allergies: patient recorded as having no known allergies to drugs attending: chief complaint: pancreatic pseudocyst major surgical or invasive procedure: ivc filter successful ct-guided 12 french pigtail catheter into the patient's known pancreatic pseudocyst. successful ct-guided placement of an 18-french drainage catheter into the patient's pancreatic pseudocyst. s/p right thoracentesis (700 cc off) and left chest drainage history of present illness: this is a 84 year old male who presented to with coffee ground emesis. on ct he was found to have a pancreatic pseudocyst. he has a history of a-fib and was on coumadin. past medical history: h/o paf formerly on amiodarone and coumadin 3vd with medical management, chf ef >60%, htn, prostate ca, cri psh: gallstone pancreatitis (), open ccy (), s/p resection prostate. social history: lives on with wife. daughter is excellent contact - : . cell . physical exam: vs: 99.2, 110, 110/70, 18, 98% 2l gen: nad chest: ctab cv: rrr abd: well-healed abdominal incision, soft, mild distention, non-tender, ext: wwp, trace edema guiac positive pertinent results: 11:55pm blood wbc-18.6* rbc-3.81* hgb-11.9* hct-35.5* mcv-93 mch-31.2 mchc-33.4 rdw-16.5* plt ct-409 08:50am blood wbc-21.3* rbc-3.58* hgb-11.2* hct-33.8* mcv-94 mch-31.4 mchc-33.2 rdw-16.7* plt ct-442* 04:37am blood wbc-14.1* rbc-2.94* hgb-9.3* hct-27.8* mcv-95 mch-31.7 mchc-33.4 rdw-17.1* plt ct-377 11:55pm blood glucose-65* urean-29* creat-1.5* na-144 k-4.6 cl-112* hco3-20* angap-17 04:05am blood glucose-108* urean-41* creat-1.8* na-144 k-4.4 cl-110* hco3-25 angap-13 04:37am blood glucose-102 urean-52* creat-1.8* na-141 k-4.0 cl-101 hco3-34* angap-10 11:55pm blood alt-13 ast-23 ck(cpk)-17* alkphos-136* amylase-28 totbili-0.9 07:15am blood alt-11 ast-22 ld(ldh)-241 ck(cpk)-15* alkphos-142* amylase-24 totbili-0.9 dirbili-0.5* indbili-0.4 04:37am blood alt-9 ast-26 ld(ldh)-206 alkphos-138* amylase-23 totbili-0.6 11:55pm blood lipase-17 04:37am blood lipase-19 11:55pm blood ck-mb-notdone ctropnt-0.03* 12:57am blood probnp-* 07:15am blood albumin-2.1* calcium-7.9* phos-3.8 mg-2.0 iron-15* 12:57am blood totprot-4.6* calcium-8.1* phos-4.0 mg-1.9 04:37am blood calcium-8.2* phos-4.1 mg-2.1 07:15am blood caltibc-118* trf-91* 08:50am blood tsh-2.4 10:45am blood vanco-26.6* . cta abd w&w/o c & recons 10:30 am impression: 1. heterogeneous peripancreatic fluid collection containing air as noted above with inferior extension within the retroperitoneum as detailed. 2. deep venous thrombosis and suggestion of small pulmonary embolism and possible pulmonary infarct. these findings are discussed with the surgical house staff at the time of dictation. 3. bilateral pleural effusions. 4. moderate ascites. . cardiology report echo study date of impression: normal global and regional biventricular systolic function. mild aortic regurgitation. mild pulmonary hypertension. dilated thoracic aorta. . ct guidance drainage 10:38 am impression: 1. successful ct-guided 12 french pigtail catheter into the patient's known pancreatic pseudocyst. . chest (portable ap) 6:41 am findings: left pigtail pleural drainage catheter is unchanged. there are moderate bilateral pleural effusions, probably right greater than left. there is asymmetric right perihilar opacity, which likely represents asymmetric pulmonary edema, probably the result of fluid overload. ivc filter is again seen. pseudocyst drainage catheter is noted, overlying the left upper abdomen, unchanged. impression: 1. moderate bilateral pleural effusions, probably right greater than left. 2. probable early asymmetric pulmonary edema, likelyas as a result of fluid overload. . ct abscess cath change 2:23 pm impression: 1. successful ct-guided placement of an 18-french drainage catheter into the patient's pancreatic pseudocyst. . chest (portable ap) 9:27 am impression: no significant interval change. . ct abscess cath change 4:08 pm through the patient's existing catheter, wire was passed and serial dilation was completed before placing a 24-french malincot catheter without incident. no complications ensued. the patient remained stable throughout his stay in the ct suite. the catheter was attached to a drainage bag to be drained by gravity. the attending radiologists were present during the entirety of the procedure. impression: 1. successful placement of a 24-french drainage catheter. this catheter is not to be removed before consulting radiology as it requires removal over a special troca device. . ct abdomen w/o contrast 1:41 pm impression: 1. status post drainage tube placement for the pseudocyst with fluid and gas, with surrounding fat stranding, slightly decreased in size since prior study. 2. unchanged free fluid in the abdomen and pelvis, with mesenteric nodes and 1.9-cm focus of another possible pseudocyst. 3. moderate amount of bilateral pleural effusion with atelectasis and moderate-sized hiatal hernia. . brief hospital course: 84 yo male with a h/o paf formerly on amiodarone and coumadin, 3vd with medical management, chf ef >60% who presented with coffee ground emesis and found to have pancreatic pseudocyst. pe/dvt: his ct on showed bilateral pe and dvt. a heparin gtt was started. vascular was consulted and we stopped the heparin in order for a filter placement. vascular successfully placed ivc filter on . atrial fibrillation: he had a history of paf and also likely related to pe. cardiology was consulted. he received 20 mg iv lopressor q4 for rate control. he was deemed a high operative risk. he was started on diltiazem for rate control. the diltiazem gtt was controlling his rate well. on , off diltiazem gtt, on lopressor 25 po with hr 80s, afib on , he continued to diuresing 8 liters of urine a day. his lasix was decreased and his goal output was -500 to 1 liter max/day. his