allergies: dapsone / cyclosporine / cefepime / aztreonam / azithromycin / vancomycin attending: chief complaint: dyspnea major surgical or invasive procedure: cardiac catheterization placement of tunneled right internal jugular central venous line history of present illness: 68yo woman with h/o nhl s/p sct in who presented to the ed with acute onset shortness of breath. she describes waking up at 5am on the day of admission because of severe pain from post-herpetic neuralgia in her left face. she then began feeling very short of breath and wheezy for the next 20 minutes. no associated chest pain. no fevers or chills. no nausea or vomiting. she has otherwise been feeling well. she denies any similar symptoms in the past. she has not had any orthopnea or prior episodes of pnd. no pleuritic chest pain, no dyspnea on exertion, no le edema or weight gain. she has been able to mow the lawn and go up a flight of stairs without any difficulty. no recent travel. she does not have a personal or family history of blood clots nor does she have a history of miscarriages. she had tacos last night for dinner. no nausea or vomiting. in the ed, initial vs were: 97.5 192/101 128 24 86% ra. her oxygen improved to 100% on nrb. she appeared to have increased work of breathing and she had b/l rales on exam; guaiac was negative. bnp was elevated at . the team was concerned about the possibility of pe, but they did not obtain cta chest because of her advanced kidney disease. the ed team felt that pe was high enough on their differential that they opted to treat with a heparin gtt. they obtained a ct head, which showed some lacunes that were new as compared to . neurology was consulted to advise whether anticoagulation would be safe. after discussing with oncology, heparin gtt was started. although the team was concerned about the possibility of heart failure, she was given sl nitroglycerin and asa but not started on lasix or bp medications. she did receive clindamycin and levofloxacin for concern of a possible rll infiltrate. she was also given prednisone 60mg x 1 because of the possibility that she might be adrenally insufficient on chronic steroids. upon arrival to the icu, she reported feeling comfortable. her pain was mild and she was not having any difficulty breathing. past medical history: - large cell lymphoma: diagnosed , s/p allogeneic sct in . has had multiple regimens of chemotherapy c/b gvhd - chronic graft vs host disease, mild (cutaneous, liver) - ckd stage v: unclear if secondary to chemotherapy, cyclosporin, or gvhd. had lue av fistula placed but found to have occluded left brachiocephalic vessel on fistalugram - hyponatremia felt to be due to increased fluid intake - s/p thyroidectomy for thyroid mass, pathology was benign - herpes zoster c/b post-herpetic neuralgia s/p nerve block social history: quit smoking 36 yrs ago. very occ etoh use. married with two daughters. formerly worked in human resources at a department store. family history: no fam history of blood clots her mom deceased age 87 of cerebral hemorrhage. father deceased age 48 of malignant hypertension. aunt deceased from breast cancer. brother massive mi at the age of 66. additional brother with hypertension and emphysema physical exam: 97.6 129/69 111 18 94% 2l very pleasant woman in no distress. perrl, eomi. left lid ptosis. cn ii-xii intact. op clear, mmm. neck supple, no thyroid enlargement, no adenopathy. s1, s2, regular tachycardia, +rub. lung with good air movement and crackles of way up b/l. abd soft and not tender, no palpable mass, no hepatomegaly. very mild asterixis r>l. strength 5/5 in ue and le b/l. no le edema. dp +2 b/l. dark discoloration of skin over arms and back. lue av fistula with palpable thrill. pertinent results: laboratory results ==================== on admission: wbc-7.2 rbc-3.53* hgb-11.5* hct-34.9* mcv-99* rdw-18.0* plt ct-226 -- neuts-74.1* bands-0 lymphs-14.2* monos-8.4 eos-2.7 baso-0.7 pt-12.1 ptt-26.2 inr(pt)-1.0 glucose-114* urean-75* creat-5.2* na-127* k-4.7 cl-96 hco3-12* calcium-7.8* phos-6.1*# mg-2.5 tsh-1.5 on discharge: wbc-5.8 rbc-3.15* hgb-9.8* hct-30.9* mcv-98 rdw-16.8* plt ct-169 pt-13.0 ptt-66.9* inr(pt)-1.1 glucose-84 urean-44* creat-3.9* na-144 k-4.1 cl-105 hco3-29 06:42am blood alt-13 ast-16 ld(ldh)-184 alkphos-63 totbili-0.2 calcium-9.1 phos-2.7 mg-2.1 microbiology ============= blood cultures : one out of two bottles staphylococcus, coagulase negative. isolated from one set only. sensitivities performed on request.. aerobic bottle gram stain (final ): gram positive cocci in clusters. blood cultures*2 : no growth rapid respiratory viral screen : **final report ** respiratory viral culture (final ): no respiratory viruses isolated. culture screened for adenovirus, influenza a & b, parainfluenza type 1,2 & 3, and respiratory syncytial virus.. detection of viruses other than those listed above will only be performed on specific