allergies: patient recorded as having no known allergies to drugs attending: chief complaint: hypertension major surgical or invasive procedure: hd line placement and dialysis initiation history of present illness: 41 y/o m with hx of hiv, stage 4 ckd secondary to mpgn, severe htn, with recent admission for ruptured cyst / le edema, presents with worsening bilateral le edema since prior discharge, shortness of breath for the past 4 days, non-radiating constant sharp substernal/epigastric pain, non-productive cough x1 day, nausea, 2 episodes of non-bilious vomiting with small specks of blood, subjective fevers and chills x 1 day. . in the ed, the patient was noted to have bp of 199/99. cxr was conistent with pulmonary edema. the patient was given morphine, nitro paste, 40mg iv lasix, hydralazine. ct scan of chest was performed which revealed bilateral pleural effusions and likely atelectasis, but possible pna at right lower lobe. the patient was started on vancomycin and cefepime for empiric treatment of hap. after sbp returned to 170s, the patient received clonidine and morphine and a second dose of inch nitro paste. vital signs of transfer included bp in 150s and hr in 70s. . he was admitted to the floor and treated for hap with vanco and cefepime. had been diuresed with a total of 40 mg iv lasix x2 and his i/os were about negative 300 cc. the night of admission, he had several small episodes of coffee ground emesis. ng lavage on the floor was negative. hct remained stable. in the early morning prior to transfer to micu, he was hypertensive with sbps to the 200s. he was complaining of headache. ekg was without changes. he was treated with his home bp meds and 60 mg iv hydral in several boluses. . patient's blood pressure did not improve so he was transfered to micu. on transfer, vitals t 99.8, tm 100.6, bp 199/108 (152/82-231/115), p 94 (73-98), r 18, 96% on ra. he looked uncomfortable, was sitting up in bed and looked worse when lying down. . in the micu, he was poorly controlled on a nitro drip but his bps improved with a labetolol drip and his headache resolved. his hct went down to 19.7 and he got 1unit prbcs with a rise to 22.0. he had a head ct that showed a new hypodensity along the left periventricular white matter. however, the findings could represent an old insult such as old infarct. because he was completely intact neurologically and his headache had resolved, an lp was not pursued. eventually the patient was put back on his home bp regimen and transferred back to the floor. past medical history: 1. hiv - he was diagnosed with hiv in . risk factors included unprotected heterosexual sex as well as intravenous drug use. his nadir cd4 count is 91 and he has no known opportunistic infections. 2. hepatitis c. genotype 1b. viral load 187,000 in . 3. cryoglobulinemia 4. cardiomyopathy with an ef of 45-50%. 5. chronic renal insufficiency - mpgn by biopsy in and hypertensive nephrosclerosis 5. gerd. 6. hypertension. 7. gynecomastia; s/p bilateral gynecomastia excision with liposuction . 8. polysubstance abuse, including cocaine and alcohol. 9. anemia, hematocrit 20-24. 10. hypertriglyceridemia - tg 282 in 11. right hydrocele. 12. a subacute infarct in the right caudate head seen on mri in 13. influenza b, . 14. erectile dysfunction. 15. depression 16. inguinal hernia repair in . 17. left ankle orif in . 18. appendectomy in . social history: history of incarceration for 4 yrs. is self-employed, unmarried. he has three children. denies alcohol. reports marijuana use daily, denies tobacco or cocaine. family history: mother and father have hypertension; has 3 bros, 3 sis: all healthy, none with htn. there is also a family history of type 2 diabetes mellitus. no family history of sudden death and premature atherosclerotic cardiovascular disease. physical exam: vitals: t: 99.0 bp: 164/89 p: 81 r: 22 o2: 95% ra i: 1.7l, o: 1l, balance +700ccs general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp at 10cm, no lad lungs: clear to ausculation bilaterally cv: regular rate and rhythm, normal s1 + s2, 3/6 systolic murmur loudest at apex, no rubs, gallops abdomen: soft, ttp in epigastric region, small well-healed scar above umbilicus with diasthasis, mildly distended, bowel sounds present, no rebound tenderness or guarding. gu: no foley ext: warm, well perfused. 