allergies: patient recorded as having no known allergies to drugs attending: chief complaint: shortness of breath major surgical or invasive procedure: thoracentesis history of present illness: ms. is a y/o woman with a history of type 2 dm, atrial fibrillations, hypertension and congestive heart failure who presented to from senior life with a chief complaint of dyspnea. per report, patient reports feeling unwell x 2 weeks. she has been treated with lasix over the past few days for hypoxia and a left pleural effusion. today, o2 sats in the 80s on 4l nc. noted by cxr in ed to have a left pleural effusion. pt was admitted to micu for cpap. did not tolerate mask well and was switch to non-rebreather mask. with diuresis on lasix, her resp status improved. thoracentesis was deferred in the micu because she was supratherapeutic on coumadin with inr 5.5. past medical history: type ii diabetes mellitus atrial fibrillation ? tia macular degeneration/mild diabetic retinopathy cognitive impairment s/p arterial thrombectomy hypertension congestive heart failure stenosis of vocal cords peripheral embolectomy back pain social history: lives at rehab. family history: nc physical exam: vitals: 99.8 145/50 80 20-28 94%ra 100%cpap gen: mildly uncomfortable on cpap, desats when taken off heent: atnc, on cpap chest: bilat rales cor: irregularly irregular, normal s1/s2 abd: soft, obese, nt/nd, ext: wwp, trace peripheral edema neuro: unable to cooperate pertinent results: 04:20pm urine blood-neg nitrite-neg protein-30 glucose-100 ketone-neg bilirubin-neg urobilngn-neg ph-5.0 leuk-neg 04:20pm urine rbc-0 wbc-0-2 bacteria-none yeast-none epi-0 03:35pm glucose-204* urea n-16 creat-1.2* sodium-138 potassium-4.8 chloride-101 total co2-24 anion gap-18 03:35pm ck(cpk)-49 03:35pm ctropnt-<0.01 probnp-5590* 03:35pm ck-mb-notdone 03:35pm calcium-9.3 phosphate-3.8 magnesium-2.0 03:35pm wbc-8.0 rbc-5.03 hgb-12.6 hct-39.2 mcv-78* mch-25.1* mchc-32.1 rdw-14.2 03:35pm neuts-63.9 lymphs-28.3 monos-6.6 eos-0.7 basos-0.5 03:35pm hypochrom-3+ poikilocy-1+ microcyt-1+ 03:35pm plt count-420 03:35pm pt-28.7* ptt-34.3 inr(pt)-5.5. . . echo (): conclusions: 1. the left atrium is mildly dilated. 2. a small secundum atrial septal defect (asd) is present. 3.there is mild symmetric left ventricular hypertrophy with normal cavity size. there is severe global left ventricular hypokinesis with relative sparing of the inferior and inferoseptal hypokinesis. overall left ventricular systolic function is severely depressed. 4. right ventricular chamber size is normal. there is focal hypokinesis of the apical free wall of the right ventricle. right ventricular systolic function appears mildly depressed. 5. the ascending aorta is mildly dilated. 6. the aortic valve leaflets are moderately thickened. there is no aortic valve stenosis. no aortic regurgitation is seen. 7.the mitral valve leaflets are mildly thickened. mild to moderate (+) mitral regurgitation is seen. 8.the estimated pulmonary artery systolic pressure is normal. 9.there is no pericardial effusion. . . cxr : chest pa and lateral: there are no previous films available for comparison. bilateral pleural effusions are present. the effusion on the left is large. underlying infiltrates in both lower lobes cannot therefore be excluded. no evidence of failure is seen. impression: bilateral pleural effusions, large on the left side, cause undermined. . . cxr pa/lat: comparison to the prior chest x-ray of shows considerable improvement in the vascular engorgement. there is a moderate sized left effusion and a small effusion at the right base. heart size is difficult to evaluate due to the overlying effusion. impression: improving appearance of the chest since with a moderate left and small right pleural effusion. 05:25am blood wbc-7.3 rbc-4.06* hgb-10.0* hct-31.2* mcv-77* mch-24.6* mchc-32.0 rdw-13.7 plt ct-271 05:25am blood plt ct-271 05:25am blood pt-12.5 ptt-26.7 inr(pt)-1.0 05:25am blood glucose-142* urean-37* creat-1.6* na-139 k-4.3 cl-103 hco3-29 angap-11 brief hospital course: a/p y/o woman with history of chf, dm2, afib on coumadin who presents from nursing home with progressive hypoxia and pleural effusions. 