allergies: remeron attending: chief complaint: lethargy, decreased po intake, nausea major surgical or invasive procedure: intubation history of present illness: pt is a 75 yo man with pmh sig for cad, s/p cabg with stress imaging with fixed reversible defect only, colon ca (normal scope ), melanoma, right middle and lower lobectomy of lung and radiation of lung as treatment of carcinoid tumor, congestive heart failure, and recent onset of atrial fibrillation who has had increased nausea over the past year with marked increase accompanied by poor po intake to only minimal fluids. he was scheduled for an elective cardiac catheterization to evaluate a cardiac etiology of his vague symtoms, as all other work-ups have been unremarkable. he was noted to have increased lethargy to the point of "difficulty to arouse" for the past few days. on day of admission he was seen by pcp at home who found him to be, oliguric & hypotensive. increased fluid replacement was not successful in increasing bp and patient was sent to ed. on presentation to the pt is unable to answer questions other than "yes/no", but history is given by family. he denies chest pain, has had some shortness of breath at rest, no orthopnea or pnd, no dysuria, nausea but no vomitting, and no fever/chills. he has had over 10 pound weight loss over the past year. past medical history: carcinoid tumor of the lung s/p rml/rll resection melanoma congestive heart failure restrictive lung disease by pfts cad - see hpi colon ca history of hepatitis/ascites after antidepressant use(?) social history: lives in with wife. was a business man by trade. has three daughters actively involved in his healthcare. no alcohol or tobacco use. physical exam: on discharge: t 98 bp 110/68 hr 70 rr 14 95%ra cachectic, very rigid posture with action and when passive, no tremor, masked facies. no jvd, no lad, no tm cardiac exam regular in rate and rhythm with normal s1/s1, sem at usb w/o radiation. lungs with decreased breath sounds on right middle to lower areas, otherwise clear. abdomen soft and scaphoid, nt, nd, nabs extremities wwp, no cyanosis/clubbing/edema, 1+ dp. neuro aaox3, mae, no tremor pertinent results: labs on admission: 08:25pm type-art po2-104 pco2-91* ph-7.18* total co2-36* base xs-2 08:00pm wbc-8.3 rbc-3.79* hgb-12.4* hct-37.3* mcv-99* mch-32.7* mchc-33.2 rdw-14.1 08:00pm alt(sgpt)-44* ast(sgot)-62* ck(cpk)-150 alk phos-78 amylase-83 tot bili-0.7 08:00pm blood glucose-146* urean-36* creat-2.8*# na-119* k-5.4* cl-79* hco3-31* angap-14 08:00pm blood ck-mb-26* mb indx-17.3* ctropnt-0.42* 03:39am blood ck-mb-27* mb indx-13.8* ctropnt-0.45* 09:14pm blood ck-mb-6 ctropnt-0.46* . ct head: findings: there is no intracranial hemorrhage, mass lesion, hydrocephalus, shift of normally midline structures, minor or major vascular territorial infarct. -white matter differentiation is preserved. osseous and soft- tissue structures are unremarkable. . echo: the left atrium is mildly dilated. 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. the right atrial appendage appears to be akinetic. the right ventricular free wall is severely hypokinetic. the left ventricular functon is moderately depressed (lvef ~30-35%) with global hypokinesis, inferior akinesis and inferobasal akinesis/dyskinesis. the aortic valve leaflets are moderately thickened. mild-moderate (+) aortic regurgitation is seen. the mitral valve leaflets are moderately thickened. an eccentric jet of mild to moderate (+) is seen directed toward the left atrial appendage. the tricuspid valve leaflets are mildly thickened. moderate tricuspid regurgitation is seen.there is no pericardial effusion. brief hospital course: respiratory failure: in the er ph 7.18, co2 98, with hypercarbic lethargy. after repeat abg revealed increasing co2, the patient was intubated. the suspected etiology of his respiratory failure was a chronic respiratory acidosis with superimposed acute metabolic acidosis from acute renal failure, causing decompensation and marked acidemia. a swan-ganz catheter was placed and numbers were consistent with hypovolemia with a small element of heart failure. pt underwent fluid resuscitation and was placed