Download Discharge Diagnoses:

Discharge Diagnoses:
Sinus bradycardia with 2:1 AV block
Hyperkalemia
End stage renal disease on hemodialysis
Coronary artery disease
Hypertension
Admission Chief Complaint:
Chest pain
Summary of HPI:
Patient is a 71 yo F with a history of ESRD on HD, CAD s/p MI, sinus bradycardia who
presented to the ED yesterday with back pain, chest pain, and shortness of breath. Because
she had been in the ED two days prior for the same symptoms (though no chest pain), she had
missed her session of dialysis on that day. She reported that lower back pain started last
Friday and was right sided, radiating down to the lateral part of her thigh but no lower. No groin
pain. She says she has had this pain in the past, but is unsure of the details. No LE weakness,
numbness/tingling or B/B incontinence. Her back pain was associated with SOB, but when she
went to the ED on Tuesday she was thought to be in good enough shape to go home. Around
that time she developed chest pain, dull, L sided, radiating to R shoulder only, not pleuritic and
not similar to the chest pain she had when she suffered an MI several years ago. She says
that she has this chest pain on occasion, about once weekly and that it usually lasts for about
30 minutes and is occasionally worse with eating and subsequently lying down. No increase in
the frequency or severity of this pain in the many years she has had it. She also c/o shortness
of breath, but no cough, fevers/chills.
Summary of Hospital Course:
In the ED, she was found to have hyperkalemia with a K of 6.3. She was given kayexalate but
vomited it. She received dilaudid and zofran IV. For her chest pain she underwent CXR which
was stable and CT angiogram of chest, abodomen, and pelvis which was negative for PE and
for dissection/aneurysm. She also underwent Xrays of her back and pelvis which were
negative for fracture but did show DJD, especially between L5/S1. Though her EKG showed
only mildly peaked T waves, while still in the ED at 5 pm, she developed transient sinus
bradycardia with possible 2:1 AVB (HR to 28) and altered mental status, both of which rapidly
improved with management of her hyperkalemia witih IV calcium chloride, insulin, D50, and
bicarbonate. She was then transferred to the MICU and underwent urgent dialysis. She was
ruled out for ACS. On 10/10 she felt back to her baseline apart from the back pain and was
transferred out of the ICU. She went to the floor and had dialysis on 10/11. On 10/12 she had a
vascular duplex study of her LUE AV fistula, demonstrating decreased velocities (final read
pending). Pt was seen by transplant/vascular surgery and urged to f/u as an outpt, as there
was no immediate intervention required for her failing AV fistula. Her back pain resolved
completely by discharge and she experienced no more chest pain or shortness of breath.
Discharge Physical Exam (key findings):
Vitals and Weights:
Vitals
TempF BP
Pulse RR
10/13 05:55 96.8
146/63 63
18
10/12 21:58 97.6
129/62 68
18
10/12 17:37 96.0
133/72 62
16
SaO2 FiO2
98
96
100
General Appearance: NAD, breathing comfortably
Chest and Lungs: bibasilar crackles, R>L
Cardiovascular: RRR, 3/6 syst murmur with S4
Abdomen: soft, NT, ND
Extremities: no LE edema
Date
10/11
10/10
10/09
Wt(kg)
60.6
60.6
60.6
Wt(lb)
133
133
133
Key Results (labs, imaging, pathology):
Last CBC Date: 10/13/08
Last CHEM Date: 10/13/08
5.1
\ 10.8 L /
-------- 93 L
/ 31.0 L \
135
| 101
| 40 H /
------------------------4.6
|
27
| 8.76 H \
74
troponins neg x2
Procedures Performed and Findings:
Hemodialysis, CT angiogram of chest
Pending Results in Need of Review:
LUE duplex of AV fistula
Patient Condition at Discharge:
much improved
Patient Disposition (home, nursing facility, e.g.):
home
Information Given to Patient:
Additional activity restrictions (lifting/driving/other): only drive if
you previously were able to do so
Diet restrictions:
kidney diet (low potassium, low phosphorous)
Allergies:
diltiazem,penicillin,metoprolol,heparin,moxifloxacin
Your complete list of medications to take:
Home Medications:
Amlodipine 10 milligram by mouth daily
Aspirin 81 mg oral enteric coated, 1 tab(s) by mouth daily
Dulcolax 10 mg 1 suppository(ies) per rectum daily as needed for constipation
HydrALAZINE 10 milligram by mouth three times a day
Ibuprofen 400 milligram by mouth as needed for pain, if tylenol isn't helpful
Isosorbide mononitrate 30 mg 3 tab(s) by mouth every am
levothyroxine 0.112 mg 1 tab(s) by mouth daily
MiraLax 17 gram by mouth daily
Omeprazole 20 milligram by mouth daily
Sevelamer 800 milligram by mouth three times a day
Simvastatin 40 milligram by mouth at bedtime
Tylenol 500 milligram by mouth every 6 hours as needed for pain
Valsartan 160 milligram by mouth
Changes from your prior medications:
clonidine was stopped
pepcid was stopped
omeprazole was started for heartburn, reflux
tylenol and ibuprofen were started for pain
hyralazine was started for blood pressure
When to call your doctor:
Call your doctor if you experience lightheadedness, fainting spells, chest
pain, shortness of breath, leg swelling, fevers, chills or any other
worrisome symptoms. If these are particularly severe, please go
immediately to the emergency room.