2+ l>r pitting edema bilaterally, no clubbing or cyanosis. pertinent results: admission labs: wbc-9.1# rbc-2.44* hgb-7.0* hct-21.8* mcv-89 rdw-13.3 plt ct-350 neuts-85.5* lymphs-7.3* monos-5.7 eos-1.3 baso-0.2 pt-16.3* ptt-32.9 inr(pt)-1.4* glucose-102* urean-43* creat-4.8*# na-142 k-4.7 cl-110* hco3-20* angap-17 alt-11 ast-15 ck(cpk)-62 alkphos-170* totbili-0.1 probnp-* lipase-20 albumin-3.4* calcium-8.6 phos-4.7* mg-3.0* lactate-0.8 k-4.6 . discharge labs: hct-20.3* glucose-136* urean-40* creat-4.0* na-140 k-4.1 cl-101 hco3-28 angap-15 ld(ldh)-775* . other pertinent labs: 12:40pm fibrino-762* 11:10am thrombn-10.7 06:25am -negative 05:50am ret aut-1.4 11:10am inh scr-neg 06:10am alt-9 ast-18 ld(ldh)-420* alkphos-122 totbili-0.3 06:10am lipase-21 06:25am totprot-6.8 iron-19* 06:25am caltibc-191* vitb12-436 folate-7.8 ferritn-1168* trf-147* 12:40pm hapto-<5* 06:25am pep-no specifi cdiff negative urine culture: yeast blood culture negative x 2 (final) . 5:02 pm urine source: cvs. **final report ** urine culture (final ): pseudomonas aeruginosa. >100,000 organisms/ml.. sensitivities: mic expressed in mcg/ml _________________________________________________________ pseudomonas aeruginosa | cefepime-------------- 2 s ceftazidime----------- 4 s ciprofloxacin--------- =>4 r gentamicin------------ <=1 s meropenem------------- 8 i piperacillin/tazo----- <=4 s tobramycin------------ <=1 s . leni: no dvt in the left lower extremity. cxr: as compared to the previous radiograph, there is no relevant change. an enlarged upper and lower lobe arteries with signs of blood flow redistribution and cardiomegaly. minimal left pleural effusion. no newly appeared focal parenchymal opacities suggesting pneumonia. no lung nodules or masses. mri w/o: encephalomalacia within the left corona radiata with associated hemosiderin staining, new since , without any acute infarct component. the findings likely represent a chronic infarction with hemorrhagic transformation or sequela of a previous hypertensive hemorrhage. while evaluation for intracranial infection is limited in the absence of intravenous contrast, there are no findings to suggest an infection. abd u/s: 1. patent hepatic vasculature. no thrombosis identified. 2. no liver lesions identified. 3. small amount of gallbladder sludge. thickened gallbladder wall is likely due to underlying disease. 4. small bilateral pleural effusions. ct head w/o: 1. tiny rounded hypodensity in the right caudate head is unchanged, previously thought to represent subacute or chronic infarct (mri ). 2. since , there is new hypodensity along the left periventricular white matter. given what appears to be ex vacuo dilatation along the frontal of the left lateral ventricle, findings may represent old insult such as old infarct. however, given the history of hiv, headache and fever, active process would be difficult to exclude. mri is recommended for more sensitive evaluation for subtle process. 3. no acute intracranial hemorrhage seen echo: the left atrium is moderately dilated. the right atrium is moderately dilated. the estimated right atrial pressure is 10-20mmhg. there is mild symmetric left ventricular hypertrophy. the left ventricular cavity is severely dilated. there is mild to moderate global left ventricular hypokinesis (lvef = 40 %). tissue doppler imaging suggests an increased left ventricular filling pressure (pcwp>18mmhg). 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 regurgitation. the mitral valve leaflets are mildly thickened. there is no mitral valve prolapse. mild to moderate (+) mitral regurgitation is seen. the estimated pulmonary artery systolic pressure is normal. there is a small 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 , the findings are similar. ct abd/pelvis: 1. small bilateral pleural effusions, right greater than left, with probable adjacent dependent atelectasis. more consolidative appearing opacity within the right lower lobe, however, could represent pneumonia. findings discussed with dr. at 1pm, . 2. moderate-sized pericardial effusion. 