on dopamine with good response and improvement in renal function, and levaquin was started for possible sepsis/pulm infection. small bump in ck and troponin postulated secondary to demand ischemia. tee done while intubated showed no change in cardiac function from previous tte at osh. on hopital day 4, it was felt that he may be volume overloaded after fluid resuscitation in setting of chf with elevated cvp, papd, and also was demonstrating low svr likely due to sepsis. decreased uop this day was thought to be due to low perfusion in setting of elevated preload and so he was placed back on renal dose dopamine and given lasix for diuresis until his numbers were consistent with euvolemia. he was soon after weaned off all pressors and extubated. pulmonary was consulted for episodes of hypercarbia during sleep, bipap was suggested but refused by patient. the plan was to follow up with pulmonary as an outpatient with a formal sleep study. as part of the work up for increased nausea and lethargy a ct scan of the head was completed which was normal. atrial fibrillation: the patient had known atrial fibrillation but was nsr on admission, and had recently been started on sotalol. he had an episode of atrial fibrillation with short reponse to 100j cardioversion, was started on amiodorone and then converted spontaneously. he was later placed on metoprolol as well. medications on admission: warfarin atorvastatin aspirin 325 mg tablet furosemide 20 mg tablet moexipril hcl 7.5 mg tablet betapace gabapentin discharge medications: 1. warfarin sodium 1 mg tablet sig: 2.5 tablets po once a day: take as directed until doseage changed by pcp according to lab work. disp:*75 tablet(s)* refills:*0* 2. atorvastatin calcium 40 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 3. trazodone hcl 50 mg tablet sig: 0.5 tablet po qhs:prn as needed for insomnia for 10 days. disp:*10 tablet(s)* refills:*0* 4. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h:prn as needed for shortness of breath or wheezing. disp:*qs qs* refills:*0* 5. amiodarone hcl 200 mg tablet sig: two (2) tablet po bid (2 times a day) for 10 days: take two pills twice per day for four days then two pills once per day for 2 weeks, then one pill once per day. disp:*44 tablet(s)* refills:*0* 6. aspirin 325 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po daily (daily). disp:*30 tablet, delayed release (e.c.)(s)* refills:*0* 7. furosemide 20 mg tablet sig: three (3) tablet po daily (daily). disp:*90 tablet(s)* refills:*0* 8. moexipril hcl 7.5 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*0* 9. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po tid (3 times a day). disp:*45 tablet(s)* refills:*0* discharge disposition: home with service facility: family & services discharge diagnosis: acute renal failure chronic respiratory acidosis congestive heart failure discharge condition: stable discharge instructions: call your pcp or return to emergency room if you develop chest pain, shortness of breath, or markedly increased lethargy. followup instructions: provider: , m.d. where: cardiac services phone: date/time: 2:15 . you must make an appointment to see dr. within two days to have you blood checked for coumadin adjustment. . please make an appointment to see dr. or dr. at pulmonary clinic in 4 weeks. call for the pulmonary clinic to make an appointment. Procedure: Continuous invasive mechanical ventilation for 96 consecutive hours or more Diagnostic ultrasound of heart Insertion of endotracheal tube Enteral infusion of concentrated nutritional substances Other electric countershock of heart Pulmonary artery wedge monitoring Transfusion of packed cells Infusion of vasopressor agent Diagnoses: Acidosis Congestive heart failure, unspecified Acute kidney failure, unspecified Atrial fibrillation Personal history of malignant neoplasm of bronchus and lung Aortocoronary bypass status Acute and chronic respiratory failure Hypotension, unspecified Personal history of malignant neoplasm of large intestine Other diseases of lung, not elsewhere classified Personal history of malignant melanoma of skin Personal history of irradiation, presenting hazards to health