quickly. It ought to be followed. 5. Pulmonary Hypertension: The patient was mildly hypoxic at presentation presumably due to exacerbation of his CHF. With diuresis this improved. ULtimately, plan is for outpatient right heart cath. The patient was also encouraged to use his CPAP at home and continue the diuresis begun in house. 6. Leukocytosis: The patient had a mild leukocytosis that was trending down at the time of discharge. He had no fevers or signs of acute infection. [**Telephone/Fax (3) 32364**] TO BE FOLLOWED IMMEDIATELY 1) Needs BMP to evaluate response to Lasix 40 mg [**Hospital1 **] 2) Needs Weight Check, was 192 Kg standing on scale at d/c EVENTUALLY 3) CBC, iron studies to follow progress on iron repletion 4) Ultimately, follow bilirubin, INR, assess liver status [**Telephone/Fax (3) **] Medications on Admission: Diovan 40mg PO qday Acetaminophen + Codeine 300mg/30mg PO q4H PRN cough ASA 325mg PO qday Furosemide 20mg PO BID - of note, pt is not sure if he takes 20mg or 40mg [**Hospital1 **] Digoxin 250mcg PO qday Metoprolol Succinate ER 75mg PO BID - pt is not sure of dose (this is per Dr.[**Name (NI) 8996**] last note) Discharge Medications: 1. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 5. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. Disp:*90 Tablet, Chewable(s)* Refills:*2* 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO twice a day: Take one pill in the morning and one at night. Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2* 8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: for constipation. Disp:*60 Capsule(s)* Refills:*2* 9. Senna 8.6 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. Disp:*30 Capsule(s)* Refills:*2* 10. Outpatient Lab Work Check Na, K, BUN, Cr on Monday [**2192-12-31**] Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Acute exacerbation of chronic systolic congestive heart failure Iron Deficiency Anemia Morbid obesity Discharge Condition: Good, not hypoxic on room air Ambulating without assistance Alert and Oriented *3 Discharge Instructions: Mr [**Known lastname 32362**], it was pleasure to participate in your care. You were admitted because you had increased swelling in your legs and difficulty breathing. This was due to an exacerbation of your heart failure. The reasons for this exacerbation are unclear though it may have been partially driven by more salty food over the Holidays or more subtle diet changes. In the hospital you received IV diuretics to help remove this fluid. You lost more than 7 litres of fluid by the time you were discharged. This is more than 15 pounds! It is crucial that you continue this progress at home by being very careful with diet, fluid intake and medication use. Your medications have been changed. You have been started on iron supplementation as your low iron seems to be contributing to your persistently low blood counts. Take your iron pills with vitamin c or fruit juice. If you get constipated on iron, you can take Colace twice daily or Senna; these are medications that you can get at the pharmacy. Please continue to take your other medications as previously described. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. MEDICATIONS 1) LASIX/FUROSEMIDE - Take 40mg tablets in the morning when you wake and again at 4pm, or a few hours before you go to sleep. You must take it twice daily. Your cardiologist may change this dose. You must follow up with your PCP for [**Name Initial (PRE) **] lab test while on this dose 2) Toprol XL - 100 mg, twice daily - this is a new dose of your heart rate medication. TAKE THIS MEDICATION TONIGHT. 3) Aspirin 325 mg, this is to prevent a clot in your heart 4) Iron, Vitamin C - you are very low on iron and vitamin c aids in absorption 5) Colace and Senna - medications for constipation, if that becomes an issue Followup Instructions: You need to have your labs checked at your PCP office We have scheduled an appointment for monday [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, MPH[**MD Number(3) 708**]:[**Telephone/Fax (1) 7976**] Date/Time:[**2192-12-31**] 12:30 You have a pre-op evaluation on the [**1-2**]. Provider: [**Name10 (NameIs) **] RM 1 [**Name10 (NameIs) **]-PREADMISSION TESTING Date/Time:[**2193-1-2**] 9:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2193-1-10**] 11:20 Completed by:[**2192-12-26**]",26,2192-12-23 23:09:00,2192-12-26 13:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,CONGESTIVE HEART FAILURE," mr. [**known lastname 32362**] is a 24 year old man with a history of non-ischemic cardiomyopathy, nyh class ii chf, ef 15-20% who presents with doe/sob over one month, acutely over one week. he was treated for acute on chronic chf exacerbation. he was diuresed with iv and then po lasix, achieving a net negative balance of ~ 7 litres. he was discharged to optimize his fluid status prior to an aicd placement by problem 1. acute on chronic chf exacerbation: underlying etiology for patients chronic heart failure was presumed to be viral in origin, could also be related to cocaine use in years prior to diagnosis or alcohol abuse. all lab testing negative except for rsv, including hiv, ebv, cmv, lyme, rpr. current exacerbation likely due to poor dietary compliance as patient does not weigh himself daily and could easily become overloaded particularly in the context of the holidays. he denied any medication noncompliance. the patient was aggressively diuresed with iv furosemide and by time of discharge he was 7 litres net negative and sent home on 40 mg of po furosemide [**hospital1 **]. 2. tachycardia: the patient had chf with rates around 100-130 at presentation. this appears to be a chronic problem per previous notes. this improved somewhat with diuresis and improvement of his respiratory status. doses of metoprolol were increased over hospitalization without change in heart rate (100-120 on telemetry). the patient should have an aicd for purposes of primary prevention given his low ef. plans are underway to finish this as an outpatient. he was discharged on 100 mg toprol xl [**hospital1 **] 3. iron deficiency anemia: the patient continued to be microcytic with indices suggestive of iron deficiency. he is also hemoglobin ac which could explain some microcytosis. no signs of active bleeding and previous ct [**last name (un) **] was negative. he was discharged on iron tid with ascorbic acid for absorption and senna/colace for constipation 4: hyperbilirubinemia/ liver dysfunction: patient had a slightly elevated inr and bilirubin at presentation with normal transaminases. both of these parameters were slightly above his previous values though he doe have a known element of non-alcoholic steatohepatitis (defined by alt/ast and us/ct evidence of fatty infiltration). given his two presumptive diagnoses (nafld/nash and congestive hepatolpathy) he is at increased risk of fibrosis. his negative transaminases and elevated bilirubin (half direct, half indirect) were likely in the setting of hepatic congestion and decreased cardiac output during his heart failure exacerbation. his bilirubin was elevated at the time of discharge, but this would not be expected to fall quickly. it ought to be followed. 5. pulmonary hypertension: the patient was mildly hypoxic at presentation presumably due to exacerbation of his chf. with diuresis this improved. ultimately, plan is for outpatient right heart cath. the patient was also encouraged to use his cpap at home and continue the diuresis begun in house. 6. leukocytosis: the patient had a mild leukocytosis that was trending down at the time of discharge. he had no fevers or signs of acute infection. [**telephone/fax (3) 32364**] to be followed immediately 1) needs bmp to evaluate response to lasix 40 mg [**hospital1 **] 2) needs weight check, was 192 kg standing on scale at d/c eventually 3) cbc, iron studies to follow progress on iron repletion 4) ultimately, follow bilirubin, inr, assess liver status [**telephone/fax (3) **] ","PRIMARY: [Acute on chronic systolic heart failure] SECONDARY: [Other primary cardiomyopathies; Jaundice, unspecified, not of newborn; Congestive heart failure, unspecified; Other chronic pulmonary heart diseases; Unspecified sleep apnea; Tachycardia, unspecified; Iron deficiency anemia, unspecified; Morbid obesity; Other chronic nonalcoholic liver disease; Unspecified disorder of liver; Leukocytosis, unspecified]","known lastname 32362**] is a 24 year old man with a history of non-ischemic cardiomyopathy, nyh class ii chf, ef 15-20% who presents with doe/sob over one month, acutely over one week. he was discharged to optimize his fluid status prior to an aicd placement by problem 1. this improved somewhat with diuresis and improvement of his respiratory status. both of these parameters were slightly above his previous values though he doe have a known element of non-alcoholic steatohepatitis (defined by alt/ast and us/ct evidence of fatty infiltration). his negative transaminases and elevated bilirubin (half direct, half indirect) were likely in the setting of hepatic congestion and decreased cardiac output during his heart failure exacerbation. leukocytosis: the patient had a mild leukocytosis that was trending down at the time of discharge.","a 24-year-old man with a history of non-ischemic cardiomyopathy, nyh class ii chf, ef 15-20% who presents with doe/sob over one month, acutely over one week. he was diuresed with iv and then po lasix, achieving a net negative balance of 7 litres. he was discharged to optimize his fluid status prior to an aicd placement." 66256,187869.0,13112,2169-12-02,13111,166051.0,2169-11-28,Discharge summary,"Admission Date: [**2169-11-23**] Discharge Date: [**2169-11-28**] Date of Birth: [**2105-9-19**] Sex: F Service: CARDIOTHORACIC Allergies: Aspirin / Ciprofloxacin / Procardia / Niacin / Biaxin / Niaspan / Ibuprofen / Crestor / Quinolones / Neosporin / Adhesive Tape Attending:[**First Name3 (LF) 3948**] Chief Complaint: Cough s/p bronchoscopy Major Surgical or Invasive Procedure: [**2169-11-24**] : Rigid bronchoscopy with black Dumon bronchoscope. Cryotherapy for debridement of granulation tissue, distal left main-stem. Balloon dilatation to 10 mm, distal left main-stem. Mechanical debridement of granulation tissue, left main-stem. [**2169-11-24**]: Flexible bronchoscopy [**2169-11-23**]: Rigid bronchoscopy. Foreign body removal (Y-stent). History of Present Illness: 64F with PMH of morbid obesity, OSA, severe COPD, and TBM s/p placement of Y-stent on [**2169-11-6**], who presented today for scheduled removal of her Y-stent. She states that since having the stent in place she has suffered from increased shortness of breath and coughing, with increased sputum and mucus production. The procedure itself was uncomplicated, but in the PACU she had nearly 2 hours of prolonged coughing which developed into pleuritic CP. She received albuterol nebs, lidocaine nebs, IV codeine, and 125mg IV solumedrol. A CXR revealed diffuse left lung collapse from mucus plugging and probable aspiration. She was placed on CPAP in the PACU with some improvement in respiratory stauts. ABG was 7.41/47/65/31. EKG was not concerning for ischemia. Cardiac enzymes were negative. The decision was made to to perform bronchoscopy at that time, but to admit to MICU for repsiraotry monitoring and possible bronch in AM if plug had not cleared by then. . Currently she endorses shortness of breath above her baseline. She has diffuse pleuritic chest pain that is non-radiating. She occasionally has spasms of uncontrollable coughing. Past Medical History: 1. Obesity. 2. History of pericarditis/tamponade secondary to polyserositis. She has been on steroids for this for the past 17 years. 3. History of pleural effusion. 4. Sarcoidosis. 5. GERD. 6. History of lung nodule status post thoracotomy with left lower lobe wedge resection and ([**Hospital1 2025**] [**2160**]). 7. Asthma. 8. Hiatal hernia. 9. OSA on nocturnal CPAP (plus 12) 10. Hypertension. 11. Lactose intolerance. 12. Tracheobronchomalacia Social History: The patient is divorced. She lives alone in [**Location (un) **], [**State 350**]. She has one son who lives close by. She has been on disability since [**2149**]. Prior to that, she worked as a financial analyst. She has a rare glass of wine. She quit smoking in [**2160**]. Prior to that she smoked a pack a day for 40 years. She has never used any illicit drugs. She denies asbestos exposure and reports no known TB exposures. She had a negative PPD test last year prior to starting Enbrel therapy. Family History: There is no family history of lung disease or sarcoid. Her mother died secondary to rectal cancer 82 years old. Notably she did have lupus. Her father died secondary to an MI at 72 years old. Her son is healthy. Physical Exam: VS: 99.6 94 113/51 24 90% 2L NC Gen: obese middle aged female, frequently coughing, but not in acute resp distress, speaking in full sentences HEENT: NC/AT, MMM Neck: obese Cor: RRR, 2/6 systolic murmur at LSB Resp: Scattered wheezes bilateral Abd: obese, s/nt/nd +BS Ext: WWP. 2+ b/l pitting edema to knee. + digital clubbing Pertinent Results: [**2169-11-26**] WBC-17.5* RBC-4.55 Hgb-12.1 Hct-35.6* Plt Ct-755* [**2169-11-25**] WBC-20.0* RBC-4.08* Hgb-10.7* Hct-31.9* Plt Ct-684* [**2169-11-24**] WBC-15.7* RBC-3.93* Hgb-10.6* Hct-30.3* Plt Ct-603* [**2169-11-23**] WBC-19.6*# RBC-4.12* Hgb-10.9* Hct-32.0* Plt Ct-624* [**2169-11-23**] Neuts-91.9* Lymphs-6.2* Monos-1.4* Eos-0.5 Baso-0.1 [**2169-11-27**] Glucose-80 UreaN-25* Creat-0.8 Na-137 K-4.1 Cl-97 HCO3-33* [**2169-11-27**] 02:35AM BLOOD K-4.0 [**2169-11-25**] Glucose-129* UreaN-21* Creat-0.6 Na-139 K-3.8 Cl-96 HCO3-32 [**2169-11-23**] Glucose-126* UreaN-8 Na-136 K-4.1 Cl-94* HCO3-31 [**2169-11-26**] CK(CPK)-36 [**2169-11-24**] CK(CPK)-29 [**2169-11-23**] CK(CPK)-40 [**2169-11-27**] BLOOD cTropnT-<0.01 [**2169-11-26**] CK-MB-NotDone cTropnT-<0.01 [**2169-11-27**] BLOOD Calcium-9.2 Phos-3.9 Mg-2.0 CXR: [**2169-11-24**] In comparison with study of [**11-23**], there has been substantial re-expansion of the left lung, presumably from expectoration of a mucus plug. Atelectatic changes persist at the left base and there is continued elevation of the left hemidiaphragmatic contour. [**2169-11-23**] In comparison with the study of [**11-17**], there has been substantial volume loss in the left lung with opacification of most of the left hemithorax following stent removal. Some patchy quality of the opacification raises the possibility of supervening aspiration or hemorrhage from recent bronchoscopy. Chest CT: [**2169-11-27**] 1. Negative examination for pulmonary embolism. 2. Long-term stability of noncalcified pulmonary nodules, consistent with a benign etiology. 3. Stable appearance of the left lower lobe post-surgical changes with scarring. 4. Coronary calcifications. 5. Mucoid impactation in bronchi of left lower lobe. Brief Hospital Course: 64F with OSA, severe COPD, and TBP s/p removal of Y-stent [**11-23**] who is admitted to the MICU post-procedurally with left lung collapse and evidence of mucus plugging and aspiration and respiratory failure. She was placed on CPAP with aggressive pulmonary toileting, chest PT and mucolytics. Intravenous steroids were started for COPD excerbation. Cardiac enzymes were negative. On [**2168-11-23**] she had Flexible bronchoscopy which showed granulation tissue distal to LMS occluding 75% of lunar. Distal airway was patent. She then procedued to the operating room for Rigid bronchoscopy, Cryotherapy for debridement of granulation tissue, distal left main-stem. Balloon dilatation to 10 mm, distal left main-stem. Mechanical debridement of granulation tissue, left main-stem. She tolerated the procedure her saturations were monitored in the ICU prior to transfer to the floor. The post procedure chest film showed some residual atelectasis and possibly effusion at the left base with elevation of the left hemidiaphragmatic contour, no recurrence of the substantial volume loss seen previously and no evidence of pneumothorax. Her oxygenation improved Sats were 91% on 2L nasal cannula. She transferred to the floor on a steroid taper, home CPAP settings, aggressive pulmonary toileting and chest PT. On [**2169-11-25**] her pain was managed with PO pain medicaiton, the foley was removed and she voided. Her diet was advanced and she ambulated in the halls. On [**2169-11-26**] she had an episode of atrial fibrillation in the 150's. She was given IV lopressor with spontaneous conversion to sinus rhythm. She was started on a standing dose of low dose beta-blocker, her lytes were repleted. On [**2169-11-27**] Chest CT was negative for pulmonary embolism. On [**2169-11-28**] her respiratory status was at baseline, she continued on a steroid taper, and was discharged to home with VNA. She will follow-up as an outpatient. Medications on Admission: # Micardis/HCTZ 40/12.5 one tablet daily # Nexium 40 mg t.i.d. # Flexeril 10 mg b.i.d. # Medrol 4 mg daily, # Zyrtec 10 mg daily # Singulair 10 mg daily # cyproheptadine 4 mg b.i.d. # Lasix 20 mg daily p.r.n. edema # Enbrel injections 50 mg every week (has not taken in the past two weeks) # Advair 250/50 one puff twice daily # Rhinocort 32 mcg two sprays per nostril daily # vitamin E # calcium # vitamin C # vitamin B12 # multivitamin # vitamin D # Imodium p.r.n. # Benadryl p.r.n # Tylenol p.r.n. Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO BID (2 times a day). 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 8. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 12. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day for 2 days. Disp:*25 Tablet(s)* Refills:*0* 13. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 3 days. 14. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 3 days: then 1 x days, then [**11-17**] tablet (5mg) x 3 days. 15. Saline Solution Sig: Three (3) ML Miscellaneous three times a day: Nebulizers . Disp:*300 * Refills:*2* 16. Micardis HCT 40-12.5 mg Tablet Sig: One (1) Tablet PO once a day. 17. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO three times a day. 18. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day. 19. Cyproheptadine 4 mg Tablet Sig: One (1) Tablet PO twice a day. 20. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day as needed. 21. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO once a day. Disp:*15 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital6 486**] Discharge Diagnosis: Obesity. History of pericarditis/tamponade secondary to polyserositis, steroids x 17 yrs History of pleural effusion. Sarcoidosis. GERD. History of lung nodule status post thoracotomy with left lower lobe wedge resection and ([**Hospital1 2025**] [**2160**]). Asthma. Hiatal hernia. OSA on nocturnal CPAP (plus 12) Hypertension. Lactose intolerance. Discharge Condition: stable Discharge Instructions: Call Dr.[**Name (NI) 14679**] office [**Telephone/Fax (1) 7769**] if develops: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production Prednisone taper 40 x 2 days, 30 x 3 days, 20 x 3 days, 10 x 3 days then 5 mg day. Please contact your rheumatologist regarding your medrol 4 mg daily. (when to start) Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] [**12-12**] @10:00am in the [**Hospital Ward Name 121**] Building [**Hospital1 **] I Chest Disease Center, [**Location (un) **] Follow-up with Dr. [**Last Name (STitle) **] [**12-12**] at 10:30 am Chest Disease Center Please follow-up with your rheumatologist regarding steroids Completed by:[**2169-11-29**]",4,2169-11-23 21:13:00,2169-11-28 13:35:00,EMERGENCY,CLINIC REFERRAL/PREMATURE,HOME HEALTH CARE,TRACHEAL BRONCHOMALASIA," 64f with osa, severe copd, and tbp s/p removal of y-stent [**11-23**] who is admitted to the micu post-procedurally with left lung collapse and evidence of mucus plugging and aspiration and respiratory failure. she was placed on cpap with aggressive pulmonary toileting, chest pt and mucolytics. intravenous steroids were started for copd excerbation. cardiac enzymes were negative. on [**2168-11-23**] she had flexible bronchoscopy which showed granulation tissue distal to lms occluding 75% of lunar. distal airway was patent. she then procedued to the operating room for rigid bronchoscopy, cryotherapy for debridement of granulation tissue, distal left main-stem. balloon dilatation to 10 mm, distal left main-stem. mechanical debridement of granulation tissue, left main-stem. she tolerated the procedure her saturations were monitored in the icu prior to transfer to the floor. the post procedure chest film showed some residual atelectasis and possibly effusion at the left base with elevation of the left hemidiaphragmatic contour, no recurrence of the substantial volume loss seen previously and no evidence of pneumothorax. her oxygenation improved sats were 91% on 2l nasal cannula. she transferred to the floor on a steroid taper, home cpap settings, aggressive pulmonary toileting and chest pt. on [**2169-11-25**] her pain was managed with po pain medicaiton, the foley was removed and she voided. her diet was advanced and she ambulated in the halls. on [**2169-11-26**] she had an episode of atrial fibrillation in the 150s. she was given iv lopressor with spontaneous conversion to sinus rhythm. she was started on a standing dose of low dose beta-blocker, her lytes were repleted. on [**2169-11-27**] chest ct was negative for pulmonary embolism. on [**2169-11-28**] her respiratory status was at baseline, she continued on a steroid taper, and was discharged to home with vna. she will follow-up as an outpatient. ","PRIMARY: [] SECONDARY: [Chronic obstructive asthma with (acute) exacerbation; Pneumonitis due to inhalation of food or vomitus; Pulmonary collapse; Other specified forms of effusion, except tuberculous; Other diseases of trachea and bronchus; Other chest pain; Atrial fibrillation; Sarcoidosis; Lung involvement in other diseases classified elsewhere; Obstructive sleep apnea (adult)(pediatric); Other chronic pain; Morbid obesity; Unspecified essential hypertension; Esophageal reflux; Diaphragmatic hernia without mention of obstruction or gangrene; Long-term (current) use of steroids; Personal history of tobacco use; Other artificial opening status]","64f with osa, severe copd, and tbp s/p removal of y-stent [**11-23**] who is admitted to the micu post-procedurally with left lung collapse and evidence of mucus plugging and aspiration and respiratory failure. on [**2168-11-23**] she had flexible bronchoscopy which showed granulation tissue distal to lms occluding 75% of lunar. mechanical debridement of granulation tissue, left main-stem. her diet was advanced and she ambulated in the halls.","64f with osa, severe copd, and tbp s/p removal of y-stent. she was placed on cpap with aggressive pulmonary toileting, chest pt and mucolytics. she was given iv lopressor with spontaneous conversion to sinus rhythm." 66264,173568.0,9141,2103-01-15,9112,133806.0,2102-08-24,Discharge summary,"Admission Date: [**2102-8-14**] Discharge Date: [**2102-8-24**] Date of Birth: [**2061-5-10**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: nausea, dry heaving, rectal bleeding Major Surgical or Invasive Procedure: cardiac catheterization History of Present Illness: Pt is a 41 yo F w/ PMHx of seizure d/o, chronic back pain, partial gastrectomy, for obesity, who presented with vague hx of intermittent nausea and dry heaving for 3-4 months, not associated w/ abdominal pain, but associated with anorexia and recently, over the past week with occasional fevers (to 102), chills, weakness, fatigue. She admits to poor PO intake over recent weeks, as well as occasional dizzyness when standing up and a syncopal episode. . (Hx below from prior admission notes and verified during Pt interview): . She has had a 25-30 pound wt loss over the past 2 months, as well as leg and arm swelling. There was no recent travel, unusual foods, sick contacts, or new pets. She also notes constipation x3 mos leading to painful straining and bloody stools, which was evaluated by flex sig at OSH showing hemorrhoids. She was started on docusate and notes loose stools lately associated with taking more laxatives. . Since admission, CT was done and showed pancolitis. GI was consulted and did upper endoscopy which was normal. Colonoscopy was aborted for poor prep. Two days ago, the patient developed sharp chest pain radiating to her shoulders, no exertional component, no change with inspiration or cough. She has had dyspnea and chest pressure for the past week that has been constant. Cardiac markers showed trop peak at 0.41 with CK/CKMB normal and no EKG changes. Cards was consulted and felt this was not an MI, maybe myocarditis, and requested TTE. This was done today showing systolic and diastolic dysfunction (LVEF 20-30%) with a small effusion and possible early tamponade. . During this admission, Pt has been persistently tachycardic (100s to 120s) and this evening Pt was noted to have a HR 130s-140s. . On review of systems, s/he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: - Epilepsy - Cholelithiasis - Degenerative disc disease - Partial gastrectomy for obesity - Lysis of adhesion 3 weeks after gastrectomy Social History: single, works at [**University/College **] as administrator. Recent breakup from boyfriend. Lives alone. Brother is a support -Tobacco history:None -ETOH: social -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: T= 97.4 BP= 104/75 HR= 104 RR= 18 O2 sat= 99% GENERAL: NAD, Alert and Oriented x3. Flat affect. HEENT: NCAT. Sclera anicteric. Pupils somewhat dilated but equally round and reactive to light and accomodation, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with non elevated JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ lower extremity and upper extremity edema. No clubbing or cyanosis SKIN: traumatic erythematous patch on R lower extremity PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: On Admission: [**2102-8-14**] 01:04PM WBC-18.5*# RBC-4.59 HGB-13.1 HCT-44.4# MCV-97# MCH-28.5 MCHC-29.5*# RDW-14.0 [**2102-8-14**] 01:04PM NEUTS-84.0* LYMPHS-11.0* MONOS-4.6 EOS-0.1 BASOS-0.3 [**2102-8-14**] 01:04PM PLT COUNT-577*# [**2102-8-14**] 01:04PM ALBUMIN-2.6* [**2102-8-14**] 01:04PM LIPASE-7 [**2102-8-14**] 01:04PM ALT(SGPT)-45* AST(SGOT)-68* ALK PHOS-159* TOT BILI-2.3* [**2102-8-14**] 01:04PM GLUCOSE-114* UREA N-12 CREAT-0.9 SODIUM-139 POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-22 ANION GAP-14 [**2102-8-14**] 03:11PM PT-17.5* PTT-37.5* INR(PT)-1.6* [**2102-8-15**] 12:00AM PLT COUNT-353 [**2102-8-15**] 12:00AM WBC-7.9# RBC-3.10*# HGB-9.1*# HCT-30.0*# MCV-97 MCH-29.2 MCHC-30.2* RDW-13.9 [**2102-8-15**] 12:00AM CALCIUM-7.3* PHOSPHATE-2.6* MAGNESIUM-2.0 [**2102-8-15**] 12:00AM LIPASE-7 [**2102-8-15**] 12:00AM ALT(SGPT)-27 AST(SGOT)-24 ALK PHOS-98 AMYLASE-15 TOT BILI-0.7 [**2102-8-15**] 12:00AM GLUCOSE-110* UREA N-12 CREAT-0.6 SODIUM-144 POTASSIUM-4.0 CHLORIDE-115* TOTAL CO2-22 ANION GAP-11 TSH [**8-16**]: 3.6 PTH [**8-16**]: 66 B12 [**8-16**]: 1835 HCG [**8-19**]: negative HIV neg HCV neg Trig 185 Vitamin B1 370 (normal) prealbumin 7 CPK ISOENZYMES CK-MB cTropnT proBNP [**2102-8-19**] 03:09AM NotDone1 0.07*2 3928* protein electrophoresis [**8-22**] normal Upep [**8-21**]: 27 (normal) . [**2102-8-14**] RUQ ULTRASOUND: 1. Cholelithiasis without secondary signs to suggest cholecystitis. 2. Echogenic liver most compatible with fatty infiltration. Please note that other forms of hepatic disease such as cirrhosis/fibrosis are not excluded. . [**2102-8-15**] CT ABD/PELVIS: 1. Pancolitis as decribed above. 2. Cystic lesion in tail of pancreas, not fully evaluated on this examination. Would recommend MRI in 6 months for further characterization. 3. Focal narrowing in sigmoid colon may represent focal collapsed bowel, however, bowel wall lesion cannot be excluded. Would recommend imaging correlation such as colonoscopy or barium study as available. . [**2102-8-16**] MRCP: 1. Severe hepatic steatosis. 2. Biliary tree shows no abnormalities. 3. Colonic wall thickening and mucosal enhancement, related to colitis as seen on recent CT scan. 4. Cystic, non-enhancing lesion in the tail of the pancreas, that is most likely in keeping with a pseudocyst, however, a side branch IPMN cannot be excluded, although less likely. A followup MRI is suggested in six months for further evaluation. 5. Jejunal biopsy negative. . [**2102-8-17**] CT ABD/PELVIS: 1. No evidence of esophageal perforation. 2. Resolution of colonic wall thickening demonstrated on prior CT. 3. Hepatic steatosis. 4. Low-attenuation lesion at the tail of the pancreas is compatible with a cyst versus dilated side branch. It is unchanged from prior recent MRCP and CT. As described on prior MRCP report, followup of this with MRCP in six months is recommended to assess for expected stability. . [**2102-8-18**] ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF= 20-30 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. Right ventricular chamber size is normal. with focal hypokinesis of the apical free wall. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is a small to moderate sized pericardial effusion. No right atrial or right ventricular diastolic collapse is seen. However, the right ventricle appears underfilled. IMPRESSION: severe anterior and apical hypokinesis/akinesis; small, primari8ly anterior pericardial effusion possibly with early tamponade. . [**2102-8-21**] CARDIAC CATHETERIZATION: 1. Selective coronary angiography in [**Last Name (un) **] left dominant system demonstrated no flow limiting lesions. The LMCA had minimal plaquing in the mid portion of the vessel. The LAD had minimal luminal irregulairites with 15% stenosis at the origin of the vessel. The distal LAD wraps around the apex with diffuse plaquing in the distal LAD. The Cx had minimal luminal irregularities and gave off a small caliber OM1, an atrial branch a modest OM2, a large LPL and a moderate LPDA. The RCA was a small nondominant vessel that initially had catheter induced vasospasm that improved after intracatheter nitroglycerine. 2. Limited resting hemodynamics revealed elevated right and left filling pressures with an RVEDP of 17 mmHg and an LVEDP of 28 mmHg. There was mild pulmonary artery hypertension with a PASP of 38 mmHg. The cardiac index was preserved at 3.3 l/min/m2. The SVR was slightly low at 754 dynes-sec/cm5 and the PVR was preserved at 69 dynes-sec/cm5. The central aortic pressure was 103/68 mmHg. There was no transaortic valve gradient on pullback from the LV to the aorta. FINAL DIAGNOSIS: 1. Coronary arteries have no flow limiting lesions. 2. Mild pulmonary arterial hypertension. 3. Severe left ventricular diastolic dysfunction. . On Discharge: Negative Lyme, MRSA swab, HIV, HCV and urine cx EBV, Vitamin D [**12-25**] and CMV are still pnd COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2102-8-23**] 05:13AM 7.5 3.03* 9.1* 29.4* 97 29.9 30.8* 15.0 431 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2102-8-23**] 05:13AM 91 12 0.7 139 3.7 107 27 9 Cosyntropin stimulation test [**8-23**]: Cortisol prior: 6.31 Cortisol 30 min after cosyntropin: 23.9 Cortisol 60 min after cosyntropin: 28.5 . Brief Hospital Course: The patient is a 41 year old female with seizure disorder, gastrectomy, degenerative disc disease who presented with vague GI complaints, weight loss, and admitted to CCU after an episode of chest pain and she was found to have severe systolic/dystolic function as well as tachycardia. On [**2102-8-24**], the patient was discharged in good condition, with stable vital signs, with appropriate outpatient follow-up arranged. Ms.[**Known lastname 31410**] hospital course was notable for: . # Hypotension: Has been intermittantly hypotensive this admission but asymptomatic, likely [**1-2**] low EF. Hct is low and drfting down. Random cortisol low normal and cortisone stimulation test was normally responsive. Pt is not orthostatic or dizzy, is able to ambulate easily and denies any symptoms. Her Lisinopril and Metoprolol was started at a very low dose. . # Upper back pain: Pt has a history of lower back scoliosis, Myofascial pain syndrome and Facet arthropathy that affects her lower back. Her upper back pain is new. Pt feels that her pain may be [**1-2**] bedrest, and is relieved by morphine. No radicular symptoms. On muscle relaxer at home and chronic narcotics (Roxicet) which pt states is ineffective. Pt reports that clonazepam did not help as an additional muscle relaxer. She was given a limited morphine PO prescription and instructed to contact the pain clinic at [**Hospital1 18**] which she had used in [**2098**]. According to the patient, they recommended surgery which she has been reluctant to do. . # Acute Systolic dysfunction: Cath [**8-21**] showed no CAD. Noted increased filling pressures and furosemide and Lasix po started. No O2 requirement or SOB at present despite fluid overload. Unclear etiology but fatigue in last few months may be related. TSH neg. Multiple viral tests performed, all negative except for EBV and CMR which are pending. Pt was discharged on Lisinopril 2.5 mg and Long acting Metoprolol with furosemide twice daily. Instructed to weigh herself daily and follow a low sodium diet. Pt will follow-up with Dr.