3. small amount of ascites with anasarca and pericholecystic fluid indicating volume overload with third spacing. 4. no evidence of bowel obstruction, hernia, or focal fluid collection. 5. probable anemia. brief hospital course: 41 y/o m with hx of hiv, ckd, htn and chf who presents to the ed with worsening pedal edema, sob and possible pna. the second day of admission was transferred to the icu with hypertensive urgency with worsening symptoms of heart failure and headache. . # hypertension: patient was initially managed in icu but eventually resumed most of his home regimen. his nifedipine and minoxidil were stopped because he had adequate blood pressure control and these were thought to be contributing to his lower extremity edema. . # headache: resolved with blood pressure control. no acute pathology seen on imaging. . # acute on chronic kidney disease: patient did not improve with lasix and dialysis was initiated. will have a tu, th, sat dialysis schedule with follow up with dr. . . # coffee ground emesis: patient had coffee ground emesis in micu. ng lavage was negative. he was continued on his ranitidine with no further episodes. . # nausea/abdominal pain: initially on narcotics for symptomatic control. imaging and labs did not reveal clear etiology. thought most likely gut edema and uremia. improved after dialysis and patient was not discharged on narcotics. . # anemia: heme was consulted and they thought most like etiology was from cryoglobulins. blood bank was also following and patient has e antibodies. after not appropriately bumping to several tranfusions, patient finally had appropriate response after being given warmed blood. patient has heme follow up. hct was at baseline prior to discharge. . # pericardial effusion: small pericardial effusion on echo. unclear etiology. likely uremic, and expected to improve with dialysis. . # elevated inr: patient's inr was elevated but this improved with vitamin k suggesting nutrtional deficiency. . # pseudomonas uti: patient was pseudomona uti that is resistant to cipro. started on cefepime and switched to ceftaz. will get ceftaz at hd to complete 1 week course. if patient uti not clearing should consider switching back to cefepime or drug with higher sensitivity than ceftaz. for sensitivities see results section. . # hiv: stable, continue current harrt . # hep c: stable medications on admission: 1. abacavir 300 mg tablet sig: two (2) tablet po daily (daily). 2. isosorbide mononitrate 30 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 3. furosemide 40 mg tablet sig: one (1) tablet po daily (daily). 4. minoxidil 10 mg tablet sig: one (1) tablet po bid (2 times a day). 5. clonidine 0.2 mg tablet sig: two (2) tablet po tid (3 times a day). 6. efavirenz 600 mg tablet sig: one (1) tablet po daily (daily). 7. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 8. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). ----9. nifedipine 60 mg tablet sustained release sig: three (3) tablet sustained release po daily (daily). 10. lamivudine 150 mg tablet sig: one (1) tablet po daily (daily). 11. sodium bicarbonate 650 mg tablet sig: one (1) tablet po tid (3 times a day). 12. multivitamin tablet sig: one (1) tablet po daily (daily). 13. ferrous sulfate 300 mg (60 mg iron) tablet sig: three y five (325) mg po daily (daily). 14. terazosin 1 mg capsule sig: three (3) capsule po hs (at bedtime). 15. gemfibrozil 600 mg tablet sig: one (1) tablet po twice a day. 16. percocet 5-325 mg tablet sig: one (1) tablet po every hours as needed for pain. 17. senna 8.6 mg tablet sig: one (1) tablet po bid (2 times a day) as needed for constipation. 18. docusate sodium 100 mg capsule sig: one (1) capsule po bid 19. ranitidine hcl 150 mg tablet sig: one (1) tablet po twice a day. 20. aranesp (polysorbate) injection 21. pravastatin 40 mg tablet sig: one (1) tablet po once a day. 22. carvedilol 25 mg tablet sig: two (2) tablet po twice a day. discharge medications: 1. abacavir 300 mg tablet sig: two (2) tablet po daily (daily). 2. isosorbide mononitrate 30 mg tablet sustained release 24 hr sig: one (1) tablet sustained release 24 hr po daily (daily). 