lopressor was increase for hr control, rate 80-90s afib. his coumadin will restart when stable. pleural effusion: he was shown to have bilateral pleural effusion. he had s/p right thoracentesis (700 cc off) and left chest drainage pigtail placed w/1100ml fluid out; resp status improved. he then had reaccumulation of fluid on the right. pulmonary was consulted. the pigtail on the left was left in place for 48 hours and then pulled on due to concern for infection. the right sided reaccumulation was partly due to fluid overload, chf. he required bipap overnight for some respiratory distress. the right side was again taped for 700cc straw colored fluid on he received albumin due to low albumin (albumin 2 on ). he then began mobilizing the fluids after initial hypovolemia and diuresed -5 liters, (1.7 in 2 hours) with cr 1.5->1.8. he was receiving lasix and his goal was -500 to 1 liter. his probnp 17,000. . pancreatic pseudocyst: he was started on broad spectrum antibiotics. he went to ct and under anesthesia had successful ct-guided 12 french pigtail catheter into the patient's known pancreatic pseudocyst on . this fluid grew out streptococcus milleri group. heavy growth. and staphylococcus, coagulase negative. moderate growth. he continued on imipenem (day 15); vanc/fluc (day 14) ct guided catheter upsize impression: 1. successful ct-guided placement of an 18-french drainage catheter into the patient's pancreatic pseudocyst. he went again for upsizing of his drain catheter on and had successful placement of a 24-french drainage catheter. this catheter is not to be removed before consulting radiology as it requires removal over a special troca device. the output was thick, tannish fluid. he continued to have a small volume of output from the drain. he needs continued drain care, including forward flushing with 20-30cc of saline and aspirating back. he will return to see dr. in 3 weeks for repeat ct. he will continue on antibiotics until that time. fen: he was npo with ivf. he was started on tpn on hd 3. his diet was slowly advanced, starting with sips. on hd 7 he tolerated a small amount of food, but had some nausea and ~50 cc of emesis. his diet was eventually liberated, but his intake was still poor. calorie counts were only ~300-800 kcal/day. he will continue to need tpn until his appetite improves. hypovolemia: he was requiring several fluid boluses for low urine output while in the icu on . after adequate hydration, he was restarted on his home lasix. discharge medications: 1. acetaminophen 325 mg tablet sig: two (2) tablet po q6h (every 6 hours) as needed for pain. 2. bisacodyl 5 mg tablet, delayed release (e.c.) sig: two (2) tablet, delayed release (e.c.) po daily (daily) as needed. 3. oxycodone-acetaminophen 5-325 mg tablet sig: 1-2 tablets po q4h (every 4 hours) as needed. 4. heparin (porcine) 5,000 unit/ml solution sig: one (1) injection tid (3 times a day). 5. metoprolol tartrate 25 mg tablet sig: one (1) tablet po tid (3 times a day). 6. atorvastatin 10 mg tablet sig: one (1) tablet po daily (daily). 7. pantoprazole 40 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po q12h (every 12 hours). 8. furosemide 20 mg tablet sig: one (1) tablet po bid (2 times a day). 9. imipenem-cilastatin 500 mg recon soln sig: one (1) recon soln intravenous q8h (every 8 hours). 10. fluconazole in saline(iso-osm) 200 mg/100 ml piggyback sig: one (1) intravenous q24h (every 24 hours). 11. vancomycin in dextrose 1 g/200 ml piggyback sig: one (1) intravenous q 24h (every 24 hours): please check vanco trough prior to 4th dose. 12. insulin regular human 100 unit/ml solution sig: sliding scale injection asdir (as directed). 13. heparin lock flush (porcine) 100 unit/ml syringe sig: one (1) ml intravenous daily (daily) as needed. discharge disposition: extended care facility: for the aged - macu discharge diagnosis: ugi bleed pancreatic pseudocyst left cfv thrombus atrial fibrillation bilateral pe pleural effusion malnutrition discharge condition: fair continue on tpn continue with drain care continue with pt discharge instructions: please call your doctor or return to the er for any of the following: * you experience new chest pain, pressure, squeezing or tightness. * new or worsening cough or wheezing. * if you are vomitting and cannot keep in fluids or your medications. * you are getting dehydrated due to continued vomitting, diarrhea or other reasons. signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * you see blood or dark/black material when you vomit or have a bowel movement. * your skin, or the whites of your eyes become yellow. * your pain is not improving within 8-12 hours or not gone within 24 hours. call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * you have shaking chills, or a fever greater than 101.5 (f) degrees or 38(c) degrees. * any serious change in your symptoms, or any new symptoms that concern you. * please resume all regular home medications and take any new meds as ordered. * continue to amubulate several times per day. * continue with drain care. followup instructions: provider: scan phone: date/time: 10:15. provider: , md phone: date/time: 11:30 . Procedure: Venous catheterization, not elsewhere classified Parenteral infusion of concentrated nutritional substances Interruption of the vena cava Thoracentesis Thoracentesis Drainage of pancreatic cyst by catheter Diagnoses: Unspecified pleural effusion Unspecified protein-calorie malnutrition Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Personal history of malignant neoplasm of prostate Chronic kidney disease, unspecified Acute venous embolism and thrombosis of deep vessels of proximal lower extremity Hemorrhage of gastrointestinal tract, unspecified Other pulmonary embolism and infarction Cyst and pseudocyst of pancreas