[**Name (NI) 3733**] for in [**Month (only) 359**]. . # Nausea, weight loss: Pt had recent CT scan which showed pancolitis, and f/u CT scan which showed interval resolution. Also w/ cholelithiasis and steatotic hepatitis. Pt w/ fairly substantial GI surgical hx. GI and surgery following with plan for outpt CT colonoscopy for further evaluation. GI also recommends outpatient MRI enterography for further evaluation. Symptoms may represent malabsorption syndrome, such as celiac sprue, or possibly related to surgical gastric resection. Albumin 2.0, thought to be contributing to her peripheral edema. EGD done, Bx showed inflmmation only. Weight loss is at least in part r/t very decreased and erratic intake. Pt describes very poor protein and calorie intake last 2 months. Spoke with pt's mother who states that pt has not worked in 2 months, is considering disability, has been increasingly isolated in her apt with limited contact with friends. Dr. [**Name (NI) 31411**], pts outpatient psychiatrist was informed of this information. Worsening depression is suspected. She is tolerating PO's at discharge. She has had extensive nutritional counseling after her gastric bypass but would consider outpatient referral again. . # Anemia: Normochromic, normocytic. On Fe supplementation as Fe studies suggest Fe deficiency. No signs of acute bleed. Had some rectal bleeding with stools recently, [**1-2**] hemmorhoids. Needs repeat outpt colonoscopy. On Fe, B12 q week, folic acid supplements. . # Epilepsy: No sz activity noted. Continued home meds of levetiracetam, venlafexime, topiramate . # Depression: See note above about poor PO intake. Increasing isolation, ahedonia and decreased intake all point to worsening depression. Psych team saw pt in house but had no recommendations as they did not have accurate information from the patient. Outpt psychiatrist was contact[**Name (NI) **] about symptoms and will f/u with pt. Note that pt is very reluctant to discuss some information with her caregivers. Medications on Admission: B12 injection 1,000mcg monthly Iron 65mg daily Zolpidem 10mg HS prn Folic acid 1mg daily Venlafaxine 300mg daily Amitriptyline 25mg HS (has not taken recently) Clonazepam 1mg daily prn anxiety Topiramate 100mg HS Tizanidine 8mg HS Roxicet 5/325 q6h prn Levetiracetam 500mg [**Hospital1 **] Omeprazole 20mg daily (no longer taking) Discharge Medications: 1. Topiramate 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Levetiracetam 250 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety. 6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Take with iron. 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) injection Injection once a week. 11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Tizanidine 4 mg Capsule Sig: Two (2) Capsule PO at bedtime. 13. Venlafaxine 150 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO once a day. 14. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 15. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Heart Failure: systolic dysfunction (EF 20-30%) and diastolic dysfunction Colitis Discharge Condition: stable Discharge Instructions: You had nausea and vomiting and were admitted to the gastroenterology service. Multiple tests were performed, you were found to have colitis, an irritation of the lining of your gastrointestinal tract. This is now resolving without treatment. Your heart rate became high and you were evaluated by the cardiology team. Your heart function is about 50% weaker than it should be. We have done many tests to find the cause of this weakness but have not identified a cause as yet. You did not have a heart attack. You need to eat a balanced diet with adequate protein and calories every day. Because your heart is weak, you may retain fluid in your legs, lungs or hands. Not eating enough protein makes your swelling worse. Weigh yourself every morning, call Dr. [**Last Name (STitle) **]""[**Doctor Last Name **] if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet Fluid Restriction: 1.5 liters per day or about 8 cups . In addition, you had a cortisol stimulation test to evaluate your low blood pressure. Please review the results of this test with your primary care provider at your next visit. . . Medication changes: 1. START Furosemide (Lasix) to decrease the amount of fluid in your body 2. Lisinopril: to help your heart pump better, this will lower your blood pressure slightly 3. Metoprolol: to slow you heart rate and help your heart work better 4. Thiamine and Vitamin C: to correct nutritional deficencies and help your anemia . Please call Dr.[**Name (NI) 3733**] if you notice any trouble breathing, increased swelling or cough. Followup Instructions: Cardiology: Provider: [**First Name4 (NamePattern1) 4648**] [**Name Initial (NameIs) **] Phone: [**Telephone/Fax (1) 62**] Date/Time: [**2102-9-12**] 2:20 . Primary Care: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD [**First Name8 (NamePattern2) 151**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 250**] Date/Time: [**9-6**] at 3:25pm. Please call insurance and change PCP. . Gastroenterology: Cystic lesion in tail of pancreas, not fully evaluated on this examination. Would recommend MRI in 6 months for further characterization. Pt needs to have a MR enterography and colonoscopy as an outpt. ",144,2102-08-14 20:53:00,2102-08-24 12:30:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ABDOMINAL PAIN," the patient is a 41 year old female with seizure disorder, gastrectomy, degenerative disc disease who presented with vague gi complaints, weight loss, and admitted to ccu after an episode of chest pain and she was found to have severe systolic/dystolic function as well as tachycardia. on [**2102-8-24**], the patient was discharged in good condition, with stable vital signs, with appropriate outpatient follow-up arranged. ms.[**known lastname 31410**] . # hypotension: has been intermittantly hypotensive this admission but asymptomatic, likely [**1-2**] low ef. hct is low and drfting down. random cortisol low normal and cortisone stimulation test was normally responsive. pt is not orthostatic or dizzy, is able to ambulate easily and denies any symptoms. her lisinopril and metoprolol was started at a very low dose. . # upper back pain: pt has a history of lower back scoliosis, myofascial pain syndrome and facet arthropathy that affects her lower back. her upper back pain is new. pt feels that her pain may be [**1-2**] bedrest, and is relieved by morphine. no radicular symptoms. on muscle relaxer at home and chronic narcotics (roxicet) which pt states is ineffective. pt reports that clonazepam did not help as an additional muscle relaxer. she was given a limited morphine po prescription and instructed to contact the pain clinic at [**hospital1 18**] which she had used in [**2098**]. according to the patient, they recommended surgery which she has been reluctant to do. . # acute systolic dysfunction: cath [**8-21**] showed no cad. noted increased filling pressures and furosemide and lasix po started. no o2 requirement or sob at present despite fluid overload. unclear etiology but fatigue in last few months may be related. tsh neg. multiple viral tests performed, all negative except for ebv and cmr which are pending. pt was discharged on lisinopril 2.5 mg and long acting metoprolol with furosemide twice daily. instructed to weigh herself daily and follow a low sodium diet. pt will follow-up with dr.[**name (ni) 3733**] for in [**month (only) 359**]. . # nausea, weight loss: pt had recent ct scan which showed pancolitis, and f/u ct scan which showed interval resolution. also w/ cholelithiasis and steatotic hepatitis. pt w/ fairly substantial gi surgical hx. gi and surgery following with plan for outpt ct colonoscopy for further evaluation. gi also recommends outpatient mri enterography for further evaluation. symptoms may represent malabsorption syndrome, such as celiac sprue, or possibly related to surgical gastric resection. albumin 2.0, thought to be contributing to her peripheral edema. egd done, bx showed inflmmation only. weight loss is at least in part r/t very decreased and erratic intake. pt describes very poor protein and calorie intake last 2 months. spoke with pts mother who states that pt has not worked in 2 months, is considering disability, has been increasingly isolated in her apt with limited contact with friends. dr. [**name (ni) 31411**], pts outpatient psychiatrist was informed of this information. worsening depression is suspected. she is tolerating pos at discharge. she has had extensive nutritional counseling after her gastric bypass but would consider outpatient referral again. . # anemia: normochromic, normocytic. on fe supplementation as fe studies suggest fe deficiency. no signs of acute bleed. had some rectal bleeding with stools recently, [**1-2**] hemmorhoids. needs repeat outpt colonoscopy. on fe, b12 q week, folic acid supplements. . # epilepsy: no sz activity noted. continued home meds of levetiracetam, venlafexime, topiramate . # depression: see note above about poor po intake. increasing isolation, ahedonia and decreased intake all point to worsening depression. psych team saw pt in house but had no recommendations as they did not have accurate information from the patient. outpt psychiatrist was contact[**name (ni) **] about symptoms and will f/u with pt. note that pt is very reluctant to discuss some information with her caregivers. ","PRIMARY: [Universal ulcerative (chronic) colitis] SECONDARY: [Acute combined systolic and diastolic heart failure; Other protein-calorie malnutrition; Other and unspecified postsurgical nonabsorption; Unspecified disease of pericardium; Cyst and pseudocyst of pancreas; Loss of weight; Anorexia; Bariatric surgery status; Dehydration; Calculus of gallbladder without mention of cholecystitis, without mention of obstruction; Hepatitis, unspecified; Congestive heart failure, unspecified; Unspecified essential hypertension; Other chronic pulmonary heart diseases; Precordial pain; Spondylosis of unspecified site, without mention of myelopathy; Myalgia and myositis, unspecified; Other specified cardiac dysrhythmias; Scoliosis [and kyphoscoliosis], idiopathic; Other iatrogenic hypotension; Other antihypertensive agents causing adverse effects in therapeutic use; Depressive disorder, not elsewhere classified; Internal hemorrhoids with other complication; Iron deficiency anemia, unspecified; Epilepsy, unspecified, without mention of intractable epilepsy; Other disorders of plasma protein metabolism]","the patient is a 41 year old female with seizure disorder, gastrectomy, degenerative disc disease who presented with vague gi complaints, weight loss, and admitted to ccu after an episode of chest pain and she was found to have severe systolic/dystolic function as well as tachycardia. ms.[**known lastname 31410**] . random cortisol low normal and cortisone stimulation test was normally responsive. pt is not orthostatic or dizzy, is able to ambulate easily and denies any symptoms. on muscle relaxer at home and chronic narcotics (roxicet) which pt states is ineffective. noted increased filling pressures and furosemide and lasix po started. multiple viral tests performed, all negative except for ebv and cmr which are pending. pt describes very poor protein and calorie intake last 2 months. had some rectal bleeding with stools recently, [**1-2**] hemmorhoids.","the patient is a 41 year old female with seizure disorder, gastrectomy, degenerative disc disease who presented with vague gi complaints. she was found to have severe systolic/dystolic function as well as tachycardia. she was discharged in good condition, with stable vital signs, with appropriate outpatient follow-up arranged." 66831,140947.0,8449,2130-07-27,8448,115882.0,2130-07-14,Discharge summary,"Admission Date: [**2130-7-10**] Discharge Date: [**2130-7-14**] Date of Birth: [**2047-4-25**] Sex: F Service: SURGERY Allergies: Penicillins / Morphine / Codeine Attending:[**First Name3 (LF) 148**] Chief Complaint: Jaundice and abdominal pain. Major Surgical or Invasive Procedure: [**2130-7-10**] - ERCP with stent removal and new stent placement. History of Present Illness: 83 year-old female presents as transfer from [**Location (un) 620**] with jaundice and abdominal pain. The patient has a known peri-ampullary cancer. She had an ERCP in [**4-/2130**] that revealed a bulky/friable major papilla and a 15 mm shouldered stricture at the ampullary level. She was stented at that time. EUS 2 days later revealed pancreas parenchyma with changes of chronic pancreatitis. Changes of acute on chronic pancreatitis noted in the head of the pancreas, and dilated pancreatic and bile duct to the ampulla. Distal CBD brushings were positive for malignancy. The patient is scheduled to have Whipple next week by Dr. [**Last Name (STitle) **]. Patient was seen for preadmission testing last week and was doing well. . However, she now presents 3 days of severe RUQ abdominal pain and jaundice. Her urine has been dark, and she has been having small brown bowel movements. She also reports vomiting on and off for 4 days. She went to the ED at [**Hospital1 18**] [**Location (un) 620**] today where she was found to be jaundiced and slightly hypotensive with SBP in 80s. Her BP responded well to IVF. She was diagnosed with cholangitis and transferred to [**Hospital1 18**] main campus for ERCP. At the time of transfer, she was mentating well and not complaining of any chest pain. She only felt slight abdominal pain. SBP ranged from mid 80s to 110. Past Medical History: PMHx: AF (not on coumadin), CAD, HTN, Hypothyroidism, Type II DM, Hypercholesterolemia, Anemia, h/o Myasthenia [**Last Name (un) **], GERD, Dysphagia, h/o Bronchitis, chronic pancreatitis, periampullary cancer. . PSHx: TAH, Sinus surgery, ORIF UE fx w/ bone grafting Social History: Retired from work in accounting office and as florist. No tobacco, alcohol, drugs. Patient will be discharged to a skilled nursing facility, where her husband resides. Family History: Non-contributory Physical Exam: On Admission: VS: 98.0 116 104/62 18 96%2L Gen: NAD. A&Ox3. HEENT: Scleral icterus. Moist mucus membranes Neck: No JVD. No LAD. No TM. CV: RRR. Pulm: CTAB. Abd: Soft. NT. ND. +BS. DRE: Normal tone. No masses. No gross or occult blood. Ext: Warm and well perfused. No peripheral edema. Neuro: Motor and sensation grossly intact. Pertinent Results: [**2130-7-10**] 10:48PM GLUCOSE-132* UREA N-35* CREAT-1.1 SODIUM-137 POTASSIUM-3.7 CHLORIDE-107 TOTAL CO2-22 ANION GAP-12 [**2130-7-10**] 10:48PM CALCIUM-7.3* PHOSPHATE-3.3 MAGNESIUM-2.0 [**2130-7-10**] 10:48PM WBC-10.7 RBC-2.65* HGB-8.7* HCT-25.7* MCV-97 MCH-32.9* MCHC-33.9 RDW-18.7* [**2130-7-10**] 10:48PM NEUTS-94* BANDS-2 LYMPHS-3* MONOS-0 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2130-7-10**] 10:48PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-2+ MICROCYT-1+ POLYCHROM-OCCASIONAL SPHEROCYT-1+ OVALOCYT-1+ TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL [**2130-7-10**] 10:48PM PLT SMR-NORMAL PLT COUNT-232 [**2130-7-10**] 10:48PM PT-15.1* PTT-25.9 INR(PT)-1.3* [**2130-7-10**] 05:50PM URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-1 PH-6.5 LEUK-NEG [**2130-7-10**] 05:50PM URINE RBC-0-2 WBC-[**1-26**] BACTERIA-FEW YEAST-NONE EPI-[**1-26**] [**2130-7-10**] 04:45PM GLUCOSE-143* UREA N-39* CREAT-1.3* SODIUM-135 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-25 ANION GAP-11 [**2130-7-10**] 04:45PM ALT(SGPT)-96* AST(SGOT)-155* CK(CPK)-72 ALK PHOS-828* TOT BILI-8.4* [**2130-7-10**] 04:45PM LIPASE-64* [**2130-7-10**] 04:45PM cTropnT-0.29* [**2130-7-10**] 04:45PM CK-MB-NotDone [**2130-7-10**] 04:45PM ALBUMIN-2.4* . Cardiology Report ECG Study Date of [**2130-7-10**]: Sinus tachycardia with atrial premature beats. Non-specific diffuse low amplitude T waves. Compared to the previous tracing of [**2130-7-6**] sinus tachycardia is new and the Q-T interval is no longer prolonged. Intervals Axes: Rate PR QRS QT/QTc P QRS T 108 116 90 362/446 38 -2 12 . [**2130-7-10**] ERCP: Distal migration of the pre-existing biliary stent in the major papilla. Pus and sludge released from the bile duct following removal of stent. Biliary stricture consistent with the patients known ampullary cancer. 10F 7cm Cotton [**Doctor Last Name **] biliary stent placed for drainage. Otherwise normal EGD to third part of the duodenum. . Cardiology Report ECG Study Date of [**2130-7-11**]: Sinus rhythm. T wave inversions in leads V1-V6. Cannot exclude myocardial ischemia. Prolonged Q-T interval. Low QRS voltage in the precordial leads. Compared to tracing #1 of [**2130-7-10**] sinus tachycardia and atrial premature beats are absent. The T wave inversion is new. Intervals Axes: Rate PR QRS QT/QTc P QRS T 69 0 84 458/473 0 -9 -142 . [**2130-7-11**] CXR: Mild pulmonary edema with low lung volumes and bibasilar atelectasis. Brief Hospital Course: The patient with a history of peri-ampullary cancer was admitted from [**Hospital1 **] [**Location (un) 620**] ED to the SICU on [**2130-7-10**] in stable condition for treatment of cholangitis. She was made NPO, started on IV fluids and IV Cipro and Flagyl, a foley was placed, and she was transfused 1 unit PRBC for a HCT 24.5 prior to ERCP. She then underwent ERCP, which revealed distal migration of the pre-existing biliary stent in the major papilla. Pus and sludge released from the bile duct following removal of stent. Biliary stricture consistent with the patients known ampullary cancer was seen. A new stent was placed. The patient was then transferred to the [**Hospital Unit Name 153**]. . [**Hospital Unit Name 153**] Course [**Date range (3) 29786**]: The patient was transferred to the [**Hospital Unit Name 153**] post ERCP for monitoring of respiratory status and continued intubation given her history of myasthenia [**Last Name (un) 2902**]. She was hypotensive, and CVL and A-line were placed. She received LR boluses and was started on levophed drip with improvement in her CVP to 16-18 and MAPs>70. UOP was approximately 20-25cc/hr. Troponin's elevated 0.19-0.29 range; no EKG changes or ST elevation. Recent persantine stress test normal. Believed to be due to demand ischemia secondary to hypotensive episode and/or sepsis. No acute cardiac events. The patient was extubated without events and transferred to the SICU for continued management. . SICU Course [**Date range (3) 29787**]: Returned to SICU NPO except medications, on IV fluids and IV antibiotics in good condition and hemodynamically stable. Electrolytes repleted, started on sips and home medications, ambulated. Cleared for transfer to the floor. . Floor Course [**Date range (3) 29788**]: Tranferred to the floor; was hemodynamically stable. Diet abvanced to clears, then regular by [**2130-7-13**] with good tolerability. Experienced no significant pain. IV fluids discontinued. Foley catheter was discontinued; the patient was able to void on her own without problem. Restarted on remaining home medications with the exception of Metoprolol, which was prescribed as 100mg [**Hospital1 **] as blood pressure and heart rate well controlled, instead of home dose of Toprol XL 250mg daily. Physical Therapy evaluated and worked with the patient prior to discharge. At the time of discharge on [**2130-7-14**], the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating with assistance, voiding without assistance, and not experiencing any significant pain. The patient was discharged to the same skilled nursing facility, where her husband has been admitted. She will return for planned Whipple surgery [**2130-8-2**]. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Aspirin EC 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Lovastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Mestinon 60 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO as needed for Anxiety. 11. Imuran 50mg PO BID. 12. Metoprolol SR 250mg (200mg + 50mg) PO daily. 13. HCTZ 25mg PO QAM. Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Hold Aspirin starting [**2130-7-19**] (two weeks prior to surgery). 5. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 8. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Mestinon 60 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO Qday-[**Hospital1 **] as needed for Anxiety. 11. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 9 days. Disp:*27 Tablet(s)* Refills:*0* 12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 9 days. Disp:*18 Tablet(s)* Refills:*0* 13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day: [**Month (only) 116**] increase to 200mg [**Hospital1 **] if indicated by BP & HR. 15. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**2-27**] hours as needed for fever or pain. Discharge Disposition: Extended Care Facility: [**Location (un) 29789**] Country Manor - [**Location (un) 29789**] Discharge Diagnosis: 1. Periampullary cancer 2. Cholangitis 3. [**First Name9 (NamePattern2) **] [**Last Name (un) **] 4. Anemia Discharge Condition: Stable Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-2**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Followup Instructions: You have been scheduled for Whipple surgery on [**2130-8-2**]. Please take nothing by mouth after midnight on [**8-2**]. Stop your Aspirin on [**2130-7-19**]. Please do NOT take your Metformin and hydrochlorothiazide the morning of surgery. You will be contact[**Name (NI) **] with other pre-operative instructions prior to this date. Please call Dr.[**Name (NI) 2829**] Office at ([**Telephone/Fax (1) 2828**] with any questions. Please call ([**Telephone/Fax (1) 7761**] to arrange a follow-up appointment with Dr. [**Last Name (STitle) **] (PCP) in [**11-25**] weeks. Completed by:[**2130-7-14**]",13,2130-07-10 17:25:00,2130-07-14 14:25:00,EMERGENCY,EMERGENCY ROOM ADMIT,SNF,ABDOMINAL PAIN," the patient with a history of peri-ampullary cancer was admitted from [**hospital1 **] [**location (un) 620**] ed to the sicu on [**2130-7-10**] in stable condition for treatment of cholangitis. she was made npo, started on iv fluids and iv cipro and flagyl, a foley was placed, and she was transfused 1 unit prbc for a hct 24.5 prior to ercp. she then underwent ercp, which revealed distal migration of the pre-existing biliary stent in the major papilla. pus and sludge released from the bile duct following removal of stent. biliary stricture consistent with the patients known ampullary cancer was seen. a new stent was placed. the patient was then transferred to the [**hospital unit name 153**]. . [**hospital unit name 153**] course [**date range (3) 29786**]: the patient was transferred to the [**hospital unit name 153**] post ercp for monitoring of respiratory status and continued intubation given her history of myasthenia [**last name (un) 2902**]. she was hypotensive, and cvl and a-line were placed. she received lr boluses and was started on levophed drip with improvement in her cvp to 16-18 and maps>70. uop was approximately 20-25cc/hr. troponins elevated 0.19-0.29 range; no ekg changes or st elevation. recent persantine stress test normal. believed to be due to demand ischemia secondary to hypotensive episode and/or sepsis. no acute cardiac events. the patient was extubated without events and transferred to the sicu for continued management. . sicu course [**date range (3) 29787**]: returned to sicu npo except medications, on iv fluids and iv antibiotics in good condition and hemodynamically stable. electrolytes repleted, started on sips and home medications, ambulated. cleared for transfer to the floor. . floor course [**date range (3) 29788**]: tranferred to the floor; was hemodynamically stable. diet abvanced to clears, then regular by [**2130-7-13**] with good tolerability. experienced no significant pain. iv fluids discontinued. foley catheter was discontinued; the patient was able to void on her own without problem. restarted on remaining home medications with the exception of metoprolol, which was prescribed as 100mg [**hospital1 **] as blood pressure and heart rate well controlled, instead of home dose of toprol xl 250mg daily. physical therapy evaluated and worked with the patient prior to discharge. at the time of discharge on [**2130-7-14**], the patient was doing well, afebrile with stable vital signs. the patient was tolerating a regular diet, ambulating with assistance, voiding without assistance, and not experiencing any significant pain. the patient was discharged to the same skilled nursing facility, where her husband has been admitted. she will return for planned whipple surgery [**2130-8-2**]. the patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. ","PRIMARY: [Unspecified septicemia] SECONDARY: [Septic shock; Cholangitis; Obstruction of bile duct; Malignant neoplasm of extrahepatic bile ducts; Chronic pancreatitis; Acute kidney failure, unspecified; Severe sepsis; Atrial fibrillation; Unspecified essential hypertension; Unspecified acquired hypothyroidism; Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled; Myasthenia gravis without (acute) exacerbation]","the patient with a history of peri-ampullary cancer was admitted from [**hospital1 **] [**location (un) 620**] ed to the sicu on [**2130-7-10**] in stable condition for treatment of cholangitis. believed to be due to demand ischemia secondary to hypotensive episode and/or sepsis. the patient was extubated without events and transferred to the sicu for continued management. at the time of discharge on [**2130-7-14**], the patient was doing well, afebrile with stable vital signs. she will return for planned whipple surgery [**2130-8-2**].","the patient with a history of peri-ampullary cancer was admitted to the sicu on [**2130-7-10**] in stable condition for treatment of cholangitis. she was made npo, started on iv fluids and iv cipro and flagyl, and a foley was placed. she then underwent ercp, which revealed distal migration of the pre-existing biliary stent in the major papill" 68140,112268.0,18626,2157-03-01,18625,190006.0,2157-02-16,Discharge summary,"Admission Date: [**2157-1-19**] Discharge Date: [**2157-2-16**] Date of Birth: [**2073-4-5**] Sex: M Service: MEDICINE Allergies: Penicillins / Bactrim Attending:[**First Name3 (LF) 898**] Chief Complaint: Transfer from [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] NH for hypotension and hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 1683**] is an 83 YOM with dementia, Type 2 Diabetes Mellitus, bladder cancer s/p resection and BCG treatment, and recently discharged for UTI who was at his nursing home yestderday when found to be having chills and lower extremity numbness. His vitals were taken and was found to be afebrile 95.7, hypotensive (79/57), tachycardic (120) and hypoxic (O2SAT: 81% on RA). His bilateral LE were found to be cold and purple. He was warmed up and put into bed and his BP stabilized in 110s, he was placed on nonrebreather and his O2 sats came up only to 87%. Per records he did not have any mental status changes. . Of note, OSH records from Mr [**Known lastname 1683**] previous D/C summary in OMR report he has had multiple recent UTIs over the past few months including multi drug resistent enterobacter on [**2156-12-12**], Proteus on [**2156-12-20**], as well as Klebsiella in [**Month (only) 359**]. Mr. [**Known lastname 1683**] was recently discharged from [**Hospital1 **] on [**2156-12-31**] for UTI with pseudomonas resistent to cipro. This admission was complicated by delirium and LE DVT for which an IVC filter was placed due to concurrent hematuria. He is not currently anticoagulated. He was discharged on meropenem for 6 days. On [**2157-1-18**] (the day prior to admission) he presented to the ED b/c of hematuria and passage of clots. He was seen by urology and foley irrigation was performed and he was sent out on Levofloxacin with plans to undergo cystoscopy with bladder biopsies and possible resection of TURBT as an outpatient. However, the following day he had his hypotensive event described above and was sent to the ED. . In the ED his vitals were 98.0 110 130/60 18 99. However, his BP dropped to 90/60 BP with sats in the 80s and a lactate of 6. CXR showed no acute pulmonary process. He was given vanc and meropenem and, had an IJ placed, 6 L fluid, and foley showed gross hematuria. He was transfered to the MICU with concern for urosepsis where his pressure stabilized and he did not require pressors. He was transfered to the medicine floor. . Upon ariving to the floor vitals were 99.2 122/60 91 20 97% on RA. . ROS: Difficult to understand pt, unsure if from dementia or adentulous. Pt alert but oriented only to self, knew he was in [**Location (un) 86**] but could not name hospital. Denied pain, SOB, but stated he was cold and thirsty. Past Medical History: 1. Pulmonary Embolism ([**2156-12-24**], IVC filter, not on anticoagulation) 2. Pancreatitis 3. Dementia 4. Type 2 Diabetes Mellitus 5. Hypertension, but not on antihypertensives 6. BPH 7. Bladder Cancer - s/p transurethral resection in [**7-31**] - completed [**3-29**] BCG treatment (missed treatment 5 [**1-25**] UTI) 8. s/p Stab Wounds 9. h/o RPR - treated in [**2119**] 10. s/p Penile Implant 11. Osteoarthritis Social History: Per previous records, patient could not complete full history with me due to his delirium and dementia. Home: lives in [**Location 4367**] [**Hospital3 400**] Facility Occupation: retired long-distance truck driver EtOH: remote history of social alcohol use; denies EtOH in > 45 years Tobacco: remote history of 1 PPD smoking history, could not tell me when he quit Drugs: denies Family History: Could not complete due to patient's dementia. Physical Exam: VS: 100.4 133/74 76 20 98% RA General: Alert, oriented to self only, lying comfortably in bed HEENT: Dry mucous membranes, edentulous, pupils equal and reactive Neck: supple, JVP not elevated, no LAD. Right IJ in place, appears clean and dry. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: 2+ pitting edema in left LE and 1+ on right, chronic venous stasis changes to skin of both LEs; DPs difficult to palpate, but feet are warm Neuro: CN grossly intact. Uses both upper extremities purposefully. Foley with red urine in bag. Responded to questions, but difficult to make out his answers, mildly agitated, not really holding coherent conversation. Pertinent Results: LABS ON ADMISSION: [**2157-1-18**] 10:00AM BLOOD WBC-11.7* RBC-4.20* Hgb-10.4* Hct-32.8* MCV-78* MCH-24.8* MCHC-31.7 RDW-14.7 Plt Ct-257 [**2157-1-18**] 10:00AM BLOOD Neuts-82.9* Lymphs-11.6* Monos-4.7 Eos-0.4 Baso-0.3 [**2157-1-18**] 10:00AM BLOOD PT-14.4* PTT-26.4 INR(PT)-1.2* [**2157-1-18**] 10:00AM BLOOD Glucose-138* UreaN-33* Creat-1.3* Na-144 K-3.9 Cl-100 HCO3-30 AnGap-18 [**2157-1-19**] 05:25PM BLOOD ALT-17 AST-16 LD(LDH)-268* AlkPhos-76 TotBili-0.3 [**2157-1-19**] 05:25PM BLOOD Lipase-68* [**2157-1-19**] 05:25PM BLOOD cTropnT-<0.01 [**2157-1-19**] 07:43PM BLOOD Hgb-8.4* calcHCT-25 O2 Sat-91 [**2157-1-19**] 08:48PM BLOOD Glucose-133* Lactate-1.2 [**2157-1-19**] 05:22PM BLOOD Lactate-6.0* K-5.0 LABS ON DISCHARGE: [**2157-2-14**] 05:53AM BLOOD WBC-6.6 RBC-3.38* Hgb-7.9* Hct-26.0* MCV-77* MCH-23.2* MCHC-30.2* RDW-18.1* Plt Ct-423 [**2157-2-15**] 06:56AM BLOOD WBC-8.0 RBC-3.57* Hgb-8.2* Hct-27.5* MCV-77* MCH-23.0* MCHC-29.8* RDW-17.5* Plt Ct-421 [**2157-2-15**] 06:56AM BLOOD Glucose-141* UreaN-12 Creat-0.6 Na-136 K-4.5 Cl-99 HCO3-29 AnGap-13 [**2157-2-15**] 06:56AM BLOOD Calcium-9.0 Phos-3.0 Mg-1.6 [**2157-2-16**] 05:43AM BLOOD WBC-7.6 RBC-3.50* Hgb-8.2* Hct-26.6* MCV-76* MCH-23.5* MCHC-30.9* RDW-18.0* Plt Ct-495* [**2157-2-16**] 05:43AM BLOOD Glucose-144* UreaN-11 Creat-0.6 Na-134 K-4.3 Cl-97 HCO3-30 AnGap-11 [**2157-2-16**] 05:43AM BLOOD Calcium-9.1 Phos-2.9 Mg-1.8 ******** CXR [**2157-1-20**]: FINDINGS: Lung volumes are markedly diminished with resultant bronchovascular reorientation at the lung bases. No consolidation or edema is evident. Tortuosity of the thoracic aorta is slightly accentuated due to the low lung volumes. Similarly, cardiac size is mildly accentuated, but remains overall within normal limits. No definite effusion or pneumothorax is seen. Extensive degenerative changes are again seen throughout the thoracic spine. There are multiple bilateral rib deformities, presumably due to remote trauma, relatively stable when compared to the prior exam. IMPRESSION: Markedly low lung volumes with no acute pulmonary process identified. RENAL U/S: FINDINGS: The right kidney measures 11.0 cm. The left kidney measures 13.1 cm. No stones, hydronephrosis or solid mass is identified. Within the lower pole of the right kidney is a 1.6 cm simple-appearing cyst. There is also a 1.6 cm simple-appearing cyst within the upper pole of the left kidney. No perinephric fluid collection is identified. Limited views of bladder reveal Foley catheter, with the bladder decompressed. There is a heterogeneous 6.7 cm mass in the bladder with vascular waveforms obtained, compatible with the patient's known bladder mass. IMPRESSION: 1. No evidence of hydronephrosis. 2. No evidence of perinephric abscess or fluid. CXR [**2-9**]: Cardiomediastinal silhouette is stable. Right PICC line tip is at the level of superior SVC. Heart size is normal. Mediastinal contour is unremarkable. There is questionable new small focal opacity at the mid portion of the left lung that might represent subpleural atelectasis/nodule seen on the chest CT from [**2157-1-29**], with no new consolidations demonstrated. The known pulmonary nodules are partially imaged on the current study due to the suboptimal sensitivity of this portable chest radiograph. Multiple rib fractures, bilateral, are unchanged since the prior study. The IVC filter is in place. . CT CHEST WITHOUT IV CONTRAST: There are numerous pulmonary nodules throughout all lobes of the lungs consistent with metastatic disease, presumably from the patient's known bladder cancer unless there is an additional unknown primary neoplasm. These are larger in the lung bases, measuring up to 12 mm bilaterally (2:36, 2:34). There is no significant pleural effusion. There is bilateral mild subsegmental dependent atelectasis. The trachea and bronchi are patent to the subsegmental levels. There is no mediastinal lymphadenopathy. Note is made of multiple slightly prominent axillary lymph nodes, which are not pathologically enlarged by size criteria. There are numerous coronary artery calcifications, as well as calcification of the aortic arch. A right upper extremity PICC terminates with the catheter tip in the lower SVC. Limited axial imaging of the upper abdomen is fairly unremarkable, although numerous renal hypodensities are again seen, which are most consistent with cysts, although better demonstrated on prior imaging studies. The superior most aspect of an infrarenal IVC filter is seen (2:56). Small hiatal hernia is present. Osseous structures demonstrate numerous left-sided chronic rib fractures at T1-9 as well as right-sided rib fractures at T1-6. No suspicious lytic or sclerotic lesions are seen. There is mild degenerative change of the thoracic spine. IMPRESSION: 1. Innumerable bilateral pulmonary nodules consistent with metastatic disease. 2. No mediastinal lymphadenopathy. 3. Chronic rib fractures bilaterally. 