1. pulm: hypoxia likely to pleural effusions. etiology of effusions most likely chf. other possibilities include pneumonia and malignancy, although pneumonia was unlikely given no white counts and afebrile. given her inr of 5.5, thoracentesis deferred until coagulopathy corrected. thoracentesis performed on after coumadin reversed. fluid sent for cytology, culture and cell count which are all pending. cxr improved post procedure with no pneumothorax. 2. coagulopathy: patient on coumadin for afib and history fo clot, now supratherapeutic at 5.5. in the micu, she was given vitamin k sc 10 mg with good effect. heparin gtt was administered until her thoracentesis. her heparin was briefly started on in the afternoon and was discontinued at 4pm. the patient should start lovenox 50mg q12 at 6pm until her inr is within the therapeutic range of . warfarin 10mg x1 dose was given prior to discharge. 3. dm2: we continued nph and riss with qid fingersticks 4. cardiac: a. ischemia: no known cad. the patient was not on aspirin, statin or betablocker. toprol was started and her calcium channel blocker was discontinued. b. pump: history of failure and found to have an elevated probnp>5000. it was unclear what tipped the patient over. she was monitored on strict i&o's, daily weights (ranged 111-112 after diuresis), iv lasix prn. echo showed ef of 20%. metoprolol was started and titrated up, her discharge dose will be toprol 50mg qd with hold parameters. c. rhythm: the patient history of atrial fibrillation and was supratherapeutic on coumadin. she was monitored on tele and remained predominantly in atrial fibrillation. 5. renal: her creatinine bumped from 1.2-1.5 to 1.6. this is likely due to a prerenal state due to low co and diuresis. lasix was held on -9. 6. fen: cardiac diet with 1.5l fluid restriction. 7. ppx: ppi, supratherapuetic inr, bowel regimen, pneumoboots 8. code: dnr/dni per documentation and discussion with healthcare proxy 9. comm: with healthcare proxy: (), daughter; ( () as alternate medications on admission: norvasc 10 mg po qd vitamin b12 100 mcg q56d colace 200 mg po qd insulin 16 units qam and 3 units qpm lisinopril 30mg po qam detrol la 4 mg po qd coumadin discharge medications: 1. insulin nph human recomb 100 unit/ml cartridge sig: sixteen (16) units subcutaneous qam. 2. insulin nph human recomb 100 unit/ml cartridge sig: three (3) units subcutaneous qpm. 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 bid (2 times a day) as needed. 5. pantoprazole sodium 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q24h (every 24 hours). 6. lisinopril 10 mg tablet sig: three (3) tablet po daily (daily). 7. albuterol sulfate 0.083 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed. 8. acetaminophen 325 mg tablet sig: 1-2 tablets po q4-6h (every 4 to 6 hours) as needed. 9. tolterodine tartrate 2 mg tablet sig: one (1) tablet po bid (2 times a day). 10. ipratropium bromide 0.02 % solution sig: one (1) neb inhalation q6h (every 6 hours) as needed. 11. warfarin sodium 5 mg tablet sig: one (1) tablet po hs (at bedtime). 12. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 13. metoprolol succinate 50 mg tablet sustained release 24hr sig: one (1) tablet sustained release 24hr po daily (daily): hold for hr<60,sbp<100 . 14. lovenox 60 mg/0.6ml syringe sig: 0.5 ml subcutaneous every twelve (12) hours: continue until inr . first dose should be given 6pm on . discharge disposition: extended care facility: for the aged - ltc discharge diagnosis: congestive heart failure secondary: type ii diabetes mellitus atrial fibrillation macular degeneration/diabetic retinopathy cognitive impairment hypertension stenosis of vocal cords back pain discharge condition: stable s/p thoracentesis discharge instructions: please take your medications as directed. followup instructions: have your inr checked regularly as you restart coumadin. last coumadin dose was 10mg on (inr=1) heparin gtt was running until 4pm on . her first dose of lovenox 60mg sc should be at 6pm. Procedure: Thoracentesis Non-invasive mechanical ventilation Diagnoses: Anemia, unspecified Congestive heart failure, unspecified Unspecified essential hypertension Acute kidney failure, unspecified Atrial fibrillation Macular degeneration (senile), unspecified Other and unspecified coagulation defects Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled Background diabetic retinopathy