3. clonidine 0.2 mg tablet sig: two (2) tablet po tid (3 times a day). 4. efavirenz 600 mg tablet sig: one (1) tablet po daily (daily). 5. aspirin 325 mg tablet sig: one (1) tablet po daily (daily). 6. ascorbic acid 500 mg tablet sig: one (1) tablet po bid (2 times a day). 7. lamivudine 150 mg tablet sig: one (1) tablet po once a day. 8. multivitamin tablet sig: one (1) tablet po daily (daily). 9. terazosin 1 mg capsule sig: three (3) capsule po hs (at bedtime). 10. gemfibrozil 600 mg tablet sig: one (1) tablet po daily (daily). 11. ranitidine hcl 150 mg tablet sig: one (1) tablet po twice a day. 12. pravastatin 20 mg tablet sig: two (2) tablet po daily (daily). 13. carvedilol 25 mg tablet sig: two (2) tablet po twice a day. 14. hydralazine 25 mg tablet sig: three (3) tablet po q8h (every 8 hours). disp:*270 tablet(s)* refills:*2* 15. ferrous sulfate 300 mg (60 mg iron) tablet sig: one (1) tablet po tid (3 times a day). disp:*90 tablet(s)* refills:*2* 16. calcium acetate 667 mg capsule sig: one (1) capsule po tid w/meals (3 times a day with meals). disp:*90 capsule(s)* refills:*2* 17. ceftazidime 2 gram recon soln sig: two (2) gram intravenous asdir for 2 doses: at dialysis on and . discharge disposition: home discharge diagnosis: primary diagnosis: hypertension anemia acute on chronic renal failure . secondary diagnosis: hiv hep c h/o polysubstance abuse discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: you were admitted to the hospital with hypertension and worsening renal failure. you were temporarily monitored in the icu because your blood pressure was difficult to control. you developed leg edema because of your worsening kidney function. we treated you with a medication called lasix to decrease the fluid in your legs and improve the function of your kidneys, but eventually you needed to initiate hemodialysis. you will continue dialysis on tuesday, thursday, and saturdays. you will also follow up with dr. . . you also have a urinary tract infection. we are treating you with an antibiotic called ceftazidime. you will get this antibiotic at dialysis for the next two sessions. . your blood count (hematocrit) was low during this hospital admission. we gave you several blood transfusions. your blood count was stable at time of discharge but you should follow up with a hematologist at the appointment listed below. . we have made the following changes to your medications: 1. restart hydralazine 75mg by mouth three times a day. 2. start calcium acetate 667mg by mouth three times a day 3. stop sodium bicarbonate 4. stop minoxidil 5. stop nifedipine 6. increase ferrous sulfate to 325mg by mouth three times a day 7. ceftazidime 2g iv at dialysis for the next two sessions . weigh yourself every morning, md if weight goes up more than 3 lbs. followup instructions: department: when: tuesday at 3:00 pm with: , md building: campus: east best parking: garage department: medical specialties when: thursday at 3:30 pm with: , m.d. building: campus: east best parking: garage department: hematology/oncology when: tuesday at 9:00 am with: , md building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: tuesday at 9:00 am with: , md building: sc clinical ctr campus: east best parking: garage department: when: wednesday at 10:30 am with: building: sc clinical ctr campus: east best parking: garage . department: cardiac services when: tuesday at 3:30 pm with: , np building: sc clinical ctr campus: east best parking: garage md Procedure: Hemodialysis Venous catheterization for renal dialysis Diagnoses: Hypertensive chronic kidney disease, malignant, with chronic kidney disease stage V or end stage renal disease Other primary cardiomyopathies End stage renal disease Renal dialysis status Anemia, unspecified Esophageal reflux Urinary tract infection, site not specified Congestive heart failure, unspecified Chronic hepatitis C without mention of hepatic coma Acute kidney failure, unspecified Alcohol abuse, unspecified Cocaine abuse, unspecified Unspecified disease of pericardium Acute on chronic systolic heart failure Asymptomatic human immunodeficiency virus [HIV] infection status Pseudomonas infection in conditions classified elsewhere and of unspecified site