request. please call virology at within 1 week if additional testing is needed. rapid respiratory viral antigen test (final ): respiratory viral antigens not detected. specimen screened for: adeno,parainfluenza 1,2,3 influenza a,b and rsv. hbsag-negative hbsab-positive hbcab-negative hcv ab-negative other studies ============== ecg : sinus tachycardia with atrial premature beats. poor r wave progression in leads v1-v3. cannot rule out old anteroseptal myocardial infarction. diffuse non-specific st-t wave abnormalities. compared to the previous tracing of there has been interval loss of r wave in leads v2-v3. chest radiograph : conclusion: added density at the right costophrenic angle is suggestive of an infiltrate. blunting of the right costophrenic angle is suggestive of a small basal effusion. ct head w/o contrast : conclusion: periventricular ischemia and scattered lacunar infarcts. no intracranial hemorrhage. ct chest w/o contrast : conclusion: 1. bibasal effusions along with increased interstitial markings and confluent ground-glass opacities predominantly in the upper lobes. the differential considerations are fluid overload, or chf. please correlate clinically. 2. scattered tiny calcific densities in the left breast may represent fibroadenomas. mammography is recommended on a non-emergent basis. 3. no mediastinal masses. transthoracic echocardiogram : conclusions the left atrium is normal in size. left ventricular wall thicknesses are normal. the left ventricular cavity size is borderline dilated. overall left ventricular systolic function is probably mildly depressed (lvef=~40-45%? %) with basal inferior hypokinesis and possible septal hypokinesis (views are technically suboptimal for assessment of regional wall motion). diastolic function could not be adquately assessed. right ventricular chamber size and free wall motion are normal. the aortic valve leaflets are mildly thickened (?#). mild (1+) aortic regurgitation is seen. the mitral valve leaflets are mildly thickened. moderate to severe (3+) mitral regurgitation is seen. the pulmonary artery systolic pressure could not be determined. there is a small pericardial effusion. there are no echocardiographic signs of tamponade. --compared with the prior study (images reviewed) of , the left ventricle is now more dilated, left ventricular systolic function is more depressed with new regional wall motion abnormality, the mitral valve chordae appear tethered, mitral regurgitation is now much more prominent. cardiac catheterization : comments: 1. selective coronary angiography of this right dominant system revealed single vessel disease. the lmca was free of critical stenoses. the lad had a bifurcation lesion with a 50% stenosis in the mid-lad and 70% stenosis in the d1 branch. the lcx and rca were widely patent. 2. resting hemodynamics revealed mildly elevated right heart filling pressures with a mean ra of 11mmhg and severely elevated left heart filling pressures with a mean pcwp of 28mmhg. the cardiac index was preserved at 3.7 l/min/m2. final diagnosis: 1. one vessel coronary artery disease. 2. severe diastolic ventricular dysfunction. brief hospital course: ms is a 68yo woman with h/o non-hodgkin's lymphoma s/p sct in and stage v ckd who presented with acute dyspnea in the setting of pain, hypertension, and volume overload. # dyspnea and hypoxia: she most likely developed flash pulmonary edema from sudden hypertension from the pain in the setting of chronic renal disease. this was supported by cxr and ct chest. she was given lasix for diuresis. to cover pe (she has had persistent tachycardia), she was started on heparin gtt. this was discontinued as the likelihood of pe was very low given hypoxia and tachycardia resolved with diuresis. she had no evidence of infection or pneumonia. she takes her pentamidine faithfully, so was unlikely to be pcp. was done during her admission to evaluate for suspected diastolic dysfunction, however showed new inferior basal wall motion abnormality and new moderate to severe mitral regurgitation, see below. # systolic chf: new diagnosis, on this admission. showed ef 40-45%, but likely overestimated given significant new mr. likely secondary to ischemic event, either from plaque rupture given family history, hyperlipidemia, or vasospasm. the patient had a cardiac catheterization which did not show evidence of occlusive disease. she was started on metoprolol, atorvastatin, and aspirin during her hospital stay. # sinus tachycardia: most likely this was secondary to pain and dyspnea, unlikely to be pe. she was empirically started on a heparin gtt, but stopped when she was no longer hypoxic. tsh was wnl. # ckd stage v: on admission, the patient had mild signs of uremia on exam and labs but denies frank symptoms apart from volume overload. unfortunately, occlusion of left brachiocephalic makes left av fistula unusable. renal was consulted during