Additional instructions (daily weights, wound care):
Monitor you weight daily.
You must tell your doctor about these issues needing further
evaluation:
-You need to see the transplant doctors regarding your AV fistula.
Your appointments:
1) Dr. PCP on Monday, October 20th at 3:20 pm
2) Dr. Transplant on Wednesday, October 22nd at 2:30 pm
3) Patient aware that she will receive phone call this week from
interventional radiology regarding setting up an appt for a fistulogram.
CT angiogram:
Reason For Exam: Chest pain radiating to back, evaluate for dissection
PROCEDURE: CT Angiography Chest, CT Angiography Abdomen/pelvis
TECHNIQUE: Initial pre-contrast scout and localizer images were obtained. Contrast
enhanced helical CT aortic angiography was then performed. Routine transaxial and
post-processed (multiplanar and/or MIP) reformations were obtained. Evaluation of the
lung parenchyma is limited to the breathing artifact.
COMPARISON: CT abdomen and pelvis without contrast December 12 2007.
CTA Findings: There is no evidence of aortic dissection or aneurysm. There is no
evidence of central pulmonary emboli.
Other Findings: On the precontrast images, there is no evidence of aortic intramural
hematoma. There is extensive calcific atherosclerotic disease of the coronary arteries,
aorta and its major branches. There is a stent within the left brachiocephalic vein. There
are surgical clips in the cholecystectomy bed. There are bilateral, nonobstructing renal
calculi. There are punctate calcifications within the spleen.
CT CHEST: On the postcontrast images, the ascending aorta is ectatic measuring 3.8 cm
in maximal diameter. There is a bovine arch, normal anatomic variant. The heart is
enlarged. There is no pericardial effusion. There are small bilateral pleural effusions and
associated minimal bibasal atelectasis.
On the lung windows, there is no pulmonary nodules, masses or consolidation.
Within the subcutaneous tissue of the superior anterior chest wall there is soft tissue
nodule measuring 2 x 1.7 cm (image 20 series 2).
CT ABDOMEN: The liver is nodular in contour consistent with cirrhosis. There is no
evidence of focal liver lesions. There is no intra-or extrahepatic biliary ductal dilatation.
The pancreas, spleen, and adrenal glands are unremarkable.
The kidneys are atrophic. There are bilateral nonobstructing renal calculi. There are
bilateral low-density lesions in the kidneys, too small to characterize. There is stable,
8mm hyperdense lesion in the lower pole of the right kidney. There is stable 2-cm
hemorrhagic cysts upper pole of the left kidney.
There is a small amount of free fluid around the liver.
CT PELVIS: There small free fluid in the pelvis. There is no pelvic mass or
lymphadenopathy. The bladder is not well distended.
CONCLUSIONS:
1. NO EVIDENCE AORTIC DISSECTION OR ANEURYSM.
2. STABLE CARDIOMEGALY.
3. CIRRHOSIS WITH TRACE AMOUNT OF ASCITES AROUND THE LIVER AND
IN THE PELVIS. NO FOCAL LIVER LESIONS.
4. ATROPHIC KIDNEYS. STABLE HYPERDENSE LESION WITHIN THE LOWER
POLE OF THE RIGHT KIDNEY AND HEMORRHAGIC CYST THE LEFT KIDNEY.
BILATERAL NONOBSTRUCTIVE RENAL CALCULI.
5. SOFT TISSUE NODULE MEASURING 2CM IN MEDIAL ASPECT OF LEFT
CHEST WALL. IT IS UNCERTAIN IF THIS IS WITHIN THE BREAST.
RECOMMEND PHYSICAL EXAMINATION OF THE REGION TO DETERMINE IF
ULTRASOUND MIGHT PROVIDE COMPLEMENTARY INFORMATION.