4. Renal hypodensities most consistent with cysts, better demonstrated on prior studies. Brief Hospital Course: 83yo gentleman with h/o bladder cancer, recurrent UTIs, and dementia called out from the MICU for continuing treatment of urosepsis. Hospital course by problem as follows. . # Urosepsis: Patient received 7 L IVF with improvement in blood pressure, never needed vasopressor support. He was started on meropenem given prior urine cx sensitivities. He was transferred to the floor the following morning. His renal function returned to baseline after volume repletion. UCx pseudomonas 10-100k, sensitive to cefepime, ceftaz, gent, [**Last Name (un) 2830**], [**Doctor Last Name **], tobra. Recurrent UTIs across last several months with documented history of proteus, enterobacter, klebsiela and pseudomonas, current urine cx showing pseudomonas. No other clear source of infection as he did not have infiltrate on CXR, no cough, no abdominal pain, BCx NGTD, and no lines on admission. PICC line placed and he was treated for 14days with meropenem. Urology consulted. Recurrent UTI's likely [**1-25**] bladder cancer and urinary retention. A Foley catheter was placed at admission. This was taken out overnight on [**2-15**]. He passed his trial of void with a 100 cc residual volume. He was noted to be incontinent of urine at baseline. . # Bladder cancer, hematuria: Urology took for cystoscopy-> 7cm tumor, unable to resect via scope. CT to assess for invasion/ lymph node involvement-> no clear evid of invasion or LN involvement however mult lung nodules concerning for metastatic disease. Med onc consulted-> Rec chest CT for accurate staging, bx for tissue diagnosis, and agreed to follow when outpatient. Given massive DVT and need for anticoagulation, discussion had with family/urology/ radiation oncology about possible palliative procedures to stop hematuria and allow for anticoagulation. Decision was made to proceed with palliative radiation tx as family wished to avoid any further invasive procedures. Palliative care also consulted. Patient underwent palliative radiation in attempt to control hematuria so that he could have anticoagulation given his large lower extremity DVT as below. . # DVT: h/o PE [**1-25**] DVT with IVC in place not anticoagulated due to history of hematuria. Patient noted to have swollen L leg-> LENI-> DVT from L common fem to L popliteal. CT scan done for staging as above showed DVT extended up to DVT filter. Anticoagulation attempted however was d/c'd as hematuria increased and patient dropped his hct. Palliative radiation therapy was given with the goal to control hematuria, however the patient did continue to bleed with anticoagulation. Given that he bled enough to require multiple transfusions during this admission, it was ultimately felt that anticoagulation should be held with the decision to re-start deferred to the outpatient setting. . # Low grade fevers: Following treatment with meropenem for urosepsis as above, patient developed recurrent low grade fevers. No clear source. UCx, BCx, and CXR negative for infection. WBC stable. In the end, thought likely due to DVT. By discharge, still having once daily temperatures to 99 F. . # Delirium : Continued on aricept. MS waxed and waned however never returned to baseline. He frequently became agitated, pulling at his PICC line and foley. He frequently required soft restraints to prevent him from injuring himself and occasionally required haldol (ECG checked and QTc wnl). After his catheter was removed the restraints were removed and he was overall much more calm. . # Anemia: baseline Hct 32-35, current Hct 25, likely [**1-25**] hematuria. Iron studies were consistent with underlying anemia of chronic disease. Guiac was negative. He was transfused a total of 5 units of PRBCs during this admission given blood loss from his friable bladder tumor. His Hct was stable around 26 prior to discharge. . # Hypernatremia, Mild, Asymptomatic: likely [**1-25**] poor PO water intake. Encouraged PO intake of water and this resolved on its own. . # Type 2 DM: controlled with ISS in house. Medications on Admission: Imipenem 750mg [**Hospital1 **] IM started [**2157-1-3**] for 3 days Ertapenem 1gm IM Qday x 4 days, started [**2157-1-3**] Decubrite 1 tab Qday tylenol 650mg Q4H PO PRN Lasix 30mg PO qday Levaquin 250mg PO x 7 days, started [**2157-1-18**] Donepezil 5mg HS Gabapentin 300mg Qday Imdur 30mg Qday Famotidine 20mg PO BID PRN itch Novalog SSI Senna 1-2 tabs [**Hospital1 **] PRN Vitamin D3 400mg, 2 tabs Qday Colace 100mg [**Hospital1 **] Citaloprom 20mg Qday Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Disp:*30 Tablet(s)* Refills:*2* 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Tablet(s) 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 8. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for dryness. Disp:*1 bottle* Refills:*2* 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 11. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Insulin Instructions Please continue to take your Humalog Insulin --Sliding Scale as taken during this admission. A full sliding scale regimen is outlined below for the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] nurses to follow. To be taken as needed at meal times and at bed time Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: PRIMARY: 1. Urosepsis 2. Bladder Cancer 3. Deep venous thrombosis SECONDARY: 1. Dementia / deliriium 2. Type 2 Diabetes Mellitus 3. Hypertension, but not on antihypertensives Discharge Condition: Mental Status:Confused - always Level of Consciousness: Lethargic but arousable Activity Status: Bedbound Discharge Instructions: It was a pleasure taking care of you during your admission at [**Hospital1 69**]. You were admitted for a urinary tract infection. You were treated with antibiotics. You had a catheter in your bladder for some time, but we took this out and you were able to urinate on your own. You received a course of radiation to help improve your bladder cancer symptoms. You have a previous diagnosis of left lower leg blood clot. We were unable to give you anticoagulant medications for this as you continued to have significant blood in your urine, requiring blood transfusion, after receiving these. We have changed some of your medications during your admission. Please continue, start, or stop your medications as below: - Continue Citalopram 20 mg daily - Continue Donepezil 5 mg daily - Continue Famotidine 20 mg twice daily - Continue polyethylene glycol for constipation as needed - Continue Senna for constipation prevention - Continue Vitamin D 800 units daily - Stop Fexofenadine - Continue Colace 100 mg twice daily - Continue Tylenol as needed for pain/fever as written - Continue using Humalog Insulin as needed with a sliding scale at meal times and bedtime as taken prior to this admission - Stop Lasix; discuss re-starting this medication as an outpatient. - Continue getting subcutaneous heparin three times daily while in [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **]. [**Doctor Last Name **] and Dr. [**Last Name (STitle) 10351**] from urologic oncology on [**3-10**] at 1 pm. . Dr.[**Name (NI) 51133**] office was called and notified that you will be going back to The [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Upon return to the [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] you will be seen by her nurse practitioner, Jiyan [**Doctor Last Name **] (#[**Telephone/Fax (1) 608**]). Ms. [**Name13 (STitle) **] will help to coordinate your next visit with Dr. [**Last Name (STitle) 4321**] at your facility. Completed by:[**2157-2-16**]",13,2157-01-19 20:13:00,2157-02-16 17:20:00,EMERGENCY,EMERGENCY ROOM ADMIT,SNF,SEPSIS," 83yo gentleman with h/o bladder cancer, recurrent utis, and dementia called out from the micu for continuing treatment of urosepsis. hospital course by problem as follows. . # urosepsis: patient received 7 l ivf with improvement in blood pressure, never needed vasopressor support. he was started on meropenem given prior urine cx sensitivities. he was transferred to the floor the following morning. his renal function returned to baseline after volume repletion. ucx pseudomonas 10-100k, sensitive to cefepime, ceftaz, gent, [**last name (un) 2830**], [**doctor last name **], tobra. recurrent utis across last several months with documented history of proteus, enterobacter, klebsiela and pseudomonas, current urine cx showing pseudomonas. no other clear source of infection as he did not have infiltrate on cxr, no cough, no abdominal pain, bcx ngtd, and no lines on admission. picc line placed and he was treated for 14days with meropenem. urology consulted. recurrent utis likely [**1-25**] bladder cancer and urinary retention. a foley catheter was placed at admission. this was taken out overnight on [**2-15**]. he passed his trial of void with a 100 cc residual volume. he was noted to be incontinent of urine at baseline. . # bladder cancer, hematuria: urology took for cystoscopy-> 7cm tumor, unable to resect via scope. ct to assess for invasion/ lymph node involvement-> no clear evid of invasion or ln involvement however mult lung nodules concerning for metastatic disease. med onc consulted-> rec chest ct for accurate staging, bx for tissue diagnosis, and agreed to follow when outpatient. given massive dvt and need for anticoagulation, discussion had with family/urology/ radiation oncology about possible palliative procedures to stop hematuria and allow for anticoagulation. decision was made to proceed with palliative radiation tx as family wished to avoid any further invasive procedures. palliative care also consulted. patient underwent palliative radiation in attempt to control hematuria so that he could have anticoagulation given his large lower extremity dvt as below. . # dvt: h/o pe [**1-25**] dvt with ivc in place not anticoagulated due to history of hematuria. patient noted to have swollen l leg-> leni-> dvt from l common fem to l popliteal. ct scan done for staging as above showed dvt extended up to dvt filter. anticoagulation attempted however was d/cd as hematuria increased and patient dropped his hct. palliative radiation therapy was given with the goal to control hematuria, however the patient did continue to bleed with anticoagulation. given that he bled enough to require multiple transfusions during this admission, it was ultimately felt that anticoagulation should be held with the decision to re-start deferred to the outpatient setting. . # low grade fevers: following treatment with meropenem for urosepsis as above, patient developed recurrent low grade fevers. no clear source. ucx, bcx, and cxr negative for infection. wbc stable. in the end, thought likely due to dvt. by discharge, still having once daily temperatures to 99 f. . # delirium : continued on aricept. ms waxed and waned however never returned to baseline. he frequently became agitated, pulling at his picc line and foley. he frequently required soft restraints to prevent him from injuring himself and occasionally required haldol (ecg checked and qtc wnl). after his catheter was removed the restraints were removed and he was overall much more calm. . # anemia: baseline hct 32-35, current hct 25, likely [**1-25**] hematuria. iron studies were consistent with underlying anemia of chronic disease. guiac was negative. he was transfused a total of 5 units of prbcs during this admission given blood loss from his friable bladder tumor. his hct was stable around 26 prior to discharge. . # hypernatremia, mild, asymptomatic: likely [**1-25**] poor po water intake. encouraged po intake of water and this resolved on its own. . # type 2 dm: controlled with iss in house. ","PRIMARY: [Unspecified septicemia] SECONDARY: [Septic shock; Acute kidney failure, unspecified; Urinary tract infection, site not specified; Acute venous embolism and thrombosis of deep vessels of proximal lower extremity; Acidosis; Hyposmolality and/or hyponatremia; Hyperosmolality and/or hypernatremia; Acute posthemorrhagic anemia; Pseudomonas infection in conditions classified elsewhere and of unspecified site; Malignant neoplasm of dome of urinary bladder; Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled; Gross hematuria; Unspecified essential hypertension; Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS); Retention of urine, unspecified; Severe sepsis; Other transfusion reaction; Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure; Hypoxemia; Other persistent mental disorders due to conditions classified elsewhere]","83yo gentleman with h/o bladder cancer, recurrent utis, and dementia called out from the micu for continuing treatment of urosepsis. a foley catheter was placed at admission. ct to assess for invasion/ lymph node involvement-> no clear evid of invasion or ln involvement however mult lung nodules concerning for metastatic disease. ct scan done for staging as above showed dvt extended up to dvt filter. given that he bled enough to require multiple transfusions during this admission, it was ultimately felt that anticoagulation should be held with the decision to re-start deferred to the outpatient setting. he frequently became agitated, pulling at his picc line and foley. he frequently required soft restraints to prevent him from injuring himself and occasionally required haldol (ecg checked and qtc wnl). # hypernatremia, mild, asymptomatic: likely [**1-25**] poor po water intake.","83yo gentleman with h/o bladder cancer, recurrent utis, and dementia called out from the micu for continuing treatment of urosepsis. patient received 7 l ivf with improvement in blood pressure, never needed vasopressor support. he was started on meropenem given prior urine cx sensitivities." 73488,199332.0,17651,2169-12-09,17650,185762.0,2169-10-23,Discharge summary,"Admission Date: [**2169-10-14**] Discharge Date: [**2169-10-23**] Date of Birth: [**2130-2-9**] Sex: M Service: MEDICINE Allergies: Ampicillin / Ancef Attending:[**First Name3 (LF) 689**] Chief Complaint: hypoxia, seizure Major Surgical or Invasive Procedure: intubation for airway protection History of Present Illness: This is a 39 yom with h/o C5 quadriplegia, MDS, and recurrent UTIs who was transferred from OSH for assessment of altered mental status. He was admitted to [**Location (un) 620**] from [**2169-10-5**] to [**2169-10-9**] with lethargy and was diagnosed with a Klebsiella UTI. He was initially treated with ertapenem and subsequently switched to ciprofloxacin for a seven day course. At the time of discharge the patient was continuing to feel weak. At baseline he can unscrew a bottle cap, drive a car and drive his wheelchair. He returned to [**Location 620**] on [**2169-10-14**] with progressive weakness in his upper extremities and lethargy. His temperature was ""running low"" but he had no fevers, chest pain, difficulty breathing, nausesa, vomiting, headaches, neck stiffness, head trauma or diarrhea but was having some mild cough and congestion. Initial vitals were notable for a temperature of 92.7. Initial urinalysis was positive and he was started on ertapenem for presumed urinary tract infection. Subsequent culture has been negative. He had a head CT which showed possible blood in the third ventricle. He was transfered to this hospital for further management. . On arrival to our emergency room his initial vs were: T 96.2 P: 61 BP: 120/71 R: 14 O2 sat 96%RA. He was seen by neurosurgery who felt he should have platelets given but no surgery was indicated. Patient was given 6 units of platelets (1 bag) and transferred to the floor. . On admission the patient was noted A&O x 3 but per his family was more lethargic than usual. Upper extremity strength was documented as as 4-/5. On [**2169-10-15**], pt had a generalized tonic clonic seizure with hypoxia of 88% on RA. He was treated with IV ativan and was subsequently post-ictal. He was placed on continuous oxygen monitoring and four liters nasal cannula with saturations in the mid 90s. There was concern for aspiration during this event secondary to increased secretions requiring deep suctioning. He was started on IV Keppra 1000 mg [**Hospital1 **]. EEG showed left mid to posterior temporal theta slowing. On [**2169-10-17**] he had a second generalized tonic clonic seizure lasting one minute. He was given IV ativan and subsequently was noted to have hypoxia to 85% on 4L nasal cannula and his respiratory rate was [**5-1**] with periods of apnea. CPAP was tried, but hypoxia persisted. He was placed on NRB. . Complicating his hospital course was a multifocal pneumonia noted on CXR, with low grade temps. He was cotninued on meropenem for UTI although cultures subsequently returned as negative. . MICU course: Pt was somnolent but arousing to voice. He did not respond to questions but would track when aroused. He did not withdraw to painful stimuli in the upper extremtities or respond to questions. Pt is noted to have episodes of bradycardia associated with hypothermia. ECG shows no apparent heart block. Antibiotic coverage was broadened to include anaerobes with Flagyl. Pt was continued on Keppra and Dilantin. . Currently, pt feels well. Denies any complaints. He denies any discomfort with his breathing. . ROS: Denies fever, chills, night sweats, headache, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. C4/C5 Spinal Cord Injury (17 y/a)due to MVA - can move arms slightly cannot move legs 2. OSA on CPAP at home 3. Seizure Disorder ('[**62**]-'[**63**]) 4. Baclofen Pump ('[**49**], '[**54**], '[**61**]). Managed at [**Hospital1 2177**]. 5. s/p appendicovesicostomy 6. Multiple past urinary tract infections including w mild UAs per [**Month (only) 116**] discharge summary, have included Klebsiella, ESBL E coli, enterococcus. Social History: Lives with roommates in house in [**Location (un) 620**], MA. Has private aides to help with ADLs. Until recent seizures, drove himself using modified car. Used to work at UPS in Marketing. Had MVA at age 17 resulting in quadriplegia. Family History: Father had [**Name2 (NI) **] in 50s. Physical Exam: Vitals - T:97.5 BP:98/56 HR:61 RR:16 02 sat:93RA GENERAL: Pleasant, well appearing male, flat affect, NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. Right eye prothesis CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP flat. LUNGS: Coarse breath sounds bilaterally. Good air movement. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No calf pain, 2+ edema to mid calf. 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 intact (right eye prothesis). Preserved sensation throughout. 0/5 strength in LE bilaterally. Delt [**2-26**] bilat. Biceps [**2-26**] bilat. Able to pronate and supinate arms but not against resistance. 0/5 wrists, fingers and entire lower extremities. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2169-10-14**] 144 108 52 ------------ 60 5.0 25 1.6 . .....8.6 2.5 ----- 51 ∆ .....25.3 N:55.4 L:36.0 M:6.0 E:1.9 Bas:0.7 . PT: 12.3 PTT: 36.2 INR: 1.0 . Urine Analysis: Bld Lg Prot 25 RBC [**5-3**] WBC [**1-26**] . Discharge Labs: 145 110 25 -------------- 75 3.7 28 1.2 . Ca 8.3, Mg 1.8, Phos 2.6 . vanc trough 34.1 [**10-15**] EEG: This is an abnormal portable EEG due to intermittent left mid to posterior temporal theta slowing that, at times, appears monomorphic and more suspicious for epileptiform activity. These findings suggest possible subcortical dysfunction in this area. Anatomic correlation is indicated. A repeat study with sphenoidal electrodes may be performed to help clarify the above findings. . [**10-15**] CXR: Bibasilar pneumonia. . [**10-15**] CT Head: CONCLUSION: No definite sign of an intracranial hemorrhage. See above report for requested potential prior outside studies and their reports. COMMENT: Seen on the lateral scout radiograph are two screws overlying the mid cervical spine and a possible intervening wire. Please provide information as to whether this finding constitutes some form of prior surgical treatment. At least the more cephalad screw was likely visible on the prior sagittal T1-weighted scans as an area of susceptibility. CONCLUSION: No definite sign of an intracranial hemorrhage. See above report for requested potential prior outside studies and their reports. COMMENT: Seen on the lateral scout radiograph are two screws overlying the mid cervical spine and a possible intervening wire. Please provide information as to whether this finding constitutes some form of prior surgical treatment. At least the more cephalad screw was likely visible on the prior sagittal T1-weighted scans as an area of susceptibility. . [**10-17**] CXR (portable): Newly developed, slightly asymmetrical pulmonary edema with new right pleural effusion, which is small to moderately large . [**10-18**] MRI Head: 1. Motion artifact degrades image quality. Areas of apparent T2 hyperintensity in the right temporal lobe may be artifactual related to the patient motion. The parenchyma is otherwise grossly unremarkable. If there is focal semiology and further clinical concern, repeat MRI of the brain as per the seizure protocol may be helpful if the patient is able to better tolerate the procedure without movement. 2. Stable prosthesis in the right orbit. 3. Fluid within the right mastoid air cells and paranasal sinuses, improved since the prior study. . [**10-18**] CXR: Previous mild pulmonary edema has resolved. Opacification in the right lower lung and accompanied downward displacement of the hilus indicates that previous area of consolidation has now collapsed. Pulmonary edema has resolved since [**10-17**]. Consolidation in the left lower lobe has worsened since [**10-13**] and could be another region of atelectasis or pneumonia. The upper lungs are now clear. Heart size is normal. Pleural effusion, if any, is minimal. ET tube is in standard placement. . [**10-19**] CXR: The patient was extubated. There is a radiopaque object projecting over the upper neck that is most likely external but should be correlated clinically. Cardiomediastinal silhouette is unchanged including minimal cardiomegaly. Compared to prior study obtained yesterday at 08:26 a.m. there is significant improvement in bibasal atelectasis and bilateral opacities consistent with resolution of the atelectatic process and decrease in pleural effusion. There is still present left retrocardiac opacity that might represent infectious process or residual atelectasis. No evidence of failure is present. Brief Hospital Course: 39 yom with h/o C5 quadriplegia, MDS, and recurrent UTIs who was transferred from OSH for assessment of altered mental status and UTI. Hospital course was complicated by HAP and tonic clonic seizures. . #Seizures/AMS: On [**2169-10-15**], pt had a generalized tonic clonic seizure with hypoxia of 88% on RA. He was treated with IV ativan and was subsequently post-ictal. He was placed on continuous oxygen monitoring and on 4L nasal cannula. He was started on IV Keppra 1000 mg [**Hospital1 **]. EEG showed left mid to posterior temporal theta slowing. On [**2169-10-17**] he had a second generalized tonic clonic seizure lasting one minute. He was given IV ativan and subsequently noted to be hypoxic to 85% on 4L nasal cannula. His respiratory rate was [**5-1**]/min with periods of apnea. He was tranferred tot he MICU where he remained seizure free. It was thought that the etiology of his seizure was infection (multifocal pneumonia noted on CXR, sputum positive for G+ cocci). Blood cultures, urine cultures, and cerebral spinal fluid showed no growth. Head CT and MRI were negative for acute process. Per neurology, he was treated with Keppra 1000mg [**Hospital1 **] and loaded with dilantin. Both antiepileptics are to be continued as outpatient per the neurology team. Dilantin levels should be checked in one week. Dilantin can be tapered as outpatient per Dr. [**Last Name (STitle) **]. #Hypoxia/Pneumonia: Patient was hypoxic and apneic post seizure with evidence of multifocal pneumonia on CXR. He was intubated to protect his airway and to allow him to have an LP and MRI. He was extubated the following day, oxygen requirement reduced until he was on room air when transferred from the MICU back to the floor. He continued BiPap at night per his home regimen. He was treated with vancomycin and aztreonam for his pneumonia. Patient will be discharged home with IV vancomycin and aztreonam to finish a 10d course. The last day of the antibiotics will be [**2169-10-26**]. On the day of discharge, patient's vanc trough was 34, so vancomycin was held. Critical care/infusion company was instructed to draw vanc trough on the morning post-discharge, and fax the result to Dr. [**Last Name (STitle) **], patient's PCP. [**Last Name (NamePattern4) **].[**Name (NI) 2056**] office was [**Name (NI) 653**], and the RN was told that goal vanc trough is 15-20. If trough > 20, continue to hold vancomycin. If vanc < 20, restart vancomycin at 1gm [**Hospital1 **], and then re-check vanc trough before the 4th dose. #Bradycardia: Pt has history of HR ranging from 38 to 70 while in the MICU. He was found to be hypothermic and was warmed with a bear hugger which improved his HR mildly. He did experience some light headedness but no chest pain or shortness of breath. EKG was unimpressive, cardiac enzymes showed mildly elevated troponins which were consistent with past measurements. No invasive measures were taken. He should be evaluated as outpatient regarding possible intervention. # Elevated troponin: Patient found to have trop of 0.25 when having bradycardic event. According to records, this seems to be his baseline. Could be related to renal dysfunction. Has had cardiology consulted in the past and no interventions were recommended. No further actions taken. . #C5 spinal cord injury: Continued Baclofen pump. Physical therapy found patient to be independent and able to live independently. #Depression: Home Zoloft was continued. . #Chronic Kidney Disease: Baseline Creatinine 1.5-1.7. Received gentle hydration, monitored urine output, renally dosed medications, trended creatinine. Cr 1.2 on discharge. . #Hypernatremia: Could be due to dehydration in the setting of sepsis. He was given D5 boluses in the MICU. He continued to have fluctuating hypernatremia. He was encouraged to take more fluids. His Na was 145 on discharge. . FEN: D5W boluses d/t hypernatremia, repleted electrolytes, advanced to normal diet after extubation. Prophylaxis: SC heparin Access: discharged with PICC Code: Full (discussed with patient) Communication: Patient, Mother( HCP) [**Telephone/Fax (1) 49141**]; Brother [**Name (NI) **] [**Telephone/Fax (1) 49142**] Disposition: home with IV antibiotics and VNA service Medications on Admission: Medications (home - per OMR note): -Keppra 500mg [**Hospital1 **] (recent dosing somewhat unclear, [**Name (NI) 620**] d/c summary says 1000 mg [**Hospital1 **]) -Trazodone 50 mg QHS: PRN -Sertraline 100 mg daily -B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). -Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. -Senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day. -Baclofen 50 mcg/mL Solution Sig: Eighteen (18) mcg Intrathecal once a day -Simvastatin 20mg PO daily -Metronidazole 500mg [**Hospital1 **] [appears not to be taking] . . MEDICATIONS (on transfer): Phenytoin 200 mg IV QHS at 10pm Phenytoin 100 mg IV BID at 7am and 2pm Desonide 0.05% Cream 1 Appl TP [**Hospital1 **] Fluocinolone Acetonide 0.01% Solution 1 Appl TP [**Hospital1 **] Ketoconazole 2% 1 Appl TP [**Hospital1 **] MetRONIDAZOLE (FLagyl) 500 mg IV Q8H, Day 1=[**10-18**] Aztreonam [**2159**] mg IV Q8H [**10-17**] @ 1519 Vancomycin 1000 mg IV Q 12H [**10-17**] @ 1135 Bacitracin Ointment 1 Appl TP QID Lorazepam 2 mg IV PRN seizure LeVETiracetam 1000 mg IV Q12H Baclofen 18 mcg/hr IT WITH PUMP TraZODONE 50 mg PO/NG HS:PRN insomnia Simvastatin 40 mg PO/NG DAILY Acetaminophen [**Telephone/Fax (1) 1999**] mg PO/NG Q6H:PRN fever or pain Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation Sertraline 100 mg PO/NG DAILY Heparin 5000 UNIT SC TID Discharge Medications: 1. Outpatient Lab Work Vancomycin trough levels drawn on AM [**10-24**]. Results should be faxed to [**First Name8 (NamePattern2) 30642**] [**Doctor Last Name **] [**Telephone/Fax (1) 36518**] 2. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). 4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours). 5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 6. B Complex Plus Vitamin C 15-10-50-5-300 mg Capsule Sig: One (1) Capsule PO once a day. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Baclofen Intrathecal 10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): 7AM and 2PM. Disp:*60 Capsule(s)* Refills:*0* 11. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)): at 10PM. 12. Aztreonam in Dextrose(IsoOsm) 2 gram/50 mL Piggyback Sig: Two (2) gram Intravenous Q8H (every 8 hours) for 3 days. Disp:*18 gram* Refills:*0* 13. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous every twelve (12) hours for 3 days: Please draw vanc trough in the AM, fax it to Dr.[**Name (NI) 2056**] Office. Hold Vanc for trough. If trough <20, give vanc 1gm q12h for 3 days. Disp:*6 gram* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: primary: hospital acquired pneumonia, urinary tract infection, mental status change, and seizures, hypernatremia secondary: chronic renal insufficiency. Discharge Condition: stable, afebrile. Discharge Instructions: You were admitted for evaluation after transfer from an outside hospital for symptoms of mental status confusion in the setting of a urinary tract infection. A CT scan at the outside hospital showed a bleed in the head, but repeat imaging here showed no evidence of bleed. During your hospitalization here, you were found to have a pneumonia. You also developed seizures, which you have not had in a long time. You were transferred to the ICU for low oxygenation which after a day improved. You were followed by neurology who adjusted your seizure medications. Medications changed during this hospitalizaiton include: --> You were started on dilantin due to active seizures. You will follow up with Dr. [**Last Name (STitle) **] to slowly stop taper off this medication. --> Please continue to take keppra for seizure prevention --> You have three more days of IV antibiotics to treat pneumonia. The last day of antibiotics will be [**2169-10-26**]. Pleae call your doctor or come to the Emergency Room if you develop shortness of breath, seizures, chest pain, bleeding, severe fatigue and weakness or any other symptom that concerns you. Followup Instructions: PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 30642**] [**Name (STitle) **], on Mon [**2169-11-6**] at 11:45am MD: Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Specialty: Neurology Date and time: Wednesday, [**11-8**] at 4pm Location: [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] bldg, [**Location (un) **] Phone number: [**Telephone/Fax (1) 541**] ",47,2169-10-14 18:37:00,2169-10-23 19:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,ALTERED MENTAL STATUS," 39 yom with h/o c5 quadriplegia, mds, and recurrent utis who was transferred from osh for assessment of altered mental status and uti. hospital course was complicated by hap and tonic clonic seizures. . #seizures/ams: on [**2169-10-15**], pt had a generalized tonic clonic seizure with hypoxia of 88% on ra. he was treated with iv ativan and was subsequently post-ictal. he was placed on continuous oxygen monitoring and on 4l nasal cannula. he was started on iv keppra 1000 mg [**hospital1 **]. eeg showed left mid to posterior temporal theta slowing. on [**2169-10-17**] he had a second generalized tonic clonic seizure lasting one minute. he was given iv ativan and subsequently noted to be hypoxic to 85% on 4l nasal cannula. his respiratory rate was [**5-1**]/min with periods of apnea. he was tranferred tot he micu where he remained seizure free. it was thought that the etiology of his seizure was infection (multifocal pneumonia noted on cxr, sputum positive for g+ cocci). blood cultures, urine cultures, and cerebral spinal fluid showed no growth. head ct and mri were negative for acute process. per neurology, he was treated with keppra 1000mg [**hospital1 **] and loaded with dilantin. both antiepileptics are to be continued as outpatient per the neurology team. dilantin levels should be checked in one week. dilantin can be tapered as outpatient per dr. [**last name (stitle) **]. #hypoxia/pneumonia: patient was hypoxic and apneic post seizure with evidence of multifocal pneumonia on cxr. he was intubated to protect his airway and to allow him to have an lp and mri. he was extubated the following day, oxygen requirement reduced until he was on room air when transferred from the micu back to the floor. he continued bipap at night per his home regimen. he was treated with vancomycin and aztreonam for his pneumonia. patient will be discharged home with iv vancomycin and aztreonam to finish a 10d course. the last day of the antibiotics will be [**2169-10-26**]. on the day of discharge, patients vanc trough was 34, so vancomycin was held. critical care/infusion company was instructed to draw vanc trough on the morning post-discharge, and fax the result to dr. [**last name (stitle) **], patients pcp. [**last name (namepattern4) **].