diff --git "a/cohort_past_history_12072022.csv" "b/cohort_past_history_12072022.csv"
new file mode 100644--- /dev/null
+++ "b/cohort_past_history_12072022.csv"
@@ -0,0 +1,135702 @@
+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
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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)]"
+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)]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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)]"
+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)]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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)]"
+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]"
+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)]"
+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)]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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)]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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)]"
+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)]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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)]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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 &#8710;
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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 &#8710;
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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 &#8710;
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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; ]"
+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]"
+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]"
+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]"
+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]"
+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; ]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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; ]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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)]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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; ]"
+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]"
+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; ]"
+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; ]"
+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; ]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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 &#8710;
+.....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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"
+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]"