her hospitalization and did not think she required acute hemodialysis. transplant surgery was consulted to discuss the possibility of placing another fistula on the right. however, given the new development of chf, this surgery was placed on hold, and a temporary hd line was placed. hemodialysis was electively initiated during her hospitalization. she had hep c and hep b antibiodies sent. a ppd was placed . all hepatitis serologies were negative and there was no induration to ppd. the patient was discharged to outpatient dialysis. # graft vs host disease: pt was continued on home prednisone after discussing with oncology. she is also on monthly pentamidine given long term steroids. # post-herpetic neuralgia: pt was continued on home pregabalin and nortriptyline for pain control. she will follow up in pain clinic. # small vessel ischemic disease on head ct: neuro was consulted and recommended aspirin, which was started. # h/o thyroidectomy: tsh was wnl. pt was continued on home dose of levothyroxine. . # hyponatremia: chronic, will monitor . # code: dnr/dni (confirmed with patient) medications on admission: prednisone 2.5mg daily (for gvhd) levothyroxine 125mcg daily nortriptyline 10mg qhs pregabalin 25mg calcium and vitamin d centrum silver pentamidine 300mg every month albuterol inhaler (almost never uses) discharge medications: 1. prednisone 2.5 mg tablet sig: one (1) tablet po daily (daily). 2. levothyroxine 125 mcg tablet sig: one (1) tablet po daily (daily). 3. nortriptyline 10 mg capsule sig: one (1) capsule po hs (at bedtime). 4. pregabalin 25 mg capsule sig: one (1) capsule po bid (2 times a day). 5. cholecalciferol (vitamin d3) 400 unit capsule sig: one (1) capsule po twice a day. 6. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: 1-2 puffs inhalation q4h (every 4 hours) as needed for sob, wheezing. 7. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). disp:*30 tablet(s)* refills:*2* 8. metoprolol tartrate 25 mg tablet sig: 0.5 tablet po twice a day. disp:*30 tablet(s)* refills:*2* 9. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 10. b complex-vitamin c-folic acid 1 mg capsule sig: one (1) cap po daily (daily). disp:*30 * refills:*2* 11. multivitamin capsule sig: one (1) capsule po once a day. discharge disposition: home discharge diagnosis: primary diagnoses: systolic and diastolic heart failure stage v chronic kidney disease post herpetic neuralgia secondary diagnoses: history of allogeneic stem cell transplant for non-hodgkin's lymphoma chronic graft versus host disease hypothyroidism discharge condition: good, stable on room air, tolerating po's, euvolemic discharge instructions: you were admitted to for evaluation of shortness of breath. you were found to have new heart failure and volume overload from your chronic kidney failure. you had a cardiac catheterization which showed evidence of coronary artery disease, but did not explain your heart failure and valve symptoms. you were also stared on hemodialysis while you were inpatient. medication changes: start metoprolol 12.5mg twice a day start aspirin 81mg daily start atorvastatin 10mg daily start nephrocaps we discontinued your calcium acetate (phoslo) and sodium bicarb. please do not take this medications any more unless asked to do so by your nephrologist. . your ppd was negative. . it is important that you see your docotrs for further follow up, as we have arranged for you (see below). . if you experience worsening shortness of breath, chest pain, fevers, chills or any other concerning symptoms please seek medical attention. followup instructions: please set up an appointment to see your pcp dr to follow up on your hospitalization. please keep your previously scheduled appointments: 01:30p , c. sc clinical ctr, hematology/oncology () 01:30p , e. sc clinical ctr, hematology/oncology () 11:10a one place (, ma), pain management center ( 11:20a , cc7 cardiology (sb) Procedure: Combined right and left heart cardiac catheterization Coronary arteriography using two catheters Hemodialysis Venous catheterization for renal dialysis Diagnoses: Chronic kidney disease, Stage V Hyperpotassemia Coronary atherosclerosis of native coronary artery Congestive heart failure, unspecified Hyposmolality and/or hyponatremia Unspecified acquired hypothyroidism Personal history of other lymphatic and hematopoietic neoplasms Other specified cardiac dysrhythmias Compression of vein Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use Complications of transplanted bone marrow Acute combined systolic and diastolic heart failure Herpes zoster with other nervous system complications Other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation Hypertensive heart and chronic kidney disease, unspecified, with heart failure and chronic kidney disease stage V or end stage renal disease Polyneuropathy due to drugs Chronic graft-versus-host disease Hyperpigmentation of eyelid