[**name (ni) 2056**] office was [**name (ni) 653**], and the rn was told that goal vanc trough is 15-20. if trough > 20, continue to hold vancomycin. if vanc < 20, restart vancomycin at 1gm [**hospital1 **], and then re-check vanc trough before the 4th dose. #bradycardia: pt has history of hr ranging from 38 to 70 while in the micu. he was found to be hypothermic and was warmed with a bear hugger which improved his hr mildly. he did experience some light headedness but no chest pain or shortness of breath. ekg was unimpressive, cardiac enzymes showed mildly elevated troponins which were consistent with past measurements. no invasive measures were taken. he should be evaluated as outpatient regarding possible intervention. # elevated troponin: patient found to have trop of 0.25 when having bradycardic event. according to records, this seems to be his baseline. could be related to renal dysfunction. has had cardiology consulted in the past and no interventions were recommended. no further actions taken. . #c5 spinal cord injury: continued baclofen pump. physical therapy found patient to be independent and able to live independently. #depression: home zoloft was continued. . #chronic kidney disease: baseline creatinine 1.5-1.7. received gentle hydration, monitored urine output, renally dosed medications, trended creatinine. cr 1.2 on discharge. . #hypernatremia: could be due to dehydration in the setting of sepsis. he was given d5 boluses in the micu. he continued to have fluctuating hypernatremia. he was encouraged to take more fluids. his na was 145 on discharge. . fen: d5w boluses d/t hypernatremia, repleted electrolytes, advanced to normal diet after extubation. prophylaxis: sc heparin access: discharged with picc code: full (discussed with patient) communication: patient, mother( hcp) [**telephone/fax (1) 49141**]; brother [**name (ni) **] [**telephone/fax (1) 49142**] disposition: home with iv antibiotics and vna service ","PRIMARY: [Pneumonia, organism unspecified] SECONDARY: [Quadriplegia, unspecified; Acute respiratory failure; Other encephalopathy; Acute kidney failure, unspecified; Urinary tract infection, site not specified; Generalized convulsive epilepsy, with intractable epilepsy; Hyperosmolality and/or hypernatremia; ; Late effect of spinal cord injury; Late effects of motor vehicle accident; Myelodysplastic syndrome, unspecified; Obstructive sleep apnea (adult)(pediatric); Other specified cardiac dysrhythmias; Depressive disorder, not elsewhere classified; Hyperpotassemia; Chronic kidney disease, Stage II (mild); Pressure ulcer, heel; Pressure ulcer, stage II]","39 yom with h/o c5 quadriplegia, mds, and recurrent utis who was transferred from osh for assessment of altered mental status and uti. #seizures/ams: on [**2169-10-15**], pt had a generalized tonic clonic seizure with hypoxia of 88% on ra. he was treated with iv ativan and was subsequently post-ictal. eeg showed left mid to posterior temporal theta slowing. his respiratory rate was [**5-1**]/min with periods of apnea. he continued bipap at night per his home regimen. patient will be discharged home with iv vancomycin and aztreonam to finish a 10d course. the last day of the antibiotics will be [**2169-10-26**]. according to records, this seems to be his baseline. fen: d5w boluses d/t hypernatremia, repleted electrolytes, advanced to normal diet after extubation.","39 yom with h/o c5 quadriplegia, mds, and recurrent utis was transferred from osh for assessment of altered mental status and uti. hospital course was complicated by hap and tonic clonic seizures. he was treated with iv ativan and subsequently noted to be hypoxic to 85% on 4l nasal cannula." 74562,138356.0,12886,2162-03-26,12885,116713.0,2162-03-13,Discharge summary,"Admission Date: [**2162-3-6**] Discharge Date: [**2162-3-13**] Date of Birth: [**2094-12-7**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: inability to speak or move right side Major Surgical or Invasive Procedure: MRI/MRA PEG ECHO History of Present Illness: Mr. [**Known lastname 39615**] is a 67-year-old right-handed man with a history of CAD, hyperlipidemia, PAF not anticoagulated, and lung cancer in remission who presents with acute onset aphemia and right hemiplegia. He was last seen normal at 10 pm last night by his daughter; his wife had already gone to bed. When his wife awoke the next morning, she found him at about 6 am lying face down on the floor, unable to speak or move his right side. His daughter came over, and thought he seemed sleepy, but noted he did look up at her when she was there. EMS was called and brought him immediately to [**Hospital1 18**] ED. NIH Stroke Scale score was 16: 1a. Level of Consciousness: 1 1b. LOC Question: 2 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 2 5a. Motor arm, left: 0 5b. Motor arm, right: 4 6a. Motor leg, left: 0 6b. Motor leg, right: 4 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 3 10. Dysarthria: UN 11. Extinction and Neglect: 0 Formal ROS is not possible. His daughter reports that last night he was sitting on the edge of his bed apparently uncomfortable, but did not complain of anything and otherwise was normal. Past Medical History: - CAD s/p MI and angioplasty [**2145**] - Paroxysmal atrial fibrillation (per last cardiology note, ""he has had atrial fibrillation when he gets acutely sick with COPD flares with pneumonias. However, he has been in sinus rhythm in the recent past."") - RUL SCLC s/p chemo and radiation [**2155**], in remission - COPD - Hyperlipidemia - ""Probable DM"" Social History: Former heavy smoker, [**2-9**] ppd for 20-30 years, but quitin [**2155**] years ago with lung cancer diagnosis. Family History: His mother died from a heart disease at the age of 75. His father died from a throat cancer at the age of 52. Physical Exam: Vitals: T: 97.9 P: 88 reg R: 20 BP: 136/95 SaO2: 100%RA General: Awake, cooperative, NAD. Labored breathing, with significant upper airway sounds. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Neck: Hard collar in place. Pulmonary: Loud upper airway sounds. Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: obese. soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Awake and alert. No speech production. Follows one-step commands, both appendicular and midline. Nods yes/no to orientation questions appropriately. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2.5 to 2mm and brisk. VFF to threat. Funduscopic exam limited by miosis. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: Partial right facial droop. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk. Flaccid in right UE and LE. No pronator drift on left. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc L 5 5 5 5 5 5 5- 5 5- 5 5 R 0 0 0 0 0 0 0 0 0 0 0 Withdraws right LE to pain, no movement of R UE. -Sensory: Grossly, he nods that he can feel light touch throughout. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 0 0 0 1 1 Plantar response was flexor bilaterally. -Coordination: Not tested on right. On left, no intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF. -Gait: Unable due to right hemiplegia. Pertinent Results: [**2162-3-12**] 06:01AM BLOOD WBC-8.9 RBC-4.50* Hgb-14.4 Hct-41.5 MCV-92 MCH-32.0 MCHC-34.7 RDW-13.2 Plt Ct-281 [**2162-3-11**] 06:00AM BLOOD WBC-9.9 RBC-4.51* Hgb-14.7 Hct-41.7 MCV-92 MCH-32.6* MCHC-35.3* RDW-13.3 Plt Ct-279 [**2162-3-10**] 08:35AM BLOOD WBC-11.5* RBC-4.90 Hgb-15.2 Hct-45.5 MCV-93 MCH-31.0 MCHC-33.3 RDW-13.6 Plt Ct-267 [**2162-3-9**] 06:15AM BLOOD WBC-9.4 RBC-4.21* Hgb-14.1 Hct-38.6* MCV-92 MCH-33.4* MCHC-36.5* RDW-12.9 Plt Ct-247 [**2162-3-8**] 06:45AM BLOOD WBC-9.1 RBC-4.18* Hgb-13.6* Hct-38.2* MCV-91 MCH-32.5* MCHC-35.6* RDW-13.1 Plt Ct-263 [**2162-3-7**] 02:27AM BLOOD WBC-9.7 RBC-4.18* Hgb-13.7* Hct-37.9* MCV-91 MCH-32.7* MCHC-36.1* RDW-13.1 Plt Ct-263 [**2162-3-6**] 07:30AM BLOOD Neuts-79.6* Lymphs-13.4* Monos-5.7 Eos-0.8 Baso-0.4 [**2162-3-12**] 06:01AM BLOOD PT-15.9* PTT-27.1 INR(PT)-1.4* [**2162-3-11**] 06:00AM BLOOD PT-16.1* PTT-26.3 INR(PT)-1.4* [**2162-3-7**] 02:27AM BLOOD PT-16.6* PTT-28.4 INR(PT)-1.5* [**2162-3-6**] 07:30AM BLOOD PT-16.0* PTT-28.1 INR(PT)-1.4* [**2162-3-12**] 06:01AM BLOOD Glucose-138* UreaN-33* Creat-0.7 Na-142 K-4.0 Cl-107 HCO3-26 AnGap-13 [**2162-3-11**] 06:00AM BLOOD Glucose-132* UreaN-33* Creat-0.8 Na-140 K-4.2 Cl-103 HCO3-27 AnGap-14 [**2162-3-10**] 08:35AM BLOOD Glucose-173* UreaN-27* Creat-0.8 Na-137 K-4.5 Cl-101 HCO3-28 AnGap-13 [**2162-3-9**] 06:15AM BLOOD Glucose-204* UreaN-22* Creat-0.8 Na-137 K-4.2 Cl-100 HCO3-27 AnGap-14 [**2162-3-7**] 02:27AM BLOOD Glucose-165* UreaN-15 Creat-0.8 Na-136 K-4.0 Cl-103 HCO3-24 AnGap-13 [**2162-3-6**] 07:30AM BLOOD Glucose-246* UreaN-15 Creat-0.7 Na-135 K-3.8 Cl-97 HCO3-26 AnGap-16 [**2162-3-6**] 07:30AM BLOOD ALT-33 AST-40 CK(CPK)-234* AlkPhos-120* TotBili-0.5 [**2162-3-7**] 02:27AM BLOOD CK-MB-3 cTropnT-<0.01 [**2162-3-12**] 06:01AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.3 [**2162-3-6**] 07:30AM BLOOD Albumin-4.4 Calcium-9.3 Phos-2.8 Mg-2.0 [**2162-3-8**] 06:45AM BLOOD Triglyc-147 HDL-40 CHOL/HD-3.7 LDLcalc-80 [**2162-3-6**] 07:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG CT HEAD: 1. Dense left middle cerebral artery with loss of definition of insular region indicative of an evolving infarct. 2. Perfusion defect in the left middle cerebral artery territory with increased transit time and decreased blood volume suggestive of an evolving infarct. 3. CT angiography of the neck demonstrates complete occlusion of the left internal carotid artery in the neck with calcification at the bifurcation. 60-70% stenosis of the right internal carotid artery is seen at the bifurcation. 4. CTA of the head demonstrates filling defect in the left middle cerebral artery M1 segment with diminished flow in the distal left MCA territory. MRI: Acute left sided basal ganglia and anterior MCA territory infarcts. No hemorrhage. Clot in the middle cerebral artery region. ECHO: Suboptimal image quality. Preserved left ventricular systolic function. No intracardiac shunt with saline contrast injected at rest (unable to cooperate with maneuvers). Brief Hospital Course: Pt was initially admitted to the neuro-ICU for observation following his acute infarct. An MRI showed an acute infarct in left MCA territory. This was likely cardio-embolic as he was noted to be in A-fib upon admission. He was started on aspirin but anticoagulation was not initiallly started because of the size of the lesion and risk for hemorrhagic conversion. His exam slowly improved and he became more alert. Despite being more alert he failed multiple swallow evaluations and had a g-tube placed on [**3-12**]. He was started on coumadin after the g-tube was placed. He should stay on aspirin 81mg until his coumadin becomes therapeutic (INR [**2-9**]). Medications on Admission: ASA 325 mg po daily Metoprolol 50 mg po bid Simvastatin 10 mg po qhs NTG SR 2.5 mg po bid Atrovent 17 mcg 2 puffs qid Albuterol 90 mcg 2 puffs q6h prn Flovent 220 mcg 2 puffs [**Hospital1 **] ProAir Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for temp > 100.4 or pain. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO Q12H (every 12 hours) as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 8. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for temp > 100.4 or pain. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 12. Nitroglycerin 2.5 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO Q12H (every 12 hours) as needed. 13. Fluticasone 110 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation [**Hospital1 **] (2 times a day). 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 19. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Left MCA Infarct AFIB Discharge Condition: Right hemiparesis, global aphasia Discharge Instructions: You were admitted for right sided weakness and difficulty speaking. This was caused by a stroke which was likley due to a blood clot from your heart. You will need to take coumadin to prevent blood clots in the future. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2162-4-12**] 9:45 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2162-4-22**] 9:10 Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2162-4-22**] 9:30 Dr. [**Last Name (STitle) **] - Call [**Telephone/Fax (1) 44**] for appointment info [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] ",13,2162-03-06 09:37:00,2162-03-13 14:15:00,EMERGENCY,EMERGENCY ROOM ADMIT,REHAB/DISTINCT PART HOSP,STROKE;TELEMETRY;TRANSIENT ISCHEMIC ATTACK," pt was initially admitted to the neuro-icu for observation following his acute infarct. an mri showed an acute infarct in left mca territory. this was likely cardio-embolic as he was noted to be in a-fib upon admission. he was started on aspirin but anticoagulation was not initiallly started because of the size of the lesion and risk for hemorrhagic conversion. his exam slowly improved and he became more alert. despite being more alert he failed multiple swallow evaluations and had a g-tube placed on [**3-12**]. he was started on coumadin after the g-tube was placed. he should stay on aspirin 81mg until his coumadin becomes therapeutic (inr [**2-9**]). ","PRIMARY: [Cerebral embolism with cerebral infarction] SECONDARY: [Chronic airway obstruction, not elsewhere classified; Dysphagia, unspecified; Coronary atherosclerosis of native coronary artery; Other and unspecified hyperlipidemia; Atrial fibrillation; Personal history of malignant neoplasm of bronchus and lung; Pure hypercholesterolemia; Personal history of tobacco use; Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled; Unspecified essential hypertension]","pt was initially admitted to the neuro-icu for observation following his acute infarct. he was started on aspirin but anticoagulation was not initiallly started because of the size of the lesion and risk for hemorrhagic conversion.",pt was initially admitted to the neuro-icu for observation following his acute infarct. an mri showed an acute infarct in left mca territory. he was started on aspirin but anticoagulation was not initially started. 74674,160180.0,12815,2176-10-29,12814,194853.0,2176-10-11,Discharge summary,"Admission Date: [**2176-10-5**] Discharge Date: [**2176-10-11**] Date of Birth: [**2098-7-21**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 425**] Chief Complaint: chest pain, wide complex tachycardia Major Surgical or Invasive Procedure: Internal Cardiac Defibrillator placement cardiac catheterization History of Present Illness: 78 y/o gentleman with chronic AF, known CAD--NSTEMI in [**8-28**] (3 x 13 mm Cypher to RPLV and 2.25 x 18 mm Cypher to LCx/OM; also found to have 3-% LMCA, 70% mLAD with an 80% D1 and 90% D2), repeat PCI in [**10-29**] with BMS to mid-LAD for 70% stenotic lesion, possible ISR in [**2174**] with DES to LAD ([**Hospital1 3278**]), AS with most recent estimate of [**Location (un) 109**] of 1.07 cm2, presents from [**Hospital1 **] ED where he was found to have an irregular wide-complex tachycardia associated with chest pain. . The patient has a history of chronic stable angina, class II Canadian Classification, able to walk about 1 mile or 1 flight of stairs before angina and SOB. Was in USOH when at 8PM tonight noted anginal equivalent only increased in intensity (SSCP radiating to L arm). Took 3 SL NTG without relief. Taken to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where found to have Wide-complex tachycardia. Given Morphine IV, metoprolol IV 5mg x 2, Amiodarone 150mg IV x 1, and started on a diltiazem bolus 20 mg and 5mg/hr gtt. Rhythm appeared to convert to sinus when he was loaded on stretcher for EMS and symptoms resolved. Since then has had no further episodes of AF and no further CP or SOB. Of note, he stopped Plavix 6 months ago at the advice of his cardiologist. . In [**Hospital1 18**] ED his vitals were T 98.6 HR 61 BP 97/40 RR 25 87% RA-> 100 % in NRB. Patient recieved 600 mg plavix x 1. His BP occasionally dropes to SBP of 80s which improved to 110s with 500cc of NS. . On arrival to CCU, patient was asymptomatic. . ROS was negative for fever, chills, abdominal pain, recent BRBPR, melena, dysuria, hematuri. Cough recently which patient attributes to allergies. On cardiac review of symptoms, in addition to above, patient notes stable 2 pillow orthopnea, no PND or claudication. Occasional RLE edema. All other review systems were negative. . Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -> CAD: NSTEMI [**2172**] PCI- DES of the r-PLV and LCx/OM, [**10-29**] PCI- BMS to LAD; [**2174**]- PCI ([**Hospital1 3278**]) [**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **] for possible ISR -> Aortic Stenosis ([**Location (un) 109**] 1.07, mean Grad 21 mmHg), EF 50% on ETT [**2172**] -> Atrial Fibrillation 3. OTHER PAST MEDICAL HISTORY: [**2172**]- CVA with residual speech difficulties Anemia GIB Anxiety Appendectomy Right Inguinal hernia Social History: Married with 1 adult son. [**Name (NI) **] is retired. Prior to retiring he was a construction worker. Quit smoking 30 years ago. Prior to quitting he smoked <1ppd for approximately 20-25 years. Denies drinking alcoholic beverages or recreational drug use. Family History: Father died of a myocardial infarction in his early 70's. His sister underwent a CABG and died from a CVA at the age of 78. His brother died of a myocardial infarction at the age of 39. Physical Exam: Gen: Pleasant, in NAD, able to follow commands HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD. JVP 12 cm. Normal carotid upstroke without bruits. CV: Soft S1S2, Irregluarlary irregular. II/VI systolic murmur best at USB. Early diastolic murmur. LUNGS: Bibasilar crackles. ABD: Soft, NT, ND. No HSM. Abdominal aorta was not enlarged by palpation. Abdominal bruit is present. EXT: 1+ edema BL. Full distal pulses bilaterally. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Grossly intact, no focal deficits. Discharge exam: 97.3 111/61 72 96% RA HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: Supple, No LAD. JVP 12 cm. Normal carotid upstroke without bruits. CV: Soft S1S2, Irregluarlary irregular. II/VI systolic murmur best at USB. Early diastolic murmur. LUNGS: CTA. ABD: Soft, NT, ND. No HSM. Abdominal aorta was not enlarged by palpation. Abdominal bruit is present. EXT: 1+ edema BL. Full distal pulses bilaterally. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Grossly intact, no focal deficits. Pertinent Results: LABS ON ADMISSION: [**2176-10-5**] 12:00AM WBC-13.5*# RBC-4.01* HGB-12.2* HCT-37.7* MCV-94# MCH-30.5 MCHC-32.5 RDW-14.0 [**2176-10-5**] 12:00AM NEUTS-88.4* LYMPHS-8.0* MONOS-2.5 EOS-0.6 BASOS-0.5 [**2176-10-5**] 12:00AM PLT COUNT-127* [**2176-10-5**] 12:00AM PT-27.5* PTT-32.9 INR(PT)-2.7* [**2176-10-5**] 12:00AM CK-MB-8 [**2176-10-5**] 12:00AM cTropnT-0.05* [**2176-10-5**] 12:00AM CK(CPK)-118 [**2176-10-5**] 12:00AM GLUCOSE-122* UREA N-29* CREAT-1.3* SODIUM-137 POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12 [**2176-10-5**] 04:49AM %HbA1c-5.6 [**2176-10-5**] 04:49AM CK-MB-30* MB INDX-9.6* cTropnT-0.59* [**2176-10-5**] 04:49AM CK(CPK)-313* [**2176-10-5**] 01:02PM CK-MB-34* MB INDX-11.1* cTropnT-0.71* [**2176-10-5**] 01:02PM CK(CPK)-306* . ECHO [**2176-10-5**]: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is moderately depressed (LVEF= 30-40 %) secondary to akinesis of the basal septum and hypokinesis of the rest of the left ventricle. There is considerable beat-tobeat variability of the left ventricular ejection fraction due to an irregular rhythm. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. The aortic valve leaflets are severely thickened/deformed. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**1-26**]+) mitral regurgitation is seen. . CARDIAC CATHETERIZATION [**2176-10-7**]: 1. Coronary angiography in this right dominant system revealed diffuse calcified coronary artery disease. The LMCA had mild disease. The LAD had widely patent stents, and total occlusion of a moderate sized diagonal seen on prior catheterization from [**2173-11-11**]. The distal 70% stenosis of the LAD was unchanged versus prior. The LCX had a widely patent stent, and mild luminal irregularities. The RCA was a large vessel, with moderate calcification and serial 40-50% stenoses. There was a large RPL that had a 60% stenosis in the mid-vessel, which was unchanged compared with prior. 2. Resting hemodynamics revealed moderate-to-severe aortic stenosis with mean gradient of 18 mmHg and estimated aortic valve area of 1.0 cm2. There were elevated left and right-sided filling pressures with mean RA pressure of 15, mean PCWP of 35 mmHg, and LVEDP of 29 mmHg. Cardiac output was mildly depressed at 4.0 L/min. . ABDOMINAL ULTRASOUND [**2176-10-7**]: 1. Atherosclerotic aorta with AAA measuring 4.1 cm at the widest diameter. Slight interval increase from the ultrasound of [**2173-10-24**]. 2. No hydronephrosis. Bilateral renal cysts. 3. No evidence of renal artery stenosis. . LABS ON DISCHARGE: WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 7.9 3.88* 11.8* 35.4* 91 30.5 33.4 14.2 150 . Glucose UreaN Creat Na K Cl HCO3 AnGap 106* 20 0.9 134 4.0 101 26 11 . PT PTT INR(PT) 14.4* 28.6 1.2* Brief Hospital Course: 78 year old gentleman with coronary artery disease with PCI in [**2174**], hypertension, moderate aortic stenosis, atrial fibrillation, presented with rest angina in the setting of rapid heart rate with wide complex tachycardia. . # CORONARIES: Presenting chest pain was concerning for unstable angina. Known CAD as above. Cardiac enzymes were cycled with peak trop at 0.92, MB 34, CK 313. Diagnostic left heart cath showed patent coronaries with prior stents in place, no evidence of renal artery stenosis. Pt received heparin drip during hospitalization, as coumadin was held in anticipation of procedures. Aspirin and plavix were started and continued at discharge. HbA1c and lipid panel as above, all normal. Statin was continued in house and at discharge, along with ACE inhibitor, beta blockade, aspirin and plavix. . # RHYTHM: Episodes of wide complex tachycardia concerning for ventricular tachycardia, orginating from left ventricular or right ventricular outflow tract. Electrophysiology study/intervention deferred in setting of highly calcific aorta and moderate aortic stenosis. Initial rate control with metoprolol. Sotalol was then started, monitored for QT prolongation. Patient then remained in persistent atrial fibrillation. Sotalol was continued, along with heparin gtt. Patient had ICD placed on [**2176-10-10**], tolerated procedure well. Metoprolol started after ICD was place. Warfarin was started one day prior to discharge. INR had been therapeutic for at least one month prior to admission. INR 1.2 on discharge, will recheck INR in three days. . # PUMP: Known moderate/severe aortic stenosis in our system and currently on exam. Cath in [**2173**] with aortic valve area of 1.07 with gradient of 21 mmHg. Transthoracic echo as above. Imdur was added to lisinopril, metoprolol, sotalol on discharge. . # Abdominal aortic aneurysm: Abdominal ultrasound showed AAA measuring 4.1 cm at the widest diameter, slight interval increase from the ultrasound of [**2173-10-24**]. . # ARF: Creatinine 1.3 on admission. Last Creatinine in our system is 0.9 in [**2173**]. Renal function improved over course of stay, 0.9 on discharge. . CODE: FULL . COMM: With patient and Wife, [**Name (NI) 39471**], [**Telephone/Fax (1) 39472**] Medications on Admission: Aspirin 325mg daily Metoprolol tartrate 75 mg [**Hospital1 **] Simvastatin 80 mg qdaily Warfarin 2mg for 2 days, then 1 mg next day, then repeat Isosorbide dinitrate 10 mg tid Lisinopril 5 mg qdaily Nitroglycerin 0.4 SL prn Discharge Medications: 1. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: one half tablet every third day. 8. Metoprolol Succinate Oral 9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual as directed as needed for chest pain. 10. Outpatient Lab Work Please check INR on Monday [**10-14**] and call results to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 719**]. 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*6 vils* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Ventricular Tachycardia Non ST elevation Myocardial Infarction Discharge Condition: stable. Discharge Instructions: You had a dangerous heart rhythm called ventricular tachycardia and was started on sotolol, a medicine to prevent this rhythm. In addition, an internal defibrillator (ICD) was placed that will shock you out of this rhythm. You cannot get the ICD dressing wet for one week. No showers of baths. You may wash your hair in a sink. You are scheduled in the device clinic in 1 week, they will check the function of the ICD and take off the dressing. No lifting more than 5 pounds with your left arm for 6 weeks, no lifting your left arm over your head for 6 weeks. You will be on antibiotics to prevent an infection at the ICD site for 3 days. You also had a cardiac catheterization that showed extensive blockages in your coronary artery. Your medicines were adjusted to help your heart function. Medication changes: 1. Sotolol: to prevent ventricular tachycardia 2. Restart your coumadin at 2 mg, you will need to check your INR on Monday [**10-14**]. 3. Decrease your aspirin to 81mg, continue taking plavix. . Please call Dr. [**Last Name (STitle) **] if your ICD fires, if you have any redness, swelling, tenderness or bleeding at the ICD site, if you have any chest pain, fevers, chills or trouble breathing. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in 3 days. Adhere to 2 gm sodium diet: information was given to you about this at discharge. . Followup Instructions: Cardiology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/time: He will see you during the device clinic appt. Device Clinic: [**Hospital Ward Name 23**] [**Location (un) 436**], [**Hospital1 18**], [**Hospital Ward Name 516**], [**Location (un) **] [**Location (un) 86**]: Date/Time: [**2176-10-18**] 3:00pm . Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Last Name (NamePattern1) 39473**], [**Location (un) 86**] Date/time: [**11-6**] at 1:30pm. . ",18,2176-10-05 02:32:00,2176-10-11 18:00:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME HEALTH CARE,CHEST PAIN," 78 year old gentleman with coronary artery disease with pci in [**2174**], hypertension, moderate aortic stenosis, atrial fibrillation, presented with rest angina in the setting of rapid heart rate with wide complex tachycardia. . # coronaries: presenting chest pain was concerning for unstable angina. known cad as above. cardiac enzymes were cycled with peak trop at 0.92, mb 34, ck 313. diagnostic left heart cath showed patent coronaries with prior stents in place, no evidence of renal artery stenosis. pt received heparin drip during hospitalization, as coumadin was held in anticipation of procedures. aspirin and plavix were started and continued at discharge. hba1c and lipid panel as above, all normal. statin was continued in house and at discharge, along with ace inhibitor, beta blockade, aspirin and plavix. . # rhythm: episodes of wide complex tachycardia concerning for ventricular tachycardia, orginating from left ventricular or right ventricular outflow tract. electrophysiology study/intervention deferred in setting of highly calcific aorta and moderate aortic stenosis. initial rate control with metoprolol. sotalol was then started, monitored for qt prolongation. patient then remained in persistent atrial fibrillation. sotalol was continued, along with heparin gtt. patient had icd placed on [**2176-10-10**], tolerated procedure well. metoprolol started after icd was place. warfarin was started one day prior to discharge. inr had been therapeutic for at least one month prior to admission. inr 1.2 on discharge, will recheck inr in three days. . # pump: known moderate/severe aortic stenosis in our system and currently on exam. cath in [**2173**] with aortic valve area of 1.07 with gradient of 21 mmhg. transthoracic echo as above. imdur was added to lisinopril, metoprolol, sotalol on discharge. . # abdominal aortic aneurysm: abdominal ultrasound showed aaa measuring 4.1 cm at the widest diameter, slight interval increase from the ultrasound of [**2173-10-24**]. . # arf: creatinine 1.3 on admission. last creatinine in our system is 0.9 in [**2173**]. renal function improved over course of stay, 0.9 on discharge. . code: full . comm: with patient and wife, [**name (ni) 39471**], [**telephone/fax (1) 39472**] ","PRIMARY: [Subendocardial infarction, initial episode of care] SECONDARY: [Acute kidney failure, unspecified; Paroxysmal ventricular tachycardia; Acute on chronic systolic heart failure; Congestive heart failure, unspecified; Atrial fibrillation; Coronary atherosclerosis of native coronary artery; Other and unspecified angina pectoris; Unspecified essential hypertension; Other and unspecified hyperlipidemia; Anemia, unspecified; Anxiety state, unspecified; Aortic valve disorders; Atherosclerosis of aorta; Abdominal aneurysm without mention of rupture]","78 year old gentleman with coronary artery disease with pci in [**2174**], hypertension, moderate aortic stenosis, atrial fibrillation, presented with rest angina in the setting of rapid heart rate with wide complex tachycardia. inr 1.2 on discharge, will recheck inr in three days. imdur was added to lisinopril, metoprolol, sotalol on discharge. # abdominal aortic aneurysm: abdominal ultrasound showed aaa measuring 4.1 cm at the widest diameter, slight interval increase from the ultrasound of [**2173-10-24**]. last creatinine in our system is 0.9 in [**2173**].","78 year old gentleman presented with rest angina in the setting of rapid heart rate with wide complex tachycardia. diagnostic left heart cath showed patent coronaries with prior stents in place, no evidence of renal artery stenosis. pt received heparin drip during hospitalization, as coumadin was held in anticipation of procedures." 75420,151414.0,8209,2190-10-22,8208,114387.0,2190-10-10,Discharge summary,"Admission Date: [**2190-10-8**] Discharge Date: [**2190-10-10**] Date of Birth: [**2123-7-4**] Sex: F Service: MEDICINE Allergies: Paxil / Benadryl / Buspar / Levaquin / Adhesive Tape Attending:[**First Name3 (LF) 425**] Chief Complaint: Pericardial effusion s/p SVT ablation Major Surgical or Invasive Procedure: electrophysiology study with incomplete ablation History of Present Illness: 66-year-old lady with history of breast and bladder cancers was admitted for elective EPS with ablation for SVT. She first noted palpitations approximately 16 years ago in the setting of high emotional distress when her son was killed while in the service. Since then, she has had palpitations in the setting of chemotherapy, and over the past years has had no more than [**3-2**] episodes per year. However, on the day of her most recent cystoscopy on [**3-5**] at [**Hospital1 69**], she experienced a tachycardia, which was terminated after she received intravenous Lopressor. The same tachycardia occurred on [**3-9**] for which she presented to [**Hospital6 17032**] Emergency Room, where the tachycardia was terminated with intravenous adenosine. The tracings of the tachycardia were reviewed by her Electrophysiologist, Dr.[**Last Name (STitle) 1911**], and thought be a narrow complex tachycardia at 150 beats/minute with an RP interval of 100-120 msec. However, immediately post adenosine, there was evidence of sinus rhythm with a fully pre-excited QRS complex consistent with a left lateral bypass tract. Since the Emergency Room visit, she has been on low-dose atenolol without further recurrences of the arrhythmia. Dr.[**Last Name (STitle) 26676**] recommended EPS with ablation and the patient was admitted today for the procedure. . During the procedure she developed hypotension to SBP of 77 mm HG. This responded to IVF and dopamine infusion to SBP of 130s. Patient was mentating appropriately. Focal views of TTE showed noncircumferential pericardial effusion with mild RA collapse without RV collapse. Her heparin was reversed with protamine. PA catheterization showed preserved CO, no equalization of filling pressures, and preserved Y descent on RA tracing. This suggested nonhemodynamically significant effusion. Patient was admitted to CCU with PA catheter for close hemodynamic monitoring. . On arrival patient complained of stable pleuritic chest pain which she had since the cath lab. She denied any shortness of breath. No other complaints. . Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: -CABG: N/A -PERCUTANEOUS CORONARY INTERVENTIONS: N/A -PACING/ICD: N/A 3. OTHER PAST MEDICAL HISTORY: - Total abdominal hysterectomy and salpingoophrectomy [**2164**] r/t endometriosis - Left breast cancer diagnosed [**2180**] s/p Left lumpectomy and radiation therapy - Papillary bladder cancer diagnosed [**2180**] s/p multiple resections and chemotherapy, finished [**2190-4-28**] - [**2190-3-5**] s/p right ureteral stent, ? transitional cell cancer of the right ureteral orifice - Anxiety . Social History: Lives with: husband Occupation: retired ETOH: no Tobacco: 35 years/ 1ppd, quit in [**2180**] Contact person upon discharge: Husband and son: [**Telephone/Fax (1) 29176**] Home Services: NO . Family History: Unremarkable for any cardiac disease . Physical Exam: VS: T=96 BP=103/58 HR=97 RR=17O2 sat= 98% 2LNC GENERAL: Pleasant lady, in NAD. Lying down flat, Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Unable to assess JVP appropriately given the patient's position. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB in anterior lung fields, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis. PULSES: Right: DP 2+ Left: DP 2+ . Pertinent Results: [**2190-10-10**] 08:50AM BLOOD WBC-14.1* RBC-3.54* Hgb-9.5* Hct-30.5* MCV-86 MCH-27.0 MCHC-31.3 RDW-14.7 Plt Ct-156 [**2190-10-10**] 08:50AM BLOOD Glucose-120* UreaN-11 Creat-0.8 Na-135 K-4.3 Cl-101 HCO3-26 AnGap-12 [**2190-10-10**] 08:50AM BLOOD Calcium-8.6 Phos-1.6* Mg-2.5 . ECG: [**2190-10-8**] at 7:23 AM NSR, rate in 70s, nl axis, early R wave transition in precordial leads, no acute ST-T changes compared to . ECG: [**2190-10-8**] at 11:58 AM Narrow complex tachycardia, rate in 140s, early R wave transition. No acute ST-T wave changes. . 2D-ECHOCARDIOGRAM [**2190-10-8**] Focused Views: Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. There is a small to moderate sized pericardial effusion primarily around the right atrium and right ventricle with minimal around the apex and inferolateral wall. There is mild right ventricular diastolic collapse. IMPRESSION: Mild-moderate loculated anterior pericardial effusion with echocardiographic evidence for increased pericardial pressure. . 2D-ECHOCARDIOGRAM [**2190-10-9**] The left ventricular cavity is unusually small. The inferior and posterior walls are hypokinetic. The rest of the left ventricle is hyperdynamic. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is a small to moderate sized pericardial effusion. The effusion appears circumferential. There are no echocardiographic signs of tamponade. No right atrial or right ventricular diastolic collapse is seen. Compared with the findings of the prior study (images reviewed) of [**2190-10-8**], the pericardial effusion appears similar in size. . HEMODYNAMICS: RAP 20, PCWP 17, Arterial oxygen 98%, RV oxygen sat 71% . EPS [**2190-10-8**]: Left lateral ventricular pre-excitation. Retrograde VA block via BT at 350 msec. Anterograde BT block at 300 msec. Atypical Induced orthodromic AVRT, CL 400 msec via left lateral BT. Difficulty crossing AV. Ablations were performed primarily at the entrent atrial acitivation site during Vpacing. Also slow pathway ablation were performed to prevent initiation of the AVRT. Ablation procedure was incomplete given hypotension as above. . CT ABDOMEN/PELVIS [**2190-10-9**]: 1. No retroperitoneal bleed. 2. Mild to moderate sized pericardial effusion with indeterminate density measurements suggesting proteinaceous fluid or blood. No obvious right atrial compression. Recommend echocardiogram 3. Right femoral line with tip located at the cavoatrial junction. 