allergies: lorazepam / egg attending: chief complaint: dyspnea major surgical or invasive procedure: none history of present illness: mrs. is a 68 yo f with chf, copd (fev1 75, on 2l baseline), mvr, aaa repair, afib, esrd on hd who presents with subacute dyspnea. patient reports these symptoms are consistent with prior chf exacerbation. patient developed dyspnea both at rest and with exertion 3 days ago, worsening le edema 3 days ago, and a productive cough of grey sputum with intermittent bloody streaks for 2 days. patient reports no chest pain, or palpitations, but does have pnd and orthopnea over this time period. she reports no dietary indiscretion or med noncompliance. patient was at hd today, and because of symptoms she presented to the ed. . in the ed, labs revealed an elevated bnp to 21,000 (priors as high as 26,000), hct 31 and wbc 10.9. patient was noted to be somewhat hypotensive from systolics 70s to 80s, but without symptoms of dizziness or altered mental status. received solumedrol 125 mg ivx1, azithromycin 500 mg po x1, and 250 cc ivf. received vanco 1g iv x1 and ctx 1g iv x1 because of hypotension. blood cultures sent. renal aware. port with subclav tunnel. has peripheral x2. shock u/s negative. cxr with mild volume overload. on transfer, vs were 92/71, 117, 28, 94% 4l. afebrile. . of note, patient was admitted - for chf exaceration, worsening by underlying copd and af. she received diltiazem drip in the icu to help control her af, and received steroids for presumed copd exacerbation. she was also trialed on cpap. edema improved with uf and patient was rapidly transitioned back to her home o2 of 2l. . on the floor, patient reports improved dyspnea and continues to deny chest pain. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies chest pain, chest pressure, palpitations, or weakness. denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. denies dysuria, frequency, or urgency. denies arthralgias or myalgias. denies rashes or skin changes. past medical history: - coronary artery disease status post cabg*4 and mvr at in - status post cabg, mvr, and aaa repair at in - stage iv chronic kidney disease (baseline cr 2.7) from embolic event during extensive surgery noted above now on dialysis - loss of all toes to embolic event during vascular surgery - hypertension - atrial fibrillation - chronic obstructive pulmonary disease - history of right sided carotid endarterectomy - depression - systolic chf ef 45% to 50% social history: she is a retired home health care worker and lives independently in mission . living at home alone. currently smoking. denies etoh. family history: father w/ coronary artery disease physical exam: admission exam: vitals: t: 98.2 bp: 106/58 p: 87 r: 26 o2: 89% 3l general: alert, oriented, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp ~ 10 cm lungs:crackles at bases bilaterally 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 gu: no foley ext: 1+ le edema, warm, well perfused, 2+ pulses, no clubbing, cyanosis, s/p toe amputations on both sides at discharge: expired at 10:25am on pertinent results: admisison labs: 09:35pm plt count-383# 09:35pm neuts-83.3* lymphs-11.5* monos-3.9 eos-0.8 basos-0.5 09:35pm wbc-10.9 rbc-3.13* hgb-10.5* hct-31.2* mcv-100* mch-33.7* mchc-33.7 rdw-15.5 09:35pm calcium-9.8 phosphate-3.1 magnesium-2.8* 09:35pm ck-mb-5 probnp-* 09:35pm ctropnt-0.12* 09:35pm ck(cpk)-59 09:35pm estgfr-using this 09:35pm glucose-69* urea n-42* creat-2.7* sodium-141 potassium-3.9 chloride-95* total co2-34* anion gap-16 12:15am lactate-1.3 12:15am comments-green top 12:35am urine mucous-rare 12:35am urine hyaline-7* 12:35am urine rbc-1 wbc-5 bacteria-none yeast-none epi-0 12:35am urine blood-neg nitrite-neg protein->600 glucose-70 ketone-neg bilirubin-neg urobilngn-neg ph-8.0 leuk-neg 12:35am urine color-yellow appear-clear sp -1.013 ekg : atrial fibrillation with rapid ventricular response. q waves in leads v1-v2. non-specific st-t wave changes. compared to the previous tracing of the non-specific st-t wave changes are somewhat less prominent. no other diagnostic interval change. cxr : no focal consolidation to suggest pneumonia. copd. unchanged small pleural effusion with chronic mild pulmonary edema. brief hospital course: mrs. is a 68 yo f with chf, copd (fev1 75, on 2l baseline), mvr, aaa repair, afib, esrd on hd who presents with hypoxic respiratory distress, with goals eventually focused on comfort at patient's request, who expired. . # hypoxic respiratory failure: most likely related to chf. patient underwent hd for fluid removal x1. she was started on prednisone and standing nebs. azithromycin was started and changed to vanc/zosyn after she desaturated with increased work of breathing. all medications were eventually discontinued after goals were focused on comfort at patient's request and morphine drip was started. patient expired at 10:25am on . family declined postmortem exam. . # hypotension: normotensive at admission to the micu after hypotension in ed. . # esrd: hd x1. continued cincacalcet and nephrocaps. . # afib: started on reduced po dose initially given hypotension and despite rvr in ed. episodes of rvr triggered diltiazem drip which was continued until morning of expiration. medications on admission: # aspirin 325 mg daily # escitalopram 20 mg daily # fluticasone-salmeterol 250-50 mcg/dose # simvastatin 80 mg daily # sevelamer carbonate 800 mg tid # nicotine 14 mg/24 hr patch 24 hr # trazodone 100 mg po qhs # levalbuterol hcl 0.63 mg/3 ml solution for nebulization sig: # docusate sodium 100 mg po bid # senna 2 tab po qhs # cinacalcet 30 mg po bid # doxercalciferol 4 mcg/2 ml, 0.5 mcg iv 3x per week. # epoetin alfa uncertain dose # ergocalciferol (vitamin d2) 50,000 unit monthly # tiotropium bromide 18 mcg capsule, w/inhalation daily (not taking) # nephplex rx 1-60-300-12.5 mg-mg-mcg-mg daily # diltiazem hcl 180 mg daily # coumadin 2 mg daily (except 3 mg friday) # buproprion 75 mg daily # dronabinol 2.5 mg daily (not taking) discharge medications: n/a discharge disposition: expired discharge diagnosis: 1. hypoxic respiratory failure 2. end stage renal disease 3. copd 4. chf discharge condition: expired discharge instructions: n/a followup instructions: n/a md Procedure: Hemodialysis Diagnoses: End stage renal disease Congestive heart failure, unspecified Atrial fibrillation Obstructive chronic bronchitis with (acute) exacerbation Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease Heart valve replaced by other means Acute respiratory failure Acute on chronic systolic heart failure