4. Left lobe hepatic cyst; could consider outpatient ultrasound for further characterization. 5. No large hematoma at right femoral entry site. 6. Stranding in mesentery, nonspecific finding. Brief Hospital Course: 66 y/o lady with history of SVT now with pericardial effusion s/p attempted EP ablation. . # Pericardial Effusion/PUMP: Patient was found to have a 1.4 cm anterior pericardial effusion after she became hypotensive during SVT ablation procedure on [**2190-10-8**]. TTE also showed mild RA collapse without any RV collapse. Emergently, patient received a right heart cath that was consistent with a non-hemodynamically signicant effusion w/o tamponade physiology, so pericardiocentesis was not felt to be indicated. (Cardiac output was preserved and there was no equalization of filling pressures.) Swan-ganz was initially left in place to monitor for development of tamponade physiology. Arterial line was also placed for blood pressure monitoring. Patient was initially hypotensive, but her blood pressure was responsive to IV fluid hydration and dopamine. Her blood pressure remained stable over the next 24 hours, and a repeat TTE on [**10-9**] did not show worsening of the pericardial effusion. Chest pain secondary to the pericardial effusion was well-controlled with Toradol and patient was discharged on ibuprofen prn for pain. . # RHYTHM: Prior to admission, SVT was thought be a narrow complex tachycardia at 150 beats/minute with an RP interval of 100-120 msec. However, immediately post adenosine, there was evidence of sinus rhythm with a fully pre-excited QRS complex consistent with a left lateral bypass tract. In EP lab, monitors showed left lateral ventricular pre-excitation, retrograde VA block via BT at 350 msec, anterograde BT block at 300 msec, and atypical induced orthodromic AVRT, CL 400 msec via left lateral BT. During the procedure, it was difficult crossing the AV, and ablations were performed primarily at the entrent atrial acitivation site during Vpacing. Also slow pathway ablation was performed to prevent initiation of the AVRT. The ablation procedure was incomplete given hypotension as above. Rhythm was monitored on telemetry and showed predominantly sinus rhythm. . # CORONARIES: Patient has no known CAD. Chest pain while inpatient was pleuritic in nature and attributed to hemopericardium. ASA was continued. . # Extensive groin manipulation: Due to extensive groin manipulation during cardiac procedures on [**2190-10-8**], patient was monitored closely for evidence of retroperitoneal bleed. In the cath lab, heparin was reversed with protamine, post cath checks were unremarkable, and a CT scan of abdomen and pelvis was negative for a retroperitoneal bleed. Hemoglobin and hematocrit remained stable throughout hospital stay. . # H/o breast CA and papillary bladder CA: Stable. Patient advised to continue outpatient follow-up per primary oncologist. . FEN: Patient was maintained on cardiac prudent diet. Electrolytes were repleted as necessary. . PROPHYLAXIS: SCD's were used for DVT prophylaxis. . CODE: FULL Medications on Admission: Atenolol 25mg daily, last dose [**2190-10-3**] Lunesta 2mg qhs Alprazolam 0.25mg daily in the am, [**1-29**] tablet at noon, 1 tablet at night PRN Simvastatin 30mg daily MVI daily Vitamin D daily Vitamin B12 500mcg daily Calcium, magnesium daily Fish oil 1000mg daily Asa 81mg daily . Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO once a day. 9. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO three times a day as needed for pain: please take with food. 10. Lunesta 2 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Supraventricular tachycardia, AVRT Pericardial effusion Secondary Diagnoses: 1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, - Hypertension 2. CARDIAC HISTORY: -CABG: N/A -PERCUTANEOUS CORONARY INTERVENTIONS: N/A -PACING/ICD: N/A 3. OTHER PAST MEDICAL HISTORY: - Total abdominal hysterectomy and salpingoophrectomy [**2164**] r/t endometriosis - Left breast cancer diagnosed [**2180**] s/p Left lumpectomy and radiation therapy - Papillary bladder cancer diagnosed [**2180**] s/p multiple resections and chemotherapy, finished [**2190-4-28**] - [**2190-3-5**] s/p right ureteral stent, ? transitional cell cancer of the right ureteral orifice - Anxiety Discharge Condition: stable and improved Discharge Instructions: You were admitted to the hospital for a procedure to fix an abnormal rhythm in your heart. The procedure was unable to be finished because of concern for build up of fluid around your heart. Ultrasounds of your heart showed that the fluid around your heart was not getting worse. You were discharged on [**2190-10-10**], and will have close follow up with Dr. [**Last Name (STitle) **]. Please follow up in 6 weeks for liver ultrasound to follow up liver cyst. No changes were made to your medications. Please see below for your follow up appointment with Dr. [**Last Name (STitle) 1911**]. Please call your physician [**Last Name (NamePattern4) **] 911 if you develop chest pain, shortness of breath, worsening palpitations, dizziness/lightheadedness, fevers, chills, or any other concerning medical symptoms. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 1911**] tomorrow, [**2190-10-11**]. Please call [**Telephone/Fax (1) 11767**]. You have another appointment with Dr. [**Last Name (STitle) 11649**] on [**2190-10-26**], see below. [**Last Name (un) 1918**] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 11767**] Date/Time:[**2190-10-26**] 10:40 ",12,2190-10-08 16:50:00,2190-10-10 13:00:00,EMERGENCY,CLINIC REFERRAL/PREMATURE,HOME,SUPRAVENTRICULAR TACHYCARDIA\SUPRAVENTRICULAR TACHYCARDIA ABLATION," 66 y/o lady with history of svt now with pericardial effusion s/p attempted ep ablation. . # pericardial effusion/pump: patient was found to have a 1.4 cm anterior pericardial effusion after she became hypotensive during svt ablation procedure on [**2190-10-8**]. tte also showed mild ra collapse without any rv collapse. emergently, patient received a right heart cath that was consistent with a non-hemodynamically signicant effusion w/o tamponade physiology, so pericardiocentesis was not felt to be indicated. (cardiac output was preserved and there was no equalization of filling pressures.) swan-ganz was initially left in place to monitor for development of tamponade physiology. arterial line was also placed for blood pressure monitoring. patient was initially hypotensive, but her blood pressure was responsive to iv fluid hydration and dopamine. her blood pressure remained stable over the next 24 hours, and a repeat tte on [**10-9**] did not show worsening of the pericardial effusion. chest pain secondary to the pericardial effusion was well-controlled with toradol and patient was discharged on ibuprofen prn for pain. . # rhythm: prior to admission, svt was thought be a narrow complex tachycardia at 150 beats/minute with an rp interval of 100-120 msec. however, immediately post adenosine, there was evidence of sinus rhythm with a fully pre-excited qrs complex consistent with a left lateral bypass tract. in ep lab, monitors showed left lateral ventricular pre-excitation, retrograde va block via bt at 350 msec, anterograde bt block at 300 msec, and atypical induced orthodromic avrt, cl 400 msec via left lateral bt. during the procedure, it was difficult crossing the av, and ablations were performed primarily at the entrent atrial acitivation site during vpacing. also slow pathway ablation was performed to prevent initiation of the avrt. the ablation procedure was incomplete given hypotension as above. rhythm was monitored on telemetry and showed predominantly sinus rhythm. . # coronaries: patient has no known cad. chest pain while inpatient was pleuritic in nature and attributed to hemopericardium. asa was continued. . # extensive groin manipulation: due to extensive groin manipulation during cardiac procedures on [**2190-10-8**], patient was monitored closely for evidence of retroperitoneal bleed. in the cath lab, heparin was reversed with protamine, post cath checks were unremarkable, and a ct scan of abdomen and pelvis was negative for a retroperitoneal bleed. hemoglobin and hematocrit remained stable throughout hospital stay. . # h/o breast ca and papillary bladder ca: stable. patient advised to continue outpatient follow-up per primary oncologist. . fen: patient was maintained on cardiac prudent diet. electrolytes were repleted as necessary. . prophylaxis: scds were used for dvt prophylaxis. . code: full ","PRIMARY: [Other specified cardiac dysrhythmias] SECONDARY: [Cardiac complications, not elsewhere classified; Unspecified disease of pericardium; Other iatrogenic hypotension; Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation; Other and unspecified hyperlipidemia; Anxiety state, unspecified; Other specified disorders of liver; Personal history of malignant neoplasm of bladder; Personal history of malignant neoplasm of breast; Other postprocedural status]","66 y/o lady with history of svt now with pericardial effusion s/p attempted ep ablation. her blood pressure remained stable over the next 24 hours, and a repeat tte on [**10-9**] did not show worsening of the pericardial effusion. also slow pathway ablation was performed to prevent initiation of the avrt. # h/o breast ca and papillary bladder ca: stable. fen: patient was maintained on cardiac prudent diet.","66 y/o lady with history of svt now with pericardial effusion s/p attempted ep ablation. tte also showed mild ra collapse without any rv collapse. emergently, patient received a right heart cath that was consistent with a non-hemodynamically signicant effusion." 85258,179741.0,29926,2131-04-11,29853,122457.0,2131-01-19,Discharge summary,"Admission Date: [**2130-12-4**] Discharge Date: [**2131-1-19**] Date of Birth: [**2090-5-18**] Sex: F Service: MEDICINE Allergies: Roxicet Attending:[**First Name3 (LF) 4057**] Chief Complaint: Nausea, Vomiting Major Surgical or Invasive Procedure: Tracheostomy thoracentesis Left VATS Mechanical Ventilation History of Present Illness: 40 yo F with unresectable esophageal cancer who was recently discharged from the hospital secondary to right neck pain. She was then discharged on [**12-1**]. Notes indicate the patient re-presented on [**12-4**] with the chief complaint of ""strange sounding airway"" and dyspnea. She was found to have a soft tissue infection lateral to the esophagus that likely represents microperforation, for which she was started on abx, and she required surgical tracheostomy for upper airway obstruction caused by her esophageal cancer. . Additionally, her MICU course was remarkable for persistent tachycardia and mild hypotension. Her heart rate remains 120s at rest with brief episodes of rates as high as 150 when she is out of bed, sinus tachycardia at all times. Her blood pressure has ranged from 70s-90s systolic, which does not appear to be new, as OMR notes document systolic blood pressures in the high 80s-low 90s at multiple visits. Evaluation as to the cause of tachycardia has included TSH (low normal), with fT4 pending; echo (nml LV and RV function, no echocardiographic signs of hemodynamically significant PE); ABG 7.46/41/114 was with pt breathing room air for 10 minutes, indicating that there is no apparent A-a gradient; a random cortisol level was low, but responded appropriately to cosyntropin. Since she appears well, with good skin turgor and adequate urine output, despite the tachycardia and hypotension, she was transferred out of the ICU. Past Medical History: #. Invasive Esophageal Squamous Squamous Cell Carcinoma: - [**2129-11-1**]: Pt arrived in America from [**Country 3587**] - [**2129-11-2**]: Pt evaluated for Odynophagia, tx with Prilosec - 11/26-30/07: Admitted fo Esophageal Web Dilations that relieved symptoms - [**1-4**]: Symptoms of odynophagia returned - [**2130-2-12**]: Referred to ENT for recurrent cervial web at C4-5 - [**2130-4-14**]: Esophageal Dilation under general anesthesia - [**5-4**]: ENT consult for bilateral submandibular pain - 5/29-30/08: Two subsequent attempts at dilation unsucessful - [**6-4**]: PEG placed for FTT - [**2130-6-7**]: Bx confirms Invasive Squamous Cell CA - [**2130-6-20**]: diagnosed [**2130-5-28**] in setting of esophageal stricture - high cervical esophageal lesion not resectable - completed therapy with Cetuximab and radiation therapy # Anemia # Upper esophageal and pharyngeal stricture; s/p PEG # Shoulder Pain # Lung lesion - NOS # Chronic pain from radiation. # Nausea and vomiting. # PEG tube site candidiasis Social History: The patient lives in [**Location 686**], MA with her cousin [**Name (NI) **] [**Name (NI) **], who is her HCP. The patient is initially from [**Country 11660**] islands, she is not currently working. Tobacco: None ETOH: None Illicits: None Family History: There is no history in her family of heart disease, gastric cancer, esophageal cancer or colon cancer or inflammatory bowel disease. Physical Exam: ADMISSION PHYSICAL EXAM VS: T = 99.4 P = 120 BP = 108/60 RR 16, O2Sat:100% GENERAL: Young female who appears older than her stated age. She is appears tired and worn. Mentation: Alert but restricted affect. Does not smile. Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Respiratory: Bibasilar crackles Cardiovascular: tachy, nl. S1S2, no M/R/G noted Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. PEG site C/D/I no odor. Appears better than during previous admission. Genitourinary: Skin: no rashes or lesions noted. No pressure ulcer Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics/Heme/Immun: No cervical lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -DTRs: 2+ biceps, triceps, No foley catheter/tracheostomy/PEG/ventilator support/chest tube/colostomy Psychiatric: Very limited affect with rare brightening. . PHYSICAL EXAM UPON ARRIVAL TO THE FLOOR: [**12-11**] Vitals: T97.9 BP96/50 HR126 RR19 O2Sat100% on 35% trach collar GEN: Thin, tired-appearing [**Location 7972**] woman HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea with sutured trach cannula COR: tachy, no M/G/R, normal S1 S2, radial pulses +2 PULM: bronchial [**Location 1440**] sounds throughout ABD: Soft, NT, ND, +BS, no HSM, no masses. PEG in place in LUQ EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: Normal turgor. No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2130-12-4**] Neck CT: 1. No mass lesions are detected within the airway to explain stridorous breathing. 2. Fluid again noted within the esophagus in the region of the thyroid gland. Also noted on prior study, possibly relating to region of stricture. 3. Slight increase in cavitary lesion within the left lung apex. NOTE ADDED AT ATTENDING REVIEW: There is a collection of air in the right neck, apparently just lateral to the esophagus, but possibly within a dilated esophagus, best seen on images 34-37 of series 2. In this location it raises the possibility of an esophageal perforation. Since it is difficult to determine the location of the lateral margin of the esophagus, it is difficult to distinguish an extraluminal collection from dilatation of the organ. An MR examination may be helpful. There is induration of the adjacent tissues, which could be a consequence of local infection, but also could arise as a result of prior radiation. . [**2130-12-4**] CT CHEST 1. Small pharyngeal or paralaryngeal abscess, phlegmon or malignancy has grown over two weeks. If the lesion is inflammatory it suggests ulceration in the hypopharynx/upper esohagus. Please see report of today's neck CT. 2. Slow growth of small left upper lobe lung cavity and a tiny right lower lobe lesion as well as a new left lower lobe lesion are concerning for multifocal metastases, or slow spread of an indolent infection. Small growing left pleural mass is more characteristic of metastasis. . [**2130-12-6**] MRI SOFT TISSUE NECK, W/O & W/CONTRAST IMPRESSION: 12 x 8 mm collection of air with small amount of fluid just anterior to the right aspect of the esophagus at the level of the thyroid gland which likely represents esophageal perforation and/or abscess. Additional considerations include esophageal diverticulum, although less likely. . TTE (Complete) Done [**2130-12-11**] at 2:38:57 PM Conclusions The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2130-2-28**], no change. . [**2130-12-12**] CTA CHEST 1. No pulmonary embolism. 2. New left posterior pleural lesion. Although this would be an atypical location for an esophageal carcinoma metastasis, the possibility of malignancy cannot be totally excluded and PET CT may provide additional diagnostic information. 3. Increase in right lower lobe and left upper lobe opacities and new left lower lobe opacity most likely represent infectios process; from the same or different [**Doctor Last Name 360**] 4. Resolution of fluid collection in the posterior parapharyngeal space compared to the CT of [**2130-12-4**]., now fluid filled . [**2130-12-17**] CXR Tracheostomy tube is again visualized. There is new left small pleural effusion with volume loss in the left lower lobe. An early infiltrate in this region cannot be totally excluded. Otherwise, the lungs are clear. . LABWORK: [**2130-12-4**] 08:42PM GLUCOSE-112* UREA N-13 CREAT-0.5 SODIUM-133 POTASSIUM-5.0 CHLORIDE-92* TOTAL CO2-29 ANION GAP-17 [**2130-12-4**] 08:42PM estGFR-Using this [**2130-12-4**] 08:42PM HCG-<5 [**2130-12-4**] 08:42PM CALCIUM-9.2 PHOSPHATE-2.4* MAGNESIUM-2.0 [**2130-12-4**] 08:42PM WBC-9.6 RBC-3.35* HGB-9.8* HCT-28.8* MCV-86 MCH-29.2 MCHC-34.0 RDW-14.7 [**2130-12-4**] 08:42PM NEUTS-81.3* LYMPHS-12.0* MONOS-5.8 EOS-0.8 BASOS-0.1 [**2130-12-4**] 08:42PM PLT COUNT-672* [**2130-12-4**] 08:42PM PT-14.3* PTT-25.5 INR(PT)-1.2* . Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2131-1-19**] 12:00AM 4.8 3.02* 9.5* 26.6* 88 31.4 35.8* 13.4 377 Source: Line-PICC [**2131-1-18**] 12:00AM 4.7 3.14* 9.5* 26.8* 85 30.4 35.6* 13.9 356 Source: Line-TLCVL [**2131-1-17**] 12:00AM 5.4 3.38* 10.2* 29.4* 87 30.1 34.6 13.8 368 Source: Line-PICC [**2131-1-16**] 12:00AM 4.0 3.51* 10.6* 30.7* 88 30.2 34.6 14.0 359 Source: Line-PICC [**2131-1-15**] 02:04AM 5.0 3.17* 9.5* 26.8* 85 30.0 35.5* 14.8 352 Source: Line-arterial [**2131-1-14**] 04:41AM 7.8 3.28* 10.2* 27.7* 84 31.1 36.9* 14.6 358 Source: Line-arterial [**2131-1-13**] 10:21PM 10.6 3.44*# 10.9*# 29.0*#1 84 31.6 37.5* 14.0 425 Source: Line-arterial [**2131-1-13**] 02:24AM 7.3 2.70* 8.2* 23.1* 85 30.4 35.6* 14.3 415 Source: Line-aline [**2131-1-12**] 06:20PM 7.4# 2.71* 8.1* 23.2* 86 30.1 35.1* 14.3 356 Source: Line-arterial ulnar [**2131-1-12**] 01:00AM 4.2 2.93* 8.8* 25.7* 88 29.9 34.1 13.9 389 [**2131-1-10**] 05:45AM 3.7* 3.08* 9.1* 26.7* 87 29.6 34.2 13.9 420 [**2131-1-9**] 06:15AM 3.7* 3.09* 9.2* 26.3* 85 29.9 35.2* 14.0 430 [**2131-1-8**] 05:35AM 3.9* 3.26* 9.8* 28.2* 87 30.1 34.8 13.9 431 [**2131-1-6**] 05:40AM 3.3* 3.24* 9.8* 27.5* 85 30.4 35.8* 14.5 409 [**2131-1-5**] 07:20AM 3.2* 3.24* 10.1* 28.1* 87 31.1 35.9* 14.4 386 [**2131-1-4**] 06:30AM 3.4* 3.60* 11.0* 31.1* 86 30.6 35.5* 14.5 431 [**2131-1-3**] 01:45PM 4.3# 3.70* 11.3* 32.2* 87 30.6 35.1* 14.5 441* [**2131-1-2**] 07:45AM 2.5* 3.06* 9.1* 27.2* 89 29.7 33.5 14.5 363 [**2131-1-1**] 06:50AM 2.4* 3.11* 9.3* 27.0* 87 29.8 34.4 14.6 386 [**2130-12-31**] 05:50AM 2.2* 3.11* 9.3* 27.2* 88 29.9 34.2 14.3 372 [**2130-12-30**] 06:00AM 2.3* 3.26* 9.9* 29.0* 89 30.4 34.2 13.9 376 [**2130-12-29**] 06:45AM 2.1* 3.07* 9.2* 27.1* 88 29.8 33.8 13.8 344 [**2130-12-28**] 05:55AM 2.1* 3.17* 9.7* 28.2* 89 30.7 34.6 14.6 381 [**2130-12-27**] 10:00AM 2.0* 3.19* 9.6* 28.2* 88 29.9 33.9 14.5 420 SPECIMNE ARRIVED IN LAB AT 12:41PM [**2130-12-26**] 06:40AM 1.7* 3.10* 9.8* 27.5* 89 31.5 35.6* 13.9 320 [**2130-12-25**] 06:15AM 2.3* 2.92* 8.9* 25.3* 87 30.4 35.1* 13.9 340 [**2130-12-24**] 05:50AM 2.7* 2.97* 9.1* 25.4* 86 30.6 35.8* 14.7 331 [**2130-12-22**] 05:35AM 2.7* 2.98* 8.8* 26.2* 88 29.4 33.5 14.9 337 [**2130-12-21**] 06:00AM 2.4* 3.03* 9.2* 26.6* 88 30.4 34.6 14.4 303 [**2130-12-20**] 05:50AM 2.3* 3.00* 8.9* 25.8* 86 29.7 34.5 15.3 308 [**2130-12-19**] 07:00AM 3.0* 3.30* 10.1* 29.2* 89 30.5 34.5 15.3 302 [**2130-12-16**] 09:05AM 3.4* 3.46*# 10.3*# 30.0* 87 29.9 34.5 15.9* 327 [**2130-12-15**] 03:35PM 29.9* [**2130-12-14**] 07:40AM 5.4 2.75* 8.2* 24.6* 90 29.8 33.3 15.7* 358 [**2130-12-13**] 08:00AM 9.0 2.99* 9.0* 26.0* 87 30.1 34.7 15.6* 378 [**2130-12-12**] 07:45AM 6.0 2.92* 8.7* 25.7* 88 29.9 34.0 15.3 387 [**2130-12-11**] 04:22AM 6.9 2.97* 8.9* 26.1* 88 30.0 34.1 15.3 415 [**2130-12-10**] 04:26AM 8.4 3.08* 9.1* 26.7* 87 29.4 33.9 15.1 457* [**2130-12-9**] 04:54AM 9.1 2.88* 8.8* 25.0* 87 30.6 35.3* 15.1 466* [**2130-12-8**] 06:10AM 7.0 3.10* 9.0* 26.8* 87 29.1 33.6 14.6 514* [**2130-12-7**] 03:47AM 12.8*# 3.43* 10.4* 30.3* 88 30.2 34.2 15.2 645* [**2130-12-6**] 03:18AM 7.9 3.23* 9.7* 27.8* 86 30.2 35.0 15.0 633* [**2130-12-5**] 10:00AM 7.4 3.19* 9.1* 27.9* 87 28.4 32.5 15.2 553* [**2130-12-4**] 08:42PM 9.6 3.35* 9.8* 28.8* 86 29.2 34.0 14.7 672* VERIFIED LABEL D IFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2131-1-12**] 06:20PM 89.5* 6.6* 2.6 1.2 0 Source: Line-arterial ulnar [**2131-1-6**] 05:40AM 57 2 20 13* 4 0 2* 1* 1* [**2131-1-5**] 07:20AM 60.3 21.8 10.3 7.5* 0.1 [**2131-1-4**] 06:30AM 62.9 25.3 7.3 4.4* 0.2 [**2131-1-3**] 01:45PM 70.2* 16.9* 7.7 5.1* 0.1 [**2131-1-1**] 06:50AM 53.0 27.4 10.5 8.7* 0.4 [**2130-12-31**] 05:50AM 56 0 36 4 1 0 3* 0 0 [**2130-12-30**] 06:00AM 39.8* 42.9* 11.6* 5.4* 0.3 [**2130-12-29**] 06:45AM 45.6* 32.4 13.0* 8.7* 0.3 [**2130-12-28**] 05:55AM 27* 3 56* 9 3 0 2* 0 0 [**2130-12-27**] 10:00AM 31* 0 40 18* 10* 1 0 0 0 SPECIMNE ARRIVED IN LAB AT 12:41PM [**2130-12-26**] 06:40AM 52.8 28.4 9.4 8.8* 0.6 [**2130-12-25**] 06:15AM 50 0 28 14* 5* 2 1* 0 0 [**2130-12-21**] 06:00AM 51.6 34.1 8.6 5.4* 0.3 [**2130-12-8**] 06:10AM 84.1* 9.3* 5.7 0.7 0.1 [**2130-12-4**] 08:42PM 81.3* 12.0* 5.8 0.8 0.1 RED CELL M O R P H O L O G Y Hypochr Anisocy Poiklo Macrocy Microcy Polychr Ovalocy Schisto [**2131-1-6**] 05:40AM NORMAL1 1+ 1+ NORMAL 1+ OCCASIONAL 1+ OCCASIONAL NORMAL MANUALLY COUNTED BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2131-1-19**] 12:00AM 377 Source: Line-PICC [**2131-1-18**] 12:00AM 356 Source: Line-TLCVL [**2131-1-17**] 12:00AM 368 Source: Line-PICC [**2131-1-16**] 12:00AM 359 Source: Line-PICC [**2131-1-15**] 02:04AM 352 Source: Line-arterial [**2131-1-14**] 04:41AM 358 Source: Line-arterial [**2131-1-13**] 10:21PM 425 Source: Line-arterial [**2131-1-13**] 02:24AM 415 Source: Line-aline [**2131-1-12**] 06:20PM 356 Source: Line-arterial ulnar [**2131-1-12**] 01:00AM 389 [**2131-1-12**] 01:00AM 14.5* 28.3 1.3* [**2131-1-10**] 05:45AM 420 [**2131-1-9**] 06:15AM 430 [**2131-1-8**] 05:35AM 431 [**2131-1-6**] 05:40AM NORMAL 409 [**2131-1-5**] 07:20AM 386 [**2131-1-4**] 06:30AM 431 [**2131-1-3**] 01:45PM 441* [**2131-1-3**] 01:45PM 13.0 27.7 1.1 [**2131-1-2**] 07:45AM 363 [**2131-1-1**] 06:50AM 386 [**2130-12-31**] 05:50AM NORMAL 372 [**2130-12-30**] 06:00AM 376 [**2130-12-29**] 06:45AM 344 [**2130-12-28**] 05:55AM 381 [**2130-12-27**] 10:00AM NORMAL 420 SPECIMNE ARRIVED IN LAB AT 12:41PM [**2130-12-26**] 06:40AM 320 [**2130-12-25**] 06:15AM NORMAL 340 [**2130-12-24**] 05:50AM 331 [**2130-12-22**] 05:35AM 337 [**2130-12-21**] 06:00AM 303 [**2130-12-20**] 05:50AM 308 [**2130-12-19**] 07:00AM 302 [**2130-12-16**] 09:05AM 327 [**2130-12-14**] 07:40AM 358 [**2130-12-13**] 08:00AM 378 [**2130-12-12**] 07:45AM 387 [**2130-12-11**] 04:22AM 415 [**2130-12-10**] 04:26AM 457* [**2130-12-9**] 04:54AM 466* [**2130-12-8**] 06:10AM 514* [**2130-12-8**] 04:25AM 17.0* 29.6 1.5* [**2130-12-7**] 03:47AM 645* [**2130-12-6**] 03:18AM 633* [**2130-12-5**] 10:00AM 553* [**2130-12-4**] 08:42PM 672* [**2130-12-4**] 08:42PM 14.3*1 25.5 1.2* HEMOLYZED, MODERATELY INTERPRET RESULTS WITH CAUTION Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2131-1-19**] 12:00AM 99 15 0.4 134 4.6 96 29 14 Source: Line-PICC [**2131-1-18**] 12:00AM 96 17 0.4 140 4.6 102 29 14 Source: Line-TLCVL [**2131-1-17**] 12:00AM 96 12 0.4 133 4.4 97 27 13 Source: Line-PICC [**2131-1-16**] 12:00AM 129* 7 0.4 133 4.5 95* 28 15 Source: Line-PICC [**2131-1-15**] 02:04AM 129* 7 0.4 138 3.6 105 26 11 Source: Line-arterial [**2131-1-14**] 04:41AM 160* 5* 0.5 137 4.2 104 25 12 Source: Line-arterial [**2131-1-13**] 10:21PM 192* 5* 0.4 135 3.6 100 27 12 Source: Line-arterial [**2131-1-13**] 02:24AM 87 4* 0.4 133 3.9 102 27 8 Source: Line-aline [**2131-1-12**] 06:20PM 99 5* 0.4 134 3.6 103 27 8 Source: Line-arterial ulnar [**2131-1-12**] 01:00AM 94 8 0.5 137 4.1 102 29 10 [**2131-1-2**] 07:45AM 104 4* 0.5 139 3.8 101 32 10 [**2131-1-1**] 06:50AM 101 4* 0.6 136 4.2 99 31 10 [**2130-12-31**] 05:50AM 77 5* 0.5 136 4.31 100 30 10 [**2130-12-30**] 06:00AM 82 4* 0.6 138 4.1 101 32 9 [**2130-12-29**] 06:45AM 118* 4* 0.6 136 4.1 99 31 10 [**2130-12-28**] 05:55AM 83 5* 0.5 137 4.0 100 31 10 [**2130-12-27**] 10:00AM 49*2 5* 0.5 138 4.1 101 31 10 SPECIMEN ARRIVED IN LAB AT 12:41PM [**2130-12-26**] 06:40AM 122* 5* 0.5 134 3.8 100 28 10 [**2130-12-25**] 06:15AM 78 6 0.5 137 3.9 102 30 9 [**2130-12-24**] 05:50AM 79 6 0.4 137 4.0 101 30 10 [**2130-12-22**] 05:35AM 83 6 0.5 138 4.3 102 32 8 [**2130-12-21**] 06:00AM 78 6 0.5 139 4.0 102 30 11 [**2130-12-20**] 05:50AM 77 7 0.5 136 3.7 101 30 9 [**2130-12-19**] 07:00AM 105 7 0.7 139 4.2 101 30 12 [**2130-12-16**] 09:05AM 106* 8 0.6 137 4.2 100 30 11 [**2130-12-14**] 07:40AM 96 6 0.5 138 4.3 104 29 9 [**2130-12-13**] 08:00AM 124* 7 0.5 134 4.2 97 31 10 [**2130-12-12**] 07:45AM 110* 7 0.5 136 4.0 102 30 8 [**2130-12-11**] 04:22AM 107* 6 0.5 137 4.0 102 29 10 [**2130-12-10**] 04:26AM 116* 7 0.6 131* 3.5 98 27 10 ADDED TSH [**12-10**] 4:40PM; [**Last Name (un) **] ADDED [**12-10**] 5:05PM [**2130-12-9**] 08:38AM 3.3 [**2130-12-9**] 04:54AM 97 8 0.6 132* 5.9*3 98 28 12 GROSS HEMOLYSIS [**2130-12-8**] 04:25AM 97 13 0.7 135 3.9 99 30 10 [**2130-12-7**] 03:47AM 142* 15 0.6 133 4.5 97 29 12 [**2130-12-6**] 03:18AM 138* 10 0.5 136 4.2 98 29 13 [**2130-12-5**] 10:00AM 115* 10 0.5 132* 4.3 95* 29 12 [**2130-12-4**] 08:42PM 112* 13 0.5 133 5.04 92* 29 17 MODERATELY HEMOLYZED SPECIMEN HEMOLYSIS FALSELY ELEVATES K HEMOLYZED, SLIGHTLY VERIFIED BY REPLICATE ANALYSIS NOTIFIED T. [**Doctor Last Name **] AT 131PM ON [**2130-12-27**] HEMOLYSIS FALSELY INCREASES THIS RESULT HEMOLYSIS FALSELY ELEVATES K. ESTIMATED GFR (MDRD CALCULATION) estGFR [**2131-1-12**] 01:00AM Using this1 Using this patient's age, gender, and serum creatinine value of 0.5, Estimated GFR = >75 if non African-American (mL/min/1.73 m2) Estimated GFR = >75 if African-American (mL/min/1.73 m2) For comparison, mean GFR for age group 40-49 is 99 (mL/min/1.73 m2) GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure ENZYMES & B ILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2131-1-14**] 04:41AM 172* Source: Line-arterial [**2131-1-13**] 10:21PM 217* Source: Line-arterial [**2131-1-2**] 07:45AM 129 [**2130-12-5**] 09:10AM 52 [**2130-12-5**] 01:35AM 48 CPK ISOENZYMES CK-MB cTropnT [**2131-1-14**] 04:41AM 2 <0.011 Source: Line-arterial [**2131-1-13**] 10:21PM 2 <0.011 Source: Line-arterial [**2130-12-5**] 09:10AM 1 <0.011 [**2130-12-5**] 01:35AM 1 LESS THAN 2 <0.01 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI LESS THAN 0.01 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2131-1-19**] 12:00AM 3.9 9.0 2.5* 2.1 Source: Line-PICC [**2131-1-18**] 12:00AM 9.4 2.5* 2.1 Source: Line-TLCVL [**2131-1-17**] 12:00AM 9.1 3.1 2.2 Source: Line-PICC [**2131-1-16**] 12:00AM 9.2 2.9 2.1 Source: Line-PICC [**2131-1-15**] 02:04AM 8.2* 1.9* 1.8 Source: Line-arterial [**2131-1-14**] 04:41AM 8.8 1.3* 1.8 Source: Line-arterial [**2131-1-13**] 10:21PM 8.6 1.6* 1.7 Source: Line-arterial [**2131-1-13**] 02:24AM 8.3* 2.8 2.1 Source: Line-aline [**2131-1-12**] 06:20PM 2.3* 7.8* 3.1 1.2* Source: Line-arterial ulnar [**2131-1-12**] 01:00AM 8.7 2.9 2.0 [**2131-1-2**] 07:45AM 6.0* 9.2 3.8 2.0 [**2131-1-1**] 06:50AM 9.3 3.7 1.9 [**2130-12-31**] 05:50AM 8.9 3.5 2.01 [**2130-12-30**] 06:00AM 9.6 3.5 2.0 [**2130-12-29**] 06:45AM 8.9 3.4 1.9 [**2130-12-27**] 10:00AM 9.0 3.3 2.0 SPECIMEN ARRIVED IN LAB AT 12:41PM [**2130-12-25**] 06:15AM 9.0 3.2 1.9 [**2130-12-24**] 05:50AM 1.9 [**2130-12-21**] 06:00AM 1.9 [**2130-12-20**] 05:50AM 9.0 3.4 1.9 [**2130-12-19**] 07:00AM 9.5 3.4 2.0 [**2130-12-16**] 09:05AM 1.9 [**2130-12-14**] 07:40AM 8.6 3.3 1.8 [**2130-12-13**] 08:00AM 8.9 3.1 1.9 [**2130-12-12**] 07:45AM 8.5 2.3* 1.9 [**2130-12-11**] 04:22AM 9.0 2.7 1.8 [**2130-12-10**] 04:26AM 8.9 2.5* 1.8 ADDED TSH [**12-10**] 4:40PM; [**Last Name (un) **] ADDED [**12-10**] 5:05PM [**2130-12-9**] 08:38AM 1.8 [**2130-12-9**] 04:54AM 9.0 3.5 1.81 GROSS HEMOLYSIS [**2130-12-8**] 04:25AM 9.1 3.2 1.8 [**2130-12-7**] 03:47AM 9.8 3.1 2.0 [**2130-12-6**] 03:18AM 10.0 3.8 1.9 [**2130-12-5**] 10:00AM 8.5 2.9 1.8 [**2130-12-4**] 08:42PM 9.2 2.4* 2.02 MODERATELY HEMOLYZED SPECIMEN HEMOLYSIS FALSELY ELEVATES Mg HEMOLYSIS FALSELY ELEVATES MG. OTHER CHEMISTRY Osmolal [**2131-1-13**] 10:21PM 277 Source: Line-arterial PITUITARY TSH [**2130-12-31**] 05:50AM 1.5 [**2130-12-11**] 04:22AM 0.12* [**2130-12-10**] 04:26AM 0.29 ADDED TSH [**12-10**] 4:40PM; [**Last Name (un) **] ADDED [**12-10**] 5:05PM THYROID T4 T3 calcTBG TUptake T4Index Free T4 [**2130-12-13**] 08:00AM 12.9* 1.02 0.98 12.6* [**2130-12-12**] 07:45AM 13.1* 122 1.9* OTHER ENDOCRINE Cortsol [**2131-1-13**] 03:34PM 31.3*1 PLEASE MEASURE THIRTY MINUTES AFTER COSYNTROPIN [**2131-1-13**] 02:59PM 21.0*1 [**2130-12-10**] 11:17PM 25.6*1 [**2130-12-10**] 10:57PM 17.91 [**2130-12-10**] 10:14PM 4.11 [**2130-12-10**] 04:26AM 0.9*1 ADDED TSH [**12-10**] 4:40PM; [**Last Name (un) **] ADDED [**12-10**] 5:05PM NORMAL DIURNAL PATTERN: 7-10AM 6.2-19.4 / 4-8PM 2.3-11.9 GYNECOLOGIC HCG [**2130-12-4**] 08:42PM <51 MODERATELY HEMOLYZED SPECIMEN <5 <5 IS NEGATIVE; 5 - 25 IS EQUIVOCAL; >25 IS POSITIVE LAB USE ONLY RedHold [**2131-1-6**] 05:40AM HOLD Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calTCO2 Base XS Intubat Comment [**2131-1-13**] 02:36AM ART 201* 48* 7.40 31* 4 [**2131-1-12**] 08:41PM ART 35 156* 44 7.42 30 4 NOT INTUBA1 TRACH MASK [**2130-12-11**] 08:46PM ART 114* 41 7.46* 30 5 [**2130-12-8**] 12:33PM ART 159* 38 7.48* 29 5 NOT INTUBATED WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate [**2131-1-12**] 08:41PM 0.8 . Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 71385**],[**Known firstname **] [**Last Name (NamePattern1) 71386**] [**2090-5-18**] 40 Female [**-7/4872**] [**Numeric Identifier 71387**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1533**] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] GOODELL/dif SPECIMEN SUBMITTED: Tracheal Tissue. Procedure date Tissue received Report Date Diagnosed by [**2130-12-8**] [**2130-12-8**] [**2130-12-13**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl Previous biopsies: [**-7/2145**] G I BIOPSY (1 JAR). [**-6/4630**] GASTRIC BX. [**Numeric Identifier 71388**] RIGHT AND LEFT SEGMENT OF FALLOPIAN TUBES (2). DIAGNOSIS: Trachea, biopsy: 1. Unremarkable cartilage. 2. Paratracheal soft tissue with acute and chronic inflammation; no malignancy identified. . Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 71385**],[**Known firstname **] [**Last Name (NamePattern1) 71386**] [**2090-5-18**] 40 Female [**Numeric Identifier 71389**] [**Numeric Identifier 71387**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1533**] Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/dif SPECIMEN SUBMITTED: posterior pleural plaque, inferior pleural plaque, upper lobe wedge. Procedure date Tissue received Report Date Diagnosed by [**2131-1-12**] [**2131-1-12**] [**2131-1-16**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dwc?????? Previous biopsies: [**-7/4872**] Tracheal Tissue. [**-7/2145**] G I BIOPSY (1 JAR). [**-6/4630**] GASTRIC BX. [**Numeric Identifier 71388**] RIGHT AND LEFT SEGMENT OF FALLOPIAN TUBES (2). DIAGNOSIS: Pleura, left posterior plaque, biopsy (A-B): Metastatic squamous cell carcinoma. Pleura, left inferior plaque, biopsy (C-D): Metastatic squamous cell carcinoma. Lung, left upper lobe, wedge resection (E-J): Metastatic squamous cell carcinoma (see note). Note: (E-J): Apart from the largest tumor nodule (2 cm in greatest dimension), multiple small foci of metastatic squamous cell carcinoma are present along the pleural surface. The surgical margin of resection appears to be free of tumor. Clinical: Esophageal mass, neck pain. Gross: The specimen is received fresh labeled with the patient's name, ""[**Known lastname 19688**], [**Known firstname **] [**Last Name (NamePattern1) **]"", the medical record number and ""pleural plaque."" It consists of a fragment of white - tan firm tissue measuring 2.5 x 1.5 x 0.6 cm, serially sectioned and partially frozen. Intraoperative exam was performed. A frozen section was performed on tissue. The frozen section diagnosis by Dr. [**Last Name (STitle) **] is ""posterior pleural plaque: metastatic carcinoma."" The remainder of the specimen is entirely submitted in A, frozen section in B. Part 2 is additionally labeled ""inferior pleural plaque."" It consists of a fragment of firm pink-tan tissue measuring 1.0 x 0.9 x 0.2 cm. The specimen is serially sliced and submitted in C-D. Part 3 is additionally labeled ""left upper lobe wedge RUSH."" It consists of a wedge resection of lung measuring 6.0 x 3.4 x 1.5 cm with a stapled margin that measures 8.0 cm in length. The pleural surface is smooth and shiny, and involved by a white mass measuring 3.0 x 1.5 cm. This area is firm on palpation. The specimen is serially sliced to reveal a 2.0 x 2.0 x 1.0 cm white tan cystic well circumscribed, nodule, located 0.4 cm from the nearest stapled margin. The mass involves the pleura. The remainder of the lung parenchyma is unremarkable. The specimen is represented as follows: E-F = pulmonary resection margin, G-I = tumor in relation to parietal pleura, J = unremarkable lung. . Brief Hospital Course: The following summary is divided into sections due to the patients prolonged hospital course: # Esophageal Cancer/Cough/SOB: The patient presented with cough and SOB. Her symptoms progressed and ENT was consulted. The patient was found to have superglottic swellling and she was transferred to the ICU for concern of possible iminent airway obstruction. A CT of the neck was concerning for perforation and this finding was reassessed with MRI which raised the possibility of abcess formation. Given these findings, throacic surgery was consulted and it was felt that the patient would benefit from tracheostomy placement for airway protection. A trach was placed by thoracics on [**2130-12-8**] which was tolerated well. Speech and swallow followed for assessment for passy muir valve. [**Hospital Unit Name 71390**] COURSE [**12-6**] through [**12-11**] . [**12-6**] - ENT - advised continued MICU care, trachea 3 mm at narrowest point and supraglottic edema, R vocal cord paralysis - Thoracics consult- likely not a tear; advised barium swallow and broad spectrum coverage, ddx perforation vs TE fistula; - Pt did not tolerate barium swallow - Added Vanco/Levo/Flagyl/Fluconazole - MR Neck - read PENDING (wet read by surgery - no ET fistula, no extaluminal air) - TFs - restart Ensure - Evaluated for worsening stridor at 0400; Inspiratory stridor noted on exam in all lung fields, but pt saturating well. Denies worsening pain. Thoracics informed. . [**Date range (3) 71391**] - MRI suggestive of micro-esophagael perf, +/- infection - (Started on Vanco Levo Fluc yesterday [**12-6**]) - ?Worsening stridor this Morning ([**12-7**]) around 4AM, self resolved. - Unless team observes persistent stridor, plan for continuing Abx, no surgical (trach) intervention at this time. - had rhoncorous [**Month/Year (2) 1440**] sounds, 3am, cleared on own. [**12-8**] - Had trachyostomy; tolerated procedure well. Weaned off vent overnight and placed on trach mask. - Per Thoracics, would attempt passy miur valve today. . [**12-9**] - c/od but no bed - ENT s/o - CXR shows trach well palced - tolerated trach proecedure well - no stridor, no n/v - restarted tube feeds - thoracics - 2 wks antibx but will follow on the floor - patient somewhat confused about cancer dx and prognosis - will need to have [**Doctor Last Name **]/[**Doctor Last Name **] to explain to patient what to expect for the future - continues to be tachycardic . 12/14-15/08 -Assessment update: noting low suspicion for esophagael cancer per Dr. [**Last Name (STitle) 174**]. Concern that chest lesion is met, but not confirmed. Re: reversibility of trach--if this was esoph perf [**1-29**] vomiting or [**1-29**] to radiation, likely temporary and may be removed s/p f/u bronch. -Refusing depression meds, psychiatry, social work -Speech and Swallow tomorrow -Gave 1 L for tachychardia . [**2130-12-10**] Spoke to oncology team re: transfer. Concern that hemodynamics are slightly worse than on admission. On admission SBPs in 90s, HR in low 100s, now SBP in 80s, HR 110s. Documented baseline blood pressures in all discharge summaries from [**2129**] have been baseline SBPs in the 80s but without tachycardia. Will check cortisol, TSH. -Cortisol noted to be quite low. Have ordered supression test. Will likely need to start treatment steroids s/p test. [**2130-12-11**] -Continuing cough apprecaited. Secretions noted. -In general, ""still""-appearing, as if in pain, but repeatedly denies. - hypotensive to 70's but not symptomatic. Tachy with normal echo. Good UOP. Summary of ICU Course: Briefly, Mrs [**Known lastname 19688**] is a 40 yo F with unresectable esophageal cancer who was recently discharged from the hospital secondary to right neck pain. She was then discharged on [**12-1**]. Notes indicate the patient re-presented on [**12-4**] with the chief complaint of ""strange sounding airway"" and dyspnea. She was found to have a soft tissue infection lateral to the esophagus that likely represents microperforation, for which she was started on abx, and she required surgical tracheostomy for upper airway obstruction caused by her esophageal cancer. . Additionally, her MICU course was remarkable for persistent tachycardia and mild hypotension. Her heart rate remains 120s at rest with brief episodes of rates as high as 150 when she is out of bed, sinus tachycardia at all times. Her blood pressure has ranged from 70s-90s systolic, which does not appear to be new, as OMR notes document systolic blood pressures in the high 80s-low 90s at multiple visits. Evaluation as to the cause of tachycardia has included TSH (low normal), with fT4 pending; echo (nml LV and RV function, no echocardiographic signs of hemodynamically significant PE); ABG 7.46/41/114 was with pt breathing room air for 10 minutes, indicating that there is no apparent A-a gradient; a random cortisol level was low, but responded appropriately to cosyntropin. Since she appears well, with good skin turgor and adequate urine output, despite the tachycardia and hypotension, she was transferred out of the ICU. The following section summarizes the patients OMED course including VATS and SICU transfer: . 40 y/o F with esophageal SCC s/p XRT, s/p tracheostomy for upper airway compromise with parapharyngeal abscess, now s/p VATs for LUL cavitary lesion and found to have metastatic esophageal CA. . #. Metastatic Esophageal CA: Patient s/p chemo and radiation. The patient was noted to have a LUL cavitary lesion on CT scan in early [**Month (only) **]. This was found to have grown by Janurary. Concern that new lung lesion is secondary to metastatic disease. A new left sided pleural effusion was seen on CT on [**1-1**]. The patient underwent thoracentesis on [**1-2**] with 700cc of clear yellow fluid drained without complication. Cytology and cultures were sent and the patient was found to have an exudative effusion. ID was consulted, fungal serologies and stool O&P were sent. The patient was ruled out for TB on two separate occasions. Sputum from [**1-5**] grew back Klebsiella Oxytoca, and on [**1-6**] Acinetobacter both of which were thought to be a contaminant. The patient was transfered to the [**Hospital Ward Name 516**] on [**2131-1-12**] to undergo a VATS resection of the the cavitary lesion. The patient underwent VATS on [**2130-1-11**] which unfortunately revealed carcinomatous plaques on the pleural wall which were confirmed frozen section. A chest tube was placed. The patient briefly required pressers while in the SICU. These were weaned and the patient was subsequently transfered back to the [**Hospital Ward Name 5074**] on [**1-15**]. Fungal serologies revealed strogyloides and the patient was given two days of Ivermectin. The patient will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. . #. s/p Trach: The patient was trached on [**12-8**] secondary to airway compromise. The patient has been breathing comfortably with trach on 35% trach mask FM; ambulating without supplemental oxygen; transient dyspnea improves with nebs, anxiolytics. The patient did not tolerate a PMV on [**1-2**] following completion of a 28 day course of Unasyn and Clindamycin (previously Augmentin). The patient did not tolerate her PMV mask on [**1-3**]. On [**1-4**] respiratory therapy attempted to use inhaled fluticasone to improve her symptoms. The patient was tolerating her PMV incrementaly more each day. On [**1-7**] the patient was noted to have increased TM requirements up to 50%. This was thought to be potentially secondary to reaccumulation of her L pleural effusion. The patients trach was changed to a 6.0 fenestrated trach on [**1-16**]. The patient was decannulated by thoracics on [**1-17**] which she tolerated. Supportive care should be continued upon discharge. . # Healthcare Associated PNA: The patient developed fevers and had continued cough following her VATS. The patient was placed empirically on Cefepime on [**1-15**], this was later changed to Levaquin upon discharge for a planned 10 day total duration of antibiotics. Cultures were NGTD at the time of discharge. . # Parapharygneal Abscess. The patient was placed initially on Augmentin. This was changed to Unasyn / Clindamycin for which she subsequently completed 28 days of treatement. ENT evaluated patient [**1-1**] no upper airway abnormality other than copious secretions. A CT Neck and Chest on [**1-2**] revealed both tetropharyngeal and retrotracheal swelling as well as soft tissue density encompassing the esophagus. This was thought to potentially represent post-radiation changes and phlegmon. No evidence of a drainable fluid collection. . #. Neutropenia: Initially thought to be secondary to patients being on augmentin. This was subsequently changed to Clindamycin/Unasyn or compazine. ANC subsequenrly resolved to 1278 [**1-1**]. . #. Anemia: Currently at baseline, no signs of active bleeding. Con't to monitor. There was question of benefit of higher transfusion threshold to reduce tachycardia. . #. Tachycardia: The patient has been persistently in sinus tachycardia 110-130 bpm. The patient was evaluate while in the ICU that indicated a low probibility for PE, no signs of CHF, and potentially subclinical hyperthyroidism although TSH WNL. There was thought that part of the ST was secondary to anxiety. Anemia also potentially played a role. - Cont Tele . #. Hypotension: Asymptomatic and maintaining MAP >= 60. Responds well to fluid bolus when systolics drift down to 70s. Continue vol challenge prn. Was briefly on pressers while in the unit, now weaned off. . #. Pain: The patients pain was well-controlled with gabapentin and methadone. The patient was written for Morphine PRN. . # Depression: The patient remains on nortriptyline for depressed mood and will not take additional treatment. Likely that some of this is related to coping with general medical illness as well as underlying depression and being away from her children. - SW will cont to follow - cont nortriptyline . #. Steroid-Induced DM: continue SSI; if requirements trend down now that off steroids, can D/C insulin Medications on Admission: Tylenol occasionaly Lactulose 30 cc tid prn Methadone 2.5 mg [**Hospital1 **] . Upon transfer out of the MICU: . Heparin 5000 UNIT SC TID Insulin SC Lactulose 30 mL PO Q8H:PRN Order date: [**12-12**] @ 0050 Levofloxacin 750 mg IV Q24H day 1 = [**12-6**] Methadone 2.5 mg PO BID Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN MetRONIDAZOLE (FLagyl) 500 mg IV Q8H day 1 = [**12-6**] Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Nortriptyline 25 mg NG HS Ondansetron 8 mg IV Q 8H Pantoprazole 40 mg IV Q12H Docusate Sodium (Liquid) 100 mg PO BID PRN Prochlorperazine 25 mg PR Q12H Fluconazole 200 mg NG Q24H day 1 = [**12-6**] Gabapentin 300 mg PO QAM & 600 mg PO QPM Vancomycin 1000 mg IV Q 12H day 1 = [**12-6**] Discharge Medications: 1. Nortriptyline 10 mg/5 mL Solution [**Month/Year (2) **]: One (1) PO HS (at bedtime). 2. Methadone 5 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO BID (2 times a day). 3. Lactulose 10 gram/15 mL Syrup [**Month/Year (2) **]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. Disp:*300 ML(s)* Refills:*2* 4. Senna 8.8 mg/5 mL Syrup [**Month/Year (2) **]: Five (5) ML PO BID (2 times a day). Disp:*300 ML(s)* Refills:*2* 5. Acetaminophen 160 mg/5 mL Solution [**Month/Year (2) **]: [**12-29**] tsp PO Q6H (every 6 hours) as needed for fever or pain. Disp:*1 Bottle* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup [**Month/Day (2) **]: Fifteen (15) ML PO Q6H (every 6 hours) as needed for cough. Disp:*200 ML(s)* Refills:*1* 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 8. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO BID (2 times a day). Disp:*600 mL* Refills:*2* 9. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed for constipation. 10. Compazine 5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every 4-6 hours as needed for nausea: crush & mix with water. . Disp:*30 Tablet(s)* Refills:*0* 11. Ativan 1 mg Tablet [**Hospital1 **]: [**12-29**] - 1 Tablet PO every 4-6 hours as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* 12. Levofloxacin 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] hospice care Discharge Diagnosis: Primary Diagnosis - Metastatic Esophageal CA - Parapharyngeal Abcess - Left Pleural Effusison - Health-Care Acquired PNA Discharge Condition: good. Patient abulating. PEG in place. Tolerating De-Cannulation. Discharge Instructions: You were admitted to hospital with shortness of [**Hospital 1440**] and wheezing. You were found to have an infection in your throat for which you received antibiotics. A breathing tracheostomy was placed so that you were able to [**Hospital 1440**]. This infection was treated and you are now able to breathe without the tube. The hole in your neck should close up on its own, you do not need to do anything about this. You were found to have a growning lesion in your left lung and you underwent an operation to removed the lesion as well as fluid. You were found to have recurrence of your esophageal cancer. Dr. [**Last Name (STitle) **] will see you in clinic to discuss chemotherapy. You were also treated for a pneumonia. You need to take 5 more days of an antibiotic called levofloxacin. Please continue to take all of your medications as listed below. A number of changes have been made. Please keep all of your appointments. Please call your doctor if you experience continued fevers, chills, shortness of [**Last Name (STitle) 1440**], chest pain, nausea, vomitting, diarrhea. Followup Instructions: With Dr. [**Last Name (STitle) 71392**] on [**1-30**] at 1:30 PM on [**Hospital Ward Name 23**] 9. Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2131-1-25**] 12:45 Provider: [**Name10 (NameIs) 4617**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 7976**] Date/Time:[**2131-1-26**] 2:15 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 8268**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2131-1-29**] 10:30 Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**] Date/Time:[**2131-2-8**] 9:00 ",82,2130-12-04 19:01:00,2131-01-19 21:25:00,EMERGENCY,PHYS REFERRAL/NORMAL DELI,HOME HEALTH CARE,"ESOPHAGEAL MASS, NECK PAIN"," the following summary is divided into sections due to the ","PRIMARY: [Malignant neoplasm of cervical esophagus] SECONDARY: [Perforation of esophagus; Secondary malignant neoplasm of lung; Malignant pleural effusion; Parapharyngeal abscess; Pneumonia, organism unspecified; Stricture and stenosis of esophagus; Unspecified disease of the jaws; Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure; Accidents occurring in other specified places; Anemia in neoplastic disease; Stenosis of larynx; Drug induced neutropenia; Penicillins causing adverse effects in therapeutic use; Accidents occurring in residential institution]",the following summary is divided into sections due to the,the following summary is divided into sections due to the nature of the project. the following summary is divided into sections due to the nature of the project. the following summary is divided into sections due to the nature of the project. 85258,125297.0,29930,2131-06-11,29926,179741.0,2131-04-11,Discharge summary,"Admission Date: [**2131-3-26**] Discharge Date: [**2131-4-11**] Date of Birth: [**2090-5-18**] Sex: F Service: MEDICINE Allergies: Roxicet Attending:[**First Name3 (LF) 477**] Chief Complaint: Stridor and fever. Major Surgical or Invasive Procedure: Tracheostomy placemnt on [**2131-3-26**]. Right subclavian line placement [**2131-3-28**]. Right subvlacian line removal. History of Present Illness: This 40-year-old female has a long history of esophageal webs and strictures. She was evaluated for this in the past and was admitted in [**Month (only) **] with worsening dysphasia. She had an EGD on [**2130-6-1**] that was successful on the third attempt and tissue biopsy at that time revealed an invasive squamous cell carcinoma. CT showed no evidence of metastases or local invasion. She was started on Cetuximab with concurrent radiation on [**2130-7-13**]. She completed her radiation therapy on [**2130-8-24**] for a total of 6600 Gy. She also completed her Erbitux therapy at that time. She was admitted on [**2130-12-4**] due to nausea and vomiting. On that admission, she was found to have evidence of tracheal obstruction. In addition, she had a CT of her neck, which was concerning for perforation. Thoracic was consulted and felt that she would benefit from a tracheostomy for airway protection, which was placed on [**2130-12-8**]. She tolerated this well. She was noted to have a left upper lobe cavitary lesion on the CT scan. She underwent a wedge resection on [**2130-1-11**], which revealed carcinomatous plaques on the pleural wall. This was confirmed to be a metastatic disease on frozen section. In terms of her tracheostomy, she was decannulated on [**2131-1-17**]. During the hospitalization she was treated for pharyngeal abscess and had issues with tachycardia as well as hypotension. She was discharged home on [**2131-1-19**]. She began a palliative chemotherapy regimen of 5-FU and carboplatin on [**2131-3-13**]. Past Medical History: PAST ONCOLOGIC HISTORY (as previously documented on last discharge summary dated [**3-18**]): ====================== This 40-year-old female has a long history of esophageal webs and strictures. She was evaluated for this in the past and was admitted in [**Month (only) **] with worsening dysphasia. She had an EGD on [**2130-6-1**] that was successful on the third attempt and tissue biopsy at that time revealed an invasive squamous cell carcinoma. CT showed no evidence of metastases or local invasion. She was started on Cetuximab with concurrent radiation on [**2130-7-13**]. She completed her radiation therapy on [**2130-8-24**] for a total of 6600 Gy. She also completed her Erbitux therapy at that time. She was admitted on [**2130-12-4**] due to nausea and vomiting. On that admission, she was found to have evidence of tracheal obstruction. In addition, she had a CT of her neck, which was concerning for perforation. Thoracic was consulted and felt that she would benefit from a tracheostomy for airway protection, which was placed on [**2130-12-8**]. She tolerated this well. She was noted to have a left upper lobe cavitary lesion on the CT scan. She underwent a wedge resection on [**2130-1-11**], which revealed carcinomatous plaques on the pleural wall. This was confirmed to be a metastatic disease on frozen section. In terms of her tracheostomy, she was decannulated on [**2131-1-17**]. During the hospitalization she was treated for pharyngeal abscess and had issues with tachycardia as well as hypotension. She was discharged home on [**2131-1-19**]. She began a palliative chemotherapy regimen of 5-FU and carboplatin on [**2131-3-13**]. PAST MEDICAL HISTORY: ==================== 1. Esophageal strictures and webs. 2. Anemia. 3. G tube placed on 06/[**2129**]. 4. History of prior constipation. 5. Tracheostomy placed on [**2130-12-8**], removed on [**2131-1-17**] 6. Hypercalcemia Social History: Originally from [**Country 3587**] and portugesse creole speaking only. EtOH: one Tobacco: none Lives at home with her cousin who cares for her. Family History: She has a maternal aunt with breast cancer. Her mother and father are alive and healthy and siblings are all alive and healthy. Physical Exam: VITAL SIGNS - Temp 95.6 F, BP 101/35 mmHg, HR 122 BPM, RR 18 X', O2-sat 96% RA . GENERAL - well-appearing woman in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - mild ronchi bilateraly, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2, tachycardic ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**5-1**] throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: On Admission: [**2131-3-26**] 12:00PM WBC-1.0* RBC-3.68* HGB-10.6* HCT-30.2* MCV-82 MCH-28.9 MCHC-35.2* RDW-14.1 [**2131-3-26**] 12:00PM PLT COUNT-209 [**2131-3-26**] 12:00PM GRAN CT-140* [**2131-3-26**] 12:00PM ALT(SGPT)-22 AST(SGOT)-28 LD(LDH)-181 ALK PHOS-85 TOT BILI-0.4 [**2131-3-26**] 12:00PM ALBUMIN-3.8 CALCIUM-10.1 PHOSPHATE-2.7 MAGNESIUM-2.0 [**2131-3-26**] 12:00PM UREA N-15 CREAT-0.5 SODIUM-136 POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-31 ANION GAP-13 [**2131-3-27**] 12:00AM PT-15.1* PTT-29.0 INR(PT)-1.3* [**2131-3-27**] 12:00AM PLT SMR-NORMAL PLT COUNT-156 . Echocardiogram [**2131-3-28**]: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . CXR [**2131-4-26**]: Portable AP chest radiograph was compared to [**2131-3-22**]. There is no significant change in the left basal consolidation and at least partially loculated left pleural effusion including the apical component. The right lung is essentially clear. The mediastinal contours are unchanged. The postsurgical sutures in the left upper lung are unchanged. There is a lucency projecting over the left apical fluid collection that may represent small loculated pneumothorax. The Port-A-Cath catheter tip is at the cavoatrial junction. The cavities in the right lung seen on the PET/CT from [**2131-3-8**] is difficult to see on both prior radiographs from [**3-22**] and the current radiograph from [**2131-3-26**] that can be either resolved or being below the limitations of the radiograph resolution . If clinically warranted, further evaluation with chest CT might be considered. . CT Abdomen/Pelvis [**2131-3-28**]: 1. Soft tissue density mass posterior to the tracheostomy catheter was seen on prior CT scan and is consistent with patient's metastatic esophageal cancer. 2. Multiple right-sided right lung as well as right pleural nodules concerning for progression of metastatic disease on that side. 3. Overall stable appearance to extensive pleural as well as parenchymal metastatic disease in the left lung. Nodular foci in the right and left lungs, however, could also represent foci of infectious process and would recommend followup to assess for change or resolution. . CT Neck: Ill-defined soft tissue associated with the esophagus in the post-cricoid region and hypopharynx in the area of prior FDG avidity. Lack of soft tissue delineation limits ability to fully evaluate. Brief Hospital Course: 40 yo F with metastatic esophageal carcinoma s/p recent initiation of carboplatin and 5fu, s/p trach in past, admitted to oncology with febrile neutropenia and transferred for concerning increased stridor and narrowed airway. . ## Stridor: Patient with history of stridor in past, leading to trach in [**10-25**] for esophageal perforation possibly in setting of nausea/vomiting and laryngeal edema. Recent PET scan with increased uptake in this area. Based on ENT evaluation, patient's airway narrowed to 1-2 mm. Area of concern from prior imaging was in cervical esophagus, so would be above area of possible trach. Pt received IV decadron without improvement. Her respiratory rate increased, there was use of accesory muscles so she was tranferred to the ICU. She was evaluated by thoracic surgeons who took her emergently to the OR for trach placement with heliox given prior. After the procedure she continued to spike fever, was tachycardic, was acutely dropping her oxygen sats. She had an emergent bronch which showed patent airways. She initally had difficulty weaning from the vent. She was weaned to trach collar on [**3-31**]. Since then she has been stable in the floor breathing in 35% humidified air via a tracheal mask. She was trainned in multiple days to use her tracheostoy and how to release the inner canula. She was able to do it by herself every single day afterwards. . # Neutropenic fever/sepsis: Patient spiking fevers to 101 on cefepime on the floor. She also spiked fever subsequently after coming back from the OR. Overnight her first night in the ICU her antibiotics were broadended to clinda, cefepime, flagyl, vanco, and ceftriaxone. She also dropped her pressures and was started on levo (weaned off on [**3-29**]) and boluses IVF to maintain a MAP> 65 and a CVP>10. On the morning of [**3-28**] these were changed to clinda/vanc/cefepime. Her fevers resolved and her clindamycin was d/c after 6 doses. She was continued on filgrastim and was no longer neutropenic as of [**2131-3-31**]. The plan was to continue a 10 day course of vanc/cefepime with day 1 being [**3-31**] and her last dose being [**2131-4-9**]. However, cefepime will not be covered by her insurance so we started ciprofloxacin instead on [**4-4**] and we recommend two days of treatment on cipro and then discontinuing the cipro. She compleated the antibiotic course in house and was afebrile afterwards. . # Sinus tachy: has been ongoing issue per last discharge summary, has been ranging in 120s in past, is of unknown etiology. Has been persistent despite fluid resuscitation, transfusion, and correction of hypercalcemia in past. EKGs sinus tachycardia. Her sinus tachycardia did not respond to fluid resuscitation in the ICU. It is possible that this could be secondary to vagus nerve infiltration of her tumor, leading to unopposed sympathetic stimulation. . # Metastatic esophageal cancer: with mets to lungs, recent PET scan showed increased disease in lung, upper esophagus, and paratracheal region. Has been recently reinitiated on carboplatin and 5FU about 1 week prior to being in the ICU. As per family meetings while in the ICU, the plan is to give her 2 week holiday and then assess and consider palliative chemotherapy. . # HCT: Pt received 2 units of packed RBCs for HCT of 23 and bumped appropriately. She has not required blood transfusion since [**3-29**]. . # Left flank/back pain: Likely secondary to mets. At home on lidocaine, methadone, tylenol. Methadone was restarted on [**3-29**]. . # FEN/GI: Pt getting tube feeds started on [**3-30**]. S & S saw pt and is ok to get ice chips, but pt was unable to tolerate liquids. She will need to be strict NPO. . # PROPHY: sc heparin, bowel regimen , PPI. . # ACCESS: right portacath, left PIV, CVL. An a-line was put in while in the ICU and d/c while in the ICU. . # Dispo: Home with free hospice. Medications on Admission: 1. Lactulose 10 gram/15 mL Syrup [**Month/Day (4) **]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation: through j tube. 2. Lorazepam 0.5 mg Tablet [**Month/Day (4) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for anxiety/nausea: through j tube. 3. Methadone 5 mg Tablet [**Month/Day (4) **]: 1-2 Tablets PO BID (2 times a day). 4. Nortriptyline 10 mg Capsule [**Month/Day (4) **]: One (1) Capsule PO HS (at bedtime). 5. Omeprazole-Sodium Bicarbonate 40-1,680 mg Packet [**Month/Day (4) **]: One (1) PO once a day: through j tube. 6. Prochlorperazine 25 mg Suppository [**Month/Day (4) **]: One (1) Rectal every six (6) hours as needed for nausea. 7. Acetaminophen 160 mg/5 mL Solution [**Month/Day (4) **]: [**12-29**] PO every six (6) hours as needed for pain. 8. Bisacodyl 10 mg Suppository [**Month/Day (2) **]: One (1) Suppository Rectal 1 to 2 times per day as needed for constipation. 9. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: 10mL PO BID (2 times a day). 10. Senna 8.8 mg/5 mL Syrup [**Month/Day (2) **]: One (1) PO twice a day. 11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Day (2) **]: Three (3) Adhesive Patch, Medicated Topical DAILY (Daily): apply to left side for no more than 12 hours at a time. 12. Guaifenesin 100 mg/5 mL Syrup [**Month/Day (2) **]: Fifteen (15) ML PO Q6H (every 6 hours) as needed. Discharge Medications: 1. Oxygen 35% continuous via tracheal mask with cool mist via [**Last Name (un) **] compressor. 2. Suction Machine Please provide with portable suction machine with trach suction catheter size 14 fr. 3. Trach Please provide with 6mm portex for tracheostomy. 4. Oxygen Please provide with oxygen tanks at home for tracheostomy humidifier at 35%. Respiratory diangosisL Esophageal cancer with laringeal involvement. Lowest SpO2 90% on RA. [**Medical Record Number 71505**]. 5. Methadone 10 mg/5 mL Solution [**Medical Record Number **]: Five (5) mililiters PO PM (). 6. Methadone 10 mg/5 mL Solution [**Medical Record Number **]: 2.5 mililiters PO AM (). 7. Lorazepam 0.5 mg Tablet [**Medical Record Number **]: 1-2 Tablets PO Q4H (every 4 hours) as needed for anxiety. 8. Lactulose 10 gram/15 mL Syrup [**Medical Record Number **]: Thirty (30) ML PO BID (2 times a day). 9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 10. Nortriptyline 10 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) mililiters PO at bedtime as needed for insomnia. Disp:*1 Liter* Refills:*0* 11. Compazine 25 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal every six (6) hours as needed for nausea. Disp:*30 Suppository* Refills:*0* 12. Acetaminophen 167 mg/5 mL Liquid [**Last Name (STitle) **]: [**5-6**] Mililiters PO every six (6) hours as needed for Pain. Disp:*500 mililiters* Refills:*0* 13. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Year (2) **]: One (1) Adhesive Patch, Medicated Topical Q12H (every 12 hours): 12 hours on, 12 hours off. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2* 14. Guaifenesin 100 mg/5 mL Syrup [**Month/Year (2) **]: 5-10 MLs PO Q6H (every 6 hours) as needed for cough, throat pain. Disp:*250 ML(s)* Refills:*0* 15. Morphine 10 mg/5 mL Solution [**Month/Year (2) **]: Five (5) Mililiters PO Q4H (every 4 hours) as needed for pain. Disp:*250 Mililiters* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 269**] Hospice Care Discharge Diagnosis: Primary Diagnosis: Respiratory Distress/Failure secondary to either chemical irritation of the airway or esophageal cancer infiltration to the esophagus. . Secondary Diagnosis: Esophageal strictures and webs. Anemia. G tube placed on [**5-/2130**] Discharge Condition: Stable, cleaning her tracheostomy herslef, walking miles in the corridor. Discharge Instructions: You were seen at the [**Hospital1 18**] for neutropenic fever after your chemotherapy. Upon arrival you mentioned that you had been having difficulty breathing during the last days. It started to get worse during the course of the first hospital day. You were seen by the ENT, who saw a very narrow arway. Since your breathing started getting worse and we were unable to help you breathe a tracheostomy was put in place. You required ICU stay. Then, you were transfered to the medical floor where you were observed. Your tube feedings were re-started. You were evaluated by speech and swallow, but everytime you had any liquids you started coughing and there is risk of aspiration and food/liquids going down the wrong pipe. Therefore we recommend you do not drink or eat anything by mouth, but everything through your J tube. . Dr. [**Last Name (STitle) **] saw you and recommended 2 weeks at home and then meet with him so you all can talk regarding how to keep helping you with your cancer. . We were able to set up free hospice at home, where you will have a tem that will help you with your feeding tubes, tracheostomy, pain and transition for better control of your symptoms. . If you have fever, chills, cough, difficulty breathing, worsening of your pain or anything else that concerns you please come back to our ER. Followup Instructions: Please make an appointment with Dr. [**Last Name (STitle) **] within 2 weeks. You can call ([**Telephone/Fax (1) 694**]. . [**2131-4-17**] 02:30p Dr [**Last Name (STitle) 1533**] in the THORACIC CLINIC to remove the stitches of your tracheostomy. [**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**] ",61,2131-03-26 18:16:00,2131-04-11 20:40:00,EMERGENCY,CLINIC REFERRAL/PREMATURE,HOSPICE-HOME,NEUTROPENIA;ESOPHEGEAL CANCER," 40 yo f with metastatic esophageal carcinoma s/p recent initiation of carboplatin and 5fu, s/p trach in past, admitted to oncology with febrile neutropenia and transferred for concerning increased stridor and narrowed airway. . ## stridor: patient with history of stridor in past, leading to trach in [**10-25**] for esophageal perforation possibly in setting of nausea/vomiting and laryngeal edema. recent pet scan with increased uptake in this area. based on ent evaluation, patients airway narrowed to 1-2 mm. area of concern from prior imaging was in cervical esophagus, so would be above area of possible trach. pt received iv decadron without improvement. her respiratory rate increased, there was use of accesory muscles so she was tranferred to the icu. she was evaluated by thoracic surgeons who took her emergently to the or for trach placement with heliox given prior. after the procedure she continued to spike fever, was tachycardic, was acutely dropping her oxygen sats. she had an emergent bronch which showed patent airways. she initally had difficulty weaning from the vent. she was weaned to trach collar on [**3-31**]. since then she has been stable in the floor breathing in 35% humidified air via a tracheal mask. she was trainned in multiple days to use her tracheostoy and how to release the inner canula. she was able to do it by herself every single day afterwards. . # neutropenic fever/sepsis: patient spiking fevers to 101 on cefepime on the floor. she also spiked fever subsequently after coming back from the or. overnight her first night in the icu her antibiotics were broadended to clinda, cefepime, flagyl, vanco, and ceftriaxone. she also dropped her pressures and was started on levo (weaned off on [**3-29**]) and boluses ivf to maintain a map> 65 and a cvp>10. on the morning of [**3-28**] these were changed to clinda/vanc/cefepime. her fevers resolved and her clindamycin was d/c after 6 doses. she was continued on filgrastim and was no longer neutropenic as of [**2131-3-31**]. the plan was to continue a 10 day course of vanc/cefepime with day 1 being [**3-31**] and her last dose being [**2131-4-9**]. however, cefepime will not be covered by her insurance so we started ciprofloxacin instead on [**4-4**] and we recommend two days of treatment on cipro and then discontinuing the cipro. she compleated the antibiotic course in house and was afebrile afterwards. . # sinus tachy: has been ongoing issue per last discharge summary, has been ranging in 120s in past, is of unknown etiology. has been persistent despite fluid resuscitation, transfusion, and correction of hypercalcemia in past. ekgs sinus tachycardia. her sinus tachycardia did not respond to fluid resuscitation in the icu. it is possible that this could be secondary to vagus nerve infiltration of her tumor, leading to unopposed sympathetic stimulation. . # metastatic esophageal cancer: with mets to lungs, recent pet scan showed increased disease in lung, upper esophagus, and paratracheal region. has been recently reinitiated on carboplatin and 5fu about 1 week prior to being in the icu. as per family meetings while in the icu, the plan is to give her 2 week holiday and then assess and consider palliative chemotherapy. . # hct: pt received 2 units of packed rbcs for hct of 23 and bumped appropriately. she has not required blood transfusion since [**3-29**]. . # left flank/back pain: likely secondary to mets. at home on lidocaine, methadone, tylenol. methadone was restarted on [**3-29**]. . # fen/gi: pt getting tube feeds started on [**3-30**]. s & s saw pt and is ok to get ice chips, but pt was unable to tolerate liquids. she will need to be strict npo. . # prophy: sc heparin, bowel regimen , ppi. . # access: right portacath, left piv, cvl. an a-line was put in while in the icu and d/c while in the icu. . # dispo: home with free hospice. ","PRIMARY: [Drug induced neutropenia] SECONDARY: [Malignant neoplasm of other specified part of esophagus; Other specified septicemias; Sepsis; Acute respiratory failure; Fever presenting with conditions classified elsewhere; Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use; Stricture and stenosis of esophagus; Anemia in neoplastic disease; Dehydration; Stridor; Backache, unspecified]","40 yo f with metastatic esophageal carcinoma s/p recent initiation of carboplatin and 5fu, s/p trach in past, admitted to oncology with febrile neutropenia and transferred for concerning increased stridor and narrowed airway. she was evaluated by thoracic surgeons who took her emergently to the or for trach placement with heliox given prior. she had an emergent bronch which showed patent airways. she initally had difficulty weaning from the vent. she also spiked fever subsequently after coming back from the or. she also dropped her pressures and was started on levo (weaned off on [**3-29**]) and boluses ivf to maintain a map> 65 and a cvp>10. as per family meetings while in the icu, the plan is to give her 2 week holiday and then assess and consider palliative chemotherapy. she has not required blood transfusion since [**3-29**]. # access: right portacath, left piv, cvl.","40 yo f with metastatic esophageal carcinoma s/p recently initiation of carboplatin and 5fu, s/p trach in past. admitted to oncology with febrile neutropenia and transferred for concerning increased stridor and narrowed airway. based on ent evaluation, patients airway narrowed to 1-2 mm." 85258,125297.0,29930,2131-06-11,29853,122457.0,2131-01-19,Discharge summary,"Admission Date: [**2130-12-4**] Discharge Date: [**2131-1-19**] Date of Birth: [**2090-5-18**] Sex: F Service: MEDICINE Allergies: Roxicet Attending:[**First Name3 (LF) 4057**] Chief Complaint: Nausea, Vomiting Major Surgical or Invasive Procedure: Tracheostomy thoracentesis Left VATS Mechanical Ventilation History of Present Illness: 40 yo F with unresectable esophageal cancer who was recently discharged from the hospital secondary to right neck pain. She was then discharged on [**12-1**]. Notes indicate the patient re-presented on [**12-4**] with the chief complaint of ""strange sounding airway"" and dyspnea. She was found to have a soft tissue infection lateral to the esophagus that likely represents microperforation, for which she was started on abx, and she required surgical tracheostomy for upper airway obstruction caused by her esophageal cancer. . Additionally, her MICU course was remarkable for persistent tachycardia and mild hypotension. Her heart rate remains 120s at rest with brief episodes of rates as high as 150 when she is out of bed, sinus tachycardia at all times. Her blood pressure has ranged from 70s-90s systolic, which does not appear to be new, as OMR notes document systolic blood pressures in the high 80s-low 90s at multiple visits. Evaluation as to the cause of tachycardia has included TSH (low normal), with fT4 pending; echo (nml LV and RV function, no echocardiographic signs of hemodynamically significant PE); ABG 7.46/41/114 was with pt breathing room air for 10 minutes, indicating that there is no apparent A-a gradient; a random cortisol level was low, but responded appropriately to cosyntropin. Since she appears well, with good skin turgor and adequate urine output, despite the tachycardia and hypotension, she was transferred out of the ICU. Past Medical History: #. Invasive Esophageal Squamous Squamous Cell Carcinoma: - [**2129-11-1**]: Pt arrived in America from [**Country 3587**] - [**2129-11-2**]: Pt evaluated for Odynophagia, tx with Prilosec - 11/26-30/07: Admitted fo Esophageal Web Dilations that relieved symptoms - [**1-4**]: Symptoms of odynophagia returned - [**2130-2-12**]: Referred to ENT for recurrent cervial web at C4-5 - [**2130-4-14**]: Esophageal Dilation under general anesthesia - [**5-4**]: ENT consult for bilateral submandibular pain - 5/29-30/08: Two subsequent attempts at dilation unsucessful - [**6-4**]: PEG placed for FTT - [**2130-6-7**]: Bx confirms Invasive Squamous Cell CA - [**2130-6-20**]: diagnosed [**2130-5-28**] in setting of esophageal stricture - high cervical esophageal lesion not resectable - completed therapy with Cetuximab and radiation therapy # Anemia # Upper esophageal and pharyngeal stricture; s/p PEG # Shoulder Pain # Lung lesion - NOS # Chronic pain from radiation. # Nausea and vomiting. # PEG tube site candidiasis Social History: The patient lives in [**Location 686**], MA with her cousin [**Name (NI) **] [**Name (NI) **], who is her HCP. The patient is initially from [**Country 11660**] islands, she is not currently working. Tobacco: None ETOH: None Illicits: None Family History: There is no history in her family of heart disease, gastric cancer, esophageal cancer or colon cancer or inflammatory bowel disease. Physical Exam: ADMISSION PHYSICAL EXAM VS: T = 99.4 P = 120 BP = 108/60 RR 16, O2Sat:100% GENERAL: Young female who appears older than her stated age. She is appears tired and worn. Mentation: Alert but restricted affect. Does not smile. Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted Ears/Nose/Mouth/Throat: MMM, no lesions noted in OP Neck: supple, no JVD or carotid bruits appreciated Respiratory: Bibasilar crackles Cardiovascular: tachy, nl. S1S2, no M/R/G noted Gastrointestinal: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. PEG site C/D/I no odor. Appears better than during previous admission. Genitourinary: Skin: no rashes or lesions noted. No pressure ulcer Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Lymphatics/Heme/Immun: No cervical lymphadenopathy noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -DTRs: 2+ biceps, triceps, No foley catheter/tracheostomy/PEG/ventilator support/chest tube/colostomy Psychiatric: Very limited affect with rare brightening. . PHYSICAL EXAM UPON ARRIVAL TO THE FLOOR: [**12-11**] Vitals: T97.9 BP96/50 HR126 RR19 O2Sat100% on 35% trach collar GEN: Thin, tired-appearing [**Location 7972**] woman HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea with sutured trach cannula COR: tachy, no M/G/R, normal S1 S2, radial pulses +2 PULM: bronchial [**Location 1440**] sounds throughout ABD: Soft, NT, ND, +BS, no HSM, no masses. PEG in place in LUQ EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +1. Plantar reflex downgoing. No gait disturbance. No cerebellar dysfunction. SKIN: Normal turgor. No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2130-12-4**] Neck CT: 1. No mass lesions are detected within the airway to explain stridorous breathing. 2. Fluid again noted within the esophagus in the region of the thyroid gland. Also noted on prior study, possibly relating to region of stricture. 3. Slight increase in cavitary lesion within the left lung apex. NOTE ADDED AT ATTENDING REVIEW: There is a collection of air in the right neck, apparently just lateral to the esophagus, but possibly within a dilated esophagus, best seen on images 34-37 of series 2. In this location it raises the possibility of an esophageal perforation. Since it is difficult to determine the location of the lateral margin of the esophagus, it is difficult to distinguish an extraluminal collection from dilatation of the organ. An MR examination may be helpful. There is induration of the adjacent tissues, which could be a consequence of local infection, but also could arise as a result of prior radiation. . [**2130-12-4**] CT CHEST 1. Small pharyngeal or paralaryngeal abscess, phlegmon or malignancy has grown over two weeks. If the lesion is inflammatory it suggests ulceration in the hypopharynx/upper esohagus. Please see report of today's neck CT. 2. Slow growth of small left upper lobe lung cavity and a tiny right lower lobe lesion as well as a new left lower lobe lesion are concerning for multifocal metastases, or slow spread of an indolent infection. Small growing left pleural mass is more characteristic of metastasis. . [**2130-12-6**] MRI SOFT TISSUE NECK, W/O & W/CONTRAST IMPRESSION: 12 x 8 mm collection of air with small amount of fluid just anterior to the right aspect of the esophagus at the level of the thyroid gland which likely represents esophageal perforation and/or abscess. Additional considerations include esophageal diverticulum, although less likely. . TTE (Complete) Done [**2130-12-11**] at 2:38:57 PM Conclusions The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2130-2-28**], no change. . [**2130-12-12**] CTA CHEST 1. No pulmonary embolism. 2. New left posterior pleural lesion. Although this would be an atypical location for an esophageal carcinoma metastasis, the possibility of malignancy cannot be totally excluded and PET CT may provide additional diagnostic information. 3. Increase in right lower lobe and left upper lobe opacities and new left lower lobe opacity most likely represent infectios process; from the same or different [**Doctor Last Name 360**] 4. Resolution of fluid collection in the posterior parapharyngeal space compared to the CT of [**2130-12-4**]., now fluid filled . [**2130-12-17**] CXR Tracheostomy tube is again visualized. There is new left small pleural effusion with volume loss in the left lower lobe. An early infiltrate in this region cannot be totally excluded. Otherwise, the lungs are clear. . LABWORK: [**2130-12-4**] 08:42PM GLUCOSE-112* UREA N-13 CREAT-0.5 SODIUM-133 POTASSIUM-5.0 CHLORIDE-92* TOTAL CO2-29 ANION GAP-17 [**2130-12-4**] 08:42PM estGFR-Using this [**2130-12-4**] 08:42PM HCG-<5 [**2130-12-4**] 08:42PM CALCIUM-9.2 PHOSPHATE-2.4* MAGNESIUM-2.0 [**2130-12-4**] 08:42PM WBC-9.6 RBC-3.35* HGB-9.8* HCT-28.8* MCV-86 MCH-29.2 MCHC-34.0 RDW-14.7 [**2130-12-4**] 08:42PM NEUTS-81.3* LYMPHS-12.0* MONOS-5.8 EOS-0.8 BASOS-0.1 [**2130-12-4**] 08:42PM PLT COUNT-672* [**2130-12-4**] 08:42PM PT-14.3* PTT-25.5 INR(PT)-1.2* . Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2131-1-19**] 12:00AM 4.8 3.02* 9.5* 26.6* 88 31.4 35.8* 13.4 377 Source: Line-PICC [**2131-1-18**] 12:00AM 4.7 3.14* 9.5* 26.8* 85 30.4 35.6* 13.9 356 Source: Line-TLCVL [**2131-1-17**] 12:00AM 5.4 3.38* 10.2* 29.4* 87 30.1 34.6 13.8 368 Source: Line-PICC [**2131-1-16**] 12:00AM 4.0 3.51* 10.6* 30.7* 88 30.2 34.6 14.0 359 Source: Line-PICC [**2131-1-15**] 02:04AM 5.0 3.17* 9.5* 26.8* 85 30.0 35.5* 14.8 352 Source: Line-arterial [**2131-1-14**] 04:41AM 7.8 3.28* 10.2* 27.7* 84 31.1 36.9* 14.6 358 Source: Line-arterial [**2131-1-13**] 10:21PM 10.6 3.44*# 10.9*# 29.0*#1 84 31.6 37.5* 14.0 425 Source: Line-arterial [**2131-1-13**] 02:24AM 7.3 2.70* 8.2* 23.1* 85 30.4 35.6* 14.3 415 Source: Line-aline [**2131-1-12**] 06:20PM 7.4# 2.71* 8.1* 23.2* 86 30.1 35.1* 14.3 356 Source: Line-arterial ulnar [**2131-1-12**] 01:00AM 4.2 2.93* 8.8* 25.7* 88 29.9 34.1 13.9 389 [**2131-1-10**] 05:45AM 3.7* 3.08* 9.1* 26.7* 87 29.6 34.2 13.9 420 [**2131-1-9**] 06:15AM 3.7* 3.09* 9.2* 26.3* 85 29.9 35.2* 14.0 430 [**2131-1-8**] 05:35AM 3.9* 3.26* 9.8* 28.2* 87 30.1 34.8 13.9 431 [**2131-1-6**] 05:40AM 3.3* 3.24* 9.8* 27.5* 85 30.4 35.8* 14.5 409 [**2131-1-5**] 07:20AM 3.2* 3.24* 10.1* 28.1* 87 31.1 35.9* 14.4 386 [**2131-1-4**] 06:30AM 3.4* 3.60* 11.0* 31.1* 86 30.6 35.5* 14.5 431 [**2131-1-3**] 01:45PM 4.3# 3.70* 11.3* 32.2* 87 30.6 35.1* 14.5 441* [**2131-1-2**] 07:45AM 2.5* 3.06* 9.1* 27.2* 89 29.7 33.5 14.5 363 [**2131-1-1**] 06:50AM 2.4* 3.11* 9.3* 27.0* 87 29.8 34.4 14.6 386 [**2130-12-31**] 05:50AM 2.2* 3.11* 9.3* 27.2* 88 29.9 34.2 14.3 372 [**2130-12-30**] 06:00AM 2.3* 3.26* 9.9* 29.0* 89 30.4 34.2 13.9 376 [**2130-12-29**] 06:45AM 2.1* 3.07* 9.2* 27.1* 88 29.8 33.8 13.8 344 [**2130-12-28**] 05:55AM 2.1* 3.17* 9.7* 28.2* 89 30.7 34.6 14.6 381 [**2130-12-27**] 10:00AM 2.0* 3.19* 9.6* 28.2* 88 29.9 33.9 14.5 420 SPECIMNE ARRIVED IN LAB AT 12:41PM [**2130-12-26**] 06:40AM 1.7* 3.10* 9.8* 27.5* 89 31.5 35.6* 13.9 320 [**2130-12-25**] 06:15AM 2.3* 2.92* 8.9* 25.3* 87 30.4 35.1* 13.9 340 [**2130-12-24**] 05:50AM 2.7* 2.97* 9.1* 25.4* 86 30.6 35.8* 14.7 331 [**2130-12-22**] 05:35AM 2.7* 2.98* 8.8* 26.2* 88 29.4 33.5 14.9 337 [**2130-12-21**] 06:00AM 2.4* 3.03* 9.2* 26.6* 88 30.4 34.6 14.4 303 [**2130-12-20**] 05:50AM 2.3* 3.00* 8.9* 25.8* 86 29.7 34.5 15.3 308 [**2130-12-19**] 07:00AM 3.0* 3.30* 10.1* 29.2* 89 30.5 34.5 15.3 302 [**2130-12-16**] 09:05AM 3.4* 3.46*# 10.3*# 30.0* 87 29.9 34.5 15.9* 327 [**2130-12-15**] 03:35PM 29.9* [**2130-12-14**] 07:40AM 5.4 2.75* 8.2* 24.6* 90 29.8 33.3 15.7* 358 [**2130-12-13**] 08:00AM 9.0 2.99* 9.0* 26.0* 87 30.1 34.7 15.6* 378 [**2130-12-12**] 07:45AM 6.0 2.92* 8.7* 25.7* 88 29.9 34.0 15.3 387 [**2130-12-11**] 04:22AM 6.9 2.97* 8.9* 26.1* 88 30.0 34.1 15.3 415 [**2130-12-10**] 04:26AM 8.4 3.08* 9.1* 26.7* 87 29.4 33.9 15.1 457* [**2130-12-9**] 04:54AM 9.1 2.88* 8.8* 25.0* 87 30.6 35.3* 15.1 466* [**2130-12-8**] 06:10AM 7.0 3.10* 9.0* 26.8* 87 29.1 33.6 14.6 514* [**2130-12-7**] 03:47AM 12.8*# 3.43* 10.4* 30.3* 88 30.2 34.2 15.2 645* [**2130-12-6**] 03:18AM 7.9 3.23* 9.7* 27.8* 86 30.2 35.0 15.0 633* [**2130-12-5**] 10:00AM 7.4 3.19* 9.1* 27.9* 87 28.4 32.5 15.2 553* [**2130-12-4**] 08:42PM 9.6 3.35* 9.8* 28.8* 86 29.2 34.0 14.7 672* VERIFIED LABEL D IFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2131-1-12**] 06:20PM 89.5* 6.6* 2.6 1.2 0 Source: Line-arterial ulnar [**2131-1-6**] 05:40AM 57 2 20 13* 4 0 2* 1* 1* [**2131-1-5**] 07:20AM 60.3 21.8 10.3 7.5* 0.1 [**2131-1-4**] 06:30AM 62.9 25.3 7.3 4.4* 0.2 [**2131-1-3**] 01:45PM 70.2* 16.9* 7.7 5.1* 0.1 [**2131-1-1**] 06:50AM 53.0 27.4 10.5 8.7* 0.4 [**2130-12-31**] 05:50AM 56 0 36 4 1 0 3* 0 0 [**2130-12-30**] 06:00AM 39.8* 42.9* 11.6* 5.4* 0.3 [**2130-12-29**] 06:45AM 45.6* 32.4 13.0* 8.7* 0.3 [**2130-12-28**] 05:55AM 27* 3 56* 9 3 0 2* 0 0 [**2130-12-27**] 10:00AM 31* 0 40 18* 10* 1 0 0 0 SPECIMNE ARRIVED IN LAB AT 12:41PM [**2130-12-26**] 06:40AM 52.8 28.4 9.4 8.8* 0.6 [**2130-12-25**] 06:15AM 50 0 28 14* 5* 2 1* 0 0 [**2130-12-21**] 06:00AM 51.6 34.1 8.6 5.4* 0.3 [**2130-12-8**] 06:10AM 84.1* 9.3* 5.7 0.7 0.1 [**2130-12-4**] 08:42PM 81.3* 12.0* 5.8 0.8 0.1 RED CELL M O R P H O L O G Y Hypochr Anisocy Poiklo Macrocy Microcy Polychr Ovalocy Schisto [**2131-1-6**] 05:40AM NORMAL1 1+ 1+ NORMAL 1+ OCCASIONAL 1+ OCCASIONAL NORMAL MANUALLY COUNTED BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2131-1-19**] 12:00AM 377 Source: Line-PICC [**2131-1-18**] 12:00AM 356 Source: Line-TLCVL [**2131-1-17**] 12:00AM 368 Source: Line-PICC [**2131-1-16**] 12:00AM 359 Source: Line-PICC [**2131-1-15**] 02:04AM 352 Source: Line-arterial [**2131-1-14**] 04:41AM 358 Source: Line-arterial [**2131-1-13**] 10:21PM 425 Source: Line-arterial [**2131-1-13**] 02:24AM 415 Source: Line-aline [**2131-1-12**] 06:20PM 356 Source: Line-arterial ulnar [**2131-1-12**] 01:00AM 389 [**2131-1-12**] 01:00AM 14.5* 28.3 1.3* [**2131-1-10**] 05:45AM 420 [**2131-1-9**] 06:15AM 430 [**2131-1-8**] 05:35AM 431 [**2131-1-6**] 05:40AM NORMAL 409 [**2131-1-5**] 07:20AM 386 [**2131-1-4**] 06:30AM 431 [**2131-1-3**] 01:45PM 441* [**2131-1-3**] 01:45PM 13.0 27.7 1.1 [**2131-1-2**] 07:45AM 363 [**2131-1-1**] 06:50AM 386 [**2130-12-31**] 05:50AM NORMAL 372 [**2130-12-30**] 06:00AM 376 [**2130-12-29**] 06:45AM 344 [**2130-12-28**] 05:55AM 381 [**2130-12-27**] 10:00AM NORMAL 420 SPECIMNE ARRIVED IN LAB AT 12:41PM [**2130-12-26**] 06:40AM 320 [**2130-12-25**] 06:15AM NORMAL 340 [**2130-12-24**] 05:50AM 331 [**2130-12-22**] 05:35AM 337 [**2130-12-21**] 06:00AM 303 [**2130-12-20**] 05:50AM 308 [**2130-12-19**] 07:00AM 302 [**2130-12-16**] 09:05AM 327 [**2130-12-14**] 07:40AM 358 [**2130-12-13**] 08:00AM 378 [**2130-12-12**] 07:45AM 387 [**2130-12-11**] 04:22AM 415 [**2130-12-10**] 04:26AM 457* [**2130-12-9**] 04:54AM 466* [**2130-12-8**] 06:10AM 514* [**2130-12-8**] 04:25AM 17.0* 29.6 1.5* [**2130-12-7**] 03:47AM 645* [**2130-12-6**] 03:18AM 633* [**2130-12-5**] 10:00AM 553* [**2130-12-4**] 08:42PM 672* [**2130-12-4**] 08:42PM 14.3*1 25.5 1.2* HEMOLYZED, MODERATELY INTERPRET RESULTS WITH CAUTION Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2131-1-19**] 12:00AM 99 15 0.4 134 4.6 96 29 14 Source: Line-PICC [**2131-1-18**] 12:00AM 96 17 0.4 140 4.6 102 29 14 Source: Line-TLCVL [**2131-1-17**] 12:00AM 96 12 0.4 133 4.4 97 27 13 Source: Line-PICC [**2131-1-16**] 12:00AM 129* 7 0.4 133 4.5 95* 28 15 Source: Line-PICC [**2131-1-15**] 02:04AM 129* 7 0.4 138 3.6 105 26 11 Source: Line-arterial [**2131-1-14**] 04:41AM 160* 5* 0.5 137 4.2 104 25 12 Source: Line-arterial [**2131-1-13**] 10:21PM 192* 5* 0.4 135 3.6 100 27 12 Source: Line-arterial [**2131-1-13**] 02:24AM 87 4* 0.4 133 3.9 102 27 8 Source: Line-aline [**2131-1-12**] 06:20PM 99 5* 0.4 134 3.6 103 27 8 Source: Line-arterial ulnar [**2131-1-12**] 01:00AM 94 8 0.5 137 4.1 102 29 10 [**2131-1-2**] 07:45AM 104 4* 0.5 139 3.8 101 32 10 [**2131-1-1**] 06:50AM 101 4* 0.6 136 4.2 99 31 10 [**2130-12-31**] 05:50AM 77 5* 0.5 136 4.31 100 30 10 [**2130-12-30**] 06:00AM 82 4* 0.6 138 4.1 101 32 9 [**2130-12-29**] 06:45AM 118* 4* 0.6 136 4.1 99 31 10 [**2130-12-28**] 05:55AM 83 5* 0.5 137 4.0 100 31 10 [**2130-12-27**] 10:00AM 49*2 5* 0.5 138 4.1 101 31 10 SPECIMEN ARRIVED IN LAB AT 12:41PM [**2130-12-26**] 06:40AM 122* 5* 0.5 134 3.8 100 28 10 [**2130-12-25**] 06:15AM 78 6 0.5 137 3.9 102 30 9 [**2130-12-24**] 05:50AM 79 6 0.4 137 4.0 101 30 10 [**2130-12-22**] 05:35AM 83 6 0.5 138 4.3 102 32 8 [**2130-12-21**] 06:00AM 78 6 0.5 139 4.0 102 30 11 [**2130-12-20**] 05:50AM 77 7 0.5 136 3.7 101 30 9 [**2130-12-19**] 07:00AM 105 7 0.7 139 4.2 101 30 12 [**2130-12-16**] 09:05AM 106* 8 0.6 137 4.2 100 30 11 [**2130-12-14**] 07:40AM 96 6 0.5 138 4.3 104 29 9 [**2130-12-13**] 08:00AM 124* 7 0.5 134 4.2 97 31 10 [**2130-12-12**] 07:45AM 110* 7 0.5 136 4.0 102 30 8 [**2130-12-11**] 04:22AM 107* 6 0.5 137 4.0 102 29 10 [**2130-12-10**] 04:26AM 116* 7 0.6 131* 3.5 98 27 10 ADDED TSH [**12-10**] 4:40PM; [**Last Name (un) **] ADDED [**12-10**] 5:05PM [**2130-12-9**] 08:38AM 3.3 [**2130-12-9**] 04:54AM 97 8 0.6 132* 5.9*3 98 28 12 GROSS HEMOLYSIS [**2130-12-8**] 04:25AM 97 13 0.7 135 3.9 99 30 10 [**2130-12-7**] 03:47AM 142* 15 0.6 133 4.5 97 29 12 [**2130-12-6**] 03:18AM 138* 10 0.5 136 4.2 98 29 13 [**2130-12-5**] 10:00AM 115* 10 0.5 132* 4.3 95* 29 12 [**2130-12-4**] 08:42PM 112* 13 0.5 133 5.04 92* 29 17 MODERATELY HEMOLYZED SPECIMEN HEMOLYSIS FALSELY ELEVATES K HEMOLYZED, SLIGHTLY VERIFIED BY REPLICATE ANALYSIS NOTIFIED T. [**Doctor Last Name **] AT 131PM ON [**2130-12-27**] HEMOLYSIS FALSELY INCREASES THIS RESULT HEMOLYSIS FALSELY ELEVATES K. ESTIMATED GFR (MDRD CALCULATION) estGFR [**2131-1-12**] 01:00AM Using this1 Using this patient's age, gender, and serum creatinine value of 0.5, Estimated GFR = >75 if non African-American (mL/min/1.73 m2) Estimated GFR = >75 if African-American (mL/min/1.73 m2) For comparison, mean GFR for age group 40-49 is 99 (mL/min/1.73 m2) GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure ENZYMES & B ILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2131-1-14**] 04:41AM 172* Source: Line-arterial [**2131-1-13**] 10:21PM 217* Source: Line-arterial [**2131-1-2**] 07:45AM 129 [**2130-12-5**] 09:10AM 52 [**2130-12-5**] 01:35AM 48 CPK ISOENZYMES CK-MB cTropnT [**2131-1-14**] 04:41AM 2 <0.011 Source: Line-arterial [**2131-1-13**] 10:21PM 2 <0.011 Source: Line-arterial [**2130-12-5**] 09:10AM 1 <0.011 [**2130-12-5**] 01:35AM 1 LESS THAN 2 <0.01 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI LESS THAN 0.01 CTROPNT > 0.10 NG/ML SUGGESTS ACUTE MI CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2131-1-19**] 12:00AM 3.9 9.0 2.5* 2.1 Source: Line-PICC [**2131-1-18**] 12:00AM 9.4 2.5* 2.1 Source: Line-TLCVL [**2131-1-17**] 12:00AM 9.1 3.1 2.2 Source: Line-PICC [**2131-1-16**] 12:00AM 9.2 2.9 2.1 Source: Line-PICC [**2131-1-15**] 02:04AM 8.2* 1.9* 1.8 Source: Line-arterial [**2131-1-14**] 04:41AM 8.8 1.3* 1.8 Source: Line-arterial [**2131-1-13**] 10:21PM 8.6 1.6* 1.7 Source: Line-arterial [**2131-1-13**] 02:24AM 8.3* 2.8 2.1 Source: Line-aline [**2131-1-12**] 06:20PM 2.3* 7.8* 3.1 1.2* Source: Line-arterial ulnar [**2131-1-12**] 01:00AM 8.7 2.9 2.0 [**2131-1-2**] 07:45AM 6.0* 9.2 3.8 2.0 [**2131-1-1**] 06:50AM 9.3 3.7 1.9 [**2130-12-31**] 05:50AM 8.9 3.5 2.01 [**2130-12-30**] 06:00AM 9.6 3.5 2.0 [**2130-12-29**] 06:45AM 8.9 3.4 1.9 [**2130-12-27**] 10:00AM 9.0 3.3 2.0 SPECIMEN ARRIVED IN LAB AT 12:41PM [**2130-12-25**] 06:15AM 9.0 3.2 1.9 [**2130-12-24**] 05:50AM 1.9 [**2130-12-21**] 06:00AM 1.9 [**2130-12-20**] 05:50AM 9.0 3.4 1.9 [**2130-12-19**] 07:00AM 9.5 3.4 2.0 [**2130-12-16**] 09:05AM 1.9 [**2130-12-14**] 07:40AM 8.6 3.3 1.8 [**2130-12-13**] 08:00AM 8.9 3.1 1.9 [**2130-12-12**] 07:45AM 8.5 2.3* 1.9 [**2130-12-11**] 04:22AM 9.0 2.7 1.8 [**2130-12-10**] 04:26AM 8.9 2.5* 1.8 ADDED TSH [**12-10**] 4:40PM; [**Last Name (un) **] ADDED [**12-10**] 5:05PM [**2130-12-9**] 08:38AM 1.8 [**2130-12-9**] 04:54AM 9.0 3.5 1.81 GROSS HEMOLYSIS [**2130-12-8**] 04:25AM 9.1 3.2 1.8 [**2130-12-7**] 03:47AM 9.8 3.1 2.0 [**2130-12-6**] 03:18AM 10.0 3.8 1.9 [**2130-12-5**] 10:00AM 8.5 2.9 1.8 [**2130-12-4**] 08:42PM 9.2 2.4* 2.02 MODERATELY HEMOLYZED SPECIMEN HEMOLYSIS FALSELY ELEVATES Mg HEMOLYSIS FALSELY ELEVATES MG. OTHER CHEMISTRY Osmolal [**2131-1-13**] 10:21PM 277 Source: Line-arterial PITUITARY TSH [**2130-12-31**] 05:50AM 1.5 [**2130-12-11**] 04:22AM 0.12* [**2130-12-10**] 04:26AM 0.29 ADDED TSH [**12-10**] 4:40PM; [**Last Name (un) **] ADDED [**12-10**] 5:05PM THYROID T4 T3 calcTBG TUptake T4Index Free T4 [**2130-12-13**] 08:00AM 12.9* 1.02 0.98 12.6* [**2130-12-12**] 07:45AM 13.1* 122 1.9* OTHER ENDOCRINE Cortsol [**2131-1-13**] 03:34PM 31.3*1 PLEASE MEASURE THIRTY MINUTES AFTER COSYNTROPIN [**2131-1-13**] 02:59PM 21.0*1 [**2130-12-10**] 11:17PM 25.6*1 [**2130-12-10**] 10:57PM 17.91 [**2130-12-10**] 10:14PM 4.11 [**2130-12-10**] 04:26AM 0.9*1 ADDED TSH [**12-10**] 4:40PM; [**Last Name (un) **] ADDED [**12-10**] 5:05PM NORMAL DIURNAL PATTERN: 7-10AM 6.2-19.4 / 4-8PM 2.3-11.9 GYNECOLOGIC HCG [**2130-12-4**] 08:42PM <51 MODERATELY HEMOLYZED SPECIMEN <5 <5 IS NEGATIVE; 5 - 25 IS EQUIVOCAL; >25 IS POSITIVE LAB USE ONLY RedHold [**2131-1-6**] 05:40AM HOLD Blood Gas BLOOD GASES Type Temp Rates Tidal V PEEP FiO2 O2 Flow pO2 pCO2 pH calTCO2 Base XS Intubat Comment [**2131-1-13**] 02:36AM ART 201* 48* 7.40 31* 4 [**2131-1-12**] 08:41PM ART 35 156* 44 7.42 30 4 NOT INTUBA1 TRACH MASK [**2130-12-11**] 08:46PM ART 114* 41 7.46* 30 5 [**2130-12-8**] 12:33PM ART 159* 38 7.48* 29 5 NOT INTUBATED WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Lactate [**2131-1-12**] 08:41PM 0.8 . Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 71385**],[**Known firstname **] [**Last Name (NamePattern1) 71386**] [**2090-5-18**] 40 Female [**-7/4872**] [**Numeric Identifier 71387**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1533**] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] GOODELL/dif SPECIMEN SUBMITTED: Tracheal Tissue. Procedure date Tissue received Report Date Diagnosed by [**2130-12-8**] [**2130-12-8**] [**2130-12-13**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl Previous biopsies: [**-7/2145**] G I BIOPSY (1 JAR). [**-6/4630**] GASTRIC BX. [**Numeric Identifier 71388**] RIGHT AND LEFT SEGMENT OF FALLOPIAN TUBES (2). DIAGNOSIS: Trachea, biopsy: 1. Unremarkable cartilage. 2. Paratracheal soft tissue with acute and chronic inflammation; no malignancy identified. . Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 71385**],[**Known firstname **] [**Last Name (NamePattern1) 71386**] [**2090-5-18**] 40 Female [**Numeric Identifier 71389**] [**Numeric Identifier 71387**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1533**] Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/dif SPECIMEN SUBMITTED: posterior pleural plaque, inferior pleural plaque, upper lobe wedge. Procedure date Tissue received Report Date Diagnosed by [**2131-1-12**] [**2131-1-12**] [**2131-1-16**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dwc?????? Previous biopsies: [**-7/4872**] Tracheal Tissue. [**-7/2145**] G I BIOPSY (1 JAR). [**-6/4630**] GASTRIC BX. [**Numeric Identifier 71388**] RIGHT AND LEFT SEGMENT OF FALLOPIAN TUBES (2). DIAGNOSIS: Pleura, left posterior plaque, biopsy (A-B): Metastatic squamous cell carcinoma. Pleura, left inferior plaque, biopsy (C-D): Metastatic squamous cell carcinoma. Lung, left upper lobe, wedge resection (E-J): Metastatic squamous cell carcinoma (see note). Note: (E-J): Apart from the largest tumor nodule (2 cm in greatest dimension), multiple small foci of metastatic squamous cell carcinoma are present along the pleural surface. The surgical margin of resection appears to be free of tumor. Clinical: Esophageal mass, neck pain. Gross: The specimen is received fresh labeled with the patient's name, ""[**Known lastname 19688**], [**Known firstname **] [**Last Name (NamePattern1) **]"", the medical record number and ""pleural plaque."" It consists of a fragment of white - tan firm tissue measuring 2.5 x 1.5 x 0.6 cm, serially sectioned and partially frozen. Intraoperative exam was performed. A frozen section was performed on tissue. The frozen section diagnosis by Dr. [**Last Name (STitle) **] is ""posterior pleural plaque: metastatic carcinoma."" The remainder of the specimen is entirely submitted in A, frozen section in B. Part 2 is additionally labeled ""inferior pleural plaque."" It consists of a fragment of firm pink-tan tissue measuring 1.0 x 0.9 x 0.2 cm. The specimen is serially sliced and submitted in C-D. Part 3 is additionally labeled ""left upper lobe wedge RUSH."" It consists of a wedge resection of lung measuring 6.0 x 3.4 x 1.5 cm with a stapled margin that measures 8.0 cm in length. The pleural surface is smooth and shiny, and involved by a white mass measuring 3.0 x 1.5 cm. This area is firm on palpation. The specimen is serially sliced to reveal a 2.0 x 2.0 x 1.0 cm white tan cystic well circumscribed, nodule, located 0.4 cm from the nearest stapled margin. The mass involves the pleura. The remainder of the lung parenchyma is unremarkable. The specimen is represented as follows: E-F = pulmonary resection margin, G-I = tumor in relation to parietal pleura, J = unremarkable lung. . Brief Hospital Course: The following summary is divided into sections due to the patients prolonged hospital course: # Esophageal Cancer/Cough/SOB: The patient presented with cough and SOB. Her symptoms progressed and ENT was consulted. The patient was found to have superglottic swellling and she was transferred to the ICU for concern of possible iminent airway obstruction. A CT of the neck was concerning for perforation and this finding was reassessed with MRI which raised the possibility of abcess formation. Given these findings, throacic surgery was consulted and it was felt that the patient would benefit from tracheostomy placement for airway protection. A trach was placed by thoracics on [**2130-12-8**] which was tolerated well. Speech and swallow followed for assessment for passy muir valve. [**Hospital Unit Name 71390**] COURSE [**12-6**] through [**12-11**] . [**12-6**] - ENT - advised continued MICU care, trachea 3 mm at narrowest point and supraglottic edema, R vocal cord paralysis - Thoracics consult- likely not a tear; advised barium swallow and broad spectrum coverage, ddx perforation vs TE fistula; - Pt did not tolerate barium swallow - Added Vanco/Levo/Flagyl/Fluconazole - MR Neck - read PENDING (wet read by surgery - no ET fistula, no extaluminal air) - TFs - restart Ensure - Evaluated for worsening stridor at 0400; Inspiratory stridor noted on exam in all lung fields, but pt saturating well. Denies worsening pain. Thoracics informed. . [**Date range (3) 71391**] - MRI suggestive of micro-esophagael perf, +/- infection - (Started on Vanco Levo Fluc yesterday [**12-6**]) - ?Worsening stridor this Morning ([**12-7**]) around 4AM, self resolved. - Unless team observes persistent stridor, plan for continuing Abx, no surgical (trach) intervention at this time. - had rhoncorous [**Month/Year (2) 1440**] sounds, 3am, cleared on own. [**12-8**] - Had trachyostomy; tolerated procedure well. Weaned off vent overnight and placed on trach mask. - Per Thoracics, would attempt passy miur valve today. . [**12-9**] - c/od but no bed - ENT s/o - CXR shows trach well palced - tolerated trach proecedure well - no stridor, no n/v - restarted tube feeds - thoracics - 2 wks antibx but will follow on the floor - patient somewhat confused about cancer dx and prognosis - will need to have [**Doctor Last Name **]/[**Doctor Last Name **] to explain to patient what to expect for the future - continues to be tachycardic . 12/14-15/08 -Assessment update: noting low suspicion for esophagael cancer per Dr. [**Last Name (STitle) 174**]. Concern that chest lesion is met, but not confirmed. Re: reversibility of trach--if this was esoph perf [**1-29**] vomiting or [**1-29**] to radiation, likely temporary and may be removed s/p f/u bronch. -Refusing depression meds, psychiatry, social work -Speech and Swallow tomorrow -Gave 1 L for tachychardia . [**2130-12-10**] Spoke to oncology team re: transfer. Concern that hemodynamics are slightly worse than on admission. On admission SBPs in 90s, HR in low 100s, now SBP in 80s, HR 110s. Documented baseline blood pressures in all discharge summaries from [**2129**] have been baseline SBPs in the 80s but without tachycardia. Will check cortisol, TSH. -Cortisol noted to be quite low. Have ordered supression test. Will likely need to start treatment steroids s/p test. [**2130-12-11**] -Continuing cough apprecaited. Secretions noted. -In general, ""still""-appearing, as if in pain, but repeatedly denies. - hypotensive to 70's but not symptomatic. Tachy with normal echo. Good UOP. Summary of ICU Course: Briefly, Mrs [**Known lastname 19688**] is a 40 yo F with unresectable esophageal cancer who was recently discharged from the hospital secondary to right neck pain. She was then discharged on [**12-1**]. Notes indicate the patient re-presented on [**12-4**] with the chief complaint of ""strange sounding airway"" and dyspnea. She was found to have a soft tissue infection lateral to the esophagus that likely represents microperforation, for which she was started on abx, and she required surgical tracheostomy for upper airway obstruction caused by her esophageal cancer. . Additionally, her MICU course was remarkable for persistent tachycardia and mild hypotension. Her heart rate remains 120s at rest with brief episodes of rates as high as 150 when she is out of bed, sinus tachycardia at all times. Her blood pressure has ranged from 70s-90s systolic, which does not appear to be new, as OMR notes document systolic blood pressures in the high 80s-low 90s at multiple visits. Evaluation as to the cause of tachycardia has included TSH (low normal), with fT4 pending; echo (nml LV and RV function, no echocardiographic signs of hemodynamically significant PE); ABG 7.46/41/114 was with pt breathing room air for 10 minutes, indicating that there is no apparent A-a gradient; a random cortisol level was low, but responded appropriately to cosyntropin. Since she appears well, with good skin turgor and adequate urine output, despite the tachycardia and hypotension, she was transferred out of the ICU. The following section summarizes the patients OMED course including VATS and SICU transfer: . 40 y/o F with esophageal SCC s/p XRT, s/p tracheostomy for upper airway compromise with parapharyngeal abscess, now s/p VATs for LUL cavitary lesion and found to have metastatic esophageal CA. . #. Metastatic Esophageal CA: Patient s/p chemo and radiation. The patient was noted to have a LUL cavitary lesion on CT scan in early [**Month (only) **]. This was found to have grown by Janurary. Concern that new lung lesion is secondary to metastatic disease. A new left sided pleural effusion was seen on CT on [**1-1**]. The patient underwent thoracentesis on [**1-2**] with 700cc of clear yellow fluid drained without complication. Cytology and cultures were sent and the patient was found to have an exudative effusion. ID was consulted, fungal serologies and stool O&P were sent. The patient was ruled out for TB on two separate occasions. Sputum from [**1-5**] grew back Klebsiella Oxytoca, and on [**1-6**] Acinetobacter both of which were thought to be a contaminant. The patient was transfered to the [**Hospital Ward Name 516**] on [**2131-1-12**] to undergo a VATS resection of the the cavitary lesion. The patient underwent VATS on [**2130-1-11**] which unfortunately revealed carcinomatous plaques on the pleural wall which were confirmed frozen section. A chest tube was placed. The patient briefly required pressers while in the SICU. These were weaned and the patient was subsequently transfered back to the [**Hospital Ward Name 5074**] on [**1-15**]. Fungal serologies revealed strogyloides and the patient was given two days of Ivermectin. The patient will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. . #. s/p Trach: The patient was trached on [**12-8**] secondary to airway compromise. The patient has been breathing comfortably with trach on 35% trach mask FM; ambulating without supplemental oxygen; transient dyspnea improves with nebs, anxiolytics. The patient did not tolerate a PMV on [**1-2**] following completion of a 28 day course of Unasyn and Clindamycin (previously Augmentin). The patient did not tolerate her PMV mask on [**1-3**]. On [**1-4**] respiratory therapy attempted to use inhaled fluticasone to improve her symptoms. The patient was tolerating her PMV incrementaly more each day. On [**1-7**] the patient was noted to have increased TM requirements up to 50%. This was thought to be potentially secondary to reaccumulation of her L pleural effusion. The patients trach was changed to a 6.0 fenestrated trach on [**1-16**]. The patient was decannulated by thoracics on [**1-17**] which she tolerated. Supportive care should be continued upon discharge. . # Healthcare Associated PNA: The patient developed fevers and had continued cough following her VATS. The patient was placed empirically on Cefepime on [**1-15**], this was later changed to Levaquin upon discharge for a planned 10 day total duration of antibiotics. Cultures were NGTD at the time of discharge. . # Parapharygneal Abscess. The patient was placed initially on Augmentin. This was changed to Unasyn / Clindamycin for which she subsequently completed 28 days of treatement. ENT evaluated patient [**1-1**] no upper airway abnormality other than copious secretions. A CT Neck and Chest on [**1-2**] revealed both tetropharyngeal and retrotracheal swelling as well as soft tissue density encompassing the esophagus. This was thought to potentially represent post-radiation changes and phlegmon. No evidence of a drainable fluid collection. . #. Neutropenia: Initially thought to be secondary to patients being on augmentin. This was subsequently changed to Clindamycin/Unasyn or compazine. ANC subsequenrly resolved to 1278 [**1-1**]. . #. Anemia: Currently at baseline, no signs of active bleeding. Con't to monitor. There was question of benefit of higher transfusion threshold to reduce tachycardia. . #. Tachycardia: The patient has been persistently in sinus tachycardia 110-130 bpm. The patient was evaluate while in the ICU that indicated a low probibility for PE, no signs of CHF, and potentially subclinical hyperthyroidism although TSH WNL. There was thought that part of the ST was secondary to anxiety. Anemia also potentially played a role. - Cont Tele . #. Hypotension: Asymptomatic and maintaining MAP >= 60. Responds well to fluid bolus when systolics drift down to 70s. Continue vol challenge prn. Was briefly on pressers while in the unit, now weaned off. . #. Pain: The patients pain was well-controlled with gabapentin and methadone. The patient was written for Morphine PRN. . # Depression: The patient remains on nortriptyline for depressed mood and will not take additional treatment. Likely that some of this is related to coping with general medical illness as well as underlying depression and being away from her children. - SW will cont to follow - cont nortriptyline . #. Steroid-Induced DM: continue SSI; if requirements trend down now that off steroids, can D/C insulin Medications on Admission: Tylenol occasionaly Lactulose 30 cc tid prn Methadone 2.5 mg [**Hospital1 **] . Upon transfer out of the MICU: . Heparin 5000 UNIT SC TID Insulin SC Lactulose 30 mL PO Q8H:PRN Order date: [**12-12**] @ 0050 Levofloxacin 750 mg IV Q24H day 1 = [**12-6**] Methadone 2.5 mg PO BID Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN MetRONIDAZOLE (FLagyl) 500 mg IV Q8H day 1 = [**12-6**] Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN Nortriptyline 25 mg NG HS Ondansetron 8 mg IV Q 8H Pantoprazole 40 mg IV Q12H Docusate Sodium (Liquid) 100 mg PO BID PRN Prochlorperazine 25 mg PR Q12H Fluconazole 200 mg NG Q24H day 1 = [**12-6**] Gabapentin 300 mg PO QAM & 600 mg PO QPM Vancomycin 1000 mg IV Q 12H day 1 = [**12-6**] Discharge Medications: 1. Nortriptyline 10 mg/5 mL Solution [**Month/Year (2) **]: One (1) PO HS (at bedtime). 2. Methadone 5 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO BID (2 times a day). 3. Lactulose 10 gram/15 mL Syrup [**Month/Year (2) **]: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. Disp:*300 ML(s)* Refills:*2* 4. Senna 8.8 mg/5 mL Syrup [**Month/Year (2) **]: Five (5) ML PO BID (2 times a day). Disp:*300 ML(s)* Refills:*2* 5. Acetaminophen 160 mg/5 mL Solution [**Month/Year (2) **]: [**12-29**] tsp PO Q6H (every 6 hours) as needed for fever or pain. Disp:*1 Bottle* Refills:*2* 6. Guaifenesin 100 mg/5 mL Syrup [**Month/Day (2) **]: Fifteen (15) ML PO Q6H (every 6 hours) as needed for cough. Disp:*200 ML(s)* Refills:*1* 7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 8. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) mL PO BID (2 times a day). Disp:*600 mL* Refills:*2* 9. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed for constipation. 10. Compazine 5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO every 4-6 hours as needed for nausea: crush & mix with water. . Disp:*30 Tablet(s)* Refills:*0* 11. Ativan 1 mg Tablet [**Hospital1 **]: [**12-29**] - 1 Tablet PO every 4-6 hours as needed for anxiety. Disp:*30 Tablet(s)* Refills:*0* 12. Levofloxacin 500 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital **] hospice care Discharge Diagnosis: Primary Diagnosis - Metastatic Esophageal CA - Parapharyngeal Abcess - Left Pleural Effusison - Health-Care Acquired PNA Discharge Condition: good. Patient abulating. PEG in place. Tolerating De-Cannulation. Discharge Instructions: You were admitted to hospital with shortness of [**Hospital 1440**] and wheezing. You were found to have an infection in your throat for which you received antibiotics. A breathing tracheostomy was placed so that you were able to [**Hospital 1440**]. This infection was treated and you are now able to breathe without the tube. The hole in your neck should close up on its own, you do not need to do anything about this. You were found to have a growning lesion in your left lung and you underwent an operation to removed the lesion as well as fluid. You were found to have recurrence of your esophageal cancer. Dr. [**Last Name (STitle) **] will see you in clinic to discuss chemotherapy. You were also treated for a pneumonia. You need to take 5 more days of an antibiotic called levofloxacin. Please continue to take all of your medications as listed below. A number of changes have been made. Please keep all of your appointments. Please call your doctor if you experience continued fevers, chills, shortness of [**Last Name (STitle) 1440**], chest pain, nausea, vomitting, diarrhea. Followup Instructions: With Dr. [**Last Name (STitle) 71392**] on [**1-30**] at 1:30 PM on [**Hospital Ward Name 23**] 9. Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2131-1-25**] 12:45 Provider: [**Name10 (NameIs) 4617**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 7976**] Date/Time:[**2131-1-26**] 2:15 Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 8268**], MD Phone:[**Telephone/Fax (1) 7976**] Date/Time:[**2131-1-29**] 10:30 Provider: [**Name10 (NameIs) **] [**Name8 (MD) 490**], MD, PHD[**MD Number(3) 708**]:[**0-0-**] Date/Time:[**2131-2-8**] 9:00 ",143,2130-12-04 19:01:00,2131-01-19 21:25:00,EMERGENCY,PHYS REFERRAL/NORMAL DELI,HOME HEALTH CARE,"ESOPHAGEAL MASS, NECK PAIN"," the following summary is divided into sections due to the ","PRIMARY: [Malignant neoplasm of cervical esophagus] SECONDARY: [Perforation of esophagus; Secondary malignant neoplasm of lung; Malignant pleural effusion; Parapharyngeal abscess; Pneumonia, organism unspecified; Stricture and stenosis of esophagus; Unspecified disease of the jaws; Radiological procedure and radiotherapy as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure; Accidents occurring in other specified places; Anemia in neoplastic disease; Stenosis of larynx; Drug induced neutropenia; Penicillins causing adverse effects in therapeutic use; Accidents occurring in residential institution]",the following summary is divided into sections due to the,the following summary is divided into sections due to the nature of the project. the following summary is divided into sections due to the nature of the project. the following summary is divided into sections due to the nature of the project. 86146,128337.0,8936,2104-02-19,8935,112417.0,2103-12-21,Discharge summary,"Admission Date: [**2103-12-16**] Discharge Date: [**2103-12-21**] Date of Birth: [**2047-1-31**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2641**] Chief Complaint: seizures Major Surgical or Invasive Procedure: none History of Present Illness: 56 yo M with PMH of alcohol abuse and alcohol withdrawal seizures who presents s/p seizures at home. Patient is Spanish speaking only so most of history obtained from his wife and some from patient as well. . Patient says he drinks vodka but says he last drink was Monday (6 days prior to presentation). His wife confirms she believes this is true. She reports that she came home from work yesterday and the patient had a black eye on the right which he told her was from a fall. He also may have vomited yesterday although this history is not clear. Then today she and her daughter witnessed him seizing. Whole body shaking with all limbs moving. No loss of bowel or bladder continence. Lasted about one min then stopped. Then started again for another min. She reports he was confused and did not know who she was afterwards. She called EMS to bring him to the ED. She reports he had this about 6 months ago and was told it was from alcohol use. She also reports that he has not been eating well secondary to his esophageal stricture which was recently dilated by GI here. . In the ED, his initial vital signs were T 98.7, BP 131/80, HR 86, RR 18, O2sat 100% RA. He was given potassium, magnesium, banana bag and ativan per CIWA scale (about 6-8mg total). Neurology was consulted in the ED as well. He had a trauma work up for CT c-spine, head and maxillary/mandible all of which were negative for fracture. CXR was unchanged with no acute process. He was sent to the ICU for further care. Past Medical History: -ETOH abuse c/b withdrawal seizures -Chronic liver disease c/b pancytopenia-f/up unclear -esophageal stricture recently dilated by Dr. [**Last Name (STitle) 174**] [**Name (STitle) 31040**] c/b pneumothoraces in [**2094**]. He completed antibiotic regimen per notes. Social History: The patient immigrated from [**Country 7192**] in [**2078**]. Married with daughters. Smokes cigars. Drinks at vodka per him and his wife, at least a pint a day. Prior notes comment on rum as well. Family History: unknown Physical Exam: General: thin, malnurished male in NAD, but tremulous. Not diaphoretic. HEENT: Has hematoma and ecchymosis over right eye which is shut. PERRL, anicteric sclera. non-injected conjunctiva. OP clear but dry MM CV: RRR soft 1/6 SEM but distant heart sounds Lungs: CTAB no w/r/r Abdomen: +BS, soft, NTND Ext: no e/c/c Neuro: difficult to assess given language difficulty. Strength seems full throughout. no neck tenderness with FROM. +asterixis. Toes mute. Reflexes in tact. Pertinent Results: [**2103-12-16**] 10:09AM BLOOD WBC-6.9 RBC-3.71* Hgb-12.7* Hct-36.2* MCV-97 MCH-34.1* MCHC-35.0 RDW-12.7 Plt Ct-114* [**2103-12-16**] 10:09AM BLOOD Neuts-70.8* Lymphs-22.9 Monos-5.6 Eos-0.2 Baso-0.5 [**2103-12-18**] 03:21AM BLOOD PT-13.4 PTT-48.8* INR(PT)-1.2* [**2103-12-16**] 10:09AM BLOOD Glucose-169* UreaN-9 Creat-0.6 Na-137 K-2.7* Cl-89* HCO3-35* AnGap-16 [**2103-12-16**] 10:09AM BLOOD ALT-21 AST-70* LD(LDH)-329* CK(CPK)-219* AlkPhos-124* TotBili-2.2* [**2103-12-16**] 10:09AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Head CT [**2103-12-16**]: The study is limited due to motion artifact. There is no intracranial mass lesion, hydrocephalus, shift of normally midline structures, major vascular territorial infarct, or intracranial hemorrhage. The [**Doctor Last Name 352**]-white matter differentiation is preserved. The study is limited due to motion artifact for the evaluation of the orbits; however, no displaced fracture is identified. There is a large right periorbital hematoma. The ocular globes appear intact. . CT Mandible, Sinus [**2103-12-16**]: The cribriform plate appears intact. The nasal septum is mildly deviated to the right. There is a small air-fluid level in the right maxillary sinus. No acute fracture is identified. Right periorbital soft tissue hematoma is seen. . CT C-Spine [**2103-12-16**]: There is no prevertebral soft tissue swelling. The alignment is maintained without spondylolisthesis. No acute fracture is identified. The odontoid process is intact. Multilevel degenerative changes, worse at the level of C5-6 and C6-7. The visualized lung apices demonstrate a left apical bleb. Bilateral apical pleural thickening. The visualized paranasal sinuses demonstrate minimal opacification of the right maxillary sinus. Soft tissue density in both external auditory canals may represent cerumen. Clinical correlation is recommended. . Chest X-ray [**2103-12-16**]: 1. Small nodular opacities within the left mid lung field, which were present on the previous chest CT, may be slightly improved. Findings may represent small airways infection or aspiration. 2. Post-surgical changes, right lung. . Barium Swallow [**2103-12-21**] (preliminary read): No esophageal diverticulum seen. Narrowing of distal esophagus with holdup of 13 mm barium tablet, without holdup of barium. No dysmotility or reflux seen. . Pending studies at the time of discharge: Final read of Barium swallow study Brief Hospital Course: 1. SEIZURES Mr. [**Known lastname **] was admitted to the MICU after having 2 witnessed seizures in the setting of alcohol withdrawal. He said that it had been 6 days since his last drink and had a history of seizures 6 months prior in the setting of alcohol withdrawal. His ETOH level was negative on tox screen. Neurology was consulted in the ED and recommended and outpatient EEG. He was put on a CIWA protocol and given Diazepam PO to treat his withdrawal. He required IV Ativan initially to control his symptoms but then was given PO Diazepam. His withdrawal sytmptoms were controlled and he had no witness seizures during this hospital stay. He was given thiamine, folate and a multivitamin and was put on a PPI. He was transferred to the medicine floor on [**2103-12-19**]. He continued to have no seizures for the remainder of his hospital course. He was scheduled for outpatient neurology follow-up and will be called by the EEG lab regarding scheduling of an outpatient EEG. . 2. ALCOHOL ABUSE Mr. [**Known lastname **] was given IV Ativan initially for withdrawal and this was later changed to PO Diazepam. He required no further benzodiazepines after [**2103-12-19**]. He was seen by the addiction social worker who suggested inpatient rehab program but he preferred to seek help at outpatient treatment centers and was given a list of programs prior to discharge. He was advised not to drink alcohol. His liver function tests were normal through his hospital course. . 3. DYSPHAGIA Mr. [**Known lastname **] had a history of dysphagia and prior EGDs with dilation. Several prior biopsies had shown no evidence of cancer. On admission he stated that he had dysphagia to thick meats such as steak. He was evaluated by a barium swallow study which showed hold-up of a 13mm barium tablet but no hold-up of the liquid barium and no diverticulum. His outpatient gastroenterologist, Dr. [**Last Name (STitle) 174**] was contact[**Name (NI) **] and suggested outpatient follow-up for this problem with another EGD and possibe sugerical referral in the future. Mr. [**Known lastname **] was given an appointment to see Dr. [**Last Name (STitle) 174**] in [**Month (only) 404**]. He was evaluated by speech and swallow who stated that he had no difficulty in swallowing above the epiglottis. He was advised not to eat steak and to seek medical attension if he had pain with swallowing or the feeling of food getting stuck in his throat. He was advised to seek medical attention if he could not maintain his weight properly with foods. . 4. PROPHYLAXIS Mr. [**Known lastname **] was put on SC heparin for DVT prophylaxis, a PPI and a bowel regimen during his hospital course. He was given a prescription for a PPI as an outpatient. . Prior to discharge, Mr. [**Known lastname **] was evaluated by PT who recommended outpatient PT for [**2-25**] more days and ambulation with a cane, as the patient was not entirely steady on his feet. Medications on Admission: none Discharge Medications: 1. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) 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). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Outpatient Physical Therapy Diagnosis: Alcohol Withdrawal, ambulate with LRAD, 1-2 visits Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: 1. Alcohol Withdrawal Seizures . Secondary Diagnoses: 2. Dysphagia 3. Alcohol Abuse 4. Fatty Liver Disease Discharge Condition: afebrile, hemodynamically stable Discharge Instructions: You were admitted to the hospital with seizures in the setting of alcohol withdrawal. You were given benzodiazepines to treat your withdrawal symptoms. Your symptoms improved and you did not require benzodiazepines any longer prior to discharge. You were evaluated by neurology for your seizures who felt that they were due to alcohol withdrawal and you should have outpatient follow-up. You had an x-ray to evaluate your esophagus during this admission. . You were started on a multivitamin, thiamine and folate during this admission. You should continue to take these at home and can buy them over-the-counter. You should take also take a proton-pump inhibitor. . You had an esophageal barium swallow study to evaluate your dysphagia. You should follow-up with Dr. [**Last Name (STitle) 174**] for this as described below. . You should follow-up with Neurology with an EEG and appointment with Dr. [**Last Name (STitle) 2340**] as described below. The EEG will be scheduled by Neurology and they will contact you on monday to schedule this. You should follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] regarding treatment for your alcoholism and further care. You were provided with phone numbers for outpatient substance abuse treatment centers on discharge. . You should call your doctor or come to the emergency room for any fevers > 100.4, chills, night sweats, seizures, weakness or numbness in any parts of your body, severe headache, vision changes, vomiting, abdominal pain or any other symptoms that concern you. Please call Dr.[**Name (NI) 31041**] office if you have any difficulty swallowing or feeling of food getting stuck in your throat. Followup Instructions: Provider: [**Name10 (NameIs) 1382**] [**Name11 (NameIs) 1383**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2103-12-31**] 10:30 Provider: [**Name10 (NameIs) **] [**Last Name (STitle) **] & DR [**Last Name (STitle) 8618**] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2104-1-16**] 2:00 . Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 174**] (Gastroenterology) [**2103-1-27**] at 1:45pm. Rhabb building [**Location (un) 453**]. [**Telephone/Fax (1) 463**] ",60,2103-12-16 17:51:00,2103-12-21 20:28:00,EMERGENCY,EMERGENCY ROOM ADMIT,HOME,ETOH WITHDRAWAL," 1. seizures mr. [**known lastname **] was admitted to the micu after having 2 witnessed seizures in the setting of alcohol withdrawal. he said that it had been 6 days since his last drink and had a history of seizures 6 months prior in the setting of alcohol withdrawal. his etoh level was negative on tox screen. neurology was consulted in the ed and recommended and outpatient eeg. he was put on a ciwa protocol and given diazepam po to treat his withdrawal. he required iv ativan initially to control his symptoms but then was given po diazepam. his withdrawal sytmptoms were controlled and he had no witness seizures during this hospital stay. he was given thiamine, folate and a multivitamin and was put on a ppi. he was transferred to the medicine floor on [**2103-12-19**]. he continued to have no seizures for the remainder of his hospital course. he was scheduled for outpatient neurology follow-up and will be called by the eeg lab regarding scheduling of an outpatient eeg. . 2. alcohol abuse mr. [**known lastname **] was given iv ativan initially for withdrawal and this was later changed to po diazepam. he required no further benzodiazepines after [**2103-12-19**]. he was seen by the addiction social worker who suggested inpatient rehab program but he preferred to seek help at outpatient treatment centers and was given a list of programs prior to discharge. he was advised not to drink alcohol. his liver function tests were normal through his hospital course. . 3. dysphagia mr. [**known lastname **] had a history of dysphagia and prior egds with dilation. several prior biopsies had shown no evidence of cancer. on admission he stated that he had dysphagia to thick meats such as steak. he was evaluated by a barium swallow study which showed hold-up of a 13mm barium tablet but no hold-up of the liquid barium and no diverticulum. his outpatient gastroenterologist, dr. [**last name (stitle) 174**] was contact[**name (ni) **] and suggested outpatient follow-up for this problem with another egd and possibe sugerical referral in the future. mr. [**known lastname **] was given an appointment to see dr. [**last name (stitle) 174**] in [**month (only) 404**]. he was evaluated by speech and swallow who stated that he had no difficulty in swallowing above the epiglottis. he was advised not to eat steak and to seek medical attension if he had pain with swallowing or the feeling of food getting stuck in his throat. he was advised to seek medical attention if he could not maintain his weight properly with foods. . 4. prophylaxis mr. [**known lastname **] was put on sc heparin for dvt prophylaxis, a ppi and a bowel regimen during his hospital course. he was given a prescription for a ppi as an outpatient. . prior to discharge, mr. [**known lastname **] was evaluated by pt who recommended outpatient pt for [**2-25**] more days and ambulation with a cane, as the patient was not entirely steady on his feet. ","PRIMARY: [Alcohol withdrawal] SECONDARY: [Unspecified protein-calorie malnutrition; Other convulsions; Alcoholic fatty liver; Other and unspecified alcohol dependence, unspecified; Thrombocytopenia, unspecified; Black eye, not otherwise specified; Unspecified fall; Conjunctivitis, unspecified; Stricture and stenosis of esophagus; Personal history of tuberculosis]","known lastname **] was admitted to the micu after having 2 witnessed seizures in the setting of alcohol withdrawal. he required no further benzodiazepines after [**2103-12-19**]. his liver function tests were normal through his hospital course. he was advised not to eat steak and to seek medical attension if he had pain with swallowing or the feeling of food getting stuck in his throat. known lastname **] was put on sc heparin for dvt prophylaxis, a ppi and a bowel regimen during his hospital course. known lastname **] was evaluated by pt who recommended outpatient pt for [**2-25**] more days and ambulation with a cane, as the patient was not entirely steady on his feet.","mr. [**known lastname **] was admitted to the micu after having 2 witnessed seizures in the setting of alcohol withdrawal. he was put on a ciwa protocol and given diazepam po to treat his withdrawal. his withdrawal sytmptoms were controlled and he had no witness seizures. he was given thiamine, folate and a multivitamin and was put on a ppi." 93632,159011.0,15560,2108-01-30,15559,199940.0,2108-01-19,Discharge summary,"Admission Date: [**2108-1-4**] Discharge Date: [**2108-1-19**] Date of Birth: [**2026-2-17**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4748**] Chief Complaint: bilateral gangrenous wounds of lower extremity Major Surgical or Invasive Procedure: [**2108-1-5**] Left fem-post tib in-situ Non-reversed saphenous veni graft History of Present Illness: 81y/o male s/p rt. athectomy of SFa and PFS with left EIA stenting [**9-20**] hospitalized [**2107-12-26**] for cellulitis anf gangrene of left heel and ulcer with ganganerous changes of rty. calf wound . under went diagnositic angiogram which demonstrated left SFA occlusion with 90% stenosis of mid PFA and single vessel via AT with occlusion of at at ankle and foot perfused by colateral circulation. Returns now for elective left fem-at bpg and perioperative antibiotics. patient was on levofloxcin without improvement of wound. Ambulates around room with walker. ABI rt. 0.68 ABI left 0.57 Past Medical History: PVD w/ bilateral gangrenous wounds of lower extremity history of Hypertension history of Gout history of BPH PSH: s/p rt. sfa/paf ahtrectomy with Lt. EIA stent [**9-20**],angio [**2107-12-26**] occluded left SFA single vessel runoff AT which occludes at ankle, foot perfused by collaterals. s/p TURP S/p hernia repairs s/p Appendectomy S/P right lower extremity DVT in [**2081**] Social History: Social history resident since d/c [**12-23**] A nursing home in [**Location (un) 620**], ma, retired, nonsmoker or drinker. Daughter involved in her care: phone [**Telephone/Fax (1) 45026**] Family History: n/c Physical Exam: Gen: NAD Card: RRR Lungs: CTAB Abd: good bowel sounds, soft, non-tender, non-distended Extrem: well perfused pulses: fem [**Doctor Last Name **] dp pt left palp dop dop dop Right palp palp palp dop Pertinent Results: [**2108-1-6**] 03:59AM BLOOD WBC-13.4* Hgb-10.5* Hct-28.9* Plt Ct-265 [**2108-1-5**] 05:02PM BLOOD Hgb-11.8* Hct-33.5* Plt Ct-344 [**2108-1-6**] 03:59AM BLOOD Plt Ct-265 [**2108-1-5**] 05:02PM BLOOD Plt Ct-344 [**2108-1-6**] 03:59AM BLOOD Glucose-92 UreaN-37* Creat-0.7 Na-144 K-3.6 Cl-116* HCO3-23 AnGap-9 [**2108-1-6**] 12:59AM BLOOD K-3.9 [**2108-1-5**] 05:02PM BLOOD Glucose-122* UreaN-39* Creat-0.7 Na-143 K-3.2* Cl-111* HCO3-24 AnGap-11 ECG Study Date of [**2108-1-4**] 12:53:52 PM Normal sinus rhythm, rate 79. Occasional atrial premature beats. CHEST (PRE-OP PA & LAT) Study Date of [**2108-1-4**] 5:23 PM AP UPRIGHT AND LATERAL CHEST: The cardiomediastinal silhouette is normal. Ill definied opacity in the right lower lobe is concerning for pneumonia. The left lung is grossly unremarkable. There is no evidence of effusion or pneumothorax. Moderate multilevel degenerative changes in the thoracolumbar spine are similar to [**2101-8-30**]. IMPRESSION: Findings are concerning for right lower lobe pneumonia. TEE (Complete) Done [**2108-1-5**] at 3:51:36 PM No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Although not seen, due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50%). Right ventricular chamber size and free wall motion are normal. There are complex (>4mm) atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). Drs. [**Last Name (STitle) 45027**] and [**Name5 (PTitle) 1391**] were notified in person of the results in the opertaing room at the time of the study. ECG Study Date of [**2108-1-5**] 11:05:30 AM Normal sinus rhythm, rate 86, with frequent atrial premature beats and brief multifocal atrial tachycardia. Brief Hospital Course: [**2108-1-4**] Patient admitted. Routine nursing care, labs, ECG, CXR were done. CXR-showed LLL pneumonia. DVT prophylaxis started. Pre-angio and consented for [**2108-1-5**]. Initial Trop .06, continued to monitor cardiac enzymes. [**2108-1-5**] Underwent successful left femoral-posterior tibial bypass. Central line/PA line, foley, and A-line were plaved. Recovered in the PACU, then transferred to [**Hospital Ward Name 121**] 5 VICU, continued w/ telemetry. Cardiology consulted for elevated Troponin- recs- maximize beta blocker and monitor cardiac enzymes. [**2108-1-6**] POD1 on lower extremity bypass pathway. Speech and swallow consult for ? aspiration pneumonia, unable to do video swallow- to be done on Monday [**1-9**], kept NPO. 1/24-25/09 POD2-3 No acute events, continue to be NPO. Started TPN. Transfused 1 unit PRBCs Hct 25.9<-33.9 on admission. Electrolytes repleted. [**2108-1-9**] POD4 speech and swallow re-evaluation at bedside, continue to have possible aspirations-recs continue to keep NPO, TPN for nutrition. Scheduled for video swallow on [**1-12**]. [**2108-1-10**] POD#5 Continues to be NPO, on TPN. No acute events. Taken to OR for wound revision of dehised L LE surgical wound. [**2108-1-11**] POD#6 somulent, breath sound with ronchi. Intubated and transfered to CTICU for pulmonary acre. Daugnter pat notifed of event.Bronchoscoopy done. findings no airway mucus or secreations , new LLL pneumonia. BAL sent.Gen surgery consulted for PEG placement.Zosyn added to Vanco for his hospital acquired pneumonia. [**2108-1-12**] POD#7 Video swalow cancelled patient still intubated.PEG placement. remains NPO and on TPN. Iv antibiotics continued. Speech and swallow signed off.low urinary out put-fluid resustated.Extubated.Transfered to VICU for continued care. [**2108-1-13**] POD#[**7-14**] no overnight events. afebrile. TPN continued. Gen. surgery- recs not to use PEG till POD 2. Noted to have large decubiti in his scarl area, wound care nurse consulted, placed in air mattress. Changed to floor status. [**2108-1-14**] POD9/2 no acute events. Started slow tube feeds via gastric tube. Continues w/ TPN via central line. Continues on antibiotics Vanco/Zosyn. [**2108-1-15**] POD10/3 No acute events. Continue tube feeds-advances to goal (60cc/h), TPN. Continues on antibiotics Vanco/Zosyn. Physical therapy consult. Rehab screening. [**Date range (1) 45028**] POD11-12/4-5 No acute events, tube feeds at goal, TPN d/c'd. Continues on Vanco/Zosyn. [**Hospital 25403**] rehab bed. L leg distal wound still draining, aced from forefoot-below knee. [**2108-1-18**] POD12/6 No acute events. Continues on Vanco/Zosyn. Physical therapy following. [**Hospital 25403**] rehab bed. [**2108-1-19**] POD13/6 D/C to rehab with one week of PO bactrim. Medications on Admission: asa 325mg po qd plavix 75 m qd altace 2.5 mg qd multivitamin ariecept 10 mg po qd zocor 40 mg po qd lopressor 12.5 mg po qd prilosec 20 mg po qd levoflox 500 mg po qd Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: PVD w/ bilateral gangrenous wounds of lower extremity Pre-admission Pneumonia-likely due to aspiration Sacral decubiti- stage III, sacral- wound care consulted-placed on air mattress Dysphagia history of Hypertension history of Gout history of BPH postoperative hypoxia [**1-16**] to progressive unilateral to bilateral pneumonia requiring intubation postopaerative faiure to thrive [**1-16**] Pna, tpn postoperative acute blood loss anemia, transfused. PSH: s/p rt. sfa/paf ahtrectomy with Lt. EIA stent [**9-20**],angio [**2107-12-26**] occluded left SFA single vessel runoff AT which occludes at ankle, foot perfused by collaterals. S/p hernia repairs s/p Appendectomy S/P right lower extremity DVT in [**2081**] Discharge Condition: Stable Discharge Instructions: LE Bypass - ambulate essential distances untill FU with Dr. [**Last Name (STitle) 1391**] - Ace wrap leg from foot-knee when ambulating - Elevate leg when sitting - no driving till FU - may shower, no tub baths - Keep wound dry and clean, call if noted to have redness, draining, swelling, or if temp is greater than 101.5 - Continue all medications as directed - Keep all FU appointments - Call Dr.[**Name (NI) 1392**] office for FU appointment Followup Instructions: Call for 2 weeks Follow-up w/ Dr. [**Last Name (STitle) 1391**] Phone: [**Telephone/Fax (1) 1393**] Completed by:[**2108-1-19**]",11,2108-01-04 14:00:00,2108-01-19 16:32:00,ELECTIVE,PHYS REFERRAL/NORMAL DELI,SNF,NONHEALING ULCER LEFT LOWER EXTREMITY," [**2108-1-4**] patient admitted. routine nursing care, labs, ecg, cxr were done. cxr-showed lll pneumonia. dvt prophylaxis started. pre-angio and consented for [**2108-1-5**]. initial trop .06, continued to monitor cardiac enzymes. [**2108-1-5**] underwent successful left femoral-posterior tibial bypass. central line/pa line, foley, and a-line were plaved. recovered in the pacu, then transferred to [**hospital ward name 121**] 5 vicu, continued w/ telemetry. cardiology consulted for elevated troponin- recs- maximize beta blocker and monitor cardiac enzymes. [**2108-1-6**] pod1 on lower extremity bypass pathway. speech and swallow consult for ? aspiration pneumonia, unable to do video swallow- to be done on monday [**1-9**], kept npo. 1/24-25/09 pod2-3 no acute events, continue to be npo. started tpn. transfused 1 unit prbcs hct 25.9<-33.9 on admission. electrolytes repleted. [**2108-1-9**] pod4 speech and swallow re-evaluation at bedside, continue to have possible aspirations-recs continue to keep npo, tpn for nutrition. scheduled for video swallow on [**1-12**]. [**2108-1-10**] pod#5 continues to be npo, on tpn. no acute events. taken to or for wound revision of dehised l le surgical wound. [**2108-1-11**] pod#6 somulent, breath sound with ronchi. intubated and transfered to cticu for pulmonary acre. daugnter pat notifed of event.bronchoscoopy done. findings no airway mucus or secreations , new lll pneumonia. bal sent.gen surgery consulted for peg placement.zosyn added to vanco for his hospital acquired pneumonia. [**2108-1-12**] pod#7 video swalow cancelled patient still intubated.peg placement. remains npo and on tpn. iv antibiotics continued. speech and swallow signed off.low urinary out put-fluid resustated.extubated.transfered to vicu for continued care. [**2108-1-13**] pod#[**7-14**] no overnight events. afebrile. tpn continued. gen. surgery- recs not to use peg till pod 2. noted to have large decubiti in his scarl area, wound care nurse consulted, placed in air mattress. changed to floor status. [**2108-1-14**] pod9/2 no acute events. started slow tube feeds via gastric tube. continues w/ tpn via central line. continues on antibiotics vanco/zosyn. [**2108-1-15**] pod10/3 no acute events. continue tube feeds-advances to goal (60cc/h), tpn. continues on antibiotics vanco/zosyn. physical therapy consult. rehab screening. [**date range (1) 45028**] pod11-12/4-5 no acute events, tube feeds at goal, tpn d/cd. continues on vanco/zosyn. [**hospital 25403**] rehab bed. l leg distal wound still draining, aced from forefoot-below knee. [**2108-1-18**] pod12/6 no acute events. continues on vanco/zosyn. physical therapy following. [**hospital 25403**] rehab bed. [**2108-1-19**] pod13/6 d/c to rehab with one week of po bactrim. ","PRIMARY: [Atherosclerosis of native arteries of the extremities with gangrene] SECONDARY: [; Ulcer of heel and midfoot; Pneumonitis due to inhalation of food or vomitus; Other respiratory complications; Disruption of external operation (surgical) wound; Pneumonia, organism unspecified; Acute posthemorrhagic anemia; Pressure ulcer, stage III; Pressure ulcer, lower back; Unspecified essential hypertension; Gout, unspecified; Dysphagia, unspecified; 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]","routine nursing care, labs, ecg, cxr were done. [**2108-1-6**] pod1 on lower extremity bypass pathway. [**2108-1-9**] pod4 speech and swallow re-evaluation at bedside, continue to have possible aspirations-recs continue to keep npo, tpn for nutrition. daugnter pat notifed of event.bronchoscoopy done. speech and swallow signed off.low urinary out put-fluid resustated.extubated.transfered to vicu for continued care. l leg distal wound still draining, aced from forefoot-below knee.","cxr-showed lll pneumonia. underwent successful left femoral-posterior tibial bypass. no airway mucus or secreations, new lll pneumonia."